Oral infections in immunocompromised patients

Abstract. The number of immunocompromised patients has increased during recent years, mainly because of more aggressive anti-cancer treatment and increased survival periods for end-stage cancer patients. Congenital and acquired immunodeficiencies are also more frequently recognized in dental practice due to increased diagnostic knowledge and increased numbers of HIV-infected persons. Oral complications and infections are related to the type and severeness of the immunodeficiency. Low amounts of immunoglobulins are known to play a role in many bacterial infections, e.g., upper respiratory tract infections, but have not yet been associated with specific oral conditions. T-cell defects tend to increase suspectibility towards oral infections with fungi and virus, and are also associated with periodontal disease in HIV-infected patients. Defects in the phagocytic system increase the risk of periodontal disease in certain patient groups. Severe granulocytopenia as observed, e.g., in leukemic patients increases the risk of septicemia with oral micro-organisms.     

Oral manifestations of viral infections in immunocompromised patients.

Viral infections are a significant cause of morbidity and mortality in immunosuppressed patients. It is clear that diseases or medical treatments that have cytostatic or cytotoxic effects on lymphocytes and disrupt cytokine production or activity increase the risk of viral infections. While the rate of viral infection varies with the nature and degree of immunosuppression, it is clear that reactivation of latent virus is the most important determinant of the types of viral infections most frequently noted in immunosuppressed patients result from the reactivation of latent virus. Herpesviruses account for the majority of oral viral infections. Herpes simplex virus, varicella-zoster virus, and Epstein-Barr virus infections nearly always result from reactivation of latent virus, while cytomegalovirus infections, besides presenting as reactivated disease, are almost as likely to present as a primary infection in susceptible hosts. Other viral pathogens potentially of concern in immunocompromised patients are enteric viruses (adenoviruses and coxsackieviruses), human papillomaviruses, and possibly the recently identified human herpesvirus type 6. Ninety-eight percent of herpes simplex virus lesions are caused by reactivated disease and tend to be characterized by large, very painful ulcerative lesions throughout the mouth. Varicella-zoster virus is also rarely seen as primary infection, and the herpes zoster lesions involving cranial nerves can cause significant morbidity, including postherpetic neuralgia, corneal scarring, cranial nerve palsies, and deafness. Distinct oral ulcerative lesions caused by Epstein-Barr virus and cytomegalovirus have only recently been described in detail and are usually associated with disseminated disease. Oral human papillomavirus lesions are noted as warts and condylomas. The contribution of enteric viruses and human herpesvirus type 6 to oral disease in immunosuppressed patients is yet to be determined.     

Oral infections due to Cytomegalovirus in immunocompromised patients

Herpes group virus infections in the immunocompromised host are associated with significant morbidity and mortality. Herpes simplex virus (HSV) and to a lesser extent varicella zoster virus (VZV) have long been recognized as causes of oral and peri-oral lesions in subjects undergoing bone marrow transplantation and in individuals infected with the Human Immunodeficiency Virus (HIV). A role for Cytomegalovirus (CMV) in such lesions is less clear and not well documented. This report describes two bone marrow transplant recipients and one individual infected with HIV in whom CMV was implicated as the cause of oral lesions. Diagnostic and management issues as well as clinical implications are discussed.     

Oral yeast infections in immunocompromised and seriously diseased patients

The number of immunocompromised patients has increased during recent years. Most fungal infections in these patients are caused by Candida, Aspergillus, Mucor, and Cryptococcus species. Patients with low granulocyte count are at the highest risk of invasive candidal infection. The commonest type of granulocytopenia is observed in connection with malignant diseases of the hematopoietic system. Cytotoxic treatment and radiotherapy of large-body areas tend to produce a significant decrease in circulating granulocytes. Early diagnosis and adequate treatment of fungal infections are mandatory for a successful outcome. In the oral cavity it is important to differentiate between colonization and invasive infection. The optimal approach to diagnosis is a combination of histology and cultivation of specimens obtained from the same site of suspected infection. Prophylaxis of oral fungal infection in immunocompromised patients is generally aimed at preventing colonization.     

Oral infections in the immunocompromised host. International Association for Dental Research Symposium 19 April 1991, Acapulco, Mexico.

This paper provides a summary of a recent International Association for Dental Research symposium, “Oral infections in the immunocompromised host.” Speakers addressed current science relative to the host defense system (oral mucosal barrier, salivary gland function, use of biologic response modifiers), as well as characteristics of bacterial, fungal and viral pathogens. Avenues for future directions in laboratory and clinical research are proposed.     

Illosis of maxillary sinus in immunocompromised patient. Case report

Aspergillosis, which was first discovered in late 19th century, is a relatively rare disease in the sinuses. In recent years, a number of invasive aspergillosis infections of the maxillary sinus in immunocompromised patients, as well as the non-invasive form of the disease, have been reported. They were caused by the materials used in endodontic treatment, like gutta-percha, antrolith and by foreign bodies. This paper reports a case of aspergillosis in the maxillary sinus of an immunocompromised patient. It is associated with a root fragment after a much earlier tooth extraction.     

Invasive aspergillosis of the maxilla in an immunocompromised patient

Patients who are immunocompromised have a high susceptibility to infection, which can be fatal. Studies have shown that patients receiving chemotherapeutic and adjunctive medications have inhibited inflammatory response to microbes, particularly those increasing the potential for the development of invasive infection. Aspergillus is a fungus often found in the atmosphere. Colonization of Aspergillus in the upper respiratory tract is common. In the immunocompromised patient, Aspergillus flavus is found to be the most frequent fungus cultured in the maxillary sinus. Because of the depressed immunologic state of the patient, A. flavus can differentiate into hyphal forms producing toxins that destroy epithelial tissues. Penetration of Aspergillus into connective and vascular tissue produces thrombosis and ultimately necrosis of hard and soft tissue.     

Oral care of the HIV-infected patient.

There are only a small number of specialized centres that cater for the dental care of the steadily increasing number of HIV-infected individuals. The responsibility will, therefore, be increasingly shared with the dental practitioner who should be knowledgeable on the basic oral management protocols involved in treating these individuals. This article summarizes some essentials of oral health care in HIV-infected individuals.     

Oral findings in three different groups of immunocompromised patients

The objective of this study was to determine the frequency of oral, dental and periodontal findings in three different groups of immunocompromised patients and in a healthy control group, to evaluate whether there is a correlation between manifestations of disease and immunologic parameters. The survey included 46 patients with a diagnosis of systemic lupus erythematosus, 48 heart transplant recipients, and 53 adult patients suffering from acute leukemias. Fifty matched healthy subjects were used as a control group. Each patient had to answer questions on medical and dental health and underwent a thorough oral, dental and serological investigation. Oral mucosal lesions were found in nearly half of all immunocompromised patients (49.6%), but in only 26% of control patients. No significant associations were found between different types of oral lesions and the underlying cause of immunosuppression. Leukemia patients showed age-unrelated higher scores in periodontal indices (P<0.05). Laboratory parameters failed to be significant in the assessment of oral health.     

Oral manifestations and dental management of immunocompromised patients

Successful management of dental problems in immunocompromised patients requires an understanding of the diverse causes of immunodeficiency so that patients may be protected from potential hazards. Consultation with the patient's physician, oncologist, or haematologist is mandatory before any invasive dental procedure if there is concern about the disease process itself or doubt about adequate levels of leukocytes or platelets. Particular attention must be paid to maintain the intact mucosal barriers in the provision of dental care.     

Oral fungal infections

Candidiasis is the most common oral fungal infection diagnosed in humans. Candidiasis may result from immune system dysfunction or as a result of local or systemic medical treatment. Because oral candidiasis is generally a localized infection, topical treatment methods are the first line of therapy, especially for the pseudomembranous and erythematous variants.Patients with dental prostheses should also be advised to disinfect the prosthesis routinely during the candidal treatment period, because the prosthesis may serve as a source of reinfection. Additionally, patients should be advised that oral hygiene aids, such as toothbrushes and denture brushes, may also be contaminated and should be discarded or disinfected. A disinfecting solution of equal parts of hydrogen peroxide and water may be used. Likewise, 2% chlorhexidine gluconate solution may be used asa disinfecting solution for dental prostheses and oral hygiene aids. Occasionally the clinician encounters a more resistant form of oral candidiasis such as the hyperplastic variant or a variant that does not respond to topical therapy. Appropriate systemic therapy should be employed for the treatment of these infections. Additionally, a biopsy should be undertaken in individuals with the hyperplastic variant of Candida because there is some degree of risk for malignant transformation. Deep fungal infections should be managed in association with appropriate medical specialists to rule out other systemic involvement. The dental health care provider plays an important part in the diagnosis and management of fungal disease, and therefore clinicians should be aware of the presenting signs and symptoms or oral fungal disease.     

Multiple oral and labial ulcers in an immunocompromised patient

Herpes simplex virus infections in immunocompromised individuals have clinical features that are often quite different from primary and secondary HSV infections in otherwise healthy people. These infections should be recognized early and treated promptly to prevent progression of the lesions and the possible systemic dissemination of the virus. Cytological and biopsy examination frequently discloses changes characteristic of HSV-1, HSV-2, or Varicella-zoster virus. To ensure the most precise diagnosis, however, these examinations should be complemented by viral isolation and serological studies.