Friday, January 16, 2015

From the Archives: HIV/AIDS and Oral Care

From the Archives: HIV/AIDS and Oral Care

HIV/AIDS Updates: HIV and Oral Care
Oral Issues Specific to HIV/AIDS Patients

[Article originally published in Out IN Jersey Magazine]

Biting the Apple. Fans appear from within the sunrise, biting the Big Apple. Photo by Alina Oswald. All Rights Reserved.
Teeth: Biting the Apple. Photo by Alina Oswald. All Rights Reserved.
The eyes may be windows to the soul, but the mouth is an open door to a person's overall health. Rigorous oral maintenance and regular checkups can play a vital role in one's oral--and overall--health. This is of special significance to HIV/AIDS patients whose already weakened immune systems make them more prone to infections.

Many health issues start in the mouth. For HIV/AIDS patients, issues like decaying teeth, dry mouth, cavities or mouth sores may signal the existence of more serious health problems. For example, dry mouth can be related to certain HAART [Highly Active Anti-Retroviral Therapy] regimens, while untreated or late detected cavities can be hosting infections that later on may spread throughout the entire body, causing significant damage; mouth sores or lesions, if cancerous, can be manifestations of HIV/AIDS-related cancers.

While a lot of information is available on a wide range of HIV/AIDS medical topics--HAART regimens, for example--information on HIV/AIDS-related oral care and oral conditions is not as abundant or easily available. In addition to the general dental problems, HIV/AIDS patients should be in particular aware of a series of issues that can affect their oral health, be that because of their compromised immune systems, HIV itself or side-effects to their medications.

Studies have shown that the cases of oral lesions and periodontal disease in people living with HIV/AIDS have significantly decreased after the advent of HAART regimens. This is because the new medications have improved patients' immune systems beyond the levels triggering certain infections, including certain oral conditions. In the same time, the new medications, especially a certain class called protease inhibitors (PIs), may be the cause of an increased number of oral warts in HIV/AIDS patients.

A 2004 study conducted by the U.S. Department of Health and Human Services has shown that eighty percent of people living with HIV/AIDS will develop at least one oral condition during the course of the disease. Over thirty oral conditions have been reported in HIV/AIDS patients since the beginning of the epidemic. Most frequent conditions include oral candidiasis (thrush), oral hairy leukoplakia (OHL), HIV-related cancers like [oral] Kaposi's sarcoma (KS) and lymphoma, also HIV-related gingivitis and periodontitis that affect the gums and teeth, xerostomia (dry mouth), caries and human papillomavirus (HPV).

Among these conditions, thrush is maybe the most common and one of the earliest signs of the disease. Thrush and/or OHL are conditions that should prompt individuals to take an HIV test. Also, HPV and xerostomia (and related issues) are most frequently met, today, in HIV/AIDS patients.

Candidiasis, or thrush, is a fungal infection occurring when the T cell count falls below 400 (measured per unit of blood). Although thrush is the most common in people living with HIV/AIDS and one of the earliest signs of the disease, it can also be caused by dry mouth, extended periods of stress, depression or use of antibiotics. The infection usually occurs inside the mouth but it can also extend to the throat and corners of the lips. When painful, thrush can cause loss of appetite, loss or distortion of taste, and discomfort. Treatment includes antifungal medication administered in the entire body (systemic) if the infection is extended, or as local application (topical).

Oral hairy leukoplakia (OHL) is a viral infection and one of the most common oral conditions found in people living with HIV/AIDS. Believed to be caused by Epstein-Barr virus--that causes mononucleosis (mono, a.k.a. kissing disease), OHL appears as white patches with a hair-like appearance (hence the name) on the walls of the mouth or on the sides of the tongue. OHL occurs when the T cell count is very low, thus it's less probable in patients who are on HAART regimens. Treatment includes ganciclovir (a medication also used to treat CMV, or cytomegalovirus, that can attack the retina and the digestive system, including the oral cavity). Also, propolis tincture (from bees) has proven to be a helpful alternative therapy.     

Nowadays, human papillomavirus (HPV)--that usually causes genital and anal warts--is more common in HIV/AIDS patients. HIV makes the HPV lesions more serious and more difficult to treat. HPV lesions can occur on the skin and in the mouth. Although lesions can be removed surgically or with laser, they can also reoccur. Infection with HPV, including infections with (HPV-16) type of HPV, can increase the risk of cervical and anal cancer. In the mouth, it can increase the risk of oral (mouth or throat) cancer. Prevention includes safe oral sexual practices.

Another very common oral condition found in HIV/AIDS patients is dry mouth, or xerostomia. One cause can be the virus itself--HIV can cause salivary disease, which can lead to swollen salivary glands and, therefore, a reduced amount of saliva in the mouth. Another cause can be the antiretroviral medications--especially certain classes of HAART regimens, for example protease inhibitors (PIs) like indinavir (Crixivan) and nucleoside analog transcriptase inhibitor (NRTI or nuke) like ddI (didanosine, Videx). Antihistamines, antihypertensives, antipsychotics and antidepressants can also cause dry mouth. Other factors include allergies and infections.

Why saliva is important? And why a dry mouth can be a serious health problem?

A dry mouth may enable food particles to remain in the mouth and build up between the teeth and the gum, thus causing tooth decay, periodontal disease, and candidiasis. A dry mouth can also cause high acid levels to persist in the mouth after eating, thus allowing the appearance of cavities, which, in turn, can further lead to infections that can spread throughout the entire body.

In HIV/AIDS patients, cavities develop at the cervical region of the tooth, that is where the crown meets the root of the tooth and where the surface consists of cementum (not enamel). Cementum is a bony substance with a faster decaying speed. The process can lead to infections of the tooth pulp (the soft tissue inside the tooth) and abscesses (infections, pus). Oral care is vital in discovering these kinds of issues in early stages. Treatment includes a technique called "scoop and fill." Using hand instruments and usually no anesthetic, dentists scoop out the damaged part of the tooth and fill it in with a temporary fluoride-based filling that prevents further decay. For abscesses, treatment options include antibiotics, in particular penicillin.

Dry mouth treatment options vary from prescription drugs and artificial saliva to therapies that stimulate the salivary glands (for instance, pilocarpine therapy) and certain herbs like demulcents, chickenweed and slippery elm. Also chewing sugarless gum or sucking on sugarless candy can stimulate more saliva.

Bacterial infections are a result of overgrowth bacteria. In HIV/AIDS patients, bacterial infections that occur in the mouth signal the virus' presence in the rest of the body. They are easier to treat but, if left untreated, undetected, or if they are detected late, they can lead to serious health problems.

Among the bacterial infections frequently met in people living with HIV/AIDS are gingivitis, also called HIV-gingivitis or linear gingival erythema (LGE), and periodontal disease, also called HIV-pertiodontitis or necrotizing ulcerative periodontitis (NUP).

Gingivitis is a chronic inflammation of the gums and it can happen to anybody. Symptoms include bad breath and bleeding. In HIV/AIDS patients, gingivitis is more severe and appears as red band-like lesions along the gumline (where teeth meet the gum). If left untreated, LGE can lead to HIV-periodontitis (NUP), which is an extremely serious condition. NUP attacks the gums, teeth and surrounding bone structure. It can cause tooth loss, bleeding and severe pain. Treatment includes antibiotics, surgical procedures and local debridement (getting rid of dead tissue).

Abnormal tissue growths, or neoplastic lesions, can be benign or cancerous. If cancerous, in the case of HIV patients, they can be manifestations of HIV-related cancers like Kaposi's sarcoma or lymphoma.

Kaposi's sarcoma (KS) is a cancer that affects a patient's skin and/or organs. It appears as purple lesions on the skin. In the mouth, KS can appear as patches or swellings on the gums, tongue, on the roof of the mouth or at the back of the mouth. KS is usually not painful but it can become painful when it interferes with other infections. When painful, oral KS lesions can affect chewing and talking, and also increase the risk of wasting associated with HIV/AIDS or affect treatment, because some medications have to be taken with food. KS usually goes away when the immune system recovers due, for example, to a HAART regimen that works for the patient. KS can be treated locally, using local administered chemotherapy or surgically removing the lesion, or in the entire body, using intravenous chemotherapy.

Lymphoma is more rare than KS and more serious. Lymphoma appears as a small lump in the mouth or near the tonsils. Only a biopsy can determine if a lesion is indeed lymphoma. Treatment includes chemotherapy.

When it comes to dental care, the first question that may occur to HIV/AIDS patients is the disclosure issue. Patients are advised to find a dentist they can trust, be that through referrals or through an AIDS Service Organization (ASO) they work with. It's always best to find a dentist that has experience working with HIV/AIDS patients and knows to look for oral signs of HIV-related illnesses, in order to monitor the progression of the disease and possibly prevent certain oral conditions from occurring. In order to do that, though, dentists have to first be aware of their patients' HIV status. Also, while living with HIV commands certain rules when it comes to dental care, the virus should not exclude patients from dental work or dental maintenance. Quite the contrary.