Assessment of Oral Health and Prevalence of oral Conditions in Human Immunodeficiency Virus-infected Subjects Visiting Antiretroviral Therapy Centers.

BACKGROUND: Weakened immune system from acquired immunodeficiency syndrome (AIDS) makes the individual prone to various opportunistic infections which are life-threatening including various carcinomas and disorders affecting the neurological system. AIMS: The present trial was done to assess the prevalence of oral presentations and treatment needs in AIDS/human immunodeficiency virus (HIV)-infected subjects visiting antiretroviral therapy centers.
MATERIALS AND METHODS: The study included 126 subjects. Oral cavity was assessed and dentition, periodontal condition, and lesions and conditions affecting the oral mucosa were identified along with their treatment needs. The collected data were subjected to statistical evaluation and the results were formulated.
RESULTS: Candidiasis was seen in 25.39% (n = 32) of total subjects. Concerning the periodontal status of HIV-infected study population, it was seen that maximum attachment loss both in males and females was within the range of 0-3 mm. Regarding decayed, missing, and filled teeth scores, these were statistically significantly higher in males (P = 0.001).
CONCLUSION: The present study concluded that the majority of subjects infected with HIV present one or more oral presentation and lesion, with candidiasis being the most common condition. Copyright:

INTRODUCTION

Acquired immunodeficiency syndrome (AIDS) is caused by human immunodeficiency virus (HIV) and is a deadly disease. AIDS itself does not lead to fatality. However, HIV leads to a broken and weaker immune system by attacking the immune system of the affected individual.[1] This weakened immune system makes the individual prone to various opportunistic infections which are life-threatening including various carcinomas and disorders affecting the neurological system. The HIV infection was first identified in homosexual males in 1981 by the Centers for Disease Control and Prevention in the USA.[2]

HIV can be transmitted from one individual to another via various routes including unprotected sex with affected individuals, sex with multiple partners, injectable drug abuses, blood transfusions, multiple needle use, and/or heterosexual route.[3] Approximately one lakh individuals died of HIV. A decrease in the trend of new affected AIDS subjects is seen with increasing in subjects seeking treatment as reported since 2014.[4]

The first AIDS case was reported in India by a sex worker from Chennai in 1986. As of 2017, approximately 21 lakh subjects had HIV in India with 0.22% adults of age 15 years to 50 years infected. India is emerging as a third country with the highest number of HIV cases after South Africa and Nigeria. The state with maximum HIV cases in India is Mizoram followed by Manipur and Nagaland.[5]

From April 2004, a program was launched in India under the National AIDS Control Program where free antiretroviral therapy (ART) was given to the subjects with AIDS/HIV. From 2004 to 2016, the number of ART centers in India increased from 8 to 528.[6] Although the ART centers were increased in number largely from 2004 to 2016, the program still needs to provide ART regimen in simple and standardized ways with negligible detrimental effects.[7]

Oral lesions also provide a valuable prognostic factor in HIV-infected subjects. Large data in the literature previously focused on the oral manifestation of AIDS and its importance. Such data are relatively scarce in the Asian population.[8] Hence, the present trial was done to assess the prevalence of oral presentations in AIDS/HIV-infected subjects visiting ART centers.

MATERIALS AND METHODS

The present cross-sectional trial was done to assess the prevalence of oral presentations in AIDS/HIV-infected subjects visiting ART centers. Furthermore, the present study was aimed to evaluate the treatment requirements and health status in AIDS/HIV subjects visiting ART center. The study included a total of 126 subjects including both males and females within the age group of 6 years to 58 years with a mean age of 27.3 years.

The subjects who gave consent for the study and were present at the days of study assessment were included in the trial. The ethical clearance for the study was given by the institutional ethical forum. Informed consent was taken verbally from all the subjects. The patients who were not in a physical or mental condition to provide consent, subjects in intensive care unit, subjects with severe psychological illness, and who were not willing to participate were excluded from the study.

After inclusion in the study, the oral cavity of all 126 subjects was assessed with disposable diagnostic instruments including a mouth mirror, tweezers, and community periodontal index probe. Furthermore, the straight probe was used to assess dental caries. For assessing and recording the dentition, periodontal condition, and lesions and conditions affecting the oral mucosa, modified Oral Health Assessment form of 1997 by the WHO was used in the present study.

The collected data were subjected to statistical evaluation and the results were formulated. The level of significance was kept at P ≤ 0.05.

RESULTS

Candidiasis was common infection that was seen in 31.81% (n = 14) of females, 32.92% (n = 27) of males, and 32.53% (n = 41) of total study subjects, followed by ANUG seen in 22.72% (n = 10) of females, 26.82% (n = 22) of males, and 25.39% (n = 32) of total subjects. The least common finding was malignancy/carcinomas seen in only 2 males and 1 female subject. Statistically significant difference among the genders was seen concerning only leukoplakia where no female had it and 6.09% (n = 5) of males had leukoplakia (p>0.0001) [Table 1].

Table 1

Oral lesions and conditions in HIV patients

Oral lesion/condition	Females (n=44)	Males (n=82)	Total (n=126)	P
Normal	36.36% (16)	24.39% (20)	28.58% (36)	0.002
Ulceration	6.81% (3)	10.97% (9)	9.52% (12)	0.10
Leukoplakia	-	6.09% (5)	3.96% (5)	0.001
Lichen planus	-	-	-	-
Pigmentation	11.36 (5)	17.07% (14)	15.07% (19)	0.10
Abscess	4.54% (2)	4.87% (4)	4.76% (6)	0.9
Bald tongue	6.81% (3)	2.43% (2)	3.96% (5)	0.02
Angular cheilitis	4.54% (2)	6.09% (5)	5.55% (7)	0.46
Candidiasis	31.81% (14)	32.92% (27)	32.53% (41)	0.62
Malignancy	2.27% (1)	2.43% (2)	2.38% (3)	0.36
ANUG (acute)	22.72% (10)	26.82% (22)	25.39% (32)	0.28

ANUG: Acute necrotizing ulcerative gingivitis

The difference in attachment loss scores was statistically significant in the male and female population for all the scores and ranges of attachment loss. It was seen that 34.09% (n = 15) females had attachment loss, whereas the value was 65.85% (n = 54) males had attachment loss which was statistically significant with a P = 0.001. Table 2 also showed corruption perceptions index scores for study subjects, where it was seen that24 females had a score of 2 which was seen in 40 males (48.78%), and the difference was statistically significant between males and females with P = 0.001 [Table 2].

Table 2

Periodontal status in HIV patients

Periodontal parameter	Females (n=44), n (%)	Males (n=82), n (%)	Total (n=126), n (%)	P
Loss of attachment (mm)
0: 0-3	59.09% (26)	42.68% (35)	48.41% (61)	0.001
1: 4-5	29.5% (13)	28.04% (23)	28.57% (36)	0.001
2: 6-8	4.54% (2)	12.19% (10)	9.52% (12)	0.001
3: 9-11	2.27% (1)	2.43% (2)	2.38% (3)	0.001
4: ≥12	0 (0)	2.43% (2)	1.58% (2)	0.001
9: Not recorded with probe	2.27% (1)	10.97% (9)	7.93% (10)	0.001
Total	34.09% (15)	65.85% (54)	54.76% (69)	0.001
Community periodontal index
0-Healthy	4.54% (2)	4.87% (4)	4.76% (6)	0.001
1-Bleeding	54.54% (24)	48.78% (40)	50.79% (64)	0.001
2-Calculus	31.81% (14)	28.04% (23)	29.36% (37)	0.001
3-Pocket (4-5 mm)	4.54% (2)	17.07% (14)	12.69% (16)	0.001
4-≥6 mm pocket	34.09% (15)	65.85% (54)	54.76% (69)	0.001
Total	59.09% (26)	42.68% (35)	48.41% (61)	0.001

Regarding decayed, missing, and filled teeth (DMFT) scores, decayed scores for males and females, respectively, were 3.38 ± 1263 and 2.76 ± 1.012 with statistically higher values in males (P = 0.001). M scores were 0.86 ± 0.676 and 0.52 ± 0.503, respectively, for males and females, which was also significantly higher in males (P = 0.001). Filled surfaces showed no statistical difference with P = 0.69; total DMFT was also statistically significantly higher in males (P = 0.001) as summarized in Table 3.

Table 3

Decayed missing and filled teeth and dentition status in human immunodeficiency virus infected study subjects

Dentition parameter (DMFT)	Mean±SD	P
Decayed
Male	3.38±1263	0.001
Female	2.76±1.012
Missed
Male	0.86±0.676	0.001
Female	0.52±0.503
Filled
Male	0.12±0.431	0.69
Female	0.09±0.374
Total DMFT
Male	4.36±1.601	0.001
Female	3.48±1.243

DMFT: Decayed, Missing and Filled Teeth, SD: Standard deviation

The treatment needs of HIV subjects were also assessed in the present study as described in Table 4. The results showed that maximum subjects, both males and females, required single-surface restorations as needed by 72.72% (n = 32) of females and 85.36% (n = 70) of males with significantly higher need in males (P = 0.001). A similar statistically significant difference was seen for pit and fissure sealant requirement, which was higher in males, 3.96% (n = 5), and in only 1 female (P = 0.01). Prosthesis, extractions, and pulpal treatments were also needed by HIV-infected subjects.

Table 4

Treatment needs in human immunodeficiency virus infected study subjects

Treatment needed	Females (n=44)	Males (n=82)	Total (n=126)	P
No treatment	2.27% (1)	2.43% (2)	2.38% (3)	0.21
Pit and fissure sealants	2.27% (1)	4.87% (4)	3.96% (5)	0.01
Single surface restoration	72.72% (32)	85.36% (70)	80.95% (102)	0.001
Restoration on more than one surface	63.63% (28)	59.76% (49)	61.11% (77)	0.39
Prosthesis	72.72% (32)	68.29% (56)	69.84% (88)	0.33
Extraction	68.18% (30)	74.39% (61)	72.22% (91)	0.3
Pulpal treatment	47.72% (21)	40.24% (33)	42.85% (54)	0.02

DISCUSSION

It was seen that approximately 70% of the study subjects having HIV and visiting ART centers had one or more oral manifestations. These findings were consistent with the findings of the previous studies by Rath and Raj.[9] in 2013 and Kumar et al.[10] in 2014 where the authors reported oromucosal lesions in 68.8% and 7% of their study subjects, respectively. In 4.76% of subjects (n = 6), the abscess was seen, which was also in agreement with the study of Kumar et al.[10] in 2014 where 3.97% of HIV subjects had an abscess.

It was seen that the most common lesion seen was candidiasis, which is a common infection that was seen in 31.81% (n = 14) of females, 32.92% (n = 27) of males, and 32.53% (n = 41) of total study subjects. These findings were similar to findings of Divakar et al.[11] in 2015 where 28.7% of subjects had candidiasis. However, results were contradictory to the study of Beena[12] in 2015 where only 11.62% of HIV subjects were seen with candidiasis. Statistically significant difference among the genders was seen concerning only leukoplakia where no female had it and 6.09% (n = 5) of males had leukoplakia with the P value of 0.001. These results were following the results of Agbelusi and Wright[13] in 2005 where they reported Kaposi's sarcoma in 2.3% of cases and by Ranganathan et al.[14] in 2007 who reported 2% leukoplakia in males.

Regarding DMFT scores, decayed scores for males and females, respectively, were 3.38 ± 1263 and 2.76 ± 1.012 with statistically higher values in males (P = 0.001). M scores were 0.86 ± 0.676 and 0.52 ± 0.503, respectively, for males and females, which was also significantly higher in males (P = 0.001). Filled surfaces showed no statistical difference with a P value of 0.69; total DMFT was also statistically significantly higher in males (P value = 0.001). These results coincided with the study of Eldidge and Gallagher[15] in 2000 and contraindicated the findings of Naidoo and Chikte[16] in 2004. More DMFT scores in AIDS-infected subjects show poorer oral health in infected subjects.

CONCLUSION

Within its limitation, the present study concluded that the majority of subjects infected with HIV present one or more oral presentation and lesion, with candidiasis being the most common condition. Periodontal status and dentition were also seen to be compromised in subjects infected with HIV. These oral manifestations can be diagnostic and can help in early detection, screening, and management of AIDS. This can also help dentists and community health-care providers in assisting the AIDS/HIV detection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.