Social aspects of HIV and their relationship to craniofacial problems: workshop 4C.

The oral research community needs an understanding of the social causes, consequences, and costs of disease in relation to oral health. This workshop concluded that HIV infection constitutes a special dental need requiring specific arrangements to facilitate oral care for infected persons. Oral manifestations of HIV infection affect everyday life, but more evidence is needed on the effects of interventions to alleviate these impacts. Other oral health habits add to the burden of HIV/AIDS-associated oral diseases and compete with them for resources. These problems are most acute where the prevalence of HIV is high and resources are scarce. Effective health promotion is therefore important in these areas. Without data on the utility of oral health care in developing countries, practical approaches are guided by societal and multidisciplinary principles. There are also important ethical considerations.

Compliance with infection control recommendations in South African dental practices: a review of studies published between 1990 and 2007.

In a country where the prevalence of infectious diseases ranks among the highest in the world, infection control in health care facilities should not be debatable. This unfortunately does not seem to be the case in South African oral health care facilities. This study is a systematic review of available literature on the adherence of South African oral health care professionals to infection control recommendations. Nine focus areas were investigated with regard to infection control practices: knowledge of infectious occupational hazards; personal hygiene and care of hands; correct application of personal protective equipment; use of environmental barriers and disposable items; sterilisation (recirculation) of instruments and handpieces; disinfection (surfaces) and sound housekeeping; management of waste disposal; quality control of dental unit waterlines, biofilms and water; as well as other special considerations. Although South African studies are limited and most of them relied on self-reports, which could have resulted in a serious overestimation of compliance, even these studies indicate serious shortcomings with regard to infection control practices in oral health care facilities in this country. This review highlights opportunity for improvement. Furthermore, it identifies possibilities for future research in infection control and also opportunities to improve infection control education for all oral health care workers in the country.

(A3) HIV Phenotypes, oral lesions, and management of HIV-related disease.

Workshop participants discussed: the role of HIV subtypes in disease; the treatment of oral candidiasis; the relationship between and among viral load, CD4+ counts, oral candidiasis and oral hairy leukoplakia, pigmentation; and the development of a reliable oral index to predict disease progression. Regarding HIV, the literature revealed that Type I (HIV-I), in particular group M, is involved in the majority (90%) of documented infections, and groups N and O to a lesser extent. Viral envelope diversity led to the subclassification of the virus into nine subtypes, or clades-A-D, F-H, J, and K-each dominating in different geographical areas. HIV-2, currently occurring mostly in West Africa, appears to be less virulent. No evidence could be produced of any direct impact of type, subtype, or clade on oral lesions, and participants believed that further research is not feasible. Oral candidiasis in patients from resource-poor countries should be prevented. When the condition does occur, it should be treated until all clinical symptoms disappear. Oral rinsing with an antimicrobial agent was suggested to prevent recurrence of the condition, to reduce cost, and to prevent the development of antifungal resistance. Lawsone methyl ether, isolated from a plant (Rhinacanthus nasutus leaves) in Thailand, is a cost-effective mouthrinse with potent antifungal activity. Evidence from a carefully designed prospective longitudinal study on a Mexican cohort of HIV/AIDS patients, not receiving anti-retroviral treatment, revealed that the onset of oral candidiasis and oral hairy leukoplakia was heralded by a sustained reduction of CD4+, with an associated sharp increase in viral load. Analysis of the data obtained from a large cohort of HIV/AIDS patients in India could not establish a systemic or local cause of oral melanin pigmentation. A possible explanation was a dysfunctional immune system that increased melanin production. However, longitudinal studies may contribute to a better understanding of this phenomenon. Finally, a development plan was presented that could provide a reliable prediction of disease progression. To be useful in developing countries, the index should be independent of costly blood counts and viral load.

Halitosis: a review.

Halitosis, or bad breath, is caused by mainly volatile sulfur compounds (VSC) as a result of bacterial breakdown of protein and can be quantitatively and qualitatively measured in the expired oral breath. In eight to ninety percent of cases, halitosis originates in the mouth due to inadequate plaque control, periodontal disease, dry mouth, faulty restorations, and in particular due to excessive bacterial growth on the posterior third of the dorsal surface of the tongue. In the remaining ten to twenty percent of cases, bad breath is caused by systemic disorders such as hepatic, pancreatic and nephritic insufficiencies, trimethylaminuria, upper and lower respiratory tract infection, medication and cases where gastric content may generate oral malodour. The methods of detecting or diagnosing halitosis are organoleptic or human sense of smell, sulfide monitoring and gas chromatography. All of these methods have limitations and disadvantages. A more accurate, analytical system which will be able to precisely detect the volatile compounds in the expired air and correlate the results to a specific cause is not yet available. Dental professionals require a good knowledge on the subject of bad breath in order to feel secure about counseling and managing patients suffering from this condition. The management of halitosis involves maintenance of plaque control, elimination of active periodontal disease and cleaning the tongue on a routine basis. Oral rinsing with a mouthwash could be indicated in some instances, as a temporary measure.

A review of candida and periodontal disease in immunocompetent and HIV-infected subjects.

The role of candida in the aetiology and pathogenesis of periodontal diseases is unclear. In spite of the organism being present in subgingival biofilm samples and in gingival biopsy specimens taken from affected subjects, it has not been possible to demonstrate that it is an active agent in these cases. There is an increase in the prevalence of candida species in the oral cavities and specifically in the subgingival biofilm of HIV-seropositive patients. However, periodontal diseases in HIV-seropositive and HIV-seronegative subjects are similar with regard to the spectrum of periodontopathic bacteria, clinical manifestation, natural course of the disease and response to treatment. Thus, it is safe to assume that candidal micro-organisms play only a minor role, if any, in the aetiology and pathogeneses of periodontal diseases in HIV-seropositive subjects.

Antifungal susceptibility of South African oral yeast isolates from HIV/AIDS patients and healthy individuals.

The in vitro antifungal susceptibility profile of 589 oral yeast isolates from HIV/AIDS patients and healthy South Africans was determined against amphotericin B, nystatin, 5-fluorocytosine (5-FC), clotrimazole, miconazole, ketoconazole, itraconazole and fluconazole. The broth microdilution method of the National Committee on Clinical Laboratory Standards was used and MIC(50) and MIC(90) determined. A 100% susceptibility to fluconazole was observed among the 466 isolates of Candida albicans. Among C. krusei, the second most common isolate, only 2.6% of isolates were susceptible to fluconazole and itraconazole. Despite the lack of previous exposure to antifungal agents, very little difference was observed in the antifungal profile between the South African isolates and isolates from the United States (U.S.), Canada and South America. South Africa has a particularly high incidence of HIV-infection and oral candidiasis is the most common oral complication in these patients. This study provides important baseline data as the isolates were collected prior to fluconazole being made freely available to HIV/AIDS patients attending government health clinics.

Necrotising ulcerative gingivitis/periodontitis as indicators of HIV-infection.

UNLABELLED: Necrotising ulcerative gingivitis/periodontitis (NUG/NUP) are well-documented oral manifestations of HIV infection/AIDS. However, no information is available regarding the predictive value of NUG in the diagnosis of HIV-infection in South Africa. OBJECTIVES: The purpose of this study was to determine a possible correlation between NUG/NUP and HIV infection in the as yet undiagnosed patients. METHODS: Eighty-six systemically asymptomatic patients were diagnosed with NUG/NUP. All patients were treated with 400 mg of metronidazole and 500 mg paracetamol, three times a day for five days. Mechanical debridement under local anesthesia was performed five days after the initial consultation. The possible involvement of HIV-infection was explained and patients were advised to have a blood test taken. RESULTS: Fifty-six patients consented and received pre- and post-test counselling. Of the fifty-six patients, thirty-nine were found to be HIV positive with CD+ T cell counts ranging between 9 and 1,205 cells/mm3. There was a statistically significant correlation between CD4+ T cells below 500 cells/mm3 (p = 0.000) as well as with CD4+ T cells below 200 cells/mm3 (p = 0.001) and NUP/NUG. CONCLUSION: From these results it is concluded that in the GaRankuwa and surrounding areas, NUG/NUP in otherwise systemically healthy individuals is strongly correlated with HIV infection, with a predictive value of 69.6 per cent (p = 0.01). It is recommended that patients presenting with these conditions be encouraged to undergo testing to establish their HIV status for appropriate referrals and management.

The treatment of oral candidiasis in a cohort of South African HIV/AIDS patients.

The purpose of this study was to determine the extent and outcome of antifungal treatment in HIV/AIDS patients. Data obtained from patients attending a hospital-based, semi-urban comprehensive care HIV clinic, were retrospectively analysed. The clinic serves patients from urban, semi-urban and rural communities. A total of 751 confirmed black heterosexual HIV/AIDS patients received routine oral examinations and surveillance swabbing for oral yeast culture. Patients received nystatin solution as prophylaxis, miconazole for clinically detectable oral candidiasis and only in severe cases or cases of chronic candidiasis were they treated with either fluconazole or itraconazole. Treatment was regarded as successful when there was an absence or resolution of clinical lesions of oral candidiasis. Nystatin prophylaxis was prescribed to 7.9% of patients, miconazole treatment to 9.7% and 3.5% received fluconazole. Of the 60 patients who received nystatin prophylaxis, 40 (66.6%) had clinically detectable candidiasis. A negative statistical correlation was found between nystatin prophylaxis and clinically detectable candidiasis. Of 72 patients who received miconazole treatment, only 3 failed to respond. Eleven of the 27 patients who received fluconazole treatment did not return for follow-up visits. In the remaining 16 patients there was no recurrence of clinical symptoms during the following 3 - 24 months after treatment with fluconazole. It is concluded that nystatin prophylaxis proved not to be effective under these particular clinical circumstances. Resistance to azole antifungal medication is not yet a problem in this black heterosexual group of South African HIV/AIDS patients.

Oral health needs of HIV/AIDS orphans in Gauteng, South Africa.

To care for HIV/AIDS orphans will put health and social services in South Africa before a major challenge. Published clinical information on South and Southern African HIV-positive children is limited to hospitalized children. A cross-sectional, prospective study was conducted on a convenience sample of HIV-positive children, living in orphanages in Gauteng, South Africa, in order to determine the oral health needs of the children. Five homes for abandoned/orphaned HIV/AIDS children were visited, 11 caregivers, excluding the nursing sisters (registered nurses), were interviewed to determine their knowledge regarding oral health. An oral examination was performed on 87 children who were not receiving antiretroviral treatment. The caregivers were knowledgeable regarding pseudomembranous candidiasis but all lacked knowledge on oral hygiene procedures and the cariogenic potential of a baby bottle. The mean age of the children ranged between 3.2 and 7 years, with one home having children older than 11 years. Rampant early childhood caries in 19 (21.8%) children was the major finding, with 5 children suffering severe pain from multiple carious teeth. In the hospice section of the homes all 12 children had clinically detectable candidiasis, while in 4 (33.3%) there was an associated bleeding and ulceration of the oral mucosa, impairing their ability to eat. The findings indicate a training need among caregivers regarding the oral health of children and a role for health professionals in preventing oral diseases and reducing suffering.

Oral yeast flora of a Kalahari population.

During an epidemiological survey of 181 individuals working or residing in the Kalahari National Gemsbok Park, swabs were taken from the dorsal surfaces of their tongues to determine a possible association between oral yeasts and clinically observed oral lesions as well as other underlying conditions detectable by serum chemistry. Identification of yeasts was performed with a commercially available identification system, namely the ATB 32C (Montalieu, Vercieu). Yeasts were isolated from 30.4 per cent (n = 55) of individuals, of whom 43.6 per cent (n = 24) had only Candida albicans, 3.6 per cent (n = 2) had C. albicans together with other yeasts and 52.7 per cent (n = 29) had other yeasts. Many of these yeasts were not the commonly encountered clinical isolates. The results revealed a significant association (p < 0.02) between yeasts (n = 55) and low serum iron concentrations (n = 50). A highly significant (p < 0.001) association was also found between smoking (n = 112) and the presence of clinically detectable oral lesions, notably leukoplakia (n = 21) and mucosal atrophy. The findings of this study reveal that a significant association exists between the oral yeast flora and serum iron and glucose, as well as between smoking and oral mucosal lesions.

Fungal infections associated with HIV infection.

Oral candidiasis is perhaps the commonest infection seen in HIV disease. The aim of this workshop was to provide a sketch of the multifarious aspects of the disease from a global perspective. To this end the panellists addressed issues such as the virulence of Candida, emergence of antifungal resistance, management of candidiasis and other exotic, oral mycotic diseases. An all-pervasive theme was the dramatic differences in the management of fungal infections consequential to the availability (or the lack) of anti-HIV drugs in the developed and the developing world. Further, the social stigmata associated with the HIV disease in many developing regions in Africa and Asia appears to modify the therapeutic strategies. Additionally, the lesser-known regional variations in the disease manifestations and therapeutic approaches were stark. Further work is direly needed to address these issues.