HIV-associated oral lesions; immunologic, virologic and salivary parameters

There are numerous reports of oral lesions in HIV-infected individuals. However, few correlate the oral lesions with laboratory parameters. This study examined oral candidiasis and hairy leukoplakia, the two most common HIV-associated oral lesions, in relation to T-cell counts, p24 core antigen levels and salivary flow rates. Oral mucosal examinations, immunologic and virologic studies and stimulated whole and parotid saliva flow rates were conducted on 135 (HIV+ = 102, HIV- = 33) homosexual or bisexual men. Results indicate that, among HIV-infected subjects, the odds of having oral candidiasis is 6 times (95% CI = 0.6-56.6) greater for subjects with T4 counts between 200-399 per mm3, and 23 times (95% CI = 2.8-193.0) greater for subjects with T4 counts less than 200/mm3 compared to subjects with T4 counts of 400/mm3 or greater. Subjects had an equal likelihood of having hairy leukoplakia at different levels of immunocompetence. The prevalence of oral candidiasis and hairy leukoplakia was higher among subjects with infectious virus in their serum, but was only statistically significant for hairy leukoplakia (p = 0.01).     

Oral manifestations related to immunosuppression degree in HIV-positive children.

Oral manifestations often found in HIV-infected children are frequently the first clinical sign of the infection. This article aims to report the prevalence of oral manifestations in soft tissues and their relationship with the degree of immunosuppression in 80 HIV-infected patients (average age 6.30 +/- 3.32 years old) at the IPPMG-UFRJ. Thirty children (38%) presented some type of oral lesion and the percentage of CD4 was lower than that found in lesion-free children (p < 0.05); 22.5% presented candidiasis, 17.5% gingivitis, 8.8% enlargement of parotids, 1.3% herpes simplex and 1.3% hairy leukoplakia. Of the 30 children with lesions, 70% showed severe immunosuppression, 23.3% moderate immunosuppression and in only 6.7% was immunosuppression absent. Oral manifestations were directly related to the degree of immunosuppression and such lesions can be considered as indicators of the progression of the HIV infection in children.     

Sentinels and signposts: The epidemiology and significance of the oral manifestations of HIV disease

A large number of studies attest to the frequency of oral disease in those with HIV infection. Most show that hairy leukoplakia and pseudomembranous candidiasis are the commonest lesions in those with HIV infection and AIDS, with higher prevalence and incidence rates correlating with falling CD4 counts and disease progression. HIV-infected individuals with oral candidiasis or hairy leukoplakia progress to AIDS more rapidly than matched controls without these lesions. Oral candidiasis and hairy leukoplakia increase with time since seroconversion. On the other hand, parotid enlargement in children appears to be associated with slower progression to AIDS. As a consequence of these and other observations, oral lesions are widely included in natural history studies, staging and classification schemes for HIV infection. In addition to their role in the diagnosis of HIV infection and as indicators of the progression of HIV disease, oral lesions are used as clinical correlates of CD4 counts and as criteria for entry into clinical trials.     

Association of cutaneous and oral diseases in HIV-infected men

OBJECTIVES: Mucocutaneous diseases are common in patients infected with human immunodeficiency virus (HIV). To identify cutaneous diseases for which HIV-infected people are at high risk, we sought those that are strongly associated with specific HIV-related oral lesions and with progression of HIV disease.
DESIGN: A cross-sectional study of HIV-positive outpatients referred to a university stomatology clinic for diagnosis and treatment of oral diseases. Each subject underwent both complete oral and cutaneous examinations.
RESULTS: Among 55 men, with a median age of 41 years and a median CD4 cell count of 125/ju.l (range 0–950/pil), 93% had active oral diseases or conditions, including candidiasis, hairy leukoplakia, ulcers, Kaposi's sarcoma (KS), and xerostomia, and 95% had skin conditions, including onychomycosis, dermatophytosis, seborrheic dermatitis, KS, folliculitis, xerosis, and molluscum contagiosum. Seborrheic dermatitis, xerosis, skin KS, and molluscum contagiosum were associated with oral HIV-sentinel lesions (oral candidiasis, hairy leukoplakia, and KS), with low CD4 cell counts, and with AIDS.
CONCLUSION: Our results suggest that xerosis and seborrheic dermatitis may be early harbingers of HIV disease progression. Their roles as predictors warrant further study, based on their associations with low CD4 cell counts and AIDS and strong co-prevalence with one of the most common HIV-related oral lesions, oral candidiasis.     

Oral manifestations in HIV/AIDS infected patients from India

OBJECTIVES: To assess types and prevalence of HIV-related oral lesions among HIV-infected individuals in south India and to correlate common oral findings with co-morbidities, gender, age and medication. SUBJECTS AND METHODS: One hundred and one patients with HIV infection or AIDS at infectious diseases units of Attavar Hospital, Mangalore, and medical wards of Kasturba Medical College, Manipal, were selected. Sociodemographic information was obtained using a structured questionnaire. Oral lesions were diagnosed according to the presumptive criteria of EEC-Clearinghouse Classification. Clinical history was retrieved from patient's medical records. RESULTS: Erythematous candidiasis (44.5%), melanotic hyperpigmentaion (34.6%) and xerostomia (29.7%) were among the most common oral manifestations. A significant association was found between oral candidiasis and advanced immunosuppression (P < 0.05). Oral hairy leukoplakia (OHL) was predominant in individuals <35 years (P < 0.05). Melanotic hyperpigmentation was significantly associated with highly active antiretroviral therapy (P < 0.05). OHL was more frequent in patients with HIV-associated tuberculosis. Linear gingival erythema was more predominant in females. CONCLUSIONS: Oral hairy leukoplakia showed a positive relationship with patients younger than 35 years. Oral candidiasis can act as a marker for immunosuppression. Angular cheilitis was predominant in the symptomatic stage.     

Risk factors associated with oral lesions in HIV-infected heterosexual people and intravenous drug users in Thailand

This study aimed to identify factors associated with the presence of oral lesions in HIV-infected individuals in Thailand, to determine the influence of gender and route of HIV transmission on the prevalence of the lesions, and to investigate whether total lymphocyte cell counts can be used as a serologic marker to predict the occurrence of oral lesions. Two hundred and seventy-eight HIV-infected heterosexual persons and intravenous drug users (IVDUs) were enrolled (230 males, 48 females). Eighty-six HIV-free subjects from the same population were included as controls (61 males, 25 females). Oral candidiasis was the most common oral lesion among HIV-infected individuals (39.6%), followed by hairy leukoplakia (HL) (26.3%), exfoliative cheilitis (18.3%), and linear gingival erythema (LGE) (11.5%). Odds ratios (ORs) for factors associated with the presence of oral lesions were as follows for advanced HIV disease defined by clinical status: symptomatic stage [OR= 18.6; 95% confidence interval (CI) 7.3-47.2], AIDS stage [OR 7.3; 95% CI 3.4-15.7] and laboratory investigation of total number of lymphocyte cell counts of 1,000-2,000 cell/mm3 [OR 2.7; 95% CI 1.4-5.1] and <1,000 cell/mm3 [OR 4.0; 95% CI 2.3-7.0], alcohol consumption [OR 3.4; 95% CI 1.3-9.1], and poor oral health [OR 1.7; 95% CI 1.0-2.9]. Men were significantly more likely to have oral lesions than women. No statistically significant difference in the presence of oral lesions was observed between heterosexuals and IVDUs. This study should help predict the risk of acquiring various types of oral lesions, given that the person is exposed to multiple risk factors compared to another who is not exposed to these factors.     

Oral manifestations of an HIV positive cohort in the era of highly active anti-retroviral therapy (HAART) in South London

BACKGROUND: Human Immunodeficiency Virus (HIV) infection is associated with oral manifestations of diagnostic and prognostic importance. With the advent of Highly Active Anti-retroviral Therapy (HAART) there is anecdotal evidence to suggest that the prevalence of oral lesions has declined. The number of prevalence studies, carried out in the era of HAART is, however, meagre. Our aim was to study the prevalence of the oral manifestations of HIV in a population, predominantly on HAART, attending a Genito-Urinary Medicine Centre in South London. METHODS: This cross sectional study included 203 adult volunteers, comprising 76% males and 24% females. One third of the subjects were from the predominantly African or Afro- Caribbean ethnic minority groups resident in London. The relationship between the prevalence of oral lesions and demographic variables, therapeutic regimes, viral load and CD4 counts were evaluated. RESULTS: One hundred (49%) of the patients had no detectable oral lesions. Oral lesions detected most frequently included oral hairy leukoplakia (9.9%), HIV associated periodontal diseases (9.9%) and oral candidiasis (4.9%). Three subjects had multiple papillomatous growths. Most cases (n = 17/20) of oral hairy leukoplakia were in individuals with a detectable (> 400 copies/ml) plasma RNA viral load. The majority (n = 8/10) of our patients with oral candidiasis had a plasma RNA viral load > 10,000 copies/ml and half (n = 5/10) had a CD4 count < 200 cells/mm3. Logistic regression analysis suggested that the presence of an oral lesion was not associated with any demographic features except for periodontal diseases which were associated with tobacco smoking (P = 0.023). CONCLUSIONS: The prevalence of so called 'strongly associated' oral lesions of HIV is low in this South London HIV-infected population on HAART, and the relative frequency is different from that cited in the literature from the pre-HAART era. The oral lesions detected were found mostly in people with low CD4 counts and high HIV-1 RNA viral loads, suggesting they were very immunocompromised, not on, or declining therapy, or that their therapy was failing.     

Oral lesions in HIV-positive dental patients--one more argument for tobacco smoking cessation

OBJECTIVE: To determine the prevalence of oral lesions associated with human immunodeficiency virus (HIV) in a population of dental patients and analyze its association with psycho-social variables and biological markers. STUDY DESIGN: The dental charts of 415 dental patients consecutively treated between May and July 2005 in a dedicated HIV dental clinic were reviewed. Oral soft tissue examinations, psycho-social and medical variables were extracted and recorded for each patient. Ethnicity, gender, HIV treatment, peripheral CD(4) counts and tobacco usage were analyzed in correlation with oral lesions associated with HIV. RESULTS: Fifty-five percent of all subjects had at least one oral lesion associated with HIV, with oral candidiasis, salivary gland enlargement and oral hairy leukoplakia being the most commonly observed conditions. Gender and ethnicity did not correlate with a higher prevalence in lesions. However, tobacco smoking correlated significantly with a higher prevalence of oral lesions, independent of CD(4) counts. CONCLUSIONS: These findings suggest that oral lesions remain commonly observed morbidities among HIV-infected dental patients independent of gender and ethnicity and that tobacco usage is a major and often underestimated risk factor for those lesions.     

Oral manifestations in HIV-positive adults from Northern Thailand

Eighty-seven HIV-infected patients in a provincial hospital in Northern Thailand were examined for oral manifestations of HIV disease and AIDS. The median age was 31.3 years. Seventy-four of the patients were women, 13 were men. 96.6% had a history of heterosexual transmission. Sixty-one patients were CDC-category A, 20 were category B and 6 were category C (AIDS). Thirty-eight percent of the patients revealed oral lesions; 23% had one oral lesion and 13.8% had two oral lesions. Common lesions were oral candidiasis (10.3% pseudomembranous candidiasis, 6.9% erythematous candidiasis and 3.4% both forms), oral hairy leukoplakia (11.5%) and exfoliative cheilitis (6.9%). Gingival linear erythema was seen in 8% of the patients; periodontal lesions and necrotising ulcerative gingivitis were not observed. Men were more commonly affected by oral manifestations than women (P < 0.004). The spectrum of oral lesions is comparable to other studies from the region, although most of these reported more men than women. Also, the degree of immunosuppression was more marked (AIDS).     

Oral manifestations associated with HIV-related disease as markers for immune suppression and AIDS

Background. Oral lesions are common findings in HIV-related disease, but little is known about their significance in predicting immune suppression among a representative group of HIV-infected persons.Methods. Oral examinations were performed on 454 patients who came to an outpatient dental clinic for dental care. CD4+ cell counts were obtained within 2 months of the examination.Results. In persons with a specific lesion and a CD4+ cell count below 200 cells/mm³ the corresponding mean CD4+ cell counts and predictive values were 149.5 cells/mm³ and 69.9% for candidiasis, 143.3 cells/mm³ and 70.1% for oral hairy leukoplakia, 126.0 cells/mm³ and 69.4% for xerostomia, 51.8 cells/mm³ and 95.1% for necrotizing ulcerative periodontitis, 98.7 cells/mm³ and 87.0% for long-standing herpes simplex virus infections, 66.6 cells/mm³ and 93.6% for Kaposi's sarcoma, and 33.7 cells/mm³ and 100% for major aphthous ulcers. The mean CD4+cell count declined with increased numbers of different concurrent lesions.Conclusion. The presence of specific oral manifestations and the number of different concurrent intraoral lesions among HIV-infected persons are associated with severe immune suppression and AIDS. Oral examinations are an essential component for early recognition of disease progression and comprehensive evaluation of HIV-infected patients.     

A prospective study of oral lesions and their predictive value for progression of HIV disease

OBJECTIVE: This report evaluates and compares individual oral lesions and combinations of lesions in predicting progression-free survival in a seroprevalent cohort of men and women with HIV infection. DESIGN: This was a prospective study of HIV-infected patients, initially AIDS-free, followed for approximately 30 months. SETTING: Patients were volunteers examined at an academic medical center and at an inner-city hospital in New York. Participants identified themselves as homosexual men or as injection drug users (IDU).OUTCOME MEASURES: The primary outcome being assessed is time from a baseline oral examination until the development of an AIDS-defining condition or death from any cause within 12 months of the last study visit. Correlation is measured by relative risk (RR).RESULTS: While oral lesions were not predictive of progression among subjects with CD4s=200, they were highly predictive of progression among those with CD4<200.For subjects with CD4<200, the only individual lesion that was significantly associated with progression-free survival was oral candidiasis (RR=4.12, P= 0.009).Positivity for one or more lesions in a set demonstrated greater prognostic value among those with CD4<200, with RR's of 6.03 (P= 0.018) for the set consisting of oral candidiasis, hairy leukoplakia, and necrotizing ulcerative gingivitis (NUG), and 8.77 (P= 0.036) for the set consisting of the above lesions plus linear gingival erythema (LGE).Analysis by cohort suggested that the improvement in correlation was stronger in homosexual men than in IDU, but this question could not be resolved conclusively with these data. CONCLUSIONS: Lesion sets might be better prognosti-cators of progression-free survival than individual lesions among HIV-infected subjects with CD4<200.Prognostic value of the core lesion set (oral candidiasis and hairy leukoplakia) was enhanced by the addition of other lesions (NUG and LGE) not usually included in HIV staging systems. These results suggest that staging systems for HIV might be improved by the inclusion of other, survival-related oral lesions.     

A retrospective analysis of oral hairy leukoplakia in South Australia

BACKGROUND: The features of oral hairy leukoplakia (OHL) have been widely reported in the literature. However, no studies have described this lesion in the Australian setting. This study retrospectively examines, with respect to specific clinical factors, the prevalence of OHL in a South Australian HIV-infected population. METHODS: Clinical data were collected from the records of 197 HIV-infected patients who had attended the Adelaide Dental Hospital between January 1986 and February 1995. Data were analysed using the chi-square test. RESULTS: The prevalence of OHL in South Australian HIV-infected patients was 45.2 per cent. The study found the presence of OHL was not related to CD4+ T-lymphocyte count or AIDS-defining illness nor did the length of time a patient had been infected with HIV relate to the presence of OHL. An association was observed between a reduced prevalence of OHL in patients who were taking antiviral medication. CONCLUSION: The prevalence of OHL in South Australia is comparable with results of other studies. This study supports the notion that OHL is not an indicator of immunosuppression in South Australian HIV-infected patients. Further longitudinal studies are required to ascertain the relationship of OHL to HIV disease progression.     

云南地区成年人类免疫缺陷病毒感染患者口腔毛状白斑发病情况分析

目的探讨云南地区成年人类免疫缺陷病毒（HIV）感染患者口腔毛状白斑（OHL）的发病情况、临床特点及其与免疫状态的关系。方法以2008年1月-2010年6月收治的1 060例成年HIV感染患者为研究对象,收集信息包括每位患者的年龄、性别、教育程度、HIV阳性确诊时间、传播途径、口干症、口腔念珠菌病、临床高效抗逆转录病毒药物的使用及CD4细胞计数等,并通过口腔检查记录OHL的发病情况,分析OHL发病与CD4细胞计数的关系。结果1 060例HIV感染者中,检出OHL患者94例（8.9%）,其平均年龄为（39.33±10.45）岁。90%的OHL发生在舌的两侧缘,70.2%的患者其CD4细胞计数低于200 mm-3。结论OHL经常发生在严重的免疫抑制的患者中,与CD4细胞计数下降有关。     

Comparison of oral lesion prevalence in renal transplant patients under immunosuppressive therapy and healthy controls

Objective:  The aim of this study was to analyse the prevalence of oral lesions in a group of renal transplant patients (RTPs) compared with healthy controls (HCs).
Subjects and methods:  The study included 500 RTPs (307 men, 193 women, mean age 53.63 years) and 501 HCs (314 men, 187 women, mean age 52.25 years). Demographic and pharmacologic data were recorded for all subjects.
Results:  Forty percent of the RTPs presented with oral lesions compared to 23.4% of HCs. The most frequent lesion was candidiasis (7.4% in RTPs, 4.19% in HCs). Lip herpes simplex lesions were observed in 2.6% of RTPs and 2.2% of HCs; aphthae were observed in 2.2% of RTPs and 1% of HCs. Xerostomia prevalence was significantly greater in RTPs than HCs (1.4% vs 0.2%). Lichen planus appeared in 0.6% of RTPs, and one RTP suffered from hairy leukoplakia.
Conclusions:  We report a lower prevalence of oral candidiasis and hairy leukoplakia in RTPs than previous reports and describe other oral conditions not presented before in prevalence studies of RTPs, such as xerostomia, aphthous ulcers and lichen planus. These oral lesion changes in RTPs and the risk of malignancy emphasize the importance of regular oral screening in these patients.     

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.     

Occurrence of corrugated white patch lesions on lateral border of tongue in lymphoma patients during cytostatic treatment

The question of whether or not there was an association between immunosuppression and occurrence of corrugated white patch lesions on the lateral border of the tongue was studied in 79 patients being treated for non-Hodgkin lymphoma or Hodgkin's disease. The mouths of 55 patients (mean age 47.8 years, 34 males, 21 females) were examined during periods of chemotherapy. All patients were HIV-seronegative. White non-removable lesions on the lateral margins of the tongue were noted in 27 patients (42.8%) 74 days after commencement of chemotherapy and 10 days after termination of medication. In 12 cases (44.4%) the lesions were bilateral. Epstein-Barr virus (EBV) DNA was found by gene amplification using polymerase chain reaction (PCR) in one of the two biopsy samples taken. No white lesion on the lateral border of tongue had been seen in any patient before treatment, nor were any evident 1 year after treatment. Leucocyte counts were significantly (P=0.001) lower when the lesion was present than when it was not detected. Before chemotherapy, 70.4% of patients with lesions and 47.6% of patients without lesions had positive salivary yeast cultures. Yeasts could be cultued from the saliva of 80.5% of patients when the lesions were present. In 2 patients clinical oral candidiasis was diagnosed at the time of the lesion. The study revealed a correlation between the occurrence of corrugated white, non-removable lesions of the lateral borders of the tongue, high salivary yeast counts and leucocytopenia. Clinical diagnosis of the lesion was consistent with oral hairy leukoplakia (OHL) or pseudo oral hairy leukoplakia (pseudo OHL), but histological studies are needed to confirm the diagnosis of the lesion. However, the lesion may be an early clinical sign of immunosuppression.     

Sensitivity, specificity, and positive predictive value of oral opportunistic infections in adults with HIV/AIDS as markers of immune suppression and viral burden

OBJECTIVES: The purpose of this study was to assess the use of human immunodeficiency virus (HIV)-related oral opportunistic infections as markers of immune suppression and viral burden in adults with HIV/acquired immunodeficiency syndrome (AIDS). METHODS: The population consisted of a single institution observational cohort involving 606 patients with HIV/AIDS with CD4 count data and 277 with plasma viral load measurements examined between 1995 and 1999 for the presence of oral manifestations of HIV. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value is reported for the association of specific oral lesions and lesion sets with CD4 counts <200 cells/mm(3) and with plasma HIV RNA >/=20,000 copies/mL. RESULTS: Lesions with moderate-to-high PPVs for CD4 <200 cells/mm(3) were as follows: Kaposi's sarcoma (100%; P =.035), pseudomembranous candidiasis (82. 2%; P <.001), linear gingival erythema (70.0%; P =.015), hairy leukoplakia (66.3%; P <.001), angular cheilitis (60.0%; P =.128), and erythematous candidiasis (58.3%; P =.061). Necrotizing ulcerative periodontal diseases, HIV salivary gland disease, oral ulcers, and oral warts had PPVs below 50%. Concurrent infection with candidiasis and hairy leukoplakia had the highest PPV of 89.3%; P <. 001. PPVs for HIV RNA >/=20,000 copies/mL ranged from 27.3% to 100%, with significant association only for pseudomembranous candidiasis. CONCLUSIONS: Specific common oral lesions are strongly associated with immune suppression, as measured by CD4 cell counts, and are modestly associated with high viral burden, thus serving as potential clinical markers of HIV viremia and the consequent destruction of the immune system with progressive HIV disease.     

Oral lesions and conditions associated with human immunodeficiency virus infection in 300 south Indian patients

BACKGROUND: Human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) is a major health problem in India. The National AIDS Control Organisation (NACO) of India reports a seropositivity 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 diagnosis and management of these patients. OBJECTIVE AND SETTING: The present report describes the oral lesions in 300 HIV positive symptomatic 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 appearance 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 < or = 200. A total of 217 (72%) of the 300 patients had some oral lesion when examined. Gingivitis (47%) and pseudomembranous candidiasis (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 submucous 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 monitoring the disease progression. This is a cost-effective procedure, which may be useful in screening large populations in developing countries like India.     

Oral manifestations of HIV infection in relation to clinical and CD4 immunological status in northern and southern Thai patients

OBJECTIVES: To assess prevalence and variations in the oral manifestations of HIV in HIV-infected subjects in southern Thailand (a new HIV epidemic) and northern Thailand (a mature epidemic), and the association with age, sex, risk behaviours, CD4 count and medication used. SUBJECTS AND METHODS: A total of 102 and 135 HIV-infected individuals were enrolled in northern and southern hospitals, respectively. Oral and haematological examination was performed after sociodemographic interview of the patients. Clinical history was retrieved from patients' medical records. RESULTS: Oral candidiasis (OC, 55%), oral hairy leucoplakia (OHL, 21%) and HIV-associated-periodontal disease (14%) were among the most common oral lesions in southern Thailand. OHL (38%), OC (25%), HIV-associated-periodontal disease (15%) were the three most common lesions in the north. A significant association was found between any oral lesion, OC, particularly the pseudomembranous type (PC), and CD4 < 200 cells mm(-3) at both sites. A negative relationship was found between systemic antifungal treatment and OC including PC and erythematous candidiasis (EC) in the southern data. OHL showed a positive relationship with male sex and a negative relationship with antiretroviral treatment in the northern site. Younger age and being a current smoker were positively associated with oral lesions in the southern group. CONCLUSION: OC, particularly PC, could be useful as a marker for immunosuppression, particularly where CD4 count cannot be determined routinely. Antifungal treatment is of benefit in the subjects who cannot afford highly active antiretroviral therapy (HAART).