Oral lesions among persons with HIV disease with and without highly active antiretroviral therapy in southern India

HIV-Related Oral Mucosa Lesions: A Cross-Sectional Study on a Cohort of Italian Patients

BACKGROUND

Human immunodeficiency virus (HIV) infection can be associated with oral mucosal diseases, including oral candidiasis and HPV infection, which are putative indicators of the immune status.

AIM AND METHODS

This retrospective cross-sectional study was aimed at assessing the prevalence of HIV-related oral mucosal lesions in a cohort of Italian HIV+ patients regularly attending the Clinics of Infectious Diseases.

RESULTS

One hundred seventy-seven (n = 177) patients were enrolled and 30 (16.9%) of them showed HIV-related diseases of the oral mucosa. They were mainly found in male patients over 35 years old, undergoing Combination Antiretroviral Therapy (cART), and with CD4+ count < 500/µL. Oral candidiasis was the most common HIV-related oral lesion. No significant correlations could be detected between the prevalence of HPV infection and other clinical parameters (lymphocyte count, cART treatment and viral load).

CONCLUSIONS

HIV-related oral mucosal diseases can correlate with immunosuppression. Early diagnosis and management of oral lesions in HIV+ patients should be part of the regular follow-up, from a multidisciplinary perspective of collaboration between oral medicine and infectious disease specialists, in an attempt to reduce morbidity due to oral lesions and modulate antiretroviral therapy according to the patient's immune status.

"Oral manifestations of HIV in accordance with CD4 count" - A cross-sectional study

Aims and Objectives

Mouth acts as a mirror for most of the underlying systemic diseases. Very few studies were done in south Indian population to observe the oral manifestations of human immunodeficiency virus (HIV) in relation to the cluster of differentiation 4 (CD4) count, and this study mainly highlights the presenting complaint of HIV patients during their dental visit. The study was aimed to determine the chief complaints of patients along with oral manifestations of HIV and correlate them to CD4 count.

Materials and Methods

One hundred consecutive HIV-positive patients were considered for the study. All the oral manifestations and the chief complaints along with the calculated CD4 counts were noted and the results were correlated. Spearman correlation was used for CD4 count and other oral manifestations.

Results

The mean CD4 counts were 421 cells/mm³ with a standard deviation (SD) of 404.34 for the most common oral manifestation of burning mouth and 176.5 cells/mm³ for the least common manifestation of malignancies. The CD4 count ranged from 120 to 1100 cells/mm³. The mean age and CD4 count were 38 years and 398.86, respectively. There was a statistically significant correlation with candidiasis and gingivitis, and the rest of the conditions were insignificant.

Conclusion

The study results suggest that the chief complaint of presentation of an HIV-positive patient is pain due to carious teeth/abscess followed by burning mouth, with candidiasis being the most common disease.

A Real-World Evidence-Based Management of HIV by Differential Duration HAART Treatment and its Association with Incidence of Oral Lesions

Background

The efficacy of highly active antiretroviral therapy (HAART) can be estimated by the immunological response and the incidence of opportunistic infections.

Objective

This study aimed at evaluating the effectiveness of different durations of HAART in terms of immunological response markers (CD4 count and CD4/CD8 ratio) along with disease progression markers (incidence of oral lesions) in Chinese patients with HIV.

Methods

This single-center, retrospective, and real-world study included patients with HIV, grouped into a treatment group and treatment-naïve group, of which the former was further divided into 6, 12, and 18 months based on the treatment duration. The CD4 and CD8 cell counts were analyzed by the FACSCalibur flow cytometry. Kruskal-Wallis test was applied to determine the outcome of different duration of HAART. Oral examination was carried out according to the WHO type IV examination.

Results

In 246 patients with HIV, CD4 counts increased significantly post-HAART compared to pre-HAART in all three treatment groups (P<.001), while CD8 count decreased significantly (P<.05) in all three treated groups. A significant association of HAART with the CD4/CD8 ratio was observed (P<.001). A significant increase in CD4 count was observed between 12-months and 18-months treatment groups (P<.05). The occurrence of oral lesions reduced significantly in the treatment group.

Conclusion

We observed a better response to the HAART regimen with 18-months of duration than 12-months and 6-months therapies and reduction in oral lesions.

Quantification of Oral Candidal Carriage Rate and Prevalence of Oral Candidal Species in HIV Patients with and Without Highly Active Antiretroviral Therapy

BACKGROUND

Most documents review decrease in the prevalence of HIV related oral lesions to the tune of 10-50% following the advent of HAART. However long term use of HAART on oral health status of HIV infected subjects is poorly documented. Also antifungal agents can effectively treat mucosal candidiasis. However their use can lead to colonization with less susceptible strains among normal susceptible strains.

AIMS AND OBJECTIVES

To know the candidal carriage rate (i.e. presence/absence of candidal growth), candidal density(CFUs/ml) & species variations (species diversity) in HIV positive individuals with and without highly active anti-retroviral therapy (HAART), attending the regional voluntary Counselling and Confidential Testing Centre (VCCTC).

MATERIALS AND METHODS

The study population were categorized into 3 groups. Method followed were Germ tube test, Chlamydospore formation test, CHROM-Agar test.

RESULTS

Quantification comparison study of candidal carriage rate, density with detection of various candidal species in the oral cavity of HIV-positive individuals with and without HAART therapy was conducted.

CONCLUSION

HIV positive individuals with HAART therapy treatment prooved higher candidal carriage rate and lower density than Non-HAART category.

Oral candidiasis in human immunodeficiency virus-infected patients under highly active antiretroviral therapy

Human immunodeficiency virus has plagued mankind since the 1980's when the first case was documented. Human immunodeficiency virus-induced immunocompromised state can lead to several systemic and local manifestations, which often culminates in mortality. Oral candidiasis was one of the most prevalent opportunistic infections noted in human immunodeficiency virus-infected patients. The advent of highly active antiretroviral therapy has led to a significant reduction in both the mortality and the morbidity of infected patients. The combined antiretroviral therapy has also led to a decrease in the incidence of opportunistic infections including oral candidiasis. Thus, the presence of well-established oral candidiasis in human immunodeficiency virus-infected patients under highly active antiretroviral therapy could be considered as an indicator of potential treatment failure. The present manuscript aims to review the published literature assessing the effect of highly active antiretroviral therapy on the incidence of oral candidiasis in human immunodeficiency virus-infected patients.

Reviewing the oral pigmented lesions of human immunodeficiency virus with emphasis on the effect of highly active antiretroviral therapy

Acquired immunodeficiency syndrome a disease with high mortality rates is caused by the well-known human immunodeficiency virus. The disease is characterized by several opportunistic infections owing to the decreased CD4 lymphocyte counts. Oral manifestations of human immunodeficiency virus are vital as they are one of the early manifestations of the disease. Also, they serve as prognostic markers as they correlate with the CD4 lymphocyte counts of the affected individuals. Human immunodeficiency virus is not only common in the adult population but also can affect pediatric patients through vertical transmission. The initial therapeutic strategy for the management of the virus was only the prevention of opportunistic infections. Later in the mid-1990s, antiretroviral therapy was introduced but there was no significant improvement in prognosis. After the advent of combination therapy or the use of three antiretroviral drugs also known as highly active antiretroviral therapy, there has been a marked reduction in human immunodeficiency virus-associated mortality rates. The highly active antiretroviral therapy has several effects on the oral manifestations of the human immunodeficiency virus. The present paper aims to review the oral pigmented lesions associated with human immunodeficiency virus with an emphasis on the effect of highly active antiretroviral therapy.

Common oral opportunistic infections in Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome: Changing epidemiology; diagnostic criteria and methods; management protocols

There were 36.9 million in the world living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) as of 2017, and new infections have seen a reduction by 18% since 2010. But this rate of decline is not sufficient for the goal of eradication of AIDS by 2030. Only 21.7  million people infected with HIV have accesses to antiretroviral therapy, with the rest at risk of the potential complications of HIV infection. It has been shown that oral lesions are diagnostic and prognostic of HIV infection, and many oral opportunistic infections continue to be a major problem, particularly in developing countries. It is therefore important that dental surgeons be aware and updated to recognize and manage the oral effects of HIV infection/AIDS. This chapter describes the classification, diagnosis, and management of oral lesions in these patients, based on our current understanding of the infection. This review also discusses the standardization of diagnosis of oral lesions in HIV infection/AIDS patients, immune reconstitution inflammatory syndrome case definition, and the research priorities formulated at the 7th World Workshop on Oral Health and Disease in AIDS.

Quantification of micronuclei in exfoliated cells of human immunodeficiency virus/AIDS-infected female patients

Background

Micronucleus (MN) is a biomarker for cytotoxicity, which is formed during cell division. Increased MN scoring has been successfully used to recognize population groups at risk for cancers of oral cavity, cervix, urinary bladder and esophagus. Incorporating MN score along with cytological smear testing gives a better and cost-effective screening for high-risk patients.

Objective

This study evaluated the effectiveness of using MN score assessed from Papanicolaou (PAP) smears, as a biomarker for chromosomal damage in human immunodeficiency virus (HIV) patients.

Materials and Methods

Oral smears of 25 female HIV/AIDS patients, without habits such as chewing or smoking tobacco, and taking antiretroviral therapy (ART) at ART center, were recruited for the study. After careful oral examination and oral rinsing with normal saline, smears were prepared on slides by scraping the buccal mucosa with a wooden spatula. All the slides were fixed in 95% ethyl alcohol and stained with PAP stain, and 1000 cells were counted per patient. Based on Tolbert et al.'s criteria, MNs were identified, and quantitative scoring of MN was done on the basis of morphological assay.

Results

Mean ± standard deviation values of frequency of MNs in HIV-infected females were 73.40 ± 19.70 and in normal females were 38.08 ± 8.56.

Conclusion

MN scoring on the epithelial cells of buccal mucosa can be used as a biomarker in screening procedures for HIV patients.

The association between oral disease and type of antiretroviral therapy among perinatally HIV-infected youth

OBJECTIVES

This study explores the association between combination antiretroviral therapy (cART) and oral health outcomes (dental and periodontal) among perinatally HIV-infected (PHIV) youth.

METHODS

We conducted a cross-sectional study of oral health among PHIV youth participating in the Oral Health substudy of the Pediatric HIV/AIDS Cohort Study (PHACS). Dentists at research sites were trained/calibrated on how to perform a standardized oral mucosal, dental and periodontal examination. They assessed the decayed-missing-filled-surfaces and teeth index (DMFS/T). The number of decayed surfaces and teeth and the number of teeth with gingival bleeding on probing for each participant were derived from the examination. Data for analysis included lifetime measurements of CD4 cell count and viral load, sociodemographic information and current/past history of ART.

RESULTS

Among 209 PHIV youth, 95% were on ART at the time of enrolment. Among 143 PHIV youth on the same cART for at least 1 year, we found that the mean decayed teeth score of those receiving cART containing an integrase inhibitor was 86% higher than that of those on cART without an integrase inhibitor after adjusting for age, lifetime proportion of unsuppressed viral load and CD4 cell count nadir. Initiating protease inhibitors before age 6 years was associated with a significantly lower DMFT score than participants who initiated at age 6 years and older.

CONCLUSION

Our study revealed that PHIV youth who received cART containing an integrase inhibitor had a significantly higher number of untreated active caries than those on cART without an integrase inhibitor. This may warrant closer dental surveillance of those receiving an integrase inhibitor.

Systematic review of the changing pattern of the oral manifestations of HIV

The purpose of the present study paper was to review the reported prevalence of the oral manifestations of HIV (OM-HIV) worldwide since 1980, and to determine the global variation in its prevalence over time. PubMed, Scopus, Embase and Google Scholar were searched. The filter "English" was used. The timeframe searched was 1980- 2015. The PRISMA flow chart was used. Data were extracted using the Joanna Briggs Institute standardized data extraction form and transferred to SPSS version 22 for analysis. The systematic review of 97 studies (70 low bias risk) showed that the prevalence of OM-HIV continue to be significant in developing countries. Globally and through all the decades, oral candidiasis remained the most commonly encountered OM-HIV, including among patients on antiretroviral therapy (ART) (26.2%). Hairy leukoplakia was more prevalent in Europe and America compared with Africa and Asia. Oral warts were reported more often in studies on patients receiving ART. Interestingly, salivary gland disease decreased in the developed world and increased in developing countries over time. Despite the changing pattern of these conditions over time, there is no evidence that the OM-HIV have become of less significance globally. Maintaining the drive for high-quality research in the subject will have an impact on less developed countries to help address oral health inequalities.

Hairy leukoplakia; lessons learned: 30-plus years

Well into the fourth decade of the HIV/AIDS pandemic, we can look back on the early years, the initial discoveries, and the broad sweep of the progress of our understanding of the nature, causes, and significance of the oral lesions seen in those infected with the virus. Prominent among these is oral hairy leukoplakia (HL), a previously unknown lesion of the mouth associated with Epstein-Barr virus (EBV) and initially seen only in people with AIDS, in the then-recognized risk groups, or those shown to be HIV positive. Subsequently, it became clear that the distribution of HL extends well beyond the HIV spectrum. In this brief review, we consider the clinical and histological features of HL, discuss how it was discovered, explore its cause, diagnosis, relationship with AIDS, pathogenesis, significance in EBV biology, options for management, and how it changes with HIV/AIDS therapy.

Incidence of Opportunistic Infections among HIV-Positive Adults on Highly Active Antiretroviral Therapy in a Teaching Hospital, India: Prospective Study

Oral manifestations in HIV infections are numerous and some of these are acknowledged as being of great importance in the early diagnosis of the disease. Many HIV-associated oral infections occur early in HIV disease, not infrequently as the presenting sign or symptom. Thus, early detection of the associated oral opportunistic infections should, in many cases, result in earlier diagnosis of HIV infection. Cytology, a simple, painless, and inexpensive method, has become a preferred method and was used in our study for early diagnosis of certain lesions. To determine the effect of highly active antiretroviral therapy on incidence rate of opportunistic infections among HIV-positive adults in a teaching hospital in India, a prospective study was conducted and the required sample size was 40. Study participants were selected randomly from the outpatient department of an HIV clinic who were currently on for antiretroviral therapy (ART). Data on age, gender, form of contagion, antiretroviral therapy at the time of review, number of CD4 lymphocytes per milliliter, and viral load were collected. Oral cytologic investigation was carried out and then stained for histopathological examination. A total of 40 individuals were examined and the incidence of opportunistic infections was 66.7% in individuals with CD4 counts less than 200, 55.6% in individuals with CD4 counts of 200 to 499, and 40.0% in individuals with CD4 counts more than 500. The incidence of opportunistic infection was higher in individuals with low CD4 counts in spite of being on ART.

A relationship between CD4 count and oral manifestations of human immunodeficiency virus-infected patients on highly active antiretroviral therapy in urban population

Introduction:

Human immunodeficiency virus (HIV) infection gradually destroys the body's immune system, which makes it harder for the body to fight infections. HIV infection causes a quantitative and qualitative depletion of CD4 lymphocyte count, which increases the risk of opportunistic infections. Thus, CD4 count is one of the key factors in determining both the urgency of highly active antiretroviral therapy (HAART) initiation and the need of prophylaxis for opportunistic infections.

Aim:

This study aims to evaluate the prevalence and variations in the oral manifestations of HIV/acquired immune deficiency syndrome patients on HAART therapy in urban population and their association with CD4 count.

Materials and Methods:

A study was conducted by screening eighty patients who were HIV positive in an urban location. Both adult and pediatric patients were screened for oral manifestations and simultaneously CD4 count was also evaluated. Patients with HIV infection for variable time period who are under HAART were considered.

Statistical Analysis:

Measures of central tendency were used to analyse the data.

Results:

HIV infection destroys the immune system of an individual, making the patient susceptible to various infections and malignancies. With the advent of antiretroviral therapy, the scenario has changed drastically. We have observed that patients with CD4 counts between 164 and 1286 show relatively few oral manifestations. Long-term HAART therapy causes pigmentation, xerostomia and angular cheilitis but is taken up quite well by the patients.

Conclusion:

In this study, eighty patients with HAART from urban population showed very minimal oral findings because of good accessibility for treatment and awareness about HIV infections. The patients who were on long-standing HAART treatment also showed minimal oral manifestation such as pigmentation and xerostomia. Hence, we conclude that recognition, significance and treatment of these lesions in patients with HIV infection do not require elaborate setup and can be treated with basic primary health care.

HIV-Associated Oral Mucosal Melanin Hyperpigmentation: A Clinical Study in a South African Population Sample

Objective. The aim of the study was to determine the prevalence of HIV-associated oral mucosal melanin hyperpigmentation (HIV-OMH) in a specific population of HIV-seropositive South Africans and to analyse the associations between HIV-OMH clinical features and the demographic and immunological characteristics of the study cohort. Material and Methods. This cross-sectional study included 200 HIV-seropositive Black subjects. The collected data comprised age, gender, CD4+ T cell count, viral load, systemic disease, medications, oral site affected by HIV-OMH, extent (localized or generalized), intensity of the pigmentation (dark or light), and smoking and snuff use. Results. Overall, 18.5% of the study cohort had HIV-OMH. Twenty-two and a half percent had OMH that could not with confidence be attributed to HIV infection, and 59% did not have any OMH. There was a significant but weak association between smoking and the presence of HIV-OMH. Conclusions. The prevalence of HIV-OMH in the study population was 18.5%, the gingiva being the most commonly affected site. It appears that the CD4+ T cell count does not play any role in the biopathology of HIV-OMH.

Impact of highly active antiretroviral therapy on oral manifestations of patients with human immunodeficiency virus/acquired immuno deficiency syndrome in South India

BACKGROUND

Human immunodeficiency virus (HIV) infection remains a global health problem, although the development of highly active antiretroviral therapy (HAART) has significantly modified the course of HIV disease into a manageable disease with improved quality-of-life mainly in the developed countries. Very few studies are available regarding effect of HAART on oral lesions in developing countries like India.

AIMS AND OBJECTIVES

The aim was to document and compare oral lesions in HIV-seropositive patients before and after HAART.

MATERIALS AND METHODS

Oral manifestations were recorded in 320 HIV seropositive patients attending to the Voluntary Counseling and Confidential Testing Centre at the Government General Hospital, Guntur, before and after treating with HAART and the results were statistically analyzed using Student's t-test and Chi-square test.

RESULTS

Oral Candidiasis was significantly reduced in patients under HAART after 3 months. Furthermore, there was decreased incidence of periodontal diseases, but increased hyperpigmentation in patients undergoing HAART.

CONCLUSION

The oral manifestations of HIV infection have changed due to the advent of HAART. Many opportunistic infections have resolved as a result of an improved immune system. Though the risk of hyperpigmentation in those with HAART has increased the prevalence of oral candidiasis and periodontal diseases were less in patients who had access to HAART.

High Accuracy of Common HIV-Related Oral Disease Diagnoses by Non-Oral Health Specialists in the AIDS Clinical Trial Group

Objective

Many studies include oral HIV-related endpoints that may be diagnosed by non-oral-health specialists (non-OHS) like nurses or physicians. Our objective was to assess the accuracy of clinical diagnoses of HIV-related oral lesions made by non-OHS compared to diagnoses made by OHS.

Methods

A5254, a cross-sectional study conducted by the Oral HIV/AIDS Research Alliance within the AIDS Clinical Trial Group, enrolled HIV-1-infected adults participants from six clinical trial units (CTU) in the US (San Francisco, New York, Chapel Hill, Cleveland, Atlanta) and Haiti. CTU examiners (non-OHS) received standardized training on how to perform an oral examination and make clinical diagnoses of specific oral disease endpoints. Diagnoses by calibrated non-OHS were compared to those made by calibrated OHS, and sensitivity and specificity computed.

Results

Among 324 participants, the majority were black (73%), men (66%), and the median CD4+ cell count 138 cells/mm³. The overall frequency of oral mucosal disease diagnosed by OHS was 43% in US sites, and 90% in Haiti. Oral candidiasis (OC) was detected in 153 (47%) by OHS, with erythematous candidiasis (EC) the most common type (39%) followed by pseudomembranous candidiasis (PC; 26%). The highest prevalence of OC (79%) was among participants in Haiti, and among those with CD4+ cell count ≤ 200 cells/mm³ and HIV-1 RNA > 1000 copies/mL (71%). The sensitivity and specificity of OC diagnoses by non-OHS were 90% and 92% (for EC: 81% and 94%; PC: 82% and 95%). Sensitivity and specificity were also high for KS (87% and 94%, respectively), but sensitivity was < 60% for HL and oral warts in all sites combined. The Candida culture confirmation of OC clinical diagnoses (as defined by ≥ 1 colony forming unit per mL of oral/throat rinse) was ≥ 93% for both PC and EC.

Conclusion

Trained non-OHS showed high accuracy of clinical diagnoses of OC in comparison with OHS, suggesting their usefulness in studies in resource-poor settings, but detection of less common lesions may require OHS.

Oral manifestations of HIV/AIDS in Asia: Systematic review and future research guidelines

Objectives

The authors have conducted a systematic review of oral manifestations of HIV from studies conducted in Asia to establish the characteristics and prevalence of individual oral manifestations in Asia, and to assess the direction of future research studies on oral manifestations of HIV in Asia.

Material and Methods

The electronic retrieval systems and databases searched for relevant articles were PubMed [MEDLINE], EBSCO, and EMBASE. The search was for limited articles published in English or with an English abstract and articles published during the period January 1995 to August 2014. The authors reached a final overall sample of 39 studies that were conducted in Asia.

Results

The median population size among all studies was 312.7 patients. Oral candidiasis [OC] was the most common oral manifestation [37.7%] in studies conducted in Asia. The overall prevalence of oral hairy leukoplakia and melanotic hyperpigmentation was computed to be 10.1% and 22.8% respectively. Thailand and India are primarily countries with maximum research on oral manifestations.

Conclusions

The research on oral manifestations of HIV in Asia has to upgrade to more interventional and therapeutic studies rather than the contemporary cross- sectional epidemiological descriptive studies. The authors have given suggestions and future directions for the implementation of clinical research of oral manifestations in HIV patients.

Key words:Oral manifestations, HIV/AIDS, Asia, Systematic review.

The effect of highly active antiretroviral therapy on the prevalence of oral manifestation in human immunodeficiency virus-infected patients in Karnataka, India

OBJECTIVES

Acquired Immunodeficiency Syndrome (AIDS) is a highly lethal, progressively epidemic viral infection characterized by profound impairment of the immune system. Oral manifestations are common in Human Immunodeficiency Virus (HIV) infected AIDS patients, and are usually the first indicator of symptom and disease progression. The main objective of the current study was to compare the prevalence of oral manifestations in HIV patients on Highly Active Antiretroviral Therapy (HAART) with those, not on HAART therapies.

MATERIALS AND METHODS

A cross sectional study was conducted among 100 patients diagnosed as human immune virus sero-positive. These patients were divided equally into two groups (50 each); Group I patients on HAART and Group II patients who were not on HAART. Information regarding age, sex and cluster of differentiation 4 cell count was obtained from the medical records. Oral examination was done, and findings were recorded by using internationally accepted presumptive clinical criteria. Statistical analysis was performed using Chi-square statistical test.

RESULTS

The presence of oral manifestations was significantly decreased in subjects on HAART (32%) compared to those who are not on HAART (56%). The most common oral lesions detected in patients on HAART were increased oral hyper-pigmentation (14%), recurrent aphthous stomatitis (8%), non-specific ulcerations (4%), pseudo-membranous candidiasis (2%), periodontitis (2%) and xerostomia (2%), whereas in non HAART oral hyperpigmentation (10%), pseudo-membranous candidiasis (8%), angular cheilitis (4%), and erythematous candidiasis (4%) and Periodontitis (14%) were more prevalent.

CONCLUSION

The number and severity of oral manifestation decreased, and even there was a change in the type of oral manifestations on HAART, which may be because of the improvement in immunity gained by the therapy.

Oral mucosal lesions and immune status in HIV-infected Indian children

OBJECTIVE

Pediatric HIV is growing at an alarming rate in developing countries. Due to their compromised immune status, children infected with HIV are prone to a number of opportunistic infections. Oral manifestations are the first signs of the disease in many of them. To assess the oral mucosal status of Indian children with HIV, based on their CD4 cell counts.

METHODOLOGY

Two hundred and twenty one HIV infected children aged 6-18 years from various HIV centers, were divided into three groups, based on their CD4 cell counts; Group 1: ≥500, Group 2: 201-499 and Group 3: ≤200 cells. The children in each group were further considered as 'prior to antiretroviral treatment (ART)' and 'on ART'. Oral mucosal examination was done based on presumptive criteria given by Ramos-Gomez for diagnosis of oro-facial lesions commonly associated with HIV infection in children. Data obtained was subjected to statistical analysis.

RESULTS

Angular cheilitis and pseudomembranous candidiasis were the frequently seen oral lesions. Children with CD4 cell count ≥500 had significantly fewer oral lesions each.

CONCLUSION

A high percentage of HIV-infected children were affected with oral mucosal lesions. There was a significant association between immune status and frequency of oral lesions.

Melanocyte biology and function with reference to oral melanin hyperpigmentation in HIV-seropositive subjects

The color of normal skin and of oral mucosa is not determined by the number of melanocytes in the epithelium but rather by their melanogenic activity. Pigmented biopolymers or melanins are synthesized in melanosomes. Tyrosinase is the critical enzyme in the biosynthesis of both brown/black eumelanin and yellow/red pheomelanin. The number of the melanosomes within the melanocytes, the type of melanin within the melanosomes, and the efficacy of the transfer of melanosomes from the melanocytes to the neighboring keratinocytes all play an important role in tissue pigmentation. Melanin production is regulated by locally produced factors including proopiomelanocortin and its derivative peptides, particularly alpha-melanocyte-stimulating hormone (α-MSH), melanocortin 1 receptor (MC1R), adrenergic and cholinergic agents, growth factors, cytokines, and nitric oxide. Both eumelanin and pheomelanin can be produced by the same melanocytes, and the proportion of the two melanin types is influenced by the degree of functional activity of the α-MSH/MC1R intracellular pathway. The cause of HIV oral melanosis is not fully understood but may be associated with HIV-induced cytokine dysregulation, with the medications commonly prescribed to HIV-seropositive persons, and with adrenocortical dysfunction, which is not uncommon in HIV-seropositive subjects with AIDS. The purpose of this article is to discuss some aspects of melanocyte biology and HIV-associated oral melanin hyperpigmentation.

Gender differences in oral manifestations among HIV-infected Brazilian adults

AIM

The purpose of this study was to compare gender differences in the prevalence of oral lesions in HIV-infected Brazilian adults.

METHODOLOGY

A retrospective study was conducted of medical records from HIV/AIDS patients from 1993 to 2004. Oral lesions were only included in this study if definitively diagnosed through microscopic analysis, therapeutic test or according to EC-Clearing house criteria.

RESULTS

A total of 750 men and 237 women were included in the study. Statistically significant differences were observed only for oral hairy leukoplakia, Kaposi sarcoma and lymphadenopathy (P < 0.01). However, a model of logistic regression showed that only oral hairy leukoplakia presented a significant association with gender and males had a significantly likelihood (four times higher than females) of presenting with this oral manifestation [OR 4.3 (95% CI: 1.39-13.36)].

CONCLUSION

These data shows that oral manifestations are less prevalent in females than in males, particularly oral hairy leukoplakia.

Oral mucosal status and salivary IgA levels of HIV-infected children

BACKGROUND

Pediatric HIV is a major world health problem, which is progressing at an alarming rate. Lesions in the mouth and in other tissues and organs (oral and systemic lesions) in pediatric HIV infection are diverse and show differences in clinical presentation and severity from that of adults. Very little data exist for oral lesions in pediatric population in India. To assess oral mucosal status of HIV-infected children and to correlate it with their salivary IgA levels.

METHODS

The study group consisted of 150 HIV-infected children aged 6-18 years. They were divided into two groups. Group 1: Children prior to anti-retroviral therapy, Group 2: Children undergoing anti-retroviral therapy (for not more than 3 years). Criteria given by Ramos-Gomez for diagnosis of oral lesions commonly associated with HIV infection in children were used to record the oral lesions. Salivary IgA levels were determined by enzyme-linked immunosorbent assay. Data obtained were subjected to statistical analysis.

RESULTS

There was a significant difference in mean secretory IgA (SIgA) levels between the groups (P ≤ 0.05). All the children had one or more oral mucosal lesions, with angular cheilitis being the most common lesion. There was a significant inverse relation between SIgA levels and individual oral mucosal lesions (P ≤ 0.05). The number of oral lesions was inversely related to the SIgA levels.

CONCLUSION

Oral mucosal lesions were a significant feature of HIV-infected infection, particularly in children prior to the onset of anti-retroviral therapy. All children showed low SIgA levels. Early recognition and management of oral conditions are important to improve the quality of life in these children.

Urban legends series: oral manifestations of HIV infection

Human immunodeficiency virus-related oral lesions (HIV-OLs), such as oral candidiasis (OC) and oral hairy leukoplakia (OHL), have been recognized as indicators of immune suppression since the beginning of the global HIV epidemic. The diagnosis and management of HIV disease and spectrum of opportunistic infection has changed over the past 30 years as our understanding of the infection has evolved. We investigated the following controversial topics: (i) Are oral manifestations of HIV still relevant after the introduction of highly active antiretroviral therapy (HAART)? (ii) Can we nowadays still diagnose HIV infection through oral lesions? (iii) Is the actual classification of oral manifestations of HIV adequate or does it need to be reviewed and updated? (iv) Is there any novelty in the treatment of oral manifestations of HIV infection? Results from extensive literature review suggested the following: (i) While HAART has resulted in significant reductions in HIV-OLs, many are still seen in patients with HIV infection, with OC remaining the most common lesion. While the relationship between oral warts and the immune reconstitution inflammatory syndrome is less clear, the malignant potential of oral human papillomavirus infection is gaining increasing attention. (ii) Effective antiretroviral therapy has transformed HIV from a fatal illness to a chronic manageable condition and as a result expanded screening policies for HIV are being advocated both in developed and in developing countries. Affordable, reliable, and easy-to-use diagnostic techniques have been recently introduced likely restricting the importance of HIV-OLs in diagnosis. (iii) The 1993 EC-Clearinghouse classification of HIV-OLs is still globally used despite controversy on the relevance of periodontal diseases today. HIV-OL case definitions were updated in 2009 to facilitate the accuracy of HIV-OL diagnoses by non-dental healthcare workers in large-scale epidemiologic studies and clinical trials. (iv) Research over the last 6 years on novel modalities for the treatment of HIV-OLs has been reported for OC and OHL.

Oral manifestations of HIV patients in South Indian population

Objectives:

To study the prevalence of oral manifestations in HIV-infected patients and to correlate oral manifestations with age, gender, severity, and clinical staging.

Materials and Methods:

Fifty patients of either sex diagnosed as HIV positive were included in the study. The data obtained were analyzed statistically using Fisher's exact test and Chi-square test.

Results:

Among the 50 HIV-infected patients, oral manifestations were found in 40 (80.0%) patients. Thirty (60%) patients were seen in the age range between 31 and 65 years, and 29 (58%) patients were females. Majority of the patients [26 (52%)] were in the clinical staging C, of whom 23 (88.5%) were with manifestations with significant statistical value (P < 0.05). Patients with CD4 count less than 200 had manifestations in 22 (88%) patients. Correlation between reduction in CD4 count and presence of manifestations was significant (P < 0.05). Twenty-eight (80%) patients without antiretroviral therapy (ART) reported with manifestations. Correlation between ART and presence of manifestations was not significant (P = 1.00).

Interpretation and Conclusion:

Oral manifestations are the indicators for the disease progression. Clinical stage C and lower CD4 count may be useful predictors for HIV, with greater prevalence of oral manifestations.

Gender differences in oral lesions among persons with HIV disease in Southern India

INTRODUCTION

In India, it is estimated that 2.5 million people are currently living with Human Immunodeficiency virus infection (HIV) of which one million are women. Given the occurrence of oral lesions in our population, we studied the patter of these lesions with respect to the role played by gender.

MATERIALS AND METHODS

3729 consecutive patients seen over a period of 10 years (from 1998 to 2008) attending the YRG CARE (Center for AIDS Research and Education), at Chennai, India constituted the study group. The oral lesions were diagnosed and the findings were entered into a database and analysed using the SPSS package SPSS11.

RESULTS

3724 adult patients (71% males 29% females) were recruited in this study. 95% and 92% of males and females respectively acquired the infection through the heterosexual route. 69% of them presented with at least one oral lesion. There was a significant difference in the occurrence of oral candidiasis (OC) (18.8% males 10.3% females, P = 0.00) and oral hairy leukoplakia (OHL) (1.2% males 0.4% females, P = 0.023) between gender. The mean CD4 counts in males (n = 1908) was 284.48 ± 222.45 and in females (n = 1087) it was 394.51 ± 274.56. Males had 2.2 times higher risk of getting OC, 3.1 times higher risk of OHL and over all males had 1.58 times of having any oral lesion compared to females. Multivariate logistic regression that the odds of having OC (OR = 1.7, 95%CI 1.2-2.2, P = 0.001) and OHL (OR = 3.1, 95%CI 1.1-8.9; P = 0.03) were significantly higher for males than for females after controlling for duration of being HIV positive, CD4 count and HAART. 1412 patients had their spouses HIV status also as HIV positive and 769 patients had their spouse HIV status as negative. 858 patients were on HARRT (627 males and 231 females) The partial correlation analysis, done between gender and CD4 counts, when controlling for HAART was r = 0.2028 (P = 0.00).

CONCLUSION

Our study confirms that males had a higher risk of oral lesions, especially OC and OHL, than females. The females in this study had a significantly higher mean CD4 counts than males. This different immunological status of the females compared to males should be taken in to consideration in the evaluation and management of HIV positive patients in our country.

Prevalence of Oral Manifestations and Their Association with CD4/CD8 Ratio and HIV Viral Load in South India

The objective of the present research was to determine the prevalence of oral manifestations in an HIV infected population from south India and evaluate their association with HIV viral load and CD4/CD8 ratio. Intraoral examination of 103 patients, whose CD4/CD8 ratio was available, were conducted. HIV viral loads were available for thirty patients only. The prevalence of oral manifestations was 80.6% (83/103). The most common oromucosal lesion was erythematous candidiasis (EC) (38.8%) followed by melanotic hyperpigmentation (35.9%). Patients having any oral manifestation had a mean CD4/CD8 ratio of 0.24. EC had positive predictive value of 85.0% for CD4/CD8 ratio <0.30. The prevalence of oral manifestations in patients taking ART was lesser (78.6%) as compared to patients not taking ART (82%). Patients having any oral manifestation had a higher HIV viral load as compared to patients not having any oral manifestations (P < 0.05). Pseudomembranous candidiasis (PC) was significantly associated with higher HIV viral loads (>20,000 copies/mL) (P < 0.05). Patients having EC had 4 times greater chance of having CD4/CD8 ratio <0.30. PC can be considered as a marker of immune suppression (HIV viral load >20,000 copies/mL).

National estimates of the characteristics of individuals infected with HIV who are likely to report and receive treatment for painful bleeding gums

Painful bleeding gums may be associated with HIV infection. This study examined the characteristics of persons reporting the symptom "painful bleeding gums" and their likelihood of accessing care. The study population consisted of persons receiving care for HIV as part of the HIV Cost and Services Utilization Study (HCSUS). In this national population, 5.3% reported painful bleeding gums. Significant differences in reporting painful bleeding gums were found between Hispanics/Whites, oral health status, and presence of other symptoms. Compared to younger persons, those in the middle age group were more likely to seek treatment, while persons with the highest CD4 counts were more likely to seek treatment than those with the lowest CD4 counts. This study showed that reporting painful bleeding gums was a function of ethnicity, other symptoms, and perceived oral health, while seeking treatment for painful bleeding gums was related to age and CD4 counts. Dentists and other health care providers can have an active role in improving the quality of life of persons living with HIV by being aware of the relationships that exist between patients with HIV and painful bleeding gums.

Overview of the oral HIV/AIDS Research Alliance Program

The Oral HIV/AIDS Research Alliance is part of the AIDS Clinical Trials Group, the largest HIV clinical trial organization in the world, and it is funded by the National Institute of Dental and Craniofacial Research, in collaboration with the National Institute of Allergy and Infectious Diseases. The alliance's main objective is to investigate the oral complications associated with HIV/AIDS as the epidemic is evolving-in particular, the effects of potent antiretrovirals on the development of oral mucosal lesions and associated fungal and viral pathogens. Furthermore, oral fluids are being explored for their potential monitoring and diagnostic role with respect to HIV disease and coinfections. This article presents an overview of the alliance, its scientific agenda, and an outline of the novel interventional and noninterventional clinical studies ongoing and developing within the AIDS Clinical Trials Group infrastructure in the United States and internationally.

Oral fungal infections: an update for the general practitioner

Oral candidosis is the most common fungal infection encountered in general dental practice. It manifests in a variety of clinical presentations which may mimic more sinister diseases, and can occasionally be refractory to treatment requiring the attention of an oral medicine specialist. Management of oral candidosis should always include a thorough investigation of underlying predisposing conditions, as the disease often presents when the patient is systemically compromised. This update highlights the pathogenesis, clinical presentation, and management strategies of oral Candidal lesions commonly encountered in dental practice.

Orofacial and systemic manifestations in 212 paediatric HIV patients from Chennai, South India

BACKGROUND

Lesions in the mouth and in other tissues and organs (oral and systemic lesions) in paediatric HIV infection are diverse and show differences in clinical presentation and severity from that of adults. Very little data exist for oral lesions in paediatric population in India.

AIM

To document and study oral and more widespread lesions in paediatric HIV seropositive patients.

DESIGN

A cross-sectional study.

SETTING

Paediatric HIV seropositive patients at tertiary centers: Ragas Dental College and Hospital and YRG CARE, Chennai, India.

PATIENTS AND METHODS

Two hundred and twelve paediatric HIV patients aged 0-14 years seen over a period of 1 year were included in the study. Clinical history, oral and systemic examinations were recorded by qualified dental surgeons and physicians.

RESULTS

One hundred and thirty-two patients had oral lesions ranging in number from one to three. Oral lesions included oral candidiasis (OC) (56.1%), gingivitis (10.8%), oral pigmentation (6.1%), depapillation of the tongue (5.7%), ulcers (4.2%), and oral hairy leukoplakia (1.4%). The most common systemic lesion observed was nonspecific lymphadenopathy (74.1%) followed by pruritic eruptions (53.8%), measles (51.4%), and tuberculosis (TB) (49.1%). Thirty-three (26%) patients were not immunosuppressed, 74 (58%) were moderately immunosuppressed, and 20 (15%) were severely immunosuppressed. Oral lesions exhibited positive correlation with lesions in other parts of the body.

CONCLUSION

Oral lesions are a common feature in paediatric HIV infection. Their management is vital to improve the quality of life of the infected children.

The Oral HIV/AIDS Research Alliance: updated case definitions of oral disease endpoints

The Oral HIV/AIDS Research Alliance (OHARA) is part of the AIDS Clinical Trials Group (ACTG), the largest HIV clinical trials organization in the world. Its main objective is to investigate oral complications associated with HIV/AIDS as the epidemic is evolving, in particular, the effects of antiretrovirals on oral mucosal lesion development and associated fungal and viral pathogens. The OHARA infrastructure comprises: the Epidemiologic Research Unit (at the University of California San Francisco), the Medical Mycology Unit (at Case Western Reserve University) and the Virology/Specimen Banking Unit (at the University of North Carolina). The team includes dentists, physicians, virologists, mycologists, immunologists, epidemiologists and statisticians. Observational studies and clinical trials are being implemented at ACTG-affiliated sites in the US and resource-poor countries. Many studies have shared end-points, which include oral diseases known to be associated with HIV/AIDS measured by trained and calibrated ACTG study nurses. In preparation for future protocols, we have updated existing diagnostic criteria of the oral manifestations of HIV published in 1992 and 1993. The proposed case definitions are designed to be used in large-scale epidemiologic studies and clinical trials, in both US and resource-poor settings, where diagnoses may be made by non-dental healthcare providers. The objective of this article is to present updated case definitions for HIV-related oral diseases that will be used to measure standardized clinical end-points in OHARA studies, and that can be used by any investigator outside of OHARA/ACTG conducting clinical research that pertains to these end-points.

Oral manifestations as predictors of immune suppression in a HIV-/AIDS-infected population in south India

The objectives of the study are to evaluate the relationship between common HIV-related oral lesions and absolute CD4+ count, age, gender, and medication used and to assess the sensitivity, specificity, positive and negative predictive value of oral manifestations for low absolute CD4+ counts. HIV-positive patients, 200, from south India were selected, whose absolute CD4+ counts were determined within 2 weeks of oral examination. Sociodemographic data was obtained using a structured questionnaire. Oral manifestations were diagnosed according to presumptive criteria of EEC-clearinghouse classification (1993). Four or more concurrent oral lesions were statistically significant with low CD4+ counts <200 cells/mm3 (P = 0.005). The highest and lowest mean CD4+ cell counts were seen in individuals with linear gingival erythema (LGE; 172.5 cells/mm(3)) and pseudomembranous candidiasis (PC; 87 cells/mm(3)), respectively. Smoking, age (<35 years), and males had a positive association with oral hairy leukoplakia (OHL; P < 0.05). Patients with CD4+ counts < 200 cells/mm(3) were associated with 15 times greater risk of PC and four times at greater risk for occurrence of any oral manifestation. Concurrent oral manifestations (>or=4) were good predictors (80-100%) of severe immune suppression. In most resource poor countries where facilities for undertaking CD4+ counts are not available, the presence of concurrent oral manifestations may be used as an indicator of deteriorating immune status.

Oral candidiasis as a marker of HIV disease progression among Zimbabwean women

OBJECTIVES

To estimate oral disease prevalence among Zimbabwean women by HIV serostatus and CD4 cell count and to assess accuracy of oral disease diagnoses made by nurses as compared with an oral surgeon.

METHODS

Standardized oral mucosa examinations were performed by trained nurse-examiners and by an oral surgeon among women recruited in Harare, Zimbabwe.

RESULTS

A total of 461 women (320 HIV-infected, 141 uninfected) were seen by nurses and an oral surgeon within a 2-week period. Oral candidiasis (OC) was the most common lesion diagnosed in nearly one quarter of HIV-infected women, whereas hairy leukoplakia and Kaposi sarcoma were found in <3%. The prevalence of OC diagnosed by nurses or the surgeon was significantly higher among women with a CD4 count <200 cells/mm than in women with a CD4 count from 200 to 499 cells/mm3 or a CD4 count >499 cells/mm3. The sensitivity of nurse examinations compared with examinations by the oral surgeon among HIV-infected women for the diagnosis of OC was 73%, the specificity was 95%, and the kappa-statistic was 0.71.

CONCLUSIONS

OC was the most common lesion in HIV-infected women and was strongly associated with a low CD4 cell count. Interexaminer agreement was good for the diagnosis of OC among HIV-infected women. This study suggests that OC may play a role, in combination with other clinical indicators as a marker of disease progression in resource-poor settings.