International Journal of Medical Research Professionals

Original Article
Comparison of Oral Manifestations in HIV Positive Children
with and without HAART
Neerav Dutta1*, Rahul Kumar Singh2, Ankit Roy3, Amitu singh4,
Rakshith shetty1, Sushma KN5
1
Senior lecturer, Department of Oral pathology,
2
Senior lecturer, 4PG student, Department of Pedodontics,
3
Senior lecturer, Department of OMR,
5
Senior lecturer, Department of Oral & maxillofacial surgery,
Vananchal Dental College and Hospital. Garhwa, Jharkhand, INDIA.
ABSTRACT
Introduction: The advent of HAART had reduced the incidence and type of oral
Article History
lesions as found in many studies. However, these studies are mostly conducted
Received: 22 Mar 2016
Revised: 29 Mar 2016 among adults and studies related to the incidence of oral lesions in children are few
Accepted: 31 Mar 2016 till date, particularly in India. Thus, the present study was carried out find
differences in the incidence of oral lesions among the HIV positive children
receiving HAART and not receiving HAART.
Material and Methods: The present study comprised a total 60 HIV positive
pediatric patients divided into two groups. Group I comprised of 30 HIV positive
children receiving HAART for a minimum of 3 months. Group II comprised of 30
HIV positive children without HAART and who came to the ART centre for first
time without previous history of anti – retroviral therapy. The oral lesions associated
with HIV infection were diagnosed based on their clinical presentation. Fisher’s chi-
square test was used to compare the lesions. Significance will be obtained using P-
value. For all the tests, a P-value of 0.05 or less was considered for statistical
significance and a P-value of 0.02 or less was considered for statistical highly
significance.
Results: The manifestations that were observed in Group I were taken into
consideration for comparing the incidence of oral manifestations. Candidiasis were
more in HIV +ve children without HAART with statistically highly significant
value.
*Correspondence to: Conclusion: The present study found that HIV infected patients receiving HAART
Dr. Neerav Dutta,
predominantly combination of stavudine, lamivudine, nevirapine, zidovudine and
Senior lecturer,
Department of Oral effiviranez for a period of less than a year, had a significantly lower prevalence of
pathology, oral lesion particularly oral candidiasis, oral hairy leukoplakia, parotid gland
Vananchal Dental enlargement and cervical lymphadenopathy.
College and Hospital.
Garhwa, Jharkhand. KEYWORDS: Anti-retroviral therapy, HAART, HIV.

INTRODUCTION
Human immunodeficiency virus (HIV) infection is 460,000 in 2001 to 420,000 in 2007. Deaths due to AIDS
considered a pandemic by the World Health among children have increased.2
Organization (WHO). From its discovery in 1981 to In India the trends indicate that shift from one group to
2006, acquired immunodeficiency syndrome (AIDS) has the next. The trends indicate that HIV infection is
killed more than 25 million people. HIV infects about spreading in two ways; from urban to rural areas and
0.6% of the world’s population. In 2005, AIDS claimed from individuals practicing high risk behavior to the
an estimated 2.4 – 3.3 million lives, of which more than general population. Data from antenatal clinics indicate
570,000 children. Most of the cases are seen in sub- rising HIV prevalence among women, which in turn
Saharan countries and developing nation.1 Globally, the contribute to increasing HIV infections in children.2
number of children living with HIV increased from 1.5 The relatively few studies of oral lesions in patients on
million in 2001 to 2.5 million in 2007. However, HAART have been conducted elsewhere and do indicate
estimated new infections among children declined from significant differences in the influence of HAART on
320 | P a g e Int J Med Res Prof.2016; 2(2); 320-23. P-ISSN:2454-6356; E-ISSN:2454-6364
 Neerav Dutta et al. Oral Manifestations in HIV Positive Children with and without HAART

types of oral lesion for example, oral candidiasis, oral therapeutic drug usage. Patients were interviewed using
hairy leukoplakia, Kaposi sarcoma, and HIV associated a standard structured case sheet performa to obtain
periodontal disease have been reported to decrease. On information regarding social and demographic details,
the other hand, HIV Salivary gland diseases, human past medical history, family history and history of
papilloma virus (HPV) associated oral lesion including previous medication if any. Previous and current
papilloma, condylomas and focal epithelial hyperplasia episodes of oral manifestations present, previous use of
(oral warts), xerostomia and recurrent oral ulceration HAART and any other medicine and current treatment
appear to have increased. There are also reports all were recorded. Current and previous oral
indicating no change in the occurrence of HIV manifestations were categorized and were recorded. An
associated oral lesion in children receiving HAART.3 oral examination was carried out by a qualified dental
The reasons for these differences are not entirely clear. surgeon. The extra-oral and peri-oral tissues were
Some authors have associated these variations with examined first, followed by the intra-oral tissues, for
differences in access to oral health care, demographic changes in size, colour and shape of anatomical areas as
and social factors, mode of HIV transmission, types of well as for clinical signs and lesions. The oral lesions
co-infections, disease stage and immune reconstitution.4 associated with HIV infection were diagnosed based on
The advent of HAART had reduced the incidence and their clinical presentation and where multiple sites were
type of oral lesions as found in many studies. However, involved, all sites were documented.
these studies are mostly done in adults and studies HAART regimens
related to the incidence of oral lesions in children are Four types of regimens of HAART were included in
few till date, particularly in India. In this context, oral this study namely:
lesions in HIV positive children receiving HAART are 1) STV+LMV+NVP
studied. Differences in the incidence of oral lesions 2) STV+LMV+EFV
among the HIV positive children receiving HAART and 3) ZDV+LMV+NVP
not receiving HAART were also studied. 4) ZDV+LMV+EFV
(STV-Stavudine, LMV- Lamivudine, NVP-Nevirapine,
MATERIALS AND METHODS EFZ- Effavirenz)
The present study comprised a total 60 HIV positive Out of the regimens any of the regime was given to the
pediatric patients randomly selected from the ART patients and was sometimes substituted or stopped
centre in Government General Hospital, Ranchi, India. because of any of the reasons such as toxicity/side
Patients were divided into two groups. Group I effects, pregnancy, newly drug available, clinical
comprised of 30 HIV positive children receiving treatment failure, immunological failure, virologic
HAART for a minimum of 3 months. Group II failure, treatment failure, poor adherence, illness
comprised of 30 HIV positive children without HAART hospitalization, patient lack of finance, patient decision.
and who came to the ART centre for first time without Fisher’s chi- square test was used to compare the lesions.
previous history of anti – retroviral therapy. The study Significance will be obtained using P- value. For all the
protocol was approved by the ethical committee of the tests, a P-value of 0.05 or less was considered for
institute as well as permission was taken from medical statistical significance and a P-value of 0.02 or less was
incharge in the ART Centre, Ranchi. Written consent considered for statistical highly significance.
was obtained from the parents of these children in a
consent form before recording the cases. Address and RESULTS
contact number was not to be taken to maintain The current study involves 30 children each in two
confidentiality. These children were selected from same groups. The antiretroviral drugs that was given to these
age group (2 years- 13 years) and same socioeconomic patients were recorded, which include, (Zidovudine,
status. The details to be taken from these children for Lamivudine, Stavudine, Nevirapine and Effiviranez and
subsequent analysis include age, oral lesions and where divided into four regimen (I-IV) (Table 1).

Table 1: Highly Active Antiretroviral Therapy (HAART) Drugs Used For Treatment
REGIMEN (GROUPS) DRUGS USED
REGIMEN I *STV+LMV+NVP
REGIMEN II *STV+LMV+EFV
REGIMEN III *ZDV+LMV+NVP
REGIMEN IV *ZDV+LMV+EFV
*NOTE: STV- Stavudine, LMV- Lamivudine, NVP- Nevirapine, ZDV- Zidovudine, EFV- effiviranez

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 Neerav Dutta et al. Oral Manifestations in HIV Positive Children with and without HAART

Table 2: Comparing incidence of oral lesion with HAART (group1) and without HAART (group-2) with chi
square value, P value and inference

Name of disease HIV +ve HIV +ve Chi Sqr ‘P’ Significance
WITH HAART WITH OUT Value value
n=30 HAART n=30
Candidiasis 7 17 6.94 0.0083 Highly Significant
Gingivitis/periodontitis 6 13 3.77 0.0522 NS
Angular chelitis 7 14 3.59 0.0581 NS
Ulcerative stomatitis 3 8 2.78 0.09 NS
Oral hairy leukoplakia 1 3 1.07 0.30 NS
Hyperpigmentation 6 1 4.04 0.04 Significant
Viral infection 1 4 1.96 0.16 NS
Kaposi’s sarcoma 0 1 1.02 0.31 NS
Cervical lymphadenopathy 7 12 1.92 0.17 NS
Parotid gland enlargement 4 10 3.35 0.07 NS
Mucocele 0 0 _ _ _
Dental caries 24 27 1.18 0.28 NS
P>0.05 Not Significant P<0.05 Significant P<0.02 HS

The oral manifestations of children in Group I (HIV +ve common and serious complication of HIV infection in
with HAART) were compared to that of Group II young children which is in accordance with the present
(without HAART). The manifestations that were study in which the prevalence of the lesion is 23.3% and
observed in Group I was taken into consideration for 56.6% respectively with HAART and without HAART
comparing the incidence of oral manifestations. The individuals.7
statistical analysis using Fishers Chi-square test showed Barasch A et al8 reported decline in the incidence or
that the statistical analysis using Fishers Chi-square test occurrence of the oral candidiasis lesion in the HIV
showed that hyperpigmentation was significantly more +subjects which is in accordance with the present study
in children receiving HAART. Candidiasis were more in in which it was seen that the prevalence of oral
HIV +ve children without HAART with statistically candidiasis is 23.3% with HAART and is remarkably
highly significant value was obtained. However the 56.6% in case of non HAART group. The prevalence of
prevalence of other lesions where statistically not HIV associated periodontal disease in the pre- HAART
significant in both the groups (Table 2). era, vary widely both in developed and developing
countries. Indicatively, reported rates of prevalence for
DISCUSSION linear gingival erythema range between 9% and 50%, for
The advent of Highly Active AntiRetroviral Therapy has necrotizing ulcerative gingivitis between 11% & 25%
reduced the mortality and morbidity rates in HIV and necrotizing ulcerative periodontitis between 1% &
positive individuals .This is due to reduction of HIV 18% and it is may be due to advent of the HAART
viral load and consequent recovery of immune system.1 therapies.9
Patients reciveing HAART are protected to some extent The higher prevalence of mucosal hyper pigmentation in
against candidiasis, salivary gland disease, Kaposi patients as HAART has been linked with increased
sarcoma and oral hairy leukoplakia.1,5 melanin production in the epithelium associated with
In the present study the diagnosis of initial infection in increased release of α-melanocyte stimulating hormone
children is established by Polymerase Chain Reaction. as a result of systematic ketoconazole and zidovudine
However, the antiretroviral drugs are not given to therapy.2
children below the age of 5 years. The CD4+Tcells are In a study conducted by Poonam et al1, a reduction in the
monitored and necessary instructions are given to the prevalence of oral lesions has been reported in HIV
parents of these children. However, antiretroviral drugs infected patients receiving HAART and regular use of
in the form of syrups are given to infants with low HAART had probably reduced the prevalence of oral
CD4+Tcell count. lesions, especially oral hairy leukoplakia and
Previous studies have shown that mother to child pseudomembranous candidiasis. The reduction in the
transmission was the dominant mode of transmission of prevalence of oral lesion is attributed to the immune
the virus to infected children the present study also recovery on treatment with HAART.
showed similar finding.6 Comprehensive guidelines for the prevention of the most
In case of oral lesions with limited cross sectional prevalent and life threatening opportunistic infections in
reports indicates that oral candidiasis is one of the person infected with the HIV virus have recently

322 | P a g e Int J Med Res Prof.2016; 2(2); 320-23. www.ijmrp.com

 Neerav Dutta et al. Oral Manifestations in HIV Positive Children with and without HAART

developed by CDC and the infectious disease society of 3. Hamza OJ, Matee MI, Simon EN, et al. Oral
America specific notes on guidelines for pediatric manifestations of HIV infection in children and adults
population are included in every sections , although a receiving highly active anti-retroviral therapy [HAART]
majority of cases firm pediatric recommendations await in Dar es Salaam, Tanzania. BMC Oral Health.
the result of controlled clinical trials. Routine childhood 2006;6:12.
vaccines are important for pediatric patients who are 4. Ranganathan K, Geethalakshmi E, Umadevi KMR,
infected with HIV. In general live viral vaccines and live Vidya KM, Kumarasamy N , Solomon S. Orofacial and
bacterial vaccines should not be given to patients with systemic manifestations in 212 paediatric HIV patients
AIDS or to patients with other clinical manifestations of from Chennai, South India. International Journal of
HIV infections.10 Side effects or intolerance to Paediatric Dentistry 2010; 20: 276–82.
antiretroviral therapy occur with moderate frequency. 5. World health organization, pediatric advocacy, toolkit:
Drug related toxicity may be acute, occurring soon after For improved pediatric HIV diagnosis, care and
a drug has been administered; subacute occurring within treatment in high HIV prevalence countries and regions.
days of administration or late occurring after prolonged 6. Adebola AR, Adeleke SI, Mukhtar M, Osunde OD,
drug administration. Severity may vary from mild to Akhiwu BI, Ladeinde A. Oral manifestation of
severe life threatening. Identification of the responsible HIV/AIDS infections in paediatric Nigerian patients.
agent allows substitution of a similar agent to which Nigerian Medical Journal : Journal of the Nigeria
virus is susceptible, children who initiate or change to a Medical Association. 2012;53(3):150-4.
new HAART regimen need to be followed to assess 7. Ketchem L, Berkowitz RJ, McIlveen L, Forrester D,
effectiveness, adherence, tolerability, and side effects of Rakusan T. Oral findings in HIV-seropositive children.
the regimen.11 Pediatric Dentistry 1990;12(3):143-7.
8. Barasch A, Safford MM, Catalanotto FA, Fine DH,
CONCLUSION
Katz RV. Oral soft tissue manifestations in HIV-positive
The present study found that HIV infected patients
vs. HIV negative children from an inner city population:
receiving HAART predominantly combination of
A two-year observational study Pediatric Dent
stavudine, lamivudine, nevirapine, zidovudine and
2000;22:215-20.
effiviranez for a period of less than a year, had a
9. M Mataftsi M, Skoura L, Sakellari D. HIV Infection
significantly lower prevalence of oral lesion particularly
and periodontal diseases: an overview of the post
oral candidiasis , oral hairy leukoplakia, parotid gland
HAART era. Oral Diseases 2010;1-13.
enlargement and cervical lymphadenopathy. There was
10. Guidelines for the Prevention and Treatment of
significant increase in hyperpigmentation in HAART
Opportunistic Infections among HIV - Exposed
group than that of non HAART group which was due to
and HIV - Infected Children. Available at:
possible side effects of anti-retroviral therapy. Progress
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr58e08
in the treatment of pediatric HIV infection has been
26a1.htm
made over the past decade with significant reduction in
11. Management of Medication Toxicity or Intolerance
morbidity and mortality. Understanding the principles of
(Last updated November 1, 2012; last reviewed
selecting HAART regimens and vigilance for toxicities
November 1, 2012. Available at:
are important for optimal management of HIV infected
https://aidsinfo.nih.gov/contentfiles/glchunk/glchunk_89
infants and children where access to medication is not a
.pdf
problem, the biggest challenge to optimizing HAART is
to maintaining adherence to medications a challenge that Source of Support: Nil.
requires ongoing assessment and interventions as the Conflict of Interest: None Declared.
patient moves from the infancy to adolescence. Copyright: © the author(s) and publisher. IJMRP is an
More studies preferably longitudinal need to be official publication of Ibn Sina Academy of Medieval
conducted for longer periods of time in order to get Medicine & Sciences, registered in 2001 under Indian
better picture on the efficacy of HAART in reducing oral Trusts Act, 1882.
lesions in children in our settings. This is an open access article distributed under the terms
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