A Systematic Review Of Three Decades Of Prevalence Of Oral Soft Tissue Infections And Conditions Among Adult HIV Patients in India

Keywords

HIV; Oral Cavity; Infections; Periodontitis; Oral Mucosa; India.

Introduction

Oral lesions are a frequent finding and present early stages of decreased immunity in HIV positive individuals. This serves as a cue for further evaluation needed to underline the depleting immunity. Thus the mouth not only serves as an indicator but also reflects the response to the treatment being provided. Most of the lesions associated with HIV are found even in individuals with compromised immunity due to other reasons (like on steroids or in diabetes mellitus) but certain lesions are characteristic hall marks of HIV/AIDS. [1-4] There is still uncertainty with regards to the exact mechanism of how HIV infection may affect the oral cavity at large. HIV is majorly spread due to the mucosal surface response of the host, which when compromised assists in acquisition and rapid spread of the virus. A breakdown of the same barrier can serve dual purposes of facilitating the spread as well as translocating the microbial products for further infection and inflammation. It is suggested though that, as a response to the infection, the immunological changes alters the physical barriers in the oral cavity also and assists in further destruction.5 It also serves as a reservoir for further spread in the form of bacteraemia and septicaemia. The EEC Clearing house classification provided the common manifestation of oral lesions in HIV affected individuals.[1] Multiple studies in literature have reported the oral side effects of HIV as well as that of ART drugs which includes erythema multiforme, hyperpigmentation, xerostomia, parotid lipomatosis, cheilitis, perioral parathesis, taste alterations, facial oedema and ulcers.[6-11] Thus oral cavity in the literal sense serves as a mirror of systemic health and conditions. There is no data reported till now on the epidemiology of oral lesions and HIV across India. This s review paper brings forward a systematic view of the papers reported in dental literature regarding the prevalence of various lesions across Indian HIV population.

Materials and Methods

We carried out a literature search using PubMed and Google scholar to access articles from January 1990 to December 2019. All freely available full text articles were selected. The key words used for searching the articles were- India, HIV, AIDS, Soft tissue, oral cavity. The inclusion criteria were-

1. All Indian based studies, reporting epidemiological data related to HIV and oral soft tissues diseases or conditions
2. All participants on ART
The initial review was done by the first author based on the title and the abstract. Later a full text review was done for the entire article. The search overall revealed 21 articles that were found eligible. The data extraction was done by the first author based on the following 09 criteria for qualitative assessment of the articles-

1. Study setting-College, hospital, NGO, home or any other place.
2. Aim and objectives clearly mentioned.
3. Sample size Formula and estimation process clearly stated.
4. Sample design mentioned which type of sampling design was followed.
5. Criteria/index used for recording.
6. Calibration of the examiners with the Kappa statistics for reliability and validity.
7. Clearly stated if generalizability is possible or not. If not, stated reasons for the same.
8. Clearly mentioned if the participants were on ART/HAART or just positive.
9. Clearly stated the inclusion and exclusion criteria.

After data extraction, all the 21 articles were independently reviewed by the rest of the authors and any discrepancy was solved by discussion and by generating a common consensus. The PRISMA guidelines was followed for reporting (Figure 01). The entire process of review and report generation was done in one month (January 2020).

Results

Of the 21 articles found eligible for study, majority were from the South part of the country. All the studies focussed on the presence of oral candidiasis except for the study by Krishna et al. [12] For the ease of reporting, we have not classified the candidiasis, but presented the overall percentage. We also classified any form of gingivitis (either bleeding on probing, de-squamative gingivitis and liner erythema gingivitis) as one category of gingivitis. Any such form of periodontitis was also considered under periodontitis. Most of the studies were reports by dental specialists only. Two studies [13, 14] reported oral manifestations as a part of the general physical examination. They were not exclusively concentrating on the oral lesions only. Kumar et al focussed only on oral candidiasis and no other oral lesions as such.[15] Only one study among the 21 reported that soft tissue lesions have no co relation with CD4 count or with ART therapy duration. [16] Rest of the studies reported of an inverse relationship between the CD4 count and the oral manifestations. Hence considering local factors like plaque and oral hygiene practices along with medications apart from ART/HAART should be taken into consideration (Table 01).

Quality assessment of the articles:

The above mentioned 09 parameters were used for quality assessment of the articles (Table 02).

Extrapolation of the data was mentioned by only 2 studies. [16, 22] The most common classification scale used was of the EC clearinghouse for soft tissue manifestation of HIV/AIDS and that by the World Health Organization Oral health Assessment 1997. Studies by Annapurna, [22] Krishna, [12] Muralidharan [16] and Dongade [30] only reported of sample size estimation and the way the samples were calculated. Even though we did not develop a scoring or a rating scale for the studies, overall quality development suggests poor patterns of reporting or at times selective reporting of the data. Not all studies have reported of periodontitis and gingivitis while reporting the lesions. Hence a major part of the information that can be useful for planning and execution is missing with the studies.

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Figure 1:

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Figure 1. Search strategy.

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Table 1:

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Table 1. List of research work selected for systematic review.

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Table 2:

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Table 2. Quality assessment of the studies included in the systematic review.

Discussion

Unlike the west, we don’t have a fixed pattern of assessment and reporting of data. All authors have used different standardized criteria for examination and classification. There is no common consensus or direction in Indian scenario for reporting data in such special groups. Also there is no equitable reporting. Most of the people covered are from the south of India. No stringent sampling technique is followed. Studies have reported if the participants were on ART/ HAART. Unfortunately no studies have been performed on those on second line ART. This is a big lacuna that needs to be addressed. As stated in before, even the ART drugs have ill effects on the oral mucosa, which may manifest in a number of ways. There is no co relation mentioned across the studies related to etiological factors for the conditions. The data presented does not actually represent the current status across the whole of India. It is always possible that some of the participants may be from risky professions like truck drivers, professional sex workers or intra venous drug abuse users. But no report of such profession risk with oral health has been mentioned in any of the articles. No study mentions about oral sex. It is necessary to record such data also because this may be one risk factor for infection transmission. It is unexplored at least in the Indian scenario. Surprisingly, the north east zone hardly finds mention in the oral diseases reporting. The South of India has a multitude of medical and dental institutions that boasts of post -graduation and further studies in dental and allied streams. Hence it is quite possible that this may lead to number of studies from this particular region of India.

The data overall does not serve the purpose of assisting in planning any comprehensive treatment procedures. The arena of managing HIV/AIDS has seen a tremendous change in the last decade. Early diagnosis and prompt treatment is the key for a sustainable institution and continuation of ART. With an improvement in the life and awareness upsurge, as dentists there is always a big challenge to the rising risks related to oral health among the patients. These highly significant and characteristic features are not just to be recorded but also to be tackled. A national data centre for collection of the oral lesions and also a plan to tackle the same is essential. While oral lesions may not be deadly like in case of HIV associated Tuberculosis or Hepatitis infections, they still alter the health slowly and gradually. As the patients undergo regular physical evaluation and drug regime revisions for systemic illness, a similar policy for an oral check-up and preceding treatment is essential. Training and sensitization for health care workers like nursing staff and multi-purpose health workers and counsellors is required for a greater out reach. India is a diverse country with a number of factors that affect health seeking behaviour patterns of the people. In a sensitive case like HIV which is already stigmatized in the society, dentists can play a pivotal role for providing health care as well as basic counselling. This expands our role as well as opens up newer avenues for the dental expertise to explore.

The review has certain limitations. We used only two search engines. Also unreported data related to conference proceedings or from NACO (National AIDS Control Organization) was not conceded. We may have missed a few articles with richer data that did not appear across indexed journals. Further reviews are needed to cover those grey areas of literature too.

Conclusion

There is a high prevalence of oral candidiasis even among HIV positive patients on ART. More data to compile is available only from South India. Rest regional data is sparse. A range of soft tissue lesions are prevalent and in higher proportions. This can serve as a step to analyse the need to have a nation-wide data and intervention strategies for tackling HIV/ AIDS associated opportunistic infections.