Fall 2007

DISCUSSION
Eruption

Though not statistically significant, HIVinfected children were more likely to have an abnormal eruption status compared to controls (69 % vs. 41 %). The HIV-infected subjects had a 58 % chance of delayed dental eruption, an 11 % chance of accelerated eruption, and a 32 % chance of appropriate eruption. The control had a 29 % chance of delay, a 14 % chance of accelerated eruption, and a 57 % chance appropriate eruption. Our results showed a greater percentage of delay than a 2000 Romanian study of HIV-infected children in orphanages which revealed a 42 % delay [5]. This result also supports 4 additional studies which noted delayed dental eruption [1], [2], [3], [4]. The results did not indicate a relationship between severity of HIV-infection (in terms of lowest CD4 % and viral load) and likelihood of delayed dental eruption. Height, in terms of a z-score, was not significantly correlated to eruption status, but those with a more positive z-score were more likely to have accelerated eruption. In the future, it would be important to expand upon the number of HIV-infected patients and control subjects aged 6 months to 14.0 years old in order to get a more accurate representation of eruption status. In addition, it would be helpful to perform a longitudinal study and follow the children to see whether or not their status of delayed, normal, or accelerated would change over time.

Salivary Flow and Plaque

The mean salivary flow rate of the HIV-infected participants was slightly higher than that of the control with a difference of 0.04 g/min. A pre-HAART study of 98 HIV-infected gay/bisexual men versus 33 controls found that parotid flow rate was not significantly different between the HIV-infected group and the control, but over the course of a year, the HIV-infected patients were more likely to experience a decrease in flow rate [15]. It would be interesting in a future study to follow up with the same patients to see if a trend such as this would be found. A 2000 study of HIV-positive women found salivary flow rates to be the same between household peers and those with HIV-infection also [10]. Within the HIV-infected population, this study did not reveal that salivary flow rate was affected by the use of HAART. As earlier studies indicated, this study showed that increased viral load is correlated with decreased salivary flow [12]. CD4 count suggested an opposite trend, so it is difficult to say whether severity of HIV-infection can be correlated to salivary flow in the same manner that earlier studies did [11]. In the future, it might be beneficial to use a different saliva collection technique to improve the accuracy. Additionally, the study could benefit from more participants.

Dental Care

Interestingly, the HIV-infected children were more likely to attend regular dentist appointments and had a decreased sugar intake versus the control, but the mean plaque score for the HIVinfected group was higher.

CONCLUSION

In summary, HIV-infected children were more likely to experience delayed dental eruption than household peers. Those with delayed dental eruption also had lower, though not statistically significant height z-scores. There was no significant difference between the salivary flow rates of the HIV-infected population versus the control. Within the HIV-infected population, patients with viral loads greater than 10,000 copies/mL tended to have decreased salivary flow versus those with viral load below 10,000 copies/mL, while those with a lowest CD4 percentage below 20 % had an increased salivary flow compared to those with a lowest CD4 % of above or equal to 20 %. The strengths of this study were the use of household peers and a hospital based population. Limitations of this study were the number of HIV-infected patients and controls, the length of the study, lack of radiographs, and the saliva collection technique.

APPENDIX
Saliva collection explanation

Scenario 1: perceived understanding level of less than 12 years old

“Did you brush your teeth today? (If answer yes, ask patient when). Did you eat or drink anything this morning? (If answer is yes, ask when). The first thing I’m going to do is use this cotton roll to catch some of the spit in your mouth. Would you like to see it? (hand child a sample cotton roll to touch). I am going to put the cotton between your cheek and teeth and leave it there for 1 minute. We will use this timer so when it beeps then I will take the cotton out of your mouth. Do you have any questions for me before we start?

Scenario 2: perceived understanding level of 12 year old child or above

“Did you brush your teeth today? (If answer yes, ask patient when). Did you eat or drink anything this morning? (If answer is yes, ask when). The first thing I’m going to do is use this cotton roll to collect your saliva. I am going to put the cotton between your cheek and teeth and leave it there for 1 minute. We will use this timer so when it beeps then I will take the cotton out of your mouth. Do you have any questions for me before we start?

Explanation of tooth counting

Scenario 1: perceived understanding level of below 12 years old

“When Dr. Reed comes in she is going to count your teeth and measure how tall they are. She is going to use two tools to help her count your teeth, a tiny mirror and ruler. Let me show you them. (show child the dental mirror and periodontal probe, allow child to touch the end of the probe to see that it is not sharp if he or she seems frightened). Do you have any questions for me? If time permits, time may be used to teach child about brushing, flossing and the dangers of ingesting too much sugar.

Scenario 2: perceived understanding level of 12 year old child or above

“When Dr. Reed comes in she is going to count your teeth and measure how tall they are. She is going to use two tools to help her count your teeth, a dental mirror and a dental ruler. Let me show you them. (show child the dental mirror and periodontal probe, allow child to touch the end of the probe to see that it is not sharp if he or she seems frightened). Do you have any questions for me? If time permits may use this time to teach child about brushing, flossing and the dangers of ingesting too much sugar.

ABOUT THE AUTHORS

At the time of this study Brooke Chase and Michelle Haynes had completed their first year of dental school, were participating in the MUSC Summer Health Professions program, and were recipients of the distinguished David E. Rogers Fellowship from the New York Academy of Medicine.

Dental eruption was Brooke’s concentration while Michelle focused on dental caries within the population of HIV-infected children and their siblings.

Brooke Chase graduated in 2005 from Hobart and William Smith Colleges in Geneva, NY.

Michelle Haynes is a 2005 graduate of the University of South Carolina in Columbia, SC.

Dr. Sandra L. Fowler is a pediatric infectious disease physician at the Medical University of South Carolina.

Dr. Susan Reed is a dentist and oral epidemiologist at the College of Dental Medicine at MUSC.

References Available Upon Request:
chase@musc.edu

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