Risk factors of HIV-related oral lesions in adults

OBJECTIVE: To assess the risk factors in the occurrence of oral lesions in HIV-positive adults. METHODS: A retrospective analytical-descriptive survey was conducted using the medical/dental records of 534 patients with oral lesions associated with HIV. The data were collected from fi ve referral centers for managing HIV and associated comorbidities in the city of Porto Alegre, Southern Brazil, between 1996 and 2011. Using a standardized form, socio-demographic and clinical data were recorded. Exclusively and defi nitively diagnosed oral pathologies were included and classifi ed according to ECC criteria on Oral Problems Related to HIV Infection. For data analysis cross-tabulations, Chi-squared tests and logistic regression models were used where appropriate. RESULTS: CD4+ counts lower than 350 cells/mm3 (p < 0.001), alcohol consumption (p = 0.011) and female gender (p = 0.031) were predisposing factors for oral candidiasis. The occurrence of hairy leukoplakia was independently associated with CD4+ counts below 500 cells/mm3, (p = 0.029) a viral load above 5,000 copies/mm3 (p = 0.003) and smoking (p = 0.005). CONCLUSIONS: Moderate and severe degrees of immunodefi ciency and detectable viral loads were risk factors for the onset of oral lesions. Smoking and alcohol consumption also increased susceptibility to the development of opportunistic infections in HIV-positive adults from Porto Alegre, irrespective of the use of antiretroviral therapy. DESCRIPTORS: AIDS-Related Opportunistic Infections, epidemiology. Oral Manifestations. Risk Factors. HIV Infections. Acquired Immunodefi ciency Syndrome. Cross-Sectional Studies. 53 Rev Saúde Pública 2013;47(1):52-9 Porto Alegre, in Southern Brazil, is the city which has the highest incidence of AIDS in Brazil (99.8:100,000 inhabitants) since 2006.a Around 21,000 cases of this syndrome had been reported reported by 2010 and occurred mostly in adults (98.5%) with a 38.7% mortality rate. HIV/AIDS remains a major public health problem in this city, attributed principally to diagnosis in late stages of the disease, delayed commencement of highly active antiretroviral therapy (HAART) and poor treatment compliment.b HIV causes the infected host to become susceptible to a wide spectrum of life-threatening secondary infections, malignant neoplasms and other disorders.1 The development of oral tissue lesions associated with HIV is a frequent clinical fi nding in Brazil.21 Despite the use of HAART, more than 50% of HIV/AIDS carriers present opportunistic infections in the oral cavity.10 Especially oral candidiasis (OC) and hairy leukoplakia (HL) which are considered to be of the utmost importance RESUMO OBJETIVO: Analisar fatores de risco para a ocorrência de lesões bucais em adultos soropositivos para o HIV. MÉTODOS: Estudo transversal, descritivo analítico de prontuários médicos/ odontológicos de 534 pacientes com lesões bucais associadas ao HIV em Porto Alegre, RS, no período de 1996 a 2011. Os dados foram coletados em cinco centros de referência em saúde para o atendimento de portadores do HIV e comorbidades associadas. Os dados sociodemográfi cos e clínicolaboratoriais foram coletados em formulários padronizados. Foram incluídos dados exclusivamente de lesões com diagnóstico defi nitivo e classifi cadas de acordo com os critérios da ECC on Oral Problems Related to HIV Infection. A análise dos dados foi realizada mediante a aplicação de tabulações cruzadas, teste do Qui-quadrado e modelos de regressão logística. RESULTADOS: Níveis de CD4+ < 350 células/mm3 (p < 0,001), consumo de álcool (p = 0,011) e sexo feminino (p = 0,031) foram predisponentes para candidíase bucal. A ocorrência de leucoplasia pilosa foi associada com contagens de CD4+ < 500 células/mm3 (p = 0,029), cargas virais > 5.000 cópias/mm3 (p = 0,003) e tabagismo (p = 0,005). CONCLUSÕES: Graus de imunodefi ciência moderados e severos e cargas virais detectáveis foram fatores de risco para o desenvolvimento de lesões bucais. O consumo de tabaco e álcool aumentou a suscetibilidade de desenvolver infecções oportunistas em adultos HIV positivos, independentemente do uso de terapia antirretroviral. DESCRITORES: Infecções Oportunistas Relacionadas com a AIDS, epidemiologia. Manifestações Bucais. Fatores de Risco. Infecções por HIV. Síndrome de Imunodefi ciência Adquirida. Estudos Transversais.

Porto Alegre, in Southern Brazil, is the city which has the highest incidence of AIDS in Brazil (99.8:100,000 inhabitants) since 2006. a Around 21,000 cases of this syndrome had been reported reported by 2010 and occurred mostly in adults (98.5%) with a 38.7% mortality rate. HIV/AIDS remains a major public health problem in this city, attributed principally to diagnosis in late stages of the disease, delayed commencement of highly active antiretroviral therapy (HAART) and poor treatment compliment. b HIV causes the infected host to become susceptible to a wide spectrum of life-threatening secondary infections, malignant neoplasms and other disorders. 1 The development of oral tissue lesions associated with HIV is a frequent clinical fi nding in Brazil. 21 Despite the use of HAART, more than 50% of HIV/AIDS carriers present opportunistic infections in the oral cavity. 10 Especially oral candidiasis (OC) and hairy leukoplakia (HL) which are considered to be of the utmost importance RESUMO OBJETIVO: Analisar fatores de risco para a ocorrência de lesões bucais em adultos soropositivos para o HIV.

CONCLUSÕES
It is pertinent to determine the risk factors that lead to the onset of oral pathologies. This knowledge will allow a better understanding of the course of HIV infection and consequently, allow identifi cation of subjects that are at risk of developing oral affections and contributing to prevention and patient management.
Despite the elevated incidence of AIDS in adults from Porto Alegre, there are few studies available that evaluate risk factors for oral affections in HIV-positive adults, especially with regard to VL. 21 This study aimed to assess the risk factors for the occurrence of oral lesions in HIV-positive adults.

METHODS
The survey methodology was based on guidelines for the epidemiological study of oral lesions associated with HIV infection provided by the World Health Organization (WHO). 9 We retrospectively reviewed the records of 534 HIV-positive adults who received medical or dental treatment at fi ve referral health centers in Porto Alegre city, Southern Brazil, between 1996 and 2011. Only the records of subjects that matched predetermined inclusion criteria were sampled: aged 15 or over, an HIV-positive exam independently confi rmed by two enzyme-linked immunosorbent assay or western blot tests and the occurrence of any oral lesions at the time of the HIV diagnosis or during the course of the disease progression. The obtainability of sociodemographical, laboratory and clinical data were also considered for inclusion.
The included patients had been previously examined as a part of their routine medical management of HIV or other related illnesses. The oral evaluation of these patients was performed under non standardized physical assets by a non-calibrated infectologists or dentist specialized in oral medicine. The professionals were experienced in the management of HIV seropositive patients and in diagnosing related comorbidities, including oral manifestations of HIV/AIDS. Only the affections that were defi nitively diagnosed by their clinical features alone or those which were absolutely diagnosed through the completion of additional clinical and laboratory tests, according to the parameters of the WHO 9 were included in the current survey. The data collection was classifi ed according to the criteria of EC-Clearinghouse on Oral Problems Related to HIV Infection. 5 Sociodemographic (age, gender, race, marital status, occupation and tobacco, alcohol and illegal drug consumption), clinical (HIV-related oral lesions, antiretroviral therapy use) and laboratory (quantitative CD4+ cell count and VL) data were recorded using a standardized form. The considered information was that which was determined closest to the date of the oral lesion appearance with a maximum range of six months before and after. 3,16 With regard to the risk factors related to an unhealthy lifestyle (use of tobacco, alcohol and illicit drugs), the subjects were classifi ed as users (who reported using legal or illegal substances in a period within six months before the onset of these affections) or non-users (who stopped the consumption of the noxious substances six months before the occurrence of oral lesions), according to data available on medical records. 16 Categorical variables were described by counts and percentages with a 95% confi dence interval (95%CI) and binomial distribution. Quantitative variables with symmetrical distribution were described using mean and standard deviation (sd), and the variables with asymmetrical distributions were described using median and percentiles. Comparisons were analyzed using cross-tabulation, the Chi-square test and a multivariate logistic regression model that was adjusted for confounding factors. P ≤ 0.05 was determined to be statistically signifi cant.
The data analyses were performed using the Statistical Package for the Social Sciences (SPSS®, Chicago, IL, USA) version 18.0 software program for Windows.
The study was conducted in compliance with the principles of the Helsinski Declaration and in agreement with the Brazilian-specifi c normative for research involving human subjects nº 196/96. It was also approved by the institutional review board of each participating institution

RESULTS
Of the 534 medical records, 51.7% of the patients were male, which resulted in a 1.1:1 male-to-female ratio. The mean age was 42.9 (sd = 11) years old, 68% of the subjects were Caucasian, 61.5% were single and 35.0% did not have any job connections. The demographic characteristics of the evaluated subjects were not statistically different in gender (p = 0.328), age (p = 0.069), race (p = 0.295), marital status (p = 0.099) or occupation (p = 0.182), although they came from fi ve different health centers.
Most of the oral lesions were diagnosed at a routine consultation, while 31.5% were observed during hospitalization. The median of CD4+ counts and VL of the patients sample was 242 cells/mm³ and 4,191 copies/ mm³, respectively ( Table 1).
The use of HAART was mentioned in the medical records of 61.0% of patients; of those, 69.3% were in compliance with the treatment at the time of oral lesion occurrence. Poor adherence to the HAART was described in 30.7% of the patients' records. However, 38.6% had not previously used antiretroviral drugs. A combination of two nucleoside reverse transcriptase inhibitor plus a non-nucleoside reverse transcriptase inhibitor (NNRTI) (Lamivudine/Zidovudine plus Efavirenz) were used for 50.0% of the treated individuals. Women were more susceptible to OC than men (OR 0.66, 95%CI 0.45;0.96, p = 0.031), and OC was also associated with chronic alcohol consumption (OR 2.38, 95%CI 1.22;4.67, p = 0.011). HL (OR 2.85, 95%CI 1.38;5.88, p = 0.005) was strongly associated with tobacco use. No correlations were observed between the different oral lesions and the proposed risk factors in the logistic regression analysis (Tables 2 and 3).

DISCUSSION
Moderate and severe degrees of immunodefi ciency and detectable viral loads were risk factors for the onset of oral lesions, irrespective of the use of HAART in Southern Brazil. Smoking and alcohol consumption contributed to a high susceptibility to the development of these affections in the evaluated subjects. No previous studies which evaluated a sample with similar characteristics or with the same scope had been conducted previously in this city, which has the greatest incidence of AIDS in Brazil. a One report evaluated the associations among HIV-associated oral lesions and CD4+ counts in 42 adults, inpatients, carriers of HIV and tuberculosis from Porto Alegre. 21 The literature on this subject is scarce in the state. 6,10 OC and HL have been associated with HIV since the beginning of the epidemic, but their prevalence has decreased after HAART began to be used. This fact is attributed to immune reconstitution accomplishment after viral replication cessation due to the use of HAART. 14 Our data indicate that OC and HL were the most common opportunistic infections, even among treated patients. These results confi rm previous estimates obtained in surveys from Porto Alegre 21 and other Brazilian reports. 14,15 The univariate analyses showed that the subjects with moderate (  HL was directly infl uenced by the progression of the infection. A VL level between 5,001 to 20,000 copies/ mm³ was independently associated with an augmented risk of developing HL (OR 8.02, 95%CI 2.04;31.52, p = 0.003) in the multivariate analysis. A longitudinal prospective study from Mexico, which provided the fi rst follow-up evaluation of the association of OC and HL with CD4+ counts and VL levels, showed that the occurrence of these pathologies is preceded by a sustained reduction of lymphocyte counts and an abrupt viral burden. 16 Individuals with high VL levels may present a complete depletion of mucosal Langerhans cells, and this localized cytopathic effect causes the impairment of mucosal immunologic protection. This cellular event is associated with fungal and viral colonisation events (especially Epstein-Barr) in HIV-positive patients. 5 The salivary levels of HIV-RNA may be higher than the plasma levels if they are enhanced by local infl ammatory conditions, which leads to the increased prevalence of oral manifestations. 17 We acquired data from medical charts and the laboratory index considered included six-month intervals before and after the appearance of oral lesions. It is possible that elevations in VL levels and decreases in CD4+ cell count were not temporally coincident. 3 The present study did not fi nd that OC and HL were inversely and signifi cantly associated with HAART use. This result is in contrast with other studies, which effectively considered these therapeutic agents as protection factors against oral lesions. 14,16 Most patients who received HAART were treated with a drug combination that contained an NNRTI (Efavirenz). Ortega et al 14 and da Silva et al 18 observed a lower prevalence of oral lesions in patients undergoing HAART with NNRTI than patients who were treated with protease inhibitors. Therapy failure due to ineffectiveness or inadequate compliance, which was elevated among the observed patients, may explain our results.
The chronic consumption of alcoholic drinks was considered to be a risk factor for OC occurrence (OR = 2.38; CI = 1.22 to 4.67; p = 0.011), and the patients who smoked had the highest risk of developing HL (OR = 2.85; CI = 1.38 to 5.88; p = 0.005), which was independent of their CD4+ counts and VL levels.
Candida albicans oxidizes salivary ethanol, which leads to a high level of acetaldehyde production. This product affects the oral mucosa by augmenting its permeability, causing atrophic areas on the surface of the epithelia that became poor in extracellular lipids due to alcohol use. Glucose concentrations of 18 g/dL easily obtained from drinks increase biofi lm formation and C.albicans adhesion, which facilitates OC occurrence. 20 The components of cigarette smoke may induce chronic infl ammation on the oral mucosae, cause damage to the innate immunity mechanisms against pathogens and inhibit cell growth by apoptosis mechanisms. These effects of smoking reduce the production of salivary enzymes and immunoglobulins and affect the production of lymphocytes, resulting in an imbalance of the oral microfl ora. These modifi cations probably encourage EBV infectivity, promoting the occurrence of HL. 7 Female gender was associated with OC occurrence. Lourenço & Figueiredo 8 described the same fi nding in Brazilian patients. The relationship between feminine sexual hormones and oral fl ora remains unclear. Downregulated levels of oestrogen would predispose the oral mucosae to C.albicans colonization. This hormone acted as a protection factor for vaginal candidiasis, 13 possibly in lower levels of oestrogen both tissues, oral and vaginal remain more susceptible to fungal infections.
A wide spectrum of oral diseases have been associated with HIV/AIDS since the beginning of the epidemic. 5 The onset of certain affections can provide valuable clinical information on HIV progression. 8 Several of these manifestations can be accurately diagnosed based exclusively on their clinical features. 5,9 Oral examination is an inexpensive and simple procedure and should be mandatory for HIV carriers, especially in low-income settings. 19 The limitations of our study are inherent to data collection from medical records not explicitly designed to explore HIV-associated oral lesions. Oral lesions may be under-reported, leading to a sub-estimation of prevalence. Both HIV carriers and AIDS patients were included. This fact would have also infl uenced the prevalence of some oral affections. Some conditions have a stronger association with HIV-infection and a few are defi nitively AIDS defi ning, possibly due to local and systemic immune variations. 4,17 Symptomatic individuals are most at risk of being affected by other systemic opportunistic diseases, which possibly enhanced the risk of developing certain oral affections. 18 Furthermore, we reported data from a single evaluation.
The retrospective analyses made comparison of our results with those presented in prospective surveys difficult. Although the accessible data carefully collected may refl ect reliable and relevant information on risk factors for oral lesion development in the observed HIV-carriers, they cannot be inferred for the whole population.
Longitudinal studies are needed to explore the dynamics of the relationship between the VL levels and CD4+ counts preceding the onset of HIV-related oral lesions, especially OC and HL, such as the ability of these pathologies to predict changes in these laboratory indices. These results will emphasize the potential use of oral opportunistic infections as early clinical markers of disease progression and HAART failure. This validation is of great importance in countries with limited resources, and there are limited data available from the developing world.
The results suggest that elevated VL levels and low CD4+ counts are risk factors for HL. Moderate to severe degrees of immunologic impairment increased the susceptibility of developing OC and HL in adult carriers of HIV. It is necessary to improve prevention, early diagnosis and the management of these pathologies in symptomatic patients, who are more susceptible to opportunistic diseases. Alcohol and tobacco are modifi able habits that should be discontinued since they have been shown to be predisposing factors for OC and HL. We did not obtain suffi cient information on substance abuse to make this a reliable independent variable in evaluating its effects on oral health. More studies are necessary in this fi eld, especially applying a more precise measurement of drug abuse. Case-control studies including HIV-positive subjects under HAART and healthy controls are required to clarify the true contribution of alcohol and tobacco to the onset of HIV-related oral lesions.