A Clinical Guide to Supportive and Palliative Care for HIV/AIDS
Chapter 8. Oral Problems
People who are HIV positive face many challenges, including oral health problems. While most oral health problems are no different from the problems faced by people who are HIV-negative, there are some distinct differences. Further, while some problems may be similar, the lack of a competent immune system can have an effect on the course of an oral disease and require a more aggressive approach to treatment, particularly so that what starts out as a minor problem does not escalate into a major problem with serious health consequences.
Palliative treatment of oral problems generally means antibiotics or antiviral medication, along with pain medication and a referral to a dentist -- usually within a day or two. For oral symptoms of HIV disease, as for other syndromes and organ systems discussed in this guide, the distinction between palliative and disease-altering interventions is often blurred. Palliative care interventions are often disease-specific, as in the use of antifungal medication for the symptoms of oral candidiasis or antiviral medication for herpes simplex stomatitis. Other symptoms such as pain or xerostomia may be treated effectively with palliative medications. Many of the oral problems that develop can be treated effectively by medical providers.
The important concern for medical providers caring for HIV-positive patients is to conduct a thorough oral exam so that if any of the common conditions are present in the patient's oral cavity, palliative care can be provided and referral to a dentist made expeditiously. Further, while immune-competent individuals can be somewhat lax regarding a six-month oral exam, all people living with HIV/AIDS should have routine examinations by a dentist every six months.
Although the information provided here is designed for providing palliative care, the most effective treatment is in fact prevention. Prevention is best achieved by regular visits with a dentist, and by having the medical provider conduct thorough examinations of the oral cavity at each check-up visit. The oral exam should inspect and document tongue, cheeks, palate and conditions of the teeth, looking for growths, abnormal mucosa, lesions and tumors -- all signs of one or more oral manifestations of HIV.
Since early in the course of the AIDS epidemic, more than 30 different oral manifestations of this disease have been reported. This section will address the seven most common oral health issues facing people who are HIV positive and the immediate treatment that can be provided. Patients with advanced disease are more likely to have the conditions described than are asymptomatic patients.
Treatments for oral problems in HIV-positive patients are specified in Table 8-1 (PDF): Medications for Oral Conditions.
Caries, or dental decay, is a common problem for everyone. Medical providers do not need to be concerned with a few carious lesions (cavities). However, rampant decay in an HIV-positive patient's teeth frequently lead to pulpal infection, followed rapidly by abscess formation, which is important to either prevent or treat promptly.
Some antiretroviral medications (e.g., indinavir) can cause decreased salivary flow, which is known to result in rampant caries; it is not uncommon for patients with decreased salivary flow to have multiple carious lesions. These lesions frequently are at the cervical area, the part of the tooth where the crown meets the roots. The tooth surface at this area is cementum, not enamel, and more likely to decay at a faster rate. Further, this can lead to an abscess formation which can be debilitating. A photo showing rampant decay in the cervical area can be seen in Color Plate 8-1 at the end of this chapter.
In cases of rampant decay, treatment should be expedited, which may mean that the dentist uses the technique called scoop and fill. As quickly as possible, and usually without anesthesia, the bulk of the decay is scooped out, using hand instruments, and then filled with a temporary filling or medium that contains fluoride, so that further decay is inhibited. The filling material of choice is glass ionomer. Once the teeth are temporized by the scoop and fill, the dentist can then go back and restore each tooth in a traditional manner.
Until the patient can be treated by a dentist, several steps can be taken by medical providers. The first, and clearly most important, is to determine if there are any cavities that have extended into the pulp, causing an infection. This is recognizable by swelling, and would be noticed by medical providers during a routine examination of the oral cavity. Infections should be treated with antibiotics, preferably penicillin. Treatment should be immediately implemented, and a referral to a dentist should occur within days. The treatment for an abscess is the same for both HIV-positive and HIV-negative patients.
If there are no obvious infections, but decay is present, particularly if the decay is extensive, palliative care consists of fluoride mouth rinses, which can be prescribed by the medical provider prior to referring the patient to a dentist. Referral should occur as soon as possible, but this is not an urgent problem.
There are artificial saliva products that can be used with patients who have active decay, resulting in part from xerostomia (dry mouth) that can be caused by medications or even HIV infection itself. However, the frequency with which these artificial saliva products have to be used may be unrealistic, and patients may prefer to use sugar-free lemon drops, which stimulate saliva, another palliative treatment that is effective. Medical providers can suggest the use of either sugar-free lemon drops or over-the-counter saliva substitutes.
Oral candidiasis is a relatively frequent problem for people who are HIV-positive. This condition has several different forms, the most common being pseudomembranous candidiasis. Candidiasis, which presents with small white patches any place in the mouth, can be mistaken for materia alba, or food particles. A photo showing pseudomembranous candidiasis is seen in Color Plate 8-2.
Pseudomembranous candidiasis is generally white, and can easily be wiped off. There may be an erythematous area or bleeding under the white patch. The patient usually notices a change in taste, with food becoming undesirable. Further, there may be pain or a burning sensation associated with this lesion.
Palliative treatment includes the use of antifungal medications. The medications most commonly used are systemic, including clotrimazole, fluconazole, and itraconazole. Treatment should be provided by whomever diagnoses this condition, the medical provider or a dentist. However, if a dentist is the first provider to diagnose candidiasis in a patient, it is important that the medical provider be informed. The presence of a candida infection is not a normal condition, and is a sign of immune dysfunction, which should be brought to the attention of the medical provider.
There are several other forms of candidiasis, all less common than pseudomembranous. When pseudomembranous candidiasis occurs at the corner of the mouth it is called angular cheilitis. (Color Plate 8-3) Palliative care requires topical antifungal medication, i.e. clotrimazole. Erythematous candidiasis usually appears on the tongue or hard palate, and has a red appearance that cannot be wiped off. The fungal infection is usually intracellular. Atrophic candidiasis usually appears on the tongue. Both of these lesions can cause altered taste sensation and/or pain and burning sensation. Palliative treatment of these conditions is the same as that for pseudomembranous candidiasis.
All forms of candidiasis should be treated promptly. Candidiasis can cause pain and can alter taste sensation, make eating even more difficult. For patients with advanced disease, particularly with wasting syndrome, untreated candidiasis can create serious problems.
As is true for most conditions, as a patient's viral load decreases, and/or the CD4 counts improve, the appearance of candidiasis decreases.
Oral Hairy Leukoplakia
Oral hairy leukoplakia was a common condition prior to the use of antiretroviral therapy and still exists, although it is less common now. The lesion is shown in Color Plate 8-4. The etiological agent for oral hairy leukoplakia appears to be the Epstein-Barr virus, in combination with the HIV virus, and the occurrence of this condition appears to be associated with a reduced CD4 count.
The lesion appears as a white patch, almost always on the lateral border of the tongue, with a very characteristic striated appearance. The lesion is benign and usually is not treated. Palliative treatment would be the use of an antiviral medication such as acyclovir or famciclovir; treatment may be considered for cosmetic reasons or if the lesions become large and bothersome to the patient. However, inasmuch as there usually are no symptoms, there is rarely need for any treatment.
Patients need to be advised that this is a condition that generally causes no problems and can disappear, particularly as the CD4 count improves. The condition does not cause any discomfort and does not cause a change in taste perception. Lesions usually last until the CD4 counts improve or the patient is receiving antiviral medication.
This condition can resemble pseudomembranous oral candidiasis; the difference is that while oral candidiasis can be wiped off, hairy leukoplakia cannot be wiped off.
Recurrent Aphthous Stomatitis (Canker Sores)
Apthous stomatitis is a common condition for all patients, irrespective of their HIV status. (Color Plate 8-5) However, in patients who are HIV positive the duration of the ulcer can be extended and aphthous ulcers minor become aphthous ulcers major more frequently. The difference between minor and major ulcers is the size (major ulcers are more than one centimeter in diameter) and the seriousness of the condition.
Recurrent aphthous lesions are generally shallow, cratered lesions with a raised, erythematous border and a gray, central pseudomembrane. HIV-positive patients can have these lesions on keratinized tissue, whereas HIV-negative patients generally do not.
These lesions are left to heal on their own in a patient with a competent immune system. However, the lesions do cause pain and can become quite large, particularly if a patient has a compromised immune system. If the lesions become secondarily infected, treatment should be implemented immediately. Accordingly, HIV-positive patients require palliative care for any lesion, irrespective of its size, to prevent it from expanding, creating potentially serious problems.
Palliative care consists of a steroid medication, most frequently topical, to prevent the possibility of an extended problem or progression to recurrent aphthous stomatitis major. Options for treating aphthous ulcers include dexamethasone solution ("swish and spit"), local steroid ointment (such as Kenalog, sometimes compounded together with an adherent paste such as Orabase), or even systemic steroids such as prednisone for patients with large lesions or suspected involvement of the esophagus or lower gastrointestinal tract. Treatment with thalidomide has recently been approved for aphthous ulcers in patients with AIDS.
Patients with advanced disease, particularly if they have wasting syndrome or are generally debilitated, have great difficulty when this lesion causes pain and decreases their ability to consume food comfortably. Early treatment is key, and palliative care should be implemented right away.
These lesions can be mistaken for recurrent herpes. Patients with either lesion have had a history of this condition and usually do not suffer from both, so a reliable history is a good method to determine the condition; viral cultures for herpes simplex can also be helpful.
Recurrent Herpes Simplex
Herpes simplex lesions, like aphthous ulcers, occur frequently irrespective of a patient's HIV status. (Color Plate 8-6) Just as aphthous ulcers can be more problematic for HIV-positive patients, the same is true for herpetic lesions. Herpes simplex lesions can be more painful, larger, and more prone to secondary infections in HIV-positive patients. Again, like aphthous ulcers, these can accelerate problems for patients with wasting syndrome by causing pain and decreasing the ability to eat comfortably.
Herpes simplex lesions start with a prodromal feeling of malaise, fever and general debilitation. This can be masked in patients who are already debilitated. There may be an itching or tingling sensation. Vesicles form, usually within 24 hours, with rupture shortly after, forming a scab. The lesion usually is not treated in an immune-competent patient, and ordinarily resolves within two weeks.
However, in immune-compromised patients treatment should be provided, and usually involves the use of a systemic antiviral medication for herpes. Topical medications do not usually work as well as systemic medications in this situation. However, if the condition is at an early stage, prior to the rupture of the vesicles, topical antiviral medication may be effective. Once the vesicles rupture or are well established, systemic treatment with antivirals is warranted, most commonly acyclovir or famciclovir.
Periodontal disease, the chronic inflammatory process that affects the ligaments and bone that support the teeth, is a condition that can occur in all patients irrespective of HIV status. However, there are several conditions that appear to be unique to individuals with a compromised immune system.
Periodontal disease -- like gingivitis, which is not associated with HIV status but can be present in individuals who are HIV-positive -- is treated by the same methods as with HIV-negative patients. The success rate does not appear to depend upon HIV status.
The gingival condition originally known as HIV-gingivitis and now called linear gingival erythema consists of a red lesion on the attached gingiva, which can be very painful and can lead to periodontal disease. (Color Plate 8-7) Ordinary gingivitis is not painful and does not lead to periodontal disease. Palliative care until the patient can get to a dentist consists of antimicrobial mouth rinses, such as chlorhexidine, and in severe cases, systemic antibiotics. Treatment should be limited to a short duration, days, or at most, one week, until the patient can be seen by a dentist.
Necrotizing ulcerative periodontitis, which previously was called HIV-periodontitis, is a painful condition that causes rapid bone loss, including the exposure of the bone, and rapid loss of attachment. This condition can result in the premature loss of teeth. (Color Plate 8-8) Treatment includes antimicrobial mouth rinses, systemic antibiotics Metronidazole or Augmentin, and when necessary, pain medication. Again, the patient should be referred to a dentist as soon as is feasible.
Palliative care does not definitively treat the underlying periodontal disease. However, frequent dental examinations and care can either prevent periodontal disease from occurring or limit the extent of the disease.
There are several opportunistic tumors that can occur in the mouth which are associated with a patient being HIV-positive. The two most frequently occurring neoplasms are Kaposi's sarcoma and non-Hodgkin's lymphoma.
Kaposi's sarcoma is the most common neoplasm in HIV-positive patients. It is a malignancy of the endothelial lining of blood vessels and appears clinically as a flat or raised, asymptomatic, purplish lesion that does not blanch with pressure. (Color Plate 8-9) Lesions often enlarge rapidly and can become exophytic. Treatment may be necessary, especially if the lesion interferes with function. Various chemotherapeutic regimens (e.g., vincristine, doxorubicin) as well as alpha-interferon may be somewhat effective, as well as radiation therapy. In many cases HAART itself can be associated with regression of KS lesions.
Non-Hodgkin's lymphoma when seen in the oral cavity is most often an exophytic soft, tumor-like mass that can enlarge rapidly. (Color Plate 8-10) Biopsy is required for diagnosis and treatment consists of radiation and/or chemotherapy. Until treatment can be implemented, palliative care is usually not required.
Neither of these conditions is seen until immune suppression is severe and patients have end-stage HIV disease.