|Year : 2016 | Volume
| Issue : 4 | Page : 124-128
Evaluation of oral manifestations and oral health status among pediatric human immunodeficiency virus patients-under anti-retroviral therapy: A cross-sectional study
Monika Aroquiadasse, Jonathan Mariappan Daniel, Srinivasan Subramanian Vasudevan, Jimsha Vanathan Kumaran
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute, Puducherry, India
|Date of Web Publication||13-Feb-2017|
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute, Puducherry
Source of Support: None, Conflict of Interest: None
Introduction: The human immunodeficiency virus (HIV) acquired immunodeficiency syndrome disease has evolved to become a social and economic catastrophe, with far-reaching implications affecting every phase of life of the diseased individual. Data on adults and children diagnosed with HIV infection are useful for determining populations needing prevention and treatment services. Oral lesions may be the presenting symptoms of HIV infection and may differ entirely from those manifested in the adult population. Aim and Objective: We aimed to evaluate the prevalence of HIV related oral lesions among pediatric HIV patients and to assess the oral health status of HIV infected children residing in a selected childcare facility in Puducherry. Materials and Methods: A cross-sectional study was conducted during September 2015 in child care facility for HIV infected children located in Puducherry U.T, India. All children <18 years, who are diagnosed with HIV infection and are put on anti-retroviral therapy (ART) or pre-ART care, were included in the study. After obtaining informed consent from the care-givers and assent of the children, they were interviewed and examined by a team comprising a qualified dental surgeon and a trained physician. Results: Majority of the children were under first-line ART (73%) and were on ART for more than 4 years. The CD4 count of 23 (52.3) was between 500–1000 cells/μL. The recent viral load assay in 32 (72.7) patients was <150/not detected. Tooth decay was the most common oral manifestation with 28 (63.6) being affected. Nonspecific lymphadenopathy 26 (59.1) was the most common coexisting systemic illness. Conclusion: This study proves that constant surveillance by monitoring the general health status, CD4 counts, viral load coupled with stringent ART care has improved the overall quality of life of these children and consequently resulted in lesser oral manifestations.
Keywords: Children, human immunodeficiency virus, oral manifestation
|How to cite this article:|
Aroquiadasse M, Daniel JM, Vasudevan SS, Kumaran JV. Evaluation of oral manifestations and oral health status among pediatric human immunodeficiency virus patients-under anti-retroviral therapy: A cross-sectional study. J Dent Res Rev 2016;3:124-8
|How to cite this URL:|
Aroquiadasse M, Daniel JM, Vasudevan SS, Kumaran JV. Evaluation of oral manifestations and oral health status among pediatric human immunodeficiency virus patients-under anti-retroviral therapy: A cross-sectional study. J Dent Res Rev [serial online] 2016 [cited 2023 Mar 29];3:124-8. Available from: https://www.jdrr.org/text.asp?2016/3/4/124/200017
| Introduction|| |
The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) disease has evolved to become a social and economic catastrophe, with far-reaching implications affecting every phase of life of the diseased individual. According to the World Health Organization (WHO) estimates, approximately 36.7 million people worldwide are living with HIV/AIDS in 2015 and of these 1.8 million are children <15 years of age. About 2.1 million people became newly infected in 2015. Globally, the number of children living with AIDS has drastically increased from 1.6 million in 2001 to 2.5 million in 2009. In the year 2009, 0.37 million children under the age of 15 years were newly infected and about 0.26 million children had died; the majority of which were under the age of 5. The WHO suggests the above disease statistics to be an underestimate because of underreporting of cases in developing countries and inadequate data on the pediatric population.
Data on adults and children diagnosed with HIV infection are more useful for determining populations needing prevention and treatment services. Oral lesions may be the presenting symptoms of HIV/AIDS or they may herald deterioration in general health; some oral lesions are also indicators of poor prognosis. The advent of ART has considerably reduced the disease burden globally; 46% of all adults living with HIV have started treatment in 2015 which has steadily increased from 23% in 2010. Similarly 49% all children living with HIV had access to treatment in 2015 compared to 21% in 2010.
With this background a study was done with the following aim and objective.
Aim and objective
We aimed to evaluate the prevalence of HIV related oral lesions among pediatric HIV patients and to assess the oral health status of HIV infected children residing in a selected childcare facility in Puducherry.
| Materials and Methods|| |
Study design and setting
A cross-sectional observational study was conducted during September 2015 in a childcare facility for HIV infected children located in Kalapet, Pondicherry; Puducherry U.T, India. The childcare facility is a children home run by a nongovernmental organization. Orphans and abandoned children who are found to be infected with HIV are sheltered in this facility.
All children <18 years, who are diagnosed with HIV infection and are put on anti-retroviral therapy (ART) or pre-ART care, were included in the study. All children were aged between 4 years and 18 years and had a confirmatory diagnosis of HIV using ELISA and/or Western blot.
Information on demographic characteristics such as age and gender, disease and treatment details including the type and duration of ART drug regime, recent CD4 counts, viral load assays, route of acquiring HIV infection, HIV status of parents, past and present history of tuberculosis (TB) and type of TB were retrieved from the treatment records. Information on Oral manifestations of HIV was recorded onto the WHO recording format for oral HIV/AIDS based on the criteria described by Greenspan et al. for the diagnosis of oral lesions in HIV/AIDS.
Permission for screening the children for oral manifestations of HIV and general oral health check-up was obtained from the childcare home. After obtaining informed consent from the care-givers and assent of the children, they were interviewed and examined by a team comprising a qualified dental surgeon and a trained physician. The oral manifestations were observed and recorded by the dental surgeon pertaining to the WHO recording format for oral HIV/AIDS, whereas the systemic manifestations were recorded by a trained physician and confirmed from the patient's treatment record. Information on demography and disease characteristics were retrieved from the treatment records maintained at the childcare facility. The presence of oral and systemic manifestations of HIV and other oral lesions were carefully examined and noted down by the investigators. The diagnosis of the lesions was made clinically and laboratory investigations were not performed to confirm them.
Data were entered and analyzed using EpiData software (EpiData Association, Odense, Denmark). Continuous variables such as age, CD4 count, and viral load were expressed in mean (standard deviation [SD]) and categorical variables were expressed as proportions.
| Results|| |
The demographics and the disease characteristics of the children included in the study are shown in [Table 1]. The mean (SD) age of the study participants was 12.6 (3.2) years. Majority of the children were under first-line ART (73%) and were on ART for more than 4 years. The review of medical records revealed that eight children previous history of Pulmonary TB in 8 (18.2) patients and 1 (2.3) with extra pulmonary TB. At the time when the study was carried out 3 (6.8) had pulmonary TB and an equal number with extra pulmonary TB 3 (6.8).
|Table 1: Demographic and disease characteristics of the study subjects (n=44)|
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[Table 2] describes the immunologic and virological characteristics of the study participants. The CD4 count of 23 (52.3) was between 500 and 1000 cells/µL. The recent viral load assay in 32 (72.7) patients was <150/not detected.
|Table 2: Immunological and virological characteristics of the study participants (n=44)|
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[Table 3] describes the oral and systemic manifestations of HIV infected children included in the study. Tooth decay (64%) was the most common oral manifestation followed by intra oral pigmentation (25%) and coated tongue (25%) as depicted in [Figure 1]. Non specific lymphadenopathy was the commonest systemic co-morbidity affecting 59% of subjects. Pruritic skin lesions (23%), respiratory tract infections (9%) and middle ear infection (9%) were other common systemic manifestations present.
|Table 3: Oral and systemic manifestations among human immunodeficiency virus infected children included in the study (n=44)|
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|Figure 1: Oral lesions among human immunodeficiency virus infected children included in the study (n = 44)|
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| Discussion|| |
Pediatric HIV infections are related to a wide range of oral manifestations. Oral manifestations of HIV/AIDS may serve as primal signs of the immune status and disease progression of the HIV infected individual. The standard drug regimens used in pediatric HIV care are pre-ART, First-line, Alternate First-line and Second-line. In our study, most of the children 32 (72.7) were under first line drug regimen and 25 (56.8) were receiving ART for 4–8 years.
The oral and systemic manifestations are different from that of adults because of the earlier acquisition of the virus and immature immune system of the pediatric patient. The most frequently associated oral lesions in pediatric HIV patients include candidiasis, herpes simplex infection, linear gingival erythema, parotid enlargement, and recurrent apthous stomatitis , candidiasis, expected to be the most common oral manifestation in Pediatric HIV patients was not observed in our study. This may be attributed to the fact that all the children in this study were under ART. After initiation of ART, there is a reported decrease in the incidence of Candidiasis., However, angular cheilitis was observed in 7 (15.9) patients. In the present study, the most common intra oral manifestation was Tooth decay 28 (63.6). Many studies support the prevalence of dental caries among HIV infected children., This can be ascribed to the high sucrose content in the anti-retro viral medications, xerostomia induced by medication or HIV infection, the need for high caloric and carbohydrate/sucrose diets, and alterations in saliva viscosity, cytokines, protease inhibitors, and immunoglobulin. Intra oral pigmentation was the second most common oral manifestation in our study population. According to the EC-Clearinghouse Classification of Oral Lesions Associated with Adult HIV Infection of September 1992, HIV-associated oral melanotic hyperpigmentation is categorized under “lesions less commonly associated with HIV infection.” Anemia and associated nutritional deficiencies are known to cause epithelial atrophy and lead to abnormal intra oral pigmentation. Earlier studies have documented increased intra oral pigmentations in HIV sero positive adults. In addition to anemia, other causes of pigmentation are the release of a melanocyte-stimulating hormone caused by dysregulation of cytokines in HIV disease, Addison's disease, and drug-induced (ART). Aphthous ulcers were present in 7 (15.9) patients similar to the studies reported from Brazil and USA., Parotid enlargement occurs in 10%–30% of HIV-infected children., The specific aetiology is unknown. Generally, it presents as a unilateral or bilateral diffuse soft swelling resulting in facial disfigurement. In this study, it was found in 2 (4.5) patients. Herpes simplex virus infection, a common childhood infection, occurs in 1.7%–24% of HIV-infected children. In the present study, Herpetic stomatitis was present in 2 (4.5) patients and Herpes Zoster in 1 (2.3) patient.
In this study, the most common coexisting systemic illness was nonspecific lymphadenopathy 26 (59.1). This was similar to reports from Italy and Africa., HIV is primarily a disease of the lymphocytes and lymph node involvement is a persistent finding during all stages and is also consistently seen sign throughout the clinical course of HIV infection.
Pulmonary TB is one of the most common systemic opportunistic infections in HIV infected individuals, particularly in India with a prevalence of 2.8%–9.4%. HIV can predispose to TB and TB can worsen immunosuppression in the HIV infected. In this study, previous history of pulmonary TB was found in 8 (18.2) patients and 1 (2.3) with extra pulmonary TB that is, Neuro TB. At the time when the study was carried out 3 (6.8) had pulmonary TB and an equal number with extra pulmonary TB, that is, Abdominal TB 3 (6.8).
Skin lesions affect more than 90% of HIV seropositive patients; lesions include papillary pruritic eruptions, herpes simplex and zoster, cutaneous TB, drug reactions, and neoplasms.
In this study, the skin lesions included Pruritic skin lesions 10 (22.7), molluscum contagiosum 2 (4.5). Other opportunistic infections seen in the study are respiratory tract infections 4 (9.1), otitis media 4 (9.1). Rare systemic manifestations such as mental retardation 2 (4.5), cytomegalovirus infection 1 (2.6), bronchiectasis 1 (2.6), hemiparesis 1 (2.6), seizure disorder 1 (2.6), drug induced psychosis 1 (2.6), and drug induced anemia 1 (2.6) were also observed in our study. Efavirenz used in ART is associated with central nervous system side effects mania, depression, suicidal thoughts, psychosis, and hallucinations. Zidovudine is the preferred nucleoside reverse transcriptase inhibitor in the first-line antiretroviral regimen in India. It is known to be associated with life-threatening toxicity like anemia. The limitation of this study is that all the lesions were diagnosed clinically and microbiological tests were not feasible to perform to confirm the same.
| Conclusion|| |
This study proves that constant surveillance by monitoring the general health status, CD4 counts, viral load coupled with stringent ART care has improved the overall quality of life of these children and consequently resulted in lesser oral manifestations. It is of paramount importance to provide training to health-care professionals on the prevention, early identification, prognostic value, and management of orofacial manifestations in pediatric HIV infection. Thus, inclusion of oral health in a comprehensive approach should be part of the overall health management of the pediatric HIV patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agbelusi GA, Wright AA. Oral lesions as indicators of HIV infection among routine dental patients in Lagos, Nigeria. Oral Dis 2005;11:370-3.
Greenspan JS, Barr CE, Sciubba JJ, Winkler JR. Oral manifestations of HIV infection. Definitions, diagnostic criteria, and principles of therapy. The U.S.A. Oral AIDS Collaborative Group. Oral Surg Oral Med Oral Pathol 1992;73:142-4.
Ramos-Gomez F. Dental considerations for the paediatric AIDS/HIV patient. Oral Dis 2002;8 Suppl 2:49-54.
Greenspan D, Greenspan JS. HIV-related oral disease. Lancet 1996;348:729-33.
Soares LF, de Araújo Castro GF, de Souza IP, Pinheiro M. Pediatric HIV-related oral manifestations: A five-year retrospective study. Braz Oral Res 2004;18:6-11.
Hood S, Bonington A, Evans J, Denning D. Reduction in oropharyngeal candidiasis following introduction of protease inhibitors. AIDS 1998;12:447-8.
Revankar SG, Sanche SE, Dib OP, Caceres M, Patterson TF. Effect of highly active antiretroviral therapy on recurrent oropharyngeal candidiasis in HIV-infected patients. AIDS 1998;12:2511-3.
Eldridge K, Gallagher JE. Dental caries prevalence and dental health behaviour in HIV infected children. Int J Paediatr Dent 2000;10:19-26.
Flaitz C, Wullbrandt B, Sexton J, Bourdon T, Hicks J. Prevalence of orodental findings in HIV-infected Romanian children. Pediatr Dent 2001;23:44-50.
Flaitz CM, Hicks MJ. Oral manifestations in paediatric HIV infection. In: Shearer WT, Hanson IC, editors. Medical Management of AIDS in Children. USA: Elsevier Science; 2003. p. 248-69.
Classification and diagnostic criteria for oral lesions in HIV infection. EC-clearinghouse on oral problems related to HIV infection and WHO collaborating centre on oral manifestations of the immunodeficiency virus. J Oral Pathol Med 1993;22:289-91.
Umadevi KM, Ranganathan K, Pavithra S, Hemalatha R, Saraswathi TR, Kumarasamy N, et al.
Oral lesions among persons with HIV disease with and without highly active antiretroviral therapy in Southern India. J Oral Pathol Med 2007;36:136-41.
Costa LR, Villena RS, Sucasas PS, Birman EG. Oral findings in pediatric AIDS: A case control study in Brazilian children. ASDC J Dent Child 1998;65:186-90.
Del Toro A, Berkowitz R, Meyerowitz C, Frenkel LM. Oral findings in asymptomatic (P-1) and symptomatic (P-2) HIV infected children. Pediatr Dent 1996;18:114-6.
Katz MH, Mastrucci MT, Leggott PJ, Westenhouse J, Greenspan JS, Scott GB. Prognostic significance of oral lesions in children with perinatally acquired human immunodeficiency virus infection. Am J Dis Child 1993;147:45-8.
Ramos-Gomez FJ, Flaitz C, Catapano P, Murray P, Milnes AR, Dorenbaum A. Classification, diagnostic criteria, and treatment recommendations for orofacial manifestations in HIV-infected pediatric patients. Collaborative Workgroup on Oral Manifestations of Pediatric HIV Infection. J Clin Pediatr Dent 1999;23:85-96.
Naidoo S, Chikte U. Oro-facial manifestations in paediatric HIV: A comparative study of institutionalized and hospital outpatients. Oral Dis 2004;10:13-8.
Gill PS, Arora DR, Arora B, Gill M, Gautam V, Karan J, et al.
Lymphadenopathy – An important guiding tool for detecting hidden HIV-positive cases: A 6-year study. J Int Assoc Physicians AIDS Care (Chic) 2007;6:269-72.
Italian Register for HIV Infection in Children. Features of children perinatally infected with HIV-1 surviving longer than 5 years. Lancet 1994;343:191-5.
Kumarasamy N, Solomon S, Flanigan TP, Hemalatha R, Thyagarajan SP, Mayer KH. Natural history of human immunodeficiency virus disease in Southern India. Clin Infect Dis 2003;36:79-85.
Grayson W. The HIV-positive skin biopsy. J Clin Pathol 2008;61:802-17.
Cavalcante GI, Capistrano VL, Cavalcante FS, Vasconcelos SM, Macêdo DS, Sousa FC, et al.
Implications of efavirenz for neuropsychiatry: A review. Int J Neurosci 2010;120:739-45.
Agarwal D, Chakravarty J, Chaube L, Rai M, Agrawal NR, Sundar S. High incidence of zidovudine induced anaemia in HIV infected patients in Eastern India. Indian J Med Res 2010;132:386-9.
[Table 1], [Table 2], [Table 3]