Oral manifestations are common for people living with Human Immunodeficiency Virus (HIV), often indicating a changing immune status. These lesions, sometimes called “sores,” appear because the virus progressively weakens the body’s defenses, allowing various opportunistic infections and conditions to take hold in the mouth. Understanding the specific appearance and type of these oral issues provides important clues about the progression of HIV infection and is highly relevant to clinical care.
Why HIV Causes Lesions in the Mouth
The underlying mechanism for oral lesions in HIV infection is the gradual destruction of CD4+ T-lymphocytes. HIV specifically targets and depletes these white blood cells, which coordinate the body’s defense against foreign invaders like fungi, viruses, and bacteria. As the CD4+ T-cell count declines, the immune system loses its ability to keep naturally occurring organisms in check, particularly those thriving in the oral cavity. This decline creates an environment where opportunistic pathogens multiply rapidly and cause visible lesions or ulcers.
The mouth naturally hosts a diverse community of microorganisms that are harmless when immunity is robust. When the CD4 count falls, these organisms become pathogenic, resulting in various oral diseases. The severity and frequency of these manifestations correlate with the degree of immune suppression, with the most severe lesions often observed when the CD4+ T-cell count drops significantly below 200 cells per cubic millimeter.
Fungal and Viral Oral Manifestations
One of the most common manifestations is Oral Candidiasis, often called thrush, a fungal infection caused by Candida albicans. This infection appears as creamy white or yellowish plaques that resemble cottage cheese, found on the tongue, inner cheeks, or palate. The hallmark of thrush is that these plaques can usually be scraped off, revealing reddened, sometimes bleeding, tissue underneath. A less common form, erythematous candidiasis, may instead appear as smooth, red patches, most often located on the hard or soft palate.
Another distinct presentation is Oral Hairy Leukoplakia (OHL), caused by the Epstein-Barr virus (EBV) reactivating under immunosuppression. OHL presents as white patches with a characteristic corrugated, folded, or “hairy” texture, typically appearing on the sides of the tongue. Unlike thrush, these lesions are firmly attached to the tissue and cannot be scraped away. OHL is highly indicative of a weakened immune system and often occurs early in the course of HIV infection.
Oral lesions caused by the Herpes Simplex Virus (HSV) become more frequent and severe with HIV infection. These typically begin as clusters of small, fluid-filled blisters that quickly rupture to form painful, shallow ulcers. In individuals with HIV, these outbreaks can be larger, more persistent, and more widespread, often affecting the lips, hard palate, and gingiva. The recurrence and severity of these viral ulcers signal a reduced capacity to manage latent viral infections.
Other Significant Lesions and Ulcers
In cases of advanced immune deficiency, a more serious lesion is Kaposi’s Sarcoma (KS), a malignancy caused by Human Herpesvirus 8 (HHV-8). Oral KS lesions typically manifest as flat patches or raised plaques ranging in color from red to purple or dark brown. These spots often first appear on the palate, but they can also be found on the gums or tongue. KS is considered an AIDS-defining illness, indicating a profound level of immune compromise.
Recurrent Aphthous Ulcers, commonly known as canker sores, are frequently observed and are generally more severe in people with HIV. These lesions are well-defined, painful, round or oval ulcers with a depressed, yellowish-gray center and a bright red border. While common in the general population, HIV-related aphthous ulcers can be significantly larger, deeper, and more debilitating, often persisting for weeks or months.
HIV-Associated Periodontal Disease involves destructive inflammation of the gums and surrounding tissues that can lead to ulceration. This condition can present as fiery red, painful, and easily bleeding gums, or as Necrotizing Ulcerative Periodontitis (NUP). NUP is a severe form characterized by the rapid loss of gum tissue between the teeth, exposed bone, and painful crater-like ulcers on the gingiva. These periodontal issues reflect a breakdown in the local immune response against oral bacteria.
Diagnosis and Management of Oral Symptoms
Any persistent or unusual oral change should prompt an immediate consultation with a healthcare provider or dentist familiar with HIV care. A professional diagnosis is necessary because several different conditions can look similar, such as distinguishing removable thrush plaques from the non-removable lesions of Oral Hairy Leukoplakia. Diagnostic methods may include a clinical examination, taking a swab for microscopic analysis of fungi, or a small biopsy for definitive identification of a lesion like Kaposi’s Sarcoma.
Management of these oral symptoms is a dual-pronged approach addressing both the local infection and the systemic immune deficiency. Localized treatments involve specific medications, such as topical or systemic antifungal agents like fluconazole for candidiasis, or antiviral drugs for HSV outbreaks. These treatments aim to resolve immediate discomfort and prevent the spread of the infection.
The most effective long-term solution for preventing the recurrence of most HIV-related oral lesions is the consistent use of Antiretroviral Therapy (ART). ART works by suppressing the HIV virus, allowing the CD4+ T-cell count to rebound and restoring the immune system’s capacity to fight opportunistic infections. As immune function improves, the incidence and severity of oral symptoms typically decrease dramatically. Therefore, new or worsening oral lesions often signal a need to evaluate the effectiveness of the current ART regimen.