Rapid progression of bone loss in HIV-associated necrotizing ulcerative stomatitis.

This report describes a case of rapidly progressive periodontal tissue breakdown and bone loss in an HIV-infected markedly immunosuppressed homosexual male. Within 6 months of initial presentation with a necrotizing ulcerative gingivitis, the lesion extended to a necrotizing ulcerative stomatitis involving the surrounding periodontium and palatal mucosa. With only partial compliance to local debridement, chlorhexidine oral rinses, and systemic metronidazole therapy, alveolar bone loss resulted in tooth mobility necessitating extraction of 2 involved teeth. This case illustrates the continuum of necrotizing ulcerative infections of the periodontium in the severely immunosuppressed patient. The implications of these oral manifestations of HIV infection are discussed.

Periodontal infection as a possible risk factor for preterm low birth weight.

Peridontal diseases are gram-negative anaerobic infections that can occur in women of childbearing age (18 to 34 years). In the present investigation we sought to determine whether the prevalence of maternal periodontal infection could be associated with preterm low birth weight (PLBW), controlling for known risk factors and potential covariates. A case-control study of 124 pregnant or postpartum mothers was performed. PLBW cases were defined as a mother with a birth of less than 2,500 g and one or more of the following: gestational age < 37 weeks, preterm labor (PTL), or premature rupture of membranes (PROM). Controls were normal birth weight infants (NBW). Assessments included a broad range of known obstetric risk factors, such as tobacco use, drug use, alcohol consumption, level of prenatal care, parity, genitourinary infections, and nutrition. Each subject received a periodontal examination to determine clinical attachment level. PLBW cases and primiparous PLBW cases (n = 93) had significantly worse periodontal disease than the respective NBW controls. Multivariate logistic regression models, controlling for other risk factors and covariates, demonstrated that periodontal disease is a statistically significant risk factor for PLBW with adjusted odds ratios of 7.9 and 7.5 for all PLBW cases and primiparous PLBW cases, respectively. These data indicate that periodontal diseases represent a previously unrecognized and clinically significant risk factor for preterm low birth weight as a consequence of either PTL or preterm PROM.

Changing prevalence of oral manifestations of human immuno-deficiency virus in the era of protease inhibitor therapy.

OBJECTIVE: The purpose of this study was to determine temporal trends in the prevalence of oral manifestations of human immunodeficiency virus (HIV). STUDY DESIGN: Five hundred seventy HIV-infected adults recruited consecutively were examined by using established presumptive clinical criteria for HIV-associated oral lesions. Prevalence of oral lesions before the widespread use of HIV protease inhibitors (February 1995 through August 1996, 8% of the early sample, n = 271) was compared with lesion prevalence in a more recent period of greater protease inhibitor use (December 1996 through February 1999, 42% of the late sample, n = 299). RESULTS: Overall prevalence of oral lesions significantly decreased from early to late periods, 47.6% to 37.5%, respectively (P =.01), with some variation by lesion type. Prevalence of hairy leukoplakia (25. 8% to 11.4%; P <.01) and necrotizing periodontal diseases (4.8% to 1. 7%; P =.03) decreased, whereas HIV salivary gland disease increased (1.8% to 5.0%; P =.04). Changes in prevalence of oral candidiasis (20.3% to 16.7%), aphthous ulcers (3.7% to 3.0%), oral warts (2.2% to 4.0%), herpes simplex virus lesions (1.8% to 2.0%), and Kaposi's sarcoma (1.1% to 0.3%) were not statistically significant (P >.20 for all comparisons). CONCLUSION: The pattern of oral opportunistic infections is changing in the era of protease inhibitor use.

Prevalence of HIV-associated periodontitis and chronic periodontitis in a southeastern US study group.

OBJECTIVES: This study estimates factors associated with the prevalence of HIV-associated periodontal diseases (HIV-P) and the severity and extent of periodontitis in HIV-infected adults from North Carolina (NC). METHODS: Data are derived from a cross-sectional study of HIV-infected adults (total n = 326, dentate n = 316) treated at the University of North Carolina Hospitals. Outcomes were a diagnosis of HIV-P and measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL). Immunosuppression was measured by peripheral blood CD4+ cells/mm3. RESULTS: In addition to persons with HIV (non-AIDS), this study included 10 percent of the AIDS cases in North Carolina. Median age was 37 years (range = 19-67); 78 percent were male and 60 percent were black. Sixty-two percent of persons had a probing pocket depth > or = 5 mm; 46% had recession > or = 3 mm, and 66 percent had attachment level > or = 5 mm in one or more sites. Cases of HIV-P (n = 15) were rare. Persons taking HIV-antiretroviral medication were one-fifth (OR = 0.20; 95% CI = 0.07, 0.63) as likely to have HIV-P as those not taking those medications, controlling for CD4+ cell counts. CONCLUSIONS: HIV-infected persons in this study group from North Carolina exhibited severe and extensive measures of adult periodontitis. A small proportion experienced a severe form of HIV-P, which was attenuated by antiretroviral therapy.

Human papillomavirus and head and neck cancer: epidemiology and molecular biology.

BACKGROUND: Human papillomaviruses (HPV) are known to cause cancers of the cervix and other anogenital tract sites. Molecular biology has provided some evidence as to the specific mechanisms involved in the HPV-related carcinogenesis. Epidemiologic and molecular biology studies have also suggested that HPV infection may be associated with cancers of the head and neck. METHODS: This review summarizes the biology of HPV and its potential etiologic role in head and neck cancer. Published reports were used to determine the prevalence of HPV in benign, precancerous, and neoplastic lesions of the oral cavity, pharynx, and larynx. The prevalence was also examined by head and neck site, HPV type, and method of HPV detection. In addition, the occurrence of HPV in normal head and neck tissue, epidemiologic factors related to HPV infection, and clinical implications are discussed. RESULTS: Overall, the frequency of HPV in benign and precancerous lesions ranged from 18.5% to 35.9%, depending upon the detection methodology. Based upon the most sensitive method of detection, polymerase chain reaction (PCR), the overall prevalence of HPV in head and neck tumors was 34.5% (416 of 1205 tumors). The majority of HPV-positive tumors contained the "high risk" HPV types 16 (40.0%) and 18 (11.9%). Among head and neck sites, HPV was most often detected in tumors of the oral cavity (59%), followed by the pharynx (43%), and larynx (33%). The frequency of HPV positivity in oral samples from healthy individuals ranged from 1% to 60%. A limited number of descriptive and analytic epidemiologic studies have indicated that age (<60 years) and sex (male) were associated with the presence of HPV in the tumor, whereas tobacco and alcohol use were not. The relationship between HPV and survival is unclear, with few comprehensive studies currently available. CONCLUSIONS: The prevalence of HPV, particularly the high-risk types, suggests a potential etiologic role for the virus in head and neck cancer. Molecular biology has provided important data on the interaction of the HPV oncoproteins with genes important in cell cycle control. Nonetheless, more basic research is needed to describe the physical state of the virus in a variety of cell types and the interaction with other genes. In addition, epidemiologic research is required to further understand the association between HPV and demographic and other risk factors as well as possible routes of transmission. Finally, much work is warranted to provide a definitive assessment of the prognostic significance of HPV in head and neck cancer.

Oral manifestations of HIV in a southeast USA population.

OBJECTIVES: Examine variations in oral manifestations of HIV by gender, race, risk behaviors, substance use and immune status in a previously unstudied population in the southeast region of the USA. DESIGN: Cross-sectional analytic study. SETTING: Academic medical center, North Carolina, USA. SUBJECTS: First 238 HIV-infected adults (76% male; 59% Black) enrolled in an ongoing longitudinal study. METHODS: Oral examination, medical chart review, sociodemographic and behavioral interview. Descriptive, bivariate, and multivariable analyses. OUTCOMES: Presence of oral manifestations of HIV. RESULTS: 50% had recent CD4 counts < 200 cells microliters-1, 48% had one or more oral lesion. Specific lesion prevalence: hairy leukoplakia (OHL) 26.5%; candidiasis (OC) 20%; HIV-associated periodontal diseases (HIV-PD) 8.8%; aphthae 4.2%; papillomas 2.5%; herpes simplex 2.1%; HIV salivary gland disease 2.1%; Kaposi's sarcoma (KS) 1.7%; other 1.3%. In bivariate analyses, OHL was associated with being male, White, having a CD4 < 200, and men who have sex with men (MSM); OC was associated with CD4 < 200 and current smoking; HIV-PD was associated with consumption of more than seven alcohol-containing drinks per week; KS was associated with being male and MSM. Significant variables in multivariable analysis for presence of any oral lesion were White, CD4 < 200, and more than seven drinks/week; for OHL were male and CD4 < 200; and for OC were White, CD4 < 200, current smoking, and not MSM. CONCLUSIONS: MSM were at increased risk for KS and OHL, not OC, while smokers were at increased risk of OC. OC, OHL, and any oral lesion were associated with immune suppression. OHL was more likely in males independent of CD4 count.

Factors associated with periodontitis in an HIV-infected southeast USA study.

OBJECTIVES: To determine the relationship of immunosuppression with measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL) in an HIV-infected population from North Carolina (NC), a state in the southeastern United States (USA). DESIGN: Cross-sectional study of HIV-infected adults (n = 326) treated at the University of North Carolina Hospitals. Clinical medical record review and sociodemographic interview data were collected. Median age of study participants was 37 years (range 19-67). Males comprised 78% and Blacks 60%. Analyses were limited to those who were dentate (n = 316). MAIN OUTCOME MEASURES: Main outcomes were cases vs non-cases of notable PPD, REC, and CAL. Immunosuppression measured by CD4+ cell count microL was the exposure of interest. RESULTS: Defined cases of PPD (n = 148) were 2.6 (95% CI = 1.3, 5.3) times less likely to occur at CD4+ cells < 200 than non-cases, whereas, cases of REC (n = 94) were 2.8 (95% CI = 1.2, 6.6) times more likely to occur at that level of severe immunosuppression, controlling for confounders. CONCLUSION: Sub-groups of persons with HIV experience a high burden of periodontitis where notable severity and extent of PPD, CAL, and REC were clearly evident at different stages of immunosuppression.

Maternal periodontitis and prematurity. Part I: Obstetric outcome of prematurity and growth restriction.

Oral Conditions and Pregnancy (OCAP) is a 5-year prospective study of pregnant women designed to determine whether maternal periodontal disease contributes to the risk for prematurity and growth restriction in the presence of traditional obstetric risk factors. Full-mouth periodontal examinations were conducted at enrollment (prior to 26 weeks gestational age) and again within 48 hours postpartum to assess changes in periodontal status during pregnancy. Maternal periodontal disease status at antepartum, using a 3-level disease classification (health, mild, moderate-severe) as well as incident periodontal disease progression during pregnancy were used as measures of exposures for examining associations with the pregnancy outcomes of preterm birth by gestational age (GA) and birth weight (BW) adjusting for race, age, food stamp eligibility, marital status, previous preterm births, first birth, chorioamnionitis, bacterial vaginosis, and smoking. Interim data from the first 814 deliveries demonstrate that maternal periodontal disease at antepartum and incidence/progression of periodontal disease are significantly associated with a higher prevalence rate of preterm births, BW < 2,500 g, and smaller birth weight for gestational age. For example, among periodontally healthy mothers the unadjusted prevalence of births of GA < 28 weeks was 1.1%. This was higher among mothers with mild periodontal disease (3.5%) and highest among mothers with moderate-severe periodontal disease (11.1%). The adjusted prevalence rates among GA outcomes were significantly different for mothers with mild periodontal disease (n = 566) and moderate-severe disease (n = 45) by pair-wise comparisons to the periodontally healthy reference group (n = 201) at P = 0.017 and P < 0.0001, respectively. A similar pattern was seen for increased prevalence of low birth weight deliveries among mothers with antepartum periodontal disease. For example, there were no births of BW < 1000 g among periodontally healthy mothers, but the adjusted rate was 6.1% and 11.4% for mild and moderate-severe periodontal disease (P = 0.0006 and P < 0.0001), respectively. Periodontal disease incidence/progression during pregnancy was associated with significantly smaller births for gestational age adjusting for race, parity, and baby gender. In summary, the present study, although preliminary in nature, provides evidence that maternal periodontal disease and incident progression are significant contributors to obstetric risk for preterm delivery, low birth weight and low weight for gestational age. These studies underscore the need for further consideration of periodontal disease as a potentially new and modifiable risk for preterm birth and growth restriction.