Journal of International Oral Health

ORIGINAL RESEARCH
Year
: 2019  |  Volume : 11  |  Issue : 3  |  Page : 137--140

The correlation of pathognomonic periodontal manifestation with CD4+ level in people live with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in a Tertiary Hospital, Surabaya, Indonesia


Alexander Patera Nugraha1, Erwin Asta Triyono2, Chiquita Prahasanti3, Irna Sufiawati4, Remita Adya Prasetyo5, Diah Savitri Ernawati6,  
1 Faculty of Dental Medicine, Airlangga University, Surabaya, Indonesia
2 Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Indonesia
3 Department of Periodontics, Faculty of Dental Medicine, Airlangga University, Surabaya, Indonesia
4 Department of Oral Medicine, Faculty of Dental Medicine, Padjajaran University, Bandung, Indonesia
5 Division of Oral Medicine, Installation of Dental and Oral Health, Dr. Soetomo General Hospital, Surabaya, Indonesia
6 Department of Oral Medicine, Faculty of Dental Medicine, Airlangga University, Surabaya, Indonesia

Correspondence Address:
Prof. Diah Savitri Ernawati
Jl. Mayjend Prof. Dr. Moestopo 47, Surabaya
Indonesia

Abstract

Aim: The prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients worldwide continue increasing annually, thus it has become a global health problem and burden. An oral manifestation can be used as the clinical biomarkers in people living with HIV/AIDS (PLWHA) using the pathognomonic periodontal manifestation, such as Necrotizing Ulcerative Gingivitis (NUG) and Necrotizing Ulcerative Periodontitis (NUP). This study aims to investigate the prevalence and correlation of pathognomonic periodontal manifestations with Cluster of Differentiation 4 (CD4+) level in PLWHA in a tertiary hospital, Surabaya, Indonesia. Materials and Methods: It presents an observational analytical study with a cross-sectional and total sampling method conducted from July to August 2014 in Dr. Soetomo General Tertiary Hospital. There were 88 HIV-seropositive patients who have not received any antiretroviral therapy yet who were recruited for this study. The patients and their guardians were explained about the study aims and participation approval which was obtained by the written informed consents. The diagnosis of NUP and NUG in PLWHA was based on its clinical features. The CD4+ level the latest 6 months was obtained from medical record as a retrospective data. The correlation between low CD4+ levels with pathognomonic periodontal manifestation in PLWHA was analyzed by Spearman's correlation test. Results: There are 9 (10.23%) PLWHA with pathognomonic periodontal manifestation, 7 (77.7%) with NUG, and 2 (22.3%) with NUP. All PLWHA (100%) have low CD4+ level (<200 cell/mm3). The Spearman's correlation shows that there are a correlation between pathognomonic periodontal manifestation with CD4+ level in PLWHA (r = −0.464) (P = 0.03; P < 0.05). Conclusion: NUG and NUP are pathognomonic periodontal manifestation found in Indonesian PLWHA which are associated with low CD4+ level reflecting the immune suppression level, and it can be used to predict HIV/AIDS stage of progression.



How to cite this article:
Nugraha AP, Triyono EA, Prahasanti C, Sufiawati I, Prasetyo RA, Ernawati DS. The correlation of pathognomonic periodontal manifestation with CD4+ level in people live with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in a Tertiary Hospital, Surabaya, Indonesia.J Int Oral Health 2019;11:137-140


How to cite this URL:
Nugraha AP, Triyono EA, Prahasanti C, Sufiawati I, Prasetyo RA, Ernawati DS. The correlation of pathognomonic periodontal manifestation with CD4+ level in people live with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in a Tertiary Hospital, Surabaya, Indonesia. J Int Oral Health [serial online] 2019 [cited 2019 Dec 12 ];11:137-140
Available from: http://www.jioh.org/text.asp?2019/11/3/137/261266


Full Text

 Introduction



The etiology of Acquired Immunodeficiency Syndrome (AIDS) is Human Immunodeficiency Virus (HIV). HIV/AIDS is the most emerging infectious disease in the world.[1] The prevalence of HIV/AIDS patients worldwide continues increasing annually, thus it has become a global health problem and burden.[2] HIV/AIDS infection in Indonesia is stated as one of Asia's fastest growing epidemics.[3] Furthermore, Indonesia is the country with the most prevalent HIV/AIDS infection.[4] People living with HIV/AIDS (PLWHA) is among the 5.2 million (4.1–6.7 million) in Asia and the Pacific at the end of 2017.[5] Indonesia's HIV/AIDS prevalence and epidemic are very dynamics and enormously.[6] The numbers of AIDS-related deaths and new HIV/AIDS infections show a declining trend in all the high-risk countries except for Indonesia during 2010–2015.[7]

There were six provinces with most growing number of HIV/AIDS prevalence in Indonesia.[8] East Java comes up as the second highest HIV/AIDS prevalence province with about 39.633 PLWHA in 2017 according to Republic of Indonesia Ministry of Health.[9] In East Java, PLWHA is all treated in Dr. Soetomo General Tertiary Hospital, which is the largest referral hospital in the eastern part of Indonesia.[10]

Due to some laboratory and economical limitations, some peripheral areas of Indonesia do not conduct the screening routinely for HIV/AIDS infection. The easy, fast, and cheap screening method of HIV/AIDS infection is needed in the peripheral areas of Indonesia.[3],[11] According to the previous studies, oral manifestations such as oral candidiasis, oral hairy leukoplakia, and linear gingival erythema have longed been studied as the HIV/AIDS clinical indicators.[3],[4],[6],[10],[11],[12] Oral manifestation can be used as clinical biomarkers in PLWHA including the pathognomonic periodontal manifestation, such as necrotizing ulcerative gingivitis (NUG) and necrotizing ulcerative periodontitis (NUP) which have a pivotal role to predict the HIV/AIDS progression rate.[10],[11],[12],[13],[14]

The most sensitive method in measuring the PLWHA immunity status is the Cluster of Differentiation 4 (CD4) cell count. Only a few studies have evaluated the relationship of CD4+ with oral manifestations. For example, a study in African which found a correlation between the increasing HIV/AIDS viral load and the low CD4+ level with the increasing prevalence of oral manifestations.[15] However, until recently, there is not any study conducted in Indonesia which attempt to assess the relationship between the pathognomonic periodontal manifestations such as NUG and NUP with CD4 in PLWHA.

Thus, the main purpose of this study was to investigate the prevalence and correlation of pathognomonic periodontal manifestations with CD4+ level in PLWHA in a tertiary hospital located in Surabaya, Indonesia. This study is expected to increase awareness and knowledge about pathognomonic periodontal manifestation that is beneficial for determining AIDS progression for Indonesian PLWHA.

 Materials and Methods



Dr. Soetomo General Tertiary Hospital Surabaya ethical committee had approved this study method (Ref no: 301/Panke.KKE/VI/2014). An analytical study with cross-sectional and total sampling and random sampling method was done during the study time frame from July to August 2014 in Dr. Soetomo General Tertiary Hospital. There were 88 HIV-seropositive patients who have not received any antiretroviral therapy to be sampled. These patients were diagnosed for HIV seropositive by the Department of Internal Medicine and Department of Clinical Pathology at Dr. Soetomo General Tertiary Hospital Surabaya. These PLWHA who were above 17 years were screened and confirmed with HIV/AIDS diagnosis based on the guideline from the Indonesian Ministry of Health and they attended the (Unit Perawatan Intermediet dan Penyakit Infeksi or Intermediate and Infectious Disease Care Unit) of Dr. Soetomo General Tertiary hospital as the referral center and the largest hospital in the Eastern part of Indonesia during the study periods.[16]

The attending parents/guardians and patients were explained about the study aims. An approval from parents/guardians and patients on the participation in the study was obtained by the written informed consents. Oral mucosal status of each patient was then assessed by some three qualified dentists from the Faculty of Dentistry, Airlangga University. To ensure the inter- and intraexaminer variability, the diagnosis perception of each dentist has been calibrated before the study began. An examination was conducted, while patient was seated in a dental chair using a disposable plastic mouth mirror and sterile gauze pads under an artificial lighting which was based on the Mensana et al. study method.[3],[11] The diagnosis of pathognomonic periodontal manifestations (both for NUP and NUG) in PLWHA was based on its clinical features according to the European Community Clearinghouse Diagnostic.[16]

The retrospective relevant data of PLWHA was obtained from their medical records and their parents/guardians which were derived from questionnaire-guided interview. The collected retrospective data were gender, age, and latest laboratory results on CD4 level with 6 months interval from the last examination according to the Indonesian Ministry of Health guidelines.[12] The viral load parameter was excluded from tis study because most of the PLWHA were not available.

The correlation between pathognomonic periodontal manifestation in PLWHA and CD4+ level was analyzed using Spearman's correlation test with confidence interval of 95% with P value 0.05 (P < 0.05) using Statistical Package for the Social Sciences (SPSS) 20.0 version for Windows (IBM, Chicago, Illinois, US).

 Results



From the total of 88 PLWHA, there are only 9 PLWHA with pathognomonic periodontal manifestation. There are 7 PLWHA dealing with NUG and 2 PLWHA possessing NUP with the low CD4+ level (<200 cell/mm3). Thus, the age and gender distributions of PLWHA with NUG or NUP were mentioned in [Table 1]. However, it is also found that there is a moderate-negative (downhill) correlation between pathognomonic periodontal manifestations with CD4+ level in PLWHA [Table 2].{Table 1}{Table 2}

The collected clinical feature of NUG is erythematous area in the gingiva, painful sensation, localized gingival edema, halitosis with metal sensation, pseudomembrane formation along with free gingiva margin, and an ulceration on the papillae without tooth mobility [Figure 1]. While the recorded clinical feature in NUP is characterized by a necrotic tissue around gingiva covered with pseudomembrane, a painful crater-like ulceration with spontaneous bleeding, positive tooth mobility due to a fast alveolar bone resorption in 3 days or weeks. Prodromal symptom such as fever and nausea sometimes occurs and other possible clinical features such as oral halitosis and/or general discomfort are also observed [Figure 2].{Figure 1}{Figure 2}

 Discussion



This study found that NUG and NUP occurrence are prevalent in male than female with age range between 45 and 64 years old. This study is not lined with the studies of Lopez et al. and Dufty et al., which mentioned that the prevalence rate of NUG varies over a wide range of ages from 6.7% in Chilean students between 12 and 21 years to 0.11% in the British Armed Forces.[17],[18] The difference might be happend due to many previous studies had gender and age-restriction samples criteria.

This study shows that the most common pathognomonic periodontal manifestation in PLWHA is NUG and NUP. There is an oral manifestation that only can occur during the HIV/AIDS infection due to immunodeficiency and immunosuppression. The immunodeficiency syndrome is the main predisposing factor that plays an important role on NUG and NUP by the downregulation of host immune response which can facilitate the bacterial pathogenicity.[19] PLWHA sustains immunodeficiency syndrome that can lead to a various clinical manifestations, including oral manifestation.[20] Immunodeficiency syndrome in PLWHA disturbs the homeostasis of the oral cavity's flora ecosystem.[4],[11],[12] The commensal normal flora in the cavity can transform into pathogen condition which can lead to oral cavity opportunistic infection.[6] There were various microbacteria that can trigger NUG and NUP such as Fusobacterium spp., Treponema spp., Selenomonas spp., and Prevotella intermedia.[17],[21]

Oral manifestations can act as a mirror that can reflect the systemic health and immunosuppression status of PLWHA.[3],[4],[6] It has been suggested that oral manifestation can reflect the condition of HIV/AIDS infection and progression.[11],[12] In this study, we found that there is a significant correlation between the prevalence of pathognomonic periodontal manifestation and low CD4+ level in PLWHA. This finding is in line with the previous studies which stated that the severe immunosuppression characterized by low CD4+ level could increase the occurrence of oral manifestation such as NUG or NUP.[11],[16],[22]

Initially, there is no study about the prevalence and the correlation of pathognomonic periodontal manifestation with low CD4+ level in Indonesia PLWHA. Thus, this study provides the data that can be useful for further study in the future. However, the previous studies in other countries mention that the degree of immunosuppression in PLWHA is significantly correlated with the low CD4+ level. It divided PLWHA into three groups that based on CD4+ level: CD4 >500 cells/mL, 200–499 cells/mL, and <200 cells/mL by Centers for Disease Control and Prevention.[23] Severe immune suppression which associated with the lowest CD4+ level was categorized to predict the progression of AIDS. The prevalence of NUG and NUP increased, while CD4+ level decreased to <200 cells/mm3.[17],[18],[24] Psychological stress, alcohol consumption, preexisting gingivitis, trauma, poor oral hygiene, malnutrition, smoking habits, and history of others systemic diseases were suggested as another NUG and NUP predisposing and risk factors; however, unfortunately, we were unable to study this due to unavailability of data.[17],[18],[21],[24]

Furthermore, the number of pathognomonic periodontal manifestation in this study is not many; we suggest for the better study design with the larger population and sample size.

 Conclusion



The prevalence of NUG and NUP as pathognomonic periodontal manifestation increases in Indonesian PLWHA associated with low CD4+ level reflecting the immune suppression level which can be used to predict HIV/AIDS stage of progression. Meanwhile, further study is needed with larger sample and area with better study design.

Informed consent

Written informed consent for patient information and images published was obtained by the patients or a legally authorized representative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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