*Ben, from Marrickville NSW, writes*: I’ve been HIV positive and on treatments for several years now. I’m doing well on my treatments (fingers crossed) but my problem is with my gums. When I brush my teeth my gums usually bleed and it doesn’t seem like any amount of gum hygiene makes any difference. Is this a side effect of my medications or are my bleeding gums caused by HIV or something else? I don’t want to lose my teeth — is there anything you can suggest that might help reduce this problem?
Dr Nick replies: Bleeding gums shouldn’t be caused by your antiretroviral medication. However, some other medications can cause a dry mouth which, in turn, can make gum problems worse.
Overall, people with HIV are more likely to have gum problems than the general population. For this reason, every positive person should have a good dentist and, ideally, have a regular visit to a dental hygienist, particularly if they have had gum problems.
The most common cause of bleeding gums is gingivitis. Good oral hygiene is an important part of preventing gingivitis and gum disease, however if you already have established gum problems it may not be enough on its own to bring you back.
Small pockets can form between your gums and your teeth and in these pockets plaque collects and inflammation begins. A dental hygienist can clean deeply into these pockets, ideally causing the gums to reattach to the tooth surfaces. Sometimes the assistance of a periodontist (a dental specialist in gum disease) is required.
A dental hygienist is a dental auxiliary who is trained in the management of gum disease and in oral health maintenance. Most of us are familiar with the “scrape and clean” that we get from the dentist. However, a hygienist is likely to be able to spend 40 minutes doing what a busy dentist only has five or 10 minutes in their schedule to do.
Good oral hygiene removes the plaque that would cause gingivitis from along the gum line. However, over time there is a build up of calcification or tartar (a bit like the stuff that forms in the bottom of a kettle), which prevents you from adequately removing all the plaque. Your hygienist scrapes this tartar off and your teeth feel smoother and cleaner.
With gum disease, pockets form down between the gum and the tooth. Plaque accumulates here too, and can’t be removed with a toothbrush. Tartar forms in these pockets and nasty levels of inflammation can ensue. Your hygienist or periodontist will look for these pockets and, if present, clean deeply inside them allowing them to heal up normally.
At the very worst, this inflammation then extends to the periodontal ligament, which is the layer of tissue which holds the tooth in your head. In 25 years time when you’ve finally beaten this bloody virus, you’ll be wanting lots of teeth to eat your breakfast with! So it’s important to act now to keep them firmly attached!
Hep C and HIV treatments?
*Martine, from Liverpool NSW, writes*: I was diagnosed with HIV in 2002 and so far haven’t been on any treatment. A couple of months ago I had a positive test for hepatitis C. My T-cells have fallen to 270 and now my doctor is recommending I start treatment for HIV, but I am worried that taking all those pills will worsen my hepatitis. Should I have treatment for hep C as well as, or instead of HIV treatment? And are there HIV drug combinations which will be easier on my liver?
Dr Nick replies: Starting HIV treatments will not necessarily worsen your hepatitis, but it’s something you and your doctor will want to watch fairly closely. You’ll want to plan carefully which medications to take, how to monitor your liver function tests (LFTs) as you start treatment and what to do if your LFTs go up.
There are some HIV medication combinations that are known to have a greater potential for causing liver problems. Although you might choose to avoid those medications altogether, close monitoring may allow you to take one of these medications. Nevirapine and ritonavir probably need the closest monitoring.
Someone starting HIV treatment for the first time has a very broad range of choices. It’s usually possible to select a combination with a low potential for liver problems.
Most hep C coinfected people’s LFTs will go up when they first start HIV treatment. This might be partly a direct drug effect, but it is also related to the stronger immune system better attacking the hep C virus and incidentally causing higher LFTs. This rise in LFTs is fairly short-lived in most people.
The decision to take hep C treatment is a different one from HIV. Just like HIV, not everyone with hep C needs treatment just yet. Unlike HIV treatment, Hep C treatment includes stimulation of your immune system to attack the hep C virus. The more healthy your immune system, the better it is likely to be at doing that. It may be, therefore, that hep C treatment might work better for you at some time in the future when your immune system has recovered it’s strength as a result of HIV treatments.
A hairy problem
*A reader writes*: I’ve been positive for 15 years and have never had to take antiviral drugs. My CD4 is 295 and viral load 3000. I saw the doctor recently who confirmed that I have a couple of small patches of hairy leukoplakia on my tongue. I’ve just moved house and job and perhaps the stress has taken its toll on my immune system even though I have to say I feel well. I’ve done a little research on the net and I was wondering if you could answer some questions about it. Is this caused by the Epstein-Barr Virus? Could I have recently picked up the EBV recently or would it have been there for a long time? What can I do to get rid of OHL? Is it simply a matter of getting my system strengthened again?
Dr Nick replies: Oral hairy leukoplakia (OHL) is a white thickening that occurs in patches along the side of the tongue. It is related to the Ebstein-Barr Virus (EBV) which most commonly causes glandular fever. Most of us are infected with EBV in our teens or early twenties and then carry the virus for life with no particular problems. There’s nothing we can do about it and it’s not possible to get rid of it.
OHL in HIV-positive people is a sign of low or borderline immunity. In the very early days the presence of OHL was used to predict an individual’s risk of progressing to AIDS, but CD4 and viral load are much more precise markers now.
If or when you start antiviral treatment, the OHL would almost certainly go away. Short of that, I’m not sure what you can do to get rid of it. It may be that were you to work to maximise your overall state of health it would improve, but I can’t know that for sure.
The antiviral drugs acyclovir and valacyclovir have some, but very limited, activity against EBV — although mostly they are active against herpes viruses, long term use of these drugs may offer some protection against a much more serious EBV-related lymphoma. There is no relation between OHL and lymphoma, however, so don’t worry that you might have it already.
OHL is of and in itself not a cause for concern. It doesn’t look very nice, but it’s not serious or dangerous. Its only relevance is as a marker of impaired immunity. However, we have much better markers of impaired immunity — namely the CD4 count.
