P.G. Robinson, BDS, LDS RCS,a H. Cooper, BDS, LDS RCS, MGDS,a and J. Hatt, BDS, LDS RCS,a London, England UNIVERSITY
COLLEGE
DENTAL
HOSPITAL
To determine the incidence of delayed healing after dental extractions in men with HIV infection, a retrospective audit was conducted of all extractions performed in a dedicated dental clinic over a 26-month period. The incidence of delayed healing in patients with HIV was compared with the incidence in those patients without HIV. Eighty men with HIV had 163 teeth extracted, which resulted in five dry sockets (3.01%). Thirty-six men thought not to have HIV had 70 extractions and three dry sockets (4.28%). Ali three dry sockets in the control group occurred in men who had tested negative for HIV antibodies in the year before their extraction. There were no other incidents of delayed healing. These findings contrast with other reports since they reveal no increase in delayed healing after extractions in men with HIV and do not support recommendations that prophylactic antimicrobials are required for extractions in this group of patients. (ORAL SURC ORAL MED ORAL PATHOL
1992;74:426-30)
ince inflammatory processesplay a central role in wound healing, there has been concern that patients with immunodeficiency associatedwith HIV infection may experience delayed wound healing. Several studies of persons with HIV have shown delayed healing after surgery, particularly anorectal surgery.tm6 Delayed healing has been included in one classification of oral manifestations of HIV infection, and this has prompted one group of authors to suggest consideration of prophylactic antimicrobial therapy for surgical procedures in these patients.7, 8 Only one study has reported delayed healing after oral surgery. Reichart et a1.9described impaired or delayed wound healing because of local infections in four male patients with AIDS-related complex or AIDS who had undergone extractions or osteotomies.This report constitutes very few casescompared with the number of personsinfected with HIV, and this possibleoral manifestation of the infection has been omitted from more recent classifications.lO,l l The most common causeof delayed healing of dental extraction sitesin general populations is dry socket (localized osteitis). In the study by MacGregorI of aClinical assistants. 7/12/39505
426
10,199 extractions, dry sockets occurred in 3.2% of cases.Patients whosegeneral health was described as “not normal” did not have a significantly different experience of dry sockets than those with “normal” health. In a more recent investigation, Meechan et al. also found an incidence of dry socketsof 3.2% in male patients after single extractions.13 Clearly, information is required as to whether patients with HIV infection experience an increased incidence of dry socketsand/or whether wound healing is delayed in any other way. However, no formal studies of healing after oral surgery have been reported in patients with HIV infection. Studies of postextraction healing are difficult to control. Many factors influence the incidence of dry sockets, including the age and gender of the patient, the patient’s use of tobacco, the number of teeth extracted at one time, the difficulty of the extraction, the type of tooth extracted, the local anesthetic agent used, the route of administration of the local anesthetic agent, and the experience of the surgeon.12-15 This article reports on a retrospective audit of a series of dental extractions performed at a dedicated dental clinic that provides care for personswith HIV diseaseand hepatitis B antigens. Since the patients at the clinic are predominantly male and since both patient groups were treated at the samesite, by the same
Volume Number
Postextraction
74 4
Table I. Number
and health status of patients
healing in men with HIV
Table II. Reasons for extraction
427
of teeth Patients
Reasons
~~ HIV positive/ AIDS Hepatitis B/ Homosexuals/ injected drug
80
163
14
5 (3.01)
36
70
3
3 (4.28)
users
oral surgeons who used the same extraction protocol and the same infection-control policy, it was possible to compare the incidence of dry socket in the two groups and eliminate: several intervening variables. METHOD
A retrospective audit was carried out of all patients given appointments for dental extractions at a hospital-based dedicated dental clinic in the period from Jan. 8, 1989, to Nov. 11, 1991. The names of patients and their hospital numbers were obtained from the clinic lists, and the case notes were located. The notes were examined by an independent assessor, and data for each extraction were entered onto a spreadsheet. The following data were collected from patients’ records: gender, patient number, date of extraction, tooth extracted, HIV status of patient, other relevant medical history, date of birth, age, reason for extraction, preoperative and perioperative complications, whether bone was removed, whether the patient was examined after the extraction, and postoperative complications. Since the gender of the patient is associated with the occurrence of dry sockets, only men were included in the study. The men were divided into two groups on the basis of their health status. One group comprised men known to have HIV infection or AIDS. A comparison group was formed of men with hepatitis B antigens, homosexual men, or men with a history of injected drug use. Creation of such a comparison group allowed the results from the group with HIV or AIDS to be compared with more general populations and with a similar group of men treated at the same clinic by the same dentists. RESULTS
Examination of the clinic lists indicated that 116 men had made 148 visits for dental extractions in the period from Jan. 8, 1989, to Nov. 11, 1991. The records for these patients were located and informa-
for
extraction
Caries et sequelae Periodontal disease Pericoronitis et sequelae
HIV/AIDS 117 36 10
Comparison
group
59 3 8
lion was collected on 233 extractions performed by the four clinic dentists. The number of patients in each group is described in Table I. Seventeen men in the comparison group had been tested and found not to have antibodies to HIV in the year before their extraction. The patients with HIV/ AIDS had a mean age of 35.1 years (SD, 7.3 years), and the mean age of the patients in the comparison group was 31.9 years (SD, 6.5 years). The reasons for the extractions in both groups are summarized in Table II. Proportionately more teeth were extracted from the group with HIV or AIDS because of periodontal diseases (x-squared = 11.13, p = 0.001) and included four teeth extracted from one man with HIV-associated periodontitis. The types of teeth extracted are summarized in Table III and were broadly similar in both groups. The distribution of the number of teeth extracted at each visit was similar in both groups. All patients who had bone removed to facilitate extraction were prescribed postoperative penicillin V (250 mg four times a day for 5 days). One patient with HIV infection was prescribed preoperative amoxicillin (3 gr orally 1 hour before surgery), because of a heart murmur. One patient with AIDS was prescribed erythromycin stearate (1.5 gr, 1 hour before surgery and 500 mg 6 and 12 hours after surgery) on the advice of his radiotherapist after radiotherapy for palatal Kaposi’s sarcoma. One patient with hepatitis B had been taking penicillin V (250 mg four times a day for the 5 days) before his extraction for periapical periodontitis. Seventy patients with HIV/AIDS and 15 patients in the comparison group were reviewed 1 week after surgery (i.e., after 55.4% of the visits). All the patients had been invited to contact the clinic if they had any problems after their extractions. Five patients with HIV infection returned with dry sockets. The first two of these were a 36-year-old man with asymptomatic HIV infection after the extraction of an upper right first molar and a 25-year-old man with asymptomatic HIV infection after routine extraction of an upper right third molar. A 34-year-old man with asymptomatic HIV infection who had been
428
Robinson, Cooper, and H&e
ORALSLJRC-
ORAL
MED ORAL PATHOL
October 1992
fable 111.Sites of 233 dental extractions
Tooth Upper teeth in HIV/AIDS group Upper teeth in comparison group Lower teeth in HIV/AIDS group Lower teeth in comparison group
1 ‘r?r ~ ~ lstand canines Premolars 2nd molars 8
24
38
4
8
110
18
13
26
6
3
16
3rd molars
taking antibiotics for a medical problem had a dry socket after routine extraction of a lower left third molar. Two men experienced dry sockets after difficult extractions that had involved bone removal-a 34-year-old man with asymptomatic HIV infection who had the lower right first molar extracted and a 33-year-old man with AIDS-related complex who had the lower right second premolar extracted. Three patients in the comparison group had dry sockets. All three had tested negative for HIV antibodies in the year before their extraction. The first was a 29-year-old man with hepatitis B who developed a dry socket after the extraction of a lower left second molar, and the secondwas a 32-year-old homosexual man with a dry socket that developed after the extraction of a lower left first molar. Both of these extractions involved the surgical removal of bone. The third casewas in a 34-year-old man after routine extraction of an upper left first molar. At l-week review, the patient was found to have a dry socket and a cloudy left maxillary antrum on a radiograph. No oro-antral communication was evident on clinical examination. Treatment for dry socket was supplemented with an antral regimen; subsequent healing was uneventful. All dry sockets in both groups were treated by irrigation with a saline solution, a dressing of butamben, iodoform, and eugenol, and analgesics. After this, healing was uneventful in all cases. Table IV compares the number of dry socketsthat occurred in the men with HIV or AIDS who had not received antibiotics immediately before or after their extractions with the number of men who had had negative HIV antibody tests in the year before their extractions and who had not received antibiotics. Four men from the HIV/AIDS group and one homosexual man who had tested HIV negative from the
Table IV. Number of teeth extracted in patients tested for HIV antibodies who did not take antibiotics immediately before or after extraction ~_ / Patients Men with HIV/AIDS Men found to be HIV negative
No. of teeth extracted I45 21
No. of dry No. of sockets extractions not reviewed (%I 2 (1.38) 1 (4.76)
36 11
comparison group reported pain on the day after their extractions. The extractions from three of these patients had required surgical bone removal. No other complications were identified in either group. DISCUSSION There are a number of reasons why these results must be treated with care. First, the samples are small. Previous studiesindicate that dry socketsoccur after approximately 3% of extractions; thus a study that involved 233 extractions would not be expected to reveal many dry sockets.“9 t3 Statistical analysis of such data would be inappropriate, and the inferences drawn from the results must be limited. However, much of our understanding of the prevention of dry socketscomesfrom smaller studies.16-18 The findings of this interim study are important becausethey have immediate relevance to personswith HIV infection, and other centers in the United Kingdom may not be able to collect and analyze a similar amount of data. This study presents more substantial evidence than any of the other literature on healing after oral surgery in personswith XIV infection.7-9 Second, the incidence of dry sockets after surgical removal of third molars is related to the experience of the surgeon.I5 In this study, three of the four clinic dentists had been qualified for at least 8 years, and had at least 1 year of experience as a specialist in an oral surgery unit. Third, all the extractions were performed in a clinic designedto have optimal levels of infection control. Therefore a low incidence of dry socketsmight be expected in patients treated by this group of dentists in this setting. It should be stressed that the implications of these two points are likely to be limited because all dentists who perform dental extractions should be proficient in the techniques, and good infection control is essential in ail dental settings. Fourth, a greater proportion of teeth were extracted from men with HIV infection becauseof periodontal diseasesthan in the comparison group (22% compared with 4.2%). One reasonfor this may be that
Volume Number
74 4
many patients in the comparison group had come to the clinic in pain on an emergency basis. Periodontal diseases do not commonly cause pain and are less likely to have been a catuse for presentation in this patient group. The influence of these factors on wound healing is not known. Finally, only one half of the wounds were reviewed after the extractions, although all the patients were advised to contact the clinic if they had any problems after their treatment. Since dry sockets are notoriously painful, it seems unlikely that a significant number of patients woluld have experienced such discomfort without seeking further care. Men with HIV infection and AIDS often come to the dedicated clinic because they are una’ble to obtain dental care elsewhere, thus it is unlikely that they would have sought treatment for dry sockets from other dentists. Of 233 extractions, only 8 resulted in a dry socket (3.4%). This figure is similar to those reported in earlier studies of extractions from different sites in the mouth.t*? l3 A higher incidence might be expected in a specialist oral surgery unit that removed proportionately more impacted third molars. In this case, however, only 28 of 233 teeth extracted were lower third molars (Table III). Dry sockets occurred after only 5 of 163 extractions (3.01%) in persons with HIV infection and after 3 of 70 extractions (4.28%) in the comparison group (all three in men who had tested negative for antibodies to HIV in the year before). Systemic antibiotics have a prophylactic elect against dry sockets,16, t7, l9 and if those patients who had taken antibiotics are excluded (Table IV), dry sockets occurred after 1.38% of extractions in persons with HIV and in one patient (4.76%) who did not have HIV infection. A discrepancy of this size is unremarkable in such a small group. Overall, the results of this audit suggest that the incidence of dry sockets in men with HIV infection is comparable to the incidence in general populations, l*, ’ 3 and no increase in the incidence was found compared with a similar group of men who were treated by the same dentists in the same setting but who did not have HIV. Prophylactic antimicrobial therapy could be deemed necessary only for specific patients if they are at greater risk of complications after surgery or if their complications are more severe. These data do not satisfy either of these: requirements and suggest that prophylactic antimicrobials are not required for dental extractions in men with HIV infection. The implications of these findings are important. Dental treatment should not be complicated unduly for any patient. Many persons with HIV infection ex-
Postextraction
healing in men with HIV
429
perience difficulty obtaining dental care, and their problems will be increased if treatment cannot be carried out routinely in general dental practice. These results indicate that this relatively traumatic form of dental treatment can be carried out on persons with HIV infection without undue risk to the patients and without the additional hurdle of taking prescribed prophylactic antibiotics. Further work is required to confirm the findings of this study. To provide data amenable to statistical analysis, such work should involve larger samples and control groups. Multicenter studies may be one way to achieve this, but they would introduce the additional variables
discussed earlier, which
may cloud
the findings. Also, the difficulties of locating a large control population of persons known not to have HIV infection have dogged other research.20 The numbers
in such a population who will also require removal of teeth will be even smaller. The assistance of Ms. K. Farley and Ms. N. Foster in identifying, locating, and assessing the patient records is gratefully acknowledged. We also thank Dr. Joanna Zakrzewska and Professor Aubrey Sheiham for reading drafts of this manuscript and for their support and encouragement. REFERENCES 1. Bayley AC. Surgical pathology of HIV infection: lessons from africa. Br J Surg 1990,77:863-8. 2. Wexner SD, Smithy WB, Milsom JW, Dailey TH. The surgical management of anorectal diseases in AIDS and pre-AIDS patients. Dis Colon Rectum 1986;29:719-23. 3. Wolkomir AF, Baron JE, Hardy HW III, Cottone FJ. Abdominal and anorectal surgery and the acquired immune deficiency syndrome in heterosexual intravenous drug users. Dis Colon Rectum 1990;33:267-70. 4. Carr ND, Mercey D, Slack WW. Noncondylomatous perianal disease in homosexual men. Br J Surg 1990;76:1064-6. 5. Wakeman R, Johnson CD, Waste11 C. Surgical procedures in patients at risk of HIV infection. J R Sot Med 1990;83:315-8. 6. Safavi A, Gottesman L, Dailey TH. Anorectal surgery in the HIV+ patient: update. Dis Colon Rectum 1991;34:299-304. 7. Pindborg JJ. Classification of oral lesions associated with HIV infection. ORAL SURG ORAL MED ORAL PATHOL 1989; 671292-5. 8. Scully C, Porter SR, Luker J. An ABC of oral health care in patients with HIV infection. Br Dent J 1991;170:149-50. 9. Reichart P, Gelderblom HR, Becker J, Kuntz A. AIDS and the oral cavity-the HIV infection: virology, etiology, origin, immunology, precautions and clinical observations in 110 patients. Int J Oral Maxillofac Surg 1987;16:129-53. 10. EEC Clearinghouse on oral problems related to HIV infection and WHO Collaborating Centre on oral manifestations of the human immunodeficiency virus: an update of the classification and diagnostic criteria of the oral lesions in HIV infection. Oral Path01 Med 1991;20:97-100. 11. Greenspan D, Greenspan JS, Schi#dt M, Pindborg JJ. AIDS and the mouth. Copenhagen: Munksgaard. 1990. 12. MacGregor AJ. Aetiology of dry socket: a clinical investigation. Br J Oral Surg 1968;6:49-58. 13. Meechan JG, Venchard GR, Rogers N, et al. Local anaesthesia and dry socket. Int J Oral Maxillofac Surg 1987;16:279-84.
430
Robinson,
Cooper, and Hatl
ORAL SLRGORALN~~DORAL October
14. Sweet JB, Butler DP. Predisposing and operative factors: elfeet on the incidence of localized osteitis in mandibular third molar surgery. ORAL SURG ORAL MED ORAL PATHOL 1978; 46:206-15. 15. Sisk AL, Hammer WB, Shelton DW, Joy ED. Complications following removal of impacted third molars: the role of experience of the surgeon. J Oral Maxillofac Surg 1986;44:855-9. 16. Curran JB, Kennett S, Young AR. An assessment of the use of prophyiactic antibiotics in third molar surgery. Int J Oral Surg 1914;3:1-6. 17. Kremankov L. Alveolitis after operative removal of third molars in the mandible. Int J Oral Surg 1981;10:173-9. 18. Tjernberg A. Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Surg 1979;8:430-4.
PATHOi 1992
19. Bystedt H, Nord CE, Nordenram A. Effect of azidocil!in, erythromycin, clindamycin, and daxycycline on postoperative complications after surgical removal of impacted third molars. fnt J Oral Surg 1980;9:157-65. 20. Cornick DER, Robinson PG. A three-year study of the periodontal condition in HIV positive men [Abstract]. J Dent Res 1991;70:688.
Reprint requests. Peter Robinson, BDS, LDS RCS University College Dental Hospital Mortimer Market London, WCIE 6AU, England
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Boundvolumes of ORALSURGERY,ORAL MEDICINE,AND ORALPATHOLOGY areavailabletosubscribers (only) for the 1991 issues from the Publisher, at a cost of $45.00 for domestic, $60.15 for Canadian, and $57.00 for international, for Vol. 71 (January-June) and Vol. 72 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must arcompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800)325-4177, ext. 4351, or (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
COLLEGE
DENTAL
HOSPITAL
To determine the incidence of delayed healing after dental extractions in men with HIV infection, a retrospective audit was conducted of all extractions performed in a dedicated dental clinic over a 26-month period. The incidence of delayed healing in patients with HIV was compared with the incidence in those patients without HIV. Eighty men with HIV had 163 teeth extracted, which resulted in five dry sockets (3.01%). Thirty-six men thought not to have HIV had 70 extractions and three dry sockets (4.28%). Ali three dry sockets in the control group occurred in men who had tested negative for HIV antibodies in the year before their extraction. There were no other incidents of delayed healing. These findings contrast with other reports since they reveal no increase in delayed healing after extractions in men with HIV and do not support recommendations that prophylactic antimicrobials are required for extractions in this group of patients. (ORAL SURC ORAL MED ORAL PATHOL
1992;74:426-30)
ince inflammatory processesplay a central role in wound healing, there has been concern that patients with immunodeficiency associatedwith HIV infection may experience delayed wound healing. Several studies of persons with HIV have shown delayed healing after surgery, particularly anorectal surgery.tm6 Delayed healing has been included in one classification of oral manifestations of HIV infection, and this has prompted one group of authors to suggest consideration of prophylactic antimicrobial therapy for surgical procedures in these patients.7, 8 Only one study has reported delayed healing after oral surgery. Reichart et a1.9described impaired or delayed wound healing because of local infections in four male patients with AIDS-related complex or AIDS who had undergone extractions or osteotomies.This report constitutes very few casescompared with the number of personsinfected with HIV, and this possibleoral manifestation of the infection has been omitted from more recent classifications.lO,l l The most common causeof delayed healing of dental extraction sitesin general populations is dry socket (localized osteitis). In the study by MacGregorI of aClinical assistants. 7/12/39505
426
10,199 extractions, dry sockets occurred in 3.2% of cases.Patients whosegeneral health was described as “not normal” did not have a significantly different experience of dry sockets than those with “normal” health. In a more recent investigation, Meechan et al. also found an incidence of dry socketsof 3.2% in male patients after single extractions.13 Clearly, information is required as to whether patients with HIV infection experience an increased incidence of dry socketsand/or whether wound healing is delayed in any other way. However, no formal studies of healing after oral surgery have been reported in patients with HIV infection. Studies of postextraction healing are difficult to control. Many factors influence the incidence of dry sockets, including the age and gender of the patient, the patient’s use of tobacco, the number of teeth extracted at one time, the difficulty of the extraction, the type of tooth extracted, the local anesthetic agent used, the route of administration of the local anesthetic agent, and the experience of the surgeon.12-15 This article reports on a retrospective audit of a series of dental extractions performed at a dedicated dental clinic that provides care for personswith HIV diseaseand hepatitis B antigens. Since the patients at the clinic are predominantly male and since both patient groups were treated at the samesite, by the same
Volume Number
Postextraction
74 4
Table I. Number
and health status of patients
healing in men with HIV
Table II. Reasons for extraction
427
of teeth Patients
Reasons
~~ HIV positive/ AIDS Hepatitis B/ Homosexuals/ injected drug
80
163
14
5 (3.01)
36
70
3
3 (4.28)
users
oral surgeons who used the same extraction protocol and the same infection-control policy, it was possible to compare the incidence of dry socket in the two groups and eliminate: several intervening variables. METHOD
A retrospective audit was carried out of all patients given appointments for dental extractions at a hospital-based dedicated dental clinic in the period from Jan. 8, 1989, to Nov. 11, 1991. The names of patients and their hospital numbers were obtained from the clinic lists, and the case notes were located. The notes were examined by an independent assessor, and data for each extraction were entered onto a spreadsheet. The following data were collected from patients’ records: gender, patient number, date of extraction, tooth extracted, HIV status of patient, other relevant medical history, date of birth, age, reason for extraction, preoperative and perioperative complications, whether bone was removed, whether the patient was examined after the extraction, and postoperative complications. Since the gender of the patient is associated with the occurrence of dry sockets, only men were included in the study. The men were divided into two groups on the basis of their health status. One group comprised men known to have HIV infection or AIDS. A comparison group was formed of men with hepatitis B antigens, homosexual men, or men with a history of injected drug use. Creation of such a comparison group allowed the results from the group with HIV or AIDS to be compared with more general populations and with a similar group of men treated at the same clinic by the same dentists. RESULTS
Examination of the clinic lists indicated that 116 men had made 148 visits for dental extractions in the period from Jan. 8, 1989, to Nov. 11, 1991. The records for these patients were located and informa-
for
extraction
Caries et sequelae Periodontal disease Pericoronitis et sequelae
HIV/AIDS 117 36 10
Comparison
group
59 3 8
lion was collected on 233 extractions performed by the four clinic dentists. The number of patients in each group is described in Table I. Seventeen men in the comparison group had been tested and found not to have antibodies to HIV in the year before their extraction. The patients with HIV/ AIDS had a mean age of 35.1 years (SD, 7.3 years), and the mean age of the patients in the comparison group was 31.9 years (SD, 6.5 years). The reasons for the extractions in both groups are summarized in Table II. Proportionately more teeth were extracted from the group with HIV or AIDS because of periodontal diseases (x-squared = 11.13, p = 0.001) and included four teeth extracted from one man with HIV-associated periodontitis. The types of teeth extracted are summarized in Table III and were broadly similar in both groups. The distribution of the number of teeth extracted at each visit was similar in both groups. All patients who had bone removed to facilitate extraction were prescribed postoperative penicillin V (250 mg four times a day for 5 days). One patient with HIV infection was prescribed preoperative amoxicillin (3 gr orally 1 hour before surgery), because of a heart murmur. One patient with AIDS was prescribed erythromycin stearate (1.5 gr, 1 hour before surgery and 500 mg 6 and 12 hours after surgery) on the advice of his radiotherapist after radiotherapy for palatal Kaposi’s sarcoma. One patient with hepatitis B had been taking penicillin V (250 mg four times a day for the 5 days) before his extraction for periapical periodontitis. Seventy patients with HIV/AIDS and 15 patients in the comparison group were reviewed 1 week after surgery (i.e., after 55.4% of the visits). All the patients had been invited to contact the clinic if they had any problems after their extractions. Five patients with HIV infection returned with dry sockets. The first two of these were a 36-year-old man with asymptomatic HIV infection after the extraction of an upper right first molar and a 25-year-old man with asymptomatic HIV infection after routine extraction of an upper right third molar. A 34-year-old man with asymptomatic HIV infection who had been
428
Robinson, Cooper, and H&e
ORALSLJRC-
ORAL
MED ORAL PATHOL
October 1992
fable 111.Sites of 233 dental extractions
Tooth Upper teeth in HIV/AIDS group Upper teeth in comparison group Lower teeth in HIV/AIDS group Lower teeth in comparison group
1 ‘r?r ~ ~ lstand canines Premolars 2nd molars 8
24
38
4
8
110
18
13
26
6
3
16
3rd molars
taking antibiotics for a medical problem had a dry socket after routine extraction of a lower left third molar. Two men experienced dry sockets after difficult extractions that had involved bone removal-a 34-year-old man with asymptomatic HIV infection who had the lower right first molar extracted and a 33-year-old man with AIDS-related complex who had the lower right second premolar extracted. Three patients in the comparison group had dry sockets. All three had tested negative for HIV antibodies in the year before their extraction. The first was a 29-year-old man with hepatitis B who developed a dry socket after the extraction of a lower left second molar, and the secondwas a 32-year-old homosexual man with a dry socket that developed after the extraction of a lower left first molar. Both of these extractions involved the surgical removal of bone. The third casewas in a 34-year-old man after routine extraction of an upper left first molar. At l-week review, the patient was found to have a dry socket and a cloudy left maxillary antrum on a radiograph. No oro-antral communication was evident on clinical examination. Treatment for dry socket was supplemented with an antral regimen; subsequent healing was uneventful. All dry sockets in both groups were treated by irrigation with a saline solution, a dressing of butamben, iodoform, and eugenol, and analgesics. After this, healing was uneventful in all cases. Table IV compares the number of dry socketsthat occurred in the men with HIV or AIDS who had not received antibiotics immediately before or after their extractions with the number of men who had had negative HIV antibody tests in the year before their extractions and who had not received antibiotics. Four men from the HIV/AIDS group and one homosexual man who had tested HIV negative from the
Table IV. Number of teeth extracted in patients tested for HIV antibodies who did not take antibiotics immediately before or after extraction ~_ / Patients Men with HIV/AIDS Men found to be HIV negative
No. of teeth extracted I45 21
No. of dry No. of sockets extractions not reviewed (%I 2 (1.38) 1 (4.76)
36 11
comparison group reported pain on the day after their extractions. The extractions from three of these patients had required surgical bone removal. No other complications were identified in either group. DISCUSSION There are a number of reasons why these results must be treated with care. First, the samples are small. Previous studiesindicate that dry socketsoccur after approximately 3% of extractions; thus a study that involved 233 extractions would not be expected to reveal many dry sockets.“9 t3 Statistical analysis of such data would be inappropriate, and the inferences drawn from the results must be limited. However, much of our understanding of the prevention of dry socketscomesfrom smaller studies.16-18 The findings of this interim study are important becausethey have immediate relevance to personswith HIV infection, and other centers in the United Kingdom may not be able to collect and analyze a similar amount of data. This study presents more substantial evidence than any of the other literature on healing after oral surgery in personswith XIV infection.7-9 Second, the incidence of dry sockets after surgical removal of third molars is related to the experience of the surgeon.I5 In this study, three of the four clinic dentists had been qualified for at least 8 years, and had at least 1 year of experience as a specialist in an oral surgery unit. Third, all the extractions were performed in a clinic designedto have optimal levels of infection control. Therefore a low incidence of dry socketsmight be expected in patients treated by this group of dentists in this setting. It should be stressed that the implications of these two points are likely to be limited because all dentists who perform dental extractions should be proficient in the techniques, and good infection control is essential in ail dental settings. Fourth, a greater proportion of teeth were extracted from men with HIV infection becauseof periodontal diseasesthan in the comparison group (22% compared with 4.2%). One reasonfor this may be that
Volume Number
74 4
many patients in the comparison group had come to the clinic in pain on an emergency basis. Periodontal diseases do not commonly cause pain and are less likely to have been a catuse for presentation in this patient group. The influence of these factors on wound healing is not known. Finally, only one half of the wounds were reviewed after the extractions, although all the patients were advised to contact the clinic if they had any problems after their treatment. Since dry sockets are notoriously painful, it seems unlikely that a significant number of patients woluld have experienced such discomfort without seeking further care. Men with HIV infection and AIDS often come to the dedicated clinic because they are una’ble to obtain dental care elsewhere, thus it is unlikely that they would have sought treatment for dry sockets from other dentists. Of 233 extractions, only 8 resulted in a dry socket (3.4%). This figure is similar to those reported in earlier studies of extractions from different sites in the mouth.t*? l3 A higher incidence might be expected in a specialist oral surgery unit that removed proportionately more impacted third molars. In this case, however, only 28 of 233 teeth extracted were lower third molars (Table III). Dry sockets occurred after only 5 of 163 extractions (3.01%) in persons with HIV infection and after 3 of 70 extractions (4.28%) in the comparison group (all three in men who had tested negative for antibodies to HIV in the year before). Systemic antibiotics have a prophylactic elect against dry sockets,16, t7, l9 and if those patients who had taken antibiotics are excluded (Table IV), dry sockets occurred after 1.38% of extractions in persons with HIV and in one patient (4.76%) who did not have HIV infection. A discrepancy of this size is unremarkable in such a small group. Overall, the results of this audit suggest that the incidence of dry sockets in men with HIV infection is comparable to the incidence in general populations, l*, ’ 3 and no increase in the incidence was found compared with a similar group of men who were treated by the same dentists in the same setting but who did not have HIV. Prophylactic antimicrobial therapy could be deemed necessary only for specific patients if they are at greater risk of complications after surgery or if their complications are more severe. These data do not satisfy either of these: requirements and suggest that prophylactic antimicrobials are not required for dental extractions in men with HIV infection. The implications of these findings are important. Dental treatment should not be complicated unduly for any patient. Many persons with HIV infection ex-
Postextraction
healing in men with HIV
429
perience difficulty obtaining dental care, and their problems will be increased if treatment cannot be carried out routinely in general dental practice. These results indicate that this relatively traumatic form of dental treatment can be carried out on persons with HIV infection without undue risk to the patients and without the additional hurdle of taking prescribed prophylactic antibiotics. Further work is required to confirm the findings of this study. To provide data amenable to statistical analysis, such work should involve larger samples and control groups. Multicenter studies may be one way to achieve this, but they would introduce the additional variables
discussed earlier, which
may cloud
the findings. Also, the difficulties of locating a large control population of persons known not to have HIV infection have dogged other research.20 The numbers
in such a population who will also require removal of teeth will be even smaller. The assistance of Ms. K. Farley and Ms. N. Foster in identifying, locating, and assessing the patient records is gratefully acknowledged. We also thank Dr. Joanna Zakrzewska and Professor Aubrey Sheiham for reading drafts of this manuscript and for their support and encouragement. REFERENCES 1. Bayley AC. Surgical pathology of HIV infection: lessons from africa. Br J Surg 1990,77:863-8. 2. Wexner SD, Smithy WB, Milsom JW, Dailey TH. The surgical management of anorectal diseases in AIDS and pre-AIDS patients. Dis Colon Rectum 1986;29:719-23. 3. Wolkomir AF, Baron JE, Hardy HW III, Cottone FJ. Abdominal and anorectal surgery and the acquired immune deficiency syndrome in heterosexual intravenous drug users. Dis Colon Rectum 1990;33:267-70. 4. Carr ND, Mercey D, Slack WW. Noncondylomatous perianal disease in homosexual men. Br J Surg 1990;76:1064-6. 5. Wakeman R, Johnson CD, Waste11 C. Surgical procedures in patients at risk of HIV infection. J R Sot Med 1990;83:315-8. 6. Safavi A, Gottesman L, Dailey TH. Anorectal surgery in the HIV+ patient: update. Dis Colon Rectum 1991;34:299-304. 7. Pindborg JJ. Classification of oral lesions associated with HIV infection. ORAL SURG ORAL MED ORAL PATHOL 1989; 671292-5. 8. Scully C, Porter SR, Luker J. An ABC of oral health care in patients with HIV infection. Br Dent J 1991;170:149-50. 9. Reichart P, Gelderblom HR, Becker J, Kuntz A. AIDS and the oral cavity-the HIV infection: virology, etiology, origin, immunology, precautions and clinical observations in 110 patients. Int J Oral Maxillofac Surg 1987;16:129-53. 10. EEC Clearinghouse on oral problems related to HIV infection and WHO Collaborating Centre on oral manifestations of the human immunodeficiency virus: an update of the classification and diagnostic criteria of the oral lesions in HIV infection. Oral Path01 Med 1991;20:97-100. 11. Greenspan D, Greenspan JS, Schi#dt M, Pindborg JJ. AIDS and the mouth. Copenhagen: Munksgaard. 1990. 12. MacGregor AJ. Aetiology of dry socket: a clinical investigation. Br J Oral Surg 1968;6:49-58. 13. Meechan JG, Venchard GR, Rogers N, et al. Local anaesthesia and dry socket. Int J Oral Maxillofac Surg 1987;16:279-84.
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14. Sweet JB, Butler DP. Predisposing and operative factors: elfeet on the incidence of localized osteitis in mandibular third molar surgery. ORAL SURG ORAL MED ORAL PATHOL 1978; 46:206-15. 15. Sisk AL, Hammer WB, Shelton DW, Joy ED. Complications following removal of impacted third molars: the role of experience of the surgeon. J Oral Maxillofac Surg 1986;44:855-9. 16. Curran JB, Kennett S, Young AR. An assessment of the use of prophyiactic antibiotics in third molar surgery. Int J Oral Surg 1914;3:1-6. 17. Kremankov L. Alveolitis after operative removal of third molars in the mandible. Int J Oral Surg 1981;10:173-9. 18. Tjernberg A. Influence of oral hygiene measures on the development of alveolitis sicca dolorosa after surgical removal of mandibular third molars. Int J Oral Surg 1979;8:430-4.
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19. Bystedt H, Nord CE, Nordenram A. Effect of azidocil!in, erythromycin, clindamycin, and daxycycline on postoperative complications after surgical removal of impacted third molars. fnt J Oral Surg 1980;9:157-65. 20. Cornick DER, Robinson PG. A three-year study of the periodontal condition in HIV positive men [Abstract]. J Dent Res 1991;70:688.
Reprint requests. Peter Robinson, BDS, LDS RCS University College Dental Hospital Mortimer Market London, WCIE 6AU, England
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