Determinants of periodontitis according to the immunological and virological prrofiles of HIV infected patients

Buolikeze Kuoh Geh
Buccodental medicine, Yaoundé I
June, 2018


Introduction:The main targets of human immunodeficiency virus are receptors of cluster of differentiation (CD4+) lymphocytes. Infection and killing of CD4+ lymphocytes or symptomatic reaction of the body to HIV infection and the spontaneous apoptosis of CD4+ lymphocytes decrease the natural defense mechanism in place leading to immunodeficiency, further disease progression, and appearance of opportunistic infections and malignancies. Certain laboratory parameters such as the CD4 count and plasma viral load have been used as markers of disease progression. In adults, HIV infection is related to a variety of periodontal lesions including necrotizing periodontal diseases and certain forms of gingivitis, periodontitis or possible exacerbation of pre-existing periodontal conditions.The introduction of highly active antiretroviral therapy (HAART) has resulted in a significant reduction in mortality and morbidity of HIV patients as well as a reduction in the occurrence of opportunistic diseases, including oral diseases. Thus, assessing the current status of periodontitis in the era of HIV “test and treat strategy” in Cameroon might provide insights for improved oral management locally.
Objectives: Evaluate the determinants of periodontitis according to the immunological and virological profiles of HIV infected patients.
Methods:A prospective, cross sectional and analytical study was conducted from January through May 2018 among HIV-infected adults (≥21 years, both ART-naïve and experienced) at CIRCB and the HIV approved treatment center of the YCH. Periodontal status was assessed by measuring the clinical attachment loss, pocket depth, plaque Index, and gingival bleeding index. Blood samples were collected for analysis of CD4, CD8 cell levels and plasma viral load, using the FACS Calibur and Abbott m2000RT respectively. Association between the periodontal profile and HIV biomarkers was performed, with p<0.05 considered statistically significant.
Results and Discussions:A total of165 participants (65.5% female) were enrolled: 44 ART-Naïve and 121 ART-experienced. The mean age of our study population was 42.3 ±10.7years (min-max: 21-67), with a considerable difference between the ART-naïve (mean age: 39.23±11.5) and ART-experienced group (mean age: 43.48±10.2 years). In our study population, the overall occurrence of periodontitis was 39.4% (65/165), with a higher burden among ART-naïve (53.2%, 23/44) compared to ART-experienced patients (34.7%, 42/121); p=0.03. This indicates that for ART-naïve patients, consulting a dental surgeon should be highly considered to prevent the occurrence or manage periodontal diseases. Regarding HIV biomarkers in the overall population,the median (IQR:) CD4, CD8, mean (±SD) CD4/CD8 and mean (±SD) viral load were as follows: 398 cells/mm3 (IQR:191,547), 783 (IQR: 549.5, 1064), 0.56 (0.4296) and 1.98 log (2.24) respectively. Specifically, for the ART-naïve population, median (IQR:) CD4, CD8, mean (±SD) CD4/CD8 and mean (±SD) viral load were as follows: 176.5 (IQR:103,431), 847(IQR:567,1147), 0.5(0.77) and3.31 log (1.16) copies, respectively; whereas for the ART-experienced population, the mean (±SD) of CD4, CD8, CD4/CD8 and viral load were as follows: 443 (IQR:249,618), 738(IQR: 539,1045), 1 (0.82) and 1.39 log (0.967) copies, respectively. Determinants of periodontal disorders were: males had a significant increase in clinical loss of attachment as compared to women (OR=6.08, p=0.005); this implies paying more attention to males in the control of periodontitis. ART-naïve patients with CD4<200 cells/mm3were thrice more likely to have periodontitis than naïve patients with CD4>200cells/mm3 (OR=3.12, p=0.06); thus stressing the forsystematic assessment of oral diseases among severely immune-compromised patients not yet on ART. However, there was no association between the occurrence of periodontitis and the CD4, CD8, CD4/CD8 and the viral load in both naïve and ART experienced groups, as well as between the ART regimen and the occurrence of periodontitis (p=0.10).
Conclusion:The overall occurrence of periodontitis was a concern in the general population of HIV-infected patients, which underscores the role of HIV as a driving factor of periodontal disease. Interestingly, ART-naïve patients (especially those severely immune-compromised: CD4<200 cells) are more affected than those on treatment, thus underlining the need for closer monitoring of the oral health of patients initiating ART. Moreover, this indication should be highly considered, in the clinical setting, when dealing with male HIV-infected patients. Therefore, independent factors of periodontitis among HIV patients in Cameroon are likely: male, ART-naïve and low CD4cells (<200cells/mm3). Within our routine clinical practice, a model (algorithm) that integrates these three key determinants would be of great relevance in guiding HIV physicians, on the selective referral of HIV-patients for dental care in Cameroon.