Oral Health Care for People Living with HIV Disease Overcoming Challenges and Barriers to Care

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Oral Health Care for People Living with HIV
Disease Overcoming Challenges and Barriers to
Care

• David A. Reznik, D.D.S.
• Chief of Dental Services
• Director, Oral Health Center
• Infectious Disease Program
• Grady Health System
• Atlanta, Georgia

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Oral Health Care

• Those who suffer the worst oral health include
  poor Americans . . . Members of racial and
  ethnic groups also experience a disproportionate
  level of oral health problems. And people with
  disabilities and complex health conditions are at
  greater risk for oral diseases that, in turn
  further complicate their health (U.S. Surgeon
  General David Satcher, May 25, 2000).

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The Basics

• Oral manifestations of HIV infection are a
  fundamental component of disease progression and
  occur in approximately 30 to 80 percent of the
  affected patient population.
• Factors, which predispose expression of oral
  lesions, include
• CD4 counts less than 200 cells/mm3
• Viral load greater than 3000 copies/mL
• xerostomia (dry mouth)
• poor oral hygiene
• smoking

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Diagnostic Significance of Oral Manifestations of
HIV/AIDS

• For those with unknown HIV status, oral
  manifestations may suggest possible HIV
  infection, although they are not diagnostic.
• For persons living with HIV disease not yet on
  therapy, the presence of certain oral
  manifestations may signal progression of disease.
• For persons living with HIV disease on
  antiretroviral therapy, the presence of certain
  oral manifestations may signal an increased viral
  load.

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Xerostomia

• Over 500 medications lead to symptoms of
  xerostomia
• Approximately 30 of people living with HIV/AIDS
  experience moderate to severe xerostomia.
• Effect of medications
• Proliferation of CD8 cells in the major salivary
  glands
• Changes in the quantity and quality of saliva
  lead to rapidly advancing dental decay and
  periodontal disease.

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Meth Mouth

• The key ingredients in meth-- lithium, muriatic
  and sulfuric acids, lye-- they are all corrosive.
  
• Xerostomia
• Bruxism
• Poor diet

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Meth Mouth damage within a one year period of
time
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Unmet need in Georgia

• Dental care is the most frequently reported
  service needed but not received in the latest
  Atlanta EMA HIV Consumer survey
• Individuals testing positive less than three
  years ago reported needing but not receiving
  dental care at significantly higher levels (46)
  when compared to those that had tested positive
  over 11 years ago (26).

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Oral Health Care Public Insurance

• In the vast majority of states, Medicaid dental
  benefits for adults are very limited and only
  cover emergency exams and limited oral surgery.
• Medicare does not have a dental benefit.
• As stated in the Surgeon Generals Report on Oral
  Health in America, public dental insurance
  programs are often inadequate. Lack of resources
  to pay for care, either out of pocket or through
  private or public dental insurance is clearly a
  barrier to care.

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Oral Health Care Ryan White CARE Act

• Oral health care services for uninsured or
  underinsured people living with HIV/AIDS can be
  funded through Title I, II, III, IV and Part F
• Part F
• Dental Reimbursement Program pays for
  uncompensated dental care services provided by
  Dental Education facilities
• Community Partnership Program links dental
  education facilities to communities with high
  unmet oral health needs.

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Reimbursement Issues

• Many local dentists are unaware that they can be
  reimbursed for services rendered!
• Charity work, etc

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Reimbursement issues

• Reimbursement rates for dental care services
  provided via the RWCA vary.
• Many grantees do not know what is fair and
  reasonable to pay for services.
• Several models, ranging from a set cost per
  visit, regardless of what services are rendered
  (Alameda County, CA, Title III) to payment of
  usual, customary and reasonable (UCR) fees
  (Michigan Title II),

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How to determine fair and reasonable rates

• American Dental Association Survey of Dental fees
• Based on region
• 2006 version available now
• 100 for ADA members 150 for non-members 300
  for businesses
• Phone number to order 1-800-621-8099

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Barriers to recruiting dentists

• Platinum age of dentistry
• New graduates burdened with debt from student
  loans
• Public health salaries no where near what
  dentists and dental hygienists can earn in the
  private sector

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Successful efforts Common Themes

• Medicaid adult dental services available
• Presence of a dental education facility willing
  to provide care
• AETC participation
• Champions
• Dental professionals associated with RWCA
• Non-dental professionals in HIV care
• Consumers

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