|Year : 2017 | Volume
| Issue : 4 | Page : 288-291
Prevalence of Oral Manifestations Among HIV-Positive Patients Undergoing Antiretroviral Treatment Visiting Chamarajanagar District Hospital: A Cross-Sectional Study
Sathyaprakash Dongade, Zainul Mohammed Wajid Sermadi, Rangaswamynayaka Manjunath, Chandramohan Priyadarshini, Mudigere Subbaiah Jayapala
Department of Dentistry, Chamarajanagar Institute of Medical Sciences, Yadapura, Karnataka, India
|Date of Submission||03-Nov-2017|
|Date of Acceptance||15-Oct-2017|
|Date of Web Publication||15-Feb-2018|
Dr. Sathyaprakash Dongade
Department of Dentistry, Chamarajanagar Institute of Medical Sciences, Chamarajanagar, Yadapura, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: The introduction of antiretroviral therapy (ART) among the HIV/AIDS patients has reduced the frequency of the oral lesions, especially oral candidiasis, necrotizing periodontal conditions, Kaposi's sarcoma, hairy leukoplakia, and recurrent oral ulcers due to reconstitution of the immune system. Aim: This study is to determine the effect of ART on the oral mucosa of HIV/AIDS patients clinically. Materials and Methods: Three hundred and seventy-three patients who are on ART were examined for oral manifestations. Results: Oral candidiasis was manifested in 64% of patients, oral pigmentation in 44.5% patients, 43% with gingival or periodontal infection, 33% with reduced salivary secretion, and 35% with dental caries. Conclusion: It was concluded that high incidence of candidiasis may be due to the habits or history of tuberculosis, pigmentation, and xerostomia due to the medication.
Keywords: Antiretroviral therapy, candidiasis, CD4 cells, oral manifestation in HIV, pigmentation, xerostomia
|How to cite this article:|
Dongade S, Wajid Sermadi ZM, Manjunath R, Priyadarshini C, Jayapala MS. Prevalence of Oral Manifestations Among HIV-Positive Patients Undergoing Antiretroviral Treatment Visiting Chamarajanagar District Hospital: A Cross-Sectional Study. J Indian Acad Oral Med Radiol 2017;29:288-91
|How to cite this URL:|
Dongade S, Wajid Sermadi ZM, Manjunath R, Priyadarshini C, Jayapala MS. Prevalence of Oral Manifestations Among HIV-Positive Patients Undergoing Antiretroviral Treatment Visiting Chamarajanagar District Hospital: A Cross-Sectional Study. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2019 May 22];29:288-91. Available from: http://www.jiaomr.in/text.asp?2017/29/4/288/225464
| Introduction|| |
Acquired immune deficiency syndrome (AIDS) was first described as a not needed clinical entity in 1981. Though at first lifestyle and behavioral factors were hypothesized to be causally related, finally in 1983 the human immunodeficiency virus (HIV) was identified as the true cause of AIDS. AIDS is a complex of symptoms and infections caused by the HIV virus as it affects the immune system. It is an acquired infection, not hereditary. Since its appearance in 1981, it has spread to become a major cause of premature death and so far, cure has not yet been found. AIDS is a global pandemic, 33.4 million people are currently living with the disease worldwide, and it has killed an estimated 2.4 million people, including 330,000 children (UNAIDS, 2010). Over three-quarters of these deaths occurred in sub-Saharan Africa, retarding economic growth and destroying human capital.
AIDS is an infectious disease caused by HIV, and is characterized by prolong immune suppression that leads to opportunistic infections, secondary neoplasms, and neurological manifestations. HIV is a retrovirus, which has a specific affinity for cluster of differentiation 4 (CD4) T helper cells. The CD4 T-lymphocyte count and viral load are the most important laboratory parameters to evaluate the diseases. The laboratory test is generally accepted as the best indicator of the immediate state of immunological competence of the patients with HIV infection and is an important determinate of the disease's stage and prognosis in seropositive individuals.
HIV-related oral lesions are frequent and often an early finding in patients with HIV infection. They affect the quality of life of the patients and are useful markers of disease progression. The oral lesions found in patients with HIV infection can be of fungal, viral, and bacterial origin. Mouth is a mirror of systemic problems. The occurrence of oral manifestations is favored by immune deterioration. Oral manifestations are present in 30–80% of HIV patients. HIV infection presents as oral problems, for example, oral candidiasis, hairy leukoplakia, ulcers, pigmentations, etc., Hence, early identification of oral findings is helpful in early diagnosis and monitoring of patients with HIV infection. Oral manifestations suggest a decrease in cluster differentiated (CD) count with increased viral load. According to the new classification given by Center for Disease Control and Prevention (CDC), clinical AIDS is defined by a CD4 count of <200 and/or a CD4 <14%.
Oral lesions and relationship with CD4 count and viral load
The hallmark of HIV disease is the progressive loss of CD4+ lymphocytes. Without intervention, an average of 60–80 cells/mm 3 is lost every year; this loss is highly variable and occurs in periods of stability and rapid decline. High viral load is also considered one of the main indicators of the progression of HIV-induced immune suppression. Several studies have shown that the higher the viral load, the quicker the progression to AIDS. The CD4 count and viral load measure the progression of the HIV disease. Several studies have shown high prevalence of oral lesions in patients with low CD4 count, <200 cells/mm 3 and high viral load: >55,000 copies/ml.
The introduction of highly active antiretroviral therapy (ART) in HIV patients has brought a dramatic reduction in morbidity and mortality rates, and patients are living longer with a better quality of life. It can only control the progress rate of the disease. Present therapeutical resources are not able to cure HIV, however, antiretroviral medication is effective enough to suppress viral replication with consequent immune recovery, and in turn HIV fatal infection into a long life chronic disease.
Oral lesions and their response to highly active antiviral treatment (HAART)
The goals of HAART should be maximal and durable viral suppression. The aim is preservation and restoration of the immune system at minimal cost to the patient. This should improve the quality of life through easy use of their regimen with minimal side effects to enhance optimum adherence. This should translate into a reduction of HIV-related morbidity including oral manifestations. Reduction of viral burden will prevent progressive immunodeficiency, decrease the risk of the emergence of resistant viruses, and possibly decrease the risk of viral transmission. It has been shown in various studies that the prevalence of HIV-related oral lesions reduces significantly with HAART. Studies examining the effect of HAART on the prevalence of individual oral manifestations mainly reported on oral candidiasis, oral hairy leukoplakia, HIV-related periodontal diseases, Kaposi's sarcoma (KS), oral papilloma, and HIV-related salivary gland disease showed reduction in the prevalence.
Aims and objectives
The aims and objective of this study are:
- To diagnose and record the oral changes in patients who are on ART
- To determine CD4 count of all the above patients; and To correlate between presence/absence and severity of oral changes and individual CD4 count.
| Materials and Methods|| |
A cross-sectional study of seropositive patients who are undergoing ART visiting the ART Center, District Hospital, Chamarajanagar were included in the study. In 373 patients oral manifestations were examined. The examiner received training on diagnostic criteria prior to conducting patient examinations. Permission was taken from the institutional ethical committee. With prior written consent from each patient, with natural light using disposable wooden spatula, disposable mouth mirror, gloves, masks, bright illuminated torch, and sterile pieces of cotton and gauze, oral examination was performed.
| Results|| |
Of the 373 patients studied for the oral manifestation, 206 were female patients and 167 males. CD4 ranged from 34 cells to 2462 cells, with mean of 538 cells. Age of the patients ranged from 3 to 74 years with mean age of 39 years. Eighty-five patients had history of tobacco habit and tuberculosis. Two hundred thirty-eight (64%) patients presented with candidiasis, pigmentation was seen in 166 (44.5%) patients, 160 (43%) with gingival or periodontal infection, 125 (33%) with reduced salivary secretion, and 130 (35%) dental caries. Other manifestations present were geographic tongue among 9 patients, herpes zoster in 4 patients, aphthous ulcer in 6 patients, 4 patients with lichen planus, and oral hairy leukoplakia was present in 4 patients.
| Discussion|| |
HIV was first reported in USA between June and July 1981. The CDC published two reports on clusters of young homosexual men who developed opportunistic infections that were chiefly detected in several immune-deficient individuals. The HIV attacks and disturbs the delicate balance of host's immune response, thereby rendering the host susceptible to a lot of life-threatening opportunistic infections, neurological disorders, unusual malignancies and oral lesions, and in HIV-associated opportunistic infections. Skin and the mucous membranes are “independent organs” of the immune system. An immunodeficiency allows even harmless saprophytes on the body surface and follicle openings to penetrate into deeper tissue layers, and thus develop life-threatening infections. Oral lesions have been reported to be early clinical features of HIV infection. These lesions are often indicators of immune suppression and can be used for early testing, diagnosis, and management of patients with HIV/AIDS. Oral lesions contribute to patients' morbidity, affecting the psychological and economic functioning of the individual and community.
ART provides effective treatment options for the patients affected with HIV/AIDS. The initial goal of ART is to improve survival without progressing to AIDS and try to alleviate the adverse effects of treatment. Immune reconstitutions via the recovery of CD4+ count serve as marker for monitoring the response to therapy because of its predictive ability for AIDS-related events and death. The overall prevalence of oral manifestations of HIV infection has changed since the advent of HAART. Several studies have shown reduction in prevalence of herpes labialis and periodontal diseases along with other lesions to more than 30% after the institution of HAART and in HIV-associated opportunistic infections.
This is the most common intraoral lesion seen among HIV-infected individuals, however, its frequency varies among studies. The most common organism involved with the presentation of candidiasis is Candida albicans. In the present study out of 373 patients, 238 patients have candidiasis accounting to 64%, and angular cheilitis in 44 patients. This is high compared to all the studies in literature, and in patients with CD4 count <200 almost all patients had candidiasis. Nayak et al. reported 39.5% candidiasis and Ravi and Rao  reported 36.11% candidiasis. These are the only two studies that were above 35% candidiasis, who are on ART. Rest of the studies showed reduced oral candidiasis.,, The high incidence of candidiasis in the present study may be due to the habits or history of tuberculosis.
Brown or brownish black macular oral hyperpigmentation, typically associated with intraleukocytic melanin or pigment in the basal cell layer or lamina propria with premature melanosomes, has been described in HIV-infected patients. Often the cause is unknown, but the identified causes include zidovudine (AZT), clofazimine, ketoconazole, and hypoadrenocorticism. As a result of adrenal Mycobacterium avium, intracellular infection usually does not respond to HAART. This is the second common finding in the present study, which is about 44%. Qadir et al. reported 63% pigmentation, Sontakke  reported 30.6% oral pigmentation, and Satyakiran  also showed similar cases of pigmentation (42.3%), which is close to our study.
This may be associated with the salivary gland enlargement but is also a common consequence of medications used by this population. Several medications used in the treatment of HIV-related disease may cause xerostomia. It has been found that specific salivary gland diseases, such as Sjogren's-like syndrome, diffuse CD8 lymphocytic infiltration, and lymphoepithelial cyst, occur during the course of HIV disease progression. In the present study, xerostomia was found in 125 (33%) patients. Satyakiran  reported 26.3% patients with xerostomia. Studies need to be conducted measuring the stimulated and unstimulated salivary flow in a longitudinal cohort of HIV positive patients initially before HAART and later at 6 months interval to accurately measure the impact of HAART on xerostomia.
Other manifestations present were geographic tongue in 9 patients, herpes zoster in 4 patients, aphthous ulcer in 6 patients, 4 patients with lichen planus, and oral hairy leukoplakia was present in 4 patients. Even though the incidence of dental caries and periodontal disease was more in the study, it was not taken into consideration because general population in the study area had similar dental caries and periodontal condition. Oladokun et al. reported that they did not find a statistically significant difference in the prevalence of oral lesions in the ART naïve population compared with those on ART. This is surprising because the goal of ART is to reduce viral load with a resultant restoration of immune function and reduced incidence of opportunistic infections. The disparity in various findings may have some racial and geographical implications. Moreover, the clinical and immunological status of the subjects at the point of evaluation may offer additional explanation for the disparity.
| Conclusion|| |
Increased incidence of oral candidiasis in patients with ART may be due to the oral hygiene, history of tuberculosis, and use of alcohol or tobacco. Increased incidence of pigmentation may be due to the medication, which requires a control study with the medications. Studies are required with more sample size with systemic diseases, oral hygiene, and habits. Further exploration of interaction between the host and ART in the HIV positive patients must be explored.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hoffmann C, Rockstroh JK (editors). HIV 2015/16: The HIV epidemic. 23rd
ed. Available from: www.hivbook.com [Last accessed on 2017 Jan 17]. p. 2.
Jindwani K, Singh K, Dadlani H. A study of oral lesions among HIV positives in a tertiary care hospital. Biomed Res 2013;24:40-2.
Shetty S, Kattappagari KK, Hallikeri K, Krishnapilli R. Evaluation of oral lesions in HIV seropositive individuals and its correlation with CD4+T-lymphocytic count. J NTR Univ Health Sci 2016;5:123-9. [Full text]
Patil N, Chaurasia VR, Babaji P, Ramesh D, Jhamb K, Sharma AM. The effect of highly active antiretroviral therapy on the prevalence of oral manifestation in human immunodeficiency virus-infected patients in Karnataka, India. Eur J Dent 2015;9:47-52.
] [Full text]
Ponnam SR, Srivastava G, Theruru K. Oral manifestations of human immunodeficiency virus in children: An institutional study at highly active antiretroviral therapy centre in India. J Oral Maxillofac Pathol 2012;16:195-202. [Full text]
Arbune M, Potarnichie O-M, Martu S. Oral manifestations among Romanian HIV patients. Int J Med Dent 2013;3:15-21.
Bodhade AS, Ganvir SM, Hazarey VK. Oral manifestations of HIV infection and their correlation with CD4 count. J Oral Sci 2011;53:203-11.
Hoffmann C, Rockstroh JK (editors). HIV 2015/16: HIV-associated skin and mucocutaneous diseases. 23rd
ed. Available from: www.hivbook.com [Last accessed on 2017 Apr 11]. p. 613-26.
Qadir S, Naseem N, Sami W, Nagi AH. Effect of anti retroviral therapy on oral lesions in HIV/AIDS Pakistan. Oral Dental J 2016;36:387-90.
Reznik DA. Perspective – Oral manifestations of HIV disease. Top HIV Med 2006;13:143-5.
Nayak SK, Das BK, Das SN, Mohapatra N, Nayak S, Bhuyan L. Oral manifestations of human immunodeficiency virus/acquired immunodeficiency syndrome and their correlation to cluster of differentiation lymphocyte count in population of North-East India in highly active antiretroviral therapy era. Contemp Clin Dent 2016;7:539-43.
] [Full text]
Ravi JR, Rao TR. Estimation of prevalence of periodontal disease and oral lesions and their relation to CD4 counts in HIV seropositive patients on antiretroviral therapy regimen reporting at District General Hospital, Raichur. J Indian Soc Periodontol 2015;19:435-9.
] [Full text]
Satyakiran GV, Bavle RM, Alexander G, Rao S, Venugopal R, Hosthor SS. A relationship between CD4 count and oral manifestations of human immunodeficiency virus-infected patients on highly active antiretroviral therapy in urban population. J Oral Maxillofac Pathol 2016;20:419-26.
] [Full text]
Rao KV, Chitturi RT, Kattappagari KK, Kantheti LP, Poosarla C, Baddam VR. Impact of highly active antiretroviral therapy on oral manifestations of patients with human immunodeficiency virus/acquired immunodeficiency syndrome in South India. Indian J Sex Transm Dis 2015;36:35-9.
] [Full text]
Sontakke SA, Umarji HR, Karjodkar F. Comparison of oral manifestations with CD4 count in HIV-infected patients. Indian J Dent Res 2011;22:732.
] [Full text]
Tappuni AR, Fleming GJ. The effect of antiretroviral therapy on the prevalence of oral manifestations in HIV-infected patients: A UK study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:623-8.
Oladokun RE, Okoje VN, Osinusi K, Obimakinde OS. Oral lesions and their association with CD4 count and viral load in HIV positive Nigerian children. Oral Health Dent Manag 2013;12:200-4.