When the human immune system is compromised, such as by the Human Immunodeficiency Virus (HIV), the body becomes vulnerable to infections that a healthy immune system would typically control. HIV specifically targets CD4 T-cells, which are important components of the body’s defenses. A reduction in these cells means the mouth, a moist environment naturally hosting various microbes, often displays early signs of lowered immunity. The oral symptoms are generally not caused directly by the HIV virus itself, but by opportunistic infections that take advantage of the body’s weakened state. These visual manifestations serve as important indicators that the immune system is struggling.
Fungal Infections and Appearance
One of the most frequent oral signs of lowered immunity is Oral Candidiasis, commonly known as thrush. This fungal infection is caused by an overgrowth of Candida yeast, which naturally lives in the mouth. Visually, it presents as creamy white, plaque-like patches on the tongue, inner cheeks, roof of the mouth, or throat.
These lesions often resemble cottage cheese or milk curds and are typically painless, though they can cause a burning sensation. A distinguishing feature is that these white patches can usually be wiped away, leaving behind a red, inflamed, and sometimes slightly bleeding surface. Candidiasis can also manifest as angular cheilitis, which appears as painful cracking, redness, and inflammation at the corners of the mouth.
Thrush is common in individuals with HIV, especially when CD4 T-cell counts drop below 200 cells/mm³. However, it is not exclusive to this condition. Oral candidiasis also frequently occurs in infants, people who wear dentures, or those using inhaled corticosteroid medications. Observing these signs indicates the need for further medical evaluation.
Viral Manifestations and Appearance
The mouth can also show visual evidence of viral infections that become more pronounced or persistent due to a weakened immune system. A condition strongly associated with HIV is Oral Hairy Leukoplakia (OHL), caused by the Epstein-Barr Virus (EBV). OHL typically presents as white, corrugated, or shaggy patches, most commonly located on the sides of the tongue.
Unlike thrush, OHL lesions cannot be easily scraped off. The texture is often described as “hairy” or “feathery” due to the folds in the tissue, and these lesions are generally painless. OHL is considered a marker of immune suppression, indicating the underlying EBV has reactivated due to the body’s inability to control it.
Another common viral manifestation is the recurrence of Herpes Simplex Virus (HSV) lesions, known as cold sores. In a person with compromised immunity, these lesions are often larger, appear more frequently, and take longer to heal. They present as clusters of small, painful, fluid-filled blisters that eventually break open, crust over, and ulcerate. While typical cold sores appear on the lips, severe or persistent HSV in individuals with HIV can sometimes involve the gums or other parts of the oral cavity.
Severe Gum Disease and Other Lesions
Certain oral conditions indicate more advanced or untreated immune suppression. Among these are the severe forms of gum disease known as Necrotizing Ulcerative Gingivitis (NUG) and Necrotizing Ulcerative Periodontitis (NUP). These conditions are characterized by rapid tissue destruction and severe pain, progressing much faster than typical gum disease.
NUG involves painful ulceration and necrosis of the gingiva and interdental papillae, often leading to spontaneous bleeding and a foul odor (halitosis). When the condition progresses to NUP, the destructive process extends deeper, causing rapid loss of the supporting bone structure. The atypical presentation of these necrotizing conditions is a strong signal of systemic immunosuppression, frequently seen in people with very low CD4 T-cell counts.
Kaposi’s Sarcoma (KS)
Kaposi’s Sarcoma (KS) is a form of cancer associated with Human Herpesvirus 8 (HHV-8). Oral KS lesions are often one of the first visible signs of this disease, presenting as purplish, reddish-brown, or blue blotches or nodules. These lesions can be flat patches or raised lumps and frequently appear on the roof of the mouth or the gums. Their color is due to the proliferation of abnormal blood vessels, suggesting a significant impact on the immune system’s ability to control the HHV-8 virus.
Xerostomia (Chronic Dry Mouth)
Xerostomia, or chronic dry mouth, is common in people with HIV, often caused by medications or direct effects of the virus on salivary glands. The lack of saliva can lead to cracked lips and an increased risk of all oral infections, as saliva provides a natural defense against microbes.
The Importance of Professional Evaluation
The appearance of any of these oral signs—whether fungal, viral, or cancerous—is not sufficient to diagnose HIV infection. While these manifestations are strongly associated with immune system compromise, they can also occur for other reasons. A definitive diagnosis of HIV requires specific blood testing to detect the virus or antibodies against it.
Anyone who observes persistent, recurring, or unusually severe oral lesions should consult a healthcare provider or dentist immediately. A medical professional can properly evaluate the nature of the lesion, conduct necessary testing, and determine the appropriate management plan. Recognizing these visual markers serves as a prompt for seeking medical attention and proper diagnosis.