Maintaining Good Dental Health

(Information provided by Project Inform, HIVdent, Dr. Peter Foltyn, Ian McKnight, and Dr. David Reznick.)

It is funny how these Survival News article ideas come to mind. This article was stimulated by both my visit to the dentist last Thursday (I was a bad girl. I had not been to see my dentist in over a year. BAD. BAD.) and by my friend Dr. Tom Sparkman, who started the Homecoming 2000 benefit "Tooth AID: A Month of Smiles." I decided to write on dental care because we have not had much focus on this topic. It is an important, yet overlooked part of HIV health care. A study conducted by the American Dental Association revealed that only 20% of Americans brush as frequently as their dentist recommends, while 44% floss daily, and 21% never floss. Yikes! We need to change those numbers. It is really not that difficult to keep our teeth and gums healthy. We just need to take a little time out every day. So?

Why is Dental Care Important for People Living with HIV?

Oral problems may be the first indication of HIV disease and may serve as a good barometer of HIV progression.
Many oral manifestations can put a strain on your immune system, and who needs that?
Oral problems may lead to tooth loss, which leads to pain when eating, which leads to bad nutrition.
Bleeding gums and open sores are possible routes of transmission for HIV and other infections.
Unusual dental problems may be a sign of HIV progression, and regular dental checkups may help your health care provider determine the best time to start treatment with HIV-fighting drugs.
90% (estimated) of people with HIV disease will present with at least one oral manifestation at some time during the course of their infection.

As I was reading, I noticed that many articles stated that mouth and throat problems are sometimes the first signs of HIV disease. I was surprised because you never hear that mentioned when we talk about "the first signs of HIV." The most common problems include: oral candidiasis, hairy leukoplakia, gingivitis, and periodontal disease, as well as dry mouth and Kaposi's Sarcoma. I will spend the rest of the article explaining the symptoms and treatment of these conditions and end with the basics of how to brush and floss. (Don't laugh -- I am not always sure I do it the correct way!)

Candidiasis

This is a common condition that occurs frequently in both the mouth and esophagus. The most common form presents itself as white patches that are found on the tongue or on the outer surfaces of the mouth. They can be large or small. Other symptoms of thrush may also include red patches on the surfaces of the mouth and tongue, or white patches that cause bleeding when removed, as well as inflamed cracks and splits in the corners of the mouth opening.

There are three predominant types of candidiasis seen in the HIV+ population:

Eryhematous candidiasis -- red, flat lesions that may appear anywhere in the oral cavity, but mainly on the tongue and/or the roof of the mouth.
Pseuomembranous candidiasis -- referred to as "thrush."
Angular Cheilitis -- appears as cracks or fissures radiating from the corners of the mouth.

Persistent candidiasis in HIV positive folks may require therapy such as fluconazole, as well as topical therapies such as nystatin, clotrimazole and amphotericin. Ketoconazole has also been used; however, it has a history of causing side effects such as rashes, nausea and, on rare occasions, jaundice. Some research says it may be less effective. It has also proven to have some interaction problems if drugs like refampicin are being used at the same time.

Some complementary therapists suggest that people with mild outbreaks can benefit from avoiding refined sugars, a source of nutrition for thrush. This means avoiding sweet or starchy foods as well as alcohol. (The Yeast Connection Handbook by Dr. William G. Crook is an excellent book to read about this subject.) Diluted tea tree oil has also been used as a mouthwash. Treatment usually lasts about two weeks.

This condition may cause mouth or throat pain, or an unusual taste. It is one of the most common illnesses that people with HIV experience. Estimates suggest that more than 90% of people with HIV will have an outbreak of thrush during their HIV illness. This is because the fungal organisms that cause thrush freely live in most human mouths.

Most outbreaks of thrush occur when the T-cell count has fallen bellow 400. However, episodes may also be experienced when other factors such as prolonged stress or depression are present. The use of antibiotics for long periods of time can also cause an outbreak to occur.

Hairy Leukoplakia

This is also a common condition. It is described as white lesions on the lateral border of the tongue. Apart from its appearance, this condition is usually without symptoms. It usually responds to a variety of antiviral agents. A virus (Epstein-Barr) that is related to herpes causes it. Treatment is usually not necessary unless taste or appearance is compromised.

Symptoms of Hairy Leukoplakia:

White streaky patches on the side of the tongue or the cheek.
Patches look corrugated (folded in appearance).
Plaques that are hard to remove.
Hair-like protrusions from the surface.

The use of acyclovir (Zovirax) will often clear up the condition as will propolis tincture. This is a product of bees that, when applied directly to the plaques, has shown some results. However, if any of these treatments are stopped, the plaques will often return.

Periodontal Disease

Periodontal disease is often a rapidly progressive and unusually painful condition. As a matter of fact, periodontal disease has been given the status of an opportunistic illness. The most likely cause of this condition is alteration of the bacterial flora in combination with immunosuppression. The suggested way to control this disease requires conscientious oral hygiene and professional treatment. Povidon idodin irrigation may help manage the acute disease state, but antibiotics are often required for successful management. Metronidazole has been the most effective antibiotic. However, some dentists may recommend penicillin or clindamycin. In severe cases, intravenous medication may be required. This disease has been known to cause pain when chewing or brushing teeth.

Symptoms of Periodontal Problems:

Bleeding after brushing your teeth.
Bad breath.
Gums that are swollen, red or tender.
Gums that have pulled away from the teeth.
Pus between the teeth and gums when the gums are pressed.
Teeth that are loose or separating.
A change in the way the teeth come together when you bite.

Gingivitis

Gingivitis literally means inflamed gums. This is a gum disease that is caused by bacteria and dental hygiene problems. It can be treated with the use of antiseptic mouthwashes such as cholrhexidine. However, many of these have alcohol, which can cause pain. Antibiotics may also be helpful.

Dry Mouth

Many people with HIV report symptoms of dry mouth. Here is a list of possible causes:

The action of the virus on salivary glands often reduces the amount of saliva in the mouth.
Many of the drugs that a person with HIV may be taking.
Mouth breathing at night. A sore throat or a dry cough often accompanies this.
Allergies such as hay fever.

If dry mouth is caused by an allergic reaction, this may be alleviated by avoiding dairy products or by taking horseradish or garlic tablets.

To Get Rid of Dry Mouth:

Rinse frequently. (Carry a bottle of water with lemon juice in it.)
Use a fluoride-containing toothpaste to brush your teeth.
Chew sugarless gum. It can help stimulate salivary flow.
Sip water throughout the day.
Suck on sugarless candy or crushed ice.

Don't underestimate the power of your saliva. It fights bacteria. Without a good flow of saliva, the growth of bacteria, candidiasis, and tooth decay increase.

Kaposi's Sarcoma

Half of people with HIV disease have been reported to have these oral lesions. Researchers have noted that the first signs of KS occur in the mouth in approximately 22% of patients. In another 45%, KS occurs in the mouth and skin simultaneously. KS may cause mouth pain or bleeding, or can be symptom-free.

This condition appears as red or purple nodules on the walls of the mouth or on the tonsils. They can also be associated with pain, bleeding, and inflammation, and bulky lesions can cause interference with the normal functions of chewing or talking.

The lesions may be treated in a number of ways. Surgical removal, localized radiotherapy or systemic chemotherapy are common treatments.

Questions and Answers with Dr. David A. Reznick

(Information from The Body, http://www.thebody.com/cgi/oralans.html)

Q: What is thrush and what causes it? What medication is used to treat thrush?

A: Thrush is a common term for pseudomembranous candidiasis, which is caused by fungal organisms. The most common causative agent is Candida albicans, but our recent research has shown an increased prevalence of non-albicans species such as Candida glabrata and Candid Krusei. The difficulties these non-albicans species bring is that, for the most part, they do not respond to exiting therapies.

Medications used to threat thrush are based on the extent of disease. For mild-to-moderate infections, I recommend topical therapies such as Mycelex troches. I do not recommend the use of nystatin swish and swallow due to the high glucose concentration (50%) as well as the length of time a person in expected to keep this medication in the mouth (five minutes). This is the time nystatin needs to be in contact with the candidal plaques to be effective. For moderate-to-severe bouts of thrush, I recommend Diflucan (fluconazole) which is dosed at 200 mg. on day one, then 100 mg. a day for the rest of a two-week period of time. Whether you are using a topical or systemic medication, treatment should last for at least two weeks; this helps prevent against recurrence of the infection.

Q: How important is it for my dentist to know about my HIV status?

A: You ask a most important question! It is my belief that oral health is an integral part of primary care; therefore, any changes in your medical history, including HIV status, should be made known to your dental care provider. Your oral health should be monitored closely as early signs of disease progression can first present in the mouth. The same can be said for a person living with many other conditions, including diabetes and cancer. Changes to the soft tissue including oral hairy leukoplakia and candidiasis can be diagnostic of increased viral load and signal a need to begin antiretroviral therapy. I believe these points are a much better reason to inform your dentist. Not all dental health care workers realize the importance of these signs and symptoms, but if made aware of your status, they may pay more attention to soft tissue exams.

Now for the reality check: Whereas attitudes toward treating HIV-infected people in the dental setting have improved, there are still providers who would rather not. Even though the Americans with Disabilities Act includes access to places of public accommodation, such as dental offices, many choose not to pursue legal action when denied care. Many do not want to risk rejection in the first place, thus the reluctance to disclose HIV status. My question to you: would you want someone taking care of your present dental needs who would not if they knew your HIV status?

Some Other Things to Consider Before Deciding on Your Dentist and Disclosing Your HIV Status:

Does the support staff make you feel comfortable and welcome?
Does the dentist put you at ease, and is he or she willing to deal with your fears?
Discuss what information will be included in your dental file and what impact, if any, this may have on your insurance.
Ask the dentist about his or her experience in treating HIV-positive patients.
Find out whether universal precautions are used to protect you from hepatitis, HIV, and other transmissible illnesses. (The answer should be yes. Have them explain the answer in detail.)
Dental care providers are required to use gloves, masks, face shields and other protective gear when dealing with all patients.
Ask if they use filtered water. If they answer is "no," bring bottled water to your check up or ask if they could provide a glass of water from their water service (if they have one) so you can rinse out your mouth after your dental work. You don't want any of the impurities from the tap water getting into your body!

Things You Can Do To Keep Your Teeth and Gums Healthy:

Brush your teeth at least twice daily.
Use a soft-bristle brush and an ADA-accepted fluoride toothpaste.
Replace your toothbrush when it begins to show wear or every three months.
Replace your toothbrush after you have had a cold.
Floss daily.
Regularly use mouthwash.
Regularly visit the dentist.
If you have problems, do not delay getting professional help.

How Do You Brush Your Teeth?

Remember the goal of brushing is to brush away plaque.
Good brushing takes three to five minutes (most people spend 30 seconds)
Gently, but thoroughly brush the teeth and gums.
Don't brush with a hard toothbrush; it can cause the gums to recede.
Brush your teeth after meals.
Brush in a gentle, circular motion.
Keep bristles at a 45-degree angle when brushing your front teeth and gums, with the bristles angled toward the gum.
Pay special attention to areas you tend to neglect: the back of your front bottom teeth, the sides of the wisdom teeth, and insides of your lower teeth.
Floss before you brush. This helps loosen debris from between your teeth and below the gum line.
On outer and inner surfaces, brush at a 45-degree angle in short, half-tooth-wide strokes against the gumline.
On chewing surfaces, hold the brush flat and brush back and forth.
On inside surfaces of front teeth, tilt brush vertically and use gentle up-and-down strokes with toe of brush.
Brush your tongue in a back-to-forth sweeping motion to remove food particles and freshen your mouth.

How Do You Floss Correctly?

Begin by wrapping an eighteen-inch strand around your middle fingers and hold a one-inch section tightly. Ease floss between your teeth. Clean up and down several times while curving around teeth and the gumline. Don't scrub.

Work floss gently and carefully between teeth, but avoid "snapping" floss against the gums.
Gently curve floss around tooth and under the gum line.
Move floss straight up and down each tooth to scrape away harmful plaque.
Always floss behind the last tooth. Unwind clean floss as you proceed.
Floss around the abutment teeth of a bridge and under artificial teeth using a floss threader.

Finally?

Don't chew on pens or pencils. It is a good way to damage the teeth.
Avoid chomping popsicles, jawbreakers or ice cubes.
If you can't brush after a meal, at least rinse with water.
Never share your toothbrush. (My boyfriend does not understand this concept. His philosophy is that if I kiss him, he can use my toothbrush. YUCK!)
If you drink sugared beverages like soda or coffee, don't sip them throughout the day. Every time you ingest a little bit of sugar, your teeth produce bacteria.
Tobacco smoke can irritate the gums.

Remember, poor oral health, and problems such as abscess formation, may lead to further suppression of the immune system. So, now that you are thinking about it, pick up the phone and call your dentist to make an appointment. Keep in mind that many dentists are booked three to four months in advance, so call as soon as you put down your newsletter!

Resources

National Resources

HIVdent.org
Web site that provides information on HIV dental care as well as referrals to HIV dental programs.

The Body: An AIDS and HIV Information Resource
www.thebody.com

Georgia Resources

Infectious Disease Oral Health Center of Grady Health System
Dr. David Reznick
Atlanta, GA
404-616-2440

Dr. Tom Sparkman
Dunwoody, GA
770-396-8061

Dr. Chip Hill
Atlanta, GA
404-724-9918

Dr. Ida Lanier
Stone Mountain, GA
770-498-3744

Dr. Bert Scannell
Atlanta, GA
404-525-2741

Robert Comer
DMD Medical College of Georgia School of Denistry
Augusta, GA
706-721-2607

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