Oral Health

Background

Examination of the oral cavity should be included in both the initial and interim physical examination of all HIV-infected patients. Patients with lesions suspected to be oral manifestations of HIV disease should be referred to a dental health expert with experience in treating oral lesions associated with HIV/AIDS. Other oral lesions may be a sign of a systemic disease, a side effect of medications, or a result of poor oral hygiene.

The following is an overview of conditions commonly seen in patients with HIV infection. See chapters Oral Hairy Leukoplakia, Oral Warts, Oral Ulceration, and Necrotizing Ulcerative Periodontitis and Gingivitis for more information about those conditions.

Xerostomia (Dry Mouth)

S: Subjective

The chief complaint may be a dry, "sticky," or possibly a burning sensation in the mouth, or an inability to "taste" food. The patient may present with difficulty swallowing.

O: Objective

The oral mucosal tissues appear dry and sometimes "shiny" in appearance. The lips may be dry and cracked, and the tongue is dry. Dental decay may be present on the cervical portion of the teeth (near the gingival margin or "gumline"). Oral candidiasis (thrush) may or may not be present.

A: Assessment

The differential diagnosis for the cause of xerostomia includes medication side effects (e.g., from anticholinergics), systemic diseases (e.g., Sjögren syndrome), adverse effects of radiation therapy, and salivary gland diseases.

P: Plan

Identify the cause of xerostomia and modify, if possible. Treat with artificial saliva products or oral lubricant products (e.g., Salivart, Biotene Oral Balance Dry Mouth Relief Moisturizing Gel, or TheraSpray). Discourage sucking on hard candies with sugar that can promote caries (dental decay); encourage patients to use sugar-free gums and candies to help promote salivary function. Promote good oral hygiene with flossing and brushing with a fluoride toothpaste, and encourage regular (every 3-4 months) dental recall visits. Severe cases of xerostomia may be treated by prescribing cholinergic stimulants such as pilocarpine (Salagen).

Burning Mouth Syndrome; Atrophic Glossitis

S: Subjective

The patient may complain of a constant burning sensation in the mouth or a numbness or tingling feeling of the tongue. Eating certain foods or spices may trigger the burning sensation. The patient also may complain of dry mouth or a metallic taste in the mouth.

O: Objective

The tongue and oral mucosal tissues may be normal in appearance or there may be a slight redness on the tip and lateral margins of the tongue. In other cases, the tongue may appear "bald," owing to the loss of papillae on the dorsal surface, and it may be "beef red" in color.

A: Assessment

Possible systemic etiologies include nutritional and vitamin deficiencies (atrophic glossitis), chronic alcoholism, medication adverse effects, diabetes mellitus, and gastric reflux. Local etiologies include denture irritation, oral habits such as tongue or cheek biting, and excessive use of certain toothpastes or mouthwashes. Psychological factors and nerve damage also may cause burning mouth. Erythematous candidiasis also can present as a burning sensation.

P: Plan

Identify the cause of the burning sensation, if possible, by review of the medical history and by performing diagnostic tests as indicated (e.g., complete blood count, biopsy, or oral cytological smears). Once the underlying cause is identified, treatment may be as simple as changing a dentifrice or eliminating the identified irritant, or the condition may require systemic treatment.

Recurrent Aphthous Ulceration (RAU)

S: Subjective

The patient complains of a painful ulcer or ulcers in the mouth that recur.

O: Objective

The typical appearance of an aphthous ulcer is a "red raised border with a depressed, necrotic (white-to-yellow pseudomembrane) center." Aphthous ulcers tend to present on nonkeratinized or nonfixed tissues such as the buccal mucosa or posterior oropharynx and may be small or large, solitary or in clusters, and can resemble intraoral herpetic lesions (although herpetic lesions tend to present on keratinized tissues such as the roof of the mouth and gingival tissues).

A: Assessment

The differential diagnosis includes traumatic ulcers and herpes simplex virus ulcers.

P: Plan

The diagnosis usually is based on appearance. For further information, see chapter Oral Ulceration.

Recurrent Herpes Simplex

S: Subjective

The patient complains of a locally painful ulcer or ulcers on the lips or intraoral areas.

O: Objective

Herpes lesions are located on the lips, gingival tissues, or the hard palate. They may appear as small vesicular lesions that rupture, forming small ulcers. They may rupture and coalesce into larger lesions.

A: Assessment

The differential diagnosis includes aphthous ulcer and traumatic ulcer.

P: Plan

The diagnosis usually is based on appearance. For further information, see chapters Oral Ulceration and Herpes Simplex, Mucocutaneous.

Periodontal Disease

The medical evaluation of patients with HIV infection should include assessment of periodontal health. Whereas the same type of plaque-induced periodontal diseases can be seen in both immunocompetent and immunosuppressed individuals, periodontal disease in HIV-infected patients can be a marker of HIV disease progression. In the HIV-infected patient with periodontal disease, it is important to distinguish whether the periodontitis represents an aggressive or chronic presentation unique to those with HIV disease. In addition, it is important to determine whether the patient has an inflammatory oral disease process that may further compromise his or her health.

Various illnesses and systemic factors (e.g., diabetes mellitus, hormonal abnormalities, medications, and malnutrition) can complicate the clinical presentation of periodontal disease. If significant periodontal disease is suspected, refer to an experienced dentist for diagnosis and treatment. Gingivitis, a milder form of periodontal disease, usually is reversible with proper professional and home oral health care. For further information on necrotizing ulcerative periodontitis or necrotizing ulcerative gingivitis, see chapter Necrotizing Ulcerative Periodontitis and Gingivitis.

S: Subjective

The patient may complain of red, swollen, or painful gums, which may bleed spontaneously or with brushing; chronic bad breath or bad taste in the mouth; loose teeth or teeth that are separating; or a "bite" that feels abnormal.

O: Objective

Examine the gingival tissues. Periodontitis appears as localized or generalized gingival inflammation. The gingivae appear bright red or reddish-purple, ulcerated, or necrotic. Spontaneous gingival hemorrhage and purulent discharge may be evident around the teeth, especially if pressure is applied to the gingivae. Fetor oris may be present.

A: Assessment

The differential diagnosis includes gingivitis, periodontitis, trench mouth, and oral abscesses. Diagnosis usually is based on appearance. Patients with severe or recalcitrant disease should be referred to a dental care provider for definitive diagnosis and treatment.

P: Plan

Treatment may include:

• Warm saline rinses
• Daily brushing and flossing
• Antimicrobial mouth rinse (e.g., Listerine, chlorhexidine)
• Antibiotic therapy

For further information, see chapter Necrotizing Ulcerative Periodontitis and Gingivitis.

Dental Caries Caused by Methamphetamine and Cocaine Use

Dental decay seen in individuals who smoke methamphetamine or crack cocaine, or use cocaine orally, often is referred to as "meth mouth."

S: Subjective

The chief complaint may be pain in one or more teeth. However, if the condition is chronic, the patient may not complain of pain.

O: Objective

In meth mouth, the enamel on all teeth or multiple teeth is grayish-brown to black in color (owing to decay), and appears "soft" (this has been described as a "texture less like that of hard enamel and more like that of a piece of ripened fruit"). Oral mucosal tissues appear dry as a result of decreased salivary flow. The gingiva appears red or inflamed, and there may be spontaneous bleeding of the gingiva around the teeth.

Another pattern of dental decay can be seen in cocaine users who rub the drug along the gingiva in order to test its strength or purity. This can lead to localized dryness of the gingival tissues. Consequently, plaque sticks to the cervical portion of the teeth in the area where the cocaine is rubbed, resulting in dental caries along the cervical portion of the teeth.

A: Assessment

The differential diagnosis includes other causes of caries.

P: Plan

Refer to a dentist for appropriate care, which may involve restorative, endodontic therapy, periodontal care, and oral surgery. In severe cases, extraction of the involved teeth and replacement with a partial or complete denture may be necessary. Encourage proper oral hygiene; evaluate sucrose intake.

Oral Cancer

S: Subjective

Oral malignancies may be symptomatic or asymptomatic. Data suggest two distinct pathways for the development of oropharyngeal cancer: one driven predominantly by the carcinogenic effects of tobacco or alcohol (or both), the other by genomic instability induced by human papillomavirus.

The patient may complain of a mouth sore that fails to heal or that bleeds easily, or a persistent white or red (or mixed) patch. The patient may note a lump, thickening, or soreness in the mouth, throat, or tongue; difficulty chewing or swallowing food; difficulty moving the jaw or tongue; chronic hoarseness; numbness of the tongue or other areas of the mouth; or a swelling of the jaw, causing dentures to fit poorly or become uncomfortable.

O: Objective

Perform a thorough evaluation of the oropharynx, as well as lymph nodes in the head and neck. Suspicious lesions may occur on the lips, tongue, floor of the mouth, palate, gingiva, or oral mucosa, and may appear as an ulcer or a soft-tissue mass or masses that can be pink, reddish, purple, white, or mixed red and white. The lesion typically is indurated and may be painful. It may enlarge rapidly between examinations.

A: Assessment

The differential diagnosis includes oral squamous cell carcinoma, lymphoma, Kaposi sarcoma, traumatic ulcer, hyperplasia, and hyperkeratosis.

P: Plan

An ulcerated lesion or symptom described above that is present for 2 weeks or longer should be evaluated promptly by a dentist or physician. If cancer is suspected, a biopsy should be obtained to make a definitive diagnosis. Treatment will be based on the specific diagnosis.

Bruxism

S: Subjective

The patient may complain of chronic facial or jaw pain, sensitive teeth, earache, or waking up with a headache or facial pain. Often, the patient is not aware that he or she is clenching or grinding the teeth. Bruxism very often is a result of increased stress or anxiety, causing the patient consciously or unconsciously to clench or grind the teeth. However, some people may be "nighttime bruxers" and grind their teeth while sleeping, often loudly enough to wake others sleeping in the same room.

O: Objective

Perform a focused evaluation of the oropharynx, jaw, and facial muscles. The teeth may appear shortened, flattened, or worn down as a result of chronic grinding or clenching of the teeth. There may be hyperkeratotic lesions on the inside of cheeks as a result of chronic grinding or biting. There may be tenderness with palpation of facial muscles.

A: Assessment

The differential diagnosis includes other causes of facial or jaw pain, such as caries, dental abscesses, and trauma.

P: Plan

Refer the patient to a dentist for treatment. Treatment may include wearing a bite guard or psychological or behavioral management therapy.

Oral Piercing

S/O/A: Subjective/Objective/Assessment

Jewelry worn in piercings in the tongue, lips, or cheeks can chip or fracture the teeth. Chronic rubbing of jewelry against the gingiva can cause the gingiva to recede, leading to periodontal problems. (These complications occur apart from procedure- or technique-associated complications associated with body piercing, such as inflammation and infection, bleeding, and transmission of bloodborne pathogens.)

P: Plan

Refer the patient to a dentist for treatment. Recommend plastic tongue jewelry as opposed to metal to prevent fracture of teeth. Removal of the jewelry may be warranted.

Maxillary Tori; Mandibular Tori

S: Subjective

The patient may complain of a "lump" in the roof or floor of the mouth, or behind the lower front teeth.

O: Objective

Exostosis of normal bone (covered by oral mucosal tissue) can appear as a nodular or lobulated protuberance centrally located on the hard palate (maxillary tori) or unilaterally or bilaterally located behind the mandibular incisors (mandibular tori). This develops slowly and the patient may become aware of exophytic growth only if the area is inadvertently traumatized.

A: Assessment

Differential diagnosis includes other benign or malignant lesions, including oral cancer.

P: Plan

No treatment is indicated unless the exostosis interferes with speech or swallowing, or removal is needed for fabrication of dentures or a partial denture. Tori are a variation of normal anatomy.

References

• Cherry-Peppers G, Daniels CO, Meeks V, et al. Oral manifestations in the era of HAART. J Natl Med Assoc. 2003 Feb;95(2 Suppl 2):21S-32S.
• Davey M. Grisly effect of one drug: "meth mouth". New York Times. June 11, 2005.
• DePaola LG. The Importance of Oral Health in HIV Disease. NUMEDIX. 2003; 4(2):68-69.
• Ibsen O, Phelan J. Oral Pathology for the Dental Hygienist; 4th ed. Philadelphia: W.B. Saunders; 2004.
• Mayo Foundation for Medical Education and Research. Canker Sore (April 15, 2004); Cold Sore (April 28, 2004); Bad Breath (July 20, 2004); Bruxism/Teeth Grinding (May 19, 2005); Burning Mouth Syndrome (September 23, 2004); Trench Mouth (October 24, 2004); and Behind Your Smile: What's Your Mouth Made Of? (February 18, 2005). Available online at Mayo Clinic Website. Accessed June 21, 2012.
• National Institutes of Health, National Institute of Dental and Craniofacial Research. Dry Mouth. Bethesda, MD: National Oral Health Information Clearinghouse; June 1999. NIH Publication #99-3174.
• National Institutes of Health, National Institute of Dental and Craniofacial Research. TMD/TMJ: Temporomandibular Disorders. Bethesda, MD: National Oral Health Information Clearinghouse; May 2005. NIH Publication #94-3487.
• Newland JR, Meiller TF, Wynn R, et al. Oral Soft Tissue Diseases: A Reference Manual for Diagnosis and Management; 2nd ed. Hudson, OH: Lexi-Comp; 2002.
• Nittayananta W, ed. Oral Manifestations of HIV Infection: Current Update with Asian Focus. Bangkok; 2004.