Oral Complications of HIV Infection

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Hairy leukoplakia is the most common oral lesion (20.4%) in HIV-infected patients. Candidiasis is the next most common lesion (5.8%).


Oral candidiasis (thrush) often precedes the development of AIDS in HIV-seropositive individuals. The most common form of oral candidiasis is pseudomembranous candidiasis, which appears as white plaques on any oral mucosal surface and may be as small as 1 to 2 mm or widespread. Lesions can be wiped off, leaving an erythematous or bleeding mucosal surface.

The erythematous form of candidiasis appears as smooth red patches on the hard or soft palate, buccal mucosa, or dorsal tongue. Angular cheilitis, due to Candida infection, produces erythema, cracks, and fissures at the corner of the mouth.

Diagnosis of oral candidiasis is by potassium hydroxide preparation of a smear from the lesion.

Oral candidiasis in patients with HIV infection usually responds to topical antifungal agents, including nystatin vaginal tablets (100,000 units tid, dissolved slowly in the mouth); nystatin oral pastilles (one 200,000 unit pastille five times daily).

Ketoconazole ( Nizoral), 200 mg PO once daily, is a systemic antifungal agent that can also be used. Fluconazole ( Diflucan) is a highly effective treatment for oral candidiasis, although resistance has been reported. Two 100-mg tablets are used on the first day, followed by one 100-mg tablet daily for 1 to 2 weeks.

Angular cheilitis usually responds to topical nystatin-triamcinolone ( Mycolog II), clotrimazole ( Mycelex), or ketoconazole ( Nizoral) cream.

Gingivitis and periodontitis

Gingivitis and periodontal disease are often seen in HIV infection, appearing as gingival erythema. Necrotizing ulcerative periodontitis occurs in 30% to 50% of AIDS patients.

Treatment involves débridement and curettage, followed by application of a topical antiseptic (povidone-iodine [Betadine]) irrigation, followed with chlorhexidine ( Peridex) mouthwashes, and a 4- to 5-day course of metronidazole ( Flagyl) 250 mg qid or Augmentin 250 mg (1 tab tid).

Herpes simplex

Oral herpes lesions are a common feature of HIV infection, occurring as recurrent intraoral lesions with crops of small, painful vesicles that ulcerate. Lesions commonly appear on the palate or gingiva.

HSV can be identified using monoclonal antibodies and immunofluorescence. Treatment consists of oral acyclovir (one 200-mg capsule taken five times a day). Foscarnet is used for lesions that are resistant to acyclovir.

Hairy leukoplakia

Hairy leukoplakia may affect the buccal mucosa, soft palate, and floor of the mouth. It appears in all risk groups for AIDS, appearing as a white thickening of the oral mucosa, often with vertical folds or corrugations. The lesions range in size from a few millimeters to involvement of the entire dorsal surface of the tongue. Hairy leukoplakia is probably caused by a reactivation of the Epstein-Barr virus.

The lesions will respond to high doses to acyclovir ( Zovirax) 800 mg orally 5 times daily for 5 days. Valacyclovir ( Valtrex) (1000 mg) or famciclovir (500 mg), given three times daily, is highly effective. For milder cases, topical applications of Retin-A or podophyllin may be helpful.

Kaposi’s sarcoma

Kaposi’s sarcoma may cause oral lesions in patients with AIDS, appearing as red or purple macules, papules, or nodules. Frequently they are asymptomatic; however, pain may result from traumatic ulceration, inflammation, or infection. Bulky lesions may interfere with speech and mastication. Diagnosis involves biopsy.

Treatment consists of surgical excision, local radiation, chemotherapy, or local injection of vinblastine.

Recurrent aphthous ulcers

Recurrent aphthous ulcers are more common among HIV-positive individuals, appearing as recurrent crops of small (1-2 mm) to large (1 cm) ulcers on the oral and oropharyngeal mucosa.

Treatment consists of fluocinonide ( Lidex), 0.05% ointment, mixed with equal parts of Orabase applied to the lesion up to six times daily, or clobetasol ( Temovate), 0.05%, mixed with equal parts of Orabase applied three times daily.

Dexamethasone (Decadron) elixir, 0.5 mg/mL used as a rinse and expectorated, is also helpful. Thalidomide is useful in the management of steroid-resistant ulcers.

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