INTRODUCTION

The acquired immunodeficiency syndrome (AIDS) is characterized by severe immunosuppression of the host, caused by the human immunodeficiency virus (HIV), manifesting in a wide range of clinical signs and symptoms, many of them having the mouth as the main site of manifestations.

The spectrum of oral abnormalities in HIV-infected patients is vast, comprising over 40 types of damage, which are presented as the primary manifestations of the disease in many situations1, 2.

We can notice in the literature that there is a predominance of some types of lesion, in which candidiasis is among the various clinical presentations. There are also periodontal diseases, hairy leukoplakia, Kaposi's sarcoma and herpes simplex among the most frequently affections reported by the authors3-9.

Candidiasis is a fungal infection owing to the presence of yeast genus Candida, which is a member of the family Cryptococcaceae; 81 species are admitted to the genus Candida, being Candida albicans the most well known and common10.

Fungal infections are present in a great number of HIV-infected patients, owing to their major abnormalities of immune functions mediated by lymphocytes T, reducing the immune status of the patient11.

As to frequency of oral candidiasis in HIV-infected patients, there are different reports, but it may reach up to 94% of the infected subjects, depending on the stage of infection and the analyzed population. The authors also point out that oral candidiasis can be used as a marker of the disease progression and predictor of increased immunosuppression 12.

Oral candidiasis is associated with xerostomia, severity of the disease, immunosuppression and patients' age over 35 years13. It is characterized in four clinical subtypes: erythematous, pseudomembranous, hyperplastic and angular keilitis 2. The erythematous form is represented by reddish areas, located especially on the palate, tongue and jugal mucosa, whereas angular keilitis affects the labial commissure with varied clinical aspects, from fissures to ulceration, associated with the erythematous and pseudomembranous types. Hyperplastic candidiasis is represented in the form of whitish plaques or nodules, firmly adhered to erythematous areas. but they are less frequent and significant and on the tongue can be mistaken by hairy leukoplakia 11.

Owing to the high incidence of this affection in HIV-infected patients, we decided to conduct an epidemiological retrospective study of the samples at Hospital Heliopolis and to compare them to the literature.

MATERIAL AND METHOD

The sample of this retrospective epidemiological study consisted of 431 medical charts of HIV-infected patients seen at the Service of Stomatology, Hospital Heliópolis - São Paulo, between April 1995 and September 2001.

The data refer to gender, age range, contagion forms and mouth manifestations.

Oral candidiasis, especially its pseudomembranous, erythematous and angular keilitis, is easy to clinically diagnose. Regardless, upon diagnosis, we conducted an exfoliate cytology10. The performance of biopsy was not recommended because it was a surgical traumatic unnecessary procedure14.

The investigation was approved by the Research Ethics Committee at Hospital Heliopolis, São Paulo.
Data collected were gathered on a computer software developed by the CDC (Center for Disease Control & Prevention), EpiInfo 6.04/2000 which related and statistically analyzed the percentage and the significance level (test X2).





RESULTS

Upon the study of 431 medical charts of HIV-infected patients from April 1995 to September 2001 we collected data concerning gender and there were 133 women (30.86%) and 298 men (69.14%) (Graph 1).
The distribution of HIV-infected patients seen by the Service of Stomatology, Hospital Heliópolis - São Paulo concerning race presented the following distribution: leukoderma - 307 (71.23%); melanoderma - 92 (21.35%); pheoderma - 30 (6.96%) and Yellow - 2 cases (0.46%) (Graph 2).

As to age range, in our sample it ranged from 15 to 60 years, the highest incidence at the age range between 31 and 40 years, with 203 cases (47.10%), followed by the age range 21 to 30 years with 135 cases (31.32%); 41 to 50 with 75 cases (17.40%); 15 to 20 years with 10 cases (2.32%) and 51 to 60 years with 8 cases (1.85%) (Graph 3).
As to contagion forms, the sample had:

 sexual contagion - 333 cases (71.26%);
 users of injecting drugs - 88 cases (20.42%);
 blood transfusion - 6 cases (1.39%);
 vertical (child of infected mother) - 1 case (0.24%);
 infectious route not informed - 3 cases (0.63%) (Graph 4).

As to stomatologic manifestations, we found: 128 cases of oral candidiasis, and the most frequent manifestation with 78 cases was pseudomembranous (most frequent site was tongue and palate), 48 cases of erythematous candidiasis (located on the palate), and 2 cases of leukoplastic candidiasis (located on the palate). In our sample, gingivitis was present and generally distributed in 72 cases. Angular keilitis located at the labial commissure was the third most frequent with 61 cases, being that 110 patients did not present any oral manifestations (Chart 1 and Graph 5).

All analyzed data considered statistically significant level at 1% (p<0.01).





DISCUSSION

The Service of Stomatology at Hospital Heliópolis is directly related to the clinic of infectious-contagious diseases of Hospital Heliópolis and since we are not reference for the treatment of pediatric patients, there were only six cases in our sample, not included in the 431 cases.

The age distribution is very characteristic - our results in the age range of 20 to 40 years are within the most frequent ranges. They are in accordance with other authors9, who analyzed 160 patients and stated that the mean age was 35.5 years. Since the age range from 20 to 40 years corresponds to the period of intense sexual activity, it is understandable why most infected patients are within this age range.

As to forms of contagion, the main one is still male homosexual intercourse in 12.99 (56 cases), in accordance with the literature15-18. However, it is important to point out that heterosexual transmission has increased significantly in past years, and it is potentially important for both men and women. The next category includes users of injecting drugs19, a fact observed in 20.42% of our sample.

In 431 reviewed patients, oral manifestations were those reported in the first visit to the Service of Stomatology. We found 110 asymptomatic cases and no oral lesion in the clinical examination (25.52%). The remaining 221 cases (74.48%) presented oral lesion. These facts can be related to the literature, which have incidences similar to ours9, 11, 16, 20.

In our study, we observed association of forms of candidiasis and presence of multiple oral sites. The cause may be related to immunosuppression caused by the reduction of CD4 lymphocytes and local factors, among which xerostomia.

Xerostomia is reduction of salivary secretion and it is frequently found in HIV-infected subjects, which can favor tissue trauma, an important condition for infection by Candida, and reduction of antimicrobial proteins13, 24-26. However, after the introduction of anti-retroviral drug therapy, there was reduction of mouth manifestations. Owing to the fact that our cases were already being treated when first seen by us, maybe that is the explanation for the great number - 110 cases (25.52%) - of patients without oral lesions.

Mouth candidiasis, especially through erythematous pseudomembranous and angular keilitis forms, is a lesion easy to be clinically diagnosed. However, when laboratory tests were required to confirm the diagnosis, exfoliate cytology was performed10. Performance of biopsy was not recommended since it is a traumatic surgical procedure that is unnecessary14.

Dental treatment of HIV-infected patients should always be planned and followed up by the physician. As a result of highly active anti-retroviral therapy (HAART) some researchers noticed a marked reduction in the occurrence of opportunistic infections. The prevalence of mouth manifestations has been through a significant decrease with the advent of HAART 26, 27. The incidence of candidiasis, hairy leukoplakia and periodontal diseases decreased; conversely, patients presented increase in salivary gland diseases26, 27.

It is important that healthcare professionals be aware of mouth manifestations in HIV-infected patients for diagnosis, treatment and consequent improvement of quality of life of these patients.

CONCLUSION

In our sample, there was prevalence of pseudomembranous candidiasis as a lesion associated with Acquired Immunodeficiency Syndrome, at the age range of 31 to 40 years. The most predominant contagion form was sexual contact and there was also greater presence of leukoderma men.

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1 Dentist, specialist in Periodontics, Master studies under course, Post-Graduation Course in Head and Neck Surgery, Hospital Heliópolis, Hosphel, São Paulo.
2 Surgeon, Department of Head and Neck Surgery and Otorhinolaryngology, Hospital Heliópolis, Hosphel, São Paulo, Ph.D. in Medicine, UNIFESP.
3 Dentist, Head of the Service of Oral-Maxillo-Facial Surgery, Hospital Heliópolis - São Paulo, Professor of Oral-Maxillo -Facial Surgery, FOUSP.
4 Head and Neck Surgeon, Department of Head and Neck Surgery and Otorhinolaryngology, Hospital Heliópolis. Hosphel, and Full Professor, Medical School, University of São Paulo.

Study conducted at Hospital Heliópolis, São Paulo, SP.

Address correspondence to: Valdinês Gonçalves dos Santos Cavassani - Rua José Patrício, 43 - Rudge Ramos - São Bernardo do Campo - SP - 09601-010 - Tel/Fax (55 11) 4368-9666 - E-mail:hmbpsa_comercial@ig.com.br

Article submitted on April 25, 2002. Article accepted on August 8, 2002