Oral Manifestations of HIV/AIDS

Classification

Group 1 - Strongly Associated (High-Yield)

1. Oral Candidiasis (Thrush)

• Most common oral manifestation of HIV/AIDS; affects >80% of AIDS patients.
• Caused by Candida albicans (part of normal flora in ~50% of the population; overgrows with immunosuppression).
• Forms:
  • Pseudomembranous (Thrush): White, gray, curd-like plaques on tongue and buccal mucosa - can be scraped off to reveal an erythematous base. This is the hallmark finding.
  • Erythematous: Red patches on hard/soft palate or dorsum of tongue.
  • Hyperplastic: Adherent white plaques that cannot be scraped off.
• CD4 correlation: Thrush increases sharply when CD4 <500 cells/mm³.
• Diagnosis: KOH smear showing pseudohyphae.
• Treatment: Fluconazole 100 mg OD for 7-14 days (first-line); clotrimazole/nystatin (second-line).
• Robbins Pathologic Basis of Disease

2. Oral Hairy Leukoplakia (OHL)

• Caused by Epstein-Barr virus (EBV) reactivation in HIV-infected individuals.
• Occurs in 3-12% of HIV-positive patients.
• Site: Lateral border of the tongue (most characteristic location).
• Appearance: White, fluffy ("hairy"), corrugated/shaggy thickenings that cannot be scraped off (unlike thrush).
• Histology: Hyperparakeratosis, acanthosis, characteristic "balloon cells" in upper spinous layer, EBV detectable in basal epithelium.
• Significance: Its presence in an otherwise asymptomatic patient is a strong indicator of HIV with moderate-to-severe immunosuppression. May portend development of full AIDS.
• Key distinction from candidiasis: OHL is adherent; lesion persists after antifungal therapy.
• Does not undergo malignant transformation.
• Cummings Otolaryngology; Robbins Pathologic Basis of Disease

3. HIV-Associated Periodontal Disease

• Fiery red band of marginal gingiva - out of proportion to the degree of dental plaque.
• Prone to hemorrhage; persists despite dental plaque removal.
• Often involves Candida and gram-negative organisms.

• Spectrum of the same pathology, with progressive gingival recession, bleeding, tissue sloughing, pain, malodor, and loss of interdental papillae.
• Rapid and painful destruction of bone and soft tissue.

• Accelerated progression of otherwise-common periodontal disease.

Gingival disease that is necrotizing or ulcerative in a previously healthy young adult is highly suggestive of HIV and warrants serologic testing.

• KJ Lee's Essential Otolaryngology; Goldman-Cecil Medicine

4. Kaposi Sarcoma (KS) of the Oral Cavity

• AIDS-defining illness. Caused by HHV-8 (Human Herpesvirus-8).
• Oral cavity is a common early site in AIDS-associated KS (in contrast to classic KS).
• A solitary genital or oral lesion may be the first manifestation of AIDS-KS.
• Appearance: Nontender, well-circumscribed, slightly raised violaceous (purple/red) lesion on the palate or gingiva.
• Diagnosis: Requires biopsy (spindle cell proliferation with slit-like vascular spaces).
• Treatment: Topical therapy is palliative; systemic chemotherapy for advanced disease.
• Tintinalli's Emergency Medicine; Campbell-Walsh Urology; Harrison's Principles

Group 2 - Less Commonly Associated

5. Recurrent Aphthous Stomatitis (RAS) / Aphthous Ulcers

• Painful oral ulcerations that recur; can be major, minor, or herpetiform type.
• Major aphthous ulcers in HIV are larger, deeper, and more persistent than in immunocompetent patients.
• Common in HIV/AIDS patients; listed as Group 1 lesion in some classifications.
• Cummings Otolaryngology

6. Herpes Simplex Virus (HSV) Stomatitis

• HSV-1 seropositivity approaches 95% in the HIV-positive community.
• Herpetic lesions are particularly persistent when CD4 <100 cells/μL.
• Appearance: Painful vesicular oral and perioral lesions that rupture and crust.
• Diagnosis: Multinucleated giant cells on Tzanck smear; viral culture.
• Treatment: Oral acyclovir/valacyclovir; IV acyclovir for immunocompromised patients with severe disease.
• Cummings Otolaryngology; Tintinalli's Emergency Medicine

7. Salivary Gland Disease & Other Notable Lesions

• Bilateral parotid enlargement (cystic lymphoid hyperplasia / lymphoepithelial cysts) - common ENT/oral finding in HIV.
• Can cause xerostomia (dry mouth), which secondarily promotes oral candidiasis.

• Non-Hodgkin Lymphoma: Rapidly enlarging oral lesion, commonly involving Waldeyer's ring; can mimic lymphadenopathy or benign ulceration.
• CMV oral ulcerations: CMV co-infects 90% of HIV patients; can cause oral ulcers, especially with advanced immunosuppression.
• Oral HPV/warts: Common, plantar, flat, oral, and genital warts all increase with HIV; warty keratoses at the angle of the mouth are characteristic of HPV in AIDS patients.
• Deep fungal infections (histoplasmosis, cryptococcosis): Oral lesions may be the first manifestation of disseminated histoplasmosis in HIV/AIDS patients.

Summary Table for Exam

• Sources: Robbins & Cotran Pathologic Basis of Disease; Cummings Otolaryngology Head and Neck Surgery; KJ Lee's Essential Otolaryngology; Tintinalli's Emergency Medicine; Goldman-Cecil Medicine