HIV and Mouth Sores

Mouth sores affect between 70% to 90% of people with human immunodeficiency virus (HIV) at some stage in the disease. In fact, the various sores, plaques, lesions, and ulcers that are commonly seen in people with HIV may be an early sign of infection. However, in other cases, they could be an indication of disease progression to acquired immunodeficiency syndrome (AIDS).

The mouth sores that can result from HIV can substantially decrease a person's quality of life, and the presence of these lesions are—in some cases—associated with their psychological health.

man with mouth sore

Mohd Akhir / EyeEm / Getty Images

Aphthous Ulcers

Aphthous ulcers are canker sores. They can occur in anyone but are more common—and tend to be more severe and recurrent—in people with HIV.

While the terms are often used interchangeably, "canker sores" and "cold sores" aren't the same thing.

The primary symptoms of aphthous ulcers are most often found on the inner surface of the cheeks and lips, tongue, the upper surface of the mouth, and the base of the gums, and may include:

  • One or more painful, red spots or bumps that develop into an open ulcer
  • White or yellow center
  • Small size (most often under one-third an inch or 1 centimeter across)
  • Whiteish-gray membrane develops as healing starts

There may also be accompanying symptoms of aphthous ulcers like:

  • Fever
  • General discomfort or uneasiness (malaise)
  • Swollen lymph nodes

Diagnosis can be tricky because the sores can look like herpes simplex virus (HSV) ulcers. But medication for HSV ulcers doesn't work on canker sores, so that's one way of ruling that out as a possibility.

In some cases, larger aphthous ulcers may require a biopsy to ensure that they are not cancerous. Canker sores are treated with:

  • Saltwater rinses
  • Mouthwashes
  • Topical anesthetic
  • Topical steroids

Aphthous Ulcers Are Not Contagious

This comes down to the confusion between canker sores (aphthous ulcers) and cold sores. Cold sores are highly contagious, thanks to a virus. Canker sores, on the other hand, are not contagious.

Herpes Simplex Virus (HSV)

There are two types of HSV: HSV-1 and HSV-2. Approximately 70% of people with HIV have HSV-2, while 95% have either HSV-1 or HSV-2.

Cold sores are more commonly linked to HSV-1 but can also involve HSV-2 when transmitted during oral sex. Outbreaks of HSV cold sores tend to be more common and severe whenever the immune system is suppressed.

The cold sores start out as lesions on lips and oral mucosa, then evolve in stages from papule (a solid, raised bump) to vesicle (a small, fluid-filled sac), to ulcer, and eventually crust.

There are several different stages of HSV cold sores, each with its own set of symptoms.

Before a cold sore becomes visible, symptoms may include:

  • Itching of the lips or skin around the mouth
  • Burning near the lips or mouth area
  • Tingling near the lips or mouth area

Then, before the cold sore blisters appear, accompanying symptoms may include:

  • Sore throat
  • Fever
  • Swollen glands
  • Painful swallowing

Lesions or a rash may form on your:

  • Gums
  • Lips
  • Mouth
  • Throat

It's also possible to have a cluster of HSV blisters, which is known as an outbreak. This may include:

  • Red blisters that break open and leak
  • Small blisters filled with clear yellowish fluid
  • Several smaller blisters that may grow together into a large blister
  • Yellow and crusty blister as it heals, which eventually turns into pink skin

In most cases, doctors and nurses can diagnose oral herpes simply by looking at it in an examination. Sometimes, they'll want to run tests on a sample of the sore, including:

  • A viral culture
  • Viral DNA test
  • Tzanck test

HSV cold sores are typically treated with antiviral medicines like acyclovir, famciclovir, and valacyclovir. There are also antiviral skin creams, but they are costly and barely shorten the outbreak.

How Long Do HSV Sores Last?

The sores typically last for one to two weeks without treatment but can reoccur because HSV persists in the body.

Oral Candidiasis

Oral candidiasis—also known as oral thrush—is the most common oral opportunistic infection affecting people with HIV or AIDS. In fact, it's the first sign of HIV in around 10% of cases.

Oral candidiasis involves the same type of fungus (Candida) that causes vaginal yeast infections.

The primary symptoms of candidiasis in the mouth and throat may include:

  • White patches on the inner cheeks, tongue, roof of the mouth, and throat
  • Redness or soreness
  • Cotton-like feeling in the mouth
  • Loss of taste
  • Pain while eating or swallowing (the main symptom of candidiasis in the esophagus)
  • Cracking and redness at the corners of the mouth

Oral candidiasis typically takes the form of white plaques that affect the oral mucosa, tongue, and both hard and soft palates.

The plaques are usually:

  • Painless and associated with a loss of taste and angular cheilitis (cracking of the skin at the corner of the patient's mouth).
  • Difficult to remove or scrape off with a tongue blade—and the process often leaves behind inflamed, painful lesions that may bleed.

Diagnosis of oral candidiasis typically involves an examination based on appearance and other risk factors. If, after scraping, the base of the plaques become red, inflamed, and start bleeding, it typically results in an oral thrush diagnosis.

The sores are typically treated with topical or oral antifungals.

Candidiasis and AIDS

Candidiasis is an AIDS-defining condition when it occurs in the:

  • Esophagus
  • Trachea
  • Bronchi
  • Lungs

Esophageal candidiasis is one of the most common infections in people living with HIV/AIDS.

Oral Hairy Leukoplakia (OHL)

Oral hairy leukoplakia (OHL) can occur in up to 50% of people with HIV who are not under any HIV treatment (ART). OHL is also a common first symptom in people with HIV.

The onset of OHL is directly linked to immune suppression and tends to occur when the CD4 count drops below 300. OHL is due to an infection with the Epstein-Barr virus.

OHL can also occur with other forms of severe immunodeficiency—like chemotherapy patients—or those who have had an organ transplant or leukemia.

While OHL is sometimes asymptomatic, the noticeable symptoms include:

  • A nontender whitish plaque along the lateral border of the tongue, which may appear and disappear spontaneously.

Some patients may experience accompanying symptoms, including:

  • Mild pain
  • Dysesthesia
  • Altered sensitivity to food temperature
  • Alteration in the taste sensation due to alteration in taste buds
  • The psychological impact of its unappealing cosmetic appearance

What Do OHL Lesions Look Like?

OHL lesions may vary in severity and appearance—with some being smooth, flat, and small, while others are irregular, "hairy," or "feathery" with prominent folds or projections.

In addition to the tongue, the sores can also be found on the buccal mucosa, and/or the gingiva.  Like oral candidiasis, OHL lesions cannot be scraped away.

Diagnosis takes place via a testing kit looking for:

  • DNA
  • RNA
  • Protein of the Epstein-Barr virus within the epithelial cells

OHL may not require any specific treatment other than antiretroviral therapy (ART), though some options include:

  • Antiviral medications
  • Topical retinoic acid
  • Cryotherapy (on occasion)

HIV-Associated Gingivitis

HIV-associated gingivitis—more commonly referred to as periodontal disease in people with HIV—takes two forms:

  • Linear gingival erythema: This itself used to be known as HIV-associated gingivitis and is the less severe of the two forms.
  • Necrotizing ulcerative periodontitis: This is the more severe of the two forms.

HIV-associated gingivitis is more commonly seen with advanced infection when the CD4 count is approaching 200.

The symptoms of HIV-associated gingivitis include:

  • Rapid loss of bone and soft tissue
  • Spontaneous reddening
  • Swelling
  • Bleeding of the gums
  • Painful ulcers at the tips of the interdental papilla and along the gingival margins

If left untreated, the cratered ulcers can trigger severe pain and tooth loss.

Many patients have had reasonable success with the following protocol:

  1. Plaque removal
  2. Local debridement
  3. Irrigation with povidone-iodine
  4. Scaling and root planing
  5. Maintenance with a chlorhexidine mouth rinse (Peridex) once or twice daily

In some cases, antibiotics are added to the regimen.

HIV-Associated Gingivitis vs. Regular Gingivitis

The biggest indications that gingivitis is associated with HIV include:

  • Rapid onset
  • The patient being in severe pain
  • Rapid destruction of an often extremely clean mouth

Human Papillomavirus (HPV)

Human papillomavirus (HPV) is most commonly associated with genital warts but can also occur in the mouth as a result of oral sex.

HPV is the most common sexually transmitted infection in the United States and comes in more than 100 different varieties. Approximately 10% of men and 3.6% of women have oral HPV, which can affect the mouth and back of the throat. It is also thought to cause 70% of oropharyngeal cancers in the United States.

Oral HPV does not have any symptoms—which is why it can be so easy to pass it along to other people without realizing it. If someone has HPV for an extended period of time, it could result in oropharyngeal cancer.

The symptoms of oropharyngeal cancer may include:

  • Abnormal (high-pitched) breathing sounds
  • Cough
  • Coughing up blood
  • Trouble swallowing, pain when swallowing
  • A sore throat that lasts more than two to three weeks, even with antibiotics
  • Hoarseness that does not get better in three to four weeks
  • Swollen lymph nodes
  • White or red area (lesion) on tonsils
  • Jaw pain or swelling
  • Neck or cheek lump
  • Unexplained weight loss

Not only does an oral HPV infection not have any symptoms, but there's also no way to test for it.

If you're experiencing some of the symptoms listed above and are concerned, it's a good idea to talk to your doctor about it. They'll examine your mouth and may order additional tests like a biopsy and imaging.

In most cases, oral HPV infections go away on their own without treatment within two years and typically don't cause any health problems.

HPV Vaccinations

Centers for Disease Control and Prevention (CDC) recommendations:

  • The HPV vaccine for routine vaccination at age 11 or 12, but it can be started as young as age 9.
  • Everyone through age 26 years—if not adequately vaccinated previously—should be vaccinated.
  • Not vaccinating those older than 26 years.

Kaposi Sarcoma (KS)

Kaposi sarcoma (KS) is the most common AIDS-defining cancer. At one point, it was frequently seen in people with AIDS, but levels decreased substantially as effective ART became available, and there were fewer people living with HIV experiencing CD4 counts falling to very low levels. Still, KS remains a strong indicator of disease progression.

KS is due to an infection with human herpesvirus-8 (HHV8).

KS can affect any part of the body and causes patches or lesions of abnormal tissue to grow under the skin, which are usually red or purple in color. This can occur:

  • In the lining of the mouth
  • Nose
  • Throat
  • Lymph nodes
  • Other organs

These patches are made of cancer cells, blood vessels, and blood cells.

While the KS skin lesions may not cause symptoms, they can spread to other parts of the body in people with HIV/AIDS. This becomes particularly serious if they spread to the digestive tract or lungs, as they can cause bleeding and make it hard to breathe.

In addition to a physical examination focusing on the lesions, your doctor may order additional tests to diagnose KS, including:

  • Bronchoscopy
  • CT scan
  • Endoscopy
  • Skin biopsy

The treatment options for KS depend on whether the person is immunosuppressed, the number and location of their tumors, and their other symptoms (including shortness of breath, coughing up blood, and leg swelling).

KS treatments include:

  • Antiviral therapy against HIV, since there is no specific therapy for HHV-8
  • Combination chemotherapy
  • Freezing the lesions
  • Radiation therapy

Unfortunately, in some cases, tumors and lesions may return after treatment.

A Word From Verywell

Many of the above-listed conditions can be avoided or resolved with the use of antiretroviral drugs—a major step forward in dealing with HIV/AIDS. In 2015, the Strategic Timing of AntiRetroviral Treatment (START) study—the first large-scale randomized clinical trial to establish that earlier antiretroviral treatment benefits all HIV-infected individuals—released new data. The findings included the fact that if HIV-infected individuals start taking antiretroviral drugs sooner, when their CD4+ T-cell count is higher, instead of waiting until the CD4+ cell count drops to lower levels, they have a considerably lower risk of developing AIDS or other serious illnesses.

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