Oral Health is Vital for People With HIV
Approximately 70 to 80 percent of people with HIV will experience thrush, oral hairy leukoplakia or another oral manifestation of HIV disease. Treating routine problems as soon as possible can prevent more serious infections, but you have to know how to look for them. At a recent forum at AIDS Project Los Angeles, Jim Formaker, D.D.S., program manager of AIDS Project Los Angeles' Greene-LeBaron Dental Clinic, discussed how to identify and treat oral abnormalities.
In his presentation, Formaker stressed the importance of "checking lymph nodes, looking for red spots, white spots or anything that looks abnormal."
Oral manifestations of HIV disease can be caused by fungal infections, bacterial infections, viral infections and neoplasms (cancers). Almost all of these infections appear in people who are not infected with HIV, but they appear more frequently and with more severity in people who are infected with HIV.
Candidiasis, a common fungus that lives in the mouths of most people, is the most common oral infection in people infected with HIV. Oral candidiasis is a yeast infection commonly referred to as thrush.
An overgrowth of this fungus may result from suppression of the immune system. Thrush can begin in the mouth and if untreated, progress down into the esophagus and the pharynx, where it can become more serious.
"Thrush should be dealt with as soon as it is recognized," said Dr. Formaker, "because any sort of infection in the body is taking up resources that your body can use to fight other things."
Thrush commonly appears on the cheeks, tongue and the hard and soft palate. The best way to diagnose thrush is by its appearance. Thrush is white or yellow in color and looks similar to cottage cheese. When wiped off with gauze or a toothbrush, it can leave red patches.
To confirm the diagnosis, a dentist or physician can perform a culture.
Atrophic thrush can be very painful and cause the tissue to become very red and smooth. Usually, however, thrush is only painful when it is aggravated by hot or spicy foods. Eating can be very uncomfortable, which can affect proper nutrition. Thrush can also cause dry mouth and taste perversion.
Treatment of thrush usually consists of Mycelex (Clotrimazole) or Nystatin troches. Troches are lozenges are dissolved slowly in the mouth five times per day for one to two weeks. Nystatin (Mycostatin) oral suspension -- commonly referred to as "swish and swallow" -- can also be used to treat thrush. One teaspoon is "swished" in the mouth for as long as possible, and either spit out or swallowed.
In situations of chronic thrush infections or where these treatments have failed, fluconazole (Diflucan) or ketoconazole (Nizoral) can be taken. One or two tablets of both drugs are taken daily for one to two weeks. In addition to treating thrush, these drugs can also be used for more systemic fungal infections.
Due to the potential development of resistant fungus, fluconazole and ketokonazole are not generally prescribed for the prevention of thrush. The high cost of these drugs has also been a great concern in recent years.
Besides appearing as spots or patches in the mouth, thrush can also appear as painful red, inflamed cracks or splits in the corners of the mouth. This type of thrush, known as Angular Cheilitis, is something quite common and often goes undiagnosed by physicians.
Easy-to-apply ointments, such as Clotrimazole, Nystatin and Triamcinolone Acetonide (Mycolog II) are the standard of care for these sores. Ointments are applied to the corners of the mouth three to six times per day until the sores clear up.
Re-infection with thrush can occur easily in people with dentures or other prosthetic appliances such as retainers, where fungus can live as easily as it does in the mouth. People who have had successful treatment for thrush need to also remove the fungus from their appliances before re-inserting them into the mouth.
Re-infection can be avoided by dropping a Mycelex or Nystatin troche into water and soaking the appliance over night for ten days. Also, Nystatin powder and Nystatin ointment or Clotrimazole ointment can be applied to appliances prior to insertion. All of these methods can help reduce the risk of re-infection with thrush.
Gingivitis, an inflammation of the gums characterized by a red band around the gumline, is primarily caused by bacterial infections. While pain is not necessarily associated with HIV-related gingivitis, someone with gingivitis may experience spontaneous bleeding while brushing and flossing, said Formaker.
Treatment of HIV-related gingivitis begins with a thorough cleaning, followed by an antibacterial solution called Peridex twice daily. Peridex has been shown to be very effective in reducing oral bacteria present in the mouth. Antibiotics like Tetracycline oral suspension taken for five to ten days can also be effective.
With proper treatment, pain resulting from gingivitis can be relieved within a few days. Left untreated, gingivitis can result in HIV-associated periodontitis, or an inflammation of the supporting tissue of the gumline. Symptoms of periodontitis include bad breath, swollen or red gums and loose teeth.
In extreme cases, HIV-associated periodontitis can quickly lead to permanent loss of soft tissue and bone. Therefore, regular brushing, flossing and dental visits are important parts of preventing gum disease.
Oral Hairy Leukoplakia
Another oral manifestation of HIV is oral hairy leukoplakia, a viral infection that is most likely caused by Epstein-Barr virus. Oral hairy leukoplakia generally appears on the cheek, underneath the tongue and most frequently on the sides of the tongue. While oral hairy leukoplakia is not typically associated with any pain, most patients seek treatment due to its appearance.
Outbreaks of oral hairy leukoplakia are characterized by white streaky patches that look folded or wrinkled. Due to protrusions from the surface, these patches have a "hairy" appearance.With the exception of these protrusions, oral hairy leukoplakia may look like thrush. However, unlike thrush, the "hairy" patches cannot be wiped off. Secondary thrush infections, which can be moderately painful, often occur on top of oral hairy leukoplakia. Despite their similar appearance, these should be treated as two separate infections.
Because oral hairy leukoplakia on its own does not cause pain, it does not have to be treated. However, if treatment is desired, high-dose acyclovir (Zovirax) followed by a lower-maintenance dose can be used to reduce or eliminate the patches.
During the induction dose period, 2,000 to 3,000 milligrams of acyclovir (Zovirax) should be taken daily. Five hundred milligrams per day is usually prescribed as the maintenance dose.
Patches will most likely recur as soon as treatment is stopped, Formaker warned. Used topically, the experimental treatment Retin A "burns off the top layer of skin and takes away the white tissue." he said.
Warts which appear in the mouth are common and can be troublesome. Warts in the mouth are caused by human papillomavirus (HPV), the same virus that causes genital warts. They can be localized and small or they can appear as multiple warts. Oral warts can be flat or cauliflower-like in appearance.
Laser surgery is commonly used to treat warts, but Formaker warns that laser surgery may spread the virus to other parts of the mouth. Instead, Formaker recommends surgical excision with a knife or cryotherapy. As with genital warts caused by HPV, the recurrence rate for oral warts is quite high.
The mouth is a common site of infection for Kaposi's sarcoma infection (KS). KS lesions are usually flat or raised purplish areas and may be painful. Over time, lesions can become darker in color and ulcerated. These lesions can also become secondarily infected with thrush, as happens with oral hairy leukoplakia. Treatment of KS generally consists of some form of chemotherapy or radiation therapy. Peridex mouth rinse used twice a day can help prevent any secondary infections.
Prevention is Important
Identifying problems early and exercising preventative care such as brushing and flossing are essential to maintaining good oral health and preventing problems.
"It is really important that people infected with HIV take care of their teeth." said Formaker. "Prevention is always an important part of treatment. That is why access to dental care is vital to people infected with HIV."
Dental Services in Los Angeles County for People With HIV/AIDS
This article was provided by AIDS Project Los Angeles. It is a part of the publication Positive Living.