Clinical

Oral manifestations of human

immunodeficiency virus
HIV is a viral infection that progressively damages the immune system. Relatively late in the infection,
oral signs can appear which signal that significant damage to the immune system has occurred.
This article describes these conditions in order to assist oral health professionals recognize them

uman
immunodeficiency
virus (HIV) is an infection
that progressively damages the
immune system over a number
of years. Eventually the immune system
becomes so damaged that infections which
would not normally present in individuals
with a healthy immune system become
apparent. These so-called opportunistic
infections occur as a result of an opportunity
afforded to the microorganism which causes
the infection by a deficiency in the persons
immune system (Underwood and Cross,
2009). These opportunistic infections can
occur in most of the organ systems within
the body, including the skin, brain, lungs,
gastrointestinal tract including the oral
cavity (Baggaley, 2008).
In this article the conditions that affect
the oral cavity, which may signal that the
immune system is incompetent, will be
appraised to assist dental nurses in the
recognition and timely referral of these
patients so that appropriate testing and
treatment can be provided.

The immune system and

immunocompromized
states
The immune system consists of
multiple cells, chemical messengers and
Chris Mulryan is a senior lecturer
in Health, University of Bolton
Email: C.Mulryan@bolton.ac.uk

564 

proteins that work together to protect

the bodys internal environment from
microorganisms whose aim is to exploit
the bodys environment in order to
sustain their own interests (Greenwood et
al, 2007). When this defence is breached
an infection is said to occur. Occasionally
the immune system will fail in such a
way that allows microorganisms, which
are normally dealt with by the immune
system, efficiently to take hold causing
what is referred to as an opportunistic
infection (Peakman and Vergani, 2009).
As well as providing protection from
infections the immune system also
provides a degree of protection against
the growth of malignant (cancerous)
cells and as such those people with a
defective immune system are also at risk
of developing certain types of malignancy
(Gervaz et al, 2011).
When the immune system fails
the person is referred to as being
immunocompromized. The cause of
such a state can be defined as either
primary or secondary. Primary immune
deficiency states are those that arise from
a deficiency of a specific component of the
immune system. These primary immune
deficiencies are rare and have a genetic
origin. They occur as a result of the
bodys inability to produce certain types
of immune cell or proteins (Griffith et
al, 2009). As primary immune deficiency
states are genetic in origin they are present
at birth.
Secondary immune deficiency states,
in contrast, are acquired during life.

These disorders have a range of causes

and may be due to medical treatments
(Joint Formulary Committee, 2011),
malignancies (Watson et al, 2006) or
infections (Baggaley, 2008).
The medical treatments that are
particularly implicated in causing
immune deficiency are those that are
used in the treatment of inflammatory
conditions such as rheumatoid arthritis,
drugs used to reduce the risk of organ
rejection in transplant patients and those
that can have a suppressive effect on
bone marrow such as anti-cancer and
anti-thyroid medicines (Joint Formulary
Committee, 2011). Malignancies that
infiltrate the bone marrow or cause
significant inflammation can suppress
immune function by reducing the
number of functional white blood cells
that are produced, or by increasing the
rate at which these are used in the tissues.
Likewise, immune function will be
damaged in patients with haematological
malignancies (Watson et al, 2006).
HIV infects a specific type of
white blood cell known as the CD4 T
lymphocyte. These cells act as a linchpin
in the immune response and serve to
activate, direct and support the actions
of other immune cells. When infected
with HIV, CD4 T lymphocytes, instead
of acting as important mediators of the
immune response, start to manufacture
copies of HIV that exit the cell and go
on to infect other CD4 T lymphocytes.
Several years after infection with HIV
the number of CD4 T lymphocytes starts
Dental Nursing October 2011 Vol 7 No 10

Clinical

HIV

The number of people living with HIV

in the UK continues to rise (Health
Protection Agency, 2008). Despite this,
more than a quarter of the people living
with HIV are unaware of the fact that
they are infected. In turn this results in
approximately half of all new cases of
HIV being diagnosed late in the course
of infection and after a time that the
individual would have benefitted from
antiretroviral therapy (National Institute
for Health and Clinical Excellence (NICE),
2011a). This has clinical significance as
patients who receive treatment late in the
course of their infection do not derive the
same benefits as early-treatment patients
(Baggley, 2008).
In response to this, NICE have issued
two sets of guidelines which intend
to increase the number of HIV tests
performed in patient populations with
an epidemiological risk of having been
exposed to HIV (NICE 2011a; 2011b).
They do this by advocating the offer
of an HIV test to defined populations
whenever blood is taken for laboratory
testing, for whatever reason or when
there is another key healthcare contact
such as admission to hospital.
In the dental practice, where blood
tests are not routine practice, additional
strategies can assist in the detection of
patients with HIV. As there are often oral
manifestations of HIV it makes sense
that when an oral pathology that may
be a feature of HIV infection is detected,
appropriate referral for HIV testing is
advised.

with HIV. The most common of these

include:
n Oral candidiasis
n Oral hairy leukoplakia
n Kaposis sarcoma.
While these conditions can occur for
reasons other than HIV infection, the
presence of such conditions should raise
the possibility of HIV infection as an
underlying pathology.

Oral candidiasis
Candidiasis is a fungal yeast infection. It
can occur in non-HIV infected patients
although the incidence of candida
infections is much increased in those
with HIV infection, affecting up to 75%

of such patients (Tam-Maury, 2011). In

non-HIV-infected patients candidiasis
usually has an explainable cause such as
treatment with inhaled corticosteroids,
antibiotics or immunosuppressive drugs;
alternatively recent illness may also
precipitate an episode of the infection.
There is logic to each of these situations
as they each represent an interruption to
normal immune system function allowing
the opportunistic candida to take hold.
In the HIV-positive individual
candidiasis usually presents when the
level of CD4 T lymphocytes has fallen
to 200 cells/mm3 or less (Bodhade et al,
2011). This is quite late in the infection
and long after the time that treatment
science photo library

to fall and, with it, the bodys ability

to fight off infection is diminished. At
this point, opportunistic microorganisms
are given liberty to take hold and cause
opportunistic infections.

Oral manifestations of
immunocompromized
states
There are a number of oral infections and
malignancies that can occur in patients
Dental Nursing October 2011 Vol 7 No 10

Figure 1. Close-up of the white tongue in an adult male patient showing thrush
(candidiasis)
565

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Clinical
co-infection with Epstein-Barr virus has
a role in its pathogenesis (Correnti et
al, 2010). Treatment with antiviral drugs
such as acyclovir can produce remission
of this condition although there is a
high recurrence rate on withdrawal of
treatment. In oral hairy leukoplakia there
are often few symptoms other than the
lesion itself and as such specific treatment
is not necessarily mandated (Wilkins,
2010). Again, however, it is important
to recognize that anti-HIV treatment to
address the underlying immune deficiency
is likely to be needed.

Kaposis sarcoma

Figure 2. Photograph of the tongue of a man suffering from AIDS, showing oral
thrush (candidiasis) and hairy leukoplakia, which appears as a white, ribbed ulcer
along the edge of the tongue
with anti-HIV drugs would have started
ideally. There are three presentations of
oral candidiasis; these are:
n Pseudomembranous candidiasis
n Erythematous candidiasis
n Hyperplasic candidiasis.
Pseudomembranous candidiasis is
the classical presentation of oral thrush,
with white plaques developing on the
tongue and mucosa membrane (Figure1).
These plaques can be scraped off easily.
Underneath the plaques is a red inflamed
base. In erythematous candidiasis there are
no plaques evident although the mouth is
painful and reddened. The tongue may
also have a smooth appearance and the lips
may be cracked, particularly at the corners.
In hyperplasic candidiasis there are raised
white plaques that are not scraped off
easily. This can lead to confusion between
this condition and leukoplakia, although
hyperplasic candidiasis should respond to
antifungal treatment unless it is a drugresistant strain.
In patients with oral candidiasis pain on
or difficulty with swallowing should raise
the possibility of oesophageal candidiasis
as coexistence is common. Absence of
such symptoms should not exclude the
566 

possibility of oesophageal candidiasis as

this can be asymptomatic in up to 40% of
cases (Tavitian et al, 1986).
Treatment with traditional topical
antifungal medicines is often effective
in treating oral candidiasis, although a
number of patients have drug-resistant
strains. For patients with oesophageal
infections systemic antifungal therapy will
be required. In HIV, antifungal drugs will
however address only the fungal infection
and not the underlying cause and as such
the condition may well become recurrent
should the underlying immune deficiency
not be addressed.

Oral hairy leukoplakia

Leukoplakialiterally meaning white
plaqueis a condition that can occur for
a range of reasons. In clinical usage it is
reserved for white plaques that do not
rub off and cannot be clinically identified
as another entity (Warnakulasuriya et al,
2007). Given this broad definition there are
obviously several conditions that can fall
into this category. Oral hairy leukoplakia
is one such condition which presents with
a white ridged lesion often on the side of
the tongue (Figure 2). It is thought that

Kaposis sarcoma is a cancer of the vascular

endothelial cells (Neal and Hoskin, 2003).
Until the advent of HIV, Kaposis sarcoma
was a rare cancer affecting mainly Jewish
and Mediterranean elderly males (Wilkins,
2010). Initially when it was encountered
Kaposis sarcoma was a cancer often
seen in those with late-stage HIV. Now
thanks to modern anti-HIV treatments
Kaposis sarcoma has again become a
rare complication of HIV, although in the
untested and untreated individual Kaposis
sarcoma can still occur. It is thought
to arise as a result of co-infection with
human herpesvirus type 8 (Fukumoto et
al, 2011). Its clinical appearance can range
from flat or raised legions through to
nodules and it has a characteristic dark
purple colour (Figure 3). It is most often
a mucocutaneous disease, although it can
affect internal organs. The lesions can
ulcerate, bleed and be painful although
in others they may be asymptomatic.
Treatment with radiotherapy is often
affective in controlling this tumour
(Neal and Hoskin, 2003). Immune
reconstitution with anti-HIV medicines
will also slow the rate of progression and
the rate at which new lesions develop.

Conclusion

There is a strong correlation between

late HIV infection and the development
or oral lesions. Given the prevalence of
undiagnosed HIV among community
groups in the UK the recognition of
Dental Nursing October 2011 Vol 7 No 10

Clinical

Key points

Immunocompromized states can be primary or secondary in origin.

Primary immunodeficiency is caused by an inbuilt deficiency in the

immune system arising from a deficiency from a specific immune
system product.

Secondary immunodeficiency occurs when a disease process or

medical treatment damages the immune system.

Opportunistic infections occur when the immune system is damaged

Fungal and viral infections, as well as malignancies in the mouth,

can be a sign of immunocompromized states.

science photo library

Referral for HIV testing can be a life-saving intervention.

Figure 3. Photograph of the interior of the mouth of a person suffering from AIDS,
showing purple lesions caused by Kaposis sarcoma affecting the hard palate
oral lesions that are suggestive of HIV
infection by oral health professionals
provides an important opportunity to
make a referral for HIV testing. While
many of the oral lesions that occur in
HIV do so after the ideal period for
starting anti-HIV medicines there still
remains benefits from starting patients on
anti-HIV medicines at this juncture. The
benefits from earlier treatment will still
be increased over delaying treatment to
a time when the immune system is more
extensively damaged and more serious
HIV-associated conditions are able to
become established leading the person to
Dental Nursing October 2011 Vol 7 No 10

seek medical help where a later diagnosis

of HIV could be made. Oral health
professionals then have an important role
in identifying those patients with HIVrelated oral lesions so that diagnoses can
be made and treatment provided within
a timescale which will afford the most
benefit for the patient.
DN
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