Vol. 91 No.

1 January 2001

ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY

ORAL AND MAXILLOFACIAL SURGERY Editor: Larry J. Peterson

Hospital course of HIV-positive patients with odontogenic

infections
John W. Carey, DMD,a and Thomas B. Dodson, DMD, MPH,b Atlanta, Ga, and Boston, Mass
EMORY SCHOOL OF MEDICINE AND MASSACHUSETTS GENERAL HOSPITAL

Objective. The study purpose was to compare and contrast the hospital course of patients who are human immunodeficiency
virus-positive (HIV+) and human immunodeficiency virus-negative (HIV–) who were admitted to manage their odontogenic
infection.
Study design. We used a retrospective case-control study design and a sample derived from patients admitted for manage-
ment of their odontogenic infections. Cases and controls were defined as patients who were HIV+ or HIV–, respectively. HIV
status was determined by patient self-report. Outcome variables included admission temperature (degrees Celsius) and white
blood cell count, number of fascial spaces infected, days with temperature >38°C, need for intensive care, and length of
hospital stay.
Results. The study sample consisted of 60 patients (10 HIV+ cases and 50 HIV– controls matched for age and sex) with a
mean age of 32.8 ± 6.6 years and was predominately male (78%). Significant differences existed between patients who were
HIV+ and those who were HIV– for the following variables: admission white blood cell count, number of days with maximum
temperature >38.0°C, and use of the intensive care unit.
Conclusions. The study results suggest that patients who are HIV+ who are admitted for management of odontogenic infection
have a significantly more intense hospital course than those who are HIV–. However, the overall length of hospital stay is not
significantly different.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:23-7)

As a general principle of surgery, patients who are
immunocompromised have an increased risk for post-
operative complications.1-5 As such, one could hypoth-
esize that patients who are immunocompromised
resulting from human immunodeficiency virus (HIV+)
infection may have a more complicated hospital course
when admitted for management of serious odontogenic
infections than patients who are HIV negative (HIV–).
The results of some studies lend support to this hypoth-
esis. Schmidt et al5 reported that the postoperative
infection rate after the treatment of mandibular frac-
aResident in training, Division of Oral and Maxillofacial Surgery,
Department of Surgery, Emory School of Medicine
Atlanta, Ga.
bDirector of Resident Training, Associate Professor, Department of
Oral and Maxillofacial Surgery, Massachusetts General Hospital
Harvard School of Dental Medicine, Boston, Mass.
Received for publication Jan 20, 2000; returned for revision Feb 16
and Mar 9, 2000; accepted for publication Aug 17, 2000.
Copyright © 2001 by Mosby, Inc.
1079-2104/2001/$35.00 + 0 7/12/111410
doi:10.1067/moe.2001.111410
tures was significantly higher for patients who are
HIV+ compared with those who are HIV–. Furthermore,
Dodson et al,6 in a retrospective study, found that when
comparing patients who were HIV+ with those who
were HIV–, those who were HIV+ had an increased
risk for postoperative infections after tooth extraction.
In addition, the complication rates increased as the
severity of HIV disease increased.
Other studies, however, report no significant differ-
ences in postoperative complication rates between
patients who are HIV+ and those who are HIV– after oral
and maxillofacial surgical procedures.7-11 In a retrospec-
tive study, Glick et al7 found the overall complication rate
for various dental procedures to be 0.9% in patients who
were HIV+ with a CD4 count <200 cells/mm3. In a more
recent prospective study, Dodson8 found no difference in
infection rates after dental extractions when comparing
patients who were HIV+ and those who were HIV–.
Additionally, it has been found that prophylactic antimi-
crobials are not required for dental extractions in the
HIV+ population.9,10 The results of a pilot study suggest

23
24 Carey and Dodson
Table I. Demographic variables grouped by HIV status
Variable HIV+
Sample size (n) 10
Mean age (y) 32.2 ± 6.36
Sex
Women 2 11
Men 8 39
Race
Black 5 40
White 5 10
that patients who are HIV+ do not have an increased risk
for developing serious odontogenic infections when
compared with those who are HIV–.11
Little is known about the risk for adverse outcomes
for patients who are HIV+ who have oral and maxillo-
facial surgical problems. As evidenced by the variable
results reported in the literature, it is inadvisable to base
treatment decisions for patients who are HIV+ solely on
the pathophysiologic concept that patients who are
immunosuppressed might have an increased risk for
postoperative complications. In addition, it is inade-
quate to assume that patients who are HIV+ will have a
more complex treatment course simply because they are
immunocompromised. To address this gap in our
knowledge, we proposed a study to compare and
contrast the hospital course of patients who are HIV+
and those who are HIV– admitted for management of
serious odontogenic infections.
MATERIAL AND METHODS
For this study, we used a case-control study design and
a study sample derived from patients admitted for treat-
ment of serious odontogenic infections between 1993
and 1998 by the Emory University Division of Oral and
Maxillofacial Surgery at Grady Memorial Hospital, in
Atlanta, Ga. A serious odontogenic infection was defined
as one requiring hospital admission for management.11
Indications for hospital admission included one or
more of the following: trismus, dysphagia, fascial space
involvement, rapidly increasing facial swelling, the
failure of oral antibiotic therapy, or the need for a
general anesthetic to operatively treat the infection.
Cases and controls were defined as patients who were
HIV+ or HIV–, respectively. Controls were matched to
cases based on age (patient age ± 5 years) and sex. Five
controls were matched with each case. HIV status was
determined based on patient self-report. We chose
patient self-report to classify HIV status because it
represented the clinical reality of managing serious
odontogenic infections in this acute-care setting. In
most cases, the patient’s HIV serostatus was not readily
available at the time of hospital admission. As such,
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
January 2001
HIV– P value
50 –
32.8 ± 6.74 P = .58
P = .89
P < .05
treatment decisions were made on the basis of patient
history rather than waiting for test results.
The primary data source was the patient’s medical
record. Study variables of interest abstracted from the
record included the following: admission temperature
(°C), admission white blood cell (WBC) count (K),
number of fascial spaces involved, days with maximum
temperature >38.0°C, need for an operation to manage
the infection, use of the surgical intensive care unit
(ICU) and length of ICU stay, need for and duration of
intubation, and length of hospital stay (LOS). The oral
and maxillofacial surgery chief resident in consultation
with an attending oral and maxillofacial surgeon deter-
mined the need for hospital admission, ICU care, intu-
bation, and duration of ICU stay. Database manage-
ment and descriptive and bivariate data analyses were
performed with SPSS for Windows, version 7.5 (SPSS,
Inc, Chicago, Ill).
RESULTS
The study sample consisted of 60 patients, 10 who
were HIV+ and 50 matched controls who were HIV–.
The mean age of the sample was 32.8 ± 6.6 years
(mean ± SD) and was predominantly male (78%)
(Table I). As expected, given the study design, there
were no statistically significant differences between
HIV+ and HIV– for the variables age and sex. The
average admission temperature was 38.0°C ± 0.7° and
38.0°C ± 0.9° for patients who were HIV– and HIV+,
respectively (P = .92). The average admission WBC
was 13.7 ± 6.3 K for HIV– and 9.1 ± 3.0 K for HIV+
(P = .03). There was no difference in the number of
fascial spaces involved between the 2 groups (HIV–,
2.5 ± 1.5, HIV+, 2.5 ± 1.4, P = .97). The number of
days with the maximum temperature > 38.0°C was 1.7
± 2.2 days for HIV– and 3.6 ± 3.7 days for HIV+ (P =
.03). All the patients who were HIV+ and 92% of those
who were HIV– required operative intervention (P =
.47). ICU care was required by 14% of the patients who
were HIV– and 50% of those who were HIV+ (P =
.02). When ICU care was needed, the ICU length of
stay was 4.6 ± 4.3 and 7.8 ± 3.7 days for patients who
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 91, Number 1
Table II. Outcome variables grouped by HIV status
Variable HIV+
Admission temperature (°C) 38.0 ± 0.9
Admission WBC (×103) 9.1 ± 3.0
No. of fascial spaces involved 2.5 ± 1.4
No. days with temperature >38.0°C 3.6 ± 3.7
Required OR treatment (%) 100
Required ICU care (%) 50
ICU LOS (d) 7.8 + 3.7
No. of days intubated 6.8 ± 3.7
Overall hospital LOS (d) 8.7 ± 5.0
were HIV– and HIV+, respectively (P = .03). All the
patients in ICU were intubated, and the mean duration
of intubation was 4.1 ± 4.1 and 6.8 ± 3.7 days for
patients who were HIV– and HIV+, respectively (P =
.27). The average hospital stay was 6.2 ± 5.6 and 8.7 ±
5.0 days for patients who were HIV– and HIV+,
respectively (P = .2) (Table II).
DISCUSSION
The results of this study suggest that patients who are
HIV+ with serious odontogenic infections have a signif-
icantly different hospital course when compared with
those who are HIV–. However, the results should be
interpreted cautiously. The use of a retrospective study
design increases the chance for bias caused by missing
data, misclassification, or selection bias. In this study, all
the data elements for each variable were present.
Because HIV status was assessed by record review and
not by serum studies, it is possible that the HIV status of
some patients was misclassified. However, the simple
fact that a patient is HIV+ may bias care and alter
hospital course. Specifically, we would hypothesize that
the patient who is HIV+, on average, may be overtreated
relative to the patient who is HIV–. As a result of either
misclassification or selection bias, it is possible that we
may have a biased assessment of the true differences in
hospital course between patients who are HIV+ and
those who are HIV– admitted for management of their
serious odontogenic infections. Despite similar clinical
presentations (same age, sex, number of fascial spaces
involved, and admission temperature), the outcome vari-
ables consistently suggested that patients who were
HIV+ had a more complicated hospital course. Although
not all the variables were statistically different between
the 2 groups, the differences between the 2 groups were
consistently similar. For example, patients who were
HIV+ required ICU care more frequently with a longer
duration of ICU stays, were intubated for a longer period
of time, and had a longer overall hospital stay.
Although this study may be criticized for depending
on patient report rather than laboratory evidence to
Carey and Dodson 25
HIV– P value
38.0 ± 0.7 P = .92
13.7 ± 6.3 P = .03
2.5 ± 1.5 P = .97
1.7 ± 2.2 P = .03
92 P = .47
14 P = .02
4.6 + 4.3 P = .03
4.1 ± 4.1 P = .27
6.2 ± 5.6 P = .2
determine HIV status, it reflects the reality that clinical
decisions are made in the absence of complete or
perfect information. It is common to diagnose and
initiate treatment before confirming the patient’s HIV
status. In addition, the HIV serostatus may still be
pending by the time the patient leaves the hospital.
Recurrent bacterial infections are well-described
phenomena for patients who are HIV infected.12-14
However, HIV infection does not appear to increase the
risk of dying from bacteremia when comparing
patients who are HIV+ and those who are HIV– with
bacteremia.15 Furthermore, most of the literature series
reports that the overall incidence of bacterial diseases
do not show any relationship with the presumptive risk
factors associated with HIV infection.16-28 Some retro-
spective cohort and case control studies, however,
suggest that patients who are HIV+ with absolute
neutrophil counts lower than 1000 × 106/L are at
increased risk for having serious bacterial infections,
compared with patients who are HIV+ who have higher
absolute neutrophil counts.29-32 In this study, we did
not measure absolute neutrophil count.
The mean admission temperature for the patients in
this sample was 38°C. This temperature may seem low,
especially for patients with infections severe enough to
require hospital admission. However, it is consistent
with another report on facial infections from the same
institution. In a sample of 339 adults (age ≥18 years)
admitted for management of facial infection, the mean
admission temperature was 37.9°C ± 0.8°.33
HIV disease covers a large clinical spectrum, ranging
from patients who are asymptomatic HIV+ to patients
with acquired immunodeficiency syndrome. As such,
one might expect different complication rates after
admission for an odontogenic infection, depending on
the severity of HIV disease.6 In this study, however, the
patients who were HIV+ were analyzed as a homoge-
nous group and not stratified on the basis of severity of
HIV disease. Although it may be more ideal to stratify
the group that is HIV+ by the severity of the disease,
that is not a practical exercise for the acute treatment of
26 Carey and Dodson
serious odontogenic infections. For the level of HIV
disease to be classified (Centers for Disease Control
and Prevention classification, A1-C3), additional labo-
ratory parameters are required beyond the information
commonly obtained from a history and physical exam-
ination. Obtaining this information can necessitate
postponing treatment. In the setting where acute treat-
ment can be rendered for a severe odontogenic infec-
tion, a delay in treatment to obtain laboratory or other
information might compromise the treatment.
Assessing the role of empiric antibiotics for the treat-
ment of severe odontogenic infections in patients who
are HIV+ is difficult. Dodson8 reported that postopera-
tive antibiotic use was not associated with postextrac-
tion complications. It should be noted, however, that
patients who are HIV+ are commonly on a course of
prophylactic antibiotic therapy for prevention of
Pneumocystis carinni pneumonia or on a course of
active antibiotic therapy for the treatment of an acute,
nonodontogenic problem.
The results of this retrospective study suggest that
patients who are HIV+, when compared with those who
are HIV–, do have a more complicated, intense hospital
course when admitted for serious odontogenic infec-
tions. We believe this topic is a fertile area for investi-
gation, and given the study’s limitations outlined in
earlier paragraphs, it would be prudent to continue
prospective investigations into this area. For those inter-
ested in pursuing this research topic, we would recom-
mend establishing objective parameters for hospital
admission/discharge, ICU admission/discharge, and
management, and establishing HIV status with serum
studies. Prospective implementation of these parame-
ters would begin to address potential misclassification
and selection biases noted in this article.
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157:1825-31. tdodson@partners.org

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