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Oral Complications of HIV Infection

Oral lesions often occur in HIV and are reflections of reduced immune function manifested as oral opportunistic conditions, which are often the earliest clinical features of HIV infection. Some, in the presence of known HIV infection, are highly predictive of the ultimate development of the full syndrome.

Oral lesions seen in association with HIV infection are classified in Table 12-1, and our general approach to the diagnosis and management of oral HIV disease is summarized in Table 12-2.


The pseudomembranous form of oral candidiasis (thrush) was described in the first group of AIDS patients and is a harbinger of the full-blown syndrome in HIV-seropositive individuals. We have shown that both oral candidiasis and hairy leukoplakia predict the development of AIDS in HIV-infected patients independently.

Table 12-1. Oral Lesions in HIV Infection




Angular cheilitis








HIV-associated gingivitis

HIV-associated periodontitis

Necrotizing stomatitis

Mycobacterium avium complex

Klebsiella stomatitis

Bacillary angiomatosis


Herpes simplex

Herpes zoster

Cytomegalovirus ulcers

Hairy leukoplakia



Kaposi's sarcoma

Non-Hodgkin's lymphoma

Squamous cell carcinoma (?)



Recurrent aphthous ulcers

Immune thrombocytopenic purpura

Salivary gland disease

Gingivitis and Periodontitis

Unusual forms of gingivitis and periodontal disease are seen in association with HIV infection. The gingiva may show a fiery red marginal line, known as linear gingival erythema, even in mouths showing absence of significant accumulations of plaque. The periodontal disease, necrotizing ulcerative periodontitis, occurs.

Other Bacterial Lesions

A few cases have occurred of oral mucosal lesions associated with unusual bacteria, includ-ins Klebsiella pneumoniae and Enterobacter cloacae. These have been diagnosed using aerobic and anaerobic cultures.

Herpes Simplex

Oral lesions due to herpes simplex virus (HSV) are a common feature of HIV infection. The condition usually occurs as recurrent intraoral lesions with crops of small, painful vesicles that ulcerate. These lesions commonly appear on the palate or gingiva. Smears from the lesions may reveal giant cells, and HSV can be identified.

Herpes Zoster

Both chickenpox and herpes zoster (shingles) have occurred in association with HIV infection. In orofacial zoster, the vesicles and ulcers follow the distribution of one or more branches of the trigeminal nerve on one side. Facial nerve involvement with facial palsy (Ramsay Hunt syndrome) also may occur.

 Cytomegalovirus Ulcers

Oral ulcers caused by cytomegalovirus (CMV) occasionally occur. These ulcers can occur on any oral mucosal surface, and diagnosis is made by biopsy and immunohistochemistry.

Hairy Leukoplakia

First seen on the tongue in homosexual men, hairy, leukoplakia has since been described in several oral mucosal locations, including the buccal mucosa, soft palate, and floor of mouth and in all risk groups for hairy leukoplakia produces white thickening of the oral mucosa, often with vertical folds or corrugations.


Oral lesions caused by human papillomavirus (HPV) can occur as single or multiple papilliferous warts with multiple white and spike-like projections, as pink cauliflower-like masses , as single projections, or as flat lesions resembling focal epithelial hyperplasia. In patients with HIV infection.

If large, extensive, or otherwise troublesome, these oral warts can be removed using surgical or laser excision. In some cases, we have seen recurrence after therapy and even extensive spread throughout the mouth.

Neoplastic Disease

Kaposi's Sarcoma

Kaposi's sarcoma (KS) in patients with AIDS produces oral lesions in many cases. The lesions occur as red or purple macules.

macules, papules, or nodules. Occasionally, the lesions are the same color as the adjoining normal mucosa. Although frequently they are asymptomatic, pain may occur because of traumatic ulceration with inflammation.


Although not seen as frequently as with oral KS, oral lesions are a common feature of HIV-associated lymphoma. A biopsy may prove that poorly defined alveolar swellings or discrete oral masses in individuals.


Several cases have been seen of oral squamous cell carcinoma, particularly of the tongue, in young homosexual males. It is not clear whether these lesions are related to HIV infection; population-based.

Other Lesions

Recurrent aphthous ulcers (RAU) are a common finding in the normal population. There is an impression, not as vet substantiated by prospective studies of incidence, that RAU are more common among HIV-seropositive individuals. These lesions occur as recurrent crops of small (1- to 2-mm) to large (1-cm) ulcers.