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

Prevalence of Oropharyngeal Candidiasis and distribution of Candida species among People Living with Human Immunodeficiency Virus in Africa: a systematic review and meta-analysis

Background

The incidence of oropharyngeal candidiasis among people living with human immunodeficiency virus in Africa is on the rise. Oropharyngeal candidiasis is mainly caused by C.albicans; however, a shift in the etiology towards non-Candida albicans species is increasing. In addition, there are variations in the epidemiological distribution of Candida species causing oropharyngeal candidiasis among people living with human immunodeficiency virus in Africa.

Objective

This review aimed to determine the prevalence of oropharyngeal candidiasis and the distribution of Candida species among people living with human immunodeficiency virus in Africa.

Materials and Methods

This systematic review protocol was registered in the base PROSPERO database prior to its conduct (CRD42021254473). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines (PRISMA-P) were followed for this study. The PubMed, Scopus and EMBASE databases were searched to identify published studies published between 1st January 2000 and 8th October 2022. The eligible studies were included in the meta-analysis and analyzed using a random effects model. The risk of bias of the included studies was assessed using the Joanna Briggs Institute quality assessment tool for prevalence studies.

Results

The database search yielded 370 titles from PubMed (n=192), EMBASE (n=162) and SCOPUS (n=16). Fourteen studies with a total of 3,863 participants were included in the meta-analysis. The pooled prevalence of oropharyngeal candidiasis was 49.0% (95% CI: 37% - 62%). A total of 2,688 Candida isolates were reported; approximately 76.6% (n=2,060) were C. albicans, and 21.7% (n=582) were non-C. albicans. Among the non-Candida albicans species, C. glabrata was the most common isolate (29.6%), followed by C. tropicalis (27.7%), C. krusei (17.0%), C. parapsilosis (8.1%) and C. dubliniensis (5.2%). Out of 14 studies, 7 (50.0%) had a low risk of bias, 5 (35.7%) had a moderate risk of bias, and 2 (14.3%) had a high risk of bias.

Conclusion

Almost half of people living with HIV in Africa have oropharyngeal candidiasis, and C. albicans remains the most frequent cause of oropharyngeal candidiasis.

Influence of oral biofilm index, caries experience, and laboratory markers of disease progression on the oral carriage of Candida in HIV-infected and non-infected children: a cross-sectional study

The present study aimed to compare the oral Candida rate between infected and uninfected children with the human immunodeficiency virus (HIV), as well as analyze the association between Candida spp. and predisposing factors of colonization, like oral biofilm index, caries experience, and laboratory markers of AIDS progression. A cross-sectional study was employed. Candida species were identified and quantified from saliva samples of 50 HIV-infected and 50 uninfected children. Biofilm index and decayed, missing, and filled teeth (dmft/DMFT) indices were assessed by oral clinical examinations. Additionally, CD4+ T lymphocyte count and viral load were obtained from medical records of the HIV-infected children. Candida species were cultured from 74% of the HIV-infected children and 46% of uninfected ones (p = 0.0076). Candida albicans and Candida parapsilosis were the most frequently isolated species in both studied groups. The isolation of Candida species was significantly higher in HIV-infected children with CD4 ≤ 15% (p = 0.0146); it had influence of mature oral biofilm and the caries index (dmft + DMFT ≥ 8) (p < 0.05) and was associated with the plasma viral load. The present data show that the HIV infection, oral biofilm index, caries experience, and laboratory markers of AIDS progression exert an influence on the prevalence of oral Candida in children.

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.

Prevalence of oral lesions in patients with AIDS: a systematic review and meta-analysis

Background Oral lesions are considered to be early clinical signs which may predict the progression of patients with acquired immune deficiency syndrome (AIDS). Due to the lack of a comprehensive study that includes oral lesions in people with AIDS, the global prevalence of oral lesions in people with AIDS was estimated by combining preliminary studies' results using meta-analysis.Material and methods Databases including PubMed, Science Direct and Scopus were searched using keywords as 'HIV', 'AIDS', 'oral candidiasis', 'Kaposi Sarcoma', 'LinearGingival Erythema' and OR operators, AND and NOT. After the elimination of duplicate documents, articles that met the inclusion criteria were selected. Quality assessment was performed based on the Newcastle-Ottawa Scale. After combining the results of preliminary studies, an overall estimate of each lesion was reported. Ninety-five studies met the criteria for inclusion in this meta-analysis.Results The global prevalence of 21 oral lesions in HIV-infected patients was estimated. The overall prevalence of oral candidiasis, pseudomembranous candidiasis, oral hairy leukoplakia, Kaposi sarcoma and erythematous candidiasis was as follows: 35% (95% CI: 28-42), 19% (95% CI: 15-22), 12% (95% CI: 11-14), 5% (95% CI: 4-6) and 18% (95% CI: 14-22).Conclusion The present meta-analysis showed that oral lesions have a high prevalence in patients with AIDS. Dentists should consider that the clinical appearance of the oral cavity reflects the overall systemic health of the patient. As such, oral lesions may be linked to underlying immunosuppression caused by AIDS.

Evaluating Knowledge, Attitude, and Behavior of Dentists on HIV/AIDS in West Java, Indonesia, in the COVID-19 Era

Purpose

HIV/AIDS is still a serious public health problem in Indonesia. It has been concerned that the coronavirus disease 2019 (COVID-19) pandemic has a serious impact on people living with HIV (PLWH). Therefore, dentists remain to have a significant role to play in the overall healthcare delivery to PLWH and reducing new HIV infections. The purpose of this study was to assess the knowledge, attitudes, and behavior of dentists in West Java about HIV/AIDS in the COVID-19 era.

Methods

This cross-sectional study was conducted by distributing online questionnaires using a Google form to dentists in West Java. We used the purposive sampling technique to recruit the participants. The questionnaire consists of characteristics of respondents, 13 questions about knowledge, 9 questions about attitudes, and 6 questions about behaviors, which has previously been tested for validity and reliability. Data were analyzed using the Spearman correlation test and the Chi-square test. Results. The Questionnaire was sent to 435 dentists in the West Java region, Indonesia, with the assistance of the Indonesian Dental Association West Java region, to participate in this study. We received completed questionnaires from 209 (48%) respondents. The results of this study showed that 44% of dentists have good knowledge, 53% have a positive attitude, and 53% have positive behavior. No significant relationship was found between knowledge and attitudes (p=0.202) and behavior (p=0.087), but there was a significant relationship between attitudes and behavior (p=0.0001).

Conclusion

About half of the dentists in West Java have good knowledge, positive attitudes, and behavior towards HIV/AIDS, but the others lack knowledge, negative attitudes, and behavior. Continuing HIV/AIDS education and training programs for dentists are still needed to keep improving their knowledge and awareness to support disease prevention and control in this COVID-19 era.

A real-world, cross sectional study of oral lesions and their association with CD4 cell counts and HIV viral load in Yunnan, China

Human immunodeficiency virus (HIV) supresses immune system, primarily cell-mediated immunity. Cluster of differentiation 4 (CD4) cell count, viral load, and oral lesions are the most important laboratory parameters to evaluate the evolution of acquired immunodeficiency syndrome. The present study aims to determine the incidence of HIV-related oral lesions with CD4 cell count and viral load in Yunnan, China.A cross-sectional study was conducted from December 2007 to December 2009, in 1812 HIV positive patients from Department of Infectious Diseases in Kunming Third People's Hospital. CD4, CD8, and viral load data were collected and analyzed statistically using SPSS 11.3.Out of 1812 HIV positive patients, 929 (51.27%) were associated with 1 or more oral lesions. The most common oral lesions observed were Candida Pseudomembranous (13.75%), Candida erythematous (10.93%), Oral hairy leukoplakia (7.95%), Aphthous ulcer (6.18%), Herpes simplex infection (5.58%). In most patients with oral lesions, the CD4 cell count was < 200/μL. The incidence of oral lesions was lower when CD4 count was > 200/μL and with undetectable (P < .01) HIV viral load. Almost no oral lesions was observed when CD4 count > 500/μL (P < .01). With highly active antiretroviral therapy, reduction in HIV-related oral lesions was observed especially in Candida erythematous, Candida Pseudomembranous, Oral hairy leukoplakia, and Aphthous ulcer.The higher incidence of oral lesions with lower CD4 count (<200/μL) in HIV-infected patients indicated importance of CD4 cell count in identifying disease progression.

Oral Manifestations in HIV-TB Co- infected Patients and Their Correlation with CD4 Count in Telangana State, India

AIMS AND OBJECTIVES

Human immunodeficiency virus (HIV)-related oral lesions are often an early finding, and they reflect the underlying immunosuppression, and tuberculosis (TB) coinfection can have further deteriorating effect. Hence, a cross-sectional study was conducted to evaluate clinical and oral presentations of patients coinfected with HIV-TB, correlating with various parameters such as the type of TB with CD4 cell count, the type of TB with oral manifestations, site of the lesion, oral manifestations with CD4 cell counts, age, and gender.

MATERIALS AND METHODS

A cross-sectional study was conducted among selected 200 patients coinfected with HIV-TB, registered at Gandhi Medical College, Hyderabad, Telangana, India, and demographic data, CD4 count, diagnosis of TB, and clinical presentation of TB were correlated with site, age, gender, and the type of lesions in the oral cavity. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, (IBM SPSS), version 20 (Chicago, IL, USA), with the chi-square test, and the significant P value for all the parameters was considered as <0.05.

RESULTS

A total of 200 patients with HIV-TB coinfection, who presented with oral lesions of 258 coinfected cases, were examined. Among which, 129 patients were with pulmonary tuberculosis (PTB), 61 patients with extrapulmonary TB, 2 patients with disseminated TB, and 8 patients with PTB and pneumonia. There were multiple oral manifestations involving different sites of oral cavity, oral candidiasis (28.5%), angular cheilitis (24.5%), linear gingival erythema (21.5%), oral hairy leukoplakia (1.5%), melanotic pigmentation (29.0%), ulcers (20.0%), depapillation of tongue (26.5%), lobulated tongue (12.0%), hairy tongue (11.5%), and papules (10.0%). The correlation of the type of TB with CD4 cell count, oral lesions with the type of TB in tongue, labial mucosa, and palate was significant.

CONCLUSION

A total of 77.5% patients coinfected with HIV-TB had shown oral manifestations emphasizing that the presence of oral lesions can be considered as a strong indicator of coinfection. The oral lesions might be used as a clinical indicator or screening mechanism in patients who were HIV seropositive for TB coinfection and should be necessarily evaluated for TB.

CD4 Cell Counts, Lipid Profile, and Oral Manifestations in HIV-Infected and AIDS Patients

Objectives

The present study aimed to evaluate CD4 cell counts, lipid profile, and oral manifestations in human immunodeficiency virus (HIV)-infected and acquired immune deficiency syndrome (AIDS) patients and their correlation with seronegative controls.

Materials and Methods

In this cross-sectional, hospital-based study, there were three groups of subjects: group A consisting of 500 healthy patients (controls), group B composed of 500 HIV-infected patients, and group C comprised of 500 AIDS patients based on their CD4 cell counts. CD4 cell counts were assessed using the CyFlow counter. Lipid profile was evaluated with the Erba EM 360 analyzer.

Results

The results were statistically significant for CD4 cell counts (P<0.001). The levels of total cholesterol (TC) and low-density lipoproteins (LDLs) were significantly decreased while triglycerides (TGs) and very-low-density lipoproteins (VLDLs) were significantly increased in AIDS patients compared to the controls and HIV-infected patients. Various results were obtained regarding oral manifestations with different levels of significance.

Conclusion

CD4 cell counts, TC, LDLs, TGs, and VLDLs were significantly changed in HIV-infected and AIDS patients compared to the controls.

Prevalence of Periodontitis and Soft Tissue Lesions among Human Immunodeficiency Virus-positive Patients on Antiretroviral Therapy in Raichur Taluk, Karnataka, India

INTRODUCTION

In countries where human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is widespread and highly active antiretroviral therapy (HAART) medications are too expensive, or patients are failing HAART, oral disease management and risk remain an important issue.

AIM

The aim of the study was to evaluate the prevalence of oral mucosal lesions and periodontitis among the HIV-positive adult patients and assess the association of these lesions with age, sex, duration of HIV, time on ART, dietary habits, and oral hygiene habits.

MATERIALS AND METHODS

Sample size was 170. Demographic data of the patients along with community periodontal index (CPI) and loss of attachment (LA) were recorded. Oral soft tissue lesions, such as ulcerations, sores, erosions, and fissures were also recorded. The study was carried out in Raichur Taluk, Karnataka, India. Convenience sampling design was followed. Statistical Package for the Social Sciences (SPSS) version 20.0 (Chicago, USA) was used for data analysis. Chi-square test was carried out; p < 0.05 was considered to be statistically significant.

RESULTS

There was no association between the oral mucosal conditions and the age and the adverse habits, such as tobacco and alcohol, CD4 count, and the time duration of HIV and ART among these patients. A higher percentage of people with 4 to 5 mm of pockets was seen with those who cleaned their teeth with a finger, which was statistically significant.

CLINICAL SIGNIFICANCE

The present study highlights the poor condition of the oral health of these patients and their unmet dental needs.

CD4 cell counts and oral manifestations in HIV infected and AIDS patients

Context

Acquired immunodeficiency syndrome (AIDS) is an acronym for AIDS caused by a retrovirus known as human immunodeficiency virus (HIV) which breaks down the body's immune system leaving a patient vulnerable to a host of life-threatening opportunistic infections, neurological disorders or unusual malignancies. According to estimates by the World Health Organization and UNAIDS, 35 million people were living with HIV globally at the end of 2013. The first AIDS case in India was detected in 1986. Seldom studies have been conducted correlating these parameters with oral manifestations in the Indian population.

Aim

The present study was carried out to evaluate the CD4 cell counts and oral manifestations in HIV-infected and AIDS patients and to correlate them with the seronegative controls.

Methodology

This was a cross-sectional, hospital-based study on individuals who were divided into three groups, Group A consisting of 500 patients who were healthy controls without any systemic illness; Group B consisting of 500 patients who were diagnosed as HIV infected and Group C consisting of 500 patients diagnosed as AIDS patients depending on their CD4 cell counts. The permission from the Ethical Committee of the Institution as well as Superintendent of Government Hospital was obtained. Evaluation of CD4 cell counts in HIV-infected and AIDS patients was done using CyFlow Counter.

Results

The results were found to be statistically significant with the P < 0.001 for the CD4 cell counts. Oral manifestations revealed varied results with different levels of significance.

Conclusion

CD4 cell counts were significantly altered in HIV-infected and AIDS patients when compared with the controls while oral manifestations revealed varied results with different levels of significance.

Oral manifestations and their correlation to baseline CD4 count of HIV/AIDS patients in Ghana

Objectives

Acquired immunodeficiency syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV). People with AIDS are much more vulnerable to infections, including opportunistic infections and tumors, than people with a healthy immune system. The objective of this study was to correlate oral lesions associated with HIV/AIDS and immunosuppression levels by measuring clusters of differentiation 4 (CD4) cell counts among patients living in the middle western regions of Ghana.

Materials and Methods

A total of 120 patients who visited the HIV clinic at the Komfo Anokye Teaching Hospital and the Regional Hospital Sunyani of Ghana were consecutively enrolled in this prospective and cross-sectional study. Referred patients' baseline CD4 counts were obtained from medical records and each patient received an initial physician assessment. Intraoral diagnoses were based on the classification and diagnostic criteria of the EEC Clearinghouse, 1993. After the initial assessment, extra- and intraoral tissues from each enrolled patient were examined. Data analyses were carried out using simple proportions, frequencies and chi-square tests of significance.

Results

Our study included 120 patients, and was comprised of 42 (35.0%) males and 78 (65.0%) females, ranging in age from 21 to 67 years with sex-specific mean ages of 39.31 years (males) and 39.28 years (females). Patient CD4 count values ranged from 3 to 985 cells/mL with a mean baseline CD4 count of 291.29 cells/mL for males and 325.92 cells/mL for females. The mean baseline CD4 count for the entire sample was 313.80 cells/mL. Of the 120 patients we examined, 99 (82.5%) were observed to have at least one HIV-associated intraoral lesion while 21 (17.5%) had no intraoral lesions. Oral candidiasis, periodontitis, melanotic hyperpigmentation, gingivitis and xerostomia were the most common oral lesions.

Conclusion

From a total of nine oral lesions, six lesions that included oral candidiasis, periodontitis, melanotic hyperpigmentation, gingivitis, xerostomia and oral hairy leukoplakia were significantly correlated with declining CD4 counts.

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.

Associations of periodontitis and oral manifestations with CD4 counts in human immunodeficiency virus-pregnant women in Thailand

OBJECTIVES

To investigate the associations of CD4 count with chronic periodontitis and human immunodeficiency virus (HIV)-related oral lesions in pregnant HIV-infected Thai women.

STUDY DESIGN

Two hundred ninety-two HIV-infected pregnant women were interviewed for health information and examined for their periodontal condition and HIV-related oral lesions during weeks 16-34 of gestation. Logistic regression, t tests and Chi-squared tests were used to examine the associations of CD4 count with oral lesions and periodontal conditions.

RESULTS

One hundred thirty-three women (45.6%) had at least 1 tooth with a periodontal pocket over 4 mm. Thirty-eight (17.76%) subjects had oral candidiasis and 53 subjects (24.77%) had oral hairy leukoplakia (OHL). Low CD4 count was significantly associated with periodontitis at odds ratio (OR) = 2.06 with 95% confidence interval (CI) = [1.00-4.27], P = .05. A significant association was found for low CD4 count with OHL with OR = 3.57, 95% CI = [1.34-9.46], P = .01.

CONCLUSIONS

Chronic periodontitis and OHL were associated with CD4 count lower than 200 cells/mm(3) in HIV-infected women.

Periodontal disease in HIV-infected adults in the HAART era: Clinical, immunological, and microbiological aspects

The introduction of highly active antiretroviral therapy (HAART) has decreased the incidence and prevalence of several oral manifestations such as oral candidiasis, hairy leukoplakia, and Kaposi's sarcoma in HIV-infected patients. Regarding periodontal disease the findings are not clear. This disease represents a group of chronic oral diseases characterized by infection and inflammation of the periodontal tissues. These tissues surround the teeth and provide periodontal protection (the gingival tissue) and periodontal support (periodontal ligament, root cementum, alveolar bone). Clinical, immunological, and microbiological aspects of these diseases, such as linear gingival erythema (LGE), necrotizing periodontal diseases (NPD) (necrotizing ulcerative gingivitis [NUG], necrotizing ulcerative periodontitis [NUP] and necrotizing stomatitis), and chronic periodontitis, have been widely studied in HIV-infected individuals, but without providing conclusive results. The purpose of this review was to contribute to a better overall understanding of the probable impact of HIV-infection on the characteristics of periodontal infections.