Oral Health Care

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A. Preventive Oral Health Care in the Primary Care Setting

Recommendations:

Primary care clinicians should educate patients about the importance of preventive oral health care, including dental visits; brushing, flossing, and rinsing; and the risk of developing oral cancer from use of tobacco and alcohol.

As part of the annual comprehensive physical examination, the clinician should examine the oral cavity visually and palpate the patient’s lips, labial and buccal mucosa, all surfaces of the tongue and palate, and the floor of the mouth. The gingiva should be examined for signs of erythema, ulceration, or recession.

When patients present with severe dental decay, clinicians should screen for behaviors and practices which contribute to a higher risk of dental caries, including but not limited to the following:

Drug use, especially crack cocaine and crystal meth
Prolonged methadone maintenance
Xerostomia (decreased salivary flow)
Untreated dental decay

1. Prevention of Dental Caries

HIV-infected patients may have a higher risk of dental caries due to decreased salivary flow, which may be a result of salivary gland disease or a side effect of ARV medications. Prevention and management of carious lesions in HIV-infected patients is the same as non-HIV-infected patients and should include diagnosis, caries risk assessment, and behavior modification to reduce caries activity.

Key Point:

Salivary gland disease and xerostomia may be associated with increased risk for dental caries.

2. Prevention of Gingival and Periodontal Disease

Common and atypical gingival and periodontal diseases have been reported in patients with HIV infection. Early recognition of these conditions may lead to timely treatment that can prevent progression of these diseases, including severe loss of attachment and bone loss.

3. Prevention of Oral Cancer

Tobacco and alcohol use substantially increase the risk of developing oral cancer. The most common symptom of oral cancer is a sore in the mouth that will not heal. Any sore or ulcer which does not resolve within a 2-week period should be considered suspicious, and the patient should be referred for definitive diagnosis. Other signs and symptoms of oral cancer include a sore throat, a lump in the cheek, and a red or white patch in the mouth.

4. Drug Use

Use of illicit drugs often causes severe dental decay, possibly as a result of bruxism, dry mouth, residual products found in methamphetamine, and decreased attention to dental hygiene. The presence of severe decay should prompt the clinician to ask questions regarding drug use, including crystal meth (the crystalline form of methamphetamine that is most often smoked) and cocaine, which can also cause gingival lesions, and nasal and palatal perforation. Refer to Screening and Ongoing Assessment for Substance Use for recommendations regarding substance use screening.

For more guidance on oral health care in the primary care setting, see Oral Health Complications in the HIV-Infected Patient, developed by the Medical Care Criteria Committee.

B. Referral to Oral Healthcare Providers

Recommendations:

Clinicians should ascertain whether their patients have a regular oral health provider and should refer all HIV-infected patients for annual hygiene and intraoral examinations, including dental caries and soft-tissue examinations.

Clinicians should promptly refer patients who present with oral mucosal, gingival, or dental lesions to an oral healthcare provider for appropriate diagnostic evaluation and treatment.

Primary care clinicians should be familiar with available oral health referral sources for patients in their care. They should discuss the importance of adhering to the oral healthcare provider’s recommendations, which may include using fluorides and antimicrobial rinses. In the later stages of HIV disease, oral lesions and aggressive periodontal breakdown are more likely; therefore, more frequent oral healthcare visits may be needed. Primary care clinicians should encourage patients to keep follow-up appointments with their oral healthcare providers.

REFERENCES

Brand HS, Gonggrijp S, Blanksma CJ. Cocaine and oral health. Br Dent J 2008;204:365-369. [PubMed]

Fischman S (ed). Emerging issues and future directions in remineralization: Proceedings of the Remineralization Symposium of 22-24 June 1999 in the Forsyth Dental Center, Boston, USA. J Clin Dent 1999;10:55-93.