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 teeth, gums, mouth 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 the oral environment

People with HIV may experience a number of changes to the oral environment. 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 (Bicarb Soda mouthwash) before eating may be useful. 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.

Thoroughly brush your teeth, at least twice a day or after meals; use toothpaste or rinses that contain fluoride; floss after meals; drink plenty of water (2 – 3 litres per day); and regularly visit your dentist.

Try to limit acidic foods such as soya sauce, wine, beer, acidic fruit juices, marinades and refined dietary sugars (confectionery, soft drinks, etc.). These foods can worsen sensations of ‘burning mouth syndrome’ that sometimes occur from oral opportunistic infections, and may increase the incidence of tooth decay.

Floss, brush, rinse. Limit sugar, drink water, stimulate saliva ...

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 (eg. amphetamines and ecstasy).2 Allergies and infections may also cause dry mouth.

Without enough saliva, food can build up in the mouth, between the teeth and gums and promote tooth decay, periodontal disease and Candidiasis. 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 plenty of liquids at or between meals is a good idea, as is rinsing your mouth often with one (1) teaspoon of bicarbonate soda dissolved in a glass of water or an alcohol-free mouthwash. Avoid sugar since it can make your mouth even drier. If this doesn’t work, an artificial salivary substitute may be recommended by your doctor or dentist.

Teeth Clenching & Grinding (Bruxism) can cause teeth and gums to become painful, sore and sensitive, and result in marked wear of the teeth. Emotional factors (eg. stress, anxiety) and physical factors (eg. 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.

Internal discolouration of teeth from illness and drugs occurs during tooth formation in children. Wear of enamel will cause exposure of the yellow grey interior of the tooth. This is the main cause of colour changes in adults. Dry mouth and some medications can cause extrinsic stain which can be removed by professional cleaning.

Most tooth discolouration can be successfully lightened through proper bleaching procedures provided by a skilled dentist. Some conditions make the discolouration more difficult to remove.

Over-the-counter products are not recommended, as bleaching should only be done under the supervision of a dentist following proper examination and diagnosis of the cause of discoloured 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 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, 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 anti-fungal medications. Topical drugs can be used for extended periods but their efficacy may be limited. Alternatively, antiseptic Chlorhexidine based mouthwash (eg. Savacol) held in the mouth for one minute then spat out, may help.

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).

Some nutritionists and dieticians recommend adding Lactobacilli Acidophilus (probiotics) to your diet, available in concentrated capsule form or in yoghurts, to promote healthy (good) bacteria in the body’s gut, throat and mouth lining. 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 which can alter the natural organisms in the mouth.
It is important to check with a dietician or your dentist before altering your diet.

Oral infections can be treated with:

1. Medications
2. Good nutrition
3. Complimentary therapies

Take some time, at least once a month, to look inside your mouth for signs of infections and sores. Check you tongue (top and bottom), lips, gums, cheeks and the roof of the mouth. Early treatment can prevent some problems from getting worse.

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.

Gingivitis is caused by the build-up of dental plaque, which can be prevented by proper brushing technique using a small-headed, soft toothbrush and fluoride toothpaste.

Chlorhexidine based mouthwashes are very good to guard against infections. Avoid antibacterial mouthwashes that contain alcohol, as the alcohol can sting inflamed areas.

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.

When symptoms of any ulcer or lesion first occur they should be mentioned to your doctor or dentist, to enable a proper diagnosis of the cause and selection of appropriate treatment, to prevent any further progression.

If you are having difficulty with your food intake and selection of foods speak to a dietician 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

• Thoroughly brush your teeth, at least twice a day or after meals.
• Use toothpaste or rinses that contain fluoride.3
• Floss after meals.
• Drink plenty of water (2 – 3 litres per day).
• Regularly visit your dentist.

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.

Getting 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.

Where do you go?

Your local dentist can continue to provide for most of your dental needs. Where they have specific concerns they can also consult with or refer you to the specialist HIV dental services at:
Sydney Dental Hospital (SDH) (Chalmers Street, Surry Hills – opposite Central Railway Station)
People with HIV/AIDS receive the same range of services available to all patients of SDH. This includes assessment, treatment and specialist care. As with all patients, there are some limitations to treatment available. To be eligible you must hold a HCC or PCC card. For an appointment phone 02 9293 3316 between 8.30am and 4.00pm Monday – Friday. When you ring for an appointment ask for an assessment under the 2.3 Program.
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.
Northern Rivers Area Health Service
Northern Rivers Area Health Service provides emergency dental treatment to eligible patients. Contact your local Community Health Dental Clinic, which is listed in the telephone book. The Area also administers a program to provide dental care for people with HIV/AIDS through private dentists. For information on this program contact the Manager, HIV/AIDS Funded Programs on 02 6620 7505.
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 co-ordinator in your area. To obtain the co-ordinator’s telephone number contact your Area Health Service, which is listed in your local telephone book. The services at these centres are funded by the NSW Health Department.
To be eligible for treatment you must be in possession of a current health care card.

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.

What you need to know about the new medicare items

From 1 July, GPs can refer patients enrolled in an Enhanced Primary Care (EPC) plan to eligible allied health professionals and dentists.

Enrolled patients are eligible for up to five allied health worker services per year on referral from their GP. Patients are also eligible for up to three dental services per year on referral from their GP. Each dental referral attracts a $73.35 rebate.

Allied health professionals and dentists can continue to charge their own fees, or they can now choose to bulk-bill Medicare. If they charge a private fee, patients can collect the rebate and their out-of-pocket costs will count toward the MedicarePlus safety net.

For further information visit www.health.gov.au/medicareplus or www.hic.gov.au

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)

Other services that can help

• Treatment Information Officer, AIDS Council of NSW (ACON) Call for up-to-date information about treatments for HIV. T (02) 9206 2036 Freecall 1800 816 518 or visit www.acon.org.au
• Albion Street Centre Nutrition Department Customised services for health care workers and people affected by HIV/AIDS and Hep C: counselling-education-training-international project development. Dietician T (02) 9332 9600; email sadlersi@sesahs.nsw.gov.au 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. T (02) 9219 7444 Freecall 1800 043 159 or visit www.hccc.nsw.gov.au
• Heterosexual HIV/AIDS Service (Pozhet) Men and women living heterosexually with HIV/AIDS. T (02) 9515 3095 Freecall 1800 812 404 (national) or visit www.pozhet.org.au
• Multicultural HIV/AIDS Service T (02) 9515 3098 or outside Sydney Freecall 1800 108 098. Mon – Fri 9am – 5pm. Bilingual/bicultural co-workers providing emotional support, advocacy and information to people living with HIV/AIDS from non-English speaking backgrounds.
• Positive Life NSW. A non-profit community organisation representing the interests of people living with HIV in NSW. T (02) 9361 6011 or Freecall 1800 245 677 or visit www.positivelife.org.au

For regional NSW HIV/AIDS and related services:

• Contacts A directory of services for people living with HIV. Available from Positive Life NSW. T (02) 9361 6011; Freecall 1800 245 667 or visit www.positivelife.org.au

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.

Acknowledgements

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

Produced by the Health Promotion Unit of Positive Life NSW.

Copyright © 2004 Queensland AIDS Council (QuAC), Queensland Positive People (QPP) & Positive Life NSW. This information may be copied for personal or organisational use provided you acknowledge QuAC & QPP and also the assistance of Positive Life NSW in the production of this fact sheet.

Funded by NSW Health.

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

This is only an extract of the text from this fact sheet; use the links at right to obtain the full content.