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.
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.
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 They did not probe for unpublished research, but did hand-search the most recent 12 months of several relevant journals so as not to miss recently published materials.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.
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.
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.
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.