A3.doc

5 th World Workshop on Oral Health and Disease in AIDS .

ABSTRACTSPosters

CLINICAL

ORAL LESIONS AND MANAGEMENT OF HIV RELATED DISEASEA2

Oral Manifestations of HIV in Pregnant Women Attending Antenatal Clinics in Johannesburg. A1

LAO Adeyemi*1, MJ Rudolph1, AO Yusuf2, JA McIntyre3, GE Gray3, N Martinson 3

1School of Public Health, University of the Witwatersrand, 2Department of Community Dentistry, University of Pretoria, 3Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg

L Adeyemi: [email protected]

Introduction: Although, several studies have been reported from outside Sub-Saharan Africa on the oral manifestations of HIV in women, no such study has yet been undertaken on oral manifestations of HIV in pregnant women in Africa. In some areas of South Africa, one in three pregnant women attending public sector health facilities is HIV positive. Oral candidiasis has been shown to be the most common oral lesion associated with HIV infection in women.

Objective: To determine the prevalence of oral manifestations in HIV positive pregnant women attending antenatal clinics in Johannesburg.

Method: A cross sectional study was conducted on HIV positive pregnant women attending antenatal clinics in three hospitals in Johannesburg, South Africa. A calibrated dentist determined HIV related oral lesions by doing a clinical examination in 128 HIV positive pregnant women using the criteria suggested by the EC/WHO. Parity, gravidity and age of the patients were collected by means of a self-administered structured questionnaire.

Results: The age range for the group was 17 to 42 years, with a mean age of 27.9 years. Twenty-eight (22%) of the group was primigravid, while 100 (78%) were multiparous. The majority of the patients, 73 (57%) were in their second trimester. Oral candidiasis and angular cheilitis were the most commonly seen oral lesions in these patients with a frequency of 78 (61%) and 51 (40%) respectively. Oral ulceration was seen in 35 (27%) of the patients. Thirty-three women (26%), presented with necrotizing ulcerative gingivitis, 6(5%) had necrotizing ulcerative periodontitis and 6(5%) had linear gingival erythema. Less than 3% of the patients presented with herpes, which was mainly extra-oral. No other HIV associated oral lesions were seen in these patients.

Conclusion: The prevalence of oral lesions associated with HIV infection for this particular sub-group is similar to results of other prevalence studies conducted elsewhere on women, though the prevalence of oral candidiasis was slightly higher in this group. The confirmation of these

findings in pregnant women emphasizes the need for diagnosis of oral lesions by all health care workers and for recommended treatment or referral.

Common Oral Lesions Seen Amongst Sero-positive Clients at a Voluntary Confidential Counseling Testing Centre in Kaduna Nigeria

UE Amanyeiwe-Adaka*, C Igbokwe, SO Ajike

Maxillofacial Unit, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria

U Amanyeiwe-Adaka: [email protected]

The occurrence of common oral lesions seen amongst sero-positive patients was investigated in 638 consecutive patients attending the FRC voluntary confidential counseling and testing (VCCT) centre from November 2002 to November 2003. Different types of oral lesions were observed in 372 (58.3%) of subjects. The most prevalent of these lesions was oral candidiasis observed in 263 (70.7%) patients. The high prevalence of oral candidiasis is similar to those reported in studies from Jos in Nigeria, Cote D'Ivoire and South Africa. The prevalence of other oral lesions was much lower, some patients had more than one type of lesion. They included aphthous ulcers 67 (18%), herpes simplex 47 (12.6%), necrotizing gingivitis 30 (8.1%), salivary gland enlargement 19 (5.1%), necrotizing periodontitis 18 (4.8%), Kaposi sarcoma 12 (3.2%), herpes zoster 7 (1.9%), oropharyngeal carcinoma 5 (1.3%), melanotic hyper-pigmentation 3 (0.8%), maculo-papular lesions 3 (0.8%) and necrotizing fasciitis 2 (0.5%). Similar findings are reported from other studies. Management of these seropositive patients at this VCCT Centre was mainly symptomatic. Patients were given multivitamin supplements and treatment for opportunistic infections. Oral candidiasis was treated with Nystatin pastilles and lozenges, whereas fulminating cases of mycotic infection were given systemic fluconazole. Twelve of the 33 patients who could afford uninterrupted ARV supply for six months had oral lesions.

Conclusion: Oral lesions occurred more frequently in patients that presented with advanced stages of the infection. Seropositive patients on ART presented with fewer oral lesions. In patients with severe opportunistic infections, commencement of ARVs combined with symptomatic treatment of the opportunistic infections and nutritional support, contributed to recovery. Reduced rates of recurrence of infections, progressive rise in CD4 count and improvement in the patients general status was noted. In resource limited settings where facilities are not available, oral lesions may be used as a marker for staging the clinical progress of HIV/AIDS.

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mailto:[email protected]



Gender Differences in Oral Manifestations among South African HIV/AIDS PatientsA3

E Blignaut*

Medical University of Southern Africa

E Blignaut: [email protected]

Objectives: To determine gender differences in numbers, age and oral manifestations among black HIV/AIDS patients attending three AIDS clinics in the Gauteng province, South Africa.

Background: In 2002 it was estimated that 6.5 million South Africans were living with HIV/AIDS, and that women of child bearing age (15-49 years) constituted half of the infected population.

Methods: A retrospective analysis was performed on data obtained over a four year period, from the primary visit of patients attending outpatient clinics at three hospitals in the Pretoria region. At the time no patients had access to antiretroviral therapy. All patients received an oral examination, irrespective of any complaints. Surveillance swabbing for Candida was also performed.

Results: Of the total patient population 1031 (67.4%) were female and 498 (32.6%) male. Of the female patients 78.5% were aged between 20 and 39 years while 76% of the male patients were 30 years and older. Localised attachment loss was more prevalent in males (p≤0.05), while linear gingival erythema and a pericoronitis around an erupting third molar was observed more frequently in females (p≤0.01 and p≤0.05 respectively). In females a significant correlation (p≤0.001) between pseudomembranous candidiasis and a CD4 cell count below 200 cells/mm3 was observed. In males erythematous candidiasis correlated significantly with a CD4 cell count below 200 cells/mm3 (p≤0.01).

Conclusion: Twice as many females than males attended the clinics and they were also younger than the male group. Differences in the prevalence of oral manifestations between males and females were demonstrated, including differences in the correlation of some lesions with a CD4 count below 200 cells/mm3.

A4

HIV Related Oral Diseases Among Women in Zimbabwe

MM Chidzonga*1, M Mwale1, L Chidzumo1, E Makura1, K Malvin2, CH Shiboski2

1University of Zimbabwe, 2 University of California San Francisco

M Chidzonga: [email protected]

Objectives: To estimate oral disease prevalence among women in Harare in relation to HIV serostatus and CD4 count, and to assess sensitivity and specificity of oral soft tissue examinations conducted by nurses compared to an oral surgeon.

Background: Because biologic assays to measure HIV disease progression are rarely accessible in sub-Saharan African countries due to prohibitive cost, we sought to investigate the use of HIV related oral lesions as potential

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 was measured and a standardized oral soft tissue examination was performed at 6-month intervals by both a nurse examiner trained in the diagnosis of HIV-related oral lesions (using ECC criteria) and an oral surgeon. The examinations were done within 2 weeks of each other when possible. We report preliminary analyses conducted on baseline data as recruitment is still ongoing. We include only those women who were seen by both nurse and oral surgeon within a 2-week window.

Results: 433 women 342 (212 HIV+, 130 HIV-) were seen by both nurse and oral surgeon within a 2-week period. Mean age was 30.2 years (range 18-47) among HIV+ women and 27.4 years (range 19-36 y) among HIV- women. Oral candidiasis (OC), predominantly pseudo-membranous, was the most common lesion diagnosed by the oral surgeon in both HIV+ and HIV- women (28% versus 18%; p=0.03), and by the nurses (22% versus 8%; p=0.001). Hairy leukoplakia and Kaposi’s sarcoma were found in 2% and <1%, respectively, of HIV+ and in none of the HIV- women (by either nurse or oral surgeon). The prevalence of OC diagnosed by the oral surgeon was significantly higher among women with CD4 count <200 than in women with CD4 count 200-499 and >499 (57%, 36%, and 7%; respectively; p=0.02). The agreement rate between nurse and oral surgeon examinations was high among HIV+ women for the diagnosis of OC (91% agreement on positive diagnoses and 90% agreement on negative diagnoses). However, the agreement rate was lower for examinations done in HIV- women as the oral surgeon found a higher prevalence of erythematous candidiasis in that group than the nurses.

Conclusion: OC was the most common lesion in HIV-positive Zimbabwean women and was strongly associated with a low CD4 count. The inter-examiner agreement rate was good for diagnoses of OC among HIV-positive women, but erythematous candidiasis remains a diagnostic challenge. These preliminary results suggest that pseudomembranous candidiasis may be used as surrogate marker of disease progression, and is reliably diagnosed by nurses.

Oro-facial Manifestations in Paediatric HIV: A

Comparative Study of Institutionalized and Hospital Out-Patients

A5S Naidoo*, U Chikte

University of the Western Cape, Cape Town, South Africa

S Naidoo: [email protected]@sun.ac.za

The aim of the study was to compare caries status and the number and type of oral mucosal lesions in HIV positive children from a hospital outpatient department and an institutionalized setting.

Oral examinations were performed using presumptive diagnostic criteria. The Fisher’s Exact and the Mann-Whitney tests were used for statistical comparison of the

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two study groups. A total of 169 children were examined of whom 42% were institutionalized and 58% hospital outpatients. One institutionalized child presented with Noma. 21% of the institutionalized population presented with Molluscum contagiosum, while none of the hospital outpatients presented with this condition.

Significantly more intra-oral mucosal lesions were observed in the hospital compared to the institutionalized group. The most frequently encountered oral lesion was candidiasis. Twice as many intraoral ulcers were recorded in the institutionalised group. Thirty nine percent of the hospitalized patients had multiple lesions compared to 28% in the institutionalised group. Almost three quarters of both populations were caries-free. The mean DMFT was higher in the hospital population. For both the permanent and primary teeth, the decayed component made up the major part of the DMFT/dmft, followed by the missing component. No fillings were recorded in either the primary or permanent teeth for both groups.

Oral lesions were common in HIV populations and were seen in both the hospital (63%) and institutionalized (45%) groups at high prevalence levels. HIV infected children should be considered high risk for caries due to the use of chronic medication, and to receive appropriate care in terms of both treatment and services.

Oral Manifestation of HIV Paediatric Cases in Chennai, South India A6

R Thavarajah*1, TR Saraswathi1, U Devi1, S Solomon2, N Kumaraswamy2, NW Johnson3, K Ranganathan1

1Ragas Dental College and Hospital, Chennai, 2 YRG CARE, Chennai, 3Guy’s, King’s & St Thomas Dental Institute, London, UK

R Thavarajah: [email protected]

Background: Of the 40 million people living with HIV globally, children constitute 2.5 million. In India there are 4.5 million people living with HIV and children infected with this infection constitute a major health problem. There are very few reports of oral lesions and conditions in Indian HIV seropositive children, even though the number of children affected by this disease is increasing.

Methods: Our study group consisted of 37 children referred to our tertiary HIV care center at Ragas Dental College and Hospital and YRG CARE, Chennai, India). ELISA and Western Blot confirmed the HIV sero status. A complete oral examination was undertaken by a trained dental surgeon and diagnosis of oral lesions was made on presumptive criteria established by the EC Clearing house, 1993 and WHO.

Results: Of the 37 pediatric cases in our cohort, 22 were males (59.5%) and 15 were females (40.5%). 84% acquired the infection through vertical transmission and 16% through blood transfusion. The lesions that were seen included candidiasis, gingivitis, parotid enlargement and cervical lymphadenopathy. The following table compares our results with published prevalence percentages. On a 6months follow up, all these oral lesions responded favorably to standard treatment protocols.

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 diagnosis and treatment.

Author , yearP.

CandidaE.

CandidaCandida

Angular chelitis

Parotid swelling

Cervical lymph

adenopa-thy

Gingivitis OHL DC

Ramos – Gomez FJ et al 2000

43% - - - - - - - -

Khongkunthian P et al 2001

- 17.8% - - - - - 6.7% --

Santos LC et al2001

- - 22.5% - 8.8% - 17.5% 1.3% -

Magalhaes MG et al 2001

18.42% 18.42% - 28.94% 18.42% - 13.5% 2.63% -

Luis Gaitan – Cepeda et al

2002- - 29.2% - 2.1% - 4.2% - -

Okunseri et al2003

- - 2.9% - 2% 1% 20.6% - 19.6%

Present 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

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Classification of Oral Diseases of HIV-Associated Immune Suppression A7

M Glick*, SN Abel, CM Flaitz, CA Migliorati, LL Patton, JA Phelan, DA Reznik

ODHIS Workshop Group – USA

M Glick: [email protected]

The present classification systems for HIV-associated oral lesions were developed in the early 1990s and have been valuable tools for both diagnostic and research purposes. With the advent of new antiretroviral therapy, the pattern of oral conditions is changing in the USA and a new classification system should be evaluated. This system should reflect changes in the epidemiology of oral lesions that are related to HIV disease and therapeutics. In addition, this system should take into account the association between the development of these lesions and the patient’s immune status. The terminology of “oral lesion” also needs to be changed to “oral disease”. Oral disease is defined as an abnormality characterized by a defined set of signs and symptoms in the oral cavity, extending from the vermilion border of the lip to the oropharynx, with the exception of salivary gland disease. Based on a review of the recent literature and expert opinion with majority consensus, the following groups of oral diseases are proposed for this revised classification system:

Group 1 ODHIS associated with severe immune suppression (CD4 < 200 cells/mm3).

Group 2 ODHIS associated with immune suppression (CD4 < 500 cells/mm3).

Group 3 ODHIS assumed associated with immune suppression.a) More commonly observed.b) Rarely reported.

Group 4 Therapeutically-induced oral diseases.

Group 5 Emerging oral diseases.

ODHIS Workshop Group - USA does recognize that oral diseases do not exclusively belong to one classification Group, and that overlap exists. The use of an immune-based classification system provides a method for identifying undiagnosed individuals, provides an additional rationale for HIV testing, effects access and type of HIV-related healthcare, and provides clinical markers for therapeutic interventions and efficacy. Despite these important advantages, the proposed ODHIS classification should be pilot tested and consensus developed before it is widely disseminated among healthcare providers. Funded by the Dental Alliance for AIDS/HIV Care (DAAC).

Smoking as a Predictor of Oral Manifestation of HIV Infection A8

OA Ayo-Yusuf*1, AS Bajomo2 and MJ Rudolph2.

1Department of Community Dentistry, University of Pretoria and 2Division of Oral Public Health, University of Witwatersrand, South Africa.

OA Ayo-Yusuf: [email protected]

Oral lesions in HIV-infected individuals are potentially useful predictors of disease progression, especially in poorly resourced societies. It is therefore important to recognise factors that may impact on their presentation and management. This cross-sectional analytical study therefore sought to determine the effect of smoking on oral manifestation (OM) of HIV/AIDS among a South African general hospital outpatient population. Study participants included one hundred and seventy-five (n=175) consenting HIV infected adults that consecutively presented at the HIV clinic on referral for routine care and support since their diagnosis of HIV seropositivity. Socio-demographic information, drug-treatment status and smoking history were obtained from the patients using a self-administered questionnaire. A systematic oral examination was also conducted on each patient by a trained and calibrated dental clinician in order to record presence of HIV-related oral lesion(s). The examiner was blinded to the completed questionnaire. Cigarette smoking prevalence was 10% (n=17), with male prevalence of 23%. Only one smoker reported to have reduced consumption since knowing of HIV status, but none had quit. Of the 76% that presented with OM, oral candidiasis was the most common oral lesion (72%). Adjusting for period since visiting (proxy for HIV history) and other variables, logistic regression analysis for presentation with OM indicated that being female (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-13.0) and regular smoking (OR, 8.6; 95% CI, 1.6-46.4) was significantly associated with higher odds of presenting with OM. The model derived explained 12% of variance in OM. The study findings suggest smoking is an important predictor of OM in the studied population. However, there is also an indication for further research.

ORAL HEALTH AND GENERAL HEALTH

The Association of Peripheral Blood Abnormalities and HIV-Associated Oral

LesionsA9D Kerdpon*1, S Sretrirutchai2, A Nilmanut3, A Geater2, K Wangrangsimakul1

1Faculty of Dentistry, Prince of Songkla University, Thailand; 2Faculty of Medicine, Prince of Sonkla University, Thailand; 3Hatyai Regional Hospital, Songkla, Thailand

D Kerdpon: [email protected]

Few data of peripheral blood abnormalities and their association with HIV-associated oral lesions are available. This study evaluated the prevalence of peripheral blood values less than normal range in HIV-infected patients and their association with number and type of HIV-associated oral lesions. One hundred and seventeen HIV-infected patients in a southern Thai hospital were included. Anemia (69.2%), leukopenia (29.1%), and lymphopenia (11.1%) were the most common haematological abnormalities. Lymphopenia was significantly associated with an increased number of HIV-associated oral lesions, the presence of any HIV- associated oral lesions and oral candidiasis (OC). Lymphopenia was not found in patients without any oral lesions. Low mean corpuscular volume (MCV) was more common among patients without any oral lesion than among

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those with OC and oral hairy leukoplakia. More studies will help to explain this finding. Lymphopenia might be a practical indicator in prediction of HIV-associated oral lesions, particularly when CD4 and viral load are not routinely accessible.

Salivary and Oral Findings in HIV-positive and HIV-negative Subjects with Well-controlled

MedicationA10W Nittayananta1*, B Nauntofte2, E Dabelsteen3, K Stoltze4, N Chanowanna1, S Jealae5

1Department of Stomatology, Faculty of Dentistry and 5Microbiological Unit, Faculty of

Medicine, Prince of Songkla University, Thailand, 2Department of Clinical Oral Physiology, 3Department of Oral Diagnostic Sciences and 4Department of Periodontology, School of Dentistry, University of Copenhagen, Denmark

A11

W Nittayananta: [email protected]

Background: Salivary glands are affected during the course of HIV infection. Many medications may have the potential to impair salivary gland function as well as to induce feelings of oral dryness. In particular, little is known about intake of medication and the presence of hyposalivation and xerostomia among HIV-infected subjects.

Objectives: The aims were to assess the prevalence of hyposalivation and xerostomia in HIV and HIV free subjects with a well-controled consumption of medications, to study the relationship between unstimulated and stimulated salivary flow rates, to identify factors associated with hyposalivation and xerostomia, and to correlate the presence of hyposalivation and xerostomia to the presence of oral candidiasis, the number of colony forming units of Candida, presence of cervical caries and number of teeth in the group of HIV infected subjects.

Subjects and methods: A cross-sectional study was performed in the two different regions of Thailand; in the north and the south. One hundred and thirty-five subjects were enrolled (56 HIV-seropositive, mean age: 34.5 years and 79 HIV-seronegative individuals, mean age: 29.5 years). Measurement of saliva flow rate comprised both unstimulated and wax-stimulated whole saliva using the draining method. The effect of HIV serostatus, stage of HIV infection; asymptomatic, and symptomatic/AIDS, and medications on the flow rates was analyzed.

Results: The unstimulated flow rates in the HIV-positive subjects and HIV-negative controls were 0.19 and 0.33 ml/min (p~0.0024). The stimulated flow rates were 1.45 and 1.62 mls/min (p~0.31). In the HIV-positive group the unstimulated flow rate was significantly higher in the asymptomatic group 0.17 ml/min, compared to the symptomatic/AIDS group 0.11 ml/min (p~0.003) whereas the mean stimulated flow rate values were 0.99 and 1.15 mls/min respectively. No significant difference was found. With respect to medication, unstimulated (or stimulated) flow rates were found to be statistically significant lower in subjects with xerostomia-inducing drugs compared with those with no medication (p~0.004). The following factors

were significantly associated with hyposalivation; sex, stage of HIV infection, risks group, systemic disease, medication, smoking habit, and alcohol consumption. Hyposalivation was found to be significantly associated with the number of 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.

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, xerogenic medications should be prescribed with special caution in this patient group.

Quality of Life and Oral Mucosal Lesions among HIV-positive Drug Addicts

SL Sujak*, Rahimah Abdul Kadir, Roziah Omar

University of Malaya, Kuala Lumpur Malaysia

SL Sujak: [email protected]

HIV-infected people are prone to oral mucosal lesions (OML) which can affect the quality of life of this population. The objective of this study was to evaluate the effect of OML on the quality of life among HIV-positive drug addicts. A cross-sectional case-control study involving 917 male drug addicts, 509 HIV-positive (case) and 408 non-HIV (control) drug addicts was carried out. The mean age of the sample was 31.2±6.5 years old. A single item global rating questionnaire was used to measure the quality of life. The prevalence of OML was measured by oral examination. The study showed that HIV-positive patients registered a lower quality of life experience (m=27.3±21.6 point) than non-HIV subjects (m=40.8±30.0 point). The difference was statistically significant (p=0.00). The study also found that 41% of the HIV-positive subjects had OML. Pseudo-membranous candidiasis was the most common lesion (21%) follow by hairy leukoplakia (12%) and erythematous candidiasis (12%). These findings suggest that the presence of OML did not affect their quality of life as shown by Pearson chi squared test. Findings from this study concluded that OML had a minor influence on the general quality of life of HIV-positive drug addicts.

HEALTH CARE NEEDSA12

Oral and Maxillofacial Surgery for the Seropositive Patient in a Resource Limited Setting

UE Amanyeiwe-Adaka*, C Igbokwe, SO Ajike

Family Resource Centre ABU, Old Hospital Complex, Kaduna, Nigeria

U Amanyeiwe-Adaka: [email protected]

Surgical management of HIV sero-positive patients in developing countries such as Nigeria is highly inadequate. This is due to the unavailability of enabling policies and infrastructures that empower both the clinician and the patients. The objective of this paper is to analyze the

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problems encountered by the average Oral Maxillofacial surgeon who has to manage sero-positive patients in an environment with little or no access to sustainable anti retroviral drug therapies and no access to affordable post exposure prophylaxis for the surgeon. The need to address these issues cannot be over-emphasized in a country with a sero-prevalence of over 5.8% and having one of the worlds highest incidences of road traffic accidents with associated fractures of the facial skeleton. In conclusion there is a need for surgeons to empower themselves with scientifically correct knowledge of post exposure chemoprophylaxis and the strict practice of universal precautions to provide care for HIV+ patients. This should enable patients to regain function of their masticatory apparatus in an environment where nutrition combined with the treatment of opportunistic infections is the cornerstone of management of the HIV infection.

Awareness of Occupational Exposure to HIV

Infection Among Dental Surgeons in Chennai, South India- Study of Knowledge, Attitudes and Behaviour (KAB)

A13S Balasundaram*

Ragas Dental College, Chenai, India

S.Balasundaram: [email protected]

Issues: HIV infection is a major global health problem. In India it is estimated that there are four to five million HIV infected patients (NACO 2003). Increasingly, dental surgeons are treating HIV infected patients and are exposed to body fluids that are a potential sources of HIV infection. The present study was undertaken to ascertain the knowledge, attitude and behavior of dental surgeons regarding occupational exposure to HIV infection.

Description: A pre-tested close-ended questionnaire with 46 items each having 5 possible response options was completed by 300 dental professionals from various dental colleges in south India. The questionnaire also had an open-ended segment to enable them to express their opinion.

Lessons learned: The study showed that dental surgeons had appropriate understanding of the risk of occupational exposure. Female dental surgeons were less willing to manage HIV infected patients than their male counterparts. Dental surgeons who graduated after 1986 were more aware of universal precautions to be followed in HIV infection, than the pre-86 graduates. Although knowledge was adequate and appropriate, and infection control procedures were followed the analysis of attitude and behavior revealed that dental surgeons were not willing to treat HIV infected patients, if they had a choice.

Recommendations: the results of this study emphasizes the importance of continuing dental education programs to focus on motivating dental surgeons to provide dental care for HIV infected patients.

Concerns Reported to Dental Protection Limited by Dental Healthcare Workers Treating

HIV Positive Patients: 1985-2002A14D Croser*

VM Clinic, Hammersmith and Fulham PCT, UK

D Croser: [email protected]

When undertaking clinical procedures it is possible that either dental healthcare workers (HCW) or patient could experience problems. Good communication between the parties will either eliminate or contain the problem. If the patient is not satisfied with the response they may complain formally through a lawyer or the national registration body. Either way the HCW is likely to face a situation with significant financial or professional ramifications. They seek assistance from a defence organisation like Dental Protection Limited (DPL) which has 22,500 member dentists ie. 70% of the total number of dentists registered in the United Kingdom and 5000 hygienists and therapists. All new potentially litigious cases are recorded under a detailed case headline, facilitating a review of the issues which have concerned HCWs whilst working with HIV positive patients over the last 18 years. The data only records situations that either threatened or resulted in legal action. There are no data on unreported problems resolved at practice level. The trend over the last 18 years has been a fall in the number of cross infection concerns registered whilst the trend has risen for patients refused treatment, when measured over the same time period. Three other significant concerns were also measured: Needlestick injuries, HIV testing and confidentiality Conclusions The incidence of concerns about cross infection has declined. The incidence of problems associated with refused treatment appears to be on the increase. Litigation against healthcare workers in general is on the increase. Financial considerations are a reality for people living with chronic illness and the difficulty of finding state funded (NHS) treatment in the UK may be an underlying issue. The 3 recent cases brought against UK HCWs hinged on poor communication rather than on a refusal to treat. All 3 HCWs knowingly cared for other HIV patients. Concerns about needlestick transmission are more numerous – possibly due to the availability of effective drug regimens and a reduction in stigma

Formulation of India-specific Protocols for Oral Aspects of HIV Care Research

and Education A15E Joshua*, TR Saraswathi, M Umadevi, S Solomon, NW Johnson, K Ranganathan

Ragas Dental College & Hospital, Chennai, India

E Joshua: [email protected]

Acquired Immunodeficiency Syndrome (AIDS)/ Human Immunodeficiency Virus (HIV) infection is a global health problem. India has the second highest number of HIV cases in the world. Dentists are encountering and treating more and more HIV patients and oral lesions are major finding in these patients. Though there are many health initiatives and the policies pertaining to dentistry are in its early stages and definitive framework is need of the hour to tackle the HIV

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pandemic effectively. A panel of national and international experts; working in the field of HIV presided over a session consisting of a group of practicing and teaching oral and maxillofacial pathologists and dental surgeons at the national conference of the Indian academy of Oral and Maxillofacial Pathologists, in New Delhi, India in December 2003. The collective experiences were deliberated on and a 13-point recommendation was framed to be sent to the dental council of India for follow up, modification and implementation.

Recommendation: The guidelines for continuing dental education programs, counselling, oral

screening/testing and relevance of alternative medicine in the screening and treatment of HIV were: 1) Continuing professional education programmes for dental surgeons should be made mandatory and should include HIV/AIDS awareness, infection control and other relevant topics. 2) Undergraduate dental education curriculum must include a strong component on blood-borne viral diseases and their implications for the dental profession, for patients and for public health. 3) Interdepartmental work in dental colleges should be encouraged for enhanced clinical care of HIV positive patients and the effective prevention of disease transmission in the community. 4) Close liaison needs to be established between the dental profession and other professional providers of health care and disease prevention. 5) A list of the locations and contact numbers of local HIV counseling and testing services should be available in every dental clinical setting. 6) The use and value of the Complementary and Alternative Medicine (CAM) approach to the management of HIV positive patients requires well-designed, well-funded research and evaluation. 7) Infection control procedures, using “Universal Precautions” are mandatory in the dental clinical setting. Understanding of these procedures must be part of mandatory CPE/CDE. Consideration should be given by the DCI to means of audit and enforcement, with sanctions. 8) Dental professionals could play a valuable role in Public education about HIV risk factors, prevention and management. 9) Messages relevant to oral health should be integrated into all public health education/ health promotion programmes. 10) Public health programmes should harness the power of “stars” of the media, sport and fashion to promote key messages about HIV and tobacco risks. There is an important role for faith-based organisations. 11) The Indian Dental Council should take appropriate measures to ensure that the dentists do not discriminate or refuse to treat patients on the grounds of their HIV status. 12) Opportunistic screening for oral manifestations of HIV, for oral cancer/pre-cancer and for manifestations of other oral soft tissue and systemic diseases is the duty of every dentist every time a patient is seen. 13) HIV testing should only be carried out by laboratories or individuals adequately trained in both technical and counseling aspects. Quality assurance methods should be in place.

A17

Association between Self Risk Perception

of Occupational HIV Infection and Hollow Needle Stick Injuries Amongst Kenyan Oral Health Practitioners

A16

M D’Lima*1, P Wanzala2, ML Chindia3

1Private Dental Practice P.O. Box 66875 00800 Westlands, Nairobi, Kenya 2Kenya Medical Research Institute P.O. Box 20752 00200 City Square, Nairobi Kenya, 3Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, University of Nairobi, Kenya.

Melvin D Lima: [email protected]

Background: Clinician perception of risk of HIV infection during dental treatment should ensure safe work practices and compliance with universal infection control guidelines. Since accidental exposure still occurs use of an effective HIV vaccine may provide adjunctive protection.

Objective: To investigate the risk of accidental exposures from hollow needle stick injuries (HNI) amongst Dentists who perceive themselves at risk of HIV infection in the workplace.

Methods: This was a cross sectional study conducted among 61 Kenyan participants at a dental conference. A simple standardized semi-structured, self administered questionnaire was used to anonymously collect basic demographic data, HIV infection during practice risk perception and knowledge about the HIV vaccine and post-exposure prophylaxis

Results: The majority (44.3%) of respondents was aged between 31 and 40 years and 68.9% were male. Of these 61.7% engaged in full or part time private practice and 45.6% of them treated between 6-10 patients per day. The majority (93.3%) felt that they were at risk of HIV infection during dental practice. Only 21.6% had access to an antiretroviral starter dose in their dental facility. The questions most infrequently answered were on the mechanism and mode of infection (84%) and the nature of the HIV vaccine (64%). The odds ratio of hollow needle stick injury occurring was highest in the 41-50 year old group. (1.5,95% CI (0.85-2.64). The Maentel-Haentzel (MH) age adjusted odds ratio was 2.02, 95% CI (0.2-15.1). The odds ratio in males was 3.75, 95% CI (021-66.7) and in females 1.28, 95% CI (0.07-24.4) with the MH gender adjusted Odds ratio of 2.12 (0.3-16.7). Homogeneity was found between odds ratios stratified for type of practice, number of patients, injury by non-hollow sharp, knowledge on the mechanism, target and nature of the Kenyan vaccine and participation in a clinical vaccine trial.

Conclusion: Age was a confounder in the risk odds ratio estimates. Effect modification was observed with gender and homogeneity was observed on questions about the vaccine. It seems that females are more cautious than males during practice and information on the HIV vaccine as adjunctive protection during practice may not vary the risk perception and safe practice.

Cost of In-patient Care for HIV-Positive Paediatric Patients at Red Cross Children's Hospital, Cape Town, South Africa

V Yengopal, S Naidoo*

University of the Western Cape, Cape Town, South Africa

S Naidoo: [email protected]@sun.ac.za

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A retrospective study was undertaken to assess the direct treatment costs for pediatric HIV+ inpatients over a one-year period at a large Children’s Hospital in Cape Town, South Africa.

Clinical and demographic data for 154 randomly selected patients (25% sample) were obtained from hospital records. Direct costs were calculated for admissions, X-rays, medication, laboratory and surgical procedures. Of the 16032 admissions in 2001, 616 (4%) were HIV+. The most common conditions diagnosed clinically on admission were failure to thrive (64%), pneumonia (54%), gastroenteritis (43%), oral thrush (42%); 54% were found to be underweight for their age and 87% were malnourished. The average length of stay in hospital was 9 days (versus 4.03 for others). The average cost for each HIV+ inpatient was R18 765.76. Admission costs formed the bulk of this amount (84%) followed by laboratory costs (9%), medication (3%), surgical (2%) and X-Rays (2%). HIV+ patients consumed 26% (R11.56 million) of the total budget (R44.65 million) for direct treatment costs. Current admission policies at the hospital appear unsustainable (4% of the patients consume 26% of the direct treatment costs) in the presence of the ever-increasing demand for care and tough measures by government to force health managers to operate within budget.

CLINICAL / BASIC SCIENCECANDIDA AND MYCOTIC INFECTIONS

Assessment of Association Between Viral

Load CD4 Count and Occurrence of Oropharangeal Candidiasis in HIV+ Patients

A18JE Leigh*, D Mercante, E Lilly, PL Fidel

Louisiana State University Health Sciences Center and Center of Excellence in Oral and Craniofacial Biology, New Orleans, LA 70112, USA

Janet E. Leigh: [email protected]

Background: OPC is the most frequently observed oral infection in HIV+ individuals. Historically, lower CD4 counts have been associated with an increased prevalence of OPC in HIV+ patients, but HIV viral load has also recently been recognized as a predictive factor. Objective: The purpose of this study was to examine the impact of viral load versus blood CD4 cell count on the prevalence of OPC through modern exploratory statistical analyses.

Methods: We investigated such associations in 49 HIV+ individuals from an outpatient clinic population in the city of New Orleans. Exploratory descriptive and graphical analyses as well as inferential methods such as logistic regression and tree classification models were used to explore and compare the predictive and classification ability of viral load and CD4 cell counts for OPC status. Analyses were adjusted for several potentially confounding variables such as use of HAART, protease inhibitors, antibiotics, or other medications, and status of patient with respect to IV drug use, smoking, and engagement in a high-risk behavior. Other covariates included age, race, and gender.

Results: The cohort consisted of virtually equal numbers of males and females and was 59% African-American and 35% Caucasian with a mean age of 42 years. Univariate analysis indicated that only viral load and CD4 counts were associated with OPC status. Analyses involving viral load and/or CD4 counts were adjusted only for IV drug use, the only significant covariate. Classification tree and logistic regression models support the finding that higher viral load is more closely associated with occurrence of OPC (OR: 2.2 [1.2, 3.6]), and is 40% less likely to misclassify OPC status as compared with using CD4 counts (OR: 0.61 [0.33, 1.11]). Conclusion: These data strongly suggests that viral load may be a better predictor of OPC status than CD4 counts

Chlorhexidine Mouth-rinse in Maintenance of Oral Candidiasis-free Period among HIV-Infected

Subjects: an Intervention StudyA19W Nittayananta*1, TA DeRouen2, P Areeratchakaran3, T Laothumthut4, K Pangsomboon1, S Petsantad5, V Vuddhakul6, H Sriplung1, MD Martin2

1Prince of Songkla University, Thailand, 2University of Washington, USA, 3Chulalongkorn University, Thailand, 4Mahidol University & Bamratnaradoom Hospital, Thailand

W Nittayananta: [email protected]

Background: Oral candidiasis is the most common oral lesion seen in HIV/AIDS subjects. Due to the underlying immune deficiency, recurrence of the lesion after successful antifungal therapy is frequently observed among the patients.

Objective: To determine if chlorhexidine mouth-rinse can be used as an intervention after antifungal therapy to prolong the time to relapse of oral candidiasis among HIV/AIDS subjects.

Subjects and methods: A double-blinded randomized clinical trial was performed in seventy-five HIV/AIDS subjects with a clinical diagnosis of oral candidiasis confirmed by culture. Oral examination and oral rinse technique to determine the number of colony forming units (CFU) of Candida were performed at the first visit. Total lymphocyte cell counts were recorded as the baseline data of the immune status of the subjects. Clotrimazole troche was used to treat oral candidiasis and the subjects were followed up every two weeks until the lesions were completely eradicated. The subjects were divided randomly into two groups. They received either 0.12% chlorhexidine mouth-rinse (n=37, aged 22-52 y, mean 34 y) or 0.9% normal saline solution (n=38, aged 22-55 y, mean 38 y), and were followed up every two weeks until the next episode of oral candidiasis was observed. Multiple regression analysis and Kaplan–Meier survival estimates, were used to analyze the data.

Results: Although the recurrence of oral candidiasis was slightly longer in the chlorhexidine than the saline group the difference between the two groups was not statistically significant (p>0.05). The following variables were significantly associated with the time of recurrence of the lesion; frequency of antifungal therapy (p~0.011), total lymphocyte cell counts (p~0.017), alcohol consumption (p~0.043), and gingival location of the lesions (p~0.048).

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The subjects who had low total lymphocyte cell counts (<1,000 cells/ml) showed shorter oral candidiasis-free periods than those with the higher counts. The number of CFU of Candida at the first visit was not significantly associated with the time to recurrence of oral candidiasis (p~0.669).

Conclusions: Chlorhexidine mouth-rinse showed a small but not statistically significant effect in maintenance of oral candidiasis-free period among HIV/AIDS subjects compared to normal saline solution. This lack of significance may be due to the small sample size. Further study with a larger number of subjects should be performed to achieve statistical significance for such a small effect, or to confirm our findings.

Typing and Clinical Relevance of Candida albicans in HIV-infected PatientsA20

M Niyombandith*1, P Pripatnanont1, W Satayasanskul1, R Teanpaisan2

1Department of Oral and Maxillofacial Surgery, 2Department of Stomatology, Faculty of Dentistry, Prince of Songkla University.

M Niyombandith: [email protected]

Typing of Candida albicans is important in epidemiological studies. However researchers have investigated the association between genotypes and biotypes of C. albicans and the clinical status of patients. The aim of this study was to investigate the relationship between genotypes, biotypes and antifungal susceptibility of C. albicans isolated from HIV-infected patients. A total of 189 strains of C. albicans isolated from 41 HIV-infected patients were investigated in the genotypic study using the randomly amplified polymorphic DNA (RAPD) method. One hundred and six strains were biotyped with the API ZYM system, API AUX 20C system and boric acid sensitivity. In addition the minimal inhibitory concentration (MICs) of ketoconazole required to inhibit 94 strains was examined. The relationship was statistically analyzed using the Chi-square test. The result showed there was no statistic significant relationship between biotypes, genotypes and antifungal susceptibility. However, the biotype and antifungal susceptibility were associated with the individual host (p=0.001, p=0.000 respectively). This study did not find any association between genotyping, biotyping and antifungal susceptibility. However, it may be useful to test the association between the biotype and antifungal susceptibility in HIV-infected individuals.

The Frequencies and Biological Properties of Candida albicans and C. dubliniensis from HIV-

Positive and -Negative Japanese A21T Ohshima*, S Namikoshi, U Yasunari, H Watanabe, N Maeda.

Tomoko Ohshima Organisation, Tsurumi University, Japan

Tomoko Ohshima: [email protected]

Introduction: Candida dubliniensis, which was originally classified as C. albicans, has been implicated in candidasis in

HIV/AIDS patients. However, there is little data on the prevalence of C. albicans and C. dubliniensis in HIV/AIDS patients in Japan.

Objectives: The aims of this study were to investigate the prevalence of C. dubliniensis and C. albicans in the Japanese and to compare the pathogenicity of these species in this population.

Methods: A total of 581 strains were isolated from 65 HIV-positive patients and 1438 HIV-negative controls. They appeared as green colonies on CHROM agar. They were typed as C. albicans A, B or C, or C. dubliniensis genotype D using PCR. In addition growth on Sabouraud's Dextrose Agar at 300C and 420C, carbohydrate assimulation, secreted aspartic proteinases (SAP) production and antifungal sensitivity of C. albicans and C. dubliniensis was assessed.

Results: More than half the isolates typed as A, 10% as B and 20% as genotype C. Genotype D was found in 10% of HIV-positive and HIV-negative subjects except in the Okinawa island area where this genotype formed between 30 to 50% of the strains isolated from HIV-negative subjects. These results showed that C. dubliniensis occurred in both HIV-positive and negative subjects, but varied from 0 to 50% dependent upon the region. The average growth rate of C. dubliniensis on Sabouraud's Dextrose Agar incubated at 30°C was low 0.5 (n=10) compared to C. albicans 0.96 (n=106). The carbohydrate assimilation tests showed no difference between the two species, although up to 75% of strains from HIV-negative subjects showed low levels of xylose assimilation. All strains of C. dubliniensis grew poorly at 42°C suggesting that growth at this temperature could be used to distinguish between the two species. Secreted aspartic proteinases (SAPs) production levels of C. dubliniensis was moderate (relative activity 0.20, n=40) but lower than C. albicans (0.25, n=117). Most C. albicans from HIV-positive patients produced low level of SAPs (0.21, n=6). Contrary to our expectation, susceptibility of C. dubliniensis to antifungal agents was higher than C. albicans (Fluconazole p<0.05; Miconazole p<0.001). C albicans isolates from HIV-positive patients showed high susceptibility especially to the azoles (Fluconazole p<0.0001: Intraconazole p<0.01; Miconazole p<0.01) whereas C. dubliniensis susceptibility was low (Miconazole p<0.01) but not resistant.

Conclusion: C. dubliniensis was less pathogenic than C. albicans. However, C. dubliniensis derived from HIV-positive patients had lower susceptibility to azoles than isolates from HIV-negative subjects. If strains are isolated from HIV-positve patients with candidiasis, inducible resistance must be considered.

In vitro Antifungal Activity of Dodonaea angustifolia, a Traditional South African

Medicinal Plant A22M Patel*, MM Coogan

Oral Microbiology, Oral Health Sciences, University of the Witwatersrand, South Africa

M Patel: [email protected]

Introduction: Oral Candidiasis is one of the most frequently opportunistic infections encountered in patients with HIV infection. Antifungal drugs are often prescribed

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for these patients. However the long-term use of antimycotic agents leads to the development of resistance. This has led to a search for alternative agents. The leaves of an indigenous South African plant Dodonaea angustifolia are used as a traditional remedy for treating oral thrush. Several acids and flavonoids have been isolated from this genus but no direct link has been established between these compounds and the reported beneficial effects.

Objective: This study investigated the antifungal properties of a crude extract of this plant.

Methods: Dodonaea angustifolia leaves were collected, dried, milled and extracted with acetone. The minimal inhibitory concentration (MIC) and percentage kill of the extracts was determined by a microtitre serial dilution technique using C. albicans ATCC 90028 and 20 oral C. albicans strains. Ten strains were isolated from HIV positive Candida carriers and 10 from HIV negative Candida carriers. A chlorhexidine gluconate mouth rinse that is recommended for oral candidiasis was used as a positive control. The MIC was performed in triplicate whereas the percentage kill was tested once on all the strains.

Results: Both the plant extract and chlorhexidine inhibited the growth of all the yeast isolates that were tested. The MIC values for the plant extract ranged from 6.25 to50 mg/ml whereas the range for chlorhexidine was 0.008 to 0.016 mg/ml. A concentration of 50 mg/ml of the crude plant extract killed all the isolates within 45 seconds whereas 2 mg/ml chlorhexidine killed 18 of the 20 isolates within 90 seconds. One of the resistant isolates from a HIV positive patient was killed after 120 seconds and the other from a HIV negative subject required 180 seconds. There was no significant difference between the results of strains isolated from HIV positive and negative patients.

Conclusion: These preliminary results indicate that Dodonaea angustifolia has antifungal properties.

Further research is required to identify the active ingredient and to test the cytotoxicity of the plant extract.

A24Antifungal Activity of Potassium

Lawsone Methyl Ether Mouthwash in Comparison with Chlorhexidine Mouthwash on Oral Candida Isolated from HIV/AIDS Subjects

A23J Prasirst1, T Leewatthanakorn1, U Piamsawad1, A Dejrudee1, P Panichayupakaranant2, R Teanpaisan1, W Nittayananta*

1Faculties of Dentistry, 2Pharmaceutical Sciences, Prince of Songkla University, Thailand

Nittayananta: [email protected]

Background: Lawsone methyl ether (2-methoxy-1,4- naphthoquinone) was first isolated from the dried flowers of Impatiens balsamina L and from the Gentianaceae family. It exhibits potent antifungal activity without obvious side effects. However, the activity of lawsone methyl ether on Candida albicans isolated from HIV/AIDS subjects has never been studied.

Objective: To determine the antifungal activity of 0.5% potassium lawsone methyl ether mouthwash compared with that of 0.12% and 0.2% chlorhexidine mouthwash on Candida albicans isolated from HIV/AIDS subjects.

Methods: An inoculum of Candida albicans isolated from 51 HIV/AIDS subjects was prepared and adjusted with 0.5 McFarland standard. 0.5 ml of the adjusted inoculum was added in four test tubes with 0.5 ml of each mouthwash, and 0.5 ml RPMI as a control. The tubes were then incubated at 37ºC for 48 h. The turbidity of each tube was compared with that of the control. The number of Candida albicans colonies was determined by culture with 100 l of the solution from each tube. Data were analyzed with one-way ANOVA.

Results: All of the test tubes with 0.5% potassium lawsone methyl ether, 0.12%, and 0.2% chlorhexidine mouthwash were clear compared with the controls. Positive culture of Candida albicans was observed in 13 out of 51 plates (25.4%) of 0.12% chlorhexidine mouthwash, 5 of 51 plates (9.8%) of 0.2% chlorhexidine mouthwash, and 4 of 51 plates (7.8%) of 0.5% potassium lawsone methyl ether. The mean number of Candida albicans colonies for each mouthwash were 3.08 (range 0-40), 0.35 (range 0-13) and 0.84 (range 0-24), respectively. Antifungal activity was found to be statistically significant different between 0.5% potassium lawsone methyl ether and 0.12% chlorhexidine mouthwash, and between the two concentrations of chlorhexidine mouthwash (p<0.05). However, no significant difference was observed between the antifungal activity of 0.5% potassium lawsone methyl ether and 0.2% chlorhexidine mouthwash (P>0.05).

Conclusions: Potassium lawsone methyl ether showed potent antifungal activity against Candida albicans isolated from HIV/AIDS subjects. Clinical trials of this mouthwash should be conducted to determine if it can be used as an alternative mouthwash in prophylaxis of oral candidiasis among HIV-infected individuals.

A Longitudinal Evaluation of Oropharyngeal Candidiasis in a Cohort of HIV Positive Patients Attending a Dedicated Clinic in New Orleans

K Shetty*, J Leigh

Department of General Dentistry, Louisiana State University Health Sciences Center, New Orleans, USA

K Shetty: [email protected]

Background: The most common oral opportunistic infection (OI) studied in HIV-positive individuals, whether pre or post HAART (Highly Active Antiretroviral Therapy) is oropharyngeal candidiasis (OPC). OPC is often one of the first clinical signs of underlying HIV infection and will occur in up to 90% of all HIV-positive persons sometimes during progression to AIDS.

Purpose: Our purpose was to conduct a longitudinal investigation into the prevalence and biological profile of OPC in a cohort of HIV-positive patients attending a dedicated HIV Dental Clinic in New Orleans from 1998 to 2004.

Study Design: Specialists in oral medicine using established presumptive clinical criteria for OPC examined 264 infected adults, who were recruited consecutively. Data included responses to a questionnaire, clinical examination

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and a histological examination of the biopsied tissue on every single presentation of oropharyngeal candidiasis.

Results: The prevalence of OPC decreased significantly in patients receiving dual- or triple-therapy HAART regimens, which included a protease inhibitor (PI) compared to patients not receiving HAART (p<0.05). There was a higher incidence (n=35) of pseudomembranous OPC among the female patients who had an infrequent history of vulvovaginal candidiasis. However there was a significant difference in the recovery of candidal infections amongst patients with a low CD4+ count on a HAART regimen which included a PI (p<0.05).

Conclusion: The pattern of OPC is changing in the era of HAART therapy. OPC still remains the most common OI in the HIV-positive person and there appears to be several levels of immune defenses against OPC. The full potential for anti-fungal therapy with PI has, however, yet to be evaluated directly, and such studies are now critical in assessing the usefulness of these agents in isolation or as part of combined therapy regimens.

PERIODONTAL DISEASE AND GINGIVITISA26

The Burden of Necrotising Ulcerative

Gingivitis and Periodontitis among Adult Patients Attending a Sexually Transmitted Infection Clinic in Johannesburg

A25SR Mtetwa*, J Yengopal, MJ Rudolph

Division of Public Oral Health, University of the Witwatersrand, Johannesburg, South Africa

S Mtetwa: [email protected]

Background: Necrotising ulcerative gingivitis (NUG) has been identified as the most common oral manifestation of HIV/AIDS seen by public sector dentists in South Africa (S A Dent J, 54: 594, 1999). Testing for HIV sero-status in adult patients is not undertaken routinely at Public Sector Clinics in Johannesburg. Esselen Street clinic, which is a sexually transmitted infections (STI) clinic based in Hillbrow, Johannesburg, provides an ideal environment to study the prevalence of this condition among HIV infected adult patients, many of whom do not know their HIV status. The patients were not self-selected for painful oral disease.

Objectives: The objectives of the study were To measure the prevalence of NUG and

Necrotising Ulcerative Periodontitis (NUP) in a STI clinic

To correlate the HIV status with NUG and NUP in patients with a positive diagnosis for NUG and NUP.

Methods: One hundred and sixty five patients whose average age was 28.8 years (range 19 to 48 years) were recruited between 25 November 2003 and 9 March 2004. A questionnaire was administered to obtain demographic details and medical and dental information and the patients

were assessed clinically to establish the absence or presence of NUG and NUP. Patients who were taking antiretrovirals, those with advanced HIV disease and those who were taking Cotrimoxazole were excluded from the study. Clinic records were checked for information on HIV status. One hundred patients were HIV negative and 56 were positive. The diagnostic criteria for HIV associated periodontal diseases of the EC-Clearinghouse (J Oral Pathol Med, 22: 289, 1993) were used to diagnose NUG and NUP. The diagnostic features of NUG included ulceration, necrosis and sloughing of one or more interdental papillae and spontaneous bleeding. Tissue destruction was limited to the gingival tissues and did not involve alveolar bone. NUP was characterized by advanced necrotic destruction of the periodontium. There was a rapid loss of the periodontal attachment, destruction or sequestration of bone, and teeth became loose. It was accompanied by severe pain and halitosis was evident.

Results: The prevalence of NUG and NUP at this clinic was 1.8 (3/165). One of the 56 HIV positive patients had NUG and NUP and two of the 109 HIV negative patients had a positive diagnosis for NUG.

Conclusion: The correlation of the HIV status with NUG and NUP in patients not self-selected for painful oral disease was weak in this setting.

Oral and Periodontal Lesions in 1700 HIV Positive Patients in South India

M Umadevi*1, K Ranganathan1, TR Saraswathi1, N Kumaraswamy2, NW Johnson3, S Solomon2

1Department of Oral Pathology, Ragas Dental College and Hospital and 2YRG CARE, VHS Hospital, Chennai, India, 3Department of Oral and Maxillofacial Medicine and Pathology, Guy’s, King’s & St Thomas Dental Institute, London, UK

M Umadevi:

Background: India is estimated to have about 4.5 million people infected with HIV. Oral lesions are common and indicative of HIV infection. Periodontal lesions form an important part of the constellation of oral manifestations in HIV positive patients. There are very few reports of oral lesions, which describe the periodontal lesions from India.

Objectives and setting: This report describes the oral lesions and periodontal lesions in particular, in 1700 HIV positive patients presenting to us at RAGAS and YRG CARE, a non governmental organization in Chennai, South India since February 1998.

Methods: Clinical diagnosis of oral lesions was based on the criteria of EC Clearing House, 1993 and WHO. The simplified Oral Hygiene index (OHI-S) and Community Periodontal Index For Treatment Needs (CPITN) was recorded as described in WHO reference and reviewed by Page and Morrison, 1994.

Results: Of the 1700 patients, there were 1251 (74%) males and 449 (26%) females. The age ranged from 7 months to 72 years. 83% of the patients were in the 21 to 40 year age group. 83% of the patients presented with at least one oral lesion. Gingivitis (69%) was the most common lesion followed by periodontitis (28%) and candidiasis (21%). 44% of patients with periodontitis were smokers.

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Periodontitis was highly associated with smoking, being 1.6 times more frequent in patients who smoke than in non-smokers (p<0.01). Patients with candidiasis were 1.7 times more likely to have periodontitis than patients without candidiasis (p<0.01). CD4 counts were available for 1070 patients of which 454 patients had CD4 counts <200 and 616 had CD4 counts >200. There was a statistically significant difference in the occurrence of candidiasis, gingivitis and periodontitis between these two groups (p<0.05).

Conclusions: Oral lesions are a feature of HIV infection. Gingivitis and periodontitis were the most common oral lesions in our study. Further studies are necessary to understand the importance of periodontitis in HIV patients in our population.

HAART THERAPY AND ORAL LESIONS

The Changing Face of Oral Lesions in

HIV/AIDS Patients Undergoing Highly Active Antiretroviral Treatment

A27K Shetty*, J Leigh

LSU Health Sciences Center, New Orleans, USA

K Shetty: [email protected]

Background: Human Immunodeficiency Virus (HIV) infection is associated with oral manifestations of diagnostic and prognostic importance. With the advent of Highly Active Anti-retroviral Therapy (HAART) there is anecdotal evidence to suggest that the prevalence of oral lesions has declined. The number of prevalence studies, carried out in the era of HAART is, however, meagre.

Purpose: The purpose of this study was to determine temporal trends in the prevalence of oral manifestations of human immunodeficiency virus (HIV) in a patient population predominantly on HAART, attending a dedicated HIV Dental Clinic in New Orleans.

Study Design: Specialists in oral medicine using established presumptive clinical criteria for HIV-associated oral lesions examined five hundred and seventy HIV-infected adults recruited consecutively.

Results: Overall prevalence of oral lesions (35.7%) significantly decreased from early to late periods with some variation by lesion type. Oral candidiasis was the most common oral soft tissue lesion (58.5%) with a striking increase in the erythematous variety. Prevalence of hairy leukoplakia, Kaposi’s sarcoma and necrotizing periodontal diseases decreased significantly (p<0.05). There was an increase in salivary-gland disease (14.3%) and a striking increase in warts: three-fold for patients on antiretroviral therapy (n=14) and six-fold for those on HAART (n=28).

Conclusion: The pattern of oral opportunistic infections is changing in the era of HAART therapy. This pattern of oral disease suggests that an increase in oral warts could be occurring as a result of the immune reconstitution of patients on HAART.

BASIC SCIENCEVIRUSES: INTERACTION AND EXPRESSION IN HIV DISEASE

Human Papillomavirus (HPV) Type 32 Specific Serum IgG Response in HIV-Infected AdultsA28

JE Cameron*1,4, JE Leigh2,4, K Shetty2,4, N Lindsey3,4, E Lilly1,4, PL Fidel1,4, ME Hagensee3,4

1Department Microbiology, Immunology & Parasitology, 2General Dentistry, 3Medicine, 4 Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center, New Orleans, LA, USA

JE Cameron: [email protected]

The incidence of oral warts has reportedly increased in HIV-infected patients during the era of HAART. We have identified HPV-32 as the primary cause of oral warts in the New Orleans HIV cohort. In order to examine defects in the host response to HPV-32, we cloned and expressed the HPV-32 L1 major capsid gene into the vaccinia virus system to use as antigen in HPV-32 specific immunological assays. Serum from 7 case patients (HIV+, with oral warts) and 50 screening patients (HIV+, without oral warts) was tested by enzyme-linked immunosorbent assay (ELISA) for HPV-32 specific IgG antibodies. HPV-32 specific responses were observed in 4/5 cases with HPV-32+ oral warts and in 48% of screening patients, but not in patients with oral warts containing other HPV genotypes. Two out of three screening patients with asymptomatic oral HPV-32 infection seroreacted to HPV-32 capsid antigen. Responses were more frequently detected in men, reflecting the demographics of patients with oral warts in the New Orleans HIV cohort. Future studies will utilize HPV-32 capsids as antigen in ELISA and cellular immune assays to examine peripheral and mucosal responses to HPV-32 infections, in order to identify markers of susceptibility to HPV-32 associated disease.

Local Immune Reactivity in Oral Warts and Oral

Hairy Leukoplakia of HIV-infected Persons

A29E Lilly, K Shetty, K Mcnulty, JE Leigh, JE Cameron, ME Hagensee, PL Fidel*

Louisiana State University Health Sciences Center and Center of Excellence in Oral and Craniofacial Biology, New Orleans, LA 70112 USA

P Fidel: [email protected]

Background: Oral hairy leukoplakia (OHL) caused by Epstein Barr virus and oral warts caused by human papillomavirus (HPV) are common infections in HIV-infected persons. Although each pathological condition occurs most often under reduced blood CD4 cell numbers, the lack of concurrent pathologies suggests that each results from unique local immune dysfunction(s).

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Objective: To evaluate local immune reactivity in oral warts and OHL through salivary cytokines and tissue-associated T cells and cytokine mRNA.

Methods: A cohort of HIV+ persons (n=48) with and without oral warts and OHL were evaluated. Salivary Th and proinflammatory cytokines were quantified in unstimulated saliva by ELISA. CD3, CD4, and CD8 T cells were identified by immunohistochemical staining of frozen tissue biopsies. Tissue-associated cytokine mRNA was evaluated by real-time PCR.

Results: Few differences were detected in any parameter. Compared to matched controls (HIV+ persons without lesions but positive for oral HPV or EBV DNA), those with OHL had increased IL-1, IL-2 and IL-10 in saliva, while those with oral warts had increased IL-1, IL-2 and decreased IL-6. CD8 T cells predominated in the tissue but in low numbers. No differences were detected between warts and lesion negative sites, while CD8 T cells were greater in lesion negative sites compared to OHL. Tissue-associated cytokine mRNA between lesion positive and lesion negative persons showed decreased IL-2 and increased TNF in those with warts, and decreased IL-1 and increased IL-6 and IL-15 in those with OHL

Conclusion: There is no pattern of changes in local immunity to explain the susceptibility to oral

warts and OHL, and overall little evidence for local immune reactivity in either lesion. It is anticipated that while immunosuppression plays an indirect role in susceptibility to infection, virologic factors are most critical to prevalence.

A31

Detailed History of HIV+ Individuals with Oral Warts Reveals the Possibility of Two

Epidemics A30ME Hagensee*, JE Cameron, JE Leigh, K Shetty, N Lindsey, P Hickman, E Lilly, PL Fidel

Louisiana State University Health Sciences Center, New Orleans, LA, USA

ME Hagensee: [email protected]

Background: It has been reported that oral warts have increased in prevalence in HIV+ individuals. To better understan this, a detailed chart history of HIV+ individuals from New Orleans with oral warts was performed.

Methods: The medical record of individuals with biopsy-confirmed oral wart was reviewed for the initial date of diagnosis of the oral lesion, any history of anal, hand warts or other HPV-related pathology, detailed history of HAART and its effectiveness and all CD4 and HIV viral load (VL) measurements. The HPV infection was genotyped by consensus PCR.

Results: Charts from 13 patients with oral warts were reviewed, comprising 819 months of care. There were 12 men, 9 were Caucasian, with an average CD4 of 256 and HIV VL of 10,683 at the time of oral wart diagnosis. HPV-32 was present in 63%. Ten were on HAART but only 5 being effective (HIV VL <400). There was evidence of 2 distinct groups: chronic - 6 men, with a long history of oral warts (8-37 months) and also having anal or hand warts, and acute - 6 men w

ith a short history of oral warts (2-15 months) and rare history of other warts. The chronic group had largely uncontrolled HIV infection (5/6 had detectable HIV VL, with frequent therapeutic changes). In contrast, the acute group had largely controlled HIV infection (1/6 had detectable HIV VL with more stable regimens). Both groups had similar average CD4 counts (245 vs. 248). The only woman had an oral wart for a short duration (2 months) but developed invasive cervical cancer 12 months later.

Discussion: Detailed histories of HIV+ individuals with oral warts reveal two epidemics in the New Orleans cohort. The chronic cases indicate a generalized susceptibility to HPV infections at any body site. The acute cases may reflect temporary changes in HPV-specific immune function, interactions with HIV medications or other changes in oral health. Future studies are indicated to better understand these clinical findings.

Site-specific Prevalence of 27 Human Papillomavirus (HPV) Genotypes in the Oral Cavity of HIV+ Individuals

N Lindsey*, JE Cameron, AF Hammons, TE Beckel, K Shetty, JE Leigh, JR Kornegay, ME Hagensee

Louisiana State University Health Sciences Center, New Orleans, LA and Roche Molecular Systems, USA

N Lindsey: [email protected]

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 site was undertaken. We are examining the prevalence of 27 genotypes using sensitive consensus PCR-based detection on DNA obtained from nine oral samples (buccal mucosa, labia, tongue, sublingual mucosa, palate, gingival, tonsils, saliva and gargle) in HIV+ subjects who have no oral warts. To date, over 300 people have been enrolled with 148 subjects having all sites screened for HPV. HPV was most prevalent in gingival (32%) and labial (29%) tissue, though all sites were susceptible. HPV+ subjects (54%) harbored HPV at anywhere from one site to all sites tested. Genotyping by Roche reverse line blot identified HPV-83 and 45 as the most prevalent genotypes. There was no apparent site-predilection associated with any genotype. Subjects with multiple HPV+ sites frequently carried the same genotypes in each site. 27% of HPV infections were untypable. The ongoing development of a rapid screening test for additional oral-specific HPV genotypes will help identify these untypable samples and promote studies of the natural history of oral HPV infection/disease in susceptible hosts.

Cytomegalovirus Co-infection in AIDS

associated Oral Kaposi’s SarcomaA32

S Meer1, M Altini1, CC Rachanis*2, H Ali1, and H Coleman1

Division of Oral Pathology1, and Oral Medicine & Periodontology2, University of the Witwatersrand, Johannesburg, South Africa

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CC Rachanis: [email protected]

Introduction: In contrast to developed countries, in South Africa we are currently experiencing an ever-increasing frequency in the number of cases of AIDS associated oral Kaposi’s sarcoma (KS). This may be ascribed to the later start of the HIV epidemic in Africa, to the fact that a greater proportion of patients is now reaching stages III and IV of the disease and to the fact that the vast majority of patients do not have access to HAART.

Objective: The aim of this investigation was to demonstrate cytomegalovirus (CMV) co-infection in oral KS and to consider its possible significance.

Methods: Twenty cases of oral KS were retrieved from the files of the Division of Oral Pathology at the University of the Witwatersrand. In all cases the patients had tested positive for HIV, but their CD4 counts were not known. As far as we know none of the patients had signs of active CMV disease. DNA was extracted from paraffin wax embedded tissue blocks using a modified phenol chloroform method and amplified using 2 rounds of PCR which yielded amplified DNA of 233 base pairs. HHV8 DNA sequences were identified using gel electrophoresis stained with ethidium bromide. In each case additional 4-μm sections were cut and immunohistochemically stained after antigen retrieval with pepsin, using the strep avidin-biotin-complex method (Dako) and CMV antiserum (Zymed, Clone DDG4, CCH2). Appropriate positive and negative controls were used throughout. The results showed the presence of HHV8 DNA sequences in all cases (20/20).

Results: CMV inclusion bodies were detected in 5 cases (5/20) appearing as enlarged cells with an

“owl’s eye” appearance. The inclusions occurred in either macrophages or endothelial cells or both. These findings do not represent the true frequency of CMV co-infection as the sample was biased. CMV infection in adult populations is very common, but although the virus is shed in many body secretions including saliva, it usually does not cause any disease. It is, however, a major source of morbidity and mortality in AIDS patients where multifocal sites of infection have been demonstrated. In the oral cavity CMV infection has been demonstrated in persistent oral ulcers in AIDS patients (35% to 53%). CMV has also been previously demonstrated in KS and is apparently frequently demonstrated using EM.

A34

Conclusion: In conclusion, the question can be asked as to what the possible significance of this not infrequent CMV co-infection in oral KS might be. The presence of inclusion bodies suggests an active infection rather than a passenger status, although there is no new evidence to support a role for CMV in the pathogenesis of KS. Is it a chance occurrence in line with widespread tissue infection? Does the KS lesional tissue provide a suitable nidus for viral replication? Is there possibly virus transactivation, or can the KS tissue act as a reservoir for CMV facilitating spread to other sites as immuno-suppression worsens? These and other questions remain to be answered.

SALIVA, BREAST MILK AND MUCOSAL FLUIDS IN HIV TRANSMISSION

HIV Antibody Screening; Saliva an Alternative to

SerumA33

S Balasundaram*

Ragas Dental College, Chenai, India

S Balasundaram: [email protected]

Background: HIV infectiion is a major health issue in India with 4-5 million people infected by the end of 2003 (National AIDS Control Organisation). Given the high burden of HIV infection relaible, rapid screening procedures are needed, Studies have shown that saliva has the potential to be a reliable alternative to blood as a diagnostic fluid. We present here the results, of two serum based screening tests available in India, for saliva.

Methods: A case control study (25 seropositive and 25 seronegative) was undertaken on patients attending the outpatients unit of Ragas Dental college and Hospital and YRG CARE Chennai; India. Saliva was collected by the 'spit-method'. Salivary antibodies to HIV were investigated using ELISA and the immuno-chromatographic test (IHC). The ELISA values were analyzed using the cut off prescribed by the manufacturer for the serum test. The IHC was modified to evaluate the colour change.

Results: Our study shows a sensitivity and specificity of 100% for the ELISA method, whereas the IHC procedure demonstrated a sensitivity of 80% and specificity of 100%.

Conclusion: The result of this study showed a sensitivity and specificity of 100% for the ELISA method, using a commercially available serum based kit. If similar results can be obtained with a larger number of patients this test could be a reliable and easy diagnostic aid in population-based screening procedures.

A Study of Salivary Flow Rate, Subjective Symptoms of Dry Mouth and Secretory IgA Levels in HIV Seropositive Patients in Chennai, South India

B Kavitha*, TR Saraswathi, MU Devi, A Bharadwaj, S Solomon, M Kumaraswamy, N Johnson, K Ranganathan

Ragas Dental College & Hospital, Chennai, India

B Kavita: [email protected]

Background: Xerostomia is classified as a lesion less commonly seen in HTV infection (EC Clearing house classification, Group 2). Xerostomia has been frequently considered synonymous to impaired salivary flow. However, it only describes the subjective complaints of dry mouth and may occur despite normal salivary gland function. The role of secretory IgA in saliva has been discussed varyingly in literature.

Methods: The study group comprised of 50 randomly selected HIV seropositive patients attending the out patient department of Ragas - YRG CARE and 50 HIV seronegative patient attending outpatient department of Ragas Dental College & Hospital. A xerostomia questionnaire was developed, and subjective symptoms of dry mouth recorded for each patient and analyzed. Saliva

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was collected using the spit method. Secretory IgA was estimated using radial immunodiffusion assay.

Results: There was a decreased unstimulated and stimulated salivary flow rate and increased perception of dry mouth in HIV sero-positive patients. Salivary secretory IgA concentration did not show any correlation with salivary flow rate. However there was a direct correlation between CD4 cell counts and salivary secretory IgA levels. There was no significant correlation between salivary secretory IgA and the presence of oral lesions.

Conclusion: Xerostomia is a major problem in HIC infection. Analysis of subjective symptoms should be undertaken along with salivary flow rate estimation to improve the management of xerostomia patients in clinical practice.

A36A35 Elevation of Salivary Antimicrobial Protein Concentrations Against Increase of Candida Depending on CD4+ Count in HIV-Positives

S Namikoshi*1, T Ohshima2, H Chiba1, N Maeda1

1Department of Oral and Maxillofacial Surgery, Tokyo Medical University, 2Dept of Opal Bacteriology, Tsurumi University School of Dental Medicine

S Namikoshi: [email protected]

An opportunistic infection, oral candidiasis, frequently occurs among human immunodeficiency virus (HIV)-positive individuals as an initial symptom in the oral cavity, particularly in individuals with less than 200/µl of CD4+ count. However, many antimicrobial proteins such as secretory leukocyte protease inhibitor (SLPI), lactoferrin, lysozyme and sIgA exist in saliva. These proteins play an important role in maintaining oral mucosal integrity. The relationship between salivary antimicrobial proteins and Candida carriage in both HIV-positive patients and healthy controls was investigated. A sample was obtained from the dorsum of the tongue and inoculated onto a selective medium for Candida, CHROMagarTM Candida (CHROMagar, Paris, France) and incubated at 300C for 48 hours. For measurement of antimicrobial proteins, stimulated whole saliva was collected using Salivette® (Sarstedt, Köln, Germany) by chewing sterile cotton wool according to the manufacture’s instruction. The concentrations of SLPI, lactoferrin and sIgA were determined by enzyme-linked immuno-sorbent assay using commercially available kits (SLPI:Quantikine®, R&D Systems, Minneapolis, MN, USA, lactoferrin:Bioxytech®, OXIS, Portland, OR, USA, sIgA:EIA s-IgA test®, MBL, Nagoya, Japan). The concentration of lysozyme was determined by a decrease in the turbidity of a Micrococcus lysodeikticus suspension. Candida carriage in the HIV group was significantly higher than the healthy control, and increased in inverse proportion to the CD4+ count. When compared to the controls, the level of SLPI in the HIV group was significantly lower, whereas sIgA was higher. The levels of lactoferrin and lysozyme in both groups were

similar. Contrary to our expectation, most antimicrobial proteins were higher in Candida-positives than negatives. All pairs of antimicrobial proteins showed significantly positive correlation. These results suggested that salivary antimicrobial proteins are elevated in reaction to the increase of Candida. When compared among HIV-positive patients who were divided into three categories based on CDC classification, most antimicrobial proteins were the lowest in category 3, suggesting the suppression of innate immunity in HIV-positive patients whose CD4+ were less than 200/µl. These results indicated the salivary antimicrobial proteins are important factors for protection against several infections including oral candidiasis. However their level was suppressed in advanced cases of HIVinfection.

Identifying Viral Characteristics Responsible for Oral Transmission of SIV through Breast Milk in Rhesus Monkeys

J Rychert1, L Fresh2, M Ratterree2, AM Amedee*1

1Louisiana State University Health Sciences Center, New Orleans, LA, USA, 2Tulane National Primate Center, Covington, LA, USA

A Amedee:

Background: Several risk factors have been identified for breast milk transmission of HIV; however, little is known about the specific viral properties responsible. Using SIV-infected lactating rhesus macaques as a model, we have shown that specific viral genotypes are transmitted, and that the level of virus expressed in milk is the most significant correlate of transmission.

Objective: The goal of this study was to characterize orally transmitted viral genotypes and evaluate the dynamics of this viral phenotype in naïve lactating macaques.

Methods: Viral envelope sequences from ten breast milk infected infants were compared with the original virus inoculum and genotypes expressed in milk. For in vivo characterization, virus was amplified from one infected infant (Macaque CK35) and used to inoculate six naïve lactating macaques.

Results: SIV envelope sequences from infants infected through breastfeeding only differed from each other and the parental virus stock over the envelope variable regions 1 and 4 (V1 and V4). Using pair wise comparisons, sequences from infants were significantly longer over the V1 sequences found in the parental stock or the milk of non-transmitting mothers, and contained more potential glycosylation sites. Naïve lactating macaques inoculated with SIV/CK35 had peak levels of milk virus similar to animals inoculated with the parental strain, but expression was more persistent. Transmission occurred rapidly in 4 of 6 mother-baby pairs infected with SIV-CK35, while rapid

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transmission was only observed in 2 of 14 mothers infected with the parental virus.

Conclusion: These results indicate that specific viral genotypes are more persistently expressed in milk, and are capable of oral transmission through milk. As interventions for breast milk transmission of HIV are designed, the SIV/CK35 isolate provides a valuable tool for targeting and deciphering the specific viral properties responsible for transmission.

Immunoglobulin A (IgA) Levels in the Oral Cavity and Respiratory Tract of HIV+ Individuals Treated with Highly Active Antiretroviral Therapy (HAAR)

P Chaiyarit*,1, HL Twigg III2, RL Gregory2

1Faculty of Dentistry, Khon Kaen University, Thailand 2Indiana University School of Medicine, Indianapolis, USA

P Chaiyarit: [email protected]

In HIV+ individuals, depletion of CD4+ T cells is associated with a loss of immune function, and the mucosa becomes susceptible to various opportunistic infections. Recent studies demonstrated that HAART increased circulating CD4+ T cells. However, limited data are available on the effect of HAART on mucosal immune responses. Thus, the objective of this study was to measure the mucosal IgA levels in the oral cavities and respiratory tracts of HIV+ individuals treated with HAART in order to provide additional evidence for the effect of HAART on the mucosal humoral immune responses. Mucosal IgA levels including IgA, IgA1, IgA2, secretory IgA (S-IgA), S-IgA1, and S-IgA2 collected from parotid saliva (PS), bronchial fluid (BF) and bronchoalveolar lavage (BAL) of HIV+ individuals were measured by enzyme-linked immunosorbent assay (ELISA). A total of 36 human subjects were recruited for this research, including 16 HIV- subjects, 12 HIV+ patients with HAART and 8 HIV+ patients without HAART. One-way analysis of variance (ANOVA) was used to compare the mucosal IgA levels among groups. There were significantly lower levels of PS IgA in HIV+ with HAART and HIV+ without HAART subjects than in HIV- subjects (p<0.05). However, total BF IgA levels from both HIV+ with HAART and HIV+ without HAART subjects were significantly increased. BAL IgA1 and S-IgA1 levels were significantly increased,

whereas BAL IgA, and S-IgA2 levels were decreased in HIV+ subjects. In summary, our findings demonstrated no significant differences of mucosal IgA levels in the oral cavity and respiratory tract of HIV+ individuals with HAART and without HAART, but there were significant effects between HIV+ and HIV- subjects.

EPITHELIAL AND NON-SPECIFIC HOST FACTORS

HIV-1 and C. albicans Regulate Expression of

Calprotectin (S100A8/A9) in Tonsillar Epithelial Cells

A37A Tangjaturonrusamee*, M Herzberg, K Ross

University of Minnesota, USA

A Tangjaturonrusamee: [email protected]

Candidiasis is a major problem in HIV-positive patients. This may relate to the increase of Candida virulence or the reduction of host defense to microbial invasion in HIV-positive patients. Calprotectin (S100A8/S100A9; MRP8/14) is an antimicrobial cytosolic protein expressed by gingival keratinocytes and tonsillar epithelial cells. Cytosol from calprotectin expressing cells contains antifungal activity. We hypothesize that calprotectin is down regulated during HIV infection leading to a reduction of the antimicrobial activity of oral epithelial cells. Tonsillar epithelial cells were tested by flow cytometry to demonstrate HIV receptors on the surface. The surfaces were negative for chemokine receptors CXCR4 and CCR5. Heparin sulphate receptors CD3, CD138, LFA-1, CD4, DC-SIGN, CD64, CD89 and CD32 were also negative but the beta-4 integrin CD104 was found on 91% of cells. Thereafter primary tonsillar epithelial cells grown in monolayer were incubated with either C..albicans (MOI 100:1) or HIV-1, IIIB or Ba-L, (MOI 1:10) for 2 hours. Viral uptake in epithelial cells and transfer to Peripheral blood mononuclear cells (PBMCs) were observed. Total RNA was extracted using TRIZOL. Expression of mRNA was analyzed by Real time RCP using TaqMan probes from Applied Biosystems for S100A8, S100A9 and TBP (Tatabox Binding Protein; endogenous control) and compared to expression of S100A8 and A9 in tonsillar epithelial cells alone. S100A8- and S100A9-specific mRNA was upregulated 8- and 29-fold respectively when cells were incubated with C..albicans. Tonsil cells incubated with HIV-1, either IIIB or Ba-L, showed a decrease in S100A8- (IIIB, 0.03 fold; Ba-L, 0.3 fold) and S100A9- (IIIB, 0.08 fold; Ba-L, 0.12 fold). In conclusion, this data shows that tonsillar epithelial cells respond to HIV-1 and C..albicans by a decrease or increase in S100A8- and A9-specific mRNA. Down regulation of calprotectin by HIV-1 may play a role in candidia infection of oral epithelial cells.

A38

Innate Host Defense in Oral Mucosal Resistance to HIV-1

T Greenwell-Wild*, G Ma, W Jin, KJ Lei, J Swisher, G Peng, SM Wahl

OIIB, NIDCR, NIH, Bethesda, MD 20892-4352, USA

T Greenwell-Wild:

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Background: Mucosal sites are vulnerable targets for HIV-1 transmission. Nonetheless, in the oral mucosa, transmission is infrequent, and although HIV-1 RNA is detected, identification of infectious virus is rare. Our earlier studies comparing innate and adaptive immune factors that might contribute to resistance revealed that components of the adaptive immune response were not discriminatory between oral and genital mucosa and blood, but differences could be detected in innate host defense molecules. Neither the levels of HIV-1 specific IgA nor IgG correlated with the inhibition of infectious HIV-1 since Ig titers were highest in blood where infectious virus was highest. Levels of the innate inhibitor, thrombospondin, did not correspond with reductions in infectious virus. By comparison, secretory leukocyte protease inhibitor (SLPI) was highest in the oral cavity where infectious HIV-1 was undetectable and lowest in peripheral blood in which infectious virus was maximal. While SLPI has been shown to inhibit HIV-1 in vitro and the distribution of SLPI at entry portals portends its involvement in defending the host from pathogens, the mechanism by which it inhibits HIV-1 has remained enigmatic.

Objectives: To define the mechanisms by which mucosally-derived SLPI influences HIV-1 infection, particularly in macrophages, which are involved in initial viral selection, dissemination and transmission of virus to CD4+ T cells and serve as long term covert reservoirs of HIV-1.

Methods: M-tropic HIV-1 was added to macrophage cultures in the presence or absence of SLPI and infection monitored by p24 levels. Membrane SLPI binding proteins were isolated by gel electrophoresis, followed by mass spectrometry and sequence analysis. The expression of the membrane binding proteins was monitored by RNA and protein analysis, including fluorescence microscopy and flow cytometry.

Results: SLPI inhibited viral infection by interaction with the host cell, rather than the virus, and blocked infection at an early stage in the viral life cycle. Isolation of membrane SLPI binding proteins revealed several candidates, including a phospholipid binding protein, characterized by immunological parameters and binding specificity. SLPI did not block HIV-1 binding, but rather inhibited post-binding and pre-reverse transcription, a point in the viral life cycle consistent with a proposed role for SLPI in inhibition of a fusogenic step.

Conclusions: Macrophages represent an important anti-viral target due to their involvement in viral selection, dissemination and transmission of HIV-1 and their ability to serve as viral reservoirs. Particularly evident is the enormous viral burden in macrophages in the later stage HIV-1/AIDS during opportunistic infections. Identification of a SLPI membrane binding protein provides new insight into its mechanism of action and reveals a new cellular cofactor supporting macrophage HIV-1 infection. These data suggest that innate host defense mediators present in the mucosa may influence HIV-1 infection and/or transmission, providing insight into potential interventional approaches.

A39A40

Permissive Factors Underlying HIV-1 Infection in the Tonsil

NM Moutsopoulos*1, T Greenwell-Wild2, N Vazquez2, J Orenstein1, SM Wahl2

1Oral Infection and Immunity, NIDCR, NIH, Bethesda, MD, 2Department of Pathology, GW University, Washington D.C.

N Moutsopoulos:

Background: The tonsils represent secondary lymphoid organs implicated in all stages of HIV-1 pathogenesis. Shortly after HIV-1 infection occurs, the tonsils become heavily infected both in the germinal center areas and in the region of the lymphoepithelium. Although it is still debated whether the tonsils are a primary, as well as secondary site of infection, it is clear that they are highly susceptible to infection and viral replication.

Objectives: To dissect the cellular and molecular mechanisms underlying the enhanced susceptibility of tonsils to HIV-1 infection in vivo and in vitro.

Methods: Tonsil tissues from HIV-1 infected and uninfected individuals were subjected to cDNA expression array and compared with peripheral blood mononuclear cells (PBMC). Gene expression profiles were confirmed through RNAse protection assays (RPA) and electrophoretic mobility shift assays (EMSA). Immunohistochemical staining of infected and uninfected tissues was performed to identify populations associated with disease pathogenesis. Additionally, in vitro infection of tonsil lymphoid cells was performed in parallel with PBMC in order to define mechanisms of susceptibility implicated in the cDNA array analysis.

Results: Compared to PBMC, a number of genes were differentially expressed in uninfected tonsils, including genes involved in signal transduction, cell cycle and transcription. Evidence for increased gene expression of the TH2 cytokines, IL-4, IL-10 and IL-6, and the transcription factor NFATc in the tonsil tissues was consistent with endogenous stimulation. In the tonsils from HIV-1 seropositive patients, an increased expression of genes encoding for antiviral, apoptotic and extracellular matrix degradation factors was observed. Additionally, immunoregulatory genes, including the cytokines IL-10 and TGF- were upregulated. Analysis of in vitro infection of tonsil lymphoid cells revealed enhanced viral susceptibility consistent with the HIV-1 localization in vivo. Furthermore, altered cytokine profiles in vitro reflected their tissue expression.

Conclusions: Persistent underlying immune stimulation in HIV-1 uninfected tonsils is consistent with their enhanced susceptibility to infection and increased viral production. Similarly, the gene profile in HIV-1+ tissues may reflect unsuccessful immune clearance of the virus, which ultimately leads to immune deterioration and local tissue destruction. Furthermore, the presence of immunosuppressive factors may contribute to this ineffective antiviral response, which may suggest potential therapeutic options, as well as furthering our understanding of mechanisms of immune regulation.

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Oral Epithelial Cell Anti-Candida Activity – Evidence Against a Presumtive Role for Carbohydrate

J Yano*, E Lilly, PL Fidel

Louisiana State University Health Sciences Center and Center of Excellence in Oral and Craniofacial Biology, New Orleans, LA

J Yano: [email protected]

Background: Host defense against oropharyngeal candidiasis (OPC) caused by the mucosal commensal organism, Candida albicans, is poorly understood. While cell-mediated immunity (CMI) by Th1-type CD4+ T cells is considered a critical host defense mechanism against OPC, innate mechanisms are considered to have protective roles as well. Among innate anti-Candida resistance mechanisms, oral epithelial cells inhibit the growth of Candida species in vitro. The mechanism of action includes a strict requirement for cell contact with no role for soluble factors or epithelial intracellular signaling. Abrogation of activity following treatment of the cells with periodic acid, but not inhibitors of proteins or phospholipids, had suggested a role for a cell surface carbohydrate. However, studies with several carbohydrate inhibitors have failed to identify any specific effector carbohydrate.

Objective: To further address the putative role for carbohydrates in the antifungal activity.

Results: Results showed that a putative effector carbohydrate released from epithelial cells by periodic acid treatment could not be regenerated or reattached. In other studies, the putative carbohydrate(s) released into the

supernatant of periodate treated epithelial cells could not competitively inhibit the antifungal activity by fresh epithelial cells. Additionally, equivalent abrogation of antifungal activity was observed irrespective of the amount of carbohydrate released by treated epithelial cells, and abrogation of antifungal activity was similarly observed following treatment with several other acids. Finally, antifungal activity was minimally affected by fixing the cells prior to coculture where the majority of cells remained impermeable to trypan blue as a measure of viability.

Conclusion: Together, these results suggest that instead of antifungal activity being mediated by an effector carbohydrate, activity is dependent on contact with intact, but not necessarily live, epithelial cells by an as yet unidentified acid-labile mechanism.

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