|Year : 2020 | Volume
| Issue : 7 | Page : 3722-3728
Oral health status and treatment needs among HIV/AIDS patients attending antiretroviral therapy center in Western India: A cross-sectional study
Pankaj Chaudhary1, Kanika Manral2, Rahul Gupta2, Aroon Kamal Singh Bengani3, Bhumit Ishvarlal Chauhan4, Deepanshu Arora5
1 Department of Public Health Dentistry, Daswani Dental College & Research Centre, Kota, Rajasthan, India
2 Department of Prosthodontics, Daswani Dental College & Research Centre, Kota, Rajasthan, India
3 Department of Oral and Maxillofacial Surgery, Daswani Dental College & Research Centre, Kota, Rajasthan, India
4 Department of Oral Medicine, Diagnosis and Radiology, Daswani Dental College & Research Centre, Kota, Rajasthan, India
5 Conservative and Endodontics, Daswani Dental College & Research Centre, Kota, Rajasthan, India
|Date of Submission||19-Mar-2020|
|Date of Decision||25-Apr-2020|
|Date of Acceptance||28-Apr-2020|
|Date of Web Publication||30-Jul-2020|
Dr. Pankaj Chaudhary
16-A, Kalyan Colony, Model Town, Jaipur 302017, Rajasthan
Source of Support: None, Conflict of Interest: None
Aims and Objectives: Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem across the globe. Among 37.9 million people are living with HIV in the world and 21.40 lakh are in India itself. The aim of this study was to assess the oral mucosal, periodontal, and dentition status of HIV/AIDS patients attending ART (antiretroviral therapy) center in Jaipur city, India. Methods and Materials: A total of 588 HIV/AIDS subjects at the ART center in Jaipur city were examined. Oral mucosal, periodontal, and dentition status was recorded using a modified WHO Oral Health Assessment form 1997. A pilot study was conducted among 50 patients. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software, version 20.0. The statistical tests that were applied for the analysis included Chi-square test, Fisher exact test, and one-way analysis of variance (ANOVA). Results: Of 588 study subjects examined, 65.6% were men and 34.4% were women. Candidiasis was the most prevalent oral lesion (32.5%) followed by acute necrotizing gingivitis (26%), hyper melanotic pigmentation (15.8%), and ulcerations (8.7%), respectively. Oral hairy leukoplakia was observed in only 3.9% and not a single case of Kaposi's sarcoma was reported. Buccal mucosa (36.7%) was the most common site of the presence of oral mucosal lesions. The mean decayed, missing, and filled teeth (DMFT) score was 4.03 ± 1.54. Almost all the subjects needed one or other form of dental treatment. Only 12% of the patients had healthy periodontium. Conclusion: Candidiasis was the most prevalent oral lesion. Efforts should be made to meet the increased treatment needs in these patients.
Keywords: Acquired immunodeficiency syndrome, antiretroviral therapy, candidiasis, human immunodeficiency virus
|How to cite this article:|
Chaudhary P, Manral K, Gupta R, Bengani AK, Chauhan BI, Arora D. Oral health status and treatment needs among HIV/AIDS patients attending antiretroviral therapy center in Western India: A cross-sectional study. J Family Med Prim Care 2020;9:3722-8
|How to cite this URL:|
Chaudhary P, Manral K, Gupta R, Bengani AK, Chauhan BI, Arora D. Oral health status and treatment needs among HIV/AIDS patients attending antiretroviral therapy center in Western India: A cross-sectional study. J Family Med Prim Care [serial online] 2020 [cited 2021 Jan 24];9:3722-8. Available from: https://www.jfmpc.com/text.asp?2020/9/7/3722/290809
| Introduction|| |
Acquired immunodeficiency syndrome (AIDS) is a fatal illness caused by the human immunodeficiency virus, which breaks down the body's immune system, leaving an individual exposed to life-threatening opportunistic infections, neurological disorders, or unusual malignancies.
The first case of AIDS was reported by CDC (Center for Disease & Control) in 1981 among homosexual men in the USA.
Globally unprotected heterosexual route is the most common route of transmission of HIV. The other modes of transmission of HIV comprise unprotected penetrative sex between men, injecting drug use, and unsafe blood transfusions or injections.
According to the UNAIDS (United Nations Program on HIV and AIDS) report in 2019, a total of 37.9 million people are living with HIV worldwide and 1.7 million people are newly infected with HIV in 2018. Worldwide, nearly there were 1 lakh death due to AIDS.
The number of people newly infected with HIV and the number of AIDS-related deaths have declined, adding to the stabilization of the epidemic. In addition, the number of people with HIV receiving treatment has increased to 15.0 million as of March 2015, a 1.4 million increase since June 2014.
In India, the first HIV case was detected in 1986 among female sex workers in Chennai. The estimated number of people living with HIV/AIDS in India was 21.40 lakh in 2017. Adult HIV prevalence among 15–49-year old people is estimated at 0.22% (0.16–0.30) in 2017. Nationally, around 69.11 thousand PLHIV died of AIDS-related causes in 2017. At 2.04%, Mizoram had the highest adult HIV prevalence in 2017, followed by Manipur at 1.43% and Nagaland at 1.15%. India is forecasted to have the third maximal number of estimated people living with HIV/AIDS, after South Africa and Nigeria.
Under the National AIDS Control Programme, provision of free antiretroviral therapy (ART) for people living with HIV/AIDS was launched on April 1, 2004 in eight government hospitals located in six states. Till October 2016, there were 528 ART centers operating in the country.
A public health access for the provision of ART implies that ART regimen should be standardized, simple to use, and should have minimum detrimental effects.
As per the report of RSACS (Rajasthan State AIDS Control Society), 23 ART centers in Rajasthan are functional.
Oral manifestations are diagnostic and prognostic indicators of HIV-infected people. Although there are a number of studies on oral manifestations of HIV infection, very little information is available on the Asian population. The oral presentation of the syndrome may not be the same everywhere.
Thus, this study was undertaken to find out the prevalence of oral conditions among HIV/AIDS patients attending ART center in Jaipur city, India.
| Methods and Materials|| |
It was a cross-sectional study which was conducted to assess the oral health status and treatment needs of 588 HIV/AIDS patients attending ART center of Jaipur city.
A pilot study was conducted among 50 patients and based on the observations the performa was modified which was used in the study.
Modified WHO Oral Health Assessment form 1997 was used to record the oral mucosal lesion/conditions, periodontal, and dentition status of the study subjects.
The oral cavity was examined using disposable tweezers, disposable mouth mirror, community periodontal index (CPI) probe, and straight probe for the presence of dental caries and oral lesions.
The ethical clearance was granted by the institutional review board and the concerned authorities.
The inclusion criteria of the study included the following:
- All the HIV/AIDS subjects present on the days of the study.
- All the subjects who gave verbal informed consent.
The exclusion criteria of the study included the following:
- Patients in ICU (intensive care unit), those with dementia.
- Subjects who were not willing to participate.
Standardization and calibration of the examiner were done. The data collected were entered in a spreadsheet program (Microsoft Excel 2007) and then subjected to analysis using Statistical Package for the Social Sciences (SPSS) software, version 20.0 by descriptive analysis. Statistical tests which were applied for the analysis included Chi-square test, Fisher exact test, and one-way analysis of variance (ANOVA). Ethical clearance was obtained from Institutional Ethical Committee dated 16.01.14.
| Results|| |
This study was conducted to assess the prevalence of oral mucosal lesion/conditions, periodontal, and dentition status of HIV/AIDS patients attending ART center in Jaipur city, India.
[Table 1] shows the distribution of study subjects according to gender. The study population consisted of 588 individuals, of which 386 (65.6%) were men and 202 (34.4%) were women.
[Table 2] shows the distribution of study subjects according to different age groups. The study subjects were divided into different age groups of 5–15 years (7.9%), 16–25 years (6.9%), 26–35 years (50.8%), 36–45 years (30.9%), and 46–55 years (3.2%).
|Table 2: Distribution of study subjects according to different age groups|
Click here to view
[Table 3] shows the association of extraoral findings with gender. Among the study subjects 88.9% had normal extraoral appearance.
[Table 4] shows the association of oral mucosal lesions/conditions with gender. Candidiasis was the most prevalent oral condition found among 32.5% of the study subjects.
[Table 5] shows the association of oral mucosal conditions (location) with gender. Buccal mucosa was the most common site of presence of oral mucosal conditions among 39.8% male and 30.6% female study subjects.
[Table 6] shows the association of periodontal status (CPI) with gender. Approximately 2% of the subjects had a healthy periodontal status. The presence of calculus was the most prevalent finding among 48.9% male and 53.9% female subjects.
[Table 7] shows the association of periodontal status (loss of attachment) with gender. The loss of attachment of 0-3 mm was seen among 49.1% subjects. The prevalence of loss of attachment of 4–5 mm among the male and female study subjects was 28.2% and 30.6%, respectively.
[Table 8] shows the mean decayed (D), missing (M), filled (F) teeth, and DMFT score according to gender. As far as the decayed, missing and filled permanent teeth are concerned, mean of decayed (D), missing (M), and filled (F) teeth was 3.21 ± 1.205, 0.72 ± 0.63, and 0.09 ± 0.41. The total mean DMFT score was 4.03 ± 1.54. The mean DMFT score of men was more as compared to women which was statistically significant.
|Table 8: Mean decayed (D), missing (M), filled (F) teeth, and DMFT score according to gender|
Click here to view
[Table 9] shows the number of study subjects with different dental treatment needs. One surface filling treatment was required by 86.7% male and 72% female study subjects, which is statistically significant. Prosthetic treatment was required by 69.1% male and 73.2% female subjects.
| Discussion|| |
This study was conducted to find out the oral mucosal, periodontal, and dentition status of HIV/AIDS patients attending ART center in Jaipur city.
Study consisted of 588 subjects of which 386 (65.6%) were males and 202 (34.4%) were females.
Progression of HIV infection is associated with a range of oral manifestations. This study shows that nearly 71.4% of the patients had one or the other form of oral mucosal conditions. This is in close agreement with the study conducted by Kumar S et al. where 75% of the 126 HIV subjects had oromucosal lesions, Rath H et al. where it was 68.8%, and in a study done by Bodhade AS et al. among 399 HIV-positive individuals where the prevalence of oral mucosal conditions was 76.70%. This finding contradicts with the study conducted by Adebola AR et al., Sroussi HY et al. and Arendorf TM et al. where the prevalence of oral mucosal conditions was 61.9%, 55%, and 60.4%. The oral lesions may have a negative impact on the nutritional health of HIV-infected individuals by reducing food intake as a result of discomfort during eating.
Lymphadenopathy among the study subjects in this study was approximately 5%. This finding is consistent with the results of the study conducted by Chidzonga MM et al. (7.1%) and contrary to the study done by Rwenyonyi CM et al. (60.8%) and Hodgson TA et al. (38.3%).
Approximately 4.8% of the subjects have abscess which is in accordance with the study done by Kumar S et al. (3.97%).
Oral candidiasis or thrush (32.5%) as the most common clinical finding in our study population. This finding is consistent with the results of the study conducted by Divakar DD et al. (27.3%), Kumar S et al. (36.51%) and in a study done by Ranganathan K et al. where the prevalence of oral candidiasis was 28.7%. This finding is not in accordance with the result of the study done by Beena JP et al. (11.62%) and Rath H et al. (16.27%).
The prevalence of angular cheilitis was observed in 5.4% of the study subjects which is in accordance with the study done by Divakar DD et al., Beena JP et al. and Bodhade AS et al. where it was 7.3%, 5% and 4.3%, respectively. This prevalence is not in agreement with the findings of Adurogbangba MI et al. (21%), Naidoo S et al. (11.8%) and Pongsiriwet S et al. (10%).
Melanotic hyperpigmentation was observed among 15.8% of the study subjects which coincides with the findings of de Faria PR et al. (14%) among 92 subjects with AIDS in Sao Paulo, Bodhade AS et al. (19.5%) and Divakar DD et al. (11.96%). It is known side effect of highly active ART. This finding is not in agreement with the result of the study done by Sharma G et al. (34.6%). Difference in number of subjects with ART in each study cohort may be the reason for the difference in prevalence of pigmentation. The prevalence of mucosal hyperpigmentation can also be linked with increased melanin production in the epithelium associated with increased release of a melanocute stimulating hormone.
In this study. the prevalence of ulceration among the study subjects was 8.7% which coincides with the results of the study done by Divakar DD et al. (7.6%) and Beena JP (11%). This finding is not in accordance with the results obtained by Kiran K et al. (19.50%) and de Francis PR et al. (18.4%).
Not a single case of Kaposi's sarcoma was reported in this study. The result of this study is consistent with the result obtained by Agbelusi GA et al. Ceballos SA et al. observed Kaposi's sarcoma in 2.3% of cases––all in homosexual males. The result of this study is consistent with the finding that oral Kaposi sarcoma has not been reported from Asian studies where heterosexual intercourse is the major route of HIV transmission.
Leukoplakia was observed in only 3.9% of the study subjects. The present finding is in agreement with the results of the study done by Ranganathan K et al. (3.7%) and Barasch A et al. (2%). According to a study done by Chattopadhyay A et al., the use of antifungal medication is a strong risk factor for oral hairy leukoplakia.
In this study, acute necrotizing gingivitis was observed in 26% of the subjects. This finding coincides with the results of the studies done by Amadi ES et al. (21.3%) and Adebola AR et al. (21.9%). And contrary to the findings of Galitis ON et al. (8.1%).
The mean DMFT score of the subjects in this study was 4.03 which coincides with the results of the study done by Eldridge K et al. (4.4). The mean DMFT score of this study is not in agreement with the result obtained from the studies done by Tututuku K et al. (1.69), Naidoo S et al. (1.43) and Kumar S et al. (12.83). Higher mean DMFT score of HIV-positive individuals indicates their poor oral health status and warrants the need of special attention toward it.
Almost all the subjects in this study needed one or the other form of dental treatment. Nearly 82% of the study subjects needed one surface filling, whereas 61.9% of the subjects required two or more surface filling. Extraction was another prevalent treatment need (73%).
In this study, the prevalence of periodontal loss of attachment was 49.1% (LOA score 0), 29.1% (LOA score 1), 9.9% (LOA score 2), 2.2% (LOA score 3) and 1.7% (LOA score 4) which is not in accordance with the results reported in the study done by Kumar S et al. where it was 7.1%, 4%, 26.2%, 37.3% and 25.4%, respectively.
The prevalence of periodontal loss of attachment greater than 4 mm among the study subjects in this study was 42.8% which does not coincide with the results of the study conducted by McKaig RG et al. (60%).
In this study, 13.7% of the study subjects had a periodontal loss of attachment 6 mm or more which is does not coincide with the result of the study conducted by Tomar SL et al. (20%).
In this study, the prevalence of pocket depth greater than 4 mm among the study subjects was 42.6% which is not in agreement with the finding reported by McKaig RG et al. where it was 51%.
Vishnu V et al. conducted a study that showed that HIV-positive patients have poor oral health status and also have less awareness about oral health. The use of antiretroviral drugs is also responsible for the development of periodontal diseases, dental caries, and oromucosal lesions.
This information can assist dental professionals, policymakers, and public health officials to meet the needs of people living with HIV/AIDS.
Role of medical professional/physicians
Updated screening recommendations give physicians an important role in assessing HIV/AIDS patients. They should encourage all patients under his/her guidance to conduct a semi-annual oral health examination and to attach to the oral health-care professional's recommendations regarding appropriate follow-up. All medical health-care providers should be aware of oral health referral sources for patients under their care. Documentation that a dental referral was made or that the patient is under the care of a dental professional should be evident within the clinical care plan of the medical record. The medical provider should forward any requested clinical information to the patient's oral health-care provider in a timely fashion.,
| Conclusion|| |
It can be concluded from this study that oral candidiasis was the most prevalent oromucosal lesion followed by acute necrotizing ulcerative gingivitis. Approximately 2% of the subjects had healthy periodontium and the mean DMFT score was 4.03 ± 1.54. Oral manifestations are diagnostic and prognostic indicators of individuals infected with HIV. Therefore, individuals infected with HIV should be evaluated carefully for the presence of oral manifestations of HIV infection which often alerts as an early alarm of HIV infection contributing toward early detection and management of HIV infection.
Thus one should know about the importance of good oral health and a dentist should be placed in all the ART centers to give oral health education and to eradicate oral health-related problems and oral infection among these immune suppressive patients. Further studies should be undertaken in various states of India, specifically now, in the era of ART to find out the changing prevalence of oral diseases, oral health status, and treatment needs. Proper coordination between medical and dental health-care professionals is required to ensure regular screening for oral lesions and appropriate early management.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Park K. Text Book of Preventive and Social Medicine. 19th
ed. 2007. Banarsidas Bhanot. India.
Solomon S, Solomon SS, Ganesh AK. AIDS in India. Postgrad Med J 2006;82:545–7.
Rao UK, Ranganathan K, Kumarasamy N. Gender differences in oral lesions among persons with HIV disease in Southern India. J Oral Maxillofac Pathol 2012;16:388-94.
] [Full text]
Kumar S, Mishra P, Warhekar S, Airen B, Jain D, Godha S. Oral health status and oromucosal lesions in patients living with HIV/AIDS in India: A comparative study. AIDS Res Treat 2014:1-4.
Rath H, Raj SC. Assessment of oral health status and treatment needs of HIV/AIDS patients visiting government hospitals and rehabilitation centers in Bangalore city. Indian J Sex Transm Dis AIDS 2013;34:59-60.
Bodhade AS, Ganvir SM, Hazarey VK. Oral manifestations of HIV infection and their correlation with CD4 count. J Oral Sci 2011;53:203-11.
Adebola AR, Adeleke SI, Mukhtar M, Osunde OD, Akhiwu BI, Ladeinde A. Oral manifestation of HIV/AIDS infections in paediatric Nigerian patients. Niger Med J 2012;53:150-4.
] [Full text]
Sroussi HY, Villines D, Epstein J, Alves MC, Alves ME. Oral lesions in HIV-positive dental patients-one more argument for tobacco smoking cessation. Oral Dis 2007;13:324-8.
Arendorf TM, Bredekamp B, Cloete CA, Sauer G. Oral manifestations of HIV infection in 600 South African patients. J Oral Pathol Med 1998;27:176-9.
Chidzonga MM. HIV/AIDS orofacial lesions in 156 Zimbabwean patients at referral oral and maxillofacial surgical clinics. Oral Dis 2003;9:317-22.
Rwenyonyi CM, Kutesa A, Muwazi L, Okullo I, Kasangaki A, Kekitinwa A. Oral manifestations in HIV/AIDS infected children. Eur J Dent 2011;5:291-8.
Hodgson TA. HIV-associated oral lesions: Prevalence in Zambia. Oral Dis 1997;3:546-50.
Divakar DD, Kheraif AL, Ramakrishnaiah R, Khan AA, Sandeepa NC, Alshahrani OA, et al.
Oral manifestations in human immunodeficiency virus infected pediatric patients receiving and not receiving antiretroviral therapy: A cross sectional study. Paediatr Croat 2015;59:152-8.
Ranganathan K, Magesh KT, Kumarasamy N, Solomon S, Viswanathan R, Johnson NW. Greater severity and extent of periodontal breakdown in 136 south Indian human immunodeficiency virus seropositive patients than in normal controls: A comparative study using community periodontal index of treatment needs. Indian J Dent Res 2007;18:55-9.
] [Full text]
Beena JP. Gingival status: An indicator of disease progression and its correlation with the immunologic profile in HIV-infected children on antiretroviral therapy. J AIDS HIV Res 2015;7:68-73.
Adurogbangba MI, Aderinokun GA, Odaibo GN, Olaleye OD, Lawoyin TO. Oro-facial lesions and CD4
counts associated with HIV/AIDS in an adult population in Oyo state, Nigeria. Oral Dis 2004;10:319-26.
Naidoo S, Chikte U. Oro-facial manifestations in paediatric HIV: A comparative study of institutionalized and hospital outpatients. Oral Dis 2004;10:13-8.
Pongsiriwet S, Iamaroon A, Kanjanavanit S, Pattanaporn K, Krisanaprakornkit S. Oral lesions and dental caries status in perinatally HIV-infected children in Northern Thailand. Int J Paediatr Dent 2003;13:180-5.
de Faria PR, Vargas PA, Saldiva PH, Böhm GM, Mauad T, de Almeida OP. Tongue disease in advanced AIDS. Oral Dis 2005;11:72-80.
Sharma G, Pai KM, Suhas S, Ramapuram JT, Doshi D, Anup N. Oral manifestations in HIV/AIDS infected patients from India. Oral Dis 2006;12:537-42.
Baghirath PV, Krishna AB, Gannepalli A, Ali MM. Oral manifestations of HIV in children receiving anti-retroviral therapy in Hyderabad, India. Eur Arch Paediatr Dent 2013;14:389-95.
Kiran K, Shetty S. Oral and periodontal manifestations among HIV population in southern India. Int J Basic Appl Med Sci 2013;3:184-9.
Agbelusi GA, Wright AA. Oral lesions as indicators of HIV infection among routine dental patients in Lagos, Nigeria. Oral Dis 2005;11:370-3.
Ceballos SA, Aguirre-Urizar JM, Bagan-Sebastian JV. Oral manifestations associated with human immunodeficiency virus infection in a Spanish population. J Oral Pathol Med 1996;25:523-6.
Kerdpon D, Pongsiriwet S, Pangsomboon K, Iamaroon A, Kampoo K, Sretrirutchai S, et al.
Oral manifestations of HIV infection in relation to clinical and CD4
immunological status in northern and southern Thai patients. Oral Dis 2004;10:138-44.
Barasch A, Safford MM, Catalanotto FA, Fine DH, Katz RV. Oral soft tissue manifestations in HIV-positive vs. HIV-negative children from an inner population: A two year observational study. Pediatr Dent 2000;22:215-20.
Chattopadhyay A, Caplan DJ, Slade GD, Shugars DC, Tien HC, Patton LL. Incidence of oral candidiasis and oral hairy leukoplakia in HIV-infected adulta in North Carolina. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:39-47.
Amadi ES, Ngwu BAF, Nwakpu KO, Ojong NA, Anyaele UP, Aballa AN, et al.
Dental caries and oral lesions among HIV/AIDS patients in Enugu and Calabar towns in Nigeria. Nat Sci 2012;10:21-5.
Nicolatou GO, Velegraki A, Paikos S, Economopoulou P, Stefaniotis T, Papanikolaou IS, et al.
Effect of PI-HAART on the prevalence of oral lesions in HIV-I infected patients. A Greek study. Oral Dis 2004;10:145-50.
Eldidge K, Gallagher JE. Dental caries prevalence and dental health behaviour in HIV-infected children. Int J Paediatr Dent 2000;10:19-26.
Tukutuku K, Muyembe-Tamfum L, Kayembe K, Mavuemba T, Sangua N, Sekele I. Prevalence of dental caries, gingivitis and oral hygiene in hospitalized AIDS cases in Kinshasa, Zaire. J Oral Pathol Med 1990;19:271-2.
Mckaig RG, Thomas JC, Patton LL, Strauss RP, Slade GD, Beck JD. Prevalence of HIV-associated periodontitis and chronic periodontitis in a Southeastern US study group. J Public Health Dent 1998;58:294-300.
Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-Seropositive military personnel. J Periodontol 1995;66:421-8.
Vishnu V, Saxena V, Verma H, Sharva V, Jain N, Sathpathy M. Oral health status & treatment needs of patient attending anti retro-viral therapy among HIV patient in Government Medical College, Bhopal-A cross-sectional study. Dent Oral Maxillofac Res 2019;5:1-5.
Ahmed A, Bugaje MA, Bubadoko AA, Ameh E. Management of AIDS associated Kaposi sarcoma in Nigerian children: A case series and review of literature. J Natl Med Assoc 2012;104:385-9.
Shiboski CH, Palacio H, Neuhaus JM, Greenblatt RM. Dental care access and use among HIV-infected women. Am J Public Health 1999;89:834-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]