When I left home at age 18, my mother imparted three sage bits of advice: If you own a car, join AAA, make sure to take care of your teeth and never forget that desperation is very unbecoming. While I can’t say that I’ve never succumbed to desperate measures, my compliance with the other two maxims would make Momma proud. My first car, a beatup 1980 Volvo, received the blessing of Saint AAA, and whenever an unexpected windfall came my way, I had my teeth cleaned or a crown done. It helped that I adored my dentist and perversely looked forward to my appointments.
Yet ever since I tested positive for HIV, vigilance about my dental health has become a much more serious matter. The mouth is in no way exempt from the ravages of this virus; indeed, whether from degraded immunity that lets microbes run rampant, or neglected dental care, or both, PWAs can face up to 40 oral problems, from abnormally severe tooth decay to dangerous mouth infections. Moreover, according to a University of Texas study published this year, cavities in the teeth of people with HIV can serve as reservoirs for fungal organisms, producing a rate of oral thrush (Candida overgrowth) four times greater than in those without HIV.
Thrush is the best known of the mouth problems that often serve as the first visible features of HIV, indicating an immune-system decline and presaging disease progression. Others include recurring canker sores, severe gum inflammation (gingivitis), Kaposi’s sarcoma (KS), lymphoma, herpes simplex, herpes zoster, warts, cytomegalovirus (CMV) ulcers and hairy leukoplakia (white patches on the side of tongue).
But pre-protease, with death knocking at their door, the last thing many PWAs lost sleep over was the state of their mouth. Surviving KS, pneumonia and meningitis, shuttling from appointment to appointment, and paying the bills took precedence. “A couple of years ago, I was barely able to buy food and pay rent, and my dentist told me I needed about $5,000 of work done in my mouth,” says William Stein of Oakland, who has had HIV for many years. “I laughed and said that if I’m not dead before the teeth that need root canals start killing me, you can just yank them all out.”
Dr. Paul Gross, a dentist in San Francisco, is familiar with this scenario. “I had patients tell me that they weren’t interested in comprehensive, long-term restorative work such as crowns and bridges because they didn’t expect to live long,” he says. “But as people feel and function better, they care what happens to their mouth and teeth.” Indeed, in the cocktail age, some PWAs find themselves alive and well—except for a mess of a mouth. Restorative and prosthetic dental care—which replaces lost teeth and fixes chipped and broken ones—can help improve your overall health, not to mention your self-image. And fastidious oral hygiene is a crucial part of preventive care for the HIV positive (see “An Ounce of Prevention”), which should be initiated early on in the disease process.
But when choosing a dentist, be aware that many are less than savvy about HIV. “The more exotic oral manifestations, such as histoplasmosis, CMV, KS, lymphoma and long-standing oral ulcers like herpes simplex, are often misdiagnosed,” explains Dr. Patrice Coons, a dentist at the Jack Sansing HIV Dental Clinic in Austin, Texas. “Oral ulcers that persist for more than two weeks should be biopsied to determine their cause. Periodontal disease [inflammation of the tissues surrounding the teeth] is usually simply treated by physicians with antibiotics, but in HIV patients that condition also requires thorough scaling [removal of plaque and calculus from teeth] and root planing [smoothing the root surface of a tooth] in addition to close follow-up to prevent recurrence.”
The take-home message for dentists: “It’s vital to properly diagnose any lesions and consult with the patient’s physician to determine treatment status,” says Dr. Vincent Rogers, professor of community dentistry at Temple University in Philadelphia. Rogers adds that the dentist should understand HIV drug combinations—both their benefits and side effects. The Austin clinic where Coons works is one of very few HIV-centered dental clinics in the nation—with staff members aware of the latest treatment options and often billing according to sliding scales—set up in response to evidence of limited PWA access to dental care (due to both lack of funds and dental discrimination). These facilities are the best place to get knowledgeable, sensitive mouth care, but there are also many dentists in private practice who offer such high-quality treatment.
As for me, my beloved Volvo has long since gone to that great junkyard in the sky and my love life has been riddled with unbecoming moments too numerous to count. But while HIV is a daily reality, all my teeth are still present and accounted for (some even happen to be gold!). With proper diet, daily maintenance and regular checkups, I intend to hold on to them until my very last chew.
HIV-specialized dental clinics exist in at least eight cities. For listings, and for more information about dental health and HIV, visit the website www.hivdent.org. Or contact your AIDS service organization for a referral to an HIV-knowledgeable dentist.
ESCAPE THE DRILL
The following recommendations for PWAs’ preventive detal health are offered by a range of dentists and alternative health professionals:
Brush at least twice a day with a fluoride toothpaste for at least one minute, covering every tooth surface and the tongue (for a refresher course in correct brushing, ask your dentist). Also floss daily. Replace your toothbrush monthly.
To kill germs, do a post-brushing swish with a small amount of diluted hydrogen peroxide (50-50 mix with water)—without swallowing any solution—followed by a water rinse. An alternative is Verdesol, an over-the-counter antiseptic mouth rinse.
For those with thrush, note that antifungal drugs such as nystatin syrup and Mycelex troches (lozenges), plus a range of other liquid forms of medication, have a high sugar content, which can promote cavities—and can even feed the thrush. Diflucan and nystatin oral tablets, as well as Mycelex vaginal suppositories (which can be used orally), are sugar-free alternatives, and several nondrug options are available, especially use of garlic and abstention from sweets (see “Home Remedies,” POZ, November 1996.)
Visit your dentist at least twice a year—more frequently if oral lesions appear.
Have your physician inspect all oral surfaces, especially the sides of the tongue, during every physical exam. Any lesions found should be aggressively treated.
A MOUTHFUL OF REMEDIES
Treatment options for common HIV-related mouth problems
Mouth pain. Pain caused by oral lesions and compromised teeth can lead to undereating and potentially dangerous weight loss. Anesthetic mouth rinses (such as prescription Cetacaine and over-the-counter [OTC] Chloraseptic) or ointments (such as Oragel or Orabase-b, both OTC) can be used to numb the area before eating. (But beware a viscous prescription rinse called Xylocaine, which can delay healing sores for several weeks.) The OTC mouth rinse Verdesol can sometimes eliminate the sores. Many people with HIV have reported success by applying clove oil to the lesions and gums with a Q-Tip.
Until mouth pain ends, eating foods that are soft, moist and smooth-textured can help. Some experts also warn people with oral lesions to avoid any foods or liquids—including those that are spicy, acidic, salty or hot—which may further irritate the mouth or throat. (One often-overlooked irritant is cinnamon, contained in some toothpastes, mouthwashes, breath mints, lipsticks, lip sunscreens, cereals and baked goods.)
Dry mouth. Spit is handy for a number of things—chewing food, cleaning glasses or the ultimate insult—but an adequate flow of saliva also helps prevent cavities. Some 400 drugs—including several HIV medications and antidepressants—cause dry mouth, making it a common problem among PWAs.
One possible saliva-booster is chugging gallons of purified water, something all PWAs should do anyway to detoxify the body. Sugarless gums may also help. There are also OTC saliva substitutes (Salivan, Sali-Synt, Mouth Kote or Orex), which add moisture and stimulate saliva production. (One study found Mouth Kote far superior to other products or plain water.) A prescription called pilocarpine (Falagen) in doses of 5 to 10 mg three times daily will often stimulate saliva production, although there may be various side effects. Meanwhile, to reduce the heightened risk of cavities, dentists advise reducing sugar intake and eating any sugary foods only with meals (to buffer the sugar’s bacteria-stimulating effects).
Gum problems. Dr. Lark Lands, POZ Science Editor and an HIV treatment expert, reports that vitamin C and bioflavonoids can help strengthen gums. Lands adds, “Coenzyme Q10—a nutrient whose levels decline as HIV progresses—has long been used in Japan to treat periodontal and gum problems.” She reports considerable improvements with use of moderate daily doses of CoQ10 (90 to 200 mgs).