Importance of differential diagnosis of EBV mucocutaneous ulcer and EBV-positive diffuse large B-cell lymphoma: A case report.

RATIONALE: Epstein-Barr virus mucocutaneous ulcers (EBVMCUs) were officially recognized as a clinicopathologic entity in the 2017 revision of the World Health Organization classification, which often occurs in the elderly or in immunosuppressive condition presented as an isolated ulcerative lesion. EBVMCUs are defined as "shallow, sharply circumscribed, mucosal or cutaneous ulcers with underlying polymorphous infiltration." It mostly involves oral mucosa, but some appear in skin or gastrointestinal tract. Typically, patients with EBVMCUs display a slow disease progression and may even undergo spontaneous regression. PATIENT CONCERNS: This report describes the case of a 76-year-old woman who visited our outpatient clinic with the chief complaint of inflammation and ulceration on lower labial, lower right lingual gingiva seemed like acute necrotizing ulcerative gingivitis, and malignancy. DIAGNOSES: She was diagnosed with EBVMCU after tissue biopsy. INTERVENTIONS: Since most oral ulcerations usually appear in nonspecific form, it is important to check thoroughly for any underlying immunosuppressive systemic conditions and laboratory test results in case of viral infection. But she has no remarkable underlying immunosuppressive disorder. OUTCOMES: For this patient, she was initially diagnosed with EBVMCU and showed spontaneous healing, but then relapsed after 4 to 6 months. The patient was re-diagnosed as EBV-positive diffuse large B-cell lymphoma (EBV-positive DLBCLs) after re-biopsy. LESSONS: EBVMCU shows similar symptoms to malignant lesions or acute necrotizing ulcerative gingivitis but shows spontaneous healing. However, in case of EBV-positive DLBCLs, failing to detect and treat the disease in its early stages can lead to a fatal outcome. Thus, this case report highlights the differential diagnosis and appropriate treatment of EBVMCU and EBV-positive DLBCLs.

Proportion of paediatric admissions with any stage of noma at the Anka General Hospital, northwest Nigeria.

INTRODUCTION: Noma is a rapidly spreading infection of the oral cavity which mainly affects young children. Without early treatment, it can have a high mortality rate. Simple gingivitis is a warning sign for noma, and acute necrotizing gingivitis is the first stage of noma. The epidemiology of noma is not well understood. We aimed to understand the prevalence of all stages of noma in hospitalised children. METHODS: We conducted a prospective observational study from 1st June to 24th October 2021, enrolling patients aged 0 to 12 years who were admitted to the Anka General Hospital, Zamfara, northwest Nigeria. Consenting parents/ guardians of participants were interviewed at admission. Participants had anthropometric and oral examinations at admission and discharge. FINDINGS: Of the 2346 patients, 58 (2.5%) were diagnosed with simple gingivitis and six (n = 0.3%) with acute necrotizing gingivitis upon admission. Of those admitted to the Inpatient Therapeutic Feeding Centre (ITFC), 3.4% (n = 37, CI 2.5-4.7%) were diagnosed with simple gingivitis upon admission compared to 1.7% of those not admitted to the ITFC (n = 21, CI 1.1-2.6%) (p = 0.008). Risk factors identified for having simple gingivitis included being aged over two years (2 to 6 yrs old, odds ratio (OR) 3.4, CI 1.77-6.5; 7 to 12 yrs OR 5.0, CI 1.7-14.6; p = <0.001), being admitted to the ITFC (OR 2.1; CI 1.22-3.62) and having oral health issues in the three months prior to the assessment (OR 18.75; CI 10.65, 33.01). All (n = 4/4) those aged six months to five years acute necrotizing gingivitis had chronic malnutrition. CONCLUSION: Our study showed a small proportion of children admitted to the Anka General Hospital had simple or acute necrotizing gingivitis. Hospital admission with malnutrition was a risk factor for both simple and acute necrotizing gingivitis. The lack of access to and uptake of oral health care indicates a strong need for oral examinations to be included in routine health services. This provision could improve the oral status of the population and decrease the chance of patients developing noma.

Patient Living with Human Immunodeficiency Virus with Gingival Pain and Oral Soreness (Red and White Lesions).

A 34-year-old male patient with poorly controlled HIV/AIDS presented with symptoms consistent with oral candidiasis and necrotizing ulcerative gingivitis. He was treated with systemic antifungal agent and topical and systemic antibiotics.

Covid-19 and oral diseases: Crosstalk, synergy or association?

The coronavirus disease 2019 (Covid-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that clinically affects multiple organs of the human body. Cells in the oral cavity express viral entry receptor angiotensin-converting enzyme 2 that allows viral replication and may cause tissue inflammation and destruction. Recent studies have reported that Covid-19 patients present oral manifestations with multiple clinical aspects. In this review, we aim to summarise main signs and symptoms of Covid-19 in the oral cavity, its possible association with oral diseases, and the plausible underlying mechanisms of hyperinflammation reflecting crosstalk between Covid-19 and oral diseases. Ulcers, blisters, necrotising gingivitis, opportunistic coinfections, salivary gland alterations, white and erythematous plaques and gustatory dysfunction were the most reported clinical oral manifestations in patients with Covid-19. In general, the lesions appear concomitant with the loss of smell and taste. Multiple reports show evidences of necrotic/ulcerative gingiva, oral blisters and hypergrowth of opportunistic oral pathogens. SARS-CoV-2 exhibits tropism for endothelial cells and Covid-19-mediated endotheliitis can not only promote inflammation in oral tissues but can also facilitate virus spread. In addition, elevated levels of proinflammatory mediators in patients with Covid-19 and oral infectious disease can impair tissue homeostasis and cause delayed disease resolution. This suggests potential crosstalk of immune-mediated pathways underlying pathogenesis. Interestingly, few reports suggest recurrent herpetic lesions and higher bacterial growth in Covid-19 subjects, indicating SARS-CoV-2 and oral virus/bacteria interaction. Larger cohort studies comparing SARS-CoV-2 negative and positive subjects will reveal oral manifestation of the virus on oral health and its role in exacerbating oral infection.

Necrotizing ulcerative gingivitis and the orthodontic patient: a case series.

Necrotizing ulcerative gingivitis (NUG) can be a painful periodontal disease that can lead to loss of the interdental papillae. It is usually accompanied by systemic signs of fever, malaise and cervical and submandibular lymphadenopathy. It is caused by the profileration of anaerobic bacteria and has been linked to smoking and immunosuppression. This case series reports the occurrence of NUG in orthodontic patients and demonstrates that there is a varying scale of severity of the condition. Orthodontists should be aware of the clinical signs of NUG to ensure early detection and treatment of their patients in order to prevent irreversible loss of the interdental papillae and reduce the likelihood of recurrence. A treatment regime is suggested.

Necrotizing periodontal diseases in HIV-infected Brazilian patients: a clinical and microbiologic descriptive study.

OBJECTIVE: Nowadays, necrotizing periodontal diseases have a low prevalence; however, a better understanding of the etiopathogenesis of these diseases is necessary for determining more adequate preventive and therapeutic strategies. METHOD AND MATERIALS: From a pool of 1,232 HIV-infected patients, 15 presented with necrotizing periodontal diseases, which were evaluated by full-mouth periodontal clinical measurements. Subgingival biofilm samples were collected from necrotizing lesions of six of these individuals. The presence and levels of 47 bacterial species were determined by checkerboard DNA-DNA hybridization. RESULTS: All 15 patients (10 had severe immunodeficiency) had been infected sexually. Thirteen patients were taking antiretroviral medication (66.7% undergoing highly active antiretroviral therapy). Regarding necrotizing periodontal diseases, necrotizing ulcerative gingivitis (60%) was more prevalent than necrotizing ulcerative periodontitis (40%). The frequency of supragingival biofilm and bleeding on probing ranged from 11.5% to 59.2% and 3.0% to 54.0%, respectively, whereas the mean probing depth and clinical attachment level were between 1.48 and 2.61 mm and 1.30 and 2.62 mm, respectively. Species detected in high prevalence and/or counts in necrotizing lesions included Treponema denticola, Eikenella corrodens, Dialister pneumosintes, Enterococcus faecalis, Streptococcus intermedius, Aggregatibacter actinomycetemcomitans, and Campylobacter rectus. In contrast, Parvimonas micra, Prevotella melaninogenica, Fusobacterium nucleatum, Eubacterium nodatum, and Helicobacter pylori were observed in the lowest mean prevalence and/or counts. CONCLUSION: Necrotizing periodontal disease lesions in HIV-infected patients present a microbiota with high prevalence and/or counts of classical periodontal pathogens, in particular T denticola, as well as species not commonly considered as periodontal pathogens, such as E faecalis and D pneumosintes. In addition, these individuals with necrotizing periodontal disease frequently display severe immunodeficiency and AIDS-defining diseases such as tuberculosis.

Periodontal diseases in children and adolescents: a clinician's perspective part 2.

UNLABELLED: The general dental practitioner and paediatric dentist are in a unique position to identify and distinguish between a seemingly innocuous condition that may be a normal physiological aberration or an early sign of severe destructive periodontal disease. Although severe destructive periodontal conditions are uncommon in children, it is essential that children receive a periodontal screening as part of their regular dental examination. Early diagnosis ensures a high likelihood of a successful therapeutic outcome, primarily by reduction of aetiologic factors, remedial therapy and development of an effective maintenance protocol. This prevents the recurrence and progression of disease and reduces the incidence of tooth loss. In the first article, we discussed the classification, plaque-induced and non plaque-induced gingival diseases, localized and generalized forms of chronic as well as aggressive periodontitis. In this second article, we discuss periodontitis as a manifestation of systemic disease, necrotizing periodontal diseases, periodontal screening and basic periodontal examination, and treatment of periodontal diseases in children and adolescents. CLINICAL RELEVANCE: Incorporation of periodontal screening in regular dental examination by dentists can help in early diagnosis and treatment of periodontal diseases. This could prevent further progression of disease and reduce the frequency of tooth loss.

Oral manifestations of HIV infection and their correlation with CD4 count.

Human Immunodeficiency Virus (HIV)-related oral lesions can be used as markers of the immune status. The present cross-sectional study was conducted to identify the oral manifestations in HIV-infected individuals and their association with reduced Cluster of Differentiation 4 (CD4) count. The study population included known HIV-positive patients. A detailed case history of 399 HIV-positive patients was obtained and general examination was carried out. Diagnosis of oral lesions was done based on presumptive criteria of EEC Clearinghouse, 1993. The CD4 count was determined in 369 patients and correlated with oral manifestations. The prevalence of oral lesions was found to be 76.70% (n = 306). Oral candidiasis (157 (39.3%)) was the most common oral lesion associated with HIV infection. Amongst various forms of oral candidiasis, erythematous candidiasis (122 (39.3%)) outnumbered the other forms. The mean CD4 count of patients with oral lesions (207 cells/mm(3)) was less than in patients without oral lesions (291 cells/mm(3)) (P = 0.002). Oral candidiasis was found to be significantly correlated to a reduced CD4 cell count below 200 cells/mm(3) (P = 0.000; Odds ratio = 3.1; 95% Confidence interval 1.9-4.9) with good sensitivity, best specificity and positive predictive value. Oral manifestations may be used as an alternative to CD4 count at field-based settings to diagnose the immune compromised status of HIV-infected individuals.

The severity, extent and recurrence of necrotizing periodontal disease in relation to HIV status and CD4+ T cell count.

South Africa ranks among the three countries with the highest prevalence of HIV infection in sub-Saharan Africa, with an estimated 29.5% of women attending antenatal clinics being infected. Necrotizing periodontal disease is a well recognized HIV-associated oral condition. The objective of this investigation was to determine a possible correlation between the extent, severity and treatment outcome of necrotizing periodontal disease in relation to a person's HIV status and CD4+ T cell count. Data from 105 consecutive patients presenting with necrotizing periodontal disease at an academic oral health centre in South Africa were analysed. All patients were provided with an opportunity to undergo voluntary counseling and testing for HIV infection, were treated for necrotizing periodontal disease and followed over a period of nine months. The mean age of the cohort was 28 years old (range 12 - 52). Of 98 (93.3%) patients unaware of their HIV serostatus at the initial visit, 59 (56.2%) consented to testing. In total 45 (42.9%) were HIV-seropositive with a mean CD4+ T cell count of 222.7 cells/microl and 14 (13.3%) were HIV-seronegative, with a significantly higher mean CD4+ T cell count of 830 cells/microl (Fisher's exact test, p < 0.001), while the status of 46 (43.8%) remained unknown. In 101 (96.2%) patients, > or = 5 tooth sites were affected, and in 27 (26%) > or = 4 mm of gingival tissue were affected. This study, which included HIV-seropositive, HIV-seronegative and persons of unknown HIV status, revealed no statistical evidence that HIV infection was associated with the extent, severity or relapse of necrotizing periodontal disease. No statistically significant association could be demonstrated between the extent, severity and recurrence of necrotizing periodontal disease and a CD4+ T cell count < or = 200 cells/microl among HIV-seropositive patients.

Surgical considerations and management of patients with mucocutaneous disorders.

Surgeons may be confronted with providing periodontal plastic or implant therapy for patients with gingival manifestations of systemic conditions. These conditions (often referred to as mucocutaneous disorders) commonly present with features of desquamative gingivitis, which was once believed to represent a disease entity. However, today, the term desquamative gingivitis is used to describe clinical features of various local or systemic diseases or disorders that result in chronic gingival lesions characterized by epithelial desquamation, erythema, ulceration, and/or vesiculobullous lesions of the gingiva. Often, other oral tissues also are involved. Mucocutaneous disorders include such disease entities as lichen planus, graft-versus-host disease, pemphigoid, pemphigus vulgaris, lupus erythematosus, erythema multiforme, and linear IgA disease. Surgeons should be able to recognize these disorders and have the tools necessary to treat these conditions so that they can render the appropriate surgical care. This article describes the diagnosis, etiology, and clinical manifestation of these disease entities, as well as the surgical considerations and management in providing care to these patients.

Necrotizing periodontal diseases in HIV-seropositive subjects: pathogenic mechanisms.

Necrotizing gingivitis (NG) is a well-known periodontal condition characterized by marginal gingival necrosis, bleeding and pain. Necrotizing periodontitis is an extension of NG into the periodontal attachment apparatus, and the two stages are referred to collectively as necrotizing periodontal diseases (NPD). Necrotizing periodontal diseases in HIV-seropositive subjects are similar with regard to the spectrum of periodontopathic bacteria, the clinical manifestations, the natural course and the response to treatment when compared to NPD in HIV-seronegative subjects. However, in the former group, there is an increase in the prevalence of candidal species and herpesviruses in the subgingival plaque and gingival biopsy specimens. In the periodontal tissues, spirochaetes, activated herpesviruses, Candida species and HIV have the capability of deregulating host innate and adaptive immune responses and of stimulating host inflammatory reactions, and may therefore explain the greater prevalence of NPD in HIV-seropositive subjects compared to immunocompetent subjects.

Necrotizing gingivitis of Kaposi sarcoma affected gingivae.

Necrotizing gingivitis and oral Kaposi sarcoma are common concomitants of HIV infection and both are regarded as indicators of HIV infection. Their simultaneous appearance in an HIV seropositive subject therefore, should be relatively common; but other reports documenting such cases could not be found. This article documents an uncommon case of necrotizing gingivitis superimposed on Kaposi sarcoma-affected gingiva, occurring in a patient with chronic periodontitis. The nature of necrotizing gingivitis and Kaposi sarcoma and the possible differential diagnosis of the periodontal attachment loss are discussed.

Oral lesions in HIV infection in developing countries: an overview.

HIV infection is a major global health problem affecting developing and developed countries alike. Oral lesions that are associated with this disease are important, since they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression. Oral lesions in HIV infection have been well-documented in developed countries, but there are fewer reports on oral lesions from developing countries. Oral candidiasis is the most common opportunistic infection seen in all continents. Kaposi's sarcoma has been reported only from Africa and Latin America, while histoplasmosis and penicilliosis were reported in patients with advanced disease from Thailand. HIV-associated salivary gland disease has a high prevalence in Africa and Latin America, especially in the pediatric group. It is clear that there are considerable regional variations in the oral manifestations of HIV infection, depending both on the populations studied and on the clinical expertise available, among other factors. Well-designed and -documented studies are necessary for the correct assessment of the nature and magnitude of the problem in developing countries, if oral health measures are to be effectively formulated for the HIV-infected.

Complex oral manifestations of an HIV-seropositive patient.

A complex manifestation of characteristic oral lesions occurring simultaneously in an HIV-seropositive patient is presented. Necrotizing ulcerative gingivitis (NUG), necrotizing ulcerative periodontitis (NUP), oral-facial herpes infection, pseudomembranous candidiasis and atypical oral ulceration are discussed. In spite of extremely low CD4+ T-cell counts of 3 x 10(6)/L and lack of anti-retroviral therapy, an AIDS patient responded favourably to standard periodontal therapy. In the follow-up period of 3 months, no recurrence of any of the oral lesions initially present occurred and no special prophylactic regimes were needed to maintain oral health. This case illustrates that appropriate management of the oral manifestations contributes significantly to improvement of the quality of life of patients in the terminal stage of HIV-AIDS.

Inflammatory cytokine profile and circulating cortisol levels in malnourished children with necrotizing ulcerative gingivitis.

Necrotizing ulcerative gingivitis (NUG), a periodontal disease traditionally associated with stressful lifestyles in young adults in developed countries, is very prevalent in socioeconomically deprived Nigerian children. Random incident cases (153) of NUG, along with their neighborhood village counterparts of comparable age and without NUG, as control, were recruited for this study. Anthropometric evaluation revealed widespread malnutrition and poor health in both groups of children, with more severe stunting in NUG cases. The poor nutritional status of the village children, with and without NUG, was also confirmed by markedly reduced levels of circulating micronutrients. Compared with the neighborhood children, NUG victims showed significant (p < 0.05 or < 0.001) increases in serum levels of interleukin (IL)-8 (+ 233%), IL-18 (+ 30%), IL-6 (+ 190%), IL-1beta (+ 341%), IL-10 (+ 186%), with a small decrease in interferon (IFN)-gamma (-19%) and nonsignificant increases in soluble tumor necrosis factor (TNF) receptors (sTNFR-p55, p75). Associated with NUG was a significant, 38% (p < 0.05) increase in plasma cortisol above the already high levels observed in the neighborhood village children, as well as some micronutrient deficiencies. The findings suggest that NUG is associated with dysregulated cytokine production, with a complex interplay of elevated levels of pro- and anti-inflammatory mediators. Such changes may serve as the common link between the seemingly unrelated risk conditions (e.g. stressful life styles, smoking, microbial infections, diabetes, malnutrition, alcoholism) traditionally implicated in the genesis of NUG, and all known to promote an increase in the blood level of cortisol, as well as a Th(1) to Th(2) cytokine shift.