J ORAL MANIFESTATIONS OF HIV INFECTION/AIDS AND THEIR INFLUENCE ON ORAL FUNCTIONS AND ORAL HYGIENE PRACTICES AMONG ADULT PATIENTS IN KENYATTA NATIONAL HOSPITAL COMPREHENSIVE CARE CENTRE. INVESTIGATOR: GIKUNDA MARY KATHURE SUPERVISORS, I INTERNAL: Dr.MACIGO FG BDS, MPH, PGD-STI ~rb) PEPARTMENT OF PERlODONTOLOGY, COMMUNITY AND PRBVENTIVE DENTISTRY.. SCHOOL OF DENTAL SCIENCES //~~;1;\\ UNIVERSITY OF NAIROBI.," \',0': '\ \ --".: C ~', f\ ~ -v -,---,) \ ' \\~ \ " o,., --:~ \ i' --- f '\\'1!' \ _,fj EXTERNAL: DR WAKOLI (Nrb), M MED \ 'i r,'~.' ';.',) DEPARTMENT OF ORAL AND MAXILLOFACIAL Sl~~.GERY, ORAL'" PATHOLOGY AND ORAL MEDICINE ", '\ \ UNIVERSITY OF NAIROBI. '., A COMMUNITY DENTISTRY PROJECT PROPOSAL SUBMITTED IN FULFILMENT OF THE DEGREE OF BACHELOR OF DENTAL SURGERY AT THE UNIVERSITY OF NAIROBI 2008. DURATION OF THE STUDY: JUNE-OCTOBER 2008 COST OF STUDY; 9400KSH SOURCE OF FUNDS: SELF
Title TABLE OF CONTENTS page Table of contents ii Abbreviati ons.iii Summary 1 Introduction and Literature review 2 Problem statement. 5 Justification of study 5 Objectives 6 Methodology 7 Study area 7 Study population 7 Study design 7 Sample size determination 7 Sampling method 8 Inclusion criteria 8 Exclusion criteria 8 Data collection 8 Minimizing errors 8 Data analysis 9 Data presentation 9 Ethical consideration 9 Limitations 9 Expected benefits 9 Budget 10 References 14 Appendix 1 12 Appendix II 15 Appendix 111. 16 11
ABBREVIA nons HIV-Human immunodeficiency virus AIDS-Acquired immune deficiency syndrome. TASO- The AIDS Support Organization CCC-Comprehensive Care Centre. WHO- World Health Organisation iii
SUMMARY Oral lesions are common in individuals with HIV infection and thus a detailed oral examination is an important part of the regular physical examination. Early recognition and treatment of these oral lesions may reduce morbidity oral hygiene practices and functions. as well as enhance patients' Oral lesions cause significant poor oral hygiene and limits oral functions, yet most are readily treated. They may be the first clinical features ofhiv infection and lead to its diagnosis. Their presence is an indication of immunodeficiency and predicts the progression of the HIV disease. Few studies have been conducted in Kenya regarding the prevalence of oral manifestations ofhiv infction/aids and their effect on oral hygiene practices and oral functions in adult patients in Kenya. The aim of this study is to determine the prevalence of different oral lesions in. HIV/ AIDS adult patients in Kenyatta national hospital and how they affect oral health and oral functions of the patients. This will be a descriptive cross-sectional study using a systematic random sampling method on patients between 18 and 65 years who are HIV sero positive. A sample size of60 subjects will be used. Clinical examination with theoretical and clinical knowledge will be used to diagnose the oral lesions. Questionnaires will be used to collect data on oral hygiene practices and oral functions. Data analysis will be done by use of packages SSPS and MS EXCEL. The means and percentages of the variables will be computed. Data will be presented in form of tables charts graphs and text. The benefits of the study include knowledge of oral lesions and thus early diagnosis and treatment which will improve the quality of life of the patients. This project will be submitted in partial fulfillment of requirements of bachelor of dental surgery in the University of Nairobi.
1.0 INTRODUCTION AND LITERATURE REVIEW HIV infection causes ~IDS, which stands for acquired immunodeficiency syndrome (HIV), which is human immunodeficiency virus. The virus damages cells of the body immune system. HlV continues to be one of the most important communicable diseases in Kenya. It causes serious morbidity, significant mortality and the loss of high numbers of potential years of life, despite considerable advances in life-prolonging treatment that have led to a substantial reduction in the number of HI V -related deaths in Kenya. Gratifyingly, HIV infection is now highly treatable. It is increasingly managed as a chronic disease, and many more patients survive for long periods. Currently, nearly fifty thousand people are infected with the human immunodeficiency virus in Kenya. The numbers of those infected continue to rise. Each year, many thousands of individuals are newly diagnosed as infected. Yet estimates suggest that almost a third of patients with HIV remain undiagnosed - many of whom will be using Primary care. HIV infection is a major global health problem affecting developing and developed countries alike. Oral manifestations of the HIV disease are common and include oral lesions and novel presentations of previously known opportunistic diseases. Careful history taking and detailed examination of the patient's oral cavity are important parts of the physical examination, and diagnosis requires appropriate investigative techniques. Early recognition, diagnosis, and treatment of HIV -associated oral lesions may reduce morbidity. 2
A study was done in Tanzania by Petersen et ai. Muhimbili University, Tanzania and Hilbert of Muhimbilli National Hospital, Tanzania 2007. The aim of this study was to investigate the awareness of the oral manifestations ofhivi AIDS and oral hygiene practices among people living with HN (PLHIV) in Dar es Salaam, Tanzania. A structured questionnaire was used to collect information from 187 participants chosen by convenience sampling from NGOs supporting PLHN. 13.4% of the participants were completely unaware of the oral manifestations ofhn/aids whereas all participants were fully aware of general symptoms of AIDS. There were no significant associations between awareness of oral manifestations and oral hygiene practices among the participants. Participants were relatively well aware of the different types of oral manifestations (e.g. oral ulcers 87%, oral candidiasis 84%) while their knowledge of the management of specific oral manifestations and the problems associated with oral manifestations was more limited? A prospective study in Coast Province General Hospital in Mombasa, Kenya, by Butt et al to clinically evaluate and document the range and pattern of oral lesions in a group of hospitalised patients with HIV -infection. Examination of all the cases included in the study was performed according to the WHO criteria. Where indicated incisional biopsy was performed to confirm the clinical diagnosis of the relevant lesions. In collaboration with the medical team, treatment was administered as per the needs of the patient in terms of anti-fungals, antivirals or topical cortisteroids. Results: Of the 61 cases, 25(41 %) were males and 36(59%) females with an age range of 19 to 65 years (mean = 34.7years), While all the cases had periodontal disease, over 80% had candidiasis of the hyperplastic, erythematous and pseudomembraneous types. Lymphadenopathy and angular cheilitis were each diagnosed in 27.9% of the cases; while oral Kaposi's sarcoma was seen in 13% of the patients. Other conditions seen included persistent oral ulceration (11.5%), oral hairy leukoplakia and herpes zoster each constituting 4.9%; herpes simplex, mucosal hyperpigmentation, parotomegaly and facial palsy each comprised six per cent and oral warts seen in one case. 3
In accordance with the pattern and prevalence of oral manifestations in the study, the results were largely consistent with those documented elsewhere. For the alleviation of the morbidity arising from the commonly occurring lesions, early detection is mandatory. Furthermore, documentation of the varied regional patterns of occurrence of these lesions may aid in the rational application of the emerging treatments.' A study in Uganda by Kampala international university, dentistry department on clients visiting T ASO clinics had the objective to establish the prevalence of oral manifestation and their influence on oral functions. A total of 514 individuals aged between 18 to 58 years were randomly recruited from the AIDS Support Organization clinics in Uganda. They were clinically examined for oral lesions under field conditions. Women constituted 74.5% of the study. Oral manifestations were recorded in 72% of the subjects among whom 70% had candidiasis of pseudo membranous, erythematous, and angular cheilitis variants. Non-Hodgkins lymphoma, atypical ulcers, necrotizing periodontitis, and hairy leukoplakia were least frequently observed in the subjects. Of those who had oral lesions, 68.4% had some form of discomfort in the mouth. Tooth brushing, chewing, and swallowing were frequently associated with discomfort. Reported forms of discomfort were dry mouth, increased salivation, and burning sensation especially on taking salty and spicy foods or acidic drinks. Only 8.5% of the subjects were taking medications specifically for oral lesions, which included antifungal, antiviral, and antibacterial agents. None of the subjects were on antiretroviral therapy. It was concluded that Oral lesions associated with HIV infection/aids in T ASO clients were a major public health problern : requiring education in recognition and appropriate management." A study was done by Brown JB, et al. in Malawi to evaluated the health effects of routine and intensified dental care and disease prevention in persons who were HIV positive. 4
The study involved 376 HIV-infected persons aged 19 to 61 years with CD4 counts between 100 and 750 into a year-long two-arm randomized controlled trial. Control group subjects (n = 185) received professional dental protective treatment and checkups at baseline, 6 months, and I year, plus dental care. Enhanced care patients (n = 191) received bimonthly protective treatment and twice-daily chlorhexidine mouth rinses to treat gingivitis. Active decay, gingivitis, oral pain, impact of oral health on functioning, and global functional status improved in both groups. The mean depth of periodontal pockets decreased 0.18 mm (control group) versus 0.27 mm (enhanced group) (p < 0.04), as did an erythema index (-1.22 versus -1.78, p < 0.01). No effects on AIDS-related complications, symptoms, or mortality were observed. It was concluded that access to dental screening, prophylaxis, and repair will significantly improve oral health, functioning and quality of life in persons with AIDS 5 The oral manifestations ofhiy infection/aids include oral candidiasis, which is frequently observed in the earliest stages ofhiv infection. It affects more than 30% of HlY -positive individuals and is seen in more than 90% of AIDS patients. Other oral lesions seen among AIDS patients include linear gingival erythema, necrotizing ulcerative periodontitis, stomatitis, gingivitis, oral hairy leukoplakia, herpes simplex virus infection, cytomegalovirus ulceration, human papilloma virus infection, recurrent aphthous ulcers, and HIV salivary gland disease. Oral lesions that are associated with this disease are important, since they affect the patient's oral hygiene practices and oral functions and are useful markers of disease progression and immunosuppressions This study will thus provide important information on oral manifestation of HIY infection/aids and their effect on oral functions and health. This will help the ministry of health to plan on provision of dignostic facilities and appropriate medication to improve patient's quality oflife. 5
2.0 PROBLEM STATEMENT,JUSTIFICATION AND OBJECTIVES. 2.1 STATEMENT OF THE PROBLEM HJV infection/aids is one of the major killer diseases in the world today. Oral lesions form one of the factors that contribute to early deaths. This follows the patient's inability to carry out their oral functions such as eating, breathing and self expression. There is also a major influence on the patients' ability to carry out oral hygiene practices which in turn predispose patients to other oral pathologies like caries and periodontitis. Documented studies show a change in pattern of mortality rate with early diagnosis of the oral lesions. The patient's oral hygiene practices also are improved when the management HIV infection/aids is done early on early diagnosis. There has also been shown an improvement in the performance of oral functions like eating. Many Kenyans are living with HIV infection/aids today. Oral lesions associated with HIV infection/aids have not been extensively studied in Kenya. 2.2 JUSTIFICATION OF THE STUDY.. A study on the oral lesions in Hl V infections/aids and their influence on oral hygiene practices and oral functions of the patients will help in designing programmes to improve the quality oflife of the patients as well as reduce their mortality rate. Early treatment of the oral lesions will enable them carry out oral functions comfortably and be in a position to maintain good oral hygiene. This will consequently reduce pressure on resources available for oral health. 6
2.3 OBJECTIVES 2.31 General objectives To describe the pattern of oral lesions and their influence on oral hygiene practices and functions among HIV infection/aids patients attending the Kenyatta National Hospital Comprehensive Care Centre. 2.32 SPECIFIC OJECTIVES 1. To describe the pattern of oral lesions among HIV/AIDS patients. 2. To assess the extent to which the oral lesions affect oral functions. 3. To assess the extent to which the oral lesions affect oral hygiene practices among the patients. 2.4 HYPOTHESIS 70% of HIV/AIDS patients have reduced frequency of brushing. 60% of the patients have difficulty in carrying out oral functions e.g chewing opening of the mouth, swallowing and talking. 2.5 VARIABLES 2.51 Socio-demographic Age Gender 2.52 Independent variables Candidiasis Pseudomembranous candidiasis Angular cheilitis Oral hairy leukoplakia Kaposi's sarcoma 2.53 Dependent variables Oral hygiene practices: Frequency of tooth brushing Oral functions: Eating, talking. 7