International Journal of Medicine Research

International Journal of Medicine Research

ISSN: 2455-7404; Impact Factor: RJIF 5.42
www.medicinesjournal.com
Volume 2; Issue 3; May 2017; Page No. 01-08

Oral manifestations in an HIV+ patients and its management

1
Dr Rita Chouhan, 2 Dr. Matin Ahmad Khan, 3 Dr. Sushilendra Kumar Chouhan, 4 Dr. Shweta Chouhan,
5
Dr. Nazma Arfeen
1
MBBS, MSc (Microbiology) Associate Professor & HOD, Department of Microbiology MGM Medical College, Jamshedpur,
Jharkhand, India
2
MBBS MSc (Biochemistry) MMSc (HIV Med) MPH, Ph.D (Public Health), PhD (HIV Medicine) Fellowship in HIV Medicine,
American Academy of HIV Medicine Specialist (AAHIVS –USA)
2
Associate Professor, Dept. of Biochemistry, Patliputra Medical College, Dhanbad, Jharkhand, India& Joint Director Care Support
&Treatment, Jharkhand State AIDS Control Society Ranchi (JD CST, JSACS), Jharkhand, India
3
MBBS. MS (Anatomy) Associate Professor & HOD, Dept. of Anatomy MGM Medical College, Jamshedpur, Jharkhand, India
4
BDS, MDS Assistant Professor, Department of Oral Pathology, RKDF Dental College & Research Centre, Bhopal,
Madhya Pradesh, India
5
BDS, Dental Surgeon, Al-Senan Dental Clinic Jamshedpur, Jharkhand, India

Abstract
Oral lesions are among the early signs of HIV infection and can predict its progression to acquired immunodeficiency syndrome
(AIDS). A better understanding of the oral manifestations of AIDS in both adults and children has implications for all health care
professionals. The knowledge of such alterations would allow for early recognition of HIV-infected patients. HIV-related oral
conditions occur in a large proportion of patients, and frequently are misdiagnosed or inadequately treated. Dental expertise is
necessary for appropriate management of oral manifestations of HIV infection or AIDS, but many patients do not receive
adequate dental care. Common or notable HIV-related oral conditions include xerostomia, candidiasis, oral hairy leukoplakia,
periodontal diseases such as linear gingival erythema and necrotizing ulcerative periodontitis, Kaposi's sarcoma, human papilloma
virus-associated warts, and ulcerative conditions including herpes simplex virus lesions, recurrent aphthous ulcers, and
neutropenic ulcers.
Oral manifestations of HIV disease are common and include oral lesions and novel presentations of previously known
opportunistic diseases Careful history taking and detailed examination of the patient's oral cavity are important parts of the
physical examination and diagnosis requires appropriate investigative techniques. Early recognition, diagnosis, and treatment of
HIV-associated oral lesions may reduce morbidity.
The present paper reviews epidemiology, relevant aspects of HIV infection related to the mouth in both adults and children, as
well as current trends in antiretroviral therapy and its connection with orofacial manifestations related to AIDS.

Keywords: HIV, AIDS, oral manifestation, oral lesions, mouth

Introduction antiretroviral therapy Even though the prevalence of specific

The HIV/AIDS pandemic has become a human and social oral lesions like candidiasis, hairy leukoplakia and Kaposi‘s
disaster, particularly in resource limited settings. Oral health sarcoma has been proven to be lower among patients on
is an important component of the overall health status in HIV HAART other conditions such as oral warts and salivary
infection and essential component of quality of life HIV gland disease have been found to be more prevalent in this
related oral abnormalities occur in 30 to 80 percent of the population as part of immune reconstitution resulting from
affected patient population Policies for strengthening oral antiretroviral therapy initiation.
health promotion and the care of HIV-infected patients have
been issued by WHO Oral health services and professionals Epidemiology of HIV infection
can contribute effectively to the control of HIV/AIDS HIV infection remains a significant health care problem.
through health education, patient care, infection control and [1]
Since Barre-Sonoussi and Gallo’s initial description of the
surveillance. Oral lesions are among the early signs of HIV human immunodeficiency virus type I (HIV-1) in 1983 and
infection and for individuals with unknown HIV status may Clavel et al. first described HIV-2 in 1986, these two viruses
suggest possible HIV diagnosis. For persons diagnosed with have been recognized for almost 34 years as the primary
HIV who are not yet on therapy, the presence of certain oral cause of the acquired immunodeficiency syndrome (AIDS)
manifestations may predict progression to AIDS Around 36.7 million people worldwide are living with HIV-
Furthermore, for patients on highly active antiretroviral AIDS (WHO 2016 report) of which around 2.1 million are in
therapy (HAART) the presence of certain oral manifestations the Indian subcontinent. The first case of AIDS was reported
may serve as surrogate markers for the efficacy of in the year 1981. Since then the disease has gone through
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various stages of changes with respect to its epidemiology as absence of antiretroviral treatment, this period of clinical
well as its manifestations. latency may last 8–10 years or more [27]. However, the term
There are several ways in which someone can become “latency period” may be misleading, given the incredibly
infected with HIV, and some of these transmission routes are high turnover of the virus and the relentless daily destruction
well defined. HIV infection can be transmitted through of CD4+ T-cells At the end of the latency period, a number of
unprotected sexual intercourse with an infected partner The symptoms or illnesses may appear that do not fulfill the
HIV virus can be transmitted through unprotected oral sex, definition of AIDS. These symptoms include slight
both from fellatio and cunnilingus, although the precise immunological, dermatological, hematological, neurological,
degree of risk of disease transmission to and from the mouth and orofacial signs.
is difficult to establish as these practices often take place Oral manifestations are among the earliest and most
along with insertive sexual intercourse. Injection or important indicators of HIV infection. At present, three
transfusion of contaminated blood or blood products groups of oral manifestations of AIDS are defined based on
(infection through artificial insemination, skin grafts, and their intensity and features. Group 1 is composed of seven
organ transplants is also possible), sharing unsterilized cardinal lesions (oral candidosis, hairy leukoplakia, Kaposi
injection equipment that was previously used by an infected sarcoma, linear gingival erythema, necrotizing ulcerative
person, and maternal-fetal transmission (during pregnancy, at gingivitis, necrotizing ulcerative periodontitis, and non-
birth, and through breastfeeding) are other transmission Hodgkin lymphoma) that are strongly associated with HIV
routes. infection. The second group includes atypical ulcers, salivary
Occupational HIV infections of healthcare or laboratory glands diseases, viral infection such as cytomegalovírus
workers may occur, but this mode of infection is not frequent. (CMV), herpes simplex virus (HSV), papillomavirus (HPV),
Transmission of HIV from an infected patient to a health-care and herpes zoster virus (HZV). On group 3 are lesion rarer
worker has been documented after parenteral or mucous- than those on groups 1 and 2, such as diffuse osteomyelitis
membrane exposure to blood. However, this risk is less than and squamous cell carcinoma. The presence of oral lesions
1%, is limited to exposure to blood, and can be further can have a significant impact on health-related quality of life.
minimized through the availability of more effective Oral health is strongly associated with physical and mental
antiretroviral therapy (ART). health, and there are significant increases in oral health needs
There remains little evidence that HIV is transmitted via oral in people with HIV infection, especially in children, and in
fluids. However, saliva seems to play an important role in an adults particularly in relation to periodontal diseases. Thus,
individual’s protection from HIV infections. The saliva of physical and mental health measures of HIV patients should
non-HIV-infected persons contains non-immune endogenous incorporate indicators of oral functioning and well-being.
inhibitors of HIV such as mucins, defensins, thrombospondin, Data obtained in the Coutler et al. study have shown that a
and various salivary proteins, in particular the secretory one-point increase in oral health was associated with a 0.05
leukocyte protease inhibitor. There is also evidence that the (p < 0.000) increase in mental health and a 0.02 increase in
hypotonicity of saliva itself exerts a significant inhibitory physical health (p = 0.031).
effect on cell-associated HIV replication.
The risk of transmission of HIV from a patient to a dental Discussion
health care worker remains very low, if not infinitesimal. Emerging and re-emerging diseases are having a profound
Transmission of HIV from an infected dental health care worldwide impact on society and on the delivery of medical
worker is also rare, although possible. Nevertheless, dental and oral health care. HIV infection leading to AIDS has been
health care workers are at risk of nosocomial acquisition of a major cause of illness and death among children, teens, and
HIV and other blood-borne viruses (BBVs), and these young adults worldwide. There remains little evidence that
individuals should be aware of, and follow available national supports transmission of HIV via oral fluids. However, saliva
guidelines on occupational exposure to BBVs. seems to play an important role in an individual’s protection
As in other virus infections, the individual course of HIV from HIV infections The risk of transmission of HIV from a
infection depends on both host and viral factors; however, the patient to a dental health care worker remains very low.
factors that may predispose one to or promote the Transmission of HIV from an infected dental health care
development of the AIDS syndrome are largely worker is also rare, although possible Although hundreds of
unknown. The clinical course of AIDS described in the millions of research dollars have been spent seeking
following sentences refers to HIV infection in the absence of successful treatment and eradication of HIV from infected
highly active antiretroviral therapy (HAART). Several individuals, that goal has yet to be achieved. A Preventive
factors, including immunological and virological variables, HIV vaccine is very technically challenging to construct,
have been reported to predict disease progression. The acute largely due to a high rate of spontaneous mutation and HIV
viral syndrome of primary HIV infection (which is defined as strain variation and, therefore is not available Undiagnosed or
the time period from initial infection with HIV to the untreated infection with HIV, results in progressive loss of
development of an antibody response) shows symptoms that immune function marked by depletion of the CD4+ T
often resemble those of mononucleosis [25]. These symptoms lymphocytes (CD4), leading to opportunistic infections and
appear within days to weeks of exposure to HIV. However, malignancies characteristic of Acquired Immunodeficiency
clinical signs and symptoms may not occur in all patients [26]. Syndrome (AIDS) Oral manifestations of HIV are common
After the acute infection, equilibrium between viral and have been important in identification of patients
replication and the host immune response is usually reached, harboring the HIV virus and in predicting the decline in their
and many infected individuals may have no clinical immune system. Early recognition, diagnosis, and treatment
manifestations of HIV infection for years. Even in the of HIV-associated oral lesions may reduce morbidity.
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Orofacial manifestations are among the earliest and most  Hyperplastic candidiasis
common clinical signs of pediatric HIV disease too. Early  Angular cheilitis is erythema and/or fissuring and cracks
diagnosis of perinatally exposed infants and children is of the corners of the mouth. Angular cheilitis can occur
especially important because the intervals between infection, with or without the presence of erythematous candidiasis
development of AIDS, and death are compressed in pediatric or pseudomembranous candidiasis.
patients. Early diagnosis allows prompt institution of both  Hyperplastic or chronic candidiasis presents as white
multi-drug therapy, which appears to be most effective when nonremovable plaques over the mucosal surface; hence
instituted early, and prophylactic therapy to forestall life- they cannot be scraped off.
threatening opportunistic infections. Oral candidiasis can extend to involve the pharynx, larynx,
HIV disease has an effect over the entire body. It is not and esophagus as well. Treatment of oral candidiasis depends
practical in the present scenario for any health personnel on the clinical type, distribution, and severity of infection.
dealing with diagnosis and treatment in humans to not Topical treatment is effective for limited and accessible
encounter this dreaded disease and its manifestations. Thus it lesions. Clotrimazole troches, nystatin pastilles, and nystatin
becomes imperative to be aware of the various forms of HIV oral suspension are effective for mild-to-moderate
manifestations. erythematous and pseudomembranous candidiasis. However,
Oral health is an important component of the overall health prolonged use of these agents can result in significant dental
status in HIV infection. Awareness of the variety of oral caries due to the fermentable carbohydrate substrates present
disorders which can develop throughout the course of HIV in the formulations. Increased risk of caries can be avoided
infection and coordination of health care services between a by using a nystatin oral suspension (100,000 units/5 ml,
physician and a dentist may improve the overall health of the rinsing mouth, and expectorating 3 times/day). Chlorhexidine
patient. The spectrum of oral manifestations is very vast in 0.12% oral rinses do not contain a cariogenic substrate and
HIV-AIDS. may be similarly effective.
Oral manifestations of HIV infection occur in 30–80% of the Topical amphotericin B can also be used in the treatment for
affected patient population The overall prevalence of oral resistant candidiasis and can be prepared by dissolving 50 mg
manifestations in HIV disease has changed since the advent in 500 ml of sterile saline (0.1 mg/ml). Clotrimazole 1%
of HAART. cream, miconazole or ketoconazole 2% cream, and nystatin
The various oral manifestations can be categorized into ointment are useful medications for angular cheilitis and for
 Infections: bacterial, fungal, viral application to a removable denture base when there is
 Neoplasms: Kaposi's sarcoma, non-Hodgkin's lymphoma candidal infection involving the underlying mucosa.
 Immune mediated: major aphthous, necrotizing stomatitis Systemic treatment for oral candidiasis involves the use of
 Others: parotid diseases, nutritional, xerostomia imidazole (ketoconazole) and triazole (fluconazole and
 Oral manifestations as adverse effects of antiretroviral itraconazole) antifungal medications. Fluconazole is given in
therapy. the dose of 100–200 mg/day. The duration of treatment with
There is no particular oral lesion which is associated only oral imidazoles usually is around 7–10 days but in cases of
with HIV-AIDS but there are certain manifestations like oral suspicion of esophageal involvement, the duration can be
candidiasis, oral hairy leukoplakia (OHL) which are extended to 21 days. As per the recent guidelines there is no
associated very frequently and are considered AIDS-defining role of prophylaxis for candidiasis in HIV patients.
diseases and have also been included in the clinical
classification of HIV by CDC in category B Histoplasmosis: Histoplasmosis is a granulomatous fungal
disease caused by Histoplasma capsulatum. The clinical
Fungal Infections presentation ranges from an asymptomatic or mild lung
Candidiasis: Oral or pharyngeal candidiasis are the infection to an acute or chronic disseminated form. Oral
commonest fungal infections observed as the initial histoplasmosis appears as chronic ulcerated areas located on
manifestation of symptomatic HIV infection Many patients the dorsum of the tongue, palate, floor of the mouth, and
can have esophageal candidiasis as well. It is usually vestibular mucosa. Focal or multiple sites can be involved. In
observed at CD4 counts of less than 300/μl. The commonest AIDS patients, histoplasmosis is rarely curable, but it can be
species of candida involved are Candida albicans although controlled with long-term suppressive therapy consisting of
nonalbicans species have also been reported. There are four the administration of amphotericin B and ketoconazole.
frequently observed forms of oral candidiasis: erythematous
candidiasis, pseudomembranous candidiasis, angular cheilitis, Cryptococcosis: Oral manifestations are quite unusual and
and hyperplastic or chronic candidiasis only two cases have been reported in the literature The
 Erythematous candidiasis presents as a red, flat, subtle lesions consist of ulcerations of the oral mucosa, but the
lesion either on the dorsal surface of the tongue and/or the clinical diagnosis of oral cryptococcus may be difficult since
hard/soft palates. Patients complain of a burning sensation other microbial infections and trauma may show similar
in the mouth more so while eating salty and spicy food. appearances. Tissue biopsy may be required for the diagnosis
Diagnosis is made on the basis of clinical examination, a and treatment involves use of amphotericin B.
potassium hydroxide preparation which demonstrates the
fungal hyphae can be used for confirmation. Viral Infections
 Pseudomembranous candidiasis appears as creamy white Oral hairy leukoplakia: These lesions are usually seen on
curd-like plaques on the buccal mucosa, tongue, and other the lateral surface of the tongue, but may extend to the dorsal
oral mucosal surfaces that can be wiped away, leaving a and ventral surfaces Lesions may be variably sized and may
red or bleeding surface appear as vertical white striations, corrugations, or as flat
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plaques, or raised, shaggy plaques with hair-like keratin usually affects children and young adults and is spread by
projections. In most cases, OHL is bilateral and direct and indirect contact. The typical lesion is an
asymptomatic. When it leads to discomfort it is usually umbilicated papule that may itch, leading to autoinoculation.
associated with superimposed candidal infection. OHL has Lesions may persist for years and eventually regress
been shown to be associated with a localized Epstein–Barr spontaneously. The occurrence of disseminated molluscum
virus (EBV) infection and occurs most commonly in contagiosum has been reported in HIV-infected patients.
individuals whose CD4 lymphocyte count is less than 200/μl. These lesions usually subside with immune reconstitution
Histological investigations reveal typical epithelial when patients are started on HAART.
hyperplasia suggestive of EBV infection. This condition
usually does not require treatment but use of oral acyclovir, Bacterial Infection
topical podophyllum resin, retinoids, and surgical removal The most common oral lesions associated with bacterial
have all been reported as successful treatments infection are linear erythematous gingivitis, necrotizing
ulcerative periodontitis, and, much less commonly, bacillary
Herpes simplex and varicella zoster virus infections: epithelioid angiomatosis and syphilis. In the case of the
Herpes simplex virus (HSV) is responsible for both primary periodontal infections, the bacterial flora is no different from
and recurrent infections of the oral mucosa. These infections that of a healthy individual with periodontal disease. Thus,
are acquired in childhood and after initial pustular lesions. the clinical lesion is a manifestation of the altered immune
The virus remains dormant, but in later stages of response to the pathogens.
immunosuppresion the virus can be activated and can lead to
various manifestations. Oral manifestations, represented by Linear erythematous gingivitis: This entity appears as a
diffuse mucosal ulcerations, are accompanied by fever, band of marginal gingival erythema, often with petechiae. It
malaise, and cervical lymphadenopathy. Ulcerations that is typically associated with no symptoms or only mild
follow the rupture of vesicles are painful and may persist for gingival bleeding and mild pain. Histological examination
several weeks. Recurrent HSV usually appears in keratinizing fails to reveal any significant inflammatory response,
oral mucosa (i.e., palate, dorsum of tongue, and gingiva) as suggesting that the lesions represent an incomplete
ulcerations but in most HIV-seropositive patients, this rule is inflammatory response, principally with only hyperemia
not followed. In these patients, the lesions may show unusual present. Oral rinsing with chlorhexidine gluconate often
clinical aspects and persist for many weeks. Contact with the reduces or eliminates the erythema and may require
varicella zoster virus (VZV) may result in varicella (chicken prophylactic use to avoid recurrence.
pox) as a primary infection and herpes zoster (shingles) as a
reactivated infection. In HIV infection, herpes zoster Necrotizing ulcerative periodontitis (NUP): This
frequently presents with early cranial nerve involvement and periodontal lesion is characterized by generalized deep
carries a poor prognostic significance. There may be osseous pain, significant erythema that is often associated
involvement of multiple dermatomes and these lesions might with spontaneous bleeding, and rapidly progressive
get secondarily infected as well. The lesions are usually destruction of the periodontal attachment and bone. The
associated with severe postherpetic neuralgias. destruction is progressive and can result in loss of the entire
alveolar process in the involved area. It is a very painful
Cytomegalovirus: CMV-related oral ulcerations, although lesion and can adversely affect the oral intake of food,
infrequent, are a recognized complication of HIV infection. resulting in significant and rapid weight loss. Patients also
The diagnosis of oral CMV is based upon the presence of have severe halitosis. Because the periodontal microflora is
large intranuclear and smaller cytoplasmic CMV inclusions no different from that seen in healthy patients, the lesion
in the endothelial cells at the base of the ulcerations. These probably results from the altered immune response in HIV
infections usually manifest in stage IV of the infection when infection. More than 95% of patients with NUP have a CD4
there is advanced immunosuppression with a CD4 count lymphocyte count of less than 200/mm3. Treatment consists
below 50. Presently, the drug of choice for CMV infection is of rinsing twice daily with chlorhexidine gluconate 0.12%,
intravenous gancyclovir. metronidazole (250 mg orally four times daily for 10 days),
and periodontal debridement, which is done after antibiotic
Human papilloma virus: In some patients with HIV therapy has been initiated.
infection, human papilloma virus (HPV) causes a focal
epithelial and connective tissue hyperplasia, forming an oral Bacillary Epithelioid Angiomatosis (BEA): This lesion
wart. In HIV-infected patients, oral HPV-related lesions have appears to be unique to HIV infection and is often clinically
a papillomatous appearance, either pedunculated or sessile, indistinguishable from oral Kaposi's sarcoma (KS). Since
and are mainly located on the palate, buccal mucosa, and both may present as an erythematous, soft mass which may
labial commissure. The most common genotypes found in the bleed upon gentle manipulation, biopsy and histological
mouth of patients with HIV infection are 2, 6, 11, 13, 16, and examination are required to distinguish bacillary epithelioid
32. Surgical removal, with or without intraoperative irrigation angiomatosis (BEA) from KS. The presumed etiological
with podophyllum resin, is the treatment of choice pathogen, Rochalimaea henselae, can be identified using
Warthin–Starry staining. Both KS and BEA are histologically
Molluscum contagiosum: Molluscum contagiosum is caused characterized by atypical vascular channels, extravasated red
by an unclassified DNA virus of the poxvirus family. Lesions blood cells, and inflammatory cells. However, prominent
appear as single or multiple papules on the skin of the spindle cells and mitotic figures occur only in KS.
buttocks, back, face, and arms. Molluscum contagiosum Erythromycin is the treatment of choice for BEA.
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Syphilis: While the prevalence of syphilis infection has risen mg/kg) in the case of large multiple ulcers and those not
significantly over the past decade, it is an uncommon cause responding to topical preparations. Alternative therapies such
of intraoral ulceration, even in HIV infection. Its appearance as dapsone 50–100 mg daily and thalidomide 200 mg daily
is no different from that observed in healthy individuals; it is for 4 weeks should be considered in recalcitrant cases. When
a chronic, nonhealing, deep, solitary ulceration; often immunosuppressant drugs are used in order to prevent
clinically indistinguishable from that due to tuberculosis, superadded fungal or bacterial infection, concurrent
deep fungal infection, or malignancy. Dark field examination antifungal medications such as fluconazole, itraconazole, and
may demonstrate treponema. Positive reactive plasma reagin antibacterial medications such as chlorhexidine gluconate
(RPR) and histological demonstration of Treponema oral rinse may be required.
pallidum is diagnostic. Combination treatment with
penicillin, erythromycin, and tetracycline is the treatment of Necrotizing stomatitis: It is an acute, painful ulceration
choice, the dosage and duration of the treatment depending which often exposes the underlying bone and leads to
on the presence or absence of neurosyphilis. considerable tissue destruction. This lesion may be a variant
of major aphthous ulceration, but occurs in areas overlying
Neoplasms the bone and is associated with severe immune deterioration.
Kaposi's sarcoma: It is the most common intraoral These lesions can also occur in edentulous areas. Like in
malignancy associated with HIV infection. The lesion may major aphthous ulceration, systemic corticosteroid
appear as a red-purple macule, an ulcer, or as a nodule or medication or topical steroid rinse is the treatment of choice.
mass. Intraoral KS occurs on the heavily keratinized mucosa,
the palate being the site in more than 90% of reported cases. Xerostomia: Xerostomia is common in HIV disease, most
KS is especially common among homosexual and bisexual often as a side effect of antiviral medications or other
males and is rarely found in HIV-infected women. Human medications commonly prescribed for patients with HIV
herpes virus (HHV8) has been demonstrated to be an infection, like angiolytics, antifungals, etc. The oral dryness
important cofactor in the development of KS. A histological is a significant risk factor for caries and can lead to rapid
examination is warranted for the definitive diagnosis of KS. dental deterioration. Xerostomia also can lead to oral
There is no cure for KS. Therapy for intraoral KS should be candidiasis, mucosal injury, and dysphagia, and is often
instituted at the earliest sign of the lesion, the goal being local associated with pain and reduced oral intake of food. Patient
control of the size and number of lesions. When only a few who has residual salivary gland function which is determined
lesions exist and the lesions are small (< 1 cm), intralesional by gustatory challenge, oral pilocarpine often provides
chemotherapy with vinblastine sulfate or sclerotherapy with improved salivary flow and consistency. Oral hygiene should
3% sodium tetradecyl sulfate is usually effective. Radiation be scrupulously maintained along with the use of dental floss.
therapy (800–2,000 cGy) is required for larger or multiple
lesions; stomatitis and glossitis are common side effects of Parotid gland disease
radiation. Although this entity has been reported in the HIV infection is associated with parotid gland disease. There
western literature but its incidence in Indian patients is quite can be gland enlargement and diminished flow of secretions.
low with only nine cases been reported till date Histologically, there may be lymphoepithelial infiltration and
benign cyst formation. The enlargement typically involves
Non-Hodgkin's lymphoma: NHL is the most common the tail of the parotid gland or, less commonly, the
lymphoma associated with HIV infection and is usually seen submandibular gland, and it may present uni- or bilaterally
in late stages with CD4 lymphocyte counts of less than with periods of increased or decreased size. The enlargement
100/mm3. It appears as a rapidly enlarging mass, less can be mistaken for a malignancy but in such cases a needle
commonly as an ulcer or plaque, and most commonly on the aspiration with yellow secretions in aspiration would help in
palate or gingivae. A histological examination is essential for making the diagnosis and in such cases further biopsy is
diagnosis and staging. Prognosis is poor, with mean survival unnecessary. Occasional swelling can be managed simply by
time of less than 1 year, despite treatment with multidrug repeated aspiration and rarely is radical removal of the gland
chemotherapy. necessary. The pathophysiological mechanism is not known,
though cytomegalovirus has been suggested to play a role.
Immune mediated oral diseases
In HIV there is immune suppression of cell-mediated Side effects of Anti Retrovial Therapy as oral
immunity as the disease progresses but at the same time there presentations
is abnormal activation of B-cell immunity. These disorders of With the widespread availability and usage of antiretroviral
the immune system also lead to various oral manifestations. therapy for the management of HIV, the clinical picture now
has shown a paradigm shift. The manifestations due to
Aphthous ulcers: They are the most common immune- adverse effects of the HAART are also observed along with
mediated HIV-related oral disorder, with a prevalence of the above-mentioned features of immunosuppresion. Thus
approximately 2–3%. These ulcers are either large solitary or one should be aware about them as well. Oral
multiple, chronic, deep, and painful often lasting much longer hyperpigmentation can be observed if a patient is on
in the seronegative population and are less responsive to zidovudine.
therapy. Treatment requires the use of a potent topical steroid Erythema multiformes is a known side effect of NNRTIs.
such as clobetesol when the lesions are accessible or Xerostomia is also observed in patients on lamivudine,
dexamethasone oral rinse when not accessible. Systemic didanosine, indinavir and ritonavir. Lipodystrophy with loss
glucocorticosteroid therapy may be required (prednisone 1 of subcutaneous fat has been reported extensively in patients
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International Journal of Medicine Research

on stavudine. Other oral effects like paresthesias, lip edema, the response to the HIV/AIDS epidemic include the support
chelitis, and taste disturbances have been observed in patients of the World Universal Public Health System, the provision
on protease inhibitors. of universal access to highly active antiretroviral therapy, and
The above-mentioned list is not the complete panorama of the creation of harm reduction projects that are politically and
manifestations which can be observed in an HIV patient but financially supported by federal governments
only an illustration of important lesions. It is thus essential Hence the prevention, diagnosis, treatment, and control of
that oral healthcare professionals recognize the hallmarks of these oral manifestations should be part of the objectives of
the illness and provide timely management for better survival every dental health professional.
of these patients.
References
Conclusions 1. Baccaglini L, Atkinson JC, Patton LL, Glick M, Ficarra
As the Oral manifestations are among the earliest and most G, Peterson DE. Management of oral lesions in HIV-
important indicators of HIV infection, a better understanding positive patients. Oral Surg Oral Med Oral Pathol Oral
these manifestations in both adults and children is a must for Radiol Endod. 2007; 103(Suppl):S50.e1-23.
all dental health care workers. Early recognition, diagnosis, 2. Bajpai S, Pazare AR. Oral manifestations of HIV.
and treatment of HIV-associated oral lesions may reduce Contemp Clin Dent. 2010; 1(1):1-5.
morbidity of the adults. Early diagnosis of perinatally 3. Barone R, Ficarra G, Gaglioti D, Orsi A, Mazzotta F.
exposed infants and children allows prompt institution of Prevalence of oral lesions among HIV-infected
both multi-drug therapy, which appears to be most effective intravenous drug abusers and other risk groups. Oral
when instituted early, and prophylactic therapy to forestall Surg Oral Med Oral Pathol. 1990; 69:169-73.
lifethreatening opportunistic infections. 4. Cameron JE, Mercante D, O'Brien M, Gaffga AM, Leigh
An understanding of the immunopathogenesis of HIV JE, Fidel PL Jr et al. The impact of highly active
infection is a major prerequisite for rationally improving antiretroviral therapy and immunodefi ciency on human
therapeutic strategies and developing immunotherapeutics papillomavirus infection of the oral cavity of human
and prophylactic vaccines. A better understanding of the oral immunodefi ciency virus-seropositive adults. Sex
manifestations of HIV/AIDS in both adults and children has Transm Dis. 2005; 32:703-9.
implications for all dental health care workers in the world. 5. Campo J, Perea MA, del Romero J, Cano J, Hernando V,
We must assume that it is almost impossible to recognize if et al. Oral transmission of HIV, reality or fiction? An
patients have, or are liable to have, HIV infection, and this update. Oral Dis 12: 219-228. 14. Scully C, Greenspan
knowledge must be reflected in the maintenance and JS (2006) Human immun nodeficiency virus (HIV)
continued updating of infection control policies in clinical transmission in dentistry. J Dent Res. 2006; 85:794-800.
practice. For that reason, it is necessary to integrate 6. Ceballos-Salobreña A, Gaitán-Cepeda LA, Ceballos-
continuous and careful medical care of oral health as a part of Garcia L, Lezama-Del Valle D. Oral lesions in
the treatment for people with HIV/AIDS. The prevention, HIV/AIDS patients undergoing highly active
diagnosis, treatment, and control of these oral manifestations antiretroviral treatment including protease inhibitors: A
should be part of the objectives of every dental health new face of oral AIDS? AIDS Patient Care STDS. 2000;
professional; these professionals should hereafter also be 14:627-35.
informed about the relationship between immunological 7. Cherry-Peppers G, Daniels CO, Meeks V, Sanders CF,
markers and the appearance of oral lesions. Key elements of Reznik D. Oral manifestations in the era of HAART. J
the response to the HIV/AIDS epidemic include the support Natl Med Assoc. 2003; 95:21S-32S.
of the World Universal Public Health System, the provision 8. Classifi Cation. and diagnostic criteria for oral lesions in
of universal access to highly active antiretroviral therapy, and HIV infection. EC-Clearinghouse on Oral Problems
the creation of harm reduction projects that are politically and Related to HIV Infection and WHO Collaborating Centre
financially supported by federal governments An on Oral Manifestations of the Immunodefi ciency Virus.
understanding of the immunopathogenesis of HIV infection is J Oral Pathol Med. 1993; 22(7):289-91.
a major prerequisite for rationally improving therapeutic 9. Dongo M, Gonçalves LS, Ferreira SM, Noce CW, Dias
strategies and developing immunotherapeutics and EP, Júnior AS. Gender differences in oral manifestations
prophylactic vaccines. A better understanding of the oral among HIV-infected Brazilian adults. Int Dent J. 2013;
manifestations of HIV/AIDS in both adults and children has 63(4):189-95.
implications for all dental health care workers in the world. 10. Ficarra G, Shillitoe EJ. HIV-related infections of the oral
We must assume that it is almost impossible to recognize if cavity. Crit Rev Oral Biol Med. 1992; 3:207-31.
patients have, or are liable to have, HIV infection, and this 11. Fraser VJ, Powderly WG. Risks of HIV infection in the
knowledge must be reflected in the maintenance and health care setting. Annu Rev Med. 1995; 46:203-211.
continued updating of infection control policies in clinical 12. French MA, Herring BL, Kaldor JM, Sayer DC, Furner
practice. For that reason, it is necessary to integrate V et al. Intrafamilial transmission of HIV-1 infection
continuous and careful medical care of oral health as a part of from individuals with unrecognized HIV-1 infection.
the treatment for people with HIV/AIDS. The prevention, AIDS. 2003; 17:1977-1981.
diagnosis, treatment, and control of these oral manifestations 13. Glick M, Cohen SG, Cheney RT, Crooks GW,
should be part of the objectives of every dental health Greenberg MS. Oral manifestation of disseminated
professional; these professionals should hereafter also be Cryptococcus neoformans in a patient with acquired
informed about the relationship between immunological immune deficiency syndrome. Oral Surg Oral Med Oral
markers and the appearance of oral lesions. Key elements of Pathol. 1987; 64:454-9.
6
International Journal of Medicine Research

14. Global AIDS Update UNAIDS report. 2016. 31. National AIDS Control Organization. Prevention of HIV
15. Gonçalves LS, Gonçalves BM, Fontes TV. Periodontal Transmission in health care Settings. In: Training
disease in HIV-infected adults in the HAART era: Module on HIV Infection & AIDS for Medical Officers
Clinical, immunological, and microbiological aspects. 3-16. 2. Health protection agency (2006) Evidence of
Arch Oral Biol. 2013; 58(10):1385-96. continuing increase in the HIV prevalence among
16. Grando LJ, Yurgel LS, Machado DC, Nachman S, injecting drug users in England and Wales. CDR
Ferguson F, Berentsen B et al. The association between Weekly. 2003; 16:51.
oral manifestations and the socioeconomic and cultural 32. Navazesh M, Mulligan R, Karim R, Mack WJ, Ram S,
characteristics of HIV-infected children in Brazil and in Seirawan H et al. Oral Substudy of the Women's
the United States of America. Rev Panam Salud Interagency HIV Study Collaborative Study Group.
Publica. 2003; 14:112-8. Effect of HAART on salivary gland function in the
17. Greenspan D, Canchola AJ, MacPhail LA, Cheikh B, Women's Interagency HIV Study (WIHS). Oral Dis.
Greenspan JS. Effect of highly active antiretroviral 2009; 15:52-60.
therapy on frequency of oral warts. Lancet. 2001; 33. Nokta M. Oral manifestations associated with HIV
357:1411-2. infection. Curr HIV/AIDS Rep. 2008; 5(1):5-12.
18. Hodgson TA, Greenspan D, Greenspan JS. Oral lesions 34. Ozbayrak S, Dumlu A, Ercalik-Yalcinkaya S. Treatment
of HIV disease and HAART in industrialized countries. of melanin-pigmented gingiva and oral mucosa by CO2
Adv Dent Res. 2006; 19:57-62. laser. Oral Surg Oral Med Oral Pathol Oral Radiol
19. Interim WHO clinical staging of HIV/AIDS and Endod. 2000; 90(1):14-5.
HIV/AIDS case definitions for surveillance: WHO- 35. Patil K, Mahima VG, Srikanth HS. Extranodal
HIV. 2005, 2. nonHodgkin's lymphoma of the gingiva in an HIV
20. Johnson NW. The mouth in HIV/AIDS: markers of seropositive patient. Indian J Sex Transm Dis. 2010;
disease status and management challenges for the dental 31(2):112-5.
profession. Aust Dent J. 2010; 55(Suppl 1):85-102. 36. Patton LL, Ramirez-Amador V, Anaya-Saavedra G,
21. Klein RS, Harris CA, Small CB, Moll B, Lesser M, Nittayananta W, Carrozzo M, Ranganathan K. Urban
Friedland GH. Oral candidiasis in high risk patients as legends series: oral manifestations of HIV infection. Oral
the initial manifestation of the acquired Dis. 2013; 19(6):533-50.
immunodeficiency syndrome. N Engl J Med. 1984; 37. Petersen PE. Policy for prevention of oral manifestations
311:354-8. in HIV/AIDS: the approach of the WHO. Global Oral
22. Kura MM, Khemani UN, Lanjewar DN, Raghuwanshi Health Program. Adv Dent Res. 2006; 19:17-20.
SR, Chitale AR, Joshi SR. Kaposi's sarcoma in a patient 38. Ramírez-Amador V, Esquivel-Pedraza L, Sierra-Madero
with AIDS. J Assoc Physicians India. 2008; 56:262-4. J, Anaya-Saavedra G, González-Ramírez I, Ponce-de-
23. Laskaris G. Color atlas of oral diseases. 3rd edition. New León S. The Changing Clinical Spectrum of Human
York: Curchill Linigvstone. 2003. Immunodefi ciency Virus (HIV)-Related Oral Lesions in
24. Lortholary O, Petrikkos G, Akova M, Arendrup MC, 1,000 Consecutive Patients: A 12-Year Study in a
Arikan-Akdagli S, Bassetti M et al. ESCMID Fungal Referral Center in Mexico. Medicine (Baltimore). 2003;
Infection Study Group. ESCMID guideline for the 82:39-50.
diagnosis and management of Candida diseases: patients 39. Ramírez-Amador V, Ponce-de-León S, Anaya-Saavedra
with HIV infection or AIDS. 2012. G, Crabtree Ramírez B, Sierra-Madero J. Oral lesions as
25. Lourenço AG, Motta AC, Figueiredo LT, Machado AA, clinical markers of highly active antiretroviral therapy
Komesu MC. Oral lesions associated with HIV infection failure:a nested case-control study in Mexico City. Clin
before and during the antiretroviral therapy era in Infect Dis. 2007; 45:925-32.
Ribeirão Preto, Brazil. J Oral Sci. 2011; 53(3):379-85. 40. Reznik DA. Oral manifestations of HIV disease. Top
26. Lynch DP, Naftolin LZ. Oral Cryptococcus neoformans HIV Med. 2006; 13(5):143-8.
infection in AIDS. Oral Surg Oral Med Oral 41. Rimkuvienė J. Priešvėžiniai ir kiti burnos gleivinės
Pathol. 1987; 64:449-53. pakitimai (Precancerous and other oral lesions). Vilnius:
27. Marcus R, Kay K, Mann JM. Transmission of human Progretus. 2003, 106-115.
immunodeficiency virus (HIV) in health-care settings 42. Rothenberg RB, Scarlett M, del Rio C, Reznik D,
worldwide. Bull World Health Organ. 1989; 67:577- O’Daniels C. Oral transmission of HIV. AIDS 12: 2095-
582. 2105. 6. Najioullah F, Barlet V, Renaudier P, Guitton C,
28. Mataftsi M, Skoura L, Sakellari D. HIV infection and Crova P, et al. (2004) Failure and success of HIV tests
periodontal diseases: an overview of the post-HAART for the prevention of HIV-1 transmission by blood and
era. Oral Dis. 2011; 17(1):13-25. tissue donations. J Med Virol. 1998; 73:347-349.
29. Metsch LR, Pereyra M, Purcell DW, Latkin CA, Malow 43. Ryder MI, Nittayananta W, Coogan M, Greenspan D,
R et al. Correlates of lending needles/syringes among Greenspan JS. Periodontal disease in HIV/AIDS.
HIV-seropositive injection drug users. J Acquir Immune Periodontol. 2000; 60(1):78-97.
Defic Syndr. 2007; 46:S72-S79. 44. Salvatori F, De Martino M, Galli L, Vierucci A, Chieco-
30. Moore LV, Moore WE, Riley C, Brooks CN, Burmeister Bianchi L et al. Horizontal transmission of human
JA, Smibert RM. Periodontal microflora of HIV positive immunodeficiency virus type 1 from father to child.
subjects with gingivitis or adult periodontitis. J AIDS Res Hum Retroviruses. 1998; 14:1679-1685.
Periodontol. 1993; 64:48-56. 45. Schiodt M, Pindborg JJ. AIDS and the oral cavity:
Epidemiology and clinical oral manifestations of human
7
International Journal of Medicine Research

immune deficiency virus infection: A review. Int J Oral

Maxillofac Surg. 1987; 16:1-14.
46. Scully C, Porter S. HIV topic update: oro-genital
transmission of HIV. Oral Dis. 2000; 6:92-98.
47. Sen S, Mandal S, Bhattacharya S, Halder S, Bhaumik P.
Oral manifestations in human immunodefi ciency virus
infected patients. Indian J Dermatol. 2010; 55(1):116-8.
48. Shiboski CH, Patton LL, Webster-Cyriaque JY,
Greenspan D, Traboulsi RS, Ghannoum M et al. Oral
HIV/AIDS Research Alliance, Subcommittee of the
AIDS Clinical Trial Group. The Oral HIV/AIDS
Research Alliance: updated case defi nitions of oral
disease endpoints. J Oral Pathol Med. 2009; 38:481-8.
49. Silverman S, Jr, Migliorati CA, Lozada-Nur F,
Greenspan D, Conant MA. Oral findings in people with
or at risk for AIDS: A study of 375 homosexual males. J
Am Dent Assoc. 1986; 112:187-92.
50. Sirois DA. Oral manifestations of HIV disease. Mt Sinai
J Med. 1998; 65:322-32.
51. Sontakke SA, Umarji HR, Karjodkar F. Comparison of
oral manifestations with CD4 count in HIV-infected
patients. Indian J Dent Res. 2011; 22(5):732.
52. Syrjanen S, Laine P, Niemela M, Happonen RP. Oral
hairy leukoplakia is not a specific sign of HIV infection
but related to immunosuppression in general. J Oral
Pathol Med. 1989; 18:28-31.
53. Thompson GR 3rd, Patel PK, Kirkpatrick WR,
Westbrook SD, Berg D, Erlandsen J et al. Oropharyngeal
candidiasis in the era of antiretroviral therapy. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod. 2010;
109(4):488-95.
54. Umadevi KM, Ranganathan K, Pavithra S et al. Oral
lesions among persons with HIV disease with and
without highly active antiretroviral therapy in southern
India. J Oral Pathol Med. 2007; 36:136-141.
55. UNAIDS Report on Global AIDS Epidemic 2016 WHO.
2016.