HIV and the mouth

January 2007     View PDF     En español

Fungal infections

Oral candidiasis
Also known as thrush, oral candidiasis is perhaps the most common oral condition in people with HIV. A healthy immune system can suppress the overgrowth of this fungus, but even a mildly compromised system may not keep the fungus in check. Most outbreaks occur when the CD4+ cell count falls below 400. But other factors may cause candidiasis, such as prolonged stress, depression and using antibiotics.

A trained dental professional can identify and distinguish the most common types of candidiasis that effect people with HIV. Symptoms may include red patches, white patches and clefts or grooves. They may or may not cause minor pain. For more information, read Project Inform’s publication, Oral Candidiasis.

Oral candidiasis may be treated with antifungal medicine given throughout the body (systemically) or applied directly to lesions. In mild cases, it’s treated directly for at least two weeks. Typical medications include Mycelex (clotrimazole) troches, Fungizone Oral Suspension (oral amphotericin B) and Nilstat (nystatin). Nystatin contains a lot of sugar, so if you use it, rinse afterwards with a fluoride (alcohol-free) mouthwash to remove the sugar. Excess sugar can help fungus and bacteria to grow.

More severe forms of candidiasis, such as esophageal candidiasis, may require systemic drugs, including ketoconazole, itraconazole and fluconazole (Diflucan). Treatment usually lasts two weeks or longer, as necessary. All of these drugs interact with commonly used anti-HIV drugs, particularly protease inhibitors. Changing your dietary habits and nutrition may also help.

In all cases, the full course of therapy should be completed even when obvious symptoms disappear beforehand. This will help prevent recurrences, though not 100% of the time. If outbreaks recur, ongoing preventive therapy may be useful.
Treatment may be started even before the first outbreak (preventive therapy, also called prophylaxis), but there’s some controversy over its effectiveness. The main concern is that the fungus may grow resistant to drugs used for preventive therapy, making these drugs ineffective if or when treatment is needed. For more information on treating and preventing candidiasis, read Project Inform’s publication, Oral Candidiasis, Vaginal Candidiasis or Systemic Candidiaisis.

Histoplasmosis
Histoplasmosis is a fungus common in the US, mostly in the valleys of the Mississippi, Tennessee, Missouri, Ohio and St. Lawrence rivers. Most infections either go unnoticed or cause mild problems, so the diagnosis can be difficult. Symptoms include cough, fever and general fatigue. Sometimes histoplasmosis can occur with mouth sores. People with very compromised immune systems are more likely to get this disease. There’s no specific treatment for just the mouth sores; histoplasmosis is treated as a general infection. HIV-positive people with this condition require lifelong treatment with low doses of itraconazole because of the extremely high rate of recurrence. For more information, read the publication, Histoplasmosis.