Oral Lesions of HIV/AIDS in Industrialized Countries

D Greenspan* (greenspand@dentistry.uscf.edu) and  J Greenspan

University of California San Francisco, CA, USA

Knowledge concerning the varied nature, clinical and biological significance, and management of the oral disease found in those with HIV infection has grown in concert with the huge and expanding body of work published on the AIDS epidemic. Oral candidiasis, Kaposi's sarcoma and lymphoma were among the earliest described lesions of AIDS seen in homosexual and bisexual men. In the subsequent 23 years, a growing body of investigation, publications and clinical experience have reinforced, confirmed and built upon those initial observations. Most of this aspect of AIDS science has been conducted in the industrially developed parts of the world, although increasing attention is being paid to exploration of these lesions in those countries where the pandemic is concentrated. Clinicians with a wide range of professional training can easily examine the mouth and pharynx. Oral lesions are often clearly visible and several can be diagnosed accurately on clinical features alone. Thus, in cases where HIV status is unknown and where HIV testing is difficult, certain oral lesions provide strong indication of the presence of HIV infection. Hairy leukoplakia, oral and pharyngeal candidiasis, and the presence of both of these oral lesions are indicators of progression to AIDS. They can parallel the decline in CD4 cell counts but may also be independent indicators of prognosis. It is therefore not surprising that certain oropharyngeal lesions, notably oral candidiasis and hairy leukoplakia, feature in all classification, staging and prognosis, systems currently in use. These observations emphasize the high importance of a thorough oral examination at every stage in the diagnosis and management of all HIV-positive patients, as well as those thought to be infected or at risk, and explain the weight given to these lesions in HIV prevention and intervention programs. It is also important to note that the presence and development of oral lesions are used as entry criteria and end points for prophylaxis, therapy and vaccine trials. Indeed, the intriguing possibility exists that some oral lesions, notably herpes simplex and the Epstein-Barr virus infection of hairy leukoplakia, may act as risk modifiers or even co-factors that actively modulate the progress of HIV infection. In recent years, it has become clear that the presence of prevalent oral lesions and their incident development are related to HIV viral load. Furthermore, they are reduced in frequency as highly active anti-retroviral therapy (HAART) becomes effective. They recur or may develop anew as HAART fails and viral resistance occurs. The type and distribution of oral lesions seem to change in people on HAART, with multiple oral warts becoming more frequent, along with salivary gland disease. These apparently paradoxical observations may relate to incomplete reconstitution of the immune system as HAART plays its role and HIV viral load falls, although other explanations cannot be excluded. The treatment needs for the huge population of HIV-infected persons relate to mucosal lesions, caries and periodontal disease, while separating out those needs that are related to HIV-infection, from the background disease load in the population presents practical problems. These problems have considerable policy implications.