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HIV in the Dental Pulp
Le t t e r s to E d it o r
the
R e co g n itio n of the im p o rtan ce of medication side effects in TMJ-muscular treatment is a consideration that practi tioners can n o t ignore if they are to successfully understand and treat TMD and related m uscular conditions. E. J. NEIBURGER, DDS WAUKEGAN, IL
that is said, the material is most stim u lating—and it is a good team. Keep u p the great work! T. M. GRABER, DMD, MSD, PhD EDITOR, AM E R IC A N JO U R N A L OF O R TH O D O N T IC S
□ T he March issue featured numerous excellent articles on T M conditions; however, few of these papers identified drug reactions as a significant factor in muscle and jo in t pain. A large num ber of people are now taking beta-blockers, calcium channel blockers, and ACE inhibitors for treatment of mild to severe cardiovascular conditions. Young adults are often placed on these drugs for c o n tro l of b o rd e rlin e h y p erten sio n . Adverse reactions to these drugs, which may cause or contribute to the severity of T M J conditions, include: muscle cramps, fatigue, depression, headaches, nervous ness, and tinnitus. These symptoms are quite common (10% of patients who take calcium ch an n el blockers experience muscle cram ping) and often are exacer bated by the frequent changes in dosage and combinations w ith other drugs. Cholesterol lowering drugs also contrib ute adverse reactions which can affect the diagnosis and treatment of TM J disorders. L ovinstatin causes m uscle cram ping, m y algia, an d h ead ach e (in 9.3% of patients); cholestyramine causes joint pain along w ith muscle cramps. I recently treated a patient with severe TM J pain (m andibular deviation, joint popping) who was refactory to splints and muscle relaxant treatment. His symptoms completely disappeared a week after he reduced his Vasotec m edication (ACE inhibitor) from 10 to 5 mg. They reap peared when he resumed normal 10 mg dosage and disappeared again when he went to 5 mg.
HIV in the dental pulp □ “Detection of HIV in the dental pulp of a patient w ith AIDS” by Dr. Michael Glick and others (November) was thought provoking and excellent. However, further in fo rm a tio n on the study w ould be helpful. In the methods section, the authors do not mention what section(s) of the HIV1 genome were used as primers for the polymerase chain reaction (PCR). Addi tionally, it would be interesting to know the ease of HIV culture and titer of virus from the p a tie n t’s p e rip h e ra l blood m ononuclear cells (PBMC). Finally, how does the PCR result from the pulp tissue compare with the PCR result from the p atien t’s PBMCs? Certainly, the most likely cells to suspect as the reservoirs of HIV would be PBMCs in the pulp. I further believe th at it should be clarified that a positive PCR reaction does not necessarily indicate the presence of infectious hum an immunodeficiency virus (HIV) but that it merely indicates that a small piece of proviral DNA hybridizable with the prim er probe DNA is present in a tissue sample. Viruses, especially HIV1, replicate w ith a high error rate and generate high percentages of defective proviruses and defective noninfectious viral particles. These defective viruses are also detectable by PCR. The infectious virus was not cultured from the pulp. Because of the tremendous concerns over infection control and occupational expo sure because of HIV, it is im portant not to raise concerns with reports of viral presence that m ight be misunderstood. DAVID ARCHIBALD, DMD, DSc T H E UNIVERSITY OF MARYLAND, BALTIMORE, COLLEGE OF DENTAL SURGERY
□ Authors’ comment: We appreciate Dr. Archibald’s comments. The primer used in the polymerase chain reaction (PCR) was an HIV specific 6.5 kb gag-pol genomic probe. Peripheral blood m ono nuclear cells (PBMC) were not examined as the diagnosis of AIDS had already been made. O ur interest concerned only the presence of HIV w ithin the pulp. T his finding has since been confirmed in more than 90% of pulpal samples examined by the PCR technique (unpublished data). We completely agree that a positive PCR reaction does not necessarily indicate the presence of infectious HIV. However, we have subsequently used m ultiple HIV specific probes for in situ hybridization that showed the presence of a high degree of H IV rep lic atio n w ith in the p u lp (unpublished data). A lthough we cannot be sure of the infectious nature of the HIV w ithin the dental pulp until we conduct in vitro studies on transfection, this result suggests a high probability of finding infectious HIV. Although these are preliminary studies, we believed it was prudent to apprise the dental community of the high possibility of infectious HIV w ithin a structure com m only encountered during dental procedures. MICHAEL GLICK, DMD DIRECTOR, INFECTIOUS DISEASE CENTER MICHAEL PLISKIN, DDS, PhD CHAIRMAN, DEPARTM ENT OF ORAL MEDICINE, AND ASSISTANT DEAN FOR CLINICAL AFFAIRS TEM PLE UNIVERSITY
Clarification o There may be some confusion regarding the ADA seal status of the Interpore IMZ Im plant system because of the layout used in the Interpore ad that appeared in the September 1989 through February 1990 is sues of The Journal. Readers should note that the HA-coated version of the Interpore product has n o t received Provisional Acceptance; only the IMZ Im plant (4.0 mm) System has been granted provisional acceptance by the Council on Dental Materials, Instruments, and Equipment.
the
R e co g n itio n of the im p o rtan ce of medication side effects in TMJ-muscular treatment is a consideration that practi tioners can n o t ignore if they are to successfully understand and treat TMD and related m uscular conditions. E. J. NEIBURGER, DDS WAUKEGAN, IL
that is said, the material is most stim u lating—and it is a good team. Keep u p the great work! T. M. GRABER, DMD, MSD, PhD EDITOR, AM E R IC A N JO U R N A L OF O R TH O D O N T IC S
□ T he March issue featured numerous excellent articles on T M conditions; however, few of these papers identified drug reactions as a significant factor in muscle and jo in t pain. A large num ber of people are now taking beta-blockers, calcium channel blockers, and ACE inhibitors for treatment of mild to severe cardiovascular conditions. Young adults are often placed on these drugs for c o n tro l of b o rd e rlin e h y p erten sio n . Adverse reactions to these drugs, which may cause or contribute to the severity of T M J conditions, include: muscle cramps, fatigue, depression, headaches, nervous ness, and tinnitus. These symptoms are quite common (10% of patients who take calcium ch an n el blockers experience muscle cram ping) and often are exacer bated by the frequent changes in dosage and combinations w ith other drugs. Cholesterol lowering drugs also contrib ute adverse reactions which can affect the diagnosis and treatment of TM J disorders. L ovinstatin causes m uscle cram ping, m y algia, an d h ead ach e (in 9.3% of patients); cholestyramine causes joint pain along w ith muscle cramps. I recently treated a patient with severe TM J pain (m andibular deviation, joint popping) who was refactory to splints and muscle relaxant treatment. His symptoms completely disappeared a week after he reduced his Vasotec m edication (ACE inhibitor) from 10 to 5 mg. They reap peared when he resumed normal 10 mg dosage and disappeared again when he went to 5 mg.
HIV in the dental pulp □ “Detection of HIV in the dental pulp of a patient w ith AIDS” by Dr. Michael Glick and others (November) was thought provoking and excellent. However, further in fo rm a tio n on the study w ould be helpful. In the methods section, the authors do not mention what section(s) of the HIV1 genome were used as primers for the polymerase chain reaction (PCR). Addi tionally, it would be interesting to know the ease of HIV culture and titer of virus from the p a tie n t’s p e rip h e ra l blood m ononuclear cells (PBMC). Finally, how does the PCR result from the pulp tissue compare with the PCR result from the p atien t’s PBMCs? Certainly, the most likely cells to suspect as the reservoirs of HIV would be PBMCs in the pulp. I further believe th at it should be clarified that a positive PCR reaction does not necessarily indicate the presence of infectious hum an immunodeficiency virus (HIV) but that it merely indicates that a small piece of proviral DNA hybridizable with the prim er probe DNA is present in a tissue sample. Viruses, especially HIV1, replicate w ith a high error rate and generate high percentages of defective proviruses and defective noninfectious viral particles. These defective viruses are also detectable by PCR. The infectious virus was not cultured from the pulp. Because of the tremendous concerns over infection control and occupational expo sure because of HIV, it is im portant not to raise concerns with reports of viral presence that m ight be misunderstood. DAVID ARCHIBALD, DMD, DSc T H E UNIVERSITY OF MARYLAND, BALTIMORE, COLLEGE OF DENTAL SURGERY
□ Authors’ comment: We appreciate Dr. Archibald’s comments. The primer used in the polymerase chain reaction (PCR) was an HIV specific 6.5 kb gag-pol genomic probe. Peripheral blood m ono nuclear cells (PBMC) were not examined as the diagnosis of AIDS had already been made. O ur interest concerned only the presence of HIV w ithin the pulp. T his finding has since been confirmed in more than 90% of pulpal samples examined by the PCR technique (unpublished data). We completely agree that a positive PCR reaction does not necessarily indicate the presence of infectious HIV. However, we have subsequently used m ultiple HIV specific probes for in situ hybridization that showed the presence of a high degree of H IV rep lic atio n w ith in the p u lp (unpublished data). A lthough we cannot be sure of the infectious nature of the HIV w ithin the dental pulp until we conduct in vitro studies on transfection, this result suggests a high probability of finding infectious HIV. Although these are preliminary studies, we believed it was prudent to apprise the dental community of the high possibility of infectious HIV w ithin a structure com m only encountered during dental procedures. MICHAEL GLICK, DMD DIRECTOR, INFECTIOUS DISEASE CENTER MICHAEL PLISKIN, DDS, PhD CHAIRMAN, DEPARTM ENT OF ORAL MEDICINE, AND ASSISTANT DEAN FOR CLINICAL AFFAIRS TEM PLE UNIVERSITY
Clarification o There may be some confusion regarding the ADA seal status of the Interpore IMZ Im plant system because of the layout used in the Interpore ad that appeared in the September 1989 through February 1990 is sues of The Journal. Readers should note that the HA-coated version of the Interpore product has n o t received Provisional Acceptance; only the IMZ Im plant (4.0 mm) System has been granted provisional acceptance by the Council on Dental Materials, Instruments, and Equipment.