Oral manifestations of HIV infection in adults
Presence of most oral lesions are Oral Candidiasis, Oral Hairy Leukoplakia, Herpes zoster and persistent infection of Herpes simplex
Various oral manifestations of HIV infection in adults have been reported. Some of these symptoms were noticed very early on when the epidemic was first discovered in homosexual people. These manifestations are often conspicuous and can be accurately diagnosed, even based on clinical signs. Hence, in cases of suspected infection in a patient that cannot be verified by serological testing, oral manifestations may provide additional evidence of HIV infection.
In addition, the appearance of oral symptoms can also help to predict the progression to AIDS. These manifestations are closely related to immunodeficiency status, manifested by a decrease in CD4 lymphocyte counts, and a weaker association with viral burden. Therefore, oral lesions are often considered markers of viremia and progressive decline of the immune system associated with disease progression.
That is why almost all oral manifestations are present in the systems currently used for the classification and prognosis of HIV infection. These points to the need for a thorough examination of the oral cavity at all stages of the disease, diagnosis and treatment of oral lesions in HIV-infected patients and in people at-risk in all prevention programs. and intervention for HIV infection. Oral manifestations are also used to monitor patients in prophylactic, therapeutic and vaccine trials.
Classification of oral lesions
There are more than 30 oral lesions associated with HIV infection. In 1992 the following classification was agreed upon after a meeting on oral HIV manifestations in London:
Lesions are closely related to HIV infection.
Candida infection: erythema, pseudomembranous form.
Periodontal disease: erythema of the gumline, necrotic ulcerative gingivitis, ulcerative periodontal necrosis.
Injuries associated with HIV infection.
Infected bacterial: Mycobacterium avium -cellulare, M. Tuberculosis.
Necrotic ulcerative stomatitis.
Salivary gland disease: dry mouth, enlarged salivary glands on one or two sides.
Infected virus : herpes simplex, HPV (condyloma acuminata, focal epithelial hyperplasia, verruca vulgaris).
Lesions can be seen in HIV-infected people.
Nhiễm vi khuẩn : Actinomyces israeli, Escherichia coli, Klebsiella pneumoniae.
Cat scratch disease.
Increased epithelial cells in the walls of blood vessels.
Candida ringworm infection: Crypyococcus neoformans, Geotrichum candidum, Histoplasma capsulatum, Aspergillus flavus.
Neurological disorders: facial paralysis, pain of the triangular nerve
Infected virus: cytomegalovirus, molluscum contagiosum.
Meaning of oral expressions
Oral lesions in staging and classification systems
The presence of oral lesions most commonly Oral Candidiasis, Oral Hairy Leukoplakia, Herpes zoster and persistent Herpes simplex are included in the surveillance system for HIV infection. The STSKTG also considers oral presentation an important criterion and has a high prognostic value.
OC and OHL, in particular, are thought to be a sign of AIDS when serological tests or T-lymphocyte counts are not possible.
Oral injury is considered an early clinical sign of HIV infection
OC is the most common opportunistic infection in Thailand and other countries, occurring in more than 90% of infected people during the transition from the absence of clinical signs to AIDS. OC occurs in HIV / AIDS infected people mainly due to the loss of host resistance
OC and OHL are early signs of HIV infection. Studies following patients from seroconversion showed that one of these lesions appeared within 1 year in 10% of patients and within 5 years in 50% of patients.
Oral lesions allow to predict the course of HIV infection
The relationship between pseudomembranous OC and the development to AIDS has been verified. A similar link is found between OHL and AIDS. Many studies have determined the high predictive value of OC, OHL and several other oral lesions on the course of HIV infection. Erythematous OC is of equal value to pseudo membrane OC, although with less attention.
A study on 3 groups in San Francisco found that when OC or OHL was present at the first visit, AIDS came earlier in those patients. A Palmer study in London showed that 80% of AIDS patients were active compared with 50% of HIV-infected (not AIDS) patients. The question to be asked is how immunodeficiency mechanisms in the oral mucosa allow opportunistic infection, activation or spread of fungi or viruses leading to the appearance of oral lesions. Some studies have concluded that it is due to the defect in antigenic processing of Langerhans cells.
Oral lesions and antiretroviral therapy and prophylactic therapy for opportunistic infections
The presence of OC and OHL is often considered an indication for the use of antiretroviral regimens and prophylaxis of other OIs. For example, because OC is closely related to Pneumocystis carinii infection, when OC is seen in the mouth, it is necessary to prevent PC pneumonia. Likewise tuberculosis is often associated with OC in the Thai. Recurrent OC and OHL infections are considered indications for initiating antiretroviral therapy.
Oral lesions are markers that allow predicting the course of HIV infection
The prognostic value of oral lesions has been determined through academic studies, on many cohorts in many countries and it is concluded that OC and OHL are closely related to the immunodeficiency expressed as cell number CD4 drops below 200 / mm³ and is inversely proportional to anti-p24 antibodies in the serum.
Complete incidence of oral lesions
This rate varies a lot depending on the studies due to the way of sampling, classifying and detecting lesions ...
In some studies OC is the most common lesion, but some studies claim to be OHL. This may be because there are few anti-fungal drugs used in developing countries. In addition, since a number of developed countries currently adopt a highly active anti-retroviral therapy (Highly Active Anti-Retroviral Therapy), there are differences above.
For OC, sometimes the pseudomembranous form is recognized more than the erythema form. Unlike the pseudomembranous form, the erythematous form is not associated with HIV infection. There is no consensus in research results on this matter.
Surprisingly, studies in Asia did not record the presence of Kaposi sarcoma, only in Thailand, while in Africa this lesion was reported, although the way of HIV infection was similar to that in Asia. means mainly through heterosexual sex. Kaposi sarcoma is most commonly seen in the West among homosexuals.
So far, studies of HIV-associated oral lesions in Asia are very limited, perhaps these lesions also have racial and geographic features and due to lack of treatment for HAART.
Factors that may affect HIV-infected oral presentation
There are studies that suggest that there is a difference in the loss of adhesion in periodontal disease between blacks and whites or whites who have more oral manifestations than vV .. but the difference is hardly significant. .
Studies often show a higher incidence of oral lesions in men, especially OHL is more abundant in men. This may be because men often include homosexuals.
Ways of HIV infection
Some studies show that there is a difference in the rate of oral lesions between people infected by sexual contact with those infected through blood transfusions, drug injection, between sexual relationships. heterosexual and heterosexual sex ... however so far there are no adequate explanations of these issues, except that behavioural differences may play a role in the occurrence of lesions. mouth.
Risk factors are associated with the occurrence of oral lesions
Research in Thailand has shown that oral lesions are associated with disease progression (manifested by clinical signs and T4 lymphocyte numbers), alcohol use, smoking, poor oral hygiene and some weakness. other factors.
Rate of oral damage increases with immunodeficiency. In developing countries where it is difficult to have a CD4 count, this number can be derived from the total number of lymphocytes. (When the total number of lymphocytes is low from 1000 - 2000 and when it is less than 1000 / mm³, it is equivalent to the number of CD4 cells falling from 200 - 500 and below 200 / mm³).
One study showed that the rate of OC, especially erythema OC increased in people who drank more than 8.5 1 absolute alcohol/year. Alcohol has the ability to atrophy and lose stratification of the epithelium of the oral mucosa, making it easy for candida to penetrate and cause atrophic damage. OHL and white lesions are less associated with alcohol intake, and the receptors for epithelial EBV are mainly dependent on the degree of differentiation of the epithelium.
Most studies show that oral lesions of OC and OHL occur earlier in smokers. In contrast, smokers have less pressure.
Oral lesions appear to be more common in patients over 30 years of age
Many oral medications can affect the appearance of mouth lesions. Antiviral and antibiotic drugs work to increase oral manifestations. Antifungal drugs may increase or decrease the risk of fungal infections depending on the study. In addition, using antidepressants works to reduce saliva secretion and susceptible to candidiasis of scarlet fever.
Combination measures with multiple antiretroviral drugs and prophylactic treatment for opportunistic infections have increased resistance and decreased the rate of oral manifestations of HIV infection except for HPV infection.
Studies show that the rate of oral manifestations decreased from 47% to 37% with active therapy against Retrovirus, OHL, OC, KS, and gum and periodontal diseases both decreased while salivary gland disease and HPV infection. increase.