Characterizing Traditionally-defined Periodontal Disease in HIV+ Adults

Periodontal disease (PD) has been associated with human immunodeficiency virus type one (HIV-1) over the past several decades (1, 2). Initial descriptions of oral health in HIV+ patients focused on extreme forms of PD (3, 4), followed later by more conventional definitions (1, 5, 6), making the comparison of study results difficult. Without appropriate and consistent characterization of PD in at-risk populations, such as those with HIV-1 infection, the level and severity of traditionally-defined PD may be underestimated, which could lead to inadequate prevention and treatment as well as a diminished sense of concern regarding periodontal health. Persons with HIV-1 infection are especially vulnerable to comorbidities; their immune systems are compromised, and in the era of highly active antiretroviral therapy (HAART), some metabolic factors (i.e. lipids, glucose and insulin levels) are altered (7). Utilization of dental care services may be restricted due to real or perceived stigma, confidentiality concerns, or economic and social factors even if access to a dentist is available. Substance abuse, psycho-social stressors, depression and denial may result in the neglect of health promoting behaviors and lead to lapses in medication adherence, which can further limit immune reconstitution and the efficacy of remaining HIV treatment options. In sum, persons with HIV have an increased risk for adverse oral and general health outcomes. There have been inconsistent reports of the levels of PD in HIV+ persons (1, 2, 5, 6, 8–16), including both high (5, 16, 17), and low (8, 9, 13) levels of PD. There are a number of possible reasons for these inconsistencies. Different definitions were used to characterize PD (2) and methodologies used to collect clinical periodontal measurements also varied (e.g. partial mouth vs. full mouth probing and the number of sites probed per tooth). Many studies reporting low levels of periodontal disease have used partial mouth periodontal data collection methodologies (6, 8, 9, 13), but partial mouth analyses can underestimate the prevalence of PD (18). Further, the prevalence of periodontal disease may vary by patient characteristics in the cohort (1, 2). Such patient characteristics may include immune factors (importantly, the distribution of the cohort’s CD4+ T-cell counts) (5, 6, 16), metabolic factors (19), utilization of dental care services (20) and oral health behaviors (21). These patient characteristics are not always well described in the literature, nor are all of these characteristics routinely included in reports of PD in HIV+ cohorts. To provide a more comprehensive view of PD in the HAART era, we clearly characterized our HIV+ cohort according to select immune and metabolic markers, the presence of subgingival bacterial pathogens, dental care utilization and oral health behaviors. We examined the level of PD in our cohort using two consensus definitions of PD (18, 22), as well as by its two distinct clinical measures (periodontal probing depth and recession) and one summary measure (clinical attachment level), as has been suggested by authors investigating the perio-systemic connection (23).