Gillian M. McCarthy

Host factors associated with HIV-related oral candidiasis : a review

Human immunodeficiency virus (HIV)-related oral candidiasis affects approximately one third of HIV-seropositive patients and more than 90% of patients with AIDS. It is necessary to identify patients who have a greater risk of candidiasis developing, so that interventions can be designed to reduce the frequency. This is particularly important because there is evidence that Candida species are immunosuppressive and therefore candidiasis may adversely affect the prognosis of patients with HIV. Susceptibility to HIV-related oral candidiasis is associated with xerostomia, severity of disease, depression of cell-mediated immunity, and older age (greater than 35 years). The frequency of HIV-related oral candidiasis is notably increased when the CD4 lymphocyte count falls to less than 300 cells/mm3. Xerostomia appears to be a better predictor of HIV-related oral candidiasis than CD4 count and should be prevented (e.g., by avoiding xerogenic drugs) and treated, when necessary, to minimize the risk of oral candidiasis.

Occupational injuries and exposures among Canadian dentists: the results of a national survey.

OBJECTIVES To measure the frequency of occupational exposures reported by dentists in Canada and to identify factors associated with occupational exposure. DESIGN A national mailed survey of a stratified random sample of 6,444 dentists with three follow-up attempts. Weighted data were analyzed using t tests, analysis of variance, and multiple logistic regression. RESULTS The response rate was approximately 66%. Occupational exposures, percutaneous injuries, and mucous membrane exposures in the last year were reported by 67%, 62%, and 29% of respondents, respectively. Fewer than 1% reported exposure to human immunodeficiency virus or hepatitis B virus (HBV). Respondents reported means of 1.5 mucous membrane and 3.0 percutaneous exposures per year. HBV immunization was reported by 91% of dentists, but of these 28% reported no post-immunization serology. Other reports of suboptimal compliance included use of a postexposure protocol by only 41% and HBV vaccination of all assistants or of hygienists by 74% and 77% of respondents, respectively. Factors associated with percutaneous exposure included non-use of postexposure protocol or puncture-proof containers for sharps disposal, treating > or =20 patients per day, and male gender. Risk factors for mucous membrane exposure included non-use of eye protection or masks. CONCLUSION This study provides evidence of the protective effect of puncture-proof containers, eye protection, and masks and raises concerns related to HBV post-immunization serology and postexposure protocols. To reduce risk of infection, educational interventions are required to improve compliance with Universal Precautions, with emphasis on comprehensive HBV immunization and post-immunization serology, the use of barriers, puncture-proof containers for sharps disposal, and postexposure protocols.

Jaw and other orofacial pain in patients receiving vincristine for the treatment of cancer

This prospective cohort study investigated orofacial pain occurring as a manifestation of vincristine neurotoxicity. Forty cancer patients (28 to 63 years of age) receiving vincristine were given baseline interviews and orofacial examinations, which were repeated weekly for 7 weeks of treatment. Twenty-two patients (55%) had neurotoxicity manifesting as orofacial pain. Onset was usually 3 days after vincristine administration; mean duration was 2 days. Twenty patients (50%) were affected in the first week: nine (22%) with severe and five (12%) with moderate pain. Symptoms were mild and infrequent in subsequent weeks. Eighteen control patients receiving chemotherapy without vincristine had no comparable orofacial symptoms. Multiple sites in the distribution of the trigeminal and glossopharyngeal nerves were affected: primarily the temporomandibular joint, mandible, throat, ears, and mandibular teeth. The frequency of orofacial pain increased with younger age. Pain was significantly associated with smaller body surface area (p less than 0.05), indicating a dose-related toxicity, and with sociodemographic variables including smoking (p less than 0.05).

Orofacial complications of chemotherapy for breast cancer

The National Institutes of Health recently recommended research initiatives to investigate oral complications of cancer chemotherapy. This prospective cohort study investigated orofacial complications of combination chemotherapy (cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone) in women with breast cancer. Thirty-four patients were given baseline interviews and examinations. Each patient was given weekly orofacial examinations and biweekly interviews for the first seven cycles of cytotoxic treatment. The orofacial complications included neurotoxicity caused by vincristine, mucositis, and candidiasis. Neurotoxicity affected 22 of 34 (65%) patients, was significantly associated with age less than 50 years (p less than 0.05), and manifested as pain in 19 of 34 (56%) patients. Mucositis affected 7 of 34 (21%) patients and was significantly associated with the occurrence of lesions of the oral mucosa at baseline examination; and smaller body surface area--indicating a dose-related toxicity (p less than 0.05). In four of the patients with mucositis (57%) granulocytopenia developed during the 7 days after the onset of mucositis. Intraoral candidiasis affected 4 of 34 (12%) patients.

A comparison of infection control practices of different groups of oral specialists and general dental practitioners

OBJECTIVE The purpose of this study was to compare the infection control practices of general dentists and dental specialty groups. METHODS A survey was mailed to 5997 dentists in 1994; the response rate was 70%. The data were analyzed with multiple logistic regression (reference group: general dentists). RESULTS When sociodemographic influences were taken into consideration, significant predictors of routine infection control practices included all of the following characteristics (odds ratios are in parentheses): 1. Gloves: being younger than 40 years of age (4.5) and being female (5.9). 2. Using gloves and changing gloves after each patient: being younger than 40 years of age (4.0), being female (3.0), being an oral surgeon (3.6), and being an orthodontist (0.2). 3. Using gloves, masks, and protective eyewear: being younger than 40 years of age (2.5), being female (2.3), and being an orthodontist, oral physician, or oral pathologist (0.2). 4. Hepatitis B vaccination for the practitioner: being younger than 40 years of age (5.1). 5. Hepatitis B vaccination for all clinical staff members: being younger than 40 years of age (1.2), being an oral surgeon (1.7), and being an orthodontist (0.6). 6. Heat sterilization of handpieces: being younger than 40 years of age (1.5), being an oral surgeon (5.4), and being an orthodontist (0.2). 7. Taking no additional precautions for patients with HIV: being younger than 40 years of age (1.7), being a periodontist (2.6), being a pedodontist (2.3), and being an oral physician/oral pathologist (4.3). CONCLUSION Improved compliance with recommended infection control procedures is required for all groups and is particularly necessary for orthodontists.

Management of oral health in persons with HIV infection

Prevention and treatment of oral disease is required to maintain quality of life and to improve prognosis of patients infected with the human immunodeficiency virus (HIV). Management requires a team approach, and close collaboration with the appropriate responsible physicians and other health care workers is necessary. Oral infection is frequent and usually opportunistic, and management is based on certain principles. Infections may disseminate and can be persistent and severe; multiple concurrent or consecutive infections with different microorganisms are frequent; fungal, viral, and parasitic infections are rarely curable; and long-term antimicrobial therapy may be required. This article reviews the management of oral candidiasis, hairy leukoplakia, and infections with herpes simplex virus, varicella-zoster virus, and cytomegalovirus. The management of Kaposis sarcoma, lymphomas, aphthous ulceration, gangrenous stomatitis, bleeding, xerostomia, and adverse drug reactions is also described. Treatment should avoid further immunosuppression and inducement of xerostomia or caries, and should be designed to avoid adverse drug reactions and possible drug interactions.

HIV-infected patients and dental care: nondisclosure of HIV status and rejection for treatment.

OBJECTIVE To investigate reports of nondisclosure of HIV-seropositivity to dentists by HIV-infected patients and their rejection for dental treatment. STUDY DESIGN An anonymous self-administered questionnaire was completed by 101 consecutive consenting HIV-infected patients. RESULTS Eighty percent of respondents (mean age, 36 years) had visited a dentist since their HIV diagnosis; 15% of these reported that they had been refused treatment because the dentist did not want to treat HIV-infected patients. Rejection was reported by 25% of respondents with heterosexual and 14% with homosexual risk factors, 11% of recipients of blood or blood products, and 8% with unknown or multiple risk factors. Refusal was not associated with economic factors. Nondisclosure of HIV-seropositivity to their current dentist was reported by 13% of respondents. No respondents attending hospitals or health units reported nondisclosure, compared with 18% of respondents attending private dental offices (p < 0.05). CONCLUSION More research is required with a larger sample to improve generalizability and to permit subgroup analysis.

Changes in dentists' infection control practices, knowledge, and attitudes about HIV over a 2-year period

OBJECTIVE To investigate changes in the infection control practices, attitudes, and knowledge of dentists as they relate to HIV/AIDS: STUDY DESIGN A comparison of responses to surveys conducted in 1992 (n = 258) and 1994 (n = 262) with the use of univariate/multivariate analyses and McNemars test for paired data. RESULTS The response rate were > 70%. There were significant increases in reports of continuing education related to HIV/AIDS, heat sterilization of handpieces, use of masks, and knowledge of risk of HIV infection after a needlestick injury. Significantly fewer respondents reported concerns about staff fears about HIV/AIDS: Reports of willingness to treat patients with HIV increased from 68% to 77%. The best predictors of willingness to treat changed from primarily infection control variables to lack of concern with respect to risk or loss of patients when treating persons with HIV. CONCLUSIONS Increased use of infection control procedures and knowledge may be partly attributable to the introduction of mandatory continuing education in 1993.