Oral Health and HIV/AIDS in Sub-Saharan Africa

Oral Health and HIV/AIDS in Sub-Saharan Africa
Oral health simply refers to the state of being free from persistent or chronic
illnesses/conditions such as mouth and facial pain, oral sores, throat and oral cancer, gum disease
as well as other disorders and diseases affecting the mouth and oral cavity (1). People who have
human immunodeficiency virus (HIV), virus that causes acquired immunodeficiency syndrome
(AIDS), are at a higher risk for oral health problems. A vast majority of these problems come
about because the individual’s immune system is weakened and thus, less able to fight off
infection (2). From the context of Sub-Saharan Africa where majority of people living with
HIV/AIDS reside, this paper discusses the oral manifestations of HIV/AIDS infections, the
relationship of HIV and oral health and the control or treatment measures that can be
Petersen (1) pointed out that oral health infections are more common among HIV-
infected people in Sub-Saharan Africa mainly because of high doctor-patient ratio, inadequate
and/or ill-equipped health facilities, insufficient oral health care personnel/dentists, lack of
commitment by governments in tackling the issue and lack of education on oral health care.
Rosenstein (3) stated that many oral health problems are found in people who are either HIV
negative or positive, although there are some vital differences. Some conditions are found almost
entirely in HIV infected people, while some that are seen in both populations happen to be more
problematic for HIV infected people, particularly those with advanced disease. An immune
system that is diminished could alter the course of oral disease and necessitate more aggressive
treatment in order to prevent minor troubles from becoming major health problems (4). The most
common oral problems affecting people with HIV/AIDS in Sub-Saharan Africa include fever
blisters, gum disease such as gingivitis and periodontitis, oral warts, cavities, oral hairy

leukoplakia, aphthous ulcers/canker sores and oral candidiasis/thrush. In addition, they may as
well experience dry mouth and this increases the risk of risk of tooth decay, which can make
eating chewing, swallowing and sometimes talking difficult (1).
Oral health problems are prevalent among HIV positive people in Sub-Saharan Africa
than anywhere else in the world, and several factors have contributed to these high levels. The
most common among them include: Lack of adequate oral health care personnel/dentists – A
vast majority of countries in Sub-Saharan Africa lack adequate dentists and other personnel
trained in oral health care. As a result, the oral health care needs of HIV positive individuals are
not met satisfactorily. Lack of education on oral health – Many people with HIV/AIDS in this
region lack knowledge on oral health infections and oral health in general. Consequently, many
continue to suffer since with the lack of knowledge, they are unable to seek diagnosis and
treatment (6).
Inadequate and/or poorly equipped health facilities – Generally, most people in Sub-
Saharan Africa with HIV/AIDS reside in rural or periurban areas, and unlike urban and
cosmopolitan areas, these regions typically have insufficient hospitals and those that exist may
be poorly equipped. Low priority given to oral health care by African governments – This is
chiefly because of the presence of many other general health problems as well as development
needs. High cost of treatment – The cost of medication and treatment for oral health infections is
very high to people with HIV/AIDS, majority of whom are poor and as such, they cannot afford
the treatment (7).
More that 30 dissimilar oral manifestations of HIV/AIDS have been documented in
several Sub-Saharan African countries including Nigeria, BurkinaFaso, Uganda, Botswana,

South Africa, Tanzania and Ethiopia. Many groups of these oral manifestations are well known
and might be neoplasms, infections or other manifestations. The most commonly known
neoplasms include Non-Hodgkin’s Lymphoma and Kaposi’s Sarcoma, while infections include
bacterial, viral or fungal. The other category is Aphthous-like ulcers, mucosa melanin
pigmentation, idiopathic thrombocytopenic and salivary gland diseases (8).
Fungal infection or Oral Candidiasis/thrush – This is a relatively common problem for
HIV positive people particularly in South Africa and Zimbabwe. People who have Candidiasis
most often notice changes regarding taste perception and this may make food undesirable (9).
This condition occurs mainly during the acute stages of HIV infection, although it occurs most
frequently when cluster of differentiation 4+ (CD4+) T-cell count falls during the middle as well
as late stages of HIV disease. (4). Pseudomembranous candidiasis – This is definitely the most
frequent form of oral candidiasis among the HIV-infected people in Sub-Saharan Africa, and it
appears as a white curd-like material and when wiped off, it exposes or reveals an underlying
erythematous mucosa. It might involve any part of pharynx or mouth (10). Hyperplastic
Candidiasis – With this condition, lesions look white and hyperplastic. Tobias (11) observed that
the white areas are as a result of hyperkeratosis. Angular cheilitis – This appears as an erythema
or fissuring either bilaterally or unilaterally at the corners of the mouth. It may appear alone or
together with another form of intraoral candidiasis (7).
Ndiaye (6) pointed out that members of the human papillomavirus (HPV) and human
herpesvirus (HHV) families are the most frequent causes of major viral infections of the oral
cavity, among HIV-infected people in most parts of Sub-Saharan Africa. Nevertheless, many
other viral infections may affect the oral cavity either as systematic or localized infections. Oral
herpes simplex – This condition is characterized by an eruption of serum-filled blisters/vesicles –

also known as fever blisters or cold sores – on the mouth, lips or face (6). Human Papillomavirus
(HPV) lesions – This commonly occurs within the oral cavity such as the lip and sides of the
tongue. The lesions in the oral cavity might appear as single exophylic, papillary or several
nodules. The lesions caused by HPV commonly appear on the skin as well as mucous
membranes of the HIV infected people, and they are very serious and very difficult to treat (7).
Cytomegalovirus (CMV) – This infection is reported to cause oral ulcers among HIV-positive
people in South Africa and parts of East Africa such Tanzania and Ethiopia. These ulcers appear
on any mucosal surface and could sometimes be confused with aphthous ulcers, necrotizing
ulcerative periodontis and lymphoma (5).
Hairy Leukoplakia (HL) – According to Thorpe (12), HL generally appears as a
corrugated or hairy, nonmovable lesion on the lateral margins of the tongue. It occurs in all the
risk groups for HIV infections in Sub-Saharan Africa, though less frequently in children than in
adults. It occurs in roughly 20% of individuals who have asymptomatic HIV infection and it
becomes more common as the CD4+ T-cell count falls (12). Because this condition is rarely
observed except when the CD4 cell count is low, it is less frequent in parts of Sub-Saharan
Africa where anti-HIV therapy is readily available for instance Southern Africa, East Africa, and
Nigeria (13).
Bajomo (14) stated that periodontal diseases are the most common oral lesions that are
associated with bacterial infection. Periodontal disease is a rather usual problem in both
symptomatic and asymptomatic HIV-infected individuals in most parts of Sub-Sahara Africa.
The infection may take two forms, necrotizing ulcerative periodontitis (NUP), and its associated
and precursor condition known as linear gingival erythema (LGE). LGE – It appears as a
different band of erythema of the gingival margin, which does not respond to removal of local

factors. It might be painful, bleed and progress to periodontal disease (14). NUP disease – This is
associated with rapid soft tissue as well as bone loss, and includes exposure of the bone,
premature loss of teeth and rapid deterioration of tooth attachment (15).
A multitude of opportunistic tumors – neoplasms or cankers, are associated with HIV
infection. Two of the most common are non-Hodgkin’s Lymphoma (NHL) and Kaposi’s
sarcoma (KS), and could manifest in the oral cavity. These two conditions are seen when the
HIV infected individual has a CD4 cell count of below 200 (7). Kaposi’s Sarcoma (KS) – This is
the most frequent neoplasm in HIV-infected people in Sub-Saharan Africa. KS may appear as a
blue, purplish, or red lesion that do not whiten with pressure, and may be raised or flat, multiple
or solitary. Non-Hodgkin’s lymphoma (NHL) – This is a common HIV-associated malignancy in
Sub-Saharan Africa. It can occur anywhere within the oral cavity, and most often occurs as a
soft, tumor-like mass that may enlarge rapidly (3).
Oral ulceration – In people with HIV/AIDS in Sub-Saharan Africa, oral ulcers are
reported with increasing frequency. Aphthous stomatitis/canker sores – Although this infection is
common regardless of HIV status, the ulcers/sores may be slow to heal in HIV-infected people.
Salivary gland disease (SGD) and xerostomia – Bilateral parotid gland enlargement commonly
occurs in people with HIV. SGD associated with HIV infection may appear as xerostomia either
with or without salivary gland enlargement. Mucosal melanin pigmentation – Multiple and single
oral mucosal macules have been reported to occur in people with HIV/AIDS in Sub-Saharan
Africa (8).
In essence, with regard to oral health, oral manifestations in HIV/AIDS-infected people in
Sub-Saharan Africa are opportunistic manifestations/infections of immune deficiency or

derangement. They are not necessarily caused directly by HIV/AIDS and they occur in
conjunction with other immune deficiency disorders (13). Many oral health problems may be
found in persons who are either HIV negative or positive, although there are some differences.
Some infections are found more frequently in People Living With HIV/AIDS (PLWHA) than the
normal population. Such infections include Aphthous stomatitis (canker sores), oral candidiasis,
and herpes simplex. Few oral health infections are found roughly exclusively in PLWHA and
include opportunistic tumors and oral hairy leukoplakia, while some that are found in both
populations happen to be more problematic for PLWHA, particularly those with advanced
disease (4).
With regard to dental caries, some medication used by PLWHA may lead to decreased
salivary flow or dry mouth, known to contribute to rampant caries. While periodontal diseases
may occur to anybody regardless of her/his HIV status, one specifically severe form, NUP, and a
related condition, LGE, appear to be unique to people with compromised immune systems. A
vast majority of the earliest manifestations of the immune suppression that are associated with
HIV infection occur within the mouth. The presence of these lesions might be an early diagnostic
sign of immunodeficiency as well as HIV infection, might change the classification of the HIV
infection stage, and is a predictor of the progression of HIV (15).
A vast majority of health systems in Sub-Saharan Africa are in very poor state and need to
be strengthened. Nevertheless, health systems in Sub-Sahara African countries have a
responsibility of improving the oral health of its HIV-infected individuals, and protect them
against the financial cost of the illnesses (4). There are several recommendations that if properly
implemented, they can significantly help to alleviate and lessen the burden of oral health
infections among HIV/AIDS-infected people in Sub-Saharan Africa. First, education should be

provided especially among the HIV positive individuals with regard to oral health infections
since many of them have little knowledge on this issue. Provision of education about the
different manifestations of oral health infections, diagnosis and treatment will play a significant
role in alleviating the infection in Sub-Saharan Africa. (3)
Secondly, Morison (15) stated that governments in the region should aim at increasing
the number of health facilities in order to adequately serve the needs of the HIV positive people
with oral health problems. A vast majority of PLWHA in Sub-Saharan Africa reside in rural and
periurban areas far from health facilities. Therefore, it is recommended that African governments
put extra effort towards establishing more health facilities in rural areas in order to adequately
meet the oral health needs of PLWHA. Third, the number of oral health personnel/dentists be
increased in order to reduce the imbalance between the personnel and population needs. Fourth,
governments should me be more committed to measures that aim at alleviating oral health
conditions among PLWHA by providing financial support that will go towards providing
medication and treatment to those who cannot afford it. (8)
People with HIV/AIDS are at a high risk for oral health problems and those in Sub-
Saharan Africa are even at a higher risk because of various challenges. Some of them include
insufficient dentists, inadequate and/or poorly equipped health facilities, lack of education on the
subject of oral health, and the low priority given to oral health care primarily due to the presence
of several other health problems and massive development needs.
Oral manifestations/infections significantly affect the quality of life of PLWHA through
difficulties in food tasting, chewing and swallowing. This problem is much endemic in Sub-
Saharan Africa since most PLWHA are in this area, that is, over 60% of all HIV/AIDS infected

people in the world (6). Some of these infections include Oral candidiasis, Angular cheilitis,
Herpes simplex, Human Papilomavirus lesions, Cytomegalovirus, Hairy Leukoplakia,
periodontal diseases, Kaposi’s Sarcoma. Some of the measures that governments in Sub-Saharan
Africa can undertake in order to alleviate the burden of oral health problems particularly among
HIV-infected people in their countries the following; Establishing more health facilities in rural
and peri-urban areas, increasing the number of dentists/oral health care personnel in existing
health facilities, sufficiently equipping health facilities and this includes provision of adequate
quantity and quality of drugs, providing oral health care education especially to those who are
HIV positive..

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