Oral Health Training Manual: Why An Oral Health Initiative?


PLWHA experience a high incidence of common oral health problems (e.g., dental decay/cavities, gingivitis), as well as other oral health problems that are directly related to HIV infection. Between 32 and 46 percent of PLWHA will have at least one major HIV-related oral health problem (e.g., bacterial, viral, and fungal infection; oral cancer; or ulcer).7

“You don’t want a healthy neck-down body. You want a healthy top-of-the-head to the tip-of-the-toe body.”

— Dr. Howell Strauss, Executive Director of AIDS Care Group of Chester, PA, a SPNS Oral Health Initiative grantee

As with the general U.S. population, PLWHA are more likely to have an unmet need for oral health care than for medical care. According to various studies, 58 to 64 percent of PLWHA do not receive regular dental care.8

Poor oral health can make it difficult to chew or swallow and can impede food intake, appetite, and nutrition, leading to poor absorption of HIV medications and leaving PLWHA susceptible to progression of their disease. Poor oral health can also interfere with medication adherence. HIV medications have side effects such as xerostomia, commonly known as dry mouth or dry mouth syndrome, which further predispose PLWHA to dental decay, periodontal disease, and fungal infections.

Treatable conditions, such as gingivitis or early periodontitis, can become serious quickly in PLWHA when the immune system is weak. Bacterial infections (i.e., dental decay and periodontal disease) that begin in the mouth can escalate to systemic infections and harm the heart and other organs if not treated, particularly in PLWHA.

While poor oral health can impact physical health in a number of ways, its psychosocial impact is equally significant. Poor oral health in PLWHA can adversely affect quality of life, lower self-esteem, and limit career opportunities and social contact as result of facial appearance, malodor, or pain. Paul, a patient at Special Health Resources of Texas (SHRT), a SPNS Oral Health Initiative grantee, knows firsthand the psychosocial impact of poor oral health. “When you’ve got bad teeth,” he remarks, “you’re confined.”

In some cases, patients may even resort to self-medication to reduce their pain from oral disease, including the use of illicit drugs and highly addictive opiates. The use of such substances can lead to even greater psychosocial concerns.

Barriers to Care

Despite the evidence that oral health and systemic health are interconnected, particularly among individuals with chronic illnesses such as HIV, access to oral health care remains elusive for many individuals.9 Many of the same barriers to oral health care for PLWHA are the same barriers that prevent them from engaging in and staying in HIV medical care.

  • Financial concerns are the primary barrier to care. These barriers can include absence of dental insurance, insufficient insurance coverage, or the inability
    to pay out-of-pocket for care.10,11
  • Stigma is another barrier to care for PLWHA. This can include finding a dentist who understands the needs of PLWHA and concerns about confidentiality.
  • Lack of oral health professionals trained and willing to treat PLWHA is another barrier to care.
  • Patient fear of and discomfort with dentists remains a significant deterrent to dental care for PLWHA, as with the rest of the population.
  • Low health literacy and lack of education about the importance of oral health often prevents patients from seeking oral health care.
  • Lack of self-efficacy navigating the health care system can make the mere task of seeking oral health care an intimidating process.

The Ryan White HIV/AIDS Program’s Continued Commitment to Oral Health

Oral health programs are supported in all Parts (Parts A–D, F) of the Ryan White HIV/AIDS Program. Oral health care is one of multiple eligible services and is a legislative priority for funding under a group of “core” primary medical services for Parts A, B, and C.

In 2010 alone, nearly $80 million was spent on oral health within all Ryan White HIV/AIDS Program Parts, and more than 141,000 duplicated Ryan White clients received oral health care services. HRSA’s dental programs include the following:

HRSA Dental Reimbursement Program (DRP)

  • DRP funds institutions with accredited dental or dental hygiene education programs to help them defray the unreimbursed costs of providing oral health care to people with HIV: http://hab.hrsa.gov/abouthab/partfdental.html#2.
  • In 2011, 56 award recipients in 21 states and the District of Columbia trained over 11,700 dental students, postdoctoral dental residents, and dental hygiene students, providing oral health care services to over 37,100 HIV-positive patients. Over $9.6 million in grant monies were awarded.

HRSA Community-based Dental Partnerships Program (CBDPP)

  • CBDPP was first funded in FY 2002 to increase access to oral health care services for HIV-positive individuals while providing education and clinical training for dental care providers, especially those in community-based settings.
  • The program initiates multipartner collaborations between dental and dental hygiene education programs and community-based dentists and dental clinics. Community-based program partners and consumers help design programs and assess their impact: http://hab.hrsa.gov/abouthab/partfdental.html#3.
  • In 2011 alone, 12 grantees in 11 states received funding through CBDPP and they, in turn, trained 3,300 dental students, postdoctoral dental residents, and dental hygiene students in HIV oral health care. This resulted in the provision of oral health services to over 5,800 HIV-positive patients.
  • CBDPP’s success is reflected in the utilization of partnerships with dental schools as a means of expanding services and patient reach among several SPNS Oral Health Initiative grantees.

State Oral Health Workforce Program

This program is just one of a number of workforce grants focused on oral health delivery that are funded by HRSA’s Bureau of Health Professions. The State Oral Health Workforce Program is designed to help States address demonstrated oral health workforce needs. To learn more, visit: http://bhpr.hrsa.gov/grants/dentistry/sohw.html.

An Opportunity: Oral Health as a Gateway to Better HIV Care

Oral health professionals can help in early diagnosis of HIV infection and referral to care, as oral lesions can be the first overt clinical presentations of HIV infection. Early detection can improve prognosis and reduce transmission because infected PLWHA may not know their HIV status. Oral health professionals can also work with clients to engage them in regular HIV primary medical care and address issues such as nutrition. Dentists can control or eliminate a local infection to avoid adverse consequences such as systemic infections, eliminate pain and discomfort, and restore oral health functions.

In some cases, elimination of pain caused by alleviated periodontal disease can help patients reduce or eliminate their use of opiates or other substances used to mitigate the pain. “We had a number of clients using opiates for many years,” says Amanda McCluskey, client services program manager at HIV Alliance of Eugene, OR. “They came into the clinic to treat their oral pain and then went into drug treatment because they no longer needed to use the opiates to control the pain.” (To learn more about opiate addiction and buprenorphine treatment, see the IHIP materials on these topics.)