HIV-AIDS is characterised by a profound immunodeficiency resulting from the depletion of CD4+ T helper lymphocytes. Thus CD4+ cell counts are used to stage HIV-AIDS and to initiate antiretroviral therapy . Earlier studies report that 90% of HIV-positive individuals present with oral manifestations of disease  including necrotizing ulcerative gingivitis and periodontitis . There is however, no consensus on the association of HIV with periodontal status [22–24]. The issue appears to be clouded by confounding factors such as the level of immunosuppression (HIV stage) and other risk factors for HIV-associated periodontitis . Community periodontal index of treatment needs (CPITN) scores were not used in this study, since previous studies considered it to overestimate the prevalence and severity of periodontal attachment loss among younger individuals, while underestimating them in the elderly [26, 27]. In CPITN or CPI (Community Periodontal Index), the mouth is divided into sextants and index or all teeth are examined for the presence or absence of periodontal pockets, calculus and gingival bleeding and the highest score for each sextant noted. Although easy to use and therefore frequently used in epidemiological studies , limitations include the lack of measurement of tooth mobility and attachment loss [29, 30] , which, along with probing pocket depth, are considered by most epidemiologists as being good indicators of periodontal disease. In addition, CPITN also assumes that a correlation exists between the presence of calculus and periodontal inflammation; an assumption which has been questioned [26, 27]. The epidemiological validity of the Ramfjord teeth in representing the periodontal status of the whole mouth has previously been established [23–28]. Although we are mindful of the limitations of partial mouth measurements such as the underestimation of both the extent and prevalence of periodontal disease reported in some studies [27, 31] and the bias reported in others [29, 30, 32], with measurement of sites on the buccal side of the tooth reported to show better reliability than measurement on the lingual side because of better visibility to the examiner, assessment of the Ramfjord teeth was found to reduce time, cost, patient, and examiner fatigue, while also providing a practical alternative to the 168 measurements for each clinical parameter required to characterise the prevalence and severity of periodontal disease in a single whole mouth using full mouth assessment .
This is one of very few studies which have attempted to associate HIV stage with periodontal indices, particularly in developing countries. A study by Vastardis et al.  examined for an association of periodontal indices with stages of HIV infection. They determined that for individuals with moderate or severe immunosuppression (CD4 + T cell count <500 cells/mm3), a significant positive correlation existed with modified gingival index and bleeding index, with no significant correlation with clinical attachment level (p = 0.0560). Unlike the present study, they, along with other researchers  could not find any significant association between periodontal indices and CD4 + T cell counts for all the individuals examined. Moreover only 39 patients were used in their study compared to the present study with a sample size of 120. Robinson et al.  also reported an association of clinical attachment destruction with progressive HIV infection but not with probing depth. It is generally expected that the lower the immunosuppression of an individual, the higher the severity of periodontal disease detected . In the present investigation, patients were divided into three groups on the basis of their HIV stage as depicted by their CD4+ counts, namely, A (<200 cells/ mm3), B (200-500 cells/mm3) and C (>500 cells/mm3). Although moderate to severe forms of periodontal disease were observed with the majority of individuals presenting with probing depths and clinical attachment levels > 5 mm, no significant associations were found between any of the periodontal indices and HIV stage. However, when examining the entire HIV + cohort, significant associations were observed between CD4+ counts and probing depth (p = 0.0434) and CD4+ counts and clinical attachment level (p = 0.0268). A relationship existed between the immunosuppression of the study group and their periodontal status, but the level of immunosuppression did not appear to favour the severity of periodontal disease. These findings are similar to those of other researchers who found periodontal disease to be less prevalent in subjects with CD4+ counts < 200 cells/mm3 than in subjects with CD4+ counts > 500 cells/mm3[26, 32–35]. They observed linear gingival erythema (LGE) and necrotizing ulcerative gingivitis (NUG) in patients comparable to our group B only but not the A nor C groups. They also reported that necrotizing ulcerative periodontitis (NUP) occurred with similar prevalence in groups A and B, but not in C. These studies support the suggestion that the use of antiretroviral therapy (ART) has modified the prevalence and course of periodontal disease in HIV-positive patients [12, 13, 35, 36] with reduced incidence of periodontal damage [37–39].
Other confounding factors such as age, smoking and oral hygiene practices were also investigated in the present study. There were significant positive relationships found between gingival index (p = 0.0396) and probing depth (p = 0.0393) with the age of the study population. Plaque index also showed a highly significant (p = 0.0018) positive relationship with age. The age range of the study population (20–55 years) may support the fact that as the individual ages, the chances of developing periodontal disease are increased . A study by Yalcin et al.  reported no association between clinical parameters and age.
Smoking showed a marked although not significant association with CD4+ cell counts (p = 0.0540), while being significantly related to plaque index, probing depth and clinical attachment loss. Hence, the present study confirmed smoking as a major risk factor for periodontal disease as found in previous studies [41–43] and highlighted the advantage of smoking cessation in improving the oral health and quality of life of HIV-positive patients [44–46].
It is generally accepted that good oral hygiene is essential in maintaining a disease-free mouth. The present study included patients who had not received dental treatment 3 months prior to the study, thus increasing their chances of developing periodontal disease. When the periodontal clinical indices were related to the oral hygiene practices, the frequency of brushing was found to be significantly associated with plaque index (p = 0.0352) but not with the other periodontal indices. However, the use of interdental aids showed significant associations with all of the periodontal indices except the probing depth. These results clearly suggest that although increased frequency of brushing may have reduced the initial plaque accumulation, the additional use of interdental aids provided better plaque control and improved gingival health. Moreover, only 10.83% of the individuals managed regular dental visits. This may be due to a host of factors including a general lack of interest for maintaining better oral hygiene, lack of access to medical and dental care or other factors beyond their control.
A significant association was established between HIV stage and brushing frequency (p = 0.0190) as well as the use of interdental aids (p = 0.0170). These results reveal that the clinical signs and symptoms of gingival and periodontal disease with reduced CD4 + T cell counts remain a significant complication of HIV infection.
In selecting the study group, no consideration was given to whether patients were on antiretroviral therapy or not, since no consistency of the effect of ART on periodontal disease progression has ever been demonstrated . Because different stages of HIV were being compared, it was considered outside of the scope of this study to include a healthy HIV-negative control group. A direct comparison of this to other studies was complicated by the lack of data reported, including the use and duration of antiretroviral therapy and adjunctive antimicrobials, the broad reference in the literature to HIV- positive subjects without referring to their HIV stage, and the lack of mention of confounding factors such as age, smoking, oral hygiene and other risk factors for periodontal diseases.