Mouth Problems

Many of the complications of HIV infection involve the mouth. Because of this, it is important for all people with HIV infection to inspect their mouths regularly, pay careful attention to oral hygiene, and get regular dental care.

Pain in the Mouth

The most common causes of pain in the mouth include thrush, oral hairy leukoplakia, herpes simplex, aphthous ulcers, and Kaposi’s sarcoma. All of these are described below. Most of them can be diagnosed largely on the basis of their appearance. The biggest problem with pain in the mouth is adequate nutrition. It obviously makes sense to avoid foods that cause pain: foods that are highly seasoned, for instance, or citrus fruits or certain vegetables that are highly acidic. Also avoid foods that are very hot or very cold. Instead, eat bland foods, foods that are soft, and nutritious liquids like milkshakes. Exactly what you eat should suit your own preference, as long as it is nutritious. (See the following sec­tion, “Problems of the Digestive System.”)

White Patches in the Mouth

White patches in the mouth, sometimes painful, often painless, are most commonly symptoms of thrush, and less commonly symptoms of oral hairy leukoplakia.

Thrush. Thrush is a yeast infection of the mouth caused by the fungus Candida albicans. Candida albicans is found in the mouths of most peo­ple; thrush occurs only when the fungus begins growing out of control. Since most people have the fungus in their mouths, thrush is not con­sidered contagious. Thrush is commonly viewed more as a nuisance than as a serious problem.

Symptoms include white or grayish-white patches that look a little like cottage cheese along the gums, along the inside of the cheeks, or on the tongue. Thrush can be unnoticeable, or it can cause pain severe enough to interfere with chewing or swallowing.

Thrush indicates advanced HIV infection but is often the first HIV- related complication. It is more frequent in people taking cortisone and antibiotics. Thrush virtually never occurs without some underlying med­ical problem. It is also one of the infections people with HIV infection who are not on HAART most frequently develop: about 80 percent of those with HIV infection have thrush at some time. The CD4 count is usually 50 to 250.

What appear to be patches of thrush can also simply be food parti­cles in the mouth. The distinction is easily made by rinsing the mouth to remove food particles. Thrush cannot be removed without direct scrap­ing, and scraping will leave an inflamed spot where the white patch was. Diagnosis of thrush in the mouth can be done by a physician simply in­specting the mouth; microscopic examination of the patch to identify the fungus can be done but is usually not necessary. Diagnosis of thrush in the esophagus is usually presumed if thrush is in the mouth and if peo­ple also have trouble swallowing. The distinction is important because thrush in the esophagus is treated differently and because it means that HIV disease is more advanced.

Common treatments for thrush include gargling with and then swal­lowing nystatin solution, sucking clotrimazole troches, or taking such pills as fluconazole (Diflucan) or itraconazole (Sporanox). All of these are prescription drugs. If any of the drugs fail, another will usually work. Thrush is generally controlled after one or two weeks of treatment. Oc­casionally people do not do well with any of these treatments, either be­cause the diagnosis was wrong to begin with or because the infection has extended to the esophagus.

In people with HIV infection, thrush tends to recur once treatment is discontinued.

to the drug and the infection to become progressively difficult to treat. The best ploy is to avoid long-term fluconazole, and to try to increase the CD4 count, avoid antibiotics, and when thrush recurs, use the gar­gles or troches.

Oral hairy leukoplakia (OHL). White patches on the tongue, along the side of the tongue, and occasionally in adjacent areas in the mouth are symptoms not only of thrush, but also of oral hairy leukoplakia (OHL). Oral hairy leukoplakia is named for its location in the mouth (oral), and its appearance as white patches (leukoplakia) with microscopic hairlike protrusions (hairy) from the tongue’s surface. The patches can be a frac­tion of an inch in diameter or they can coat most of the tongue. Some people with oral hairy leukoplakia have a sore mouth and occasionally have voice changes.

The symptoms of OHL resemble the symptoms of thrush, though OHL is somewhat less common. Sometimes the first clue to a diagnosis of OHL is that the person does not respond to treatment for thrush. The best way to distinguish clearly between thrush and OHL is to look at tissue taken by biopsy under the microscope. Often the patch itself is sufficiently distinctive in appearance to make a biopsy unnecessary. Most people discover the patches themselves, when they examine their mouths.

There is little need for treatment except for pain, for interference with nutrition, or for voice changes. The usual treatment is HAART, but if that doesn’t work, you can use acyclovir, taken by mouth. Occasion­ally other antiviral drugs like ganciclovir are also successful. The patches disappear within two or three weeks when treated, but like thrush, they recur when the medicine is discontinued.

Sores, Blisters, or Ulcers on the Lips or in the Mouth

Sores or blisters on the lips or in the mouth or throat are usually caused by one of two conditions. One is an infection by the virus herpes simplex; the other is a condition called aphthous ulcers, whose cause is unknown.

Herpes simplex. The sores in the mouth called cold sores or fever blis­ters can be an infection caused by the herpes simplex virus. The sores usually start as an area of irritation or pain that becomes inflamed, then forms a watery blister that breaks and forms an open sore with pus, and finally scabs over and heals. The sores occur on the lips, in the mouth along the cheeks, on the roof of the mouth or palate, or on the back of the mouth. These sores are usually round or oval, measure about a quar­ter of an inch or less in diameter, and can have a characteristic red bor­der. The sores of herpes can be very painful and often interfere with chewing; when in the back of the mouth or in the esophagus, the sores can interfere with swallowing.

Herpes simplex remains in the nerves serving the area of the mouth for the remainder of the person’s life; it can be reactivated and cause new sores. The interval between outbreaks is unpredictable, but outbreaks are frequently associated with stress, exposure to sunlight, surgery, colds, menstrual periods, fever, and pneumonia. These associations ex­plain the common name of these sores: cold sores or fever blisters.

Infections of the mouth from herpes simplex are extremely common: probably 50 percent of healthy Americans have had this infection at some time. Herpes simplex infections of the mouth are more frequent, more severe, last for longer periods and are harder to treat in people with advanced HIV infection.

The usual treatment is with acyclovir (Zovirax), famciclovir (Fam­vir), or valacyclovir (Valtrex) taken by mouth, or penciclovir applied to the sores. All treatments work best if taken early; often they’re not taken at all because the benefit from them is so modest.

Aphthous ulcers. Aphthous ulcers are open sores that may look like her­pes simplex sores, occurring in the mouth, usually on the inside surface of the cheeks, on the gums, and on the tongue. Aphthous ulcers are usually very painful, especially when touched or when food or liquids pass over them. The pain can severely limit a person’s desire to eat. Like thrush and herpes, the ulcers may extend to the esophagus and impair the ability to swallow. The ulcers can occur in people with or without HIV infection, but they are more common and severe in those with HIV infection. They can occur when the CD4 count is high.

Aphthous ulcers are often mistaken for herpes simplex infection, which they resemble. But laboratory tests of aphthous ulcers do not show any specific microbe, and the treatment for herpes simplex infec­tion is unsuccessful in treating aphthous ulcers. The cause of these ul­cers is not known. Aphthous ulcers are not transmitted to others. They may recur over a period of many years.

The usual treatment is to rinse the mouth with viscous lidocaine (2% concentration) or to take a combination of viscous lidocaine and benadryl by mouth. Both are available without prescription. Severe ulcers may re­quire prescription drugs such as corticosteroids taken either as a pill or as a gel applied to the surface of the ulcer, or thalidomide in pill form. Aph­thous ulcers in the esophagus are usually treated with corticosteroids or thalidomide and usually respond well. Thalidomide is effective but very hard to get because it is a major cause of birth defects in pregnant women.

Bluish or Purplish Bumps in the Mouth

Raised or thickened tissue that is bluish or purplish is a symptom of Ka­posi’s sarcoma (KS) in the mouth. Most people with KS in the mouth also have KS on the skin (see above, “Skin Problems”), though this is not invariably so. KS can appear anywhere in the mouth but most fre­quently appears on the roof, or hard palate. The tumors can cover a rel­atively small area or they can be spread over the entire palate. Common complications of KS in the mouth include pain, bleeding, or intrusion of the tumors onto the teeth causing tooth loss. In many cases, KS in the mouth causes few problems; it either remains stable for prolonged peri­ods or simply grows very slowly.

In the absence of pain, bleeding, or intrusion of KS onto the teeth, there is little reason to treat the tumors. When treatment is appropriate, the KS tumors can be surgically removed if small, or treated with radi­ation, lasers, or chemotherapy using cancer drugs. Which treatment is used will depend on the location of KS tumors, the severity of the symp­toms, and the bias of the physician. The person with KS obviously needs to agree to the treatment the physician recommends; agreement should be based on an explanation of the benefits, the costs, the convenience, and the side effects of various treatments.

Bleeding Gums

Bleeding gums are usually a symptom of gingivitis. Gingiva is the med­ical term for the gums, and itis means inflammation. Some people have severe bleeding of the gums, severe pain, and severe gingival disease with rapid tooth loss over a period as short as two or three months. This rapid loss of the structure that supports the teeth is called periodontitis.

The cause of gingivitis and periodontitis is not clearly established. Most dentists think the cause is the same bacteria normally present in the mouth, which have, for some reason, gone out of control. Like other conditions, gingivitis is also common in people without HIV infection, but it is more frequent and more severe in those with the infection. Care must be taken to distinguish gum bleeding caused by gingivitis from bleeding caused by the low numbers of blood platelets that are a part of ITP, which is an entirely different complication of HIV infection. The distinction between the two is easily made by a blood test that counts the number of platelets, or by consultation with a dentist, who will iden­tify diseases of the teeth and gums.

For gingivitis and periodontitis, the treatment is usually mouth­washes containing germicides, such as chlorhexidine in a concentration of 0.12 percent (Peridex) or povidone-iodine (Betadine). Both can be purchased in most pharmacies; Peridex requires a prescription, and Be­tadine does not. For people who have extensive periodontitis, the den­tal procedure usually recommended is removal of plaque by planing and scaling, a procedure done by dentists. In many cases, antibiotic treat­ment with metronidazole (Flagyl) is also recommended. These treat­ments should be accompanied by rigorously doing what your dentist has always told you to do: use dental floss, brush regularly with a soft tooth­brush, and see a dentist regularly.