Looking AIDS in the Mouth
Being a practicing general dentist in Manhattan -- specifically Greenwich Village -- for 35 years, I've seen the worst of the AIDS epidemic and, if such a word can apply, the best. Back in the late '70s and early '80s, AIDS was a little-known entity with, sadly, dire consequences. Most of us did our jobs, but those were difficult times. HIV was territory that most dentists had never explored. We learned a lot and did what we could. While some of us insisted that we not strip away all semblance of dignity from people with the virus and deny them the simple basics of dental care, many dentists did not even want these patients in their waiting rooms.
The early days were full of flat-out sadness: the families of many gay men virtually denied their existence and shoved them away to NYC -- even paid for them to stay away -- yet came out of the woodwork when they passed on to grab whatever they could. I recall a 21-year from the upper east side whose parents didn't want him to go to the family dentist because he would have to tell him he was HIV positive, and they didn't want the dentist to know they had a gay son. Conversely, I saw an old Italian man -- who for years wanted nothing to do with his gay son -- carry him up the stairs of my office during his last days, not giving a damn what anyone thought.
My years as a dentist have taught me that the mouth is often the first part of the body to show the signs of certain diseases: diabetes, stress, allergies, etc. But the hardest to have to relate to any patient were anomalies tied to AIDS: thrush, Kaposi's Sarcoma, advanced oral herpes, etc. Back then, this was a death sentence, and as a dentist, I really wasn't prepared to pass on that kind of information. My information was often greeted with resentment: "What do you know? You're just a dentist!" There would be hysteria at times, as most of the gay community knew enough about the disease to know what to ask and to look imploringly in your face for any sign other than the worst.
HIV and Oral Health
Oral health problems that are normally minor can be exacerbated when the immune system is compromised. Let's face it, when problems in the mouth occur, pain is a common byproduct, and HIV patients just don't need this additional distraction and aggravation. I guess you can use oral problems as a barometer that you're not keeping up with your maintenance -- an early-warning system, so to speak.
From a dental health point of view, dry mouth is probably the most common problem seen in people with HIV. It can be caused by HIV meds like Crixivan and Videx, or by HIV itself. And non-HIV meds like alpha interferon, antidepressants, blood pressure meds, antihistamines, etc., can also cause dry mouth.
Saliva is a great barrier and cleanser -- it washes away bacteria and acids formed by foods that can cause serious gingivitis, or gum disease. Actually, the mouth is the filthiest part of the body, with the highest count of bacteria. And the last thing any immune-compromised person needs is the introduction of more bacteria into the body thru bleeding gums. One of the fastest ways anything can get into the body is through mucous membranes. And low saliva increases the risk of cavities, which can quickly grow and become abscesses, so regular checkups are essential for anyone with dry mouth.
Unfortunately, there aren't really many good medications to promote salivation. Just keeping hydrated and using fluoride rinses to keep decay at bay is the best thing I can recommend. There are mouth rinses and artificial saliva products out there now for dry mouth. Use them, or use sugar-free candies to stimulate saliva production. Have your dentist familiarize you with the tissues in your mouth so you can be aware of any strange lesions.
Oral candidiasis, called thrush, is also common in people with HIV, and can appear in a number of different forms. Often people with thrush notice white patches on the tongue or elsewhere in the mouth. They may also have a burning sensation or pain, and food may taste strange, making it hard to eat. Candidiasis can also occur at the corners of the mouth and be mistaken for chapped lips. Other types may appear on the roof of the mouth and appear red rather than white.
No matter how it occurs, thrush should be treated promptly. People can use lozenges such as Mycelex, or pills like Diflucan. But no matter what treatment you use, it's important to take all the doses prescribed, even after the thrush appears to be gone, since resistant strains can develop and become much harder to treat. People who have recurrent thrush should keep meds on hand and learn how to identify the signs so they can restart treatment immediately, without waiting for their next appointment. Thrush that moves into the esophagus leads to an AIDS diagnosis, since it is a serious condition.
Canker sores (aphthous ulcers) are something most people have had at some point in their life, whether or not they have HIV. But in people with HIV, they may be slow to heal, and can grow quite large. They are not contagious and their cause is not known.
If they don't heal on their own, they can increase in size and cause a great deal of pain. This can lead to difficulty eating and even make swallowing dangerous. So, while people with normal immune systems can wait for these sores to heal on their own, people with low CD4 counts should get treatment no matter how small the sores are. There are ointments available, such as Kenalog or Lidex, or a dexamethasone rinse can be used. Prednisone or thalidomide pills are also available for more advanced cases.
Oral herpes is caused by the virus known as HSV-1. This is the virus that causes cold sores (different from HSV-2 which causes blisters on the genitals). In people with a normal immune system, herpes blisters usually heal in a couple of weeks without treatment.
But once again, in people with HIV, the lesions may be larger and more painful, and they may lead to secondary infections and interfere with the ability to eat. People with lower CD4 counts should consider antivirals like Famvir, Valtrex, or Zovirax. While there are ointments available, they often don't work as well as systemic meds.
ANUG (acute necrotizing ulcerative gingivitis), is a painful, inflamed, punched-out appearance of the gums, in the same category as Vincent's infection (trench mouth). It is often caused by stress -- something many chronically sick people have to deal with, so the cycle becomes self-perpetuating. Often the only recourse is to keep the mouth as clean as possible, or just treat the symptoms with an antimicrobial mouth rinse or pain meds.
Home care is most important. You can see the dentist every week for a cleaning, but if you don't do that work in front of that mirror, you're asking for trouble. Brush, floss, get frequent cleanings -- these simple things will go a long way to maintaining a decent quality of life. Maintenance, maintenance, maintenance.
It's been a privilege caring for people with AIDS since the beginning of this worldwide epidemic. Difficult at times, but mostly rewarding. Every single patient deserves special attention, regardless of personal feelings and agendas. Dentists should never forget the simple reason we all got into this to begin with -- to heal the sick.
Charles Dorato is a dentist in Greenwich Village, New York.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication ACRIA Update. Visit ACRIA's website to find out more about their activities, publications and services.