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“I’ve heard of hairy palms, but a hairy tongue?!” HIV & oral health concerns

, by San Francisco AIDS Foundation

Twice a month, the San Francisco AIDS Foundation program Positive Force hosts free The Dr. Is In events for our HIV-positive community. Dr. Neal Sheran, the Special Populations Clinical Chief at the HIV clinic at Mission Neighborhood Health Center, selects speakers for the event that share information about HIV health and wellness and other topics of concern for people living with HIV.

mouthThis month, Dr. Sheran invited Caroline Shiboski, DDS, PhD, professor of oral medicine at UCSF, to talk about the oral health conditions she treats—and what people living with HIV (and everyone) can do to keep their mouths healthy and pain-free. Here’s what we learned.

The intersection of HIV and oral health

Dr. Shiboski introduced the topic of oral health by first explaining the type of health conditions she treats, and how she’s seen her field of medicine change over the past few decades.

Even though Shiboski is a dentist, she explained that she doesn’t treat people’s teeth—she helps treat conditions that affect the soft tissues in the mouth, the oral mucosa, the salivary gland, and other parts of the mouth like the tongue and lips. “Many systemic diseases, like HIV and AIDS, manifest themselves in the mouth,” she explained, with opportunistic infections like thrush oftentimes affecting people living with HIV.

When she started treating patients in San Francisco in 1989, many people who attended her clinic were HIV-positive. “The waiting room was like a social scene—people all knew each other,” she said. Now, with powerful antiretrovirals (ARVs) that keep opportunistic infections at bay, “I’ll see an HIV-positive patient maybe only every other month.”

Still, there are conditions that people living with HIV (and everyone) can look out for so they know when to seek treatment.

Hairy tongues and other strange (but not clinically significant) oral conditions

Dr. Shiboski first explained a few oral conditions—that may look or feel strange—that aren’t symptomatic of a serious illness or health problem.

scalloped tongue

Scalloped tongue (Photo: Caroline Shiboski, DDS, PhD)

Scalloped tongue can happen to people who clench their teeth. People get an impression of their teeth on their tongue, and/or on their teeth.

Geographic tongue will look like areas that are “bald”—areas stripped of the papillae—on the tongue that will change locations over time.

Elongated filiform papillae will look like the tongue is coated or furry. If people with this condition drink coffee or tea, the papillae can be stained black, which will look like someone has a “black, hairy tongue.” Elongated filiform papillae can be caused by taking certain medications and can be removed by oral medicine providers with an exfoliant.

geographic tongue

Geographic tongue (Photo: Caroline Shiboski, DDS, PhD)

Leukodema is a white film that can show up on the inside of the cheeks.

Exostosis is a bony protuberance on the palate. They’re sometimes called the “bunions of the mouth,” said Shiboski.

Case studies: KS, cancer, thrush and more

Shiboski presented a series of case studies, complete with pictures, to show examples of conditions that people living with HIV (and others) can look out for.

The bottom line, she said, is that if something in your mouth doesn’t look or feel right—and the problem persists for two weeks—it’s time to see a doctor.



Thrush (Photo: Caroline Shiboski, DDS, PhD)

Thrush is caused by an overgrowth of a yeast bacteria—candida—in the mouth. It’s more common in people who are immunosuppressed, which can be people living with HIV or AIDS and people who are on immunosuppressant drugs (for example, after an organ transplant). Thrush shows up in the mouth as white “plaques.”

Shiboski described the 40-year old patient who she treated with an antifungal medication for thrush. “The first question that came to my mind, was, ‘why did this person get thrush?’ I had a suspicion that he might be HIV-positive, but I don’t send people in for HIV tests since people who receive HIV tests need the counseling that comes along with that test. So, I called the patient’s primary care provider, and had them order the HIV test.”

Kaposi Sarcoma (KS) in the mouth

KS of the mouth

Kaposi Sarcoma of the mouth (Photo: Caroline Shiboski, DDS, PhD)

Shiboski described seeing a 25 year old man, who was living with HIV but not on ARVs, who had a lump in his mouth. He’d had it for eight months, and Shiboski diagnosed it as KS. “We rarely see KS in the mouth these days. In the ‘80s and ‘90s we saw it a lot, but not much anymore.”

Necrotizing ulcerative periodontis

Another condition that was more common in the late ‘80s, necrotizing ulcerative periodontis, is caused by an anaerobic bacteria. The bacteria causes a rapid destruction of the soft tissue and bone that supports the teeth, so it’s important to get treatment for this dangerous condition right away. If you remove the necrotic tissue, you can save the teeth, said Shiboski.

Oral warts

“It’s interesting,” said Shiboski, we used to see a lot more oral warts in the late ‘90s, when patients first started taking ARVs. We don’t see that as much now.” After showing a picture of what oral warts look like, Shiboski described a case of a 35 year old

Oral warts

Oral warts (Photo: Caroline Shiboski, DDS, PhD)

man who came to her clinic for the lumps inside his cheeks, that had been there for two years. Usually, oral warts are  “nuisance” to treat, said Shiboski. They can be removed with a laser, but usually not all at once. Instead, warts that are in areas that are bothersome are selectively removed.

Bacterial infection of an ulcer

Shiboski described a patient she treated who had recently received a kidney transplant, so was immunosuppressed. The person had an ulcer that had been colonized with bacteria, so was inflamed and painful.

“A traumatic ulcer can be small, and not that big of a deal. But if someone’s CD4 count is low, or they’re taking immunosuppressant drugs, you can get bacteria colonization of the ulcer.” Doctors have to use a two-step process to treat these ulcers—first, to kill the bacteria, and then to use a topical steroid to treat the ulcer.

Hiptoplasmosis in the mouth

Shiboski described another kidney transplant patient, who was on immune suppressant drugs, with mouth lesions. The patient, from a rural area, developed a fungal infection called hiptoplasmosis. It’s caused by breathing in the spores of fungus which can sometimes be found in bird and bat droppings—which is why people in rural areas are more often affected.

“It’s unusual to see this in the mouth. It usually shows up in the lungs before it causes symptoms in the mouth.”



Syphilis sores (Photo: Caroline Shiboski, DDS, PhD)

This sexually transmitted infection syphilis can present as sores in the mouth. Shiboski described a patient who had painful sores on his tongue, who thought they were getting bigger.

“I was worried about cancer, but he had sores on the other side of his tongue too.” It turned out that the man was infected with syphilis. “This is rare, that we see this,” said Shiboski.

Squamous cell carcinoma

The danger with oral squamous cell carcinoma is that it needs to be caught and treated right away. Once is spreads to the lymph nodes, said Shiboski, there’s less than a 50% survival rate after five years.

“The earlier the diagnosis, the less morbidity there is. It’s really important to get this diagnoses as quickly as possible.”

Shiboski showed a picture of a man, was had been HIV-positive since 1985, who developed squamous cell carcinoma on his tongue. “He got an incision on the tongue [to treat the cancer],” said Shiboski. “The tongue heals very well.”

General oral health advice

Get your mouth examined on a regular basis, advised Shiboski. In the U.S., about 80% of the dental disease happens in about 20% of the population (likely the people who don’t have access or don’t seek out dental care). See the end of this article for low-cost dental care options in the Bay Area.

Ask your dentist to do a soft tissue exam (if they don’t already). It only takes about five minutes for a dentist to examine the gums, tongue, and other soft tissues of the mouth.

Keep it simple, and skip the mouthwash. You don’t need to buy a lot of products to keep your mouth healthy. Shiboski recommends brushing with a mild fluoride toothpaste. “That will be much better for your soft tissue than a bright blue toothpaste that says it will whiten your teeth and provide tartar control,” she said. Floss your teeth daily to remove plaque build-up. She doesn’t recommend mouthwash, which can kill the “good” bacteria that grows in our mouths. If you do want to rinse with something after brushing, she recommends mixing a teaspoon of baking soda with lukewarm water.

Free/low-cost dental services in San Francisco

The Native American Health Center offers affordable family dental care (there is no residential, tribal or ethnic requirement to use the clinic). They have two locations that are BART-accessible. Call 415.621.8056 or visit https://www.nativehealth.org/content/san-francisco-dental.

University of the Pacific School of Dentistry offers free services through the HIV Care program. Call 415.929.6448 for an intake appointment and look here for more information http://www.dental.pacific.edu/dental-services/clinics-and-services/care-(hiv)-dental-services.

University of the Pacific School of Dentistry offers low-cost dental care to people over age 14. Call 415.929.6501 Monday through Friday, 8:30 am – 12:30 pm and from 2 pm – 4:30 pm, or visit http://www.dental.pacific.edu/dental-services/clinics-and-services/san-francisco-main-clinic.

South of Market Health Center Dental Clinic offers comprehensive dental care on a sliding scale for people without insurance and people who do not qualify for Medi-Cal, Healthy San Francisco or Medicare. They also take many insurance plans. Call 415.503.6033 for more information or visit http://www.smhcsf.org/services.html.



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