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INTRODUCTION
People
are living with HIV and AIDS throughout the world and in all walks of
life. Health care professionals and researchers press forward to further
understand the biological systems involved in HIV/AIDS and work to improve
the quality of life for those affected. Part of this effort incorporates
an understanding of the oral cavity including dental eruption patterns.
Before the widespread use of Highly Active Antiretroviral Therapy (HAART)
[1], numerous studies reported delayed dental eruption. For example,
a 1994 study found that 31% of its 40 HIV-infected children aged 2.1
to 11.3 years old had delayed dental development [2]. Two studies with
data collection from 1993-1994 found that HIV-infected children had
increased retention of primary teeth and delayed eruption of permanent
teeth [3], [4]. A Romanian study which had 30% of its HIV-infected patients
on antiretroviral therapy noted delayed eruption in 42% of its participants,
accelerated eruption in 12%, appropriate eruption in 46%, and overretained
primary teeth in 25% of its population [5]. A different pre-HAART study
found that those HIV-infected individuals at age 3 with an average CD4
count of 200 had 2 fewer teeth per child than those with an average
CD4 count of 800 [6]. Another pre-HAART study found 2 out of 28 HIV-infected
children to have delayed dental development. Both children were from
a group categorized as P-2 or symptomatic [7]. Similarly, a study performed
after the initiation of HAART found that those HIV-infected individuals
with more severe symptoms were more likely to have delayed dental eruption
than those with less severe symptoms [8]. A study published in 2003
examined a population of HIV-infected children who began treatment with
monotherapy, but progressed to dual therapy and then HAART treatment.
This study also found delayed eruption of permanent teeth and retained
deciduous teeth [1].
When considering
the oral health of those with HIV-infection, salivary flow rate can
also be considered. Salivary flow rate impacts the likelihood that a
patient may develop dental caries or oral candidiasis. One 2000 study
has shown that those on antiretrovirals have a decreased salivary flow
rate when compared to those not using antiretrovirals [9], while another
2000 study of women found that patients not on anti-retroviral therapy
were more likely to have a flow rate of 0 mL/min than those who were
on the therapy [10]. A 2003 study revealed that those with early stage
HIV-infection have decreased flow rates versus a control [11], while
a different study showed that with an increased viral load, patients
are more likely to experience dry mouth symptoms [12].
The proposed study
contributes a new avenue to the current knowledge base because previous
studies were either performed outside of the United States, used data
collected before the initiation of HAART treatment, or did not control
for familial and environmental factors. This study compares a population
of HIV-infected children to their non-infected household siblings (peers).
Additionally, this study provides a baseline eruption sequence database
specific to this population at the Medical University of South Carolina
(MUSC) Outpatient Pediatric AIDS Clinic (OPAC). This sequencing would
also allow medical professionals to more quickly identify serious or
unusual delays, and for implementation of preventative procedures for
these patients. Additionally, the information on salivary flow rates
adds to research regarding dental caries prevalence and the overall
oral health of this population.
METHODS
Subjects
The parents/guardians of a convenience sample of HIV-infected children
who receive outpatient care at MUSC in Charleston, SC were asked by
the attending physician to take part in a cross-sectional study. Their
household peers were invited to participate and constitute the control
group. The parent/guardian signed informed consent and HIPAA forms as
did those 11 years and older who signed assent per MUSC IRB # 16297.
The study comprised 16 HIV-infected females and 14 HIV-infected males
along with 4 uninfected male household peers and 6 uninfected female
household peers aged 10 months old to 225 months (18.75 years) old.
The data were collected from June 1st to July 20th 2006. |
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Questionnaire
Questionnaires were administered to record information including frequency
of dental visits, use of fluoride toothpastes, frequency of brushing,
and intake of sugar filled beverages. Patients above 12 years of age
filled out the questionnaire with help from his or her parent if necessary.
If the patient was under 12 years of age, his or her parent or guardian
filled out the questionnaire regarding the child.
Saliva
Collection
A preweighed cotton roll was inserted into the patient’s upper
right cheek at the parotid duct and kept in place for 1 minute. The
cotton roll was then removed and placed back into the polystyrene vial.
The combined weight of the saturated cotton roll and the polystyrene
vial were then measured on the analytical scale. Salivary flow rate
could then be calculated by subtracting the original weight of vial
and cotton roll from the weight of the saturated roll and vial.
Eruption
All teeth were included except third molars. The examiner began in the
upper right quadrant with the most distal tooth and progressed across
in sequential order from tooth number “2” to “28”
or “a” to “t” depending on which teeth were
present. Present teeth were measured using the periodontal probe for
eruption status and were visually examined. Permanent teeth were designated
as either less or greater than 3 mm erupted in reference to the interproximal
papilla. Primary teeth were designated as either less or greater than
3 mm erupted when measured on the mid-buccal surface. Measurements should
be made parallel to the long axis of the tooth from the tip of highest
cusp to the gingiva (measure to interproximal papilla in permanent teeth
and mid-buccal on primary teeth. If neither a primary nor a permanent
tooth was present in a given location in the mouth, this meant a tooth
was “absent.” Parents and/or patients will be questioned
about the absent tooth/teeth. The examiners used their best judgment
to determine if a tooth was delayed or had been extracted due to injury
or decay. The source of norm for eruption was an American Dental Association
chart [13].
Plaque
Accumulation
Each tooth was visually examined for dental plaque accumulation using
a surface reflecting mirror. The examiner began in the upper right quadrant
with the most distal tooth and progressed across in sequential order
from tooth number “2” to “28” or “a”
to “t” depending on which teeth were present. One number
was assigned to each tooth based on the following criteria and an average
was determined to give the patient one plaque score. A subject was assigned
a 0 if there was no plaque accumulation in the gingival margin, 1 if
there was no visible plaque accumulation with the naked eye although
a probe detects plaque accumulation at the free gingival margin, 2 if
there was moderate plaque accumulation visible with the naked eye either
within the gingival pocket, on the gingival margin, and/or on the adjacent
tooth surface. A 3 was assigned if there was abundant plaque accumulation
within the gingival pocket, on the gingival margin, and/or on the adjacent
tooth surface [14]. Upon completion of the examinations, participants
received an age appropriate toothbrush and small tube of toothpaste.
Chart Abstraction
Information was abstracted from the patient’s medical chart including
date of birth, gender, CD4 #, CD4 %, lowest CD4#, lowest CD4%, viral
load, years with HIV, AIDS status, HAART medications, poverty level,
Medicaid participation, and race/ethnicity.
Statistical
Analysis
Double data entry was done using Epi- Data© for preliminary cleaning
of data. The results were compared using the student T-test for continuous
variables and Chi-square test for categorical variables.
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