Linear Gingival Erythema Research Articles

Periodontal Status of HIV‐1 and HIV‐2 Seropositive and HIV Seronegative Female Commercial Sex Workers in Senegal

Comprehensive studies of 92 commercial sex workers in Senegal, Africa included an oral examination in which we obtained measurements of decayed, missing, and filled (DMF) teeth; plaque index; gingival index; recession; probing depth (PD); clinical attachment loss (CAL); and the presence of HIV-associated periodontal lesions, under conditions wherein the examiner was unaware of the subject's HIV status. Twenty-seven subjects (29%) were HIV seropositive, 19 of whom were positive for HIV-1, 7 positive for HIV-2, and 1 positive for both. Most subjects were not taking any medications and previous dental care was limited. HIV-seronegative and HIV-seropositive subjects were similar in mean age, number of DMF teeth, percentage of sites with visible plaque, and number of sites with recession. However, the frequency of sites with gingival bleeding, with PD > or = 6 mm, and with CAL > or = 6 mm was significantly greater in seropositive than seronegative subjects. No differences were observed between HIV-1 and HIV-2 positive subjects. About 26% of HIV-seropositive subjects and about 5% of the seronegative subjects exhibited at least one site with concurrent PD > or = 6 mm and CAL > or = 6 mm. HIV-associated periodontal lesions were seen in 3 HIV-seropositive subjects (2 linear gingival erythema, 1 necrotizing periodontitis). One HIV-seronegative subject exhibited necrotizing gingivitis. In this population with multiple risks to oral health, both HIV-1 and HIV-2 infections were associated with a significantly increased prevalence of periodontal disease.

Some unusual oral lesions in HIV infection: comments on the current classification.

Of the numerous oral lesions reported in HIV-infected patients, four entities will be discussed in this paper: linear gingival erythema; cystic lymphoid hyperplasia of the parotid gland; oral non-Hodgkin's lymphoma; and oral squamous cell carcinoma. Based on the literature and the author's personal experience, it appears that linear gingival erythema is perhaps a specific HIV-associated periodontal lesion, but that insufficient data are available in the literature yet to classify this periodontal lesion as a lesion that is strongly associated with HIV infection. On the other hand, cystic lymphoid hyperplasia of the parotid gland has been rather widely reported and has characteristic histopathological features that would justify consideration of this lesion as highly indicative of an underlying HIV infection. Oral non-Hodgkin's lymphoma, at present regarded as a lesion 'strongly associated with HIV infection', is less characteristic in this respect and should merely be classified as 'a lesion seen in HIV infection'. Oral squamous cell carcinomas, not included in the most recent International Classification of Oral Manifestations of HIV infection, should be listed in Group 3 of that classification, representing 'lesions seen in HIV infection'. Further criteria should be developed that will enable distinctions to be made between lesions 'strongly associated with', 'less commonly associated with', and 'seen in' HIV infection.

A prospective study of oral lesions and their predictive value for progression of HIV disease.

This report evaluates and compares individual oral lesions and combinations of lesions in predicting progression-free survival in a seroprevalent cohort of men and women with HIV infection. This was a prospective study of HIV-infected patients, initially AIDS-free, followed for approximately 30 months. Patients were volunteers examined at an academic medical center and at an inner-city hospital in New York. Participants identified themselves as homosexual men or as injection drug users (IDU). The primary outcome being assessed is time from a baseline oral examination until the development of an AIDS-defining condition or death from any cause within 12 months of the last study visit. Correlation is measured by relative risk (RR). While oral lesions were not predictive of progression among subjects with CD4 > or = 200, they were highly predictive of progression among those with CD4 < 200. For subjects with CD4 < 200, the only individual lesion that was significantly associated with progression-free survival was oral candidiasis (RR = 4.12, P = 0.009). Positivity for one or more lesions in a set demonstrated greater prognostic value among those with CD4 < 200, with RR's of 6.03 (P = 0.018) for the set consisting of oral candidiasis, hairy leukoplakia, and necrotizing ulcerative gingivitis (NUG), and 8.77 (P = 0.036) for the set consisting of the above lesions plus linear gingival erythema (LGE). Analysis by cohort suggested that the improvement in correlation was stronger in homosexual men than in IDU, but this question could not be resolved conclusively with these data. Lesion sets might be better prognosticators of progression-free survival than individual lesions among HIV-infected subjects with CD4 < 200. Prognostic value of the core lesion set (oral candidiasis and hairy leukoplakia) was enhanced by the addition of other lesions (NUG and LGE) not usually included in HIV staging systems. These results suggest that staging systems for HIV might be improved by the inclusion of other, survival-related oral lesions.

Epidemiology and diagnosis of HIV-associated periodontal diseases.

A review of periodontal disease as a manifestation of HIV infection suggests a shift in emphasis over the past 5 years. Initially the focus was on newly described forms of periodontal disease (i.e., HIV-associated gingivitis or linear gingival erythema (LGE); HIV-associated periodontitis or necrotizing ulcerative periodontitis (NUP). While the clinical definition of LGE varies from study to study, an association between LGE and Candida infection has been described. Furthermore, the prevalence of NUP is quite low and this disorder is associated with severe immunosuppression. In contrast, the focus today is on the accelerated rate of chronic adult periodontitis occurring in seropositive patients. While the organisms that characterize adult periodontitis in seronegative individuals are present in subgingival plaque from seropositive individuals, reports suggest that atypical pathogens are also present (i.e., Mycoplasma salivarium, Enterobacter cloacae). Recent studies from our laboratory have identified a novel strain of Clostridium isolated from the subgingival plaque of injecting drug users that has pathologic potential. This organism, however, was found in both seropositive and seronegative individuals in this cohort, suggesting an association with lifestyle rather than serostatus. In addition, data has been published examining the local host response in periodontitis in seropositive individuals. Distinctly elevated levels of IgG in gingival crevicular fluid (GCF) have been observed in seropositive patients. Furthermore, data from our laboratory examining inflammatory mediators in GCF (polymorphonuclear leukocyte lysosomal enzyme beta-glucuronidase and the pro-inflammatory cytokine interleukin-1 beta) suggests an altered response in patients with HIV infection. The alteration manifests as the absence of the expected strong correlation between polymorphonuclear leukocyte activity in the gingival crevice and clinical measures of existing periodontal disease, as well as elevated levels of interleukin-1 beta in sites with deeper probing depths. Therefore, it can be concluded that the progression of periodontal disease in the presence of HIV infection is dependent upon the immunologic competency of the host as well as the local inflammatory response to typical and atypical subgingival microorganisms.

Dental lesions: Diagnosis and treatment

Oral health care has been an integral part of the care of patients with HIV infection and AIDS since the disease was first identified in the early eighties. The spectrum of HIV-associated opportunistic diseases occurring in the oral cavity propelled dental health care providers to the forefront of patient care. Infection control issues soon became important in oral health care for patients infected with HIV, and for the first decade these two issues overshadowed the concerns about appropriate management of the dental needs of HIV-infected patients. Several concerns need to be considered in the management of dental care for patients infected with HIV. These include decreased salivary flow and increased sugar intake, prevention and management of routine inflammatory gingival and periodontal disease as well as the atypical forms of gingival and periodontal disease associated with HIV infection (linear gingival erythema [LGE], necrotizing ulcerative gingivitis [NUG] and necrotizing ulcerative periodontitis [NUP]). Finally, although reports of complications secondary to dental treatment of HIV-infected individuals are rare, it is important to consider those factors related to the medical status of HIV-infected patients which may interfere with oral health care. These include potential bleeding problems related to thrombocytopenia and disease or medication related liver abnormalities, increased risk of local infection particularly in patients with severe neutropenia and adverse effects of multiple medications taken by HIV patients. Prevention and management of dental and periodontal disease in HIV-infected individuals is important to self esteem, quality of life and maintenance of adequate nutritional intake. Oral health care continues to be an important component of overall health care for HIV-infected patients.

Oral lesions in Thai heterosexual AIDS patients: a preliminary study.

To study the types of oral lesions in Thai heterosexual AIDS patients. Cross-sectional study and single centre. Medical ward of the Prince of Songkla University Hospital, Thailand, from June 1994 to May 1995. Heterosexual AIDS patients who had been admitted because of opportunistic infections and/or neoplasms. Types of oral lesions, opportunistic systemic diseases present and drugs in use, as well as the lymphocyte count, were recorded in each patient. Mycological investigations by the oral rinse technique were also performed. 41 patients were examined (32 male, 9 female; aged 19-53 years, median 29 years). Oral lesions were found in 35 (85%) patients as follows: oral candidiasis (31), hairy leukoplakia (3), aphthous ulcer (3), linear gingival erythema (2), non-Hodgkin's lymphoma (2) and histoplasmosis (2). CANDIDA ALBICANS: was isolated in 31 patients. There was correlation between the clinical signs of oral candidiasis and the colony-forming units of Candida (Mann-Whitney U test; two-tailed P = 0.0007). Oral candidiasis was the most common lesion. It is of interest that non-Hodgkin's lymphoma was the only neoplasm detected. We conclude that oral lesions among Thai heterosexual AIDS patients may differ from those in other countries.

Periodontal disease in HIV seropositive patients and its relation to lymphocyte subsets.

This study was performed to determine the type of periodontal pathology found in a group of HIV+ patients and its relation to serum levels of CD4. The sample consisted of 101 individuals: intravenous drug users (84%), homosexuals (7%), and heterosexuals (10%). Each patient was examined clinically and radiographically. Periodontal clinical parameters included gingival index and probing depth and loss of attachment on four sites per tooth. Severity of disease was defined as the most severe lesion found: gingivitis, or early, moderate, or advanced periodontitis. CD4 counts were determined on 64 of these patients. Associations between severity of the disease and gender and CD4 counts were analyzed using the Mantel Haenszel chi square test, while associations between severity and age and CD4/CD8 ratio were analyzed using the Kruskal-Wallis test. No disease was found in 14.8% of the sample, gingivitis was found in 21.8%, early periodontitis in 43.6%, moderate periodontitis in 10.9%, and advanced periodontitis in 8.9%. Linear gingival erythema (LGE) was seen in 17.8% of all patients and necrotizing periodontitis (NUP) in 4.9%. No statistically significant differences were observed between the severity of the disease and CD4 counts.

Immunohistochemical study of linear gingival erythema from HIV-positive patients.

Severe forms of periodontal disease are frequent in patients with acquired immunodeficiency syndrome (AIDS). Linear gingival erythema (LGE) is a progressive disease described in HIV-positive patients and is considered to be an early stage of necrotizing periodontitis. Although clinical and microbiological differences are reported in LGE and non-specific gingivitis (NSG), a comparative immunopathological approach of both has not been performed yet. The purpose of this study was to compare relative populations of T-lymphocytes, B-lymphocytes, neutrophils, macrophages and IgG bearing plasma cells in gingival biopsies from sites exhibiting LGE and from sites exhibiting NSG. A biotin-streptavidin amplified system was used for identification of the following antigens: CD3 (T-lymphocytes), CD20 (B-lymphocytes), elastase (neutrophils), CD68 (macrophages) and IgG (plasma cell's secretors of IgG). The results have demonstrated decrease proportions of T-lymphocytes, macrophages and high percentage of neutrophils and IgG bearing plasma cells in LGE. In contrast with NSG, many neutrophils cells in LGE were found inside oral gingival epithelium. Our results highlight the idea that progressive periodontal disease is not only characterized by increased tissue inflammation, but, in addition, by significant changes in the proportion of specific inflammatory cells. The high number of neutrophils along the gingival epithelium is probably associated with the severe gingival necrosis reported in AIDS patients.

The Relationship of Candidiasis to Linear Gingival Erythema in HIV‐Infected Homosexual Men and Parenteral Drug Users

Periodontal status was evaluated in two cohorts participating in a study of the natural history of human immunodeficiency virus (HIV) infection. One cohort consisted of 77 seropositive and 44 seronegative homosexual men, and the other cohort was comprised of 44 seropositive and 39 seronegative parenteral drug users (PDU). No differences were observed between seropositive and seronegative individuals within a cohort in terms of clinical periodontal parameters (percent of sites with > or = 4 mm probing depth, percent of sites exhibiting bleeding on probing, mean oral hygiene index). The PDU displayed more existing periodontal disease than the homosexual men. Periodontal disease in the seropositive individuals in both cohorts was not strictly related to the number of CD4+ lymphocytes. Linear gingival erythema (LGE), defined as an erythematous band of at least 2 mm extending between adjacent papilla, was observed in all 4 groups. Seropositive homosexual men displayed more LGE than seronegative homosexual men (16.6% vs. 11.4%) and seronegative PDU displayed more LGE than seropositive PDU (38.5% vs. 29.5%), but neither difference was significant. LGE tended to be related to reduced numbers of CD4+ lymphocytes, but this relationship did not reach statistical significance. A statistically-significant relationship was found between the presence of intraoral candidiasis and LGE in seropositive homosexual men: 42.9% of these subjects with candidiasis had LGE, while only 12.7% of the subjects without candidiasis had LGE (P < .05). For the seropositive PDU, 35.3% of the individuals with candidiasis had LGE and 25.9% of the subjects without candidiasis displayed LGE, but the difference was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Classification and diagnostic criteria for oral lesions in HIV infection

A consensus has been reached on the classification of the oral manifestations of HIV infection and their diagnostic criteria, based on presumptive and definitive criteria. The former relate to the initial clinical appearance of the lesion and the latter are often the result of special investigations. Candidiasis, hairy leukoplakia, specific forms of periodontal disease [linear gingival erythema, necrotising-(ulcerative) gingivitis and necrotising(ulcerative) periodontitis], Kaposi's sarcoma and non-Hodgkin's lymphoma are strongly associated with HIV infection. Lesions less commonly associated with HIV infection and lesions seen in HIV infection, but not indicative of the disease, are also listed.