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19. ORAL MANIFESTATIONS

Oral lesions are among the earliest clinical indicators of HIV infection in both
adults and children. Lesions are usually quite typical and a diagnosis may be
made from their characteristic clinical appearance. Table 19.1 lists the
lesions more commonly encountered in adults and children with HIV
infection.
Table 19.1 Oral lesions that occur more frequently in adults and children with
HIV infection
Candidiasis - including pseudomembranous, erythematous or hyperplastic
candidiasis or angular cheilitis
Hairy leukoplakia
Herpes simplex virus infection
Herpes zoster virus infection
Molluscum contagiosum
Kaposis sarcoma
Gingival and periodontal lesions - including linear gingival erythema,
necrotising ulcerative gingivitis, necrotising ulcerative periodontitis, necrotising
stomatitis
Salivary gland disease including parotid gland enlargement and
lymphoepithelial cysts
Dental caries
Submandibular, submental and cervical lymphadenopathy
Cancrum oris
Non-Hodgkins lymphoma

19.1 Candidiasis
Candidiasis is strongly associated with immunosuppression. The clinical
presentation varies considerably:

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Pseudomembranous candidiasis
This is commonly known as thrush. Lesions may be located anywhere in the
oral cavity including the palate, dorsum of tongue and cheek buccal mucosa.
Lesions are creamy white or yellow loosely adherent plaques that are
removable and can be wiped off leaving a reddened or occasionally bleeding
surface. The condition may persist for months.
Erythematous candidiasis
This form appears as red areas and patches or spots that are not removable
or as white spots or plaques that are adherent to the dorsum of tongue.
Lesions can be interspersed with pseudomembranous candidiasis.
Angular cheilitis
This conditions appears as fissures and reddening at the angles of the
mouth. It is often associated with itching and burning. Often there is bleeding
from the angles of the mouth and crusting in this area.
Hyperplastic candidiasis
This appears as raised, firm, adherent and unscrapable white plaques on
the buccal mucosa that appears thick red.
19.1.2 Management
The following treatment is recommended for oral candidiasis:
Treatment of oral
candidiasis
Drug
Nystatin oral
suspension
Nystatin lozenges

Codes
B E
B E

Adult dose
200000
units
OR
200000
units

Route
PO

Frequency
Five times
a day

Duration
14 days

Sucked

Five times
a day

14 days

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In severe cases or if the above treatment fails the following regimens may
be used:
Alternate treatment of oral
candidiasis
Drug
Miconazole oral gel 2%

Codes
B N

Ketoconazole

B E

Amphotericin B lozenges

A N

Fluconazole

B N

Itraconazole

S N

Adult dose
OR
200mg
OR
10mg
OR
100mg
OR
200mg

Route
Applied to
mouth

Frequency
BID

Duration
10 days

PO

OD

7 days

Sucked

QID

10 days

PO

OD

7 days

PO

OD

7 days

19.2 Kaposis sarcoma

Lesions of Kaposis sarcoma in the mouth appear as red, blue or purplish
flat or raised, solitary or multiple plaques or nodules and may be found
anywhere on the buccal mucosa. Common lesions are seen on the palate,
gingiva, tongue and buccal mucosa.
19.2.1 Management
Treatment needs to be individualized and will depend on the number, size
and location of lesions. Good oral hygiene should be practiced by the patient
and radiotherapy, cytotoxic chemotherapy and surgical excision may be
necessary. See CANCER CHAPTER
19.3 Oral ulceration
Oral ulcers are commonly encountered in persons with HIV infection. There
are a number of different causes of such ulcers. Ulcers may vary in size
from 1mm to more than 2cm in diameter. Usually oral ulcers are painful and
if extensive may affect chewing and deglutition. The ulcers are similar to

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apthous ulcers and usually have a red base that is covered in purulent
material.
19.3.1 Management
The following principles should be followed when managing oral ulcers in
persons with HIV infection:
Pain reduction through appropriate use of analgesics

Reduction of ulcer duration

Increasing disease-free intervals

Performing a biopsy to exclude malignancy in large suspicious ulcers

Patients with oral ulcers should be treated as follows

0,2 % chlorhexidine digluconate mouth rinse 2-4 times daily, and

1% topical povidone iodine applications, and

Topical applications of triamcinolone acetonide in orabase 00.1% 8

hourly, and

Topical antibiotic application as mouthwash using doxcycline 100mg

three times daily for 3 days

19.4 Periodontal (gum) diseases

Gum disease occurs commonly in persons who do not practice good oral
hygiene. Many different forms of gum disease have been reported in
persons with HIV infection. These are described below:
19.4.1 Necrotizing ulcerative gingivitis
This is usually of sudden onset when the patient notices spontaneous
bleeding from the gums. The gingival tissue becomes red, inflamed and
oedematous. There is rapid loss of soft tissue and ulcers appear at the tips
of the interdental papilla and gingival margins. The condition is associated
with severe pain. Ulcers heal with crater formation.

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Management

Oral hygiene is necessary with tooth brushing, flossing and rinsing

with 0.2% chlorhexidine gluconate 2-4 times daily, Plus

Scaling and local debridement, Plus

Topical 1% povidine-iodine irrigation

Mobile teeth may need to be splinted or extracted

19.4.2 Necrotizing ulcerative periodontitis (NUP)

There is rapid loss of supporting bone and soft tissue in isolated areas with
loosening and loss of teeth and there is severe pain and spontaneous
bleeding with sequestration of bone and halitosis.
Management

Oral hygiene (as above), Plus

Plaque removal, Plus

Local debridement, Plus

Irrigation with povidone iodine, Plus

Scaling and polishing, Plus

Metronidazole 200mg three times daily for 5 days, Plus

Amoxycillin 500mg three times daily for 5 days

19.4.3 Necrotizing Stomatitis

This condition extends from the gingival and involves the buccal mucosa.
Management

Oral hygiene, Plus

Local debridement, Plus

Removal of tooth and sequestra, Plus

Metronidazole 200mg three times daily for 5 days, Plus

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Amoxycillin 500mg three times daily for 5 days

19.4.4 Linear gingival erythema

This appears as a fiery red gingival line 2-3mm broad along the teeth
margins and is often associated with petechiae-like lesions and diffuse red
lesions on the attached gingiva or oral mucosa. Plaque may be present
Management

Oral hygiene is necessary with tooth brushing, flossing and rinsing

with 0.2% chlorhexidine gluconate 2-4 times daily.

19.4.5 Cancrum Oris

This is an extension of necrotizing stomatitis and is associated with necrosis
and sequestration of bone. Teeth become loose and may exfoliate. There is
usually loss of soft tissue and bone.
Management

Oral hygiene, Plus

Debridement, Plus

Sequestrectomy, Plus

Metronidazole 200mg three times daily for 5 days, Plus

Amoxycillin 500mg three times daily for 5 days, Plus

Fluid and electrolyte replacement, Plus

Improvement of general nutrition, Plus

Surgical reconstruction later

19.5 Non-Hodgkins lymphoma

This may occur anywhere in the oral cavity. The condition presents as firm,
painless swelling son the mucous membrane of the mouth. Lesions may be
ulcerated or fungating and there may be bone destruction.

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Management

A biopsy should be performed to confirm the diagnosis and surgical

remove should be carried out. Patients with lymphoma will require
chemotherapy or radiotherapy.

19.6 Salivary gland disease

19.6.1 Parotid gland enlargement
Painless, diffuse soft swelling of one or both parotid glands is a fairly
common manifestation of HIV infection especially in children. Patients
usually complain of noticing swelling of the face and a feeling of dry mouth.
Management

For dry mouth give: salivary substitutes, moisturizing or lubricating

solutions or artificial saliva. Glycerin may be useful in alleviating
symptoms. Stimulation of salivary flow with sugarless chewing gum
may also be useful.

Topical fluoride applications to teeth should be practiced daily to

prevent tooth decay.

Thorough oral hygiene and dietary control should be practiced to

avoid caries

If there is parotitis appropriate antibiotics and analgesics may be

used.

19.6.2 Lymphoepithelial cyst

This appears as a painless swelling in the parotid gland or submandibular
gland area. It comprises of an accumulation of cysts and is unsightly.
Management

Surgical excision for cosmetic purposes.

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19.7 Caries
There is multiple decay on tooth surfaces and necks of teeth
Management

Thorough oral hygiene is necessary: tooth brushing with a

toothpaste with fluoride, flossing of teeth and use of topical
varnish, gels or rinses.

Dietary control is essential - Limit sugar and sugary foods. Note

that due to high sugar content of some medications, topical fluoride
gels or rinses should be used daily, if frequently prescribed.

Regular dental check-ups are essential to maintain healthy teeth and

gums.

19.8 Hairy leukoplakia

Oral hairy leukoplakia occurs in HIV-infected patients as well as in some
immunosuppressed transplant recipients. It presents as raised, white,
corrugated lesions of the oral mucosa, especially on the lateral aspect of the
tongue. It is a non-malignant lesion of epithelial cells. It is commonly
mistaken for oral candidiasis with which it is commonly found.
Management

No specific treatment is available for the condition.

Good oral hygiene

Anti-retroviral therapy may clear the lesion

19.8 Herpes zoster

The herpes virus, varicella zoster, often causes disseminated infection after
initial exposure. In children initial infection results in the development of
chicken pox, though most persons that become infected develop no
symptoms and signs of infection. Skin and oral lesions may occur. On the
face, zoster lesions are unilateral and follow the distribution of the maxillary
mandibular branches of the trigeminal nerve.

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Management

Acyclovir 800 mg oral 5 times daily to 14days; or

Valacyclovir 1000 mg oral 8 hourly for 7 days; or

Famciclovir 250 mg 8 hourly for 7 days

Post-herpetic neuralgia is a common and serious debilitating

problem. It causes severe pain in a dermatomal distribution usually
at the site of the lesions. Pain control is often necessary and be
achieved with mild analgesics such as paracetamol. If pain control is
not achieved with this then non-steroidal anti-inflammatory drugs
may be used or failing this amitryptiline, cabamazepine or phenytoin
may be tried.

19.9 Herpes simplex

Lesions of herpes simplex may be found on gums, hard palate and lips.
Lesions appear as vesicles that rupture to produce painful irregular ulcers.
Often the patient has fever and malaise. Oral lesions are often associated
with cervical lymphadenitis.
Management

Usually no specific treatment is necessary. If lesions are extensive,

recurrent and persistent antiviral therapy should be commenced.
Antibiotics may be necessary if there is secondary bacterial
infection.

Patient should be rehydrated if dehydrated and advised on good

nutrition.

The patient may need analgesics and the application of 2% viscous

lidocaine gel every 3-4 hours is useful.