Oral lesions in Thai heterosexual AIDS patients: a preliminary study

Systematic review of the changing pattern of the oral manifestations of HIV

The purpose of the present study paper was to review the reported prevalence of the oral manifestations of HIV (OM-HIV) worldwide since 1980, and to determine the global variation in its prevalence over time. PubMed, Scopus, Embase and Google Scholar were searched. The filter "English" was used. The timeframe searched was 1980- 2015. The PRISMA flow chart was used. Data were extracted using the Joanna Briggs Institute standardized data extraction form and transferred to SPSS version 22 for analysis. The systematic review of 97 studies (70 low bias risk) showed that the prevalence of OM-HIV continue to be significant in developing countries. Globally and through all the decades, oral candidiasis remained the most commonly encountered OM-HIV, including among patients on antiretroviral therapy (ART) (26.2%). Hairy leukoplakia was more prevalent in Europe and America compared with Africa and Asia. Oral warts were reported more often in studies on patients receiving ART. Interestingly, salivary gland disease decreased in the developed world and increased in developing countries over time. Despite the changing pattern of these conditions over time, there is no evidence that the OM-HIV have become of less significance globally. Maintaining the drive for high-quality research in the subject will have an impact on less developed countries to help address oral health inequalities.

(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.

Oral manifestations of HIV/AIDS in Asia: Systematic review and future research guidelines

Objectives

The authors have conducted a systematic review of oral manifestations of HIV from studies conducted in Asia to establish the characteristics and prevalence of individual oral manifestations in Asia, and to assess the direction of future research studies on oral manifestations of HIV in Asia.

Material and Methods

The electronic retrieval systems and databases searched for relevant articles were PubMed [MEDLINE], EBSCO, and EMBASE. The search was for limited articles published in English or with an English abstract and articles published during the period January 1995 to August 2014. The authors reached a final overall sample of 39 studies that were conducted in Asia.

Results

The median population size among all studies was 312.7 patients. Oral candidiasis [OC] was the most common oral manifestation [37.7%] in studies conducted in Asia. The overall prevalence of oral hairy leukoplakia and melanotic hyperpigmentation was computed to be 10.1% and 22.8% respectively. Thailand and India are primarily countries with maximum research on oral manifestations.

Conclusions

The research on oral manifestations of HIV in Asia has to upgrade to more interventional and therapeutic studies rather than the contemporary cross- sectional epidemiological descriptive studies. The authors have given suggestions and future directions for the implementation of clinical research of oral manifestations in HIV patients.

Key words:Oral manifestations, HIV/AIDS, Asia, Systematic review.

HIV-associated Kaposi sarcoma: pathogenic mechanisms

Kaposi sarcoma (KS) is a multicentric angioproliferative disorder characterized by spindle cell proliferation, neo-angiogenesis, inflammation, and edema. Human herpesvirus (HHV)-8, a gamma-herpesvirus, is a critical factor, but is not alone sufficient for the initiation of KS. Other cofactors such as human immunodeficiency virus (HIV), host-derived cytokines, chemokines, and growth factors are required for the development of KS. Whether HIV-associated KS is a reactive hyperplastic inflammatory lesion or a true neoplasm is still controversial. It is likely that HIV-associated KS begins as a reactive disorder that in some cases progresses to a monoclonal, an oligoclonal, and a polyclonal neoplasm.

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 candidosis and associated Candida species in HIV-infected Cambodians exposed to antimycotics

Although human immundeficiency virus (HIV) infection is endemic in Southeast Asia, data on oral mycotic flora in this disease in Asians are sparse. The aim of this study was to determine the prevalence of Candida species in HIV-infected Cambodians with oral candidosis, unexposed (group 1) and exposed to antimycotics (group 2) and a healthy population (group 3). In 161 HIV patients with oral candidosis (group 1: 121 pts; group 2: 40 pts) and in 81 controls (group 3) swab samples of tongue and palate were obtained. Oral candidosis was detected in 100 and 70% of groups 1 and 2 respectively. Candida spp. were isolated from 91 and 100% of groups 1 and 2, respectively, and from 79% of controls. Candida albicans was the most common, with non-albicans species such as C. tropicalis and C. krusei being notable. Our data indicate that variants of oral candidal infections in HIV disease are similar to those seen in the pre-HAART era. The particularly high rate of C. krusei isolation in all groups is noteworthy.

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.

Occurrence and Management of Opportunistic Infections Associated with HIV/AIDS in Asia

Illnesses, diseases and malignancies occur among HIV-infected individuals along a continuum. These are directly correlated with the degree of immune suppression and are caused by common patho gens and opportunistic infections. In decreasing order offrequency, frequent opportunistic infections and malignancies that occur in Asia are: Mycobacterium tuberculosis, Cryptococcus neoformans, Candida spp., Herpes simplex, Cryptosporidium parvum, Pneumocystis carinii, Toxoplasma gondii, non-Hodgkin's lymphoma and Kaposi's sarcoma. The association of morbidityand mortality due to co-infection with HIV and M.tuberculosis has become more evident in the region. Natural history studies conducted in Mumbai and Bangkok have reported incubation periods from infection to AIDS of eight and nine years respectively. Despite the advent of antiretroviral therapy (ART) and improved affordability of the generic drugs, only 30,000 (2 to 3 per cent) of the estimated 1.3 million eligible persons with AIDS in South Asia are presently on AR T. Apparently, the focus of the low-cost care in the region still continues to be of care and management of prevalent opportunistic infections. As care practices start to include ART over the next few years, there will be consequent change in the occurrence of opportunistic infections and need for their prophylaxis.

Oral non-Hodgkin lymphomas: studies of EBV and p53 expression

OBJECTIVES

The aims of the study were to assess sociodemographic and clinicopathologic characteristics of patients with oral non-Hodgkin lymphomas (NHLs) and the expression of Epstein-Barr virus (EBV) and p53.

MATERIALS AND METHODS

The clinical and pathologic features of 11 patients with oral NHLs were studied. The expression of EBV mRNA and p53 protein were studied by means of in situ hybridization and immunohistochemical methods in 11 formalin-fixed, paraffin-embedded specimens from these patients.

RESULTS

The patients' age ranged from 13 to 70 years with the mean of 42 years. Human immuno-deficiency virus (HIV) status was documented in five of the 11 patients and three were known to be HIV-positive. The most common locations were gingiva and alveolar mucosa. Pain and tenderness were major symptoms of the patients. The most common histologic subtype was diffuse large-cell, intermediate-grade NHL. Eight of 11 cases (72.7%) showed positive expression of p53 protein. Four of 10 cases (40%) expressed EBV-encoded RNA (EBER) transcripts. All known HIV-positive cases were EBV-positive.

CONCLUSIONS

The findings suggest that appropriately expressed p53 protein may play a role in tumorigenesis of oral NHLs. In addition, EBV may be involved with the pathogenesis of oral NHLs particularly in patients with HIV infection.

Prognostic significance of HIV-associated oral lesions and their relation to therapy

The oral manifestations of HIV infection have been considered to be of value in assessing disease progression in the developed world. However, the potential use of oral lesions as prognostic markers in resource-poor countries has yet to be fully investigated. There is reasonably compelling evidence in the developed world for an association between oral lesions and viral load. However, the true nature of this association is less clear and there are few data available from the developing world. With the introduction of HAART, a change in prevalence of the oral manifestations of HIV infection has been observed, including regression of oral candidiasis, Kaposi's sarcoma and oral hairy leukoplakia. However, oral condylomata and herpes simplex virus infection appear to persist with HMRT therapy. Further research in partnership with resource-poor countries is required to document disease progression and the associated oral lesions in both adults and children.

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.

Oral histoplasmosis in Brazil

OBJECTIVE

We report 10 cases of histoplasmosis with oral manifestations seen in a teaching hospital in Brazil.

STUDY DESIGN

This is a retrospective study of the sociodemographic, clinicopathologic, and treatment data of these cases.

RESULTS

Overall, 8 of 10 cases were seropositive for human immunodeficiency virus (HIV), whereas 2 were negative. The predominant oral manifestations found in HIV-seropositive patients were ulcers, oral pain, and odynophagia; both of the HIV-seronegative patients were symptom-free. HIV infection was suspected in 7 cases because of the presence of oral lesions of histoplasmosis. Asthenia, fever, weight loss, lymphadenopathy, and hepatosplenomegaly were found only in HIV-seropositive patients. Radiographs in 3 out of 10 patients suggested pulmonary involvement. Amphotericin B was the antifungal therapy chosen, and clinical remission of oral lesions occurred in an average of 30 days (accumulated doses: 500-1500 mg). Itraconazole was very effective as a follow-up treatment in terms of prevention of recurrence.

CONCLUSION

Histoplasmosis only rarely affects HIV-seronegative patients; however, the possibility of hidden immunodepression should be considered when oral manifestations of histoplasmosis are present.

Co-existence between oral lesions and opportunistic systemic diseases among HIV-infected subjects in Thailand

BACKGROUND

The purpose of this study was to determine whether any relationship exists between the occurrence of oral lesions and opportunistic systemic diseases among HIV-infected subjects.

METHODS

A cross-sectional analytical study was performed in two hundred and seventy-eight HIV-infected heterosexual persons and intravenous drug users (IVDUs)(230 males and 48 females, aged 16-65 years, mean 31.9 years). Eighty-six HIV-free subjects from the same population were included as controls (61 males and 25 females, aged 17-63 years, mean age 33.1 years). The following information was recorded for each patient: age, gender, risk group and stage of HIV infection, immune status, medication, systemic disease and presence of oral lesions.

RESULTS

Oral candidiasis was the most common oral lesion among HIV-infected individuals (40%), followed by hairy leukoplakia (HL)(26%). The three most common systemic diseases among the subjects were tuberculosis (TB)(53%), cryptococcosis (14%) and Pneumocystis carinii pneumonia (PCP)(11%). Logistic regression analysis revealed a significant association between the occurrence of TB and the presence of oral candidiasis (OR 2.8; 95% CI 1.6-4.8; P < 0.001), and the occurrence of PCP and the presence of HL (OR 2.2; 95% CI 1.1-4.3; P < 0.001). Positive predictive values of any oral lesions and oral candidiasis in predicting TB were 87% (95% CI 73.0-94.6) and 67% (95% CI 51.9-80.0), respectively.

CONCLUSIONS

We concluded that oral candidiasis might be used as a clinical marker for TB, and HL for PCP. Recognition of the lesions by health-care providers may indicate the need for more intensive clinical and laboratory monitoring and possibly initiation of prophylaxis against these opportunistic systemic infections.

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.

Oral manifestations of HIV infection in a group of predominantly ethnic Chinese

A total of 32 HIV-infected, predominantly ethnic Chinese individuals from Hong Kong were examined for oral mucosal lesions over a period of 1 year. The commonest oral lesion found was minor aphthous ulceration (27.4%), while xerostomia (17.8%), ulceration NOS (not otherwise specified; 12.3%), hairy leukoplakia (11.0%) and erythematous candidiasis (6.9%) were less frequent; Kaposi's sarcoma was notable for its absence. When the relationship between the number of oral lesions with age, risk group, medication taken, CDC staging and CD4+ count of the study group was investigated, a significantly higher number of oral lesions was associated with use of AZT, homosexuals and CDC stage IV; in contrast, a smaller number of lesions was found in those on antiparasitics and multivitamins (all P<0.05). When compared with studies from other parts of the world, the frequency of oral lesions appeared to be less common in the current study group. However, due to a lack of similar studies from the Asian region, especially in ethnic Chinese, it is not clear whether this difference could be attributed to racial, social or geographic factors.

Behçet's disease and complex aphthosis

Behçet's disease is a complex multisystem disease diagnosed by means of clinical criteria. Clinical features include oral and genital aphthae, pustular vasculitic cutaneous lesions, and ocular, gastrointestinal, and vascular manifestations. We believe that complex aphthosis, characterized by oral or oral and genital ulcers, may be a forme fruste of Behçet's disease. Although the pathogenesis of both Behçet's disease and complex aphthosis remain unknown, immune factors, infectious agents, and effector mechanisms are implicated. Treatment is based on the severity of systemic involvement and includes topical therapies as well as colchicine, dapsone, thalidomide, and immunosuppressive agents.

Oral lesions in a group of Thai people with AIDS

OBJECTIVES

The objectives of the study were to assess the prevalence of oral lesions present in Thai people with AIDS and to determine whether gender influences the occurrence of oral lesions.

SUBJECTS AND METHODS

Extra- and intra-oral examinations were performed on 124 AIDS patients (90 men, aged 19-62 years, median 30 years; and 34 women, aged 19-41 years, median 28 years).

RESULTS

Oral lesions were found in 102 patients (82%). Pseudomembranous candidiasis was the most common lesions, (n = 67; 54%) followed by erythematous candidiasis (n = 31; 25%), and hairy leukoplakia (n = 16; 13%). Other lesions were atypical ulcers (n = 14; 11%), periodontal disease (n = 9; 7%), angular cheilitis (n = 8; 6%), and infection with herpes simplex virus (n = 6; 5%). Non-Hodgkin's lymphoma was the only detected neoplasm (n = 5; 4%). Other lesions caused by fungi were histoplasmosis (n = 5; 4%) and penicilliosis (n = 2; 2%). Xerostomia was also found to be a common condition (n = 79; 63%). Most patients had a total number of lymphocytes of less than 1000 cell mm-3 (n = 85; 68%).

CONCLUSIONS

The types of oral lesions observed in AIDS patients in Thailand show some similarities with studies from other countries. The prevalence of oral lesions did not appear to be influenced by gender.