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Oral health management of 97 patients living with HIV/AIDS in Ribeirão Preto, São Paulo, Brazil

Abstract

Considering the changes antiretroviral therapy (ART) has brought to the treatment of HIV infection, the current clinical and laboratory profiles of HIV/AIDS individuals referred to oral health centers are crucially important in instructing dentists about the oral health management of these patients. The aim of the present study was to determine the clinical and laboratory profiles of HIV-infected individuals referred to a clinic for patients with special needs between 2005 and 2012 by retrospectively analyzing their dental records. A total of 97 records of HIV patients referred to the School of Dentistry of Ribeirão Preto, Universidade de São Paulo - USP, were analyzed. The Mann-Whitney test was used to determine the associations between mean CD4+ counts, mean viral load, and the presence of HIV-related oral lesions (HIV-OL). Most of the patients were male, and their mean age was 38.3 years. Eighty-nine (92%) patients were on regular ART, 77 (79.4%) had a CD4+ count higher than 200 cells/mm3, and 63 (64.9%) had an undetectable viral load. Twenty patients (20.6%) presented with some HIV-OL, including pseudomembranous and/or erythematous candidiasis and angular cheilitis, which were correlated with a low CD4+ count and with an undetectable viral load (p < 0.05). Among the branches of dentistry, periodontics, followed by surgery and restorative dentistry, was the most sought-after specialty, and no intercurrent events were observed during the dental treatment. It may be concluded that there are no restrictions on the dental treatment of patients on regular ART, It is important, though, that the treatment be based on local characteristics and on the prevention of oral diseases.

HIV Infections; Dental Care; Mouth Mucosa


Introduction

The acquired immunodeficiency syndrome (AIDS) prevents the immune system from inhibiting the continuous replication of the human immunodeficiency virus (HIV), which, in turn, reduces cell-mediated immunity, thus predisposing to the development of opportunistic diseases.1Wilson E, Tanzosh T, Maldarelli F. HIV diagnosis and testing: what every healthcare professional can do (and why they should). Oral Dis. 2013 Jul;19(5):431-9.Although the global number of new HIV infections has declined by 19% over the past decade, the disease remains endemic and is still a major health public problem worldwide.2World Health Organization. Global health sector strategy on HIV/AIDS 2011-2015. Geneva: World Health Organization; 2011. In Brazil, it is estimated that 734,000 people were living with HIV until 2014, with 39.7 new cases registered annually in the last five years. In total, 278,306 people died of AIDS between 1980 and 2013.3Brasil. Boletim epidemiológico HIV/AIDS. Brasília (DF): Ministério da Saúde; 2014.

The combined use of antiretroviral drugs, since 1996, has resulted in a significant decrease in the incidence of opportunistic infections and in lower mortality rates, in addition to improving the quality of life of these patients.4Teixeira PR, Vitoria MA, Barcarolo J. Antiretroviral treatment in resource-poor settings: the Brazilian experience. AIDS. 2004 Jun;18 Suppl 3:S5-7. Notwithstanding, multidisciplinary approaches to HIV-infected patients are still needed, given their physical and social conditions.5Naidoo P. Barriers to HIV Care and Treatment by Doctors: A review of the literature. S Afr Fam Pract. 2006;48(2):5. HIV patients may present with HIV-related oral lesions (HIV-OL) and bone marrow abnormalities, both of them of importance to dental practitioners. The former may affect 80% of the patients diagnosed with AIDS6Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus. Bull World Health Organ. 2005 Sep;83(9):700-6. and are important markers of immunosuppression, whereas the latter include different degrees of dysplasia in one or more cell lines, which may be strongly associated with peripheral blood cytopenia, resulting in anemia, granulocytopenia, and thrombocytopenia.7Tripathi AK, Misra R, Kalra P, Gupta N, Ahmad R. Bone marrow abnormalities in HIV disease. J Assoc Physicians India. 2005 Aug;53:705-10.,8Spiga MG, Weidner DA, Trentesaux C, LeBoeuf RD, Sommadossi JP. Inhibition of beta-globin gene expression by 3’-azido-3’-deoxythymidine in human erythroid progenitor cells. Antiviral Res. 1999 Dec 31;44(3):167-77.,9Calenda V, Chermann JC. The effects of HIV on hematopoiesis. Eur J Haematol. 1992 Apr;48(4):181-6. These two groups of disorders usually cause uncertainty among dentists about the diagnosis of HIV-OL and also about the risk of infections and excessive bleeding after dental procedures.

Considering the changes in the management of HIV infection brought about by antiretroviral therapy (ART), and also the uncertainty surrounding the dental treatment of this group of patients, it is paramount that the current clinical and laboratory profiles of HIV-infected patients referred to oral health centers be provided, helping dentists with the oral health management of these patients and also contributing to reducing the stigma associated with the disease. Thus, the aim of the present study was to build up the clinical and laboratory profiles of HIV-infected individuals referred to a clinic for patients with special needs of the School of Dentistry of Ribeirão Preto, São Paulo, Brazil.

Methodology

Patients

Records of HIV individuals treated at the clinic for patients with special needs of the School of Dentistry of Ribeirão Preto, Universidade de São Paulo - USP, between 2005 and 2012, and also treated at the Special Unit for the Treatment of Infectious Diseases (Unidade Especial de Tratamento em Doenças Infecciosas - UETDI) of the Clinical Hospital, School of Medicine of Ribeirão Preto (Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo– HC-FMRP-USP), University of São Paulo, were included in the study. The study protocol was approved by the Research Ethics Committee of the School of Dentistry of Ribeirão Preto (CAAE: 0088.0.138.000-10), and all patients signed a written informed consent form in accordance with the Declaration of Helsinki.

Methods

Information about age, sex, diagnosis of HIV infection, CD4+ count, viral load, opportunistic infections, coinfections, noninfectious comorbidities, ART, presence of HIV-OL, and type of dental treatment required was investigated. All patients should be 18 years or older and have recent CD4+ and viral load results. Both CD4+ count and viral load were checked immediately before starting the dental treatment, and four months later if the duration of dental treatment was longer than four months. The oral cavity was evaluated in different time periods based on the number of dental appointments required for the whole dental treatment. Regarding ART, the patients whose treatment compliance was confirmed by the analysis of their records were considered to be on regular ART, and those without treatment compliance were considered to be on irregular use of ART. A complete blood count was obtained from those patients who required oral surgical procedures.

Statistical analysis

The Mann-Whitney test was used to estimate the significance in the difference between mean CD4+ count and median viral load, and their associations with the presence of HIV-OL. Statistical significance was assumed when p < 0.05. All statistical analyses were performed using the GraphPad Software Inc (San Diego, California, USA).

Results

Patients’ characteristics

Records of 97 HIV patients were included in this study, and their clinical and laboratory profiles are described in Table 1. HIV infection was diagnosed by ELISA and confirmed by the Western blot technique in all patients, and HIV-OL were identified according to the Classification and Diagnostic Criteria for Oral Lesions in HIV Infection.1010 Classification and diagnostic criteria for oral lesions in HIV infection. EC-clearinghouse on oral problems related to HIV infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. J Oral Pathol Med. 1993 Aug;22(7):289-91. The mean age of HIV patients was 38.3 ± 10.46 with a range of 6 to 61 years, and there was a predominance of male individuals (67/97; 69.1%). Most of the patients had a CD4+ count higher than 200 cells/mm3 (77/79.4%) and an undetectable viral load (63/64.9%). The most frequent opportunistic infections were cerebral toxoplasmosis and pneumonia, while hepatitis C (10/10.3%) and tuberculosis (9/9.2%) were the most frequent coinfections. Some patients presented with noninfectious comorbidities, including diabetes mellitus, hypertension, and hyperlipidemia. Eighty-nine patients (92%) were on regular ART and had been treated for an average of two years and four months (range: three months to 12 years). Only eight patients (8%) did not use ART regularly.

Table 1
Clinical profile of HIV-infected patients referred to the clinic for patients with special needs of the School of Dentistry of Ribeirão Preto, USP, from 2005 to 2012.

Twenty patients (20.6%) presented with some HIV-OL, including pseudomembranous and/or erythematous candidiasis (Figure 1a), and angular cheilitis (Figure 1b). Seventeen patients (17.5%) had only one HIV-OL, two patients (2.06%) presented with two different HIV-OL, and only one patient (1.03%) presented with three HIV-OL simultaneously. Only HIV-related oral fungal infections were considered. Those related to a removable prosthesis were excluded. The types and frequency of HIV-OL found in this study are described inTable 2. In general, the presence of HIV-OL was correlated with a low CD4+ count and with an undetectable viral load (Figures 2a and 2b). The 20 patients with HIV-OL had a mean CD4+ count of 277 cells/mm3, compared to 506 cells/mm3 in the 73 patients without HIV-OL. Conversely the CD4+count, patients who presented with any HIV-OL had a mean viral load of 62 copies/mL and patients who did not present HIV-OL had a mean viral load lower than 50 copies/mL.

Figure 1
(A) Clinical manifestation of pseudomembranous candidiasis in an HIV patient; (B) Clinical manifestation of angular cheilitis in an HIV patient.

Table 2
Prevalence of HIV-OL diagnosed during oral examination.

Figure 2
(A) Distribution of CD4+ count based on the presence or not of HIV-OL in 97 patients living with HIV/AIDS in Ribeirão Preto, Brazil, referred to the clinic for patients with special needs of the School of Dentistry of Ribeirão Preto, USP, from 2005 to 2012; (B) Distribution of viral load based on the presence or not of HIV-OL in 97 patients living with HIV/AIDS in Ribeirão Preto, Brazil, referred to the clinic for patients with special needs of the School of Dentistry of Ribeirão Preto, USP, from 2005 to 2012.

Among the branches of dentistry, periodontics, followed by surgery and restorative dentistry, was the most sought-after specialty (Table 3). In general, the complete dental treatment required between one and 18 weeks (mean of 10 weeks), depending on the patient’s needs. Only three patients required more than four months for prosthetic rehabilitation. A complete blood count was obtained from patients (n = 42) who required oral surgical procedures. No patient had a neutrophil count of less than 500 cells/mL and a platelet count of less than 50,000 cells/mm3. There was no intercurrent event during the dental treatment of these patients; no prophylactic antibiotic was necessary; and there was no hemorrhagic episode associated with invasive procedures.

Table 3
Prevalence of dental specialties among HIV-infected patients.

Discussion

This study analyzed the clinical and laboratory profiles (CD4+count and viral load) of HIV patients referred to a specialized oral health center. Most of the HIV-infected patients in this study were male (67/69%) and the male to female ratio was 2.23:1. Male predominance was demonstrated by previous studies conducted in Brazil and also in other countries, such as Mexico, India, and Nigeria.1111 Kumar S, Mishra P, Warhekar S, Airen B, Jain D, Godha S. Oral health status and oromucosal lesions in patients living with HIV/AIDS in India: a comparative study. AIDS Res Treat. 2014;2014:480247. doi: 10.1155/2014/480247.,1212 Bakhshaee M, Sarvghad MR, Khazaeni K, Movahed R, Hoseinpour AM. HIV: an epidemiologic study on head and neck involvement in 50 patients. Iran J Otorhinolaryngol. 2014 Apr;26(75):97-104.,1313 Deshpande JD, Giri PA, Phalke DB. Clinico-epidemiological profile of HIV patients attending ART centre in rural Western Maharashtra, India. South East Asia J Public Health. 2012 Jul-Dec;2(2):16-21.,1414 Ramirez-Amador V, Anaya-Saavedra G, Calva JJ, Clemades-Pérez-de-Corcho T, López-Martínez C, González-Ramírez I, et al. HIV-related oral lesions, demographic factors, clinical staging and anti-retroviral use. Arch Med Res. 2006 Jul;37(5):646-54. The mean age of our patients was 38.3 ± 10.46. This finding is also consistent with several studies that reported a high number of patients with a mean age between the third and fourth decades of life.1111 Kumar S, Mishra P, Warhekar S, Airen B, Jain D, Godha S. Oral health status and oromucosal lesions in patients living with HIV/AIDS in India: a comparative study. AIDS Res Treat. 2014;2014:480247. doi: 10.1155/2014/480247.,1212 Bakhshaee M, Sarvghad MR, Khazaeni K, Movahed R, Hoseinpour AM. HIV: an epidemiologic study on head and neck involvement in 50 patients. Iran J Otorhinolaryngol. 2014 Apr;26(75):97-104.,1313 Deshpande JD, Giri PA, Phalke DB. Clinico-epidemiological profile of HIV patients attending ART centre in rural Western Maharashtra, India. South East Asia J Public Health. 2012 Jul-Dec;2(2):16-21.,1414 Ramirez-Amador V, Anaya-Saavedra G, Calva JJ, Clemades-Pérez-de-Corcho T, López-Martínez C, González-Ramírez I, et al. HIV-related oral lesions, demographic factors, clinical staging and anti-retroviral use. Arch Med Res. 2006 Jul;37(5):646-54.,1515 Adedigba MA, Ogunbodede EO, Jeboda SO, Naidoo S. Patterns of oral manifestation of HIV/AIDS among 225 Nigerian patients. Oral Dis. 2008 May;14(4):341-6. The male predominance and age range observed in the present study might be due to the profile of this sexually and economically active population.

Candidiasis is the most common opportunistic infection among HIV-infected patients.1616 Ranganathan K, Hemalatha R. Oral lesions in HIV infection in developing countries: an overview. Adv Dent Res. 2006 Apr 1;19(1):63-8. In the present study, there was a high prevalence of erythematous and pseudomembranous candidiasis among HIV-OL. As it would be difficult to rule out any systemic influence on fungal lesions, those cases of candidiasis that healed after adherence to hygiene recommendations and after the placement of new removable prostheses were regarded as denture stomatitis rather than as HIV-OL. Our data are consistent with previous studies that demonstrate candidiasis is the most common HIV-OL.1111 Kumar S, Mishra P, Warhekar S, Airen B, Jain D, Godha S. Oral health status and oromucosal lesions in patients living with HIV/AIDS in India: a comparative study. AIDS Res Treat. 2014;2014:480247. doi: 10.1155/2014/480247.,1414 Ramirez-Amador V, Anaya-Saavedra G, Calva JJ, Clemades-Pérez-de-Corcho T, López-Martínez C, González-Ramírez I, et al. HIV-related oral lesions, demographic factors, clinical staging and anti-retroviral use. Arch Med Res. 2006 Jul;37(5):646-54. Two interesting Nigerian studies1515 Adedigba MA, Ogunbodede EO, Jeboda SO, Naidoo S. Patterns of oral manifestation of HIV/AIDS among 225 Nigerian patients. Oral Dis. 2008 May;14(4):341-6.,1717 Anteyi KO, Thacher TD, Yohanna S, Idoko JI. Oral manifestations of HIV-AIDS in Nigerian patients. Int J STD AIDS. 2003 Jun;14(6):395-8. observed pseudomembranous candidiasis as the most frequent HIV-OL, followed by cheilitis and erythematous candidiasis. In a previous study, pseudomembranous candidiasis was detected in 10.8% of participants, angular cheilitis in 13.9%, oral hairy leukoplakia in 11.8%, and erythematous candidiasis in 6.9%.1818 Lourenco AG, Figueiredo LT. Oral lesions in HIV infected individuals from Ribeirao Preto, Brazil. Med Oral Patol Oral Cir Bucal. 2008 May;13(5):E281-6.

CD4+ count, along with the presence of opportunistic infections, remains one of most reliable parameters for the clinical staging of patients and for the decision of when to initiate treatment.1919 Lourenco AG, Motta AC, Figueiredo LT, Machado AA, Komesu MC. Oral lesions associated with HIV infection before and during the antiretroviral therapy era in Ribeirao Preto, Brazil. J Oral Sci. 2011 Sep;53(3):379-85. In the present study, the prevalence of HIV-OL was strongly associated (p = 0.007) with low CD4+ levels (usually less than 200 cells/mm3). Similarly to our results, Adurogbangba et al.2020 Adurogbangba MI, Aderinokun GA, Odaibo GN, Olaleye OD, Lawoyin TO. Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult population in Oyo State, Nigeria. Oral Dis. 2004 Nov;10(6):319-26. reported a strong association between HIV-OL and low CD4+ counts, mainly when the latter were below 500 cells/mm3. As with CD4+ counts, viral load is also related to oral manifestations. Participants of the current study with a high viral load showed a higher frequency of HIV-OL, regardless of their CD4+ count (p = 0.03). Bravo et al.,2121 Bravo IM, Correnti M, Escalona L, Perrone M, Brito A, Tovar V, et al. Prevalence of oral lesions in HIV patients related to CD4 cell count and viral load in a Venezuelan population. Med Oral Patol Oral Cir Bucal. 2006 Jan 1;11(1):E33-9. in Venezuela, also observed a strong association between the prevalence of oral lesions and HIV viral load, regardless of the CD4+ count. Although the CD4+ count has been considered a better indicator of disease progression, a high viral load may be strongly associated with HIV-OL, regardless of the cell-mediated immunity, as demonstrated in our study.

Asymptomatic HIV patients can be treated as any other dental patient, as shown with the 97 patients of this study. Nowadays, few patients need to have their treatment plan modified, since ART keeps the immune system generally stable.2222 Patton LL. Hematologic abnormalities among HIV-infected patients: associations of significance for dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Nov;88(5):561-7. However, no consensus exists over the indications of antibiotics in conjunction with dental procedures, especially those that cause bleeding. There is no scientific evidence that supports the need of antibiotic prophylaxis to prevent bacteremia and/or oral complications after dental procedures in HIV patients.2323 Glick M, Abel SN, Muzyka BC, DeLorenzo M. Dental complications after treating patients with AIDS. J Am Dent Assoc. 1994 Mar;125(3):296-301.,2424 Patton LL, Shugars DA, Bonito AJ. A systematic review of complication risks for HIV-positive patients undergoing invasive dental procedures. J Am Dent Assoc. 2002 Feb;133(2):195-203.,2525 Shirlaw PJ, Chikte U, MacPhail L, Schmidt-Westhausen A, Croser D, Reichart P. Oral and dental care and treatment protocols for the management of HIV-infected patients. Oral Dis. 2002;8 Suppl 2:136-43. Some authors, however, recommend antibiotic prophylaxis before invasive dental procedures (dental surgery or periodontal treatment) in patients with a CD4+ count lower than 200 cells/mm3 associated with a neutrophil count of less than 500 cells/mL.2626 Reznik DA, Bednarsh H. HIV and the Dental Team. The role of the dental professional in managing patients with HIV/AIDS. Dimensions of Dental Hygiene 2006;4(6):14-16. As no patients presented any of the problems mentioned above, owing possibly to the fact that 92% were on ART, we did not treat them with antibiotic prophylaxis.

Although rare, HIV patients may present with immune thrombocytopenia as a complication of HIV infection; however, only severe thrombocytopenia (less than 50,000 cells/mm3) leads to excessive bleeding during invasive dental procedures.2222 Patton LL. Hematologic abnormalities among HIV-infected patients: associations of significance for dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Nov;88(5):561-7.,2525 Shirlaw PJ, Chikte U, MacPhail L, Schmidt-Westhausen A, Croser D, Reichart P. Oral and dental care and treatment protocols for the management of HIV-infected patients. Oral Dis. 2002;8 Suppl 2:136-43. Among the participants of the present study, none had a platelet count of less than 50,000 cells/mm3, and no excessive bleeding was verified in those patients submitted to periodontal treatment and/or oral surgery.

Conclusion

No intercurrent events related to dental treatment were observed in this study, and few patients presented with HIV-OL. Despite the risks of HIV-OL and of oral complications after dental procedures discussed in this paper, there are no restrictions on the dental treatment of stable patients on regular ART. It is important, though, that the treatment be based on local characteristics and on the prevention of oral diseases. The presence of HIV-OL was directly associated with a low CD4+ count and with a high viral load, confirming the efficacy of these parameters as markers of immunosuppression.

Acknowledgments

The authors are grateful to Ms. Benedita Viana Rodrigues for her assistance with the records. Dr. Danieli Cristina da Silva thanks the Fundação de Amparo à Pesquisa do Estado de São Paulo – FAPESP (Protocol #: 2010/18246-8) for the financial support (fellowship).

References

  • 1
    Wilson E, Tanzosh T, Maldarelli F. HIV diagnosis and testing: what every healthcare professional can do (and why they should). Oral Dis. 2013 Jul;19(5):431-9.
  • 2
    World Health Organization. Global health sector strategy on HIV/AIDS 2011-2015. Geneva: World Health Organization; 2011.
  • 3
    Brasil. Boletim epidemiológico HIV/AIDS. Brasília (DF): Ministério da Saúde; 2014.
  • 4
    Teixeira PR, Vitoria MA, Barcarolo J. Antiretroviral treatment in resource-poor settings: the Brazilian experience. AIDS. 2004 Jun;18 Suppl 3:S5-7.
  • 5
    Naidoo P. Barriers to HIV Care and Treatment by Doctors: A review of the literature. S Afr Fam Pract. 2006;48(2):5.
  • 6
    Coogan MM, Greenspan J, Challacombe SJ. Oral lesions in infection with human immunodeficiency virus. Bull World Health Organ. 2005 Sep;83(9):700-6.
  • 7
    Tripathi AK, Misra R, Kalra P, Gupta N, Ahmad R. Bone marrow abnormalities in HIV disease. J Assoc Physicians India. 2005 Aug;53:705-10.
  • 8
    Spiga MG, Weidner DA, Trentesaux C, LeBoeuf RD, Sommadossi JP. Inhibition of beta-globin gene expression by 3’-azido-3’-deoxythymidine in human erythroid progenitor cells. Antiviral Res. 1999 Dec 31;44(3):167-77.
  • 9
    Calenda V, Chermann JC. The effects of HIV on hematopoiesis. Eur J Haematol. 1992 Apr;48(4):181-6.
  • 10
    Classification and diagnostic criteria for oral lesions in HIV infection. EC-clearinghouse on oral problems related to HIV infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. J Oral Pathol Med. 1993 Aug;22(7):289-91.
  • 11
    Kumar S, Mishra P, Warhekar S, Airen B, Jain D, Godha S. Oral health status and oromucosal lesions in patients living with HIV/AIDS in India: a comparative study. AIDS Res Treat. 2014;2014:480247. doi: 10.1155/2014/480247.
  • 12
    Bakhshaee M, Sarvghad MR, Khazaeni K, Movahed R, Hoseinpour AM. HIV: an epidemiologic study on head and neck involvement in 50 patients. Iran J Otorhinolaryngol. 2014 Apr;26(75):97-104.
  • 13
    Deshpande JD, Giri PA, Phalke DB. Clinico-epidemiological profile of HIV patients attending ART centre in rural Western Maharashtra, India. South East Asia J Public Health. 2012 Jul-Dec;2(2):16-21.
  • 14
    Ramirez-Amador V, Anaya-Saavedra G, Calva JJ, Clemades-Pérez-de-Corcho T, López-Martínez C, González-Ramírez I, et al. HIV-related oral lesions, demographic factors, clinical staging and anti-retroviral use. Arch Med Res. 2006 Jul;37(5):646-54.
  • 15
    Adedigba MA, Ogunbodede EO, Jeboda SO, Naidoo S. Patterns of oral manifestation of HIV/AIDS among 225 Nigerian patients. Oral Dis. 2008 May;14(4):341-6.
  • 16
    Ranganathan K, Hemalatha R. Oral lesions in HIV infection in developing countries: an overview. Adv Dent Res. 2006 Apr 1;19(1):63-8.
  • 17
    Anteyi KO, Thacher TD, Yohanna S, Idoko JI. Oral manifestations of HIV-AIDS in Nigerian patients. Int J STD AIDS. 2003 Jun;14(6):395-8.
  • 18
    Lourenco AG, Figueiredo LT. Oral lesions in HIV infected individuals from Ribeirao Preto, Brazil. Med Oral Patol Oral Cir Bucal. 2008 May;13(5):E281-6.
  • 19
    Lourenco AG, Motta AC, Figueiredo LT, Machado AA, Komesu MC. Oral lesions associated with HIV infection before and during the antiretroviral therapy era in Ribeirao Preto, Brazil. J Oral Sci. 2011 Sep;53(3):379-85.
  • 20
    Adurogbangba MI, Aderinokun GA, Odaibo GN, Olaleye OD, Lawoyin TO. Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult population in Oyo State, Nigeria. Oral Dis. 2004 Nov;10(6):319-26.
  • 21
    Bravo IM, Correnti M, Escalona L, Perrone M, Brito A, Tovar V, et al. Prevalence of oral lesions in HIV patients related to CD4 cell count and viral load in a Venezuelan population. Med Oral Patol Oral Cir Bucal. 2006 Jan 1;11(1):E33-9.
  • 22
    Patton LL. Hematologic abnormalities among HIV-infected patients: associations of significance for dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999 Nov;88(5):561-7.
  • 23
    Glick M, Abel SN, Muzyka BC, DeLorenzo M. Dental complications after treating patients with AIDS. J Am Dent Assoc. 1994 Mar;125(3):296-301.
  • 24
    Patton LL, Shugars DA, Bonito AJ. A systematic review of complication risks for HIV-positive patients undergoing invasive dental procedures. J Am Dent Assoc. 2002 Feb;133(2):195-203.
  • 25
    Shirlaw PJ, Chikte U, MacPhail L, Schmidt-Westhausen A, Croser D, Reichart P. Oral and dental care and treatment protocols for the management of HIV-infected patients. Oral Dis. 2002;8 Suppl 2:136-43.
  • 26
    Reznik DA, Bednarsh H. HIV and the Dental Team. The role of the dental professional in managing patients with HIV/AIDS. Dimensions of Dental Hygiene 2006;4(6):14-16.

Publication Dates

  • Publication in this collection
    2015

History

  • Received
    13 Jan 2015
  • Accepted
    26 May 2015
  • Received
    06 July 2015
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