|Year : 2022 | Volume
| Issue : 2 | Page : 183-187
Epidemiological evaluation of maternal periodontal status in human immunodeficiency virus seropositive pregnant women in India
Sunkavilli Ravi Kiran, Yudheera Karnam, Bammidi Niharika
Department of Periodontology, Lenora Institute of Dental Sciences, Rajhamundry, Andhra Pradesh, India
|Date of Submission||05-Jun-2021|
|Date of Decision||10-Jan-2022|
|Date of Acceptance||26-Mar-2022|
|Date of Web Publication||8-Jun-2022|
Sunkavilli Ravi Kiran
Department of Periodontics, Lenoral Institute of Dental Sciences, Rajhamundry, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Human immunodeficiency virus (HIV) infection in pregnancy was the most common complication in some developing countries. This has major implications for the management of pregnancy and birth. Periodontal disease in HIV-infected pregnant women leads to a hyperinflammatory state which may have an impact on developing fetus. Aim: The evaluation of gingival and periodontal health in HIV seropositive pregnant women. Methods: A sample of 432 HIV seropositive pregnant women visiting the antiretroviral therapy center from January 2016–December 2016 were included in the present study. Information concerning demographic profile, medical history, and oral health information was recorded in a case sheet pro forma. Several measures of periodontal health such as bleeding on probing, plaque index, pocket depth (PD), and clinical attachment loss were obtained and analyzed by using Chi-square test of independence and P value (P < 0.05, statistically significant). Results: Three hundred and ninety-six participants (91.6%) had gum bleeding on >1 tooth. In gingivitis, the distributions of mild, moderate, and severe gingivitis were about 64 (14.81%), 192 (44.44%), and 140 (32.41%) participants, respectively. Participants without periodontitis (without a single PD ≥4 mm) were about 202 (46.76%). Two hundred and thirty participants (53.2%) had periodontal pockets (≥4 mm) on ≥1 tooth. In periodontitis, the distributions of mild, moderate, and severe periodontitis were 28.70%, 15.74%, and 8.80%, respectively. Conclusion: Ninety-two percent of HIV pregnant women have shown gingival inflammation. Periodontitis was observed in 51% of HIV pregnant women. This observation strengthens the importance of oral health care in HIV-positive pregnant women.
Keywords: Gingivitis, human immunodeficiency virus pregnant women, maternal periodontal health
|How to cite this article:|
Kiran SR, Karnam Y, Niharika B. Epidemiological evaluation of maternal periodontal status in human immunodeficiency virus seropositive pregnant women in India. J Indian Assoc Public Health Dent 2022;20:183-7
| Introduction|| |
Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) has been a global health problem for several decades, even though the development of antiretroviral therapy (ART) has modified the course of chronic disease into longer periods of survival and improved quality of life. India is the third-largest HIV epidemic country in the world. As per the latest HIV estimates report (2019) of the Government, India is estimated to have around 23.49 lakh people living with HIV/AIDS in 2019, wherein Andhra Pradesh ranked 2nd with 3.14 lakh people. HIV infection in pregnancy has become the most common complication of pregnancy in some developing countries and has major implications for the management of pregnancy and birth.,,
The periodontal diseases in HIV-seropositive patients include common as well as less conventional forms of gingivitis and periodontitis. Periodontal diseases are a group of infectious diseases caused by predominantly Gram-negative, anaerobic, and microaerophilic bacteria that colonize the subgingival area. Inflamed periodontal tissues produce a significant amount of pro-inflammatory cytokines, mainly IL-1 β, IL-6, prostaglandin E2, and tumor necrosis factor-alpha which may have systemic effects on the host. Offenbacher et al. found that periodontal infection may be a potential independent risk factor for preterm low birth weight. In 1931, Galloway identified that the focal infection found in teeth, tonsils, sinuses, and kidneys pose a risk to the developing fetus. Galloway summarized that the removal of a known focal infection which had demonstrated to be a source of danger to any pregnant woman which was more beneficial than allowing the infection to harbor throughout the pregnancy. He suggested that all foci of infection should be removed early in pregnancy.
Oral health care and dental knowledge were necessary to prevent these oral infections in HIV pregnant women because the inflammatory burden in periodontal infections might affect the developing fetus. However, there had been a limited number of studies available in the literature regarding the status of periodontal infection in HIV-positive pregnant women, especially in India. Most of the studies available were done with a limited sample size. Hence, this study aimed at assessing the periodontal status among HIV pregnant women in the Vijaywada region, Krishna district of Andhra Pradesh state.
| Methods|| |
The study sample consisted of 432 HIV seropositive pregnant women visiting the ART Centre, Vijayawada, Andhra Pradesh, India, from January 2016 to December 2016. All the participants were undergoing highly active antiretro viral therapy. All confirmed HIV-positive pregnant patients (13th–34th week of gestation) with age 18 years or older having at least two teeth in each quadrant were included in the present study.
The current study protocol was approved by the institutional ethical committee. The patients who accorded their consent were examined. Information concerning demographic profile, medical and health history, and oral health information was recorded in a case sheet pro forma. Variables such as age, body mass index (BMI), gestational age, CD4 counts, antiretroviral used, hypertension, diabetes mellitus, and genital infection were confirmed by the medical chart.
All clinical examinations were carried out by a single-experienced dentist using a calibrated periodontal probe, University of North Carolina No. 15, to ensure consistency of measurements. A periodontal examination was performed, which includes several parameters such as plaque index (Silness and Loe in 1964), bleeding on probing, probing pocket depth (PD) (distance between the gingival margin and the bottom of the periodontal sulcus), clinical attachment level (AL) (calculated as the sum of probing PD and gingival recession, i.e., distance between the gingival margin and cement enamel junction). Clinical AL and periodontal PD were examined and recorded simultaneously for six positions (mesiobuccal, mid-buccal, distobuccal, mesiolingual, mid lingual, and distolingual) on each tooth. Gingivitis was determined by the presence of gingival bleeding when participants underwent probing of periodontal pockets. If there was any bleeding site on a tooth, the tooth was diagnosed as having gingivitis. Gingivitis was categorized by percentages of teeth exhibiting bleeding on probing (BOP) in four levels as none (0%), mild (0.10%–20%), moderate (21%–40%), and severe (>41%). This study categorized periodontitis by the percentage of teeth that has periodontal pockets of >4 mm in four levels as none (0%), mild (0.1%–20%), moderate (21%–40%), and severe (>41%). Soft and hard tissue examination was performed to evaluate any HIV-associated lesions.
The collected data were subjected to statistical analysis using SPSS Software Version 12.0 (SPSS inc, IBM, Armonk, NY). The Chi-square test of Independence is used to determine if there is a significant relationship between two nominal (categorical) variables. A P < 0.05 was considered statistically significant.
| Results|| |
In the present study, 276 women with the age range of 16–24 years and 156 women with an age range of 24–35. The main mode of transmission of HIV was through the heterosexual route which was about 81%. This was followed by an unknown mode of transmission for about 19%. Primiparity was observed in 388 participants (89.81%) and 44 participants (11%) were experiencing their second pregnancy. Demographic details are shown in [Table 1].
|Table 1: Distribution of respondents by different factors such a age, education, body mass index, parity|
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The mean CD4 count of the participants in this study was 412.3 ± 176.1. 62.50% of participants CD4 count was in the 200–500 cells/mm3 range. Only 4 patients had CD4 count <200 and the remaining 36.57% (158 participants) had CD4 count >500. All the participants were in the WHO AIDS clinical stage-1. In this study group, for about 47.69% were in the range of 13–19 weeks of gestation at the time of enrolment, the other 43.06% belonged to 30–33 weeks of gestation, and 9.26% of the participants were in the gestational age range of 20–29 weeks [Table 2].
|Table 2: Distribution of respondents by CD4, gestation at enrollment, and who clinical stage|
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Out of 432 HIV-positive pregnant women, participants without Gingivitis (i.e., without any single bleeding site) were 36 (8.33%). Three hundred and ninety-six participants (91.6%) had gum bleeding on >1 tooth. In gingivitis, the distributions of mild, moderate, and severe gingivitis were at 64 (14.81%), 192 (44.44%), and 140 (32.41%) participants, respectively. In our study, the majority of the gingivitis cases belong to “Moderate Gingivitis” category. Participants without periodontitis (i.e., those without a single PD ≥4 mm) were 202 (46.76%). Two hundred and thirty participants (53.2%) had periodontal pockets (≥4 mm) on ≥1 tooth. In periodontitis, the distributions of mild, moderate, and severe periodontitis were 124 (28.70%), 68 (15.74%), and 38 (8.80%) participants, respectively. The distribution of respondents by gingivitis and periodontitis is shown in [Table 3].
In this study, the majority of the periodontitis cases were found to be in the mild periodontitis category. We did not find any significant association between CD4 count with gingivitis and periodontitis at P > 0.05 [Table 4] and [Table 5].
| Discussion|| |
A total of 432 HIV-positive pregnant women who visited the antiretroviral therapy center, Vijayawada, were enrolled on the study. A complete case history which includes all the demographic details, personal history, and medical history of the participants will be collected. Age is an important risk factor for gingival conditions. This study includes the age range of 18–35 years with a mean age of 23.7. In our study group, 68.98% of the participants were within the normal range of BMI, (18–35) 31.02% belonged to the underweight category (BMI <18). There were no obese women in this study group. Research stated that obese persons develop inflammation in periodontal tissues, Hence, we eliminated the obesity from the risk category by including more women within the normal range of BMI. Literacy denotes the ability to read and write. The study showed that 16.20% of the participants were illiterates and the remaining 83.8% were literates. Among the literates, 43.06% had primary education, 29.63 had secondary education, and the remaining 11.11% had completed their graduation. Literacy has a major role in the progression of HIV. Poor literacy is a social barrier to access healthcare services and to appropriate health treatment among patients living with HIV. In this study group, 47.69% were in the range of 13–19 weeks of gestation at the time of enrolment, the other 43.06% belonged to 30–33 weeks of gestation, and 9.26% of the participants were in the gestational age range of 20–29 weeks.
ART is the treatment of people infected with HIV using anti-HIV drugs. The standard treatment consists of a combination of at least three drugs (often called “highly active ART” or highly active ART [HAART]) that suppress HIV replication. The study showed that about 356 participants (82.4%) are already on highly active anti-retroviral therapy at the time of enrolment. The remaining 76 patients who were recently diagnosed with HIV had started the treatment after the enrollment. Most of the patients are under HAART therapy which helps in maintaining CD4 count within normal range. The mean CD4 count of the participants in this study was 412.3. 62.50% of participants CD4 count was in the 200–500 cells/mm3 range which was similar to the study of, Choromańska et al., Fricke et al., Pattrapornnan et al., where a majority of the patients were in the same range. In this study, selection bias was avoided by excluding all the traditional risk factors and confounding variables such as diabetes, hypertension, cardiovascular diseases, any other infections and habits such as smoking and alcohol consumption.
Periodontal health was defined as the absence of PDs ≥4-mm and absence of attachment loss ≥2 mm, with no bleeding on probing. The quantitative measure was employed for this study. The quantitative measure indicates that the periodontitis level by using the frequency of the teeth that were affected or have ≥4 mm probing depth and converting it into a percentage. This study used a quantitative approach which was also used in the studies of Boggess et al.
The mean plaque score obtained was 0.43. The finding was similar to that of Yeung et al. Changes in hormone levels during pregnancy promote an inflammatory response that increases the risk of developing gingivitis and periodontitis. As a result of varying hormone levels without any changes in the plaque levels, 50%–70% of all women will develop gingivitis during their pregnancy.
In our study, the majority of the gingivitis cases belong to moderate gingivitis (44.4%) followed by severe gingivitis (32.4%) category. The above findings were in contrast to the study of Pattrapornnan et al., Samant et al. where most of the gingivitis cases were in the low percentage. Participants without periodontitis (i.e., those without a single PD ≥4 mm) were counted as 202 (46.76%). This finding was in contrast to the study of López and Guerra. where a majority of the periodontitis cases were found to be in the mild periodontitis (28.7%) category similar to the studies of Pattrapornnan et al. The increased levels of the hormones progesterone and estrogen can affect the small blood vessels of the gingiva, making it more permeable., This increases the mother's susceptibility to oral infections, allowing pathogenic bacteria to proliferate and contribute to inflammation in the gingiva. This hyper-inflammatory state increases the sensitivity of the gingiva to the pathogenic bacteria found in dental biofilm. Deterioration of health status, expressed with the decrease of the absolute number of CD4 lymphocytes is accompanied by the intensification of pathological periodontal changes. However, in our study, majority of patients are in a normal range of CD4 that may be the reason for almost half of the patients are with no periodontitis and the majority are in mild periodontitis.
As far as the association between CD4 cells and periodontitis was concerned, we found no significant association of CD4 with either gingivitis or periodontitis as the P = 0.32 and 0.09. Low CD4 counts below 200 that have been associated with chronic periodontitis in many cross-sectional studies because of severe immune deficiency., ART may reduce periodontal disease morbidity by suppression of host-derived cellular immune responses in HIV infection which are major mediators of periodontal destruction and reduced number of opportunistic microbes with increase CD4 count.,, The lack of knowledge and awareness toward the oral health importance was observed in HIVseropositive pregnant women during the study.
Future studies with larger sample sizes of HIV seropositive pregnant women along with parallel comparisons between healthy and HIV-infected pregnant populations still need to be investigated.
| Conclusion|| |
Around 92% of HIV-positive pregnant women have shown gingival inflammation and 51% has shown periodontal inflammation (majority are mild periodontitis) in the present study. This observation strengthens the importance of oral health care in HIV-positive pregnant women. We strongly recommend that the complete dental examination in all HIV seropositive pregnant women along with an extra need for preventive oral health services during the prenatal period. This study has provided valuable insight into the oral health of pregnant women with HIV infection. As prevention with care, support and treatment form the two key pillars of all HIV/AIDS control efforts in India, so there is a need to expand oral health care and preventive measures for HIV pregnant women.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sadatmansouri S, Sedighpoor N, Aghaloo M. Effects of periodontal treatment phase I on birth term and birth weight. J Indian Soc Pedod Prev Dent 2006;24:23-6.
] [Full text]
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et al.
Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996;67:1103-13.
Galloway CE. Focal infection. Am J Surg 1931;14:643-5.
Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condtion. Acta Odontol Scand 1964;22:121-35.
Pattrapornnan P, DeRouen TA, Songpaisan Y. Increased risks of preterm birth and a low-birth-weight baby in Thai human immunodeficiency virus-positive pregnant women with periodontitis. J Periodontol 2012;83:1372-81.
Wu Y, Dong G, Xiao W, Xiao E, Miao F, Syverson A, et al.
Effect of aging on periodontal inflammation, microbial colonization, and disease susceptibility. J Dent Res 2016;95:460-6.
Martinez-Herrera M, Silvestre-Rangil J, Silvestre FJ. Association between obesity and periodontal disease. A systematic review of epidemiological studies and controlled clinical trials. Med Oral Patol Oral Cir Bucal 2017;22:e708-15.
Palumbo R. Discussing the effects of poor health literacy on patients facing HIV: A narrative literature review. Int J Health Policy Manag 2015;4:417-30.
Choromańska M, Waszkiel D. Periodontal status and treatment needs in HIV-infected patients. Adv Med Sci 2006;51 Suppl 1:110-3.
Fricke U, Geurtsen W, Staufenbiel I, Rahman A. Periodontal status of HIV-infected patients undergoing antiretroviral therapy compared to HIV-therapy naive patients: A case control study. Eur J Med Res 2012;17:2.
Boggess KA, Lieff S, Murtha AP, Moss K, Beck J, Offenbacher S. Maternal periodontal disease is associated with an increased risk for preeclampsia. Obstet Gynecol 2003;101:227-31.
Yeung SC, Stewart GJ, Cooper DA, Sindhusake D. Progression of periodontal disease in HIV seropositive patients. J Periodontol 1993;64:651-7.
Kornman KS, Loesche WJ. The subgingival microbial flora during pregnancy. J Periodontal Res 1980;15:111-22.
Samant A, Malik CP, Chabra SK, Devi PK. Gingivitis and periodontal disease in pregnancy. J Periodontol 1976;47:415-8.
López LM, Guerra ME. Caries experience and periodontal status during pregnancy in a group of pregnant women with HIV+infections from Puerto Rico. J AIDS Clin Res 2015;6:434.
Moore S, Ide M, Coward PY, Randhawa M, Borkowska E, Baylis R, et al.
A prospective study to investigate the relationship between periodontal disease and adverse pregnancy outcome. Br Dent J 2004;197:251-8.
Boggess KA, Beck JD, Murtha AP, Moss K, Offenbacher S. Maternal periodontal disease in early pregnancy and risk for a small-for-gestational-age infant. Am J Obstet Gynecol 2006;194:1316-22.
Madianos PN, Bobetsis YA, Offenbacher S. Adverse pregnancy outcomes (APOs) and periodontal disease: Pathogenic mechanisms. J Periodontol 2013;84:S170-80.
Fokam J, Geh BK, Sosso SM, Takou D, Ngufack ES, Nka AD, et al.
Determinants of periodontitis according to the immunological and virological profiles of HIV-infected patients in Yaoundé, Cameroon. BMC Oral Health 2020;20:359.
Khammissa R, Feller L, Altini M, Fatti P, Lemmer J. A comparison of chronic periodontitis in HIV-seropositive subjects and the general population in the Ga-Rankuwa area, South Africa. AIDS Res Treat 2012;2012:620962.
Gonçalves LS, Gonçalves BM, Fontes TV. Periodontal disease in HIV-infected adults in the HAART era: Clinical, immunological, and microbiological aspects. Arch Oral Biol 2013;58:1385-96.
Mataftsi M, Skoura L, Sakellari D. HIV infection and periodontal diseases: An overview of the post-HAART era. Oral Dis 2011;17:13-25.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]