Page 4 - GP Spring 2024

Oral Manifestations of Long-Term Highly Active
Antiretroviral Therapy (HAART)

Authors: Athman Sivaseelan, Aanchal Parmar, Angela M. De Bartolo, DDS and Analia Veitz-Keenan, DDS, FAGD

HAART Therapy Overview: and finally to restore function so that the pa- oral lesions in HIV-positive patients: sys-
Highly active antiretroviral therapy tient’s ability to eat is not disturbed. tematic review and meta-analysis was con-
(HAART) is a treatment regimen for the ducted by V.L. de Almeida et al. This sys-
management of human immunodeficien- Methodology: tematic review calculated the relative risk
cy virus type 1 (HIV-1). The success of Pubmed and Cochrane were the elec- between studies in the random-effects mod-
HAART is based on the co-administration tronic databases used for the purposes of el. When comparing the various outcomes
of three or more antiretroviral medications this review. Our search was conducted to of HAART therapy the authors found a
in combination with different methods of identify articles that explore the impact of moderate decrease in the risk of various oral
action. This, in turn, inhibits the viral repli- HAART therapy on the oral manifestations manifestations which includes: erythem-
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cation and spread of viruses that have devel- of HIV-infected individuals. Ninety articles atous candidiasis (RR 0.54, 95% CI 0.33–
oped resistance to one or two of the agents. mentioned oral manifestations in relation to 0.88), pseudomembranous candidiasis (RR
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Typically, of the 25+ medications available HIV and immunocompromised status. Of 0.49, 95% CI 0.24–0.97), oral herpes (RR
for use, the standard antiretroviral “cock- the ninety studies, the search was further 0.28, 95% CI 0.09–0.87), and oral hairy
tail” will include a combination of two refined to include the influence of HAART leukoplakia (RR 0.41, 95% CI 0.22–0.76).
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nucleoside reverse transcriptase inhibitors therapy and overall prevalence, which pro- This decrease in risk through the interven-
and a non-nucleoside reverse transcriptase duced 18 relevant studies. Finally, three ar- tion of HAART therapy was found to a less-
inhibitor or integrase strand transfer inhib- ticles were chosen, comprising two system- er degree in outcomes such as salivary gland
itor. However, despite the multifaceted atic reviews and a cross-sectional study. disease and recurrent oral ulcerations. At
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approach, this regimen is not a cure-all but the same time, there was an increased prev-
rather looks to reduce mortality and viral After the selection of the studies to be in- alence of oral mucosal hyperpigmentation
load, prevent transmission, and improve im- cluded, critical appraisal forms were utilized (RR 1.65, 95% CI 1.16– 2.32). 8
mune function and overall quality of life. 2 to assess the overall quality of the studies
and evaluate the existence of biases and lim- The final study entitled Oral hyperpigmen-
HAART and Oral Manifestations - itations that may impact the methodology of tation as an adverse effect of highly active
Pathophysiology: each article. In order to accomplish this, the antiretroviral therapy in HIV patients: A
Oral manifestations such as oral lesions study type, intervention, control, outcomes, systematic review and pooled prevalence
(OL), oral candidiasis (OC), and oral hairy key results, associated figures, and overall by Radithia et al. This systematic review
leukoplakia (OHL) are important prognostic quality were examined individually. aims to look at a single oral manifestation
factors of human immunodeficiency virus of HAART therapy: hyperpigmentation.
(HIV) infection, the presence of which is Results: The analysis revealed that the prevalence
indicative of HIV infection with profession- Three studies were conclusively selected of oral hyperpigmentation is 25% (95% CI:
al to acquired immune deficiency syndrome based on a comprehensive evaluation of key 11%, 38%; I2: 99%) for patients undergoing
(AIDS). Patients with low CD4+ T-lym- factors, including their methodology, adher- HAART. This localized or general hyper-
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phocyte counts (i.e., <200 cells/mL) are ence to inclusion criteria, reported results, pigmentation can be found anymore in the
predisposed to HIV-associated oral infec- and overall study quality. oral cavity, but it is found most commonly
tions that require specific treatment. Most on the tongue, gingiva, and buccal mucosa. 9
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HIV-associated oral conditions are caused The first study, Effects of long-term use of
by opportunistic infections, such as those HAART on the oral health status of HIV-in- Discussion:
mentioned above, which occur progressive- fected subjects, conducted by Nittayananta All studies were observational studies fea-
ly due to immune system deficiency. 6 et al. 2010, examined various oral manifes- turing a cross-sectional review as well as
tations of HIV-infected individuals taking two systematic reviews. Many oral mani-
HAART and Dental Implications: HAART over both the short-term and long- festations were present in multiple studies
While the implication of HAART therapy term compared to HIV-infected individuals of the three included studies. However, the
has helped reduce the frequency of many not on HAART. It revealed a decrease in the only outcome present in all studies is oral
opportunistic infections and oral manifes- prevalence of specific HIV-related oral le- hyperpigmentation.
tations, oral care providers must regularly sions in the short term, including orofacial
check for signs and symptoms of infections pain (P < 0.01,), periodontal pockets (P < The increased prevalence of oral hyper-
that may appear after viral therapy failure or 0.01), and oral lesions (P < 0.01). However, pigmentation after the implementation of
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increased immunosuppression. Additional- a noteworthy finding was that long-term use HAART therapy is one particular effect that
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ly, patients should be counseled about fac- of HAART was associated with a higher risk was corroborated across all studies. This
tors that pose additional risks, such as smok- of developing oral lesions, with these short- finding is particularly important for dental
ing, which increases their risk for common term benefits regressing over time and now practitioners to keep note of for patients
HIV-associated opportunistic infections being higher risk because of the increased undergoing antiretroviral for a number of
such as candidiasis and hairy leukoplakia as length of the therapy (P < 0.05). This un- reasons. This may present an aesthetic issue
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compared to non-smokers. Other modifiable derscores the need for continuous monitor- for the patient unaware of the pigmentation,
risk factors include the concurrent use of al- ing and managing oral health in individuals but it is also important for the dental practi-
cohol and safe-sex counseling. Before all on prolonged HAART therapy. tioner not to misdiagnose the hyperpigmen-
else, the priority is first to relieve pain and tation as another melanotic-pigmented oral
manage the infection, followed by a preven- The second study, Impact of highly active manifestation.
tion regimen to prevent concomitant disease antiretroviral therapy on the prevalence of

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