An assessment of adverse effects of antiretroviral therapy on the development of HIV positive children by observation of dental mineralization chronology.

BACKGROUND: The difference between dental age (DA) and chronological age (CA) indicates an advance or delay in comparison with the normal standard. Considering that DA has a very close correlation with CA in a developing child, this study aimed to investigate the relationship between the effects of antiretroviral therapy on the development of HIV positive children, by observing the timing of dental mineralization. METHODS: A retrospective examination was made of the medical records and dental panoramic radiographs of 50 HIV-positive pediatric patients, aged 37-168 months of age. Through these radiographs, their DA was estimated and compared with their CA. RESULTS: The mean DA was significantly lower than the mean CA in the entire studied sample (P < 0.01). There was a statistical difference between children who received antiretroviral drugs and those who used no drugs (P = 0.02), i.e. the non-treated individuals presented practically no difference between CA and DA, while the treated patients showed a difference of 10.67 months. CONCLUSION: We conclude that the DA of HIV infected children was delayed when compared to the CA, and there was a positive association between the use of antiretroviral therapy and a delay in the chronology of dental mineralization in the sample.

Temporomandibular joint disorders during HIV infection: a case report.

Temporomandibular disorders (TMD) is a term reflecting chronic, painful, craniofacial conditions usually of unclear etiology with impaired jaw function. Human immunodeficiency virus (HIV)-infected patients often report chronic pain and pathologies targeting body joints during retroviral therapy. Although both conditions may share similar secondary disorders, no conclusive cause-effect relationship has been found linking the TMD to the HIV-antiviral treatment. This report describes a case of TMD associated with HIV infection during active retroviral therapy. Clinicians should be aware that treatment of an HIV-infected patient with TMD requires an interdisciplinary team approach.

Effect of HAART on salivary gland function in the Women's Interagency HIV Study (WIHS).

OBJECTIVE: To determine the impact of highly active antiretroviral therapy (HAART) on salivary gland function in human immunodeficiency virus (HIV) positive women from the Women's Interagency HIV Study (WIHS). DESIGN: Longitudinal cohort study. SUBJECTS AND METHODS: A total of 668 HIV positive women from the WIHS cohort with an initial and at least one follow-up oral sub-study visit contributed 5358 visits. Salivary gland function was assessed based on a dry mouth questionnaire, whole unstimulated and stimulated salivary flow rates, salivary gland enlargement or tenderness and lack of saliva on palpation of the major salivary glands. MAIN OUTCOME MEASURES: Changes in unstimulated and stimulated flow rates at any given visit from that of the immediate prior visit (continuous variables). The development of self-reported dry mouth (present/absent), enlargement or tenderness of salivary glands (present/absent), and absence of secretion on palpation of the salivary glands were binary outcomes (yes/no). RESULTS: Protease Inhibitor (PI) based HAART was a significant risk factor for developing decreased unstimulated (P = 0.01) and stimulated (P = 0.0004) salivary flow rates as well as salivary gland enlargement (P = 0.006) as compared with non-PI based HAART. CONCLUSIONS: PI-based HAART therapy is a significant risk factor for developing reduced salivary flow rates and salivary gland enlargement in HIV positive patients.

Essential medical issues related to HIV in dentistry.

Management of HIV infection has progressed dramatically since the disease was first recognized, to the point that HIV infection is now considered a chronic condition. Some of these new approaches in management are related to the strides that have been made in understanding the pathogenesis of this condition. Such changes in medical care may also affect the provision of oral health care. Dental providers must therefore be aware of current management practices. This paper reviews current approaches to managing HIV-related disease.

Efficacy and tolerance of HCV treatment in HIV-HCV coinfected patients: the potential interaction of PI treatment.

PURPOSE: To evaluate tolerance and efficacy of an open-label interferon-ribavirin treatment and their determinants in 62 HCV-HIV coinfected patients in routine followup. METHOD: Patients received at least 6 and up to 12 months of combination interferon alpha-2b (peg or not) plus ribavirin. Determinants of therapeutic success were estimated by a multivariate logistic regression. RESULTS: Five patients stopped the study, 4 were lost to follow-up, and 53 participated in the entire therapeutic protocol. Among these 53, the end-of-treatment results showed complete clearance of HCV-RNA in 17 (32%). A sustained virologic response (SVR) after 6 or 9 months was observed in 9 (17%) patients, 3 relapsed, and data were not available for 5. Genotype 3a (odds ratio [OR] = 14.4; confidence interval [CI] = 1.84-110.3) favored SVR and treatment with protease inhibitor (PI) therapeutic resistance (OR = 14.4; CI = 1.01-200); as well, a higher fibrosis score tended to increase resistance (p =.11). Adverse events were reported by 24/53 patients (45.3%). CONCLUSION: HCV therapy associating interferon and ribavirin in HCV-HIV coinfected patients is well accepted even if tolerance is moderate. Treatment permitted SVR in at least 17% of the cases. This is likely when patients initiate treatment at the early fibrosis stage and are infected with genotype 3a. The potential interaction with PI therapy should be explored.

Suction-assisted lipectomy for lipodystrophy syndromes attributed to HIV-protease inhibitor use.

The addition of HIV-protease inhibitors to the arsenal of therapies for the treatment of HIV infection has resulted in significant suppression of viral load such that HIV-positive individuals experience reduced morbidity and extended life expectancy. Recently, a number of syndromes have been described involving abnormal fat distribution that may be associated with prolonged HIV-protease inhibitor therapy. These syndromes include hypertrophy of the cervicodorsal fat pad ("buffalo hump"); a tendency toward increased central adiposity ("protease paunch"); adiposity in the submental, mandibular, and lateral cheek regions of the face; and hypertrophy of adipose tissue in the breast in women. A peripheral lipodystrophy, or fat-wasting, in the extremities and face (particularly the malar and nasolabial fold regions) has also been observed. As these patients live longer and healthier lives, many are beginning to seek surgical correction of the disfigurements. In this regard, we present a review of the literature regarding these recently described syndromes to familiarize plastic and reconstructive surgeons with the unique deformities encountered in this ever-increasing patient population. We also present our results with suction-assisted lipectomy for treatment of these deformities. Physical findings, pathogenesis, and surgical management are discussed.

Anti-retroviral drugs--implications for dental prescribing.

Many patients with HIV/AIDS are now being treated with two or more drugs to reduce HIV viraemia and boost CD4 T-cell counts. Patients are using these drugs earlier in the course of their disease and so GDPs are likely to encounter them in practice. The drugs have dramatically altered short term prognosis but are potent and have potentially serious drug interactions. Some of these drugs have interactions with drugs used in the dental care setting and this paper sets out to summarise those that are relevant in this area.

[Erythema multiforme caused by saquinavir]. / Erythème polymorphe au saquinavir.

BACKGROUND: Saquinavir is a protease inhibitor used for the treatment of HIV infection. Adverse skin reactions have been rare. We report here the first case of erythema multiforme in a patient given saquinavir. CASE REPORT: A 32-year-old man was seropositive for HIV and consulted due to the development of round maculo-papular lesions centered on a bulla and two erosive lesions of the palate five days after the introduction of saquinavir. Histology was compatible with erythema multiforme. After withdrawal of saquinavir, the skin and mucosal lesions regressed in 15 days, with no recurrence at 3 months. DISCUSSION: Adverse skin reactions to saquinavir are exceptional (eruptions, pruritus). We describe here the first case of erythema multiforme caused by saquinavir (imputability criteria 12 BO). Due to the structural analogy of saquinavir with other protease inhibitors (indiravir, ritonavir, nelfinavir) it would be difficult to prescribe a compound of the same class.

A patient's guide to protease inhibitors.

AIDS: Dosage guidelines and side effects of three currently available protease inhibitors (saquinavir, ritonavir, indinavir) reveal very different patterns. Dosage regimens are as follows: saquinavir, 3 capsules every 8 hours with food; ritonavir, 6 capsules every 12 hours with food; and indinavir, 2 capsules every 8 hours on an empty stomach. Ritonavir has the severest side effects, including nausea, diarrhea, and initially, tingling feeling of the mouth, arms, or legs. The drugs work best when taken with well-studied medicines such as AZT, d4T, and ddI.^ieng

Saquinavir plus ritonavir reduce viral load by 99.9 percent.

AIDS: A combination of two protease inhibitors, saquinavir (Invirase) and ritonavir (Norvir), may produce a median drop in viral load of 99.9 percent. Several dosage variations were tested. The most common side effects of the combination regimen included tingling around the mouth, diarrhea, fatigue, and nausea. A low level of toxicity was found. This combination may be used for people who have failed other protease inhibitor therapy or have developed a resistance to nucleoside analogues.^ieng

The kissing question and other ICAAC highlights.

AIDS: Simplified findings from some of the presentations at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) are presented. A virus associated with Kaposi's sarcoma (KS) may be transmitted through saliva. Homosexual or bisexual activities are primary risk factors for African Americans with KS. Intravenous infusions of IL-2 and indinavir increases CD4 counts significantly. AIDS progression in children is associated with decreased levels of IL-2. The duration of therapy with IL-2 is more important than the dose. Pharmacists are essential for ensuring that drugs are prescribed properly and do not conflict with other drugs or allergies. Combination therapies are increasingly seen as more effective.^ieng

Ritonavir (Norvir).

AIDS: Ritonavir (Norvir), a protease inhibitors, was approved for HIV treatment by the Food and Drug Administration (FDA). Studies have shown that ritonavir helps people live longer and delays the progression of the illness. One study showed that the death rate for the treated group was half that of the group taking a placebo. Ritonavir should be taken with meals. Many people cannot tolerant the side effects, including nausea, vomiting, weakness, diarrhea, elevated liver enzymes, and numbing around the mouth. Ritonavir affects the way other drugs are absorbed by the body, and its use should be closely monitored for toxic reactions.^ieng

HIV topic update: protease inhibitor therapy and oral health care.

Protease inhibitors have been a major advance in the management of HIV disease and have reduced the frequency and severity of many complications, including some oral lesions. They may also be of value in the management of occupational exposures to the virus. However, they may produce adverse effects including oral symptoms such as paraesthesia, taste disturbances and xerostomia, and may interact with a number of drugs used in oral health care. This article summarises the current situation.

Orofacial effects of antiretroviral therapies.

This paper summarises some of the oral adverse effects of antiretroviral agents. Some are related to bone marrow suppression which may also predispose to mouth ulcers. Erythema multiforme and toxic epidermal necrolysis are especially well recognized in HIV disease, particularly as reactions to sulphonamides and to antiretroviral agents. Oral lichenoid reactions have been described in HIV disease often relating to zidovudine use. Didanosine has also produced erythema multiforme and not unusually induces xerostomia, again by an unknown mechanism. Xerostomia may be seen in up to one-third of patients taking didanosine. Taste abnormalities are common with the protease inhibitors and oral and perioral paraesthesia can be a disturbing adverse effect. Ritonavir in particular can give rise to circumoral paraesthesia in over 25% of patients. Indinavir can also produce cheilitis.