Research Article A Study Of Oral Manifestation Of HIV/AIDS Lalit Shrimali

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1 International Journal of Oral & Maxillofacial Pathology. ;1(1):-1 Available online at 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 3-% 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 cases, 31(6%) were males and 19(3%) were females with an age range of to 9 years (mean=.6 years). While all the cases had periodontal disease, over 7% had candidiasis, xerostomia in %, lymphadenopathy in % and angular cheilitis was seen in % of the cases. Other conditions seen included persistent oral ulceration (%), oral hairy leukoplakia (%), herpes zoster (%), parotomegaly(%) and facial palsy(%). 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. ;1(1):-1. International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved. Received On: /9/ Accepted On: // According to the World Health Organization (WHO) report around 33. million people world wide are living with Acquired immune deficiency syndrome (AIDS) of which around 3. million are in India. Oral manifestations are seen in 3-% of the patients of HIV.(1-) Studies have shown that 9% of patients with HIV will have at least one oral manifestations during the course of disease.(3-) Oral manifestations can suggest, decreased cluster differentiated (CD+) T cell count,() and increased viral load,(6) which might also aid in diagnosis, progression, and prognosis of the disease.(7-) 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 patients were selected who were between ages of to 9 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.() 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.6 years (range -9 years). Age range 3-9 years constituted % of the study sample. 6% cases were male and 3% were female. % reported heterosexual contact as their route of HIV infection. Oral manifestations were recorded in 76% at the patients of which 7% had candidasis. 76% patients who had oral lesions, had discomfort maximum during tooth brushing, chewing & swallowing, dry mouth, burning International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved

2 A study of oral manifestation of HIV/AIDS 9 sensation especially on taking salty and spicy foods. (Table 1) Description Percent subjects Age (years) Gender Male: Female 31: 19 6:3 Mode of HIV infection Heterosexual Mother to child Unknown Oral lesion present Yes No Discomfort in the mouth Tooth brushing Chewing Swallowing Drinking Speaking 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 7% patients of which main variant was hyperplastic, erythematous and pseudomembranous types. Lymphadenopathy in % and angular cheilitis in % were noted. Xerostomia in %, recurrent aphthous ulceration in %, oral hairy leukoplakia in %, herpes zoster in %, parotomegaly in % and facial palsy in % were noted. Some subjects have more than one oral manifestation.(table ) Description 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 Table : Distribution of oral manifestations in the subjects Distribution of systemic manifestation in the patients of HIV were, 6% had chronic gastroenteritis, % presented with dysphasia, with resulting wasting and weight loss, % had respiratory tract infections, % had pulmonary tuberculosis and % had central nervous system manifestations comprising of chronic headache, confusion, loss of memory and cranial nerve paralysis. (Table 3) Description subjects Percent Chronic gastroenteritis Respiratory tract infection Dysphasia Pulmonary tuberculosis Central nervous system manifestation 3 6 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.() Clinical feature ranges from asymptomatic to severe clinical illness and immunodeficiency.(1) 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,(1) South Africa,() and Zimbabwe.(1) 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 % of the present. Angular cheilitis occur with or without erythematous or pseudomembranous candidiasis. Recurrent aphthous ulcer seen in % of the patient. They present as very painful ulcers on labial, buccal mucosa, and soft palate. They present as minor, major or

3 Lalit shrimali 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 CD+ lymphocyte is less than cells/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 -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 CD+ cells in salivary glands. Xerostomia occurs in the late course of disease. However with the introduction of antiretroviral treatment oral manifestations have markedly decreased.(-1) With antiretroviral therapy oral candidasis, oral hairy leukoplakia, Kaposi s sarcoma and HIV-associated periodontal. disease have reported to decrease,(19,,1) 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.(- ) Oral hairy leukoplakia can be diagnostic in absence of other identified cause of immunosuppression.(3) Reported prevalence of this lesion can be %,() but in present study was only %. Kaposi`s sarcoma has been seen in 1% of patients with AIDS() and many of these patients have oral lesion,(6) but in present study no case was found. Similar results have been seen in studies done in India,(7) 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-31, Rajasthan. Acknowledgement : All Staff in the Dept. Of Medicine, Geetanjali Medical College And Hospital, Udaipur-31, Rajasthan. References 1. Grando LJ, Yurgel LS, Machado DC, Nachman S, Ferguson F, Berentsen B, et al. The association between oral manifestations and the socioeconomic and cultural characteristics of HIVinfected children in Brazil and in the United States of America. Rev Panam Salud Publica 3;1:-.. Ceballos-Salobrena A, Gaitan-Cepeda LA, Ceballos-Garcia L, Lezama-Del Valle D.Oral lesions in HIV/AIDS patients undergoing highly active antiretroviral treatment including protease inhibitors: A new face of oral AIDS? AIDS Patient Care STDS ;1: McCarthy GM. Host factors associated with HIV-related oral candidiasis. A review. Oral Surg Oral Med Oral Pathol 199;73:-6.. Greenspan D, Schiodt M, Greenspan JS, Pindborg JJ. AIDS and the Mouth: Diagnosis and Management of Oral Lesions. Copenhagen: Munksgaard; Margiotta V, Campisi G, Mancuso S, Accurso V, Abbadessa V. HIV infection: oral lesions, CD + cell count and viral

4 A study of oral manifestation of HIV/AIDS load in an Italian study population. J Med 1999;: Ramirez-Amador V, Esquivel-Pedraza L, Sierra-Madero J, Anaya-Saavedra G, Gonzalez Ramirez I, Ponce-de-Leon S. The changing clinical spectrum of HIVrelated oral lesions in consecutive patients. A twelve year study in a referral centre in Mexico. Medicine 3;: Birnbaum W, Hodgson TA, Reichart PA, Sherson W, Nittayannanta SW, Axell TE. Prognostic significance of HIVassociated oral lesions and their relation to therapy. Oral Dis ;:1-.. Greenspan JS, Greenspan D. The epidemiology of the oral lesions of HIV infection in the developed world. Oral Dis ; : Glick M, Muzyka BC, Lurie D, Salkin LM. Oral manifestations associated with HIVrelated disease as markers for immune suppression and AIDS. Oral Surg Oral Med Oral Pathol. 199; 77:3-9.. The status and Trends of Global HIV/AIDS pandemic. Official satellite symposium: final Report, july -6, 1996:1-31. Zakrzewska JM, Robinson P, and Williams IG. Severe oral ulceration in patients with HIV infection a case series. Oral Dis. 1997;3 (suppl l): S Porter S, and Scully C. HIV: the surgeon`s perspective Part. Diagnosis and management of non malignant oral manifestations. Br J Oral Maxillofac Surg 199; : Butt FM, Chandia ML, Veghela VP, Mandalia K. Oral manifestations of HIV/AIDS in Kenyan provincial hospital. East Afr Med J. 1999; 7: Tukutuku K, Muyembe Tamfum L, Kayembe K et al. Oral manifestations of AIDS in a herosexual population in a Zaire hospital. J Oral Pathol Med.199; 19:-. 1. Jonsson N, Zimmemen M, Chidzonga MM, Jonsson K. Oral manifestations in Zimbabwean HIV/AIDS patients referred to a specialist center. Cent Afr J Med. 199;:31-.. Ceballos Salobreoa A, Gaitan Cepeda LA, Ceballos Garcia L, Lezama del valle D. Oral lesions in HIV/AIDS patients undergoing highly active antiretroviral treatment including protease inhibitors. A new face of Oral AIDS? AIDS Patient care STDS.;1: Grando LJ, Yurgel LS, Machado DC, Nachman S, Ferguson F, Berentsen B et al. The association between oral manifestations and the socioeconomic and cultural characteristics of HIV infected children in Brazil and the United States of America. Rev Panam Salud Publica.3;1:-. 1. Patton LL. McKaig R, Strauss R, Rogers D, Eron JJJ. Changing prevalence of oral manifestations of human immunodeficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endo.; 9: Greenspan D, Gange SJ, Phelan JA, Navazesh M, Alves ME, MacPhail LA et al. Incidence of Oral lesions in HIV-1- infected women : reduction with Haart. J Dent Res. ;3:1-.. Schmidt-Westhausen AM, Priepke F, Bergmann FJ, Reichart PA. Decline in the rate of oral opportunistic infections following introduction of highly active antiretroviral therapy. J oral pathol Med ;31: Ramirez Amador V, Esquivel-pedraza L, Sierra-Madero J, Anaya-Saaverda G, Gonzalez-Ramirez I, Ponce-de-leon S. The changing clinical spectrum of human immunodeficiency Virus {HIV} - related oral lesions in 1, consecutive patients. A 1 year study in a referral Center in Mexico. Medicine [Baltimore] 3;:39-.. Shetty K, Leigh J. The Changing Face of Oral Lesions in HIV/AIDS. Patients Undergoing Highly Active antiretroviral Treatment. AIDS Patient Care STDS ;1: Hollander H, Greenspan D, Stringari S, Greenspan J, Schiodt M. Hairy leukoplakia and the acquired immunodeficiency syndrome [letter]. Ann Intern Med. 196;:9.. Lifson AR, Hilton JF, Westenhouse JL, canchola AJ, Samuel MC, Katz MH, et al. Time from seroconversion to oral candidasis or hairy leukoplakia amoung homosexual and bisexual men enrolled in three prospective cohorts. AIDS. 199;: Beral V, Peterman TA, Berkelmann RL, Jaffe HW. Kaposi`s sarcoma among

5 1 Lalit shrimali persons with AIDS: a sexually transmitted infection? Lancet. 199;33: Keeney K, Abaza N, Tidwel O, Quinn P. Oral Kaposi`s sarcoma in acquired immune deficiency syndrome. J Oral Maxillofac surg. 197; : Kura MM, Khemani UN, Lanjewar DN, Raghuwanshi SR, Chitale AR, Joshi SR. Kaposi`s sarcoma in a patient with AIDS. J Assoc Physicians India ;6:6-. Address For Correspondence Dr Lalit Shrimali Opposite B N College Subhash Nagar Udaipur, Rajasthan, India Ph: drlalitshrimali@yahoo.co.in Source of Support: Nil, Conflict of interest: None declared.

Oral Health & HIV. Professor Sudeshni Naidoo Department of Community Dentistry University of the Western Cape

Oral Health & HIV. Professor Sudeshni Naidoo Department of Community Dentistry University of the Western Cape Oral Health & HIV Professor Sudeshni Naidoo Department of Community Dentistry University of the Western Cape Importance & relevance of Oral HIV Lesions >70% of HIV+ve patients present with oral manifestations