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Surgical Crown Lengthening in a Population with Human Immunodeficiency Virus: a Retrospective Analysis<Link Href="#Jper0

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Surgical Crown Lengthening in a Population with Human Immunodeficiency Virus: a Retrospective Analysis<Link Href= Volume 83 • Number 3 Case Series Surgical Crown Lengthening in a Population With Human Immunodeficiency Virus: A Retrospective Analysis Shilpa Kolhatkar,* Suzanne A. Mason,† Ana Janic,* Monish Bhola,* Shaziya Haque,‡ and James R. Winkler* Background: Individuals with human immunodeficiency virus (HIV) have an increased risk of developing health problems, including some that are life threatening. Today, dental treatment for the population with a positive HIV diagnosis (HIV+) is comprehensive. There are limited reports on the outcomes of intraoral sur- gical therapy in patients with HIV, such as crown lengthening surgery (CLS) with osseous recontouring. This report investigates the outcome of CLS procedures performed at an urban dental school in a population of individuals with HIV. Specifically, this retrospective clinical analysis evaluates the healing response after CLS. Methods: Paper and electronic records were examined from the year 2000 to the present. Twenty-one in- dividuals with HIV and immunosuppression, ranging from insignificant to severe, underwent CLS. Pertinent details, including laboratory values, medications, smoking history/status, and postoperative outcomes, were recorded. One such surgery is described in detail with radiographs, photographs, and a videoclip. Results: Of the 21 patients with HIV examined after CLS, none had postoperative complications, such as delayed healing, infection, or prolonged bleeding. Variations in viral load (<48 to 40,000 copies/mL), CD4 cell count (126 to 1,260 cells/mm3), smoking (6 of 21 patients), platelets (130,000 to 369,000 cells/mm3), and neutrophils (1.1 to 4.5 · 103 /mm3) did not impact surgical healing. In addition, variations in medication reg- imens (highly active anti-retroviral therapy [18]; on protease inhibitors [1]; no medications [2]) did not have an impact. Conclusions: The results of this retrospective analysis show the absence of postoperative complica- tions after CLS in this population with HIV. Additional investigation into this area will help health care practitioners increase the range of surgical services provided to this group of patients. JPeriodontol 2012;83:344-353. KEY WORDS Bone and bones; crown lengthening; facial bones; HIV; oral surgical procedures, preprosthetic. * University of Detroit Mercy School of Dentistry, Department of Periodontics and Dental Hygiene, Detroit, MI. † Graduate Periodontics Program at the University of Michigan, Ann Arbor, MI. ‡ Private practice, Odessa, TX. indicates supplementary video in the online Journal of Periodontology. doi: 10.1902/jop.2011.110318 344 J Periodontol • March 2012 Kolhatkar, Mason, Janic, Bhola, Haque, Winkler he introduction of highly active antiretroviral MATERIALS AND METHODS therapy (HAART) has lead to reduction in the An 11-year retrospective analysis of paper and elec- Tincidence of new acquired immune deficiency tronic records (Institutional Review Board #0910-23) syndrome (AIDS) cases and the morbidity and mor- at the University of Detroit Mercy School of Dentistry tality associated with human immunodeficiency virus (UDMSOD), Detroit, MI, was conducted, and 21 indi- infection (HIV).1-3 In the initial stages of the HIV epi- viduals with HIV were identified who underwent CLS. demic, dental treatment was focused on the manage- The HIV+ status of patients is based on self-reporting ment of HIV-associated oral lesions. Based on a survey in the health history questionnaire and from the infor- of dental professionals’ attitudes toward the treatment mation provided by their treating physicians. Presurgi- of the population with HIV, some suggested that this cal laboratory values for each patient consisted of the population required treatment in specialized centers.4 following: 1) CD4 cell count; 2) total white blood cell Other investigators have suspected this population to count (WBC); 3) viral load; 4) neutrophil, platelet have higher complication rates after dental procedures count, hemoglobin, and hematocrit values. Other per- but found no significant difference among individuals tinent details, including medical history, medications, with HIV+ and HIV-negative status (HIV-).5 smoking status, and postoperative (PO) outcomes, Today, the population with HIV has the potential were recorded. None of the patients required antibiotic for an increased life expectancy as a result of advances prophylaxis, and none were prescribed antibiotics in their overall care. Routine comprehensive care is of- postoperatively. ten the primary dental need for well-managed patients All procedures were performed by periodontal fac- with HIV. This treatment may include preprosthetic ulty and periodontal residents at the UDMSOD under § surgery, such as vestibuloplasty, soft-tissue grafting, local anesthesia. PO management included written implant placement, implant-related procedures, and and verbal PO instructions and prescriptions for ibu- crown lengthening (CLS). profen (600 or 800 mg; every 6 to 8 hours as needed According to a practice profile survey in 2003, CLS is for pain) and 0.12% chlorhexidine gluconate mouth one of the most common reasons for periodontal sur- rinse (15 mL; twice daily). All patients were seen at gery.6 Restoring teeth to their proper anatomic form, 1, 2, and 4 weeks PO for clinical evaluation. function, and esthetics requires preparing a well-de- Different factors were analyzed and compared rel- fined restorative margin. For example, this may not ative to the surgical outcome. For example, maxillary be obtainable in the presence of subgingival decay, versus mandibular, anterior versus posterior surgical crown/root fracture, or endodontic perforation. CLS site, males versus females, smoking status, duration makes the margins easily accessible for accurate im- of HIV+ status, and faculty versus resident performing pressions and ultimately results in good marginal the procedure were compared. adaptation of the restoration. In addition, CLS can A detailed description of the presurgical prepara- tion, surgical procedure, and PO healing of one case achieve longer clinical crowns7-11 and reestablish (#17) is provided below. The other CLS were per- the biologic width12,13 by removal of hard and soft tis- formed in a similar manner with minor changes made sues.14-16 The general consensus is that CLS should to the flap design and amount of the bone removal create ‡3 mm of sound tooth structure between the necessary based on the clinical situation. A summary alveolar crest and the restorative margin.17-19 There- of all 21 cases can be found in Table 1. fore, surgical intervention in the form of CLS is often necessary.20 Detailed Description of the Procedure Performed Reports of intraoral surgical procedures in a popula- in Case #17 tion with HIV are mainly limited to extractions,21-24 im- A 62-year-old African American man was referred plant placement,25-32 and vestibuloplasty using palatal to the Graduate Periodontics Clinic at the UDMSOD. soft-tissue grafts.33 There are isolated reports of other Recurrent subgingival decay was noted on the dis- periodontal surgical procedures, including the use of tal surfaces of both the first and second maxillary a lateral sliding flap and resin-modified glass ionomer right premolars (Fig. 1). After caries removal and for the management of an isolated recession defect.34 reevaluation, invasion of the biologic width was ob- To our knowledge, this is the first documentation that served on teeth #4 and #5, and CLS was conse- describes CLS with osseous recontouring in a popula- quently indicated. tion with HIV. In this retrospective analysis, only one A review of the patient’s medical history indicated individual had a CD4 count of <200 cells/mm3. The re- that he was diagnosed with HIV in 1987 and has since maining 20 patients had immunosuppression levels been regularly monitored by his physician. His medi- that were generally mild (<500 cells/mm3 in eight pa- cal history stated that he was positive for hepatitis B, tients) to no significant immunodeficiency (>500 cells/ § 2% lidocaine HCL with 1:100,000 epinephrine, Benco Dental, Wilkes- 3 35 mm in 12 patients). Barre, PA. 345 346 Surgical Crown Lengthening in a Population with HIV Table 1. A Summary of Medical History, Laboratory Values, Medications, Surgical Dates, and Surgical Outcomes of 21 Cases Other Patient’s Date Medical HAART Date of Osseous Sex, Age of HIV Conditions/ Treatment CD4 Viral Load Neutrophils Total WBC Platelets Hemoglobin Hematocrit Tooth Crown Date of Surgery (Years) Diagnosis Smoking (Yes/No) (Cells/mm3) (Copies/mL) (·103/mm3) (·103/mm3) (·103/mm3) (g/dL) (%) # Lengthening Restoration Complications* Medications (Yes/No) Male, 55 1992 History of Yes 126 3,100 3.9 6.1 165 13.4 40 5, 6, 18 Apr 2003 May 2003 None Aptivus, Ye s non-Hodgin’s Norvir, lymphoma, hip Truvada replacement, smoker Male, 53 2003 Penicillin allergy, Yes 210 400 1.4 3.4 235 15.5 45.5 32 Feb 2005 Dec 2005 None Atripla, Ye s non-smoker Kaletra, Trizivir Male, 53 1984 Hepatitis B, Yes 240 40,000 2.5 5.9 202 13.1 39.1 30 Feb 2004 Mar 2004 None Kaletra, Ye s non-smoker Tenofovir Male, 37 1993 Heart murmur, No 272 5,500 3.8 5.9 207 13.9 42.2 8 Feb 2004 Apr 2004 None None Yes seasonal allergies non-smoker Male, 69 2007 Depression, Yes 355 <48 3.8 4.3 194 12.4 36.8 3 Jan 2009 Jan 2009 None Reyataz, Ye s hypertension, Novor, non-smoker Truvada Male, 57 2004 Hepatitis B, Yes 370 <48 2.6 5.4 189 17.8 51.2 31 Oct 2009 Jan 2010 None Kaletra Ye s smoker (Lopinavir/ Ritonavir), Truvada Male, 44 2003 Penicillin Yes 373 248 1.5 4.2 227 14.6 44.2 31 Jul 2010 Dec 2010 None Atripla Yes allergy, non-smoker Male, 53 1983 None, Yes 400 2,000 1.1 3.7 130 14.5 40.7 14 Jan 2004 March 2004 None Atazanavir Ye s non-smoker (Reyataz), Tenofovir, Ritonavir (Norvir), Didonzine (Videx) Female, 20 1991 Non-smoker Yes 486 1,160 1.7 3.8 256 12 37 3 Mar 2010 Jul 2010 None Truvada, Ye s Norvir, Reyataz Female, 57 1993 Hepatitis Yes 536 <50 2.7 5.1 168 14.8 40.5 20 Apr 2002 Sep 2002 None Combivir, Ye s Volume 83 • Number 3 B and C, Viralept one pack/day smoker Male, 59 2001 Hypertension, Yes 574 <48 2.8 5.2 219 13.9 41.7 31 Jan 2009 Jul 2009 None Tenofovir, Ye s non-smoker Emtricitabine, Epzicom Table 1.
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