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The Oral Signs and Symptoms of HIV

 

 

Index

The general diagnostic signs of AIDS
The Bangui definition of AIDS
AIDS related fungal infections
Oral Candidiasis (Thrush)
Angular Cheilitis (dry, cracked corners of the lips)
AIDS related viral infections
Hairy leukoplakia (a tongue symptom)
Herpes Zoster (Shingles)
Herpes Simplex (cold sore virus)
Primary Herpes Stomatitis 
A note on Genital Herpes
Human Papillomavirus (HPV) (causes warts)
Tumors and growths (Neoplasms)
Kaposi's Sarcoma
Non Hodgkin's Lymphoma
Bacterial infections associated with AIDS
Acute Necrotizing Periodontitis
Acute Necrotizing Gingivitis
Acute Necrotizing Oral Stomatitis
Geographic tongue

The general signs and symptoms of AIDS

HIV generally makes its presence known in two separate stages.  The first stage is called "Acute retroviral syndrome" and happens about two weeks after acquisition of the virus.  These symptoms are similar to those seen in a severe case of the flu or Mononucleosis (fever, malaise, sore throat, headache, cough, diarrhea, vomiting etc).  During this period, the virus is multiplying vigorously and a blood test will usually demonstrate the presence of HIV.  In many people, this stage will resolve spontaneously within two to three weeks, and if the patient has simply toughed out the illness without seeing a physician, he may not realize that he actually is infected with HIV.  

A long period (called a latency period) may elapse between this primary infection and the more serious secondary stage of the disease which has been labeled Acquired Immune Deficiency Syndrome, or AIDS for short.    The latency period is generally between 5 and 15 years, with the majority of patients developing AIDS at about eight to ten years, and about one percent not developing AIDS at all.   AIDS is characterized by secondary infections caused by organisms that take advantage of the patient's compromised immune response.   It is generally a combination of these "opportunistic infections" and the direct effects of HIV (the virus itself) which cause the two classes of signs and symptoms characteristic of the later stages of the disease and discussed below.

The Bangui definition of AIDS (The classic definition of AIDS)

Major signs

Unexplained weight loss greater than 10% of body mass
Fever lasting longer than a month
Chronic diarrhea of longer than one month duration

Minor Signs

Persistent coughing
Itchy dermatitis (red, itchy skin, often with tiny pustules--pruritic dermatitis)

Recurrent Shingles (painful skin eruptions over the skin on one part of the body caused by the chickenpox virus, Herpes zoster.) 

Fungal infections of the mouth and throat in younger persons not otherwise likely to get this disease.

Chronic, severe, recurring Herpes Simplex (similar to shingles but not confined to one part of the body)

Lymphadenopathy (generalized swelling of the lymph nodes, especially those of the head and neck)

The Bangui definition assumes that the presence of two of the major signs accompanied by one or more of the minor signs is an indication of severe suppression of the immune system, and in the third world may lead to the presumptive diagnosis of AIDS. (There are actually about thirty signs of the disease, however those mentioned above are the most common.)  The Bangui definition was the primary means of diagnosis for HIV in the US and other Western countries prior to the introduction of serological (blood) tests that prove the existence of the virus in the body.  It is still used extensively in Africa to define AIDS and HIV, but it is no longer considered diagnostic in Western countries.  Even given a presumptive diagnosis of AIDS based on the Bangui definition, the presence of HIV cannot be assumed.  A blood test must confirm that the the virus is actually present. 

In the United states, the appearance of any disease characteristic of a severe immune deficiency in an otherwise healthy, young person is reason enough for the diagnosing doctor to recommend an HIV blood test. The discussion that follows involves the sorts of signs that might elicit such a recommendation from your dentist.

If you have come here to look for images of lumps, bumps, sores or discolorations that you noticed in the mirror this morning, this is one of four pages with images you may find useful.  Read this page,

Then proceed to three other pages on which you will find more images of both normal and abnormal oral structures and lesions 

Fungal Infections

Candidiasis(Thrush)

Pharyngial Candidiasis Candidiasis on tongue

 

Thrush

Thrush is a common problem for infants since their immune systems are not yet fully developed. In healthy adults, however, thrush infections happen only rarely, and usually are an indication of a lowered immune response.  Often it is due to illnesses other than AIDS such as general viral infections or stress related fatigue.  It is characterized by creamy white, soft plaques that are easily scraped off the mucosa (the lining of the mouth) revealing a red, inflamed patch underneath.  This type is seen in the picture to the right.  It is easily treated with topical antibiotics like Nystatin.

The image above, top left shows pharyngeal candidiasis.  The pharynx is the throat, and pharyngeal candidiasis is an indication of the severe immune system depression characteristic of AIDS.  This form of yeast infection was considered pathognomonic of AIDS until it was realized that persons who use inhaled steroid medications for the treatment of asthma are also prone to this sort of infection.  (Once again, the presence of pathognomonic signs of a disease, --which means observable things that are frequently associated with a particular disease-- do not necessarily mean that the patient has that disease, but a blood test is strongly recommended in such cases.)   Oral and pharyngeal candidiasis are not contagious.

Angular Cheilitis

Angular CheilitisAngular cheilitis is a very common condition.  It is a fungal infection of the corners of the lips.  It can plague healthy people who tend to have moist lips, especially in the cold winter months.  This condition is caused by a persistent fungal infection, and left untreated, tends to remain active for many months.  It generally looks like a reddened,  dry area at the corners of the lAngular Cheilitisips.  The severe, white, ulcerated variety shown to the left is more indicative of the type seen in AIDS.  Even a severe case like this, by itself, does not indicate that the patient has AIDS.  It is easily treated with Nystatin cream which is simply an antibiotic that kills the fungus.  Angular cheilitis is not contagious.  click the image on the left to see more images of angular cheilitis.

Viral associated signs of HIV

Hairy Leukoplakia

Hairy LeukoplakiaHairy leukoplakia is one of the most common HIV associated oral signs.  It is a white, corrugated or "hairy" "coating" on the lateral borders of the tongue.  Unlike thrush, it is not easily scraped off.  It is painless, but patients occasionally complain of its appearance and texture.  It is caused by the body's reaction to the Epstein-Barr virus (responsible for Mononucleosis), and can be eliminated with a viral antibiotic like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®).  This condition is rarely seen in patients not infected with  HIV.  However, some healthy patients may develop a "callous"  on the lateral borders of the tongue due to the nervous habit of continually scraping the tongue over the teeth.  This can lead to embarrassment if the dentist suggests an AIDS test to a person who believes such a suggestion is an insult!  It is never meant as a value judgment.  Hairy Leukoplakia is not contagious.  click the image to see a larger version of this image and more information on hairy leukoplakia.   

Herpes Zoster (Shingles)

Shingles on faceHerpes Zoster (better known as shingles) is caused by the same virus that causes Chicken Pox.    Herpes zoster "hides out" in a somatic nerve branch after the initial Chicken Pox infection (which usually happens in childhood), and flares up again later in life when the immune system begins to fail.  Shingles is common in otherwise healthy elderly persons.  It generally does not occur in younger people unless they are concurrently infected with the AIDS virus.  The distribution of the rash on the body is the key to the diagnosis of shingles, and distinguishes the herpes zoster virus from other forms of herpes viruses.  The distribution of the rash caused by herpes zoster in shingles is almost always on one side of the body, and is confined to the distribution of a single nerve root.  The skin surface distribution of each spinal or cranial nerve is called a dermatome.  The image on the left shows a rash which is confined to the dermatome defined by the third branch of the trigeminal nerve.  It is outlined in blue to make it easier to see.  Click the image to see larger images, as well as a great deal more on the concept of somatic dermatomes.  Shingles infections are quite painful, and they generally go away after four or five weeks, but shingles may reoccur again at a later date.  It frequently leaves those so afflicted with "postherpetic neuralgia" (PHN),  which is severely sensitive skin, well after the infection.  

Oral Herpes ZosterPersons infected with HIV are prone to this disease if they have previously been infected with Chicken Pox.  For people with AIDS, this condition can be severe and even life threatening.  In the mouth, it is identified by its distribution. It is limited to one side of the affected organ.  The image to the right shows the Herpes zoster virus infecting half of the upper posterior palate.  It is easy to confuse Herpes zoster with Herpes simplex which may occur in the same distribution purely by chance.  While the Herpes simplex virus is contagious, Shingles, surprisingly is not.  Since a large percentage of the population already has been exposed to Chicken pox, most people harbor an immunity to Herpes zoster, and the probability that anyone will develop this disease depends more on the state of their immune system than on recent exposure to the virus.

Herpes Simplex (the "cold sore" or "fever blister" virus)

Cold soreHerpes Simplex (type I) is the virus that causes  cold sores in normal, healthy adults.  The image at the right shows a typical cold sore, sometimes called a fever blister due to its propensity to appear when the patient has a cold or other febrile (fever causing) illness.  This is another bug that, like Shingles, tends to "hang out" in a nerve root for  the life of the patient after the initial infection, which often occurs in childhood.  Once infected, the patient remains infected for life.  However the  virus remains dormant inside the nerve root most of the time until the patient suffers an illness or other problem which lowers his immune response.  The virus takes advantage of the drop in immune response to flare up in the typical cold sore seen in this image.  Click the image above for more on Herpes simplex.

Primary Herpes StomatitisThis image is what the initial infection may look like when a child, or young adult is first infected with the Herpes Simplex virus.  This is called "Primary Herpes stomatitis", and as you can see, it can look quite severe with blisters both inside and outside the mouth.  ("Stomatitis" means inflammation of the entire mouth.)  The patient is quite sick, but this primary infection will disappear after 10-14 days with rest and lots of fluids.  In healthy people, this infection happens only once in a lifetime.  The presence of the virus only becomes apparent in adulthood whenever a cold sore appears.  

Herpes GingivitisWhenever an adult appears in a clinic with a case of Primary Herpes Stomatitis, this infers a severely depressed immune response, and the dentist might consider referring the patient to a physician for diagnosis of an underlying disorder.  Adults presenting with severe herpes stomatitis should consider being tested for HIV.  It must be remembered, however, that a primary herpes stomatitis can happen at any time of life if the patient has never before had a cold sore.  Click on the image to see larger views of this condition.

Patients with AIDS have immune systems much more depressed than normal people with a cold or the flu.  AIDS victims may get not only recurrent cold sores, but recurrent (repeating) cases of full blown Herpes Stomatitis as well.  Whenever an adult appears in a clinic with a case of Primary Herpes Stomatitis, this infers a severely depressed immune response, and the treating physician or dentist may suspect an undiagnosed HIV infection underlying the Herpes infection. New antibiotics like acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®) are effective in suppressing the Herpes. 

Intraoral Herpes simplex

Intraoral Herpes Simplex

Herpes simplex blisters can sometimes occur in the oral cavity on tissues not generally associated with cold sores.  They always happen on tissue that is firmly bound down to underlying bone, such as the gums immediately around the teeth or on the roof of the mouth.  As you can see, the appearance of this infection in the mouth can easily be confused with Herpes Zoster (shingles), especially if it occurs on only one side of the mouth.  The viruses are closely related, and the blisters in the oral cavity can look identical.

The presence of this type of infection in the mouth does not indicate the presence of HIV, although this infection is more common in AIDS patients than in the non-HIV population.  This can happen to anyone who harbors the Herpes Simplex virus.  Left alone, provided the patient is not immunologically compromised, it disappears in 10 to 14 days and may be treated with acyclovir (Zovirax®), famciclovir (Famvir®) or valacyclovir (Valtrex®) for quicker recovery.  The herpes simplex virus is very contagious and if one person in a family develops a cold sore, then others in the family may develop one as well. 

For more basic information on the various forms herpes simplex takes, visit HerpesEductaion.Org.

A Note on Genital Herpes

Herpes Simplex type I (HSV-1) tends to infect the face and oral cavity. This virus is the one responsible for traditional cold sores, as well as primary herpes stomatitis.  However, there is a second variety of Herpes that prefers to infect the genital areas.  Herpes Simplex Type II (HSV-2)  is called "genital Herpes" because of its tendency to be transmitted sexually.  Both HSV-1 and HSV-2 produce similar lesions.  The difference between them is their site specific preferences.  Both varieties establish latency (in other words, they take up permanent residence) in nerve roots and once established, tend to cause occasional recurrent outbreaks with active lesions (sores) in areas of the body serviced by that particular somatic nerve root.   Herpes Simplex type 1 prefers to live in the trigeminal nerve root where it causes lesions in the mouth and on the face.  HSV-2 takes up residence in the sacral ganglion, located at the base of the spine, where it may cause genital lesions (see the dermatome chart on the Herpes zoster page).

Even though each type of Herpes virus has site specific preferences, they are genetically similar, and can take up residence in nerve roots in other parts of the body, including in each other's territory.  However, outside of their own home territories neither virus is especially virulent, and rarely cause recurrent outbreaks. 

HSV-2 (genital herpes) causes approximately 90% of all cases of genital herpes outbreaks.  The other 10% is caused buy HSV-1.  Genital herpes caused by HSV-1 is generally much milder than that caused by HSV-2.   HSV-1, the "cold sore virus",  is usually transferred to the genital area by direct oral/genital contact, but upon occasion can be transferred from a patient's mouth to their own genitals (or someone else's) by simple manual transfer.  Thus the use of saliva as a lubricant can transfer HSV-1 to the genital area.  Most people infected with HSV-1 in the genital area have few, if any, outbreaks after the initial episode.  HSV-2 prefers to live in this area and causes a much more virulent infection there. 

On the other hand, HSV-1 causes almost all cases of oral and facial herpes.  Oral herpes caused by HSV-2 is not likely to cause recurrent infections, except in immunocompromised patients.

For more on this subject, visit this page.

Human Papillomavirus lesions (warts)

PapillomaWarts are caused by a virus.  In the oral cavity, they tend to be somewhat flatter than the type occurring on hands, but if they are dried with air, the tiny projections characteristic of regular warts become evident.  The causative agent is the Human Papillomavirus (HPV).  These growths generally are not painful and can be ignored unless they interfere with appearance or function.  Persons infected with HIV may develop very large, multiple warts.  They may be removed using lasers, cautery or cold steel blades.  The presence of oral warts is not in itself an indication of AIDS, although some strains of the virus are associated with squamous cell carcinoma (oral cancer).  HPV is contagious. Click on the image for more information on HPV and its association with oral and cervical cancer

Neoplasms (tumors, or "growths" )

Kaposi's Sarcoma (KS) (pronounced "cap-o-zeez")

Kaposi's Sarcoma is a form of cancer consisting  of an overgrowth of tiny blood vessels.  It is generally dark red or deep purple.  It may be flat, but sometimes presents as a swollen mass.  The lesions are rarely painful, unless they become secondarily infected.  Thus good oral hygiene is important in the management of these tumors when they occur in the mouth. 

Kaposis on armKaposi's Sarcoma is most frequently seen on the skin.   However tumors can occur in the gastrointestinal tract and the oral cavity as well.  Lesions in the oral cavity occur mostly on the palate (the roof of the mouth).  Kaposi's  is technically a form of cancer, however there is evidence that it is actually the result of a secondary infection with Herpes virus type VIII.  An abundance of this virus is found in the saliva of infected individuals.   However, the virus causes Kaposi's Sarcoma only in patients with very compromised immune systems.  It is believed that in most Kaposismodern cases, Herpes virus type VIII is transferred through deep kissing.

Kaposi's tumors were once seen exclusively in elderly men with compromised immune systems.  Today, however, they are seen more frequently in young men with AIDS.  The occurrence of one of these lesions anywhere on the body of a young man is indicative of the presence of HIV. Kaposi's is rarely seen in women, even women infected with HIV.  It is also rarely found in men who have contracted AIDS by way of intravenous drug use.  It is not known why women and heterosexual males with AIDS do not generally get Kaposi's sarcoma, although there is probably an association between the gay lifestyle and the transfer of the herpes type VIII virus. Kaposi's occurs as the initial manifestation of AIDS in approximately 11% of patients.

Kaposis

Lymphoma (lymphatic cancer)

Lymphoma on soft PalateNon Hodgkin's Lymphoma (NHL) is a form of cancer.  It starts in a lymph node and then  spreads to other areas of the body through the  blood vessels and the lymphatic system.  Before the era of AIDS, Non Hodgkin's lymphoma usually affected older individuals (median age 67).  Unfortunately, since the beginning of the AIDS epidemic the incidence of NHL has increased substantially in younger persons.  Lesions like those in the image to the right, especially when present in a younger person, may be the first indication that a patient has an HIV infection.   NHL is usually accompanied by a generalized lymphadenopathy (generalized swelling of the lymph nodes).  However, persons with no history of immunosuppression (or HIV)  may contract the  disease.  Click the image for more information on this condition and its relation to HIV.

Bacterial diseases associated with AIDS

Periodontal Disease

 Gingival erythemaIn order to understand how periodontal disease  (gum disease) affects persons with AIDS, it will be helpful to read my explanation of regular periodontal disease, since the process in HIV infected people is the same (albeit more severe and much more rapidly  progressing) as in otherwise healthy people.  The treatment for HIV infected persons is also the same as the treatment for otherwise healthy persons with

Linear Gingival erythema Periodontal disease, except that irrigation with Betadine (an Iodine solution) and more aggressive antibiotics are used.

In light of the fact that Gum Disease in HIV infected patients is so similar to the variety seen in the normal population, it is unlikely that a dentist would draw a parallel  between the presence of this process and the presence of HIV until the condition presented itself like the picture below and to the right.

Necrotizing periodontitisThe image to the right shows a case of necrotizing ulcerative periodontitis.  The difference between periodontitis and gingivitis is the degree of bony involvement and the depth of the pocketing.  The white, red and bleedy area under the necks of the lower teeth is indicative of necrotizing  (in the process of dying) tissue. While the process can be halted by aggressive intervention from a dentist and periodontal health maintained by good oral hygiene, the damage to the gums and bone is permanent. Periodontal disease is caused by poor oral hygiene and is not contagious.

Acute Necrotizing Ulcerative gingivitis (trench Mouth)

ANUG (Acute Necrotizing Gingivitis)A less severe form of this condition  found in the non HIV infected population (also seen in early stages of AIDS) is called Acute Necrotizing Ulcerative Gingivitis (ANUG), formerly called "Trench mouth".  In ANUG,  only the  gingiva immediately surrounding the teeth becomes necrotic.  ANUG is often found in people with poor oral hygiene who are either ill or under extreme physical or emotional stress. (It was named "trench mouth" because it was common in soldiers who fought in the trenches during world war I.  These men were certainly under extreme physical and emotional stress, and had little opportunity to brush their teeth.)

ANUG, being a bacterial infection, is very easily treated by gentle cleaning of the teeth and irrigation of the affected gums with 3% hydrogen peroxide.  The bacteria that take advantage of a patient's run-down condition tend to be anaerobic which means that they die in the presence of oxygen.  Hydrogen peroxide liberates oxygen (hence the bubbles) when it is exposed to blood, and the oxygen acts as an antiseptic and speeds healing of the damaged gum tissue.  The patient is sent home with a prescription for Penicillin and instructions on cleaning the teeth to prevent further problems.  ANUG is not contagious.

Dentists today rarely see cases of ANUG, however the disease is making a comeback in communities in which there is a lot of drug addiction.  It is especially prevalent in populations of methamphetamine addicts and is a part of the syndrome now known as Meth Mouth.

Acute Necrotizing Oral Stomatitis 

Necrotizing StomatitisThis condition is never seen except in a hospital setting.  If the immune system is severely compromised, the body is unable to fight off bacterial infections that a normal immune system is able to combat easily.  Without a functioning immune system, normal environmental bacteria can attack a living body in the same way they would attack a dead body.  HIV attacks the immune system, immobilizing it.  Without a properly functioning immune system, there is no defense against parasitic bacteria and viruses, and a living body can start to decay.

 

Other indications of immune deficiency

Geographic tongueGeographic tongue--This condition is thought to be an oral form of psoriasis (a common skin condition), and is characterized by the disappearance of the filiform papillae from irregular patches on the top surface of the tongue.  These patches then "heal" up and reoccur on another part of the tongue at a later date.  One can see lesions in varying stages of healing over large expanses of the tongue.  The cause of this condition is unknown.  These patients often complain of pain when eating sharp foods.  The condition can be treated with topical application of steroid gels or mouth rinses.  In general, however, it is not treated.  Geographic tongue is not a contagious condition.  This condition might be seen more frequently in AIDS patients, however the presence of geographic tongue does NOT mean that the patient has AIDS.  It may be more prevalent in persons with HIV because the virus attacks the immune system, and psoriasis is caused by a mal fun ti on of the immune system.  Click the image on the right for a larger view.

<<==AIDS, the epidemiology and origin

HIV, The virus==>>

 

 

 

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