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1.  The feasibility, acceptance and key features of a prevention-focused oral health education program for HIV+ adults 
AIDS care  2013;26(6):763-768.
Poor oral health is common in HIV+ adults. We explored the feasibility, acceptance and key features of a prevention-focused oral health education program for HIV+ adults. This was a pilot sub-study of a parent study in which all subjects (n=112) received a baseline periodontal disease (PD) examination and provider-delivered oral health messages informed by the Information-Motivation-Behavioral Skills (IMB) Model. Forty-one parent study subjects were then eligible for the sub-study; of these subjects, a volunteer sample was contacted and interviewed 3–6 months after the baseline visit. At the recall visit, subjects self-reported behavior changes that they had made since the baseline. PD was re-assessed using standard clinical assessment guidelines and results were shared with each subject. At recall, individualized, hands-on oral hygiene coaching was performed and patients provided feedback on this experience. Statistics included frequency distributions, means and chi-square testing for bivariate analyses. Twenty two (22) HIV+ adults completed the study. At recall, subjects had modest, but non-significant (p>0.05) clinician observed improvement in PD. Each subject reported adopting, on average, 3.8 (± 1.5) specific oral health behavior changes at recall. By self-report, subjects attributed most behavior changes (95%) to baseline health messages. Behavior changes were self-reported for increased frequency of flossing (55%) and tooth-brushing (50%), enhanced tooth-brushing technique (50%), and improved eating habits (32%). As compared to smokers, non-smokers reported being more optimistic about their oral health (p=.024) at recall and were more likely to have reported changing their oral health behaviors (p=.009). All subjects self-reported increased knowledge after receiving hands-on oral hygiene coaching performed at the recall visit. In HIV+ adults, IMB-informed oral health messages promoted self-reported behavior change; subjects preferred more interactive, hands-on coaching. We describe a holistic clinical behavior change approach that may provide a helpful framework when creating more rigorously-designed IMB-informed studies on this topic.
doi:10.1080/09540121.2013.845291
PMCID: PMC3943585  PMID: 24134855
HIV; Oral Health; periodontal disease; Behavior Theory; prevention and communication
2.  Effect of Nadir CD4+ T Cell Count on Clinical Measures of Periodontal Disease in HIV+ Adults before and during Immune Reconstitution on HAART  
PLoS ONE  2013;8(10):e76986.
Background
The contribution of HIV-infection to periodontal disease (PD) is poorly understood.  We proposed that immunological markers would be associated with improved clinical measures of PD.
Methods
We performed a longitudinal cohort study of HIV-infected adults who had started highly active antiretroviral therapy (HAART) <2 years. PD was characterized clinically as the percent of teeth with ≥1 site with periodontal probing depth (PPD) ≥5.0mm, recession (REC) >0mm, clinical attachment level (CAL) ≥4.0mm, and bleeding on probing (BOP) at ≥4 sites/tooth and microbiologically as specific periodontopathogen concentration. Linear mixed-effects models were used to assess the associations between immune function and PD.
Results
Forty (40) subjects with median 2.7 months on HAART and median nadir CD4+ T-cell count of 212 cells/μl completed a median 3 visits. Over 24 months, CD4+ T-cell count increased by a mean 173 cells/µl (p<0.001) and HIV RNA decreased by 0.5 log10 copies/ml (p<0.001); concurrently, PPD, CAL and BOP decreased by a mean 11.7%, 12.1%, and 14.7% respectively (all p<0.001). Lower nadir CD4+ T-cell count was associated with worse baseline REC (-6.72%; p=0.04) and CAL (9.06%; p<0.001). Further, lower nadir CD4+ T-cell count was associated with a greater relative longitudinal improvement in PPD in subjects with higher baseline levels of Porphyromonas gingivalis (p=0.027), and BOP in subjects with higher baseline levels of Porphyromonas gingivalis or Treponema denticola (p=0.001 and p=0.006 respectively). Longitudinal changes from baseline in CD4+ T-cell count and level of HIV RNA were not independently associated with longitudinal changes in any clinical markers of PD.
Conclusion
Degree of immunosuppression was associated with baseline gingival recession. After HAART initiation, measures of active PD improved most in those with lower nadir CD4+ T-cell counts and higher baseline levels of specific periodontopathogens. Nadir CD4+ T-cell count differentially influences periodontal disease both before and after HAART in HIV-infected adults.
doi:10.1371/journal.pone.0076986
PMCID: PMC3795634  PMID: 24146949
3.  A Prospective Cohort Study of Periodontal Disease Measures and Cardiovascular Disease Markers in HIV-Infected Adults 
AIDS Research and Human Retroviruses  2011;27(11):1157-1166.
Abstract
The determinants of HIV-associated cardiovascular disease (CVD) are not well understood. Periodontal disease (PD) has been linked to CVD but this connection has not been examined in HIV infection. We followed a cohort of HIV-infected adults to ascertain whether PD was associated with carotid artery intima media thickness (IMT) and brachial artery flow-mediated dilation (FMD). We performed a longitudinal observational study of HIV-infected adults on HAART for <2 years with no known heart disease. PD was characterized clinically and microbiologically. Cardiovascular disease was assessed by IMT/FMD. Linear mixed models assessed cross-sectional and longitudinal associations between PD and FMD/IMT. Forty three HIV+ adults completed a median of 24 (6–44) months on the study. Defining delta to be the change in a variable between baseline and a follow-up time, longitudinally, on average and after adjusting for change in time, CVD-specific and HIV-specific potential confounding covariates, a 1-log10 increase in delta Porphyromonas gingivalis was associated with a 0.013 mm increase in delta IMT (95% CI: 0.0006–0.0262; p=0.04). After adjusting for the same potential confounding covariates, a 10% increase in delta gingival recession was associated with a 2.3% increase in delta FMD (95% CI: 0.4–4.2; p=0.03). In a cohort of HIV-infected adults, an increase in subgingival Porphyromonas gingivalis, a known periodontal pathogen, was significantly associated with longitudinal increases in IMT, while increased gingival recession, which herein may represent PD resolution, was significantly associated with longitudinal improvement in FMD. In the context of HIV infection, PD may contribute to CVD risk. Intervention studies treating PD may help clarify this association.
doi:10.1089/aid.2010.0320
PMCID: PMC3206743  PMID: 21443451

Results 1-4 (4)