International Journal of Oral & Maxillofacial Pathology.

2010;1(1):8-12
Available online at http://www.journalgateway.com

Research Article
A Study Of Oral Manifestation Of HIV/AIDS
Lalit Shrimali

Abstract
Background: In India, patients exposed to the Human Immunodeficiency Virus (HIV) infection are
increasing and about 30-80% of patients present with oral manifestations of the disease and only
a few studies have been performed to document this observation. Objective: To clinically evaluate
and document the oral lesions in patients with HIV infections. Methods: In clinically suspected
cases of HIV diagnosis was done by two consecutive screening tests using the Enzyme-linked
immunosorbent assay (ELISA) technique. Where indicated incisional biopsy was performed to
confirm the clinical diagnosis of the relevant lesions. All cases were examined according to the
WHO criteria. Prior to the examination each patient had undergone counseling. Results: of the 50
cases, 31(62%) were males and 19(38%) were females with an age range of 20 to 59 years
(mean=36.6 years). While all the cases had periodontal disease, over 72% had candidiasis,
xerostomia in 32%, lymphadenopathy in 42% and angular cheilitis was seen in 36% of the cases.
Other conditions seen included persistent oral ulceration (22%), oral hairy leukoplakia (2%),
herpes zoster (8%), parotomegaly(10%) and facial palsy(8%). Conclusion: For reducing morbidity
from HIV, early detection is necessary, therefore physicians must look for oral manifestation in
suspected cases of HIV which aid in early diagnosis and treatment.
Key Words: Oral Manifestation; HIV; AIDS; Oral Candidiasis;

Lalit Shrimali. A Study Of Oral Manifestation Of HIV/AIDS. International Journal of Oral & Maxillofacial
Pathology. 2010;1(1):8-12. ©2010 International Journal of Oral and Maxillofacial Pathology. Published by
Publishing Division, Celesta Software Private Limited. All Rights Reserved.
Received On: 10/09/2010 Accepted On: 11/11/2010

According to the World Health Organization tuberculosis. Patients were diagnosed by

(WHO) 2008 report around 33.8 million two consecutive enzyme linked
people world wide are living with Acquired immunosorbent assay (ELISA), screening
immune deficiency syndrome (AIDS) of tests for HIV infection. Proper counseling
which around 3.8 million are in India. Oral was done to educate the patient. Oral
manifestations are seen in 30-80% of the examination was performed according to the
patients of HIV.(1-2) Studies have shown WHO criteria.(10) Where indicated incisional
that 90% of patients with HIV will have at biopsy and microbiological specimens were
least one oral manifestations during the taken for histopathological & microbiological
course of disease.(3-4) Oral manifestations examination done using haematoxylin &
can suggest, decreased cluster eosin stains in addition to organism culturing
differentiated 4(CD4+) T cell count,(5) and respectively. All lesions were evaluated
increased viral load,(6) which might also aid clinically & recorded according to Centers
in diagnosis, progression, and prognosis of for Disease Control and Prevention (CDC)
the disease.(7-8) Risk of oral complication classification of patients with HIV infection.
increases with immunologic deterioration.(9)
Oral examination is therefore useful for early Results
diagnosis, which can prolong asymptomatic The mean age of the subjects was 36.6
period, delay disease progression, prevent years (range 20-59 years). Age range 30-49
opportunistic infections with proper years constituted 44% of the study sample.
education and counseling of patient. 62% cases were male and 38% were
female. 82% reported heterosexual contact
Methods as their route of HIV infection. Oral
In this study 50 patients were selected who manifestations were recorded in 76% at the
were between ages of 20 to 59 years of age. patients of which 72% had candidasis. 76%
Patients were also having systemic patients who had oral lesions, had
manifestations also such as chronic discomfort maximum during tooth brushing,
gastroenteritis, dysphasia, wasting chewing & swallowing, dry mouth, burning
syndrome, pneumonia and disseminated

©2010 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved
 A study of oral manifestation of HIV/AIDS 9

sensation especially on taking salty and Distribution of systemic manifestation in the

spicy foods. (Table 1) patients of HIV were, 60% had chronic
No. of gastroenteritis, 22% presented with
Description Percent
subjects dysphasia, with resulting wasting and weight
Age (years)
20-29 04 08 loss, 50% had respiratory tract infections,
30-49 22 44 16% had pulmonary tuberculosis and 10%
40-49 16 32 had central nervous system manifestations
50-59 8 16 comprising of chronic headache, confusion,
Gender
Male: Female 31: 19 62:38
loss of memory and cranial nerve paralysis.
Mode of HIV infection (Table 3)
Heterosexual 41 82 No. of
Mother to child 0 0 Description subjects Percent
Unknown 09 18 Chronic gastroenteritis 30 60
Oral lesion present Respiratory tract infection 25 50
Yes 38 76 Dysphasia 11 22
No 12 24 Pulmonary tuberculosis 8 16
Discomfort in the mouth Central nervous system 5 10
Tooth brushing 32 64 manifestation
Chewing 14 28 Table 3: Distribution of systemic
Swallowing 11 22 manifestation in the Patients of HIV.
Drinking 9 18
Speaking 5 10
Table 1: Distribution of age, gender, mode Discussion
of infection, oral lesions and discomfort in Oral manifestations are common in HIV
the mouth of the subject. infected persons and usually are first
indicator of progression to symptomatic
Distribution of oral manifestations in the disease.(11) Clinical feature ranges from
subjects include, Oral candidasis in 72% asymptomatic to severe clinical illness and
patients of which main variant was immunodeficiency.(12) It is seen that with
hyperplastic, erythematous and the progression of disease, oral
pseudomembranous types. manifestation were more frequent &
Lymphadenopathy in 42% and angular indicates poor prognosis. There is no
cheilitis in 36% were noted. Xerostomia in pathognomic oral lesion associated with
32%, recurrent aphthous ulceration in 22%, HIV-AIDS, but some like oral candidiasis are
oral hairy leukoplakia in 2%, herpes zoster associated very frequently. Oral candidiasis
in 8%, parotomegaly in 10% and facial is a predictor of HIV disease progression.
palsy in 8% were noted. Some subjects Candida albicans is the main etiologic factor
have more than one oral of oral candidiasis, although other species of
manifestation.(Table 2) candida may be seen. Candidasis was
No. of predominantly hyperplastic, erythematous
Description Percent
subjects and pseudomembranous types, this finding
Candidasis is similar to studies in Africa, eg in
Hyperplastic 36 72
Erythematous 18 36
Kenya,(13) Zaire,(14) South Africa,(2) and
Pseudo membranous 11 22 Zimbabwe.(15) Erythematous candidiasis
Angular cheilitis 8 16 presents as red flat lesion on hard or soft
Xerostomia 18 36 palate, and on tongue. Pseudomembranous
Recurrent aphthous 16 32
ulceration 11 22
candidiasis presents as white curd like
Atypical ulcers 5 10 lesion on buccal mucosa and tongue.
Parotomegaly 5 10 Angular cheilitis presents as redness,
Necrotizing gingivitis 4 8 ulceration & fissuring along the mouth, in
Herpes zoster 4 8
Recurrent herpes labialis 4 8
present study we have seen in about 36% of
Facial palsy 4 8 the present. Angular cheilitis occur with or
Necrotizing periodontitis 1 2 without erythematous or
Oral hairy leucoplakia 1 2 pseudomembranous candidiasis.
Kaposi`s sarcoma 0 0
Nonspecific lessions 2 4
Recurrent aphthous ulcer seen in
Table 2: Distribution of oral manifestations 22% of the patient. They present as very
in the subjects painful ulcers on labial, buccal mucosa, and
soft palate. They present as minor, major or
10 Lalit shrimali
herpetiform aphthous. Minor ulcer usually
heals without scarring, whereas in major
ulcer scarring in common and and
herpetiform present as crops of small lesion.
Severe recurrent aphthous ulcer usually
suggest HIV disease progression & seen
when CD4+ lymphocyte is less than
100cells/ul.
Periodontal diseases are common in
both asymptomatic & symptomatic HIV
patients, usually seen as necrotizing
ulcerative periodontitis & linear gingival
erythema. It has sudden onset with loss of
bone and soft tissue. In linear gingival
erythema there is 2-3mm red band along
marginal gingiva. In necrotizing ulcerative
gingivitis there is ulceration sloughing &
necrosis of one or more interdental papillae
with rapid loss of soft tissue & teeth
associated with pain, bledding & halitosis.
Necrotizing ulcerative periodontitis is usually
indicative of severe immune suppression,
which presents as severe pain, teeth loss,
bleeding, foul odour, rapid loss of soft tissue
and bone.
Xerostomia may be a factor
responsible for dental decay, it may be side
effect of drugs or may be due to proliferation
of CD8+ cells in salivary glands. Xerostomia
occurs in the late course of disease.
However with the introduction of
antiretroviral treatment oral manifestations
have markedly decreased.(16-18) With
antiretroviral therapy oral candidasis, oral
hairy leukoplakia, Kaposi’s sarcoma and
HIV-associated periodontal. disease have
reported to decrease,(19,20,21) in contrast
HIV-salivary gland disease, human
papilloma virus (HPV)-associated oral
lesions including papilloma, condylomas and
focal epithelial hyperplasia, xerostomia &
recurrent oral ulceration have increased.(20-
22) Oral hairy leukoplakia can be diagnostic
in absence of other identified cause of
immunosuppression.(23) Reported
prevalence of this lesion can be 42%,(24)
but in present study was only 2%.
Kaposi`s sarcoma has been seen in
15% of patients with AIDS(25) and many of
these patients have oral lesion,(26) but in
present study no case was found. Similar
results have been seen in studies done in
India,(27) which shows very low incidence in
India with only nine case have been
reported till date.
Patients with HIV may not have
regular dentist checkup, so physicians must
regularly examine patient of suspected HIV
for oral manifestations and make strong
working relationship with dentist to provide
diagnostic insight & valuable treatment.
Conclusion
Almost all patients with HIV infection will
contract oral diseases during the course of
illness, and antiretroviral therapy had
markedly decrease the oral manifestation.
For reducing morbidity from HIV, early
detection is necessary, therefore physicians
must look for oral manifestation in suspected
cases of HIV which aid in early diagnosis
and treatment.
Author Affiliation
Dr. Lalit Shrimali. Assistant Professor, Dept. Of
Medicine, Geetanjali Medical College And
Hospital, Udaipur-313024, Rajasthan.
Acknowledgement : All Staff in the Dept. Of
Medicine, Geetanjali Medical College And
Hospital, Udaipur-313024, Rajasthan.
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Source of Support: Nil, Conflict of interest: None declared.