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Oral Soft Tissue Manifestations in HIV-Positive Vs. HIV- Negative Children from an Inner City Population: a Two-Year Observational Study

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Oral Soft Tissue Manifestations in HIV-Positive Vs. HIV- Negative Children from an Inner City Population: a Two-Year Observational Study Scientific Article Oral soft tissue manifestations in HIV-positive vs. HIV- negative children from an inner city population: A two-year observational study Andrei Barasch, DMD, MDSc Monika M. Safford, MD Frank A. Catalanotto, DMD Daniel H. Fine, DDS Ralph V. Katz, DMD, PhD Dr. Barasch is an assistant professor, University of Connecticut School of Dental Medicine, Farmington, CT; Dr. Safford is an assistant professor, University of Medicine and Dentistry of New Jersey, Newark, NJ; Dr. Catalanotto is a professor and dean, University of Florida School of Dental Medicine; Dr. Fine is a professor, University of Medicine and Dentistry of New Jersey, Newark, NJ; and Dr. Katz is a professor, Department of Basic Sciences, New York University, College of Dentistry, New York, NY. Correspond with Dr. Barasch at [email protected] Abstract Purpose: Data accrued after two years of longitudinal obser- population, mostly due to the greater number of infected vation of oral soft tissue lesions in a cohort of HIV-infected children adults. As a result, knowledge of HIV infection manifestations and comparisons to a group of uninfected controls is presented. in children is still evolving and few data from longitudinal stud- Subjects and methods: One hundred and four HIV-positive ies have been published. subjects were enrolled from an inner city pediatric HIV clinic and In a recent article, Kline has reviewed these data and noted HIV-negative household peers served as control. Oral exams were a high frequency of oral lesions in HIV-infected children, with performed at six-month intervals while laboratory data of interest candidiasis being by far the most common oral ailment. He were obtained from the children’s medical records. also reported a high prevalence of parotid enlargement and Results: HIV-positive children had significantly more oral soft herpetic stomatitis. However, the author acknowledged the lack tissue lesions than their HIV-negative peers. In particular, the of information on pathogenesis of HIV-associated oral mani- prevalence of candidiasis, linear gingival erythema and median festations in children.7 The current article presents results from rhomboid glossitis were high. However, oral lesions were not good a longitudinal assessment of prevalence of oral soft tissue le- predictors of mortality and only candidiasis was associated with a sions and their correlations with relevant blood laboratory low CD4 count. values, and mortality in a group of mostly ethnic minority Conclusions: Oral soft tissue lesions were common among HIV- pediatric HIV-positive subjects recruited from a specialized care positive children. While candidiasis was correlated with advanced center, compared to a control group of household peers. disease, oral lesions were not good predictors of mortality. (Pediatr In this study, the well-known, more colloquial term “pedi- Dent 22:215-220, 2000) atric AIDS” was replaced by “HIV-infected.” Primarily, this latter term is broader and better defines our patient popula- espite a recent drop in the number of new cases in the tion that included children with little or no effects of the U.S., Human Immunodeficiency Virus (HIV) infec- disease, in addition to late stage, immunocompromised sub- Dtion in pediatric populations remains a growing pub- jects. Additionally, we did not want to create the false lic health concern of the 1990s, particularly among inner city impression that all enrolled subjects were imminently close to populations and ethnic minorities.1 While recent advances in death and physically debilitated. While the CDC classification therapy and prevention are beginning to show promising re- for pediatric HIV infection was not used as a defining variable, sults in economically developed countries, the number of patients were classified by CD4 counts, which, at the time the pediatric infections worldwide has been growing at an alarm- study was performed were the best-known surrogate markers ing rate: an estimated 10 million people younger than age 18 for disease progression and mortality. will be HIV-infected by the year 2000.2-5 Despite therapeutic advances in the US, the mortality rate in pediatric populations Methods continues to be high.5 Additionally, as survival increases, at- This report presents data accumulated on all patients (HIV- tention will be focused on improving quality of life through infected and controls) enrolled who participated in one or more reduction of morbidity. Thus, understanding of manifestations of the five visits performed over a two-year period. Consecu- of oral disease will become increasingly important. tive examinations for each subject were completed within five The spectrum of clinical manifestations in HIV-infected to seven months from the previous examination. While not all children differs in important ways compared to their adult subjects were present at all five visits (see Results section), analy- counterparts, mostly due to differences in the viral-induced im- ses of interest included data obtained from all enrolled children. munopathologic changes in these two different age groups.6 To For oral lesion-specific analyses, each lesion on a given subject date, considerably more study has been dedicated to the latter was counted only once, regardless of the number of visits at Received April 19, 1999 Revision Accepted February 15, 2000 Pediatric Dentistry – 22:3, 2000 American Academy of Pediatric Dentistry 215 Table 1. Distribution of Ethnic Group and Sex by HIV Status at Baseline HIV Positive HIV Negative Male Female Total (%) Male Female Total(%) Total Patients (%) African-American 39 43 82 (79) 33 21 54 (81) 137 (80) Latino 7 7 14 (14) 7 5 12 (17) 26 (15) Caucasian 4 4 8 (8) 0 1 1 (2) 9 (5) Total 50 54 104 (100) 40 27 67 171 (100) which that lesion was present in the same child or the number Virus transmission in the HIV-positive group occurred ver- of examinations the child had undergone. tically at birth in 100 cases; the remaining children were Baseline assessment of the patients included a complete infected through blood transfusion (N=1) or factor VIII cryo- blood count with differential values (CBCD), CD4 (T4) lym- precipitate treatment (N=3). For the 171 subjects, age at phocyte count, plasma immunoglobulin levels, and a thorough baseline ranged from 2 to 15 years with a mean of 7.1±3.8 years oral soft tissue examination. A trained research assistant ex- (6.7±3.8 and 7.8±3.7 for infected and control subjects, respec- tracted all laboratory and medical data from the child’s medical tively); 47% of the subjects were female and 95% were records. Analyses of association of oral lesions with patients’ minorities (136 African-American and 26 Hispanic) (Table 1). immune status were based on these baseline values. Demo- Among the minority subjects, 60% (N=82) of the African- graphic data obtained included age, gender, and race. Based American and 54% (N=14) of the Hispanic children were upon age at baseline, subjects were divided into three groups HIV-positive. corresponding to their stage of dental development: 2-5 years Seventy-one percent of the original subjects (N=121, 68 old (primary dentition), 6-11 years old (mixed dentition) and HIV-positive and 53 controls) completed visit five examina- 12-15 years old (permanent dentition). For demographic tion (e.g., were followed up for two years). Patient attrition analyses, only baseline age data were used. was due to death (N=19), hospitalization of HIV-positive sub- The oral soft tissue examinations were performed by one jects (N=15), or withdrawal of the HIV-negative child from the of two blinded, experienced oral medicine clinicians. These study due to death of the HIV-positive sibling (N=11); in five exams were performed in a dental chair using a tongue blade, cases the cause of no participation is unknown. Loss of sub- dental mirror and sterile gauze under adequate lighting. While jects was relatively equally distributed across gender, age, and the patients’ HIV status was not revealed at the visit, the physi- ethnic group categories. cal condition of some infected patients strongly suggested their Baseline CD4 lymphocyte counts for the HIV-infected seropositivity. Lesions were documented based on their clini- group ranged from 0 to 2,147 cells/ml (mean 539 + 518). The cal appearance and results were recorded on standardized forms. mean percentage of CD4 cells from the total number of lym- All soft tissues of the oral cavity, including the lips, buccal phocytes was 19% + 14%, with CD4/CD8 ratios ranging from mucosa, tongue, soft and hard palate, floor of the mouth, at- 0.00-6.77 (mean 0.52 + 0.80). The mean neutrophil count was tached and non-attached gingivae, salivary gland, and the 2,120 + 1,405 cells/ml. Viral loads were not routinely measured oropharynx were thoroughly examined. Fungal and microbial for these subjects during the study period. Ninety-four percent oral cultures were obtained at all examinations from both HIV- of the HIV-infected children were treated with one or more infected and control children. Microbiological results are reverse transcriptase inhibitors but none received protease in- presented and analyzed elsewhere. Following each semiannual hibitor medication during the study period. examination, all children were referred to dental services and The frequencies of oral lesions are presented in Table 2. actively encouraged to obtain appropriate treatment whenever Overall, over the two-year period, 76% of the HIV-positive it was clinically indicated. subjects (N=78) had a lesion in at least one examination, as com- Statistical analyses consisted of comparisons across groups pared to only 36% of the control group. HIV-positive children made using either a Chi-square analysis of the appropriate con- were approximately twice more likely (odds ratio [OR]=1.98, tingency table, Fischer’s exact test, or a t-test of independent 95% confidence interval [CI] 1.43-2.75) to have a clinical oral group means.
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