Hesperian Health Guides
Common Problems Caused by HIV and How to Treat Them
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There are many infections that occur in the mouth, such as a cold sore or gum infection. Most of these infections are not caused by HIV and do not usually cause serious problems. But all infections are serious when a person has been infected with HIV because the virus makes the person’s body weak and unable to fight off infection. Smoking or chewing tobacco can also make problems in the mouth worse. Many infections for people with HIV, including mouth infections, can be prevented by taking 480 mg of cotrimoxazole 2 times a day with lots of water.
The main problems in the mouth for persons with HIV are:
- white or yellow patches
- open sores
- gum infections
- cold sores or blisters
- dark-colored skin patches
- dry or painful mouth and throat
1. White or yellow patches in the mouth (thrush, oral candidiasis)
Thrush is the most common infection in the mouth seen in people with HIV infection. Thrush can also be a problem for people who do not have HIV.
- A burning or swelling feeling in the mouth, especially when eating spicy foods. Because of pain, eating and swallowing become more and more difficult.
- The skin inside the mouth is usually covered with white, yellow, or red patches. If you try to remove the white patches with a clean cloth, they will come off, but sometimes leave a bleeding red surface underneath. In some people they may not come off easily. In a few people, there are no white patches. Instead, the skin of the mouth is red and blotchy. It may look very rough.
- Sometimes there are painful cracks
at the corners of the mouth that will
not heal and sometimes bleed.
Gently scrub the tongue and gums with a clean cloth or soft toothbrush 3 or 4 times a day. Then rinse the mouth with salt water and spit it out (do not swallow). In addition, if possible, use any ONE of these remedies:
- Put 2.5 ml (½ teaspoon) of nystatin solution in the mouth and hold it there 2 minutes and then swallow it. Do this 5 times a day for 14 days. OR,
- Use either gentian violet or chlorhexidine gluconate mouthwash. OR,
- Cut or break a 100 mg clotrimazole vaginal insert into 2 pieces. In the morning, put 1 piece in the mouth and let it slowly melt there. Use the second piece at night. The package may say: “Do not take by mouth.” This means do not swallow it. It is safe to let it melt in the mouth, making sure it covers the whole inside of the mouth, and then spit it out. Do this 2 times a day for 7 days (14 days if the infection is very bad). OR,
- Depending on how bad your problem is, suck one or two 100,000 Unit nystatin lozenges, 4 or 5 times a day for 10 to 14 days.
If thrush is very bad, or if it moves into your throat and makes it hard to swallow, you may try one of these stronger medicines instead of the remedies above. (But do not take either of these medicines if you are pregnant or breastfeeding):
- Take 400 mg of fluconazole by mouth. The next day take 200 mg of fluconazole once each day for 14 days. But if you do not feel better in 3 to 5 days, increase the dose to 400 mg once each day. OR,
- Take one 200 mg tablet of ketoconazole, by mouth, once a day with food for 14 days.
2. Sores of the skin of the mouth (ulcers)
|Open sores (ulcers) that can appear anywhere in the mouth. Usually the skin around the sores is red. The sores in this picture are on the inside of the top lip.|
Most people from time to time have had a small open sore (ulcer) in the mouth caused by an infection that has destroyed the skin in that area. It is usually painful and can make eating and speaking difficult for 1 or 2 weeks. The ulcer heals if the mouth is kept clean. For people with HIV infection, the healing process can be very slow and sometimes the sore area in the mouth becomes very large. This is especially true if the person is taking anti-retroviral medicines to weaken HIV, such as zidovudine (AZT).
The skin lining the mouth or on the tongue is broken and will probably look much redder than the skin that is not broken.
Keep the area clean to control the infection and to help the skin heal. Clean the sores with a cotton swab dipped in 1% povidone iodine. Also, see other methods for keeping the mouth clean.
Also give antibiotics if:
- the skin around the ulcer is very swollen, AND
- you feel soft lumps (lymph glands) underneath the lower jaw bone.
Give 500 mg of amoxicillin by mouth, 3 times a day for 7 days. (Not safe for people allergic to penicillin. Anyone who is allergic to penicillin will also be allergic to amoxicillin and ampicillin).
OR 100 mg of doxycycline by mouth, 2 times a day for 7 days. (Not safe for women who are pregnant or breastfeeding).
OR 500 mg of tetracycline by mouth, 4 times a day for 7 days. (Not safe for women who are pregnant or breastfeeding).
OR 500 mg of erythromycin, 4 times a day for 7 days.
3. Infection of the gums (Vincent's infection, trench mouth)
Many people have some infection of the gums around their teeth. The amount of infection depends on how clean the mouth is kept and how well a person’s body can fight off disease. If the mouth and gums are not kept clean, the infection may get so bad that it will spread to the jaw bone and other tissues nearby and the teeth will eventually loosen and fall out.
Because the body of someone with HIV infection is less able to fight off disease, any gum infection will quickly get worse if the person does not keep his mouth and teeth clean. This can be very serious. If a person with HIV loses his teeth and cannot eat, he will become even more ill.
- The gums are red, puffy, and very painful.
- There may be yellow liquid (pus) oozing from the gum around one or more teeth. • The gums between several teeth have sores (ulcers).
- The person’s mouth smells very bad.
If the infection of the gums is very bad and advanced (as it can be for a person with HIV), the signs may include:
- red, raw ulcers of the gums.
- the roots of the teeth will show.
- pieces of the jaw bone can be seen at the bottom of the ulcers.
- some teeth are loose.
- Keep the area clean to control the infection and to help the skin heal. See information on other methods for keeping the mouth clean.
- Very gently remove the tartar around the teeth. Be especially careful not to cause damage to the gums.
Also give antibiotics if:
- the neck is sore or stiff, and there are soft lumps just underneath the lower jaw bone.
Give 500 mg of amoxicillin by mouth, 3 times a day for 7 days. Women who are pregnant or breastfeeding can use this treatment.
OR for persons allergic to amoxicillin, give 100 mg of doxycycline by mouth, 2 times a day for 7 days.
OR give 500 mg of tetracycline by mouth, 4 times a day for 7 days. Do not give tetracycline to pregnant women because it can harm a baby’s developing teeth.
OR for women who are pregnant or breastfeeding, and are allergic to amoxicillin, give 500 mg of erythromycin by mouth, 4 times a day for 7 days.
- the gums between the teeth have ulcers, and the person’s mouth smells bad.
Give 500 mg of metronidazole by mouth, 2 times a day for 7 days.
Once the area is clean and the infection is controlled, take out any teeth that are very loose.
More serious gum infection (gangrene of the face, Noma, Cancrum Oris)
In the most severe gum infection, the jaw bone will become infected and this can spread through the cheek to the face. This will be very easy to see, as parts of
the face and jaw rot away and smell bad. It happens mainly to very sick children (usually one to four years old), but can also happen to adults with HIV infection.
Get medical help as quickly as you can — in a hospital if possible.
In the meantime, see the information on cleaning and treating the gangrene.
See information about medicines (antibiotics) for children. For an adult, give the following:
For an adult who is able to swallow:
- give 400 mg of metronidazole by mouth, 3 times a day for 10 days,
- OR if you cannot get metronidazole give 450 mg of clindamycin by mouth, 4 times a day, for 5 days.
- OR if clindamycin is not available give 500 mg of erythromycin by mouth, 4 times a day, for 10 days.
Note: : Clindamycin and erythromycin are safe to use for women who are pregnant or breast feeding. Metronidazole should be avoided in the first 3 months of pregnancy and while breastfeeding. If a woman is breastfeeding and taking clindamycin and it gives her baby diarrhea, she should stop taking the medicine.
For an adult who cannot swallow:
- inject 2,000,000 (2 million) Units of penicillin G into a large muscle, 3 times a day, for 7 days.
For an adult who is allergic to penicillin,
- inject 600 mg of clindamycin into a large muscle, 4 times a day, for 5 days.
If you give the medicines by injection, change to medicines by mouth once the person starts to feel better. But do not stop giving the medicines until the 7 to 10 days have passed.
4. Cold sores or fever blisters
Many people get cold sores or fever blisters caused by the herpes virus. People who become infected with herpes carry the virus forever. Most people are infected as children.
The herpes sores can come and go. The herpes sores usually heal after 1 or 2 weeks. But for persons infected with HIV, the sores come more often and last much longer.
- One or more small, sometimes painful, red blisters appear on the lips and skin around the mouth. In people with HIV infection, they also appear just inside the lips, and on the gums and the roof of the mouth.
- The blisters burst and become small open sores that often spread into each other.
- After the blisters on the lips burst, a yellow crust forms over them.
The herpes sores can pick up other infections, particularly in people with HIV infection. Also, the liquid inside the sores and blisters can spread infection. If herpes is spread to the eyes, it can cause blindness. Keep fingers and hands away from sores because they contain very active virus. It is very important to wash the hands before and after touching the face or eyes.
Medicine cannot kill the herpes virus. Keep the area clean to control any infection in the sores and to help them heal. Keep fingers and hands away from the sores, and drink lots of fluids. See information about other methods of keeping the mouth clean.
- Begin treatment as soon as you feel a tingling, before the cold sore appears. This may stop the sore from developing or developing so severely.
- A medicine called acyclovir may also help. Give 200 mg by mouth, 5 times a day for 7 to 10 days. You can also apply a small amount of acyclovir ointment on the sores 6 times a day for 7 days. It is OK to use them both at the same time. Acycolvir works best if taken or used early in the infection, before the blisters burst, if possible.
- If the sores are infected, give 500 mg of amoxicillin, 3 times a day for 7 days.
OR for persons allergic to amoxicillin, give 100 mg of doxycycline, 2 times a day for 7 days.
OR for a woman who is allergic to penicillin, and is pregnant or breastfeeding, give 500 mg of erythromycin, 4 times a day for 7 days.
- Antibacterial ointments such as neomycin or bacitracin can also help to prevent and control other infections that get into the sores. Stop using the acyclovir and spread a small amount of anti-bacterial ointment on the infected skin outside the mouth (not in the mouth) 2 to 5 times a day for about 5 days.
- To help ease the pain of sores outside the mouth, stop using acyclovir and cover the area with a dry powder, like baby powder, talc, or cornstarch. Do not use medicated powders as they can make the open sores sting very badly. Wash hands carefully before and after using powder.
5. Red or purple patches in the mouth (Kaposi's sarcoma)
Some people infected with HIV will get red- or purple-colored patches in the mouth. These patches are called Kaposi’s sarcoma and they can also appear elsewhere on the body. Kaposi’s sarcoma can be an early sign of HIV infection.
Painless patches that look like swollen bruises around or inside the mouth. The red or purple color is more obvious in the mouth. The patches rarely become infected and painful, usually only if they burst.
Get advice from a health worker or doctor who is experienced with the problems of HIV. People who are taking antiretroviral medicines (ARVs) tend not to get this kind of cancer. And starting treatment with ARVs can keep it from getting worse. Sometimes very strong anti-cancer medicines are used. Also, some medicines for treatment of varicose veins can be helpful.
6. Dry or painful mouth and throat
Many people with AIDS have difficulty eating near the end of their lives because of a dry or painful mouth and throat. But it is important to eat nutritious food during a sickness, even a serious sickness like AIDS. The person will feel much more comfortable and have less pain and infection if he or she can eat well.
A dry mouth can be caused by an infected swelling in the glands of the mouth that usually make spit (saliva). This is most common for people taking ARVs (anti-retroviral medicines). A painful mouth can be caused by other infections and problems that come with HIV and AIDS. See information about how to treat an infection of the spit gland. For help with eating if the mouth is very dry or sore, try the following:
- Eat soft foods in small pieces that are easy to chew and swallow.
- Cook foods until they are soft and tender.
- Mix foods with liquids to make them easier to swallow.
- Keep a small bottle of drinking water with you all the time.
- Use a straw to drink fluids.
- Do not eat hot or spicy foods. They can irritate a sore mouth and throat.
- If it is difficult to swallow, tilt the head back a little, or move it forward.
- Rinse the mouth with clean water often. This will remove food and germs, and help with healing.