Mouth and Throat Problems
Part of A Practical Guide to HIV Drug Side Effects
Figuring Out the Cause
There are a number of causes of mouth and throat problems, including infections, antiretroviral drugs and other medications, nutritional issues, oral cancer or other medical conditions and poor dental hygiene. A trip to a doctor or dentist is needed to determine the cause. Developing a treatment plan will depend on the specific problem. Below we discuss common issues such as infections, canker sores, dry mouth and dental problems. Most of the time, once the underlying issue is resolved, the mouth problem clears.
Note that changes in the mouth can be a sign of a rare but serious allergic reaction to a drug. The reaction, called Stevens-Johnson syndrome, usually develops within two weeks of starting a new drug, including some antiretroviral drugs. This reaction results in rash, fever, nausea and other allergy-like symptoms accompanied by tingling, inflammation and blisters in the nose or mouth or on the lips. This reaction is very serious and potentially fatal. The section Rash and Other Problems of the Skin, Hair and Nails has additional information on this reaction. A person experiencing these symptoms should seek medical care right away.
In people with HIV who are not on antiretroviral therapy, mouth problems -- and more specifically mouth ulcers -- can be a sign of a weakening immune system that has left them vulnerable to an opportunistic infection or other condition. Opportunistic infections and conditions that can affect the mouth include Kaposi's sarcoma, oral and esophageal candidiasis (commonly called thrush), hairy leukoplakia and mouth or throat ulcers caused by herpes simplex or cytomegalovirus (CMV). More rarely, mouth lesions can be caused by Mycobacterium avium complex (MAC) and oral fungal lesions can be associated with histoplasmosis, geotrichosis or cryptococcus.
People with these infections require immediate attention and need to start antiretroviral therapy. Antiretroviral therapy allows the immune system to rebuild itself, at least partially, resulting in a dramatic decrease in the risk of these infections.
Other mouth and throat infections and conditions can occur in people with HIV regardless of CD4 count. These include herpes simplex, which causes painful cold sores on the lip or ulcers on the palate, and herpes zoster, which is the cause of chicken pox and shingles. Shingles can cause pain and multiple lesions on one side of the mouth, with the mouth pain lingering long after the initial lesions have healed.
Human papilloma virus (HPV, the cause of warts), bacteria -- either an overgrowth of bacteria normally found in the mouth or newly introduced bacteria -- and lymphoma can also cause mouth and throat conditions. Some sexually transmitted infections, including chlamydia, gonorrhea and syphilis, can also infect the mouth or throat and produce sore throat, tonsillitis or oral ulcers. Some of these lesions, especially with primary syphilis, are not painful, making them easy to miss. Proper treatment of such infections or conditions is key to clearing up these mouth or throat problems.
Mouth sores such as canker sores (also called aphthous ulcers) are common and usually form on the soft pinkish-red tissue inside the lips and cheeks and on the bottom or sides of the tongue. It is thought that the hyperactivity of the immune system in HIV disease can contribute to the development of these painful sores. Antiretroviral treatment counters this hyperactivity, so very severe forms of canker sores are less common today than in the past. It can be helpful for people who are experiencing recurrent, severe canker sores and who are not on antiretroviral therapy to begin such treatment. The antiretroviral drug saquinavir (Invirase) can cause mouth ulcers, but it is not commonly used nowadays.
Certain micronutrient deficiencies, specifically in iron, zinc, niacin, folate, glutathione, carnitine and vitamin B12 can occur in people with HIV and can predispose them to canker sores. Regular use of a potent multivitamin mineral formula can help prevent most of these deficiencies. Glutathione deficiency can be countered with 600 mg of N-acetyl-cysteine, taken three times daily with meals. The most efficient way to boost carnitine levels is the use of acetyl-L-carnitine (500 mg, three times daily with meals). Note that this nutrient is seldom included in multivitamins. See the appendix on vitamin B12 for more information about this key vitamin for people with HIV.
Consuming too many acidic foods can cause canker sores in some people. Cutting back on tomatoes and products made with them, citrus fruits and their juices, coffee, pickled products, vinegars and other acidic foods can help. Canker sores can also be caused by local injury to the mouth, such as when you accidentally bite the inside of your cheek or tongue. There may also be a genetic link since canker sores are more likely to occur in people from families where they are common. Emotional stress and lack of sleep are also known to cause canker sores. Some people find they occur more often at certain times during their menstrual cycles.
As a first step, many people treat canker sores simply by rinsing their mouth with salt water several times a day. The rinse is gargled in the mouth for one to two minutes then spit out before repeating one or two times. Although canker sores will usually go away on their own within a week to 10 days, topical and oral treatments are available when the sores are frequent or cause significant pain or difficulty eating. Don't be afraid to raise the issue of ongoing canker sores with your doctor.
The use of topical corticosteroid creams and gels is the most common treatment for canker sores. These work by suppressing the immune activation that contributes to the development of these lesions. Such products must be used carefully, however, since the resulting localized immune suppression can lead to an increased risk of oral infections.
As long as the sores remain, topical anesthetic sprays can be used to numb the area and lessen pain when eating or swallowing. A mouth rinse consisting of viscous lidocaine, Benadryl elixir, and nystatin can help eliminate the pain of mouth sores. This rinse is prepared by a pharmacist. An opiate painkiller is sometimes added if the ulcers are particularly painful. If the lesions are only in the mouth cavity, this rinse can be swished and gargled for the two minutes, then spit out. If the lesions extend down into the throat, it can be used as a "swish and swallow" agent, rinsing it around the mouth for a couple of minutes and then swallowing it.
Dexamethasone, a corticosteroid, can also be added to the mixture. But before treatment with dexamethasone is begun, it is important to make sure the lesions are not caused by herpes viruses or other infections that could worsen with use of a steroid agent. If dexamethasone is added to the rinse, it is better not to swallow the mixture but to spit it out after the two-minute gargle. This will avoid the possible immune suppression that such a steroid agent could induce.
Another rinse sometimes used is called Miles mixture. It consists of hydrocortisone, nystatin and tetracycline. This mixture should not be swallowed, since hydrocortisone also suppresses the immune system. Some doctors and pharmacists have found that brushing the colouring agent gentian violet over mouth sores is a useful treatment. Again, it is important to be sure these sores are not caused by fungi or viruses.
For people with very serious canker sores that recur frequently, thalidomide has been shown to be effective. Thalidomide has serious side effects, including severe birth defects if taken during pregnancy. It should only be used under the close care of a doctor.
This article was provided by Canadian AIDS Treatment Information Exchange. Visit CATIE's Web site to find out more about their activities, publications and services.
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