The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 8: Oral ProblemsPalliative treatment includes the use of antifungal medications. The medications most commonlyused are systemic, including clotrimazole, fluconazole, and itraconazole. Treatment should be providedby whomever diagnoses this condition, the medical provider or a dentist. However, if a dentistis 26 the picas first provider to diagnose candidiasis in a patient, it is important that the medical providerbe informed. The presence of a candida infection is not a normal condition, and is a sign ofimmune dysfunction, which should be brought to the attention of the medical provider.There are several other forms of candidiasis, all less common than pseudomembranous. Whenpseudomembranous candidiasis occurs at the corner of the mouth it is called angular cheilitis.(Color Plate 8-3) Palliative care requires topical antifungal medication, i.e. clotrimazole.Erythematous candidiasis usually appears on the tongue or hard palate, and has a red appearancethat cannot be wiped off. The fungal infection is usually intracellular. Atrophic candidiasisusually appears on the tongue. Both of these lesions can cause altered taste sensation and/orpain and burning sensation. Palliative treatment of these conditions is the same as that forpseudomembranous candidiasis.All forms of candidiasis should be treated promptly. Candidiasis can cause pain and can altertaste sensation, make eating even more difficult. For patients with advanced disease, particularlywith wasting syndrome, untreated candidiasis can create serious problems.As is true for most conditions, as a patient’s viral load decreases, and/or the CD4 counts improve,the appearance of candidiasis decreases.ORAL HAIRY LEUKOPLAKIA■ Oral hairy leukoplakia was a common condition prior to the use of antiretroviral therapy andstill exists, although it is less common now. The lesion is shown in Color Plate 8-4. The etiologicalagent for oral hairy leukoplakia appears to be the Epstein-Barr virus, in combination with the HIVvirus, and the occurrence of this condition appears to be associated with a reduced CD4 count.The lesion appears as a white patch, almost always on the lateral border of the tongue, with avery characteristic striated appearance. The lesion is benign and usually is not treated. Palliativetreatment would be the use of an antiviral medication such as acyclovir or famciclovir;treatment may be considered for cosmetic reasons or if the lesions become large and bothersometo the patient. However, inasmuch as there usually are no symptoms, there is rarely needfor any treatment.Patients need to be advised that this is a condition that generally causes no problems and candisappear, particularly as the CD4 count improves. The condition does not cause any discomfortand does not cause a change in taste perception. Lesions usually last until the CD4 countsimprove or the patient is receiving antiviral medication.This condition can resemble pseudomembranous oral candidiasis; the difference is that whileoral candidiasis can be wiped off, hairy leukoplakia cannot be wiped off.RECURRENT APHTHOUS STOMATITIS (CANKER SORES)■ Apthous stomatitis is a common condition for all patients, irrespective of their HIV status.(Color Plate 8-5) However, in patients who are HIV positive the duration of the ulcer can beextended and aphthous ulcers minor become aphthous ulcers major more frequently. The differencebetween minor and major ulcers is the size (major ulcers are more than one centimeterin diameter) and the seriousness of the condition.170U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau