Addressing the oral health needs of people living with HIV/AIDS
People living with HIV/AIDS often experience an assortment of oral health ailments. In fact, the mouth can be the first place that symptoms from HIV infection appear.
So it's particularly important for HIV-positive people to keep on top of their dental checkups, and for dentists to be aware of the complications they can face. At Tufts University School of Dental Medicine (TUSDM), the curriculum now incorporates training at a Boston day program dedicated to improving quality of life for those living with HIV, as part of a unit focusing on care for vulnerable populations.
At the heart of the arrangement is the nonprofit Boston Living Center (BLC), which for more than 30 years has provided a wealth of services, and a welcoming space, for people living with HIV/AIDS, substance-use disorder, and other chronic conditions. Before the pandemic, volunteers from the dental school conducted oral health screenings at the Stanhope Street building and referred those in need of further care to the Tufts clinics. The arrival of COVID-19 necessitated a virtual substitute, with dental students providing online oral health education.
In September 2022, with in-person activity back on track, the dental school incorporated the BLC into its community service learning curriculum for third-year students. The students complete rotations—periodic on-site visits—at either BLC or facilities for veterans or the elderly.
"These are not patients who traditionally come to our school clinics on their own," says Karin Arsenault, D94, assistant professor of public health and community service, who supervises the students during these rotations. "These are individuals that we go out to, and let them know how important their oral health is."
About six to 10 BLC members will turn out for the voluntary screenings each time they are held. If after the checkup further treatment is recommended, those who don't have their own dentist are encouraged to book an appointment at the TUSDM comprehensive care clinic, where the same student who screened them will most likely become their provider.
"When the patients come in, they can be fearful coming to a dental school. It's nice for them to meet our dental students first where they're comfortable," says Kathryn Dolan, assistant professor in the public health and community service department.
In most cases, these patients haven't had dental care for a significant period of time—a situation that was only exacerbated by the pandemic—and their treatments can take several appointments to complete. "The dental students really get to know their patients and they build up a relationship," Dolan says. "The students begin to understand the difficulties that vulnerable people encounter in the health care system."
Some 1,300 people participate in a wide range of programs offered by the BLC. The majority live below or near the federal poverty level, and about a third are considered "precariously housed."
For people living with HIV/AIDS who don't have dental insurance or who are underinsured, the federal Ryan White HIV/AIDS Program provides money for oral health care, which can be a much-needed safety net for BLC members. But even with that financial support, only about 40% of those referred to the Tufts clinics follow through.
The reasons that many BLC members don't pursue dental care usually have nothing to do with their teeth, and everything to do with other barriers they face—the variables known as social determinants of health. "I would say that's where the difficulty lies," says Arsenault.
"Some of these people are homeless; they're food insecure; they're medically complex. They're dealing with substance use. They're dealing with anxiety and depression. Obviously dental is not at the forefront," Arsenault says. "I think it's been sort of an eye-opening experience for our students to realize that. I think that's been one of the most important aspects—learning that there are these social determinants."
And while the focus of the clinical training for DMD students is on comprehensive care, addressing the full gamut of oral health needs, many of the patients from BLC have a shorter-term perspective—fixing immediate problems that interfere with everyday functioning.
"They might be interested in just getting that tooth extracted, the one that's giving them so much pain that they can't sleep, or eat, or go to work; or they might want to replace that front tooth that's broken, because now they can't go on a job interview," Arsenault says.
People living with HIV/AIDS are susceptible to a long list of oral conditions. According to the National Institutes of Health, these can include chronic dry mouth and its consequences; inflammation of the gums, known as gingivitis; bone loss around the teeth, known as periodontitis; canker sores, warts, or blisters; oral candidiasis, a fungal infection known as thrush; and hairy leukoplakia, which causes a rough, white patch on the tongue. People with HIV/AIDS are also more likely to develop cavities.
"They're obviously much more susceptible to infections because they have a weakened immune system," Arsenault says. "They tend to have more oral disease than the average individual, or once we do extractions, maybe healing will take longer."
For patients who also have substance-use disorder, particular attention needs to be paid to the question of pain management. "You have to be very careful in terms of your selection of narcotics to be used, so we tend to completely avoid any opioid products and stay with the more traditional, like Tylenol and ibuprofen," Arsenault says.
"Some patients don't necessarily want to admit they're HIV positive or have AIDS, because of the stigma associated with that," Arsenault says. "And so we have to be very aware of how we talk to them and how we ask certain questions."
That's a key point, says Arika Neal-Branch, D24. Communication can often be a stumbling block for the students, even with patients who are open about their HIV status.
"I think most of it is not knowing how to navigate the conversations" between provider and patient, says Neal-Branch. "There could be a lot of timidness about bringing up any triggers for the patient, so the appointment may be short; or you may not ask pressing questions, but it may be information that you need to get a better understanding."
Neal-Branch was one of three TUSDM students who, as Tisch Summer Fellows in 2022, spent time at BLC. A total of nine dental students received the fellowships, sponsored by Tisch College of Civic Life, to strengthen the connections between the dental school and the outside agencies like BLC where students do their community service rotations.
An outgrowth of that summer project was the creation of the dental students' Community Centered Care Club, where students volunteer at the BLC and other partner sites, in addition to the screenings they do as part of their coursework. The club has also hosted an interprofessional event with students from Tufts School of Medicine.
Early in the HIV/AIDS epidemic, there was apprehension among some dentists and other medical practitioners about treating people who tested positive for HIV. Even dental schools and private practices that readily treated these patients would usually have separate operatories or special hours for them, Arsenault says.
The adoption of infection control practices known as universal precautions—measures designed to protect the health care team from exposure to blood or other bodily fluids—helped mitigate that, she says. "As soon as we had a better understanding how HIV could be transmitted, slowly some of the stigma associated with it started to go away, at least from the provider side."
"But at the center, it was so uplifting and positive," Neal-Branch says. "People were laughing and there was so much connection. That's what I appreciated the most."