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  1. 1. 5th World Workshop on Oral Health and Disease in AIDS . ABSTRACTS PostersCLINICAL findings in pregnant women emphasizes the need for diagnosis of oral lesions by all health care workers and forORAL LESIONS AND MANAGEMENT OF HIV recommended treatment or referral.RELATED DISEASEA2A1 Common Oral Lesions Seen Amongst Sero- Oral Manifestations of HIV in positive Clients at a Voluntary Confidential Pregnant Women Attending Counseling Testing Centre in Kaduna Antenatal Clinics in Johannesburg. NigeriaLAO Adeyemi*1, MJ Rudolph1, AO Yusuf2, JA McIntyre3, UE Amanyeiwe-Adaka*, C Igbokwe, SO AjikeGE Gray3, N Martinson 3 Maxillofacial Unit, Ahmadu Bello University Teaching1 School of Public Health, University of the Witwatersrand, Hospital, Kaduna, Nigeria2 Department of Community Dentistry, University of U Amanyeiwe-Adaka: mfuugo@yahoo.comPretoria, 3Perinatal HIV Research Unit, University of theWitwatersrand, Johannesburg The occurrence of common oral lesions seen amongst sero- positive patients was investigated in 638 consecutiveL Adeyemi: benjo2010@yahoo.com patients attending the FRC voluntary confidentialIntroduction: Although, several studies have been reported counseling and testing (VCCT) centre from November 2002from outside Sub-Saharan Africa on the oral manifestations to November 2003. Different types of oral lesions wereof HIV in women, no such study has yet been undertaken on observed in 372 (58.3%) of subjects. The most prevalent oforal manifestations of HIV in pregnant women in Africa. In these lesions was oral candidiasis observed in 263 (70.7%)some areas of South Africa, one in three pregnant women patients. The high prevalence of oral candidiasis is similarattending public sector health facilities is HIV positive. Oral to those reported in studies from Jos in Nigeria, Cotecandidiasis has been shown to be the most common oral DIvoire and South Africa. The prevalence of other orallesion associated with HIV infection in women. lesions was much lower, some patients had more than one type of lesion. They included aphthous ulcers 67 (18%),Objective: To determine the prevalence of oral herpes simplex 47 (12.6%), necrotizing gingivitis 30manifestations in HIV positive pregnant women attending (8.1%), salivary gland enlargement 19 (5.1%), necrotizingantenatal clinics in Johannesburg. periodontitis 18 (4.8%), Kaposi sarcoma 12 (3.2%), herpesMethod: A cross sectional study was conducted on HIV zoster 7 (1.9%), oropharyngeal carcinoma 5 (1.3%),positive pregnant women attending antenatal clinics in three melanotic hyper-pigmentation 3 (0.8%), maculo-papularhospitals in Johannesburg, South Africa. A calibrated lesions 3 (0.8%) and necrotizing fasciitis 2 (0.5%). Similardentist determined HIV related oral lesions by doing a findings are reported from other studies. Management ofclinical examination in 128 HIV positive pregnant women these seropositive patients at this VCCT Centre was mainlyusing the criteria suggested by the EC/WHO. Parity, symptomatic. Patients were given multivitamin supplementsgravidity and age of the patients were collected by means of and treatment for opportunistic infections. Oral candidiasisa self-administered structured questionnaire. was treated with Nystatin pastilles and lozenges, whereas fulminating cases of mycotic infection were given systemicResults: The age range for the group was 17 to 42 years, fluconazole. Twelve of the 33 patients who could affordwith a mean age of 27.9 years. Twenty-eight (22%) of the uninterrupted ARV supply for six months had oral lesions.group was primigravid, while 100 (78%) were multiparous.The majority of the patients, 73 (57%) were in their second Conclusion: Oral lesions occurred more frequently intrimester. Oral candidiasis and angular cheilitis were the patients that presented with advanced stages of themost commonly seen oral lesions in these patients with a infection. Seropositive patients on ART presented withfrequency of 78 (61%) and 51 (40%) respectively. Oral fewer oral lesions. In patients with severe opportunisticulceration was seen in 35 (27%) of the patients. Thirty-three infections, commencement of ARVs combined withwomen (26%), presented with necrotizing ulcerative symptomatic treatment of the opportunistic infections andgingivitis, 6(5%) had necrotizing ulcerative periodontitis nutritional support, contributed to recovery. Reduced ratesand 6(5%) had linear gingival erythema. Less than 3% of of recurrence of infections, progressive rise in CD4 countthe patients presented with herpes, which was mainly extra- and improvement in the patients general status was noted. Inoral. No other HIV associated oral lesions were seen in resource limited settings where facilities are not available,these patients. oral lesions may be used as a marker for staging the clinical progress of HIV/AIDS.Conclusion: The prevalence of oral lesions associated withHIV infection for this particular sub-group is similar toresults of other prevalence studies conducted elsewhere onwomen, though the prevalence of oral candidiasis wasslightly higher in this group. The confirmation of these________________________________________________________________________ 36
  2. 2. 5th World Workshop on Oral Health and Disease in AIDS .A3E Blignaut* Gender Differences in Oral Manifestations among South African HIV/AIDS Patients markers for HIV disease progression as an inexpensive alternative. Methods: We recruited HIV+ and HIV- women from 2 prospective cohort studies (HIVNET and WHO) in Harare. HIV serostatus was assessed at baseline. CD4 count wasMedical University of Southern Africa measured and a standardized oral soft tissue examination was performed at 6-month intervals by both a nurseE Blignaut: eblignaut@medunsa.ac.za examiner trained in the diagnosis of HIV-related oralObjectives: To determine gender differences in numbers, lesions (using ECC criteria) and an oral surgeon. Theage and oral manifestations among black HIV/AIDS examinations were done within 2 weeks of each other whenpatients attending three AIDS clinics in the Gauteng possible. We report preliminary analyses conducted onprovince, South Africa. baseline data as recruitment is still ongoing. We include only those women who were seen by both nurse and oralBackground: In 2002 it was estimated that 6.5 million surgeon within a 2-week window.South Africans were living with HIV/AIDS, and thatwomen of child bearing age (15-49 years) constituted half Results: 433 women 342 (212 HIV+, 130 HIV-) were seenof the infected population. by both nurse and oral surgeon within a 2-week period. Mean age was 30.2 years (range 18-47) among HIV+Methods: A retrospective analysis was performed on data women and 27.4 years (range 19-36 y) among HIV-obtained over a four year period, from the primary visit of women. Oral candidiasis (OC), predominantly pseudo-patients attending outpatient clinics at three hospitals in the membranous, was the most common lesion diagnosed byPretoria region. At the time no patients had access to the oral surgeon in both HIV+ and HIV- women (28%antiretroviral therapy. All patients received an oral versus 18%; p=0.03), and by the nurses (22% versus 8%;examination, irrespective of any complaints. Surveillance p=0.001). Hairy leukoplakia and Kaposi’s sarcoma wereswabbing for Candida was also performed. found in 2% and <1%, respectively, of HIV+ and in none ofResults: Of the total patient population 1031 (67.4%) were the HIV- women (by either nurse or oral surgeon). Thefemale and 498 (32.6%) male. Of the female patients 78.5% prevalence of OC diagnosed by the oral surgeon waswere aged between 20 and 39 years while 76% of the male significantly higher among women with CD4 count <200patients were 30 years and older. Localised attachment loss than in women with CD4 count 200-499 and >499 (57%,was more prevalent in males (p≤0.05), while linear gingival 36%, and 7%; respectively; p=0.02). The agreement rateerythema and a pericoronitis around an erupting third molar between nurse and oral surgeon examinations was highwas observed more frequently in females (p≤0.01 and among HIV+ women for the diagnosis of OC (91%p≤0.05 respectively). In females a significant correlation agreement on positive diagnoses and 90% agreement on(p≤0.001) between pseudomembranous candidiasis and a negative diagnoses). However, the agreement rate wasCD4 cell count below 200 cells/mm3 was observed. In lower for examinations done in HIV- women as the oralmales erythematous candidiasis correlated significantly with surgeon found a higher prevalence of erythematousa CD4 cell count below 200 cells/mm3 (p≤0.01). candidiasis in that group than the nurses.Conclusion: Twice as many females than males attended Conclusion: OC was the most common lesion in HIV-the clinics and they were also younger than the male group. positive Zimbabwean women and was strongly associatedDifferences in the prevalence of oral manifestations with a low CD4 count. The inter-examiner agreement ratebetween males and females were demonstrated, including was good for diagnoses of OC among HIV-positive women,differences in the correlation of some lesions with a CD4 but erythematous candidiasis remains a diagnosticcount below 200 cells/mm3. challenge. These preliminary results suggest that pseudomembranous candidiasis may be used as surrogateA4 marker of disease progression, and is reliably diagnosed byHIV Related Oral Diseases Among Women in nurses. Zimbabwe A5MM Chidzonga*1, M Mwale1, L Chidzumo1, E Makura1, KMalvin2, CH Shiboski2 Oro-facial Manifestations in Paediatric HIV: A1 University of Zimbabwe, 2 University of California San Comparative Study of Institutionalized andFrancisco Hospital Out-PatientsM Chidzonga: mmchidzonga@medsch.uz.ac.zw S Naidoo*, U ChikteObjectives: To estimate oral disease prevalence among University of the Western Cape, Cape Town, South Africawomen in Harare in relation to HIV serostatus and CD4count, and to assess sensitivity and specificity of oral soft S Naidoo: snaidoo@sun.ac.zatissue examinations conducted by nurses compared to an The aim of the study was to compare caries status and theoral surgeon. number and type of oral mucosal lesions in HIV positiveBackground: Because biologic assays to measure HIV children from a hospital outpatient department and andisease progression are rarely accessible in sub-Saharan institutionalized setting.African countries due to prohibitive cost, we sought to Oral examinations were performed using presumptiveinvestigate the use of HIV related oral lesions as potential diagnostic criteria. The Fisher’s Exact and the Mann-________________________________________________________________________ 37
  3. 3. 5th World Workshop on Oral Health and Disease in AIDS .Whitney tests were used for statistical comparison of the Background: Of the 40 million people living with HIVtwo study groups. A total of 169 children were examined of globally, children constitute 2.5 million. In India there arewhom 42% were institutionalized and 58% hospital 4.5 million people living with HIV and children infectedoutpatients. One institutionalized child presented with with this infection constitute a major health problem. ThereNoma. 21% of the institutionalized population presented are very few reports of oral lesions and conditions in Indianwith Molluscum contagiosum, while none of the hospital HIV seropositive children, even though the number ofoutpatients presented with this condition. children affected by this disease is increasing.Significantly more intra-oral mucosal lesions were observed Methods: Our study group consisted of 37 children referredin the hospital compared to the institutionalized group. The to our tertiary HIV care center at Ragas Dental College andmost frequently encountered oral lesion was candidiasis. Hospital and YRG CARE, Chennai, India). ELISA andTwice as many intraoral ulcers were recorded in the Western Blot confirmed the HIV sero status. A completeinstitutionalised group. Thirty nine percent of the oral examination was undertaken by a trained dentalhospitalized patients had multiple lesions compared to 28% surgeon and diagnosis of oral lesions was made onin the institutionalised group. Almost three quarters of both presumptive criteria established by the EC Clearing house,populations were caries-free. The mean DMFT was higher 1993 and WHO.in the hospital population. For both the permanent andprimary teeth, the decayed component made up the major Results: Of the 37 pediatric cases in our cohort, 22 werepart of the DMFT/dmft, followed by the missing males (59.5%) and 15 were females (40.5%). 84% acquiredcomponent. No fillings were recorded in either the primary the infection through vertical transmission and 16% throughor permanent teeth for both groups. blood transfusion. The lesions that were seen included candidiasis, gingivitis, parotid enlargement and cervicalOral lesions were common in HIV populations and were lymphadenopathy. The following table compares our resultsseen in both the hospital (63%) and institutionalized (45%) with published prevalence percentages. On a 6monthsgroups at high prevalence levels. HIV infected children follow up, all these oral lesions responded favorably toshould be considered high risk for caries due to the use of standard treatment protocols.chronic medication, and to receive appropriate care in termsof both treatment and services. Conclusion: Given the morbidity of the oral lesions it is essential that information regarding oral lesions in pediatric population in India should be gathered for early diagnosisA6 and treatment. Oral Manifestation of HIV Paediatric Cases in Chennai, South IndiaR Thavarajah*1, TR Saraswathi1, U Devi1, S Solomon2, NKumaraswamy2, NW Johnson3, K Ranganathan11 Ragas Dental College and Hospital, Chennai, 2 YRGCARE, Chennai, 3Guy’s, King’s & St Thomas DentalInstitute, London, UKR Thavarajah: drtroobanmds@rediffmail.com Cervical P. E. Angular Parotid lymph Author , year Candida Gingivitis OHL DC Candida Candida chelitis swelling adenopa- thyRamos – Gomez FJ 43% - - - - - - - - et al 2000 Khongkunthian P - 17.8% - - - - - 6.7% -- et al 2001 Santos LC et al - - 22.5% - 8.8% - 17.5% 1.3% - 2001 Magalhaes MG 18.42% 18.42% - 28.94% 18.42% - 13.5% 2.63% - et al 2001 Luis Gaitan – Cepeda et al - - 29.2% - 2.1% - 4.2% - - 2002 Okunseri et al - - 2.9% - 2% 1% 20.6% - 19.6% 2003Present study 2004 16.2% 5.4% 18.8% 10.8% 2.7% 5.4% 21.6% 2.7% 35.1% P- Pseudomembranous; E- Erythematous; OHL- Oral Hairy Leukoplakia; DC- Dental Caries________________________________________________________________________ 38
  4. 4. 5th World Workshop on Oral Health and Disease in AIDS . 1 Department of Community Dentistry, University of Pretoria and 2Division of Oral Public Health, University of Witwatersrand, South Africa. OA Ayo-Yusuf: lekan.ayoyusuf@up.ac.za Oral lesions in HIV-infected individuals are potentially useful predictors of disease progression, especially in poorlyA7 resourced societies. It is therefore important to recognise Classification of Oral Diseases of HIV- factors that may impact on their presentation and Associated Immune Suppression management. This cross-sectional analytical study thereforeM Glick*, SN Abel, CM Flaitz, CA Migliorati, LL Patton, sought to determine the effect of smoking on oralJA Phelan, DA Reznik manifestation (OM) of HIV/AIDS among a South African general hospital outpatient population. Study participantsODHIS Workshop Group – USA included one hundred and seventy-five (n=175) consentingM Glick: glickmi@umdnj.edu HIV infected adults that consecutively presented at the HIV clinic on referral for routine care and support since theirThe present classification systems for HIV-associated oral diagnosis of HIV seropositivity. Socio-demographiclesions were developed in the early 1990s and have been val information, drug-treatment status and smoking historyuable tools for both diagnostic and research purposes. With t were obtained from the patients using a self-administeredhe advent of new antiretroviral therapy, the pattern of oral c questionnaire. A systematic oral examination was alsoonditions is changing in the USA and a new classification sy conducted on each patient by a trained and calibrated dentalstem should be evaluated. This system should reflect change clinician in order to record presence of HIV-related orals in the epidemiology of oral lesions that are related to HIV lesion(s). The examiner was blinded to the completeddisease and therapeutics. In addition, this system should tak questionnaire. Cigarette smoking prevalence was 10%e into account the association between the development of t (n=17), with male prevalence of 23%. Only one smokerhese lesions and the patient’s immune status. The terminolo reported to have reduced consumption since knowing ofgy of “oral lesion” also needs to be changed to “oral disease HIV status, but none had quit. Of the 76% that presented”. Oral disease is defined as an abnormality characterized b with OM, oral candidiasis was the most common oral lesiony a defined set of signs and symptoms in the oral cavity, ext (72%). Adjusting for period since visiting (proxy for HIVending from the vermilion border of the lip to the oropharyn history) and other variables, logistic regression analysis forx, with the exception of salivary gland disease. Based on a r presentation with OM indicated that being female (oddseview of the recent literature and expert opinion with majori ratio [OR], 3.8; 95% confidence interval [CI], 1.1-13.0) andty consensus, the following groups of oral diseases are prop regular smoking (OR, 8.6; 95% CI, 1.6-46.4) wasosed for this revised classification system: significantly associated with higher odds of presenting with OM. The model derived explained 12% of variance in OM.Group 1 ODHIS associated with severe immune The study findings suggest smoking is an important suppression (CD4 < 200 cells/mm3). predictor of OM in the studied population. However, thereGroup 2 ODHIS associated with immune suppression is also an indication for further research. (CD4 < 500 cells/mm3).Group 3 ODHIS assumed associated with immune suppression. ORAL HEALTH AND GENERAL HEALTH a) More commonly observed. A9 b) Rarely reported. The Association of Peripheral BloodGroup 4 Therapeutically-induced oral diseases. Abnormalities and HIV-Associated OralGroup 5 Emerging oral diseases. LesionsODHIS Workshop Group - USA does recognize that oral D Kerdpon*1, S Sretrirutchai2, A Nilmanut3, A Geater2, Kdiseases do not exclusively belong to one classification Gro Wangrangsimakul1up, and that overlap exists. The use of an immune-based cla 1ssification system provides a method for identifying undiag Faculty of Dentistry, Prince of Songkla University,nosed individuals, provides an additional rationale for HIV t Thailand; 2Faculty of Medicine, Prince of Sonklaesting, effects access and type of HIV-related healthcare, an University, Thailand; 3Hatyai Regional Hospital, Songkla,d provides clinical markers for therapeutic interventions and Thailandefficacy. Despite these important advantages, the proposed D Kerdpon: kduangpo@ratree.psu.ac.thODHIS classification should be pilot tested and consensus developed before it is widely disseminated among healthcare Few data of peripheral blood abnormalities and theirproviders. Funded by the Dental Alliance for AIDS/HIV Ca association with HIV-associated oral lesions are available.re (DAAC). This study evaluated the prevalence of peripheral blood values less than normal range in HIV-infected patients andA8 their association with number and type of HIV-associated Smoking as a Predictor of Oral oral lesions. One hundred and seventeen HIV-infected Manifestation of HIV Infection patients in a southern Thai hospital were included. Anemia (69.2%), leukopenia (29.1%), and lymphopenia (11.1%)OA Ayo-Yusuf*1, AS Bajomo2 and MJ Rudolph2. were the most common haematological abnormalities. Lymphopenia was significantly associated with an increased________________________________________________________________________ 39
  5. 5. 5th World Workshop on Oral Health and Disease in AIDS .number of HIV-associated oral lesions, the presence of any mls/min respectively. No significant difference was found.HIV- associated oral lesions and oral candidiasis (OC). With respect to medication, unstimulated (or stimulated)Lymphopenia was not found in patients without any oral flow rates were found to be statistically significant lower inlesions. Low mean corpuscular volume (MCV) was more subjects with xerostomia-inducing drugs compared withcommon among patients without any oral lesion than among those with no medication (p~0.004). The following factorsthose with OC and oral hairy leukoplakia. More studies will were significantly associated with hyposalivation; sex, stagehelp to explain this finding. Lymphopenia might be a of HIV infection, risks group, systemic disease, medication,practical indicator in prediction of HIV-associated oral smoking habit, and alcohol consumption. Hyposalivationlesions, particularly when CD4 and viral load are not was found to be significantly associated with the number ofroutinely accessible. colony forming units of Candida. However, no statistically significant association between hyposalivation and cervical caries (p~0.55) or number of teeth (p~0.13) was observed.A10 Salivary and Oral Findings in HIV-positive and HIV-negative Subjects with Well-controlled Medication Conclusions: Our study indicated that various medications taken among HIV-infected individuals affect their salivary flow rates and feeling of oral dryness. Since saliva plays a key role in maintaining oral functions and protecting the oral hard and soft tissues, xerogenicW Nittayananta1*, B Nauntofte2, E Dabelsteen3, K Stoltze4, medications should be prescribed with special caution inN Chanowanna1, S Jealae5 this patient group.A11 1 Department of Stomatology, Faculty of Dentistry and 5 Microbiological Unit, Faculty of Quality of Life and Oral Mucosal Lesions among HIV-Medicine, Prince of Songkla University, Thailand, positive Drug Addicts2 Department of Clinical Oral Physiology, 3Department of SL Sujak*, Rahimah Abdul Kadir, Roziah OmarOral Diagnostic Sciences and 4Department ofPeriodontology, School of Dentistry, University of University of Malaya, Kuala Lumpur MalaysiaCopenhagen, Denmark SL Sujak: slsujak@pd.jaring.myW Nittayananta: nwipawee@ratree.psu.ac.th HIV-infected people are prone to oral mucosal lesionsBackground: Salivary glands are affected during the course (OML) which can affect the quality of life of thisof HIV infection. Many medications may have the potential population. The objective of this study was to evaluate theto impair salivary gland function as well as to induce effect of OML on the quality of life among HIV-positivefeelings of oral dryness. In particular, little is known about drug addicts. A cross-sectional case-control study involvingintake of medication and the presence of hyposalivation and 917 male drug addicts, 509 HIV-positive (case) and 408xerostomia among HIV-infected subjects. non-HIV (control) drug addicts was carried out. The mean age of the sample was 31.2±6.5 years old. A single itemObjectives: The aims were to assess the prevalence of global rating questionnaire was used to measure the qualityhyposalivation and xerostomia in HIV and HIV free of life. The prevalence of OML was measured by oralsubjects with a well-controled consumption of medications, examination. The study showed that HIV-positive patientsto study the relationship between unstimulated and registered a lower quality of life experience (m=27.3±21.6stimulated salivary flow rates, to identify factors associated point) than non-HIV subjects (m=40.8±30.0 point). Thewith hyposalivation and xerostomia, and to correlate the difference was statistically significant (p=0.00). The studypresence of hyposalivation and xerostomia to the presence also found that 41% of the HIV-positive subjects had OML.of oral candidiasis, the number of colony forming units of Pseudo-membranous candidiasis was the most commonCandida, presence of cervical caries and number of teeth in lesion (21%) follow by hairy leukoplakia (12%) andthe group of HIV infected subjects. erythematous candidiasis (12%). These findings suggest thatSubjects and methods: A cross-sectional study was the presence of OML did not affect their quality of life asperformed in the two different regions of Thailand; in the shown by Pearson chi squared test. Findings from this studynorth and the south. One hundred and thirty-five subjects concluded that OML had a minor influence on the generalwere enrolled (56 HIV-seropositive, mean age: 34.5 years quality of life of HIV-positive drug addicts.and 79 HIV-seronegative individuals, mean age: 29.5years). Measurement of saliva flow rate comprised bothunstimulated and wax-stimulated whole saliva using the HEALTH CARE NEEDSdraining method. The effect of HIV serostatus, stage of HIV A12infection; asymptomatic, and symptomatic/AIDS, andmedications on the flow rates was analyzed. Oral and Maxillofacial Surgery for the Seropositive Patient in a Resource LimitedResults: The unstimulated flow rates in the HIV-positive Settingsubjects and HIV-negative controls were 0.19 and 0.33 ml/min (p~0.0024). The stimulated flow rates were 1.45 and UE Amanyeiwe-Adaka*, C Igbokwe, SO Ajike1.62 mls/min (p~0.31). In the HIV-positive group the Family Resource Centre ABU, Old Hospital Complex,unstimulated flow rate was significantly higher in the Kaduna, Nigeriaasymptomatic group 0.17 ml/min, compared to thesymptomatic/AIDS group 0.11 ml/min (p~0.003) whereas U Amanyeiwe-Adaka: mfuugo@yahoo.comthe mean stimulated flow rate values were 0.99 and 1.15________________________________________________________________________ 40
  6. 6. 5th World Workshop on Oral Health and Disease in AIDS .Surgical management of HIV sero-positive patients in focus on motivating dental surgeons to provide dental caredeveloping countries such as Nigeria is highly inadequate. for HIV infected patients.This is due to the unavailability of enabling policies andinfrastructures that empower both the clinician and the A14patients. The objective of this paper is to analyze the Concerns Reported to Dentalproblems encountered by the average Oral Maxillofacial Protection Limited by Dentalsurgeon who has to manage sero-positive patients in an Healthcare Workers Treatingenvironment with little or no access to sustainable anti HIV Positive Patients: 1985-2002retroviral drug therapies and no access to affordable postexposure prophylaxis for the surgeon. The need to address D Croser*these issues cannot be over-emphasized in a country with asero-prevalence of over 5.8% and having one of the worlds VM Clinic, Hammersmith and Fulham PCT, UKhighest incidences of road traffic accidents with associated D Croser: david@croser.demon.co.ukfractures of the facial skeleton. In conclusion there is a needfor surgeons to empower themselves with scientifically When undertaking clinical procedures it is possible thatcorrect knowledge of post exposure chemoprophylaxis and either dental healthcare workers (HCW) or patient couldthe strict practice of universal precautions to provide care experience problems. Good communication between thefor HIV+ patients. This should enable patients to regain parties will either eliminate or contain the problem. If thefunction of their masticatory apparatus in an environment patient is not satisfied with the response they may complainwhere nutrition combined with the treatment of formally through a lawyer or the national registration body.opportunistic infections is the cornerstone of management Either way the HCW is likely to face a situation withof the HIV infection. significant financial or professional ramifications. They seek assistance from a defence organisation like Dental Protection Limited (DPL) which has 22,500 member A13 dentists ie. 70% of the total number of dentists registered in Awareness of the United Kingdom and 5000 hygienists and therapists. All Occupational new potentially litigious cases are recorded under a detailed Exposure to case headline, facilitating a review of the issues which have HIV Infection Among Dental Surgeons concerned HCWs whilst working with HIV positive patients in Chennai, South India- Study of over the last 18 years. The data only records situations that Knowledge, Attitudes and Behaviour either threatened or resulted in legal action. There are no (KAB) data on unreported problems resolved at practice level. TheS Balasundaram* trend over the last 18 years has been a fall in the number of cross infection concerns registered whilst the trend has risenRagas Dental College, Chenai, India for patients refused treatment, when measured over theS.Balasundaram: bbaallaa2002@yahoo.co.in same time period. Three other significant concerns were also measured: Needlestick injuries, HIV testing andIssues: HIV infection is a major global health problem. In confidentiality Conclusions The incidence of concerns aboutIndia it is estimated that there are four to five million HIV cross infection has declined. The incidence of problemsinfected patients (NACO 2003). Increasingly, dental associated with refused treatment appears to be on thesurgeons are treating HIV infected patients and are exposed increase. Litigation against healthcare workers in general isto body fluids that are a potential sources of HIV infection. on the increase. Financial considerations are a reality forThe present study was undertaken to ascertain the people living with chronic illness and the difficulty ofknowledge, attitude and behavior of dental surgeons finding state funded (NHS) treatment in the UK may be anregarding occupational exposure to HIV infection. underlying issue. The 3 recent cases brought against UK HCWs hinged on poor communication rather than on aDescription: A pre-tested close-ended questionnaire with refusal to treat. All 3 HCWs knowingly cared for other HIV46 items each having 5 possible response options was patients. Concerns about needlestick transmission are morecompleted by 300 dental professionals from various dental numerous – possibly due to the availability of effective drugcolleges in south India. The questionnaire also had an open- regimens and a reduction in stigmaended segment to enable them to express their opinion.Lessons learned: The study showed that dental surgeonshad appropriate understanding of the risk of occupationalexposure. Female dental surgeons were less willing tomanage HIV infected patients than their male counterparts. A15 Formulation of India-specific Protocols for Oral Aspects of HIV Care Research and EducationDental surgeons who graduated after 1986 were more awareof universal precautions to be followed in HIV infection, E Joshua*, TR Saraswathi, M Umadevi, S Solomon, NWthan the pre-86 graduates. Although knowledge was Johnson, K Ranganathanadequate and appropriate, and infection control procedureswere followed the analysis of attitude and behavior revealed Ragas Dental College & Hospital, Chennai, Indiathat dental surgeons were not willing to treat HIV infected E Joshua: drtroobanmds@redriffmail.compatients, if they had a choice. Acquired Immunodeficiency Syndrome (AIDS)/ HumanRecommendations: the results of this study emphasizes the Immunodeficiency Virus (HIV) infection is a global healthimportance of continuing dental education programs to problem. India has the second highest number of HIV cases________________________________________________________________________ 41
  7. 7. 5th World Workshop on Oral Health and Disease in AIDS . A16in the world. Dentists are encountering and treating moreand more HIV patients and oral lesions are major finding in Associationthese patients. Though there are many health initiatives and between Selfthe policies pertaining to dentistry are in its early stages and Riskdefinitive framework is need of the hour to tackle the HIV Perception of Occupational HIVpandemic effectively. A panel of national and international Infection and Hollow Needle Stickexperts; working in the field of HIV presided over a session Injuries Amongst Kenyan Oral Healthconsisting of a group of practicing and teaching oral and Practitionersmaxillofacial pathologists and dental surgeons at thenational conference of the Indian academy of Oral and M D’Lima*1, P Wanzala2, ML Chindia3Maxillofacial Pathologists, in New Delhi, India in 1 Private Dental Practice P.O. Box 66875 00800 Westlands,December 2003. The collective experiences were Nairobi, Kenya 2Kenya Medical Research Institute P.O. Boxdeliberated on and a 13-point recommendation was framed 20752 00200 City Square, Nairobi Kenya, 3Department ofto be sent to the dental council of India for follow up, Oral and Maxillofacial Surgery, Faculty of Dental Sciences,modification and implementation.A17 University of Nairobi, Kenya. Recommendation: The Melvin D Lima: md11261@rediffmail.com guidelines for continuing dental education Background: Clinician perception of risk of HIV infection programs, counselling, during dental treatment should ensure safe work practicesoral screening/testing and relevance of alternative medicine and compliance with universal infection control guidelines.in the screening and treatment of HIV were: 1) Continuing Since accidental exposure still occurs use of an effectiveprofessional education programmes for dental surgeons HIV vaccine may provide adjunctive protection.should be made mandatory and should include HIV/AIDS Objective: To investigate the risk of accidental exposuresawareness, infection control and other relevant topics. 2) from hollow needle stick injuries (HNI) amongst DentistsUndergraduate dental education curriculum must include a who perceive themselves at risk of HIV infection in thestrong component on blood-borne viral diseases and their workplace.implications for the dental profession, for patients and forpublic health. 3) Interdepartmental work in dental colleges Methods: This was a cross sectional study conductedshould be encouraged for enhanced clinical care of HIV among 61 Kenyan participants at a dental conference. Apositive patients and the effective prevention of disease simple standardized semi-structured, self administeredtransmission in the community. 4) Close liaison needs to be questionnaire was used to anonymously collect basicestablished between the dental profession and other demographic data, HIV infection during practice riskprofessional providers of health care and disease prevention. perception and knowledge about the HIV vaccine and post-5) A list of the locations and contact numbers of local HIV exposure prophylaxiscounseling and testing services should be available in every Results: The majority (44.3%) of respondents was ageddental clinical setting. 6) The use and value of the between 31 and 40 years and 68.9% were male. Of theseComplementary and Alternative Medicine (CAM) approach 61.7% engaged in full or part time private practice andto the management of HIV positive patients requires well- 45.6% of them treated between 6-10 patients per day. Thedesigned, well-funded research and evaluation. 7) Infection majority (93.3%) felt that they were at risk of HIV infectioncontrol procedures, using “Universal Precautions” are during dental practice. Only 21.6% had access to anmandatory in the dental clinical setting. Understanding of antiretroviral starter dose in their dental facility. Thethese procedures must be part of mandatory CPE/CDE. questions most infrequently answered were on theConsideration should be given by the DCI to means of audit mechanism and mode of infection (84%) and the nature ofand enforcement, with sanctions. 8) Dental professionals the HIV vaccine (64%). The odds ratio of hollow needlecould play a valuable role in Public education about HIV stick injury occurring was highest in the 41-50 year oldrisk factors, prevention and management. 9) Messages group. (1.5,95% CI (0.85-2.64). The Maentel-Haentzelrelevant to oral health should be integrated into all public (MH) age adjusted odds ratio was 2.02, 95% CI (0.2-15.1).health education/ health promotion programmes. 10) Public The odds ratio in males was 3.75, 95% CI (021-66.7) and inhealth programmes should harness the power of “stars” of females 1.28, 95% CI (0.07-24.4) with the MH genderthe media, sport and fashion to promote key messages about adjusted Odds ratio of 2.12 (0.3-16.7). Homogeneity wasHIV and tobacco risks. There is an important role for faith- found between odds ratios stratified for type of practice, nubased organisations. 11) The Indian Dental Council should mber of patients, injury by non-hollow sharp, knowledge ontake appropriate measures to ensure that the dentists do not the mechanism, target and nature of the Kenyan vaccine anddiscriminate or refuse to treat patients on the grounds of participation in a clinical vaccine trial.their HIV status. 12) Opportunistic screening for oralmanifestations of HIV, for oral cancer/pre-cancer and for Conclusion: Age was a confounder in the risk odds ratiomanifestations of other oral soft tissue and systemic diseases estimates. Effect modification was observed with genderis the duty of every dentist every time a patient is seen. 13) and homogeneity was observed on questions about theHIV testing should only be carried out by laboratories or vaccine. It seems that females are more cautious than malesindividuals adequately trained in both technical and during practice and information on the HIV vaccine ascounseling aspects. Quality assurance methods should be in adjunctive protection during practice may not vary the riskplace. perception and safe practice.________________________________________________________________________ 42
  8. 8. 5th World Workshop on Oral Health and Disease in AIDS . of New Orleans. Exploratory descriptive and graphical analyses as well as inferential methods such as logisticCost of In-patient Care for HIV-Positive Paediatric regression and tree classification models were used toPatients at Red Cross Childrens Hospital, Cape Town, explore and compare the predictive and classification abilitySouth Africa of viral load and CD4 cell counts for OPC status. AnalysesV Yengopal, S Naidoo* were adjusted for several potentially confounding variables such as use of HAART, protease inhibitors, antibiotics, orUniversity of the Western Cape, Cape Town, South Africa other medications, and status of patient with respect to IVS Naidoo: snaidoo@sun.ac.za drug use, smoking, and engagement in a high-risk behavior. Other covariates included age, race, and gender.A retrospective study was undertaken to assess the directtreatment costs for pediatric HIV+ inpatients over a one- Results: The cohort consisted of virtually equal numbers ofyear period at a large Children’s Hospital in Cape Town, males and females and was 59% African-American andSouth Africa. 35% Caucasian with a mean age of 42 years. Univariate analysis indicated that only viral load and CD4 counts wereClinical and demographic data for 154 randomly selected associated with OPC status. Analyses involving viral loadpatients (25% sample) were obtained from hospital records. and/or CD4 counts were adjusted only for IV drug use, theDirect costs were calculated for admissions, X-rays, only significant covariate. Classification tree and logisticmedication, laboratory and surgical procedures. Of the regression models support the finding that higher viral load16032 admissions in 2001, 616 (4%) were HIV+. The most is more closely associated with occurrence of OPC (OR: 2.2common conditions diagnosed clinically on admission were [1.2, 3.6]), and is 40% less likely to misclassify OPC statusfailure to thrive (64%), pneumonia (54%), gastroenteritis as compared with using CD4 counts (OR: 0.61 [0.33, 1.11]).(43%), oral thrush (42%); 54% were found to be Conclusion: These data strongly suggests that viral loadunderweight for their age and 87% were malnourished. The may be a better predictor of OPC status than CD4 countsaverage length of stay in hospital was 9 days (versus 4.03for others). The average cost for each HIV+ inpatient was A19R18 765.76. Admission costs formed the bulk of this Chlorhexidine Mouth-rinse inamount (84%) followed by laboratory costs (9%),medication (3%), surgical (2%) and X-Rays (2%). HIV+ Maintenance of Oralpatients consumed 26% (R11.56 million) of the total budget Candidiasis-free Period among(R44.65 million) for direct treatment costs. Current HIV-Infected Subjects: an Intervention Studyadmission policies at the hospital appear unsustainable (4% W Nittayananta*1, TA DeRouen2, P Areeratchakaran3, Tof the patients consume 26% of the direct treatment costs) in Laothumthut4, K Pangsomboon1, S Petsantad5, Vthe presence of the ever-increasing demand for care and Vuddhakul6, H Sriplung1, MD Martin2tough measures by government to force health managers to 1operate within budget. Prince of Songkla University, Thailand, 2University of Washington, USA, 3Chulalongkorn University, Thailand, 4 Mahidol University & Bamratnaradoom Hospital, ThailandCLINICAL / BASIC SCIENCE W Nittayananta: nwipawee@ratree.psu.ac.thCANDIDA AND MYCOTIC INFECTIONS Background: Oral candidiasis is the most common oral lesion seen in HIV/AIDS subjects. Due to the underlying A18 immune deficiency, recurrence of the lesion after successful Assessment of antifungal therapy is frequently observed among the Association patients. Between Viral Load CD4 Count and Occurrence of Objective: To determine if chlorhexidine mouth-rinse can Oropharangeal Candidiasis in HIV+ be used as an intervention after antifungal therapy to Patients prolong the time to relapse of oral candidiasis among HIV/ AIDS subjects.JE Leigh*, D Mercante, E Lilly, PL Fidel Subjects and methods: A double-blinded randomizedLouisiana State University Health Sciences Center and clinical trial was performed in seventy-five HIV/AIDSCenter of Excellence in Oral and Craniofacial Biology, New subjects with a clinical diagnosis of oral candidiasisOrleans, LA 70112, USA confirmed by culture. Oral examination and oral rinseJanet E. Leigh: jleigh@lsuhsc.edu technique to determine the number of colony forming units (CFU) of Candida were performed at the first visit. TotalBackground: OPC is the most frequently observed oral lymphocyte cell counts were recorded as the baseline datainfection in HIV+ individuals. Historically, lower CD4 of the immune status of the subjects. Clotrimazole trochecounts have been associated with an increased prevalence of was used to treat oral candidiasis and the subjects wereOPC in HIV+ patients, but HIV viral load has also recently followed up every two weeks until the lesions werebeen recognized as a predictive factor. Objective: The completely eradicated. The subjects were divided randomlypurpose of this study was to examine the impact of viral into two groups. They received either 0.12% chlorhexidineload versus blood CD4 cell count on the prevalence of OPC mouth-rinse (n=37, aged 22-52 y, mean 34 y) or 0.9%through modern exploratory statistical analyses. normal saline solution (n=38, aged 22-55 y, mean 38 y), andMethods: We investigated such associations in 49 HIV+ were followed up every two weeks until the next episode ofindividuals from an outpatient clinic population in the city oral candidiasis was observed. Multiple regression analysis________________________________________________________________________ 43
  9. 9. 5th World Workshop on Oral Health and Disease in AIDS . A21and Kaplan–Meier survival estimates, were used to analyze The Frequencies and Biologicalthe data. Properties of Candida albicansResults: Although the recurrence of oral candidiasis was and C. dubliniensis from HIV-slightly longer in the chlorhexidine than the saline group the Positive and -Negative Japanesedifference between the two groups was not statistically T Ohshima*, S Namikoshi, U Yasunari, H Watanabe, Nsignificant (p>0.05). The following variables were Maeda.significantly associated with the time of recurrence of thelesion; frequency of antifungal therapy (p~0.011), total Tomoko Ohshima Organisation, Tsurumi University, Japanlymphocyte cell counts (p~0.017), alcohol consumption Tomoko Ohshima: oshima-t@tsurumi-u.ac.jp(p~0.043), and gingival location of the lesions (p~0.048).The subjects who had low total lymphocyte cell counts Introduction: Candida dubliniensis, which was originally(<1,000 cells/ml) showed shorter oral candidiasis-free classified as C. albicans, has been implicated in candidasis iperiods than those with the higher counts. The number of n HIV/AIDS patients. However, there is little data on the prCFU of Candida at the first visit was not significantly evalence of C. albicans and C. dubliniensis in HIV/AIDS paassociated with the time to recurrence of oral candidiasis tients in Japan.(p~0.669). Objectives: The aims of this study were to investigate theConclusions: Chlorhexidine mouth-rinse showed a small prevalence of C. dubliniensis and C. albicans in the Japanesbut not statistically significant effect in maintenance of oral e and to compare the pathogenicity of these species in this pcandidiasis-free period among HIV/AIDS subjects opulation.compared to normal saline solution. This lack ofsignificance may be due to the small sample size. Further Methods: A total of 581 strains were isolated from 65 HIV-study with a larger number of subjects should be performed positive patients and 1438 HIV-negative controls. They appto achieve statistical significance for such a small effect, or eared as green colonies on CHROM agar. They were typedto confirm our findings. as C. albicans A, B or C, or C. dubliniensis genotype D usin g PCR. In addition growth on Sabourauds Dextrose Agar at 300C and 420C, carbohydrate assimulation, secreted asparticA20 proteinases (SAP) production and antifungal sensitivity of Typing and Clinical Relevance C. albicans and C. dubliniensis was assessed. of Candida albicans in HIV- infected Patients Results: More than half the isolates typed as A, 10% as B and 20% as genotype C. Genotype D was found in 10% ofM Niyombandith*1, P Pripatnanont1, W Satayasanskul1, R HIV-positive and HIV-negative subjects except in the OkinaTeanpaisan2 wa island area where this genotype formed between 30 to 501 Department of Oral and Maxillofacial Surgery, % of the strains isolated from HIV-negative subjects. These2 Department of Stomatology, Faculty of Dentistry, Prince of results showed that C. dubliniensis occurred in both HIV-poSongkla University. sitive and negative subjects, but varied from 0 to 50% depen dent upon the region. The average growth rate of C. dubliniM Niyombandith: cmali@ratree.psu.ac.th ensis on Sabourauds Dextrose Agar incubated at 30°C was l ow 0.5 (n=10) compared to C. albicans 0.96 (n=106). The cTyping of Candida albicans is important in epidemiological arbohydrate assimilation tests showed no difference betweestudies. However researchers have investigated the n the two species, although up to 75% of strains from HIV-nassociation between genotypes and biotypes of C. albicans egative subjects showed low levels of xylose assimilation. Aand the clinical status of patients. The aim of this study was ll strains of C. dubliniensis grew poorly at 42°C suggesting tto investigate the relationship between genotypes, biotypes hat growth at this temperature could be used to distinguish band antifungal susceptibility of C. albicans isolated from etween the two species. Secreted aspartic proteinases (SAPsHIV-infected patients. A total of 189 strains of C. albicans ) production levels of C. dubliniensis was moderate (relativeisolated from 41 HIV-infected patients were investigated in activity 0.20, n=40) but lower than C. albicans (0.25, n=117the genotypic study using the randomly amplified ). Most C. albicans from HIV-positive patients produced lopolymorphic DNA (RAPD) method. One hundred and six w level of SAPs (0.21, n=6). Contrary to our expectation, sustrains were biotyped with the API ZYM system, API AUX sceptibility of C. dubliniensis to antifungal agents was highe20C system and boric acid sensitivity. In addition the r than C. albicans (Fluconazole p<0.05; Miconazole p<0.00minimal inhibitory concentration (MICs) of ketoconazole 1). C albicans isolates from HIV-positive patients showed hrequired to inhibit 94 strains was examined. The igh susceptibility especially to the azoles (Fluconazole p<0.relationship was statistically analyzed using the Chi-square 0001: Intraconazole p<0.01; Miconazole p<0.01) whereas Ctest. The result showed there was no statistic significant . dubliniensis susceptibility was low (Miconazole p<0.01) brelationship between biotypes, genotypes and antifungal ut not resistant.susceptibility. However, the biotype and antifungalsusceptibility were associated with the individual host Conclusion: C. dubliniensis was less pathogenic than C.(p=0.001, p=0.000 respectively). This study did not find any albicans. However, C. dubliniensis derived from HIV-association between genotyping, biotyping and antifungal positive patients had lower susceptibility to azoles thansusceptibility. However, it may be useful to test the isolates from HIV-negative subjects. If strains are isolatedassociation between the biotype and antifungal from HIV-positve patients with candidiasis, induciblesusceptibility in HIV-infected individuals. resistance must be considered.________________________________________________________________________ 44
  10. 10. 5th World Workshop on Oral Health and Disease in AIDS .A22 In vitro Antifungal Activity of J Prasirst1, T Leewatthanakorn1, U Piamsawad1, A Dodonaea angustifolia, a Dejrudee1, P Panichayupakaranant2, R Teanpaisan1, W Traditional South African Nittayananta*Medicinal Plant 1 Faculties of Dentistry, 2Pharmaceutical Sciences, Prince ofM Patel*, MM Coogan Songkla University, ThailandOral Microbiology, Oral Health Sciences, University of the Nittayananta: nwipawee@ratree.psu.ac.thWitwatersrand, South Africa Background: Lawsone methyl ether (2-methoxy-1,4-M Patel: Patelms@dentistry.wits.ac.za naphthoquinone) was first isolated from the dried flowers of Impatiens balsamina L and from the Gentianaceae family. ItIntroduction: Oral Candidiasis is one of the most exhibits potent antifungal activity without obvious sidefrequently opportunistic infections encountered in patients effects. However, the activity of lawsone methyl ether onwith HIV infection. Antifungal drugs are often prescribed Candida albicans isolated from HIV/AIDS subjects hasfor these patients. However the long-term use of never been studied.antimycotic agents leads to the development of resistance.This has led to a search for alternative agents. The leaves of Objective: To determine the antifungal activity of 0.5%an indigenous South African plant Dodonaea angustifolia potassium lawsone methyl ether mouthwash compared withare used as a traditional remedy for treating oral thrush. that of 0.12% and 0.2% chlorhexidine mouthwash onSeveral acids and flavonoids have been isolated from this Candida albicans isolated from HIV/AIDS subjects.genus but no direct link has been established between these Methods: An inoculum of Candida albicans isolated fromcompounds and the reported beneficial effects. 51 HIV/AIDS subjects was prepared and adjusted withObjective: This study investigated the antifungal properties 0.5 McFarland standard. 0.5 ml of the adjusted inoculumof a crude extract of this plant. was added in four test tubes with 0.5 ml of each mouthwash, and 0.5 ml RPMI as a control. The tubes were thenMethods: Dodonaea angustifolia leaves were collected, incubated at 37ºC for 48 h. The turbidity of each tube wasdried, milled and extracted with acetone. The minimal compared with that of the control. The number of Candidainhibitory concentration (MIC) and percentage kill of the albicans colonies was determined by culture with 100 µl ofextracts was determined by a microtitre serial dilution the solution from each tube. Data were analyzed with one-technique using C. albicans ATCC 90028 and 20 oral C. way ANOVA.albicans strains. Ten strains were isolated from HIV positiveCandida carriers and 10 from HIV negative Candida Results: All of the test tubes with 0.5% potassium lawsonecarriers. A chlorhexidine gluconate mouth rinse that is methyl ether, 0.12%, and 0.2% chlorhexidine mouthwashrecommended for oral candidiasis was used as a positive were clear compared with the controls. Positive culture ofcontrol. The MIC was performed in triplicate whereas the Candida albicans was observed in 13 out of 51 platespercentage kill was tested once on all the strains. (25.4%) of 0.12% chlorhexidine mouthwash, 5 of 51 plates (9.8%) of 0.2% chlorhexidine mouthwash, and 4 of 51Results: Both the plant extract and chlorhexidine inhibited plates (7.8%) of 0.5% potassium lawsone methyl ether.the growth of all the yeast isolates that were tested. The MIC The mean number of Candida albicans colonies for eachvalues for the plant extract ranged from 6.25 to50 mg/ml mouthwash were 3.08 (range 0-40), 0.35 (range 0-13) andwhereas the range for chlorhexidine was 0.008 to 0.016 mg/ 0.84 (range 0-24), respectively. Antifungal activity wasml. A concentration of 50 mg/ml of the crude plant extract found to be statistically significant different between 0.5%killed all the isolates within 45 seconds whereas 2 mg/ml potassium lawsone methyl ether and 0.12% chlorhexidinechlorhexidine killed 18 of the 20 isolates within 90 seconds. mouthwash, and between the two concentrations ofOne of the resistant isolates from a HIV positive patient was chlorhexidine mouthwash (p<0.05). However, no significantkilled after 120 seconds and the other from a HIV negative difference was observed between the antifungal activity ofsubject required 180 seconds. There was no significant 0.5% potassium lawsone methyl ether and 0.2%difference between the results of strains isolated from HIV chlorhexidine mouthwash (P>0.05).positive and negative patients.A24 Conclusions: Potassium lawsone methyl ether showed Conclusion: These potent antifungal activity against Candida albicans isolated preliminary results from HIV/AIDS subjects. Clinical trials of this mouthwash indicate that Dodonaea should be conducted to determine if it can be used as an angustifolia has alternative mouthwash in prophylaxis of oral candidiasisantifungal properties. Further research is required to identify among HIV-infected individuals.the active ingredient and to test the cytotoxicity of the plant A Longitudinal Evaluation of Oropharyngealextract. Candidiasis in a Cohort of HIV Positive Patients Attending a Dedicated Clinic in New Orleans A23 K Shetty*, J Leigh Antifungal Activity of Department of General Dentistry, Louisiana State Potassium University Health Sciences Center, New Orleans, USA Lawsone Methyl Ether Mouthwash in Comparison with Chlorhexidine K Shetty: kshett@lsuhsc.edu Mouthwash on Oral Candida Isolated Background: The most common oral opportunistic from HIV/AIDS Subjects infection (OI) studied in HIV-positive individuals, whether________________________________________________________________________ 45
  11. 11. 5th World Workshop on Oral Health and Disease in AIDS .pre or post HAART (Highly Active Antiretroviral Therapy) study the prevalence of this condition among HIV infectedis oropharyngeal candidiasis (OPC). OPC is often one of the adult patients, many of whom do not know their HIV status.first clinical signs of underlying HIV infection and will The patients were not self-selected for painful oral disease.occur in up to 90% of all HIV-positive persons sometimesduring progression to AIDS. Objectives: The objectives of the study were  To measure the prevalence of NUG andPurpose: Our purpose was to conduct a longitudinal Necrotising Ulcerative Periodontitis (NUP) in ainvestigation into the prevalence and biological profile of STI clinicOPC in a cohort of HIV-positive patients attending a  To correlate the HIV status with NUG and NUPdedicated HIV Dental Clinic in New Orleans from 1998 to in patients with a positive diagnosis for NUG and2004. NUP.Study Design: Specialists in oral medicine using Methods: One hundred and sixty five patients whoseestablished presumptive clinical criteria for OPC examined average age was 28.8 years (range 19 to 48 years) were264 infected adults, who were recruited consecutively. Data recruited between 25 November 2003 and 9 March 2004. Aincluded responses to a questionnaire, clinical examination questionnaire was administered to obtain demographicand a histological examination of the biopsied tissue on details and medical and dental information and the patientsevery single presentation of oropharyngeal candidiasis. were assessed clinically to establish the absence or presence of NUG and NUP. Patients who were taking antiretrovirals,Results: The prevalence of OPC decreased significantly in those with advanced HIV disease and those who werepatients receiving dual- or triple-therapy HAART regimens, taking Cotrimoxazole were excluded from the study. Clinicwhich included a protease inhibitor (PI) compared to records were checked for information on HIV status. Onepatients not receiving HAART (p<0.05). There was a higher hundred patients were HIV negative and 56 were positive.incidence (n=35) of pseudomembranous OPC among the The diagnostic criteria for HIV associated periodontalfemale patients who had an infrequent history of diseases of the EC-Clearinghouse (J Oral Pathol Med, 22:vulvovaginal candidiasis. However there was a significant 289, 1993) were used to diagnose NUG and NUP. Thedifference in the recovery of candidal infections amongst diagnostic features of NUG included ulceration, necrosispatients with a low CD4+ count on a HAART regimen and sloughing of one or more interdental papillae andwhich included a PI (p<0.05). spontaneous bleeding. Tissue destruction was limited to theConclusion: The pattern of OPC is changing in the era of gingival tissues and did not involve alveolar bone. NUP wasHAART therapy. OPC still remains the most common OI in characterized by advanced necrotic destruction of thethe HIV-positive person and there appears to be several periodontium. There was a rapid loss of the periodontallevels of immune defenses against OPC. The full potential attachment, destruction or sequestration of bone, and teethfor anti-fungal therapy with PI has, however, yet to be became loose. It was accompanied by severe pain andevaluated directly, and such studies are now critical in halitosis was evident.assessing the usefulness of these agents in isolation or as Results: The prevalence of NUG and NUP at this clinic waspart of combined therapy regimens. 1.8 (3/165). One of the 56 HIV positive patients had NUG and NUP and two of the 109 HIV negative patients had aA26 positive diagnosis for NUG. PERIODONTAL Conclusion: The correlation of the HIV status with NUG DISEASE AND and NUP in patients not self-selected for painful oral GINGIVITIS disease was weak in this setting. A25 Oral and Periodontal Lesions in 1700 The Burden of HIV Positive Patients in South India Necrotising Ulcerative M Umadevi*1, K Ranganathan1, TR Saraswathi1, N Gingivitis and Periodontitis among Kumaraswamy2, NW Johnson3, S Solomon2 Adult Patients Attending a Sexually 1 Department of Oral Pathology, Ragas Dental College and Transmitted Infection Clinic in Hospital and 2YRG CARE, VHS Hospital, Chennai, India, Johannesburg 3 Department of Oral and Maxillofacial Medicine andSR Mtetwa*, J Yengopal, MJ Rudolph Pathology, Guy’s, King’s & St Thomas Dental Institute, London, UKDivision of Public Oral Health, University of theWitwatersrand, Johannesburg, South Africa M Umadevi:S Mtetwa: mtetwas@sph.wits.ac.za Background: India is estimated to have about 4.5 million people infected with HIV. Oral lesions are common andBackground: Necrotising ulcerative gingivitis (NUG) has indicative of HIV infection. Periodontal lesions form anbeen identified as the most common oral manifestation of important part of the constellation of oral manifestations inHIV/AIDS seen by public sector dentists in South Africa (S HIV positive patients. There are very few reports of oralA Dent J, 54: 594, 1999). Testing for HIV sero-status in lesions, which describe the periodontal lesions from India.adult patients is not undertaken routinely at Public SectorClinics in Johannesburg. Esselen Street clinic, which is a Objectives and setting: This report describes the oralsexually transmitted infections (STI) clinic based in lesions and periodontal lesions in particular, in 1700 HIVHillbrow, Johannesburg, provides an ideal environment to positive patients presenting to us at RAGAS and YRG________________________________________________________________________ 46
  12. 12. 5th World Workshop on Oral Health and Disease in AIDS .CARE, a non governmental organization in Chennai, South Results: Overall prevalence of oral lesions (35.7%)India since February 1998. significantly decreased from early to late periods with some variation by lesion type. Oral candidiasis was the mostMethods: Clinical diagnosis of oral lesions was based on common oral soft tissue lesion (58.5%) with a strikingthe criteria of EC Clearing House, 1993 and WHO. The increase in the erythematous variety. Prevalence of hairysimplified Oral Hygiene index (OHI-S) and Community leukoplakia, Kaposi’s sarcoma and necrotizing periodontalPeriodontal Index For Treatment Needs (CPITN) was diseases decreased significantly (p<0.05). There was anrecorded as described in WHO reference and reviewed by increase in salivary-gland disease (14.3%) and a strikingPage and Morrison, 1994. increase in warts: three-fold for patients on antiretroviralResults: Of the 1700 patients, there were 1251 (74%) males therapy (n=14) and six-fold for those on HAART (n=28).and 449 (26%) females. The age ranged from 7 months to Conclusion: The pattern of oral opportunistic infections is72 years. 83% of the patients were in the 21 to 40 year age changing in the era of HAART therapy. This pattern of oralgroup. 83% of the patients presented with at least one oral disease suggests that an increase in oral warts could belesion. Gingivitis (69%) was the most common lesion occurring as a result of the immune reconstitution offollowed by periodontitis (28%) and candidiasis (21%). patients on HAART.44% of patients with periodontitis were smokers.Periodontitis was highly associated with smoking, being 1.6times more frequent in patients who smoke than in non- BASIC SCIENCEsmokers (p<0.01). Patients with candidiasis were 1.7 times VIRUSES: INTERACTION AND EXPRESSIONmore likely to have periodontitis than patients withoutcandidiasis (p<0.01). CD4 counts were available for 1070 IN HIV DISEASEpatients of which 454 patients had CD4 counts <200 and A28616 had CD4 counts >200. There was a statisticallysignificant difference in the occurrence of candidiasis, Human Papillomavirus (HPV)gingivitis and periodontitis between these two groups Type 32 Specific Serum IgG(p<0.05). Response in HIV-Infected AdultsConclusions: Oral lesions are a feature of HIV infection.Gingivitis and periodontitis were the most common oral JE Cameron* , JE Leigh2,4, K Shetty2,4, N Lindsey3,4, E 1,4lesions in our study. Further studies are necessary to Lilly1,4, PL Fidel1,4, ME Hagensee3,4understand the importance of periodontitis in HIV patients 1in our population. Department Microbiology, Immunology & Parasitology, 2 General Dentistry, 3Medicine, 4 Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center, New Orleans, LA, USAHAART THERAPY AND ORAL LESIONS JE Cameron: jcamer@lsuhsc.edu A27 The incidence of oral warts has reportedly increased in The Changing HIV-infected patients during the era of HAART. We have i Face of Oral dentified HPV-32 as the primary cause of oral warts in the Lesions in HIV/ New Orleans HIV cohort. In order to examine defects in the AIDS Patients Undergoing Highly Active host response to HPV-32, we cloned and expressed the HPV Antiretroviral Treatment -32 L1 major capsid gene into the vaccinia virus system to u se as antigen in HPV-32 specific immunological assays. SerK Shetty*, J Leigh um from 7 case patients (HIV+, with oral warts) and 50 screLSU Health Sciences Center, New Orleans, USA ening patients (HIV+, without oral warts) was tested by enz yme-linked immunosorbent assay (ELISA) for HPV-32 specK Shetty: kshett@lsuhsc.edu ific IgG antibodies. HPV-32 specific responses were observBackground: Human Immunodeficiency Virus (HIV) ed in 4/5 cases with HPV-32+ oral warts and in 48% of screinfection is associated with oral manifestations of diagnostic ening patients, but not in patients with oral warts containingand prognostic importance. With the advent of Highly other HPV genotypes. Two out of three screening patients wActive Anti-retroviral Therapy (HAART) there is anecdotal ith asymptomatic oral HPV-32 infection seroreacted to HPVevidence to suggest that the prevalence of oral lesions has -32 capsid antigen. Responses were more frequently detectedeclined. The number of prevalence studies, carried out in d in men, reflecting the demographics of patients with oralthe era of HAART is, however, meagre. warts in the New Orleans HIV cohort. Future studies will uti lize HPV-32 capsids as antigen in ELISA and cellular immuPurpose: The purpose of this study was to determine ne assays to examine peripheral and mucosal responses to Htemporal trends in the prevalence of oral manifestations of PV-32 infections, in order to identify markers of susceptibilihuman immunodeficiency virus (HIV) in a patient ty to HPV-32 associated disease.population predominantly on HAART, attending adedicated HIV Dental Clinic in New Orleans.Study Design: Specialists in oral medicine usingestablished presumptive clinical criteria for HIV-associatedoral lesions examined five hundred and seventy HIV- A29 Local Immune Reactivity in Oral Warts and Oral Hairy Leukoplakia ofinfected adults recruited consecutively. HIV-infected Persons________________________________________________________________________ 47
  13. 13. 5th World Workshop on Oral Health and Disease in AIDS .E Lilly, K Shetty, K Mcnulty, JE Leigh, JE Cameron, ME Methods: The medical record of individuals with biopsy-Hagensee, PL Fidel* confirmed oral wart was reviewed for the initial date of diag nosis of the oral lesion, any history of anal, hand warts or otLouisiana State University Health Sciences Center and her HPV-related pathology, detailed history of HAART andCenter of Excellence in Oral and Craniofacial Biology, New its effectiveness and all CD4 and HIV viral load (VL) measOrleans, LA 70112 USA urements. The HPV infection was genotyped by consensusP Fidel: pfidel@lsuhsc.edu PCR.Background: Oral hairy leukoplakia (OHL) caused by Results: Charts from 13 patients with oral warts wereEpstein Barr virus and oral warts caused by human reviewed, comprising 819 months of care. There were 12 mpapillomavirus (HPV) are common infections in HIV- en, 9 were Caucasian, with an average CD4 of 256 and HIVinfected persons. Although each pathological condition VL of 10,683 at the time of oral wart diagnosis. HPV-32 waoccurs most often under reduced blood CD4 cell numbers, s present in 63%. Ten were on HAART but only 5 being effthe lack of concurrent pathologies suggests that each results ective (HIV VL <400). There was evidence of 2 distinct grofrom unique local immune dysfunction(s). ups: chronic - 6 men, with a long history of oral warts (8-37 months) and also having anal or hand warts, and acute - 6 mObjective: To evaluate local immune reactivity in oral en with a short history of oral warts (2-15 months) and rarewarts and OHL through salivary cytokines and tissue- history of other warts. The chronic group had largely uncontassociated T cells and cytokine mRNA. rolled HIV infection (5/6 had detectable HIV VL, with frequMethods: A cohort of HIV+ persons (n=48) with and ent therapeutic changes). In contrast, the acute group had larwithout oral warts and OHL were evaluated. Salivary Th gely controlled HIV infection (1/6 had detectable HIV VLand proinflammatory cytokines were quantified in with more stable regimens). Both groups had similar averagunstimulated saliva by ELISA. CD3, CD4, and CD8 T cells e CD4 counts (245 vs. 248). The only woman had an oral wwere identified by immunohistochemical staining of frozen art for a short duration (2 months) but developed invasive cetissue biopsies. Tissue-associated cytokine mRNA was rvical cancer 12 months later.evaluated by real-time PCR. Discussion: Detailed histories of HIV+ individuals withResults: Few differences were detected in any parameter. oral warts reveal two epidemics in the New Orleans cohort.Compared to matched controls (HIV+ persons without The chronic cases indicate a generalized susceptibility to HPlesions but positive for oral HPV or EBV DNA), those with V infections at any body site. The acute cases may reflect teOHL had increased IL-1, IL-2 and IL-10 in saliva, while mporary changes in HPV-specific immune function, interactthose with oral warts had increased IL-1, IL-2 and decreased ions with HIV medications or other changes in oral health. FIL-6. CD8 T cells predominated in the tissue but in low uture studies are indicated to better understand these clinicalnumbers. No differences were detected between warts and findings.lesion negative sites, while CD8 T cells were greater inlesion negative sites compared to OHL. Tissue-associatedcytokine mRNA between lesion positive and lesion negative Site-specific Prevalence of 27 Human Papillomaviruspersons showed decreased IL-2 and increased TNF in those (HPV) Genotypes in the Oral Cavity of HIV+ Individualwith warts, and decreased IL-1 and increased IL-6 and sIL-15 in those with OHLA31 N Lindsey*, JE Cameron, AF Hammons, TE Beckel, K Conclusion: There is no pattern Shetty, JE Leigh, JR Kornegay, ME Hagensee of changes in local immunity to Louisiana State University Health Sciences Center, New explain the susceptibility to oral Orleans, LA and Roche Molecular Systems, USAwarts and OHL, and overall little evidence for local immunereactivity in either lesion. It is anticipated that while N Lindsey: nlinds@lsuhsc.eduimmunosuppression plays an indirect role in susceptibilityto infection, virologic factors are most critical to prevalence. Incidence of oral warts has recently increased in HIV+ individuals. Since little is known about the natural history of oral HPV infection, a comprehensive analysis of the prevalence of all oral HPV genotypes and the infection siteA30 Detailed History of HIV+ was undertaken. We are examining the prevalence of 27 Individuals with Oral Warts genotypes using sensitive consensus PCR-based detection Reveals the Possibility of Two on DNA obtained from nine oral samples (buccal mucosa,Epidemics labia, tongue, sublingual mucosa, palate, gingival, tonsils, saliva and gargle) in HIV+ subjects who have no oral warts.ME Hagensee*, JE Cameron, JE Leigh, K Shetty, N To date, over 300 people have been enrolled with 148Lindsey, P Hickman, E Lilly, PL Fidel subjects having all sites screened for HPV. HPV was most prevalent in gingival (32%) and labial (29%) tissue, thoughLouisiana State University Health Sciences Center, New all sites were susceptible. HPV+ subjects (54%) harboredOrleans, LA, USA HPV at anywhere from one site to all sites tested.ME Hagensee: mhagen@lsuhsc.edu Genotyping by Roche reverse line blot identified HPV-83 and 45 as the most prevalent genotypes. There was noBackground: It has been reported that oral warts have apparent site-predilection associated with any genotype.increased in prevalence in HIV+ individuals. To better unde Subjects with multiple HPV+ sites frequently carried therstan this, a detailed chart history of HIV+ individuals from same genotypes in each site. 27% of HPV infections wereNew Orleans with oral warts was performed.________________________________________________________________________ 48