PROCAARE: CLINICAL SCIENCE--ORAL MANIFESTATIONS PART I

[Albert Shaw <ashaw@usa.healthnet.org>]

KEYWORDS: ORAL MANIFESTATIONS/ CANDIDIASIS/ ORAL HAIRY LEUKOPLAKIA/ 
KAPOSI'S SARCOMA/ LYMPHOMA
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PART I:

Reference: Weinert, M., Grimes, R.M., Lynch, D.P. (1996).  Oral 
manifestations of HIV infection.  Ann. Intern. Med. 125: 485-96.

This review summarizes the common oral manifestations of HIV infection, 
and recommends a thorough oral examination at regular intervals for 
HIV-infected patients and for any suggestive sign or symptom.
The authors' recommendations are listed below:

The 4-minute oral examination:
1. Examine external lips for vesicles and macerated tissues at corners of 
   the mouth (15 seconds).
2. Evert upper and lower lips to visualize the intraoral labial mucosa 
   while observing for ulcers, coatings, or masses (30 seconds).
3. Retract cheeks with a tongue blade to:
   a. visualize buccal mucosa and observe for ulcers, coatings or masses 
     (15 sec. per side)
   b. examine teeth and gums for loose or missing teeth, erythema, gum 
      recession, edema, bleeding along gingival margin, ulcers, 
      coatings, and masses (15 sec. per side)
   c. massage parotid gland to observe expression of salive from stenson 
      gland (15 sec.)
4. Use bi-digital palpation (one finger inside mouth and thumb on 
   outside) to assess for masses on the mucosal surfaces, upper and lower 
   vestibule, and lips (30 sec.)
5. Ask patient to touch palate with tongue, and examine the floor of the 
   mouth for ulcers, coatings and masses.  Palpate floor for masses and 
   salivary stones.  Massage parotid gland to assess submandibular function 
   (30 sec.) 
6. Grasp protruded tongue and rotate it to each side, looking for 
   masses, ulcers, and coatings.  Bimanual palpation of floor of mouth to 
   examine for submandibular and sublingual lymphadenopathy (30 sec.)
7. Depress tongue and examine hard and soft palate and oropharynx for 
   asymmetric palatal elevation, erythema, exudates, masses, coatings, and 
   ulcers (30 sec.)

The authors divide oral manifestations of HIV infection into four 
categories, based on clinical appearance.

White or yellowish-white nonulcerative lesions:
1. Angular cheilitis--consisting of macerated, white (occasionally 
   erythematous) radiating fissures at the corners of the mouth; commonly 
   accompanied with intraoral candidiasis.
2. Pseudomembranous candidiasis--creamy, yellow-white, easily removed 
   plaques on palate, buccal and labial mucosa, and dorsal tongue; removal 
   of plaques reveals a red, painful, bleeding surface.
3. Hyperplastic candidiasis--similar appearance to oral hairy 
   leukoplakia, with diffuse white adherent lesions (painful or burning or 
   sometimes asymptomatic) along buccal mucosa.
4. Oral hairy leukoplakia--white, nonremovable lesion with corrugated 
   surface; lesions are painless and poorly demarcated, and may have "hairy" 
   fingerlike projections leading from the main lesion.  Location: usually 
   lateral tongue, occasionally buccal mucosa.

Oral candidiasis is treated with topical (nystatin or clotrimazole) or 
systemic (fluconazole or other azoles in the case of resistance, or 
topical or systemic amphotericin B for refractory cases) antifungal 
therapy.  Oral hairy leukoplakia is usually asymptomatic, and therapy is 
elective.  Both topical sclerosing agents and systemic therapy with 
acyclovir may be effective, though lesions recur when therapy is stopped.

Red or reddish-purple nonulcerative lesions of the oral mucosa:

1. Erythematous candidiasis--diffuse or discrete, red, nonremovable 
   plaques on palate, buccal and labial mucosa, and tongue.
2. Kaposi's sarcoma--in early disease, usually painless red or bluish 
   purple macules, papules or nodules; may progress to bulky tumors in 
   advanced disease.  Predominantly found on hard palate or gingiva.
3. Non-Hodgkin's lymphoma--firm, initially painless alveolar masses 
   progressing to painful, focal swelling or poorly defined lesions 
   involving lymphoid tissue of gingiva, palate, or tonsillar region.

Treatment decisions for Kaposi's sarcoma depend upon the extent of 
systemic involvement; for disease localized to the oral cavity, 
intralesional vinblastine or alpha-interferon have been reported to be 
effective, as have sclerosing agents such as 3% sodium tetradecyl 
sulfate.  Systemic chemotherapy is required for the therapy of 
non-Hodgkin's lymphoma.

The second part of this summary will discuss oral ulcers, periodontal 
disease, and salivary gland disorders.