The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 8: Oral ProblemsCARIES■ Caries, or dental decay, is a common problem for everyone. Medical providers do not need tobe concerned with a few carious lesions (cavities). However, rampant decay in an HIV-positive26 picaspatient’s teeth frequently lead to pulpal infection, followed rapidly by abscess formation, whichis important to either prevent or treat promptly.Some antiretroviral medications (e.g., indinavir) can cause decreased salivary flow, which isknown to result in rampant caries; it is not uncommon for patients with decreased salivary flowto have multiple carious lesions. These lesions frequently are at the cervical area, the part of thetooth where the crown meets the roots. The tooth surface at this area is cementum, not enamel,and more likely to decay at a faster rate. Further, this can lead to an abscess formation whichcan be debilitating. A photo showing rampant decay in the cervical area can be seen in ColorPlate 8-1 at the end of this chapter.In cases of rampant decay, treatment should be expedited, which may mean that the dentistuses the technique called scoop and fill. As quickly as possible, and usually without anesthesia,the bulk of the decay is scooped out, using hand instruments, and then filled with a temporaryfilling or medium that contains fluoride, so that further decay is inhibited. The filling material ofchoice is glass ionomer. Once the teeth are temporized by the scoop and fill, the dentist canthen go back and restore each tooth in a traditional manner.Until the patient can be treated by a dentist, several steps can be taken by medical providers. Thefirst, and clearly most important, is to determine if there are any cavities that have extended intothe pulp, causing an infection. This is recognizable by swelling, and would be noticed by medicalproviders during a routine examination of the oral cavity. Infections should be treated with antibiotics,preferably penicillin. Treatment should be immediately implemented, and a referral to adentist should occur within days. The treatment for an abscess is the same for both HIV-positiveand HIV-negative patients.If there are no obvious infections, but decay is present, particularly if the decay is extensive, palliativecare consists of fluoride mouth rinses, which can be prescribed by the medical provider priorto referring the patient to a dentist. Referral should occur as soon as possible, but this is not anurgent problem.There are artificial saliva products that can be used with patients who have active decay, resultingin part from xerostomia (dry mouth) that can be caused by medications or even HIV infectionitself. However, the frequency with which these artificial saliva products have to be usedmay be unrealistic, and patients may prefer to use sugar-free lemon drops, which stimulatesaliva, another palliative treatment that is effective. Medical providers can suggest the use ofeither sugar-free lemon drops or over-the-counter saliva substitutes.VIIIORAL CANDIDIASIS■ Oral candidiasis is a relatively frequent problem for people who are HIV-positive. This conditionhas several different forms, the most common being pseudomembranous candidiasis. Candidiasis,which presents with small white patches any place in the mouth, can be mistaken for materia alba,or food particles. A photo showing pseudomembranous candidiasis is seen in Color Plate 8-2.Pseudomembranous candidiasis is generally white, and can easily be wiped off. There may be anerythematous area or bleeding under the white patch. The patient usually notices a change intaste, with food becoming undesirable. Further, there may be pain or a burning sensation associatedwith this lesion.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 169