Pediatric Oral Manifestations of HIV-A Case Report with Review

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Pediatric Oral Manifestations of HIV- A Case Report with Review
Authors
Dr M. Chandrasekhar, Dr Marisetty Charitha, Dr Ayesha Thabusum,
Dr G. Chandrasekhar, Dr Naresh Naik
Department of Oral Medicine and Radiology, Government Dental College and Hospital, Kadapa
Andhra Pradesh, India
Abstract
Oral Manifestations of immune suppression may take the form of opportunistic infection, and neoplasia.
While this case has focused on gingival manifestations, these tissues cannot be evaluated in isolation. The
presence of involvement of other oral tissues such as the cheek or tongue with manifestations associated
with HIV such as hairy leukoplakia, Kaposi’s sarcoma at these sites, and candidiasis in addition to
periodontal manifestations may further increase the clinical suspicion of underlying immunesuppression
and progression of the immunosuppressive state.
Keywords: Child, Acquired Immunodeficiency Syndrome, Oral manifestations.
Introduction
Acquired Immunodeficiency Syndrome (AIDS) is
a systemic disease caused by the Human
Immunodeficiency Virus (HIV), which affects the
individual’s immune system and makes him or her
more susceptible to other diseases of systemic
origin, such as oral lesions1. First case of AIDS
were reported in 1980s and its was heterosexual
transmission has grown over time, affecting a
large number of women of childbearing age and
capable of transmitting HIV virus to their
children2. This vertical root of transmission, from
mother to child is considered the main factor for
the increasing prevalence of this disease in
pediatric patients2-4 and it can occur during
pregnancy, childbirth or through breastfeeding5-6.
HIV infection currently affects more than 2
million children under the age of 15 years old
worldwide and it is associated with numerous life-
long comorbidities for this population6-7.
Immunosuppression leads to opportunistic
infections, mainly that affect the oral cavity, such
as oral candidiasis8 where as in pediatric HIV-
positive patients this problem become more worse
due to immature immune system that leads rapid
disease progression2-6 Different types of oral
lesions in HIV-infected pediatric patients such as:
candidiasis8, gingivitis, oral hairy leukoplakia,
Kaposi’s sarcoma parotid enlargement and herpes
simplex. HIV-infected patients have demonstrated
an increased frequency and severity of atypical
periodontal disease. These lesions have been
termed HIV-associated gingivitis (HIV-G) and
HIV-associated periodontitis (HIV-P). HIV-
Gingivitis is characterized clinically by a mild
but distinctive gingivitis with erythema of the free
gingiva and punctate erythematous lesions of the
attached gingiva and alveolar mucosa. HIV-P is
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characterized by extreme pain, extension of
periodontal defects past the attached gingiva into
the mucosa with bone exposure, sequestration,
and spontaneous bleeding. Such lesions have
been characterized clinically and managed
through various treatment regimens. Patients with
human immunodeficiency virus (HIV) infection
often suffer from persistent, painful ulcers that
commonly occur on the soft palate, buccal
mucosa, tonsillar area or tongue, which are
referred to as aphthous ulcers. Patients suffering
from the lesions may experience a decreased
quality of life secondary to severe pain, dysphagia
and weight loss. Although viruses (such as herpes
simplex), bacteria and fungi have been implicated
as possible causes, there is an evidence of
infection is the primary cause of recurrent
aphthous ulcers. The following case involves a
patient who had the clinical characteristics of
HIV-G aphthous ulcer in 10 year old female child.
Case Report
A 10-year-oldfemale child who was diagnosed as
HIV positive since 5 years came to the
Department of Oral Medicine and Radiology with
a chief complaint of bleeding from gums with
minor stimuli since a period of one month and
pain in inner surface of lower lip since 10 days.
Her family history revealed that both parents and
one sibling suffered with HIV – positive and
passed away 4 years back. Physical examination
of the oral cavity showed that generalized
marginal erythematous gingiva and inflamed inter
dental papilla with profuse bleeding on probing
and two small ulcers of size 0.25x0.25 cm on the
labial mucosa of lower lip these ulcers are
surrounded by erythematous hialo ring, rest of the
oral cavity is normal without any abnormality.
Laboratory investigations of this patient revealed
that the total CD4cell count is 1212cells/cumm.
Based on the history and clinical findings it was
provisionally diagnosed as HIV associated
gingivitis and Aphthous ulcers of lower lip.(fig1
and 2)
Figure 1 Inflamed interdental papilla
Figure 2 Aphthous ulcers
Discussion
Oral and perioral lesions are common in patients
infected with human immunodeficiency virus
(HIV), are often the presenting feature, and may
predict deterioration in general health and a poor
prognosis (Scully et al. 1991). HIV-infected
patients have head and neck manifestations at
some stage of disease (Rosenberg et al. 1989) and
oral lesions are often early signs (Schiodt &
Pendborg 1989, Winkler & Robertson 1992).A
broad range of periodontal diseases has been
reported in HIV-infected persons including both
common and less conventional forms of gingivitis
and periodontitis, bacterial, mycotic and viral
infections, as well as neoplasms involving
periodontium. Due to the varied periodontal
manifestations it is possible to recognize this
condition in the early stages. Distinctive form of
periodontitis unique to HIV-infected individuals

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has been described as a new entity characterized
by a rapid onset, progression and destruction of
both soft and hard tissue, in contrast to the
common slowly progressing form of adult
periodontitis (San Giacomo et al. 1990).Where as
the first report indicating an association between
HIV-infection and periodontal diseases was
published in 1985(Dennison et al. 1995).The
periodontal diseases in HIV-seropositive patients
include common as well as less conventional
forms of gingivitis and periodontitis. An updated
classification of EC-Clearhouse on HIV-related
periodontal disease includes 3 conditions: (1)
linear gingival erythema, (2) necrotizing
ulcerative gingivitis (NUG) and (3) necrotizing
ulcerative periodontitis (NUP). All 3 conditions
are clinical diagnosis without any definitive
criteria11.
Conventional chronic gingivitis: This condition
is characterized by red to bluish red, edematous
gingival tissue usually with swollen interdental
papillae and increased tendency to bleeding.
Swango et al. (1991), showed significantly more
bleeding sites and destruction of interdental
papillae in HIV-seropositive patients with more
than 400 CD4T-cell counts compared to those
with counts of less than 40012.
Chronic gingivitis with band shaped/ or
punctate erythema: This condition is described
as distinctive form of erythema of free gingiva,
attached gingiva and alveolar mucosa. Two of the
most prominent features of this condition are
linear erythematous band involving the free
gingival margins and punctate or diffuse erythema
of the attached gingiva. The free gingiva tends to
hemorrhage spontaneously, while the associated
teeth usually have only light plaque formation.
The strong resistance of this gingivitis to the usual
local treatment measures is striking studies
conducted by Barr et al. (1992) and Swango et al.
(1991) revealed no correlation between immune
suppression and this condition since equal
numbers of cases had CD4T-cell counts above and
below 400/mm (Schiodt & Pindborg 1987). The
microbiological findings of HIV-associated
gingivitis are consistent with that of conventional
periodontitis and different from that of
conventional gingivitis that suggests a close
relationship between this gingivitis form and
periodontal break down (Murray et al.1991)
Recurrent Aphthous Ulceration- Recurrent
aphthous ulceration usually is limited to non-
keratinized mucous membranes. The lesions begin
as small raised papules on the mucosa with central
blanching that creates a white appearance. They
undergo a central necrosis to form a shallow ulcer
approximately 2-10 mm in diameter. The ulcers
show a central, slightly depressed grayish fibrin
border and surrounding erythematous halo11.
Recurrent aphthous ulcers usually occur singly
and resolve within 10-14 days. RAU appears to
affect about 20% of the population, while the
prevalence within a random population has been
reported as being about 2%. RAU more frequently
seen in immuno deficient children, particularly
those with chronic granulomatous disease and
severe combined immune deficiency disease. Oral
aphthous ulcers in HIV are associated with a low
CD4 count and increased inversion of the CD4+/
CD8+ ratio12.Oral ulceration in HIV have been
traditionally divided as ulcerations, not otherwise
specified (NOS) (group 2) and recurrent aphthous
stomatitis (group 3). Aphthous ulcers in HIV are
similar to those occurring in seronegative patients,
presenting as minor (less than 5mm diameter),
major (>10mm) and herpetic form (multiple ulcers
of 1-3mm)13. The diagnostic criteria of major
aphthous ulcers in HIV as set out by Phelan et al14
includes the following: large painful ulcers >1cm
present for more than 10 days, a negative viral
culture and no infectious aetiology; with
improvement on topical tetracycline application
and resolution with topical or systemic steroids.
Conclusion
Oral lesions are more frequently found in HIV
infected children due to immature immune
system. Hence a thorough, knowledge of various
Oral manifestations which reciprocates the state of
immunesuppression is very important for an oral

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physician in order to provide proper symptomatic
treatment and proper dosage of ART which can
improve the overall symptoms and provide a
better quality of life in children.
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