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ORIGINAL RESEARCH  
Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 351-355
Age-related – oral manifestations and co-morbidities in human immunodeficiency virus-infected/acquired immune deficiency syndrome adults in Hyderabad, India


1 Department of Oral Pathology and Microbiology, Panineeya Dental College and Research Centre, Hyderabad, Telangana, India
2 Department of Oral Medicine and Radiology, SGT University, Budhera, Gurgaon, Haryana, India

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Date of Submission03-Mar-2015
Date of Decision09-Apr-2015
Date of Acceptance25-Aug-2015
Date of Web Publication20-Oct-2015
 

   Abstract 

Background: The objective of the study was to clinically evaluate age-related - oral manifestations and co-morbidities in different age groups of human immunodeficiency virus-infected/acquired immune deficiency syndrome adults. Materials and Methods: A cross-sectional study was conducted among 200 adult patients aged above 20 years at infectious diseases units, medical wards and ART centre of Gandhi Medical Hospital, Hyderabad. Oral manifestations were diagnosed according to the presumptive criteria of EC-Clearinghouse Classification, and clinical data were retrieved from patient's medical records. Chi-square test was used for statistical analysis. Results: Men (72%) in the young age group of 21–30 years were commonly affected. Heterosexual mode of transmission was most common in all the age groups, and the overall distribution were statistically significant (P < 0.05). Most common oral findings seen in 21–30 years of age were depapillation (90%), hyperpigmentation (70% and 72%) in 31-40 and 41–50 years old and linear gingival erythema (68%) in above 50 years of age group. The various co-morbidities included the recurrent bacterial and skin infections (64% and 62% respectively) in the younger age group. Renal and cardiac diseases with pulmonary tuberculosis (74%) were commonly observed in middle-aged and elders. Conclusions: The underlying oral manifestations and co-morbidities could become very important variables that must be taken into account in determining treatment efficacy or health policy.

Keywords: Age, co-morbidities, human immunodeficiency virus, oral manifestations

How to cite this article:
Krishna AB, Gannepalli A, Baghirath PV, Khaled S, Shailaja S, Anuradha C. Age-related – oral manifestations and co-morbidities in human immunodeficiency virus-infected/acquired immune deficiency syndrome adults in Hyderabad, India. Indian J Dent Res 2015;26:351-5

How to cite this URL:
Krishna AB, Gannepalli A, Baghirath PV, Khaled S, Shailaja S, Anuradha C. Age-related – oral manifestations and co-morbidities in human immunodeficiency virus-infected/acquired immune deficiency syndrome adults in Hyderabad, India. Indian J Dent Res [serial online] 2015 [cited 2019 May 23];26:351-5. Available from: http://www.ijdr.in/text.asp?2015/26/4/351/167624


Worldwide, life expectancy has been increasing over the last several decades, even in developing countries, leading to a greater number of living individuals ≥60 years. There will be approximately 2 billion people surviving ≥60 years in the world by 2025, the majority of whom (80%) will reside in developing countries.[1]

About 34.2 million people worldwide have been infected with human immunodeficiency virus (HIV).[2] Approximately 2.3 million people were estimated to be infected with HIV in India in 2009, and the estimated adult prevalence was 0.31%. India has the third-highest number of people living with HIV accounting for about four out of 10 people infected with the deadly virus in the Asia-Pacific region, according to a UN report. The report by UNAIDS, the United Nations Programme on HIV/acquired immune deficiency syndrome (AIDS), said that 19 million of the 35 million people living with the virus globally do not know their HIV-positive status and so ending the AIDS epidemic by 2030 will require smart scale up to close the gap.[3]

HIV-infected patients may have a greater risk of oral manifestations and co-morbidities compared with the general population. The availability of several therapeutic regimens has transformed HIV infection from a life-threatening disease into a chronic condition. Older patients with HIV infection constitute a new treatment challenge in terms of the cumulative effects of ageing and antiretroviral therapy.

Physiological changes observed with ageing, including increased risk of infection, reduced immunocompetence, the appearance of several comorbid conditions which can affect the disease process and complicate its management, and interactions among antiretrovirals and drugs used for the treatment of other diseases, underline the need for age-related evaluations of treatment and management strategies. Hence, a cross-sectional study was undertaken to clinically evaluate age-related - oral manifestations and co-morbidities in different age groups of HIV- infected/AIDS adults.


   Materials and Methods Top


Study design, study population, and study area

A cross-sectional study was conducted among 200 adult patients aged above 20 years at infectious diseases units, medical wards and ART centre of Gandhi Medical Hospital, Hyderabad. The seropositive adults who were recently diagnosed to be HIV-infected/AIDS subjects and who were willing to participate in the survey were selected in the present study. HIV-infected/AIDS subjects with a history of highly active antiretroviral therapy (HAART) or any other medication were excluded from the study.

Ethical considerations

The study protocol was reviewed by the Ethical Committee of Panineeya Dental College and Research Centre, Hyderabad and was granted ethical clearance. Official permissions were obtained from Gandhi Medical Hospital.

Sample selection

Patients were divided into four age groups of 50 each: 21–30, 31–40, 41–50, and above 50 years old HIV-infected/AIDS were considered.

Proforma details





  • General information: Age, gender, mode of transmission, presence of HIV-related systemic disease, and oral manifestations
  • Clinical examination: The clinical examination was carried out by the well trained and calibrated examiner (AMM) according to Type III examination of the WHO Oral Health Survey Basic Methods.[5] Sterile and disposable ice-cream wooden sticks, mouth mirrors, explorers, and a normal (incandescent) head-mounted light were used for examination. All the standard precautions for infection control were followed during the study.


    • Oral manifestations: Oral lesions were diagnosed according to the presumptive criteria of EC-Clearinghouse Classification on oral problems related to HIV infection and World Health Organization (WHO) collaborating center on oral manifestations of the immunodeficiency virus.[4] The clinical parameters examined were hyperpigmentation, linear gingival erythema, angular cheilitis, oral hairy leukoplakia, oral ulcers, depapillation, erythematous, and pseudomembranous candidiasis, necrotizing ulcerative gingivitis, and other lesions (soreness of mouth, swollen papillae, burning mouth syndrome, patches or papules on palate, blisters)
    • Clinical history was retrieved from patient's medical records, and co-morbidities were recorded. The clinical parameters examined were pulmonary and extrapulmonary tuberculosis, skin infections, recurrent bacterial infections, gastric diseases, renal diseases, cardiac diseases, pneumonia, liver diseases, eye infections, and other systemic diseases (bone disorders, psychological issues, tuberculous-meningitis, weight loss, loss of appetite, vaginal candidiasis, toxoplasmosis, cytomegalovirus retinitis, nail changes, breathlessness, hepatitis-B, asthma, chronic obstructive pulmonary disease, hypertension, diabetes, ear infections, and esophageal ulcers).




Statistical analysis

The recorded data were compiled and entered into a spreadsheet computer programme (Microsoft Excel 2007) and then exported to SPSS version 14 (SPSS Inc., Chicago, IL, USA) for analysis. Chi-square test was used for statistical analysis. Statistical significance was set at <0.05 level.


   Results Top


In our study, the majority were men (61%) and in all the age groups, men showed higher prevalence with the highest being in 21–30 years of age [Table 1]. The prevalence was higher among women in the age group of 31–40 years in comparison with other age groups. The overall distribution was not statistically significant (P > 0.05). In all the age groups, heterosexual mode of transmission was most common, though in age group of 21–30 years of age, homosexual mode of transmission and few other modes (blood transfusion, unsafe injections, sharing needles, and mother to child) were also present. In elderly population above 50 years of age, other modes of transmission were also seen. This distribution in the mode of transmission was statistically significant (P < 0.05).
Table 1: Distribution of study population according to age, gender, and mode of transmission

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Most common oral findings seen in 21–30 years of age were depapillation (90%), followed by hyperpigmentation (78%), oral hairy leukoplakia and angular cheilitis (76%) each. Hyperpigmentation (70%), ulcerations, and xerostomia (66%) were most prevalent among 31–40 years age group. Hyperpigmentation (72%), angular cheilitis, and erythematous candidiasis (70%) among 41–50 years and linear gingival erythema (68%), erythematous candidiasis (66%), hyperpigmentation (64%) in subjects above 50 years were recorded. Other than hyperpigmentation, pseudomembranous candidiasis and others categorized lesions, all the other oral manifestations were found to be statistically significant (P < 0.05) in their distribution with regard to age [Table 2].
Table 2: Distribution of oral manifestations according to age of the study population

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The various co-morbidities associated with the HIV-infected/AIDS subjects included the recurrent bacterial and skin infections (64% and 62% respectively) in the younger age group. Renal diseases and pulmonary tuberculosis (74%) were commonly observed in the fourth decade. The elderly population (41–50 and above 50 years) were found commonly suffering from cardiac diseases (68% and 78%), renal diseases (58% and 68%), and skin infections (70% and 60%), respectively [Table 3]. However, the skin, recurrent bacterial and eye infections were not statistically significant (P > 0.05) when compared with different age groups.
Table 3: Distribution of co-morbidities according to age of the study population

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In all the age groups, two to three number of oral manifestations were more prevalent. Though more than three oral manifestations were less frequent, it was more in the younger age group [Figure 1]. Similarly up to two co-morbidities were common in all age group. However, the prevalence of more than two numbers of co-morbidities showed a continuous increase in relation to the age [Figure 2].
Figure 1: Number of oral manifestation per patient in each age group

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Figure 2: Number of co-morbidities per patient in each age group

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   Discussion Top


Chronic conditions associated with aging such as non-AIDS-defining malignancies, cardiovascular diseases, and other end-organ diseases and deaths attributable to these conditions have increased in HIV/AIDS cohorts.[6],[7],[8] In our study, the majority of subjects affected were men (72%) which is a similar finding observed in most of the studies from South Asian countries.[9],[10],[11] Similar findings were also reported in the overall HIV population in Brazil and Rio de Janeiro State.[12] The peak distribution in age (21–30 years) reflects the status of HIV epidemic in India. A high prevalence of HIV infection in this age group could lead to a decrease in working force and have an adverse effect on the socioeconomic status of our country.

In this work, we found that older HIV-infected patients differ from younger patients in epidemiology, timing of HIV diagnosis, age-specific health challenges, and organ dysfunctions. Heterosexual contact (85.5%), as found in most other Asian studies, was the major route of transmission in the majority of the subjects.[11],[13],[14] A higher rate of HIV transmission through heterosexual contacts (52.8%) was found in older patients compared with younger controls.[15] In older patients, a very high rate of transmission through other sources (30%) of HIV exposure was found.

Several studies have shown a high prevalence of oral lesions in HIV-infected individuals.[16],[17],[18],[19] In this study, majority patients had at least one type of oral manifestation. Previous studies from Thailand,[9] Cambodia,[20] and India [21] have shown slightly higher prevalence rates of 82%, 86%, and 90%, respectively. Oral manifestations mainly developed in the second and third decade of life.[22] Patients <50 years showed at least two oral manifestations, but those above 50 years demonstrated more than two oral manifestations.

Hyperpigmentation was predominant (around 70%) in our patients. This difference, however, was not statistically significant (P = 0.488) among different age groups. Oral hairy leukoplakia was seen in around 45% of patients compared with 38% of patients in a study in Northern Thailand,[23] 11% of HIV-infected patients in Hong Kong [24] and 2.1% HIV-infected individuals in India.[10] The cause for the variation in the prevalence of hairy leukoplakia is not clear. The reasons could be attributed to diagnosis alone on the basis of presumptive criteria, difficulty in differentiation between candidal lesions and hairy leukoplakia, all of which could lead to misdiagnosis.

The prevalence of xerostomia in 31–40 years of age group was 66%. This finding was found to be consistent with other studies.[10],[25] A combination of various factors such as HAART, other medications, and subclinical salivary gland disease due to HIV may have been contributory factors to xerostomia. Direct attribution to HIV infection is difficult to justify, though the association of xerostomia with HIV has been documented previously.[26]

In our study, no association between pseudomembranous candidiasis; necrotizing ulcerative gingivitis and age was observed. Candida albicans oxidizes salivary ethanol, which leads to a high level of acetaldehyde production which effects oral mucosa by augmenting its permeability causing atrophic areas on the surface of the epithelia. Other lesions found in individuals with high viral load levels may present a complete depletion of mucosal Langerhans cells and this causes localized cytopathic effect further causing the impairment of mucosal immunologic protection.[27]

The most frequent comorbid conditions in older patients were cardiovascular and endocrine-metabolic diseases,[28],[29] while in the younger population recurrent bacterial infections and chronic liver diseases were the main comorbid conditions.[30],[31],[32] Despite their young age, our HIV-infected patients are suffering from a large number of co-morbidities, so we can consider them cases of multimorbidity, leading to prolonged hospitalizations, therapeutic challenges, and subsequently increased medical expenses.[33] Consistent with the literature, more than two co-morbidities were observed among the patients aged over 40 years and above. Results from a recent study conducted in Italy showed similar results.[34]

The limitations in our present study includes the cross-sectional nature which does not allow for conclusions regarding causality; for example, we are unable to determine whether the increased rates of age-related medical co-morbidities is a cause of accelerated aging in HIV+ adults. Further, longitudinal studies on the impact of aging on the HIV/AIDS population are still necessary. Also with regard to the demographic characteristics of the study samples, our HIV+ groups were predominantly men, which limit the generalizability of our findings. Despite these limitations, our findings are of significant public health interest.


   Conclusion Top


The results indicate that with an increase in the age of HIV-infected/AIDS patients there is a high prevalence of oral lesions in conjunction with similar prevalence of systemic diseases. Physiologically as the age increases, the function of any organ, and immune status of the person is gradually diminished. In HIV/AIDS patients as the condition progresses, virus further weakens the immune system leading to multiple oral manifestations and an increase in susceptibility to severe infections and diseases causing failure of organ function leading to comorbid conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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34.
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Correspondence Address:
Sana Khaled
Department of Oral Pathology and Microbiology, Panineeya Dental College and Research Centre, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.167624

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