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# Management of Dental Patients Who Are HIV-Positive

*Evidence Reports/Technology Assessments, No. 37*

Arthur J Bonito, PhD, Lauren L Palton, DDS, Daniel A Shugars, DDS, PhD, Kathleen N Lohr, PhD, Jessica P Nelson, BA, James D Bader, DDS, MPH, and Anne W Jackman, MSW.

Agency for Healthcare Research and Quality (US)2002 Mar

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## Structured Abstract

#### Objectives:

 With an estimated 900,000 persons with HIV/AIDS in the United States living                    longer, many are seeking to obtain routine dental care, as well as relief from                    the discomfort and disability associated with concomitant oral lesions. The                    questions addressed in this report on the management of HIV-positive dental                    patients include whether (1) invasive but common dental procedures present added                    risk of complications for patients with HIV/AIDS, (2) selected oral conditions                    are useful (A) markers of recent change in HIV serostatus or (B) indicators of                    immunosuppression, and (3) specific available antifungal drugs can (A)                    efficaciously prevent or (B) effectively treat oral candidiasis in HIV/AIDS                    patients.

#### Search Strategy:

 The researchers performed automated searches of MEDLINE and EMBASE to identify                    published research that contained evidence related to the questions. The MEDLINE                    searches were tailored to each of the questions and their subparts, but the                    EMBASE searches could not be so specific as to address the subparts separately.                    They did not probe for unpublished research, but did hand-search the most recent                    12 months of several relevant journals so as not to miss recently published                    materials. Keywords were used to limit the search to dental procedures, oral                    conditions, and research designs of interest.

#### Selection Criteria:

 Only research articles written in English on the human population with confirmed                    HIV/AIDS were included in the review. There were also specific inclusion                    criteria related to each of the questions. These included the specific dental                    procedures and complications (Question 1); specific oral conditions and their                    sensitivity, specificity, and positive and negative predictive values vis-?-vis                    recent seroconversion and severe immunosuppression (Questions 2A and 2B); and                    specific antifungals with a comparison or control group, confirmation of oral                    candidiasis, and reports for persons with HIV/AIDS alone (Questions 3A and                    3B).

#### Data Collection and Analysis:

 The researchers performed dual reviews of titles or abstracts on a total of                    1,308 articles to identify potentially useful articles to obtain, abstract, and                    include in evidence tables for the five questions combined. These were reduced                    to 139 articles. A single reviewer read each article identified and determined                    whether it met the inclusion criteria for a particular question. Excluded                    articles at this stage were independently reviewed to ensure that they did not                    warrant inclusion. Included articles were abstracted by single abstractors and                    then independently confirmed by one of the report authors when preparing the                    evidence tables and analyzing the results. This process reduced the total number                    of articles included in the five evidence tables to 34.

#### Main Results:

 On the question of whether persons with HIV/AIDS are at greater risk of                    complications from specific invasive dental procedures -- extractions,                    endodontics, orthognathic surgery, periodontal therapy, dental implants,                    prophylaxis, or root planing and scaling -- than similar patients without                    HIV/AIDS, the researchers found only four studies of extractions and one of                    endodontic treatment that met their criteria. For endodontic treatment as well                    as all of the remaining treatments except extractions, they judged the evidence                    to be insufficient, whereas for extractions they judged the evidence lacking in                    strength to be rated as more than poor.

With respect to the question of whether hairy leukoplakia, oral candidiasis,                    necrotizing ulcerative periodontitis, oral ulcers, or parotid swelling can serve                    as markers of recent seroconversion, the researchers concluded -- based on the                    lack of studies on any of the conditions that met their criteria, except for one                    dealing with oral candidiasis -- that the evidence is insufficient.

On the question of whether any of these conditions, linear gingival erythema, or                    Kaposi's sarcoma are useful as indicators of severe immunosuppression, there                    were more studies and stronger evidence regarding some of the conditions. With                    no studies of parotid swelling, and very few studies of necrotizing ulcerative                    periodontitis and linear gingival erythema, there was clearly insufficient                    evidence on their use as indicators. The evidence regarding the other conditions                    was rated as either fair or good -- in some cases for use as an indicator, in                    other cases against such use.

There was insufficient evidence for the prophylactic effectiveness against oral                    candidiasis of available antifungal agents except fluconazole. We judged the                    evidence to be good that fluconazole is effective in preventing new and                    recurrent episodes of oral candidiasis.

With respect to the treatment effectiveness of these same antifungal drugs, we                    judged that there was insufficient evidence regarding conclusions about the                    effectiveness of amphotericin B suspension as a treatment for oral candidiasis                    in persons with HIV/AIDS. The evidence for the other drugs as treatments for                    oral candidiasis was strong enough to be considered good. Although all were                    effective, fluconazole and itraconazole seemed to be more effective than the                    others.

#### Conclusions:

 The literature available to address the questions asked in this report about the                    management of HIV-positive dental patients is uneven. We cannot conclude, based                    on the literature found, that there is no greater risk of infection, delayed                    healing, or excessive bleeding for persons with HIV/AIDS having any of several                    invasive dental procedures. In fact, there were only multiple studies of                    extractions, and while they were suggestive that there is no difference,                    limitations in designs and analyses prevent drawing conclusive results even for                    extractions.

The evidence is insufficient to say whether any of a variety of oral conditions                    can be taken as markers of seroconversion; however, there is fair evidence that                    two conditions (oral candidiasis and Kaposi's sarcoma) may be reasonable                    clinical indicators of severe immunosuppression based on their positive                    predictive values, and that another (oral ulcers) is not. The evidence is good                    that hairy leukoplakia is not a reasonable indicator of severe                    immunosuppression, even in a clinical setting.

The evidence of effectiveness was best for questions involved with prevention or                    treatment of oral candidiasis in HIV-positive persons. The evidence of                    effectiveness as a preventive treatment was good for fluconazole and nystatin,                    but insufficient for other antifungals. There was also good evidence of                    treatment effectiveness against oral candidiasis for fluconazole, itraconazole,                    nystatin, ketoconazole, and clotrimazole.

## Contents

                          - Expand All
                          - Collapse All

                        - Preface
                        - Summary
                        - 1. Introduction                           - Primary Objectives and Scope of This Evidence Report
                          - Prevalence, Burden of Illness, and Variations in Practice in the United States
                          - Organization of the Report
                        - 2. Methodology                           - Overview
                          - Key Questions and Causal Pathways
                          - Literature Searches
                          - Search Terms
                          - Title, Abstract, and Article Review
                          - Data Abstraction
                          - Quality Rating of Articles
                        - 3. Results                           - Increased Risk Associated with Selected Routine Dental Procedures: Key Question 1
                          - Selected Oral Conditions as Markers of Recent HIV Seroconversion: Key Question 2A
                          - Selected Oral Conditions as Indicators of Severe Immunosuppression: Key Question 2B
                          - Efficacy of Antifungal Agents Used to Prevent Oral Candidiasis: Key Question 3A
                          - Effectiveness of Antifungal Agents Used to Treat Oral Candidiasis: Key Question 3B
                          - Results for Antifungal Treatment Effectiveness
                        - 4. Conclusions                           - Grading the Evidence
                          - Increased Risk Associated with Selected Routine Dental Procedures
                          - Selected Oral Conditions as Markers of Recent HIV Seroconversion
                          - Selected Oral Conditions as Indicators of Severe Immunosuppression
                          - Efficacy of Antifungal Agents Used to Prevent Oral Candidiasis
                          - Effectiveness of Antifungal Agents Used to Treat Oral Candidiasis
                        - 5. Recommendations for Future Research                           - Future Research Needs Regarding Complications from Dental Procedures
                          - Future Research Needs Regarding Oral Conditions as Markers of Recent HIV Seroconversion
                          - Future Research Needs Regarding Oral Conditions as Indicators of Severely Immunocompromised Status
                          - Future Research Needs Regarding Use of Antifungals for Oral Candidiasis Prevention
                          - Future Research Needs Regarding Use of Antifungals to Treat Oral Candidiasis
                        - 6. Evidence Tables                           - Glossary for Evidence Tables
                        - Appendixes                           - Appendix A. Acknowledgments
                          - Appendix B. Selection, Composition, and Role of the Technical Expert Advisory Group
                          - Appendix C. Selection, Names, and Tasks of Peer Reviewers
                          - Appendix D. Data Abstraction Forms
                          - Appendix E. Quality Rating Scales
                        - References
                        - Bibliography

                          - Expand All
                          - Collapse All

Prepared for: Agency for Healthcare Research and Quality, U.S. Department                of Health and Human Services.1                 Contract No. 290-97-0011, No.                    6. Prepared by: Research Triangle Institute-University of North Carolina.

#### Suggested citation:

Bonito AJ, Patton LL, Shugars DA, et al. Management                    of dental patients who are HIV-positive. Evidence Report/Technology Assessment                    No. 37 (Contract 290-97-0011 to the Research Triangle Institute-University of                    North Carolina at Chapel Hill Evidence-based Practice Center). AHRQ Publication                    No. 01-E042. Rockville (MD): Agency for Healthcare Research and Quality. March                    2002.

The authors of this report are responsible for its content. Statements in the report                should not be construed as endorsement by the Agency for Healthcare Research and                Quality or the U.S. Department of Health and Human Services of a particular drug,                device, test, treatment, or other clinical service.

                        - 1
                        - 
6000 Executive Boulevard, Suite 300, Rockville, MD 20852. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK33702

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