1. Guide to Oral Health Care for People Living with HIV/AIDS
Introduction to Oral Health: Oral Screening and Dental Management
March 7, 2014
Oral Health

2. Introduction
HRSA/HAB sponsored curriculum designed to assist primary care providers to recognize and manage oral health and disease for people living with HIV/AIDS.
Benefits of oral health integration in primary care:
Improve earlier linkage to oral health care
Reduce avoidable complications including oral-systemic
Reduce burden/costs of preventable diseases
Improve OH literacy of health care professionals and public
Webinar series
Chapters 1-2: March 7, 2-4 PM ET
Chapters 3-5: March 28, 2-4 PM ET
Webcasts on TARGET Center: (

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4. Guide to Oral Health Care for People Living with HIV/AIDS
Chapter 1: Oral Health
Oral Health
This chapter provides an overview of oral health and trains the primary care clinician to recognize normal oral anatomy and to perform a systematic oral screening examination for his/her patients.

5. Chapter 1: Course Authors: Consultants: Series Editor:
Jeffery D. Hill, D.M.D.
Lauren L. Patton, D.D.S.
Theresa G. Mayfield, D.M.D.
Consultants:
Vincent C. Marconi, M.D.
Series Editor:
David A. Reznik, D.D.S.
HRSA, HIV/AIDS Bureau consultant:
Mahyar Mofidi, D.M.D., Ph.D.
Acknowledgements:
Course Committee Authors:
Jeffery D. Hill, D.M.D.
Lauren L. Patton, D.D.S.
Therese G. Mayfield, D.M.D.
Consultants:
Vincent C. Marconi, MD
Series Editor:
David A. Reznik, D.D.S.
HRSA, HIV/AIDS Bureau consultant:
Mahyar Mofidi, D.M.D., Ph.D.
Last Modified: February, 2014

6. Chapter 1: Oral Health Educational Objectives
Answer the question “What is oral health?”
Discuss the importance of oral health
Review the burden of oral disease
Recognize the appearance of healthy normal oral anatomy and common variants of normal
Learn a systematic approach to an efficient oral screening technique
The educational objectives for the dental management chapter are to:
Answer the question “What is oral health?”
Discuss the importance of oral health
Review the burden of oral disease
Recognize the appearance of healthy normal oral anatomy and common variants of normal
Learn a systematic approach to an efficient oral screening technique

7. Goals of Oral Screening in the Primary Care Setting
Assess the oral cavity for the presence of diseases
Dental caries and periodontal diseases
Mucosal diseases
Oral and oropharyngeal cancers
Acute infections
Enhance access to oral health care
Prompt referral for management of acute care needs and pathology
Referral for prevention and maintenance of oral health
Facilitate communication between the medical and dental team
Promote patient oral health literacy
Recognize importance of oral health to overall health
Encourage prevention and self-care
Goals of oral screening in the primary care setting serve several functions.
First, to assess the oral cavity for the presence of diseases such as:
Dental caries and periodontal diseases, mucosal diseases, oral and oropharyngeal cancers, and acute infections
And second, to enhance access to oral health care. This includes:
Prompt referral for management of acute care needs and pathology
Referral for prevention and maintenance of oral health
Facilitating communication between the medical and dental team
Promoting patient oral health literacy
Recognizing the importance of oral health to overall health
Encouraging oral disease prevention and oral self-care
References:
Institute of Medicine. Committee on an Oral Health Initiative. Advancing Oral Health in America. Washington, DC: National Academies Press; 2011.
HealthyPeople.gov. Accessed March 13, 2013.

8. What is Oral Health?
The health of the mouth and craniofacial (skull and face) structures.
Freedom from oral and craniofacial diseases and conditions such as:
Dental caries
Periodontal diseases
Cleft lip and palate
Oral and facial pain
Oral and oropharyngeal cancers
Among patients with HIV/AIDS, freedom from other oral mucosal disease, such as oral candidiasis, herpetic ulcers, oral warts, and salivary gland disorders.
What is Oral Health?
It is commonly defined as “The health of the mouth and craniofacial (skull and face) structures.”
More specifically, oral health means freedom from oral and craniofacial diseases and conditions such as:
Dental caries, periodontal diseases, cleft lip and palate, oral and facial pain, and
oral and oropharyngeal cancers
Among patients with HIV/AIDS, freedom from other oral mucosal diseases, such as oral candidiasis, herpetic ulcers, oral warts, and salivary gland disorders is important for oral health.
References:
US Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health;

9. Importance of Oral Health
“While good oral health is important to the well-being of all population groups, it is especially critical for people living with HIV/AIDS (PLWHA). Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.” -U.S. Public Health Service Surgeon General Regina M. Benjamin, MD, MBA
U.S. Public Health Service Former Surgeon General Regina M. Benjamin, MD, MBA, recently stated:
“While good oral health is important to the well-being of all population groups, it is especially critical for PLWHA. Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.”
References:
US Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health;
US Department of Health and Human Services. Oral Health. Healthy People Available at:
Benjamin RM. Oral health for people living with HIV/AIDS. Public Health Rep. 2012;127 Suppl 2:1-2.
Health Resources and Services Administration (US), HIV/AIDS Bureau. Oral health: people with HIV/AIDS [cited 2011 Jun 30]. Available from:
oralhealth/hivaids.html

10. Importance of Oral Health
Good oral health:
Improves our ability to perform functions that represent the very essence of our humanity:
Speak and smile
Smell and taste
Touch and kiss
Chew and swallow
Make facial expressions to show feelings and emotions
Allows us to avoid pain and disability caused by oral diseases
Provides protection against microbial infections and environmental insults
Good oral health is important because it:
Improves our ability to perform functions that represent the very essence of our humanity: such as the ability to speak and smile, smell and taste, touch and kiss,
chew and swallow, and make facial expressions to show feelings and emotions
Allows us to avoid pain and disability caused by oral diseases
Provides protection against microbial infections and environmental insults
References:
US Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health;
US Department of Health and Human Services. Oral Health. Healthy People Available at:
Benjamin RM. Oral health for people living with HIV/AIDS. Public Health Rep. 2012;127 Suppl 2:1-2.
Health Resources and Services Administration (US), HIV/AIDS Bureau. Oral health: people with HIV/AIDS [cited 2011 Jun 30]. Available from:
oralhealth/hivaids.html

11. Burden of Oral Disease Dental Caries Periodontal Disease
32% of US adults with ≤ high school education have untreated dental caries
Periodontal Disease
47% of US adults ≥ 30 years have mild to severe periodontitis
Mucosal Disease
36% of HIV-infected adults on HAART experienced ≥ 1 oral lesion over 2 years follow-up
41,380 new oral and pharyngeal cancers expected in 2013
Disorders of the Craniofacial Complex
Impact of oral diseases:
Jeopardizes general health and increases morbidity and mortality
Restricts activity in school, work and home
Significantly diminishes quality of life
Creates an economic burden for individual, family and society
The two most common oral diseases in society are dental caries and periodontal diseases, caused by bacterial infections, that can lead to tooth loss and edentulism.
According to recent NHANES analyses:
32% of US adults with a high school education or less have untreated dental caries.
47% of US adults age 30 years or older have mild to severe periodontitis.
Both of these diseases are more common in socially and financially disadvantaged individuals.
Mucosal diseases are more common among immune suppressed patients. A recent study from Alabama found that 36% of HIV-infected adults on highly active anti-retroviral therapy (HAART) experienced at least one oral lesion over 2 years follow-up. The most deadly oral mucosal diseases are the malignancies, with 41,300 new cases of oral cavity and pharynx cancers estimated to occur in 2013.
Disorders of the Craniofacial Complex are less common but include cleft lip and palate and chronic facial pain and temporomandibular joint diseases.
Impact of oral diseases include:
Jeopardizes general health and increases morbidity and mortality
Restricts activity in school, work and home
Significantly diminishes quality of life
Creates an economic burden for the individual, his/her family and society
References:
Elani HW, Harper S, Allison PJ, Bedos C, Kaufman JS. Socio-economic inequalities and oral health in Canada and the United States. J Dent Res. 2012;91(9):
Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and J Dent Res. 2012;91(10):
Tamí-Maury IM, Willig JH, Jolly PE, et al. Prevalence, incidence, and recurrence of oral lesions among HIV-infected patients on HAART in Alabama: a two-year longitudinal study. South Med J. 2011;104(8):561-6.
Siegel R, Naishadham D, Jemal A. Cancer statistics, CA Cancer J Clin. 2013;63(1):11-30.
US Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health;
Box: The Burden of Oral Disease and Disorders.

12. Elements of the Mouth
Teeth, gingiva and supporting connective tissues, ligaments and bone
Hard and soft palate
Soft mucosal tissue lining the mouth and throat
Tongue
Lips
Muscles of mastication
Salivary glands
Upper and lower jaws connected with the skull by the temporomandibular joint
The Elements of the Mouth include:
Teeth and gingiva and supporting connective tissues, ligaments and bone
Hard and soft palate
Soft mucosal tissue lining the mouth and throat
Tongue
Lips
Muscles of mastication
Salivary glands
Upper and lower jaws connected with the skull by the temporomandibular joint
References:
US Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health;

13. Extraoral and Intraoral Examination
Extraoral Examination
Inspection of face, head and neck:
Facial contour and symmetry
Changes on the skin
Preauricular, submandibular, anterior cervical, posterior auricular, and posterior cervical lymph nodes
Muscles of mastication
Salivary glands
Temporomandibular joint
Intraoral Examination
Inspection of the internal mouth structures:
Teeth, gingiva, and supporting connective tissues, ligaments and bone
Hard and soft palate
Soft tissues lining the mouth and throat
Tongue
Lips
An assessment of oral health includes both intraoral and extraoral examination.
Extraoral Examination focuses on inspection of face, head and neck, including:
Facial contour and symmetry
Changes on the skin
Preauricular, submandibular, anterior cervical, posterior auricular, and posterior cervical lymph nodes
Muscles of mastication
Salivary glands
Temporomandibular joint
Intraoral Examination includes inspection of the internal mouth structures, including:
Teeth, gingiva, and supporting connective tissues, ligaments and bone
Hard and soft palate
Soft tissues lining the mouth and throat
Tongue
Lips
References:
Accessed March 13, 2013.

14. Systematic Approach to the Oral Screening
Armamentarium
Gloves
Light source
Exam light
Otoscope light
Pen light
2x2 gauze
Tongue depressor
Disposable dental mirror
Allow 3-5 minutes for complete exam
Techniques
Visual inspection
Bidigital palpation
Gently squeeze between thumb & forefinger
Compression
Gently press against bone with forefinger
Using a systematic approach to the oral examination assures no area is inadvertently omitted. This should take not longer than 3-5 minutes and can be done faster with experience, once a routine is established.
The armamentarium to support an oral exam in primary care settings includes: gloves; a light source, such as an exam light, otoscope light, or pen light; one 2x2 gauze for grabbing the tongue and wiping any mucosal surface material; and a tongue depressor or disposable dental mirror.
The techniques of the exam include: visual inspection, bidigital palpation (gently squeezing tissues between thumb & forefinger) and compression (gently pressing tissues against bone with the forefinger).
References:
Accessed March 13, 2013.

15. Lips Shape, color, texture Labial commissures Vermillion border
symmetry
Labial commissures
corners of the mouth
Vermillion border
junction of facial skin and lip mucosa
Wet/dry line
junction of inner and outer lip mucosa
The lips should be examined for shape, color and texture, being sure to note symmetry of right and left, including the labial commissures (corner of the mouth), the vermillion borders (junction of lip and facial skin) and the wet/dry line (junction of inner, more moist lip mucosa and outer, less moist lip mucosa). As we age and are exposed to sunlight, the vermillion border becomes less distinct.
Common normal variation:
Fordyce granules - ectopic sebaceous glands appearing as small yellowish “grains of sand” beneath the labial mucosal surface; commonly accumulate in the lips near the corner of the mouth; (please see slide 29)

16. Lips and labial mucosa Bidigital palpation firm but pliable
slightly nodular
minor salivary glands
Bidigital palpation of the lips should reveal them to be firm but pliable and slightly nodular reflecting the multiple minor salivary glands that lie just beneath the labial mucosal surface.

17. Labial mucosa and vestibule
Labial frena
maxillary frenum
mandibular frenum
Reflect lips
smooth, glistening, moist
vascular
Within the labial vestibule lie the maxillary and mandibular labial frena. Frena are verticle bands of oral mucosa that attach the lip to the alveolar mucosa at the midline and limit the movement of the lips; there are also maxillary and mandibular buccal frena connecting the cheeks to the alveolar ridge in the pre-molar areas.
In a healthy state, reflecting the lips reveals a smooth, glistening, moist mucosa with vascular elements often vaguely visible beneath the surface.

18. Mucogingival junction
Keratinized tissue, often “bound” to bone and less vascular in appearance in healthy tissue
Gingiva
Hard palate
Non-keratinized tissue, “non-bound” to bone and more vascular in appearance
Buccal mucosa
Soft palate
Floor of mouth
The mucogingival junction is the junction of the keratinized tissue of the gingiva and non-keratinized tissue of the labial vestibule. Keratinized tissue has a thicker “keratin” surface which better obscures the underlying vasculature in the connective tissue, giving it a lighter appearance when in a healthy state.
Identifying this junction aids in narrowing the differential diagnosis for oral ulcers. Aphthous ulcers appear most commonly on non-keratinized mucosa while recurrent herpetic ulcers appear most commonly on keratinized mucosa.
Primary herpes may appear on keratinized (e.g. gingiva) and/or non-keratinized mucosa. Recurrent labial herpetic lesions are often seen on the vermillion border of the lips.

19. Buccal mucosa
Color, texture
pink, smooth, moist
The buccal mucosa is the inner lining of the cheek. Color and texture are normally pink, smooth and moist. The parotid gland is emptied by Stensen’s duct, which is located in the buccal mucosa near the upper molars.
Common normal variations:
1. linea alba - horizontal white line; hyperkeratinization of buccal mucosa due to cheek biting along occlusal plane; occurs in dentulous areas only; usually bilateral
2. leukoedema - bluish-white opalescence of the buccal mucosa with a “spider web” appearance which disappears when tissue is stretched
3. physiologic melanin pigmentation - normal variations in the amount of melanin deposits can be seen in the buccal mucosa; racial pigmentation occurs most commonly in African-Americans

20. Buccal mucosa and vestibule
Parotid gland
palpate to check for
tenderness
firm nodules
Stensen’s duct
opposite maxillary 2nd molar
gently depress to check salivary flow
The parotid gland and Stensen’s duct are common places for salivary gland inflammation (sialadenitis) due to duct obstruction by salivary stones (sialolithiasis).
Sialolithiasis may be asymptomatic, or the patient may complain of a painful swelling in the cheek which tends to worsen when eating; it may also lead to sialadenitis, a painful (usually bacterial) infection of the salivary gland. Symptoms may include pain, swelling and a foul-tasting discharge from the duct.
“Milking” the parotid gland can be done by pressing on the cheek, from the back of the mandible under the ear, across the cheek towards the lips, while holding the cheek out to observe a normal clear saliva fluid discharge from the duct opening.

21. Palatal mucosa Hard palate Soft palate pink, firm
thick keratinized tissue
pinpoint red macules
minor salivary glands
Soft palate
pinkish-orange, movable
thin non-keratinized tissue
The palate is divided into hard and soft palate and connected by the vibrating line. When the patient says “Ahh” the soft palate moves up to this line. The hard palate is typically pink, firm, and has thick keratinized tissue with red pin-point macules representing ducts of minor salivary glands. The soft palate is a pinkish-orange color, with thin non-keratinized tissue that is movable.
Common normal variations include:
1. palatal torus – boney growth at the midline of the central or posterior hard palate; covered by firm keratinized tissue.
2. physiologic melanin pigmentation may also be seen in the palate, especially the hard palate, as melanin deposits tend to gather more in the keratinized than the non-keratinized mucosa. Most commonly seen in African-Americans, melanin pigmentation of the lateral area of the posterior hard palate could be confused with Kaposi’s Sarcoma.

22. Anterior palatal mucosa
Rugae
firm ridges in anterior hard palate
Incisive papilla
between maxillary central incisors
The rugae, firm ridges in the anterior hard palate, and the incisive papilla, located on the anterior hard palate just behind the maxillary central incisors, are common areas for traumatic injury, such as burns and lacerations.

23. Dorsal tongue Median lingual sulcus Covered with papillae
Consistently firm and pliable
The dorsum or top of the tongue has a median or midline sulcus, is covered by fine filiform and fungiform papillae throughout with a “V” shaped collection of circumvallate papillae in the area of the posterior tongue that run from lingual tonsil on the right to lingual tonsil on the left.
Common normal variations include:
1. geographic tongue – benign condition resulting from the patchy loss of papillae on the top & sides of the tongue; clinically appears as one or more “bald” areas with a whitish-yellow border; patient may complain of slight irritation or burning sensation, especially with salty or spicy foods; the exact cause is unknown; also known as benign migratory glossitis as the location of the borders that create aa “map-like” appearance of the tongue surface, will change over time.
2. fissured tongue – benign condition characterized by cracks or grooves in the top of the tongue; grooves may vary in size, depth & pattern and are usually asymptomatic; food debris may become imbedded causing local irritation and bad breath; gentle brushing of the tongue will help to alleviate symptoms; the exact cause is unknown; also known as scrotal tongue.
3. hairy tongue – benign condition caused by a decrease in desquamation and increase in keratin buildup on the filliform papillae on the top of the tongue, resulting in a shaggy or “hairy” appearance; contributing factors include poor oral hygiene, soft diet and smoking; usually asymptomatic, but patients may complain of abnormal taste, bad breath or unsightly appearance; gentle tongue brushing will help alleviate symptoms; may become secondarily infected with fungus.
4. coated tongue – common benign condition resulting from the overgrowth of the papillae of the tongue trapping bacterial plaque, food debris and dead cells; usually concentrated toward the posterior dorsal tongue; fungal organisms (Candida species) may also be present, and while pseudomembranous candidiasis can occur on any oral mucosal surface, it is unlikely that it would appear only on the tongue.
Resource:

24. Ventral & lateral tongue
very thin mucosa
lingual veins (a)
lingual frenum (b)
Lateral
note normal vertical “striped” appearance along border
The ventral surface of the tongue is covered with very then mucosa revealing lingual veins. Varicosities of the veins may be a normal variation in some people. The lingual frenum attaches the ventral tongue to the floor of the mouth.
The lateral borders of the tongue are at the junction of the dorsal and ventral surfaces and have typical vertical corrugations giving a mucosal-colored “striped” appearance along the border. This normal mucosal-colored texture should not be confused with the lesion oral hairy leukoplakia that occurs in this area.
Oral Hairy Leukoplakia (OHL), caused by an Epstein-Barr virus infection, appears as vertically corrugated white patches along the lateral border of the tongue; the white plaque is caused by an overproduction of keratin (hyperkeratosis) and epithelial hyperplasia, accentuating the normal vertically-striped architecture, and resulting in the shaggy or hairy appearance; OHL can spread to the dorsal surface of the tongue, and, rarely, may appear on the buccal mucosa. OHL cannot be removed by wiping with cotton gauze.

25. Floor of mouth Very thin mucosa Lingual frenum Lingual caruncles
Wharton’s duct
Submandibular glands
Duct of Bartholin
Sublingual glands
The floor of mouth, examined by asking the patient to raise his/her tongue to the roof of the mouth, is covered by thin mucosa.
The lingual caruncles are found bilaterally at the base of the lingual frenum.
A common normal variation is the presence of mandibular tori– benign growths of dense bone along inside (lingual) border of the mandible; covered by relatively thin keratinized tissue; asymptomatic and no treatment is needed unless interfering with speech, chewing or wearing of a removable dental prosthesis. They can vary in size, but increase in size very slowly so the patient should be able to report that these lumps have been present for a long time. They may be single or multiple, unilateral or bilateral in distribution.

26. Gingiva Pink, firm, stippled Normal physiologic melanin pigmentation
knife-edged margins
gingiva lies flat against the tooth
pointed interdental papillae
fills space between teeth
Gingiva in the healthy state is pink, firm and stippled with knife-edged margins and pointed interdental papillae that fill the space between teeth, unless teeth are separated by diastemas, or spacing between tooth crowns.
Common normal variations:
1. physiologic melanin pigmentation – normal melanin deposits appearing brown to bluish-brown; seen more in keratinized tissue, but also in buccal mucosa; may be affected by smoking, medications and pregnancy; most commonly seen in African-Americans.
2. amalgam tattoo – a bluish-black macular lesion of the gingiva or alveolar or buccal mucosa caused by the implantation of silver amalgam filling material during tooth restoration or extraction; asymptomatic and does not require treatment. They are most often seen near teeth with amalgam restorations or crowns.
Normal physiologic melanin pigmentation

27. Teeth 32 adult permanent Variations in color Check for
molars, pre-molars, canines, incisors
Variations in color
white, yellow, gray
Check for
plaque
soft deposits of bacteria & food debris
calculus
hard calcified deposits of plaque and mineral salts from saliva
decayed, missing teeth
tooth mobility
There are up to 32 adult permanent teeth, although congenital absence of third molars (wisdom) teeth is common, followed by premolars and lateral incisors. Tooth color varies from the original whiter color to yellow and gray, with aging and exposure to intrinsic (tooth pulp death may result in gray or pink color; use of tetracycline during tooth development can result in gray coloring) or extrinsic factors (wine, tea, tobacco, chlorhexidine and other medications may stain the tooth surface or tooth calculus).
Teeth should be examined for the presence of plaque (an indication of inadequate oral hygiene), calculus (an indication of need for a professional dental cleaning), and decayed, missing or mobile teeth that indicate a need for other professional dental care.
There are many tooth-numbering systems used in the US; the one illustrated here is the most commonly accepted.

28. Common normal variations (1)b c
Several common normal variations are shown here:
a. Melanin in the midline raphe and a palatal torus at the junction of hard & soft palate
b. Bilateral mandibular tori
c. Brown hairy tongue in a heavy smoker

29. Common lesions & normal variations
Mucocele (a)
clear to bluish translucency
mucous cyst caused by rupture or obstruction of minor salivary gland duct
Irritation fibroma (b)
pink, same as surrounding tissue
benign proliferation of dense fibrous tissue
Fordyce granules (c)
yellowish-white
ectopic sebaceous glands
Several common lesions and normal variations are shown here:
A mucocele is a mucous cyst caused by rupture or obstruction of a minor salivary gland duct; It is clear to bluish in translucency
Irritation fibroma is a benign proliferation of dense fibrous tissue which is mucosal colored
Fordyce granules are ectopic sebaceous glands that are yellowish-white in color

30. Common normal variations (2)
a. fissured or scrotal tongue (below)
Common normal variations:
Fissured tongue or scrotal tongue in an African-American male; also note staining of the dorsal surface, caused by cigarette smoking
Plaque and calculus build-up in a caucasian male with poor oral hygiene; also note staining of the lingual surfaces of the teeth, caused by cigarette smoking and drinking coffee
b. facial surfaces (top right) and lingual surfaces (bottom right) with plaque & calculus

31. Oral health screening video

32. Questions?
The end.

33. Guide to Oral Health Care for People Living with HIV/AIDS
Chapter 2: Dental Management
Dental Management
This chapter addresses the role of the primary care medical clinician in recognizing the oral systemic connections and effectively referring and coordinating oral health care with the dentist.

34. Chapter 2: Dental Management
Course Author:
Lauren L. Patton, D.D.S.
Consultant:
Vincent C. Marconi, M.D.
Series Editor:
David A. Reznik, D.D.S.
HRSA, HIV/AIDS Bureau Consultant:
Mahyar Mofidi, D.M.D, Ph.D.
Acknowledgements:
Course Committee Author:
Lauren L. Patton, DDS
Consultants:
Vincent C. Marconi, MD
Series Editor:
David A. Reznik, DDS
HRSA, HIV/AIDS Bureau Consultant:
Mahyar Mofidi, D.M.D, Ph.D.
Last Modified: February 2014

35. Chapter 2: Learning Objectives
Educational Objectives
Discuss oral-systemic connections in PLWHA
Recognize the role of the primary care clinician in promoting oral health
Describe the elements of effective medical-dental collaboration and effective dental referral
Standardized format for making referrals
Describe required labs needed by dental team
Dental management concerns of dentists (bleeding and infections)
Providing feedback to referring primary care provider
The educational objectives for the dental management chapter are to:
Discuss oral-systemic connections in PLWHA
Recognize the role of the primary care clinician in promoting oral health
Describe the elements of effective medical-dental collaboration and effective dental referral, including
A standardized format for making referrals
Required labs needed by the dental team,
Dental management concerns of dentists (bleeding and infections), and
Providing feedback to the referring primary care provider

36. Oral-Systemic Connections in People Living with HIV/AIDS
Oral health is critical for overall health and psychological well-being.
The mouth is a mirror of health or disease.
Mucosa
Saliva
Emerging evidence suggests both:
non-HIV oral pathogens may undermine HAART success, with periodontal disease exacerbating HIV viremia
chronic untreated HIV disease may contribute to the acceleration of age-appropriate periodontal disease
During the past 30 years of the HIV epidemic, there has been a resurgence in interest in exploring oral-systemic connections.
The Surgeon General’s Report on “Oral Health in America,” published in 2000, observed that oral health is a critical component of overall health and one cannot be truly healthy without maintenance of oral health.
Findings from the recent HRSA SPNS Oral Health Care Initiative indicate access to oral care for low-income people living with HIV/AIDS increases self-reported overall well-being.
Emerging evidence suggests non-HIV oral pathogens, such as bacteria and host cell products resulting from inflammation, may undermine HAART success by regulating HIV replication in latently infected cells. In this way periodontal disease may exacerbate HIV viremia. In addition untreated chronic HIV disease may accelerate age appropriate periodontal disease.
Moreover, the mouth can be seen as an accessible noninvasive window to general health or disease.
The rapid expansion of salivary diagnostics, including detection of salivary biomarkers of systemic disease, allows dental providers to screen for systemic diseases in the dental office.
Today, the ability to identify suspicious oral mucosal lesions and to screen for HIV antibodies with rapid point-of-care tests, using oral mucosal transudate, allow HIV disease to be detected through oral examination and salivary diagnostics.
References:
U.S. Department of Health and Human Services. Oral Health in America. A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health;
Bachman SS, Walter AW, Umez-Eronini A. Access to oral health care and self-reported health status among low-income adults living with HIV/AIDS. Public Health Rep. 2012;127 Suppl 2:55-64.
Wong DT. Salivaomics. J Am Dent Assoc. 2012;143(10 Suppl):19S-24S.
Reznik DA. Screening for infectious diseases in the dental setting. Dent Clin North Am 2012;56(4):
Wahl SM, Redford M, Christensen S, Mack W, Cohn J, Janoff EN, et al. Systemic and mucosal differences in HIV burden, immune, and therapeutic responses. J Acquir Immune Defic Syndr 2011;56(5):
González OA, Ebersole JL, Huang CB. Oral infectious diseases: a potential risk factor
for HIV virus recrudescence? Oral Dis 2009; 15(5):
Huang CB, Emerson KA, Gonzalez OA, Ebersole JL. Oral bacteria induce a differential
activation of human immunodeficiency virus-1 promoter in T cells, macrophages and
dendritic cells. Oral Microbiol Immunol 2009; 24(5):
Alpagot T, Remien J, Bhattacharyya M, Konopka K, Lundergan w, Duzgunes N.
Longitudinal evaluation of prostaglandin E2 (PGE2) and periodontal status in HIV+
patients. Arch Oral Biol 2007; 52(11):

37. Impact of Patient Lifestyle Behaviors
Tobacco
Lung cancers and heart disease
Oropharyngeal cancer, oral candidiasis, periodontal disease
Smoking is the major modifiable death risk factor for PLWHA
Alcohol
Liver disease
Oropharyngeal cancer
Recreational Drugs
Poor nutrition and hygiene, blood-borne infections
Poor oral hygiene, rampant dental caries (meth mouth)
Poor Dietary Habits
Faster HIV disease progression
More dental caries and tooth loss
One needs to appreciate that a patient’s lifestyle behaviors contribute to his/her oral disease and increases the risk of chronic disease and death.
These may include:
Tobacco use that is
Known to increase risk of lung cancer and heart disease and also increases the risk of oropharyngeal cancer, oral candidiasis and periodontal diseases. Smoking is a major modifiable risk factor for death. Smoking rates among HIV –positive US residents in medical care have been shown to be twice higher (42% vs. 21%) than among those without HIV, leading the CDC to recommend physicians prioritize smoking cessation efforts after treatment for HIV.
Excess alcohol use that is
Known to lead to liver cirrhosis and hepatic failure, and also causes oropharyngeal cancers. For patients with HCV, the first step in management of those with an “alcohol problem” is ensuring alcohol cessation is accomplished.
Use of recreational drugs that
Contributes to poor nutrition and hygiene, elevates risk of blood-borne infections, results in poor oral hygiene practices and in some cases rampant dental decay as in users of methamphetamine, where the condition is referred to as “meth mouth”.
Poor Dietary habits that include high sugar content and lack of needed vitamins and minerals leading to malnutrition may result in faster HIV disease progression, more extensive dental caries and more rapid tooth loss. It is the position of the American Dietetic Association that oral health and nutrition have a synergistic bidirectional relationship.
References:
Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169(15):
Warnakulasuriya S, Dietrich T, Bornstein MM, Casals Peidró E, Preshaw PM, Walter C, et al. Oral health risks of tobacco use and effects of cessation. Int Dent J. 2010;60(1):7-30.
Goldstein BY, Chang SC, Hashibe M, La Vecchia C, Zhang ZF. Alcohol consumption and cancers of the oral cavity and pharynx from 1988 to 2009: an update. Eur J Cancer Prev. 2010;19(6):
Hamamoto DT, Rhodus NL. Methamphetamine abuse and dentistry. Oral Dis. 2009;15(1):27-37.
Mdodo R, Frazier E, Mattson C, Sutton M, Brooks J, Skarbinski J. Cigarette smoking among HIV+ adults in care: Medical Monitoring Project, US, th Conference on Retroviruses and Opportunistic Infections. March 3-6, Atlanta. Abstract 775.
National Institutes of Health Consensus Development Conference Statement: Management of hepatitis C: Hepatology 2002;36:S3-S20.
Swaminathan S, Padmapriyadarsini C, Yoojin L, Sukumar B, Iliayas S, Karthipriya J, et al. Nutritional supplementation in HIV-infected individuals in South India: a prospective interventional study.
Clin Infect Dis Jul 1;51(1):51-57.
Touger-Decker R, Mobley CC; American Dietetic Association. Position of the American Dietetic Association: oral health and nutrition. J Am Diet Assoc. 2007;107(8):

38. Antiretroviral Drug Effects on the Oral and Facial Region
Xerostomia
Decreased saliva increases risk of dental caries and candida infections
Fat redistribution
Facial fat wasting and parotid lipomatosis
Taste disturbances
Oral and perioral paresthesias
Antiretroviral drugs have been shown to have adverse side effects in the oral cavity and facial region. The primary care clinician should be aware of these and monitor the patient for their occurrence.
These may include:
Xerostomia.
Decreased saliva production and flow increases the risk of dental caries and candida infections.
Fat redistribution that can lead to facial fat wasting giving a cachectic appearance and parotid lipomatosis, leading to swelling and enlargement in the bilateral jaw area.
Taste disturbances of varying character
And oral and perioral paresthesias.
References:
Scully C, Diz Dios P. Orofacial effects for antiretroviral therapies. Oral Dis. 2001;7(4):
Diz Dios P, Scully C. Adverse effects of antiretroviral therapy: focus on orofacial effects. Expert Opin Drug Saf. 2002;1(4):

39. Spread of Oral Infections
Bacteria (oral β streptococci and other species from dental abscesses or periodontal collections):
Spread locally, regionally or distantly for extension
Intraoral abscess, sinusitis, facial and periorbital cellulitis, submandibular or retropharyngeal abscess and airway compromise, or brain abscesses
Aspiration pneumonia
Bacteremia and possible distant site infection, infective endocarditis
Fungus (Candida): oral to esophagus
Virus (HSV, HPV): oral to genital;
oral to anal
The oral cavity is filled with thousands of microorganisms. Oral microbial infections can spread locally or distantly.
Bacteria (oral β streptococci, such as Strep mutans, and other species from dental abscesses or periodontal collections):
Can spread locally, regionally or distantly by extension causing:
Intraoral abscesses, sinusitis, facial and periorbital cellulitis,
submandibular and retropharyngeal abscess and airway compromise, or
brain abscesses
Can be inhaled causing aspiration pneumonia
Can become disseminated in the blood stream causing bacteremias and possible distant site infections, as in infective endocarditis
Candida can spread from oral cavity to esophagus, particularly in patients with severe immune suppression
HSV and HPV oral viral infections can be transmitted to genital and anal sites
References:
Wade WG. The oral microbiome in health and disease. Pharmacol Res. 2013;69(1):
Pace CC, McCullough GH. The association between oral microorganisms and aspiration pneumonia in the institutionalized elderly: review and recommendations. Dysphagia. 2010;25(4):
Parahitiyawa NB, Jin LJ, Leung WK, Yam WC, Samaranayake LP. Microbiology of odontogenic bacteremia: beyond endocarditis. Clin Microbiol Rev. 2009;22(1):46-64.

40. Role of the Primary Care Clinician in Promoting Oral Health
Screening/detection of oral disease
History, risk assessment, examination
Coaching for oral disease risk avoidance and promoting oral hygiene practices
Evaluate and initially manage acute dental disease
Referral to a dentist for acute/chronic dental disease ongoing medical, surgical, restorative or rehabilitative management
Monitoring for disease progress or having obtained dental treatment intervention
The Primary Care Clinician plays an important role in detecting unmet dental needs and promoting oral health.
He/she may be the first line in screening or detecting oral diseases, including dental caries, periodontal disease and oral mucosal lesions, during a routine visit or one in which the patient presents with an oral complaint.
This role may further include:
Coaching or encouraging the patient to avoid known risk factors for oral disease (such as avoiding tobacco use, limiting sugary drinks and foods that cling to the teeth, avoiding frequent snacking and sipping, and limiting alcohol use) and promoting oral hygiene practices
Evaluating and initially managing acute dental disease.
Referring the patient with acute/chronic dental disease to a dentist for ongoing medical, surgical, restorative or rehabilitative dental management.
Monitoring the patient for oral disease progression or having followed through with recommendation and referrals for dental treatment intervention.
References:
Ramirez JH, Arce R, Contreras A. Why must physicians know about oral diseases? Teach Learn Med. 2010;22(2):
Sheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol. 2000;28(6):
Davis MM, Hilton TJ, Benson S, Schott J, Howard A, McGinnis P, Fagnan L. Unmet dental needs in rural primary care: a clinic-, community-, and practice-based research network collaborative. J Am Board Fam Med. 2010;23(4):

41. Oral Disease Screening/Detection
Symptomatic (may have chief complaint)
Toothache/mouth pain
Missing teeth
Gum bleeding
Growth or ulcer
Swellings
Difficulty eating or swallowing
Asymptomatic (observed on oral exam)
Inflamed gums
White or red/purple patches or ulcers/growths
Blackened or broken teeth
Oral disease screening and detection is easiest for the medical care provider when the patient presents with a dental complaint that draws attention to the oral health issue.
Complaints may include: Toothache/mouth pain, Missing teeth, Gum bleeding, Growths or Ulcers, Swellings, and Difficulty Eating or Swallowing.
In these or other patients, oral examination may reveal asymptomatic oral conditions that also warrant a complete diagnosis and treatment such as: Inflamed gums, White or Red/Purple patches or ulcers/growths, and Blackened or Broken teeth.
References:
Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995;274(17):

42. Oral Disease Prevention
Mechanical/Behavioral:
Diet control: limit sugary, sticky food and drinks
Tobacco avoidance and limiting alcohol use
Brushing teeth twice a day for 2 minutes
Flossing once daily
Brushing the top of the tongue
Use of a fluoride containing toothpaste
Avoid excessively abrasive toothpastes
Reserve tooth whitening until oral health is established
Prevention of common oral diseases involves both mechanical and behavioral self care aspects.
These include:
Limiting intake and frequency of sugary, sticky food and drinks in the diet,
Avoiding tobacco products and limiting alcohol use,
Brushing all teeth thoroughly twice a day for 2 minutes with a soft bristle toothbrush. The brush can be manual or electric/rotary based on patient’s preference.
Brushing the top of the tongue may help those who complain of bad breath.
Ideally, flossing of teeth should be done once daily to remove dental plaque in the interproximal (between contacting teeth) areas where the toothbrush can not reach.
Use of a fluoride containing toothpaste will help prevent decay.
Soft bacterial plaque that is retained on teeth at the gum area and “fed” by sugars creates an acid (low pH) environment that breaks down tooth enamel causing tooth decay. It also irritates the gums causing inflammation and when left undisturbed will mineralize into hard calculus or tartar causing further progression of periodontal disease with recession and pocketing.
Excessively abrasive toothpastes should be avoided as they contribute to tooth sensitivity. At home tooth whitening may also lead to during treatment tooth and gum sensitivity and should be voided until oral health is established. However, home-based nightguard vital tooth bleaching with 10% carbamide peroxide has been shown to have limited long term side effects.
References:
Baelum V. Dentistry and population approaches for preventing dental diseases. J Dent. 2011;39 Suppl 2:S9-19.
Department of Health & British Association for the Study of Community Dentistry. Delivering Better Oral Health. An evidence-based toolkit for prevention. (2009) available from: accessed Feb. 10, 2013.
Chattopadhyay A, Patton LL. Smoking as a risk factor for oral candidiasis in HIV-infected adults. J Oral Pathol Med Dec 4. doi: /jop [Epub ahead of print]
Macdonald E, North A, Maggio B, Sufi F, Mason S, Moore C, et al. Clinical study investigating abrasive effects of three toothpastes and water in an in situ model. J Dent. 2010;38(6):
Boushell LW, Ritter AV, Garland GE, Tiwana KK, Smith LR, Broome A, et al. Nightguard vital bleaching: side effects and patient satisfaction 10 to 17 years post-treatment. J Esthet Restor Dent. 2012;24(3):

43. Dental Caries and Gingivitis Prevention
Chapter 4: Dental Management
Dental Caries and Gingivitis Prevention
Medications:
Decay prevention: fluorides
Prescription strength brush-on gel/paste- e.g. 1.1% NaF Prevident® gel or Prevident ® 5000 plus paste [apply small amount to brush and brush for 2 minutes once daily; spit out excess]
0.4% Stannous fluoride gel (OTC but often stored under the counter)- e.g. Gel-Kam® or Flo-Gel® apply small amount to brush and brush for 2 minutes once daily; spit out excess]
Anticavity fluoride mouthrinses- e.g. ACT® (OTC), Fluorigard ® (OTC) [10ml rinse and spit]
OTC toothpaste
Gingivitis prevention:
antibacterial mouth rinses- e.g. 0.12% chlorhexidine [1/2 oz rinse and spit BID]
Higher risk
Rx NaF gel/paste
SnFL gel OTC
Fl mouthrinse
Medications also play an important role in oral disease prevention. Therapeutic mouthrinses can be used for a variety of reasons such as freshening breath, reducing plaque and tartar, and preventing gingivitis and tooth decay.
The most important ingredient to prevent decay is use of fluorides. In addition to the low level of fluoride in most toothpastes (0.1% of 1000 parts per million), supplemental fluorides are available in over the counter mouthrinses, under the counter gels, and prescription strength gels or toothpastes. As shown in the pyramid, higher strength fluoride treatments are needed based on risk assessment for dental decay. General instructions for maximizing effectiveness of high dose topical fluorides is for the patient to not eat, drink or rinse for 30 minutes after use.
Antibacterial mouth rinses such as 0.12% chlorhexidine or Listerine® can be used to prevent gingivitis.
Some notes of caution. Mouthrinses may temporarily mask the malodor of periodontal disease by helping to reduce plaque and decreasing the level of gingivitis, but periodontal disease will require dental professional treatment.
Many OTC and prescription mouthrinses are in an alcohol base. These should be avoided in patients with excessively dry mouths or alcohol dependencies.
Chlorhexidine can stain the deposits on teeth a brown color, but this is removable with a dental prophylaxis.
References:
Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E. Minimal intervention dentistry for managing dental caries – a review: report of a FDI task group. Int Dent J. 2012;62(5):
Baelum V. Dentistry and population approaches for preventing dental diseases. J Dent. 2011;39 Suppl 2:S9-19.
Department of Health & British Association for the Study of Community Dentistry. Delivering Better Oral Health. An evidence-based toolkit for prevention. (2009) available from: accessed Feb. 10, 2013.
toothpaste
Lower risk

44. Elements of Effective Medical-Dental Collaborations
Common areas
Medically complicated patients
Bleeding-prone patients
Patients at risk for infections
Anxious patients
Common areas where medical-dental collaboration is important include care for:
Medically complicated patients. Significant cardiovascular and hepatic disease comorbidities are not uncommon among PLWHA. Those with very low CD4 counts are also more likely to have significant comorbidities.
Bleeding-prone patients. Coagulopathies may result from medications, liver disease, thrombocytopenia, or inherited hemostatic disorders.
Patients at risk for infections. There is no need to prescribe prophylactic antibiotic coverage for dental patients with low CD4 counts. However, patients with critically low neutrophil counts, such as an ANC below 500 cells/mm3, antibiotic prophylaxis may be warranted.
Anxious patients may need additional antianxiety medications for supportive management.

45. Guidelines for Antibiotic Prophylaxis Prior to Dental Treatment
Guidelines Addressing at Risk Medical Conditions
Recommended
Consider
Not recommended
Prior infective endocarditis, prosthetic heart valve, congenital heart disease (only 3 specific indications), cardiac transplantation recipients who develop cardiac valvulopathy (AHA 2007) X
Orthopedic implant (total joint replacements) (AAOS/ADA 2013)
Cardiovascular implantable electronic device (AHA 2011)
Nonvalvular cardiovascular devices. e.g. pacemakers, defibrillators, LVADs, ventriculoatrial shunt, peripheral vascular stents, vascular graphs including hemodialysis, coronary artery stents, venal caval filters, intracardiac or arterial patches (AHA 2003)
There are several established guidelines for antibiotic prophylaxis in dentistry.
Physician consultation by the dentist regarding possible recommendation or need for antibiotic prophylaxis prior to invasive dental procedures is common.
The 2007 Scientific statement from the American Heart Association on Prevention of Infective Endocarditis recommends antibiotic prophylaxis, such as one dose of 2 gm amoxicillin or 600 mg clindamycin po minutes prior to dental treatment, for patients with prosthetic heart valves, a prior history of infective endocarditis, congenital heart disease (only 3 specific indications) , and cardiac transplantation recipients who develop cardiac valvulopathy.
For patients with prosthetic total joint replacements (orthopedic implants), the 2012 Clinical Practice Guideline from the American Academy of Orthopedic Surgeons and American Dental Association, found limited literature to support a recommendation of discontinuing routine antibiotic coverage of patients for dental procedures, while having practitioners rely on their experience and clinical judgment as well as patient preferences and values. Prior 2003 guidelines recommended consideration of antibiotic coverage for invasive dental treatment for immune suppressed patients with prosthetic joints, including those with HIV infection. Please contact the patient’s orthopedist to verify the need or lack thereof for antibiotic premedication prior to invasive procedures for PLHIV.
AHA statements in 2003 and 2011, for patients at risk for infection related to cardiovascular implantable electronic and other nonvalvular cardiovascular devices, do not recommend antibiotic coverage prior to dental treatment.
Effective referrals for routine and emergency care between medical and dental providers is important to allow the patient to receive a broader scope of care tailored to his/her individual health needs.
References:
Migliorati CA, Madrid C. The interface between oral and systemic health: the need for more collaboration. Clin Microbiol Infect. 2007;13 Suppl 4:11-6.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumative Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, et al. A summary of the update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. J Am Dent Assoc 2011;142(2):
Baddour LM, Bettmann MA, Bolger AF, Epstein AE, Ferrieri P, Gerber MA, et al. Nonvalvular cardiovascular device-related infections. Circulation 2003;108(16):
Watters W 3rd, Rethman MP, Hanson NB, Abt E, Anderson PA, Carroll KC, et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2013:21(3):
American Dental Association; American Academy of Orthopedic Surgeons: Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 2003;134(7):895-9.
Foot note:
# 1. unrepaired cyanotic congenital heart disease (CHD), including palliative shunts and conduits; 2. completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure; 3. repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).

46. Management of Bleeding For Patients on Anticoagulant and Antiplatelet Agents
Warfarin: For general dental procedures, no modification needed; single tooth extractions can be done with INR<3.5 with local hemostatics; for complex elective surgery, warfarin may need to be discontinued at least 24 hours in advance. A presurgical treatment INR should be obtained.
Low molecular weight heparins: no need to discontinue for routine dental care; hold am dose only for surgical procedures.
Plavix and Aspirin: no need to discontinue.
Dabigatran/rivaroxaban: no need to discontinue for routine dental care; for complex elective surgery, drug may need to be discontinued at least 24 hours in advance.
Primary closure and use of adjunctive local hemostatic measures is recommended for surgical procedures in bleeding prone patients when possible.
Management for dental procedures that involve bleeding (including most uncomplicated tooth extractions) for patients on:
Warfarin: For general dental procedures, no modification needed; single tooth extractions can be done with INR<3.5 with local hemostatics; for complex elective surgery, warfarin may need to be discontinued at least 24 hours in advance. A presurgical treatment INR should be obtained for the patient on warfarin. May need to consider inpatient admission for INR reversal, heparinization and re-anticoagulation with warfarin thereafter.
Low molecular weight heparins: no need to discontinue for routine dental care; hold am dose only for surgical procedures
Plavix and Aspirin: no need to discontinue
Dabigatran/rivaroxaban: no need to discontinue for routine dental care; for complex elective surgery, it may need to be discontinued at least 24 hours in advance.
Primary closure and use of adjunctive local hemostatic measures is recommended for surgical procedures in bleeding prone patients when possible.
References:
Firriolo FJ, Hupp WS. Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113(4):
Brewer AK. Continuing warfarin therapy does not increase risk of bleeding for patients undergoing minor dental procedures. Evid Based Dent 2009;10(2):52.
Aframian DJ, Lalla RV, Peterson DE. Management of dental patients taking common hemostasis-altering medications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103 Suppl:S45.e1-11.
Hong CH, Napeñas JJ, Brennan MT, Furney SL, Lockhart PB. Frequency of bleeding following invasive dental procedures in patients on low-molecular weight heparin therpy. J Oral Maxillofac Surg 2010;68(5):975-9.

47. Unmet Need and Barriers to Oral Care
Cost, access to dental care, fear of dental care, indifference to dental care, logistical issues such as transportation, language and cultural barriers
Concerns about HIV status
disclosure/privacy, long delays before appointments and long waiting room times
For children with HIV
poor interpersonal communication between dental staff and caregiver/child
shame/anger and family illness
caregiver dental fear and low prioritization of dental care
People living with HIV/AIDS have unmet dental care needs resulting from multiple barriers.
The three main barriers to obtaining needed oral care among people living with HIV/AIDS are:
Cost
Access to dental care and
Fear of dental care
Patient indifference to dental care and logistical issues, such as transportation difficulty, and language and cultural barriers add to unmet need.
Patients may have concerns about confidentiality and disclosure of their HIV status in the dental setting. Long delays before appointments and long waiting room times further reduce the chance of appointment attendance.
For low-income Medicaid-eligible children with HIV and their caregivers, the most commonly expressed barriers to dental care are
poor interpersonal communication between dental staff and caregiver/child
shame or anger and family illness
caregiver dental fear and low prioritization of dental care.
References:
Jeanty Y, Cardenas G, Fox JE, Pereyra M, Diaz C, Bednarsh H, et al. Correlates of unmet dental care needs among HIV-positive people since being diagnosed with HIV. Public Health Rep. 2012;127 Suppl 2:17-24.
Rohn EJ, Sankar A, Hoelscher DC, Luborsky M, Parise MH. How do social-psychological concerns impede the delivery of care to people with HIV? Issues for dental education. J Dent Educ. 2006;70(10):
Broder HL, Russell S, Catapano P, Reisine S. Perceived barriers and facilitators to dental treatment among female caregivers of children with and without HIV and their health care providers. Pediatr Dent. 2002;24(4):301-8.

48. Oral Healthcare Access Barriers
Low motivation or lack of awareness of importance of oral health
Dental anxiety and fear
Shortage of dentists trained and willing to treat patients with HIV/AIDS
Lack of dental insurance coverage
Limited financial resources
Declining levels of adult dental Medicaid coverage
Many people living with HIV/AIDS face barriers to oral healthcare access including:
Low motivation or lack of awareness of importance of oral health.
Dental anxiety and fear.
Shortage of dentists trained and willing to treat people living with HIV/AIDS.
Lack of dental insurance coverage. Dental insurance coverage is much less prevalent than medical insurance coverage and an estimated only 36% of employed adults participate in employer dental insurance benefit plans.
Limited financial resources.
Declining levels of adult dental Medicaid coverage. States are required to provide dental benefits for children under Medicaid and the Children’s Health Insurance Program (CHIP) to minimally include relief of pain and infections, restoration of teeth and maintenance of dental health, but have flexibility to determine what dental benefits are provided to adults. While most states provide at least emergency dental services such as extraction of infected teeth, less than half provide comprehensive dental care and the trend is for states to reduce or eliminate coverage as there are no minimal requirements.
Of note: Medicare is not a source of general dental coverage for adults. Veteran dental care benefits and VA dental care eligibility are based on a number of factors including service-related disability; therefore a lot of VA patients are in need of a referral to an outside dental program
References:
Shiboski CH, Palacio H, Neuhaus JM, Greenblatt RM. Dental care access and use among HIV-infected women. Public Health. 1999;89(6):834-9.
Patton LL, Strauss RP, McKaig RG, Porter DR, Eron JJ Jr. Perceived oral health status, unmet needs, and barriers to dental care among HIV/AIDS patients in a North Carolina cohort: impacts of race. J Public Health Dent. 2003;63(2):86-91.
Shiboski CH, Cohen M, Weber K, Shansky A, Malvin K, Greenblatt RM. Factors associated with use of dental services among HIV-infected and high-risk uninfected women. J Am Dent Assoc. 2005;136(9):
Singer R, Cardenas G, Xavier J, Jeanty Y, Pereyra M, Rodriguez A, Metsch LR. Dental anxiety and the use of oral health services among people attending two HIV primary care clinics in Miami. Public Health Rep. 2012;127 Suppl 2:36-44.
Fox JE, Tobias CR, Bachman SS, Reznik DA, Rajabiun S, Verdecias N. Increasing access to oral health care for people living with HIV/AIDS in the U.S.: baseline evaluation results of the Innovations in Oral Health Care Initiative. Public Health Rep. 2012;127 Suppl 2:5-16.
Dental Care.
McGinn-Shapiro M. Medicaid Coverage of Adult Dental Services. State Health Policy Monitor. Oct Nat Acad State Health Policy. Available at: Accessed March 2013.
Information for Veteran Dental Patients. Available at:

49. Overcoming Financial Access Limitations
Oral Health Programs supporting dental care services for PLWHA:
HRSA Ryan White HIV/AIDS Program Dental Reimbursement Program to dental educational programs
HRSA Ryan White HIV/AIDS Program Community-Based Dental Partnership Program
Dental programs funded through other parts of the Ryan White HIV/AIDS Program
Other lower cost dental care options:
County health department or federally qualified health center with dental clinic
Dental school or hospital dental residency clinic
Community-based free dental health clinic projects
Other dental resources: contact state dental society
Oral Health programs supporting dental care services for PLWHA under the Ryan White HIV/AIDS Program include programs funded through Parts A, B, C and D as well as the Dental Reimbursement Program to dental educational programs that provide oral health care to PLWHA and the Community-Based Dental Partnership Program.
In addition lower cost dental care may be available in the following settings:
County health departments or federally qualified health centers (FQHCs) with dental clinics
Dental schools or hospital-based dental residency clinics
Community-based free dental health clinic projects
For other dental resources, providers and patients may contact their state dental society.
References:
For a list of prior grantees for Part F Ryan White HIV/AIDS Program dental clinics search at this website
The Ryan White HIV/AIDS Program. Available at:

50. General Dentist
Most referrals should be to a general dentist convenient to the patient.
Role:
Assess risk, diagnose existing oral disease/conditions, encourage disease prevention.
Establish dental treatment plan in consultation with the patient and when complexities exist, consultation and/or coordination with the primary care provider.
Plan may involve referral of components of care to dental specialists.
Dental recall (recare) appointment interval of 3-12 months established.
Most primary care provider referrals for patients with dental needs should be to a general dentist convenient to the patient.
The general dentist will assess dental risk and diagnose existing oral diseases and conditions through history, examination and dental radiographs and will encourage disease prevention.
A dental treatment plan will be made in consultation with the patient and when complexities exist, consultation and/or coordination with the primary care provider.
There are often options of dental treatment plans with higher and lower costs.
Dental treatment may involve referral of components of recommended dental care to dental specialists, such as an endodontist, orthodontist, or oral and maxillofacial surgeon.
A dental recall or recare appointment interval of 3-12 months will typically be established with the practice’s dental hygienist, with recare interval depending on the patient’s individual dental risk assessment.

51. Elements of an Effective Dental Referral
How (does the referring dental office receive referrals? Fax, phone, letter, electronic. Ask and follow their format and process.)
Who (patient information including age, contact information, medical information; do include HIV infection along with other medical conditions and past history of medical/surgical care)
Why (for specific issue/concern such as toothache with abscess, missing teeth so can’t chew, purple lesion needing biopsy, broken teeth needing repair, bleeding gums/bad breath from periodontal disease, oral growth to r/o cancer)
What (consultation only, consult and treat)
When (emergency, urgency, routine)
Referred by: referring primary care provider’s name and office contact information
Appropriate referrals among professionals are integral to quality healthcare management.
When two or more healthcare providers are involved in the treatment of a patient, communication between them is essential. Referrals should cover the following elements:
How (does the referring dental office receive referrals? Fax, phone, letter, electronic. Ask and follow their format and process.)
Who (patient information including age, contact information, medical information; do include HIV infection along with other medical conditions and past history of medical/surgical care)
Why (for specific issue/concern such as toothache with abscess, missing teeth so can’t chew, purple lesion needing biopsy, broken teeth needing repair, bleeding gums/bad breath from periodontal disease, oral growth to r/o cancer)
What (consultation only, consult and treat)
When (emergency, urgency, routine)
Referred by: referring primary care provider’s name and office contact information
References:
Hess BJ, Lynn LA, Holmboe ES, Lipner RS. Toward better care coordination through improved communication with referring physicians. Acad Med. 2009;84(10 Suppl):S
McColl E, Newton J, Hutchinson A. An agenda for change in referral—consensus from general practice. Br J Gen Pract. 1994;44(381):

52. Standardized Format for Making Dental Referrals
Consult/evaluation only vs. dental assessment and treatment
Patient’s and/or physician’s specific oral health concerns
Upcoming medical/surgical treatment
Patient contact information
Name/contact for patient or legal guardian if patient is a minor or not legally competent to consent
Language barriers
Patient medical history, medications, allergies, labs
Patient with substance use history and/or narcotic use contract should be identified
Patient with significant dental anxiety should be noted
Providers should follow a standardized format to assure no essential elements are omitted.
The referral should specify if the referring medical provider desires a consultation/evaluation only or desires complete dental assessment and treatment.
It should include the patient’s and/or physician’s specific concern about the patient’s oral health (e.g. abscessed teeth, bleeding gums, oral growth) and any upcoming medical/surgical treatment around which dental care needs to be coordinated.
Patient contact information is essential including name/contact for patient or his/her legal guardian if the patient is a minor or not legally competent to consent. Any language barriers, such as Spanish speaking only or deafness should be noted.
The patient’s medical history, medications, allergies, labs should be included.
Patients with substance abuse history and/or an active narcotic use contract should be identified.
Patients with significant dental anxiety should be noted.

53. Medical Information Dentists Need
Medical history
Medications
Allergies
TB skin test results
Most recent labs
Medical information that dental consultants need includes:
Medical history, including comorbidities
Medications
Allergies
Most recent annual TB skin test results
Most recent labs, usually within 6 months
The quality of the referral outcome from the referring primary care provider’s perspective may relate directly to the amount of referral information originally sent to the dental consultant.
References:
Hansen JP, Brown SE, Sullivan RJ Jr, Muhlbaier LH. Factors related to an effective referral and consultation process. J Fam Pract Oct;15(4):651-6.
Magalhães MG, Greenberg B, Hansen H, Glick M. Comorbidities in older patient with HIV: a retrospective study. J Am Dent Assoc. 2007;138(11):

54. Required Labs Needed By Dental Team
Basic HIV labs:
Absolute CD4 count
HIV RNA (viral load)
CBC with differential
Coags:
PT/INR
aPTT
If hemophiliac:
baseline deficient factor level (e.g., Factor VIII activity)
inhibitor titer (e.g., BIA)
Dental care providers need to be provided with or have access to results of the patient’s most recent basic laboratory studies.
These include the most recent absolute CD4 count, HIV RNA (viral load), CBC with differential and coagulation tests if they exist.
If the patient is a hemophiliac, the baseline deficient factor level (e.g. Factor VIII activity) and presence and activity of any inhibitors should also be provided to the dentist.
Some dental teams may request additional laboratory studies such as RPR and GC/Chlamydia test results. If the patient is a diabetic, the HBA1C will be of value to the dentist.
References:
Patton LL, Shugars DC. Immunologic and viral markers of HIV-1 disease progression: implications for dentistry. J Am Dent Assoc. 1999;130(9):
Patton LL. Hematologic abnormalities among HIV-infected patients: associations of significance for dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88(5):561-7.

55. Providing Feedback to Referring Primary Care Provider
Dentists should work with the primary care provider to monitor HIV progression and treatment failure.
When the dentist diagnoses new onset oral manifestations of HIV (such as oral candidiasis), the dentist should consult with the patient and, with consent, the referring primary care provider to address the health issue as a team.
Interprofessional communication should also target engaging and retaining the patient in dental care.
Dentists should work with the primary care provider to monitor HIV progression and treatment failure.
When the dentist diagnoses new onset oral manifestations of HIV (such as oral candidiasis), the dentist should consult with the patient and, with consent, the referring primary care provider to address the health issue as a team. Occurrence of new onset oral candidiasis may indicate a weakening immune system and need for the primary care provider to reassess CD4 count.
Interprofessional communication should also target engaging and retaining the patient in dental care.
Patients should be asked by the primary care provider for feedback on their experiences communicating with the referring dentist and his/her office staff.
References:
Benjamin RM. Oral health care for people living with HIV/AIDS. Public Health Rep. 2012;127 Suppl 2:1-2.
Tamí-Maury I, Willig J, Vermund S, Jolly P, Aban I, Hill J, Wilson CM. Contemporary profile of oral manifestations of HIV/AIDS and associated risk factors in a Southeastern US clinic. J Public Health Dent. 2011;71(4):
Hess BJ, Lynn LA, Holmboe ES, Lipner RS. Toward better care coordination through improved communication with referring physicians. Acad Med. 2009;84(10 Suppl):S

56. Summary Oral and systemic health are interrelated.
Dental management is most effective when coordinated with overall health management.
Primary care clinicians play an important role in supporting their patients overall health including oral health.
Dental management is affected by patient’s social and financial resources, behaviors, and dental access.
In summary:
Oral and systemic health are interrelated.
Dental management is most effective when coordinated with overall health management.
Primary care clinicians play an important role in supporting their patients overall health including oral health.
Dental management is affected by patient’s social and financial resources, behaviors, and dental access.

57. Questions?
The end.