Endodontic and HIV: myths and realities about the dental care protocol: systematic review and meta-analysisABSTRACT
Objective The objective of this systematic review was to analyze dental care for patients with HIV, particularly in the context of endodontic treatments.
Methods Five reviewers conducted searches in electronic databases including EBSCOhost, Cochrane, PubMed, and Lilacs from 2014 to 2024, followed by a manual search and extraction of citations for all eligible articles based on inclusion criteria.
Results A total of 1,031 citations were examined, with 400 duplicate articles. Three hundred and twenty-two studies that do not include protocols or endodontic management methods were excluded. Ultimately, 4 articles were included in this review that met the inclusion criteria.
Conclusion The implementation of strict biosecurity protocols and the personalization of treatment based on the assessment of the health of patients with HIV are essential to minimize the risks of infection and improve recovery in endodontic procedures. Rigorously applying biosecurity protocols, such as using physical barriers and sterile materials, is crucial to reduce the possibility of cross-contamination during endodontic treatments in patients with HIV.
Indexing terms
Dentistry; Endodontics; HIV; Systematic review
RESUMO
Objetivo O objetivo desta revisão sistemática foi analisar o atendimento odontológico a pacientes com HIV, particularmente no contexto de tratamentos endodônticos.
Métodos Cinco revisores realizaram buscas em bases de dados eletrônicas, incluindo EBSCOhost, Cochrane, PubMed e Lilacs, abrangendo o período de 2014 a 2024, seguidas de busca manual e extração de citações de todos os artigos elegíveis com base nos critérios de inclusão.
Resultados Um total de 1.031 citações foram examinadas, sendo 400 artigos duplicados. Trezentos e vinte e dois estudos que não incluíam protocolos ou métodos de manejo endodôntico foram excluídos. Ao final, 4 artigos que atendiam aos critérios de inclusão foram incorporados a esta revisão.
Conclusão A implementação de protocolos rigorosos de biossegurança e a personalização do tratamento, com base na avaliação da saúde de pacientes com HIV, são essenciais para minimizar os riscos de infecção e melhorar a recuperação em procedimentos endodônticos. A aplicação rigorosa de protocolos de biossegurança, como o uso de barreiras físicas e materiais estéreis, é fundamental para reduzir a possibilidade de contaminação cruzada durante tratamentos endodônticos em pacientes com HIV.
Termos de indexação
Odontologia; Endodontia; HIV; Revisão sistemática
INTRODUCTION
Systemic diseases are mostly spontaneous, meaning they are unexpected, and the Human Immunodeficiency Virus (HIV) is a disease that impedes the human body’s ability to confront infections. This disease represents a significant public health problem worldwide. However, in Ecuador, according to the Ministry of Public Health (MSP), the first cases date back to 1984. Current figures indicate that between 2014 and 2022, there were between 3,000 and 5,000 cases reported each year. It is worth mentioning that morbidity has increased, considering that data from previous decades showed between 2,000 and 3,000 patients. Therefore, it is crucial to deepen our understanding in case a patient with this condition seeks dental care [1-3].
This research aims to gather as much updated information as possible regarding the care and protocols that endodontic specialists must follow when treating patients with HIV. There is a limited amount of research on this topic, with the last document dating back to 2022. One of the objectives of this research is to provide the necessary confidence for endodontic specialists to carry out any required treatments for these patients without inconvenience.
Sometimes, when a patient with HIV visits the endodontist or any other dental specialist, including general dentists or dental students during their internships, some individuals may feel apprehensive about treating a patient with this condition due to fear of contagion or a lack of knowledge on how to handle the situation. This research seeks to clarify any doubts regarding the dental management of patients with HIV, particularly in the context of endodontics [4-6].
It is essential to distinguish between a patient with HIV and one who has progressed to AIDS, as this factor is critical in determining the treatment methods for each individual. A patient with AIDS is systemically compromised, and their health status can fluctuate rapidly. Therefore, this research will focus on the endodontic management of patients with HIV who have not yet reached the AIDS stage [7-9].
HIV leads to a significant decrease in the human body’s immune system, meaning that the infection can alter the body’s defense mechanisms against pathogens that cause periapical or pulp diseases. In such infections, microorganisms present in the periradicular system can directly or indirectly induce an anti-inflammatory response, resulting in various pathologies that disseminate from the infected root canal system [10-12].
METHODS
This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, specialized in dental research. A question was formulated based on the PICO format (Patient/Population, Intervention, Comparison, Outcome) to address the proper management and biosecurity protocol when performing endodontic treatment on HIV patients.
The population included HIV patients diagnosed with symptomatic irreversible pulpitis, asymptomatic irreversible pulpitis, pulp necrosis, previously initiated therapy, previously treated teeth, or traumatic pulp exposures with persistent clinical or radiographic signs/symptoms of periapical pathology requiring non-surgical endodontic treatment. The interventions included biosecurity measures applied during non-surgical endodontic treatment, and the outcomes included a lower incidence of cross-contamination in patients with HIV disease. The standardized question was as follows: What specific biosecurity guidelines should be followed in the endodontic management of HIV/AIDS-diagnosed patients to ensure the protection of both dental staff and patients during treatment?
Inclusion criteria considered randomized clinical trials, cohort studies, case-control studies, cross-sectional studies, and prospective or retrospective studies conducted on HIV patients and reported in English between 2014 and 2024. Studies involving patients with irreversible pulpitis, pulp necrosis, previously initiated therapy, previously treated teeth, or systematic traumatic pulp exposures relevant to the topic, and studies that included biosecurity management in HIV patients were also included. Exclusion criteria included in vitro studies, non-randomized studies on HIV patients before 2014 that did not include training outcomes on the management of systemic diseases, literature reviews, and systematic reviews related to the topic, studies involving patients with HIV/AIDS, studies conducted before 2014, case reports, case series (without controls), cell cultures, laboratory studies, animal studies, and review articles, as well as scientific manuscripts on Acquired Immunodeficiency Syndrome (AIDS) patients that did not include endodontic protocols or management methods.
Based on the PICO question, medical subject heading terms were combined with the Boolean connector “AND” to identify relevant studies. The keywords used in English were: (HIV and endodontic), (HIV and endodontic and biosecurity), (HIV and protocol and endodontic), (HIV and protocol and periapical), (HIV and periapical and security), and (HIV and endodontic and treatment) in the databases EBSCOhost, Cochrane, PubMed, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS, Latin American and Caribbean Literature in Health Sciences) from 2014 to 2024. All included studies were written in English.
Four independent reviewers (G.M, J.F, A.G, and M.A) conducted an exhaustive search of the electronic literature databases mentioned above. The literature search was carried out between February 28 and March 14, 2024. The studies found as a result of the bibliographic search were categorized by database and are shown in the flowchart (figure 1).
The search results were exported to the Rayyan - Intelligent Systematic Review program, and duplicates were removed using the tools of that program. The reviewers selected the articles that met the inclusion and exclusion criteria, and the titles or abstracts were analyzed according to the inclusion criteria. If the title or abstract did not provide sufficient information for the decision of inclusion or exclusion, the full text of the articles was read, and the same eligibility criteria described above were applied.
Four authors (G. M., A. G., J. F., and M. A.) independently reviewed the titles and abstracts of the articles from the search results, and the full texts of potentially relevant articles were reviewed and selected based on the inclusion and exclusion criteria. After reading the titles and abstracts, four independent reviewers (G. A. M. V., J. M. F. Q., M. J. A. V., and A. E. G. G.) selected the articles to include. Disagreements between the reviewers were resolved by consensus after discussion and evaluation by a third investigator (I.R.G.M.). Data extraction included general information identifying the study (author and year), study topic, objective, design, and sample.
Two reviewers (G. A. M. V. and A. E. G. G.) independently assessed the potential risk of bias using Review Manager 5.4.1 software. In case of disagreements, a third reviewer (J. M. F. Q.) was consulted to reach a consensus. Each item was evaluated by addressing specific guiding questions, resulting in a rating of “low risk of bias” (for negative responses), “high risk of bias” (for positive responses), or “unclear” (for missing information). Duplicated articles that were preselected using the “Rayyan – Intelligent Systematic Review” program will be excluded, as well as articles eliminated for not covering the studied topic, articles conducted on animals, and those not available in Spanish or English.
RESULTS
Initially, 1,031 potentially relevant studies were identified across all searched databases. A total of 400 duplicates were excluded, leaving 631 articles. After excluding the articles that did not meet the inclusion criteria, 4 articles remained (chart 1).
Risk of Bias within Studies
Figures 2A and 2B show the risk of bias in the included articles that report a case. The included clinical trial studies were individually assessed for each domain of risk of bias (figure 2A). Three studies were considered to have a high risk due to concerns related to allocation concealment, participant blinding, selective reporting, and other factors.
DISCUSSION
Dental care in the field of endodontics requires specific biosecurity protocols from the specialist. When this is related to patients with HIV (Human Immunodeficiency Virus), it must be noted that this disease is highly contagious, and its primary routes of transmission are parenteral, sexual, and percutaneous. The TDIC (The Dentists Insurance Company) Risk Management staff asserts that standard precautions must be observed within biosecurity guidelines, including hand hygiene, which should be performed according to the protocols of the National Center for Preventive Programs and Disease Control [13].
Regarding the protection of dental personnel, standard infection prevention and control measures should be strictly implemented, including the use of appropriate personal protective equipment such as gloves, disposable caps, masks, protective eyewear or face shields, and gowns when indicated. Safe practices should be followed during the handling of needles, sharps, and sterile instruments, while environmental surfaces must be properly cleaned and disinfected after each patient. In addition, obtaining a comprehensive medical history, reviewing the patient’s current antiretroviral therapy, immune status, and complementary laboratory tests when indicated are essential for appropriate treatment planning and minimizing the risk of complications. Although endodontic procedures may involve exposure to blood and other body fluids, antibiotic prophylaxis should only be prescribed for patients with specific medical indications, such as those at high risk of infective endocarditis, and should not be routinely administered solely because a patient is living with HIV [14-16].
Before the intervention, the patient’s accessories and jewelry should be removed. The specialist should then proceed to apply physical barriers for both parties. The patient will wear a disposable surgical gown, a disposable permeable cap, eye protection, chest protection, and, in some cases, auditory protection. Subsequently, the endodontist will don their protective barriers. The mask will help protect the airways from splashes of blood or contaminant aerosols, covering both the nose and mouth [17].
The use of double gloves is necessary; as endodontic treatment involves exposure to fluids in the working environment. The attire should include a disposable surgical gown, which will be used exclusively during dental care and the procedure to avoid contact with bodily fluids and contaminated surfaces. Eye protection should be worn to prevent contamination from fluids and aerosols smaller than 5 μm (such as spray from the triple syringe or high-speed handpiece during the pulpal chamber opening). During the intervention, it is recommended that all materials be sterile to prevent cross-contamination [18-21].
The anesthetic solutions used for these patients do not differ from those used in healthy patients, as there are no special contraindications, the most commonly used anesthetic solutions are 2% lidocaine with epinephrine and 4% articaine with epinephrine, which differ in their duration of effect and latency, lidocaine has a duration of effect of 120 minutes (2 hours), while articaine lasts for 148 minutes (2 hours and 28 minutes). However, lidocaine has a faster onset time, at 0.67 minutes, compared to articaine’s 0.86 minutes [22-24].
Once the patient is anesthetized, the isolation material is placed, which consists of: (a) clamps that embrace the dental piece, used according to the tooth being treated; (b) rubber dam; (c) rubber dam perforator; (d) rubber dam frame; (e) gingival barrier to ensure absolute isolation [5]. On the other hand, Fontes indicates that there are different types of rubber dams, with various shapes, sizes, and textures; however, the most commonly used for endodontics is of medium and strong thickness, measuring 5 inches. Another important characteristic is the color; options include black, green, blue, gray, pink, purple, beige, and lavender, but lighter colors are preferred, as they provide better reflection of the operative field.
The treatment is performed according to the diagnosis evaluated by the endodontist. The irrigation of the canals for a patient with HIV+ will be carried out using sodium hypochlorite, which effectively eliminates the tissue to be removed and also acts against bacteria, viruses, and spores. During obturation, care must be taken in handling instruments to avoid cross-contamination [13].
After the intervention, disposable materials such as surgical gowns, chest drapes, gloves, paper towels, cottons, and gauzes should be considered highly contagious and placed in red plastic bags, which must be labeled. Sharp objects will be disposed of in rigid containers [17].
The materials used must undergo disinfection and sterilization processes. They are placed in a container with sodium chloride at 5000 ppm for thirty minutes, followed by sterilization. After treatment, the sponge from the file drum must be discarded, and the files and spacers used should be sterilized if they maintain their proper shape; otherwise, they must be discarded. Stainless steel staples and paper points must be sterilized in an autoclave. The radiographs taken should be rinsed under running water and then disinfected in 70% alcohol for 5 minutes. For needles or scalpels, a pre-disinfection in 2.5% sodium hypochlorite for 30 minutes is necessary. The disinfection of surfaces and work equipment should always be performed at the end of the day [13].
If the specialist has wounds or dermatological lesions, they should not handle the patient. In the event of blood or fluid splashes on the skin, it is necessary to wash immediately with soap or a sodium hypochlorite-based disinfectant [25].
According to Tibúrcio-Machado et al. [13], the treatment to be employed will be based on the clinical assessment obtained from the patient. Thus, prior to the dental appointment, a consultation with the treating professional for their illness is required, as well as laboratory studies: liver function, renal function, and a complete blood count, due to the medication the patient may be taking. Once the dental treatment has been performed, patient monitoring should be conducted within 24 to 72 hours, as the development of a periapical lesion can cause destruction of the periapical bone due to the infiltration of T cells and the secretion of cytokines that occur in that area, resulting in altered periapical repair [26].
CONCLUSION
The rigorous application of biosecurity protocols, such as the use of physical barriers and sterile materials, is essential to reduce the possibility of cross-contamination during endodontic treatments in patients with HIV. These protocols not only protect dental staff but also the patient, ensuring the efficacy and safety of the treatment.
Endodontic treatment in HIV patients should be based on a thorough assessment of their health status, considering factors such as viral load and immunological status. The implementation of individualized management enhances the quality of treatment, thereby reducing complications and ensuring the effective recovery of periapical tissues.
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How to cite this article
Gavilánez-Gaibor AE, Morales-Valladares GA, Figueroa-Quintana JM, Armas Vaca MJ, García Merino IR. Endodontic and HIV: myths and realities about the dental care protocol: systematic review and meta-analysis. RGO, Rev Gaúch Odontol. 2026;74:e20260036. http://dx.doi.org/10.1590/1981-863720260036 20240065
Data Availability
The research data are available in the body of the document.
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