1.

Oral Infectious Diseases

Introduction
Oral infections constitute some of the most common and costly forms of infections in humans. In this regard, dental caries and periodontal diseases occur in nearly 95% of the general public, particularly in the expanding aging sector. Although fluoride and other preventive efforts have led to a dramatic decline in caries, the ability to control the actual infection has been limited. Attempts to block oral infections by preventing colonization of the tooth, epithelium or gingival sulcus by oral pathogens is still largely based on laborintensive and nonspecific personal hygiene measures. Similarly preventing viral or opportunistic fungal infections of the oral mucosal tissues is a growing challenge due to the increased frequency of compromised individuals with suppressed salivary flow or immune protection due to pharmacological medical treatment of an aging population. The oral cavity is a complex ecosystem in which a rich and diverse microbiota has evolved. The wide range in pH, Eh, nutrient availability, shedding and non-shedding surfaces, salivary and crevicular fluids select for localized, discrete microbial climax communities which may fluctuate in composition and metabolic activity but reach a kind of homeostasis in balance with the host. Changes in the environment, whether imposed by illness, debility, behavior, diet, or medications disturb the homeostasis and lead to endogenous infections or susceptibility to exogenous infections.

Unique Features of Oral Cavity

The mouth is the major portal of microbial contamination at the entrance to the alimentary tract. It is a moist environment through which microorganisms pass to distal sites if they are not able to adhere to or be retained on one of the diverse oral surfaces. The mouth can be contaminated by any infected object it contacts, either intentionally or accidentally. Why particular microorganisms colonize and others pass through as transients is an intriguing question in oral microbial ecology. The oral cavity is bathed in saliva, a fluid with remarkable properties for protecting the host from microbial infections. About one liter is produced per day from the major glands (parotid, submandibular, sublingual) and minor glands. Antimicrobial activity of saliva is provided by various proteins which protect by different mechanisms. Certain proteins (mucinous and nonmucinous glycoproteins; lysozyme) have microbial agglutinating activity, which would foster the disposal of bacteria by the bathing fluid or competitively block access of bacteria to their natural binding sites on mucosal surfaces or on the teeth. Salivary immunoglobulins, predominantly

secretory IgA, recognize and bind surface molecules specifically and provide analogous but acquired protection. Several proteins, such as lysozyme histatins, transferrin, lactoferrin, and lactoperoxidase, have antimicrobial properties in vitro. Saliva also contains buffering systems, such as bicarbonate and low molecular weight peptides, which neutralizes harmful acid end products of microbial metabolism. Salivary proteins as well as soluble bacterial products, such as glucosyltransferases, serve as bacterial receptors that initiate the formation of the biofilm called dental plaque. Saliva is also the repository for populations of shed microorganisms and their metabolites and enzymes, such as proteinases and sialidases, which can degrade salivary and epithelial surface molecules and affect the colonization of non-oral pathogens. Since saliva has such a protective function, salivary deficiency often leads to opportunistic infections with pathogenic bacteria, fungi, and viruses.

Saliva
Of all the organs in the craniofacial-oral-dental complex, it is perhaps the salivary glands and their remarkable secretory product, saliva, that forge the strongest link between oral and systemic health. Salivary function is extremely sensitive to changes in our general well-being, ranging from subtle effects of over-the-counter cold medications to the devastation of life-threatening disease. Even the ancients recognized an association between the human condition and saliva, which served as judge and jury in cases of wrongdoing. A suspect was given a mouthful of dry rice. If his anxiety reduced his saliva flow so that he could not swallow it, the verdict was guilty as charged. To this day, "cotton mouth" betrays all of us at some point in our lives, signaling to the world that our nerves have taken control.

Gatekeeper
With its vast antimicrobial arsenal, saliva represents a remarkable evolutionary selective advantage for the host against invading pathogens such as HIV, the fungus Candida albicans, and a host of bacteria associated with oral and systemic diseases. Secretory antibodies, for example, directed against viral pathogens such as poliovirus and cold viruses, as well as the anti-HIV agent SLPI, are found in saliva. Large salivary glycoproteins called mucins appear to have antiviral properties as do cystatins, a family of cysteine-rich proteins that are active against herpes viruses. Saliva also contains histatins, antifungal proteins that are potent inhibitors of candida, which is normally kept in check at extremely low levels in the mouth. When the oral balance is upset, however, by HIV infection or other

immunosuppressive and debilitating disorders, antifungal defenses are overwhelmed and candida flourishes uncontrolled. Reinforcing saliva's antiviral and antifungal activity are salivary constituents that thwart bacterial attack. These enzymes destroy the opposition by various mechanisms, including degrading bacterial membranes, inhibiting the growth and metabolism of certain bacteria, and disrupting vital bacterial enzyme systems. Functioning in concert, these and other protective factors in saliva help to maintain the oral environment in optimal working order and restore it to more normal conditions when disturbed. Immune protection in the oral cavity derives from mucosal and systemic immunity pathways common to most body surfaces, including IgA, IgG and IgM, neutrophils, macrophage, and lymphocytes. Antigens traversing the oral mucosa can stimulate tonsils ringing the oropharynx, as well as regional lymph nodes. Being a major site for mucosal protection, the tissues surrounding the oral cavity can serve as a research model for studying lymphocyte traffic and local antibody synthesis. The mouth is also unique for being lined with stratified squamous epithelium, which can be keratinized (e.g., tongue dorsum) or nonkeratinized (e.g., gingival crevice). The mucosa presents a unique structure and ecological pressure, as the mitotic rate apparently increases in response to microbial burden. In addition to providing a barrier function, desquamation serves as an innate defense. Epithelia lining the gingival crevice might also act as a source of antimicrobial peptides (defensins) and inflammatory mediators generated in response to periodontal infections. Certainly the teeth, themselves, represent a unique feature of the human body, being the only mineralized, non-shedding structures that protrude through the mucosa into a contaminated environment. This provides an opportunity for microbial communities to congregate as biofilms on smooth surfaces as well as in stagnant environments like the fissures and interproximal surfaces. The site of penetration of the teeth through the mucosa provides an anatomically shallow gingival crevice, which may become deeper and inflamed in response to periodontal infections. The pocket is a stagnant environment which supports a highly diverse, mixed microbial community. The environment is highly reduced, an ecological condition that selects for fastidious anaerobes. Due to their metabolism, the environment becomes rather alkaline, which promotes the mineralization of the bacterial masses into calculus, which binds them tenaciously to the dental root surface. The infection causes an increased flow of tissue transudate, crevicular fluid, which is enriched for serum proteins. Polymorphonuclear leukocytes routinely

migrate across the junctional and sulcular epithelium into the gingival crevice, in response to host and bacteria chemotactic factors. Restorative and prosthetic materials provide additional surfaces that are unique to the oral cavity. With the advent and popularity of osseointegrated implant replacements for missing teeth, the surfaces to which salivary proteins and bacteria bind to form biofilms is becoming even more diverse. Since infections of implanted devices present such a challenge in medicine, readily accessible dental implants may serve as a convenient and appropriate in vivo model for testing concepts of prevention of such infections.

Infections Unique to the Oral Cavity

Periodontitis "Periodontitis" includes a group of inflammatory conditions of infective etiology which lead to loss of tooth support manifested as net resorption of alveolar bone and collagen attachment to the tooth's cementum. Decades of research have identified a mixed but limited consortium of bacterial species, among the dozens to hundreds of species in the subgingival community, as particularly virulent or associated with disease progression. These include Porphyromonas gingivalis, Bacteroides forsythus, Actinobacillus actinomycetemcomitans, Prevotella intermedia, Prevotella nigrecens, Treponema denticola and other Treponema sp., Campylobacter sp., Selenomonas sp., Fusobacterium sp., Peptostreptococcus, and some Streptococcus sp. The inflamed periodontal pocket offers a unique, anaerobic, environment, enriched with host transudates and exudates, which favors the growth and opportunistic emergence of fastidious species which usually comprise a minor proportion of the microbiota of the gingival crevice in health. It is an alkaline environment which favors mineralization of the microbial biofilm to form tenacious calculus, which complicates the clinical management of the infections. Peri-implantitis "Peri-implantitis" is a reactive inflammatory condition of the tissues surrounding dental implants in response to bacterial communities which establish in the periimplant sulcus. It is analogous to periodontitis, but the contribution of the chronic inflammation and the bacterial infection to loss of stability and loss of osseointegration, i.e. failure of the implants, is more controversial than the contribution of infection to progression of periodontitis. Implants placed in the mouths of partially edentulous individuals become colonized by periodontal pathogens from reservoirs on the remaining teeth. Failed implants with clinical signs of infection usually yield elevated levels of many of the Gram-negative anaerobes associated with periodontitis, but association of P. gingivalis and A. actinomycetemcomitans with failing

implants is less frequent than reported for progressive periodontitis. The soft tissue infection around implants can be treated by the same antimicrobial protocols that are successful in the arrest of periodontitis activity, but reestablishment of osseointegration has not been reported as a consistent outcome. One major difference between periodontitis and peri-implantitis is the lack of cementum and calculus in the latter. Combined with the absence of a periodontal ligament, these may account for distinct pathways of pathogenesis. There is little depth and precision in the published research into the course of peri-implantitis and unique features of such infections. Yet, periimplantitis has the potential to serve as an interesting and significant model for studying biofilm-associated infections. The major outcome variable can be monitored by survival analysis, and thus peri-implantitis may have a more clearly defined endpoint than that used for monitoring outcomes related to periodontitis.

DentalCaries
Caries is a unique disease in which diet selectively drives shifts in the proportional distribution and metabolic activities among commensal bacteria, such as mutans streptococci (S. mutans and S. sobrinus) and Lactobacillus sp., in dental plaque. In this regard, teeth provide a unique opportunity to study biofilm-related infections confined to mineralized tissue. Periodic availability of fermentable carbohydrates drives an existing biofilm microbiota toward sustained glycolysis and resultant acidogenesis. Dietary sucrose can also be metabolized into polysaccharides that serve as receptors for cariogenic bacteria. The organic acid end products cause subsurface demineralization and then cavitation of the tooth surface. Although industrialized countries have experienced a remarkable reduction in caries incidence in children during the past few decades, the prevalence of children and adults who experience caries on retentive tooth surfaces, including roots, is still more than 90%. Recent evidence suggests cariogenic bacteria are transmitted from mothers to their children during the eruption of primary molars and initial lateral tooth contacts. Pulpitis/PeriapicalPeriodontitis Like periodontitis, pulpal and periapical conditions are due to mixed infections most often following a shift in the microbiota toward Gram-negative anaerobes. The most compelling research over the past decade has been the clear demonstration in animals, including primates, that periapical lesions occur only in response to infection and that immunological responses tend to limit rather than exacerbate the extent of the lesions. While these infections are distinct in distribution and precipitating factors from periodontitis, (most follow pulp exposure from deep carious lesions, infected periodontal pockets via accessory canals, or fractures), research into the virulence factors of pulpal and periapical pathogens has relied heavily on advances in periodontal research. There is some complementary work in the area of cytokine biology

by one group concentrating on pulpal and periapical infections. The critical mass of biologists studying root canal infections is comparatively very small, and much of the biology done would fall into the arena of applied clinical research. OpportunisticMucosalInfections The mucosal surfaces of the mouth are susceptible to a wide range of fungal and viral infections which are most usually opportunistic relative to the host's immune, salivary flow, or prosthodontic status. These infections are most common at the extremes of the age spectrum except for their occurrence in youths, young adults, and middle aged individuals who are either immunodeficient or chemotherapeutically immunosuppressed. The clinical significance of such infections can range from bothersome to lethal. They can occur as isolated oral infections or become systemically disseminated. They are often the result of suppressed cell-mediated immunity. Oral candidiasis. There are several clinical manifestations of oral candidiasis, most often evident under conditions in which the host defenses and indigenous bacterial microbiota are unable to suppress the emergence of Candida albicans. This may occur in infants just past their peak passive immune protection from their mothers; in individuals with acquired immunodeficiency, severely reduced salivary flow due to chemo- or radiotherapy for cancer; or in unhygienic denture wearers. Additional species of Candida as well as Histoplasma, Blastomyces, Aspergillus, and Cryptococcus also have the potential to cause oral lesions, often as part of a systemically disseminated condition. Pathogenesis and treatment of candidiasis is a major thrust in infectious diseases research. There is considerable activity in the areas of adhesion, extracellular enzymes and cellular dimorphism, and their effects on virulence. A gene for regulating dimorphism has recently been cloned. One of the major challenges in mycology is to develop useful antifungal agents. The most common oral agent now in use, fluconazole, is experiencing a rise in resistance among Candida strains. Moreover, immunodeficient and immunosuppressed individuals who take this drug are experiencing more frequent infections with diverse Candida species that are more resistant. Research into the pathogenesis and treatment strategies for oral candidiasis has potential to contribute greatly to knowledge impacting on fungal infections in the gastrointestinal tract and vagina. Viral infections. Several species of viral pathogens are transmitted by body fluids, including saliva, and can infect cells and cause lesions in the oral cavity. These include minor vesiculo-ulcerative lesions, self-limiting febrile illnesses like mononucleosis, disseminated life-threatening conditions, and even a few types of neoplasms. Many viruses with impact in the oral cavity belong to the Herpes virus group.

Herpes simplex (HSV) 1 causes the majority of cases of oral and pharyngeal infections and is transmitted via saliva. Primary infection is most often subclinical. Herpetic gingivostomatitis is an acute form which is most common in infancy and less frequent with age. It is characterized by painful ulcers accompanied by fever and malaise. Protective immunity is usually acquired, but like most herpes infections, HSV 1 can be reactivated from the latent stage in neural ganglion cells and give rise to clinically bothersome manifestations like "cold sores" and oral vesicular lesions. Immunologically compromised and immunosuppressed individuals are at high risk for severe or potentially lethal recurrent infections. HSV 2 is of genital origin but can cause oral lesions if transmitted by oral-genital contact. Cytomegalovirus (CMV) also causes clinically significant infections in neonates and immunosuppressed individuals. It can be transmitted by saliva, and the salivary glands are among the organs affected in the disseminated form of infection. CMV is a risk to persons with suppressed cell-mediated immunity following organ transplants. It has also been associated with mixed infections in AIDS patients. Epstein-Barr Virus (EBV) transmits via infected saliva and infects B lymphocytes. It is associated with clinical cases of infectious mononucleosis, a condition characterized by lymphadenopathy, fever, malaise, oral and pharyngeal ulcers, and splenomegaly. This condition can either be selflimiting, in most cases, or give rise to severe systemic complications. EBV has also been associated with malignancies such as Burkitt's lymphoma, nasopharyngeal carcinoma, and lymphomas in immunocompromised patients. In HIV-infected individuals, EBV is considered the agent which causes the clinical condition hairy leukoplakia which most often manifests on the lateral border of the tongue. Varicella-Zoster Virus (VZV) is involved in the primary infection chickenpox, which is spread by nasopharyngeal secretions and manifests commonly with oral vesicluar lesions. The virus can remain latent in dorsal root or cranial nerve ganglia and reemerge later in life to cause the very painful condition known as herpes zoster. Lesions often involve the skin and oral mucosa overlying the course of the trigeminal nerve. The infection can be lifethreatening in immunosuppressed individuals. Hepatitis viruses B and C (HBV and HCV) are significant to oral infection research in that they are readily transmitted via contact with infected blood, and thus pose a risk to health-care workers, including dentists and dental hygienists. HBV is also present in saliva. Though there is substantial reduction of risk by immunization with a recombinant hepatitis B vaccine, the virus is used in research as an important target for improving disinfection methods.

Human immunodeficiency virus (HIV), through its global impact on the increased risk of serious opportunistic infections, is a key pathogen which should continue to be the focus of oral infectious diseases research. HIV seropositive individuals can manifest periodontal conditions, candidiasis, and some clinical signs of viral infections as early indicators of conversion to AIDS or they may suffer from an increased frequency of minor oral infections. HIV viral load is detectable in oral tissue by reverse transcriptase-PCR.

Unique Infectious Diseases Research Opportunities Using the Oral Cavity As a Model

Ecology. The essence of most problems of infection and immunity in the oral cavity is the imbalance of established homeostasis due to opportunistic emergence of pathogenic species within the mixed microbiota in susceptible hosts. The most advanced disease conditions, for example early onset advanced periodontitis or rampant dental caries, affect persons whose individual characteristics, both biological and behavioral, put them at considerable risk for extreme manifestations of tissue damage in the face of infection with the most virulent oral microorganisms. Oral infections are essentially problems in microbial ecology. Thus the oral cavity provides a unique and accessible group of environments in which to study concepts and principles of the dynamics of mixed microbial communities and their impact on maintenance of health and susceptibility to disease. There is enormous potential to use the oral cavity to define paradigms for microbial life within mixed communities in vivo. Whether driven by population density, metabolites, or physiologic stress, knowledge of intermicrobial regulatory pathways is just beginning to emerge. The oral environment offers a unique opportunity to study such relationships in models that have both ecological and pathogenic significance, and to study many of them in vivo. Biofilms. The penetration of tooth surfaces and implants through the mucosa provides a "real life" situation for studying parasitic life in biofilms of significance for health and disease. Several avenues of research that have emerged in the past decade indicate that the physiology of microorganisms growing on a surface or in a dense community on a surface differs from that of microorganisms growing in suspension. Even their antimicrobial sensitivity appears to be altered. Many conceptual, technological, methodological, and applied research advances relevant to biofilms have been advanced through studies of oral microorganisms. Yet, it is only since the recent introduction of genetic methods to study transcriptional regulation that attention has been focused on the underlying mechanisms which account for the observed phenomena of altered physiological properties of bacteria existing in biofilms. Moreover, in terms of pathogenesis of dental disease, especially dental caries, the physical properties of the biofilm, including the polysaccharide

matrix as well as its microbial composition, is considered a highly significant determinant of disease progression. Ready access to biofilms in the oral cavity and decades of experience designing in vivo experiments in humans should provide an opportunity to study principles of density-dependent physiological responses, gene regulation relevant to colonization, and pathogenicity of infections. Some investigative work has been initiated in this topical area, but greater intensity is probably warranted. Without doubt, the next several decades will see an increased prevalence of dental implants to replace teeth in partially edentulous individuals. Considering the ease with which the superstructure of dental implant prostheses can be removed, a model for studying intact oral biofilms, formed in vivo, over time is feasible. Since implanted medical devices in extraoral tissues are usually beyond ready access, the oral implants offer a unique opportunity for defining principles of preventing and treating biofilms associated with prostheses which penetrate mucosal tissues. Secretions. A parasitic lifestyle on mucosal or tooth surfaces requires adaptation to avoid disposal by bathing secretions. In the case of saliva, a great deal is already known of the composition and antimicrobial properties, including considerable knowledge of the potential for harnessing secretory immunity as a preventive strategy. Yet, precise knowledge of bacteriacombining domains of most salivary molecules still remains to be studied, even those known to serve as bacterial receptors when absorbed as salivary pellicle constituents on teeth. Although some definition of mucosal pellicles has been advanced in the past decade, little is known of its contribution to epithelial barrier function or if biotechnical enhancement of protective functions of such pellicles is feasible. Similarly, the potential to use saliva as a delivery vehicle for boosted antimicrobial therapy remains to be explored. Therefore, salivary-bacterial interactions in the oral cavity may serve as a model for generating knowledge of the infection protection role of secretions in general. OpportunisticInfectionsin the MedicallyCompromised The oral cavity is a sensitive site for early onset of infections in a compromised host. This is probably due to its being a common route of contamination and due to its amphipathic microbiota, which harbors potential pathogens held in balance by less pathogenic species. Reduction in salivary flow or reduction in immune competence can lead to serious fungal and viral infections. These often appear as multiple infections simultaneously, either prior to or concomitant with serious systemic involvement. The oral cavity, then, can serve as a target for research into the nature of opportunistic infections in general and certainly as a test site for antiviral and antifungal therapy.

Sourceof less virulentvectors . The oral cavity provides dozens of indigenous species which evidently colonize humans efficiently and yet induce no deleterious clinical outcomes. Such species may provide a wide array of vectors for studying regulation of single genes or clusters of genes of pathogenic bacteria in vivo. More thought could also be directed to the use of indigenous oral organisms as vaccine carriers in place of the attenuated pathogens which have been investigated in detail. Thus the oral cavity can be viewed as a primary research target for unique infections such as dental caries, periodontal diseases, infections of mucosa lined with squamous epithelium, and opportunistic infections due to diet, malnutrition, lifestyle habits, immunodeficiency, or immunosuppression. Alternatively, the oral cavity can also be viewed as a primary research target for advancing fundamental understanding of mixed infections, biofilms on natural and implanted non-shedding surfaces, microbial interactions with components of secretions, and innate/acquired mucosal immunity. The study of oral infections is also critical for the long-term maintenance of systemic health, considering the recently emerging data relating oral infectious diseases to cardiovascular disease, stroke, pneumonias, untoward outcomes of reproduction, gastroenteric disorders, and a source of oral viruses with putative significance in carcinogenesis. Therefore, in this age of advancing biotechnology and integration of biological and health sciences, accelerated scholarly research into the nature of oral infections should discover new directions, avenues, and innovations for preventing oral disease and potentially for reducing the morbidity of some major systemic illnesses or conditions.

Prevention and Control of Oral Infectious Diseases

Background Effective strategies to prevent and control infectious diseases require a basic understanding of the causative agent, the pathogenesis of the disease, and the individuals at risk. Intervention can occur at any of these three points in the natural history of the disease. Attempts to control oral infections have met with limited success. Two of the most common oral infectious diseases, caries and periodontal disease, are among the most common bacterial infections of humans. Although many years of research on these diseases have helped elucidate the pathogens, pathogenesis, and host response, efforts to rationally control these diseases are limited and often infective. Cariesand Periodontitis: The causative organisms and pathogenic mechanisms of both caries and periodontal disease appear to be members of the commensal flora. Under the appropriate environmental conditions, these pathogens increase in numbers and directly exert damaging effects on the oral tissues (e.g., tooth or gingival tissue.) In addition, the host response to the biofilm and to products released by the plaque bacteria, is marked by

chronic inflammation, enhanced production of matrix metalloproteinases and other histiolytic enzymes and destruction of the gingival connective tissue and bone surrounding the teeth. Thus, any attempts to prevent and control oral infections, such as caries and periodontitis, must be aimed at selectively blocking the growth of the bacteria, production and release of virulence factors, and, in the case of periodontitis, perpetuation of host inflammation. Unfortunately, the individuals most at risk for these oral infections are still poorly defined. Therapy is directed at removing the infectious agents, and repairing the lesions. Traditional paradigms for restoring carious lesions are being replaced by newer strategies that emphasize disease prevention and conservation of tooth structure. Periodontal diseases are generally treated with scaling and root planning together with adjunctive antimicrobial agents. Advances in periodontal regeneration techniques promise to lead to effective repair and regeneration of gingival connective tissue and supporting alveolar bone. Viral Infections: Other infections of the oral cavity are relatively rare, affecting a small percentage (less than 5%) of the population. For example, there are a series of viral infections of the mucous membrane that produce disease with a primary acute phase and a secondary recurrent phase. This transmissible infection is caused by herpes simplex virus, usually type 1, and less commonly type 2. Patients develop painful intra- and extra-oral ulcers which are painful with or without regional lymphadenitis, fever, and malaise. The disease is usually self-limiting with healing in 7 to 10 days. Treatment involves relieving symptoms, preventing secondary infection, and the use of systemic acyclovir, especially in immunocompromised patients who are more susceptible to herpes simplex infection. Prevention now is limited to several empirical approaches with unknown efficacy. Varicella zoster can also occur in the oral cavity and represents a reactivation of the latent herpes varicella virus present after initial varicella infection, usually chickenpox. Reactivation is precipitated by factors including thermal, inflammatory, radiologic, or mechanical trauma. Lesions are usually unilateral, following the distribution of nerve branches and dermatome. Therapy with acyclovir is reasonably successful, however, prevention is not presently effective. Opportunisticmicrobialinfections: Oral opportunistic infections occur in immunosuppressed patients, and patients receiving antineoplastic agents and radiation therapy. These may be caused by overgrowth of opportunistic oral organisms which infect ulcerated areas that chemotherapeutic agents have destroyed. Treatment includes the use of chlorhexidine gluconate mouthrinse which helps control the infection. Other treatment is directed to providing comfort. Candidiasis also occurs in the oral cavity and is caused by Candida albicans, a yeast-like fungus. C. albicans is an opportunistic organism which tends to proliferate with the use of broad spectrum antibiotics, corticosteroids, medicines that reduce salivary output, and cytotoxic agents. Xerostomia, diabetes mellitus, poor oral hygiene, prosthetic oral appliances, and suppression of the immune system, e.g., as occurs with HIV infection, are

often predisposing conditions for development of candidiasis. Candidiasis may appear as pseudomembranous, atrophic erythomatus, or in chronic hyperplastic forms. Disinfection of all infected oral surfaces and prostheses with antifungal agents such as nystatin ointment or ketoconazole creams are effective. Prevention of candidiasis is presently not effective. Emerginginfectiousdiseaseswith oral manifestations: Many infectious diseases have oral manifestations, including actinomycoses; necrotizing ulcerative gingivitis; hand, foot, and mouth disease; leprosy; mycoses; NOMA and oral infections associated with gonorrhea, syphilis, tuberculosis, HIV infections, papovaviridae infections. Management of these infections is accomplished through topical therapy as well as management of any underlying systemic condition. Prevention is not possible with present knowledge. Efforts to control infectious diseases have generally targeted the pathogen, the mechanisms of pathogenesis, or the host. These include the following approaches: Cleanlinessand PhysicalRemovalof PathogenicBacteria Sanitation is still the most effective way to prevent many types of transmissible diseases. The principles of sanitation are used daily by the general public (e.g., hand washing) and clinicians (e.g., sterilization of surgical instruments). In the oral cavity, complete removal of the bacterial flora is impractical and, since the oral flora protects against serious infections, undesirable. A certain level of oral hygiene is possible through brushing, flossing and professional care, and reduces the buildup of dental biofilms (i.e., plaque) associated with malodor, caries and gingivitis/periodontitis. Oral hygiene may not be effective in preventing infections caused by viruses and fungi. Since oral pathogens are frequently found in normal "healthy" oral biofilms, more information is needed on what is an acceptable level of pathogens in plaque. BlockTransmission/Acquisitionof Pathogens This approach is closely associated with cleanliness and sanitation. Examples include the use of masks, gloves, and condoms to prevent the spread of the pathogen (e.g., hepatitis viruses and HIV). Recent studies indicate that oral bacteria are transmitted between spouses, and from parents to children. These data suggest methods to prevent transmission of the oral bacteria may be one strategy for preventing oral infectious diseases. PhysicalBarriersBetweenHost and Pathogen Dental sealants have proved to be highly effective in preventing pit and fissure dental caries, particularly when provided to patients at high risk for dental caries, i.e., previous caries history, high salivary mutans streptococci levels,

inadequate oral hygiene, deficient fluoride exposure, low socioeconomic status, xerostomia and familial caries patterns. ControlEnvironmentConditionsThat FavorVirulence Reduced intake of processed sugars to reduce caries and the elimination of periodontal pockets that favor growth of gram negative anaerobic bacteria are examples of this approach. EarlyDetection This approach assumes that the pathogen cannot be completely blocked and pathogenesis will inevitably occur. Early diagnosis of the onset of the disease can limit damage to the host tissues. In oral diseases, research on identifying the precavitation stage for caries, and biomarkers for periodontititis are examples of this approach. BiologicalModifiers Research on disease pathogenesis has produced a wealth of information on host biological molecules (e.g., cytokines and proteinases) that are critical to the diseases process. Parallel studies in protein chemistry and immunology have revealed inhibitors and enhancers of these molecules. Intervention studies using biological response modifiers, such as interleukin-1 receptor antagonist and matrix metalloproteinase inhibitors, show promise for this approach. Antibiotics/Antimicrobial/Chemotherapy In infectious disease medicine, the most rational approach to prevention and control of the diseases is to eliminate the pathogen or reduce the number of pathogen organisms to the point that the host defenses can easily block infection. However, this paradigm for disease control is not completely acceptable for oral infections, in which a normal flora is desirable and the microbial pathogen is often a member of the normal "healthy" flora. Fluoride treatments have been used to strengthen the teeth against acid demineralization and may also have antimicrobial effects on cariogenic bacteria. Additional research is underway on antimicrobial and anti-biofilm approaches to reducing caries. Chlorhexidine and iodine solutions are examples of antimicrobial approaches to prevention of caries and gingivitis/periodontitis. Local and systemic antibiotics are particularly useful in treating residual infections with subgingival microflora. Systemic antibiotics show promise in treating A. actinomycetemcomitans-related infections and some P. gingivalis-associated forms of periodontitis where the organism invades the tissue and is

inaccessible to normal host defenses and mechanical removal by the clinician. Vaccines Since the demonstration by Jenner in 1776 of active protection against smallpox, vaccination has been shown to be one of the safest and most costeffective ways to prevent infectious diseases. Interestingly, more deaths are prevented by vaccines than by antibiotics. With almost two hundred years of empirical and experimental research on the immune system, much is now known about the stimulation and functioning of the host immune system. These studies have resulted in some remarkable successes: deaths due to diphtheria, tetanus, whooping cough, have dropped sharply; vaccinia (smallpox) was eradicated from the world in 1979; and polio was eradicated from the Americas in 1994. Public health officials expect polio to be totally eradicated in 2000. Other viruses considered reasonable targets for elimination are measles and rubella. Vaccination against meningococcal meningitis may also be worldwide within the next few decades. It should be emphasized that approximately one third of world deaths are from infection; however approximately one third of these could be prevented by complete use of existing vaccines. Research to reduce dental caries and periodontitis by vaccination is underway and shows some promise for success. Vaccination with various antigens of S. mutans, including peptide vaccines and glucosyltransferase, successfully protects rodents and primates from dental caries. Vaccines to bacteria associated with periodontitis, particularly Porphyromonas gingivalis, may be useful in preventing the adult forms of periodontitis. Vaccines to boost the host innate immune system (e.g., stimulation of neutrophils, release of lactoferrin or defensin peptides), are being tested and show some promise. Education/BehaviorModification Behavior, such as smoking, diet, brushing/flossing, plays a major role in the development of the common forms of oral infectious diseases. A logical assumption is that a change in disease-promoting behavior would reduce the risk of disease and thus lead to oral health. Efforts to educate the public regarding good oral hygiene practices and change behaviors have met with mixed success. Nevertheless, this approach holds great promise and deserves increased attention.

Research Needs, Opportunities and Recommendations PreventionandControlof Oral InfectiousDiseases

Recommendation Need Develop fast, economical and accurate Biomarkers for oral ways to diagnose oral infections. infections could accelerate epidemiology research as well as studies on pathogenesis. Develop new ways to block the Tissue destruction pathogenesis of oral infections. associated with oral infection and chronic inflammation could be reduced.

Opportunities Support the identification of biomarkers and developmen corresponding diagnostic as oral infectious diseases.

Support research to develop specific inhibitors of microbia proteases and other potentia virulence factors produced b pathogens.

Investigate probiotic approac (i.e., whole bacteria replacem therapy) to eliminate pathog members of the microbiota.

Continue studies of speciesspecific antimicrobial molecu (e.g., bacteriocins) that influe microbial colonization and gr Gain more knowledge on all forms of This is an opportunity to Characterize innate antimicr immunity, including innate immunity. learn more about how the factors found in saliva and host protects itself from oral produced by epithelial cells. infections. Support basic and clinical re on mucosal immunity and or tolerance. Fully characterize human tonsils, adenoids, an associated tissues as possib mucosal inductive sites. New vaccines, biological modifiers and Traditionally, vaccines have Support research on the therapeutic agents are needed to been a successful way to development of vaccines for combat oral infectious diseases. prevent infectious diseases.infections. For example, iden In particular, ways to enhance the virulence-associated antigen immune response to biofilms are develop better adjuvants for needed. mucosal immune responses Study the effect of biofilms o activity of antibodies and oth host-derived antimicrobial molecules. Reduce or eliminate the effects of oral Recent evidence suggests Examine the association of o infections on systemic health. a link between oral infection and hematogenous infections and systemic spread to the etiology and diseases or conditions. pathogenesis of systemic dis These studies could help to elucidate the link between the oral cavity and the rest

of the body. In vivo models are needed to evaluate Animal experimentation vaccines and the role of oral infections continues to be useful in systemic diseases. approach to translate basic science into clinical practice.

Identify better animal models the efficacy of potential vacc for oral infectious diseases, as intervention studies to as the relationship between ora infections and systemic dise

Source:Reportfromthe NIDRInfectiousDiseasesPlanningWorkshopHeldNov. 10-12, 1997, Bethesda, MD

2. First Encounters: Transmission of Infectious Oral Diseases From Mother to Child

It is an interestingparadoxthat a mothercan exposean infantto infectiousmicrobes throughintimatecontact,yet she can also transfera numberof diverseantibodies throughher breastmilk that conferimmunityagainstsomeof the very microbesthat infectedher duringpregnancy.Furthermore,the mother'soral healthcan be a major determinantof or risk factorin the healthof the developingfetusor newborninfant. Recently,a numberof newbasic, translationaland patientorientedresearchstudies haveidentifieda potentiallyremarkableassociationbetweenmaternaltransmissionof infectiousoral microbesfrommotherto fetusduringpregnancy,duringthe birth processandfrommotherto child after birth. Understandingthesefirst encountersis potentiallyverysignificantin tryingto understandthe etiologyand pathogenesisof manyopportunisticoral infections. The Link Between Oral Microbes and Low Birth Weight The humanfetus, the newborninfantand the youngchild are all exposedto infectious microbesandare at increasingrisk of developinginfectiousdiseases.Ironically, mostof the microbesto whichwe are exposedare transmittedfromour primarycaregiver, usuallyour mother.Thepresenceof diseasecausingmicrobes_viruses,bacteria,yeast

andparasites_canactuallyinfluencethe termlengthof a pregnancy,the birth weight anddevelopmentof the newborn,and eventhe ability of newbornsto thrivein the world theyenter. Transientor prolongedviremiaor bacteremiamayinduceextremematernal or fetal tissueresponsesand result in seriousdiseaseconditions. Just as the state or conditionof pregnancycan affect the motheradversely,it now appearsthat a mother'spoororal healthcan adverselyaffect the healthof the fetusand newborn.Lowbirth weight,or LBW,of lessthan2,500gramsor 1 poundis a major worldwidepublichealthproblem.For example,morethan6 percentof the nearly4 millioninfantsbornin the UnitedStatesin 1995wereLBW.LBWinfantsconfronta significantsurvivaldisadvantagethat accountsfor almostonehalf of our nation'sinfant mortality, as well as a numberof congenitalmalformationsand disorders,including respiratorydistresssyndromeand neurodevelopmental,cardiovascularandcraniofacial malformations. Nowthereis a newclue to the originsof LBW.Recentstudiesfromthe Universityof NorthCarolina,ChapelHill, andthe Universityof Alabamaat Birminghamhaveindicated that poormaternalperiodontalhealthcan increasethe infant'spotentialfor LBWand possiblyfor pretermor prematurebirth (at less than37 weeks'gestation).In the North Carolinastudy,the scientificresearchteamdiscoveredthat womenwith periodontal diseasewereseventimesmorelikely to deliverLBWbabiesprematurely. A largercasecontrolledstudyconductedat the Universityof Alabamaat Birmingham (reportedby A. Dasanayake)usedextensivedata analysesto determinewhether periodontalhealthwasan independentfactorinfluencingLBW.Comparedwith control subjectsand with a low probabilityof naturaloccurrence,the numberof healthy sextants(in otherwords,the divisionof eacharchdentitioninto bicuspid,molarand cuspidregions)in the mouthsof motherswith LBWbabieswassignificantlylower(0.4 vs. 1.1, P = .001). The numberswith bleedinggingiva(5.6 vs. 4.9, P = .001) and dental calculus(4.0 vs. 3.2, P = .01) weresignificantlyhigher.Comparingthe ratio of the probabilityof the occurrenceof LBWto nonoccurrenceof LBWundertheseconditions (oddsratio, or OR) withina 95 percentconfidencelimit, or CL, the scientificteam discoveredthat motherswith morehealthysextants(OR=0.3, 95 percentCL = 0.12 to 0.72) had a statisticallylowerrisk of givingbirth to LBWbabies.Thesestudiesprovidea potentiallysignificantassociationbetweenLBWanda mother'spoorperiodontalhealth as an independentrisk factor. Manyotherfactorsare alsoinvolvedin bothprematureand low birth weight,or PLBW, babies.Gramnegativefusiformbacteria,and otherbacterial infectionsin boththe genitourinarytract and the mouth,mayeitherreleasebacterialendotoxinsor inducea maternaland/orfetal tissueresponseto theseopportunisticinfections,thereby producingPLBWinfants. The gramnegativeanaerobicinfectionis postulatedto provide a reservoirof lipopolysaccharidesthat can triggermaternaland/orfetal tissuederived cytokines,mediatorsof inflammationsuchas interleukin1 [(beta)(IL-1 (beta)), tumor necrosisfactoralpha(TNFalpha)andprostaglandinE2 (PGE 2). Eachof thesematernal

or fetal tissuederivedmoleculeshas beenfoundto be capableof inducingpreterm labor. First Encounters:Transmissionof InfectiousOral DiseasesFromMotherto Child It becomesreasonableto surmisethat maternaltransmissionof oral microbesinitiated througha transientbacteremiaduringthe third trimesterof pregnancycouldinvoke upperand lowergenitourinarytissuereleaseof cytokinesand prostaglandins,which subsequentlyinduceprematuredevelopmentand pretermlabor. Theanatomical pathwaysmayincludetransit throughthe vascularsystemof the placenta,throughthe amnioticfluid andacrossthe gut endothelium(Figure).

Figure.Suggestedanatomicalpathwaysfor maternaltransmissionof oral microbesor their tissuederivedinflammatorymediatorsduringpregnancy. Placenta

Oral Cavity Oral InfectiousDiseases

v Transmitting Infection, Transferring Immunity

The newbornhumaninfantdrawsits first breathinto a mouththat is usuallydevoidof microbes.Withinminutesto hours,the newbornmouthis colonizedwith viruses, bacteria,yeastand protozoathat mayremainin his or her mouthuntil death.The microbialoral flora, mostof whichare consideredbeneficial, are transmittedinto the baby'smouthfroma varietyof environmentalsources:salivadropletsin the air, a breast,a nipple, a fingeror evenbreastmilk. Breastmilk, in fact, is importantin supplyingthe infantwith immunological components,or humoralantibodies.Someof thesefactorsare selectivefactorsthat can affect the intestinalmicrofloraby enhancementof the growthof desirablebacteriaand by nonspecificinhibitionof somemicrobesthroughthe biologicalactivityof lysozyme, lactoferrin,interferonand leukocytes(macrophages;thymusderivedIymphocytes,or T cells; bonemarrowderivedIymphocytes,or B cells; and granulocytes). Antibodiesproducedby the motherto variouschallengesfromthe environmentare knownto be transmittedfromthe motherto the developingfetusthroughthe placenta. The concentrationsof the diverseantibodiesthat conferpassiveimmunityto the newbornbabyare evenhigherin the colostrum(first milk) at the initiationof maternal nursingof the baby(Box, "Targetsof Colostrum/BreastMilk SecretoryIgA"). Importantly,all classesof immunoglobulins,or Ig _includingIgG, IgM, IgE andevenhigh levelsof secretoryIgA, or sIgA_arefoundin varyingamountsin the humanmaternal colostrum.SecretoryIgA attachesto the infantmucosalepitheliumand preventsthe attachmentof specificinfectiousagents.Levelsof sIgAin maternalmilk havebeen isolated,characterizedand foundto be specificagainstcertaininfectiouspathogens suchas entericandrespiratoryviral and bacterial microbes. It has beenlearnedthat the concentrationof this kindof passiveimmunitytransferred frommotherto infantcan increasein responseto maternalexposureto specific antigens.Thus,the infantis providedwith environmentallyspecificantibodiesin the

colostrum/breastmilk that providethe babywith a level of protectionduringthe first 6 monthsof immunologicalsystemdevelopmentand maturity(Table). First Encounters:Transmissionof InfectiousOral DiseasesFromMotherto Child Targetsof Colostrum/BreastMilk SecretoryIGA BacteriaViruses Escherichia coli Cytomegalovirus Pneumococci Poliovirus Haemophilus influenzae Respiratorysyncytialvirus Klebsiella pneumoniae Rotavirus Rubella ProteinsEukaryoticParasites ToxinsChlamydia trachomatis VirulencefactorsGiardia lamblia E. coli toxin Lipopolysaccharide Vibrio cholerae Fungi(Yeast) Candida albicans Oral InfectiousDiseases NonantibodyDefensesin Colostrum/BreastMilk AgentEffect NonantibodyAntibacterialFactors GMl-like gangliosidesInhibit Escherichia coli and Vibrio cholerae enterotoxin Oligosaccharidegrowthfactorfor Lactobacillus growthcreatesacid gut

Lactobacillus bifidus conditionsthat suppressharmfulorganisms Fatty acidsand monoglyceridesActivationof lipidswith a lipasegivesthese products,whichact on grampositivebacteria LactoferrinBindsFe+++andinhibitsbacterial growth LysozyrneLysesbacteriaby cleavingN-acetyl muramincacid LactoperoxidaseInhibitsgrowth/killsbacteria Peroxideand ascorbateInhibitsgrowth/killsbacteria NonantibodyAntiviral Factors Alpha2 macroglobulinlikeproteinInhibitsinfluenzaand parainfluenza hemagglutininactivity NonimmunoglobulinfactorInhibitsrotavirusinfections Fatty acids(polyunsaturated)Inhibit envelopeviruses Interferona Inhibitsrespiratorysyncytialvirusinfection Anti InflammatoryFactors LactoferrinInhibitscomplement LysozymeInhibitschemotoxins CatalaseDegradesH202 Lipidand nonlipidfactorsInhibit leukocytes ProstaglandinE InhibitsT cells PregnancyassociatedglycoproteinInhibitsT cells

First Encounters:Transmissionof InfectiousOral DiseasesFromMotherto Child

v The Lifelong Growth of Oral Microbes

In the humanmouth,thereare oftenmoremicroorganismsthanthereare peoplein the entireworld. Someof theseopportunisticmicroorganismspreferthe cheekfor habitation;otherspreferthe backof the tonguein an anaerobiccrevice;still others enjoythe wet, oxygendeprivedareabetweenthe toothsurfaceand the periodontal tissues.Of course,the microbialecologicalconditionsin the mouthare extremely sensitiveto the challengesthat confrontthe humanthroughoutthe lifespanand, therefore,can oftenchangeprecipitously.Frombirth to death,the mouth'scontinued exposureto opportunisticinfectiouspathogensis in balancewith host immunity;the balancebetweentheseprofoundlyimportantprocessesoftenservesas a mirrorfor the detectionof not only oral pathologybut majorsystemicdiseases. The growthof thesemicrobesin the infant'smouthfollowsa patternof microbial ecologicalsuccession.A few pioneerspeciessettle and nest, creatinga habitatthat is friendlyto otherspecies,whichthenmovein to join the microbialecosystem.Whenthe first deciduousteethbeginto eruptinto the mouth,anothergroupof microbes_includingthe dental cariescausingStreptococcusmutans_jointhe microbial ecosystemand take up residence.Whenthe compositionof salivachangesduring puberty,yet anothergroupof microbesimmigratesand flourishesin the ecosystem. Finally, the averageadult mouthcontainsa complexgroupof organisms,consistingof morethan400 differentmicrobialspecies(mostlybacteria)and eachwith its own preferredhabitat. In a so- called"cleanmouth,"therecan be 1,000to 100,000bacteria attachedto eachtoothsurface.

Oral InfectiousDiseases

v All in the Family

Epidemiologistshavepublishedmanystudiesdeterminingthe transmissionof organismswithinfamiliesand largercommunitiesand populations.Someof the best

documentedstudiesinvolvingthe mouthdescribethe transmissionof microbes associatedwith the etiologyof dental cariesandperiodontaldiseasesand, most recently,the transmissionof AIDSfrommotherto child. CommunicatingS. mutans. In 1959, NIDRsponsoredresearchscientistsisolatedthe bacterialspeciesS. mutans, nowconsideredthe majoretiologicalagentin human dentalcaries. S. mutans consistsof a numberof differentsubspeciesor different strainsthat vary in growthcharacteristicsand in the pathologytheyproduce.Because the presenceof teethor othernondesquamatingsurfacesis a prerequisitefor stable colonizationof the microbe,infantsacquirethesebacteriaduringdeciduoustooth eruptionin their sixthmonthof life. Publishedreportshavesuggestedthat childrenacquireS. mutans fromtheir mothers, throughfrequentandintimatecontact,in the first two yearsof life whenthe bacteriaare initially transferred.Scientistsin the dental schoolat the Universityof Alabamain Birminghamrecentlyreportedthe resultsof a longitudinalstudyof 34 motherinfant pairs and sevenfathers,whoshareda specifichousehold.Their studyprovided importantdocumentationsupportingthe hypothesisthat maternaltransmissionof S. mutans is critical to the formationof the microbialecosystemin the newborninfant's mouth.Theydeterminedindividualstrainsof S. mutans usinggenotypingor DNA fingerprinting.Thesensitivityandspecificityof this technologyprovidedthe scientific teamwith the necessaryconfidenceto identifyand characterizethe oral bacteriaof mothersand their infantsfrombirth to approximately3 yearsof age, with samplingat 3monthintervals. The genotypesof S. mutans isolatedfromthe infantsat the timeof initial acquisition werehomologousto thoseisolatedfromthe mother'ssalivain 71 percentof the motherinfantpairs. Thefidelitybetweenstrainsof S. mutans in mothersand their female infants(88 percent), in contrastto thoseisolatedfromthe maleinfants(55 percent), indicatedthat in the groupstudiedthe conservationof S. mutans withinthe motherinfantpairswassexspecific. In no instancedid theydeterminehomologyof genotype betweenfatherand infant, or betweenfathersand mothers,furthersupportingthe hypothesisthat transmissionand acquisitionof S. mutans followsmaternallinesvery early in infancyandearlychildhood. The lackof maternalpaternalsharingof microbialgenotypesmayindicatethat S. mutans is difficult to transmitoutsideof the theoretical"windowof infectivity"period, First Encounters:Transmissionof InfectiousOral DiseasesFromMotherto Child whichoccursduringchildhoodat a medianage of 26 months.It is also possiblethat motherstransferto their infantsnot only maternalimmunoglobulinsvia the placenta andcolostrum,but also a complementaryset of indigenousmicrobescapableof coexistingwith thesematernallyderivedor directedimmunityfactors.If the passively acquiredmaternalimmunoglobulinsplay a role in determiningwhichstrainsof microbescan colonizethe infant, theyalsomayfunctionin excludingthe father's microbialstrains.Additionalresearchis requiredto substantiatetheseinterpretations.

Communicatingperiodontalpathogens. Anotherareaof activemolecular epidemiologicalinvestigationsinvolvesthe transmissionof the periodontalpathogens betweenmembersof extendedfamilies.Becauseof the prevalenceof periodontitisin the adult population,this diseaseand its transmissionwithinthe populationhavebeen extensivelystudied.Moleculartoolssuchas geneticfingerprintingtechnologyhave beenappliedto the identificationand characterizationof anaerobicbacteria_the microbesthat live withoutoxygenandthat are associatedwith the etiologyof periodontaldiseases.Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Treponema denticola, Bacteroides forsythus and Prevotella intermedia are someof the specificbacteriaassumedto be engagedin the etiologyof periodontaldiseases. A moderateformof periodontitisoccursin 40 percentof the populationolderthan12 yearsof age, and moderateperiodontaldestructionhas beenreportedin 80 percentof the populationolderthan65 yearsof age. A recentcollaborativestudybetweenfaculty in the schoolsof medicineanddentistryat TheOhioStateUniversitylinkedP. gingivalis with clinicalindicatorsof periodontaldiseasesuchas increased periodontalpocketdepthand increasedtoothattachmentloss. The studywasdesigned to betteridentifythe risk factorsassociatedwith the varyingdiseaseprocessand thus facilitatethe eventualdevelopmentof preventivestrategies. The OhioStateinvestigatorsusedthe polymerasechainreaction,or PCR,a procedure that allowsamplificationand sequencingof DNAbetweenprimers.PCRis specificand sensitiveenoughto detectthe verylow levelsof P. gingivalis foundin childrenbut has the efficiencyneededto analyzea largenumberof sampleswith a highconfidence level. Theydeterminedthe colonizationstatusof 564 membersof 104 multigenerational familiesandcomparedit with concordancein the generalAmericanpopulation. Statisticalanalysesof the concordancein eachentirefamilywereobtained;a coreunit wasconsideredto consistof threegenerationsand includedthe oldestchild, both parentsand a grandparent.Theconcordancewithinentire familiesand for spouses, childrenand their mothers,childrenand their fathers,adultsand their mothers,and siblingswasstudiedand comparedwith the concordancethat wouldbe expectedif P. gingivalis wasrandomlydistributedin the entirehumanpopulationstudied. Oral InfectiousDiseases The researchersdiscoveredthat contactwith an infectedfamilymembersubstantially increasedthe relativerisk of colonizationof theseintrafamilialpairs. Microbial colonizationbetweenspousessuggeststhat althoughP. gingivalis is mostcommonly acquiredduringchildhood,it mayalso be acquiredlater in life. Importantly,the results supportthe hypothesisthat transmissionof P. gingivalis, whilecommonwithin families(especiallybetweenmotheror primarycaregiverand child), wouldseemto be ratherunusualoutsidethe immediatefamily.

First Encounters:Transmissionof InfectiousOral DiseasesFromMotherto Child

v Conclusion: The Prospect Ahead

Studieson maternaltransmissionof oral microbialinfectionsindicatethe requirement for closecontactand sharingof microorganisms,andnewapproachesto preventing andtreatingdiseasesof the mouthare beinginvestigated.Oneareaof interestinvolves the preventionof the maternaltransferof infectiousbacteriato the child duringthe socalledwindowof infectivity. Onepotentiallyimportantquestionto consideris the following:If womenwhocarryvery infectiousstrainsof S. mutans havetheir teeth, gingivaandoral mucosarigorouslytreatedwith antisepticsor antibioticsand thentheir toothsurfacesvarnishedduringthe critical timeof their child'ssusceptibility, will the childrenavoidcontractingthe infectiousmicrobesfromtheir mothers?Studiesfocusing on this questionare nowunderway.

The developmentof vaccinesagainstthe mostinfectiousoral bacteria, suchas S. mutans, has longbeendiscussedbut is nowreceivingrenewedeffort. Furtherstudyof the approximately60 proteinsfoundin salivacoulddiscloseadditionalcomponentslike the antibacteriallysozymeor an antiviral componentthat is activeagainstcomponents of the microbialoral flora. Researchis also beingconductedthat surveysmanydifferent infectiousoral bacteriain hopesof findingonethat producesan antibioticlike molecule activeagainstopportunisticinfectiousbacteria.Yet otherresearchteamsare studying howto blockor inhibit bacteriain producingtheir uniqueadhesives,whichaid in attachmentand eventualcolonization,thusproducingbiofilmson toothor evenimplant surfaces.In the next 5 or 10 years, we shouldexpectthat suchNIDR-supported scientificresearchwill makeimportantclinical progresstowardunderstandingand controllingthe transmissionof infectiousmicrobesinto andthroughthe mouth.

Oral InfectiousDiseases For AdditionalInformation Resources ChaouatG, ed. Theimmunologyof the fetus. BocaRaton,Fla.: CRCPress,Inc.; 1990. DasanayakeAP. Pregnantwomen'spoorhealthandlow birth weight. Presentedat SunstarChapelHill Symposium,PeriodontalDiseaseandHumanHealth;March24-25, 1997;ChapelHill, N.C.: Universityof NorthCarolina,ChapelHill. HauthJC, et al. Reducedincidenceof pretermdeliverywith metronidazoleand erythromycinin womenwith bacterial vaginosis.N Engl J Med 1995;333(26): 1732-6.

Li Y, CaufieldPW. Thefidelity of initial acquisitionof mutans streptococci by infantsfromtheir mothers.J Dent Res 1995;74(2):681-5. OffenbachS, et al. Periodontalinfectionas a possiblerisk factorfor pretermlow birth weight. J Periodontol 1996;67(10)(Supplement):1103-13. Tuite-McDonnellM, et al. Concordanceof Porphyromonas gingivalis colonization in families. J Clin Microbiol 1997;35(2):45561.

Organizations NationalInstituteof Allergyand InfectiousDiseases Officeof Communications NationalInstitutesof Health Bethesda,MD. 20892 (301) 496-5717 NationalInstituteof ChildHealthand HumanDevelopment PublicInformationandCommunicationBranch NationalInstitutesof Health Bethesda,MD20892 (301) 496-5133 NationalInstituteof DentalResearch Informationoffice NationalInstituteof Health Bethesda,MD20892 (301) 496-4261

3.
Oral Opportunistic Infections: Link to Systemic Diseases

The periodontium,comprisedof the gingiva,boneand othersupportingtissuesthat anchorthe teeth, playsa key role in the interplaybetweenoral healthand systemic disease.Infectionin thesetissues,primarilyby gramnegativeanaerobicbacteria, can initiatea seriesof inflammatoryandimmunologicchangesleadingto the destructionof connectivetissueand bone.Longconsidereda localizedinfection,periodontaldiseases are nowlinkedto a varietyof conditionswith systemicimplications.

ChronicDegenerativeDiseases
Periodontitis, advancedinfectionof the periodontiumthat oftencausestoothmobility andtoothloss, appearsto sharegeneticallydeterminedrisk factorswith severalother chronicdegenerativediseasessuchas ulcerativecolitis, juvenilearthritis, and systemic lupuserythematosus.Recentresearchpointsto specificgeneticmarkersassociated with increasedproductionof the pro-inflammatorycytokinesinterleukin1 andTNF as strongindicatorsof susceptibilityto severeperiodontitis. This recentfindingcould leadto early identificationof peopleat mostrisk for severeperiodontaldiseaseand initiationof appropriatetherapeuticinterventions.

DiabetesMellitus
The destructiveinflammatoryprocessesthat defineperiodontaldiseaseare closely intertwinedwith diabetes.Personswith non-insulin-dependentdiabetesmellitus (NIDDM)are threetimesmorelikelyto developperiodontaldiseasethannondiabetic individuals.Addsmokingto the mix, and the chancesof developingperiodontitiswith loss of toothsupportingboneare 20 timeshigher.An increasedrisk for destructive periodontaldiseasealso holdsfor personswith insulin-dependentdiabetesmellitus (IDDM).

Oral InfectiousDiseases Muchof whatis knownaboutthe periodontalcomplicationsof diabeteshas been learnedfromthe PimaIndiansof Arizona,whohavethe highestreportedratesof NIDDM in the world. NIDCRsupportedresearchin the Pimacommunityhas shownthat periodontalinfectionis moreprevalent,moresevere,and developsat an earlier age in this populationthanin nondiabeticpersons.As diabetesincreasesin severity, the rate at whichvital toothanchoringboneis lost accelerates.PimaIndianswith NIDDMare 15 timesmorelikelyto be edentulousthanthosewithoutdiabetes. Nowthereis evidencethat a historyof chronicperiodontaldiseasecan disruptdiabetic control, suggestingthat periodontalinfectionsmayhavesystemicrepercussions.The exactnatureof this complexrelationshipis not clear. It is likely, however,that increased geneticsusceptibilityto infection,impairedhost response,and the excessive productionof collagenasefoundin periodontaldiseasemayall play importantrolesin NIDDM.Similaritiesin the etiologyof periodontaland othercomplicationsof diabetes havealsoemerged. Studieshaveshown,for example,that hyperglycemiais the commonbasisfor diabetic complicationsin the eyes, kidneysand nerves.Glucosein highconcentrationsattaches to othermolecules,stimulatingchemicalreactionsthat produceadvancedglycosylation endproducts.Theselargemoleculesaccumulatein tissues,causingdamageand disruptingnormalfunction.Scientistssuspectthat thesecellularreactionsfigureas well in the tissuedestructionseenin periodontaldisease.

Investigatorsare alsoexaminingthe interplaybetweenperiodontalinfectionand metaboliccontrol. Acuteviral and bacterial infectionsare knownto induceinsulin resistance,whichdisruptsbloodglucosecontrol. Factorsincludingstress, fever, catabolism,andelevatedlevelsof hormonesantagonisticto insulinsuchas growth hormone,cortisol, and glucagonlikelyplaya role in the developmentof insulin resistanceduringinfection.

It is possible,then, that chronicgramnegativeinfectionswith persistentproductionof bacterialtoxins,like periodontaldisease,couldhavethe samedeleteriouseffect. If so, wouldeliminationor controlof periodontalinfectionimprovemetaboliccontrolof diabetes? To explorethis hypothesis,researchersdesigneda treatmentprotocolspecificallyto managediabetesassociatedperiodontitisin a groupof PimaIndianswith poorlycon

Oral OpportunisticInfections:Linkto SystemicDiseases trolledNIDDM.Theyfoundthat debridement(deepcleaningto removehardenedplaque belowthe surfaceof the gingiva), combinedwith an antimicrobialsolutionand a 2-week regimenof the antibioticdoxycycline_chosenfor its anticollagenaseactivity_resultedin significantshort-termimprovementin the concentrationof hemoglobinA1c, a measure of averagebloodglucoselevelsover3 months. A controlgroupreceivingonly debridementdid not sharethe gainsin periodontal health, improvedhemoglobinA1clevels, and reducedhyperglycemiathat the treatment groupexperienced. Thesefindingsoffer evidencethat chronicinfectionssuchas periodontaldisease worsenglycemiccontroland that eliminatingtheseinfectionscouldenhancemetabolic controlin personswith diabetes.Additionallarge-scalestudiesare neededto further evaluatethe effectsof treatingperiodontitison bloodglucoselevels. Futureresearch shouldalsoexamine,in otherpopulations,the relationshipbetweensevereperiodontal diseaseand poorglycemiccontrolthat has beenevidencedin the PimaIndian community. Whileworkproceedson the oral complicationsof diabetes,otherstudiesare exploring the molecularpathogenesisof the disease.NIDCRresearchershaveidentifiedan importantmarkerprotein,IA-2 , for insulin-dependentdiabetesmellitus,an autoimmunedisorderwhichaffectscloseto one millionpeoplein the UnitedStates alone.

Destructiveautoantibodies,whichattackthe body'sowninsulin-producingbeta cells, are the basisof the existing,laborintensivediagnostictest for IDDM.However,the recentidentificationof targetproteinsin the pancreas,suchas IA-2 , that react with theseautoantibodiesmakesit possibleto developa rapidand effectivetest to screen largepopulationsfor IDDM. IA2, whenusedin combinationwith two otherknownmarkerproteins,IA-2 andGAD 65, recognizedautoantibodiesin 90 percentof personswith IDDM.The presenceof autoantibodiesto the markerproteinsin otherwisenormalindividualswasalso highly predictivein identifyingthoseat risk of developingthe disease.In addition,these proteinsare candidatesfor immunetolerancestudies,whichattemptto preventthe developmentof destructiveautoantibodiesandsubsequentIDDM. The investigatorsare hopefulthat their demonstrationof the proteinsas majortargetsof the autoimmuneattackwill aid in uncoveringthe actual causeof the diseaseprocess.

Oral InfectiousDiseases

Heart Disease
A numberof studieshaveshownthat peoplewith periodontitisare morelikely to developcardiovasculardiseasethanindividualswithoutperiodontalinfection.Onesuch studysuggeststhat the risk of fatal heart diseasedoublesfor personswith severe periodontaldisease. Part of the link betweenthesetwo diseasesmaybe discoveredthroughnovel investigationsof the opportunistic,infectiousbacteriathat colonizethe mouth. Scientiststheorizethat certaintypesof thesebacteria, whichformbiofilmsand cause periodontaldisease,alsoactivatewhitebloodcells in the bodyto releaseproinflammatorymediatorsthat maycontributeto heart diseaseand stroke. To explorethe underlyinginflammatoryresponsescommonto bothdiseases,NIDCR granteesare examiningperiodontaldiseasemeasures(pocketdepthwheregingival tissueshavepulledawayfromtoothsurfacesand wherethereis lossof tissue)and biologicalresponsesin 14,000peopleenrolledin an extensivestudyof heart disease sponsoredby the NationalHeart, Lungand BloodInstitute.Scientistswill also analyze gingivalcrevicularfluid constituentsthat maycontainpro-inflammatorymediators associatedwith heart disease,as well as bloodsamplesto identifyantibodiesto periodontalpathogens. The researchteamwill comparethesemeasureswith clinical indicatorsof heart disease, ultrasoundmeasuresof carotidvesselthickening,and the occurrenceof heart attacks, stroke,and deathto determineif thereis a correlation.Shouldthe link betweenoral diseaseand heart diseasebe firmlyestablished,futurestudieswill focuson identifying

the specificbiologicalfactorsinvolvedand transferringthis knowledgeto prevent disease.

Oral OpportunisticInfections:Linkto SystemicDiseases

PretermLowBirth WeightBabies
Emergingevidencemaylink severeperiodontaldiseasein pregnantwomento a sevenfoldincreasein the risk of deliveringpretermlow birth weightbabies.NIDCRsupportedresearchersestimatethat as manyas 18 percentof the 250,000premature low-weightinfantsbornin the UnitedStateseachyear maybe attributedto infectious oral disease. The emotional,social, and economiccostsassociatedwith thesesmall babiesare staggering.Hospitalcostsalonesurpass$5 billionannually.Whencoststo societyin termsof sufferingandmanaginglong-termdisabilitiesoftenassociatedwith prematurity are considered,this figureescalatesdramatically. In a recentstudy,mothersof pretermlow-weightnewbornswerefoundto have significantlymoresevereperiodontaldiseasethandid mothersof fullterm,normal weightbabies.Investigatorsbelievethat the molecularpathogenesismaybe similarto that characterizedfor othermaternal,bacterial, opportunisticinfections,suchas genitourinaryinfections,that are associatedwith low-weightpretermbirths. Scientiststheorizethat oral pathogensreleasetoxinsthat reachthe humanplacentavia the mother'sbloodcirculationand interferewith fetal growthanddevelopment,which has beenshownto occurin animalstudies.The oral infectionalso promptsaccelerated productionof inflammatorymediatorsPGE 2 and TNF that normallybuild to a threshold level throughoutpregnancy,thencue the onsetof labor. Instead,the elevatedlevelsof theseinflammatorymediatorstriggerprematuredelivery. Takinginto accountall the knownrisk factorsfor prematurebirth, the researcherscould identifyno otherreasonfor the relationshiptheyhadfoundbetweensevereperiodontal diseaseand pretermlow-weightbirths. Additionalresearchis neededto confirmthis

intriguingfindingandto determineif treatingand preventingperiodontaldiseasewould reducethe incidenceof thesehighrisk births.

4.
Acquired Immunodeficiency Syndrome

The oral effectsof systemicdiseaseare by no meanslimitedonly to the periodontium. All of the tissuesin the oral cavityare fair gamefor a varietyof insults, eitherdirectly frominfection,or indirectlyas part of the systemicdiseaseprocess.Thereis perhapsno betterillustrationof the involvementof oral tissuesin systemicdiseasethanthe oral manifestationsof AIDS.

v Oral Lesions
Sincethe acquiredimmunedeficiencysyndromewasfirst recognizedin the United Statesin 1981, the mouthhas provideda remarkablelaboratoryfor the studyof this emerginginfectiousdiseasethat targetsthe immunesystemfor destruction.Thefirst clinicalreportsof this syndromeindicatedthat lesionsin the oral cavitywerecommon andoftenoccurredearly in the courseof the disease.Oral healthscientistsinitiatednot

only clinical studiesto definethe oral signsand symptoms,but also a basicresearch strategyto understandthe molecularvirologyand immunologyof AIDS. Studiesof the naturalhistoryand epidemiologyof HIV/AIDSdocumentedthat the fungal diseaseoral candidiasisis the mostcommonopportunisticinfectionseenin HIVinfectedpatients,followedby a secondoral lesiontermedhairy leukoplakia.A whitish lesionfrequentlyseenon the sideof the tongue,hairyleukoplakiais stronglyassociated with the EpsteinBarr virusand is a reliablepredictorof AIDS. A comparisonof HIV-positivepatientswith similarCD4counts(a measureof the body's immuneresponse)revealedthat thosewith oral candidiasisor hairyleukoplakiatendto developmajoropportunisticinfectionsor progressto AIDSmorerapidlythanpatients withouttheselesions.Also, the oddsof developingoral candidiasisincreaseas the CD4 countsof infectionfightingT cells decrease.In parts of the worldwherediagnostic bloodtestsfor HIV are not available,the presenceof theseoral lesionsin otherwise asymptomaticadultscan be usedas an indicatorof HIV infection. A numberof studiesare examiningcandidaspeciesto determinethe mechanisms involvedin the conversionof this harmlessfunguscommonlyfoundin the mouthto an Oral InfectiouisDiseases aggressiveinfectiouspathogen.NIDCRsupportedresearchto characterizethe entire genomeof Candidaalbicanswill acceleratethis process.Otherstudiesare focusingon drugresistantcandidaand the potentialuse of genetherapyto bolsterlevelsof histatin, a potentantifungalagentnormallyfoundin the saliva. Clinicaltrials are alsounderway to determineif scrupulousoral hygiene,the use of antimicrobialmouthrinses,and regulardental carecan preventor reduceoral complicationsin HIV patientswith severelycompromisedimmunesystems.

Anti-HIV Action
Despitethe presenceof HIV-associatedlesionsin the mouthand their implicationsfor escalatingdisease,studiesby NIDCRand otherNIH-supportedscientistssuggestthat HIV is not spreadthroughcasualcontactwith saliva. Researchhas shownthat HIV is easilyculturedfromthe bloodand spinalfluid of AIDSpatients,but not fromthe saliva of HIV/AIDSpatientswith oral lesions.Of particularinterestis the findingthat human salivademonstratesanti-HIV activity. The intensesearchfor protectiveconstituentsin salivaled NIDCRinvestigatorsto a relativelysmall proteincalledsecretoryleukocyteproteaseinhibitor, or SLPI, which attachesto the surfaceof monocytesand T cells and blocksinfectionby HIV. SLPI may help explainwhyAIDSdoesnot appearto be spreadby saliva, but muchaboutits possibleprotectiveeffect remainsunknown.The next stepsare to determinethe protein

bindingsiteson monocytesand T cells, the role SLPI playsin HIV entryinto host cells, andits potential as a protectiveagentagainstHIV transmission. FutureNIDCRdirectionsin HIV/AIDSresearchincludeexpandingbothour knowledgeof the natural historyand epidemiologyof oral transmissionand manifestationsof HIV in variouspopulations(includingwomen,children,adolescentsand minorities), and our understandingof opportunisticinfectionsand mucosalimmunity.The searchfor therapeuticinterventions,syntheticdrugsand vaccines,andinnovativedelivery systemswill also be an importantpart of the NIDCRresearchportfolio.

BindingSite Identified
Essentialto progressin this areais a betterunderstandingof just whathappensat the

AcquiredImmunodeficiencySyndrome HIV/monocyteand HIV/lymphocyteinterface.Oneof the longstandingchallengesin AIDSresearchhas beenfiguringout exactlyhowgp120,the largeproteinon the surface of HIV, latchesontothe CD4targetreceptoron T cells in the first stepin HIV infection. Studiesspearheadedby NIDCRscientistshavenowidentifiedthat bindingsite, called C4, and determinedhowit recognizesits targetreceptor.Thesefindingsopenthe door not only for the designof newdrugsand vaccinesto fight HIV infection,but also for the developmentof interventionsto blockthe initial interactionbetweenHIV andcells and therebyinhibit infection.

Macrophages:HIV Reservoirs
Studiescontinueon the cellularand molecularmechanismsunderlyingimmune dysfunctionin HIV/AIDS,as well as on the pathogenesisof AIDSrelatedopportunistic infections.A newfindingin this area underscoresthe importanceof controlling opportunisticinfectionsin AIDSpatients.

It has beenknownfor sometimethat CD4T cells are the primarytargetof HIV infection andthat their destructionleadsto a weakenedimmunesystemand susceptibilityto opportunisticmicroorganisms.As HIV infectionprogressestowardAIDS,the CD4T cells are the chief sourceof newvirus, creatinga cycleof escalatingvirusproduction andT cell death. The paradoxhas beenhowthe levelsof HIV continueto increaseover the courseof AIDS,at the sametimethe T cell populationdramaticallydecreases. Investigatorshavenowidentifiedtissuemacrophagesas an unexpectedsourceof new virusand point to opportunisticinfectionsas a triggerthat sets off a waveof HIV production.Examinationof lymphnodesfromAIDSpatientswith a varietyof common opportunisticinfectionsrevealedfrom5 to over 100 timesthe numberof virusproducingmacrophagesthanwerefoundin the nodesof HIV patientsfree of such infections. The individualmacrophagesalsodemonstrateda muchhigherlevel of virusproduction. Althoughthe actual mechanismthat switchesmacrophagesfromHIV carriersto producersis not yet known,the researchhas importantimplications.Preventingor eliminatingopportunisticinfectionsis not only essential to the immediatewell-beingof the patient, but can also slowthe cycleof virusproductionthat leadsto furtherimmune systemdamage.

Source:NationalInstituteof Dentaland CraniofacialResearch NationalInstitutesof Health

5.
Biofilms, Microbial Ecology and Antoni Van Leeuwenhoek

Bacteriaare remarkablyadeptat survivingfeast and famine,capableof adjustingtheir needsto accommodatehighlydiverseenvironments.Scientificinquiryhas discovereda numberof the microbialcharacteristicsthat facilitatebacteria'sagile adaptationsto changingenvironments.Amongthemis the capacityto formand maintainbiofilms. Manyof us havehadthe experiencewhilehikingto haveslippedor fallenon wet rocks near a stream.This is not only becausewatertumblesovertheserocksand makesthem hazardous,but alsobecausecoloniesof slippery,slimycreaturesoftenwill havemade suchrocksurfacestheir home.Amongthe culpritsmostlikely to fell a hikeris somethingcalled"biofilm,"a communityof affluentand well-fed bacteria. Biofilmis the communcalformin whichbacteriapreferto live. Ironically, though,it is not howmostpeopleor evenmicrobiologistshavethoughtaboutthe habitatof bacteria. The commonperceptionis that theyare isolatedindividualmicrobes.But whenfoodis truly plentiful, bacteriaadoptthe sedentarylife of livingin a biofilmcommunity.They adhereto an invitingsurfacebeit a rock, a tooth, a dental implant,removabledental prosthesesor evenwaterpumpingmachineryor the hull of a boat. In such environments,theyswitchon the genesthat makethe thick, slimycoveringthat gives themtheir communityname. This slimeprotectsthem;a bacteriumresidingin a biofilmis hiddenfrompredatorsand is 500 timesmoreresistantto antibioticsthanwhenfree floating.It also acts as a net to catchfood. In the 17th century,a dry goodsmerchantnamedAntonivan Leeuwenhoekfirst observed"animalcules"swarmingon all livingor deadmatter. Leeuwenhoek'scuriosity andinventivenesswereremarkable.He documentedone microscopicobservationafter another.He discoveredthe "animalcules"in the tartar on his teeth and, evenafter meticulouscleansing,the remainingopaquedepositsisolatedbetweenhis teeth"as thickas if it werebatter."Thesedeposits,he observed,containeda mat of variousforms of bacteria. Biofilmsper se werenot recognizeduntil 1978and it has takenalmosttwo Oral InfectiousDiseases decadesfor cliniciansand scientiststo take anotherand evenmoreseriouslook. In July 1996,the NationalInstituteof DentalResearchin Bethesda,Md., hostedan international conferencecalled"MicrobialEcologyand InfectiousDisease",whichincludedNobel laureateJoshuaLederburg.Twomonthslater, the AmericanSocietyfor Microbiology hosteda conferenceon biofilmsin Snowbird,Utah. All this renewedinterestarosein part froma growingrecognitionof the sheerhavocthat biofilmscan wreak. For instance,biofilmsare implicatedin the rejectionof artificial dental and medical prosthesesand in a numberof infectiousdiseases.Wenowappreciatethat biofilmsare

everywhere:on teeth, insidethe gut andthe bladder,on rocksby streamsand evenin waterpumpingmachines. A numberof scientificinvestigationsare beginningto unravelthe conditionsunder whichbacteriaformor do not formbiofilms.Bacteriacan subsistin extremehabitats.If biofilmsare whathappensto bacteriathat fall on goodtimes,shrinkageto an ultramicro bacterium,or UMB,is whathappenswhentimesget verytough. Bacteriafacedwith overt starvationpacktheir DNAinto tight bundles,virtuallyshut downtheir metabolicactivitiesandshrinkby two-thirds.TheseUMBthencan remain dormantin this statefor years, decadesor possiblycenturies,floatingin freshor salt wateror buriedfar underground. TheseUMBare extremelydifficult to detect. For example,UMBformsof cholera(the bacteriagenusandspeciesVibriocholerae)cannotbe detectedin waterusingso-called standardtestsandoncedetected,theyare too small to be observedby light microscopy andrequiretransmissionor scanningelectronmicroscopyfor detectionand identification. However,whenthesebacteriaencountera newsourceof food, theyunpacktheir bundledDNA,switchtheir genesbackon and resumetheir free-floatingor stationary communitylifestyle. Oneof the best waysto test for cholerain wateris to add a lot of food, wait for four hoursand thenlookfor the free-floatingformof a developingcholeracommunity.Feed this planktonicforma little morefood, and thesecholerabacteriawill fattenup and form a biofilm.The reverseis true as well. All bacteria,whenstarved,takethe UMBform.It is this ability to changefromoneformto anotherthat makesbiofilmsso interestingandso able to evadeantibiotictherapy. The vast majorityof microbessuchas bacteria(examples:Streptococcusmutans, Actinobacillusactinomycetemcomitans)and yeast(example:Candidaalbicans)growas biofilmsin an aqueousenvironment.In the mouth,biofilmsnaturallyformon the sur Biofilms,MicrobialEcologyand AntoniVanLeeuwenhoek facesof teeth, dentalprostheses,implantsand oral epithelium.Thesebiofilmscan be benignor pathogenic,releasingharmfulproductsand toxinsfromharboringpathogenic microbes.Infectiousdiseasessuchas dental caries, periodontaldiseasesandinfections associatedwith dental implantsare remindersof our needto improveour scientific understandingof biofilms. Biofilmsalsoappearto be responsiveto host factorssuchas diet and immunestatus. Immunodeficienciessuchas thoseconnectedwith HIV-relatedinfectionsoftenare associatedwith overt expansionsin bacteriaas well as yeastbiofilms.The formationof biofilmson heart valves,hip and otherjoint prostheticreplacements,catheters,

intrauterinedevices,waterlinesand evencontactlenseshas becomean almost$20 billionhealthproblemfor the Americanpeople. Advancesin scientificinstrumentationas well as experimentaldesignsare rapidly advancingour knowledgeof biofilmsin healthand disease.For example,confocal microscopyand atomicforcetunnelmicroscopy,coupledwith computerassisteddigital imaginginstrumentation,providescientistswith novelstrategiesto observeand analyze biofilmsin their naturalenvironments.Progressin developingbiomarkersfor nucleic acids,proteinsand carbohydratesfurtherenablesscientiststo assessbacterialor yeast growth,viability and evenmetabolismundervariousbiofilmcommunityconditions.The denseand compactarrangementof bacteriain oral biofilmsmakesdental plaque_appreciatedby Leeuwenhoekas he peeredthroughhis handheld microscopes almost300 yearsagooneof the mostpromisingecologynichesin whichto investigate behavioral,biologicalandphysicalproperties. Suchscientificapproaches,whichincludegenetransferbetweenbacteria, are beginningto disclosethe ultrastructure,moleculargenetics,physiologyand virulence of definedbiofilmswith respectto varyinghost responses. Fromsuchinvestigationsinto the basicbiologyof bacteriaand yeastlivingin biofilms, it is anticipatedthat newstrategiesfor increasinglymorespecificand moresensitive antibacterialor antifungaltherapieswill emergefor clinicaldentistryandmedicine.The early 20th centurywasplaguedby horribleinfectiousdiseasesthat tooka severetoll on humanity:pneumonia,cholera,tuberculosis,diphtheriaand whoopingcough.In 1928, Sir AlexanderFlemingdiscoveredthe first antibioticpenicillin. Ironically,as we move into the 21st centuryalmost70 yearslater, infectiousdiseasesremainthe leadingcause of deathworldwide. As we continueinto the next millenniumandacknowledgea timeof changing demographicsandchangingpatternsof humandisease,it becomesimperativeto acceleratescientificandtechnologicalprogresstowardunderstandingand controlling biofilms.In addition,whatis also differenttoday,as comparedwith the beginningof the 20th century,is that the worldis a smallercommunity,and thesenewor reemerging infectious Oral InfectiousDiseases diseasesare nowonly a planeride away. "Themicrobethat felledone child in a distantcontinentyesterdaycan reachyours todayand seeda globalpandemictomorrow",said JoshuaLederburg,Ph.D., the Nobel LaureatefromRockfellerUniversity,NewYork. Meanwhile,the productsof biofilmscontinueto inflict a burdenof sufferingon the Americanpeople.A largeproportionof the populationsuffersfromdental cariesand periodontaldiseases.Althoughthe prevalenceof dentalcariesamongschoolaged childrenhas declinedin the last severaldecades,recentnationalsurveysindicatethat

the averageschoolchildhas at least onecavityin permanentteethby age 9, three cavitiesby age 12 andeight cavitiesby age 17. Weare learningthat vertical transmissionof certainbacteriafromthe caregiverto the child maybe significantin the etiologyof rampantinfantdeciduoustoothdecay. Concurrentinfectionsand the mother'snutritionalstatusduringpregnancycan further compromisethe integrityof the formingdental mineralizedtissuesas well as the infant's developingimmunesystem.Weneeda broaderfocusthanonebasedonly on improper infant-feedingpracticesto addressthis devastatingand costlycondition. Weclearlyhavea great deal moreto learnaboutthe beterogeneityof infantdental caries.Nearly25 percentof children5 to 17 yearsof age (almost24 millionAmerican children)havefive or moredecayed,missing,or filled teeth. Accordingto a 198687 NIDRsurvey,about50 percentof childrenaged5 to 17 yearswerecompletelyfree of decayand of restorationsin their permanentteeth. However,the averageadult in the UnitedStateshas from10 to 17 decayed,missingor filled permanentteeth. Patientsneedto be informedof the infectiousnatureof oral diseasesandthe currently availablemeasuresto controlandpreventinfection.For dental caries, fluoridesin a varietyof formsare availableand, togetherwith dental sealants,can ensureprevention in mostcases.Fluorideandchemotherapeuticmouthrinsesfor dental plaque(biofilm) preventionare recommended,basedon evidenceof risk reductionfromthese interventions.In addition,phenolicantisepticmouthwasheshavebeenassociatedwith a 28 to 34 percentreductionin dentalplaquebiofilmsat six-monthfollowup. Chlorhexidinegluconaterinses,whencombinedwith toothbrushing,havebeen reportedto reduceoral biofilmssuchas dental plaqueby 50 to 55 percent.At the time this articlewaswritten,this productwasnot readilyavailablein the UnitedStates withouta prescription. Abouthalf of all adultshavegingivitisand 80 percenthaveexperiencedsomedegreeof periodontaldisease.Andin the contextof changingdemographics,with almost32 millionAmericansnow65 yearsof age or older, 95 percentof this populationhas periodontitisand morethanone-third has moderateto-severeperiodontaldisease. Biofilms,MicrobialEcologyand AntoniVanLeeuwenhoek Almost22 percentof Americanadultsover the age of 45 yearsandhalf of adultsover 65 years(15 millionpeople)are edentulous. Infectiousdiseasessuchas dentalcariesand periodontaldiseasescan be exacerbated by personalbehaviorssuchas poordiet, alcoholabuseand tobaccoproductuse. They alsocan be aggravatedby medicationsusedto treat coexistingdiseases,suchas diabetes,Sjogren'ssyndromeand a numberof immunodeficiencydiseasesand disorders(includingHIV infection).Underthesemoderateto-extremeconditions,oral bacteriaandyeastbiofilmsare highlyresponsiveas reflectedin their biologicaland

physicalpropertiesthedelicatebalancebetweenopportunisticinfectionsand a compromisedhost immunity.The host immuneresponseto pathogenicmicrobesis oftennot effectiveand cannotremovethe biofilm.Oral bacteriaor yeastwithinbiofilms are highlyresistantto host immunoglobulinsor antibioticand antifungaltreatments becauseof changesin diffusionpolysaccharidepolymersthat supportthe biofilm. This presentsan opportunityfor investigatorsto revisit previouslyheld assumptions and, as a result, to investigatethe complexitiesof biofilms.Researchmayguidethe developmentof "smarttherapies"andapproachesto inhibit or eliminatemicrobesunder variousenvironmentalconditions.The NIDRis currentlysupportingseveralresearch studiesdesignedto improvethe removalof biofilmsand to assist in the deliveryof highlysensitiveand specifictherapeuticsto oral bacterialand yeastmicrobeswithin biofilms.Thescientificdiscoveriesandnewknowledgeaboutoral microbesin biofilms will serveas catalystsfor translationalresearch,whichmaylead to patient-oriented clinicaltrials and eventualfinal regulatoryapprovalof newtherapies(suchas new antimicrobialtherapiesand newantibiotics). Basicandtranslationalscientificresearchprovidesthe fuel requiredfor the engineof biotechnologyand clinicaltrials. Our challengeis to makethis sciencetransfermore effectiveand moreefficientto the benefit of patients,healthprofessionalsand pharmaceuticalcompaniesalike. As healthprofessionals,we havean excellentopportunityto providementoringand counselingfor our patientsand our staff memberson the principlesof microbial ecologyin termsof biofilms.Wecan advisethemof the associationsbetween opportunisticmicrobes(viruses,bacteria,yeastandparasites)and the host immune system,the challengesof multi-drugresistantbacteria,the principlesand practiceof a healthydiet and approachesfor the reductionof risk factorsthat influencehealth.

1. SlavkinHC, CohenDW.Oral microbiology.Curr Adv Oral Biol 1979:1(5).

Source:NationalInstituteof DentalResearch NationalInstitutesof Health

6.

Infection and Immunity

Most americans think of it as a cold sore that comes and goes. But, the herpes virus is a highly contagious microbe that never really leaves.

Eight out of every10 Americanadultsare infectedwith the herpessimplexvirus, or HSV.The virusis eitherdormantwithina varietyof tissuesor is activatedand highly contagious.As a contagiousvirus, HSVis eitherthe directcauseor a cofactor associatedwith a numberof differentdiseasesand disorders.Its best known manifestation:the commoncold sore. The cold sore, or herpeticlesion,typicallyshows redness,swelling,pain and heat over an eightto 10 day period.After that, its clinical signsand symptomsappearresolved,leavingno apparentscar. But the virusleaves with a promiseto return. The virus, infectingthe lips, oral mucosaor tongue,can be transmittedto the handor eyes_andit can be transmittedto anotherperson,expandingthe sphereof influenceof this highlycontagiousmicrobe. HSValso can be associatedwith otherdiseasesor disordersthat compromisethe immunesystemsuchas proteincaloriemalnutritionand AIDS.The virusprovidesoral healthprofessionalsan excellentopportunityto reassesstheir appreciationof infection andimmunity.Wecan learnfromHSV. For thousandsof years, rednessand swelling,with pain and heat, havebeenrecognized as the four cardinalsignsof inflammation.AulusCorneliusCelsusin the first century describedthe typicalreactionof fleshto microbes.Sincethen, astutehealth-care professionalshaveappreciatedthat inflammationis the host'sresponseto traumatic injuriesas well as to microbeinfections. Inflammationis our protectiveresponseto dilute, destroyor compartmentalizeboththe infectiousagent(infectiousmicrobessuchas viral, bacterial, fungalor parasitic invasion)and the injuredtissue. Oral InfectiousDiseases Redness,swelling,pain, heat and lossof functionare clinical characteristicsof HSV. Microscopically,the virusinvolves:

1. dilationor injuryto capillaries,arteriolesand venules;

2. exudationof fluidsincludingplasmaproteins; 3. leukocyticmigrationinto the inflamedarea with the releaseof cytokines. Twentiethcenturysciencehas provideda foundationfromwhichwe can appreciatethe sequenceand timingof the dramathat unfoldswheninfectionmeetsimmunity.TheHSV strategicallyusestwo viral geneproductsglycoproteinsD and B_toattachto the host cell. Immunologically,the HSVproductsare identifiedas foreignantigensby immunoglobulins(IgAantibodies)or by receptorson thymusderivedlymphocytesthat bindto specificdeterminants(viral specificgeneproductsor epitopes)associatedwith HSVproducts. The inflammatoryprocessactivatesthe inflammatoryreactionwith increasedbloodflow (redness),increasedvascularpermeability(swelling),increasedleukocytemigrationand infiltrationwith attendantproductionof cytokinesand eventualdestructionof the infectiousagents(pain, heat andpossiblylossof function). The actualdestructionof HSVantigensis a functionof the immunemechanisms mediatedby phagocyticcells. Thephagocyticcells mayeitherlive in the tissuesite or be recruitedinto the tissuefroma distance.Macrophagesand Kupffer'scells are central playersin this dramabetweeninfectionand immunity. HSVis a clevervirus, capableof producingmoleculeson the surfacesof HSVinfected cells that mimicnormalimmunoglobulins,thusfakingthe host immuneresponse.HSV alsohaslearnedto producelymphokineand cytokineinhibitors,curbingthe host's attemptsto destroythe infection. Froma Darwinianperspective,infectionmeetsimmunityis highdrama.It is a drama that presentsa sophisticatedconfrontationof the opportunisticmicrobe(virus, bacteria, fungi, parasite)vs. the highlyevolvedhumanimmunesystem,with its enormous capacityto confrontdiversityand providean advantagefor the host againsta changing microbialenvironment. The "simple"cold sore has manylessonsto teach.Humanity'srecognitionof cold sores is so longstandingthat it has led to complacentacceptance.Descriptionsof the infectionhavebeendocumentedin early Greekmanuscripts,particularlyin the writings of Hippocrates(460-377 B.C.). Scholarsof Greekcivilizationdefinethe wordherpesto Infectionand Immunity mean"creepor crawl,"describingthe spreadingnatureof the visual skin lesion.The early, imprecisevisualdescriptionsof the sore endedin the 20th centurywhen,in 1919, Lowensteindescribedthe infectiousnatureof the causativevirus(herpessimplex)and demonstratedthat the virusretrievedfromthe lesionsof the sore produceda similar lesionon the corneaof a rabbit. Herpesvirusesare ubiquitousand havebeenisolatedfrombaboons,chimpanzees, monkeys,cows,horses,birdsand fish. Mostanimalspecieshaveyieldedat least one

herpesvirusuponexamination.Nearly100 herpesviruses,fromall sources,havebeen characterized,at least partially. In humans,six membersof the virusfamilyHerpesviridaehavebeenisolated:

1. 2. 3. 4. 5. 6.

HSVtype1 (coldsores)and type 2 (genital lesions); varicellazoster, or VZV(chickenpox,shingles); humancytomegalovirus,or HCMV; EpsteinBarr virus, or EBV(mononucleosis); humanherpesvirus6, or HHV6 (roseola); herpesB virus, an old-worldmonkeyvirusthat resultsfromthe bite of a monkey,is highlypathogenicin humansbut rarelypassesfromone personto another.

A newherpesvirusidentifiedin 1996, humanherpesvirus8, or HHV8, is associated with Kaposi'ssarcoma,or KS. KS producespurplishlesionsthroughoutthe bodyas a result of uncontrolledgrowthof bloodvessels.Proofof HHV8's role in KS will require manyadditionallongtermstudies. Like manyviruses,the herpesvirusestake up permanentresidencein the bodyonce theyare introduced.After an initial infection,the virusgoesinto hiding,escapingthe host'simmunesystemby remaininglatentin a specificgroupof cells, causingno apparentharmto the host. The exactcell in whichtheyremainlatent variesfromone virustypeto the next. In cells harboringthe latent virus, the viral genomestake the form of closedmoleculesandonly a small subsetof virusgenesare expressed.Production of infectiousprogenyvirusis invariablyaccompaniedby the irreversibledestructionof the infectedcell. All of the humanherpesviruseshavebeendetectedin the saliva sometimeduringinfection. The HSVtypes1 and 2 are the best known.Type1 is usuallyresponsiblefor the sores on Oral InfectiousDiseases or near the face(cold sores,feverblistersor oral herpes).Mostadultsin the United Statescarrythis virusand somesufferperiodicboutsof cold sores. Type2 usuallyis involvedin producinggenital sores(genital herpes).About16 percent of Americansbetween15 and 74 yearsof age (30 millionpeople)carrythis virus. The two virustypesare verysimilar, and eithertypecan infect the mouthand genitals. Some peopleare infectedwith bothtypes. Mostpeopleinfectedwith HSVneverdevelopany symptoms.Reportsfroma numberof studiesindicatethat abouthalf of the peoplewith HSV2 antibodiesdo not knowthat they'reinfected,yet theyare still capableof transmittingthe infection.

Primaryinfectionwith HSVcan producegreatvariabilityin clinical symptomsfrombeing totallyasymptomaticto sufferingwith combinationsof sorethroat, ulcerativeand vesicularlesions,gingivostomatitis,edemaof the mucosalmembranes,localized Lymphadenopathy,anorexiaand malaise. The incubationperiodfor HSVrangesfromtwo to 12 days. In children,the infection characteristicallyinvolvesa swellingof the gingivaland buccalmucosa,makingit difficult or impossibleto swallowliquids.The clinical illness,accompaniedby feverand pain fromthe lesion,generallylasts two to threeweeks.After infection,the virusgoes into hiding,enteringnerveendingsand travelingto ganglia(clustersof nervecells). Howoftenthe viral infectionrecursvariesfrompatientto patient. Factorsthat trigger recurrencein humansare poorlydefinedbut includefever, stressandexposureto ultravioletlight. Infectionrecurswhenthe virusis activatedin the gangliaand travels downthe nerveto the surfaceof the skin whereit replicates. Recurrencetakesplacein phases:

1. prodrome:warningsymptomsthat last less thansix hoursand includetingling and itchingat the site of outbreak; 2. inflammation:swellingandrednessat the site beforeoutbreak,indicatingthat both virusandantibodieshavearrived; 3. blisters:appearancewithin24 to 48 hoursafter prodromeof oneor several small fluid-filled vesiclesor tiny red bumpsor tendernessmostcommonlyat the vermilionborderof the lip; Infectionand Immunity 1. ulcers:occurringwithin72 hoursafter prodrome,oftenaccompaniedby pain; the blistersleak fluid, leavingwet-lookingsores; 2. crusts:soresdry within96 hours,forminga scabthat indicateshealing;virus diminishes,with healingover two to threedays; 3. healing:completewithineight to 10 days;newskin forms;virusreplicationis complete,and the virusretreatsbackup to the host gangliawhereit remains, protectedfromthe host'simmunologicalattack. For mostpeople,a herpesoutbreakis confinedto recognizablevariationsof the classicalsymptoms.Whileoutbreakscan be physicallyand emotionallyuncomfortable, andsometimespainful, the infectionis usuallyself-limitingand resultsin complete healingof the infectedsite. The virusin the inflamedsite, however,is infectiousandcan be transmittedto a new site on the host'sbody(autoinoculation)or to anotherpersonthroughcontactwith any part of the bodywherethe virusfindsa wayto penetratethe skin.

Transmissionin mostcasesrequiresdirectskin-to-skin contactbetweenthe infected site anda receptivesite. Riskof transmissionis highestwhenthe virusis active. But first outbreaksor primarylesionsare the mostinfectiousbecausetheyincludemore virusparticleson the skin, and the lesionspersistfor a longerperiod. HSValso can be transmittedwhenthe infectedpersonis asymptomatic.About1 percent of the time, mostpeoplesymptomaticallyshedtracesof the virus, sometimesfrom lesionsthat are too small to be noticed. Autoinoculationandtransmissionby skin contactcan haveseriouscomplications. Dentalprofessionalsare at particularrisk of developinga complicationknownas herpeticwhitlow.Causedby HSV1 or -2, whitlowdevelopson the handand is found oftenamonghealthprofessionalswhotreat herpesinfectedpatients.It is the same diseaseas oral or genital herpeswith the samesymptoms,but it is veryvisibleand oftenvery painful. Theconstantuse of protectiveglovesand otheruniversal precautions,includingsterilizationanddisinfectiontechniques,can preventherpetic transmissionin the dental office. Ocularherpes,an infectionof the eye, is mostoftencausedby autoinoculation. Fortunately,ocularherpesresolvesitself withouttreatmentabouthalf the timeand does not recur. Still, the infectioncan lead to seriousdamageand evenblindness. Oral InfectiousDiseases Ocularherpescan take the formof conjunctivitisor "pinkeye," an inflammationof the mucousmembraneunderthe eyelidand over the wholescleraof the eyeball. Conjunctivitisis irritatingbut causesno permanentdamage. Herpeticinfectionof the corneais calledkeratitis, whichcausessuperficialbranching ulcerationscalled"dendrites."This conditionis oftenself-limitingand mayor maynot causepermanentdamage. Herpeticiritis, an infectionof the iris andotherpartsof the inner eye, becomeschronic andcan lead to opacificationof the corneaandblindness.Earlytreatmentis key to avertingthe moreseriousconsequencesof all formsof ocularHSV. Eight of 10 peoplewith first timeHSVinfectionsanda few with recurrencesalsocontract viral meningitis. The virusinflamesthe meningessurroundingthe brain, but not the brainitself. Symptomsincludesevereheadaches,aversionto light and nausea,which go awayon their own,leavingno permanentdamage. Amongthe rarestof complicationsis herpesencephalitis, affectingfewerthanone in 65,000Americanseachyear. In adults, this encephalitisis usuallycausedby HSV1, and in newbornsby HSV2. The braininfectioncausesswellingand inflammationandunless quicklycontrolledcan result in permanentbrain damageand death.Themostserious concernsaboutherpesvirusinfectionsare the consequencesfor infectednewborns.

Herpesviruses,as permanentresidentsof the body,affect severalotherdiseases. Recentresearchshowsthat HSVmaycauseacute, idiopathicfacial paralysis(Bell's palsy), thoughmorestudiesare neededto confirmthis observation. A numberof studiesdatingbackto the late 1970ssuggestthat womenwith a historyof genital herpesare at greaterrisk of contractingcervicalcancer.Here, too, furtherstudy is needed. As notedearlier, herpesmayhavea link to Kaposi'ssarcoma.It is also being investigatedfor a possiblecausalrelationshipwith the humanimmunodeficiencyvirus, whichcausesAIDS.Theseexamplesunderscorethe interestresearchscientistshavein determiningwhetherthe oftendismissed"coldsore"virushas a moredeviousand influentialrole in the pathologiesof the humanbody. Diagnosisof an HSVinfectionis oftendoneby the nakedeye. But thereare several moredefinitivediagnosticmethods,someof whichcan distinguishbetweenHSV1 and HSV2. The gold standardfor diagnosinga virusis alwaysisolationand culture.But this takesseveraldays, and a negativeculturedoesnot necessarilymeanabsenceof virus. Infectionand Immunity Othermethodsinclude:

1. immunofluorescence,or IF, wherecells are scrapedfromthe lesion,placedon a slideand stainedwith fluorescenttaggedHSVantibodies,whichbind specificallyto any HSVpresentin the cells; 2. immunoperoxidase,or IP, whichalso bindswith cells but can amplifythe virus contentfor easieridentification; 3. the enzymelinkedimmunosorbentassay,or ELISA,whichis moresensitive thaneitherIF or IP; the infectedspecimenis combinedwith commercialHSV antibodies,an enzymeand their chemicalsand followedfor a colorchangethat occursonly in the presenceof HSV. Still otherserologicalassaysmeasureantibodiesthat showprior infectionwith either HSV1 or HSV2, althoughthe distinctionbetweentypesis difficult. Researchon drugtherapiesfor HSVhas focusedmainlyon treatinggenital herpesto preventsexualtransmissionand the effectson newborns.Sinceits introductionin 1985, oral acyclovirhas beenthe preferredtreatmentfor genital herpes.It also has beenfound effectivein treatingoral herpes.TheU.S. Foodand DrugAdministrationis reviewingan applicationthat wouldextendoral acyclovir'suse in treatingoral herpes. Peoplewhosufferfromfrequentboutsof HSVcan take acyclovirdaily for up to one year. Unfortunately,though,it is not a cure for the virusthat remainsin the body.The druginterfereswith virusexpression;it doesn'tkill it.

FoscarnetalsodisruptsHSVreplicationbut mustbe givenintravenouslybecauseit is not readilyabsorbablein the stomach.Idoxuridineandvidarabinehavebeeneffectivein treatingocularherpesbut are ineffectivein treatingotherformsof HSV. Vidarabineis useful in treatingherpesencephalitis,herpeszosterand neonatalherpes. Manyothercompoundshavebeenreportedas havinganti-HSVimpactin the laboratory, but furtherstudiesare neededto determinetheir effectivenessin humans. Oral herpesis usuallytreatedby the time-tried methodsof keepingthe blistersclean anddry, beingcarefulnot to touchthe soresand spreadthe virusto newsites, and avoidingcontactswith peoplein waysthat couldtransmitthe virus. Researchersat the NationalInstituteof Dental Researchconfirmedthat sunscreenon the lips can preventsuninducedrecurrencesof herpes.Mostotherpreventive measureshavenot beenexaminedundercontrolledstudies. Oral InfectiousDiseases In late September1996, the first topicalantiviral creamfor treatingcold soresreceived FDAapproval.Marketedas Denavir, the creamcontainspenciclovir, which,like acyclovir, is activeagainstHSVreplication.Denaviris reportedto reducethe durationof HSVpain and speedlesionhealing. The central goal in researchingthe herpesvirusis the developmentof a vaccine becausepreventionis the best defense.A vaccinewouldbe effectiveonly in peoplewho havenot contractedHSV.It wouldoffer protectionand start to breakan infectiouscycle that involvesso muchof the population. Small clinicalstudiesshowthat a newvaccineconsistingof viral glycoproteinsfound on the virus' exterioris capableof safelystimulatingan immuneresponsein both infectedand uninfectedstudyparticipants.Largerstudiesare neededto demonstrate the vaccine'seffectivenessin preventinginfection. Otherpotentialvaccineswoulduse a live-viruspreparationin whichthe HSVvirulence factorshavebeenremoved. In the dental office, oral herpesmustbe treatedwith respectand with all the precautions due an infectious,opportunisticdisease.Thereis clearlymuchmoreto the common cold sorethanmostof us ever imagined.

Infectionand Immunity FORADDITIONALINFORMATION

Centersfor DiseaseControland PreventionWebsite http://www.cdc.gov HerpesHotline openMondaythroughFriday,9 a.m. to 7 p.m. Easterntime 1-919-361-8488 HerpesResourceCenter P O Box13897 ResearchTrianglePark, N.C. 27709 NationalInstituteof Allergyand InfectiousDiseases Offceof Communications NationalInstitutesof Health Bethesda,MD. 20892 (301) 496-5717 NIAIDWebsite: http://www.niaid.nih.gov NationalInstituteof DentalResearch Informationoffice NationalInstitutesof Health Bethesda,MD20892 (301) 496-4261 NIDRWebsite: http://www.nidr.nih.gov

7.
The A, B, C, D and E of Viral Hepatitis

The word"hepatitis"conjuresup a visionof someonewhoseskin and/orconjunctivais yellowed(jaundice)becauseof the depositionof bile pigmentsthat a damagedliver is unableto removefromthe circulatingblood.Liverinflammationcan be causedby factorssuchas alcoholabuse,somemedicationsand trauma,as well as by certain viruses. Generaldentists,oral surgeons,physicians,dental hygienists,dental assistants,nurses andhealthprofessionstudentstop the list of the peopleat highrisk for whom vaccinationprotectionis recommended.Since1987, the AmericanDentalAssociation has encourageddentistsand their staff membersto take advantageof the hepatitisB vaccineand postvaccinationtestingto protectthemselves,their co-workersand their patientsfromhepatitisB infection.In 1992, the ADAexpandedthis recommendationto includethe vaccinationof dental students,preclinicaland clinical facultyand staff againstinfectiousdiseases(for example,mumps,measles,rubellaand hepatitisB). The viral inflammationhas someaspectsthat makethe infectedpersonpotentially harmfulto others.Peoplemaybe chronicallyor acutelyinfectedbut not knowthat they havethe diseasebecausetheyhaveno symptoms.However,theystill havethe ability to spreadthe disease.A personcan becomean asymptomaticchroniccarrierof the diseaseafter beinginfectedwith any oneof the severalhepatitisviruses(suchas B, C or D). The only protectionagainstinfectionfor the healthcareproviderandthe patientis vaccination.

v The Five Types of Hepatitis

Viral hepatitiscomprisesat least five differentvirusesthat differ in surfaceantigens, typeof nucleicacid, modeof infection,lengthof viral incubationand pathogenicityand the ability to producea chronicdiseasethat can progressto fulminatingliver failureor Oral InfectiousDiseases hepatocellularcarcinoma.All five formsof viral hepatitiscan causean acuteillness,and all five havevirulenceandinducepathologyprimarilyon the infectedliver. HepatitisA virus. EachhepatitisA virus, or HAV,is a small virusabout.026 micrometersin diameterand is transmittedby the oral-fecal route. HAVcan producean acuteillnesswith a viremiaof four-to-eight weeks.Its debilitatingsymptomsare often flu like: fever, fatigue,muscleandjoint aches,as well as possiblenausea,vomitingand pain in the liver area. Recoverymaytake as longas a year. The acuteinfectionis clinicallysilent in approximately90 percentof infectedpeople.In about10 percentof patients,acuteHAVinfectionresultsin jaundice,but the risk of liver failureis very low, andthereis no risk of chronicity.Recoveryis associatedwith lifelongimmunity.The virusis spreadby eatingcontaminatedfoodor drinkingcontaminatedwateror ice cubes,by closepersonalcontactor by sharingdirty needles.In the UnitedStateseach year, 138,000peoplebecomeinfectedby and 100 die of HAV. HepatitisB virus. HBV,the causeof "serumhepatitis,"is classifiedas a hepadnavirus. Electronmicrographsof infectedseraof peoplehas shownthreemorphologicalforms of hepatitisB virus:complete,sphericaland filamentous.Thecompletevirion(Dane particle)is about.042 mm.The sphericalandfilamentousformsof the virusrepresent viral coat material, or HBVsAg,producedin excessby the infectedhepatocyte. After infectionof hepatocytesor mononuclearcells, viremiaeitheris transient,lasts four-to-eight weeksor is chronic.In 90 percentof infectedpeople,acuteinfectionis clinicallysilent or producessymptomsthat mimicflu, includingfever, headache,muscle acheand fatigue.About15 to 20 percentof patientsdevelopshort-termarthritislike problems.In 10 percentof patients,acuteinfectioncan result in jaundice.In acute hepatitiswith jaundice,the risk of fulminantliver failureis about1:100. Ten percentof patients,irrespectiveof any acutereaction,can developa chronicinfection,either inactiveor active. Patientswith chronicactivehepatitiscausedby HBVhavea highrisk of developingcirrhosis.Antibodiesagainstthe HB surfaceantigen,HBsAg,can neutralizethe virus, thuspreventinginfection.The antigenhas beenusedas a vaccine since1975and becamegenerallyavailablein 1982. TwootherHBVantigenshavebeendetectedin humans:hepatitisB Coreantigen,or HBcAg,whichis not detectablefree in the serum,andthe hepatitisE antigen,HBeAg, associatedwith highinfectivity. Antibodyto the coreantigencan be detectedduring

acuteillness,especiallyat the beginningof the illness,and antibodyto the E antigen maypoint to a lowerdegreeof infectivityand reducedlikelihoodof becominga carrier. HBVinfectionand its sequelae,however,still are one of the majorcausesof morbidity anddeathin man.Globally,morethan2 billionpeopleare infectedwith HBV,and 350 millionpeopleare chroniccarriers,at highrisk of deathfromchronicactivehepatitis, The A, B, C, D, E of Viral Hepatitis cirrhosisandprimaryhepatocellularcarcinoma.Between1 millionand 1.5 million peopledie eachyear of HBVinfection,makingit one of the majorcausesof morbidity anddeathworldwide.If the vaccinewasusedmorewidely, the diseasecouldbe preventedalmostcompletely. By the end of 1992, 41 countriesworldwidecraftednationalpoliciesto give HBVvaccine to all newborns.In someparts of the world, the majormodeof transmissionis from child to child or motherto child, andvaccinatingnewbornswouldbreakthis cycle. The vaccineis 90 to 95 percenteffectivein preventingvirusinfectionandthe carrierstate. AlthoughHBVvaccineis easilyobtainedin the UnitedStateseachyear, an estimated 300,000peoplebecomeinfected.Thevirusis mostcommonlytransmittedby shared needles,by highrisk sexualbehavior,froma motherto her newbornand in the healthcaresetting.Saliva, blood,semen,tears, vaginalsecretions,milk and otherbodilyfluids are the majorsourcesof infection.In approximately30 to 40 percentof cases,the methodof transmissionis unknown. Childrenare at the greatestrisk. About90 percentof babieswhobecomeinfectedat birth with HBVandup to half of the youngsterswhoare infectedbeforethe age of 5 yearsbecomechroniccarriers. In an effort to eliminatechroniccarriers, the U.S. Centers for DiseaseControland Prevention,or CDC,recommendsthat all newbornsbe vaccinated.Othergroupsrecommendthat pregnantwomenbe screenedfor HBsAgas part of their routineprenatalcare. If theyare infected,their babiesshouldbe given hepatitisB immuneglobulinas well as vaccineimmediatelyafter birth. Dentists,oral hygienistsand oral surgeonswhoare routinelyexposedto bloodon the job are at the top of the list for contractingHBV.Safe and protectiveHBsAgvaccines againstHBVexist. To be fully protective,threeinjectionsare required:the second injectiononemonthafter the first and the third injectionsix monthslater. Thevaccine providesimmunityfor 10 to 20 years. In 1987, the CDCestimatedthat 12,000of the 300,000hepatitisB virusinfections occurredamonghealthcare workers,and approximately250 of thosepeoplediedas the result of infection.In 1991, 81 percentof the dentistswhoparticipatedin the ADA's HealthScreeningProgram,conductedeachyear at the ADAannualsession,reported havingreceivedthe HBVvaccine_asubstantialincreasefromthe 1987level of 56 percent.Serologicdata fromthe HSPfor the years1981to 1989indicateda decreasein the numberof dentistsnaturallyinfectedwith HBVfrom15 percentto 8 percent.

Immunizationand increasinguse of universalprecautionsprobablywereresponsiblefor the decrease. Oral InfectiousDiseases HepatitisC virus. Acuteinfectionwith hepatitisC virus, or HCV,is clinicallysilent in 95 percentof infectedpeople.Theremaining5 percentdevelopjaundice.In 60 to 70 percentof patientsexposedto HCV,a chronicinfectiondevelopsthat is associatedwith chronichepatitisand fluctuatingserumtransaminaseactivities. Cirrhosisdevelopsin 10 to 20 percentof thesepatients.Thedelayfrominitial infectionto the developmentof cirrhosisusuallyis 10 to 30 yearsbut sometimesis shorter(five to 10 years). With the adventof newtests to screenblooddonors,a very small percentageof peoplewith HCV currentlybecameinfectedthroughbloodtransfusions.HCVappearsto be spreadmainly throughunprotectedsexualcontact, sharedneedles,recipientsof previouslyuntested bloodproductsand healthcare workers,althoughthe methodof infectionis unknownin manycases.HCVis the mostcommonformof chronicviral hepatitisin the United Statesandappearsto be a majorfactorin the 25,000deathseachyear that are caused by chronicliver disease. HepatitisD virusor delta hepatitis. Infectionwith the hepatitisD virus, or HDV,is the severestformof viral hepatitis. It leadsto cirrhosisin up to 70 percentof cases,often withina few yearsof the onsetof disease.It accountsfor less than5 percentof the casesof chronichepatitis. HDVoccursonly in patientswhohaveacuteor chronicHBV hepatitisandare HBsAgpositive.HDVis coatedby the HBVcoat antigenHBsAg.An anti-HDVassayis availablefor diagnosingthe infection,whichshouldbe suspectedin patientswhohavechronicHBVinfectionbut haveclinicalsignsof acutehepatitis. VaccineprotectionagainstHBValso servesagainstHDV. HepatitisE virus. HepatitisE virus,or HEV,is an epidemicformof hepatitisthat shares somecharacteristicswith HAV,suchas a lack of a chronicphaseand enteric transmissionprimarilyin underdevelopedcountrieswith contaminatedwatersupplies. Outbreakshavenot beenobservedin the UnitedStates,but at least 20 epidemicshave occurredin 17 othercountries.

The A, B, C, D, E of Viral Hepatitis

v Diagnosis
Diagnosingany of the hepatitisvirusesis generallydonewith teststhat recognizeeither circulatingviral antigensor circulatingantibodiesto viral antigens.HepatitisE remains a diagnosisof exclusion,as clinicallyapplicableserologicassaysfor it are not readily available. HepatitisA. Testsfor hepatitisA virusare availableto screenfor antibodyto hepatitisA. The antibodyis detectableat the onsetof illnessand persistsfor the patient'slifetime. HepatitisB. A numberof laboratorytests, includingradioimmunoassayor enzyme_ linkedimmunosorbentassay,can detectHBsAg.The antigenoftenappearsbefore symptomsdevelopand disappearswith recovery.If the antigenremainssix months after recovery,the personmayhavechronicdiseaseor be a carrierof the virus. Antibodyto the antigenusuallypersistsfor manyyearsand protectsagainstfurther infection. HBcAgcannotbe detectedin the blood,but antibodyto the antigencan be detectedat highlevelsduringthe beginningof the illnessand decreaseover time. In chronic carriers,highlevelsof antibodymaypersistfor a lifetime. HBeantigenand antibodyto the antigencan be detectedby commercialtests. Presence of the antigenindicateshighinfectivity. Liverfunctiontestsoftenare diagnosticof hepatitisvirusinfection.Highlevelsof the liver enzymesaspartatetransaminase,or AST,and alaninetransaminase,or ALT, are of particularimportance. HepatitisC. A newtest is nowavailableto detectantibodyto hepatitisC. Theantibodyis presentin 50 percentof peoplewhohaveacuteantibodyand in almostall peoplewho havehepatitisC. HepatitisD. Until recently,this viruscouldbe diagnosedonly by liver biopsy.A blood test is nowavailableto detectantibodyto delta antigen(a proteinfoundinsidethe hepatitisD virus).

Oral InfectiousDiseases

v Treatment
Thereare no treatmentsof provenbenefit for acuteviral hepatitisexceptbed rest, a healthydiet and avoidanceof alcoholicbeverages.Usually, acuteviral hepatitisis selflimiting.Mostpatientsexperiencecompleterecovery,with restorationof liver function andclearanceof the virus. Specifictherapymustbe approachedwith caution.The hepaticdysfunctionaccompanyingacutehepatitisaltersdrugmetabolismin the liver so that medicationsare oftennot well-tolerated.Also, by the timesymptomsappear,the viral replicationis usuallydecreasingor has ceasedand antiviral drugswouldhavelittle effect. Antiviral agents. Twoantiviral agentshavebeenshownto havesomebenefit for some patientswith acutehepatitis:ribavirinand alphainterferon. Ribavirinresemblesthe nucleosideguanosine,a buildingblockof nucleicacid. It can substitutefor guanosinein nucleicacid synthesisbut, becauseof its differentstructure, it interfereswith furthersynthesisof the nucleicacid molecule.It has broadactivity againsta numberof RNAand DNAvirusesin vitro with few sideeffects. However,its effectivenessagainsthepatitisviruseshas not beenevaluatedin well-controlledstudies andmaygivemodestresults. Alphainterferonis a naturalhumancell proteinmadeby macrophagesand B cells in responseto viral infection.Alphainterferonand the relatedbetainterferonattachto a cell surfacereceptor,whichinducesa set of intracellularenzymesthat inhibit the virus's infectionof the cell andits replication.Thereis little evidenceto suggestthat alpha interferonis effectivein treatingacutehepatitisB and D and somepreliminaryevidence that it maybe beneficialin treatingacutehepatitisC. Alphainterferonhas beenshownto be effectivefor somepatientsin inducingsustained remissionsin all threetypesof chronichepatitis, B, C andD. In chronichepatitisB, therapyfor 16 weekscan inducelong-termremissionin 25 to 40 percentof patientsand, ultimately,loss of HBsAgin 50 percentof thosewhorespondto treatment.In chronic hepatitisC, therapyfor 24 to 48 weekscan inducetemporaryremission,includinglack of detectableviral RNAand improvementin liver histologyin 50 percentof patientsand sustainedremissionin 25 percentof the patients.In chronichepatitisD, prolonged treatmentwith alphainterferoncan causeremissionin up to 50 percentof the patients; however,the remissionrarelyis sustainedafter treatment. However,a numberof side effectsare attributedto alphainterferontreatment,including sustainedflulikesymptoms;decreasein platelets,whitebloodcells and hematocrit; developmentof autoantibodies;psychologicalsymptoms;andneurologicalsymptoms. Moreresearchis neededto increasethe agent'sefficacyand safetyand to understand whysomepatientsdo not respondto it at all.

The A, B, C, D, E of Viral Hepatitis

v Conclusion
Recentbreakthroughsin understandinghepatitisB makethe futuretherapyof this diseasepromising.In the past few years, animalmodelshavebeendevelopedfor drug testing,and cell culturehas beenfoundthat can allowreplicationof the virus. Other technologicaladvancesoffer newareasfor possibletherapyfor hepatitis, including monoclonalantibodiesagainstHBsAg,HBVantigen_specificT cells and antisense oligonucleotides.Manyantiviral andimmunomodularyagentsare underevaluation, includinginterleukin2, gammainterferon,acyclovir, ganciclovirand suraminand combinationsof drugs.Muchworkremainsto be done. Our best approachto the controlandpreventionof hepatitisis vaccinationof susceptiblepopulations,especiallyhealth-careworkers,with HBVvaccineand, under specialcircumstances,with HAVvaccine.Wealsomustcontinueto observegood barrierprotectiontechniqueswhendealingwith patients.

Oral InfectiousDiseases For AdditionalInformation AmericanLiver Foundation 1425PomptonAvenue CedarGrove,NJ 07009 Phone(800) 223-0179or (201) 256-2550 Centersfor DiseaseControland Prevention/NationalCenterfor InfectiousDiseases Divisionof Viral andRickettsialDiseases HepatitisBranch Atlanta,GA30533 Phone(404) 332-4555(TheHepatitisHotline) NationalDigestiveDiseasesInformationClearinghouse 2 InformationWay

Bethesda,MD208923570 Phone(301) 654-3810 NationalInstituteof AllergyInfectiousDiseases InformationOffice 31 CenterDrive, MSC2560 Bethesda,MD208922560 Phone(301) 496-5717

8.
AIDS Research

Oral Transmissionof HIV: Discussion Oral Transmissionof HIV: Recommendations OpportunisticInfections:Discussion OpportunisticInfections:Recommendations MucosalImmunityand Vaccines:Recommendations Therapeutics:Discussion

Basedon reviewof the past decadeof NIDRintramuralresearchand extramuralAIDS andHIV-relatedresearch,two importantconceptsrelevantto HIV infectionand oral medicinehaveemerged:

1. Of the almost 500 million dental visits every year, only 1 report of HIV transmission has been substantiated. Furthermore, salivary levels of cultivable HIV are extremely low or undetectable even in situations where infected blood occurs in the mouths of patients. This suggests that components of saliva/oral fluids provide some level of protection from oral transmission of HIV. Opportunities for development of therapeutics potentially derived from such oral fluid/salivary components should be investigated. 2. Intrinsic differences between the oral mucosa and other mucosal surfaces in the body (e.g., nasopharyngeal, gastrointestinal, vaginal) may mediate unique interactions with HIV. In addition, the immunology and natural defenses of the oral cavity may have novel characteristics that merit further study. Otherquestionsthat arisefromresearchto dateincludethe following.

1. Immunosuppression as a result of HIV infection appears to create permissive condi Oral InfectiousDiseases tions for the activation of other viruses found in the human host. In the oral cavity, these include the herpes simplex viruses (HSVs), Epstein-Barr virus (EBV), human Herpes-8 (HHV-8) and human papillomavirus (HPV). How immunosuppression results in viral reactivation of all these agents should be further explored. 2. The associations of oral hairy leukoplakia with EBV, HPV with oral papillomatosis and Kaposi's sarcoma with HHV-8 as a result of HIV-related immunosuppression are well recognized. Does activation of these viruses influence the development of oral malignancies/neoplasms? 3. How does the viral load in saliva correlate with that in serum? Could noninvasive salivary diagnostic assays be used to monitor the progression or treatment of HIV disease?

4. Novel lymphoid compartments in the oral cavity such as the tonsils, and Waldeyer's ring may be critical reservoirs of both viral pathogens and immune cells; as such, they warrant further investigation. 5. The neurotropism of HSV for trigeminal ganglia and the central nervous system (CNS) merits further study as a model of HIV neurotropism.

AIDSResearch

v Oral Transmission of HIV: Discussion

Oral (receptive) sex maybe a moreprevalentrouteof HIV transmissionthan currentlyperceived.Dr. DanielMalamud,Universityof Pennsylvania,reportedon a study(Schackeret al. Annalsof InternalMedicine,1996)showingthat in 12 subjects wherethe precisedate of seroconversioncouldbe identified,4 (= 33 percent)reported oral-genital contactas their sole risk factor. Youngpeopleand adolescentsare particularlyat risk, becausetheyincreasinglyperceiveoral sex as a safe, "nonintimate" activity. Whileonlysuggestive,thesestudiesindicatea needto derivereliableestimates of the risk of HIV infectionas a consequenceof oral sex. Oral viral load needsto be assessedto determinewhetherit is sufficientto providea significantrisk of infectionand warrantsintensivestudy.It is importantto determine whethersalivaryfactorsare protective(andto whatdegree)and whatrole they mayplay in the casualtransmissionof HIV via the oral cavity/fluids.

Oral markers: It is also of interestto determinewhethercomponentsof the oral cavity/fluidsmayprovidemarkersfor the developmentof diagnosticreagentseitherfor HIV or for geneticfactorsthat influencesusceptibilityto HIV/AIDS.Secondaryreceptors, usingcorrelatesof oral transmissionwith thoseat othermucosalsurfaces,and postexposureoral prophylaxisare relatedtopicsthat deserveattention. Viral entry: The site(s) of virusentryafter oral exposureto HIV maydiffer by age; tonsilsmayplayan importantrole for oral HIV transmissionin adults, whilethe primary virusentrypoint(s)alongthe gastrointestinaltract maybe differentin neonates/infants andcouldinvolvethe stomach. Breast feeding as a routeof HIV transmissionmayhavedifferentimplicationsfor worldwidepopulationsthanit doesfor U.S. subjects,the central issuebeingexposure to milk-borneHIV overnursingperiodsof short or longduration. Cofactors: Manycofactorsmaycontributeto oral transmissionof HIV. Theseinclude viral (HSV,EBV,HHV8, HPV), fungal(Candida)and otherfungaland microbial infections,as well as xerostomia,oral cancers,oral ulcers,leukoplakia,andthe inflammationthat accompaniesany of theseconditions.Whetheropportunistic infectionssimplyoccurwith HIV or affect susceptibilityto HIV transmissionrequires clarificationin infant, adolescent,and adult populations,whereeffectsmayvary. Mechanisms of disease and pathogenesisassociatedwith opportunisticinfections shouldbe furtherexploredat the molecular,geneticand genomiclevels. Suchstudies are importantnot only in the fundamentalscientificnatureof their investigation,but Oral InfectiousDiseases alsoin relationto their increasingrelianceon the developmentandrefinementof emergingtechnologiesin DNAsequenceanalysisand genomicinformatics.DNA sequenceanalysisand assemblyof selectgenomessuchas Candidaalbicansand oral microbialpathogensshouldbe supportedand can providea basisfor interdisciplinary andinteragencylinkages.

AIDSResearch

v Oral Transmission of HIV: Recommendations

Oral transmissionis a routeof HIV infectionin neonatesand infantsand severalrecent publicationssuggestthat oral-genital contactin adultsleadsto systemicHIV infection andAIDS.Oral transmissionincludesin utero, intrapartum,postpartum(breastmilk), andexchangeof bodyfluidsduringheterosexualand homosexualoral-genital sexual activity. Therisksof becominginfectedthroughindividualacts of unprotected rectal/vaginalintercourse,singleincidentsof professionalneedlestick injury, or IV drug injectionare known.In contrast, the relativerisksof infectionthroughthe oral route remainunknown.

NaturalHistoryandEpidemiology
Epidemiologicalinvestigationsneedto be conductedto evaluatethe possible contributionof oral transmissionof HIV, takinginto accountcarefullyevaluated individual(homosexualandheterosexual)practicesof oral-genital contact.Modulating factorsmightincludeconditionsor practicesthat influencethe integrityof the oral mucosa,oral health, nutrition,inhibitorysubstancesin saliva, and the influenceof alcohol,drugs,and othersubstances.

As viral load is knownto be an importantdeterminantof risk of HIV transmission,it is necessaryto determinethe viral loadin bodyfluids, includingpre-ejaculatoryfluid, ejaculate,cervical/vaginalfluids, oral fluids, and breastmilk, duringbothprimaryand chronicHIV infection.Thesamefluidsshouldalso be examinedin HIV-infected individualsundergoingantiviral therapy.

EtiologyandPathogenesis
The mechanismof virusentryafter oral exposureshouldbe studiedin applicablemodel systems,includingprimates.Keyissuesare the site(s) of viral entryafter oral exposure alongthe oropharyngealand gastrointestinaltract acrossmucosalsurfaces,the identity of initial targetcells, initial site(s) of replication,and the relativeefficiencyof oral infectionas comparedto otherroutesof exposure.Otherfactorsthat shouldbe studied includevirustropism,coreceptorusage,and cell-free versuscell-associatedvirus transmission.The influenceof host factorssuchas age on permittingsystemicinfection after oral exposureneedsto be investigated.Wheneverpossible,correlatesof primate andhumanstudiesshouldbe investigatedto ensurerelevance.

Oral InfectiousDiseases

Behavioraland Social ScienceResearch

Social and behavioralstudiesare neededto documentthe typesof sexualactivity relatedto oral-genital contact, and effectiveapproachesto bothunderstandingand changingthesebehaviorsneedto be explored.

Therapeutics Shouldoral transmissionof HIV proveto be a significantrisk, the potential for prophylaxisbeforeand after oral exposureneedsto be assessed.Dependingon the site of virusentryafter oral exposure,this couldincludesystemicas well as topicalagents.

AIDSResearch

v Opportunistic Infections: Discussion

Predisposing factors: Poordental hygiene,poornutritionand inadequatedental caremaycontributeto or serveas predisposingfactorsfor increasesin the developmentor severityof oral lesionsin HIV-infectedindividuals.However,periodontal diseaseoccursin HIV-infectedindividualswithoutthesefactors.Thereare uncommon manifestationsof periodontaldiseasesthat appearto be uniqueto HIV-infectedpersons, suchas necrotizingulcerativeperiodontitis.Whetheror not periodontaldiseaseor other oral lesionsplay a role in, or contributeto, oral transmissionof HIV or other opportunisticinfectionshas not beendetermined. Candidiasis as a sentinel condition in the onsetof AIDSis manifestin 80-100 percentof the HIV-infectedpopulation.Studiesof the organismand its mechanismsof pathogenesisand interactionwith the host providea bridgebetweenNIDRsponsored AIDSresearchand otherresearchon the role of HIV immunosuppressionin the activationof andsusceptibilityto opportunisticinfections(OIs). Candidiasisfurther allowsa comparisonof the oral mucosawith vaginalandgastrointestinalmucosal surfaces.Becauseoneof the importantrolesof mucosaltissueis barrierprotection, chronicinflammationdueto Candidaor otherpathogensmayaffect susceptibilityto HIV or otherinfections. Potentiationof infection:Therole of opportunisticpathogensin potentiating/facilitating HIV transmission/infectionand pathogenesisshouldbe furtherexplored.

Correlates of immune dysfunction: Whilethe correlationbetweenopportunistic infectionsand immunedysfunctionis well recognized,the cellular/molecularcorrelates of mucosaland systemicimmunocompromisehavenot beendefined.Changesin systemicandmucosalimmunefunctionin relationto susceptibilityand presentationof opportunisticinfectionsshouldalso be defined.The short- and long-termeffectsof antiretroviraltherapyon the reductionor eliminationof opportunisticinfectionsneedto be determined. Cancers of the oral cavity, particularlyKaposi'ssarcomaand lymphoma,relate directlyto HIV/AIDSand are associatedwith prior infectionwith EBV,HSV,HHV8 or HPV.Squamouscell carcinoma,the primarycancerof the mouth,doesnot appearto be morefrequentin HIV/AIDS,althoughthe role of chronicinflammationdue to opportunisticinfections,periodontaldisease,andHIV-associatedimmunosuppression has not beendefined. Aphthous ulcers: The etiologyof theselesionsis anothermatterof concern.While theseare commonin HIV-infectedindividuals,a pathogeneticlink with HIV mayexist.

Oral InfectiousDiseases

v Opportunistic Infections: Recommendations

A numberof opportunisticinfectionshaveuniqueoral manifestationsand are of special relevanceto oral healthand HIV disease.AgentscausingtheseOIs mayserveas facilitatorsof HIV infection,and infectiondue to thesepathogensmaypromoteHIV spreadthroughimmunosuppressionand othereffectson the host. Notably,our knowledgeof opportunisticinfectionsin the oral cavityand their relationshipto HIV diseaseis morecompletethanthe relationshipbetweentheseinfectionsandHIV at othersitesin the body. Consequently,the molecularmechanismsof host-pathogen interactionsshouldnowbe addressed. Areasof particularinterestincludethe following:

EtiologyandPathogenesis
Viral Pathogens

1. The role of viruses (HHV-8, EBV, HPV) as etiologic agents of tumors of the oral cavity should be explored further. In particular, the role of HHV-8,

the least well-known of the herpes family of viruses, should be explored in relation to Kaposi's sarcoma. 2. Studies of herpes and human papillomaviruses as transactivators of HIV gene expression are warranted. 3. Research on how EBV and cytomegalovirus (CMV) affect HIV pathogenesis through their effects on immune function should be explored. Reciprocally, the effects of HIV immunpathogenesis on the activation/reactivation of EBV, CMV and HSV should be studied. 4. Studies should be conducted of HSV as a model for neurotropic spread, gene expression, and reactivation of HIV in lymphocytes, macrophages, and neurons of the peripheral and central nervous systems. 5. The mechanisms of HHV-8 transmission and pathogenesis, specifically at the mucosal surface, should be explored.

Infectionand Immunity BacterialPathogens

1. The extent to which destruction of mucosal integrity, chronic inflammation and other host immune effects associated with gingivitis and periodontal diseases facilitates HIV infections and spread should be investigated. 2. The effects of HIV infection on oral microbial ecology in relation to diseases caused by opportunistic pathogens merits further study.

FungalPathogens Candidashouldbe studiedas a modelfor understandingthe host-pathogenrelationship at the mucosal,cellular, andmolecularlevel.

Therapeutics

Researchshouldbe conductedto identifynovelmoleculartargetsfor preventionand controlof opportunisticoral infections.

Oral InfectiousDiseases

v Mucosal Immunity and Vaccines: Recommendations

Therapeutics:Discussion
Opportunisticinfectionsof the oral cavityoffer uniqueopportunitiesfor NIDRto partner with otherICDsand the pharmaceuticalindustryin developingnewdrugsand other interventionsas well as newmethodsof administration(e.g., transmucosal)for proven therapies.Oral cavitylesionsthat facilitateHIV infectionand/ortransmissionand opportunisticpathogensthat mayincludeHIV are amongthe targets. Clinicalevaluationof oral fluidspresentsanotherpartneringopportunity,particularly with regardto monitoringpharmacokinetics,HIV viral load, immunoglobulins/antibodies,surrogatemarkers,and broaddiagnostics.Studiesof the role of oral fluidsin evaluatingefficacyof treatmentandprogressionof diseasein adultsand childrenare still in their early stages,but NIDRis an appropriatepartnerin suchresearch.