AIDS Institute: Oral Health Care for People with HIV Infection

Oral Health Care for People with HIV Infection
July, 1995

Contents

Oral Examination in Primary Care

Treatment for Common Oral Conditions

Oral Examination of Children and Adolescents

Oral Lesions Associated with HIV Infection

Oral health care is an important component of medical care for people with HIV infection. The lack of healthy, functioning dentition can interfere with quality of life, complicate the management of medical conditions, and create or exacerbate nutritional and psychosocial problems. Prevention and early detection of oral disease and prompt referrals to dental care providers can often mitigate the debilitating and painful effects of untreated oral disease.

Oral Examination in Primary Care

An examination of the oral soft tissues should be a component of a medical evaluation for all individuals with HIV infection and individuals at risk for HIV infection.

The oral soft tissue examination should include inspection of the vermilion of the lips; the upper and lower labial mucosa; right and left buccal mucosa; the hard and soft palate; the dorsal, ventral, and lateral aspects of the tongue; the floor of the mouth; and the gingiva.

Particular attention should be paid to the gingival tissues. The rapidly destructive periodontal disease that occurs in association with HIV infection is marked by pain and ulceration of the gingiva. It is particularly important that patients with this condition be referred to a dentist as soon as possible, since early identification and treatment can prevent further destruction of the periodontal tissues and loss of teeth.

People with HIV infection are known to be at risk for opportunistic oral mucosal diseases associated with immune deficiency. Abnormalities that may be noted include "thrush" (pseudomembranous candidiasis), mucosal erythema (suggestive of erythematous candidiasis), mucosal ulcers, and lesions consistent with Kaposi's sarcoma (see illustrations). Some of these, such as oral candidiasis and hairy leukoplakia, may occur before HIV infection has been identified and before more severe opportunistic diseases develop.

Several different types of oral mucosal ulcers occur in people infected with HIV. These ulcers may be destructive and persist until appropriately treated. They may be caused by viruses, such as herpes simplex, or by drugs, especially zalcitabine (ddC). Microbiologic culture, mucosal smear, or biopsy may be necessary to determine the cause of these ulcers. Aphthous-like ulcers of unknown etiology occur in people with HIV infection. These may respond to topical or systemic corticosteroid therapy.

For suggested treatments of oral conditions associated with HIV infection, see below.

The HIV primary care provider should reinforce the importance of preventive oral health measures such as brushing, flossing, and use of fluorides and oral bactericidal rinses.

Medications and Oral Health

Common side effects of medications given to people with HIV infection may interfere with their oral health. Salivary flow may be diminished by anticholinergics or adrenergic inhibitors resulting in xerostomia. Gingival hyperplasia may be caused by phenytoin. Oral candidiasis may be exacerbated by antibiotics. Didanosine (ddI) and zalcitabine (ddC) may cause painful oral ulcers. High sugar content of some medications such as clotrimazole may increase the risk of dental caries. Other side effects of medications commonly used in the treatment of HIV, such as anemia, thrombocytopenia, and neutropenia may be manifested in the oral cavity through bleeding or infection.

Oral Examination by Dentists

As recommended for the general population in the United States, people with HIV infection should have a comprehensive oral examination by a dentist at least semiannually. More frequent evaluations by a dentist or dental hygienist are usually necessary when immune deficiency progresses and oral lesions develop.

In order to monitor the medical status of patients with HIV infection before and during dental treatment, the dental care provider may require information from the primary medical care provider. This may include current medications, results of the most recent CD4+ lymphocyte count and complete blood count (particularly neutrophils), platelet count, and coagulation studies. Information concerning a patient's ability to keep scheduled appointments and the patient's ability to tolerate dental procedures is helpful in planning dental treatment. To the extent possible, dental and medical appointments should be made for the same day. Since dental care may be a priority for patients, such scheduling may help the patient keep health care appointments.

People with HIV infection are at increased risk for oral diseases such as dental caries and periodontal disease, which also occur in immunocompetent individuals. Salivary gland disease associated with HIV infection also may cause decreased salivary flow and xerostomia.

A comprehensive oral evaluation should include the following:

Determination of the patient's chief complaint(s), if any.

A medical history and determination of the patient's medical status.

An assessment of the head and neck.

An oral soft-tissue examination, including perioral tissues and oral mucosa.

Radiographs when appropriate.

Examination of the gingival and periodontal structures.

Development of an appropriate treatment plan and discussion of the plan with the patient.

There are no data supporting the need for routine antibiotic coverage when providing dental treatment to people with HIV infection. Patients who are at risk for bacterial endocarditis, however, will require the use of the antibiotic protocol established by the American Heart Association. Information concerning the patient's risk of bacterial endocarditis may be requested from the primary medical care provider.

A plan should be developed for prevention of oral disease. Emphasis should be placed on preventive techniques and improved self-care, such as brushing, flossing, and use of fluorides and oral rinses.

TREATMENT FOR COMMON ORAL CONDITIONS
IN ADULTS WITH HIV DISEASE

CONDITION	TREATMENT	COMMENTS
CANDIDIASIS	SYSTEMIC THERAPY Ketoconazole 200mg/day Fluconazole 100mg/day	Need normal gastric acidity. Avoid H-2 antagonists, antacids, terfenadine. Rifampin decreases levels of ketoconazole. Not the first choice because of expense and concern about resistance. Increases levels of phenytoin, oral hypoglycemics and warfarin.
CANDIDIASIS	TOPICAL THERAPY Clotrimazole troches 5x/day or clotrimazole cream. Nystatin oral suspension, pastilles, ointment, cream, or vaginal tablets.	Preparations combining antifungal and corticosteroid ointments and creams are useful for angular cheilitis. Troches 3-5x/day may prevent recurrence of oral candidiasis.
HERPES SIMPLEX	Acyclovir 200 mg 5x/day for 10 days	Lesions often heal without treatment. Acyclovir may quicken healing. Acyclovir- resistant HSV is increasingly reported.
APHTHOUS ULCERS	Fluocinanide ointment 0.05% or clobetasol propionate 0.05% mixed in equal parts with Orabase, and applied 6x/day. Dexamethasone or betamethasone elixir as oral rinse 4-6x/day or soaked on gauze and applied 5-10 minutes q.i.d. Tetracycline 250 mg dissolved in 50cc water applied on sponge q.i.d.	Thalidomide trials are under way for treatment of nonresponsive aphthous ulcers. (MUST EXCLUDE PREGNANCY) Use sucralfate suspension 10cc alone or with viscous lidocaine 10cc and diphenhydramine 25 mg in 5cc water, swish and swallow before meals for symptomatic relief.
HAIRY LEUKOPLAKIA	May respond to acyclovir 200 mg 5x/day. There are reports that ZDV can be effective.	Maintenance therapy may be required. Treatment is usually cosmetic.
PERIODONTAL AND GINGIVAL DISEASE	Clorhexidine mouth rinse can be a helpful adjunct to other treatments.	REFER TO A DENTIST FOR EITHER CONDITION.

Oral Examination of Children and Adolescents*

The medical sequelae of HIV infection in children include potential chronic progressive illnesses that can interfere with appropriate and consistent oral health behaviors and preventive care. Oral function can be compromised further by the significant carbohydrate content of dietary supplements often prescribed for children who are malnourished or who fail to thrive. Tooth decay, painful dentition, untreated oral lesions or periodontal disease may cause an inability to chew, leading, in turn, to poor nutrition. Because of the variety of oral health complications associated with HIV disease, dentists should be involved in the primary care of pediatric patients with HIV infection.

Preventive Care

Preventive measures provided by the child's caregiver and the medical/dental team are especially critical for children with HIV infection. Dental sealants and optimal fluoride supplementation, both systemic and topical, are key to prevention of oral disease and malnutrition.

Physical Examination of the Pediatric Patient

The pediatric clinician should examine the oral cavity as part of the routine pediatric examination. Caries and gingivitis occur commonly in children, particularly as a result of baby-bottle tooth decay. HIV infection and changes in salivary functioning (xerostomia) contribute to the severity of plaque-related diseases.

In addition to examining the oral cavity for signs of poor dentition and gingivitis, the pediatric clinician should be aware of oral lesions that occur commonly in children with HIV, including the following:

Oral candidiasis is the most common soft-tissue lesion in children with HIV infection. Pseudomembranous oral candidiasis, or thrush, is seen most frequently. Erythematous candidiasis and angular cheilitis are also commonly observed in children. Oral mycostatin suspension (2 to 5 ml 4-6x/day) or clotrimazole troches 3-5x/day can be used for treatment. Systemic treatment with azoles may be necessary.

Parotid swelling usually presents without symptoms. Swelling spontaneously resolves and recurs, and usually presents bilaterally.

Xerostomia occurs in children, although the etiology is not well understood. Sugarless gum and frequent consumption of water are often used to control symptoms.

Linear gingival erythema occurs most commonly adjacent to the upper and lower anterior teeth. These lesions usually do not cause clinical problems or interfere with nutrition. HIV periodontitis does not appear frequently in children.

Aphthous ulcers occur in children, causing pain and impaired ability to eat. Topical corticosteroids, a tetracycline rinse, and Orabase® can be useful. Didanosine may need to be discontinued if ulcers are associated with its use.

Herpetic stomatitis recurs more commonly and is often more aggressive in children with HIV. Acyclovir may prevent recurrent lesions. Consultation with a specialist is recommended.

Hairy leukoplakia is rare in children and appears to resolve spontaneously.

General Recommendations

Feeding behaviors and nutritional requirements that increase more frequent intake of fermentable carbohydrates (formula, juices, milk, dietary supplements), especially when delivered with bottles, promote growth and development of candidiasis. Residue of all foods and medicines on oral tissues and teeth must be removed by rinsing with water and mechanical cleansing with gauze, washcloth, or soft toothbrush. This activity should begin as soon as the child is identified as HIV-seropositive. Oral rinsing, nutrition, medication management, and cleansing of the entire mucosal tissues beginning at birth appear to control the oral candidal burden and delay progression of oral candidiasis.

Review of the nutritional status of children may suggest the presence of vitamin deficiencies that can cause conditions such as angular cheilitis.

* Excerpted from "Management of Children and Adolsecents with HIV nfection." Oral Health Care for Adults, Adolescents and Children with HIV Infection. 1995 (Second Edition). New York: New York State Department of Health, AIDS Institute.

Oral Lesions Associated with HIV Infection

(click on thumbnail for fullsize image)

Angular chelitis	Persistent non-infectious (aphthous-like) ulceration of the oral mucosa	Pseuodomembraneous candidiasis	Kaposi's sarcoma
Hairy leukoplakia	Necrotizing ulcerative periodontal disease	Ulceration of the oral mucosa due to Herpes simplex	Linear gingival erythema