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J Am Dent Assoc, Vol 138, No 11, 1468-1475.
© 2007 American Dental Association |  |
RESEARCH |
A retrospective study
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Methods. The authors reviewed the charts of 162 patients with HIV who were 50 years or older who had sought dental treatment from 2000 through 2006. The authors abstracted patients’ self-reported clinical comorbidities and laboratory-verified HIV-related and hematologic values.
Results. A total of 88.8 percent of the study subjects had at least one comorbidity. Comorbidity prevalence was 44.4 percent for hepatitis C virus, 41.4 percent for hypertension, 16.7 percent for psychiatric disorders, 16.1 percent for chronic obstructive pulmonary disease, 15.4 percent for anemia and 14.8 percent for heart disease. Significantly more subjects with a CD4+ cell count of less than 200 per cubic millimeter were anemic compared with subjects with counts of 200/mm3 or more.
Conclusions. HIV-positive patients 50 years or older have a broad range of comorbidities that may affect the provision of oral health care.
Clinical Implications. Whether these patients have clinically severe or less well-controlled comorbidities that may require modification of oral health care treatment remains to be determined.
Key Words: HIV infection; aging; cardiovascular diseases; hypertension; hepatitis virus; anemia
Abbreviations: ALT: Alanine aminotransferase • ANC: Absolute neutrophil count • AST: Aspartate aminotransferase • COPD: Chronic obstructive pulmonary disease • HAART: Highly active antiretroviral therapy • HCV: Hepatitis C virus • Hgb: Hemoglobin • IDU: Injecting drug users • MSM: Men who have sex with men • VL: Viral load • WBC: White blood cell count
The HIV/AIDS epidemic in the United States has changed dramatically over the last decade. Significant improvements in the clinical management of HIV and advances in pharmacotherapy have changed the course of HIV, transforming it from a highly fatal disease to a chronic condition that can be managed over time. At the threshold of the HIV/AIDS epidemic’s fourth decade, the number of people who receive diagnoses of HIV/AIDS and the number of deaths continues to decline in the United States, while the number of older adults living with HIV/AIDS continues to grow. The Centers for Disease Control and Prevention has indicated that the cumulative number of AIDS cases among American adults older than 50 years of age quintupled over the last decade.1 More recently, the estimated number of AIDS cases by year of diagnosis increased 3.8 percent from 2000 to 2004 in the 20- to 49-year-old age group and 29 percent from 2000 to 2004 in the 50-year-old or older group. Approximately one in five people with HIV in the United States is 50 years or older.1–3
Concomitant with the changes in the course of HIV/AIDS are changes in the types and presentations of comorbidities seen in these patients. People with HIV may have comorbidities owing to the presence of underlying conditions that were present before they developed HIV, coinfection with other infectious diseases such as hepatitis B virus and hepatitis C virus (HCV), HIV-related medical consequences and central nervous system complications, or the adverse effects of certain medical treatments. As a result of the widespread use of new pharmacotherapies and the aging of the infected population, new comorbidities such as cardiovascular disease and diabetes have emerged.4–6
Given the interrelationships between oral health and general health that involve most organ systems, many diseases can affect oral health care delivery. HIV provides a dramatic example of this medical-dental interaction. The consideration of comorbidities is particularly important in the delivery of oral health care to older patients with HIV, as they may have a greater array of and more complex medical conditions associated with their HIV infection or the aging process. To date, no studies have assessed the presence of comorbidities that are important in oral health care delivery to older patients with HIV post–highly active antiretroviral therapy (HAART) era.
At a time when the prevalence of comorbidities in people with HIV is changing, dental professionals should assess the prevalence and presentation of comorbidities to determine the need for dental treatment modifications.7,8 We conducted a retrospective study to determine the prevalence of selected clinical and hematologic comorbidities that may affect the delivery of oral health care to older patients with HIV.
A trained oral health care professional (M.G.M.) abstracted data from medical history forms, laboratory reports and notes from the dental chart. Specifically, she abstracted demographic information (age, sex, race/ethnicity), clinical data (self-reported primary route of HIV transmission, alcohol and tobacco use, illicit drug use, self-reported comorbidities, antiviral medication use), laboratory-verified HIV-related data (CD4+ cell counts, HIV viral load [VL] levels) and other laboratory information (total white blood cell count [WBC]), hemoglobin level [Hgb], absolute neutrophil count [ANC], alanine aminotransferase level [ALT], aspartate aminotransferase level [AST] and platelet count) from the initial visit. She abstracted laboratory values within one month of the initial visit.
The comorbidities that had the potential to warrant dental modifications9 included viral hepatitis, hypertension, psychiatric disorders, chronic obstructive pulmonary disease (COPD), anemia, heart disease (coronary artery disease, including myocardial infarction, cardiomyopathy, heart murmur), stroke, diabetes mellitus, kidney disease, neurological disorders, orthopedic disease, bleeding disorders, cancer and tuberculosis. We determined the prevalence of each comorbidity among people 50 years or older who had HIV, as well as their immune, anemia (Hgb < 13 grams per deciliter for men and < 12 g/dL for women), leukopenia (WBC < 4.0 x 109/liter), neutropenia (ANC < 1,000 microliters) and thrombocytopenia (platelet count < 50 x 109/L) statuses. We also determined the incidence of critically low levels of Hgb that are considered important in the delivery of oral health care (< 9.0 g/dL).10
We used
SUBJECTS AND METHODS
TOP
ABSTRACT
SUBJECTS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
We conducted a retrospective review of the dental charts of 162 patients 50 years or older who sought treatment at the Oral Medicine Clinic of the New Jersey Dental School, University of Medicine and Dentistry of New Jersey, Newark, from 2000 through 2006. The institutional review board of the University of Medicine and Dentistry of New Jersey, Newark, approved our study. 
2 or Fisher exact tests, as appropriate, to test the association among the sex distributions for the clinical comorbidities, hematologic comorbidities and HIV-related laboratory data (CD4+ cell count, VL). We also used 2 or Fisher exact tests to assess the relationship between CD4+ cell counts and VL with select hematologic variables (ANC, Hgb level and platelet count); we separated the CD4+ cell counts into three categories (< 200 per cubic millimeter, 200–499/mm3 and 
500/mm3), and we separated VL into three categories (undetectable, < 10,000 copies per milliliter and 10,000 copies/mL). We set a significance level of P < .05 for all statistical tests. We performed all statistical analyses by using a software package (SAS, Version 9.1, SAS Institute, Cary, N.C.).
RESULTS
TOP
ABSTRACT
SUBJECTS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
REFERENCES
Among 162 subjects 50 years or older, 119 (73.5 percent) were men and 43 (26.5 percent) were women (Table 1
). The racial/ethnic distribution was 130 (80.3 percent) African-American, 14 (8.6 percent) white, 16 (9.9 percent) Hispanic and 2 (1.2 percent) unknown. The subjects’ ages ranged from 51 to 84 years, with a mean of 57 years. The primary HIV transmission categories were injecting drug users (IDU) (n = 50, 30.9 percent) and heterosexual behavior (n = 48, 29.6 percent). They were followed by men who have sex with men (MSM) (n = 8, 4.9 percent) and blood transfusion recipients (n = 3, 1.9 percent). Twelve (7.4 percent) subjects reported having multiple risk factors, and 41 (25.3 percent) reported having an unknown risk or had no information. Of the 160 subjects who reported tobacco use, 80 (50 percent) were current smokers. Of the total study sample of 162 subjects, 74 (45.7 percent) reported past injected drug use, nine (5.6 percent) reported current use, and 79 (48.8 percent) reported that they had never used any injected drugs. Among the 162 subjects, 117 (72.2 percent) were receiving HAART therapy.
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shows the prevalence of comorbidities reported for all study subjects and the distribution by sex. A total of 144 of the 162 study subjects (88.8 percent) reported having at least one comorbidity. Among those who reported having a comorbidity, 26 (18.0 percent) reported having one, 40 (27.8 percent) reported having two, and 78 (54.2 percent) reported having three or more. Among all study subjects, 72 (44.4 percent) reported having HCV, 67 (41.4 percent) reported having hypertension, 27 (16.7 percent) reported having psychiatric disorders, 26 (16.1 percent) reported having COPD, 25 (15.4 percent) reported having anemia, and 24 (14.8 percent) reported having heart disease. The rate of HCV ranged from 37.5 percent among MSM to 66.7 percent among blood transfusion recipients.
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The CD4+ cell count, HIV VL and hematologic profile of subjects with available data are shown in Table 3 (page 1472). Among the 124 subjects with available data on CD4+ cell counts, 91 (73.0 percent) had cell counts of less than 500/mm3, and 37 (29.8 percent) had cell counts of less than 200/mm3. Sixty-three (52.1 percent) of the 121 study subjects with available data on VL counts had undetectable VL, and 11 (9.1 percent) had a VL count of 10,000 copies/mL or greater. Among the 137 subjects with available data on Hgb levels, 53 (38.7 percent) had abnormal levels, and four (2.9 percent) had critically low levels. Among the 118 subjects with available on AST data, 74 (62.7 percent) had abnormal values. Among the 117 subjects with available ALT data, 60 (51.3 percent) had abnormal values. Among the 140 subjects with available WBC data, 42 (30 percent) had low levels of WBC (< 4,000/mL). Among the 118 subjects with available ANC data, 13 (11 percent) had critically low levels (< 1,000 µL). Among the 132 subjects with available platelet count data, 1 (0.8 percent) had critically low platelet counts (< 50,000). We found no sex differences for any variable.
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, we found no association (data not shown). Table 4 (page 1473) shows the results of our analysis of CD4+ cell count and HIV VL with ANC, platelet count, abnormal Hgb level (anemic) and critically low Hgb level. We found that 60.0 percent of subjects with a CD4+ cell count of less than 200/mm3 were anemic compared with 23.5 percent of subjects with a CD4+ cell count of 200/mm3 or greater (P < .001). In an analysis of the three categories of CD4+ cell count categories, we found that 60 percent of subjects in the lowest CD4+ cell count category (< 200/mm3) had anemia compared with 7 percent of subjects in the highest CD4+ cell count category ( 500/mm3) (data not shown). We found no associations between CD4+ cell count and ANC or platelet count. We used logistic regression to assess the relationship of CD4+ cell count and abnormal Hgb levels, adjusting for VL. Subjects with a CD4+ cell count of less than 200/mm3 had five times greater odds of having abnormal Hgb levels compared with subjects with a CD4+ cell count of 200/mm3 or greater (odds ratio = 5.20; 95 percent confidence interval = 1.94 to 13.96). We detected no significant associations between the CD4+ cell count and ANC. We found no significant association of VL with ANC, Hgb levels or platelet counts.
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DISCUSSION |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Viral hepatitis. Authors from France who produced a mortality report of all hospital wards known to treat patients with HIV identified cancer, viral hepatitis and cardiovascular disease as the top three non–AIDS-defining causes of death in the era of HAART.11 Authors of a recent study of 23,441 patients with HIV who were followed prospectively found that liver-related deaths were the most common cause of death after AIDS.12
Since HCV and HIV have common transmission risk factors, HCV is a common comorbidity among patients with HIV. Among IDUs and patients with hemophilia, rates of coinfection may be as high as 70 to 95 percent, as compared with 1 to 12 percent among MSM.13 In the population of urban older people with HIV who we studied, the rate of HCV ranged from 37.5 percent among MSM to 66.7 percent among those who had received blood transfusions, while the HCV rate ranged from 46 percent for IDUs and 50 percent for heterosexual patients (data not shown). As subjects self-reported their primary route of HIV transmission, we do not know if this is a true reflection of the prevalence among particular risk groups. The reported prevalence rate among the general population in the United States, however, is markedly lower (approximately 2.5 percent).14 Although our study population had a higher prevalence of HCV infection than did the general population, it was lower than that reported for patients coinfected with HIV. It is possible that our older study population includes those who have survived longer, owing to less severe HCV-induced liver disease. Our study population’s relatively low liver transaminase levels may support such a conclusion.
While modifications to dental treatment are not necessary for patients with asymptomatic viral hepatitis,15 dental professionals should request a medical consultation with the patient’s physician to determine the severity of any associated liver disease before providing dental care. Patients with HCV may have chronic active hepatitis, which can lead to compromised liver function and may interfere with hemostasis and altered drug metabolism.
Hypertension. The prevalence of hypertension, a primary risk factor for cardiovascular disease and stroke, is likely to increase as the population with HIV ages. The prevalence of hypertension in patients with HIV also has increased as a result of the more widespread use of HAART, particularly with certain classes of drugs. The 41.4 percent prevalence of hypertension among our study population is higher than that reported for adults older than 20 years with HIV (33 percent),16 but lower than that reported among the general older adult population in the United States (men aged 55–64 years, 45.8 percent; aged 65–74 years, 58.5 percent; 75 years and older, 68.8 percent; and women aged 55–64 years, 54.6 percent; aged 65–74 years, 74.3 percent; 75 years and older, 81.7 percent).16 It is not clear why there is such a discrepancy between our study population and other people of the same age groups. This, however, may be an indication of patients with HIV seeing a physician more often and addressing early signs of high blood pressure.
Important considerations for assessing the delivery of oral health care in older patients with HIV and hypertension include the patient’s clinical disease status (for example, controlled or uncontrolled, presence of signs or symptoms), the length of time that the patient has been hypertensive, and the presence or history of target organ disease. For patients with controlled hypertension, modifications to dental treatment are not necessary. However, depending on the patient’s history of target organ damage and the presence of signs and symptoms of hypertension, clinicians should assess patients individually, as modifications to dental treatment—including avoiding elective dental care—may be warranted.17
Psychiatric disorders. Psychiatric disorders in populations of people with HIV exceed general-population estimates significantly in the United States. Rates of depression range from 20 to 37 percent in people with HIV.18 Cognitive impairment increases as the immune system worsens and HIV progresses.19 Although the use of HAART has been associated with improvements in cognitive performance, data suggest there is no change in the frequency of cognitive abnormalities after widespread use of HAART.20 Furthermore, the prevalence of minor HIV-associated cognitive impairment is rising among patients on HAART as a result of the increased survival time.21
The reported prevalence of psychiatric disorders in our study population was 16.7 percent, which is slightly lower than the 20 to 37 percent in a previous report.18 Dental treatment modifications may be necessary in patients with psychiatric disorders owing to interactions between different analgesic agents and the antidepressant/antipsychotic class of drugs.17 Therefore, clinicians should take a thorough history of medication use when caring for patients with HIV and psychiatric disorders.
COPD. COPD includes chronic bronchitis, emphysema and asthma, which are characterized by chronic obstruction of the flow of air through the airways and out of the lungs. COPD affects more than 5 percent of the general adult population and occurs mainly in elderly people in whom it causes significant morbidity and mortality.22 The authors of a recent study of U.S. veterans found a 10 percent prevalence rate of COPD in people with HIV compared with a 9 percent prevalence rate in people who did not have HIV.23 After adjusting for potential effect modifiers, subjects with HIV had 1.47 greater odds of having COPD compared with subjects who did not have HIV, suggesting that HIV is an independent risk factor.
Current smoking was associated with increased mortality and decreased quality of life, as well as increased respiratory symptoms, COPD and bacterial pneumonia.24 These findings suggest that smoking cessation should be emphasized for patients with HIV.
A total of 16.1 percent of our study population reported having COPD, suggesting that COPD may be more common in older patients with HIV than in patients who did not have HIV or in the general U.S. adult population. When determining oral health care delivery strategies in these patients, clinicians should establish whether the disease is stable or unstable. Patients with unstable COPD (for example, those having a shortness of breath, a productive cough or an oxygen saturation level less than 91 percent) should avoid elective dental treatment. When treating patients with COPD, clinicians should monitor oxygen saturation levels, have an extra oxygen tank available and give careful consideration to the patient’s use of additional medications.17
Anemia. The prevalence of anemia among people with HIV varies widely by sex and race/ethnicity, with rates ranging from 12 to 95 percent, depending on the study setting.25 In general, reported rates are higher among blacks and among women. Data from a large cohort of women with HIV indicated a 71 percent greater prevalence of anemia among women compared with men. Although the use of HAART has been associated with a reduction in the prevalence of anemia in women with HIV, anemia remains an important comorbidity.
Our data suggest that anemia, as determined by abnormal Hgb levels, is common (38.7 percent) among adults 50 years or older who have HIV. We found critically low levels (< 9 g/dL), which are important when determining dental treatment, in only 2.9 percent of the subjects.
Although there is little risk of exacerbating anemia with routine dental procedures, depending on the severity and underlying cause of the anemia, dental treatment modifications that minimize blood loss may be warranted. The underlying cause of the anemia, specifically whether bone marrow suppression is involved, and the severity of the condition are important factors for clinicians to consider when planning treatment for these patients. The potential impact of people with HIV’s having anemia is highlighted in longitudinal studies of women with HIV in which anemia (< 12 g/dL) was associated independently with decreased survival or increased mortality.26,27
Neutropenia. The prevalence of neutropenia varies widely in patients with HIV; reported prevalence ranges from 10 to 50 percent.28,29 The authors of a recent longitudinal study of women with HIV suggests that the progression of HIV, as measured by deceasing CD4+ cell counts and increasing HIV RNA levels, is associated significantly with developing neutropenia, while HAART was associated with resolving neutropenia.30 ANCs less than 1,500/µL are associated with patients’ increased susceptibility to bacterial and fungal infections, and lower neutrophil counts are associated with increased risks.31 Eleven percent of our study subjects had an ANC of less than 1,000/µL, which was slightly higher than the 7 percent rate reported in the longitudinal study of women with HIV.30 While older patients with HIV may not have a greater rate of neutropenia than do younger patients with HIV, given the increased susceptibility to infection patients with neutropenia have, clinicians should recognize this condition and consider administering antibiotic prophylaxis to patients when warranted.17
Cytopenia. The incidence and severity of cytopenia generally are correlated to the stage of the HIV infection.31 Our results confirmed that among older patients with HIV, those with CD4+ cell counts of less than 200/mm3 were the most likely to have anemia, suggesting that a Hgb level assessment is warranted among older patients with HIV who have low CD4+ cell counts (less than 200/mm3).
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FOOTNOTES |
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