Introduction

Research Article

A Study Of Oral Manifestation Of HIV/AIDS

Lalit Shrimali

Abstract

Background: In India, patients exposed to the Human Immunodeficiency Virus (HIV) infection are increasing and about 30-80% of patients present with oral manifestations of the disease and only a few studies have been performed to document this observation. Objective: To clinically evaluate and document the oral lesions in patients with HIV infections. Methods: In clinically suspected cases of HIV diagnosis was done by two consecutive screening tests using the Enzyme-linked immunosorbent assay (ELISA) technique. Where indicated incisional biopsy was performed to confirm the clinical diagnosis of the relevant lesions. All cases were examined according to the WHO criteria. Prior to the examination each patient had undergone counseling. Results: of the 50 cases, 31(62%) were males and 19(38%) were females with an age range of 20 to 59 years (mean=36.6 years). While all the cases had periodontal disease, over 72% had candidiasis, xerostomia in 32%, lymphadenopathy in 42% and angular cheilitis was seen in 36% of the cases. Other conditions seen included persistent oral ulceration (22%), oral hairy leukoplakia (2%), herpes zoster (8%), parotomegaly(10%) and facial palsy(8%). Conclusion: For reducing morbidity from HIV, early detection is necessary, therefore physicians must look for oral manifestation in suspected cases of HIV which aid in early diagnosis and treatment.

Key Words: Oral Manifestation; HIV; AIDS; Oral Candidiasis;

 

Lalit Shrimali. A Study Of Oral Manifestation Of HIV/AIDS. International Journal of Oral & Maxillofacial Pathology. 2010;1(1):8-12. ©2010 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved.

Received On: 10/09/2010      Accepted On: 11/11/2010

 


According to the World Health Organization (WHO) 2008 report around 33.8 million people world wide are living with Acquired immune deficiency syndrome (AIDS) of which around 3.8 million are in India. Oral manifestations are seen in 30-80% of the patients of HIV.(1-2) Studies have shown that 90% of  patients with HIV will have at least one oral manifestations during the course of disease.(3-4) Oral manifestations can suggest, decreased cluster differentiated 4(CD4+) T cell count,(5) and increased viral load,(6) which might also aid in diagnosis, progression, and prognosis of the disease.(7-8) Risk of oral complication increases with immunologic deterioration.(9) Oral examination is therefore useful for early diagnosis, which can prolong asymptomatic period, delay disease progression, prevent opportunistic infections with proper education and counseling of patient.

Methods

In this study 50 patients were selected who were between ages of 20 to 59 years of age. Patients were also having systemic manifestations also such as chronic gastroenteritis, dysphasia, wasting syndrome, pneumonia and disseminated tuberculosis. Patients were diagnosed by two consecutive enzyme linked immunosorbent assay (ELISA), screening tests for HIV infection. Proper counseling was done to educate the patient. Oral examination was performed according to the WHO criteria.(10) Where indicated incisional biopsy and microbiological specimens were taken for histopathological & microbiological examination done using haematoxylin & eosin stains in addition to organism culturing respectively. All lesions were evaluated clinically & recorded according to Centers for Disease Control and Prevention (CDC) classification of patients with HIV infection.

Results

The mean age of the subjects was 36.6 years (range 20-59 years). Age range 30-49 years constituted 44% of the study sample. 62% cases were male and 38% were female. 82% reported heterosexual contact as their route of HIV infection. Oral manifestations were recorded in 76% at the patients of which 72% had candidasis. 76% patients who had oral  lesions, had discomfort maximum during tooth brushing, chewing & swallowing, dry mouth, burning sensation especially on taking salty and spicy foods. (Table 1)

Description

No. of subjects

Percent

 Age (years)

20-29

30-49

40-49

50-59

 

04

22

16

8

 

08

44

32

16

Gender                  

Male: Female

 

31: 19

 

62:38

Mode of HIV infection

Heterosexual

Mother to child

Unknown

 

41

0

09

 

82

0

18

Oral lesion present

Yes

No

 

38

12

 

76

24

Discomfort in the mouth

Tooth brushing

Chewing

Swallowing

Drinking

Speaking

 

32

14

11

9

5

 

64

28

22

18

10

Table 1: Distribution of age, gender, mode of infection, oral lesions and discomfort in the mouth of the subject.

 

Distribution of oral manifestations in the subjects include, Oral candidasis in 72% patients of which main variant was hyperplastic, erythematous and pseudomembranous types. Lymphadenopathy in 42% and angular cheilitis in 36% were noted. Xerostomia in 32%, recurrent aphthous ulceration in 22%, oral hairy leukoplakia in 2%, herpes zoster in 8%, parotomegaly in 10% and  facial palsy in 8% were noted. Some subjects have more than one oral manifestation.(Table 2)

Description

No. of subjects

Percent

Candidasis

        Hyperplastic

        Erythematous

        Pseudo membranous

Angular cheilitis

Xerostomia

Recurrent aphthous ulceration

Atypical ulcers

Parotomegaly

Necrotizing gingivitis

Herpes zoster

Recurrent  herpes labialis

Facial palsy

Necrotizing periodontitis

Oral hairy leucoplakia

Kaposi`s sarcoma

Nonspecific lessions

 

36

18

11

8

18

16

11

5

5

4

4

4

4

1

1

0

2

 

72

36

22

16

36

32

22

10

10

8

8

8

8

2

2

0

4

Table 2: Distribution of oral manifestations in the subjects

Distribution of systemic manifestation in the patients of HIV were, 60% had chronic gastroenteritis, 22% presented with dysphasia, with resulting wasting and weight loss, 50% had respiratory tract infections, 16% had pulmonary tuberculosis and 10% had central nervous system manifestations comprising of chronic headache, confusion, loss of memory and cranial nerve paralysis. (Table 3)

                

Description

No. of subjects

 

Percent

Chronic gastroenteritis

Respiratory tract infection

Dysphasia

Pulmonary tuberculosis

Central nervous system manifestation

30

25

11

8

5

60

50

22

16

10

Table 3: Distribution of systemic manifestation in the Patients of HIV.

 

Discussion

Oral manifestations are common in HIV infected persons and usually are first indicator of progression to symptomatic disease.(11) Clinical feature ranges from asymptomatic to severe clinical illness and immunodeficiency.(12) It is seen that with the progression of disease, oral manifestation were more frequent & indicates poor prognosis. There is no pathognomic oral lesion associated with HIV-AIDS, but some like oral candidiasis are associated very frequently. Oral candidiasis is a predictor of HIV disease progression. Candida albicans is the main etiologic factor of oral candidiasis, although other species of candida may be seen. Candidasis was predominantly hyperplastic, erythematous and pseudomembranous types, this finding is similar to studies in Africa, eg in Kenya,(13) Zaire,(14) South Africa,(2) and Zimbabwe.(15) Erythematous candidiasis presents as red flat lesion on hard or soft palate, and on tongue. Pseudomembranous candidiasis presents as white curd like lesion on buccal mucosa and tongue. Angular cheilitis presents as redness, ulceration & fissuring along the mouth, in present study we have seen in about 36% of the present. Angular cheilitis occur with or without erythematous or pseudomembranous candidiasis.

Recurrent aphthous ulcer seen in 22% of the patient. They present as very painful ulcers  on labial, buccal mucosa, and soft palate. They present as minor, major or herpetiform aphthous. Minor ulcer usually heals without scarring, whereas in major ulcer scarring in common and and herpetiform present as crops of small lesion. Severe recurrent aphthous ulcer usually suggest HIV disease progression & seen when CD4+ lymphocyte is less than 100cells/ul.

Periodontal diseases are common in both asymptomatic & symptomatic HIV patients, usually seen as necrotizing ulcerative periodontitis & linear gingival erythema. It has sudden onset with loss of bone and soft tissue. In linear gingival erythema there is 2-3mm red band along marginal gingiva. In necrotizing ulcerative gingivitis there is ulceration sloughing & necrosis of one or more interdental papillae with rapid loss of soft tissue & teeth associated with pain, bledding & halitosis. Necrotizing ulcerative periodontitis is usually indicative of severe immune suppression, which presents as severe pain, teeth loss, bleeding, foul odour, rapid loss of soft tissue and bone.

Xerostomia may be a factor responsible for dental decay, it may be side effect of drugs or may be due to proliferation of CD8+ cells in salivary glands. Xerostomia occurs in the late course of disease.

However with the introduction of antiretroviral   treatment oral manifestations have markedly decreased.(16-18) With antiretroviral therapy oral candidasis, oral hairy leukoplakia, Kaposi’s sarcoma and HIV-associated periodontal. disease have reported to decrease,(19,20,21) in contrast HIV-salivary gland disease, human papilloma  virus (HPV)-associated oral lesions including papilloma, condylomas and focal epithelial hyperplasia, xerostomia & recurrent oral ulceration have increased.(20-22) Oral hairy leukoplakia can be diagnostic in absence of other identified cause of immunosuppression.(23) Reported prevalence of this lesion can be 42%,(24)  but in present study was only 2%.

Kaposi`s sarcoma has been seen in 15% of patients with AIDS(25) and many of these patients have oral lesion,(26) but in present study no case was found. Similar results have been seen in studies done in India,(27) which shows very low incidence in India with only nine case have been reported till date.

Patients with HIV may not have regular dentist checkup, so physicians must regularly examine patient of suspected HIV for oral manifestations and make strong working relationship with dentist to provide diagnostic insight & valuable treatment.

Conclusion

Almost all patients with HIV infection will contract oral diseases during the course of illness, and antiretroviral therapy had markedly decrease the oral manifestation. For reducing morbidity from HIV, early detection is necessary, therefore physicians must look for oral manifestation in suspected cases of HIV which aid in early diagnosis and treatment.

Author Affiliation

Dr. Lalit Shrimali. Assistant Professor, Dept. Of Medicine, Geetanjali Medical College And Hospital, Udaipur-313024, Rajasthan.

Acknowledgement : All Staff in the Dept. Of Medicine, Geetanjali Medical College And Hospital, Udaipur-313024, Rajasthan.

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Address For Correspondence

Dr Lalit Shrimali

Opposite B N College

Subhash Nagar Udaipur,

Rajasthan, India

Ph: 0091.9414166465

E-Mail: drlalitshrimali@yahoo.co.in

 


 

 

Source of Support: Nil, Conflict of interest: None declared.


 

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