FOR INDIVIDUALS LIVING WITH

HIV/AIDS

ORAL HYGIENE INSTRUCTIONS

History of HIV/AIDS Since 1981 when HIV/AIDS was first described, an estimated 60 million people

have been infected, of whom some 20 million have died.

The human immunodeficiency virus (HIV) is a retrovirus that infects cells of the human immune system, destroying or impairing their function. In the early stages of infection, the person has no symptoms. However, as the infection progresses, the immune system becomes weaker, and the person becomes more susceptible to so-called opportunistic infections.

The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS) which is the final stage of HIV infection. It can take years for a person infected with HIV, even without treatment, to reach this stage. Having AIDS means that the virus has weakened the immune system to the point at which the body has a difficult time fighting infections. When someone has one or more of these infections and a low number of T cells, he or she has AIDS.

Overall Health Vs Oral Health

Because the immune system is compromised in HIV positive patient , over all health does have an impact on Oral health. The affect and results are usually much worst than the average person who has a healthy dentition.

Infections of the mouth can lead to abscessed teeth and gums. Unlike other forms of gum disease, necrotizing ulcerative gingivitis (NUG) develops rapidly as well as Thrush which is a yeast infection of the mouth.

Oral manifestations of HIV infection are a key indicator of disease progression. These lesions occur in up to 80% of the affected patient population.

For patients on antiretroviral therapy who have responded well and have undetectable HIV viral load, the presence of oral lesions may signify treatment failure.

For patients with known HIV infection who are asymptomatic and, therefore, not on antiretroviral therapy, the presence of oral lesions may signify progression of disease.

Purpose of this ModuleThis module was developed by Jo-Ann Blake,RDH,MPH and Jennifer Webster-

Cyriaque, DDS, PhD.The goal of this module is to educate patient in the following:

1) The manifestation of gum disease and caries relative to their systemic condition.

2) Provide proper homecare care instructions, utilizing OHI and gingival assessment.

3) Provide the procedure for plaque control and removal for those with removable appliances.

4) Inform patients of the different types of Bacterial Superinfections as it relates to their HIV/AIDS status

Importance of Patient Education

The main objective is for plaque control.

This in turn will control disease eg: Gingival or Periodontal.

Reduce the incidence of caries.

The Importance Intra-Oral Self Examination

Because of patients HIV/AIDS status it is important that they are able to identify the changes that occur in their Oral cavity.

Knowing the normal anatomical structures of the oral cavity will help in identifying any abnormality.

Patients will be educated on how to distinguish those structures that are normal from those that are abnormal.

Eruption Chart

Tooth Composition The part of the tooth that we see in the mouth is the crown. The outside

of the crown is covered with very hard enamel, the next layer of the tooth is softer and is called dentin, and the inner chamber of the crown is the pulp where connective tissue, nerves, and blood vessels are found.

The pulp supplies the tooth with nutrients, repair materials, and sensations. The dentin protects the pulp and supports the outer enamel.

The enamel, in turn, protects the dentin and provides a hard surface for chewing.

The root is covered with a protective layer called cementum. Like the pulp, the root contains connective tissue, nerves, and blood. The root acts as an anchor for the tooth to be held in the surrounding bone. The root is further stabilized in the bony socket and nourished by the periodontal ligament.

Tooth Composition Pictured

Mouth: Healthy Vs Unhealthy

CavitiesHow do cavities form? The hard, outside covering of your teeth is called enamel. Enamel is

very hard, mainly because it contains durable mineral salts, like calcium. Mineral salts in your saliva help add to the hardness of your teeth. Mineral salts, however, are prone to attack by acids. Acid causes them to break down.

The plaque that forms on your teeth and doesn't get washed away by saliva or brushed away by your toothbrush produces acid as it eats up sugar. This acid is produced inside the plaque and can't be easily washed away by your saliva. The acid dissolves the minerals that make your tooth enamel hard. The surface of the enamel becomes porous - tiny holes appear. After a while, the acid causes the tiny holes in the enamel to get bigger until one large hole appears. This is a cavity.

Cavities cont’dIn HIV/AIDS individuals, rampant carries can result from a number of

sources. Here are some examples:1)Methamphetamine use: which can cause rampant tooth decay. Some

users describe their teeth as “blackened, stained, rotting, crumbling or falling apart.” Often, the teeth cannot be salvaged and must be extracted. The extensive tooth decay is attributed to the drug’s acidic nature and its tendency to dry the mouth. A methamphetamine “high” lasts up to 12 hours which can lead to long periods of poor oral hygiene. An added effect of this can also result in craving high-calorie, carbonated, sugary beverages or grinding or clench the teeth, all of which can harm teeth.

Cavities Cont’d2) Xerostomia: (Dry mouth) can

occur due to use of various HIV/AIDS medications. This can cause a reduction in the amount of saliva in the mouth. Besides being uncomfortable, the lack of saliva in the mouth can lead to gum and tooth decay as well as other problems. Xerostomia can be relieved by sucking on sugarless candy or chewing sugarless gum. Commercial artificial saliva also may alleviate the discomfort.

List of alternative products for Dry Mouth

Option 1: Moi-Stir moistening solution – Kingswood Lab. Inc. - Pump Spray

Option 2: Mouthkote oral moisturizer - Parnell Pharmaceuticals, Inc. - Aqueous Solution

Option 3: Glandosane mouth moisturizer - Kenwood Therapeutics - Aqueous Solution sprayed into the mouth

Option 4: Optimoist oral moisturizer - Colgate-Palmolive - Oral moisturizer, aqueous solution.

Dentinal Hypersensitivity Occurs when dentin is exposed. Dentin is the porous part of the tooth

below the outer protective enamel covering. Protection is lost when the gums recede and the enamel or cementum is worn away.

Patient’s can experience hypersensitivity to the following stimuli.

E.g.

1) Heat

2) Cold

3) Sweets

4) Other ( sour, acids, pressure from brushing or chewing)

This is treatable in most cases, please let your dental professional know so that It can be addressed.

Halitosis (Bad Breath)

Bad breath can be the result of odor causing

bacteria and the following are contributors:

1) Particles of food that remain in the mouth

2) Dry mouth

3) Tobacco products

4) Sign of a medical disorder

Relationship of Plaque and Tartar to Gum Disease

What is Plaque? A sticky, colorless coating of

bacteria that is constantly forming on the teeth. Saliva, food, and fluids combine to produce these deposits that collect on the teeth. It is also the primary factor in gum disease.

Plaque begins forming on the

teeth 4 to 12 hours after brushing, which is why it is so important to brush at least twice a day and floss daily.

Tartar/Calculus

What is Tartar? (Calculus) A hard mineral deposit that forms on teeth, which provides a

surface for additional plaque to adhere to and grow.

Without proper brushing and flossing, plaque and tartar can build up and extend below the gumline promoting the following: Gingivitis, Periodontitis and Advanced Periodontitis.

Gingivitis

In gingivitis, the gums become red and swollen. They can bleed easily. Most people can reverse this with daily brushing and flossing and seeing their dentist regularly.

Untreated gingivitis can lead to periodontitis.

Periodontitis

At this stage, plaque spreads to the roots and infection occurs, damaging the supporting bone and fibers.

Gums may separate from the teeth and start to recede.

Pockets may form below the gumline trapping plaque and food, and eventually causing teeth to shift or loosen. When this happens, the teeth may have to be removed in order to prevent further damage.

Advanced Periodontitis

At this stage, gums recede further and separate from the tooth. – Pus may develop– Bone continues to deteriorate

Ten Warning Signs of Periodontal Disease

1) Do you have a bad taste in your mouth? 2) Do you have bad breath? 3) Do your gums look red or swollen? 4) Are your gums tender? 5) Do your gums bleed when you brush or floss? 6) Are your teeth loose? 7) Are your teeth sensitive? 8) Do you have pain when you chew? 9) Do you see pus around your teeth and gums? 10)Do you have tartar formation-creamy, brown, hard masses

on your tooth surfaces?

Avoiding Caries and Periodontal DiseaseThe best defense against caries and periodontal disease isKeeping it from ever getting started.

Practice consistent and thorough homecare: This can be achieve by implementing the following: E.g.

Brushing Flossing Rinsing Eating properly

We brush, floss and rinse , in order to help remove the bacteria from the teeth. If it is not removed properly or in a timely manner it multiplies and in turn presents a threat to the underlining structures causing irreversible damage.

Avoiding Carries and Periodontal Disease cont’d Brush your teeth twice a day with an ADA-accepted fluoride

toothpaste. Replace your toothbrush every three or four months, or sooner if the bristles are frayed. A worn toothbrush won't do a good job of cleaning your teeth.

Clean between teeth daily with floss or an interdental cleaner. Decay–causing bacteria still linger between teeth where toothbrush bristles can’t reach. This helps remove plaque and food particles from between the teeth and under the gum line.

Eat a balanced diet and limit between-meal snacks. Visit your dentist regularly for professional cleanings and oral

exams. Antimicrobial mouth rinses and toothpastes reduce the bacterial

count and inhibit bacterial activity in dental plaque, which can cause gingivitis.

Fluoride mouth rinses help reduce and prevent tooth decay.

Proper Technique for Brushing

How do I brush my teeth? (Use a Soft to Medium Brush with an ADA recommended toothpaste)

Place your toothbrush at a 45-degree angle against the gums.

Move the brush back and forth gently in short (tooth-wide) strokes.

Brush the outer tooth surfaces, the inner tooth surfaces, and the chewing surfaces of the teeth.

Use the "toe" of the brush to clean the inside surfaces of the front teeth, using a gentle up-and-down stroke.

Brush your tongue to remove bacteria and freshen your breath

Patients should brush minimum 2x daily

Proper Technique for Flossing

How do I floss my teeth? Break off about 18 inches of floss and wind most of it

around one of your middle fingers. Wind the remaining floss around the same finger of the opposite hand. This finger will take up the floss as it becomes dirty. Hold the floss tightly between your thumbs and forefingers.

Guide the floss between your teeth using a gentle rubbing motion. Never snap the floss into the gums.

When the floss reaches the gum line, curve it into a C shape against one tooth. Gently slide it into the space between the gum and the tooth.

Hold the floss tightly against the tooth. Gently rub the side of the tooth, moving the floss away from the gum with up and down motions.

Repeat this method on the rest of your teeth.

Don't forget the back side of your last tooth.

Dental ProsthesesHow to care for Dentures? (Full and Partials) Remove your denture at night. All tissues deserve a rest. Keeping your dentures in full-time

can lead to inflamed gums and over growth of bacteria and fungi.

When they are not being worn, keep dentures submerged in fresh water. Denture material should not be allowed to dry out as the dentures may warp.

Never attempt to file or adjust your denture. Your dentist should make the adjustments for you.

If you notice a sudden change in the fit of your denture consult your dentist immediately.

Clean your denture daily with a commercially available denture cleaning product and a special denture brush. Always remember to rinse your dentures thoroughly after cleaning.

The use of a denture adhesive may provide an extra measure of comfort and confidence. Consult your dentist for a proper application.

Your denture and all oral tissues should be evaluated by your dentist on a regular basis. This will assure proper fit of dentures.

Importance of a Balanced Nutrition For people living with HIV, meals are a fundamental part of their

care plan. Oral pain or discomfort, however, can lead to problems with eating; both reducing intake of nutrients and impeding an important life activity. Collins 2007

Because of the increased burden placed on the metabolism of HIV-positive people, caloric intake needs to be higher. Collins

2007 What and when you eat affects the health of your teeth and risk

for tooth decay. Good nutrition also play a significant role on the body’s immune

system which in turn helps in maintaining healthy gums. Good Food habits are important in the development and control

of plaque.

Nutritional Consumption

Outcome/Results With proper homecare eg:

brushing, flossing, a balance nutrition and regular cleanings/visits to your Dentist/Dental Hygienist, patients should see a significant reduction in the accumulation of plaque, tartar and caries. This in turn will improve your oral health and ultimately produce a health smile.

Common Oral InfectionsTypes:

Fungal Infections:– Candidiasis – Angular Cheilitis

Viral Infections:– Cytomegalovirus– Herpes Simplex Type 1– Herpes Zoster Virus (Shingles)– Oral Warts– Oral hairy Leukoplakia

Bacterial Infections:- Neccrotizing Ulcerative Periodontitis and Necrotizing Ulcerative Gingivitis- Linear gingival erythema

Neoplasms:– Kaposi’s Sarcoma– Non-Hodgkins Lymphoma

Other Oral Manifestations

- Salivary gland disease- Apthous Ulcers

Oral Fungal Infections

Candidiasis: Pseudomembranous candidiasis (PC) is also known

as thrush. It appears as creamy white or yellowish patches on the tongue or inside the mouth that can be wiped off, leaving a red, raw, or bleeding surface.

Erythematous candidiasis (EC) presents as a red, flat lesion commonly found on the tongue or the hard or soft palate.

Angular (candidal) cheilitis appears as cracks or fissures radiating from the corners of the mouth.

Oral Viral Infections Oral warts caused by humanpapilloma virus may be

cauliflowerlike, spiky, or raised with a flat surface. Herpes simplex virus Type 1, a fairly common problem,

appears as blisters on the lips. Oral hairy leukoplakia (OHL) is caused by the Epstein-Barr

virus. Herpes zoster (shingles) is a reactivation of the

varicellazoster virus—the same virus that causes chicken pox. Cytomegalovirus (CMV) infection, an HIV-related

opportunistic infection, presents on rare occasions as a large, painful ulcer that may be on any part of the mouth.

Bacterial Oral Infections

Necrotizing ulcerative periodontitis (NUP) and necrotizing ulcerative gingivitis (NUG) are both periodontal diseases. 

Linear gingival erythema (LGE) presents as a red band where the gums and teeth meet and may be accompanied by occasional bleeding.

Neoplasms

Kaposi’s sarcoma (KS) is still the most common oral malignancy seen in connection with HIV infection.

Non-Hodgkin’s lymphoma occasionally presents as a large, ulcerated mass on the palate or gums.

Other Oral Manifestation

Salivary gland disease may occur at any time during the course of HIV disease and as a side effect of medications.

Apthous ulcers—commonly known as canker sores—are small, round ulcers that appear on the soft tissue in the mouth (e.g., the inside of the cheeks, the sides of the tongue, or the throat).