OTHER MANIFESTATIONS

Oral Manifestations of HIV infection
By Drs. Deborah Greenspan and John S. Greenspan

Oral Ulcers

Oral ulcers of several types are seen in association with HIV infection. The most common variety is a severe form of the recurrent aphthous ulceration, which is seen the general population. Other causes of oral ulcers that have been mentioned include lymphotna, herpes group virus infections, mycobacterial ulcers, and, rarely, fungal ulcers caused by histoplasma and cryptococcus. In addition, necrotizing ulcerative periodontitis and a variant that affects soft tissue, necrotizing stomatitis, must be considered in the differential diagnosis. The appearance of some oral ulcers is consistent with recurrent aphthous ulcers. Others are larger, may not be recurrent, and may fall into the category of necrotizing stornatitis. Recurrent aphthous ulcers may range in size from 1 mm to 5 mm for minor aphthae, to as much as 2 crn for major aphthae. The latter may be very persistent and painful and can interfere with speech and swallowing. A typical aphthous ulcer has a red halo and regular margins and is covered with a grayish pseudomembrane.
Recurrent aphthous ulcers have been treated with topical steroids such as fluocinonide 0.05% ointment mixed with equal parts Orobase and applied six times daily; clobetasol 0.05% ointment mixed with equal parts of Orobase and applied three times daily; or dexamethasone elixir 0.5 mg/5 ml used as a mouth rinse two to three times per day and expectorated. However, thalidomide has recently been approved for this indication and is likely to become the drug of choice.

Salivary Gland Disease and Xerostomia.

Complaints of dry mouth in HIV-infected people are often caused by medications that interfere with salivary secretion, such as antihistamines, antianxiety medications, antidepressants, and ddI. Other patients may experience enlargement of the major salivary glands with or without xerostomia. This is associated with a CD8 lymphocyte infiltration of salivary glands and sometimes other organs; it is also associated with a slightly slower progression of HIV disease. Management of xerostomia should include sucking on sugarless candies or chewing gum and using salivary substitutes. Some patients may benefit from the stimulation with pilocarpine (5 mg, three times a day). Use of topical flouride rinses should be encouraged to prevent an increase in caries.