Prevalence and classification of HIV-associated oral lesions

OBJECTIVES

An International Workshop addressed the prevalence and classification of HIV/ AIDS associated oral lesions.

DESIGN

Five questions provided the framework for discussion and literature review. What is the prevalence of oral lesions in children and adults? Should the accepted classification of HIV-related oral lesions be modified in the light of recent findings? Why is there a gender difference in the prevalence of oral lesions in developed and developing countries? Are there unusual lesions present in developing countries? Is there any association between modes of transmission and the prevalence of oral lesions?

RESULTS

Workshop discussion emphasized the urgent need for assistance in the development of expertise to obtain accurate global prevalence data for HIV-associated oral lesions. Oral candidiasis has been consistently reported as the most prevalent HIV-associated oral lesion in all ages. Penicilliosis marneffei, a newly described fungal infection, has emerged in South-east Asia. Oral hairy leukoplakia and Kaposi's sarcoma appear to be associated with male gender and male-to-male HIV transmission risk behaviours. These lesions occur only rarely in children.

CONCLUSIONS

Additional prevalence data are needed from developing countries prior to substantially altering the 1993 ECC/WHO Classification of oral lesions associated with adult HIV infection. The workshop confirmed current oral disease diagnostic criteria.

Oral manifestations and dental status in paediatric HIV infection

OBJECTIVE

To describe the incidence and prevalence of oral manifestations of HIV infection in a population of perinatally infected children.

DESIGN

Retrospective and prospective study of a cohort of perinatally HIV-infected children.

SETTING

Community hospital and community-based paediatric clinic.

SAMPLE AND METHODS

Forty perinatally HIV-infected children with a median age of 12 months were eligible and selected for the study, which included a medical chart review from birth and prospective follow-up. Each child was examined quarterly for oral manifestations, tooth eruption, and for 27 children, caries and periodontal status.

RESULTS

The incidence of pseudomembranous candidiasis was 43% (95% CI, 27-58%) within 6 months of birth. Oral candidiasis (defined as pseudomembranous or erythematous) was positively associated with low CD4 counts and the occurrence of plaque. Children with low CD4 counts were also found to have fewer teeth than children with high CD4 counts, after adjusting for age.

CONCLUSIONS

Oral manifestations are common in paediatric HIV infection and are possible predictors of HIV disease progression. Primary care of HIV-infected children should include periodic oral examinations to monitor their HIV disease progression and to alleviate symptoms associated with oral opportunistic infections.

Assessment of early childhood caries and dietary habits in a population of migrant Hispanic children in Stockton, California

OBJECTIVE

This study estimated the prevalence of early childhood caries (ECC) and related behavioral risk factors in a population of low-income, Mexican-American children in Stockton, California.

METHODS

We collected data for 220 children ages six years or less using a parent-completed questionnaire and clinical dental examinations during the Su Salud Health and Education Fair in July 1995. We employed five case definitions of ECC: buccal or lingual caries on one or two primary maxillary incisors; caries on any surface of one or two primary maxillary incisors; and five decayed, missing (due to caries), or filled primary teeth.

RESULTS

The prevalence of ECC ranged from 12.3 percent to 30.5 percent, depending upon the case definition. More than 17 percent of children age two years had one primary maxillary incisor affected by caries on the buccal or lingual surface; 13.2 percent had two affected. Mean age at weaning from breast--or bottle-feeding and patterns of bottle use during sleep did not differ significantly between children with ECC and those without. There were no clear patterns of cariogenic food frequency and disease status.

CONCLUSIONS

Our findings question whether feeding patterns with human breast milk, formula, or bovine milk are sufficient etiologic factors for this condition.

Cost-effectiveness model for prevention of early childhood caries

This study presents and illustrates a model that determines the cost-effectiveness of three successively more complete levels of preventive intervention (minimal, intermediate, and comprehensive) in treating dental caries in disadvantaged children up to 6 years of age. Using existing data on the costs of early childhood caries (ECC), the authors estimated the probable cost-effectiveness of each of the three preventive intervention levels by comparing treatment costs to prevention costs as applied to a typical low-income California child for five years. They found that, in general, prevention becomes cost-saving if at least 59 percent of carious lesions receive restorative treatment. Assuming an average restoration cost of $112 per surface, the model predicts cost savings of $66 to $73 in preventing a one-surface, carious lesion. Thus, all three levels of preventive intervention should be relatively cost-effective. Comprehensive intervention would provide the greatest oral health benefit; however, because more children would receive reparative care, overall program costs would rise even as per-child treatment costs decline.

Classification, diagnostic criteria, and treatment recommendations for orofacial manifestations in HIV-infected pediatric patients. Collaborative Workgroup on Oral Manifestations of Pediatric HIV Infection

The criteria for diagnosis of HIV-related oral lesions in adults are well established, but corresponding criteria in the pediatric population are not as well defined. The Collaborative Workgroup on the Oral Manifestations of Pediatric HIV infection reached a consensus, based upon available data, as to the presumptive and definitive criteria to diagnose the oral manifestations of HIV infection in children. Presumptive criteria refer to the clinical features of the lesions, including signs and symptoms, whereas definitive criteria require specific laboratory tests. In general, it is recommended that definitive criteria be established whenever possible. Orofacial manifestations have been divided into three groups: 1) those commonly associated with pediatric HIV infection; 2) those less commonly associated with pediatric HIV infection; and 3) those strongly associated with HIV infection but rare in children. Orofacial lesions commonly associated with pediatric HIV infection include candidiasis, herpes simplex infection, linear gingival erythema, parotid enlargement, and recurrent aphthous stomatitis. In contrast, orofacial lesions strongly associated with HIV infection but rare in children include Kaposi's sarcoma, non-Hodgkin's lymphoma, and oral hairy leukoplakia. Treatment recommendations, specific for this age group, have been included for some of the more common HIV-related orofacial manifestations.

Oral aspects of HIV infection in children

Most infants with congenital HIV infection appear normal at birth. Clinical difficulties usually begin as the first year proceeds, and in about half of the children oral manifestations are the first signs. Oral manifestations are commonly found in HIV-positive asymptomatic and pediatric AIDS patients, they are the earliest clinical signs of HIV infection and disease progression in children, and may be used as diagnostic markers, especially in developing countries. Studies have established an accurate association between oral manifestations and progression of HIV disease in children. Since the mouth is easily accessed for clinical examination, the important oral signs should be utilized in the diagnosis and early intervention of AIDS in these vulnerable populations.

Risk factors for HIV-related orofacial soft-tissue manifestations in children

A retrospective review of the medical records of 492 children perinatally exposed to the human immunodeficiency virus (HIV) compared the prevalence of orofacial soft-tissue manifestations in HIV-infected and noninfected children, identified risk factors for occurrence of orofacial lesions in HIV-infected children, and investigated specific orofacial lesions as indicators of progression of HIV disease. Application of eligibility criteria and the Centers for Disease Control classification of pediatric HIV infection resulted in selection of a study group of 91 HIV-positive children and a control group of 185 HIV-seronegative children who had seroreverted. Analysis of oral lesions showed that 67% of the study group and 8% of the control group had oropharyngeal candidiasis (OPC), 4% of the study group and 0% of the control group had parotid enlargement, and 3% of the study group and 0% of the control group had herpes simplex; all three differences were significant at P < 0.04. No statistically significant association was found between OPC and the risk factors of gender, ethnicity, or mode of delivery (vaginal versus cesarean). However, OPC was associated significantly with all progression markers examined: failure to thrive, use of antiretroviral agents, lower CD4 counts, and development of acquired immunodeficiency syndrome (AIDS). Orofacial manifestations are common in pediatric HIV infection and may serve as markers of infection and predictors of progression of HIV disease to AIDS.

Prevalence and treatment costs of infant caries in Northern California

To determine the prevalence of infant caries in low-socioeconomic-status children and to analyze the costs of their treatment, we retrospectively evaluated 357 children, ages eight months to seven years, who were treated during 1992 at a university-associated medical center in Northern California. Infant caries was diagnosed by several different standards, and prevalence varied according to the diagnostic criteria employed: 27 percent by the presence of any labiolingual lesion on the maxillary incisors; 32 percent by the presence of at least two carious maxillary incisors; 27 percent by the presence of at least three carious maxillary incisors; and 36 percent by a dmft > or = 5. Prevalence was higher among boys than girls (37 percent versus 27 percent), and highest in the group ages 3-4 years (43 percent). The cost of dental treatment increased with deft and ranged from $408 for deft 2-5 to $1725 for deft 16-20. Many patients failed to comply with recommended treatment for reasons of cost. Our results showed that (1) the prevalence of infant caries varies depending upon the clinical criteria used for diagnosis; (2) the cost of rehabilitating primary dentition increases in proportion to the number of teeth involved; and (3) low-income patients avoid treatment of infant caries for a variety of reasons related to the cost involved.