HIV and Your Oral Health

Signs and Symptoms of Oral Infections in People With HIV

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Oral infections and diseases of the mouth, teeth, and tongue are common in people with HIV, ranging in severity from mild, self-resolving sores to more serious conditions that require immediate medical intervention. The causes of these infections are equally varied and can include a number of fungal and bacterial agents.

Fungal Infections

Fungal infections of the mouth can be caused by a specific fungus or present as part of a broader systemic infection.

Two of the most common fungal infections are:

Oral candidiasis

  • Commonly known as thrush, this fungal infection is found on the tongue and oral mucosa.
  • Presents as white patches that can be easily scraped off with a toothbrush or tongue depressor.
  • Typically diagnosed by its appearance or by examining a smear under a microscope.
  • Treated with anti-fungal medications such as fluconazole or clotrimazole troche.


  • While this fungal infection typically presents on other parts of the body, oral lesions can occur.
  • Appears as an ulcer of the oral mucosa.
  • Diagnosis are made by biopsy.

Viral Infections

Viral infections of the mouth can appear different times in the course of HIV infection. Some can present early when the person's immune system is moderately (or even mildly suppressed), while others can appear in later stages when the immune system is compromised. They include:

Herpes simplex (HSV) 

  • A type of herpes virus that can present in the mouth and genital area.
  • Appears as fluid filled vesicles that rupture and crust.
  • Symptoms include painful and itching vesicles.
  • Diagnosis is typically made by culturing the lesions and the fluid contained in the vesicles.
  • There is no cure for HSV, but outbreaks can be shortened or prevented by using antiviral medications such as acyclovir.

    Herpes zoster (HZV)

    • Commonly known as shingles, the infection is caused by the reactivation of the varicella zoster virus (i.e., the virus that causes chickenpox).
    • Typically causes fluid-filled vesicles on the skin but can also affect the oral muscosa.
    • Oral symptoms often mimic tooth pain and often advance to open ruptures and ulcers.
    • The lesions usually appear in a linear pattern along a nerve root.
    • Diagnosis is made by both the appearance and distribution of the lesions.
    • Like other types of herpes virus, there is no cure but antiviral medications can be used to shorten the course of infection.

    Human papillomavirus (HPV)

    • Typically causes genital warts, but can occasionally cause oral lesions.
    • Such lesions are found most often in people with HIV.
    • The type of HPV that causes oral warts is a bit different from those casuings genital warts.
    • The oral warts appear as single or multiple nodules which resemble cauliflower.
    • Diagnosis is made by biopsy.
    • The lesions can be surgically removed, but relapses frequently occur.

    Cytomegalovirus (CMV)

    • While it is fairly rare, oral lesions from cytomegalovirus (CMV) have been reported.
    • Lesions often look similar to apthous ulcers but are not red and inflamed around the edges. Instead they appear necrotic (meaning the cells are dying).
    • CMV ulcers are diagnosed by biopsy.
    • Ulcers will resolve with medications (such as ganciclovir) used to treat active CMV infection.

    Oral hairy leukoplakia (OHL)

    • Caused by the Epstein Barr virus.
    • Present as an corrugated or hairy-looking white lesion along the sides of the tongue.
    • In contrast to thrush, the lesion cannot be scraped off.
    • OHL more common in people with lower CD4 counts..
    • Studies suggest that persons with OHL tend to progress faster to AIDS than those who don't.
    • Diagnosed can be made by appearance from an experienced clinician, although a definitive diagnosis requires a biopsy.
    • OHL does not require treatment, and most often resolves with HIV therapy.

      Bacterial Infections

      Periodontal disease is a chronic inflammatory process caused by a bacteria that can affect the tissue and bone structures supporting the teeth. While periodontal disease can occur in anyone, two specific types are frequently seen in persons with severe immune suppression:

      Necrotizing ulcerative periodontitis (NUP)

      • Formerly known as HIV periodontal disease, NUP is considered a marker for a severely compromised immune system.
      • Characterized by severe pain and bleeding with rapid and significant bone and tissue loss.
      • Symptoms include premature tooth loss and a foul odor from the mouth.
      • If left untreated, this NUP can cause systemic symptoms throughout the body.
      • Treatment includes the removal of dead and infected tissue by a dental professional using a chlorhexidine gluconate solution.
      • Oral antibiotics are also indicated, as is pain control to ensure the person is able to eat.

      Linear Gingival Erythema (LFE) 

      • Commonly called red band gingivitis because of its characteristic red band appearance.
      • The band appears along the gum line and may be accompanied by bleeding and pain.
      • Antifungal medications are not the treatment.
      • As with NUP, treatment involves removal of dead issue by a dentist, as well as twice daily mouth rinses with chlorhexidine.
      • Treated with oral antibiotics and improved oral hygiene at home.

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