The advent of HAART (highly active antiretroviral therapy) has emerged as a boon for patients suffering from chronic HIV infection or type 1 HIV infection. Most HAART has 2-3 classes of antiretroviral drugs comprising protease inhibitors, nucleoside, or non-nucleoside analog reverse transcriptase inhibitors. However, when it comes to the use of the highest patient comforting and functional titanium implants for replacing edentulous areas in these individuals or even for normal surgical and prosthetic crown and bridging procedures, the dental surgeon ensures that there are no secondary complications or pre-existing infections before starting or consenting for dental treatment. Also, the viral load and serology parameters vary due to continuous drug therapy for HIV infection.
What Is the Pathophysiology of the Disease in HIV Patients?
HIV patients often refrain from providing necessary information pertaining to their medical history because it may be known or unknown whether their medical condition can affect the dental treatment. In order to help determine the patient's stage in HIV, the past CD4 count medications and medical reports are necessary to be obtained from the patient's health care provider or physician. The dental surgeon should learn about how the infection has affected the patient's life which will tend to establish an honest rapport and communication between the patient and the dentist.
HIV-infected individuals are at an increased risk of other chronic infections like hepatitis, tuberculosis, neurologic diseases, and also allergy can cause adverse drug reactions in individuals where the disease has progressed or advanced. When any of these associated infections exist, it may result in emergence of resistant strains that can further worsen the general prognosis of the patient when elective dental treatment is done, and it should be avoided in high-risk individuals.
The manner of HIV transmission also has implications for dental treatment, such as the need for antibiotic prophylaxis in patients with a history of intravenous drug usage, narcotic usage in substance abuse, and in certain coagulopathies. Specific oral complications, either due to ulceration, dry mouth or xerostomia, progressive periodontal disease, and candidiasis, are associated in these individuals.
Medical history should also be considered in the active HIV infections, including:
Human immunodeficiency virus (HIV) causes progressive immune system failure, weakening the body's defense against pathogens. HIV- positive patients become vulnerable to the development of opportunistic infections. HIV-associated oral lesions, such as oral candidiasis, hairy leukoplakia, HIV-associated gingivitis and periodontitis, Kaposi sarcoma, non-Hodgkin lymphoma, xerostomia, and destructive carious diseases, can be very common. Atypical periodontal necrotic ulceration and an increased incidence of herpetic infections have also been documented.
What Are the Exclusion Criteria for Dental Procedures?
These are the list of criteria that can hamper any dental treatment and hence should be strictly evaluated by the dentist and preferably be excluded from dental treatment as it can create unnecessary or unwanted systemic complications.
Severe immunodeficiency with a high recurrence of opportunistic infections.
Severe parafunction (bruxism).
Inadequate bone volume (division D based on the Misch classification).
Disorders for which surgical procedures were contraindicated.
Lack of collaboration.
Lack of oral hygiene
What Are the Complications Associated With Dental Implants?
The complications are especially severe when these individuals get a dental implant or prosthetic crowns or bridging done, leading to failure in the implant or prosthetic part.
1. Prosthesis Failure: A prosthesis had to be replaced due to implant failure.
Implant removal due to mobility.
Progressive marginal bone loss due to peri-implantitis.
Any mechanical complications that render the implant not usable (e.g., implant fracture).
Follow-up after six months of implant insertion, and followed by every year. The stability of each individual implant being assessed manually by tightening the abutment screws with the removed prostheses.
3. Biological and Prosthetic Complications: Most common in cases of peri-implantitis (defined as a progressive bone loss with the sign of infection around an osseointegrated implant) also noticed along with patient symptoms like the presence of pain, pus, paraesthesia in the mandible, and implant fracture. Immediately loaded implants using all-on-four treatment in immunocompromised but immunologically stable patients with good oral hygiene have been documented by implantologists. The need for implementation of strict follow-up protocols to prevent the onset and progression of peri-implant diseases in HIV-positive patients had significantly better results. Successful placements of immediate implants into fresh extraction sockets, that is, immediate placement, reduced total treatment time, allowing the preservation of alveolar bone levels during failed healing events.
What Are the Dental Management Strategies for HIV Patients?
The evaluation of an HIV-infected individual is crucial to the success of dental treatment and procedural planning. This depends on four major factors:
Hemostasis or cessation of bleeding.
Drug actions or intersections (depending on the patient's past and present drug history).
Pre-existing illnesses or infections.
Co-operation or patient complaints towards dental treatment.
Management strategies by the physician mainly include a step by step assessment of the patient considering the dates and the values for CD4 levels (to know the extent of immune system damage and the progress of the disease), plasma HIV RNA levels (to access the magnitude of viral replication and complete blood count including RBC, hematocrit, platelet count, total neutrophil, lymphocyte, granulocyte, and total white cell count).
Serological parameters (CD4 cell count, CD4 or CD8 ratio, and HIV RNA) need to be measured to identify any variations in patients' immune statuses and to verify patient compliance and response to antiretroviral treatment. This is because the viral load is changed or altered in response to certain medications in the immune system in HIV- positive patients. But it is not the same as in HIV-negative patients, and the primary stability is not impacted, and postoperative complications such as non-healing wounds or risk of infection occur in low percentages if there is an adequate level of CD4+ and there is no neutropenia. Similarly, the dental surgeon should obtain a list of all prescription medications taken currently, along with an INR assessment (for analyzing the coagulation status) so that the timing of dental procedures can be scheduled accordingly, especially during the administration of local anesthesia.
What Are Post-Surgical Instructions to Be Followed?
After surgery, mouth rinsing with a chlorhexidine digluconate containing solution (0.12 % or 0.2 %), twice per day for ten days, in addition to the recommended standard post-surgical medication, that is, 1 g Amoxicillin and Clavulanic acid two times per day for seven days after surgery, and non-steroidal anti-inflammatory drugs are taken post-surgery. All patients are usually instructed to avoid rough brushing and any trauma to the surgical site and recommended to follow a soft diet.
HIV candidates in the current times have become candidates for dental surgery and prosthetic treatment like crowns, bridges, and implants. However, the mandatory or elective procedures are done by considering the exclusion criteria to prevent oro-systemic complications in those patients and after careful systemic assessment by the physician and also considering the dental surgeon's consent and evaluation.
Frequently Asked Questions