Oral lesions in HIV infection in developing countries: an overview

HIV infection is a major global health problem affecting developing and developed countries alike. Oral lesions that are associated with this disease are important, since they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression. Oral lesions in HIV infection have been well-documented in developed countries, but there are fewer reports on oral lesions from developing countries. Oral candidiasis is the most common opportunistic infection seen in all continents. Kaposi's sarcoma has been reported only from Africa and Latin America, while histoplasmosis and penicilliosis were reported in patients with advanced disease from Thailand. HIV-associated salivary gland disease has a high prevalence in Africa and Latin America, especially in the pediatric group. It is clear that there are considerable regional variations in the oral manifestations of HIV infection, depending both on the populations studied and on the clinical expertise available, among other factors. Well-designed and -documented studies are necessary for the correct assessment of the nature and magnitude of the problem in developing countries, if oral health measures are to be effectively formulated for the HIV-infected.     

Oral lesions of HIV and AIDS in Asia: An overview

The magnitude of HIV infection in the Asian region is increasing dramatically. Oral disease represents an important health problem for HIV-infected individuals, because of its diagnostic, prognostic and therapeutic implications. The documentation and reporting of HIV infection and AIDS in most of the Asian countries has been superficial. Though the epidemiology of HIV infection in Asia has been studied by many investigators, few attempts have been made to summarise the data and assess the magnitude of the problem, the mode of transmission, the spread of infection and clinical pattern of illness. A review of the literature shows that there is hardly any published data on oral manifestations of HIV infection or AIDS from the Asian region. However, some preliminary information is available on the type of lesion presenting in patients from India and Thailand. These observations suggest that oral manifestations are common in HIV-infected and AIDS patients. The pattern of occurrence of various lesions reported appears to show variation from those reports from other parts of the world, but no definitive conclusion can be drawn from these preliminary observations. Further epidemiological studies are necessary to substantiate the present understanding of the nature of oral lesions found in Asian countries.     

Oral lesions, HIV phenotypes, and management of HIV-related disease: Workshop 4A

The workshop considered 5 questions related to oral lesions, HIV phenotypes, and the management of HIV-related disease, with a focus on evidence and challenges in resource-poor settings. First, are oral lesions unique with respect to geographic location or phenotype? Second, how useful would an oral lesion index be to predict HIV in resource-poor countries with no access to CD4 counts or viral load? Third, what are the latest methods and delivery modes for drugs used to treat oral lesions associated with HIV? Fourth, what is the role of the oral health care worker in rapid diagnostic testing for HIV? Fifth, what ethical and legal issues are to be considered when managing the HIV patient? The consensus of the workshop was the need for additional research in 4 key areas in developing countries: (1) additional investigation of comorbidities associated with HIV infection that may affect oral lesion presentation and distribution, especially in pediatric populations; (2) the development of region-specific algorithms involving HIV oral lesions, indicating cumulative risk of immune suppression and the presence of HIV disease; (3) well-designed clinical trials to test new therapies for oral lesions, new treatments for resistant oral fungal and viral diseases, effectiveness of therapies in children, and new drug delivery systems; and (4) the role of the oral health care worker in rapid diagnostic testing for HIV in various regions of the world.     

The global changing pattern of the oral manifestations of HIV

The significance of the oral manifestations of HIV has been widely recognised since the start of the epidemic. It is estimated that more than 38 million people are living with HIV currently, with more than a third presenting with oral manifestations. Access to optimum clinical management and effective treatment in resource‐rich countries has led to a remarkable decrease in some of the oral manifestations in the HIV population but this is not mirrored in developing countries, where most HIV‐positive patients reside. In this paper, a review of the literature since the start of the HIV infection in different parts of the world is presented to highlight the current significance of the oral conditions in this population. Oral candidiasis was repeatedly reported as the most encountered oral manifestation of HIV in different countries, including in studies on groups on anti‐retroviral therapy. Over time salivary gland disease was reported less in developed countries but was encountered more in developing countries. There is evidence to show that the prevalence of oral warts increased with the establishment of anti‐retroviral therapy. A review of the worldwide prevalence of HIV‐related oral conditions indicates that except for oral hairy leucoplakia, the prevalence of all other nine commonly reported oral conditions remained the same or increased over time. Oral opportunistic infections in HIV‐infected patients are an ongoing clinical burden mainly in developing countries. Maintaining research in the subject and improving access to HIV treatment will help address the oral health inequalities around the world.     

Dental considerations for the paediatric AIDS/HIV patient

HIV infection and AIDS are spreading rapidly among the world's children, especially among African-American and Hispanic children in the USA, and those in developing countries. Although recent research has identified several ways of preventing perinatal transmission of HIV, most of these methods are too expensive for widespread use in developing countries, where the epidemic is most severe. Oral manifestations are early and common clinical indicators of HIV infection and progression in children, as in adults, although the specific manifestations differ between adults and children. Oropharyngeal candidiasis is the most common sign of HIV infection in children and is significantly associated with markers of HIV disease progression. Other common oral manifestations in children include herpes simplex, linear gingival erythema, parotid enlargement and recurrent aphthous ulceration. Further research is needed on the ways in which oral manifestations can be used as predictors of disease progression; on the impact of the limited availability of health care for impoverished families who are disproportionately affected by HIV infection; and on supportive care and its impact on infected children's quality of life.     

Oral lesions of HIV disease and HAART in industrialized countries

The epidemiology of HIV-related oral disease in industrialized nations has evolved following the initial manifestations described in 1982. Studies from both the Americas and Europe report a decreased frequency of HIV-related oral manifestations of 10-50% following the introduction of HAART (highly active antiretroviral therapy). Evidence suggests that HAART plays an important role in controlling the occurrence of oral candidosis. The effect of HAART on reducing the incidence of oral lesions, other than oral candidosis, does not appear as significant, possibly as a result of low lesion prevalence in industrialized countries. In contrast to other oral manifestations of HIV, an increased prevalence of oral warts in patients on HAART has been reported from the USA and the UK. HIV-related salivary gland disease may show a trend of rising prevalence in the USA and Europe. The re-emergence of HIV-related oral disease may be indicative of failing therapy. A range of orofacial iatrogenic consequences of HAART has been reported, and it is often difficult to distinguish between true HIV-related oral disease manifestations and the adverse effects of HAART. A possible association between an increased risk of oral squamous cell carcinoma and HIV infection has been suggested by at least three epidemiological studies, with reference to the lip and tongue. These substantial and intensive research efforts directed toward enhancing knowledge regarding the orofacial consequences of HIV infection in the industrialized nations require dissemination in the wider health care environment.     

Prevalence and classification of HIV-associated oral lesions

OBJECTIVES: An International Workshop addressed the prevalence and classification of HIV/AIDS associated oral lesions.
DESIGN: Five questions provided the framework for discussion and literature review. What is the prevalence of oral lesions in children and adults? Should the accepted classification of HIV-related oral lesions be modified in the light of recent findings? Why is there a gender difference in the prevalence of oral lesions in developed and developing countries? Are there unusual lesions present in developing countries? Is there any association between modes of transmission and the prevalence of oral lesions?
RESULTS: Workshop discussion emphasized the urgent need for assistance in the development of expertise to obtain accurate global prevalence data for HIV-associated oral lesions. Oral candidiasis has been consistently reported as the most prevalent HIV-associated oral lesion in all ages. Penicilliosis marneffei, a newly described fungal infection, has emerged in South-east Asia. Oral hairy leukoplakia and Kaposi's sarcoma appear to be associated with male gender and male-to-male HIV transmission risk behaviours. These lesions occur only rarely in children.
CONCLUSIONS: Additional prevalence data are needed from developing countries prior to substantially altering the 1993 ECC/WHO Classification of oral lesions associated with adult HIV infection. The workshop confirmed current oral disease diagnostic criteria.     

Oral aspects of HIV infection in children

Most infants with congenital HIV infection appear normal at birth. Clinical difficulties usually begin as the first year proceeds, and in about half of the children oral manifestations are the first signs. Oral manifestations are commonly found in HIV-positive asymptomatic and pediatric AIDS patients, they are the earliest clinical signs of HIV infection and disease progression in children, and may be used as diagnostic markers, especially in developing countries. Studies have established an accurate association between oral manifestations and progression of HIV disease in children. Since the mouth is easily accessed for clinical examination, the important oral signs should be utilized in the diagnosis and early intervention of AIDS in these vulnerable populations.     

US1HIV – changing patterns in HAART era,patients’ quality of life and occupational risks

Oral manifestations are early and important indicators of HIV‐infection. Several lesions with strong association to HIV infection have been described: oral candidiasis (OC), oral hairy leukoplakia (OHL), Kaposi's sarcoma (KS), Non‐Hodgkin‐Lymphoma (NHL), necrotising ulcerative gingivitis and periodontitis. These lesions may be present in up to 50% of patients with HIV‐infection and up to 80% of those with AIDS. Changing patterns in HAART era: With the advent of highly active antiretroviral therapy (HAART) the prevalence of OC, OHL and HIV – associated periodontal disease has decreased in adults. The prevalence of KS has not changed. However, there has been an increase in HPV‐associated oral lesions (papillomas, condylomas and focal epithelial hyperplasia) and HIV‐related salivary gland disease. In children receiving HAART no change in the prevalence of HIV‐related oral lesions has been found. Quality of life: The presence of oral lesions has a marked impact on health related quality of life. HIV‐associated orofacial lesions may lead to facial disfigurement (KS, NHL) or may impair speech and swallowing. Consequently, weight loss and pain may be result. Studies have shown that patients with OC, angular cheilitis and OHL have a high score of decayed teeth (DMFT). Xerostomia and taste disturbances may also be factors with impact on quality of life. Occupational risks: Occupational exposure to HIV has resulted in 57 documented cases of HIV sero‐conversion among healthcare workers in the US (December 2001). Exposure to HBV and HCV carries a much higher risk of occupational infection than that for HIV‐exposure.     

Urban legends series: oral manifestations of HIV infection

Human immunodeficiency virus‐related oral lesions (HIV‐OLs), such as oral candidiasis (OC) and oral hairy leukoplakia (OHL), have been recognized as indicators of immune suppression since the beginning of the global HIV epidemic. The diagnosis and management of HIV disease and spectrum of opportunistic infection has changed over the past 30 years as our understanding of the infection has evolved. We investigated the following controversial topics: (i) Are oral manifestations of HIV still relevant after the introduction of highly active antiretroviral therapy (HAART)? (ii) Can we nowadays still diagnose HIV infection through oral lesions? (iii) Is the actual classification of oral manifestations of HIV adequate or does it need to be reviewed and updated? (iv) Is there any novelty in the treatment of oral manifestations of HIV infection? Results from extensive literature review suggested the following: (i) While HAART has resulted in significant reductions in HIV‐OLs, many are still seen in patients with HIV infection, with OC remaining the most common lesion. While the relationship between oral warts and the immune reconstitution inflammatory syndrome is less clear, the malignant potential of oral human papillomavirus infection is gaining increasing attention. (ii) Effective antiretroviral therapy has transformed HIV from a fatal illness to a chronic manageable condition and as a result expanded screening policies for HIV are being advocated both in developed and in developing countries. Affordable, reliable, and easy‐to‐use diagnostic techniques have been recently introduced likely restricting the importance of HIV‐OLs in diagnosis. (iii) The 1993 EC‐Clearinghouse classification of HIV‐OLs is still globally used despite controversy on the relevance of periodontal diseases today. HIV‐OL case definitions were updated in 2009 to facilitate the accuracy of HIV‐OL diagnoses by non‐dental healthcare workers in large‐scale epidemiologic studies and clinical trials. (iv) Research over the last 6 years on novel modalities for the treatment of HIV‐OLs has been reported for OC and OHL.     

Oral lesions of HIV infection in developing countries

HIV infection has spread rapidly within developing countries since it was first recognized in the early 1980s. The purpose of this paper is to review the prevalence of oral lesions associated with HIV infection (oral HIV) in the developing world, and to identify additional factors that may complicate the presentation of these lesions. Direct comparison of regional and local prevalence studies within Africa, India and Thailand is speculative because there are few reports available. Furthermore, inherent differences in study design, data collection, standardization and calibration of health workers make any inferences inconclusive. Additional prevalence studies of oral HIV lesions associated with systemic disease or social conditions, such as poverty or malnutrition, are needed. In order to provide a basis for the diagnosis and treatment of HIV-associated oral lesions in the developing world, it is important to recognize any confounding factors that may impact on their presentation and management. Elucidation of these various factors may provide a basis for treatment within the developing and developed world.     

Management of the oral mucosal lesions seen in association with HIV infection

Oral lesions cause considerable morbidity in association with HIV infection. Their successful management depends upon accurate diagnosis and the use of appropriate therapy. Various treatment approaches are described for some of the common oral lesions including Kaposi's sarcoma, oral candidiasis, hairy leukoplakia and recurrent oral ulcers associated with HIV disease. This paper will discuss the therapies available in the USA and UK. In other countries some of the drugs discussed will be available in different doses and preparations. In addition other drugs may be available in other parts of the world that are not licensed for use in the USA or UK, and their availability may vary.     

(A1) Identification of oral health care needs in children and adults, management of oral diseases

The workshop considered five questions reviewing the identification of international oral health care needs of children and adults, and the management of oral diseases in resource-poor countries: (1) What is the role of the dental profession in the management of the HIV-infected individual? (2) Identifying health care needs-What are the epidemiology and disparities of HIV-associated oral lesions in children from different continents? (3) How effective is HIV treatment in controlling oral diseases? (4) Could we develop basic inexpensive oral and dental care protocols for economically deprived HIV-infected patients? and (5) What is the best method of arranging resources to meet the oral health care needs of people with HIV disease? The consensus of the workshop participants was that there is a need to re-target research efforts to non-established market economy countries and prioritize research in these regions to children with HIV disease. It will be important to assess commonalities and variations in oral health needs across geographical and cultural boundaries, and research efforts should be centralized in resource-poor countries to support multi-center longitudinal standardized studies. It is essential that oral health research be integrated into other health care research programs, to make these research priorities and public health initiatives feasible.     

Clinical markers of immunodeficiency and mechanism of immune reconstitution inflammatory syndrome and highly active antiretroviral therapy on HIV: workshop 3A

Antiretroviral therapy (ART) has improved survival and changed the disease pattern of HIV infection. However, ART may cause serious side effects, such as metabolic and cardiovascular complications. In addition, immune reconstitution inflammatory syndrome (IRIS) is being increasingly reported in relation to ART. The article presents the consensus of a workshop around 4 key issues: (1) the differences in the response of adults and children to highly active antiretroviral therapy, (2) the mechanism of the new HIV entry inhibitors and its effect on oral markers, (3) the pathogenesis of IRIS and the contradictory findings of the possible oral lesions related with IRIS, (4) and the benefits and barriers associated with using ART in the developing and developed world. The consensus of the workshop was that there is a need for future studies on the oral manifestations of HIV in individuals treated with new ARTs-especially, children. IRIS was considered a promising field for future research; as such, workshop attendees recommended formulating an IRIS-oral lesions case definition and following strict criteria for its diagnosis.     

Transmission of HIV in the dental clinic and elsewhere

This review focuses on the risk of transmission of HIV in dental practice in developed and developing countries; and as a result of oral sex, perinatal transmission and breast feeding. Postexposure prophylaxis (PEP) and practical measures to control cross-infection with TB are also discussed. There are few data from resource-poor countries where prevalence of HIV and risk of infection are higher – issues that deserve priority. Available information indicates that the risk of HIV transmission in the dental office is very low. Transmission of HIV from three healthcare workers to patients has been confirmed, including a dentist who infected six patients. There are >300 reports (102 confirmed) of occupational transmission to healthcare workers, including nine dental workers (unconfirmed). Exposure to HIV has been reported by 0.5% dentists/year. The risk of HIV infection after percutaneous exposure (0.3%) can be reduced by 81% with zidovudine PEP. However, risk assessment is required to assess the need and appropriate regimen. The risk of HIV transmission associated with orogenital sex exists, but is considered extremely low: barrier protection is recommended. Conversely, the proportion of babies who acquire HIV from untreated HIV-seropositive mothers is 15–25% in developed countries and 25–45% in developing countries. The frequency of HIV transmission attributable to breastfeeding is 16%. Airborne transmission of TB can be avoided by the prompt referral of known/suspected cases of active TB for chemotherapy, deferral of elective procedures until patients are not infectious, and the use of appropriate standard/isolation precautions including adequate ventilation of treatment areas.     

HIV感染与牙周疾病相关性的研究进展

艾滋病(AIDS)是由感染人类免疫缺陷病毒(HIV)引起的人体免疫功能缺陷疾病,近年来,与艾滋病相关的慢性疾病的研究引发了学者的广泛关注。人们对与HIV相关的慢性病及其相互关系的研究日益增多。HIV感染后很长一段时间没有明显的临床症状,但多数患者在早期就可能出现各种口腔病损,如白色念珠菌病、口腔毛状白斑、HIV相关性牙周病变、卡波西肉瘤以及非霍奇金淋巴瘤等,其中HIV相关性牙周病变较常见。因此,通过牙周组织检查对艾滋病的早期发现具有重要意义。本文将从HIV感染患者的牙周病变表现以及艾滋病与牙周病变发展的关系予以综述。     

Sentinels and signposts: The epidemiology and significance of the oral manifestations of HIV disease

A large number of studies attest to the frequency of oral disease in those with HIV infection. Most show that hairy leukoplakia and pseudomembranous candidiasis are the commonest lesions in those with HIV infection and AIDS, with higher prevalence and incidence rates correlating with falling CD4 counts and disease progression. HIV-infected individuals with oral candidiasis or hairy leukoplakia progress to AIDS more rapidly than matched controls without these lesions. Oral candidiasis and hairy leukoplakia increase with time since seroconversion. On the other hand, parotid enlargement in children appears to be associated with slower progression to AIDS. As a consequence of these and other observations, oral lesions are widely included in natural history studies, staging and classification schemes for HIV infection. In addition to their role in the diagnosis of HIV infection and as indicators of the progression of HIV disease, oral lesions are used as clinical correlates of CD4 counts and as criteria for entry into clinical trials.     

Common oral opportunistic infections in Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome: Changing epidemiology; diagnostic criteria and methods; management protocols

There were 36.9 million in the world living with human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) as of 2017, and new infections have seen a reduction by 18% since 2010. But this rate of decline is not sufficient for the goal of eradication of AIDS by 2030. Only 21.7  million people infected with HIV have accesses to antiretroviral therapy, with the rest at risk of the potential complications of HIV infection. It has been shown that oral lesions are diagnostic and prognostic of HIV infection, and many oral opportunistic infections continue to be a major problem, particularly in developing countries. It is therefore important that dental surgeons be aware and updated to recognize and manage the oral effects of HIV infection/AIDS. This chapter describes the classification, diagnosis, and management of oral lesions in these patients, based on our current understanding of the infection. This review also discusses the standardization of diagnosis of oral lesions in HIV infection/AIDS patients, immune reconstitution inflammatory syndrome case definition, and the research priorities formulated at the 7th World Workshop on Oral Health and Disease in AIDS.     

Oral manifestations of HIV infection in infants: a review article

The vast majority of children with HIV infection present oral manifestations among the first signs of illness. These lesions are not produced directly by the virus, but are manifestations associated with HIV infection, and are not pathognomic of the infection itself. Some of these oral lesions have a prognostic value with regard to progression of the infection and the appearance of AIDS; independently of other, more commonly used markers. The essential risk factors that influence the development of such oral manifestations are the low number of CD4+ lymphocytes, xerostomia, and the lack of anti-retroviral therapy. Opportunist infections, such as mycoses -- including pseudomembranous oral candidiasis, are found with higher frequency; followed by the herpetic viral infections. The oral lesions that appear in infected children differ in prevalence from those found in seropositive adults, some, such as parotid hypertrophy, present more exclusively in children, others, such as periodontal bacterial infections and Kaposi's Sarcoma, are lesions that predominate in the adult HIV-infected population. Given the current impact of the pandemic caused by HIV, it is the responsibility of dental professionals to prevent, detect, treat and control the oral lesions in those patients infected with HIV. All of which will be reflected in a reduction in transmission, lower mortality and greater long-term survival for infected children.