Success of Implant Placement in Patients with Human Immunodeficiency Virus

Success of Implant Placement in Patients with Human Immunodeficiency Virus

Osman Khan; Kathryn Gauch; Alison Newgard, D.D.S.; Ezzard Rolle, D.D.S.

ABSTRACT

With the development of effective antiviral medication, patients with human immunodeficiency virus (HIV) are living longer, with fewer comorbidities. Because HIV is a chronic disease, patients are looking for long-term solutions to dental care. As dental providers, it is important that we treat patients to the standard of care. Currently, implants are the standard of care for treating edentulous areas. Dental providers may be hesitant to recommend implants in patients with complex medical conditions like HIV. However, research has shown that if a patient with HIV is well-controlled, dental implant success is the same as with a healthy non-HIV infected patient.

The human immunodeficiency virus (HIV) infection is a condition that has become more prevalent in the population due to the development of medications that control the disease. As the disease has progressed from acute to a more chronic condition, there has been an increased need for long-term dental care for patients living with HIV. The HIV crisis in the United States began as a bicoastal epidemic, primarily in large cities.[1] Over the past four decades, the epidemiology of HIV has changed (Table 1). According to the CDC, over one million Americans were living with HIV at the end of 2019.

HIV infects specific CD4 helper (CD4) lymphocyte cells in the immune system. This makes affected individuals more susceptible to opportunistic infections, some of which are observed in the oral cavity (Table 2). In many cases, untreated HIV infection leads to acquired immunodeficiency syndrome (AIDS).[3] AIDS is defined by a CD4 cell count below 200 cells/mm^3.[3]

Clinically, HIV is well-controlled if the CD4 cell count is above 500 cells/mm^3 and the viral load is undetectable.[3] Uncontrolled HIV can increase the risk of cardiovascular, metabolic, neurological and renal comorbidities.[4] Antiretroviral therapies have been shown to be extremely effective in preventing the progression of the disease.[5]

Current research has indicated that the most effective therapy is highly active antiretroviral therapy (HAART). HAART prevents the virus from duplicating itself.[3,4] HAART therapy is a combination of three drugs—two drugs of the nucleoside/nucleotide reverse transcriptase inhibitors (NRTI) class plus one drug that is either an integrase strand transfer inhibitor (INSTI), non-nucleoside reverse transcriptase inhibitor (NNRTI) or a boosted protease inhibitor (PI).[4]

Due to the initiation of HAART, the HIV+ population has seen a decrease in comorbidities and mortality. The transition of the disease from acute, life-threatening to long term has led more HIV+ individuals to seek extended dental care.[6] Therefore, more dental practitioners are treating patients with HIV and are turning to research to identify safe and effective means for treating these patients with various dental needs.

In recent years, implants have become a popular and effective treatment choice for patients presenting with missing teeth. From 1999 to 2016, dental implant placement increased by 5.7% and is projected to increase by an additional 20% by 2026.[7] This is due to the stability and osseointegration into the bone that, when successful, allows for a reliable treatment choice for patients.

While implants are becoming the standard of care for edentulous patients who present with no significant medical conditions, practitioners may be hesitant to place implants in patients with more complex medical conditions and etiologies because of potential complications to success and perceived lack of evidence. This report will look at the success rate of and approach to implants as a treatment option for edentulous areas in patients living with HIV.

Success Rate of Implant Placement in HIV+ Patients

Implants have increased prosthetic options and are becoming a standard procedure for treating edentulous areas. As with any surgical procedure, case selection and review are important for success. Common reasons for implant failure are peri-implantitis, osseointegration failure, primary infections and prosthesis failure.[4]

Research has found implant placement to be a suitable treatment option for patients living with HIV that is controlled, especially if these patients are undergoing HAART treatment.[3] The overall survival rate of implants placed in HIV+ patients is above 90%, which was comparable to the survival rate in healthy patients without HIV.[3] In cases that did fail, there was no evidence to suggest that the cause of implant failure was from antiretroviral therapy or the disease itself.[5]

The most important factor associated with implant success in HIV+ patients was an undetectable or low viral load and elevated CD4 count.[3] If the CD4 count is greater than 200 cells/mm^3 and the HIV status is controlled and stable, literature indicates there is no significant difference in the success of implant placement between HIV+ and HIV- patients.[8]

While HAART is an effective means to control the disease, there are side effects to consider with implant placement. The HAART regimen has been associated with osteoporosis and osteopenia.[4] Since implant placement success is dependent on osseointegration into the bone, these bone metabolic issues may cause concerns for longterm success.[4]

Some surgeons choose to prescribe prophylactic antibiotics prior to implant placement, although there is no clear evidence supporting or contradicting its use. Some studies suggest that antibody prophylaxis prior to placement of implants may lower the risk of implant failure in HIV+ patients due to the immunocompromising nature of the disease.[9-11] However, other trials demonstrate that antibiotic prophylaxis prior to implant placement may not be clinically relevant, as it is not shown to reduce postoperative infection or failure.[11] The growing concern for antibiotic resistance should also be considered when prescribing prophylactic antibiotics in the dental practice.[12] Antibiotic resistance is a global problem and antibiotics should be prescribed based on clear guidelines, guided by clinical evidence.

Conclusion

Current literature shows that dental implant placement for HIV+ patients has a favorable prognosis, similar to that of HIV- patients. Controlling viral load plays a significant role in the success of implant placement for HIV+ patients. Therefore, it is important to assess the immune competence of the patient before attempting implant therapy. However, certain medications in the HAART therapy may affect osseointegration. Further studies are necessary.

Queries about this article can be sent to Dr. Newgard at an2621@cumc.columbia.edu.

REFERENCES

1. Sullivan PS, et al. Epidemiology of HIV in the USA: epidemic burden, inequities, contexts, and responses. Lancet 2021;397(10279):1095-1106.

2. Braunstein SL, et al. Epidemiology of reported HIV and other sexually transmitted infections during the COVID-19 pandemic, New York City. J Infect Dis 2021;224(5):798-803.

3. Sivakumar I, et al. Does HIV infection affect the survival of dental implants? A systematic review and meta-analysis. J Prosthet Dent 2021;125(6):862-869.

4. Sivakumar I, et al. Do highly active antiretroviral therapy drugs in the management of HIV patients influence success of dental implants? AIDS Rev 2020;22(1):3-8.

5. Rubinstein NC, et al. Retrospective study of the success of dental implants placed in HIVpositive patients. Int J Implant Dent 2019;5(1):30.

6. Sabbah A, et al. A retrospective analysis of dental implant survival in HIV patients. J Clin Periodontol 2019;46(3):363-372.

7. Elani HW, et al. Trends in dental implant use in the U.S., 1999-2016, and projections to 2026. J Dent Res 2018; 97(13):1424-1430.

8. Gherlone EF, et al. A prospective longitudinal study on implant prosthetic rehabilitation in controlled HIV-positive patients with 1-year follow-up: the role of CD4+ level, smoking habits, and oral hygiene. Clin Implant Dent Relat Res 2016;18(5): 955-964.

9. Vidal F, et al. Dental implants and bone augmentation in HIV-infected patients under HAART: case report and review of the literature. Spec Care Dentist 2017; 37(3):150-155.

10. Laskin DM, et al. The influence of preoperative antibiotics on success of endosseous implants at 36 months. Ann Periodontol 2000;5(1):166-74.

11. Momand P, et al. Effect of antibiotic prophylaxis in dental implant surgery: a multicenter placebo-controlled double-blinded randomized clinical trial. Clin Implant Dent Relat Res 2022;24(1):116-124.

12. Chrcanovic BR, Albrektsson T, Wennerberg A. Prophylactic antibiotic regimen and dental implant failure: a meta-analysis. J Oral Rehabil 2014;41(12):941-56.

Osman Khan is a dental student, Columbia University College of Dental Medicine, New York, NY.

Kathryn Gauch is a dental student, Columbia University College of Dental Medicine, New York, NY.

Alison Newgard, D.D.S., is assistant professor, Columbia University College of Dental Medicine, Section of Cariology and Restorative Sciences, Division of Operative Dentistry, New York, NY.

Ezzard Rolle, D.D.S., is assistant professor, Columbia University College of Dental Medicine, Section of Cariology and Restorative Sciences, Division of Operative Dentistry, New York, NY.