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

doi:10.4103/2348-2915.200017

ORIGINAL ARTICLE

Year : 2016 | Volume : 3 | 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

Correspondence Address:
Monika Aroquiadasse
Department of Oral Medicine and Radiology, Mahatma Gandhi Postgraduate Institute, Puducherry
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2348-2915.200017

Abstract

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.^[1] 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.^[2] 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.^[3] 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.^[1]

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.

Study subjects

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.

Study variables

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.^[4]

Study procedure

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.

Statistical analysis

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.^[5] 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 ^[6],[7] 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.^[8],[9] 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.^[10],[11] 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.^[12] 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,^[13] 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).^[14] Aphthous ulcers were present in 7 (15.9) patients similar to the studies reported from Brazil and USA.^[15],[16] Parotid enlargement occurs in 10%–30% of HIV-infected children.^[17],[18] 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.^[18] 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.^[19],[20] 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.^[21]

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%.^[22] 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.^[23]

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.^[24] 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.^[25] 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

Nil.

Conflicts of interest

There are no conflicts of interest.

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