Introduction:
Oral lesions are often noticed clearly, and several conditions can be diagnosed accurately based on oral manifestations. In cases where HIV (human immunodeficiency virus) status is unknown, and HIV testing is complex, specific oral lesions strongly indicate HIV infection. The oral lesions associated with HIV are important, as they affect the patient's quality of life and are also useful markers of disease progression and immunosuppression. Oral lesions are often advocated and used as entry criteria for prophylaxis therapy and vaccine trials.
What Are the Oral Lesions Associated With HIV?
The oral lesions that are strongly associated with HIV are:
-
Periodontal lesions.
-
Herpes simplex virus infection.
-
Kaposi sarcoma.
-
Oral hairy leukoplakia.
-
Oral squamous cell carcinoma.
-
Molluscum contagiosum.
-
Thrombocytopenic purpura.
1) Oral Candidiasis:
It is the most common intraoral opportunistic fungal infection strongly associated with HIV infection. It has been reported that oral or esophageal candidiasis in HIV-infected patients may indicate an advanced stage of AIDS. The four clinical patterns of oral candidiasis seen are as follows:
-
Pseudomembranous Candidiasis - It clinically appears as white to yellowish-white plaques. These lesions can be easily scraped off, exposing red areas. The lesions cover a large area of more than one site in the oral cavity. It also extends to involve the oropharynx and esophagus.
-
Erythematous Candidiasis - This type of candidiasis is clinically seen as red lesions. It is commonly located on the upper surface of the tongue, buccal mucosa, and palate. When it occurs on the tongue, it is referred to as central papillary atrophy.
-
Hyperplastic Candidiasis - In hyperplastic candidiasis, there are characteristic white plaques that cannot be wiped off. This candidiasis type can be differentiated from other oral white lesions depending on how they respond to topical or systemic antifungal therapy. Diagnosis can be confirmed by biopsy, with fungal hyphae seen on the keratinized layers of the epithelium.
-
Angular Cheilitis - Fissuring and scaling of the angles of the mouth clinically characterize this lesion. This lesion is a mixed infection of Candida albicans and Staphylococcus aureus.
Diagnosis and Treatment - Candidiasis can be diagnosed with its clinical appearance. The PAS (Periodic acid-Schiff) staining for candidal hyphae of biopsied tissue or smears from the lesions or culturing the organism on Sabouraud's agar helps with the diagnosis. The topical application of antifungal agents such as Nystatin or Clotrimazole can effectively treat Candidiasis. The systemic antifungals used are Fluconazole or Itraconazole. Although systemic azoles produce longer disease-free intervals, these are more frequently associated with drug interactions and drug resistance.
2) Periodontal Lesions:
It may become rapidly destructive, which is difficult to manage. Anaerobic bacteria play a dominant role. Aggressive necrosis and ulceration of the gingival margin (necrotizing ulcerative gingivitis) may occur. It spreads to adjoining oral mucosa and palate, leading to necrotizing stomatitis (NS). Extension of ulcer can lead to bone destruction, tooth loosening, and loss. These lesions are associated with pain, fever, gingival bleeding, and foul breath.
Diagnosis and Treatment - Initially, it would be identified with bleeding gums and non-plaque induced gingivitis. This is followed by the destruction of one or more interdental papilla and marginal gingiva. In chronic cases of periodontitis, increased loss of periodontal attachment and bone exposure may confirm the diagnosis. Mouthwashes with povidone-iodine followed by chlorhexidine help with periodontal infections. Local debridement of necrotic material may be needed. Antibiotics (Clindamycin, Metronidazole, Amoxicillin-Clavulanate) are given in severe infection.
3) Herpes Simplex Virus (HSV) Infection:
Herpes labialis is clinically seen as blisters on the lip and adjacent facial skin, rapidly breaking down to produce shallow ulcers. Intraoral lesions on the gingiva are referred to as acute herpetic gingivostomatitis. Lesions may extend to involve the palate, pharynx, and tonsils. The lesions present as numerous pinhead-sized vesicles, which collapse to form small ulcers, exhibiting a red base covered with yellow fibrin. The persistence of active sites of HSV infection for more than 1 month in a patient with HIV infection is one of the accepted definitions of AIDS.
Diagnosis and Treatment - Mucosal herpes simplex virus infections cannot be accurately diagnosed with clinical examination. Laboratory diagnosis such as herpes simplex virus DNA polymerase chain reaction (PCR) and viral culture is used to diagnose the HSV-associated mucocutaneous lesions. These lesions can be treated with the administration of oral Acyclovir.
4) Herpes Zoster:
Herpes zoster is a recurrent viral infection seen in HIV-infected patients. It presents a clinical course that is more severe in disease prevalent populations than in immunocompetent patients. In AIDS patients, herpes zoster begins as a unilateral cluster of vesicles and ulcers in a classical dermatome distribution. However, it later extends beyond the dermatomal boundary and heals by scarring.
Diagnosis and Treatment - The polymerase chain reaction is the best test to confirm the diagnosis in HIV patients. It is used to rapidly detect varicella-zoster DNA, and it is widely used now. Oral Acyclovir, Famciclovir, and Valacyclovir are the drugs of choice in the treatment of herpes zoster.
5) Kaposi’s Sarcoma:
The mouth is the common site for Kaposi’s sarcoma. The lesions are red or violet, flat, raised, and nodular, usually found over the hard palate. Bulky lesions may ulcerate and bleed. They may cause pain and swallowing problems.
Diagnosis and Treatment - Diagnosis is made by biopsy of lesions and is examined with Warthin-Starry stain. Treatment features intralesional Vinblastine or surgical removal. Systemic chemotherapy is indicated for widespread or dispersed forms.
6) Oral Hairy Leukoplakia:
It is a white corrugated lesion presumed due to EBV (Epstein-Barr virus). It occurs mostly on the lateral borders of the tongue but may involve adjacent buccal mucosa. It does not transform into malignancy. The presence of this lesion is highly suggestive of concurrent HIV infection and is more prevalent in advanced disease.
Diagnosis and Treatment - The presence of Epstein-Barr virus could confirm oral hairy leukoplakia, where the in situ hybridizations, PCR, or immunohistochemistry help confirm the diagnosis. Antiviral, antifungal, and antiretroviral therapy may improve the condition. Surgical excision may help prevent remission.
7) Aphthous Ulcers:
Aphthous ulcers present as recurrent, round, shallow, and painful ulcers of variable sizes and duration typically found on the non-keratinized oral mucosa. Oral ulcers in patients infected with the human immunodeficiency virus are large and more extensive. They usually measure more than 2 cm in diameter with regular borders.
Diagnosis and Treatment - Blood test, culturing the lesions, taking the biopsy of the lesion, and examining it under the microscope helps confirm the diagnosis. Aphthous ulcers respond to topical steroids. Chlorhexidine and tetracycline rinses have been reported to be useful in treating herpetiform aphthae.
8) Oral Squamous Cell Carcinoma:
It has been reported in HIV or AIDS patients with the same frequency as in the general population associated with the same risk factors but at a younger age. A few suggested causes are increased chance of human papillomavirus infection and impaired recognition of foreign pathogens.
Diagnosis and Treatment - It can be diagnosed by histological examination and surgical biopsy, and they are the gold-standard treatment to confirm the diagnosis. The treatment consists of surgical resection, chemotherapy, and radiotherapy.
9) Molluscum Contagiosum:
Molluscum contagiosum or water warts is an infection of the skin caused by a pox virus. It appears as shiny, white, and skin-colored dome-shaped papules that often demonstrate a central depressed crater.
Diagnosis and Treatment - It can be diagnosed with bumps on the skin, and to confirm the diagnosis, the doctor might scrape a bit and examine under the microscope. In patients with AIDS, numerous lesions may be present, and histologically, it exhibits large intracytoplasmic inclusions known as molluscum bodies. Cryotherapy is recommended for large and disfiguring lesions. Antiviral drugs like Cidofovir, Imiquimod, and Interferon are effective. In addition, surgical methods like electrodessication, curettage, and laser surgery are used when they do not respond to medicines.
10) Thrombocytopenic Purpura:
Thrombocytopenic purpura in HIV or AIDS is characterized by decreased production of platelets due to medications, malnutrition, immunological alterations, microbial invasion, or the course of HIV disease. Pinpoint petechiae characterizes oral thrombocytopenic purpura following minor trauma and even mastication. Spontaneous gingival hemorrhage is a common oral manifestation.
Diagnosis and Treatment
Blood tests revealing increased median CD4 cells and low platelet counts are related to HIV disease progression. Platelet transfusions or corticosteroid therapy may be beneficial if the cause is removed.
Conclusion
There are many oral lesions that are associated with the human immunodeficiency virus. However, periodontitis, pseudomembranous candidiasis, and oral hairy leukoplakia are the most common oral lesions that are widely observed. With the help of antiviral and antifungal medications, these oral lesions can be managed, and it requires medical supervision. Hence reach out to your doctor to plan your best course of treatment at the earliest.
