Positive Life NSW

Taking care of your mouth and teeth is a very important, yet often overlooked, part of maintaining general health.

Oral health refers to the condition of your mouth – teeth, gums, tongue and throat. Their condition can significantly affect your physical and emotional wellbeing, including comfort, appearance, self-image, self-esteem, interpersonal relationships, diet and speech, and further impact upon other health conditions.¹

Changes to your mouth

People with HIV may experience a number of changes to the mouth. Discussed below are a number of the more common changes.

Taste Changes can occur as a common side effect from some HIV drugs and other medications, or due to fungal infections such as Candidiasis. Rinsing the mouth clean with a neutral tasting mouthwash (one teaspoon of bicarbonate of soda in water) before eating may be useful. You can also use a commercial mouthwash containing essential oils (e.g. Listerine), but they will contain flavours, colours and other ingredients including alcohol.

Moist foods with a strong flavour through the addition of herbs, spices and sauces may assist in masking any altered taste sense. Although strong spicy foods mask taste changes, they may not necessarily be appropriate food choices for maintaining weight or improving gut function. It is advisable to seek advice from an experienced HIV dietician.

Try to limit acidic foods such as fruit juices, all carbonated (soft) drinks including mineral water, wine, beer, marinades, vinegar and soya sauce. Acidic drinks should be part of a meal. Acidic foods and drinks will contribute to dental decay and sensitivity especially in recession areas in adults.

Dry Mouth (Xerostomia) is due to lack of saliva. There are a variety of causes, including HIV infection, which can cause swollen salivary glands, some HIV drugs, other medications (eg. diuretics, antihypertensives, antihistamines, antidepressants, bronchodilators, antipsychotic drugs) and recreational drugs  (e.g. amphetamines and ecstasy).²

Saliva balances acid food, begins digestion, helps remineralisation of teeth and provides lubrication and immune defence. Without enough saliva, food can build up in the mouth, between the teeth and gums and promote tooth decay, periodontal disease and Candidiasis.

Stimulate saliva production by choosing chewy foods and limiting dry flour and sugar dense foods such as biscuits and cakes.When the mouth is dry it may be useful to try sucking ice, chewing sugarless gum, and eating moist raw foods such as celery, lettuce, apples, melons, paw paws, mangoes, fresh herbs, etc.

Drinking tap water at meals or taking small regular sips of water between meals will be helpful. (If you use a water filter choose a brand that leaves a trace of fluoride (e.g. Brita) to help remineralisation of teeth surfaces.) Small regular sips are less likely to wash out existing saliva. You can also rinse your mouth with bicarbonate of soda in water or alcohol-free mouthwash.

Plain unflavoured milk can give a prolonged relief from dry mouth between meals. Saliva substitutes can be bought over the counter from the chemist (Biotene) or from your dentist (GC Dry Mouth Gel). Smearing olive oil across your teeth can also give some lubrication without increasing decay risk but needs to be limited if you are controlling your fat intake.

Teeth Clenching and Grinding (Bruxism) can cause teeth and gums to become painful, sore and sensitive, and result in marked wear of the teeth. Emotional factors (e.g. stress, anxiety) and physical factors (e.g. abnormal bite, crooked teeth and nutritional factors) are thought to be involved. Some HIV drugs which affect sleep, mood or anxiety levels may cause a higher likelihood of Bruxism.

Some antidepressant medications and recreational drugs such as amphetamines and ecstasy may also contribute to teeth grinding.

Relaxing at night before bed and seeking ways to reduce stress levels may be one strategy. Proper dental care for irritating bite abnormalities may be another. Your dentist may also suggest wearing a mouth guard at night to prevent tooth grinding.

Tooth Discolouration is an alteration in the appearance of the teeth, beyond the natural variations in tooth colour, which occur among individuals. Your dentist will advise whether the discolouration is external or internal (part of the tooth).

Teeth surfaces can be stained externally by tobacco smoke (nicotine); caffeine and tannin containing foods (such as tea, coffee, cola, chocolate and berries); and also by deposits of calculus (hardened plaque or tartar build-up). The next most common cause of colour change to the thin outer layer of white enamel is abrasive wear which increases as we age, but can be hastened by acidic diets, acid reflux or vomiting. (If you vomit you should first rinse with fluoridated tap water to remove acid then wait 30 minutes before thorough cleaning using a fluoride toothpaste to remineralise the tooth surface.) Internal discolouration can also occur during tooth development if Tetracycline antibiotic is used as a child (uncommon) or later in life if the nerve dies (common). Amphetamine use has also been associated with tooth discolouration (yellowing).

External staining will be improved by stopping smoking, improving oral hygiene, whitening fluoride toothpastes (not over the counter gels used in mouth-guards) and professional cleaning. Internal tooth discolouration may be lightened by professional bleaching by a dentist. Some conditions may need to be masked by facings or crowns. You should avoid abrasive toothpastes which wear away the thin outer layer of white enamel on your teeth.

Oral infections

Oral Candidiasis (Thrush) is a fungal infection of the mouth and/or throat. The infection can take several different forms, but most commonly there are small or large white or bright red  patches on the roof of the mouth, tongue, inside cheeks, and the mouth may feel furry, sore or itchy. These fungal organisms live in most human mouths, but a weakened immune system can make it easier for this fungus to grow. 

All efforts should be made to control Candidiasis early, since protracted Candidiasis will result in significant taste disturbance, loss of appetite and subsequent weight loss and debilitation.

Several antifungal medications are available including the topical treatments (applied directly onto the infection areas) such as Nystatin, Clotrimazole, Amphotericin B and Miconazole, and systemic (drug) treatment with Fluconazole. However, there is some debate as to the best way to prevent and treat Candida outbreaks, mostly due to the ability of the infection to develop resistance to some antifungal medications. Topical drugs can be used for extended periods but their efficacy may be limited. Alternatively, antiseptic Chlorhexidine based mouthwash (e.g. Savacol). Avoid mouthwashes, which contain alcohol, as the alcohol may cause mouth burning.

Nutritional approaches to prevent and treat Candidiasis are controversial and complicated. In some individual circumstances, too much refined sugar, alcohol, caffeine, and nicotine can make Candida worse. Some vitamin and mineral deficiencies have also been associated with Candida overgrowth (iron, folate, zinc, vitamin B12). 

The addition of cultures with lactobacilli acidophilus (probiotic yoghurts and drinks such as Yakult) can make a difference only if you briefly hold the solution in your mouth before swallowing. Garlic is believed to have antifungal properties, but some evidence exists which suggests avoiding garlic supplements if taking Saquinavir and other Protease Inhibitors due to drug interactions.

Before adding or subtracting components to and from your diet, it is important to remember there are many individual factors, which can stimulate Candida overgrowth. This includes certain drugs – especially antibiotics and corticosteroids – which can alter the natural organisms in the mouth.

It is important to check with a dietician or your dentist before altering your diet.

Angular Chelitis is a mixed fungal and bacterial infection, causing inflamed red patches and cracks in the corners of the mouth. It can be treated with antifungal creams such as Daktarin. Often there is also bacterial infection in the area, which should be cleaned regularly with Betadine. Applying Vaseline or cocoa butter to the area once the infection has been treated may help keep the skin moisturised and prevent further cracking.

Gingivitis and Periodontitis are gum infections characterised by swelling and bleeding of the gums when brushing or flossing. Breakdown of the attachment seal between the teeth and gums occurs, which causes the gums to recede or crevices (pockets) to form. Bad breath may also occur due to the build-up of bacteria between the teeth and in these pockets.

Bleeding gums is the earliest sign of Gingivitis.  Without proper dental and health care intervention, more serious problems can occur such as “Necrotising Ulcerative Periodontitis” – a severe infection and ulceration of the gums and mouth lining.

Chronic Periodontitis is more common and less likely to give pain in its early stages, but will cause progressive bone loss around teeth and is a major cause of tooth loss in all adults.

Gum disease is caused by bacteria in a film which grows every day (dental plaque). Brushing and cleaning between your teeth is aimed at removing this film as frequently and as thoroughly as possible – twice a day is a good routine. Both manual and electric toothbrushes are recommended. Following thorough mechanical cleaning mouthwashes containing essential oils (Listerine) may be used daily and mouthwashes containing Chlorhexidine (Savacol) may be recommended by your dentist for a specific time. If you have a dry mouth you may want to avoid the astringent effect of alcohol containing mouthwash.

It is important that if you are diagnosed with gum disease you reduce or cease smoking. There is very good evidence to show that smoking will make gum disease worse, it will hide the symptoms and will reduce the effectiveness of treatment.

Other conditions

Oral Ulcers (Aphthous Ulcers) occur on the mucous membranes (mouth surfaces) and present as painful, red, inflamed open sores, making eating certain foods uncomfortable. They are most commonly caused by an overzealous immune system following immune reconstitution from HIV therapy, although a declining immune system, HIV medication side effects, and trauma to the area may also lead to oral ulcers. They may also be a symptom of other viruses such as the Herpes Simplex Virus (HSV), Cytomegalovirus (CMV) or the Coxsackie virus.

Any sore or lump, any numbness or stiffness  in your mouth, cheeks lips or tongue which does not disappear within two weeks should be discussed with your dentist or doctor. If in doubt check it out. Oral cancer is the sixth most common cancer in Australia and 75% occurs in smokers.

If you are having difficulty with your food intake and selection of foods speak to a dietitian who can help you devise a sustainable food-energy diet that does not irritate your mouth when you eat, and helps prevent against weight loss.

General guidelines for good oral health

• Brush your teeth twice a day, after meals if possible
• Use a fluoride toothpaste³
• Clean between your teeth every day with interdental brushes or floss
• Drink water between meals
• Stop smoking
• Visit your dentist regularly

Where dentures or other dental prosthetics are fitted (crowns, bridges, braces, etc.) correct cleaning and maintenance are also important. Dentures that fit poorly can also negatively impact upon your oral health and comfort. Your dentist or oral health professional can provide solutions to these problems.

Gettting the most from a visit to your dentist

Planning a course of action for dental care and treatment is important for people with HIV. Your
dentist is a partner in developing this plan and is there to provide you with information and treatment options. Optimally, any course of treatment should be made with you, your doctor and your dentist working in partnership.

Do I need to disclose my HIV status?

While there is no legal requirement for people with HIV to disclose their  status to a health care provider, HIV infection can present some unique oral problems and therefore disclosure to a dentist you can trust may result in improved health care outcomes.

To ensure you get the best possible health care, it is your responsibility to provide as much information as possible about your health. This includes medical history, any medication or complimentary therapies you are taking, and whether you are being treated by another health care provider.

Talk to your peers and doctor. Talking to people in similar circumstances can help you determine whether disclosure of HIV status is an option that might have some benefits.

Whether you disclose or not, you have the right to expect fair and adequate treatment provided in a caring, non-discriminatory manner. Additionally, there is no onus, or legal requirement, to disclose your HIV status for the protection of a health care worker (including dentists). All health care workers providing any clinical service are trained in procedures that reduce their risk of blood to blood exposure. They should treat everyone the same way using clinical health and safety procedures.

Ring and ask if the dental clinic has worked with people with HIV and/or is familiar with HIV oral complications as a way to make the topic of disclosure easier. 

Privacy and your personal information

Health information and your medical history are considered to be privileged information disclosed to your health care providers. You have the legal right to expect confidentiality of your health care information and health condition(s) in all aspects when you attend a dental clinic.

What you need to know about dental services provided by Medicare for people with chronic and complex conditions

Under the Medicare chronic diseases dental scheme, Medicare benefits are available for most services provided by a dentist, dental specialist or dental prosthetist in private dental surgeries.

To be eligible, you mush have a chronic medical condition and complex care needs and your oral health must be impacting on, or likely to impact on, your general health. This means that you will need to be managed by your GP under certain care plans. In most cases people with HIV will qualify.

You should talk to you GP about whether you are eligible for these plans.  If you are eligible, your GP must complete the plans prior to you having you first dental service. You may already have care plans in place. If so, you should talk to your GP about whether you are eligible for referral to dental services.  Under the scheme, eligible patients can receive up to $4,250 of Medicare rebated dental services over a period of two calendar years.  If you are unable to find a dentist who bulk-bills, you may have to pay the gap between the fee charged by the dentist and the amount of the rebate paid by Medicare for that specific dental service. This can vary depending upon the dentist.

For further information, talk with you GP, or visit http://www.idgp.org.au/images/stories/Services/Closingthegap/dental_acce...

When did you last visit your dentist?

• Dental care and treatment is an important element in the planning of your overall health care.
• Good oral hygiene can assist in minimising your exposure to opportunistic infections.
• Good oral health is conducive to better dietary habits and hence better nutrition.
• Some clinical aspects of HIV infection and the side effects of its treatments, make dental care more problematic but also more necessary.

Ask your doctor, dentist or health care provider to refer you to one of the listed services.

For people living in Sydney and South Western Sydney LHN

Appointments for Oral Health Services at Sydney Dental Hospital are available if you are eligible . You must provide name, date of birth, contact address and phone numbers, Medicare and up-to -date Health Care or Pension card numbers.

The referring clinician will send an email to Leanne Thompson who will then contact you directly to make an appointment for an assessment.

St Vincent’s Hospital Dental Clinic (Victoria Street, Darlinghurst)

The St Vincent’s Hospital Clinic provides basic general dental treatment, oral surgery (removal of wisdom teeth), oral biopsy and management of some oral problems arising from HIV infection. For an appointment phone 02 8382 3129.

Other non-Metropolitan Areas

If you are from a non-metropolitan area your local HIV/AIDS services can advise you whether there are any specific local dental arrangements in place. For local information discuss this with the HIV/AIDS service coordinator in your area. To obtain the coordinator’s telephone number contact your Area Health Service, which is listed in your local telephone book.

To be eligible for treatment you must be in possession of a current health care card.

Other services that can help

• Treatment and Client Support Officer ACON: Call for up-to-date information about treatments and client services. Ph (02) 9206 2036, Freecall 1800 816 518 or visit www.acon.org.au
• Albion Street Centre Nutrition Development: Customised services for health care workers and people affected by HIV/AIDS and Hep C: counselling-education-training-international project development. Ph (02) 9332 9600 or visit www.sesahs. nsw.gov.au/albionstcentre/clinical/nutrition
• Health Care Complaints Commission (HCCC): Monitors, investigates and resolves complaints about health care providers and health care services in NSW. Ph (02) 9219 7444, email hccc@hccc.nsw.gov.au or visit www.hccc.nsw.gov.au
• Heterosexual HIV/AIDS Service (Pozhet): Men and women living heterosexually with HIV/AIDS. Freecall 1800 812 404 or visit www.pozhet.org.au
• Multicultural HIV/AIDS Service: Ph (02) 9515 5030 or outside Sydney Freecall 1800 108 098. Mon – Fri 9am – 5pm. Bilingual/bicultural co-workers providing emotional support, advocacy and information to people with HIV from non-English speaking backgrounds.
• Positive Life NSW: A non-profit community organisation representing the interests of people living with HIV/AIDS in NSW. Ph (02) 9361 6011 or Freecall 1800 245 677 or visit www.positivelife.org.au. For regional NSW HIV and related services: Contacts: a directory of services for people with HIV visit www.positivelife.org.au/contacts

HIV & Oral Health Websites

• www.hivdent.org Extensive information on oral health care.
• www.projectinform.org Useful oral health information. Search for terms and conditions listed in this resource.
• www.aidsmap.com Information and factsheets on oral health conditions and treatments.
• www.colgate.com/oralcare Dental health fact and information sheets.

Footnotes

1. Oral health conditions may increase your risk of heart disease, lung disease, and stroke. In pregnant women, oral health conditions may increase the risk of having a premature baby.
2. The use of recreational drugs can also cause other direct health compromising effects. Additionally, many of these drugs are known to cause drug interactions with HIV medications, which can lead to treatment failure or toxicity and increased side effects. For further information on drug interactions and health effects of recreational drugs, contact the Treatments Officer (ACON), or speak to your doctor.
3. Fluoride helps prevent tooth decay by building up the tooth enamel and resisting any acid breakdown of tooth enamel (the hard mineralised outer white shell of the teeth that gives them strength).

References and further reading

HIV Human Immunodeficiency Virus Dental Care. E Coates, B Scopacasa, R Logan. South Australian Dental Service.

Hepatitis C Dental Care. Bronwyn Scopacasa (BDS FRACDS), Liz Coates (MDS FADI FICD), Richard Logan (BDS MDS), Special Needs Unit, Adelaide Dental Hospital.

Australian Society for HIV Medicine (ASHM). Positive Information for Patients (PIP), Chapter 7.09: Lifestyle and Health Promotion, Oral Care Recommendations; Chapter 5.20: Oral Conditions of HIV Infection (www.ashm.org.au)

Acknowledgements

Positive Life NSW would like to thank Healthy Communities and Queensland Positive People (QPP) for their generous support in the development of this factsheet. This fact sheet is based on a resource developed and written by Peter Watts, Treatments Officer, Healthy Communities.

Copyright © 2011 Healthy Communities, Queensland Positive People (QPP) and Positive Life NSW – HIV Service Delivery for people with HIV visit www.positivelife.org.au/contacts

This information may be copied for personal or organisational use provided you acknowledge Healthy Communities amd QPP and also the assistance of Positive Life NSW in the production of this fact sheet.

This fact sheet was produced with the assistance of an unconditional grant from Gilead Sciences Pty Ltd.