Indian Journal of Dental Research

: 2019  |  Volume : 30  |  Issue : 4  |  Page : 521--526

Periodontal health status among HIV-seropositive pregnant women

Narendra Dev Jampani, Ravi Kiran Sunkavilli, Vajra Madhuri Songa, Lahari Buggapati, Srinivasa Reddy Pathagunti 
 Department of Periodontics, Dr. NTR University of Health Sciences, Government Dental College and Hospital, Vijayawada, Andhra Pradesh, India

Correspondence Address:
Dr. Ravi Kiran Sunkavilli
Department of Periodontics, Lenora Institute of Dental Sciences, Rajahmundry - 533 294, Andhra Pradesh


Aims and Objective: Routine oral health care is essential for those living with HIV (human immunodeficiency virus) infection, especially in pregnant women. Hormonal changes during pregnancy, immunosupression in HIV along with bacterial load in periodontal infections strongly influence the pregnancy outcomes. The aim of this study was to evaluate the periodontal health status in HIV seropositive pregnant women in Andhra Pradesh, India. Materials and Methods: This study includes a sample of 90 divided into three groups; HIV seropositive pregnant women (group PH; n = 30), HIV seropositive nonpregnant women (group H; n = 30), and healthy pregnant women without HIV infection (group P; n = 30). Clinical examination includes the recording of probing depths (PD), clinical attachment level (CAL), plaque index (PI), gingival index (GI), and periodontal screening and recording index (PSR) were assessed in three groups. Statistical analysis was done by Mann–Whitney U-test and Wilcoxon paired test using the software SPSS version 17. Results: Clinical parameters do not show any significant variation between the three groups. But slightly higher mean PD and CAL levels was observed in HIV seropositive pregnant and nonpregnant women compared with healthy pregnant women without HIV infection. About 13% of severe gingivitis cases were observed in HIV seropositive pregnant group compared with 6% in HIV seropositive and 3% in healthy pregnant group. Conclusions: Presence of slightly higher percentage of severe gingivitis in HIV seropositive pregnant women strengthens the fact of extra need for preventive oral health services during the prenatal period and provides recommendations for promoting maternal oral health in regional antiretroviral therapy centers in India.

How to cite this article:
Jampani ND, Sunkavilli RK, Songa VM, Buggapati L, Pathagunti SR. Periodontal health status among HIV-seropositive pregnant women.Indian J Dent Res 2019;30:521-526

How to cite this URL:
Jampani ND, Sunkavilli RK, Songa VM, Buggapati L, Pathagunti SR. Periodontal health status among HIV-seropositive pregnant women. Indian J Dent Res [serial online] 2019 [cited 2020 Nov 28 ];30:521-526
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Human Immunodeficiency Virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) remains a global health problem of unprecedented dimension. India has the third largest HIV epidemic in the world. According to National AIDS Control Organization, the total number of people living with HIV (PLHIV) in India is estimated at 21.17 lakhs (17.11–26.49 lakhs) in 2015. Undivided Andhra Pradesh and Telangana have the highest estimated number of PLHIV (3.95 lakhs). It was evaluated that out of 27 million pregnancies every year in India, nearly 49,000 occur in HIV-positive mothers.[1] Infection is presently viewed as one of the major causes of preterm low birth weight deliveries, and it represents 30%–50% of all cases. HIV infection in pregnancy has become the most common medical complication of pregnancy.[2],[3],[4] Adverse pregnancy outcomes have been reported in HIV seropositive women include the rates of spontaneous abortion, low birth weight babies, and preterm labor.[5],[6],[7]

Periodontal disease and dental caries are the two most familiar oral health problems of bacterial inception, in human population. Research suggests that transmission of inflammatory mediators and bacterial products of periodontal infection into the fetoplacental unit through blood stream, potentially leading to adverse pregnancy outcomes.[2],[3],[4] Routine oral health care is necessary to prevent these oral infections. Such care is crucial for HIV seropositive pregnant patients, because individuals with a compromised immune system need to avoid bacterial infections.[8],[9]

The relationship between chronic periodontitis and HIV infection is not clear and various conflicting opinions exist regarding the prevalence of chronic periodontitis and HIV infection.[10],[11],[12] Several microbiological and immunological studies have failed to show any major differences between the HIV-seropositive subjects with chronic periodontitis compared with HIV-seronegative controls.[13],[14],[15] Some studies reported a higher prevalence of periodontitis with greater attachment loss in HIV-seropositive subjects compared with HIV-seronegative controls. Localized gingival recession is responsible for the greater severity of periodontal destruction in HIV-seropositive subjects compared with HIV-seronegative subjects.[12],[16],[17],[18]

There are numerous studies that evaluate the relationship between HIV infection and the periodontitis, but their association in HIV seropositive pregnant women has not been investigated much, especially in India. As prevention, care, and support along with treatment form the two key pillars of all HIV/AIDS control efforts in India, there is a need to expand oral health care and preventive measures for HIV pregnant women.[1] So, the main purpose of this study was to assess the periodontal health status among HIV-seropositive pregnant women from Krishna District, Andhra Pradesh, India.

Specific aims of the study were to analyze and compare the periodontal health status among HIV seropositive pregnant women, HIV-seropositive nonpregnant women, and healthy pregnant women without HIV infection by measuring the clinical parameters associated with chronic periodontitis such as probing depths (PD), clinical attachment level (CAL), plaque index (PI), gingival index (GI), and periodontal screening and recording index (PSR).

 Subjects and Methods

This study was designed as a hospital-based cross-sectional study, performed at the Department of Obstetrics and Gynecology, Government General Hospital, and Regional ART Centre in Vijayawada, Andhra Pradesh, between July and October 2015. The institutional Ethics Committee of Government Dental College and Hospital, Vijayawada, approved the study. The study population comprised 60 HIV-seropositive women and 30 healthy pregnant women without HIV infection. Participants were enrolled after signing an informed consent form. The participants were divided into three groups; HIV-seropositive pregnant women under highly active antiretroviral (HAART) therapy (group PH; n = 30), HIV-seropositive nonpregnant women under HAART (group H; n = 30) and healthy pregnant women without HIV infection (group P; n = 30). All the three groups were matched with regard to age (19–35 years) and socioeconomic status. Socioeconomic status was represented by monthly family income. Three groups were constituted and subjects were categorized into either lower class (<1,500 to 5,000), middle class (5,000–15,000), and upper class (≥15,000).[19] Patients with habits of smoking, pan chewing, and having systemic diseases such as diabetes and hypertension were excluded from the study. Seropositivity was confirmed in all HIV-infected patients by the ELISA (enzyme-linked immune sorbent assay)test and classification of the lesions was based on their clinical aspects.

Clinical examination included the recording of PI, GI, PSR, PD, CAL using the World Health Organization (WHO) periodontal probe, and community periodontal index of treatment needs (CPITN) probe by a single experienced dentist to ensure consistency of measurements. Periodontal examination was performed, which included a number of parameters, the PD (distance between the gingiva and the bottom of the periodontal sulcus) and GR (distance between the gingiva and the cement–enamel junction) were recorded at four sites per tooth (mesiobuccal, distobuccal, mid-buccal, and lingual). The CAL was calculated as the sum of PD and GR. The definition of periodontal disease was the presence of >30% of the sites with clinical attachment loss ≥4 mm.

The gingival index was scored according to Löe and Silness,[20] where 0 = normal gingiva; 1 = mild inflammation, slight change in color, slight edema, and no bleeding on probing; 2 = moderate inflammation, redness, edema and glazing, and bleeding on probing; and 3 = severe inflammation, marked redness and edema, ulceration, and tendency to spontaneous bleeding. A total score of 0.1–1.0 considered as mild gingivitis, 1.1–2.0 considered as moderate gingivitis, and 2.0–3.0 considered as severe gingivitis. The plaque index was scored according to silness and loe,[21] where 0 = no plaque; 1 = a film of plaque adhering to the free gingival margin and adjacent area of the tooth. The plaque may be seen in situ only after application of disclosing solution or by using the probe on the tooth surface; 2 = moderate accumulation of soft deposits within the gingival pocket, or the tooth and gingival margin which can be seen with the naked eye; 3 = abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin.

The PSR is a WHO-accepted detection system for periodontal disease and is subdivided into five codes. The periodontal status was assessed based on the PSR by using the CPITN probe. The dentition was divided into six sextants: 17–14, 13–23, 24–27, 47–44, 43–33, and 34–37. Subjects were then classified into five categories defined by the codes: Code 0 = healthy gum; Code 1 = presence of bleeding; Code 2 = presence of calculus; Code 3 = presence of pockets of 4–5 mm; Code 4 = pocket over 6 mm; Code X = Sextant absent or fewer than two teeth. A PSR score ≥3 was retained to define the presence of periodontitis. PSR is effective in estimating periodontal disease severity and is on average nine times faster than a conventional evaluation. In fact, periodontal screening using PSR can be completed under 2 min.[22],[23],[24]

HIV-related oral-mucosal lesions were screened according to Oral HIV/AIDS Research Alliance case definitions.[25] Information related to demographic features, general health, pregnancy-related history, HIV infection history, and immunological status were obtained from the direct questionnaire and patients medical records.

Statistical analysis

All the data were entered into Microsoft excel program and analysed using the Statistical Package for Social Sciences (SPSS). Mann–Whitney U-test and Wilcoxon paired test, and logistic regression analyses were performed to explore associations. P values < 0.05 were regarded as statistically significant.


[Table 1] gives the basic details of the mean age, socioeconomic status, time of diagnosis of HIV, and mean CD4 count and mean decayed, missing, and filled teeth index (DMFT) among the three groups. All the 60 patients had acquired the infection through heterosexual contact. The three groups were closely matched for age with a mean of 24.53 ± 2.56 in group PH, 24.93 ± 2.42 in group H, and 24.97 ± 2.31 in group P. About 42% of the women subjects had carious teeth and 27% had missing teeth with a mean DMFT (decayed, missing, and filled teeth index) of 1.90 ± 1.88 in group PH, 1.97 ± 1.71 in group H, and 1.40 ± 1.35 in group P. About 91% of the patients are from low socioeconomic status and 9% from the middle class. About 86% of the HIV-seropositive pregnant patients and 73% of the HIV-seropositive nonpregnant women were diagnosed within duration of <6 months. Most of the patients were diagnosed during routine blood investigations after confirmation of pregnancy in group PH. Mean CD4 count in group PH is 453.23 ± 176.1 compared with 451.87 ± 144.5 in group H. Both HIV-seropositive pregnant and nonpregnant women are under HAART therapy.{Table 1}

[Table 2] and [Table 3] show the mean values of PI, GI, and severity of gingivitis in the three groups. The mean GI was higher in the group PH (1.10 ± 0.71) compared with group P and H (0.74 ± 0.68 and 1.04 ± 0.66). On comparing the three groups, there is no significant association with P value = 0.113. About 13% of severe gingivitis cases were observed in group PH compared with 6% in group H and 3% in group P. About 33% of healthy cases were observed in group P compared with 13% in groups H and P.{Table 2}{Table 3}

[Table 4] shows the mean values of PD, CAL, and PSR. There were no significant differences between the groups regarding PSR (group PH = 1.51 ± 0.73; group H = 1.51 ± 0.66; group P = 1.36 ± 0.68), CAL (group PH = 2.50 ± 0.59 mm; group H = 2.58 ± 0.83 mm; group P = 2.29 ± 0.56), or PD (group PH = 1.87 ± 0.36; group H = 1.96 ± 0.78; group P = 1.76 ± 0.36). The mean PD, CAL and PSR is slightly higher in HIV seropositive non-pregnant and pregnant women compared to healthy pregnant women. Out of the 60 HIV-seropositive women, 4 cases of the linear gingival erythema (3 in group PH and 1 in group H), and 2 cases of oral candidiasis (2 in group H) was observed.{Table 4}


The association between the periodontal disease and various systemic disorders has been well documented in the literature from the past decade, indicating either positive or negative association. The relation between periodontal disease during pregnancy and increased risk of premature labor andlow birth weight due to periodontal infection is still controversial among the researchers. Some authors demonstrated that immunosuppression associated with HIV infection and hormonal changes identified with pregnancy build the risk of periodontal inflammation.[8],[26],[27],[28] Most of the studies in the literature focus on the HIV-seropositive patients only they did not include control groups to explore the further association.[29],[30],[31] Recently, from the past 4–5 years studies have primarily compared HIV-seropositive patients with uninfected patients.[32],[33],[34] Particularly, while considering the HIV-seropositive pregnant patients, studies were exceptionally scarce.[9],[26] Therefore, the main objective of this study was to evaluate the periodontal health status among HIV seropositive pregnant women and also to correlate it with age-matched control groups (HIV seropositive non pregnant and healthy pregnant women).

This study demonstrates that all the three groups have similar mean PD, CAL, PI, GI, and PSR measurements and that HIV infection does not pose any significant risk for periodontal destruction. This finding was similar to various studies, which followed the natural progression of chronic periodontitis in HIV-seropositive and seronegative patients.[18],[31],[35]

Out of the 60 HIV-seropositive women, 4 cases of the linear gingival erythema and 2 cases of oral candidiasis was observed. Various authors reported that oral candidiasis is the most common manifestation of HIV seropositive patients.[36],[37],[38] Pedreira et al.[39] observed oral candidiasis in 28% of HIV-seropositive patients and the authors express that vast majority of the oral lesions manifested with the reduction in the CD4 count. Sontakke et al.[40] demonstrated that there was a positive relation between the CD4 levels and advancement of oral lesions in HIV-seropositive patients.

The results of this study demonstrates that mean GI was marginally higher in the group PH (1.10 ± 0.71) compared with group P and H (0.74 ± 0.68 and 1.04 ± 0.66), respectively, without any significant association. About 13% of severe gingivitis cases were observed in HIV-seropositive pregnant group compared with 6% in HIV-seropositive nonpregnant and 3% in healthy pregnant group. About 20% of severe gingivitis cases were observed in the HIV-seropositive pregnant and nonpregnant women. The primary cause for poor maternal oral health is the hormonal imbalance and dietary variations that occur during the pregnancy along with immunosuppression in HIV infection.[41],[42] These results emphasis the need of extra care and treatment measures to prevent the periodontal diseases among HIV-seropositive women.

Periodontal parameters (PD and CAL) do not show any significant variation between the three groups. But slightly higher mean PD and CAL levels was observed in both HIV-seropositive pregnant and HIV-seropositive nonpregnant women compared with healthy pregnant women without HIV infection. This finding might be because of the fact that improvement in the immune status of HIV-seropositive women under HAART. The mean CD4 count of HIV-seropositive pregnant women in this study was 453 ± 144, which is above the level of CD4 count <200 cells/mm 3 that thought to be strongly associated with periodontal destruction.[43],[44] Vernon et al.[45] demonstrated that extent of periodontal disease were high in HIV-seropositive patients especially in those with CD4+ T-cell counts of 200 cells/mm 3. Various studies reported that increase in PDs along with prevalence of periodontal diseases (gingivitis and periodontitis) was observed in HIV seropositive patients with CD4 count below 200 cells/mm 3.[27],[46],[47],[48] Vastardis et al.[44] in their study observed the gingival inflammation in severely immunocompromised HIV-positive patients with CD4 cell counts of <200 cells/mm 3, and in patients with CD4 cell counts of >500 cells/mm 3, there was no association between CD4 cell count and periodontal indices. Various studies in the post-HAART era recommended that initiation of antiretroviral therapy may reduce periodontal disease morbidity by improving the immune status.[49],[50] Recent studies insist the concept that HIV associated immune changes may not contribute to the development and progression of chronic periodontitis. This is because of the suppression of host-derived cellular immune responses in HIV infection which are major mediators of periodontal destruction and reduced number of opportunistic microbes with increase CD4 count.[32]

Although it is not considered in the study protocol, an important observation made in this study period was the lack of knowledge and awareness towards the oral health importance during pregnancy among HIV-seropositive women.


Our study does not find any significant variation of periodontal health status among HIV seropositive pregnant and nonpregnant women compared with healthy control group. Presence of slightly higher percentage of severe gingivitis in HIV-seropositive pregnant women strengthens the fact that extra need for preventive oral health services during the prenatal period and provide recommendations for promoting maternal oral health in regional ART centers in India. This study has provided valuable insight into the oral health of pregnant women with HIV infection. However, this study was undertaken with small sample of HIV-seropositive pregnant women, further studies with large number of subjects is required to draw strong convincing results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1National AIDS Control Organization, HIV Sentinel Surveillance. India HIV estimation statistics 2015 technical report. Available from: [Last accesed on Mar 2018].
2Corbella S, Taschieri S, Del Fabbro M, Francetti L, Weinstein R, Ferrazzi E. Adverse pregnancy outcomes and periodontitis: A systematic review and meta-analysis exploring potential association. Quintessence Int 2016;47:193-204.
3Burdet J, Rubio AP, Salazar AI, Ribeiro ML, Ibarra C, Franchi AM. Inflammation, infection and preterm birth. Curr Pharm Des 2014;20:4741-8.
4Perunovic ND, Rakic MM, Nikolic LI, Jankovic SM, Aleksic ZM, Plecas DV, et al. The association between periodontal inflammation and labor triggers elevated cytokine levels in pre-term birth: A cross-sectional study. J Periodontol 2015;8:1-13.
5Ezugwu EC, Iyoke CA, Nkwo PO, Ezegwui HU, Akabueze JC, Agu PU. Unintended pregnancy among HIV-positive pregnant women in Enugu, Southeast Nigeria. Int J Gynaecol Obstet 2016;132:60-3.
6HIV in pregnancy review – UNAIDS. Available from: [Last accesed on Mar 2018]
7Xiao PL, Zhou YB, Chen Y, Yang MX, Song XX, Shi Y, et al. Association between maternal HIV infection and low birth weight and prematurity: A meta-analysis of cohort studies. BMC Pregnancy Childbirth 2015;15:246.
8González OA, Ebersole JL, Huang CB. Oral infectious diseases: A potential risk factor for HIV virus recrudescence? Oral Dis 2009;15:313-27.
9López LM, Guerra ME. Caries experience and periodontal status during pregnancy in a Group of pregnant women with HIV+ infections from Puerto Rico. J AIDS Clin Res 2015;6:434.
10Patton LL. Current strategies for prevention of oral manifestations of human immunodeficiency virus. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;121:29-38.
11Stanford TW, Rees TD. Acquired immune suppression and other risk factors/indicators for periodontal disease progression. Periodontol 2000 2003;32:118-35.
12Robinson PG, Boulter A, Birnbaum W, Johnson NW. A controlled study of relative periodontal attachment loss in people with HIV infection. J Clin Periodontol 2000;27:273-6.
13Ferreira DC, Gonçalves LS, Siqueira JF, Carmo FL, Santos HF, Feres M, et al. Subgingival bacterial community profiles in HIV-infected Brazilian adults with chronic periodontitis. J Periodontal Res 2016;51:95-102.
14Zhang F, He S, Jin J, Dong G, Wu H. Exploring salivary microbiota in AIDS patients with different periodontal statuses using 454 GS-FLX titanium pyrosequencing. Front Cell Infect Microbiol 2015;5:55.
15Yeung SC, Taylor BA, Sherson W, Lazarus R, Zhao ZZ, Bird PS, et al. IgG subclass specific antibody response to periodontopathic organisms in HIV-positive patients. J Periodontol 2002;73:1444-50.
16John CN, Stephen LX, Joyce Africa CW. Is human immunodeficiency virus (HIV) stage an independent risk factor for altering the periodontal status of HIV-positive patients? A South African study. BMC Oral Health 2013;13:69.
17Kistler JO, Arirachakaran P, Poovorawan Y, Dahlén G, Wade WG. The oral microbiome in human immunodeficiency virus (HIV)-positive individuals. J Med Microbiol 2015;64:1094-1101.
18Ravi JR, Rao TRG. Estimation of prevalence of periodontal disease and oral lesions and their relation to CD4 counts in HIV seropositive patients on antiretroviral therapy regimen reporting at District General Hospital, Raichur. J Indian Soc Periodontol 2015;19:435-9.
19Gundala R, Chava VK. Effect of lifestyle, education and socioeconomic status on periodontal health. Contemp Clin Dent 2010;1:23-6.
20Löe H, Silness J. Periodontal disease in pregnancy I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
21Silness J, Löe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and perio- dontal condition. Acta odontol Scand 1964;22:112-35.
22Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J. Development of the World Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J 1982;32:281-91.
23Landry RG, Jean M. Periodontal screening and recording (PSR) index: Precursors, utility and limitations in a clinical setting. Int Dent J 2002;52:35-40.
24Lo Frisco C, Cutler R, Bramson JB. Periodontal screening and recording: Perceptions and effects on practice. J Am Dent Assoc 1993;124:226-9, 231-2.
25Shiboski CH, Patton LL, Webster-Cyriaque JY, Greenspan D, Traboulsi RS, Ghannoum M, et al. The oral HIV/AIDS research alliance: Updated case definitions of oral disease endpoints. J Oral Pathol Med 2009;38:481-8.
26Pattrapornnan P, DeRouen TA. Associations of periodontitis and oral manifestations with CD4 counts in human immunodeficiency virus-pregnant women in Thailand. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:306-12.
27Ranganathan K, Magesh KT, Kumarasamy N, Solomon S, Viswanathan R, Johonson NW. Greater severity and extent of periodontal breakdown in 136 South Indian human immunodeficiency virus seropositive patients than in normal controls: A comparative study using community periodontal index of treatment needs. Indian J Dent Res 2007;18:55-9.
28Chokkaiyan S, Arumugam SC, Kumar S, John LB, Ghose S. Periodontitis as a risk factor for preterm labour and low birth weight among pregnant women attending a tertiary care teaching hospital. Int J Reprod Contracept Obstet Gynecol 2015;4:1804-10.
29Diniz Barreto LP, Melo Dos Santos M, Gomes BD, Lamas CD, Silva DG, Silva-Boghossian CM, et al. Periodontal conditions in HIV+patients under haart from a metropolitan area of Rio De Janeiro. J Periodontol 2015;26:1-11.
30Rao KV, Chitturi RT, Kattappagari KK, Kantheti LP, Poosarla C, Baddam VR. Impact of highly active antiretroviral therapy on oral manifestations of patients with human immunodeficiency virus/acquired immuno deficiency syndrome in South India. Indian J Sex Transm Dis 2015;36:35-9.
31Khongkunthian P, Grote M, Isaratanan W, Plyaworawong S, Reichart PA. Oral manifestations in HIV-positive adults from Northern Thailand. J Oral Pathol Med 2001;30:220-3.
32Khammissa R, Feller L, Altini M, Fatti P, Lemmer J. A comparison of chronic periodontitis in HIV-seropositive subjects and the general population in the Ga-Rankuwa area, South Africa. AIDS Res Treat 2012;620962.
33Umeizudike KA, Ayanbadejo PO, Savage KO, Nwhator SO, Akanmu AS, Ogunleye O. Comparative periodontal status of human immunodeficiency virus-positive patients and controls in a dedicated human immunodeficiency virus clinic in Nigeria. Niger J Clin Pract 2016;19:35-40.
34Goldberg BE, Mongodin EF, Jones CE, Chung M, Fraser CM, Tate A, et al. The oral bacterial communities of children with well-controlled HIV infection and without HIV infection. PLoS One 2015;10:7.
35Holmstrup P, Westergaard J. Periodontal diseases in HIV-infected patients. J Clin Periodontol 1994;21:270-80.
36Gaitán-Cepeda LA, Martínez-González M, Ceballos-Salobreña A. Oral candidosis as a clinical marker of immune failure in patients with HIV/AIDS on HAART. AIDS Patient Care STDS 2005;19:70-7.
37Perezous LF, Flaitz CM, Goldschmidt ME, Engelmeier RL. Colonization of candida species in denture wearers with emphasis on HIV infection: A literature review. J Prosthet Dent 2005;93:288-93.
38Sharma G, Oberoi SS, Vohra P, Nagpal A. Oral manifestations of HIV/AIDS in Asia: Systematic review and future research guidelines. J Clin Exp Dent 2015;7:e419-427.
39Pedreira EN, Cardoso CL, Barroso Edo C, Santos JA, Fonseca FP, Taveira LA. Epidemiological and oral manifestations of HIV-positive patients in a specialized service in Brazil. J Appl Oral Sci 2008;16:369-75.
40Sontakke SA, Umarji HR, Karjodkar F. Comparison of oral manifestations with CD4 count in HIV-infected patients. Indian J Dent Res 2011;22:732.
41Gemaque K, Giacomelli Nascimento G, Cintra Junqueira JL, Cavalcanti de Araújo V, Furuse C. Prevalence of oral lesions in hospitalized patients with infectious diseases in northern Brazil. Sci World J 2014;15:586075.
42George A, Johnson M, Blinkhorn A, Ellis S, Bhole S, Ajwani S. Promoting oral health during pregnancy: Current evidence and implications for Australian midwives. J Clin Nurs 2010;19:3324-33.
43Gonçalves LS, Ferreira SM, Silva A Jr, Villoria GE, Costinha LH, Colombo AP. Association of T CD4 lymphocyte levels and chronic periodontitis in HIV-infected brazilian patients undergoing highly active anti-retroviral therapy: Clinical results. J Periodontol 2005;76:915-22.
44Vastardis SA, Yukna RA, Fidel PL, Leigh JE, Mercante DE. Periodontal disease in HIV-positive individuals: Association of periodontal indices with stages of HIV disease. J Periodontol 2003;74:1336-41.
45Vernon LT, Demko CA, Whalen CC, Lederman MM, Toossi Z, Wu M, et al. Characterizing traditionally defined periodontal disease in HIV+adults. Community Dent Oral Epidemiol 2009;37:427-37.
46Patil N, Chaurasia VR, Babaji P, Ramesh D, Jhamb K, Sharma AM. The effect of highly active antiretroviral therapy on the prevalence of oral manifestation in human immunodeficiency virus-infected patients in Karnataka, India. Eur J Dent 2015;9:47-52.
47Robinson PG, Sheiham A, Challacombe SJ, Zakrzewska JM. The periodontal health of homosexual men with HIV infection: A controlled study. Oral Dis 1996;2:45-52.
48Fricke U, Geurtsen W, Staufenbiel I, Rahman A. Periodontal status of HIV-infected patients undergoing antiretroviral therapy compared to HIV-therapy naive patients: A case control study. Eur J Med Res 2012;17:2.
49Gonçalves LS, Gonçalves BM, Fontes TV. Periodontal disease in HIV-infected adults in the HAART era: Clinical, immunological, and microbiological aspects. Arch Oral Biol 2013;58:1385-96.
50Mataftsi M, Skoura L, Sakellari D. HIV infection and periodontal diseases: An overview of the post-HAART era. Oral Dis 2011;17:13-25.