Self-awareness of premalignant oral lesions among veterans attending six U.S. Veterans Affairs Medical Centers.

Early identification is key to reducing the morbidity and mortality of oropharyngeal cancer. This study identified factors associated with self-awareness among patients newly diagnosed with a premalignant oral lesion. Data describing sociodemographics, medical/dental histories, tobacco/alcohol use and oral health were obtained by questionnaire and clinical examination of 73 veterans at six U.S. Veterans Affairs Medical Centers. Lesion types included homogenous and non-homogenous leukoplakia, smokeless tobacco lesion (STL), papilloma, lichen planus and erythroplakia. Prior to diagnosis, 29 subjects (39.7%) were unaware of their lesion. In bivariate analyses, lesion self-awareness was associated with anatomic location, multifocal/generalized appearance, pain, oral sores, and cigar use (p<0.05). Awareness varied with lesion diagnosis and was more likely with STL and less likely with homogenous leukoplakia (p<0.05). In multivariate analyses, awareness was predicted by the presence of a lesion on easily visible mucosa (adjusted odds ratio, OR=11.2) and a history of mouth sores (OR= 11.2). These findings identified marked variations in patient self-awareness of oral premalignant conditions.

Risk indicators for oral candidiasis and oral hairy leukoplakia in HIV-infected adults.

OBJECTIVES: Oral candidiasis (OC) and oral hairy leukoplakia (OHL) are the most common oral mucosal diseases associated with HIV infection. Independent risk indicators associated with these sentinel opportunistic diseases have not been established in mixed race and gender adult populations in the southeast USA. The purposes of this study were 1) to estimate prevalence of OC and OHL among an HIV-1 positive adult population, and 2) to develop explanatory multivariable models for each disease outcome. METHODS: This cross-sectional study evaluated 631 adult dentate HIV-1 seropositive persons examined for HIV-associated oral mucosal diseases between 1995 and 2000 at University of North Carolina Hospitals in Chapel Hill, North Carolina using data collected from medical record review, interview questionnaire and clinical examination. We analyzed the data using t-tests, anova, and unconditional logistic regression. RESULTS: Prevalent OC was associated with low CD4+ cell count [<200 cells/microl, adj. OR = 12.7 (95%CI: 4.9-32.9)], antiretroviral combination therapy [OR = 0.6 (0.3-0.9)], and current smoking [OR = 2.5 (1.3-4.8)]. Prevalent OHL was associated with low CD4+ cell count [<200 cells/microl, OR = 7.2 (2.7-18.9)], antifungal medication use [OR = 1.8 (1.1-2.9)], current recreational drug use [OR = 2.5 (1.3-4.9)], and male gender [OR = 2.5 (1.3-4.8)]. CONCLUSIONS: While CD4+ cell count, and antiretroviral medication were important risk indicators for OC, and OHL, cigarette smoking appears to be an important risk indicator for OC in HIV-1-infected populations.

Incidence of oral candidiasis and oral hairy leukoplakia in HIV-infected adults in North Carolina.

OBJECTIVES: To establish incidence rates and risk factors for HIV-associated oral candidiasis (OC), oral hairy leukoplakia (OHL), and any HIV-associated oral diseases (HIV-OD). DESIGN: This prospective, cumulative case-control study followed 283 initially oral disease-free HIV-1-infected men and women for 2 years. Incidence rate ratios (IRR) and incidence proportions for OC, OHL, and HIV-OD were estimated. Multivariable analyses using Poisson regression determined the most parsimonious best-fitting model explaining the outcomes. RESULTS: Incidence rate (per 1000 person-months) was 9.3 for OC, 6.8 for OHL, and 13.5 for HIV-OD. Incidence of OC was associated with low CD4 count (adjusted IRR = 3.0 (95% CI = 1.7, 5.1)), smoking (IRR = 1.9 (1.0, 3.8)) and combination antiretroviral therapy (IRR = 0.3 (0.1, 0.8)). Incidence of OHL was associated with low CD4 count, conditional upon smoking status. Conclusions Low CD4 count and smoking are important risk factors for HIV-associated OC and OHL. Antiretroviral medications are protective for OC but not for OHL.

Salivary secretory leukocyte protease inhibitor and oral candidiasis in human immunodeficiency virus type 1-infected persons.

Oropharyngeal candidiasis, typically caused by Candida albicans, is the most common oral disease associated with human immunodeficiency virus type 1 (HIV-1) infection. Secretory leukocyte protease inhibitor (SLPI), a 12-kDa antiprotease, suppresses the growth of C. albicans in vitro. To determine whether the mucosal protein plays a role in protecting oral tissues against fungal infection, we conducted a cross-sectional study investigating the oral and systemic health and salivary SLPI levels in 91 dentate HIV-1-infected adults receiving medical care in the southeastern United States. Participants with a self-reported history of clinical oropharyngeal candidiasis during the previous 2 years constituted the test group (n = 52), while the comparison group (n = 39) had no oropharyngeal candidiasis during that period. Data collected from medical records, oral examination, and SLPI enzyme-linked immunosorbent assay quantitation of whole saliva were analyzed by t test, analysis of variance, linear regression, and unconditional logistic regression. The test group had a significantly higher mean salivary SLPI level than the comparison group (1.9 microg/ml versus 1.1 microg/ml, P < 0.05). Linear regression modeling identified CD4 cell count and history of oropharyngeal candidiasis as key predictors of salivary SLPI and revealed a significant interaction (P < 0.05) between immunosuppression (CD4 cell count below 200 cells/ microl) and positive history of oropharyngeal candidiasis in predicting salivary SLPI level. By logistic regression modeling, a salivary SLPI level exceeding 2.1 microg/ml, low CD4 count, antiretroviral monotherapy, and smoking were key predictors of oropharyngeal candidiasis. These data support a key role for SLPI in the oral mucosal defense against C. albicans. The antimicrobial mucosal protein may serve as an indicator of previous oropharyngeal candidiasis infection among immunosuppressed persons.

Education in HIV risk screening, counseling, testing, and referral: survey of U.S. dental schools.

According to Centers for Disease Control and Prevention estimates, thousands of Americans are infected with HIV but are unaware of their infection status. National disease prevention goals to identify and treat these individuals will benefit from HIV risk screening, counseling, testing, and referral services conducted in nontraditional settings and the use of alternative diagnostic methods such as oral fluid-based HIV antibody testing. Using a mail survey of the fifty-four U.S. dental schools (85 percent response rate), this study assessed the teaching and practice of HIV risk screening, as well as the opinions of dental educators regarding HIV counseling and testing and a possible role for oral fluid-based HIV antibody testing in dental offices. All responding dental schools have curriculum and clinical education training regarding HIV behavioral risks, medical history, and use of oral manifestations as indicators of HIV Educators felt risk screening and referral for HIV counseling and testing was part of a dentist's professional role. One-third of respondents indicated they might include HIV counseling and testing using a rapid oral fluid-based HIV antibody test in their clinics. However, these respondents lacked confidence that graduating dentists have the skills and willingness to conduct HIV counseling and testing in dental practice. Lack of training in prevention counseling was seen as a primary barrier.