DOI: 10.1111/odi.

13397

WW8 PROCEEDINGS

Management of third molar surgery in HIV-positive patients

Syarifah Nova Amiza Zam1 | Melita Sylvyana2 | Endang Sjamsudin3

1
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, RSUP Dr. Abstract
Hasan Sadikin, Padjadjaran University, Background: Third molar surgery is a common procedure performed by oral and
Bandung, Indonesia
2 maxillofacial surgeons. This kind of surgery is predictable, and complications are in-
Department of Oral and Maxillofacial
Surgery, RSUP Dr. Hasan Sadikin, Bandung, frequent. Immune deficiency is one of the considerations for the prevention of com-
Indonesia
plications. HIV patients may be immune deficient. Third molar surgical procedures
3
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Padjadjaran
are associated with bleeding and increased risk of infection. Improvement in oral
University, Bandung, Indonesia hygiene must be encouraged, such as pre-operative scaling. Prophylactic antibiotics

Correspondence
Syarifah Nova Amiza Zam, Department
of Oral and Maxillofacial Surgery, Faculty
of Dentistry, RSUP Dr. Hasan Sadikin,
Padjadjaran University, Bandung 40161,
Indonesia.
Email: novayudo@gmail.com
and history of anti-retroviral therapy should be considered.
Case report: 7 cases of third molar surgery in HIV patients were handled at the oral
and maxillofacial surgery department. Intraoral examination showed typical lesions
of HIV patients such as oral candidiasis, hairy leucoplakia, necrotizing ulcerative peri-
odontitis, oral ulcers and also pericoronitis of third molars. Radiological examination
showed impacted teeth in the upper and lower the third molar region. Third molar
treatment was carried out as elective surgery under general anaesthesia. Prophylactic
antibiotics were given to the patients as standard of care.
Conclusion: Treatment planning for HIV-positive patients follows the same sequence
as with other patients, and the priorities are to remove local infection and prevent
further dental disease. Third molar surgery in HIV-positive patients can improve den-
tal health which can affect the quality of life. Prophylactic antibiotic should be used
to prevent infections. Bleeding control also needed to avoid complications.

KEYWORDS
dental extractions, HIV patients, third molar surgery

1 |  I NTRO D U C TI O N management protocol for them (Nagaraj, 2013). Dental therapeutic

Human immunodeficiency virus (HIV) infection has been part of
world's experience since 1981 and is considered a global pandemic
with cases reported from virtually every country. Despite the fact
that HIV still has no known cure, treatment with highly active an-
tiretroviral therapy suppresses HIV replication and prolongs and im-
proves the quality of life of these patients. Many people living with
HIV seek routine dental care. Among the various dental treatments
provided, third molar surgery is an integral part and although the oral
surgeon is confronted with an increasing number of HIV-infected
patients, there remains uncertainty with regard to appropriate
procedures involve blood and saliva that may contain a variety of
blood–borne pathogens and microorganisms, such as HIV. This en-
vironment has become a helpful setting for early detection because
most lesions of HIV infection present orally during the first stages of
the disease. Accordingly, dentists fall into the high-risk category for
cross-contamination (Prabhu et al., 2014).
Infections may be transmitted in the dental operatory through
several routes, including direct contact with blood, or oral fluids, indi-
rect contact with contaminated instruments, equipment or environ-
mental surfaces. The average risk of HIV transmission among health
care professionals has been reported to be 0.3% for percutaneous

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. All rights reserved

Oral Diseases. 2020;26(Suppl. 1):145–148.  |

wileyonlinelibrary.com/journal/odi     145
146       | ZAM et al.

injury and 0.1% for mucosal exposure (Beltrami, Williams, Shapiro,
& Chamberland, 2000). Although the risk of HIV transmission in
the dental office is low, the consequences of being infected are
life-threatening. Risk assessment is not always feasible, adherence
to universal precautions and appropriate waste disposal are critical
to prevent occupational exposure (Agarwal, Agarwal, Shrivastava, &
Shrivastava, 2015).
Tooth impaction is a pathological situation where a tooth fails to
attain its normal functional position. An impacted tooth is a tooth
which is completely or partially unerupted and is positioned against
another tooth, bone or soft tissue so that its further eruption is un-
likely, and angle of impaction is described according to its anatomic
position. Various causes have been suggested in the literature for
the impaction of the teeth. It has been suggested that the gradual
evolutionary reduction in the size of the human mandible/maxilla
has resulted in too small mandible/maxilla that may accommodate
the corresponding teeth. It has also been found that the modern diet
does not offer a decided effort in mastication, resulting in loss of
growth stimulation of jaws, and thus, the modern man has impacted
and unerupted teeth (Santosh, 2015). Impaction may occur because
there is no path of eruption due to tooth development in an abnor-
mal position or obstruction by a physical barrier such as another
tooth, odontogenic cyst or tumour (Soeprapto, Latif, & Julia, 2011).
Third molar surgery, as one of the most common procedures per-
formed by oral and maxillofacial surgeons, is a procedure by which
the last molar is removed by means of an open operation. The inci-
sion may only detach the gingival margin from the tooth, or it may be
more extensive, resulting in the preparation of a carefully designed
mucoperiosteal flap. The purpose of the flap is to bring into direct
vision the alveolar bone, as well as any pathologic condition that may
be associated with the tooth. One should exercise care to prevent
operative trauma, which in the ordinary use of forceps so frequently
causes periostitis and swelling of the face, with a great deal of suf-
fering. This kind of surgery is predictable, and complications are
infrequent. Immune deficiency is one of the considerations for the
prevention of complications. Third molar surgical procedures may
have excessive bleeding and increased risk of infection (Abel, Croser,
Fischman, Glick, & Phelan, 2000). Improvements in oral hygiene
must be encouraged, such as pre-operative scaling. Prophylactic an-
tibiotics and history of anti-retroviral therapy should be considered
in treatment planning.
2 | C A S E R E P O RT
7 cases of third molar surgery in HIV patients were handled at the
oral and maxillofacial surgery department. Intraoral examination
showed typical lesions of HIV patients such as oral candidiasis, hairy
leukoplakia, necrotizing ulcerative periodontitis, oral ulcers and peri-
coronitis of third molars (Figure 1).
During 6 months of period (January 2019–June 2019), seven
male HIV-positive patients between 21 and 35 years old presented
with one or more impacted teeth as their chief complaint. These pa-
tients brought their most recent CD4+ examination results. Medical
history and panoramic radiographs were examined. Radiological ex-
amination showed impacted teeth in upper and lower third molar
regions (Table 1).
Third molar treatment in these patients was carried out as elec-
tive surgery under general anaesthesia. As pre-operative screening
for general anaesthesia, we also completed a laboratory examination
and thorax X-ray. Pre-operative scaling was done a day before the
surgical procedure. The number of teeth removed differed among
patients. Most received removal of 4 third molars (upper and lower
jaw), but some patients also had extraction of other teeth with in-

F I G U R E 1   Panoramic radiograph showing an impacted fected/necrotic pulps. Prophylactic antibiotics were used as stan-
mandibular left and right third molar with pericoronal dard of care. Cefazolin 1 g intravenously 45 min before intubation
radiolucency was used. Preparation for third molar surgery was not different

TA B L E 1   Patients demographics

No. Name Age Teeth removed Level of impaction CD4+ count Complication

1. Mr. YS (1,547,285) 32 y.o 18, 14, 28, 37, 48 Class IB and IIA 400 None
2. Mr. LTB (1,763,725) 35 y.o 28, 38, 37 Class IA and IIB 600 None
3. Mr. DS (1,685,190) 34 y.o 38, 48, 24, 46 Class IA and IIB No data available None
4. Mr. B (1,630,050) 22 y.o 38, 48, 36, 46 Class IIIB No data available None
5. Mrs. DA (1,004,315) 30 y.o 18, 28, 38, 48 Class IIA 200 None
6. Mr. Pr (1,756,591) 26 y.o 38, 48, 36, 46 Class IIA and IIB 360 None
7. Mr. Z a  (1,643,670) 30 y.o 18, 28, 38, 48 + 25, Class IIB and IIIA 633 None
37, 36, 47
a
Patient describe in Figure 1.
ZAM et al.
between patients who were HIV positive or HIV negative, or of un-
known HIV status. Standard universal precautions and protection
such as haircap, gloves, liquid-resistant disposable gown, mask, gog-
gles and disposable shoe covers were used during the surgery for
operator and assistant. We prepared disposable equipment for the
surgical intervention, and we protected the dental handpiece with
disposable cover. Bone burs were used minimally to prevent blood
contamination. Third molar surgical procedures were performed in
the same sequence as with other patients, starting with the intuba-
tion, aseptic and atraumatic techniques were used to minimize the
introduction of pathogens and post-operative complications. After
the surgery, we encouraged improvements in oral hygiene to mini-
mize the risk of post-operative complications.
3 | D I S CU S S I O N
The surgical handling of people with HIV infection is challenging due
to its multidisciplinary nature, its medical complexity, physical mani-
festations, the need for standard infection control procedures, and
the associated stigma and discrimination. There are several points
to note when managing a patient with HIV/AIDS in the dental set-
ting. The first concern is what laboratory values the office needs and
the interval at which they should be made available. A measure of
patients' CD4, or T-cell count and viral load should be included in a
referral and/or medical history, as most patients have these labora-
tories checked every 6 months. The cascade's definition of retention
is two medical visits at least 3 months apart within 1 year. Many
patients will know their CD4 count and viral load information. Many
asymptomatic patients with undetectable HIV viral load and CD4
counts greater than 300 cells/mm3 will have these laboratories taken
on an annual basis (Lesko, Tong, Moore, & Lau, 2017).
The provision of dental care for people who are HIV-positive is
essential for their overall health and well-being. Studies suggested
that knowledge may affect attitudes towards treatment of HIV/AIDS
patients. A thorough understanding of the barrier will help us to
avoid the stigma of treating HIV/AIDS-infected patients. Procedures
to avoid transmission between patients and dental care workers and
from one patient to another should be routinely applied, regardless
of whether patients are known to be HIV-positive. Dentists should
be taught that universal precautions should be used with all patients,
since dentists and patients themselves will not always be aware of
who is HIV-positive (Neenu, Sharma, Padma, & Alashetty, 2017).
Proper infection control should be practiced and knowledge of prac-
titioners improved by conducting intervention programmes.
A major concern for any clinician treating HIV-infected patients
is to minimize the risk of exposure for themselves, their staff and
other patients. Dental procedures frequently cause bleeding and
exposure to infected blood which is a known means of HIV trans-
mission. Saliva has not been shown to transmit HIV in a dental set-
ting, but the potential for exposure to bloody saliva does exist. Risk
screening is a brief assessment of behavioural and clinical factors as-
sociated with transmission of HIV. Risk screening identifies patients
|
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at greatest risk for transmitting HIV so that prevention and refer-
ral recommendations can be focused on these patients (Henderson
et al., 2010). Percutaneous exposure to blood has been reported
among dental workers with cutting devices such as scalers, burs;
smaller gauge hollow–bore needles and explores and also during use
of device or afterwards during cleanup/disassembly or recapping.8
These injuries can be prevented if dental workers are adhering to
the current recommendations for safe handling of needles and other
sharp instruments. Preventing other injuries may require additional
interventions such as development of safer devices and continued
modifications in work practice.
The decision to perform dental extractions and other oral surgi-
cal procedures for patients with HIV should be based on the same
criteria as for all patients. If a questionable health status influences
anticipated oral surgery, the dentist must consult with the patient's
physician. Surgical procedures must be performed in a manner that
minimizes bleeding and avoids bringing oral pathogens into the
deeper fascial planes and oral spaces to prevent increased risk of
infection. Improvements in oral hygiene should be encouraged to-
gether with pre-operative scaling to minimize the risk of post-opera-
tive complications. Treatment planning must be done on an individual
basis, so an individualized assessment in every case is needed. Teeth
with a poor prognosis may be maintained instead of extracted if a
patient is deemed a poor candidate for tooth replacement.
There is no significant difference between the number of
post-operative complications in patients with HIV infection versus
uninfected patients. From the consensus of the workgroup partici-
pants of the Dental Alliance for AIDS/HIV Care (DAAC): Principles
of Dental Management for the HIV-infected Dental Patient, the clin-
ical decision to prescribe antibiotic therapy should be made on an
individual, case-by-case basis, so that the routine use of antibiotic
prophylaxis following oral surgery in patients with HIV disease is not
a must.8 Oral surgery procedures are invasive; thus, patients with
CD4+ cell counts below 100 cell/mm3 should be evaluated for neu-
tropenia. If the neutrophil count is below 500 cells/mm3, patients
should receive antibiotics pre-operatively and post-operatively
(Abel et al., 2000). In this study, we undertook third molar surgery if
the patient's CD4+ cell was more than 100 cell/mm3 and neutrophil
count minimum was 500 cells/mm (Agarwal et al., 2015). It has been
established that indiscriminate use of antibiotics in patients with HIV
disease may put them at risk of developing opportunistic infections
such as candidiasis.
Localized osteitis or “dry socket” is one of the common com-
plications associated with an extraction which occurs in 3%–4%
among the general population and this complication rate is similar
in the HIV-positive group. (Bluum, 2002). The incidence of post-op-
erative complications in all patients is associated with and affected
by many factors, including the type and size of the tooth extracted;
the number of teeth to be extracted; high counts of intraoral aero-
bic and anaerobic bacteria; age of the patient; whether or not the
patient smokes; and the experience of the surgeon (Bluum, 2002).
All of these factors must be considered whenever extractions are
contemplated. For all patients, regardless of HIV status, the use of
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148       ZAM et al.
aseptic and atraumatic surgical techniques is essential to minimize
the introduction of pathogens into a surgical wound and to reduce
post-operative complications. Pre-operative scaling of the teeth to
be extracted may also help reduce the rate of post-operative infec-
tions and should be considered in tandem with educating and moti-
vating patients to improve their oral hygiene.
Excessive bleeding can occur even if haemostasis appears nor-
mal. Immune thrombocytopenia is a known complication of HIV
disease. For patients undergoing extensive surgical procedures and
those with increased bleeding tendencies, a full haemostatic function
assessment should be performed before surgery. Molar extractions
can be safely performed in patients with HIV disease who have
platelet counts above 50,000/mm3. However, oral surgery proce-
dures should be postponed, if possible, when haemoglobin levels fall
to 7.0 g/dl or below (Henderson et al., 2010). If no tests are available
and if extractions must be performed immediately, a simple bleeding
time test can be performed by the dentist to determine whether the
patient's haemostatic function is acceptable. An increased bleeding
time (>9 min) indicates a need to assess quantitative and qualitative
platelet function. The use of a prophylactic, intra-alveolar socket
medicament after oral surgery may prevent delayed healing in pa-
tients with HIV. This is a consideration for patients with a history of
delayed healing or those having multiple extractions.
4 |  CO N C LU S I O N
Treatment planning for HIV patients follows the same sequence as
with other patients. The priorities are to remove local infection and
prevent further disease. Third molar surgery in HIV patients may im-
prove dental health and quality of life. Antibiotic prophylaxis should
be considered in severely neutropenic patients. Bleeding control is
also needed to avoid complications. Close collaboration with the pa-
tient's physician is recommended. Routine antibiotic prophylaxis is
contraindicated. Haemostatic function assessment is recommended
before extensive surgery for those with increased bleeding tenden-
cies. Aseptic and atraumatic techniques should be used to minimize
the introduction of pathogens and post-operative complications,
and improvements in oral hygiene should be encouraged together
with pre-operative scaling to minimize the risk of post-operative
complications. Removal of partially erupted third molars in the ab-
sence of oral disease is needed to reduce the possibility of problems
later in the course of the patient's HIV disease (especially in younger
patients).
AU T H O R C O N T R I B U T I O N S
S. N. A. Zam, M. Sylvyana and E. Sjamsudin conceived of the pre-
sented idea. S. N. A. Zam and M. Sylvyana developed the theory
and handled the patients. S. N. A. Zam collecting patients data.
E. Sjamsudin verified the analytical methods. M. Sylvyana and E.
Sjamsudin encouraged S. N. A. Zam to investigate [a specific aspect]
and supervised the findings of this work. All authors discussed the
results and contributed to the final manuscript.
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How to cite this article: Zam SNA, Sylvyana M, Sjamsudin E.
Management of third molar surgery in HIV-positive patients.
Oral Dis. 2020;26(Suppl. 1):145–148. https://doi.org/10.1111/
odi.13397