1. HIV Oral Health Review Evaluation Center for HIV and Oral Health Boston University School of Public Health Health & Disability Working Group

2. Why is Dental Care Important? It’s important for EVERYONE!!! If you are infected with HIV, good oral health and regular dental care become more important. –Many first signs of HIV appear in the mouth. – Simple dental problems may become more serious quickly with a weak immune system. –Problems may be treated more easily if found early.

3. Why do oral complications occur? Changes in your immune system From the drugs used to treat HIV Same as everyone else – poor oral hygiene, smoking, aging

4. HIV-positive individuals should: Have frequent dental exams, cleanings and prompt care Brush and floss daily or as recommended by your dentist Examine face, neck and mouth weekly Inform your dentist or physician of any changed in the face, neck or mouth. Inform your dentist of your medical history and HIV status.

5. CD4 cell count, HIV viral load and oral lesions  HIV viral load and oropharyngeal Candida colonization (Oral Dis 2000;6:158)  CD4 cell count and periodontitis (Oral Dis 2000;6:158)  CD4 cell count and oral candidiasis, and  HIV viral load and oral leukoplakia (J Acq Imm Def Synd 2000;25:44)  CD4 count,  HIV viral load and oral candidiasis (J Med Microbiol 2000;49:985) Note: CD4 20,000 becomes predictive for oral lesions

6. Infections in the Mouth Plaque is a film on the dental tissues that attracts bacteria. Oral infections: –Gingivitis – early stage of gum disease –Periodontitis and Periodontal Disease – advanced stage of gum disease which includes bone loss (linked to increased risk of stroke and heart attack) –Dental caries (cavities)

7. Too much of a “normal” thing? Is there such a thing as good bacteria? Normal flora – micro-organisms that ordinarily grow on and in the human body (streptococci, staphylococci, candida, neisseria, etc) However, when conditions change the normal environment in which these micro-organisms live in our mouth, this can cause them to increase in number resulting in infection.

8. What can we do on a daily basis to improve oral health?

9. Tooth Brushing Outer and Inner surfaces Hold brush at a 45 degree angle with half-tooth wide strokes Chewing surfaces Hold the brush flat and brush back and forth.

10. Tooth Brushing Inside surfaces of front teeth Tilt brush vertically and use gentle up-and-down strokes with toe of brush. Don’t forget the tongue! Brush in a back-to-front sweeping motion to remove food particles and freshens breath

11. Or Just Use the “Shake, Rattle N’ Roll” Method… You should brush for 2 minutes, so try humming a song you like or reciting the words in your mind.

12. Dental Floss Technique Wrap an 18-inch strand around your middle fingers and hold a one-inch section tightly. Ease floss between the teeth. Clean up and down several times while curving around teeth at the gingival margin. Don't scrub!

13. Dentures Brush your gums, tongue and palate every morning with a soft-bristled brush before you insert your dentures to stimulate circulation in your tissues and help remove plaque. Make sure and brush your dentures with a denture brush and denture cleanser

14. So what do the structures in our mouth look like up close?

15. The Tooth….. Tooth enamel is hard and porous. It consists of many closely-packed rods made of minerals. When you eat, acid forms on the outside of the tooth and seeps into the enamel's pores

16. Important Tooth Structures Enamel - hard, white outer layer of a tooth; the hardest substance in the body. Pulp - the soft tissue around the tooth that contains nerves, blood vessels, and connective tissue. Dentin - This is the main tissue that forms the shape of the tooth. Dentin is the material which exists between the pulp and the enamel Enamel Dentin Pulp

17. Dental Caries When you eat, acid forms on the outside of the tooth and seeps into the enamel's pores. This demineralization process can produce a weak spot in the tooth's surface. If unchecked, the enamel can decay and cause a cavity –dental caries

18. Dental Caries Tooth decay often begins on biting surfaces, between the teeth, and on exposed roots.

19. What is de-mineralization? A process in which minerals are removed from the molecular structure of the tooth – caused by acids in the foods we eat and can lead to holes (cavities) in the tooth structure. Teeth Gums Minerals removed from teeth Cavities are formed

20. What is re-mineralization? A process in which minerals are returned to the molecular structure of the tooth itself Teeth Gums Minerals

21. How can we re-mineralize our teeth? Water with fluoride Fluoridated toothpaste Fluoride mouth rinses ( alcohol vs. no alcohol) Topically applied fluorides –Gels Professionally applied Prescribed home therapy –Fluoride varnish

22. Why is Saliva Important? It helps digest food It protects teeth from decay It prevents infection by controlling bacteria and fungi in the mouth It makes it possible to chew food and swallow Can be a great and cheap lubricant for sex!

23. Xerostomia (dry mouth) Sip water Suck on crushed ice Humidifiers at night Avoid liquids containing caffeine or alcohol Commercial artificial saliva Discontinuation of xerostomia-inducing drugs Stimulation of salivary flow This may cause increase in cavities and periodontal disease

24. “Dry Mouth” Side effects of some medicines. More than 400 medicines can cause the salivary glands to make less saliva. Medicines for high blood pressure and depression often cause dry mouth. Disease. Some diseases affect the salivary glands. Sjögren's Syndrome, HIV/AIDS, diabetes, and Parkinson's disease can all cause dry mouth. Radiation therapy. The salivary glands can be damaged if they are exposed to radiation during cancer treatment. Chemotherapy. Drugs used to treat cancer can make saliva thicker, causing the mouth to feel dry. Nerve damage. Injury to the head or neck can damage the nerves that tell salivary glands to make saliva.

25. Symptoms a sticky, dry feeling in the mouth trouble chewing, swallowing, tasting, or speaking a burning feeling in the mouth a dry feeling in the throat cracked lips a dry, tough tongue mouth sores an infection in the mouth

26. Oral Manifestations Seen in Persons Living with HIV

27. Effects of Dry Mouth

29. Lymphadenopathy – disease of the lymph nodes - Often times referred to as “swollen glands/lymph nodes” - Can be caused by cancers, infections, diseases of the immune system

30. What are lymph nodes? Small round structures present all over the body that are involved in protecting the body from infections Tiny bean shaped gland – main locations include the neck, armpits, groin Filter fluid through your body that capture infectious organisms and destroy with the white blood cells.

32. Thrush Fungal infection White curd-like Wipes off Red below Appears on buccal mucosa or tongue

33. What is it? This HIV-positive patient has signs of advanced oral hairy leukoplakia (OHL) on the lateral border of his tongue. OHL is caused by the Epstein- Barr Virus, a type of herpes virus also responsible for mononucleosis.

34. What is it? Oral warts secondary to HPV (Human Papillomavirus)

35. HPV – Human Papillomavirus Is a papillomavirus that infects the skin and mucous membranes of humans Commonly known for causing genital warts and increased risk of cervical, penile, and anal cancer The types of HPV that cause warts don’t cause cancer and vice versa – some HPV infections have little to no symptoms Oral HPV is thought to be caused in large by oral sex with a partner who has genital HPV Studies are now showing an increased risk of oral cancers with HPV infection

36. THRUSH White curd-like Wipes off Red below Appears on buccal mucosa or tongue

37. KAPOSI’S SARCOMA or “KS” Most common malignancy in HIV Is associated with a type of herpes virus KS often shows up as purple discoloration on the skin, but can affect internal organs and the lining of the mouth as well While KS is usually not a fatal illness, it can cause significant disability and disfiguration.