Karem López Ortega

Oral manifestations after immune reconstitution in HIV patients on HAART.

In order to verify possible association between immune reconstitution inflammatory syndrome (IRIS) and oral manifestations (OMs), we selected AIDS patients who had low CD4 count before the initiation of highly active antiretroviral therapy (HAART) and who returned three months later for therapy evaluation. The oral lesions observed three months after the initiation of HAART were evaluated and associated with the type of antiretroviral therapy (ART), CD4 count and HIV-RNA load levels (before and three months after HAART initiation). A total of 105 patients matched the selected criteria. Immune reconstitution (IR) was identified in 35.2%. Among these patients, the mean CD4 cell count rose from 105.97 to 330.29 and the mean viral load dropped from 168.005 (log 5.22) to 21.852 (log 4.33). There was no significant difference in age (P = 0.78), sex (P = 0.41) or previous history of ART (P = 0.55) between IR and non-IR patients. In the IR group, the most common OM was parotid enlargement (57.14%) (P = 0.019), whereas in the non-IR group candidiasis (46.15%) was the most common OM. The results of our study suggest that the parotid gland enlargement found in the studied population might be an IRIS event, as it was found in patients with IR three months after the initiation of HAART.

Impact of PI and NNRTI HAART-based therapy on oral lesions of Brazilian HIV-infected patients

BACKGROUND The incidence of oral lesions related to human immunodeficiency virus (HIV) infection have been investigated after treatment with highly active antiretroviral therapy (HAART) including protease inhibitors (PI) but no data are available on the effect of non-nucleoside reverse transcriptase inhibitor (NNRTI)-based therapy on incidence of acquired immunodeficiency syndrome (AIDS) oral manifestations or impact of HAART on oral manifestations of HIV infection in Brazil. The aim of this study was to describe the effects of anti-HIV therapy on the incidence of oral lesions during 17 years of AIDS epidemics in a Brazilian population. METHODS From 1989 to 2006, we collected data from 1595 consecutive HIV patients at the Special Care Dentistry Center, São Paulo, Brazil. We compared the effect of PI- and NNRTI-based antiretroviral therapy (ARVT) on the annual incidence of Kaposi sarcoma (KS), oral candidiasis (OC) and hairy leukoplakia (HL). The chi-squared test was used to test the association between oral lesions and therapeutic regimen (P < 0.05). RESULTS None of patients on ARVT presented with KS. Patients who used (nucleoside reverse transcriptase inhibitors) NRTI + PI were 0.9 times as likely to present with HL as those who used NRTI + NNRTI. This finding, however, was not statistically significant (P = 0.5). The relative risk for OC was 0.8 in patients with PI-based HAART. The increased risk among those on PIs was statistically significant (P = 0.004). CONCLUSIONS The superiority of NNRTI regimens in decreasing OC incidence is consistent with current therapeutic guidelines which recommend NNRTI-based therapy as the treatment of choice for initial ARVT.

Treatment of central giant cell lesions using bisphosphonates with intralesional corticosteroid injections

Central giant cell lesions are benign intraosseous proliferative lesions that have considerable local aggressiveness. Nonsurgical treatment methods, such as intralesional corticosteroid injections, systemic calcitonin and interferon have been reported. Recently, bisphosphonates have been used to treat central giant cell lesions. A case of a 36-year-old male with a central giant cell lesion crossing the mandibular midline was treated with intralesional corticosteroids combined with alendronate sodium for the control of systemic bone resorption. The steroid injections and the use of bisphosphonates were stopped after seven months when further needle penetration into the lesion was not possible due to new bone formation. After two years, the bony architecture was near normal, and only minimal radiolucency was present around the root apices of the involved teeth. The patient was followed up for four years, and panoramic radiography showed areas of new bone formation. Thus far, neither recurrence nor side effects of the medication have been detected.

Primary malignant melanoma of the oral cavity: a case report.

A 43‐year‐old white man was referred to the Special Care Dentistry Center of the School of Dentistry, University of São Paulo, Brazil, for the diagnosis of an extensive nodular lesion of the maxillary gingiva.

Recessive dystrophic epidermolysis bullosa—oral rehabilitation using stereolithography and immediate endosseous implants

Dental management of patients with epi-dermolysis bullosa (EB) is challenging because of the severe soft tissue lesions associated with this disease. A case history is presented where two immediate endosseous implants were placed in the mandible of a patient with recessive dystrophic EB using computer-aided technology to plan the surgery and prosthetic rehabilitation. After a 24-month follow-up, the prosthesis was stable with healthy asymptomatic soft tissue around the implants. The stereolithographic model provides a precise and noninvasive copy of the mandibular and maxillary arches of patients with EB for rehabilitation of the dentition with immediate endosseous implants and a prosthesis.

HIV-associated oral plasmablastic lymphoma and role of adherence to highly active antiretroviral therapy:

Plasmablastic lymphoma (PBL) is an HIV-associated non-Hodgkins lymphoma that primarily affects the oral cavity. We describe the case of an HIV patient with a lesion in the maxilla that lasted four months. He was diagnosed with PBL and received highly active antiretroviral therapy as well as chemotherapy and local radiotherapy. The lesion regressed after the third cycle of chemotherapy. The patient interrupted antiretroviral treatment and the lesion recurred. The immune reconstitution secondary to the use of antiretroviral therapy seems to participate in the regression of PBL and maintains the remission of the tumour, but it might not be enough to prevent the development of PBL.

Oral and dental abnormalities in Barber-Say syndrome.

A previously unreported case of Barber–Say syndrome is described with special attention to dental manifestations. A 7‐year‐old female with multiple congenital anomalies such mammary gland hypoplasia, hypertrichosis, ectropion, and redundant skin was seen at the School of Dentistry of the University of São Paulo. Oral examination revealed macrostomia, broad alveolar ridges, gingival fibromatosis, taurodontism, delayed tooth eruption, and malocclusion. Dental treatment included gingivoplasty and orthodontic treatment.

An assessment of adverse effects of antiretroviral therapy on the development of HIV positive children by observation of dental mineralization chronology.

BACKGROUND The difference between dental age (DA) and chronological age (CA) indicates an advance or delay in comparison with the normal standard. Considering that DA has a very close correlation with CA in a developing child, this study aimed to investigate the relationship between the effects of antiretroviral therapy on the development of HIV positive children, by observing the timing of dental mineralization. METHODS A retrospective examination was made of the medical records and dental panoramic radiographs of 50 HIV-positive pediatric patients, aged 37-168 months of age. Through these radiographs, their DA was estimated and compared with their CA. RESULTS The mean DA was significantly lower than the mean CA in the entire studied sample (P < 0.01). There was a statistical difference between children who received antiretroviral drugs and those who used no drugs (P = 0.02), i.e. the non-treated individuals presented practically no difference between CA and DA, while the treated patients showed a difference of 10.67 months. CONCLUSION We conclude that the DA of HIV infected children was delayed when compared to the CA, and there was a positive association between the use of antiretroviral therapy and a delay in the chronology of dental mineralization in the sample.

Diagnosing secondary syphilis in a patient with HIV

hoke. As he was in full spinal immobilisation he was unable o maintain his own airway without continuous suction and aw thrust. He was in considerable pain from the mobility of is mandible. Because of the bleeding, pain, and difficulty managing is airway it was necessary to reduce and stabilise the anteior fracture of the mandible. However, there was no oral nd maxillofacial equipment for many miles. A straightened aper clip was used as a temporary bridle to stabilise and educe the fracture, which reduced the pain and blood loss, nd enabled the airway to be maintained safely. Local anaesthetic with epinephrine was infiltrated into the ubmucosal space of the left anterior mandible. One end of a traightened paper clip of 0.5 mm diameter was inserted with eedle holders between the lower left premolar teeth and the ame end was passed back out through the gap between two entral incisor teeth. While the fracture was reduced manually ith the teeth in occlusion, the paper clip was wound tight in clockwise fashion. Fig. 1 shows a radiograph of the paper lip in place. The paper clip allowed the patient to be transferred safely o the regional maxillofacial unit. We think that this simple technique (with appropriately esigned equipment) should be part of standard training in mergency medicine (and Advanced Trauma Life Support) nd would encourage current trainees in emergency medicine o spend some time on attachment in oral & maxillofacial urgery. Emergency departments with or without on-site oral maxillofacial services should maintain a small collection f appropriate equipment for such emergencies and be cometent in their use.

Mandibular lesion in an HIV-positive patient.

patient’s CD4 cell count was 58 cells/mm 3 and his viral load was 13,000 copies/mL, his antiretroviral treatment had been changed to zidovudine, didanosine, and nevirapine. An oral examination showed a papillomatous lesion in the alveolar mucosa and interdental papilla, between the lower right canine and first premolar. The lesion was histologically diagnosed as condyloma acuminatum. The lower left first and second premolars had increased mobility, which was also observed in the adjacent alveolar bone. Although the surrounding gingival and alveolar mucosae were erythematous, painful, and swollen, no periodontal pocket was observed during periodontal probing or on panoramic radiographs. The hypothesis of alveolar bone fracture was rejected, because the patient denied any trauma to the affected region (Figs 1A,B). Periapical radiographs showed a radiolucent line that enveloped both the lower left canine and first premolar, from the alveolar ridge to the apical region (Figs 1C,D). Laboratory tests were performed. The levels of lipoproteins, cholesterol, triglycerides, glycemia, bilirubin, and antiphospholipid antibodies were normal, as was the platelet count. Although the patient presented with mild anemia, blood-coagulation tests and a complete blood count were within the reference range. Liver and renal function tests were normal, and his venereal disease research laboratory was negative.