Enzyme production by Candida albicans and Candida dubliniensis in periodontal HIV-positive patients receiving and not receiving antiretroviral therapy.

Candida dubliniensis (Cd) and Candida albicans (Ca) are the most frequently isolated yeasts in HIV+ patients. Some of the enzymes produced by these yeasts are considered virulence factors since they contribute to pathogenicity of Candida spp. The aim of the present study was to compare production of enzymes such as phospholipase (Ph), proteinase (P), and hemolysin (H) by Cd and Ca strains isolated from periodontal HIV-positive patients receiving and not receiving highly active antiretroviral therapy (HAART). Subgingival biofilm samples were obtained using paper points, and a sample of oral mucosa was taken using a swab. Phenotypic and molecular methods were used to isolate 39 strains of Candida, including 25 strains of Cd and 14 strains of Ca, obtained from 33 periodontal pocket samples and 6 oral mucosa samples collected from 15 HIV+ patients (8 receiving and 7 not receiving HAART). Malt egg-yolk agar, albumin agar and blood agar were used to evaluate pH, P and H production respectively. The strains were inoculated in duplicate and incubated at 37 ºC. Colony and halo diameters were measured. A greater proportion of Ca was observed in patients not receiving HAART, and a higher proportion of Cd was observed in those under HAART, Chi2 p< 0.001. Phospholipase production was observed in 92.9% percent of isolated Ca strains but in none of the isolated Cd strains. Proteinase production was high in Ca and Cd strains isolated from patients not receiving HAART. Hemolysin production was observed in all the studied strains, though it was significantly higher (p=0.04) in Ca and Cd strains isolated from patients not receiving HAART. To sum up, the proportion of Candida dubliniensis strains was highest in the subgingival biofilm of patients receiving HAART, and Cd strains were found to express fewer virulence factors than Ca strains.

Las levaduras más aisladas en pacientes VIH+ son Candida dubliniensis (Cd) y Candida albicans (Ca). Algunas de sus enzimas constituyen factores de virulencia ya que favorecen la diseminación tisular. El objetivo fue comparar la producción de enzimas como fosfolipasa (F), proteinasa (P) y hemolisina (H) en cepas de Cd y Ca aisladas de pacientes VIH+ tratados y no tratados con antirretrovirales (TARGA). Se realizó la toma del biofilm de placa subgingival con conos de papel y la muestra de la mucosa bucal con hisopo. Se aislaron y tipificaron por métodos fenotípicos y moleculares 39 cepas: 25 de Cd y 14 Ca, obtenidas 33 de bolsas periodontales y 6 de mucosa bucal de 15 pacientes VIH+ (8 con y 7 sin tratamiento). Se utilizó agar malta con yema de huevo, agar albúmina y agar sangre para demostrar la producción de F, P y H, respectivamente. Se inocularon por duplicado e incubaron a 37°C. Se midieron los diámetros de las colonias y los de hidrólisis alrededor de las mismas. Se observó mayor proporción de Ca en los pacientes sin tratamiento y mayor proporción de Cd en los con tratamiento; Chi2 p< 0.001. El 92,9% de las Ca estudiadas, fueron productoras de fosfolipasa. En tanto que ninguna Cd produjo la enzima. En cuanto a la producción de proteinasa se observa una alta producción tanto en las cepas de Ca, como en las Cd aisladas en los pacientes no tratados. Todas las cepas estudiadas produjeron hemolisina, observándose una diferencia estadísticamente significativa (p=0,04) en ambas especies a favor de la alta producción de la enzima en las cepas obtenidas de pacientes no tratados. Podemos concluir que en el biofilm subgingival, en los pacientes bajo TARGA, se aíslan mayor proporción de Candida dubliniensis las cuales expresan menos factores de virulencia.

Microbiological study of the subgingival biofilm in HIV+/HAART patients at a specialized dental service.

The aim of this study was to describe the microbiological profile of HIV patients under highly active antiretroviral treatment (HAART). This crosssectional study comprised 32 HIV patients with periodontal disease (PD) who had been under HAART for more than 6 months. Information about the patients' medical history was obtained from clinical records. Clinical dental examination was performed by a calibrated researcher using standard dental instruments to determine probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP). A total 4,765 periodontal sites were evaluated, 125 of which were also studied microbiologically. Subgingival biofilm samples were obtained using sterile paper points; one set was used for microbiological culture studies and the other for endpoint PCR. Statistical analysis was performed using KruskalWallis and posthoc DunnBonferroni contrast tests. All participants were on HAART at the time of the study, and 90.6% had a viral load below 50 copies / mm3. Prevalence of periodontally active sites was low in the study population. Microbiological studies: Black pigmented anaerobic bacteria and fusiform CFU counts were significantly higher in samples from sites with BOP and PD ≥4mm (p 0.020 and p 0.005, respectively). Molecular Assays: Detection of Porphyromonas gingivalis (p 0.002), Tannerella forsythia (p 0.023) and Treponema denticola (p 0.015) was significantly more frequent at sites with BOP and PD ≥4mm. Conclusions: The patients living with HIV/AIDS under HAART studied here had low prevalence of clinical periodontal disease signs. However, significant detection of P. gingivalis, T. denticola, and T. forsythia in periodontal active sites, and the involvement of these microorganisms as potential HIV reactivators, show the importance of creating awareness among dental health professionals of the need for close dental and periodontal monitoring in HIV patients.

El objetivo de este estudio fue describir el perfil microbiológico del biofilm subgingival de los pacientes con VIH bajo tratamiento antirretroviral de alta actividad (TARGA). El estudio comprendió a 32 pacientes VIH seropositivos con enfermedad periodontal (EP) que se encontraran en tratamiento con TARGA por más de 6 meses. Los antecedentes médicos de los pacientes se obtuvieron de las historias clínicas. El examen clínico instrumental (profun didad de sondaje (PS), nivel de inserción clínico (NIC) y sangrado al sondaje (SS)) fue realizado con instrumental odontológico estándar por un investigador calibrado. De este modo, se evaluaron un total de 4.765 sitios periodontales de los cuales 125 fueron estudiados microbiológicamente. Las muestras de biope lícula subgingival se obtuvieron empleando conos de papel estéril. Las muestras se emplearon en estudios microbiológicos y moleculares por PCR de punto final. El análisis estadístico se realizó según KruskalWallis y pruebas de contrastes posthoc de DunnBonferroni. El 90,6% de la población en estudio presentó carga viral inferior a 50 copias/mm3. La prevalencia de sitios periodontales activos fue baja (1%). Los recuentos de bacterias anaerobias estrictas pigmentadas de negro y fusiformes fueron significativamente más altos en muestras de sitios periodontales con SS positivo y PS ≥4 mm (p 0.020 y p 0.005). La detección molecular de Porphyromonas gingivalis (p 0.002), Tannerella forsythia (p 0.023) y Treponema denticola (p 0.015) fue significativamente mayor en los sitios con SS y PS ≥4mm. La prevalencia del 1% de enfermedad periodontal en el grupo de pacientes estudiados fue menor a la esperada, sin embargo; la detección significativa de P. gingivalis, T. denticola y T. forsythia en sitios periodontales activos y su potencial participación como agentes reactivadores del VIH, nos alerta de la importancia de crear conciencia en los profesionales de la salud (médicos y odontólogos) acerca de la necesidad de un monitoreo minucioso del estado periodontal de pacientes con características semejantes a las descriptas en la muestra poblacional estudiada.

Assessment of physicians' perception of HIV+ patients' oral health.

The aim of this study was to design and validate an instrument for establishing perceptions of oral health held by physicians treating people living with HIV/AIDS. In order to design the instrument, four domains were identified that could measure the object of study and a 22-item questionnaire was created. The domains established were: knowledge of oral health; personal experience with oral health care; knowledge of oral health regarding HIV/AIDS; professional medical practices. To validate the instrument 50 physicians specializing in infectious diseases from public hospitals of Buenos Aires city completed the questionnaire using a Likert-type scale with 5 categories. The reliability of the instrument was assessed with the test and retest method at 30 days; internal consistency with Cronbach's alpha coefficient; content validity was determined by expert opinion; construct validity with the extreme groups method (Mann Whitney test, p < 0.05). All participants completed the test and retest questionnaires. Their mean age was 37.7 +/- 0.9 years; 36% were female and 64% male. The average experience in medical practice was 8.7 +/- 0.6 years. The instrument proved to be reliable as shown by the value of r(s) = 0.94 in the test-retest method; a satisfactory intra-item consistency was shown by Cronbach's alpha coefficient value of 0.91. The differences between the results of the groups of physicians in the extreme groups were statistically significant (p < 0.001). It is concluded that the instrument designed to measure the perception of oral health of physicians treating people living with HIV/AIDS is valid. However it would be desirable to enlarge the sample and determine criterion validity by comparison with other instruments.

Assessment of physicians´perception of HIV+ patients´oral health

El objetivo de este trabajo fue construir y validar un instrumento capaz de caracterizar las percepciones de los médicos tratantes de los pacientes que viven con VIH/SIDA respecto de la salud bucal. El diseño del instrumento consistió en la identificación de los cuatro dominios que podrían medir elobjeto en estudio y en la elaboración de un cuestionario de 22 items. Los dominios establecidos fueron: conocimientos sobre la salud bucal; experiencia personal con la atención odontológica; conocimientos sobre la salud bucal respecto del VIH/SIDA; prácticas médicas profesionales. Para la validación del instrumento, participaron 50 médicos especialistas en infectología de hospitales públicos de la CABA, quienes completaron anónima y voluntariamente el cuestionario diseñado empleando una escala de frecuencia tipo Likert de 5 categorías. Se evaluó la confiabilidad mediante la aplicación de test y retest a los 30 días; consistencia interna, mediante el coeficiente α de Cronbach; la validez del contenido, se determinó por opinión de expertos; la validez de construcción fue evaluada mediante el método de grupos extremos (prueba deMann Whitney, p < 0.001). El 100 por ciento de los participantes realizó el test y re-test del cuestionario. La edad promedio fue 37.7 ± 0.9 años; 36 por ciento de género femenino y 64 por ciento masculino, con una media de 8.7 ± 0.6 años de ejercicio profesional. El instrumento resultó confiable ya que en el test-retest se obtuvo una correlación de rs = 0.94. El coeficiente α de Cronbach fue de 0.91, demostrando una satisfactoria coherencia intraitems.Las diferencias correspondientes a los resultados de los grupos de médicos ubicados en los extremos resultaron estadísticamente significativas (p < 0.001). Concluimos que el instrumento elaborado para medir la percepción de los médicos tratantes de los pacientes que viven con VIH/SIDA respecto de la salud bucal resultó válido...

Impact of oral health care needs on health-related quality of life in adult HIV+ patients.

The aim of this work was to determine the social impact of oral conditions on health-related quality of life in adult HIV+ patients and create a predictive model. The oral health impact profile questionnaire OHIP-49 was randomly administered to 200 HIV+ adults patients of any age and either sex at the High Risk Patients Dental Care Unit (CLAPAR I), School of Dentistry, University of Buenos Aires. Argentina. For each of the 49 items, participants indicated their responses on a five point Likert-type frequency scale ranging from "never" to "very often". Oral health needs were assessed through the CCITN (Community Caries Index of Treatment Need) and CPITN (Community Periodontal Index of Treatment Need). The Mann-Whitney test was used to compare the OHIP-49 score between male and female respondents. The Kruskal-Wallis test was used to assess score differences among the OHIP-49 domains. Altogether, 50% of the respondents were male and 50% were female, aged 36.45 +/- 0.70 years and 38.03 +/- 0.78 years respectively. The assessment of oral health care needs revealed a great need for treatment. Mean CCITN was 11.15 +/- 0.35 and CPITN was 2.41 +/- 0.12. The average total OHIP-49 score (83) revealed a high level of social impact, which was higher for female compared to male respondents (Z(T) = 2.08, p = 0.037). The domains concerning functional limitation (domain 1), physical pain (domain 2) and psychological discomfort (domain 3) showed higher levels of social impact (H = 395.06, p < 0.0001). The social impact observed in these domains was higher for female compared to male patients. In the correlation analysis, oral conditions, age, gender and social impact were significantly associated. These results demonstrate that unmet oral health care need impairs the quality of life of HIV+ patients and suggest the need of comprehensive oral health care interventions.

Dental beliefs in HIV+ patients with different oral health care needs.

The aim of this work was to assess the score variation of scales 1 and 2 of the DCBS (Dental Coping Beliefs Scale) of beliefs on oral health regarding oral health needs, clinical progression of the viral infection, medical care needs, age and gender in HIV+ patients. The DCBS was randomly administered to 102 HIV+ patients at the "Juan A. Fernandez Hospital", Buenos Aires, Argentina. For each of the 29 items, patients indicated their responses on a five point scale ranging from "strongly disagree" to "strongly agree". Oral health needs were assessed through the CCITN (Community Caries Index of Treatment Need) and the CPITN (Community Periodontal Index of Treatment Need). Data on CD4 cell count, pharyngeal-esophageal candidiasis, tuberculosis, pneumonia and hospitalization because of HIV-related opportunistic diseases were recorded. A linear regression model was built in which the number of items reporting wrong dental beliefs was the dependent variable and the remaining variables were independent. Altogether 65.7% were male (36.0 +/- 0.87 y.o.) and 34.3% were female (36.11 +/- 1.21 y.o.) patients. The eight independent variables were significant for the model (F(8.93)= 93.20, p < 0.05; R = 0.80). The estimated parameters were all positive except for CD4 cell counts. The results demonstrate that the DCBS was useful to identify HIV+ patients as a caries and periodontal disease risk group because of their wrong dental beliefs and suggests the need of dental education interventions.

Dental beliefs in HIV+ patients with different oral health care needs

The aim of this work was to assess the score variation of scales 1 and 2 of the DCBS (Dental Coping Beliefs Scale) of beliefs on oral health regarding oral health needs, clinical progression of the viral infection, medical care needs, age and gender in HIV+ patients. The DCBS was randomly administered to 102 HIV+ patients at the "Juan A. Fernandez Hospital", Buenos Aires, Argentina. For each of the 29 items, patients indicated their responses on a five point scale ranging from "strongly disagree" to "strongly agree". Oral health needs were assessed through the CCITN (Community Caries Index of Treatment Need) and the CPITN (Community Periodontal Index of Treatment Need). Data on CD4 cell count, pharyngeal-esophageal candidiasis, tuberculosis, pneumonia and hospitalization because of HIV-related opportunistic diseases were recorded. A linear regression model was built in which the number of items reporting wrong dental beliefs was the dependent variable and the remaining variables were independent. Altogether 65.7% were male (36.0 ± 0.87 y.o.) and 34.3% were female (36.11 ± 1.21 y.o.) patients. The eight independent variables were significant for the model (F(8,93) = 93.20, p < 0.05; R = 0.80). The estimated parameters were all positive except for CD4 cell counts. The results demonstrate that the DCBS was useful to identify HIV+ patients as a caries and periodontal disease risk group because of their wrong dental beliefs and suggests the need of dental education interventions.

El propósito de este trabajo fue evaluar la variación del puntaje registrado para las subescalas 1 y 2 de la escala de creencias relativas a la salud bucal (DCBS) en relación a la necesidad de tratamiento odontológico, la progresión clínica de la infección viral, la necesidad de tratamiento medico, la edad y el genero de pacientes VIH+. El cuestionario correspondiente a la DCBS se administro aleatoriamente a 102 pacientes VIH+ concurrentes al Hospital Juan A. Fernandez, Buenos Aires, Argentina. Para cada una de las 29 proposiciones de las subescalas 1 y 2 de la DCBS los pacientes indicaron su parecer en una escala tipo Likert de 5 grados que iban desde “completamente en desacuerdo” hasta “completamente de acuerdo”. La necesidad de tratamiento odontológico se determino a través del Índice de Necesidad de Tratamiento de Caries de la Comunidad (INTCC) y del Índice de Necesidad de Tratamiento Periodontal de la Comunidad (INTPC). De la historia clínica medica de cada paciente se recabaron datos correspondientes al recuento de linfocitos T CD4, episodios de candidiasis faringoesofagica, tuberculosis, neumonía y hospitalización a raíz de enfermedades oportunistas afines a la infección por el VIH. Se construyo un modelo de regresión lineal tomando como variable dependiente el numero de proposiciones que reflejaban creencias erróneas sobre salud bucal mientras que las restantes variables en estudio se tomaron como independientes. El 65.7% de los pacientes en estudio correspondió a pacientes de genero masculino (36.0 ± 0.87 anos de edad) y el 34.3% restante a pacientes de genero femenino (36.11 ± 1.21 anos de edad). Las ocho variables independientes resultaron significativas para el modelo lineal (F(8,93) = 93.20, p < 0.05; R = 0.80). Los parámetros estimados para el modelo resultaron positivos excepto para el recuento de linfocitos T CD4. Los resultados indican que la DCBS resulta un instrumento útil para identificar a los pacientes VIH+ como un grupo de riesgo de caries y enfermedad periodontal dadas las creencias erróneas sobre salud bucal que poseen y sugieren la necesidad de intervenciones educativas de salud bucal en estos pacientes.