Dental Problems

Taking care of the teeth and mouth is important for people with HIV. Eating, drinking, talking, breathing, kissing or even touching the area around the mouth can bring elements of the outside world into the body. Those elements include life-giving food and water. They also include life-threatening germs, bacteria and viruses.

The mouth is the first stage of digestion. It has its own bacteria and organisms to help. Food that doesn’t get swallowed can decay between the teeth. This can cause infections that spread to other parts of the body.

Among the reasons for taking good care of the mouth, gums and teeth are:

• Problems with the mouth, tongue, throat, gums or teeth may be the first sign that HIV infection exists or is getting worse.
• Regular visits to the dentist help find and treat infections and other conditions before they become serious.
• Good mouth care can get rid of bacteria.  This eases the strain on the immune system.
• Open sores and exposed tissue inside the mouth help infections invade the body.

Symptoms

The most common mouth problems that a person with HIV may get include:

• Canker sores. Nearly everyone gets these shallow, crater-like sores inside their lips or cheeks. In people with HIV, these sores may be slow to heal. They often grow to nearly half an inch. In HIV-positive people, the sores may appear on harder tissue such as the roof of the mouth. They can be mistaken for cold sores (an infection by herpes simplex). The sores can be quite painful. It can be hard to eat with the sores. This makes wasting or keeping up strength harder.
• Dry mouth. Many people with HIV get a dry mouth, throat or both. This can lead to tooth decay and gum problems unless it is treated. Untreated cavities can lead to infections.
• Gingivitis and periodontitis. This is gum disease.  People with these conditions will have swollen, red, bleeding gums. The tissue and bones that support the teeth may also be affected. They may also have bad breath. Gingivitis and periodontitis cause gaps in the seal between the gums and the teeth. Periodontal disease can affect anyone. Two forms are mostly likely to be seen in people with weak immune systems. Linear gingival erythema causes a red, band-like lesion at the gum line. It is painful and bleeds. When it gets worse, it can become necrotizing ulcerative periodontitis. Necrotizing ulcerative periodontitis causes the soft tissue and bone around the teeth to erode. The teeth can become loose and fall out without treatment.
• Hairy leukoplakia. This is a white, streaky spot on the sides of the tongue that looks hairy. It looks like thrush, but the spots can’t be scraped away. It can appear in other parts of the mouth. This is believed to be caused by the Epstein-Barr virus, which is linked to infectious mononucleosis. It is rarely seen unless the CD4 cell count is low. It is much less common in people who are using combination anti-HIV therapy.
• Herpes simplex infection. There are two main herpes viruses. Herpes simplex 1 affects the face, lips or mouth. (These are sometimes called cold sores or fever blisters.) Herpes simplex 2 affects the genital or anal area. A herpes outbreak usually shows up as blisters. Before the outbreak, a person may feel unwell or have a fever. In someone who is already ill, this may be hard to recognize. There may be itching or tingling feelings in the area where the blisters are going to appear. The blisters usually burst and then form a scab. People with HIV may get larger, more painful herpes outbreaks more often than people without HIV. 
• Human papillomavirus infection. This virus causes genital and other warts. People with HIV infection can get warts in the mouth, lips and sides of the tongue. These are raised, dull white and fleshy bumps. They can be smooth or rough and may look like tiny cauliflowers. These warts are harder to treat in people with HIV. More people with HIV may get these warts. There may be more of them in people who have HIV. One type of this virus, HPV-16, has been linked to cancers of the mouth in throat, particularly when a person also smokes or drinks alcohol.
• Kaposi’s sarcoma. This is a tumor caused by blood vessels growing in an out-of-control tangle. This causes red, purple spots. These are often seen first in the roof of the mouth.
• Non-Hodgkin’s lymphoma. This condition can lead to a soft-tumor-like mass in the mouth. It may grow quickly.
• Thrush (oral candidiasis). This shows up as white patches on the mouth and throat. When they are wiped, they leave a raw, red patch.

Causes

Different problems have different causes. Common problems and their causes include:

• Canker sores: the cause is unknown.
• Dry mouth: HIV-infection itself or anti-HIV drugs. Crixivan (indinavir) or Videx (didanosine or ddI) may cause dry mouth. Other drugs that may cause dry mouth are interferon alpha, used to treat chronic hepatitis B and C; some antidepressants; drugs used to lower blood pressure; antihistamines to fight allergies; antipsychotics to prevent mental disturbances such as hallucinations; and drugs to make the body let go of water (diuretics).
• Not brushing and flossing the teeth often. Brushing cleans the surfaces of teeth of bacteria and left over food. Flossing removes left over food from between teeth and around the gums.
• Not seeing a dentist regularly. A dentist can clean the teeth and gums more deeply than a person can at home. A dentist also checks for infections and treat cavities.
• Thrush: a yeast infection

Risk Factors

HIV infection weakens the body’s ability to fight off infections. Bacteria and other organisms that might not be a problem for a person with a strong immune system can become serious problems in someone with HIV. Failing to brush and floss the teeth regularly or see a dentist every six months makes the risks greater. 

Prevention

Good habits help prevent dental, gum and mouth problems.  These include:

• Brushing the teeth often with a soft bristled brush and fluoride toothpaste. Brushing should be done in tiny circles from one side of the mouth to the other. The back of the teeth and the tongue need special attention. Tooth brushing should take at least two minutes.
• Flossing the teeth at least daily. This should be done after meals and before brushing.  The floss should be pushed gently between the teeth and gum to loosen food and decaying matter. At first, there may be some bleeding of the gums.  This goes away the more often a person flosses.
• Using a fluoride mouthwash. This helps prevent bacteria that cause cavities and gum disease. It should be used twice a day.
• Visiting the dentist at least every six months. This helps keep tabs on possible problems before they become serious.
• Not smoking. Smoking is linked to cancers of the mouth and throat. These are less treatable than other types of cancers.
• Limiting alcoholic drinks. Alcohol is linked to cancers of the mouth and throat. They are common and less treatable than other types of cancer.
• Practicing safe oral sex. This will help avoid human papillomavirus infection.

Diagnosis

Most mouth, teeth or gum problems can be see on examination by a doctor or dentist. No blood tests or diagnostic scans are needed to diagnose them. 

Treatment

A person with HIV should have any mouth, gum or teeth problems treated, no matter what his or her CD4 cell count is. Gum surgery, root canals, braces or retainers to straighten teeth, implants, bleaching and bridges can all be done safely and well, regardless of a person’s CD4 cell count.

It is helpful if a person with HIV sees a dentist with experience treating people with HIV. Some conditions that go with having HIV can be mistaken for less serious conditions. In addition, some common conditions need special treatment in a person who has HIV.

Treatments for specific mouth, gum and teeth problems include:

• Dry mouth. Sugar-free citrus candies like lemon drops may be helpful. Artificial saliva products can help in people with active tooth decay resulting in part from drug-related dry mouth.
• Canker sores. These can be treated with a steroid rubbed on the sore. These include triamcinolone (Kenalog®) or fluocinonide (Lidex®) mixed with Orabase® ointment. A dexamethasone liquid rinse may also be used. Sometimes a steroid that works on the whole body is needed. This includes prednisone, although it has some risks. Thalidomide has recently been approved in the U.S. for treating canker sores. It can, however, make a person sleepy.
• Linear gingival erythema gum disease. A mouth rinse that fights microbes should be used until a specialist in gum disease (a periodontist) can be seen. Sometimes an antibiotic will be given for up to a week.
• Necrotizing ulcerative periodontitis gum disease. This may be treated with antimicrobial mouth rinses, antibiotics and pain medication when necessary.
• Gum disease. In general, gum disease may be treated by getting rid of the dead tissue around a tooth, surgery or antibiotics. The earlier gum disease is treated the better. This helps prevent tooth loss. A person who smokes should quit to avoid making gum disease worse.
• Hairy leukoplakia. This usually goes away on its own. Good mouth care helps prevent hairy leukoplakia.
• Herpes simplex. Antiviral drugs such as acyclovir (Zovirax®), famciclovir (Famvir®), or valacyclovir (Valtrex®) may be given to keep herpes outbreaks from happening.
• Human papillomavirus. The warts associated with this virus can be removed by surgery or burned away with an electrical current. The warts often come back. As a result, usually only the largest warts that get in the way of eating, talking or breathing are removed.
• Kaposi’s sarcoma. These spots may go away once antiretroviral therapy is started. Often no particular treatment is given for oral Kaposi’s sarcoma unless it gets in the way of chewing or talking. In such cases, drugs such as doxorubicin (Doxil®) or paclitaxel (Taxol®) may be given. Chemotherapy aimed just as the spot itself may be used. Sometimes the spots are removed with surgery. If there are many spots, radiation may be used.
• Thrush. All forms of thrush should be treated as soon as possible. Sometimes antifungal creams or pills are used. These include the cream clotrimazole (Lotrimin®) or the antifungal drug fluconazole (Diflucan®). If thrush keeps coming back after treatment, it may be a sign that the cavities (sinuses) beside and above the nose are infected. This may need treatment as well.