SCIENTIFIC ARTICLE

Osseointegrateddental implants as alternative therapy to bridge construction or orthodonticsin youngpatients: sevenyears of clinical experience Philippe D. Ledermann,DDS Thomas M. Hassell, DDS,PhD Arthur F. Hefti, DDS,PD Abstract Youngpatients often require fixed bridgeworkor orthodontictherapy in cases of traumatic tooth loss or congenitally missing teeth. Dentalimplants represent an alternative to the moreconventional treatment methods.We report positive experienceover a seven-year period with 42 titanium Ha-Ti implants in 34 patients aged 9 to 18 years. Fourteen implants were placed into preparedtooth sockets immediatelyafter traumatic luxation of anterior teeth in 12 patients aged9 to 18 years (medianage 16). Anadditional 22 patients (medianage 15.5, range 11 to 18) also received implants (N = 28), but these wereplaced only after healing of extraction sites, or as substitutes for congenitally missing teeth. Implants remainedin situ for an averageof 7.7 monthsbefore loading. Duringthe healing period, three implants were lost due to additional traumaand one becameinfected. The 38 remainingimplants osseointegrated and since have been loaded for five to 79 monthsin successful function. There was no difference between immediateand delayed implants in clinical success. These experiences demonstratethat appropriate, versatile, osseointegrated implants can provide a successful treatment methodfor youngpatients, without damagingadjacent teeth. (Pediatr Dent 15:327-33, 1993)

Introduction Edentulous spaces often exist in children and adoles- the mucosal inflammation that is almost inevitable with cents due to trauma and congenital absence of permanent temporaryacrylic-based partial dentures. In children, the teeth. Traditional therapeutic approaches have included teeth most frequently lost to trauma are the incisors. Orth- removable partial dentures, fixed prostheses with mini- odontic movementof canines mesially to close spaces is mal tooth preparation (e.g., the "Marylandbridge"), and usually esthetically disappointing as well as costly and orthodontic movementof teeth to close spaces. All of time consuming. Perhaps most important is that after a these treatment modalities have distinct disadvantages; tooth is lost, an inescapable sequela is the rapid resorption most are temporary solutions at best and costs can be of alveolar bone. Indeed, in most cases, only a very thin substantial. In recent years, tremendoussuccess in tooth crestal bony lamella remains after healing of the alveolus, replacement has been achieved in adults using root-form with clinically obvious horizontal and orofacial depres- titanium dental implants. This success is due in major part sions. In a child patient missingan incisor, the may to pioneering clinical studies in Scandinavia (for review find implantation impracticable because of inadequate see Branemark, 19831). bone mass at the site if the dentist waits until iaw growth There has been a reluctance to employ implant therapy is complete. Inadequate bone also can seriously compro- in children and adolescents whose jaw growth is incom- mise the esthetic result achieved with conventional bridge- plete. Early attempts to replace teeth in very young pa- worklater. Implant placementas near to the time of tooth tients using vitreous carbon and ceramic implants were loss as possible could obviate these negative consequences. plagued by very poor success.2, 3 These are the likely rea- This paper reports on titanium root-form implants in sons whythe dental literature contains meager informa- children and adolescents, addressing the question of sub- tion about implantology in pediatric and why sequent alveolar bone growth and positional stability of implant therapy as an alternative to fixed prosthetics or immediate implants--an aspect of implantology about in young patients has not been advocated. whichlittle is known. The premise for the present clinical report is that chil- Methods and materials dren and adolescents maybe excellent candidates for tooth- replacement procedures incorporating the newer titanium Typeof implant root-form implants for several important reasons. For The Ha-Ti titanium implant system (Mathys Corpora- example, in the case of a single missing anterior tooth, tion of North America, Charlotte, NC), introduced in 1985, whenthe adjacent teeth are caries free, an implant pre- was used in our patients. The Ha-Ti implant features a cludes the necessity to prepare the teeth to receive bridge- highly polished neck with the dimension of a natural work. A replacement tooth on an implant also precludes tooth, and a step-screw implant shape analogous to a

Pediatric Dentistry: September/October1993 - Volume15, Number5 327 Table1. Site of andreason for Ha-Tiimplant placement and possible, an attempt was made to place the implant only success/failurestatistic after the pubertal growth spurt had concluded, as deter- mined from the age graphs of Bj6rk & Skieller. 6-9 This is Site Numberof Implants reflected in the average age of the patients at time of Maxilla implant placement (Table 2). Right central (#8) 16 The decision to implant immediately after tooth loss or Left central (#9) 12 to wait a certain period of time was madecase-by-case by the on the following basis: Rightlateral (#7) 5 1. Immediate implants were placed: Left lateral (#10) 5 ¯ In patients with traumatic tooth loss, if they were Right canine (#6) 1 treated within 72 hr after the incident; or Left canine (#11) 1 ¯ If teeth were extracted for reasons not involving osseous alveolar pathology (e.g., pulpitis, Mandible nontreatable tooth fracture); or 1 Right first premolar(#28) ¯ In cases of iatrogenic tooth loss, e.g., failed end- Left first premolar(#21) 1 odontic therapy not associated with infection. Total numberof implants 42 2. Delayed implants were placed: ¯ In cases of congenitally missing teeth if the overly- Reasonsfor implant placement ing retained primary tooth was mobile, immedi- ately after removingthe primary tooth; or Tooth loss due to trauma 25 ¯ In edentulous spaces in which a primary tooth had Congenital absence of permanenttooth 10 been missing for more than one year and the per- Rootresorption, fracture, etc. 7 manent tooth was congenitally absent; or ¯ If a tooth had to be extracted and there was clinical Total numberof implants 42 or radiographic evidence of pathology of the al- Success~failurestatistic veolus. Placement of the implant was delayed in such cases until the site healed, normally 2-3 Total numberof implants placed 42 months. Implants lost due to trauma 3 The alveolar ridge was examined clinically and radio- graphically for sufficient alveolar width. Guided tissue 1 Implants lost due to infection regeneration procedures1°," were used to enhance osse- Numberof successful implants 38 (90%) ous support in two cases that exhibited bony dehiscence after the implant was completely inserted. The procedure involved® placing individually trimmed pieces of Gortex ® natural tooth root. All superstructure elements are high- (W.L. Gore and Associates, Tucson, AR) or Vicryl (John- precision prefabricated and are interchangeable. The Ha- son & Johnson, New Brunswick, NJ) membrane over the Ti implant system has been described in detail as applied portion of the implant that was exposed due to bony in adult patients.4, ~ dehiscence, overlapping compact bone on both sides of the defect. Membraneswere affixed using resorbable Placementof implants sutures, then the mucosa was sutured to place over the From May 1985 through May1992, 42 Ha-Ti implants membraneand the implant healing cap. We attempted to were placed in 34 subjects, aged 9 to 18 years. The risks of obtain primary closure of the mucosaover each implant. the procedure and alternative treatment options were fully However, in some cases the implant healing cap became explained to the patients and the patients’ parents, who exposed during the postoperative course. All patients acknowledgedinformed consent in writing by signing the received an antibiotic postsurgically: Rovamycine® final treatment plan. Thirty-eight of the implants were (Spiramycin, Spezia, Switzerland, 250 mg, 2 tid, for four used to replace maxillary central and lateral incisors. Other days) and a nonsteroidal analgesic (mefenamic acid, sites were canines and premolars (Table 1). Whenever Ponstel®, Parke Davis, 250 mg, 2 tid, two to four days prn). Suture removal was per- Table2. Ageof patientsat timeof implantplacement by gender formed 8-10 days post- Gender Implants~Patients Mean+ SD(Years) Median(Years) Range(Years) surgically, at which time the wound was carefully in- Female 24/18 14.2 + 2.4" 14 9 - 18 spected and cleansed with an Male 18/16 16.1 1.6" 16 13 - 18 aqueous 0.2% chlorhexidine Both 42/34 15.1 + 2.2 16 9 - 18 solution. Implants in the maxilla ¯ P = 0.021. were permitted to remain

328Pediatric Dentistry: September/October 1993- Volume15, Number5 Table3. Ageof patientsat timeof implantplacement by typeof implant tested three times in succes- sion, and the meanPeriotest Implant Type Implants~Patients Mean+ SD (Years) Median(Years) Range(Years) value recorded. Peri-implant Delayed 28/22 15.1 + 2.0" 15.5 11- 18 tissue health was evaluated Immediate 14/12 15.1 2.7" 16 9 - 18 and quantified at the mesial, distal, and buccal aspects of Both 42/34 15.1 + 2.2 16 9- 18 the implant by measuring ¯ P = 0.993. the sulcus fluid flow rate as described1B by R6din et al. Table4. Lengthof healingperiod by gender Standard filter paper strips with a notch near the tip were Gender Implants Mean+ SD (Months) Median(Months) Range(Months) placed at the entrance of the Female 22 7.1 + 2.1" 7 5- 15 gingival sulcus and allowed to remain in situ for 3 min. Male 16 8.4 4.8" 6 5 - 20 The amount of fluid was Both 38 7.7 + 3.5 6.5 5-20 measured linearly, and re- ° P=0.819. corded to the nearest 0.1 mm as the average value of three strips per implant. Patients covered and not loaded for a minimumof six monthsafter were reinstructed in procedures and placement, mandibular implants for five months. These remotivated at each recall appointment. healing times were based on the well-known differences The results presented in this paper are reported as in osseous trabecular structure between the maxilla and mean values + S.D. and ranges based on the number of the mandible, as well as on the clinical observation of implants placed, rather than the numberof patients treated. hundreds of Ha-Ti implants placed in adult patients over The data were further broken downby gender since girls a5 5 1/2-year period. traverse9 their pubertal growth spurt earlier than boys. After complete healing, a special tissue punch was used The frequency distributions for the variables age, length of to expose the implant. The punch (Mathys Corporation of healing period, and length of followup after loading were North America, Charlotte, NC)is a low-profile trephine markedly skewed because of the longitudinal nature of that is used in a low-speed handpiece; the punch is size these clinical observations, so medians also were tabu- matchedto the implant diameter, so it excises exactly the lated. The nonparametric Mann-Whitney U rank-sum appropriate mass of gingiva overlying the implant heal- test was applied whenthe requirements for t-testing were ing cap. No sutures are required at the uncovering ap- not fulfilled. pointment. The implants then were examined for Results (stability, immobility,and lack of cratering around the implant neck). After removing the healing To date (October 1992), the minimumpostloading fol- cap, an impression post was screwed to place and the low-up period has been five months; the maximumpe- impression madeusing elastomeric material. Loading the riod 79 months. As shownin Table 1, a total of 42 implants implants occurred 10 days later when definitive super- were placed in 34 patients. The reasons for implant place- structures were seated. All of the implants were restored ment were traumatic tooth loss or congenital absence of using precision-milled, porcelain-fused-to-gold single permanent teeth in 35 cases. Twenty-four implants were crowns, affixed without cement by means of a transversal placed in 18 female patients, and 16 male patients received screw, as previously described.4 After seating the defini- 18 implants (Table 2). Femalepatients were statistically tive crowns, all implants were followed on a six-month significantly younger(P = 0.021) than male patients. In recall interval. situations, implant placement was performed after an appropriate wound healing period (delayed implant). Documentation Fourteen implants were placed immediately after trau- Each implant case was documentedusing clinical intra- matic tooth loss (Table 3). After a total study period oral photography. In addition, radiographic surveys were seven years, 38 implants remained in situ, loaded and madeincluding: a panoramicfilm, appropriate periapical fully functional; this is approximatelya 90%success rate. films, and lateral cephalometric radiographs if indicated The 10%failure rate is misleading in this context, and is (e.g., if overlaps occurred in other films, or if patients discussed below (see Discussion). experienced symptoms). Photographs and radiographs The healing period was slightly longer for males as were madeat appropriate intervals (see Results). comparedto females (Table 4), but the difference was not Osseointegration was assessed at each recall appoint- statistically significant (P = 0.819). Table 5 reveals that ment using percussion and the Periotest ® (Siemens, there was no statistically significant difference between Bensheim, Germany) instrument. 12 Each implant was the healing time given for delayed implants as compared

PediatricDentistry: September/October 1993- Volume15, Number5 329 Table 5. Length of healing period by implant type to immediate implants. The length of the unloaded heal- Implant Type Number Mean + SD (Months) Median (Months) Range (Months) ing period for the 38 implants Delayed 25 8.0 ± 4.2' 6 5-20 ranged from five to 20 months. The mean healing Immediate 13 7.0 1.4' 7 5-10 period of the study sample Both 38 7.7 ± 3.5 6.5 5-20 was 7.7 months. After load- 'P=0.691. ing by placement of the de- finitive restoration, the im- Table 6. Length of followup after loading by gender plants have been followed between five and 79 months Gender Implants Mean + SD (Months) Median (Months) Range (Months) (Tables 6 & 7). The mean over- Female 22 41.4 ± 20.1' 39 14-79 all follow-up period for the total sample after loading has Male 16 27.4 20.9' 18.5 5-73 been 35.5 months (median = Both 38 35.5 ± 21.3 34 5-79 34 months).

•P= 0.019. Figures 1-6, illustrate es- thetic restorations of the im- Table 7. Length of followup after loading by implant type plants, most of which were in the anterior segment. Implant Number Mean ± SD (Months) Median (Months) Range (Months) Clinically, the soft tissue re- Delayed 25 36.4 ± 24.0* 34 5-79 sponse to the subgingivally located interface between the Immediate 13 33.8 15.8' 34 14-59 implant and the prefabri- Both 38 35.5 + 21.3 34 5-79 cated superstructure crown •P= 0.853. was favorable. Neither gin- gival recession nor gingival hyperplastic responses were encountered. An interesting observation in those cases followed over longer periods of time was an apparent shortening of the implant-born crowns (Figs 5 & 6). This was a trompe-l'oeil, however, resulting from continued growth of the alveolar bone in the adolescent patients and continued eruption of the adjacent natural teeth into their final positions. This phe- nomenon, observed so far on a subset of only 38 loaded implants, may eventually be a universal observation, since almost all of the young patients are still growing. Sulcus fluid flow rates (SFFR) and Periotest® measure- ments were documented on a subset of 32 implants se- lected on the basis of patient cooperation and accessibility of the implants for the tests. All SFFR measurements were within a narrow range of values (0-1.2 mm), comparing favorably to SFFR around healthy natural teeth13—sug- gesting that the patients' oral hygiene efforts were gener- ally adequate—and that the Ha-Ti crown margins were compatible with gingival health. The Periotest values were between -5.0 and -1.5 units, indicating virtual immo- bility of the implants12 and suggesting successful osseointegration at the time of measurement. The radiographic findings were unremarkable, exhib- iting no evidence of bone loss around any of the remaining 38 implants during the follow-up period of 79 months. Discussion Fig 1. The radiographic situation seven years after This report presents information concerning 42 Ha-Ti placing Ha-Ti implants. Note the excellent osseous adaptation of the implant and the lack of radiolucent implants placed in 34 children and adolescents over a areas, indicating persisting osseointegration. seven-year period. The results support the use of dental

330 : September/October 1993 - Volume 15, Number 5 implants as an alternative to fixed prostheses or orthodon- tics in young individuals, especially those who are near- ing or have already achieved complete alveolar bone growth. Factors favoring the placement of implants in these young patients would include the excellent local blood supply, positive immunobiologic resistance, as well as the generally uncomplicated osseous healing. A possible com- plicating factor for dental implantation in children is in- complete jaw growth and incomplete eruption of perma- nent teeth adjacent to the implant site. Whenever possible, dental implants should not be placed in males before age 13 or in females before age II.9- '"•15 One factor that may favor early implant placement, even in young patients, is anticipated osseous atrophy. Good evidence16 supports Fig 2. The clinical situation six years after seating the Ha-Ti alveolar resorption after tooth loss. Such a resorbed area, crowns.

Fig 3. The single tooth abutment, which is seated on a 14-mm Fig 4. Clinical view one month later with individual Ha-Ti Ha-Ti implant with a 6-mm-diameter neck. The implant had porcelain-fused-to-metal crown replacing tooth 21. been placed six months previously in this 14-year-old girl (April 1989).

Fig 6. Because the Ha-Ti implant system provides a transverse screw rather than cement to secure the crown, it was possible Fig 5. Clinical picture three years after crown placement (March 1992). Note that the Ha-Ti crown appears too short to remove the crown and add additional porcelain to the incisal incisally; this is due to continued growth of the facial skeleton edge, and then to reseat the crown using a new transverse over the three-year period. screw. As shown in this figure, the original Ha-Ti crown has successfully been adapted to this patient's changed intraoral relationships.

Pediatric Dentistry: September/October 1993 - Volume 15, Number 5 331 especially whenthe resorption occurs in the buccolingual This report of seven years’ experience placing and re- dimension, often makes successful placement of an im~ storing Ha-Ti dental implants in children and adolescents plant difficult or even impossible, and also compromises for replacement of congenitally missing teeth and in post- conventional bridge construction. Clinical experience has traumatic cases supports using implants as an alternative demonstrated that when a root-form implant is placed to conventional prosthetic solutions. Followup on 42 im- into an alveolus immediatelyafter tooth loss, the degree of plants placed in 34 patients for an average of 35.5 months resorption can be minimized. Even when narrow bone (range -- 5 to 79 months) has been associated with dimension results in a dehiscence after implantation, success rate of 90%. An important contrast between this guided tissue regeneration can induce new bone forma~ report and previous attempts in pediatric dental tion around implants 11,17.18~specially around implants implantology is that our failures (4 implants = 10%)were that were placed immediately in extraction sockets and not related to implant failure or the fact that the patients after destructive (traumatic) tooth luxation. This was cor- were children. Three of the failures occurred because of roborated in this report, in which guided tissue regenera- subsequent traumatic facial injuries incurred by the chil- tion using membraneswas successfully applied for alveo- dren during the healing phase, and one implant failed lar ridge augmentation in two patients exhibiting because the surgeon placed an implant into an alveolus dehiscences after implant placement due to insufficient that showedclinical signs of infection. alveolar bone width. Despite our success, each dentist must exercise caution The clinical and radiographic information provided in in child patients in whomadditional significant alveolar this report demonstrates that dental implants remain stable bone growth is anticipated (i.e., children who have not in position and orientation despite additional growth of traversed the pubertal growth spurt). Decisions to im- the alveolar bone and facial skeleton. plant in young patients also need to be tempered by the The superstructure crown in the Ha-Ti system is never desire to prevent bone resorption and the attendant alveo- cemented onto the implant base, or onto any type of cop- lar deformity. ing. Rather, the crown is affixed with a titanium trans- This study was supported by a Dr. Robert Mathys Research Founda- verse screw which, when torqued to place, presses the tion grant #FGRM03A. precision prefabricated margin of the crown onto the im- Dr. Ledermannis in private practice, Bern, Switzerland. Dr. Hassell plant. The microscopic gap between the crown and the is a professor and chairman, Department of , Univer- implant is only 2-4 ~tm in expanse; by comparison, the sity of Florida, Gainesville, Florida. Dr. Hefti is a professor, Depart- marginal gap of conventional cast crowns is normally 50- ment of Periodontology, University of Florida, Gainesville. Reprint 300 ~tm. An additional obvious advantage is that Ha-Ti requests should be sent to: Dr. Philippe Ledermann, Nydeggstalden crowns can be removed easily at any time by simply tak- 2, CH-3011 Bern, Switzerland. ing out the transverse screw. If adjacent teeth continue to 1. Br~nemarkPI: Osseointegration and its experimental background. erupt and the crown appears too short, additional porce~ J Prosthet Dent 50:399-410, 1983. 2. Scholz F, d’Hoedt B: Der Frontzahnverlust im jugendlichen Gebiss lain can be added to the incisal edge. The same is true in - Therapiem6glichkeiten durch Implantate. Dtsch Zahnarztl Z the case of fracture of porcelain due to trauma. 39:416-24, 1984. Dental implants in children have been attempted by 3. Frisch E, Pehrsson K, Engelke W, Sennhenn S, Jacobs HG: Beitrag several other authors using other implant types with less zur Problematik der Implantation im Oberkiefer-Frontzahn- thana favorable results. For example, Scholz & d’Hoedt bereich. Z Zahn~irztl lmplantol 6:108-10, 1990. 4. Ledermann PD, Mathys R, Frischherz R: Ein neues used the T6binger implant in 8- to 11-year-olds and expe~ Implantationskonzept fiir den Einzelzahnersatz: Das Ha-Ti rienced a failure rate of 46%over two years. In their Schraubenimplantat. Schweiz Monatsschr Zahnmed 98:40-50, patients older than 12 years, however, the failure rate was 1988. only 18%. 5. Ledermann PD, Markwalder TH, Frischherz R: Das Ha-Ti Frisch and coworkers3 placed ceramic implants in chil- Implantat. F~infeinhalb Jahre klinische Erfahrung. Schweiz Monatsschr Zahnmed101:610-20, 1991. dren, permitted them to heal uncovered and unloaded for 6. Bj6rk A: Variations in the growth pattern of the humanmandible: three months, and experienced a failure rate of 67%over longitudinal radiographic study by the implant method. J Dent two years. Whenthey used the same type of implant but Res 42:400-11, 1963. with a closed procedure, the authors claimed a success 7. Bj6rk A: Sutural growth of the upper face studied by the implant method. Acta Odontol Scand 24:109-27, 1966. rate of 83%;however, the deep incorporation in the bone 8. Bj6rk A, Helm S: Prediction of the age of maximumpubertal of the ceramic implants was associated with esthetic prob- growth in body height. Angle Orthod 37:134-43, 1967. lems, and implant fractures occurred frequently. This had 9. Bj6rk A, Skieller V: Facial development and : an been described also by Markwalder29In sum, the earlier implant study at the age of puberty. AmJ Orthod 62:339M~3,1972. clinical studies of implants in young patients by Frisch et 10. Gottlow J, NymanS, Karring T, Lindhe J: Newattachment forma- tion as a result of controlled tissue regeneration. J Clin Periodontol al., 3 Fritzmeier et al., 2° Mairgiinther et al., 21 and Scholz& a 11:494-503, 1984. d’Hoedt suggest that the relatively high failure rates that 11. Becker W, Becker BE: Guided tissue regeneration for implants have been reported could not be traced to the fact that the placed into extraction sockets and for implant dehiscences: Surgi- patients were young but rather to failures of the implant cal techniques and case report. IntJ Periodontics Restorative Dent systems themselves. 10:376-91, 1990.

332 Pediatric Dentistry: September/October1993 - Volume15, Number5 12. Schulte W, d’Hoedt B, Lukas D, MaunzM, Steppeler M: Periotest tion: A report of two cases, hnt J Oral Maxillofac Implants 5:9-14, for measuring periodontal characteristics~Correlation with pe- 1990. riodontal bone loss. J Periodontal Res 27:184-190, 1992. 18. Buser D, Hirt H-P, Dula K, Berthold H: Membrantechnik/Orale 13. Ri~din HJ, Overdiek HF, Rateitschak KH: Correlation between Implantologie. Schweiz Monatsschr Zahnmed 102:1490-1505, sulcus fluid rate and clinical and histological inflammationof the 1992. marginal gingiva. Helv Odontol Acta 14:21-26, 1970. 19. Markwalder TH: Ober zehnj~ihrige klinische Erfahrungen mit 14. Pyle SI, Waterhouse AM,Greulich W~V:A radiographic standard verschiedenen Implantatsystemen am Zahnarztlichen Institut der of reference for the growing hand and wrist. Chicago: Press of Universit~it Basel. Medical thesis, University of Basel (Switzer- Case Western Reserve University, 1971. land), 1991. 15. Tanner JM: Growth at adolescence. 2nd Ed. Oxford: Blackwell 20. Fritzemeier CU, Lentrodt J, H61tje W, Osborn JF: Bisherige Scientific, 1962. Erfahrungen mit dem T6binger Sofortimplantat aus Aluminium- 16. Atwood DA: The problem of reduction of residual ridges, In Oxydkeramik. Dtsch Zahn~irztl Z 36:579-84, 1981. EssentiaLs of Complete Denture , Winlder S, ED. 21. Mairgiinther R, Nentwig GH, Schneider M: Das Frialit-Implantat Philadelphia: WBSaunders Co, 1979. Typ Miinchen. Ergebnisse nach iiber 5-j~ihriger klinischer 17. NymanS, Lang NP, Buser D, Br~igger K: Bone regeneration adja- Anwendung.Z Zahn~irztl Implantol 6:115-19, 1990. cent to titanium dental implants using guided tissue regenera-

Updated HIV early care guidelines released AMAemphasizes greater role for primary care doctors Primary care can do as muchfor patients with early-stage HIVas specialists, according to updated treatment guidelines released by the AmericanMedical Association at its media briefing on AIDSin Berlin in June. ’q’he messageof the guidelines for physicians and patients is that all primary care physicians can provide appropriate medical care to patients in the early stages of HIVinfection," said Paul Volberding, MD,Professor of Medicine, University of California, San Francisco, and chairman of the AMAAdvisory Group on HWEarly Care Guidelines. Volberding said HIV Early Intervention: AMAPhysician Guidelines, second edition, provide primary care physicians necessary information to diagnose and treat patients with early-stage HIVinfection. "There is the perception that advances in HWcare are occurring too rapidly for the average to keep current," Volberding said. "But the rapid changes are happening more in the treatment of opportunistic infections which occur in a patient in the end stages of AIDS;care recommendationsfor patients in the early stages of HIVinfection are relatively stable." He continues: ’q~hese guidelines will give physicians the knowledgeand reassurance they need to treat all facets of HIVcare in its early stages," he said. "Physicians should also knowthe assistance of AIDSspecialists is necessary." The guidelines detail howa physician should go about the initial work-upof a HIV-positive patient. This should include identifying the stage of the disease, taking a patient’s history (including questions about blood transfusions and donations, immunizations, medications, and social and sexual history). Physicians should also be alert for conditions that might presage HIVinfection and those that occur in conjunction with it, including tuberculosis. The guidelines pay particular attention to the medical and psychosocial concerns of women,more of whomare becominginfected. In addition to discussing gynecological exams and the exacerbated nature of concomitant diseases (other sexually transmitted diseases, yeast infections), the guidelines emphasizephy- sician sensitivity to a woman’sreproductive concerns and her traditional role as family caregiver. The guidelines also discuss recent study results suggesting early monotherapy with zidovudine (AZT) may need to be supplemented or replaced over time to continue the clinical and immunologicalbenefits of antiviral drugs.

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