Oral Mucosal Lesions in Children Living with Human Immunodeficiency Virus: A Critical Narrative Review of Clinical Phenotypes, Antiretroviral-era Evidence and Care Implications

Oral mucosal disease remains clinically relevant among children and adolescents living with human immunodeficiency virus (HIV), even as antiretroviral therapy has transformed survival and the expression of opportunistic infection. Its interpretation is nevertheless complicated by the use of broad, inconsistently defined outcomes that combine mucosal lesions with dental caries, salivary-gland enlargement, lymphadenopathy and periodontal conditions. This critical narrative review examines the clinical spectrum, epidemiological variability, immunological associations, diagnostic challenges and care implications of oral mucosal lesions in paediatric HIV. Evidence from observational studies, paediatric cohorts, systematic reviews and authoritative clinical guidance was interpreted with attention to diagnostic validity, comparison groups, treatment-era differences and geographical inequities. Oropharyngeal candidiasis is the best-documented infection, but fungal carriage should not be equated with symptomatic disease. Ulcerative lesions, herpesvirus-associated disease, papillomatous lesions, gingival inflammation and pigmentation require careful differential diagnosis because their causal relationship with HIV or its treatment is neither uniform nor specific. Although antiretroviral exposure is generally associated with fewer opportunistic oral infections, pooled estimates and cross-sectional contrasts are vulnerable to substantial heterogeneity and confounding. Paediatric clinical studies also produce strikingly different lesion estimates depending on whether the outcome is restricted to the mucosa and whether children have achieved virological suppression. The most defensible model is therefore not a fixed hierarchy of HIV-specific oral signs, but a context-sensitive assessment integrating lesion morphology, age, viral control, immune history, medication exposure, nutrition, local disease and access to dentistry. Priorities include standardised mucosal case definitions, longitudinal studies in contemporary treatment cohorts, appropriately characterised microbiological disease and evaluation of integrated dental–HIV care. Oral assessment should complement, rather than substitute for, virological monitoring and comprehensive paediatric healthcare.