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).     

广西地区64例人免疫缺陷病毒感染及艾滋病感染患者口腔病损的临床观察

目的　了解广西人免疫缺陷病毒感染及艾滋病感染(HIV/AIDS)患者口腔病损状况,为我国HIV/AIDS人群口腔疾病的防治提供依据。方法　以经广西区疾病控制中心确诊为HIV/AIDS患者64例为调查对象,由专业人员采集病史,进行口腔专科检查,并将详细记录的结果与世界卫生组织艾滋病感染口腔表征协作中心制定的艾滋病口腔表征分类及诊断标准相比较。结果　64名HIV/AIDS患者,年龄范围为5月~64岁,平均年龄36·1岁,其中男53人,女11人。48名有口腔主诉,以口干、疼痛、吞咽困难为主;口腔表现为口腔念珠菌病39例、口干症20例、口腔溃疡11例、艾滋病相关的牙周病7例、单纯疱疹病毒感染口炎6例、带状疱疹3例、口腔毛状白斑2例、卡波济肉瘤和淋巴节炎各1例。结论　口腔念珠菌病是HIV/AIDS患者最常见的口腔表征,多数患者伴有口干、唾液分泌减少。口腔溃疡患病率与正常群体相比没有提高,但是溃疡严重程度增加。提示HIV/AIDS患者常伴有口腔表征, 并且部分口腔表征出现较早。     

Association of asymptomatic oral candidal carriage, oral candidiasis and CD4 lymphocyte count in HIV-positive patients in China

OBJECTIVES: To compare the prevalence of asymptomatic oral candidal carriage in healthy volunteers with human immunodeficiency virus (HIV)-positive patients in China, as well as to investigate the relationship between CD4+ lymphocyte count and oral candidal colonization or oral candidiasis. METHODS: Oral candidal carriage and oral candidiasis were investigated in 101 patients with HIV-infection seen at Youan Hospital, Beijing, China. Two hundred and seventeen healthy volunteers were involved as a control. Culture from saliva was used to test for the presence of oral Candida. CD4+ lymphocyte count was measured by flow cytometry. All data were analyzed statistically by SAS. RESULTS: Asymptomatic oral candidal carriage rate (28.6%) in HIV-positive group was similar to that in the healthy group (18.0%; P = 0.07). No significant difference in CD4+ lymphocyte count was found between oral Candida carriers and non-carriers among HIV-positive subjects (P = 0.89). However, the frequency of oral candidiasis increased with the decrease in CD4+ lymphocyte count (P < 0.0001), and pseudomembranous candidiasis was predominant in HIV-positive patients with CD4+ <200 cells microl(-1) (66.7%). CONCLUSIONS: In HIV-positive subjects, asymptomatic oral candidal colonization is not related to CD4+ lymphocyte count of blood, and the carriage rate is similar to that in the healthy population. Oral candidiasis is more likely to be observed in HIV-positive patients who have a low CD4+ lymphocyte count.     

Oral pseudomembranous candidiasis, herpes simplex virus-1 infection, and oral mucositis in head and neck cancer patients receiving radiotherapy and granulocyte-macrophage colony-stimulating factor (GM-CSF) mouthwash

Oral pseudomembranous candidiasis (OPC) was evaluated in 61 patients receiving head and neck radiotherapy (RT). Herpes simplex virus-1 (HSV-1) reactivation was also investigated in 14 patients. According to the agreed protocol, granulocyte-macrophage colony-stimulating factor (GM-CSF) mouthwash was administered in 46 patients with radiation-induced ulcers. Candidiasis was diagnosed in 31 patients. Candida albicans was the most frequent isolate. Multiple Candida species were isolated from the lesions of four patients. Concurrent candidiasis and radiation-induced ulcers were observed in 17 patients. Viral culture and the polymerase chain reaction disclosed the presence of HSV-1 in five patients. Twenty of the 46 patients, with initial mucositis grade II and grade III, completed RT with mucositis grade I, indicating a beneficial effect of GMCSF mouthwash, although further controlled studies are necessary to verify that. In conclusion, OPC was an important infection in patients undergoing radiotherapy. The role of HSV-1 in oral mucositis during head and neck radiotherapy needs additional study.     

Low prevalence of oral mucosal lesions in HIV-1 seropositive African women

In Nairobi (Kenya) 334 women prostitutes of whom 80.5% were HIV-1 positive, were examined for oral mucosal lesions; 15.6% of seropositive, and 4.6% of seronegative, women had oral mucosal lesions, predominantly oral candidiasis. In the seropositives, 8.6% had erythematous, 1.1% had hyperplastic candidiasis, and 0.4% had hairly leukoplakia as the only oral lesions; 0.4% had a combination of erythematous and hyperplastic candidiasis, and 1.5% had combinations of pseudomembranous and erythematous candidiasis in the presence of hairly leukoplakia. Of the 211 seropositive women for whom we knew the first date on which a positive serologic test was obtained, the likelihood of developing an oral mucosal lesion was found to be dependent on the duration of seropositivity. The low incidence of oral mucosal lesions in this population may be due to the relatively recent acquisition of HIV-1 infection.     

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.     

Periodontal disease in heterosexuals with acquired immunodeficiency syndrome

We studied the prevalence and severity of periodontal disease among 181 heterosexual men and women with AIDS. Included were 167 (92%) intravenous drug users (IVDU) and 14 sexual partners of persons at risk for AIDS. Periodontal disease was seen in 71 of 78 (91%) women compared to 75 of 103 (73%) men. Gingivitis was the most severe form of periodontal disease in 7 (9%) women and 15 (15%) men. Increased severity of periodontal disease was seen in women as compared with men (P less than .001); among subjects with periodontitis, 48 (75%) of 64 women had moderate to advanced disease compared to 32 (53%) of 60 men. For individuals with periodontitis, the extent of involvement was associated with severity; 90% of subjects with advanced periodontitis had all 4 quadrants affected. Concurrent oral manifestations of AIDS, including candidiasis, hairy leukoplakia, ulcers and Kaposi's sarcoma were present in 167 (92%) subjects. We conclude that HIV-associated gingivitis and HIV-associated periodontitis are common in heterosexual men and women with AIDS and are often accompanied by other oral manifestations of AIDS. The reason periodontal disease is more severe in women is not known. Clinicians should be aware that these disorders occur in heterosexuals as well as in homosexual men. Further study will be necessary to delineate the pathogenesis of these disorders.     

Oral lesions in children born to HIV–1 positive women

A cohort of 69 children born to HIV-1 positive women was studied to evaluate types, prevalences and relationships to clinical stages of HIV-1-related oral lesions. In addition, relationships among C. albicans biotypes, clinical features of oral candidiasis and HIV-1 disease were investigated. C. albicans biotypes did not correlate with clinical features of oral lesions, disease stages and CD4⁺ lymphocyte count. Of 8 patients with recurrent oral candidiasis. 4 changed clinical features and 5 changed biotype. Our study pointed out the high frequency (28.9%) of oral lesions, especially caused by fungi and the importance of the examination of the oral cavity in children born to HIV-1 positive women.     

Oral Candida isolates in patients undergoing radiotherapy for head and neck cancer: prevalence, azole susceptibility profiles and response to antifungal treatment

Oral pseudomembranous candidiasis and mucositis were assessed in 39 patients receiving a total dose of 39-70 Gy radiotherapy for head and neck cancer. Mucositis was scored using the Radiation Therapy Oncology Group criteria, and oral candidiasis was diagnosed on the basis of clinical evaluation and quantitative laboratory findings. Radiation-induced mucositis was observed in 9/39 patients. Only 3/39 patients discontinued radiotherapy due to acute severe mucosal effects. Candidiasis (colony-forming units 35 to > or = 60/lesion) associated with mucositis was diagnosed in 30/39 patients: the most frequent aetiology of the infection was Candida albicans (n = 23), followed by Candida glabrata (n = 3), Candida krusei (n = 2), Candida tropicalis (n = 1) and Candida kefyr (n = 1). Patients with confirmed oral pseudomembranous candidiasis were treated with either fluconazole 200 mg/day or itraconazole 200 mg/day for 2 weeks. Clinical improvement and concomitant negative Candida cultures (mycologic cure) were the criteria determining a response to antifungal treatment. Etest revealed very low voriconazole MICs (0.004-0.125 microg/ml) for all isolates, and fluconazole resistance for eight C. albicans strains (MIC > 64 microg/ml) and for the C. krusei isolates (MIC > 32 microg/ml). The same strains showed itraconazole susceptibility dose dependence (MIC 0.5 microg/ml). Despite the itraconazole susceptible dose dependent MIC readings, all patients with oral pseudomembranous candidiasis caused by these strains responded to antifungal treatment with 200 mg/day itraconazole. Oral mycologic surveillance of patients undergoing radiotherapy for head and neck malignancies and susceptibility testing of isolates may be indicated in cases with mucositis-associated confirmed oral pseudomembranous candidiasis to ensure prompt administration of targeted antifungal treatment. On the basis of the low MIC values found, clinical evaluation of voriconazole is indicated for management of oral pseudomembranous candidiasis refractory to other azoles.     

Gender differences in human immunodeficiency virus-related oral lesions: an Italian study

OBJECTIVE: The purpose of this study was to investigate the relationship between oral lesions and gender, age, CD4(+) cell count, human immunodeficiency virus-1 (HIV-1) viral load, antiretroviral therapy, and route of transmission in a group of HIV-infected (HIV+) persons from the Mediterranean region. STUDY DESIGN: The participants in this study were HIV+ adults who sought dental care between January 1999 and June 1999 in the Department of Oral Medicine (University of Palermo, Italy). RESULTS: One hundred thirty-six HIV+ adults came in for an initial oral examination. Their mean age was 35.2 years (SD +/- 7.97), and 33% were women. Their mean CD4(+) cell count was 325.3 x 10(6) /L (SD +/- 225.8), and their HIV-1 viral load was 39,168.3 copies/mL (SD +/- 144,256.1). Oral lesions were found in 47% of the study group, as well as in 56.5% of women (n = 46) versus 45.5% of men (n = 90; P =.05). Oral candidiasis was the most common disease; it is significantly associated with women (P =.004), CD4(+) cell count (P =.005), and HIV-1 viral load (P =.0003). No significant relationships were found between any types of oral lesions and age, antiretroviral therapy, or route of transmission (P >.2). CONCLUSION: The prevalence of HIV-related oral lesions was significantly higher in women than in men, especially for oral candidiasis, the most common lesion observed related to immune status and HIV-1 viral load.     

Oral yeast carriage in patients with advanced cancer

The aim of this study was to investigate oral yeast carriage amongst patients with advanced cancer. Oral rinse samples were obtained from 120 subjects. Yeasts were isolated using Sabouraud's dextrose agar and CHROMagar Candida, and were identified using a combination of the API 20 C AUX yeast identification system, species-specific PCR and 26S rDNA gene sequencing. Oral yeast carriage was present in 66% of subjects. The frequency of isolation of individual species was: Candida albicans, 46%; Candida glabrata, 18%; Candida dubliniensis, 5%; others, < 5%. The increasing isolation of non-Candida albicans species is clinically important, since these species are often more resistant to antifungal drugs. Oral yeast carriage was associated with denture wearing (P = 0.006), and low stimulated whole salivary flow rate (P = 0.009). Identification of these risk factors offers new strategies for the prevention of oral candidosis in this group of patients.     

The treatment of oral candidiasis in a cohort of South African HIV/AIDS patients.

The purpose of this study was to determine the extent and outcome of antifungal treatment in HIV/AIDS patients. Data obtained from patients attending a hospital-based, semi-urban comprehensive care HIV clinic, were retrospectively analysed. The clinic serves patients from urban, semi-urban and rural communities. A total of 751 confirmed black heterosexual HIV/AIDS patients received routine oral examinations and surveillance swabbing for oral yeast culture. Patients received nystatin solution as prophylaxis, miconazole for clinically detectable oral candidiasis and only in severe cases or cases of chronic candidiasis were they treated with either fluconazole or itraconazole. Treatment was regarded as successful when there was an absence or resolution of clinical lesions of oral candidiasis. Nystatin prophylaxis was prescribed to 7.9% of patients, miconazole treatment to 9.7% and 3.5% received fluconazole. Of the 60 patients who received nystatin prophylaxis, 40 (66.6%) had clinically detectable candidiasis. A negative statistical correlation was found between nystatin prophylaxis and clinically detectable candidiasis. Of 72 patients who received miconazole treatment, only 3 failed to respond. Eleven of the 27 patients who received fluconazole treatment did not return for follow-up visits. In the remaining 16 patients there was no recurrence of clinical symptoms during the following 3 - 24 months after treatment with fluconazole. It is concluded that nystatin prophylaxis proved not to be effective under these particular clinical circumstances. Resistance to azole antifungal medication is not yet a problem in this black heterosexual group of South African HIV/AIDS patients.     

Oral fungal colonization and oral candidiasis in renal transplant patients: the relationship to Miswak use

OBJECTIVES: The aim of this study was to determine and compare the prevalence of oral candidal colonization and oral candidiasis in a group of medically stable renal transplant patients (RTPs) and age and sex-matched healthy control (HC) subjects. STUDY DESIGN: The oral cavities of 58 RTPs and 52 HC subjects were clinically examined for the presence of oral candidiasis. Oral fungal colonization was determined by using the concentrated oral rinse technique. RESULTS: Prevalence of oral fungal colonization was not significantly higher in RTPs than in HC subjects (74.1% vs 59.6%, respectively; P =.1), but the density of growth was significantly higher in RTPs (P <.0017). Oral candidiasis was diagnosed in 15.5% of RTPs but in none of HC subjects (P =.002). RTPs who used a chewing stick (Miswak: Salvadora persica ) for oral hygiene had a significantly lower prevalence of oral candidiasis (P =.04) compared with other RTPs. CONCLUSIONS: RTPs are at high risk of developing oral candidiasis. More clinical investigations are needed to determine the antimycotic effect of Miswak. Regular oral screening is recommended for RTPs.     

Oral manifestations among people living with HIV/AIDS in Tanzania

Background : This study aimed to determine the prevalence of various oral and peri‐oral manifestations in people living with HIV/AIDS in Tanzania. Methods : A cross sectional study. A total of 187 persons with HIV infection were recruited from non‐governmental organisations serving people living with HIV/AIDS, 16.6% were males and females 83.4%. Information on weight and height, as well as extra oral and intra oral examinations for different manifestations were gathered. Treatment and referral for special care were offered. Results : At least one oral lesion was present in 45% of the participants. Candidiasis (28.9%) and non‐tender lymphadenopathy (11.8%) were the most common lesions. Candidiasis occurred most frequently on lips/mucosa, and the tongue, and pseudomembranous candidiasis was the most frequent type. Candidiasis occurred with several other conditions and was statistically significantly associated with low body mass index (BMI). Conclusion : This community survey carried out in an African sub‐Saharan country showed that oral lesions are frequent among people living with HIV/AIDS. As emphasised by the World Health Organization Global Oral Health Programme, national HIV/AIDS programmes should incorporate oral health components.     

Clinical trial of oral malodor treatment in patients with periodontal diseases

Pham TAV, Ueno M, Zaitsu T, Takehara S, Shinada K, Lam PH, Kawaguchi Y. Clinical trial of oral malodor treatment in patients with periodontal diseases. J Periodont Res 2011; 46: 722–729. © 2011 John Wiley & Sons A/S Background and Objective: Only a few clinical research studies have assessed different therapeutic approaches to oral malodor in subjects affected by periodontal diseases. The aim of this study was to evaluate the effects of periodontal treatment and tongue cleaning on oral malodor parameters in periodontitis and gingivitis patients. Material and Methods: The subjects were 102 periodontitis and 116 gingivitis patients with oral malodor. Oral malodor was measured by organoleptic test and Oral Chroma™. Oral health status, including tooth conditions, periodontal health, tongue coating and proteolytic activity of the BANA test in tongue coating were assessed. Subjects in each periodontal disease group were randomly assigned into two subgroups depending on the sequence of treatment: periodontal treatment and tongue cleaning. Oral malodor and oral health parameters were compared by groups and sequence of treatment. Results: For subjects in the periodontitis group, there were statistically significant reductions in oral malodor after periodontitis treatment or tongue cleaning; however, major reductions were found after periodontitis treatment. For those in the gingivitis group, there were also statistically significant reductions in oral malodor after gingivitis treatment or tongue cleaning, but the most marked reductions were observed after tongue cleaning. At the completion of treatment, all oral malodor parameters fell below the threshold levels in all subgroups. Conclusion: The present study indicated that periodontal treatment played an important role and tongue cleaning contributed to a lesser extent to reduction in oral malodor in periodontitis patients. In contrast, tongue cleaning alone can be the primary approach to reduce oral malodor in gingivitis patients.     

Recurrent oral condylomata acuminata and hairy leukoplakia: an early sign of myelodysplastic syndrome in an HIV-seronegative patient

Oral hairy leukoplakia (OHL) has been observed in all risk groups seropositive for HIV infection. Recently, this lesion has also been described in HIV-seronegative patients with immunosuppression of iatrogenic origin. We report on a HIV-1 and HIV-2 seronegative, heterosexual man affected by refractory anemia with ringed sideroblasts (myelodysplastic syndrome), who developed recurrent oral condylomata acuminata and OHL as an early clinical manifestation. The diagnosis of OHL was confirmed by identifying Epstein-Barr viral particles by electron microscopy and by in situ DNA hybridization. HIV infection was ruled out using polymerase chain reaction and testing for HIV-1 and HIV-2 antibodies.     

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).     

Self-care intervention to reduce oral candidiasis recurrences in HIV-seropositive persons: a pilot study

OBJECTIVES: This single-blind randomized controlled pilot study evaluated the efficacy of a behavioral intervention program, PRO-SELF: Candidiasis, to reduce time to recurrence of oral candidiasis over 6 months in susceptible HIV-seropositive persons. The intervention involved instruction by dentists on improving oral hygiene, minimizing sugar intake, and self-diagnosing candidiasis. METHODS: Participants were adults with oral candidiasis responsive to antifungals who presented to the UCSF Stomatology Clinic between 1997 and 2000. At 2-3 weeks of follow-up visits, a dentist "examiner", masked to group assignment, quizzed participants as to the presence of candidiasis, and assessed candidiasis status. A second, unmasked dentist "instructor" then delivered the program to intervention participants. Participants recorded dietary and oral hygiene practices in 24-h recall diaries: intervention participants at each visit and controls at initial and final visits. RESULTS: At randomization, CD4+ cell counts (cells/mm(3)) were 298 +/- 188 among 18 intervention participants and 396 +/- 228 among 17 controls. The candidiasis recurrence rates at 6 months were 78% among intervention compared with 88% among control participants (hazard ratio 0.72; 95% CI 0.35-1.50). Performing oral hygiene after meals/snacks showed the largest relative improvement: intervention-control difference in proportion of meals/snacks affected was 24% (95% CI -1 to 48%). Self-diagnoses of candidiasis were inaccurate, possibly because of mild episodes. CONCLUSIONS: The results weakly indicate that regular instruction from healthcare professionals helps patients delay candidiasis recurrence by improving oral hygiene. Among HIV-seropositive persons, those with poor oral hygiene, and high-sugar diets are most likely to benefit.     

Prevalence of Candida species in AIDS patients and HIV-free subjects in Thailand

Teanpaisan R, Nittayananta W: Prevalence of Candida species in AIDS patients and HIV-free subjects in Thailand. J Oral Pathol Med 1998; 27: 4–7. © Munksgaard, 1998.
The purpose of this study was to examine the prevalence of Candida species among groups of HIV-infected and HIV-free subjects in Thailand and to ascertain whether particular Candida species were associated with HIV infection. Oral rinse specimens were collected from 45 AIDS patients (CDC stage IV), 74 HIV-free healthy subjects, and 42 HIV-free patients who had clinical candidiasis. Yeasts recovered in culture were identified and quantified. The mean ages of the cohorts were 30.75 ± 8.19 years (AIDS group), 28.50 ± 7.98 (HIV-free healthy group) and 41.83 ± 12.25 years (HIV-free candidiasis group). Yeasts were isolated from 30/45 (66.66%, range 6.6 ± 10²-5.7 × 10⁶ CFU/ml) of the AIDS group, 8/74 (10.81%, range 8.0 × 10¹-3.5 × 10⁴ CFU/ml) of the HIV-free healthy group, and 24/42 (57.14%, range l.0 × 10 10²-1.1 × 10⁵ CFU/ml) of the HIV-free candidiasis group. There were statistically significant differences in the Candida colony counts between the AIDS group without oral candidiasis and the healthy group ( P =0.0078) and between the AIDS group with candidiasis and the HIV-free, oral candidiasis group ( P = 0.0003). Candida albicans was the most common species recovered from AIDS patients (29 out of 30; 96.66%).     

Co-existence between oral lesions and opportunistic systemic diseases among HIV-infected subjects in Thailand

BACKGROUND: The purpose of this study was to determine whether any relationship exists between the occurrence of oral lesions and opportunistic systemic diseases among HIV-infected subjects. METHODS: A cross-sectional analytical study was performed in two hundred and seventy-eight HIV-infected heterosexual persons and intravenous drug users (IVDUs)(230 males and 48 females, aged 16-65 years, mean 31.9 years). Eighty-six HIV-free subjects from the same population were included as controls (61 males and 25 females, aged 17-63 years, mean age 33.1 years). The following information was recorded for each patient: age, gender, risk group and stage of HIV infection, immune status, medication, systemic disease and presence of oral lesions. RESULTS: Oral candidiasis was the most common oral lesion among HIV-infected individuals (40%), followed by hairy leukoplakia (HL)(26%). The three most common systemic diseases among the subjects were tuberculosis (TB)(53%), cryptococcosis (14%) and Pneumocystis carinii pneumonia (PCP)(11%). Logistic regression analysis revealed a significant association between the occurrence of TB and the presence of oral candidiasis (OR 2.8; 95% CI 1.6-4.8; P < 0.001), and the occurrence of PCP and the presence of HL (OR 2.2; 95% CI 1.1-4.3; P < 0.001). Positive predictive values of any oral lesions and oral candidiasis in predicting TB were 87% (95% CI 73.0-94.6) and 67% (95% CI 51.9-80.0), respectively. CONCLUSIONS: We concluded that oral candidiasis might be used as a clinical marker for TB, and HL for PCP. Recognition of the lesions by health-care providers may indicate the need for more intensive clinical and laboratory monitoring and possibly initiation of prophylaxis against these opportunistic systemic infections.