How Can HIV Affect the Tongue? - TheBody

dentist appointment

While anyone can experience problems related to the teeth and mouth, people with HIV more often experience these concerns, with anywhere from 32% to 46% of people living with HIV having at least one significant HIV-related oral health issue in their lifetime. These issues can potentially indicate underlying issues such as undiagnosed HIV infection, an unsuppressed viral load, or co-infection with a sexually transmitted infection (STI) like human papillomavirus (HPV), herpes simplex virus-1 (HSV-1), or syphilis.

Awareness is key—and if something feels "out of whack," it's a good prompt to seek help, according to Lina Rosengren-Hovee, M.D., M.P.H., an infectious disease specialist and assistant professor at the University of North Carolina-Chapel Hill. "Any lesions in the mouth; any oral ulcers, patches of redness or soreness in the mouth or tongue; anything that persists for more than a few days: You need to be seen by a doctor," she said.

How Does HIV Affect the Tongue?

Because many conditions that affect the tongue in people living with HIV are not always painful, they can be easy to miss. Signs and symptoms vary, but may include:

  • Candidiasis: White or creamy patches on the tongue, and inside the mouth and throat. When wiped away, there may be redness or bleeding.

  • Canker sores: Red sores—sometimes with a yellowish-gray film—on the tongue and inside of the cheeks.

  • HSV-1: Red sores that appear on the roof of the mouth.

  • Hairy leukoplakia: White patches—potentially thick and hair-like—on the side of the tongue, and sometimes inside the cheeks and lower lips.

  • Warts: Very small, rough, cauliflower-shaped, white, gray, or pinkish lumps inside the lips.

Here's a closer look at several of the most common oral health conditions a person living with HIV may experience.

Oral Candidiasis

Worldwide, oral candidiasis (also called thrush) is the most commonly occurring oral health condition in people with HIV. One of the most important risk factors of this fungal infection is a low CD4 T-cell count (below 200 cells/mm3), which is usually indicative of a person whose HIV is undiagnosed or not being effectively treated, leading to a weakened immune system.

"Candidiasis [is] absolutely a sign of HIV, and as the T cell count goes lower, there's more risk of getting an oral infection," said Andres Pinto, D.M.D., a professor of oral and maxillofacial medicine and diagnostic sciences at Case Western Reserve School of Dental Medicine.

Fortunately, in today's era of more effective drugs for HIV treatment, there is better HIV control and fewer cases of oral candidiasis that advance to the point where they require an oral medicine specialist.

"Except for people that haven't been diagnosed or started medications, I see candidiasis mostly in people that are noncompliant with medications," noted Temitope Tolulope Omolehinwa, B.D.S, D.ScD., D.M.D, an oral medicine specialist, researcher, and assistant professor of oral medicine at Penn Dental Medicine University of Pennsylvania.

Oral Ulcers & Oral Herpes

Two primary types of oral ulcers tend to occur in people with HIV: aphthous ulcers (canker sores), which appear as red sores with a thin yellow film covering and occur mostly on the tongue and the inside of the cheeks and lips; and herpes-related red sores (fever blisters) that mostly occur on the roof of the mouth.

Oral ulcers are generally mild. However, in people with severely compromised immune systems (i.e., people with advanced-stage HIV, or AIDS), they are more likely to be quite painful, and may react to foods and beverages that are especially salty, sour, or spicy.

Oral Hairy Leukoplakia

Oral hairy leukoplakia is usually caused by the Epstein-Barr virus, but can also be associated with fungal infections like candidiasis. The lesions look similar to candidiasis but they can't be wiped away, and eventually they become flat lesions with hair-like growths on the side of the tongue.

Research suggests that hairy leukoplakia disproportionately affects men (~80%), and that about half of cases occur among people in their 40s. Both Rosengren-Hovee and Omolehinwa noted that hairy leukoplakia occurs mostly in people with very weak immune systems.

Oral Warts

Oral warts show up in the mouth as small, raised areas of skin tissue that often have what Omolehinwa describes as a cauliflower-like appearance. These wounds appear inside the lips and under the tongue. Some researchers believe that cases might be due to the body's initial response to a new HIV treatment regimen, Pinto said.

Oral Hyperpigmentation

Oral hyperpigmentation—flat, dark brown or black spotting—occurs on the tongue, under the tongue, on the roof of the mouth, and on the gums. The spots don't cause any other symptoms.

Recent study findings suggest that they occur in about 25% of people with HIV taking HIV medications, although other research has found it is especially common in people with advanced HIV disease.

Omolehinwa says that it's not uncommon to see oral hyperpigmentation in her Black patients. "We're having a hard time determining if they're physiologic (due to increased melanin activity), or if patients are allergic to medication, of if they are the result of HIV or HIV treatment," she explained.

Dry Mouth (Xerostomia)

Another common symptom is a dry feeling on and under the tongue and in the mouth. Known clinically as xerostomia (i.e., dry mouth), it often distorts taste, impairs speaking and swallowing, and also increases the risk for developing cavities, gum and bone infections, and candidiasis (thrush).

While dry mouth is most likely to affect people with a low CD4 count, Pinto also explained that it's more universal experience. "Any medication that alters the balance of the immune system can cause problems with saliva and saliva quantity," he said. This includes high blood pressure and respiratory medications, painkillers, diabetes drugs, antidepressants, drugs for anxiety, and of course, antiretroviral therapy for HIV—something to keep in mind when discussing mouth-related issues with your physician.

Other Mouth Complications of HIV

Oral conditions, especially dental cavities and gum and bone infections, have traditionally been found more often in people with HIV than people without HIV—although recent research in this area has focused on areas where consistent access to both effective dental care and effective HIV treatment may be more difficult than in much of the U.S., such as India, Iran, and Uganda.

These issues are triggered by factors related to imbalances in the oral microbiome. They might also be related to the bacteria, viruses, and fungi that are resistant to multiple drugs; in recent years, this has resulted in more severe infections that don't respond to treatment.

HIV—particularly HIV that is not effectively suppressed by medications—can also be related to:

  • Gingivitis, or gum disease, causing irritation, swelling, and redness.

  • Kaposi sarcoma, the first signs of which are flat, red lesions on the tongue and tissues of the oral cavity. As the condition develops, they multiply into firm, purple nodules. Early diagnosis is important as it is highly treatable.

  • Human papillomavirus (HPV) is a primary cause of many different types of cancer, including those of the head and neck. Compared to the general population, people living with HIV have more than twice the risk for developing this type of cancer, which can often be found as oral lesions in the mouth and throat.

I Have A Mouth Infection: Can I Spread HIV Through Kissing or Oral Sex?

This question comes up frequently, but the answer always remains an almost-certain no—both for kissing and for oral sex.

"Generally, HIV is not spread through the mouth; you have to have a lot of conditions lined up for it to be transmitted that way: you have to have a detectable viral load; broken skin or bleeding; and your partner also has to have broken skin," Rosengren-Hovee said.

That said, you can spread other sexually transmitted infections (STIs) that show up on the tongue and oral cavity, like HPV or herpes. "All of these conditions can be transmitted to a sexual partner," said Pinto, who advised that people with any concerns about their tongue, teeth, or mouth "get a diagnosis, get treatment, and wait until it heals; kind of take a holiday from any intercourse or sexual activity."

Key Takeaways

It's important to keep in mind that the most common oral problems are treatable and manageable—and can most likely be prevented, or diagnosed and treated early, by:

  • Receiving regular health and STI screenings.

  • Getting yearly visits for dental screenings and cleanings.

  • Taking your HIV medications as recommended.

  • Being mindful of potential symptoms.

"If you have a sore throat; symptoms; things like swollen lymph nodes—all of these things could be an indicator that you have an infection brewing in your mouth," said Rosengren-Hovee. "If anything feels or looks different or off, then advocating for yourself and getting in to see a provider to take a look is always the best idea."

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