How HIV Can Affect the Tongue

The human immunodeficiency virus (HIV) can affect areas of the mouth and throat. Oral symptoms are common for people with HIV, with anywhere from 30% to 80% of individuals experiencing some type of mouth sore or lesion.

In some cases, tongue or mouth issues are the first signs of an HIV infection. If these oral symptoms sound familiar, consider seeking your healthcare provider's advice for early screening and treatment.

How HIV Can Affect the Tongue

Laura Porter / Verywell

HIV is a disease that attacks the immune system. When the immune system is suppressed, it leaves the body vulnerable to infections that don’t typically happen in people with healthy immune systems.

Some of these conditions (such as oral thrush and oral herpes) are opportunistic infections. As the name suggests, disease-causing viruses and bacteria take advantage of the body’s weakened state and produce symptoms that can affect the tongue. 

Oral Thrush

Oral thrush is a yeast infection caused by the fungus Candida. Candida is normally present in the mouth but overgrows and causes infection when the immune system is down. It can affect multiple areas in the mouth, including the tongue, inner cheeks, gums, the roof of the mouth, and the back of the throat.

When oral thrush strikes the tongue, it's usually painless. Creamy white plaques (sometimes described as cottage cheese-like in appearance) can be scraped off using a tongue depressor (or similar instrument) by a healthcare professional. Some people also experience a "cottony" feeling in the mouth and a loss of taste.

Treatment

Oral and topical antifungals help treat oral thrush. Oral medications like fluconazole are generally preferred over topical agents because you take them once a day and they're easier to tolerate. Additionally, they can treat thrush all over the body (for instance, in the esophagus).

Topical antifungals, including clotrimazole lozenges or a nystatin suspension, require multiple doses, sometimes up to five per day. They can also have an unpleasant taste. Miconazole buccal tablets (a tablet applied between the gum and cheek) are given once a day but need to stay in place for at least six hours to be effective.

Benefits of Topical Agents vs. Oral Meds

Topical agents limit your exposure to harsh treatments because they don't affect your whole body. Localized treatment lowers the risk of side effects and drug interactions. If thrush hasn't spread to the esophagus, treatment courses can be completed in just one to two weeks.

Oral Hairy Leukoplakia 

Oral hairy leukoplakia (OHL) can occur if the Epstein-Barr virus (EBV) gets reactivated in individuals with HIV. EBV infection in childhood is usually mild or asymptomatic. Mononucleosis (“mono”) is how EBV typically shows up in adolescents and adults. 

After these early infections, the virus stays quiet in certain cells of the body. Over 90% of adults around the world are thought to have EBV, many without active symptoms. When the immune system is weakened, EBV can reactivate and cause OHL.

OHL looks like white patches with a folded appearance. Hair-like growths may emerge from the folds. OHL typically occurs on the sides of the tongue but can form elsewhere in the mouth as well. Unlike with oral thrush, the white patches cannot be removed or scraped off. OHL is usually painless but can cause some discomfort or taste changes.

Treatment

OHL lesions are generally asymptomatic and benign. Most people don't require specific treatment for OHL. Instead, managing the underlying HIV infection with antiretroviral therapy (ART) and boosting immune function helps clear up and prevent future flare-ups.

In some cases, your healthcare provider may suggest ways to improve comfort, restore your tongue's cosmetic appearance, and minimize the folds of the plaques where other bacterial or viral infections may occur.

Topical agents, oral antiviral medications such as Zovirax (acyclovir) or Valtrex (valacyclovir), or even surgical removal may be recommended. Unfortunately, without immune system improvements through ART, there's a high chance of recurring issues.

Oral Herpes

Cold sores around the outside of the mouth are caused by oral herpes. However, these lesions can also show up inside the mouth, on the gums, on the roof of the mouth, on the inside the cheeks, and on the tongue.  

The herpes simplex virus type 1 (HSV-1) is responsible for oral herpes. It's easily spread from one person to another. People often get infected with HSV-1 in childhood, and it stays with them for the rest of their lives.

In the United States, about 50% of people ages 14 to 49 are positive for HSV-1.

An outbreak starts with a prodrome (signs of a developing lesion). Prodromes can cause burning, tingling, or itching sensation around the mouth. Soon after, a painful, fluid-filled blister forms. These blisters eventually open, leaking the fluid within. They usually crust over and heal four to six days later.

Treatment

Oral herpes is treated with oral antiviral agents such as Valtrex (valacyclovir), Famvir (famciclovir), and Zovirax (acyclovir). The treatment lasts five to 10 days.

Healthcare providers may advise taking medication every day even when not experiencing an outbreak (called chronic suppressive therapy). Chronic suppressive therapy is helpful for people with frequent infections that keep coming back after treatment. It's paired with the same antiviral oral medicines.

Hyperpigmentation

Oral melanin hyperpigmentation describes when mouth tissues look darker. It's more common in individuals with darker skin tones. Oral hyperpigmentation in HIV-positive people often happens inside the cheeks but may also be seen on the tongue. The darkening may range from light brown to black as single or multiple patches.

HIV-associated oral hyperpigmentation can be caused by the HIV infection itself or medications used to treat HIV, such as zidovudine. Hyperpigmentation develops either within two years of contracting HIV or within a couple of months after starting zidovudine.

Treatment

HIV-associated oral hyperpigmentation is asymptomatic and does not require any specific treatment. However, be sure to discuss any darkened areas inside the mouth with your healthcare professional. Your healthcare provider can help you determine if these symptoms represent a different condition that can be treated separately.

Oral Warts

The human papillomavirus (HPV) is responsible for oral warts. HPV is a sexually transmitted virus, although there is some evidence for nonsexual transmission, as with kissing or from mother to baby during childbirth.

HIV-positive individuals are at a higher risk of HPV infection. Oral warts caused by HPV can be light pink, white, or gray in color and can be cauliflower-like in appearance.

Treament

Oral warts are benign. They may be removed with:

  • Cryotherapy (freezing of the wart, typically with liquid nitrogen)
  • Electrosurgery (removal using a low-voltage electrical probe)
  • Laser therapy
  • Topical treatment with trichloroacetic acid
  • Surgery

Preventive Oral Care

It's not always practical to protect yourself against infections. Treating HIV with ART and restoring immune function is essential to your overall health. It's also crucial to practice oral hygiene using these tips: 

  • Brush teeth at least twice per day with fluoride toothpaste and floss at least once per day.
  • Don't smoke or use tobacco products. Smoking harms oral health and specifically increases the risk of OHL and HPV.
  • Limit alcohol intake.
  • Rinse your mouth every time inhaled corticosteroids are used to prevent oral thrush. Inhaled corticosteroids can be found in inhaler medications used to treat asthma or chronic obstructive pulmonary disease (COPD).
  • Schedule dentist appointments at least twice per year for preventive cleanings and checkups.

Various medications and medical conditions can cause dry mouth, increasing the risk of infections and tooth decay. Sipping on water or sugarless drinks, sucking on sugarless hard candy, or chewing sugarless gum may help.

An artificial saliva product can help keep the mouth wet. Speak with your healthcare provider if you have a dry mouth due to medication changes.

A Word From Verywell

HIV can produce several conditions that affect the tongue. Be sure to monitor your tongue and mouth for changes regularly and report any issues to your healthcare provider. Keeping your provider informed will help catch signs of HIV progression and give you the resources needed to maintain good health.

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12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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