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Oral infections related to HIV/AIDS

Viral Infections

Mouth conditions caused by viruses can be painful and are rarely entirely eliminated from a person's body. There are, however, effective treatments that can treat current and suppress future outbreaks.

Herpes simplex

Herpes simplex virus (HSV) Type 1, which causes blisters on the lips, is fairly common in the general population and even more so in people living with HIV. In addition to sores on the lips, herpes type 1 can appear inside the mouth, as "bubbles" on the gums and in the mouth, particularly in firmer tissue, like the roof of the mouth. Herpes sometimes appears on the back or sides of the tongue or cheeks. Herpes sores can be accompanied by fever, pain and loss of appetite. They can either be small and almost painless or they can be troublesome, extensive and persistent. Often, they're left untreated because they clear up after a relatively short period of time. Sores slow to heal can be treated with 1,000-1,600mg acyclovir (Zovirax) daily for seven to ten days. Rinsing with hydrogen peroxide mouthwashes can also help.

Herpes zoster

Herpes zoster (Vericella Zoster Virus, VZV) is a reactivation of the same virus that causes chicken pox. Outbreaks produce sores on the skin or in the mouth. The sores begin as "bubbles" and then rupture and crust over. Oral lesions also begin as "bubbles," but they later rupture to form ulcers, or open sores. Treatment should be started as soon as possible and involves using 500mg oral famciclovir (Famvir) every eight hours for seven days or 800mg oral acyclovir five times a day for 7-10 days.

Hairy leukoplakia

Oral hairy leukoplakia (OHL), believed to be caused by the same virus that causes mononucleosis (mono), called Epstein Barr virus (EBV), is one of the most common HIV-related oral conditions. It's not dangerous and can occur very early in HIV disease. It may, however, indicate an increasing risk of other, more serious illnesses.

Symptoms of OHL include white patches on the sides of the tongue or walls of the mouth. They look corrugated, or folded, with hair-like particles along the folds. OHL is rarely (if ever) painful and while annoying (people do complain about its appearance and texture), it's not serious or life-threatening. OHL can be easily confused with other conditions, so a biopsy may be necessary to definitively diagnose it.

Hairy leukoplakia can be treated with 2.5-3mg acyclovir once a day for 2-3 weeks. It has also been reported that ganciclovir (Cytovene), tretinoin (Retin-A), and podophyllin (Podocon-25) can be effective. For those interested in alternative therapies, propolis tincture (a product of bees) has shown some favorable results when applied directly to the lesions. Unfortunately, all these treatments must be taken continuously because lesions return if treatment is stopped. There's some evidence that acyclovir may suppress breakouts, but other evidence suggest that it's ineffective in treating this condition.

Cytomegalovirus (CMV)

Cytomegalovirus (CMV) mostly occurs in people with late stage disease, and only very rarely does it manifest in the mouth. Some dentists, however, report that they find CMV in ulcers on the inner lining of the mouth in people with CMV disease. These sores can be widespread and have been seen on the gums, cheeks and roof of the mouth. Since oral CMV ulcers can look like other ulcers, a biopsy may be necessary to identify CMV of the mouth. When ganciclovir (in the vein, followed by oral drug) is used to treat CMV disease, the oral ulcers recede.

Human papillomavirus (HPV)

Human papillomavirus (HPV) is the same virus that causes genital and anal warts. In people living with HIV, HPV lesions can begin to appear on the skin and inner lining of the mouth. In the mouth, they look like typical warts: cauliflower-like, "spiky," orslightly raised with a flat surface. It's not currently thought that oral warts can become cancerous. Surgical or laser removal is the most effective way to treat them. However, recurrence is common, so removal should probably be reserved for lesions that interfere with overall appearance or normal activities like chewing, swallowing or talking.

Fungal infections

Oral Candidiasis

Also known as thrush, oral candidiasis is perhaps the most common oral conditions in people with HIV. A healthy immune system can suppress the overgrowth of this fungus, but even a mildly compromised immune system may not keep the fungus in check. Most outbreaks occur when the CD4+ cell count falls below 400. But other factors may cause candidiasis, such as prolonged stress, depression, and use of antibiotics.

A trained dental professional can identify and distinguish the most common types of candidiasis that effect people with HIV. Symptoms may include red patches, white patches and clefts or grooves. They may or may not cause minor pain. For more information, read Project Inform's Oral Candidiasis.

Oral candidiasis may be treated with antifungal medication delivered systemically (throughout the body) or applied directly to lesions. In mild cases, it's treated directly for at least two weeks. Typical medications include clotrimazole (Mycelex) troches, oral amphotericin B (Fungizone Oral Suspension), and nystatin (Nilstat). Nystatin contains a lot of sugar, so if you use it, rinse afterwards with a fluoride (alcohol-free) mouthwash to remove the sugar. Excess sugar can help fungus and bacteria to grow.

More severe forms of candidiasis, such as esophageal candidiasis, may require systemic drugs, including ketoconazole, itraconazole, and fluconazole (Diflucan), with treatment usually lasting two weeks or longer, as necessary. All of these drugs have interactions with commonly used anti-HIV drugs, particularly protease inhibitors. Dietary and nutritional changes may also help.

In all cases, the full course of therapy should be completed even when obvious symptoms disappear beforehand. This will help prevent recurrences, though not 100% of the time. If outbreaks reoccur, ongoing preventative therapy may be useful.

Treatment may be started even before the first outbreak (preventive therapy, also called prophylaxis), but there's some controversy over its effectiveness. The main concern is that the fungus may grow resistant to drugs used for preventive therapy, making these drugs ineffective if or when treatment is required. For more information on treating and preventing candidiasis, call Project Inform's hotline at 1-800-822-7422, or visit our Web site, for more written materials.

Histoplasmosis

Histoplasmosis is a fungus prevalent in the United States particularly in the valleys of the Mississippi, Tennessee, Missouri, Ohio, and St. Lawrence rivers. Most infections are either unnoticeable or cause mild problems, so the diagnosis can be difficult. Symptoms include cough, fever and general fatigue. Sometimes histoplasmosis can be accompanied by mouth sores. People with very compromised immune systems are more likely to get this disease. There's no specific treatment for just the mouth sores; histoplasmosis is treated as a general infection. HIV-positive people with this condition require lifelong treatment with low doses of itraconazole because of the extraordinarily high rate of reoccurrence.

Concerns for HIV positive people considering or who currently have dentures

People who have already experienced extensive tooth loss from gum disease are encouraged to consider dentures, partials or "bridges." A healthy diet is important inmaintaining good general health. And since unwanted weight loss (wasting syndrome) and malnutrition is a fairly common and serious problem for people with HIV, anything that interferes with eating should be addressed. Therefore, dentures and bridges can be very important for people unable to eat properly. Also, dentures may help restore speech, appearance and self-esteem that may be affected because of tooth loss.

For those considering or currently using dentures, the following are things to consider:

  • Optimally, dentures should be easy to insert and remove and comfortable enough to wear regularly.
  • They should be designed to not interfere with other oral conditions such that they avoid contact with painful sores.
  • Dentures or partials aren't a substitute for good oral health. You still need to take care of your mouth even if you've lost some teeth!
  • Dentures and partials need to be cleaned as thoroughly and as often as natural teeth.
  • Consult you dentist about any special needs or problems you have or are concerned about with regard to dentures or partials.
Other oral conditions of HIV disease

The two most common conditions that may not be caused by an infection include dry mouth and small round mouth sores (called aphthous ulcers).

Dry mouth (Xerostomia)

Dry mouth, or xerostomia, is a common condition in HIV disease that may have a variety of causes. HIV disease itself may cause dry mouth because HIV-relatedsalivary disease causes swollen salivary glands (glands in the mouth that produce saliva, or spit). That, in turn, reduces the amount of saliva in the mouth. A dry mouth is also a side effect of some anti-HIV drugs and other medications like antihistamines and antidepressants. Allergies and infections may also cause dry mouth.

Though it may not seem serious, leaving dry mouth untreated may lead to problems. Without enough saliva, food can build up in the mouth, between the teeth and gums and promote tooth decay, periodontal disease and candidiasis. Furthermore, a lower flow of saliva can cause high acid levels to persist long after eating, which can wear out the enamel on the teeth leaving them more susceptible to cavities and other problems.

Fortunately, dry mouth is fairly simple to overcome and treat. One easy way is to chew sugarless gum, which stimulates more saliva. Sucking on sugarless candy, crushed ice or lozenges can produce similar effects. Drinking plenty of liquids at or between meals is a great idea, as is rinsing your mouth often with warm salt water or mouthwash (preferable alcohol-free mouthwash). Avoid sugar since it can make your mouth even drier and encourage the growth of fungus.

Some prescription drugs may help alleviate dry mouth. In particular, artificial saliva is available and some people may benefit from pilocarpine therapy designed to stimulate the salivary glands. Herbs like demulcents, chickenweed and slippery elm may also help combat dry mouth, though it's unclear if these herbs have herb-drug interactions with commonly used anti-HIV therapies.

Aphthous ulcers

Aphthous means "little round," thus aphthous ulcers are little round sores in the mouth. They tend to form on "soft" tissue in the mouth, like the inside of the cheeks, on the sides of the tongue or into the throat. These ulcers can develop in HIV-negative people, but people living with HIV may experience more severe and prolonged ulcers. They may be a side effect of certain anti-HIV therapies, though even people not taking anti-HIV medications may experience them.

The sores are usually very painful when touched or when food or liquids pass over them. They can even be so severe that a person will be tempted to avoid eating or drinking altogether. A typical ulcer has a red halo and is covered by a grayish layer or membrane. They're generally mistaken for herpes sores, and the exact cause of them is still not known.

Treatment can involve using steroids applied directly on the ulcers, though there is not a great success rate of treatment. A mixture of fluocinonide (Lidex) and Orobase, one of clobetasol (Cormax, Temovate) and Orobase, or a dexamethasone (Decadron) elixir is effective. An experimental therapy, thalidomide, has shown to be very effective in treating aphthous ulcers in studies, though it is not without side effects. Side effects may include fatigue, pain and tingling in the hands and feet (called peripheral neuropathy) and rarely, low neutrophil counts (called neutropenia). Note: thalidomide should NOT be used by pregnant women or women who are planning to become pregnant while using the therapy. It can cause serious birth defects if used even once during the first trimester of pregnancy. Sometimes aphthous ulcers resolve without any treatment.

Commentary

A February 1999 study discovered an overall decline in the incidence of the most common oral lesions in people living with HIV. But it also showed an increase in the number of cases of oral warts and linked this increase to protease inhibitor use. Another study has shown that people using anti-HIV therapy and optimal prevention for infections were less likely to get candidiasis in their throat, suggesting that stopping the destruction of the immune system by HIV can enhance the body's ability to control this fungal infection.

Planning a course of action for dental care and treatment is important for people living with HIV. Your dentist is a partner in developing this plan, there to provide you withinformation about your options, potential risks and benefits, as well make recommendations. Optimally, any course of treatment should be made together, with you, your doctor and your dentist working in partnership

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