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Clinical

Oral manifestations of human
immunodeficiency virus
HIV is a viral infection that progressively damages the immune system. Relatively late in the infection,
oral signs can appear which signal that significant damage to the immune system has occurred.
This article describes these conditions in order to assist oral health professionals recognize them

H

uman
immunodeficiency
virus (HIV) is an infection
that progressively damages the
immune system over a number
of years. Eventually the immune system
becomes so damaged that infections which
would not normally present in individuals
with a healthy immune system become
apparent. These so-called opportunistic
infections occur as a result of an opportunity
afforded to the microorganism which causes
the infection by a deficiency in the person’s
immune system (Underwood and Cross,
2009). These opportunistic infections can
occur in most of the organ systems within
the body, including the skin, brain, lungs,
gastrointestinal tract including the oral
cavity (Baggaley, 2008).
In this article the conditions that affect
the oral cavity, which may signal that the
immune system is incompetent, will be
appraised to assist dental nurses in the
recognition and timely referral of these
patients so that appropriate testing and
treatment can be provided.

The immune system and
immunocompromized
states
The immune system consists of
multiple cells, chemical messengers and
Chris Mulryan is a senior lecturer
in Health, University of Bolton
Email: C.Mulryan@bolton.ac.uk

564 

proteins that work together to protect
the body’s internal environment from
microorganisms whose aim is to exploit
the body’s environment in order to
sustain their own interests (Greenwood et
al, 2007). When this defence is breached
an infection is said to occur. Occasionally
the immune system will fail in such a
way that allows microorganisms, which
are normally dealt with by the immune
system, efficiently to take hold causing
what is referred to as an opportunistic
infection (Peakman and Vergani, 2009).
As well as providing protection from
infections the immune system also
provides a degree of protection against
the growth of malignant (cancerous)
cells and as such those people with a
defective immune system are also at risk
of developing certain types of malignancy
(Gervaz et al, 2011).
When the immune system fails
the person is referred to as being
immunocompromized. The cause of
such a state can be defined as either
primary or secondary. Primary immune
deficiency states are those that arise from
a deficiency of a specific component of the
immune system. These primary immune
deficiencies are rare and have a genetic
origin. They occur as a result of the
body’s inability to produce certain types
of immune cell or proteins (Griffith et
al, 2009). As primary immune deficiency
states are genetic in origin they are present
at birth.
Secondary immune deficiency states,
in contrast, are acquired during life.

These disorders have a range of causes
and may be due to medical treatments
(Joint Formulary Committee, 2011),
malignancies (Watson et al, 2006) or
infections (Baggaley, 2008).
The medical treatments that are
particularly implicated in causing
immune deficiency are those that are
used in the treatment of inflammatory
conditions such as rheumatoid arthritis,
drugs used to reduce the risk of organ
rejection in transplant patients and those
that can have a suppressive effect on
bone marrow such as anti-cancer and
anti-thyroid medicines (Joint Formulary
Committee, 2011). Malignancies that
infiltrate the bone marrow or cause
significant inflammation can suppress
immune function by reducing the
number of functional white blood cells
that are produced, or by increasing the
rate at which these are used in the tissues.
Likewise, immune function will be
damaged in patients with haematological
malignancies (Watson et al, 2006).
HIV infects a specific type of
white blood cell known as the CD4 T
lymphocyte. These cells act as a linchpin
in the immune response and serve to
activate, direct and support the actions
of other immune cells. When infected
with HIV, CD4 T lymphocytes, instead
of acting as important mediators of the
immune response, start to manufacture
copies of HIV that exit the cell and go
on to infect other CD4 T lymphocytes.
Several years after infection with HIV
the number of CD4 T lymphocytes starts
Dental Nursing October 2011 Vol 7 No 10

appropriate referral for HIV testing is advised. more than a quarter of the people living with HIV are unaware of the fact that they are infected. NICE have issued two sets of guidelines which intend to increase the number of HIV tests performed in patient populations with an epidemiological risk of having been exposed to HIV (NICE 2011a. 2011a). While these conditions can occur for reasons other than HIV infection. Despite this. additional strategies can assist in the detection of patients with HIV. 2011b). In the HIV-positive individual candidiasis usually presents when the level of CD4 T lymphocytes has fallen to 200 cells/mm3 or less (Bodhade et al. alternatively recent illness may also precipitate an episode of the infection. In response to this. the body’s ability to fight off infection is diminished. As there are often oral manifestations of HIV it makes sense that when an oral pathology that may be a feature of HIV infection is detected. 2008). Oral manifestations of immunocompromized states There are a number of oral infections and malignancies that can occur in patients Dental Nursing October 2011 Vol 7 No 10 Figure 1. In turn this results in approximately half of all new cases of HIV being diagnosed late in the course of infection and after a time that the individual would have benefitted from antiretroviral therapy (National Institute for Health and Clinical Excellence (NICE). There is logic to each of these situations as they each represent an interruption to normal immune system function allowing the opportunistic candida to take hold. 2011). for whatever reason or when there is another key healthcare contact such as admission to hospital. They do this by advocating the offer of an HIV test to defined populations whenever blood is taken for laboratory testing. the presence of such conditions should raise the possibility of HIV infection as an underlying pathology. antibiotics or immunosuppressive drugs. Close-up of the white tongue in an adult male patient showing thrush (candidiasis) 565 . This has clinical significance as patients who receive treatment late in the course of their infection do not derive the same benefits as early-treatment patients (Baggley. with HIV. This is quite late in the infection and long after the time that treatment science photo library to fall and. opportunistic microorganisms are given liberty to take hold and cause opportunistic infections. In the dental practice. Oral candidiasis Candidiasis is a fungal yeast infection. At this point. affecting up to 75% of such patients (Tamí-Maury. with it.Clinical HIV The number of people living with HIV in the UK continues to rise (Health Protection Agency. 2008). where blood tests are not routine practice. In non-HIV-infected patients candidiasis usually has an explainable cause such as treatment with inhaled corticosteroids. It can occur in non-HIV infected patients although the incidence of candida infections is much increased in those with HIV infection. 2011). The most common of these include: n Oral candidiasis n Oral hairy leukoplakia n Kaposi’s sarcoma.

2011). Treatment with radiotherapy is often affective in controlling this tumour (Neal and Hoskin. Initially when it was encountered Kaposi’s sarcoma was a cancer often seen in those with late-stage HIV. ribbed ulcer along the edge of the tongue with anti-HIV drugs would have started ideally. Now thanks to modern anti-HIV treatments Kaposi’s sarcoma has again become a rare complication of HIV. however. Immune reconstitution with anti-HIV medicines will also slow the rate of progression and the rate at which new lesions develop. 1986).science photo library Clinical co-infection with Epstein-Barr virus has a role in its pathogenesis (Correnti et al. 2003). Given the prevalence of undiagnosed HIV among community groups in the UK the recognition of Dental Nursing October 2011 Vol 7 No 10 . showing oral thrush (candidiasis) and hairy leukoplakia. It is thought that Kaposi’s sarcoma is a cancer of the vascular endothelial cells (Neal and Hoskin. This can lead to confusion between this condition and leukoplakia. it is important to recognize that anti-HIV treatment to address the underlying immune deficiency is likely to be needed. with white plaques developing on the tongue and mucosa membrane (Figure 1). 2010). 2003). The tongue may also have a smooth appearance and the lips may be cracked. Treatment with traditional topical antifungal medicines is often effective in treating oral candidiasis. Oral hairy leukoplakia is one such condition which presents with a white ridged lesion often on the side of the tongue (Figure  2). although in the untested and untreated individual Kaposi’s sarcoma can still occur. Until the advent of HIV. It is thought to arise as a result of co-infection with human herpesvirus type 8 (Fukumoto et al. The lesions can ulcerate. In hyperplasic candidiasis there are raised white plaques that are not scraped off easily. 2010). Photograph of the tongue of a man suffering from AIDS. Given this broad definition there are obviously several conditions that can fall into this category. Underneath the plaques is a red inflamed base. antifungal drugs will however address only the fungal infection and not the underlying cause and as such the condition may well become recurrent should the underlying immune deficiency not be addressed. In clinical usage it is reserved for white plaques that do not rub off and cannot be clinically identified as another entity (Warnakulasuriya et al. Again. 2007). Kaposi’s sarcoma was a rare cancer affecting mainly Jewish and Mediterranean elderly males (Wilkins. There are three presentations of oral candidiasis. although hyperplasic candidiasis should respond to antifungal treatment unless it is a drugresistant strain. In oral hairy leukoplakia there are often few symptoms other than the lesion itself and as such specific treatment is not necessarily mandated (Wilkins. although a number of patients have drug-resistant strains. 2010). These plaques can be scraped off easily. Oral hairy leukoplakia Leukoplakia—literally meaning white plaque—is a condition that can occur for a range of reasons. Conclusion There is a strong correlation between late HIV infection and the development or oral lesions. Pseudomembranous candidiasis is the classical presentation of oral thrush. Absence of such symptoms should not exclude the 566  possibility of oesophageal candidiasis as this can be asymptomatic in up to 40% of cases (Tavitian et al. For patients with oesophageal infections systemic antifungal therapy will be required. In patients with oral candidiasis pain on or difficulty with swallowing should raise the possibility of oesophageal candidiasis as coexistence is common. bleed and be painful although in others they may be asymptomatic. Its clinical appearance can range from flat or raised legions through to nodules and it has a characteristic dark purple colour (Figure  3). In HIV. It is most often a mucocutaneous disease. In erythematous candidiasis there are no plaques evident although the mouth is painful and reddened. although it can affect internal organs. particularly at the corners. which appears as a white. Kaposi’s sarcoma Figure 2. Treatment with antiviral drugs such as acyclovir can produce remission of this condition although there is a high recurrence rate on withdrawal of treatment. these are: n Pseudomembranous candidiasis n Erythematous candidiasis n Hyperplasic candidiasis.

Spence R. Medical Foundation for AIDS & Sexual Health. Peutherer J.Vergani D (2009) Basic and Clinical Immunology. Front Microbiol 175: Epub 2011 Aug 25 Gervaz P. London Tamí-Maury IM. and management. and Recurrence of Oral Lesions Among HIV-Infected Patients on HAART in Alabama: A Two-Year Longitudinal Study. science photo library „„ Referral for HIV testing can be a life-saving intervention. National Institute for Health and Clinical Excellence (2011a) Increasing the Uptake of HIV Testing to Reduce Undiagnosed Infection and Prevent Transmission Among Men who Have Sex with Men. Walker BR. Hazarey VK (2011) Oral manifestations of HIV infection and their correlation with CD4 count. 2nd edn. Cowan MJ. Ganvir SM. Figure 3. London: 383–408 567 . Arnold. South Med J 104(8): 561–6 Tavitian A. Churchill Livingstone Elsevier. Health Protection Agency. London Peakman M. can be a sign of immunocompromized states. J Allergy Clin Immunol 124(6): 1152–60 Health Protection Agency (2008) HIV in the United Kingdom: 2008 report. Acta Odontol Latinoam 23(2): 117–23 Fukumoto H. London Neal AJ. London Bodhade AS. Ann Intern Med 104(1): 54–5 Underwood JCE. NICE. Photograph of the interior of the mouth of a person suffering from AIDS. Hoskin PJ (2003) Clinical Oncology: Basic Principles and Practice. 3rd edn. Cross SS (2009) General and Systematic Pathology. While many of the oral lesions that occur in HIV do so after the ideal period for starting anti-HIV medicines there still remains benefits from starting patients on anti-HIV medicines at this juncture. Johnson NW. Oxford Griffith LM. 61st ed. Churchill Livingstone Elsevier. London. DN Baggaley R (2008) HIV for Non-HIV Specialists. Rosenthal LE (1986) Oral candidiasis as a marker for esophageal candidiasis in the acquired immunodeficiency syndrome. González X. Oxford University Press. Kanno T. Perrone M. Rivera H (2010) Human papillomavirus and Epstein Barr virus in oral hairy leukoplakia among HIV positive Venezuelan patients. J Oral Pathol Med 36(10): 575–80 Wilkins EGL (2010) HIV infection and AIDS. Avila M. Slack R. World J Gastroenterol 17(25): 2987–91 Greenwood D. Katano H (2011) Pathology of Kaposi’s Sarcoma-Associated Herpesvirus Infection. NICE. van der Waal I (2007) Nomenclature and classification of potentially malignant disorders of the oral mucosa. Oxford Warnakulasuriya S. Twelves C (2006) Oncology. London Joint Formulary Committee (2011) British National Formulary. Churchill Livingstone. Raufman JP. Durmishi Y. Churchill Livingston Elsevier. London National Institute for Health and Clinical Excellence (2011b) Increasing the Uptake of HIV Testing to Reduce Undiagnosed Infection and Prevent Transmission Among Black African Communities Living in England. showing purple lesions caused by Kaposi’s sarcoma affecting the hard palate oral lesions that are suggestive of HIV infection by oral health professionals provides an important opportunity to make a referral for HIV testing. Willig JH. Davidson’s Principles and Practice of Medicine. „„ Opportunistic infections occur when the immune system is damaged „„ Fungal and viral infections. The benefits from earlier treatment will still be increased over delaying treatment to a time when the immune system is more extensively damaged and more serious HIV-associated conditions are able to become established leading the person to Dental Nursing October 2011 Vol 7 No 10 seek medical help where a later diagnosis of HIV could be made. as well as malignancies in the mouth. Ralston SH (eds). „„ Secondary immunodeficiency occurs when a disease process or medical treatment damages the immune system. diagnosis. J Oral Sci 53(2): 203–11 Correnti M. Allal AS. 5th edn. Barer M (eds) (2007) Medical Microbiology. Notarangelo LD et al (2009) Improving cellular therapy for primary immune deficiency diseases: recognition. Jolly PE et al (2011) Prevalence. Oral health professionals then have an important role in identifying those patients with HIVrelated oral lesions so that diagnoses can be made and treatment provided within a timescale which will afford the most benefit for the patient. 17th edn. In: Colledge NR. Hasegawa H. Barrett A. Calmy A. „„ Primary immunodeficiency is caused by an inbuilt deficiency in the immune system arising from a deficiency from a specific immune system product. British Medical Association and Royal Pharmaceutical Society. Morel P (2011) Squamous cell carcinoma of the anus – an opportunistic cancer in HIV-positive male homosexuals. Incidence.Clinical Key points „„ Immunocompromized states can be primary or secondary in origin. Edinburgh Watson M.

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