Access and management of HIV-related diseases in resource-constrained settings: a workshop report.

With advancement of medical interventions, the lifespan of people living with HIV has increased globally. However, low- and middle-income countries (LMICs) which bear the greatest burden of the HIV pandemic face a constant challenge in addressing the treatment needs of immune-suppressed patients. An analysis of the current management protocols and access to medication in resource-poor settings was conducted at this workshop, with emphasis on the situation in resource-poor settings. The participants developed a consensus document based on the need to respond to the constantly changing HIV pandemic. Provision of oral health care must be guided by interconnecting principles based on population based strategies that address upstream determinants of health. Basic oral health coverage in developing countries can only be realized with a strong foundation at the primary health level. Early diagnosis of HIV-related comorbidities including the adverse effects of ARVs is essential for the improvement of treatment outcomes. Standardization of oral health care delivery mechanisms will facilitate evaluation at national and regional levels. Oral health care workers have a moral obligation to participate in sustained campaigns to reduce the social stigma associated with HIV/AIDS in their work places at every stage of the referral chain. Future research also needs to realign itself towards prevention using the common risk factor approach, which has a broader impact on non-communicable diseases, which are increasingly affecting patients with HIV/AIDS as their life expectancies increase.

The child and adolescent with HIV in resource poor countries.

UNLABELLED: Although sub-Saharan Africa caries the burden of paediatric and adult HIV/AIDS infections, the epidemic is spreading most rapidly in the Middle East and North Africa Region where between 2005 and 2013, AIDS-related deaths increased by 66% in comparison with a worldwide fall of 35%. For the first time, in 2011, more than half of people in need of antiretroviral drugs were receiving them, with coverage reaching 54%; yet only 28% of children have access to HIV treatment. This review sought to provide an update of paediatric and adolescent oral HIV/AIDS issues in resource poor countries. OBJECTIVES: To review the literature on paediatric & adolescent HIV with a focus on oral lesions as predictors of HIV infection; as markers of the efficacy of HAART and quality of life; caries risk; management of oral lesions; and epidemiological tests for clinical significance of oral lesions. METHODS: A search strategy was developed for PubMed to identify papers on paediatric oral HIV. Publications in English were selected on the basis that their titles and abstracts were relevant to the review objectives. The reference lists of included papers were screened for additional articles. The time-search for publications was limited from 2009 to 15 October 2014. RESULTS: Papers on the prevalence of oral lesions lacked standardization in diagnostic criteria and the introduction of HAART had significantly reduced prevalence; oral lesions remain useful predictors for HIV infection and as markers for the efficacy of HAART. Evidence suggest that caries risk is increased with HIV infection; management of oral lesions is inconsistent with available resources and surprisingly little recent information has been published in the past 5 years. Revised case definitions are proposed for large-scale epidemiologic studies with the development of an oral lesion index showing promise. Oral health quality of life indicators for children and adolescents are becoming important as more of these indicators are being developed and their negative oral impacts in individuals with oral lesions are now well established. CONCLUSIONS: Paediatric and adolescent oral HIV research needs to be prioritized as current studies are few and are characterized by poor quality study designs, small study samples and a lack of multicentre collaborations. There is a lack of high quality evidence for a number of interventions available for management of oral lesions.

Strategies for Oral Health Research in Africa and the Middle Eastern Region.

The highest burden of diseases worldwide is in low- and middle-income countries, but due to lack of capacity and inadequate infrastructure, research output from these countries is unable to address existing and emerging challenges in health care. Oral health research has particularly been hampered by low prioritization, resulting in insufficient development of this sector. There is an urgent need for research correlating oral health to upstream social and environmental determinants and promoting the common risk factor approach for prevention of noncommunicable diseases. Population-wide preventive measures for oral health care are more effective than purely curative approaches, especially for vulnerable groups who have limited access to information and appropriate health care. This article identifies priorities and proposes strategies for researchers, stakeholders, and policy makers for the initiation and sustenance of appropriate oral health care research. The proposed interventions are intended to promote collaboration, capacity building, and health advocacy. Local ownership in multinational research projects in low- and middle-income countries, complemented by skills transfer from high-income countries, is encouraged to ensure that regional health needs are addressed. Emphasis is placed on a shift toward translational research that has a direct impact on oral health care systems.

Oral health needs and barriers to accessing care among the elderly in Johannesburg.

OBJECTIVES: The study sought to determine barriers to accessing oral health services amongst the elderly residing in retirement villages in Johannesburg. The objectives were to determine the normative and perceived oral health needs, the barriers experienced and the predictors of oral health utilisation. MATERIALS AND METHODS: This was a cross-sectional study. Three hundred and eight (n=308) participants were recruited from 10 retirement villages in Johannesburg. Data were collected from questionnaires and clinical oral examinations assessing the DMFT and CPITN scores. RESULTS: The clinical findings of the oral health status indicated a caries experience of 46%, whilst 58% of participants suffered from periodontal conditions. Sixty four percent (64%) acknowledged the need to visit a dentist, however only 28% of the study population had utilised oral health care in the past 12 months, due to perceived barriers. The barriers most frequently reported included the belief that they were not able to afford dental treatment and the lack of transport availability. The multivariate analysis indicated that a significant positive predictor of utilisation was Perceived Need. CONCLUSION: Though oral health access was freely available in the public sector and normative and perceived need for oral health care were high, the barriers experienced prevented 72% of the participants from utilising oral health services.

Chlorhexidine for the prevention of alveolar osteitis.

This systematic review assessed the efficacy of chlorhexidine for the prevention of alveolar osteitis and occurrence of adverse reactions. Databases were searched until 20 April 2011. Trial inclusion criteria were: titles/abstracts relevant to topic; prospective 2-arm (or more) clinical study design. Trial exclusion criteria were: not all entered subjects accounted for; subjects of both groups not followed up the same way; lack of computable data; chlorhexidine not the primary test agent; duplication of data; outcome of interest other than incidence of alveolar osteitis. Individual datasets were extracted from accepted articles. Bias risk in trials was assessed. 10 of 13 included trials were accepted. From these, 16 dichotomous datasets were extracted. Two of six application protocols favoured chlorhexidine over placebo: Single application of 0.2% chlorhexidine gel placed in the socket immediately after extraction versus placebo gel (RR 0.40; 95% CI: 0.18-0.90; p=0.03) and 0.12% chlorhexidine rinse applied on day of surgery and used twice daily for 7 days postoperatively versus placebo rinse (RR 0.50; 95% CI: 0.27-0.93; p=0.03). These results are negated due to high bias risk. Chlorhexidine did not cause higher adverse reactions than placebo. Further high-quality randomised control trials are needed.

Dental caries prevalence in children attending special needs schools in Johannesburg, Gauteng Province, South Africa.

INTRODUCTION: Anecdotal evidence from clinical data in Johannesburg suggests that there is a high burden of dental caries among children with special health care needs (CSHCN) in Johannesburg. OBJECTIVES: To determine the prevalence of dental caries and Unmet Treatment Needs in children with cerebral palsy, hearing, learning and mental disabilities attending special needs schools in Johannesburg and to compare these with data from the National Children's Oral Health Survey (NCOHS) METHODS: This cross-sectional analytical study comprised of 882 children attending five special needs schools in Johannesburg. Stratified randomised sampling of the participating schools was done and the schools were stratified by disability. Caries status was recorded via the dmft/DMFT index using WHO criteria and guidelines. RESULTS: The mean age of the participants was 10.5 years; with a caries prevalence of 27.55% and 33.56% in the primary and permanent dentition respectively. The highest unmet treatment need of 100% was found in the permanent dentition of the hearing impaired group followed by 90.77% in the primary dentition of the cerebral palsy group. In general no significant difference was found when the dmft/DMFT for CSHCN and NCOHS were compared except in the hearing impaired age groups four to five and six (both primary dentition) where significantly higher dmft scores (3.58 vs. 2.4; 3.85 vs. 2.9; p < 0.05) were found. CONCLUSION: Children with special health care needs had lower caries prevalence compared with the general population and higher unmet treatment needs regardless of the type of disability.

Caries prevalence among HIV-infected children between four and ten years old at a paediatric virology out-patients ward in Johannesburg, Gauteng Province, South Africa.

INTRODUCTION: There remains controversy in the literature as to whether children with HIV are at greater risk for caries than healthy children. OBJECTIVES: To determine the caries prevalence and unmet treatment needs (UTN) in a cohort of HIV+ive children between the ages of four and ten years who were attending the Charlotte Maxeke Paediatric Virology out-patients ward and to compare the results with the data of the National Children's Oral Health Survey (NCOHS). METHODS: This descriptive, analytic study comprised of a sample of 277 children attending the Paediatric Virology out patients ward at the Charlotte Maxeke Hospital over a one year period. The caries status was measured using WHO guidelines and criteria. RESULTS: Among the 93 children aged between four and five years, the caries prevalence of the primary dentition was 70.9%; the dmft was 5.1 and the UTN was 99.6%. In the 62 six year olds and 122 seven to ten year olds, the caries prevalence in the primary teeth was 62.9% and 67.2%; the dmft was 4.2 and 4 and the UTN 100% and 87.8% respectively. The mean dmft of the four, five and six year olds was significantly higher than those reported in the NCOHS. The four, five and sx-year old HIV positive children had a 1.4 times higher risk of caries development than children from the general population (p < 0.002). CONCLUSION: This cohort of HIV-infected children had significantly higher caries prevalence, dmft and UTN than did children from the general population.

Caries status among children in the West Rand District of Gauteng Province, South Africa.

INTRODUCTION: There is a lack of data about the prevalence and clinical consequences of dental caries in the West Rand. However dental caries does appear to be a substantial public health problem in Gauteng. OBJECTIVE: This study set out to determine the prevalence and clinical consequences of dental caries among school children in the West Rand district of Gauteng. METHODOLOGY: This was a cross-sectional study comprised of 800 pre-school and primary school children six to eight years old. Cluster sampling was used to select the participating schools. The oral health status was determined by using the DMFT/dmft and PUFA/pufa indices. RESULTS: Of the 800 children, 282 were in the four to five year old age group and 518 were six to eight years old. For four to five year olds the mean dmft score was 2.24 and the prevalence of caries 49%. The clinical consequence of caries was scored with a mean pufa index of 2.9 and the percentage of untreated decay was 47%. For six to eight year olds the mean DMFT/dmft scores were 0.1 and 2.4 respectively and the prevalence of caries 46%. The clinical consequence of caries scored with the PUFA/pufa index was 0.0 and 3.4 respectively and the percentage of untreated decay was 44%. CONCLUSION: There are high levels of untreated caries in children in this district. The pufa scores ndicate that children suffer serious consequences of untreated decay.

Failure rate of high-viscosity GIC based ART compared with that of conventional amalgam restorations--evidence from an update of a systematic review.

INTRODUCTION: Atraumatic Restorative Treatment (ART) involves using only hand instruments for removing carious tooth tissue and then restoring the resulting cavity with an adhesive restorative material. OBJECTIVE: To answer the question as to whether, in patients with carious cavities of any class in primary and permanent teeth, ART restorations with high-viscosity glass-ionomer cement (GIC) have a higher failure rate than amalgam restorations placed after drilling, in tooth cavities of the same size, dentition and follow-up period. METHODS: Thirteen databases were searched for relevant trials up to January 2012. Hand-searching was performed for non indexed journals. References of included trials were checked. Prospective, clinical controlled trials with a followup period of at least one year were selected. The investi gated outcome was restoration failure. Meta-analysis was conducted and internal trial validity was assessed in-depth. RESULTS: Twenty trials were accepted for review. The majority of the results show no differences between the types of intervention. The current evidence indicates that the failure rate of high-viscosity GIG/ART restorations is not higher than, but is similar to that of conventional amalgam fillings after periods longer than six years. There is a risk that these results are affected by bias and confirmation by further trials is recommended.

Teachers' knowledge of emergency management of traumatised teeth in preschools.

UNLABELLED: Dental trauma remains one of the major oral health problems in childhood and is the cause of much pain and distress. It may occur as a result of a sports mishap, an altercation or a fall while playing inside the school premises. Prompt and appropriate management of traumatised teeth is essential for a good prognosis of an injured tooth. AIM AND OBJECTIVE: The aim of the study was to assess teachers' knowledge of emergency management of traumatized teeth in early childhood developmental centres (ECDCs). METHOD: A cross sectional self-administered questionnaire was used to collect data among teachers in ECDCs in Hillbrow and Berea suburbs, Johannesburg, South Africa. RESULTS AND CONCLUSION: Almost all respondents (98.1%) were female; 59.6% were between 20 and 29 years of age. Almost a quarter of the centres were not registered and 39.1% of the school teachers were not formally qualified as ECDCs teachers. A small percentage (11.5%) received dental emergency training as a part of their school health education programs. Knowledge of ECDCs teachers on the emergency management of traumatized teeth appeared inadequate; in the event of emergency dental trauma, substantial number of teachers would not be able to respond appropriately. All teachers should have training on basic management of dental trauma.

Pediatric oral HIV research in the developing world.

This article is a review of the literature between 2003 (since the last workshop) and April 2009 (Beijing workshop). It focuses on the prevalence of oral lesions associated with HIV infection, oral lesions as predictors of HIV infection, oral lesions as markers of the efficacy of highly active antiretroviral treatment and quality of life, caries risk, the management of oral lesions, and epidemiologic tests for clinical significance of oral lesions.

Social aspects of HIV and their relationship to craniofacial problems: workshop 4C.

The oral research community needs an understanding of the social causes, consequences, and costs of disease in relation to oral health. This workshop concluded that HIV infection constitutes a special dental need requiring specific arrangements to facilitate oral care for infected persons. Oral manifestations of HIV infection affect everyday life, but more evidence is needed on the effects of interventions to alleviate these impacts. Other oral health habits add to the burden of HIV/AIDS-associated oral diseases and compete with them for resources. These problems are most acute where the prevalence of HIV is high and resources are scarce. Effective health promotion is therefore important in these areas. Without data on the utility of oral health care in developing countries, practical approaches are guided by societal and multidisciplinary principles. There are also important ethical considerations.

Caries-preventive effect of resin-modified glass-ionomer cement (RM-GIC) versus composite resin: a quantitative systematic review.

AIM: To determine whether resin-modified glass-ionomer cement (RM-GIC), when compared with composite resins (CR), offers a significant caries-preventive effect. STUDY DESIGN: Quantitative systematic review. METHODS: Five databases were searched until 29 July 2010. Inclusion criteria were: relevant to review question related to orthodontic or restorative treatment; published in English; prospective clinical 2-arm study. Exclusion criteria were: no computable data reported; study groups not followed up in the same way. References of included articles were checked. The outcome measure was absence of carious lesions. Dichotomous datasets for both groups were extracted from accepted trials. Trials were assessed for selection-, detection/performance, attrition and publication bias. RESULTS: Of the 11 trials included, 6 were accepted and 24 datasets extracted; 17 datasets showed no difference after 4 weeks to >25 months. There were 7 datasets that favoured (p < 0.05) RM-GIC after 12 - 24 months. The results are limited by risk of selection-, detection-/performance bias and attrition bias. Risk of publication bias was identified. CONCLUSIONS: The overall results showed either no difference between the materials, or indicated that RM-GIC has a superior caries-preventive effect. The clinical meaning of this result remains uncertain due to risk of bias. High-quality randomised control trials are needed in order to answer the review question conclusively.

Therapeutic effect of glass-ionomers: an overview of evidence.

The requirements for an ideal restorative material include adhesion to tooth structure (enamel and dentine) and an ability to withstand the traumas of occlusion. However, some level of an anticaries effect is also desirable. After a long history of glass-ionomer cement (GIC) development, an evidence base in support of the therapeutic effect of GIC, particularly with regard to its anticaries effect, is emerging. This evidence is increasingly presented through systematic reviews of clinical GIC application and, to a certain extent, relates to a caries-preventive effect of the material itself. However, the strength of evidence supporting other aspects of GIC, such as a higher remineralizing effect, fluoride uptake in hard tooth tissue and fluoride release of GIC, is limited. Nevertheless, the results of these in situ and laboratory trials provide valuable insights into factors that facilitate understanding of the clinical efficacy of GIC.

Salt fluoridation: a meta-analysis of its efficacy for caries prevention.

UNLABELLED: The aim of this meta-analysis was to assess the caries preventive effect of Salt fluoridation (SF) in the permanent dentition in children. THE OBJECTIVES WERE TO COMPARE: (1) the caries preventive effects of SF versus no exposure in different age cohorts (6-8; 9-12; and 13-15 years old); (2) SF versus other community based interventions (milk or water fluoridation [WF]). METHODS: 9 English and 2 non-English databases were searched for papers that reported on the caries preventive effect of groups (with controls) that were exposed to SF in the form of mean DMFT scores with standard deviations. Differences in exposed and nonexposed groups were computed on the basis of weighted mean differences (WMDs) with 95% confidence intervals (CIs). RESULTS: For 6-8 year olds, the pooled reduction in DMFT scores was -0.98 [95% CI: -1.68 to -0.29]; for 9-12 year olds, it was -2.13 [95% CI: -2.55 to -1.70] and for the 13-15 year old groups, -4.22 [95% CI: -6.84 to -1.55]. All the analyses favoured the SF groups (p <0.001). For SF versus WF, there was no difference (-0.11 reduction [95% CI: -0.29 to +0.07]). CONCLUSION: Within limitations, the pooled estimates of the WMDs for the different age cohorts favoured SF versus no exposure.

Resin-modified glass-ionomer cements versus resin-based materials as fissure sealants: a meta-analysis of clinical trials.

AIM: To appraise quantitatively current evidence regarding the caries-preventing effect of resin-modified glass-ionomer cement (RM-GIC) fissure sealants in comparison to that of resin-based fissure sealants. STUDY DESIGN: Systematic review with meta-analysis. METHODS: 8 Anglophone databases and 2 Lusophone databases were searched until 15 April 2009, using a pre-determined search strategy. Clinical trials were considered for inclusion if their titles/abstracts were relevant to the topic, published in English, Portuguese or Spanish and had a two-arm longitudinal study design. The outcome measure of the caries-preventive effect was caries absence on sealed teeth. Two reviewers independently extracted data from the accepted articles in order to complete a 2x2 table for meta-analysis. The unit of interest was the tooth, and the number of caries-free teeth (n) at the end of each time interval (6, 12 and 24 months) was compared against the total number of evaluated teeth (N). STATISTICS: Datasets were assessed for their clinical and methodological heterogeneity, following Cochrane guidelines, and only homogeneous datasets were combined for meta-analysis, using a random effects model (RevMan 4.2). Differences in the caries-preventive effect were computed on the basis of the combined Relative Risk (RR) with 95% confidence interval (CI). RESULTS: Of the 212 articles identified, only 6 trials were included. From these, 19 separate datasets were extracted. For the pooled data, equivalent caries-preventive effects were observed at 6 months (RR= 0.98, 95% CI 0.95- 1.00; p = 0.08); 12 months (RR=1.00, 95% CI 0.96-1.04, p = 0.99) and 24 months (RR=1.01, 95% CI 0.84-1.21, p = 0.91). The 36-month data (not pooled) favoured resin-based sealants (RR 0.93, 95% CI 0.88-0.97, p = 0.002). CONCLUSIONS: This meta-analysis found no conclusive evidence that either material was superior to the other in preventing dental caries.

Absence of carious lesions at margins of glass-ionomer and amalgam restorations: a meta- analysis.

AIM: To report on the absence of carious lesions at margins of glass ionomer cement (GIC) and amalgam restorations. METHODS: Six Anglophone and 1 Lusophone databases were searched for articles up to 5 January 2008. Inclusion criteria for articles were: (i) titles/abstracts relevant to topic; (ii) published in English, Portuguese or Spanish language; (iii) reporting on a randomised control trial. Exclusion criteria were: (i) insufficient random allocation of study subjects (ii) operator and subject not blinded, where appropriate; (iii) not all entered subjects accounted for at trial conclusion; (iv) subjects of both groups not followed up the same way. Articles were accepted only if they complied with all the criteria. Ten articles complied with the inclusion criteria and were selected for review. From these 4 were rejected and 6 articles reporting on 8 separate studies accepted. Due to aspects of heterogeneity, studies were sub-grouped before meta- analysis. RESULTS: Significantly less carious lesions were observed on single-surface GIC restorations in permanent teeth after 6 years as compared to restorations with amalgam (OR 2.64 - CI 95% 1.39 - 5.03, p= 0.003). No studies investigating multiple-surface restorations on permanent teeth were identified. Studies investigating carious lesions at margins of restorations in primary teeth showed no difference between both materials after 3 and 8 years. CONCLUSIONS: Carious lesions at margins of single-surface GIC restorations are less common than with amalgam fillings after 6 years in permanent teeth. No difference was observed in primary teeth. More trials are needed in order to confirm these results.

Early-phase dental students' motivations and expectations concerning the study and profession of dentistry.

This study investigated the career choice and aspirations of early phase dental students in the four dental schools in South Africa, namely the University of the Western Cape (UWC), University of the Witwatersrand (Wits), University of Limpopo (Medunsa) and University of Pretoria (UP). Willing participants completed a self-administered questionnaire (n=184). Motivations for entering a dentistry programme were similar across race and university, with wanting a secure job most often stated as an important factor. For a third of respondents, dentistry was not a first choice. Amongst the White students, it was a first choice for 82% compared with 59% amongst Black Africans. Expected income five-years after graduation also differed significantly across race and university, with White and UP students expecting to earn considerably higher than the others. About 36% of students were concerned about the levels of personal debt related to studying, with the White and Asian students less concerned. Those who expected lower levels of income from the profession were more concerned about personal debts. Most students planned to enter general dental practice (GDP) after community service, almost all White and Wits students expressed this intention, compared with only 35% of Black Africans and 39% of Medunsa students. Orthodontics and Maxillofacial & Oral Surgery were the most popular specialities of choice. The professional attribute "Has a friendly manner and good relationship with patients" was ranked high most often. In conclusion, career advice may not need to be tailored differently for the different racial groups. There is however a need for further investigations on how to address the concerns of financial security which may be realised by the practice of dentistry, and in particular the racial disparities observed in expectations of the profession. This study further highlights the need for government financial assistance for students from under-represented groups.