Oral Ulceration

The diagnosis of HSV and aphthous ulcers usually is made on the basis of characteristic lesions. If diagnosis is uncertain, it is possible to perform HSV culture or HSV antigen detection using direct florescent antibody (DFA) testing on oral ulcerations that appear on keratinized tissues or the dorsal and lateral surfaces of the tongue, scraping near the margin of the lesion or unroofing a fresh vesicle, if available, and scraping the base. The sensitivity of HSV testing decreases when collections are taken from older, resolving herpetic areas; herpetic lesions >72 hours old usually will not yield a positive culture.

If other diagnoses are suspected, perform culture or biopsy as indicated.

Note that syphilis is very common in some HIV-infected populations. For patients in whom primary syphilis (manifested by an oral chancre) is suspected, perform (or refer for) darkfield examination; check Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) results (note that VDRL or RPR may be negative in primary syphilis); see Syphilis chapter for further information.

If HSV culture is positive, or if HSV is strongly suspected due to the appearance of the lesions or the patient's history, treat with HSV antiviral medication (eg, acyclovir, famciclovir, or valacyclovir) while awaiting results of culture. Do not use topical steroids without a concomitant oral HSV antiviral if the lesion is of possible herpetic etiology. Refer to Herpes Simplex, Mucocutaneous chapter for more complete information regarding management and treatment of HSV lesions.

Recalcitrant aphthous ulcerations should be treated with topical corticosteroids (eg, fluocinonide 0.05% or clobetasol 0.05% ointments mixed 1:1 with Orabase). For multiple small lesions or lesions in areas where topical ointments are difficult to apply, consider dexamethasone elixir (0.5 mg/5 mL). Rinse 3 times daily with 5 mL for 1 minute, then expectorate. As with all oral topical steroids, advise the patient not to drink or eat for 30 minutes after rinsing. Continue treatment for 1 week or until lesions resolve.

Some aphthous ulcers may respond to one of the various "magic mouthwashes" that contain combinations of antibiotic, antifungal, corticosteroid, antihistamine, and anesthetic medication. The inclusion of an antihistamine (eg, diphenhydramine) and/or anesthetic (eg, lidocaine) may be helpful in treating pain associated with these ulcers.

For large or extensive aphthous ulcers, systemic corticosteroids may be needed: prednisone 40-60 mg orally daily for 1 week followed by a taper should prove beneficial. If this is ineffective, refer for biopsy to rule out CMV, other infection, or neoplastic disease.

For patients with major oral aphthous ulcers that are recalcitrant to other therapies, thalidomide 200 mg daily for 2 weeks may be considered. Thalidomide should not be used in women of childbearing potential due to its teratogenicity. It must be used very carefully with thorough patient education and 2 concomitant methods of birth control.

Pain control may be needed in order for the patient to maintain food intake and prevent weight loss. Most of the topical treatments noted above will ease pain as well as treat the ulcer. Additional considerations for pain control include:

	For small accessible ulcerations, topically apply Orabase Soothe-N-Seal (2-octyl cyanoacrylate) directly to the lesion every 4-6 hours. (This is an over-the-counter product.)
	Oral anesthetics: Various products are available such as gels, viscous liquids, or sprays (eg, benzocaine, lidocaine). These may be applied topically or swished and expectorated. They will provide temporary relief, but also may lead to a temporary loss of taste sensation.
	Systemic: If topical treatments are inadequate, consider systemic analgesics, eg, nonsteroidal anti inflammatory drugs or opiates. Refer to the Pain Syndrome and Peripheral Neuropathy chapter.

Assess nutritional status and consider adding liquid food supplements. Suggest soft, nonspicy, or salty foods if the ulcer is interfering with food intake. Refer to a registered dietitian if client is having pain, problems eating, or weight loss.

Refer to an oral health specialist or an HIV-experienced dentist as needed.