Dentist Dr Trevor Morris talks with Lance Feeney about dry mouth and how to prevent it.
Dr Trevor Morris has established a reputation over a twenty four year period for high quality dental treatment and care among people with HIV. He practises from his Holdsworth House Dental Practice in Oxford Street Darlinghurst.
Recently we discussed the improvements in peoples’ oral health after the introduction of combination therapy. The bad old days of KS lesions, fungal infections and hairy Leucoplakia – to name just a few - have thankfully receded into history, but are there new environmental factors influencing our oral health in the time of effective anti-viral treatments and HIV?
Before and after combination anti-viral therapy
Combination therapy produced significant improvement in health for people with HIV. Opportunistic oral conditions abated as viral replication was controlled and immune function returned. Serious conditions such as Kaposi ’s sarcoma resolved spontaneously and fungal infections occurred less frequently, and with less severity. Between 1996 and 2000, many of the symptoms and signs associated with poor immune function began to disappear as the uptake of anti-HIV treatment increased. From around 2000 to 2005, people with HIV were presenting at dental surgeries in much the same way as those who were HIV negative.
Before ant-viral therapy as CD4 T cells crept below about 300, there was a predictable and increasing deterioration in people’s health. Oral conditions were often the first sign that all was not well. Hairy Leukoplakia and painful red fungal infections were most common.
In 2008 the situation is quite different. If you have a CD4 T-cell count of 300, it is likely you won’t be experiencing any of these symptoms. Management of HIV is much more sophisticated and while some of the numbers may be low, immune function is generally better protected and consequently more effective.
During the early 1990s big parties were in their hey-day and many party goers would go for days with little rest. In the weeks that followed it was not uncommon to see quite an increase in severe mouth infections - once again fungal and also ulcerative gingivitis. Unprotected and vulnerable immune systems were overwhelmed by exhaustion. It can still happen but we seemed to have learned few lessons along the way.
Saliva: the lubricant of the mouth
Our mouths are probably the part of our body that encounters the greatest attack to our immune systems and the important protection in the mouth comes from saliva. Generally, the more saliva one has the better. Saliva quality is also important. If it is particularly thick and slimy, then it doesn’t wet the surfaces of the mouth as well and acids as well as organisms are left undiluted.
HIV-positive people with lower T-cells - especially not taking anti-viral treatment - will often report some alteration to their saliva. They become more likely to report either dry or slimy feeling mouth. We are now able to test saliva quality and flow with simple test kits costing about $60. We can then be more scientific and work out whether we need to introduce mouth-washes or other aids to improve the performance of saliva.
If someone is having trouble eating because their mouth is very dry, then the simple solution is to drink while they are eating to wet the mouth and help digestion. There are also saliva replacement products. These tend to be quickly swallowed and are very helpful when saliva levels are very low and they help soothe the skin lining in the mouth. People however, need to be strongly motivated, because you have to keep using them throughout the day.
Many people are unaware of dry mouth – presumably because they are too busy, or not so body conscious. Where saliva levels are diminished we commonly see raised decay rates involving unusual tooth surfaces. The cost of repair soon adds up and our ability to maintain teeth once they are repaired is also diminished if the problem of dry mouth is not resolved.
You can also help control the negative effects of dry mouth by reducing your intake of sugar. Sugar is one of the principal contributing factors of decay especially where its consumption is frequent. Making changes here is dependent on the individuals’ motivation. It is not easy for some to change their diet but where sugar levels are reduced the results are always worthwhile.
The causes of dry mouth
Dry mouth can be caused by a range of factors; however there are some general trends that are worth noting.
It could be argued that we are living in a faster more stressful world with more constant pressures. Stress hormones tend to dry our mouths. Most of us are familiar with a dry mouth at times when we are nervous. That’s why a glass of water is always provided for public speakers. We all get stressed at times but for some of us being stressed has become the norm.
Then when we are busy we often forget to drink enough water. You might begin the day well hydrated but with business and distraction, forget to keep drinking water as the day progresses. Well hydrated in the morning dry in the afternoon! Saliva flow rates fall and ones breath may also deteriorate as bacteria proliferate.
We are also increasingly accessing prescription medications for a range of health conditions both HIV related and non-HIV related. A very large number of drugs list dry mouth as a potential side-effect. This can vary from person to person and it may or may not be significant. Certainly some anti-viral medications fall into this category. It is not a reason to stop taking them but we do need to modify our oral health care to compensate. If you are unsure ask your dentist.
Each year new products enter the market. Lifestyle drinks; new concoctions to help us through exercise or hopefully to energize us through a hard day or maybe during a long night. What we don’t know is that they often contain mild stimulants that dry our mouths, and to make matters worse, still are frequently both sweet and acidic. If you wanted to make the perfect food to breakdown teeth you couldn’t do much better. Moderation is one thing but some people report using these drinks every day.
Street drugs are also used in some parts of the gay community. Amphetamines are more popular than ever. Academically they are linked to the syndrome of “Meth Mouth”. Essentially they help us to push our bodies beyond normal limits. They cause dry mouth directly and many who use them are drawn to sugary or acidic drinks which exacerbate the saliva problem. Surface enamel is softened by the acid and then quickly worn away from clenching and grinding; another side effect of the drugs. Teeth age more quickly than ever. Now and then we see 20 year olds with teeth that look twice their age. Another scenario involves the older person who has gum recession leading to exposed soft root surfaces. Decay on root surfaces is harder to treat and more often leads to the loss of teeth.
Alcohol if we drink frequently also dries our mouth. If it is mixed with sugar the effect is once again compounded.
Cigarette smoking also dries the mouth with similar possible effects. More noteworthy smoking has a strong association with gum disease. A general guideline is that if you smoke more than ten cigarettes per day, and if you have any tendency to gum disease, it is likely to be accelerated many times. Nicotine reduces blood flow to our gums and thus the interface between our gums and the plaque that resides on our teeth is altered, making it harder to control the bacteria that make up plaque. Our body begins to lose the battle as the bone and gums that support our teeth breakdown leading to loose teeth. Three cigarettes a day should not cause any problem. Once you reach ten a day we begin to see rapid progression of untreated gum disease.
There is a clear relationship between oral health and self-esteem. People, who have problems with their teeth, lose social confidence. When people have poor self-esteem they are less likely to care about themselves. They tend to give up. They tend to neglect themselves. These factors then snowball, and make the situation worse.
Individuals may not be able to change all or some of the above circumstances, however it is no reason to take a head in the sand approach. The cost is too great. Instead, cooperation with an understanding dentist can make a world of difference. We are not there to judge you, but to help you experience better health for longer, whatever that may require.
Preventing dry mouth
We know that brushing your teeth every day with fluoride toothpaste makes a significant difference in controlling plaque and thus controlling decay and gum disease. If you brush your teeth twice a day, the incidence of decay is demonstrably further reduced. So we can say that brushing twice a day is a way of saving quite a lot of decay and expensive treatment. We have no doubt that if people are able to, flossing will further reduce disease in the mouth. Drinking adequate water throughout the day and avoiding excessive use of high acid, high sugar drinks and foods can also tip the scales in your own favor.
There are also products on the market – like mouthwashes, and mineralizing crèmes which can help. You need dialogue with a dental professional. We can work out what products are best for you in terms of cost and effectiveness. Each mouth is just a little different. Early intervention is far better than allowing problems to develop. We like to think that our professional experience can assist in this way.
Some of us are just lucky and some have to work harder to keep things under control. Feedback from a professional about what is happening and what you may need to do is invaluable. It is not uncommon to tell people that they don’t need some of the products they are using.
You won’t know if you don’t ask.
If you have HIV in 2008, the news is better than ten years ago. It’s not so much a battle with HIV as keeping yourself in a better state of health. There are two principal factors challenging your oral health. Here we have focused on dry mouth and how it has a strong association with lifestyle, medications; prescription and non-prescription drugs. The other factor is gum disease and that, for the majority of people, can be quite well managed with the help of a good dental team. Early intervention is best. It’s cheaper easier and the outcomes are better.
Lance Feeney is the Senior Project Officer – Systemic Advocacy – Positive Life NSW. For more information you can contact Lance:
Phone: (02) 9361 6011
Fax: (02) 9360 3504
Email: lancef@positivelife.org.au [6]
Website: www.positivelife.org.au [7]