Frequent Oral Diseases in HIV Positive and AIDS Patients

Dr. Heddie O. Sedano, DDS

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Oral Ulcers

Around 50% of AIDS patients present oral ulcerations during the course of their disease. These ulcers can be classified as minor aphtous ulcers also called recurrent aphtous ulcers (RAU) and major aphtous ulcers (MAU). RAU occur in non-keratinized mucosas and their frequency in AIDS patients is not any different than that in the general population. RAU have a prolongued course in AIDS patients as well as being more painful and difficult to treat. These ulcers are shallow in appearance and are generally covered with a whitish pseudomembrane. MAU are generally seen in AIDS patients with severe immunodepression (median CD4 T-lymphocyte count 100 cell/mm3 or below). These large ulcers develop generally on the border of the tongue, floor of the mouth, buccal mucosa and nasopharynx. They are crater-like in appearance with elevated borders and covered with a white-yellowish pseudomembrane. These lesions are very painful. Generally an erythematous halo can be seen surrounding the ulcer and they may be accompanied by regional lymphadenopathy. It is imperative that a biopsy be taken of these types of ulcers in order to rule out neoplasia, such as B-cell lymphoma. The origin of these ulcers is varied and several studies have demonstrated the presence of herpes simplex virus type 1 and 2, cytomegalovirus, histoplasma capsulatum, cryptococcus neoformans and tuberculous bacillus. Therefore, their treatment will vary according to the type of microorganisms which has produced the ulcer. Many of these ulcers do not show any microbial component.

TREATMENT


Figure 1. Two major ulcers on the tongue of an HIV infected 34 year-old man. These ulcers are crater-like with elevated borders and covered by a yellowish pseudomembrane. The patient had intense pain. Also note the profuse pseudomembranous candidal infection on the tongue.
Figure 2. This major aphtous ulcer affecting the right buccal mucosa was seen in a 30 year-old HIV infected man. Note the large erythematous halo surrounding the ulcer. This lesion has been present for over two months. Biopsy did not reveal any specific causative agent.

Topical steroids can be effective in the treatment of multiple RAU and MAU

NOTE: reevaluate at the end of one week NOTE: reevaluate at the end of one week Recurrent MAU can also be treated as follows: NOTE: reevalute after one week. If there is no improvement, alternative treatment should be considered including systemic steroids. Before instituting systemic steroid therapy, the patient's physician should be contacted.

When these ulcers are produced by the cytomegalovirus it may indicate a generalized infection with the virus, in such cases systemic treatment with antiviral medications (acyclovir or gancyclovir) is indicated. Alternative forms of treatment have included intralesional injection with triamcinolone acetonide and systemic thalidomide.

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Recent References to Oral Ulcers(with abstracts)
Salivary Gland Enlargement

Classification