Oral Lesions in HIV Disease

Oral features of HIV / AIDS reflect the T-cell immune defect and are, thus, mainly the consequence of fungal or viral infections. The most common are candidiasis (candidosis) and hairy leukoplakia. Necrotizing gingivitis, accelerated periodontitis, Kaposi sarcoma, lymphomas, salivary gland disease, ulcers of various infective causes and other lesions may be seen.

Oral lesions may indicate HIV infection that is previously undiagnosed, be used in staging and therapy decisions, or cause the individual pain or esthetic problems.

HIV-related oral candidiasis

Oral candidiasis is the most common opportunistic infection in HIV-infected persons, often the initial manifestation of HIV symptoms, seen at some point in at least 90% of HIV-infected persons, seen in all groups at risk, especially HIV-infected intravenous drug users. Oral levels of C. albicans and other yeasts are increased in HIV infection, and infection is common.

Oral candidiasis is related to the immune defect, dry mouth and other salivary changes in HIV infection, smoking and prolonged antimicrobial use.

Clinical features of HIV-related oral candidiasis

Thrush (pseudo membraneous candidiasis) is one of the most obvious oral lesions in HIV infection and tends to be associated with lower CD4 counts. Other types of candidiasis may also be seen, especially:

  • Erythematous (this form of candidiasis may be a common early oral manifestation of HIV infection and presents as pink or red macular or patchy lesions, typically on the palate and back of tongue and often mixed with white lesions),

  • angular stomatitis (cheilitis),

  • median rhomboid glossitis,

  • hyperplastic candidiasis

Management of HIV-related oral candidiasis

  • Early treatment of oral candidiasis in HIV disease is warranted, not only because of the discomfort, but also because foci may act as reservoirs for spread, particularly to the esophagus.

  • Predisposing factors, such as smoking and dry mouth should be controlled first.

  • Antiretroviral and protease inhibitor treatment of HIV infection may aid resolution

  • Antifungals, topical therapy of candidiasis is often successful initially within about 14 days but relapses are common and these agents are not always accepted by children.

  • Antifungal prophylaxis should be considered

Hairy leukoplakia

Hairy leukoplakia is a common corrugated (or hairy) white lesion usually seen on the tongue mainly in HIV / AIDS and other immunocompromising states. Hairy leukoplakia may be associated with EBV, typically affects the lateral margins of the tongue, produces a white lesion that is not removed by wiping with a gauze. This lesion is not known to be pre-malignant or cancerous, but is a predictor of bad prognosis, and may be associated with lymphoma elsewhere.

Management of hairy leukoplakia

Treatment is not often required, but the condition often resolves with acyclovir or other agents active against EBV, or with antiretroviral agents.

Kaposi sarcoma

Kaposi sarcoma has been called ‘gay cancer’ by some since it is transmitted sexually and seen rarely in HIV-infected children or hemophiliacs. The lesion is caused by virus HHV-8, which is transmitted sexually, often as a co-infection with HIV. Like all herpesviruses, HHV-8 is a DNA virus, which is seen commonly where hygiene is poor and remains latent after infection. The virus is found in saliva.

Clinical features of Kaposi sarcoma

Presents initially as symptomless red, blue or purple macules (patches), progresses to papules (small skin elevations), nodules or ulcers and may become painful. The lesion often involves the skin or mucosa in the head and neck, is most common around the face (especially on the nose) and mouth, and occur especially at the hard/soft palate junction of the front upper gums.

Management of oral Kaposi sarcoma

Management of oral Kaposi sarcoma is often with intralesional injections of vinblastine, or systemic chemotherapy. Kaposi sarcoma responds badly to irradiation.


Lymphomas are seen increasingly in AIDS and are often non-Hodgkin’s lymphomas, and are part of a widespread disease. This lesion is seen as a lump or ulcer in the upper gums/ fauces, associated with EBV, and is fairly resistant to therapy.

Management of lymphoma is with chemotherapy.

Gum and periodontal disease

Necrotizing ulcerative gingivitis and periodontitis can be features of HIV infection, and typically these occur disproportionately to the level of oral hygiene and plaque control. The lesions are painful, localized, and can cause rapid alveolar bone loss.

Management of gum and periodontal disease

Management is with improved oral hygiene, removal of dead tissues, chlorhexidine and sometimes with antibiotic metronidazole.

Mouth ulcers

Mouth ulcers may appear in HIV disease but are of course, common lesions in many non-HIV-infected persons. Ulcers may be unrelated to the HIV infection or may be related to:

  • aphthous-type ulcers, especially the major type,

  • tumors, such as Kaposi sarcoma or lymphoma,

  • opportunistic pathogens, such as the herpesviruses, fungi or mycobacteria,

  • drug use.

They may be part of a widespread disease such as disseminated lymphoma.

Management of mouth ulcers

Management depends on the cause, but chlorhexidine and topical analgesics can be helpful. Antimicrobials or other specific therapies are often indicated to control the lesions, depending on the cause.

Other orofacial lesions

A wide spectrum of other orofacial lesions can be seen in HIV / AIDS, including the following:

  • Cervical lymph node enlargement, as part of persistent generalized lymph node enlargement

  • Chronic sinusitis, which may be related to bacterial or increasing fungal pathogens

  • Parotitis (infection of the parotid gland), chronic oral candidiasis, herpetic stomatitis and dry mouth seen particularly in HIV-infected children

  • Herpes simplex virus (HSV) infections – chronic ulcers anywhere but often on tongue, hard palate or gums.

  • Human papilloma virus (HPV) infections, in particular genital warts in or around the mouth, increased by HAART

  • Salivary gland disease

  • Cranial neuropathies, such as facial palsy, pain or sensory loss