Mouth Full of Problems: A Crisis in HIV Dental Care
AIDSmeds September 8, 2009

Too few people with HIV get the routine oral health care they need to stay healthy. The teetering economy, experts say, might make the situation a whole lot worse.

Not accessing dental care can be deadly. In early 2007, a 12-year-old boy named Deamonte Driver from suburban Washington, DC, died of an infection that had spread from an abscess in his mouth to his brain. His family’s Medicaid had lapsed because of a technicality, so he didn’t get care until his mother took the by then very ill boy into an emergency room. Experts say an $80 tooth extraction, if done early enough, could have saved his life.

Though Driver’s HIV-status was never reported, and there hasn’t been wide press coverage of a similar story involving an openly HIV-positive person, David Reznick, DDS, head of the HIV Dental Alliance in Atlanta, says that all the necessary ingredients to create such a tragedy are already in place—and could be getting worse.

People with HIV are simultaneously more likely than their HIV-negative counterparts to have more frequent and more serious oral health issues, while being less likely to have the funds and insurance to cover necessary procedures. The public support that is available for providing clinical oral health care to people with HIV, Reznick says, is drying up as various states confront catastrophic budget crises. “We’re just not seeing enough [funding] increases to take care of the people we already serve,” Reznick laments, “So it’s an overwhelming need and no resources to pay for it.”

Open Wide

People rarely think—at least until their face is horribly swollen and they’re immobilized with pain—that oral health care can have much of an impact on their overall well-being. According to Reznick, however, a neglected mouth can lead to more than localized tooth pain: Tooth and gum infections can spread to other parts of the body, and mouth pain can cause people to go without necessary nutrition—and even cause them to forgo their HIV medications.

“If you’re in an extraordinary amount of pain, you’re not going to be able to take your medications,” he explains. “If you don’t have any teeth to chew with, how are you going to get the nutrition you need to stay healthy?”

Reznick also has concerns about chronic inflammation from untreated periodontal disease. A growing number of studies are illuminating the role of inflammation in a variety of non-AIDS-related health problems such as cardiovascular disease. The link between gum and heart disease has been proposed in HIV-negative people, and some evidence suggests it to be true.

For all of these reasons, preventive dental care can have a tremendous influence on a person’s overall well-being.

Unfortunately, many people with HIV don’t know or understand the importance of regular preventive dental care. According to the Health Resources and Services Administration (HRSA), people with HIV who are uninsured are three times as likely to have untreated dental needs as people with HIV who have insurance. HRSA also states, “Moreover, oral infections, mouth ulcers and other severe dental conditions associated with HIV infections go untreated more than twice as often as other health problems related to the disease.”

Roadblocks to Care

Reznick says that HIV stigma and cultural habits against seeking dental care are two big reasons that people fail to go to the dentist regularly even when they have coverage or access to a dentist through public or private benefits. But even among people who want to go to a dentist as often as is recommended—at least once every six months for a thorough cleaning and checkup—lack of insurance or comprehensive public benefits can mean going without. Given the severe budget woes of most states right now, publicly funded dental care is not expanding sufficiently to meet the growing epidemic. In fact, in many areas it is shrinking.

In most cities and towns, the only options for people without dental insurance are oral care programs covered by the Ryan White CARE Act or Medicaid. Ryan White, however, has been essentially flat-funded for several years, and Medicaid dental coverage, already stingy in many states, is beginning to disappear. “Without the Ryan White dollars, there’s minimal access,” Reznick says. “With states that had adult benefits through Medicaid who have lost them, it’s caused a gigantic crunch.”

“We’re struggling to keep up with the need,” Reznick explains, “because people are living longer, and more people are getting tested and entering into the system of care. So we’re literally booked through until November, and I have eight dental chairs and over three full-time dentists and three hygienists, and we’re having a very difficult time meeting the need.”

Reznick hopes that policymakers and people living with HIV understand the consequences of too-little access to good oral health care. Aside from the pain and illness it will almost certainly cause, Reznick contends, it will also end up costing more money in the long run. He is hoping for increases, rather than additional cuts, to services. When people don’t get preventive care, Reznick says, “they end up in the emergency department, and that’s going to cost the public a whole lot more than if they would have kept the benefits in place.”