Oral Diseases (2000) 6, 152–157
 2000 Macmillan Publishers Ltd All rights reserved 1354-523X/00 $15.00
www.nature.com/od
HIV Disease
Oral lesions and conditions associated with human
immunodeficiency virus infection in 300 south Indian
patients
K Ranganathan1, BVR Reddy1, N Kumarasamy2, S Solomon2, R Viswanathan1, NW Johnson3
1
Department of Oral Pathology, Ragas Dental College and Hospital, Chennai, India; 2YRG CARE, VHS Hospital, Chennai, India;
3
Department of Oral and Maxillofacial Medicine and Pathology, Guy’s, King’s & St Thomas’ Dental Institute, London, UK
BACKGROUND: Human immunodeficiency virus infection/
acquired immunodeficiency syndrome (HIV/AIDS) is a
major health problem in India. The National AIDS Con-
trol Organisation (NACO) of India reports a seropositiv-
ity of 25.03 per thousand for the whole country, as of
October 1999. In spite of this high prevalence there are
very few reports of oral lesions and conditions in Indian
HIV/AIDS patients, which are important in early diag-
nosis and management of these patients.
OBJECTIVE AND SETTING: The present report
describes the oral lesions in 300 HIV positive sympto-
matic patients presenting to us at RAGAS-YRG CARE, a
non-governmental organisation in Chennai, South India,
over a period of 9 months in 1998.
METHOD: Lesions were diagnosed on clinical appear-
ance using international criteria.
RESULTS: Of the 300 patients 89% had acquired the
infection through heterosexual contact. There were 205
males and 95 females, aged from 7 months to 72 years.
Forty-seven percent of the patients were in the age group
21–30 years. CD4 counts were ascertained for 105
patients, 64 (62%) had CD4 counts ⭐200. A total of 217
(72%) of the 300 patients had some oral lesion when
examined. Gingivitis (47%) and pseudomembranous can-
didiasis (33%) were the most common oral lesions. The
other oral lesions seen were oral mucosal pigmentation
(23%), erythematous candidiasis (14%), periodontitis
(9%), angular cheilitis (8%), oral ulcers (3%), oral hairy
leukoplakia (3%), hyperplastic candidiasis (1%), oral sub-
mucous fibrosis (2%) and one case of leukoplakia.
CONCLUSIONS: Oral lesions occur commonly in HIV
infection. A comprehensive oral examination may not
only suggest HIV disease but may also be useful in moni-
toring the disease progression. This is a cost-effective
Correspondence: Dr K Ranganathan, Department of Oral Pathology, Ragas
Dental College and Hospital, 116, Dr. Radhakrishnan salai, Mylapore,
Chennai: 600 004, India. Tel: ⫹91 44 8546666, Fax: ⫹91 44 8555410,
E-mail: ranjay얀md3.vsnl.net.in
Received 13 September 1999; revised and accepted 14 December 1999
procedure, which may be useful in screening large popu-
lations in developing countries like India.
Oral Diseases (2000) 6, 152–157
Keywords: HIV; AIDS; oral lesions; candidiasis; oral pigmen-
tation; India
Introduction
Human immunodeficiency virus infection/acquired immuno-
deficiency syndrome (HIV/AIDS) has come to occupy a
pandemic status. The UNAIDS/WHO working group on
global HIV/AIDS and STD surveillance report (UNAIDS,
1998) states that:
‘33.4 million people are living with HIV infection at the end of 1998, of
which 1.2 million are children. In 1998 alone 5.8 million newly affected
people have been reported and 2.5 million people have died of AIDS. This
represents almost a fifth of the total 13.9 million AIDS deaths since the
beginning of the epidemic. One in every 100 adults in the sexually active
ages 15–49 worldwide are infected and a majority of HIV infected people,
that is around 90%, live in the developing world. If the present scenario
continues, it is estimated that more than 40 million people will be living
with HIV infection by the year 2000.’
India, with its population close to 1 billion, is estimated
to have about 3–5 million people affected with AIDS, and
this is rapidly increasing. The National AIDS Control
Organisation (NACO) of India (NACO, 1998) estimates
that 2.3% of the population are HIV sero-positive. In one
high risk group, truck drivers in Chennai (formerly
Madras), South India, HIV infection quadrupled from 1.5%
in 1995 to 6.2% in just 1 year (Solomon S et al, 1997).
These figures are alarming in that a major portion of the
Indian population resides in the rural areas from where
reporting is patchy.
Given these figures it is essential that every facet of this
pandemic be studied and reported to assist medical and
para-medical professionals in informed decision making
towards early diagnosis, appropriate management and
follow-up of HIV/AIDS patients.
There are few reports of the oral manifestations of HIV

infection from the Indian sub-continent (Anil and Challa-
combe, 1997). In this context we studied the clinical pres-
entations and prevalence of oral lesions in HIV sero-posi-
tive patients in Chennai, South India. To our knowledge
this is the single largest report of oral manifestations from
India so far published.
Patients and method
Three hundred consecutive HIV/AIDS patients attending
the YRG CARE (Centre for AIDS Research and
Education), over a period of 9 months (February 1998 to
October 1998) constituted the study group. All attended, or
were referred, because of known or suspected HIV disease.
Sources of infection were confirmed by a trained counsel-
lor. Confirmation of HIV sero-status for all patients was by
ELISA (Merind Diagnostics, Belgium) and Western blot
(Biotechnology kit, Singapore). CD4 cell counts were per-
formed for only 105 patients, who could either afford the
expense or were funded by projects requiring specific cri-
teria. A diagnosis of AIDS was made on the basis of criteria
set by the Centers for Disease Control, USA (CDC, 1993).
A thorough history was taken, clinical oral examination
and systemic examination were performed by trained dental
surgeons and physicians respectively, and the findings
recorded in a standard format. The data were coded and
entered into a database program (FoxPro) to enable com-
parisons to be made and to easily append follow up details.
Statistical analysis was performed using SPSSTM package.
The P values were computed using Chi square (␹2) test.
The oral lesions were diagnosed according to the criteria
established by the EC Clearinghouse and WHO (EC Clear-
inghouse, 1993), as follows.
Oral candidiasis
Shiny erythematous areas of mucosa, sometimes with white
patches interspersed. The four clinical subtypes are charac-
terised as:
(1) Erythematous type: red area without removable white
spots or plaques.
(2) Pseudomembranous type: white removable spots or
plaques.
(3) Hyperplastic type: firm, adherent, unscrapable white
plaques.
(4) Angular cheilitis: fiery red commissures with a fissur-
ing or cracking appearance.
All the above types totally resolved with anti-fungal ther-
apy (topical application of clotrimazole 3–4 times a day for
a minimum of 14 days) in our study. This response to anti-
fungal therapy was used to confirm the diagnosis.
Oral hairy leukoplakia (OHL)
Non-scrapable, corrugated white plaques that did not
respond to anti-fungal therapy. These were always on the
lateral borders of the tongue. In our study these lesions
responded to aciclovir.
The different ulcers were diagnosed as follows:
Herpes simplex ulcers Small vesicles (2–6 mm in
diameter) followed by ulcers on attached mucosa and dem-
Oral lesions in 300 south Indian HIV positives
K Ranganathan et al
153
onstration of viral cytopathic effect in haematoxylin and
eosin stained smears from ulcers. The diagnosis was con-
firmed by response to aciclovir.
Recurrent aphthous ulcers Clinical presentation—recur-
rent ulcers on non-attached mucosa, and absence of viral
cytopathic effect in haematoxylin and eosin stained smears
from ulcers. All the ulcers responded to topical steroids.
Traumatic ulcers Association with sharp tooth/prostheses.
Oral submucous fibrosis (OSMF)
Presence of burning sensation, limitation of mouth opening,
palpation of fibrous bands and/or leathery consistency of
large areas of oral mucosa, and history of areca nut chew-
ing.
Leukoplakia
White plaque that cannot be scraped off and is not attribu-
table to any known cause, other than tobacco use.
Gingivitis
Distinctive dusky red, cyanosed free gingiva, presence of
bleeding on probing and/or spontaneous bleeding.
HIV-gingivitis (Linear gingival erythema)
Gingiva which presents an unusual clinical appearance,
such as fiery red band along the margin of the gingiva, with
or without focal enlargement of the gingiva in an otherwise
healthy oral cavity. No ulceration present, nor pockets or
loss of attachment.
Periodontitis
Presence of pockets ⭓4 mm in one or more sites. All teeth
present were probed around the whole circumference with
a blunt periodontal probe, with William’s markings.
Oral (melanin) pigmentation
Brown/brownish-black, spotty/diffuse macules, usually
occupying areas greater than 1 cm, and asymmetrical in dis-
tribution.
Results
The 300 HIV sero-positive patients included 110 AIDS
patients. Of these 300 patients, 165 were new patients who
had been diagnosed HIV positive, for the first time by us,
and had received no previous treatment. The remaining 135
were patients diagnosed elsewhere as being HIV positive
and referred to us: they had received variable and largely
undocumented treatment.
Of the 300 patients 205 were men and 95 women. The
youngest patient was a 7-month-old male who had acquired
the infection from his mother. The oldest patient was a 72-
year-old male paramedic who had acquired the infection
through an accidental needle prick injury. The following
are the number of patients in the various age groups: 12
patients (seven males and five females) in 1–10 years, 15
patients (four males and 11 females) in 11–20 years, 142
patients (85 males and 57 females) in 21–30 years, 101
patients (87 males and 14 females) in 31–40 years, and 30
Oral Diseases
 Oral lesions in 300 south Indian HIV positives
K Ranganathan et al

154
patients (22 males and eight females) above 40 years.
Eighty-one percent of the patients were in the age group
21–40 years.
Of the 300 patients 268 (186 males and 82 females) had
acquired the infection through heterosexual contact, two
male patients were intra-venous drug users, 13 (seven males
and six females) through blood transfusion, seven (two
males and five females) by vertical transmission, three (two
males and one female) by needle prick injury. In seven
patients (five males and two females) the source of infec-
tion could not be determined. The major source of infection
was through heterosexual contact (89.3%). The next major
source of infection was contaminated blood during blood
transfusion (4.3%) the reasons for which were: one patient
for haemophilia, two for leukemia and the remaining 10
related to surgical procedures. Two male patients were
intravenous drug users, seven were infected by vertical
transmission, one by accidental needle prick injury, two due
to intra-muscular injections and in seven the definitive
source could not be determined.
CD4 counts were available for 105 patients. Of these 64
patients had CD4 counts above 200 and 41 below 200.
Of the 300 patients 83 (28%) had no lesions, 89 (29%)
had only one lesion and 128 (43%) had more than one
lesion. In 34 (11.3%) patients the oral manifestations were
the first presenting complaint (Table 1). The oral lesions
and conditions observed included candidiasis, gingivitis,
pigmentation, periodontitis, ulcers, oral hairy leukoplakia
(OHL), oral submucous fibrosis (OSMF) and leukoplakia.
Extensive oral candidiasis was the most common oral
finding, 98 (32.7%, 73 males and 25 females) presented
with the pseudomembranous type, 43 (14.3%, 36 males and
seven females) with the erythematous type, three (two
males and one female) with the hyperplastic type and 23
(7.7%, 15 males and eight females) with the angular chei-
Table 1 Oral lesions in 300 HIV positive patients
Oral lesions Male Female
litis form. Sixty percent of the patients with candidiasis
were tobacco smokers. There was a positive correlation
between smoking and candidiasis (P ⬍ 0.0028). In the 105
patients with known CD4 counts, 80.5% (33/41) of the
patients with CD4 count below 200 had oral candidiasis
compared to 32.8% (21/64) of the remainder.
Oral ulcers were present in 10 patients (3% nine male
and one female). Three were aphthous ulcers, one was due
to herpes (responded to anti-retroviral-aciclovir), five were
traumatic and one was non-specific.
Sixty-eight patients (22.7% 47 males and 21 females)
had brown to brownish black oral pigmentation. These pig-
mented areas were very distinctive and different from racial
oral pigmentation, in that they were spotty/diffuse patches,
usually occupying areas greater than 1 cm, and were asym-
metrical in distribution.
Five male patients had OSMF. One 34-year-old male
patient with a history of smoking tobacco (40/day/15 years)
had leukoplakia of the buccal mucosa.
A total of 141 (47%, 92 male and 49 female) patients
had marginal gingivitis (diagnosed based on the colour of
the gingiva, bleeding on probing and presence of spon-
taneous bleeding), while 26 (8.7%, 17 male and nine
female) had periodontitis (more than one pocket depth
⭓4 mm), 48 had linear gingival erythema, while two male
patients had severe destructive periodontitis.
Of the 105 cases for which CD4 counts were available,
64 (61%) patients had CD4 counts above 200 and 41 (39%)
CD4 counts below 200. The oral lesions of these patients
are listed in Table 2. Oral lesions were present in both
groups and except for gingivitis all types of lesions were
more prevalent in the CD4 ⭐200 group. Not all of these
differences reached statistical significance, however,
because of the small numbers.
Interestingly, candidiasis was present in patients with
CD4 counts ⭐200 and ⬎200 (80.5% and 32.8%
respectively). The proportion of people with candidiasis
was significantly more in the CD4 ⭐200 group than the
Total (%) CD4 ⬎200 (P ⬍ 0.001) group. Also, of the two patients

Candidiasis 126 41 167 (55.7%)

Pseudomembranous 73 25 98 (32.7%) Table 2 Oral lesions of 105 HIV positive patients for whom CD4 counts
Erythematous 36 7 43 (14.3%) were available
Hyperplastic 2 1 3 (1%)
Angular cheilitis 15 8 23 (7.7%) Oral lesions CD4 ⭐200 CD4 ⬎200 Total
(41) (64) (105)
Gingivitis 92 49
Linear gingival erythema (48) 141 (47%)
Gingivitis (93) Male Female Male Female

Pigmentation 47 21 68 (22.7%) Candidiasis 26 7 12 9 54

Pseudomembranous 13 3 6 5 27
Periodontitis 17 9 26 (8.7%) Erythematous 9 0 4 2 15
Hyperplastic 1 1 0 0 2
Ulcers 9 1 Angular cheilitis 3 3 2 2 10
Herpes Simplex (1) Gingivitis 19 6 17 12 54
Aphthous Major (3) 10 (3%) Pigmentation 11 1 7 5 24
Traumatic (5) Periodontitis 5 0 2 0 7
Non-specific (1) Ulcers 3 0 0 1 4
Oral hairy leukoplakia 1 0 1 0 2
Oral hairy leukoplakia 6 2 8 (2.7%) Oral sub mucous fibrosis 1 0 0 0 1
Oral submucous fibrosis 5 0 5 (1.7%) Leukoplakia 1 0 0 0 1
Leukoplakia 1 0 1 (0.3%) Asymptomatic (no oral 7 2 12 10 31
Asymptomatic 53 30 83 (27.6%) lesions)

Oral Diseases
 Oral lesions in 300 south Indian HIV positives
K Ranganathan et al

Table 3 Number of oral lesions in HIV (non-AIDS) and AIDS patients
No. of oral HIV (190) AIDS (110) Total (300)
lesions
0 62 (32.1%) 21 (19.1%) 83
1 65 (34.2%) 35 (31.8%) 100
2 41 (21.6%) 26 (23.6%) 67
ⱖ3 23 (12.1%) 28 (25.5%) 51
with oral hairy leukoplakia (both males) one had CD4
⬍200 while the other had CD4 ⬎200. Though the number
of patients was not sufficient to arrive at statistically sig-
nificant conclusions we present these data as a preliminary
result. At present we are in the process of estimating CD4
counts for a greater number of patients.
Table 3 shows the number of oral lesions in AIDS and
non-AIDS HIV patients. A total of 32.1% of the non-AIDS
HIV patients had no oral lesions compared to 19.1% of
AIDS-patients with no oral lesions. When patients with
three or more lesions were considered there were twice as
many AIDS patients (25.5%) as non-AIDS HIV patients
(12.1%).
Table 4 lists the systemic findings in the 300 patients
with HIV disease, for those both with and without oral
lesions. The oral lesions listed here are not necessarily due
to the systemic conditions against which they are tabulated.
Pulmonary tuberculosis (32%) was the most common sys-
temic disease followed by pharyngeal candidiasis (23%),
herpes zoster (10%), tinea infection of the skin (8.0%),
eosinophilic folliculitis (7.7%), gastroenteropathy (5.3%),
herpes simplex—genital (5.3%), extra-pulmonary tubercu-
losis (5%), bacterial skin infection (3.0%), Pneumocystis
carinii pneumonia (2.3%), leukorrhoea (2%), cryptococcal
meningitis (1%), veneral warts (1%), toxoplasmosis (1%),
cytomegalovirus retinitis (0.7%) and scabies (0.3%). Eighty
patients (26.7%) had no systemic disease.
The EC-Clearing house and WHO collaborating centre
(1993) have classified oral problems into three groups. The
155
oral lesions diagnosed in our cohort with reference to this
classification are as follows.
Group 1 (lesions strongly associated with HIV
infection) Pseudomembranous candidiasis (33%), ery-
(27.7%) thematous candidiasis (14%), OHL (3%), and LGE (16%).
(33.3%)
(22.3%)
The other lesions in this group which were not present in
(17%) our cohort were—Kaposi’s sarcoma (KS), non-Hodgkin’s
lymphoma (NHL), necrotising ulcerative gingivitis and nec-
rotising ulcerative periodontitis. The absence of KS and
NHL in our cohort is not unusual. The relatively low inci-
dence of KS and NHL in Asia compared to the western
countries is consistent with other reports (Anil and Challa-
combe, 1997).
Group 2 (lesions less commonly associated with HIV
infection) Melanotic hyperpigmentation (23%), ulceration
NOS (1/300) and herpes simplex (1/300).
Group 3 (lesions seen in HIV infection) Recurrent aphth-
ous stomatitis (3/300).
Lesions seen in our cohort but not included in the EC-
Clearing house and WHO collaborating centre (1993)
classification include angular cheilitis (8%), hyperplastic
candidiasis (1%), periodontitis (9%), traumatic ulcers,
OSMF (2%) and leukoplakia (1/300). Angular cheilitis and
hyperplastic candidiasis are clinical variants of oral candidi-
asis.
Table 5 compares the prevalence of oral lesions in our
study with a few studies from other parts of the world
and India.
Of the 217 patients with oral lesions, 171 had some sys-
temic disease and of the 83 patients with no oral lesions
49 had some systemic disease. The positive predictive value
of an oral lesion for systemic disease was 0.78 and the
predictive value of systemic disease for the presence of an
oral lesion was 0.79. The 34 patients who did not have
any systemic or oral findings were identified during routine
screening of apparently asymptomatic spouses and/or chil-
dren of HIV positive patients.

Table 4 Systemic features of the 300 HIV/AIDS patients (there were patients with more than one systemic finding)

Systemic features Patients without any oral Patients with any oral lesion Total (/300)
lesion (/83) (/217)

Pulmonary tuberculosis 11 (13.3%) 85 (39.2%) 96 (32.0%)

Pharyngeal candidiasis 0 69 (31.8%) 69 (23.0%)
Herpes zoster 4 (4.8%) 26 (11.9%) 30 (10.0%)
Tinea infections 6 (7.2%) 18 (8.3%) 24 (8.0%)
Eosinophilic folliculitis 5 (6.0%) 18 (8.3%) 23 (7.7%)
Gastroenteropathy 4 (4.8%) 12 (5.5%) 16 (5.3%)
Herpes simplex 2 (2.4%) 14 (6.5%) 16 (5.3%)
Extra-pulmonary tuberculosis 6 (7.2%) 9 (4.2%) 15 (5.0%)
Bacterial skin infection 4 (4.8%) 5 (2.3%) 9 (3.0%)
Pneumocystis carinii pneumonia 0 7 (3.2%) 7 (2.3%)
Leukorrhoea 2 (2.4%) 4 (1.8%) 6 (2.0%)
Cryptococcal meningitis 1 (1.2%) 2 (0.9%) 3 (1.0%)
Venereal warts 0 3 (1.4%) 3 (1.0%)
Toxoplasmosis 0 3 (1.4%) 3 (1.0%)
Cytomegalovirus retinitis 1 (1.2%) 1 (0.5%) 2 (0.7%)
Scabies 0 1 (0.5%) 1 (0.3%)
Asymptomatic 34 (41%) 46 (21.2%) 80 (26.7%)

Oral Diseases
 Oral lesions in 300 south Indian HIV positives
K Ranganathan et al
156
Table 5 Comparison of oral lesions in patients with HIV disease from different regions of the world
Oral lesions UKa (n = 120) USAb (n = 375)
Candidiasis 47 87
Oral hairy leukoplakia 27 23
Kaposi’s sarcoma 15 80
Necrotising periodontal disease 6 19
Non-Hodgkin’s lymphoma – –
Atypical/Aphthous ulcer 7 3
a
Palmer et al (1996); bSilverman et al (1986); cTukutuku et al (1990); dNittayananta and Chungpanich (1996); eAnil and Challacombe (1997);
f
Present study
Discussion
Oral lesions play an important role in the clinical manage-
ment of HIV/AIDS patients. Schiødt et al (1990) in their
study in Tanzania have observed that certain oral lesions,
especially oral candidiasis and oral hairy leukoplakia have
a high predictive (85%) value for HIV/AIDS. Oral candidi-
asis and oral hairy leukoplakia are more common in HIV
positive than HIV negative patients and the lesions can lead
to the diagnosis of HIV in a majority of cases (Greenspan
et al, 1987; Laskaris et al, 1992). Oral candidiasis, severe
Herpes zoster and OHL have been used as indicators for
initiation of anti-retro viral therapy and to assess the patient
progress in clinical trials (Fischl et al, 1990; Kinloch-De
Loes et al, 1995; Carpenter et al, 1996; US PHS, 1993;
Greenspan, 1997). Oral lesions are a component of the dif-
ferent HIV/AIDS classification schemes including the
WHO revised classification and CDC AIDS classification
(1993). In fact the WHO system emphasises the use of oral
candidiasis and OHL as signs of AIDS in places where HIV
serology or CD4 counts may not be available (such as in
much of India and other developing countries) and other
causes of immunosuppression are not present.
Oral manifestations are important not only in early diag-
nosis but also in monitoring the progress to AIDS. In
addition the awareness generated by the information dis-
seminated to the dental and medical practitioner would lead
to better surveillance and good infection control practices.
The oral lesions are often characteristic and in a majority
of cases can be diagnosed by their clinical features alone.
When necessary smears and biopsies can be performed with
minimum morbidity.
Our study shows that oral manifestations are a common
feature in HIV infected patients in South India. The male:
female ratio was 2:1 in our study and importantly, hetero-
sexual transmission was the major source of infection. We
presume this reflects the pattern of HIV acquisition in the
South Indian community as a whole. The male preponder-
ance in our study group was due to promiscuous heterosex-
ual behaviour rather than homosexual practices.
Pulmonary tuberculosis was the most common systemic
disease. This is consistent with the high prevalence of 61%
pulmonary tuberculosis in HIV patients in Tamilnadu,
South India, as reported by Kumarasamy et al (1995).
Though there was a high prevalence of pulmonary tubercu-
losis (32%) in our study there were no oral lesions of
tuberculosis. This was followed by pharyngeal candidiasis
(23%), which correlates with the high prevalence of oral
Oral Diseases
Zairec (n = 83) Thailandd (n = 124) Indiae (n = 42) Indiaf (n = 300)
94 66 98 167
11 13 10 8
12 – – –
17 – 41 –
– 4 – –
– 11 5 4
candidiasis (55.7%) in this group. Seventy-two percent of
our patients had oral lesions.
Oral candidiasis is an opportunistic infection considered
to be one of the lesions commonly associated with
HIV/AIDS (EC Clearing House, 1993). In HIV/AIDS
patients it presents in the following forms: pseudo-membra-
nous, erythematous, hyperplastic and angular cheilitis. Of
all the forms pseudo-membranous is the most common.
Whilst prevalence reports vary from 11–96% around the
world, many give rates greater than 50% (Kolokotronis et
al, 1994). The few published reports from India quote fig-
ures based on small study populations, of 69% for HIV
positive patients without AIDS and 98% and 92% for AIDS
patients (Anil and Challacombe, 1997; Mirdha et al, 1993).
Our finding of an overall prevalence of 55% for all HIV
positive (AIDS and non-AIDS) patients is consistent with
the above-mentioned figures. The pseudo-membranous
form was the most common followed by the erythematous
form, angular cheilitis and the hyperplastic form, also con-
sistent with the above-mentioned reports
Since its first report in 1984, oral hairy leukoplakia,
caused by the Epstein–Barr virus (EBV), has become a
marker of immunosupression due to HIV/AIDS or other
causes (Greenspan et al, 1984, Kolokotronis et al, 1994).
In the present study only eight of the 300 patients had oral
hairy leukoplakia. This is consistent with other low preva-
lence reports from Asian countries. The reasons suggested
for these low figures are that EBV infection is more com-
mon in homosexual transmission and this mode comprises
a low figure in Asian countries, as in our study too. Sec-
ondly the EBV infection may be associated with a sub-type
of HIV different from that occurring in the Asian countries
(Anil and Challacombe, 1997).
Three characteristic presentations of periodontal disease
are associated with HIV infection (Robinson, 1997). They
are necrotising periodontal disease, atypical gingivitis such
as linear gingival erythema and exacerbated attachment
loss. In our present study 47% had gingivitis while 8.7%
had moderate to severe destructive periodontitis. However,
given the high prevalence of periodontal diseases in the
normal population of India, further studies with matched
normal controls are necessary to draw any inference con-
cerning our cohort. It is also necessary, for further inter-
national comparisons, for there to be an agreement on diag-
nostic criteria (Johnson, 1997). The severe forms of
necrotising gingivitis and periodontitis in HIV disease are
uncommon, and there is little evidence to support acceler-

ated progression of chronic adult periodontitis in these
patients (Robinson et al, 2000)
OSMF is a common problem in the Indian subcontinent,
it is estimated that around 2.5 million people are affected
here, given the wide use of areca (betel) nut in its various
forms (Symposium, 1997). This is the first known report
of OSMF in HIV infected patients but this is probably
coincidental given the wide prevalence of areca nut chew-
ing in the south Indian population. The natural history of
this disease in the context of immunosuppression merits
further study. The leukoplakia in one patient was conse-
quent to heavy smoking.
In conclusion the prevalence and clinical presentation of
oral lesions in HIV/AIDS patients in Chennai, South India:
candidiasis, oral hairy leukoplakia, pigmentation, ulcers,
gingivitis and periodontitis, OSMF and leukoplakia is
described. Given their high prevalence and the relative sim-
plicity of an oral examination, these oral lesions may have
utility in screening Indian populations for HIV disease.
Acknowledgements
The authors thank Dr RE Amalraj, Madras University, for his
advice on the statistical analysis. We are grateful to all the staff
members of YRG CARE, Chennai, for their assistance during the
study. We are also grateful to Dr R Gunaseelan, Secretary, Ragas
Dental College and Hospital for his encouragement throughout
this project.
References
Anil S, Challacombe SJ (1997). Oral lesions of HIV and AIDS
in Asia: an overview. Oral Dis 3 (Suppl 1): S36–S40.
Carpenter CCJ, Fischl MA, Hammer SM et al (1996). Antiretrovi-
ral therapy for HIV infection in 1996. JAMA 276: 146–154.
CDC (1993). Revised classification systems for HIV infection and
expanded surveillance and definition for AIDS among ado-
lescents and adults. MMWR 41: 1–19.
EC—Classification on oral problems related to HIV infection and
WHO Collaborating Centre on Oral Manifestation of the
Immuno Deficiency Virus (1993). Classification and diagnostic
criteria for oral lesions in HIV infection. J Oral Pathol Med
22: 289–291.
Fischl MA, Richman DD, Hamen N et al (1990). The safety and
efficacy of Zidovudine in the treatment of subjects with mildly
symptomatic HIV Type I infection. Annals Intern Med 112:
727–737.
Greenspan D, Greenspan JS, Conant M (1984). Oral hairy leuko-
plakia in male homosexuals: evidence of association with both
papilloma virus and a herpes group virus. Lancet 2: 831–834.
Greenspan D, Greenspan JS, Heart NG et al (1987). Relation of
oral hairy leukoplakia to infection with HIV and the risk of
developing AIDS. J Infect Dis 155: 475–481.
Oral lesions in 300 south Indian HIV positives
K Ranganathan et al
157
Greenspan JS (1997). Sentinels and signposts: the epidemiology
and significance of the oral manifestations of HIV disease. Oral
Dis 3 (Suppl 1): S13–S17.
Johnson NW (1997). Essential questions concerning periodontal
diseases in HIV infection. Oral Dis 3 (Suppl 1): S138–S140.
Kinloch-de Loes S, Hirschel BJ, Hoen B et al (1995). A controlled
trial of zidovudine in primary HIV infection. N Engl J Med
333: 408–413.
Kolokotronis A, Antoniades D, Mandraveli K et al (1994).
Immunological status in patients infected with HIV infection
with oral candidiasis and hairy leukoplakia. Oral Surg Oral
Med Oral Pathol 78: 41–46.
Kumarasamy N, Solomon S, Paul SAJ et al (1995). Spectrum of
opportunistic infection among AIDS patients in Tamilnadu,
India. Int J STD and AIDS 6: 447–449.
Laskaris G, Hadjivassiliou M, Stratigos J (1992). Oral signs and
symptoms in 160 Greek HIV-infected patients. J Oral Pathol
Med 21: 120–123.
Mirdha BR, Banerjee U, Seth S et al (1993). Spectrum of oppor-
tunistic fungal and parasitic infections in Hospital AIDS
patients. CARC Calling 6: 9–10.
National Aids Control Organisation, Monthly update (1998). Sur-
veillance of HIV infection/AIDS cases in India. http://
www.nic.in/naco/update.html
Nittayananta W, Chungpanich S (1996). Oral lesions in a group
of Thai people with AIDS. Third International Workshop on
Oral Manifestations of HIV. London. Abstract p 2.20.
Palmer GD, Robinson PG, Challacombe SJ et al (1996). Aetio-
logical factors for the oral manifestations of HIV infection.
Oral Dis 2: 193–197.
Robinson PG (1997). Treatment of HIV associated periodontal
disease. Oral Dis 3 (Suppl 1): S238–S240.
Robinson PG, Boulter A, Birnbaum W, Johnson NW (2000). A
controlled study of relative periodontal attachment loss in
people with HIV infection. J Clin Periodontol (in press).
Schiødt M, Bakilava PB, Hiza JF et al (1990). Oral candidiasis
and hairy leukoplakia associated with HIV infection in Tan-
zania. Oral Surg Oral Med Oral Pathol 69: 591–596.
Silverman S, Migliorati C, Greenspan D et al (1986). Oral find-
ings in people with or at high risk for AIDS: a study of 375
homosexual males. J Am Dent Assoc 112: 187–192.
Solomon S, Kumaraswamy N, Ganesh BK et al (1997). Preva-
lence and risk factors of HIV-1 and HIV-2 infection in urban
and rural areas in Tamilnadu, India. J STD and AIDS 8: A1025,
1–6.
Symposium (1997). Abstracts of the oral submucous fibrosis
experts symposium. Oral Dis 3: 276–291.
Tukutuku K, Muyembe-Tamfun L, Kayembe K et al (1990). Oral
manifestations of AIDS in a heterosexual population of Zaire
hospital. J Oral Pathol Med 19: 232–234.
UNAIDS/WHO epidemiological fact sheet (1998) UNAIDS/
WHO working group on global HIV/AIDS and STD surveil-
lance, December: http://www.unaids.org
US Public Health Service Task Force on Anti-pneumocystic
prophylaxis in patients with HIV (1993). Recommendation for
prophylaxis against pneumocystis carinii pneumonia for per-
sons infected with HIV. J Acquir Immune Defic Syndr 6: 46–65.
Oral Diseases