Orofacial and systemic manifestations in 212 paediatric HIV patients from Chennai,South India

International Journal of Paediatric Dentistry 2010; 20: 276–282 Background. Lesions in the mouth and in other tissues and organs (oral and systemic lesions) in paediatric HIV infection are diverse and show differences in clinical presentation and severity from that of adults. Very little data exist for oral lesions in paediatric population in India. Aim. To document and study oral and more widespread lesions in paediatric HIV seropositive patients. Design. A cross‐sectional study. Setting. Paediatric HIV seropositive patients at tertiary centers: Ragas Dental College and Hospital and YRG CARE, Chennai, India. Patients and methods. Two hundred and twelve paediatric HIV patients aged 0–14 years seen over a period of 1 year were included in the study. Clinical history, oral and systemic examinations were recorded by qualified dental surgeons and physicians. Results. One hundred and thirty‐two patients had oral lesions ranging in number from one to three. Oral lesions included oral candidiasis (OC) (56.1%), gingivitis (10.8%), oral pigmentation (6.1%), depapillation of the tongue (5.7%), ulcers (4.2%), and oral hairy leukoplakia (1.4%). The most common systemic lesion observed was nonspecific lymphadenopathy (74.1%) followed by pruritic eruptions (53.8%), measles (51.4%), and tuberculosis (TB) (49.1%). Thirty‐three (26%) patients were not immunosuppressed, 74 (58%) were moderately immunosuppressed, and 20 (15%) were severely immunosuppressed. Oral lesions exhibited positive correlation with lesions in other parts of the body. Conclusion. Oral lesions are a common feature in paediatric HIV infection. Their management is vital to improve the quality of life of the infected children.     

HIV infection: clinical features and treatment of thirty-three homosexual men with Kaposi's sarcoma.

The clinical findings of patients with oral Kaposi's sarcoma are reviewed. These oral findings commonly included candidiasis, hairy leukoplakia, gingivitis associated with human immunodeficiency virus (HIV), periodontitis, and other symptoms, including xerostomia. The other common symptoms of HIV disease that may be of importance in leading to a diagnosis are reviewed in this patient group. Treatment by local radiotherapy or by intralesional vinblastine of these oral Kaposi's sarcomas resulted in successful palliation, with more than 50% regression of the lesions in 80% of the patients treated.     

Oral manifestations of AIDS: an overview

Infection with the human immunodeficiency virus (HIV) may cause a variety of oral lesions, such as candidiasis, periodontal disease, hairy leukoplakia, Kaposi's sarcoma and a number of miscellaneous lesions and conditions. One hundred HIV-infected patients, including AIDS patients, referred to a University Hospital in Amsterdam, were examined orally. Most patients were initially seen by the Department of Internal Medicine, the oral examination by a well-trained dentist being part of the routine screening of all HIV-infected patients. In 80 per cent of all patients one or more HIV-related lesions of the oral mucosa was recorded. In 6 per cent of those patients the oral lesion was the first manifestation of the HIV infection. Hairy leukoplakia was observed in 15 per cent of all patients. Candidiasis proved to be the most common oral disease. In patients with full-blown AIDS the pseudomembranous form of candidiasis was the most common one, while in HIV-infected patients the erythematous type prevailed. These results emphasize the role of the dentist in making an early diagnosis of HIV infection.     

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.     

Prevalence of oral lesions among HIV-infected intravenous drug abusers and other risk groups

To study the prevalence of oral manifestations, we examined 217 patients infected with the human immunodeficiency virus (HIV). Most of our patients were intravenous drug abusers (IVDAs) (65%). Other risk categories were represented by IVDAs who were also male homosexuals or bisexuals (11%), male homosexuals and bisexuals (16%), sexual partners of HIV-infected patients (5%), and hemophilic persons and recipients of blood transfusions (3%). Forty-six patients were women and 171 were men, with a median age of 27 years (range, 11 to 65 years). At the time of first examination, 38% of patients had asymptomatic HIV infection, 36% had lymphadenopathy syndrome, 17% had AIDS-related complex, and 9% had AIDS. Oral manifestations were observed in 89 (41%) patients. Of these, 15 had asymptomatic infection, 23 had lymphadenopathy syndrome, 27 had AIDS-related complex, and 24 had AIDS. Increasing severity of disease was significantly associated with higher prevalence of oral lesions (p less than or equal to 0.0001). Candidiasis was the most common oral lesion, followed by hairy leukoplakia. Kaposi's sarcoma, melanotic macules, herpes labialis, condyloma acuminatum, perioral molluscum contagiosum, and bacterial glossitis due to Escherichia coli infection were found in a small number of patients. Results of culture for fungi, available for 203 patients, revealed that 51% of patients with positive Candida cultures had clinical evidence of candidiasis. Our study demonstrates that oral lesions are also important signs of HIV infection among IVDAs. Early diagnosis of these manifestations is becoming increasingly significant in the practice of dentistry.     

Gingival lesions of HIV infection in 178 Greek patients.

One hundred seventy-eight HIV-infected Greek patients were examined and the gingival lesions were recorded. At the time of oral examination, 77 patients were HIV positive, 53 had ARC, and 48 had AIDS. The mean age of the patients was 36.6 years; 158 were men and 20 were women. Fifteen different gingival lesions were recorded. Necrotizing gingivitis (10.1%), gingivitis (5.0%), periodontitis (18.5%), candidiasis (5.8%), and Kaposi's sarcoma (5.0%) were the most common lesions observed. Oral lymphomas and other lesions were recorded in low numbers. Our findings show that dentists should be aware of gingival lesions of HIV disease because some of them are common and diagnostically important.     

Oral manifestations of HIV infection in 600 South African patients

Arendorf TM, Bredekamp B, Cloete CAC, Sauer G: Oral manifestations of HIV infection in 600 South African patients. J Oral Pathol Med 1998; 27: 176-9. C Munksgaard, 1998. Oral lesions associated with HIV infection, as classified by the EC-Clearinghouse on Oral Problems related to HIV infection and the WHO Collaborating Centre on Oral manifestations of the immunodeficiency virus, were studied in 600 consecutive HIV-infected patients in Cape Town, South Africa. One or more lesions were seen in 60.4% of cases. Combined candidal lesions were evident in 37.8%, hairy leukoplakia in 19.7% and combined gingival/periodontal lesions in 8.5% of patients seen. Lesions less commonly recorded include oral ulceration (2.9%) and Kaposi's sarcoma (1.5%). The clinical range of lesions seen is similar to those reported elsewhere, but socio-cultural differences allowed no reliable comparison. More than a quarter of our patients had oral soft tissue discomfort necessitating treatment; in 3.3% these were the presenting symptom. This indicates a potential major public health concern requiring education in recognition and appropriate referral and management.     

Oral manifestations in HIV/AIDS infected patients from India

OBJECTIVES: To assess types and prevalence of HIV-related oral lesions among HIV-infected individuals in south India and to correlate common oral findings with co-morbidities, gender, age and medication. SUBJECTS AND METHODS: One hundred and one patients with HIV infection or AIDS at infectious diseases units of Attavar Hospital, Mangalore, and medical wards of Kasturba Medical College, Manipal, were selected. Sociodemographic information was obtained using a structured questionnaire. Oral lesions were diagnosed according to the presumptive criteria of EEC-Clearinghouse Classification. Clinical history was retrieved from patient's medical records. RESULTS: Erythematous candidiasis (44.5%), melanotic hyperpigmentaion (34.6%) and xerostomia (29.7%) were among the most common oral manifestations. A significant association was found between oral candidiasis and advanced immunosuppression (P < 0.05). Oral hairy leukoplakia (OHL) was predominant in individuals <35 years (P < 0.05). Melanotic hyperpigmentation was significantly associated with highly active antiretroviral therapy (P < 0.05). OHL was more frequent in patients with HIV-associated tuberculosis. Linear gingival erythema was more predominant in females. CONCLUSIONS: Oral hairy leukoplakia showed a positive relationship with patients younger than 35 years. Oral candidiasis can act as a marker for immunosuppression. Angular cheilitis was predominant in the symptomatic stage.     

Oral lesions as indicators of HIV infection among routine dental patients in Lagos, Nigeria

OBJECTIVES: To document the incidental oral lesions of human immunodeficiency virus (HIV) infection, the pattern and frequency of the lesions based on clinical presentation and oral manifestations in routine dental patients who tested positive in Nigeria. SUBJECTS AND METHODS: The study was conducted at the Oral Diagnosis/Oral Medicine clinic of the Lagos University Teaching Hospital, Lagos, Nigeria between May 2002 and April 2003. During this period, all patients with oral lesions suggestive of HIV/acquired immunodeficiency syndrome (AIDS) as described in the EEC-WHO Classification and diagnostic criteria of oral lesions of HIV were counseled and offered voluntary HIV testing. All the 35 patients who consented and tested positive were included in this study. RESULTS: Of a total of 700 patients 53 patients with oral lesions suggestive of HIV/AIDS were seen, thirty-eight (72%) consented to HIV screening, 15 patients (28%) refused. Thirty-five patients (92%), mean age 36 +/- 13 years were confirmed positive for HIV. Oral candidiasis was the commonest lesion seen (43%) the second common being Herpes zoster (23%). Other lesions seen included erythema multiforme in two (6%), facial palsy in two (6%) and oral hairy leukoplakia in one (3%). CONCLUSION: An oral mucosal lesion may be the presenting lesion of HIV/AIDS in routine patients attending the dental clinic. Oral health care workers should practice optimal infection control based on the Centers for Disease Control 'Standard Precautions' guidelines on infection control for all patients to minimize occupational transmission of HIV.     

Oral manifestations in 45 HIV-positive children from Northern Thailand

Forty-five Northern Thai children with HIV infection or AIDS were examined for oral manifestations. Of these children, 51.1% (n=23) were asymptomatic (category N), 48.9% were mildly, moderately or severely symptomatic (category A, B, C) and 48.9% (n=22) revealed oral lesions. Eleven patients (24.4%) showed one oral lesion, eight (17.8%) had two and three (6.6%) had three oral lesions. Erythematous candidiasis was the most common lesion (17.8%). Oral hairy leukoplakia was seen in 6.7% (n=3). Geographic tongue, not usually considered to be associated with HIV infection, was seen in 6.7% (n=3). Only 15 patients (33.3%) received antiretroviral therapy (ART). Comparison of patients with or without ART did not show differences in the prevalence of oral lesions. More studies in Thai HIV-infected children are needed to reveal the prevalence of oral manifestations, as well as for the predictive value of the most common or specific oral manifestations.     

Prevalence of orodental findings in HIV-infected Romanian children

BACKGROUND: Romania, the pediatric AIDS capital of the world, has tremendous unmet dental care needs for children and adolescents with HIV infection. The purpose of this study was to assess the prevalence of orodental conditions in symptomatic HIV-positive children from Constanta, Romania. METHODS: The children underwent dental examinations and treatment at Constanta Municipal Hospital by a volunteer team of dental healthcare professionals from the United States. Oral lesions and dental caries were recorded during an 8-day period prior to initiating comprehensive dental care. RESULTS: The study population consisted of 173 children (88 males; 85 females) with a mean age of 8.8 years (range 6 to 12 years). The primary HIV risk factor was contaminated needle reuse and/or blood products (88%). The most common oral and perioral lesions included: candidiasis (29%), ulcers (15%), salivary gland disease (9%), necrotizing ulcerative gingivitis/periodontitis (5%), linear gingival erythema (4%), labial molluscum contagiosum (3%), oral warts (2%), hairy leukoplakia (2%), and herpes zoster (1%). One or more oral/perioral lesions occurred in 55% of the children. Severe dental caries was noted in the majority of children (dfs/dft 16.9/3.7 and DMFS/DMFT 8.1/3.1). Over-retention of primary teeth (25%) and delayed eruption (42%) were common. Postoperative complications included delayed clotting (common) and thrombocytopenia-induced bleeding disorders (4%). CONCLUSIONS: The oral healthcare needs of Romanian HIV-infected children are considerable, with the majority living with persistent, symptomatic oral disease.     

Classification, diagnostic criteria, and treatment recommendations for orofacial manifestations in HIV-infected pediatric patients. Collaborative Workgroup on Oral Manifestations of Pediatric HIV Infection

The criteria for diagnosis of HIV-related oral lesions in adults are well established, but corresponding criteria in the pediatric population are not as well defined. The Collaborative Workgroup on the Oral Manifestations of Pediatric HIV infection reached a consensus, based upon available data, as to the presumptive and definitive criteria to diagnose the oral manifestations of HIV infection in children. Presumptive criteria refer to the clinical features of the lesions, including signs and symptoms, whereas definitive criteria require specific laboratory tests. In general, it is recommended that definitive criteria be established whenever possible. Orofacial manifestations have been divided into three groups: 1) those commonly associated with pediatric HIV infection; 2) those less commonly associated with pediatric HIV infection; and 3) those strongly associated with HIV infection but rare in children. Orofacial lesions commonly associated with pediatric HIV infection include candidiasis, herpes simplex infection, linear gingival erythema, parotid enlargement, and recurrent aphthous stomatitis. In contrast, orofacial lesions strongly associated with HIV infection but rare in children include Kaposi's sarcoma, non-Hodgkin's lymphoma, and oral hairy leukoplakia. Treatment recommendations, specific for this age group, have been included for some of the more common HIV-related orofacial manifestations.     

Oral candidiasis and hairy leukoplakia correlate with HIV infection in Tanzania

We report a detailed study on oral lesions and their association with the WHO revised provisional case definition of AIDS as well as serologic signs of HIV infection among 186 patients in Dar Es Salaam, Tanzania. The patient material consisted of 39 hospitalized suspected AIDS patients, 44 medical nonsuspected patients, 53 dental outpatients, and 50 patients with sexually transmitted diseases. The male:female ratio was 2.1:1 on average. Oral examination was done without knowledge of the HIV status of the patients. Among 39 suspected AIDS patients 97% had WHO AIDS criteria and 90% were seropositive for HIV. Among the 147 patients not suspected of having AIDS 18 (12%) had AIDS criteria and 15% had serologic evidence of HIV infection. The presence of WHO AIDS criteria correlated significantly with the presence of HIV antibodies, but not with HIV antigen. Oral lesions were found in 54% of those with AIDS criteria and 52% of HIV-infected patients, as compared to 3% and 6% of the patients without AIDS criteria and HIV infection, respectively (p less than 0.01). Among patients with AIDS atrophic candidiasis occurred in 21%, pseudomembranous candidiasis in 23%, hairy leukoplakia in 36%, herpetic stomatitis in 2%, Kaposi's sarcoma in 4%, and nonspecific ulcer in 4%. The presence of oral lesions had a high predictive value for presence of AIDS criteria as well as for presence of HIV infection in this hospital setting. All patients should have a thorough oral examination and the presence of the aforementioned oral lesions should lead to testing for HIV infection.     

Oral manifestations in 101 Cambodians with HIV and AIDS.

BACKGROUND: The HIV/AIDS epidemic in Cambodia has become a major problem in the last 7-8 years, mainly because in this formerly war-stricken country the socioeconomic situation is only slowly improving. Since only very few studies have been published to date on the oral health status of Cambodian HIV/AIDS patients, it was the purpose of the present investigation to study oral manifestations in Cambodian patients with HIV disease. METHODS: One hundred one Cambodian patients with HIV infection or AIDS were examined for the presence of oral manifestations in one medical center in Phomh Penh, Cambodia. RESULTS: Sixty-three men and 38 women with a median age of 32 years were examined (age range 7.5-63.5 years). Of these patients, 42.6% were smokers, 46.5% of men were heavy drinkers and 90.5% of men were promiscuous compared with 5.3% of women. The most frequent AIDS-defining diseases were wasting syndrome (54.5%), Pneumocystis carinii pneumonia (PcP) (19.8%) and tuberculosis (18.8%). Puritic papular eruption, a common cutaneous manifestation in HIV-infected patients, was seen in 17.8% of patients. Candida-associated infections of the oral cavity were most common. Among the patients, 52.5% revealed pseudomembranous candidiasis and 35.6% had bilateral hairy leukoplakia. Only 10% of patients had no oral lesions. Also common were necrotising ulcerative gingivo-periodontal diseases (27.7%). CONCLUSION: The general health status of 101 Cambodian patients with HIV infection and AIDS was poor, and they demonstrated a large number of oral manifestations. Antiretroviral therapy is presently not available and only a fraction of patients receives antimycotic treatment (25.7%). HIV infection and the AIDS epidemic in Cambodia have become a serious problem and patients urgently need adequate diagnosis and antiretroviral therapies.     

Dental and oral lesions in HIV infected patients: a study in Brazil

AIM: To determine the prevalence of dental and oral lesions, as well as treatment need, in a group of HIV sero-positive Brazilians. In addition, to test the association between oral manifestation of HIV infection and age, sex, mode of transmission and drug therapy. METHOD: All HIV seropositive patients attending a dedicated dental clinic in Recife were invited to participate in the study. They were all examined by one trained and calibrated examiner and interviewed by one trained interviewer. RESULTS: 161 of 204 patients (78.9%) agreed to participate in this study. Most of the participants were male (76%), had acquired HIV sexually (74.5%), and were taking some form of antiretroviral therapy (70.8%). 33.5% had one or more oral manifestation of HIV. Candidiasis was the most common (28.6%), followed by hairy leukoplakia (9.3%), Kaposi sarcoma (2.5%), ulceration (2.5%), herpes simplex (1.2%), papiloma (0.6%), and 4.4% had periodontal disease. Only 1.2% reported xerostomia. There were no differences in the prevalence of oral manifestations of HIV infection between age groups, sexes, modes of transmission and types of drug therapy (P>0.05). The mean DMF-T score was 19 (SD 8) and 78.9% needed some form of dental treatment. CONCLUSIONS: While the prevalence of oral manifestations of HIV/AIDS was low in this sample of HIV seropositive Brazilians, dental status was poor and need for dental treatment was high.     

Oral manifestations associated with human immunodeficiency virus infection in a Spanish population

A study was made of the oral manifestations in 396 patients with human immunodeficiency virus (HIV) infection. The following risk groups were established: intravenous drug users (79.5%), homosexuals (7.8%), homosexual intravenous drug users (3.3%). heterosexuals (8.1%) and hemophiliacs/transfusion patients (1.3%). The oral lesions, in decreasing order of frequency, were: periodontal disease (78.28%). candidiasis (65.65%). hairy leukoplakia (16.16%). herpes simplex virus lesions (5.30%), Kaposi's sarcoma (2.27%), recurrent aphthous ulceration (RAS) (1.01%), lichen planus (0.5%), non-Hodgkin's lymphoma (0.25%). tuberculous lesion of the tongue (0.25%) and ulcerations of uncertain etiology (0.25%). Attention is drawn to the greater predominance of these lesions in patients with CD4 values of less than 200/mm³, compared with those who have higher lymphocyte counts.     

Oral mucosal Langerhans'' cells as target, effector and vector in HIV infection

The mechanism underlying a transition of the oral cavity mucosal epithelium towards susceptibility to opportunistic infections in HIV-seropositive patients was investigated. Phenotypic markers CD1a, HLA-DR, and CD86 of oral mucosal Langerhans' cells (LCs), p17 core protein of human immunodeficiency virus (HIV), and CD45RO of memory T cells were labeled on oral hairy leukoplakia lesional biopsies and clinically normal autologous tissue of HIV-infected patients. HIV p17 protein was detected in association with mucosal LCs, mainly within the lesional epithelium. There were significant correlations between the detection of HIV p17 and the depletion of LCs, and between the depletion of LCs and the presence of hairy leukoplakia lesions. Conjugates of activated LCs and memory T cells were also evident in the submucosal area of lesional biopsies. The findings from this study support the hypothesis that oral mucosal LCs are also the target of HIV infection. Cytopathic changes of LCs caused by productive HIV infection may contribute to selective depletion of LCs, which may impair the mucosal immunologic protection against colonization by microorganisms causing HIV-associated oral mucosal lesions.     

Oral HIV lesions and oral health behaviour of HIV-positive patients attending the Queen Elizabeth II Hospital, Maseru, Lesotho.

AIM: The aim of the study was to determine the prevalence of oral mucosal lesions strongly associated with HIV infection and to assess the oral health behaviour among patients attending Queen Elizabeth II Hospital in Maseru. The objectives were: (i) to determine the prevalence of group 1 lesions in HIV-positive patients according to the ECC/WHO classification; (ii) assess the oral hygiene practices of these patients; and (iii) make recommendations based on the findings. METHODOLOGY: A questionnaire was administered by an interviewer to a sample of 270 patients with a serological diagnosis of HIV infection to assess their oral health behaviour; they were then examined for oral manifestations. The assessment of oral health behaviour involved determining the regularity and frequency of oral hygiene practices, and use of mouth wash, interdental and other adjunct cleaning aids. The presumptive criteria as defined by the ECC/WHO classification were used for diagnosis of the oral mucosal lesions. Results were entered and analysed using Epi info-6 statistical software RESULTS: The prevalence of specific oral mucosal lesions in order of occurrence was pseudomembranous candidiasis 27%, erythematous candidiasis 26%, angular cheilitis 14%, hairy leukoplakia 12%, ulcerations 12%, necrotising gingivitis 5%, linear gingival erythema 3%, and non-Hodgkin's lymphoma and Kaposi's sarcoma less than 1%. This pattern reflects the findings in other regional studies where pseudomembranous candidiasis is often the most common lesion found. Nearly all patients reported cleaning their mouths; 82% did it every day. Mouth wash and interdental cleaning aids were not often used. CONCLUSIONS: A high prevalence (73%) of oral mucosal lesions was found. Oral candidiasis was the most common group of lesions (54%). The oral hygiene practices reported by the patients were considered acceptable.     

Oral manifestations of HIV infection in 75 Dutch patients

Seventy-five consecutive HIV-infected patients, including 33 AIDS cases were examined. One or more oral mucosal lesions were observed in 57 (76%); candidiasis was the most common finding (52%). Others included hairy leukoplakia (16%), periodontal disease (16%) and Kaposi's sarcoma (4%). Diversity of study design and methods allowed no reliable comparison with other reports.