Management of Periodontal Disease - AIDS Institute Clinical Guidelines

Introduction

Dental Standards of Care Committee, January 2017

In some patients with HIV infection, immunosuppression may allow the development of oral and periodontal lesions [Baccaglini et al. 2007]. Periodontal lesions associated with HIV infection include linear gingival erythema (LGE) and necrotizing periodontal diseases, which are subclassified as necrotizing ulcerative gingivitis (NUG), necrotizing ulcerative periodontitis (NUP), and necrotizing ulcerative stomatitis (NUS/NS). NUP and NUS/NS may represent different stages of the same pathologic process, with NUP being a more advanced stage of NUG [Kaplan et al. 2009; Ryder et al. 2010]. As the population with HIV ages, patients may develop chronic conditions that can contribute to an exacerbated or enhanced progression of chronic adult periodontitis [Stabholz et al. 2010].

The identification of periodontal diseases may be critical even in patients receiving ART. While the introduction of highly-active antiretroviral therapy (ART) has significantly reduced this incidence [Mataftsi et al. 2011], the occurrence of oral and periodontal infections despite ART may indicate the failure of ART or the development of viral resistance [Mataftsi et al. 2011]. HIV-associated periodontal diseases, along with oral infections, are considered serious complications of HIV infection. The incidence of periodontal infections in patients with HIV is lower than the incidence of oral infections [Ryder et al. 2010].

Management of periodontal lesions in patients with HIV has changed little in the past 30 years [Ryder et al. 2010; Gonçalves et al. 2013]. Basic periodontal therapy provided at regular periodic intervals can effectively reduce periodontal inflammation in HIV patients [Valentine et al. 2016]. Removal of local irritants from the root surfaces, mechanical debridement of necrotic tissues, and appropriate use of local and systemic antibiotics remain important components in the management of HIV-associated gingival and periodontal diseases. The interaction between bacteria and Candida may play a key role in the etiology of periodontal lesions; therefore, management of HIV-associated periodontal lesions involves treating both bacteria and fungi [Pihlstrom et al. 2005]. Multiple factors affect response to treatment, including immune status and personal oral hygiene practices of keeping the mouth, gums, and teeth clean [Alpagot et al. 2004].

KEY POINT

Chronic nonhealing lesions may indicate a more serious condition, and oral health care providers can use biopsies to identify any neoplastic changes [Ryder et al. 2012].

References

Alpagot T, Duzgunes N, Wolff LF, et al. Risk factors for periodontitis in HIV patients. J Periodontal Res 2004;39(3):149–57. [PubMed]

Baccaglini L, Atkinson JC, Patton LL, et al. Management of oral lesions in HIV-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007:103 Suppl:S50.e1–23. [PubMed]

Gonçalves LS, Gonçalves BM, Fontes TV. Periodontal disease in HIV-infected adults in the HAART era: Clinical, immunological, and microbiological aspects. Arch Oral Biol 2013;58(10):1385–96. [PubMed]

Kaplan JE, Benson C, Holmes KK, et al. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2009;58(RR-4):155, 160–61. [PubMed]

Mataftsi M, Skoura L, Sakellari D. HIV infection and periodontal diseases: an overview of the post-HAART era. Oral Dis 2011;17(1):13-25. [PubMed]

Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. Lancet 2005;366(9499):1809–20. [PubMed]

Ryder MI, Nittayananta W, Coogan M, et al. Periodontal disease in HIV/AIDS. Periodontol 2000 2012;60(1):78–97. [PubMed]

Stabholz A, Soskolne WA, Shapira L. Genetic and environmental risk factors for chronic periodontitis and aggressive periodontitis. Periodontol 2000 2010;53:138–53. [PubMed]

Valentine J, Saladyanant T, Ramsey K, et al. Impact of periodontal intervention on local inflammation, periodontitis, and HIV outcomes. Oral Dis 2016;22 Suppl 1:87–97. [PubMed]

Linear Gingival Erythema (LGE)

Dental Standards of Care Committee, January 2017

Presentation and Diagnosis

LGE characteristically presents as a distinct 2- to 3-mm-wide linear erythematous band limited to the free gingival margin (see Appendix: Photo- and Radiographs of Periodontal Disease Associated with HIV Infection for images).

LGE typically presents at the anterior teeth initially [Cherry-Peppers et al. 2003], with subsequent progression to the posterior dentition [Ryder et al. 2012]. Clinically, it may be difficult to distinguish LGE from severe gingivitis in patients with poor plaque control. LGE lesions do not resolve or respond to conventional periodontal therapy, including plaque control and root planing and scaling. Initial biopsy is not indicated for diagnosis unless the tissue does not heal after follow-up, because no microscopic appearance specific to LGE exists. X-rays may be used to rule out alveolar bone involvement.

KEY POINT

A lack of response to conventional periodontal therapy is a key diagnostic feature of LGE; LGE is refractory to standard plaque control.

LGE is classified as a gingival disease of fungal origin by the American Academy of Periodontology because Candida is the primary etiological factor [Armitage 1999]. LGE lesions often resolve with topical and/or systemic antifungal treatment. Data are unavailable to establish whether LGE will evolve into a more severe form of periodontal disease; however, LGE may be a predecessor to the necrotizing ulcerative periodontal diseases that present in some patients with HIV [Gonçalves et al. 2013]. If LGE lesions do not resolve after 1 month of therapy, biopsy may then help indicate a different diagnosis [Ryder et al. 2012].

Treatment

Conventional periodontal therapy does not adequately treat LGE, likely because of the presence of yeast within the gingival tissues [Patton 2000]; Candida is the etiological factor. Treatment for LGE includes oral hygiene instructions and mechanical supragingival debridement using minimal pressure on soft tissue to remove plaque [Herrera et al.2014]. Oral antimicrobial rinses are effective for treating LGE. As a first-line treatment, patients should rinse twice daily with a 0.12% chlorhexidine gluconate suspension (a broad-spectrum oral antimicrobial) and be re-examined after 2 weeks. If lesions are persistent, topical antifungal medications can be used [Cherry-Peppers et al. 2003].

References

Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4(1):1–6. [PubMed]

Cherry-Peppers G, Daniels CO, Meeks V, et al. Oral manifestations in the era of HAART. J Natl Med Assoc 2003;95(2 Suppl 2):21S-32S. [PubMed]

Herrera D, Alonso B, de Arriba L, et al. Acute periodontal lesions. Periodontal 2000 2014;65(1):149–77. [PubMed]

Patton LL. Sensitivity, specificity, and positive predictive value of oral opportunistic infections in adults with HIV/AIDS as markers of immune suppression and viral burden. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90(2):182–88. [PubMed]

Ryder MI, Nittayananta W, Coogan M, et al. Periodontal disease in HIV/AIDS. Periodontol 2000 2012;60(1):78–97. [PubMed]

Necrotizing Ulcerative Gingivitis and Necrotizing Ulcerative Periodontitis (NUG/NUP)

Dental Standards of Care Committee, January 2017

Necrotizing ulcerative gingivitis (NUG) and necrotizing ulcerative periodontitis (NUP) are periodontal conditions that may be present in patients who do not have HIV infection, but both are more commonly associated with HIV infection and other systemic conditions [Bodhade et al. 2011].

Because of their similar clinical appearance and treatment, most studies have tended to classify NUG and NUP together as necrotizing periodontal lesions. Additionally, Candida organisms may be present in the tissues of NUP sites among patients with HIV, which suggests that Candida may have a role in HIV-associated NUP. Because of the presence of Candida in both LGE and NUG/NUP lesions, the possibility exists that LGE is a precursor to the development of NUG/NUP lesions. NUG and NUP are considered to be on the spectrum of the same pathologic process [Bodhade et al. 2011; Ryder et al. 2012; Patton et al. 1998; Robinson et al. 1998]; hence, early diagnosis and intervention will be effective in treating necrotizing periodontal diseases.

Presentation and Diagnosis

NUG, formerly referred to as acute necrotizing ulcerative gingivitis (ANUG), characteristically presents as a rapid onset of ulcerations of the interdental papilla with gingival bleeding and severe pain. Lesions are typically described as having a “punched out” appearance of the papilla, and the affected tissue appears to be covered with a fibrinous pseudomembrane (see Appendix: Photo- and Radiographs of Periodontal Disease Associated with HIV Infection for images). Biopsy is not initially indicated for diagnosis unless the tissue does not show evidence of healing.

NUP lesions are similar in appearance to NUG lesions; however, NUP lesions extend into and destroy the alveolar bone. Patients with NUP frequently present with exposed bone, gingival recession, and tooth mobility. These clinical signs and symptoms do not necessarily involve the entire periodontium; only localized areas of the tooth-bearing bone and associated soft tissues may be affected. NUP is characterized by a rapid destruction of bone that often leads to tooth loss, severe deep jaw pain, widespread soft-tissue necrosis, bleeding, and fetid mouth odor. Other signs and symptoms of NUG and NUP include swelling of the regional lymph nodes, fever, and malaise. These clinical findings do not present in all patients and are considered secondary presentations of disease. The presence of NUP may be indicative of severe or worsening immunosuppression [Bodhade et al. 2011; Ryder et al. 2012].

Treatment

Treatment initiation as soon as possible following the diagnosis of acute NUG/NUP is important to alleviate pain and tissue destruction. The well-established standard of care for NUG/NUP treatment by the oral health care provider includes debridement of infected areas; scaling and root planing of the teeth as needed; and intrasulcular lavage/irrigation with either 0.12% chlorhexidine gluconate or, as an alternative, 10% povidone iodine [Herrera et al. 2014]. This standard of care is based on the principle of eliminating or reducing the microbial load by mechanically removing debris and plaque [Hofer et al. 2002]. Such practices have been rigorously used over many years in the management of periodontal diseases in patients with HIV infection [Ryder et al. 2012; Winkler et al. 1989; Holmstrup and Westergaard 1994; Mealey 1996]. In severe cases or in nonresponding conditions, systemic antimicrobials should be used as an adjunct to standard treatment [Herrera et al. 2014]. Because the use of prophylactic antibiotic therapy might risk candidiasis [Herrera et al. 2014; Mealey 1996], the best option for antimicrobial therapy is metronidazole with an antifungal agent to prevent development of a secondary manifestation of oral candidiasis. Once the acute disease is under control, definitive treatment, such as root planning and scaling as needed, and therapy for pre-existing gingivitis or periodontitis should be provided. These include adequate therapy for the pre-existing gingivitis or periodontitis, instructions on adequate oral hygiene practices at home, and supportive therapy such as periodontal recall maintenance [Herrera et al. 2014; Hofer et al. 2002].

Broad spectrum antibiotics are effective for treatment of periodontal diseases in patients with HIV [Murray 1994]. Follow-up treatment includes daily antimicrobial rinses and systemic antibiotics, specifically metronidazole 250 mg 3 times per day, for 7 to 14 days. Metronidazole is effective as an adjunct systemic antibiotic for treating periodontal diseases in patients with HIV [Winkler and Robertson 1992]. If the patient cannot tolerate metronidazole, clindamycin 150 mg four times per day or amoxicillin-clavulanate 875 mg twice per day for 7 to 10 days may be prescribed. Extraction of affected teeth may be necessary if the bone loss is severe. Use of systemic antibiotics increases the patient’s risk of developing candidiasis; therefore, concurrent, empiric administration of an antifungal agent should be considered to maintain balance between treatment and potential negative side effects [Ryder 2000].

During the acute and healing stages of NUP, frequent recall visits are needed to administer the necessary periodontal therapies, assess tissue response, and monitor the patient’s oral hygiene performance. Periodontal maintenance is generally indicated every 3 months once the infection is controlled [Ryder et al. 2012].

Favorable treatment responses to HIV-associated periodontal disease usually occur when the disease is addressed as early as possible [Ryder et al. 2012]. Patients treated for NUP may develop repeated episodes, especially when oral hygiene practices are not good. NUP can be insidious, localized, and not necessarily related to plaque. Once clinical stabilization has occurred, visits every 3 months will allow for detection and prevention of disease recurrence at an incipient stage [Ryder et al. 2012].

References

Bodhade AS, Ganvir SM, Hazarey VK. Oral manifestations of HIV infection and their correlation with CD4 count. J Oral Sci 2011;53(2):203–11. [PubMed]

Herrera D, Alonso B, de Arriba L, et al. Acute periodontal lesions. Periodontal 2000 2014;65(1):149–77. [PubMed]

Hofer D, Hämmerle CH, Grassi M, et al. Long-term results of supportive periodontal therapy (SPT) in HIV-seropositive and HIV-seronegative patients. J Clin Periodontal 2002;29(7):630–37. [PubMed]

Holmstrup P, Westergaard J. Periodontal diseases in HIV-infected patients. J Clin Periodontal 1994;21(4):270–80. [PubMed]

Lucartorto FM, Franker CK, Maza J. Postscaling bacteremia in HIV-associated gingivitis and periodontitis. Oral Surg Oral Med Oral Pathol 1992;73(5):550-54. [PubMed]

Mealey BL. Periodontal implications: Medically compromised patients. Ann Periodontal 1996;1(1):256–321. [PubMed]

Murray PA. Periodontal diseases in patients infected by human immunodeficiency virus. Periodontal 2000 1994;6:50–67. [PubMed]

Patton LL, McKaig R. Rapid progression of bone loss in HIV-associated necrotizing ulcerative stomatitis. J Periodontal 1998;69(6):710–16. [PubMed]

Robinson PG, Sheiham A, Challacombe SJ, et al. Gingival ulceration in HIV infection. A case series and case control study. J Clin Periodontal 1998;25(3):260–67. [PubMed]

Ryder MI, Nittayananta W, Coogan M, et al. Periodontal disease in HIV/AIDS. Periodontol 2000 2012;60(1):78–97. [PubMed]

Ryder MI. Periodontal management of HIV-infected patients. Periodontal 2000 2000;23(1):85–93. [PubMed]

Winkler JR, Murray PA, Grassi M, et al. Diagnosis and management of HIV-associated periodontal lesions. J Am Dent Assoc 1989;119(Suppl):25S–34S. [PubMed]

Winkler JR, Robertson PB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:145–50. [PubMed]

Necrotizing Ulcerative Stomatitis and Necrotizing Stomatitis (NUS/NS)

Dental Standards of Care Committee, January 2017

Presentation and Diagnosis

NUS/NS may be an extension of NUP into the adjacent supporting bone, leading to osteonecrosis and subsequent sequestration of the surrounding bone.

Patients may present with pronounced residual soft tissue and bony defects in the affected areas following treatment and healing of the necrotic tissues [Armitage 1999; Ryder et al. 2012; Horning and Cohen 1995]. If the tissue does not heal, soft tissue biopsy is indicated to exclude other potential diagnoses, such as the increased risk of cancer in patients with HIV [Chen et al. 2015].

When the soft tissue destruction is no longer contained to the soft tissue and bone of the oral cavity, this condition can be clinically consistent with noma disease (also referred to as cancrum oris), which is more often seen in the pediatric population and is associated with severe or life-threatening malnourishment [Feller et al. 2014].

Treatment

PERIODONTAL DISEASE PRESCRIPTION DOSING

Preferred: Metronidazole, 250 mg three times per day for 7 days
Alternative: Augmentin, 500 mg two times per day for 7 days
For patients allergic to penicillin: Clindamycin, 300 mg three times per day for 7 days
As needed for pain: Rinse with 2 teaspoons of xylocaine 2% viscous solution

Broad spectrum antibiotics are effective for treatment of periodontal diseases in patients with HIV [Murray 1994; Patton and McKaig 1998]. Metronidazole is very effective as an adjunct systemic antibiotic for treating periodontal diseases in patients with HIV [Winkler and Robertson 1992]. Metronidazole is effective against gram-negative bacteria that are typically involved in periodontal diseases. Augmentin can be used as an alternative if the patients have gastrointestinal problems with metronidazole. Both 0.12% chlorhexidine gluconate and 10% povidone iodine are effective treatment modalities and either may be used in office and at home as an antimicrobial rinse [Hofer et al. 2002]. Local anesthetic may be indicated for pain management during removal of necrotic debris, scaling, and root planing.

References

Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4(1):1–6. [PubMed]

Chen CH, Chung CY, Wang LH, et al. Risk of cancer among HIV-infected patients from a population-based nested case-control study: implications for cancer prevention. BMC Cancer 2015;15:133. [PubMed]

Feller L, Altini M, Chandran R, et al. Noma (cancrum oris) in the South African context. J Oral Pathol Med 2014;43(1):1–6. [PubMed]

Hofer D, Hämmerle CH, Grassi M, et al. Long-term results of supportive periodontal therapy (SPT) in HIV-seropositive and HIV-seronegative patients. J Clin Periodontal 2002;29(7):630–37. [PubMed]

Horning GM, Cohen ME. Necrotizing ulcerative gingivitis, periodontitis, and stomatitis: clinical staging and predisposing factors. J Periodontal 1995;66(11):990-8. [PubMed]

Murray PA. Periodontal diseases in patients infected by human immunodeficiency virus. Periodontal 2000 1994;6:50–67. [PubMed]

Patton LL, McKaig R. Rapid progression of bone loss in HIV-associated necrotizing ulcerative stomatitis. J Periodontal 1998;69(6):710–16. [PubMed]

Ryder MI, Nittayananta W, Coogan M, et al. Periodontal disease in HIV/AIDS. Periodontol 2000 2012;60(1):78–97. [PubMed]

Winkler JR, Robertson PB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:145–50. [PubMed]

Chronic Pre-Existing Periodontal Disease

Dental Standards of Care Committee, January 2017

Presentation and Diagnosis

About half of the U.S. population >30 years of age is affected by chronic periodontal disease, and the prevalence of periodontal disease increases with age [Eke et al. 2015]. No data currently exist to indicate the extent to which HIV-infection may accelerate the destruction of periodontal tissues in the population with HIV. However, the occurrence of rapid attachment loss may indicate severe immunosuppression [Ryder et al. 2012; Mealey 1996]. Pre-existing periodontal disease can be diagnosed by clinical characteristics and radiographic examination for bone loss as recommended by the American Academy of Periodontology [Armitage 1999; Academy of Periodontology 2000]. The clinical characteristics for chronic periodontitis include the presence of periodontal pockets, clinical attachment loss, and bleeding on probing. Radiographic analysis can reveal the presence of periodontal bone loss with horizontal or vertical bony defects. Increased mobility of teeth may also be observed in association with clinical attachment loss and bone loss.

Treatment

Scaling and root planing is recommended for nonsurgical treatment of periodontal disease [Academy of Periodontology 2000]. Surgical therapy, including flap debridement and extraction of teeth, can be performed without postoperative complications. Prior to surgical therapy, consultation with the patient’s physician may be indicated to obtain information regarding hematological levels of immune cells. Low neutrophil counts may indicate the adjunct use of systemic antimicrobial therapy.

References

Academy of Periodontology. Parameters of care. J Periodontol 2000;71(5 Suppl): i–ii, 847–83. [PubMed]

Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol 1999;4(1):1–6. [PubMed]

Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol 2015;86(5):611–22. [PubMed]

Mealey BL. Periodontal implications: Medically compromised patients. Ann Periodontal 1996;1(1):256–321. [PubMed]

Ryder MI, Nittayananta W, Coogan M, et al. Periodontal disease in HIV/AIDS. Periodontol 2000 2012;60(1):78–97. [PubMed]

All Recommendations

Dental Standards of Care Committee, January 2017

ALL RECOMMENDATIONS: MANAGEMENT OF PERIODONTAL DISEASE IN PATIENTS WITH HIV

LGE Treatment

Oral health care providers should treat LGE promptly before it evolves into a more severe form of periodontal disease. (A2)
Oral health care providers should treat LGE with superficial debridement of affected tissue and antimicrobial rinse and schedule a follow-up appointment to determine if the patient is responding to treatment. (A2)

NUG/NUP Treatment

Oral health care providers should treat NUG and NUP to prevent destruction of periodontal tissues. X-rays will determine the severity of the periodontal bone loss. (A2)
Oral health care providers should treat the acute stage of NUG/NUP in the clinical setting as soon as possible after diagnosis; treatment should include superficial debridement of infected areas, root planing and scaling, and lavage/irrigation with an antimicrobial rinse (see text for antimicrobial irrigation options). (A2)
Oral health care providers should provide patients with a treatment plan for follow-up home care that includes daily antimicrobial rinses (see text for antimicrobial options) and instructions for and reinforcement of the importance of good oral hygiene and maintenance following treatment of acute disease and thereafter. (A2)
For patients with severe or nonresponding NUG/NUP, oral health care providers should prescribe systemic antibiotics and concurrent treatment with an antifungal agent, as specified below. (A3)

NUG/NUP Follow-Up

Oral health care providers should evaluate healing within 7 days of treatment and perform additional debridement if necessary. (A3)
Clinicians should reevaluate the patient 2 months after treatment to determine the need for further intervention. (A3)

NUS/NS Treatment

Oral health care providers should perform biopsy and refer patients to an oral surgeon, clinical pathologist, or oral medicine specialist when NUS/NS is diagnosed. (A2)
Oral health care providers should treat NUS/NS with debridement of necrotic bone and soft tissue and concurrent antimicrobial therapy, as specified below. (A3)
Clinicians should include the following as part of the treatment plan for patients with periodontal disease:
- Use of a pre-procedural antimicrobial rinse (A2)
- Local debridement and disinfection using a 0.12% chlorhexidine gluconate or 10% povidone iodine (A2)
- Removal of necrotic debris and sequestration, along with scaling and root planing, with local anesthesia to proceed as tolerated by patient but no later than within 7 days of diagnosis (A2)
- Reinforcement of oral hygiene and home care instructions and prescriptions, including:
  - Daily use of an antimicrobial rinse for 30 days
  - Antibacterial therapy
  - Nutritional supplementation/advice
  - Periodontal prescriptions (B2)

Chronic Pre-Existing Periodontal Disease Treatment

Oral health care providers should follow standard procedures for the management of chronic pre-existing periodontitis. (A3)
Treatment for pre-existing periodontitis should follow the current standard guidelines. (A3)
Clinicians should perform additional diagnostic procedures (biopsy, cytologic smear, or culture) for lesions that show no healing within 10 days or refer the patient to a periodontist as indicated. (A3)

Appendix: Photo- and Radiographs of Periodontal Disease Associated with HIV Infection

November 2016

Photographs courtesy of Dr. Gwen Cohen Brown and the Dental Hygiene Department of New York City College of Technology

Patient with linear gingival erythema (LGE)

Patient with necrotizing ulcerative periodontitis (NUP)

Patient with linear gingival erythema (LGE) and necrotizing ulcerative periodontitis (NUP)

Patient with necrotizing ulcerative gingivitis (NUG)

Patient with localized bone loss

How This Guideline Was Developed

This guideline was developed by the New York State (NYS) Department of Health (DOH) AIDS Institute (AI) Clinical Guidelines Program, which is a collaborative effort between the NYSDOH AI Office of the Medical Director and the Johns Hopkins University School of Medicine, Division of Infectious Diseases.

Established in 1986, the goal of the Clinical Guidelines Program is to develop and disseminate evidence-based, state-of-the-art clinical practice guidelines to improve the quality of care provided to people who have HIV, hepatitis C virus, or sexually transmitted infections; people with substance use issues; and members of the LGBTQ community. NYSDOH AI guidelines are developed by committees of clinical experts through a consensus-driven process.

Committee on Dental Standards of Care for Adult HIV Care Guidelines

The NYSDOH AI charged the Committee on Dental Standards of Care with developing evidence-based recommendations for clinicians in NYS who provide care to individuals with HIV. The purpose of the Management of Periodontal Disease clinical practice guideline is to provide clinicians throughout NYS with the recommendations needed to successfully diagnose and treat patients with periodontal lesions.

Committee Makeup: Members of the Commitee on Dental Standards of Care (see Box A1: Committee on Dental Standards of Care Leaders and Members, below) were appointed by the NYSDOH AI to ensure representation of clinical practice in all major regions of the state, relevant medical disciplines and subspecialties, key NYS agencies, community stakeholders, and patient advocates. Individuals confirmed as Committee members are required to disclose any potential conflicts of interest; disclosures are reviewed and approved by the NYSDOH AI Office of the Medical Director (see Funding and Disclosure of Potential Conflicts of Interest, below).

Committee Role: Committee members actively participate in guideline development, including evidence review, drafting of recommendations and text, manuscript review, consensus approval of all recommendations, and rating of recommendations.

Committee Leadership: Working with the lead author, the Committee on Dental Standards of Care Planning Group of Committee leaders reviewed and refined the manuscript, facilitated consensus approval of all recommendations, and addressed feedback from the committee at large.

Johns Hopkins University (JHU) Editorial Role: The JHU editorial team coordinated, guided, and documented all Committee activities and edited the guideline material for clarity, flow, and style.

Committee on Dental Standards of Care Planning Group (all Committee members and reviewers are listed in Box A1, below)

Stephen N. Abel, DDS, MSD, Chair
Bruce D. Agins, MD, MPH, AI Medical Director
Christopher J. Hoffmann, MD, MPH, JHU Principal Investigator

AIDS Institute and JHU Editorial and Program Management Team

Tracy Hatton, MPH, AI Guidelines Program Manager
Lyn C. Stevens, MS, NP, ACRN, Office of the Medical Director
Mary Beth Hansen, MA, JHU Guidelines Project Director
Johanna Gribble, MA, JHU Medical Editor
Jen Ham, MPH, JHU Medical Editor
Rachel Lastra, JHU Medical Editor
Jesse Ciekot, JHU Program Coordinator

Box A1: Committee on Dental Standards of Care Leaders and Members (when this guideline was developed)
Unless noted otherwise, committee members had no disclosures of financial relationships with commercial entities

Leadership

Chair: Stephen N. Abel, DDS, MSD, University at Buffalo-SUNY, New York, NY
Medical Director: Bruce D. Agins, MD, MPH, New York State Department of Health (NYSDOH) AIDS Institute (AI), New York, NY
JHU Principal Investigator: Christopher J. Hoffmann, MD, MPH, Johns Hopkins University School of Medicine, Baltimore, MD

Contributing Members

Victor M. Badner, DMD, MPH, North Bronx Healthcare Network, Bronx, NY
Mary Therese Biltucci, RDH, MA, University of Rochester, Rochester, NY
Stanley J. Boyd, DMD, Healthy Chelsea Dentistry, New York, NY
Gwen Cohen Brown, DDS, FAAOMP, New York City College of Technology, Brooklyn, NY
Dolores Cottrell-Carson, DDS, MSHA, New York State Board for Dentistry, Albany, NY
Maria de los Angeles Figueroa, DMD, Bronx-Lebanon Hospital Center, Bronx, NY
Robert D. Kelsch, DMD, Northwell Health, Manhasset, NY
Michael A. Kozlowski, DDS, Unity Dental Group, Rochester, NY
Abhiram Maddi, DDS, MSc, PhD, School of Dental Medicine, University at Buffalo, Buffalo, NY
Kareem J. Merrick, DDS, Harlem Unity Community Clinic, New York, NY
Calix Ramos-Rodriguez, DMD, Lutheran Medical Center, Brooklyn, NY
Miriam R. Robbins, DDS, MS, Winthrop University Hospital, Mineola, NY
Dara J. Rosenberg, DDS, MS, MPH, St. Barnabas Hospital, Bronx, NY
Terrence T. Thines, DDS, MS, SUNY Upstate Medical University, Syracuse, NY

NYS Program and Consumer Liaisons

Mary J. D’Silva, DDS, Department of Corrections and Community Supervision Liaison, Albany, NY
Britta Viereckl-Prast, DMD, Department of Corrections and Community Supervision Liaison, Bedford Hills, NY
Jahlove Serrano, Consumer Advisor, NYSDOH AI Consumer Advisory Committee, New York, NY

External Peer Reviewers

John T. Grbic, DMD, MMSc, Columbia University Medical Center, New York, NY
Mark I. Ryder, DMD, University of California San Francisco School of Dentistry, San Francisco, CA

Funding and Disclosure of Potential Conflicts of Interest (COIs)

Funding: NYS funds supported development of the Management of Periodontal Disease guideline through a grant awarded to the JHU School of Medicine, Division of Infectious Diseases, from the NYSDOH AI.

Conflicts of interest: All active Committee members, invited consultants and coauthors, peer reviewers, and program staff are required to disclose financial relationships with commercial entities, including gifts that may be actual conflicts of interest or may be perceived as conflicts. These individuals must disclose financial relationships annually, for themselves, their partners/spouses, and their organization/institution. On their annual disclosures, Committee members are asked to report for the previous 12 months and the upcoming 12 months. Box A2, below, lists reported conflicts.

Management of COIs: All reported financial relationships with commercial entities are reviewed by the NYSDOH AI guidelines program to assess the potential for undue influence on guideline recommendations made by the Committee.

All guideline recommendations received consensus approval of the full Committee, and the final review and approval of the recommendations was performed by the Committee Chair and the NYSDOH AI Medical Director and Deputy Medical Director, none of whom reported conflicts of interest.

Evidence Collection and Review

The NYSDOH AI guideline development process is based on a strategic search and analysis of the published evidence. Box A2 illustrates the evidence review and selection process.

Box A2: Evidence Collection and Review Processes

NYSDOH AI and Committee Dental Standards of Care defined the goal of the guideline: To provide evidence-based clinical recommendations to guide practitioners in successfully diagnosing and treating periodontal lesions in patients with HIV.
The Committee appointed a lead author who conducted a systematic literature search in PubMed using MeSH terms; all searches were limited to studies that 1) were published within the previous 5 years; 2) involved only human subjects; and 3) were published in English.
Lead author reviewed studies identified through searches and excluded based on the following criteria: Publication type, study design, participants, and clinical relevance to the guideline.
Author and editorial staff conducted additional searches using PubMed and online databases to identify:
- Studies published prior to the 5-year search limit.
- Studies published during the guideline development process.
- Recent conference abstracts.
- Older studies known to provide strong evidence in support of specific recommendations or to undergird expert opinion.
Lead author developed and all Committee members reviewed and approved evidence-based guideline recommendations:
- Planning group reviewed, deliberated, refined, and approved draft recommendations.
- Committee members reviewed, provided written comment on, deliberated, and reached consensus on recommendations.
- Planning group reviewed the cited evidence and assigned a 2-part rating to each recommendation to indicate the strength of the recommendation and the quality of the supporting evidence; consensus reached on ratings.
- Additional evidence identified and cited during the rating process (see below).
Ongoing update process:
- JHU editorial staff will surveil published literature on an ongoing basis to identify new evidence that may prompt changes to existing recommendations or development of new recommendations.
- JHU editorial staff will ensure that the Committee reviews new studies at least four times per year, and more often if newly published studies, new drug approval, or drug-related warning indicate the need for an immediate change to the published guideline.
- JHU editorial staff will track, summarize, and publish ongoing changes to the guideline.
- Committee will review and approve substantive changes to, additions to, or deletions of recommendations.
- Committee will initiate a full review of the guideline 4 years after the original publication date.
NYSDOH AI will publish a comprehensive update 5 years after the original publication date.

Recommendation Development and Rating Process

The clinical recommendations presented in this guideline were developed by consensus based on a synthesis of the current evidence collected through the systematic search described above. If no data were available, the recommendations are based on expert opinion, and this status is indicated in the rating and in the text.

The Planning Group met via teleconferences over approximately 10 months to finalize the guideline and reach consensus on recommendations and rationale. Once consensus among the Planning Group members was reached, the guideline was reviewed by the full Committee on Dental Standards of Care, and consensus was reached on all recommendations. These deliberations were conducted by teleconference and through Committee comments submitted in writing. Committee review discussions were recorded, and recordings were reviewed carefully to ensure that all decisions and changes were captured and integrated into the manuscript.

Members of the Planning Group then individually reviewed the evidence for each recommendation and assigned a 2-part rating (see below). The individual ratings were compiled into a report distributed to all raters, and conference call discussions were held to deliberate ratings for which consensus was needed. Once all raters agreed on the interpretation of evidence and ratings for all recommendations, the guideline was sent to the NYSDOH AI for review and approval.

AIDS Institute HIV Clinical Guidelines Program Recommendations Rating Scheme
Strength of Recommendation	Quality of Supporting Evidence
A = Strong	1 = At least 1 randomized trial with clinical outcomes and/or validated laboratory endpoints
B = Moderate	2 = One or more well-designed, nonrandomized trial or observational cohort study with long-term clinical outcomes
C = Optional	3 = Expert opinion

Guideline Updates

Members of the MCCC will monitor developments in PrEP in an ongoing structured manner to maintain guideline currency. Once the guidelines are published on the program website: www.hivguidelines.org, any updates will be made to the HTML document as needed as new peer reviewed literature on PrEP is published.

Notification of newly published studies will be automated, and the Planning Group will review new data at least every 4 months. Newly published data that provide support for existing recommendations will be cited in the text, and the studies will be added to the reference list(s).

If newly published data prompt a revision to recommendations or rationale, the Planning Group will propose appropriate edits and determine whether the changes warrant review and approval by the entire MCCC. If MCCC review is required, a conference call will be convened for that purpose. Deletion of existing recommendations, addition of any new recommendations, and/or substantive changes to existing recommendations will prompt MCCC review and consensus.

If a new medication or formulation is approved, the Planning Group will be convened via conference call to examine the data, consider inclusion in the guideline, and determine the need for MCCC review and approval.

The full guideline will be reviewed and updated on the 4th anniversary of original publication to prepare for publication of an updated guideline on or before the 5th anniversary of original publication.