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Oral Signs of HIV Infection
Oral lesions are significant features of HIV and AIDS infections and, in fact, are often the first physical manifestation of the disease. As clinicians, it is our responsibility to be able to recognize and identify those lesions associated with HIV infection. The presence or absence of certain lesions can often act as predictors to the overall progression of the disease in a diagnosed patient. However, it is important to note that the presence of oral lesions alone should not be used to diagnose HIV but should prompt the clinician to encourage further testing.
Fungal Infections
The most common oral lesion associated with HIV infection is candidiasis, predominately attributed to Candida albicans. Candida is a normal oral flora found in almost 50% of the mouths in healthy adults. However, in an immunocompromised patient, it is able to thrive and becomes readily apparent upon examination. Oral candidiasis can be found in over a quarter of patients with HIV disease and over 90% of patients with AIDS. Clinically, it can have one of four different appearances: erythematous or atrophic candidiasis, pseudomembranous candidiasis, hyperplastic or chronic candidiasis, and angular cheilitis. In the case of pseudomembranous candidiasis, the infection is superficial and can be removed by scraping with a wooden tongue blade. Treatment with oral nystatin suspension, clotrimazole troches, or a 0.12% chlorhexidine gluconate mouth rinse is generally effective. Treatment will differ depending on how the candida presents itself in the mouth. Some forms are more invasive and require systemic treatment. Table 1 gives the complete treatment protocol. Recurrences are common and ultimately may require treatment with ketoconazole and fluconazole.
Pseudomembranous candidiasis
Pseudomembranous candidiasis
Hyperplastic candidiasis
Drug
|
Route
|
Indication
|
Dose
|
| nystatin suspension |
topical |
erythematous and pseudomembranous |
500,000 U/5 cc, 1 tsp rinse and swallow 4x/day |
| clotrimazole troche |
topical |
erythematous and pseudomembranous |
10 mg troche, 1 troche 5x/day |
| chlorhexidine 0.12% |
topical |
erythematous and pseudomembranous |
1 tsp rinse and spit 3x/day |
| ketoconazole and fluconazole |
systemic, oral |
all types |
100 - 200 mg tab, 2 stat, 1 tab/day |
| ketoconazole 2% cream |
topical |
angular cheilitis |
apply 4xday |
Treatment protocol for fungal infections in HIV patients
Viral Infections
Many of the viral infections found in the oral cavity of HIV infected individuals develop early in the illness and, if left untreated, can persist for the duration of the illness. Herpesvirus causes most of the viral infections in these patients with the main culprits being herpes simplex (HSV) and Epstein-Barr (EBV) viral infections. Less common viral infections in the oral cavity include cytomegalovirus(CMV), human papilloma virus(HPV) and varicella-zoster virus (VZV).
Herpes simplex virus appears intraorally as multiple, small ulcerations that form in a cluster. These lesions may be painful in the early stages but should resolve within 10 days in an otherwise healthy patient. In HIV infected patients, these lesions may take upwards of 1 month to resolve. Likewise, in HIV infected individuals, the lesions are often found in poorly keratinized areas of the oral cavity such as buccal and labial mucosa. These sites are rarely infected in healthy individuals. Most cases are treated with 2g/day systemic acyclovir.
Herpes labialis (early stage inf.)
Herpes labialis (late stage inf.)
Epstein-Barr viral infections produce a lesion known as Oral Hairy Leukoplakia. This lesion was once thought to be pathognomonic for HIV infection but that belief has recently been reassessed after OHL lesions were found in patients with other immunosuppressive diseases. These lesions appear as a white, corrugated, non-wipable patch that typically appears on the lateral border of the tongue. Candida infections may be superimposed over the OHL making it painful for the patient and difficult to diagnose. Otherwise, the lesion is asymptomatic and requires no treatment other than for the sake of cosmetics.
Human papilloma virus, also known as an oral wart, forms a hyperplastic connective tissue lesion. More than 50 strains of HPV exist. The treatment of choice is surgical excision.
Papilloma
Cytomegalovirus, or CMV, causes a singular, deep ulceration most often involving the buccal mucosa. This lesion is clinically indistinguishable from other ulcer-like lesions. However, it is important to recognize the possibility that a lesion of this type is caused by CMV due to the serious nature of its sequelae. These include retinitis and meningitis, which are seen in a vast majority of postmortem AIDS patients. CMV has increased pathogenicity in immunosuppressed people and, similar to other herpes viruses, has immunosuppressive characteristics. In order to make a definitive diagnosis, a biopsy and histological exam are required.
Bacterial Infections
Necrotizing ulcerative periodontitis (NUP) is a very aggressive form of gum disease characterized by rapid destruction of the bone, generalized bone pain, spontaneous bleeding and overall significant attachment loss. This condition has been linked to microorganisms frequently associated with periodontal disease such as the Treponema and Selenomonas species, Fuscobacterium nucleatum, Prevotella intermedia, and Porphyromonas gingivalis. The aggressive nature of this disease is attributed to the immunosuppressed state of the patient, which is why it is commonly seen in individuals with AIDS. In fact, 95% of patients with NUP have a CD4 lymphocyte count of less than 200/mm3. Typical treatment consists of perio debridement with adjunctive antibiotic therapy and twice daily chlorhexidine gluconate 0.12% rinses.
Neoplasms
Kaposi sarcoma is the most common neoplasm in AIDS infected individuals. It is characterized by a flat, plaque phase that progresses into a multicolored, raised tumor. The most common intraoral site is the palate (both soft and hard) but the lesion has also been seen on the facial gingiva. Lesions may also occur outside of the mouth, generally on the skin of the lower extremities. KS is far more common in homosexual and bisexual AIDS patients due to the presence of a certain type of human herpes virus (HHV8). This virus is thought to be an important cofactor in the incidence of KS. Diagnosis of KS requires a histologic examination and currently there is no cure.
KS (early stage lesion)
KS (late stage lesion)
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