5th World Workshop on Oral Health and Disease in AIDS .
ABSTRACTS
Posters
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5th World Workshop on Oral Health and Disease in AIDS .
CLINICAL
ORAL LESIONS AND MANAGEMENT OF HIV RELATED DISEASE
A2
A1
Oral Manifestations of HIV in Pregnant Women Attending Antenatal Clinics in Johannesburg.
LAO Adeyemi*1, MJ Rudolph1, AO Yusuf2, JA McIntyre3, GE Gray3, N Martinson 3
1School of Public Health, University of the Witwatersrand, 2Department of Community Dentistry, University of Pretoria, 3Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg
L Adeyemi:
Introduction: Although, several studies have been reported from outside Sub-Saharan Africa on the oral manifestations of HIV in women, no such study has yet been undertaken on oral manifestations of HIV in pregnant women in Africa. In some areas of South Africa, one in three pregnant women attending public sector health facilities is HIV positive. Oral candidiasis has been shown to be the most common oral lesion associated with HIV infection in women.
Objective: To determine the prevalence of oral manifestations in HIV positive pregnant women attending antenatal clinics in Johannesburg.
Method: A cross sectional study was conducted on HIV positive pregnant women attending antenatal clinics in three hospitals in Johannesburg, South Africa. A calibrated dentist determined HIV related oral lesions by doing a clinical examination in 128 HIV positive pregnant women using the criteria suggested by the EC/WHO. Parity, gravidity and age of the patients were collected by means of a self-administered structured questionnaire.
Results: The age range for the group was 17 to 42 years, with a mean age of 27.9 years. Twenty-eight (22%) of the group was primigravid, while 100 (78%) were multiparous. The majority of the patients, 73 (57%) were in their second trimester. Oral candidiasis and angular cheilitis were the most commonly seen oral lesions in these patients with a frequency of 78 (61%) and 51 (40%) respectively. Oral ulceration was seen in 35 (27%) of the patients. Thirty-three women (26%), presented with necrotizing ulcerative gingivitis, 6(5%) had necrotizing ulcerative periodontitis and 6(5%) had linear gingival erythema. Less than 3% of the patients presented with herpes, which was mainly extra-oral. No other HIV associated oral lesions were seen in these patients.
Conclusion: The prevalence of oral lesions associated with HIV infection for this particular sub-group is similar to results of other prevalence studies conducted elsewhere on women, though the prevalence of oral candidiasis was slightly higher in this group. The confirmation of these findings in pregnant women emphasizes the need for diagnosis of oral lesions by all health care workers and for recommended treatment or referral.
Common Oral Lesions Seen Amongst Sero-positive Clients at a Voluntary Confidential Counseling Testing Centre in Kaduna Nigeria
UE Amanyeiwe-Adaka*, C Igbokwe, SO Ajike
Maxillofacial Unit, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
U Amanyeiwe-Adaka:
The occurrence of common oral lesions seen amongst sero-positive patients was investigated in 638 consecutive patients attending the FRC voluntary confidential counseling and testing (VCCT) centre from November 2002 to November 2003. Different types of oral lesions were observed in 372 (58.3%) of subjects. The most prevalent of these lesions was oral candidiasis observed in 263 (70.7%) patients. The high prevalence of oral candidiasis is similar to those reported in studies from Jos in Nigeria, Cote D'Ivoire and South Africa. The prevalence of other oral lesions was much lower, some patients had more than one type of lesion. They included aphthous ulcers 67 (18%), herpes simplex 47 (12.6%), necrotizing gingivitis 30 (8.1%), salivary gland enlargement 19 (5.1%), necrotizing periodontitis 18 (4.8%), Kaposi sarcoma 12 (3.2%), herpes zoster 7 (1.9%), oropharyngeal carcinoma 5 (1.3%), melanotic hyper-pigmentation 3 (0.8%), maculo-papular lesions 3 (0.8%) and necrotizing fasciitis 2 (0.5%). Similar findings are reported from other studies. Management of these seropositive patients at this VCCT Centre was mainly symptomatic. Patients were given multivitamin supplements and treatment for opportunistic infections. Oral candidiasis was treated with Nystatin pastilles and lozenges, whereas fulminating cases of mycotic infection were given systemic fluconazole. Twelve of the 33 patients who could afford uninterrupted ARV supply for six months had oral lesions.
Conclusion: Oral lesions occurred more frequently in patients that presented with advanced stages of the infection. Seropositive patients on ART presented with fewer oral lesions. In patients with severe opportunistic infections, commencement of ARVs combined with symptomatic treatment of the opportunistic infections and nutritional support, contributed to recovery. Reduced rates of recurrence of infections, progressive rise in CD4 count and improvement in the patients general status was noted. In resource limited settings where facilities are not available, oral lesions may be used as a marker for staging the clinical progress of HIV/AIDS.
A3
Gender Differences in Oral Manifestations among South African HIV/AIDS Patients
E Blignaut*
Medical University of Southern Africa
E Blignaut:
Objectives: To determine gender differences in numbers, age and oral manifestations among black HIV/AIDS patients attending three AIDS clinics in the Gauteng province, South Africa.
Background: In 2002 it was estimated that 6.5 million South Africans were living with HIV/AIDS, and that women of child bearing age (15-49 years) constituted half of the infected population.
Methods: A retrospective analysis was performed on data obtained over a four year period, from the primary visit of patients attending outpatient clinics at three hospitals in the Pretoria region. At the time no patients had access to antiretroviral therapy. All patients received an oral examination, irrespective of any complaints. Surveillance swabbing for Candida was also performed.
Results: Of the total patient population 1031 (67.4%) were female and 498 (32.6%) male. Of the female patients 78.5% were aged between 20 and 39 years while 76% of the male patients were 30 years and older. Localised attachment loss was more prevalent in males (p≤0.05), while linear gingival erythema and a pericoronitis around an erupting third molar was observed more frequently in females (p≤0.01 and p≤0.05 respectively). In females a significant correlation (p≤0.001) between pseudomembranous candidiasis and a CD4 cell count below 200 cells/mm3 was observed. In males erythematous candidiasis correlated significantly with a CD4 cell count below 200 cells/mm3 (p≤0.01).
Conclusion: Twice as many females than males attended the clinics and they were also younger than the male group. Differences in the prevalence of oral manifestations between males and females were demonstrated, including differences in the correlation of some lesions with a CD4 count below 200 cells/mm3.
A4
HIV Related Oral Diseases Among Women in Zimbabwe
MM Chidzonga*1, M Mwale1, L Chidzumo1, E Makura1, K Malvin2, CH Shiboski2
1University of Zimbabwe, 2 University of California San Francisco
M Chidzonga:
Objectives: To estimate oral disease prevalence among women in Harare in relation to HIV serostatus and CD4 count, and to assess sensitivity and specificity of oral soft tissue examinations conducted by nurses compared to an oral surgeon.
Background: Because biologic assays to measure HIV disease progression are rarely accessible in sub-Saharan African countries due to prohibitive cost, we sought to investigate the use of HIV related oral lesions as potential markers for HIV disease progression as an inexpensive alternative.
Methods: We recruited HIV+ and HIV- women from 2 prospective cohort studies (HIVNET and WHO) in Harare. HIV serostatus was assessed at baseline. CD4 count was measured and a standardized oral soft tissue examination was performed at 6-month intervals by both a nurse examiner trained in the diagnosis of HIV-related oral lesions (using ECC criteria) and an oral surgeon. The examinations were done within 2 weeks of each other when possible. We report preliminary analyses conducted on baseline data as recruitment is still ongoing. We include only those women who were seen by both nurse and oral surgeon within a 2-week window.
Results: 433 women 342 (212 HIV+, 130 HIV-) were seen by both nurse and oral surgeon within a 2-week period. Mean age was 30.2 years (range 18-47) among HIV+ women and 27.4 years (range 19-36 y) among HIV- women. Oral candidiasis (OC), predominantly pseudo-membranous, was the most common lesion diagnosed by the oral surgeon in both HIV+ and HIV- women (28% versus 18%; p=0.03), and by the nurses (22% versus 8%; p=0.001). Hairy leukoplakia and Kaposi’s sarcoma were found in 2% and <1%, respectively, of HIV+ and in none of the HIV- women (by either nurse or oral surgeon). The prevalence of OC diagnosed by the oral surgeon was significantly higher among women with CD4 count <200 than in women with CD4 count 200-499 and >499 (57%, 36%, and 7%; respectively; p=0.02). The agreement rate between nurse and oral surgeon examinations was high among HIV+ women for the diagnosis of OC (91% agreement on positive diagnoses and 90% agreement on negative diagnoses). However, the agreement rate was lower for examinations done in HIV- women as the oral surgeon found a higher prevalence of erythematous candidiasis in that group than the nurses.
Conclusion: OC was the most common lesion in HIV-positive Zimbabwean women and was strongly associated with a low CD4 count. The inter-examiner agreement rate was good for diagnoses of OC among HIV-positive women, but erythematous candidiasis remains a diagnostic challenge. These preliminary results suggest that pseudomembranous candidiasis may be used as surrogate marker of disease progression, and is reliably diagnosed by nurses.
A5
Oro-facial Manifestations in Paediatric HIV: A Comparative Study of Institutionalized and Hospital Out-Patients
S Naidoo*, U Chikte
University of the Western Cape, Cape Town, South Africa
S Naidoo:
The aim of the study was to compare caries status and the number and type of oral mucosal lesions in HIV positive children from a hospital outpatient department and an institutionalized setting.
Oral examinations were performed using presumptive diagnostic criteria. The Fisher’s Exact and the Mann-Whitney tests were used for statistical comparison of the two study groups. A total of 169 children were examined of whom 42% were institutionalized and 58% hospital outpatients. One institutionalized child presented with Noma. 21% of the institutionalized population presented with Molluscum contagiosum, while none of the hospital outpatients presented with this condition.
Significantly more intra-oral mucosal lesions were observed in the hospital compared to the institutionalized group. The most frequently encountered oral lesion was candidiasis. Twice as many intraoral ulcers were recorded in the institutionalised group. Thirty nine percent of the hospitalized patients had multiple lesions compared to 28% in the institutionalised group. Almost three quarters of both populations were caries-free. The mean DMFT was higher in the hospital population. For both the permanent and primary teeth, the decayed component made up the major part of the DMFT/dmft, followed by the missing component. No fillings were recorded in either the primary or permanent teeth for both groups.
Oral lesions were common in HIV populations and were seen in both the hospital (63%) and institutionalized (45%) groups at high prevalence levels. HIV infected children should be considered high risk for caries due to the use of chronic medication, and to receive appropriate care in terms of both treatment and services.
A6
Oral Manifestation of HIV Paediatric Cases in Chennai, South India
R Thavarajah*1, TR Saraswathi1, U Devi1, S Solomon2, N Kumaraswamy2, NW Johnson3, K Ranganathan1
1Ragas Dental College and Hospital, Chennai, 2 YRG CARE, Chennai, 3Guy’s, King’s & St Thomas Dental Institute, London, UK
R Thavarajah:
Background: Of the 40 million people living with HIV globally, children constitute 2.5 million. In India there are 4.5 million people living with HIV and children infected with this infection constitute a major health problem. There are very few reports of oral lesions and conditions in Indian HIV seropositive children, even though the number of children affected by this disease is increasing.
Methods: Our study group consisted of 37 children referred to our tertiary HIV care center at Ragas Dental College and Hospital and YRG CARE, Chennai, India). ELISA and Western Blot confirmed the HIV sero status. A complete oral examination was undertaken by a trained dental surgeon and diagnosis of oral lesions was made on presumptive criteria established by the EC Clearing house, 1993 and WHO.
Results: Of the 37 pediatric cases in our cohort, 22 were males (59.5%) and 15 were females (40.5%). 84% acquired the infection through vertical transmission and 16% through blood transfusion. The lesions that were seen included candidiasis, gingivitis, parotid enlargement and cervical lymphadenopathy. The following table compares our results with published prevalence percentages. On a 6months follow up, all these oral lesions responded favorably to standard treatment protocols.
Conclusion: Given the morbidity of the oral lesions it is essential that information regarding oral lesions in pediatric population in India should be gathered for early diagnosis and treatment.
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5th World Workshop on Oral Health and Disease in AIDS .
Author , year / P.Candida / E. Candida / Candida / Angular chelitis / Parotid swelling / Cervical lymph
adenopa-thy / Gingivitis / OHL / DC
Ramos – Gomez FJ et al 2000 / 43% / - / - / - / - / - / - / - / -
Khongkunthian P et al 2001 / - / 17.8% / - / - / - / - / - / 6.7% / --
Santos LC et al
2001 / - / - / 22.5% / - / 8.8% / - / 17.5% / 1.3% / -
Magalhaes MG et al 2001 / 18.42% / 18.42% / - / 28.94% / 18.42% / - / 13.5% / 2.63% / -
Luis Gaitan – Cepeda et al
2002 / - / - / 29.2% / - / 2.1% / - / 4.2% / - / -
Okunseri et al
2003 / - / - / 2.9% / - / 2% / 1% / 20.6% / - / 19.6%
Present study 2004 / 16.2% / 5.4% / 18.8% / 10.8% / 2.7% / 5.4% / 21.6% / 2.7% / 35.1%
P- Pseudomembranous; E- Erythematous; OHL- Oral Hairy Leukoplakia; DC- Dental Caries
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5th World Workshop on Oral Health and Disease in AIDS .
A7
Classification of Oral Diseases of HIV-Associated Immune Suppression
M Glick*, SN Abel, CM Flaitz, CA Migliorati, LL Patton, JA Phelan, DA Reznik
ODHIS Workshop Group – USA
M Glick:
The present classification systems for HIV-associated oral lesions were developed in the early 1990s and have been valuable tools for both diagnostic and research purposes. With the advent of new antiretroviral therapy, the pattern of oral conditions is changing in the USA and a new classification system should be evaluated. This system should reflect changes in the epidemiology of oral lesions that are related to HIV disease and therapeutics. In addition, this system should take into account the association between the development of these lesions and the patient’s immune status. The terminology of “oral lesion” also needs to be changed to “oral disease”. Oral disease is defined as an abnormality characterized by a defined set of signs and symptoms in the oral cavity, extending from the vermilion border of the lip to the oropharynx, with the exception of salivary gland disease. Based on a review of the recent literature and expert opinion with majority consensus, the following groups of oral diseases are proposed for this revised classification system: