Diagnosis and Management of the Oral Manifestations of HIV Infection and AIDS

A Comparative Study of Oral Candidal Carriage and Its Association with CD4 Count between HIV-Positive and Healthy Individuals

Aims and Objectives:

To correlate asymptomatic oral candidal carriage in HIV-positive patients and normal individuals and determine its association with CD4 count.

Material and Methods:

Forty HIV-positive patients and forty healthy individuals were included in this study. Saliva from both groups was collected by the spitting method. The saliva from each individual was incubated aerobically on Sabouraud Dextrose agar with antibiotics at 37°C. The germ tube method was used for differentiation of candidal species, whether the Candida albicans or non- Candida albicans. Surface count method was used to count the number of colonies of candida species. Data were analyzed by chi square and Mann-Whitney test.

Results:

Oral candidal carriage was found in 22 out of 40 (55%) HIV-positive patients. In healthy volunteers, oral candidal carriage was found in 6 out of 40 (15%) individuals ( p value = 0.0002), which is significantly higher. Similarly, density carriage in the HIV-positive patients was found to be significantly higher than that in the HIV-negative group ( p value = 0.002). However, oral yeast carriage was not associated with CD4 count (correlation coefficient r = −0.087).

Conclusion:

Within the limits of the study, we concluded oral candidal carriage rate and density carriage higher in HIV-positive patients than in healthy individuals.

Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult population in Oyo State, Nigeria

OBJECTIVE

The objective of this study was to define the oro-facial lesions associated with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) in an adult population in Oyo state, Nigeria and to relate these with the level of immune suppression as measured by the CD4 counts.

MATERIALS AND METHOD

The study population consisted of 679 consecutive subjects who were seen at the state-owned blood bank. Information on demography, medical and medication histories were obtained. Oro-facial examinations were carried out according to Greenspan et al [Oral Surg Oral Med Oral Pathol (1992)73:142-144]. HIV sero-prevalence status was determined for all patients. CD4+ T-lymphocyte count was carried out for those sero-positive for HIV and 31 randomly selected HIV-negative subjects. Data were analyzed using the chi-square test, Fisher's exact test, Student's t-test and odds ratio where appropriate.

RESULTS

Eighty-one (11.9%) of the entire study sample were confirmed HIV positive. The prevalence of specific oral lesions by HIV sero-status revealed that pseudomembranous oral candidiasis and angular cheilitis occurred significantly and more frequently in HIV-positive subjects (33.3 and 21% respectively) than those who were HIV negative (4.3 and 1.8% respectively, P < 0.05). The mean CD4 count of the HIV-positive subjects was 452 cells mm(-3), s.d. 137, while it was 602 cells mm(-3), s.d. 251, for the HIV negatives. The difference was statistically significant (P = 0.000). Forty-four (66.7%) subjects with CD4 counts <500 cells mm(-3) had oro-facial lesions whereas among those with CD4 counts >500 cells mm(-3) only 22 (33.3%) had oro-facial lesions (OR = 4.57).

CONCLUSION

The type of oro-facial lesions most commonly associated with HIV/AIDS in Oyo state, Nigeria, has been shown to be pseudomembranous oral candidiasis. This was followed by angular cheilitis. These lesions, although found in HIV-negative subjects, were in a lower proportion as compared with HIV-positive subjects. Mean CD4 counts were lower in HIV-positive subjects and this was associated with greater prevalence of oro-facial candidiasis and angular cheilitis.

HIV/AIDS orofacial lesions in 156 Zimbabwean patients at referral oral and maxillofacial surgical clinics

OBJECTIVE

To document the prevalence, age and gender distribution and clinical features of HIV/AIDS orofacial lesions in patients referred to the two largest Oral and Maxillofacial specialist centers in Harare, Zimbabwe, and compare the findings with those from other parts of the world.

DESIGN

Descriptive study.

SETTING

Oral and Maxillofacial Surgical Clinics at specialist referral hospitals; Harare Central Hospital and Parirenyatwa Government Hospital, Harare, Zimbabwe.

SUBJECTS

A total of 7800 consecutive patients referred for various orofacial conditions were examined. From this group, 156 patients with orofacial lesions of or suggestive of HIV/AIDS were further interviewed and examined by the oral and maxillofacial surgeon in charge of the clinics.

METHODS

Head, neck and oral examinations were carried out. Oral examination was carried out using mouth mirror and dental light in a dental chair. HIV/AIDS orofacial lesions were recorded and diagnosed using the EC Clearing House Criteria on Oral Problems related to HIV Infection (1993).

RESULTS

There were 79 males and 77 females. Male:female ratio 1:1; age range 1-56 years; candidiasis (55.1%) was the most common lesion with the pseudomembranous type (55.8%) predominating. High prevalences of Kaposi's sarcoma (18.6%), salivary gland disease (12.2%) and cancrum oris (3.8%) were noted. Heterosexual contact and mother to child transmissions appear to be the mode of transmission.

CONCLUSION

The spectrum of orofacial lesions is similar to that in other countries. This study shows a high prevalence of candidiasis, Kaposi's sarcoma, salivary gland disease, non-Hodgkin's lymphoma, cancrum oris and rampant caries.

Oral manifestations of an HIV positive cohort in the era of highly active anti-retroviral therapy (HAART) in South London

BACKGROUND

Human Immunodeficiency Virus (HIV) infection is associated with oral manifestations of diagnostic and prognostic importance. With the advent of Highly Active Anti-retroviral Therapy (HAART) there is anecdotal evidence to suggest that the prevalence of oral lesions has declined. The number of prevalence studies, carried out in the era of HAART is, however, meagre. Our aim was to study the prevalence of the oral manifestations of HIV in a population, predominantly on HAART, attending a Genito-Urinary Medicine Centre in South London.

METHODS

This cross sectional study included 203 adult volunteers, comprising 76% males and 24% females. One third of the subjects were from the predominantly African or Afro- Caribbean ethnic minority groups resident in London. The relationship between the prevalence of oral lesions and demographic variables, therapeutic regimes, viral load and CD4 counts were evaluated.

RESULTS

One hundred (49%) of the patients had no detectable oral lesions. Oral lesions detected most frequently included oral hairy leukoplakia (9.9%), HIV associated periodontal diseases (9.9%) and oral candidiasis (4.9%). Three subjects had multiple papillomatous growths. Most cases (n = 17/20) of oral hairy leukoplakia were in individuals with a detectable (> 400 copies/ml) plasma RNA viral load. The majority (n = 8/10) of our patients with oral candidiasis had a plasma RNA viral load > 10,000 copies/ml and half (n = 5/10) had a CD4 count < 200 cells/mm3. Logistic regression analysis suggested that the presence of an oral lesion was not associated with any demographic features except for periodontal diseases which were associated with tobacco smoking (P = 0.023).

CONCLUSIONS

The prevalence of so called 'strongly associated' oral lesions of HIV is low in this South London HIV-infected population on HAART, and the relative frequency is different from that cited in the literature from the pre-HAART era. The oral lesions detected were found mostly in people with low CD4 counts and high HIV-1 RNA viral loads, suggesting they were very immunocompromised, not on, or declining therapy, or that their therapy was failing.

Prevalence and incidence of oral lesions--the changing scene

A range of oral mucosal and periodontal lesions is associated with HIV infection and HIV disease progression. These are often symptomatic and require treatment in themselves, and also have a diagnostic and prognostic role in the management of the underlying HIV disease. These lesions have been broadly divided into: (a) those strongly associated with HIV such as oral candidoses, oral hairy leukoplakia and Kaposi's sarcoma; (b) those less strongly associated such as swellings of the major salivary glands; and (c) those least commonly associated such as recurrent aphthous ulcers. Overall the prevalence and severity of these lesions inversely correlate with the level of immunosuppression. With the passage of time, there has been improved understanding of the disease pathogenesis resulting in the development of new drugs to combat this infection. Medication has changed from monotherapy to current triple combination therapy (Highly Active Anti-Retroviral Therapy). This review looks at the impact of changing therapy on the prevalence of the various oral lesions associated with HIV. It finds a decrease in the prevalence of the oral lesions in the era of combination therapy as compared to earlier periods. It also shows a change in the types of lesions which predominate with those previously placed amongst the strongly associated lesions no longer being predominant in the era of combination therapy where such treatment is available.

Prevalence of HIV-associated periodontitis and chronic periodontitis in a southeastern US study group

OBJECTIVES

This study estimates factors associated with the prevalence of HIV-associated periodontal diseases (HIV-P) and the severity and extent of periodontitis in HIV-infected adults from North Carolina (NC).

METHODS

Data are derived from a cross-sectional study of HIV-infected adults (total n = 326, dentate n = 316) treated at the University of North Carolina Hospitals. Outcomes were a diagnosis of HIV-P and measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL). Immunosuppression was measured by peripheral blood CD4+ cells/mm3.

RESULTS

In addition to persons with HIV (non-AIDS), this study included 10 percent of the AIDS cases in North Carolina. Median age was 37 years (range = 19-67); 78 percent were male and 60 percent were black. Sixty-two percent of persons had a probing pocket depth > or = 5 mm; 46% had recession > or = 3 mm, and 66 percent had attachment level > or = 5 mm in one or more sites. Cases of HIV-P (n = 15) were rare. Persons taking HIV-antiretroviral medication were one-fifth (OR = 0.20; 95% CI = 0.07, 0.63) as likely to have HIV-P as those not taking those medications, controlling for CD4+ cell counts.

CONCLUSIONS

HIV-infected persons in this study group from North Carolina exhibited severe and extensive measures of adult periodontitis. A small proportion experienced a severe form of HIV-P, which was attenuated by antiretroviral therapy.

Association between carriage of oral yeasts, malnutrition and HIV-1 infection among Tanzanian children aged 18 months to 5 years

The objective was to determine whether there is an association between carriage of oral yeasts, malnutrition and HIV-1 infection among Tanzanian children. A case-control study design within a cross-sectional study was used, and the outcome was carriage of oral yeasts. The exposure variables were malnutrition and HIV-1 antibody, and confounders to be adjusted for were age, sex, and breastfeeding. The study was carried out in Dar-es-Salaam, Tanzania, in two maternal and child health (MCH) clinics that offer routine medical checkups to all expectant mothers and children aged between 0 and 5 years in the catchment area. A total of 882 children aged between 18 months and 5 years participated. Smears from the tongue and buccal mucosa were examined for oral yeasts. Malnutrition was categorized according to standards on the MCH chart and World Health Organization/Centers for Disease Control (WHO/CDC) standards as weight-for-height (wasted), weight-for-age (underweight), and height-for-age (stunted). HIV-1 infection was determined by an enzyme-linked immunosorbent assay. Reactive sera were confirmed by Western Blot. About 27% of the children were slightly or severely malnourished according to standards on the MCH chart. According to WHO/CDC standards, 2.6% were wasted, 16.3% were underweight, and 29.6% were stunted. Fourteen (1.6%) were seropositive for HIV-1 antibody. Hyphal forms and blastospores were much more frequent among children infected with HIV-1 with odds ratios ranging from 3.8 (95% CI: 1.3;11.2) to 6.2 (95% CI: 2.1;18.4) depending on categorization of malnutrition. Malnutrition was a risk factor, too, albeit to a much lesser and insignificant degree. The study supports our previous findings that malnutrition may predispose to carriage of oral yeasts and subsequent infection. However, in this study population HIV infection was clearly the predominant risk factor.

Association between carriage of oral yeasts and malnutrition among Tanzanian infants aged 6-24 months

OBJECTIVE

To determine if there is an association between carriage of oral yeasts and malnutrition in infants.

DESIGN

A case-control study within a cross-sectional study. The dependent variable was carriage of oral yeasts. The exposure variable was malnutrition and confounders to be adjusted for were age, sex, and breast-feeding.

SETTING

A maternal and child health clinic in Dar-es-Salaam, Tanzania that offers routine medical check-ups to all expectant mothers and children aged between 0 and 5 years in its catchment areas.

SUBJECTS AND METHODS

972 infants aged 6-24 months participated. Smears from the tongue and cheek mucosa were examined for candidal hyphae and blastospores. Malnutrition was categorized according to Tanzanian standards (weight-for-age) and World Health Organization (WHO) standards (weight-for-height and height-for-age).

MAIN OUTCOME MEASURE

Carriage of oral yeasts (hyphae and blastospores).

RESULTS

Carriage of oral yeasts was significantly higher in the 227 malnourished compared with the 745 well nourished adjusted for confounders. Odds ratio for presence of hyphae in smears from the severely malnourished (weight-for-age) was 4.5 (90% CI: 2.0-10.0). Odds ratio for presence of hyphae was 2.3 (90% CI: 1.1-4.8) when weight-for-height were used to categorize for malnutrition.

CONCLUSION

The study tends to confirm the generally held view that malnutrition may predispose to carriage of oral yeasts and subsequent oral candidiasis.

Sinusitis in HIV-infected patients: a clinical and radiographic review

PURPOSE

To describe the clinical, radiographic, and laboratory features of sinus disease in human immunodeficiency virus (HIV)-infected individuals.

PATIENTS

Seventy-two patients with a history of sinusitis identified from 1,461 consecutive admissions (667 patients) to the HIV ward at The Johns Hopkins Hospital.

METHODS

Retrospective chart review.

SETTING

The Johns Hopkins Hospital.

RESULTS

Sinusitis was identified in 72 HIV-infected patients, predominantly individuals with a CD4 cell count of less than 200/mm3. A history of respiratory infections such as bacterial pneumonia, bronchitis, and otitis media was common. Although nasal congestion and postnasal drainage were found in the majority of patients, symptoms of sinusitis were often nonspecific and the diagnosis was incidental in 28 patients (33%). Magnetic resonance imaging or computed tomography was significantly more sensitive than plain radiography (p less than 0.001) in defining the extent of the disease, particularly with posterior sinus involvement, which occurred in the majority of the patients. The number of radiologically abnormal sinuses correlated inversely with the CD4 count. Although the majority of patients responded at least partially to antibiotic therapy, only 15% had complete resolution of clinical symptoms. Fifty-eight percent of patients had clinical and/or radiographic evidence of recurrent/persistent sinus infection, and chronicity correlated with a CD4 count less than 200/mm3 (p less than 0.001).

CONCLUSIONS

Sinusitis in HIV-infected patients is common, severe, and difficult to treat. Patients with CD4 counts less than 200/mm3 are prone to disease involving multiple sinuses that responds incompletely to antibiotic therapy, often resulting in chronic sinusitis. Unlike the immunocompetent host, the majority of the HIV-infected patients with advanced immunodeficiency develop posterior sinus disease.

Management of oral health in persons with HIV infection

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

Otolaryngologic aspects of acquired immunodeficiency syndrome

Currently, most patients with AIDS present with a manifestation involving the head, neck, or respiratory tract. The otolaryngologist may be the first physician to evaluate the patient with HIV infection and, therefore, must be aware of the various manifestations. The otolaryngologist may also be involved in diagnosing and managing the disease through modalities such as biopsy, endoscopy, tracheotomy, and other surgical procedures. In all phases of care, it is important to retain a medically appropriate and psychologically supportive environment. Although universal precautions should be followed in all phases of care, there is no need to avoid the supportive gestures such as handshaking and shoulder patting. These contacts can be most comforting to patients. Physicians should also be aware of all sources of information and medical assistance within the community that might be of further assistance to patients. The AIDS epidemic presents an enormous challenge to all health care providers. Good interdisciplinary communication among the various specialists involved in the AIDS epidemic will promote increased standards of patient care. Such communication will also provide information and support for physicians who are uncomfortable with the challenges of this epidemic.

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.

Thalidomide: treatment of severe recurrent aphthous stomatitis in patients with AIDS

An increasing number of AIDS patients have been noted to suffer severe recurrent aphthous stomatitis (RAS), a condition often associated with high morbidity that remains unresponsive to conventional therapeutic interventions. In two cases thalidomide was administered to successfully treat AIDS patients with RAS. Both patients experienced complete abatement of pain shortly after therapy was initiated. Ulcerations that were present for months resolved after three or four weeks of thalidomide therapy without any adverse effects. Thalidomide appears to be an effective agent for the treatment of severe RAS unresponsive to traditional therapies.

Neutrophil function and oral disease

The pathological sequela of reduced neutrophil function in the oral cavity and the mechanisms behind dysfunction have added to our understanding of infectious diseases. Numerous examples have been given, and the overriding conclusion must be that any impairment of neutrophil function will lead to some degree of increased susceptibility to infection. Perhaps the tissue most sensitive to pathological changes in the oral cavity is the periodontium. In cases of severe neutrophil dysfunction, there is severe periodontal breakdown, but also in cases of "mild" neutrophil dysfunction, where there is no other infection, such as in individuals with LJP, there is severe periodontal breakdown. The molecular basis of neutrophil dysfunction is beginning to be understood in individuals with LJP, LAD, CGD, and AIDS. It is our hope that further research in this area will help to delineate the pathogenesis of these and other oral diseases.