SYSTEMATIC REVIEW

Does HIV infection affect the survival of dental implants? A

systematic review and meta-analysis
Indumathi Sivakumar, BDS, MDS, MFDS RCPS,a Sivakumar Arunachalam, BDS, MDS, FDS RCSEd,b
Suchismita Choudhary, BDS, MDS,c and Muaiyed Mahmoud Buzayan, BDS, MClin Dent, AF AAMPd

Rehabilitation with dental im- ABSTRACT

plants for edentulous patients is
Statement of problem. Immunosuppression and coinfections associated with human
a compelling alternative to immunodeficiency virus (HIV) infection pose a relative contraindication for dental implant
traditional removable prosthe- therapy. However, although implants have been placed in patients with HIV with reasonable
ses, but the success of the dental success, how HIV infection affects their survival is unclear.
implant is based on osseointe-
Purpose. The purpose of this systematic review of the literature and meta-analysis was to analyze
gration. Any event that affects the data on the survival of dental implants in patients with HIV.
the integrity of the attachment
could compromise the dental Material and methods. A search for relevant articles published up to November 2019 was
performed in PubMed/Medline and Cochrane databases, Clinicaltrials.gov, and Google Scholar.
implant stability and result in
1-9
Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adopted
failure. Nevertheless, the for the conduct of the systematic review. The most pertinent data were extracted and pooled for
survival of dental implants in a qualitative and quantitative analyses with 95% confidence intervals. Heterogeneity was analyzed
healthy population has been by using I-squared statistics.
reported to be about 96%.10 A Results. A total of 8 studies involving 411 individuals with HIV and 1109 implants were included in
few reports have assessed the the meta-analysis. The mean follow-up period was 2.8 years. A pooled estimate of 95% of implant
survival of dental implants in survival rate with 95% confidence interval(92% to 96%) was noted. Heterogeneity across the 8
immunocompromised in- studies was found to be 41% with moderate true variability.
dividuals, including those with Conclusions. This systematic review demonstrated that HIV infection does not pose a serious threat
human immunodeficiency virus to implant survival on short-term evaluation, but the evidence is of low quality. (J Prosthet Dent
(HIV) infection.11-18 2020;-:---)
HIV infection is a global
pandemic, impacting world public health. In accordancw the CD4 cell count increases as HIV infection is
with the World Health Organization, 37.9 million people controlled with appropriate treatment that is prescribed
worldwide were living with HIV at the end of 2019.19 HIV throughout life. The treatment comprises highly active
destroys specific CD4 helper lymphocyte cells in the antiretroviral therapy (HAART) to control the HIV
immune system, making the affected individuals more infection.24-27 At present, there are 7 classes of drugs to
susceptible to opportunistic infections.20 A diagnosis of treat HIV infection that have changed the course of the
acquired immune deficiency syndrome is rendered when disease from an acute life-threatening condition to a
the CD4 cell count drops below 200 cells/mm3 (normal long-term disease.28,29 Accordingly, patients with HIV
3 21-23
CD4 cell count: 500 to 1500 cells/mm ). Generally, increasingly demand functional and esthetic dental care.

a
Senior lecturer in Prosthodontics, Faculty of Dentistry, SEGi University, Selangor, Malaysia.
b
Associate Professor, School of Dentistry, International Medical University, Malaysia.
c
Lecturer in Prosthodontics, Faculty of Dentistry, SEGi University, Selangor, Malaysia.
d
Senior Lecturer, Faculty of Dentistry, University of Malaya, Malaysia.

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Clinical Implications
Based on the limited evidence, dental implant
therapy in patients with HIV is a viable option with
low morbidity. However, clinicians should be wary
of potential complications from drug therapy, the
infectious state of the virus, HIV coinfections, and
peri-implant disease.
Little is known about the interaction between HIV
infection, drug therapy, and implant survival.30-33 Studies
have reported that certain drugs used in the HAART
regimen (tenofovir disoproxil fumarate and protease in-
hibitors [PI]),34,35 and HIV infection per se36-38 are
associated with osteoporosis and osteopenia in the long
term. HIV infection has also been identified as only a
relative contraindication to implant therapy provided the
infected individual is free of severe immunosuppression
or bleeding disorders.39 Nevertheless, few reports have
demonstrated the success of dental implants in patients
with HIV in the short term.40-46 Baron et al18 reported
complete oral rehabilitation using 12 Brånemark implants
in a female patient infected with HIV, hepatitis B, and
hepatitis C. Two years after implant placement, she had
minimal peri-implant bone loss with no signs of peri-
implantitis. A recent prospective cohort study with a
sample size of 16 noted a 10% failure rate in patients with
HIV compared with 5% to 7% in healthy patients.47
Given the nature of HIV infection, associated HIV coin-
fections, complications of drug therapy, and short-term
reports on the success of dental implant therapy,48,49
further analysis is warranted to provide a plausible
explanation. Thus, the purpose of this systematic review
and meta-analysis was to determine the survival of dental
implants in patients with HIV.
MATERIAL AND METHODS
This review followed the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses guidelines.50 The
review protocol was registered in the International Pro-
spective Register of Systematic Reviews
(CRD42017073202). At the outset, a research question
was formulated using the Population, Intervention,
Comparison, and Outcome framework (Table 1).
Scientific publications reporting studies involving
patients who had tested positive for HIV and who had
received at least 1 dental implant were considered.
Randomized controlled studies, nonrandomized
controlled studies, prospective cohort studies, retrospec-
tive cohort studies, and case series were included. The
additional inclusion criterion was that the studies had a
minimum mean follow-up of 6 months. No restriction
was placed on the language of the publication. Exclusion
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Table 1. PICO framework
Focus Question Does HIV Infection Affect the Survival of Dental Implants?
Participants Patients with HIV
Intervention Dental implants
Comparison HIV-negative patients
Outcomes 1. Cumulative survival and success of dental implants
2. Marginal bone loss and any other complications
Study design Randomized controlled trials
Nonrandomized controlled trials
Prospective cohort studies
Retrospective studies
HIV, human immunodeficiency virus; PICO, Participant, Intervention, Comparison, and
Outcome.
criteria included review papers, animal studies, case re-
ports, and multiple publication of the same pool of
participants.
An electronic search was conducted in PubMed,
Cochrane Registry, CENTRAL, Google Scholar,
clinicaltrials.gov, and journal databases (Wiley, Elsevier,
Quintessence Publishing) up to November 2019 to
identify relevant studies. The reference source from all
the selected full-text articles and review articles on the
subject were also manually searched to identify relevant
studies. The databases search strategy and key words are
presented in Table 2. Titles and abstracts of the poten-
tially qualifying studies were scrutinized by 2 indepen-
dent reviewers (I.S., S.A.). The reviewers conducted the
assessment of the full texts independently for relevance.
Any disagreement between the reviewers was resolved
by consensus with a third reviewer (S.C.).
Data were extracted by 2 reviewers independently
from each included study and entered into a specifically
designed electronic spreadsheet that included the
following information: name of the author, year of pub-
lication, study design, sample size, total number of im-
plants, mean CD4 cell count, viral load, type of HAART
therapy, number of patients with diabetes, smokers, type
of prosthesis, number of failed implants, reasons for
implant failure, mean follow-up duration, mean marginal
bone loss, complications, cumulative implant survival,
and cumulative prosthesis survival. Unclear data from the
primary studies were clarified by contacting the authors
concerned.
Assessment of the selected studies was performed
independently using the quality assessment tool for
observational cohort and cross-sectional studies.51 This
assessment tool contained 14 questions focusing on the
assessment of the internal validity of the study. Each
study was evaluated based on the information of the
study design and execution and how well the con-
founding factors were handled to minimize bias.
Accordingly, the studies were rated as good, fair, or poor.
The kappa (k) coefficient was used to formalize an
agreement between the reviewers with data extraction.
Heterogeneity was evaluated by using the I-squared
Sivakumar et al
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Table 2. Search strategy

Population HIV-positive patients #1 (((((((("hiv infections"[MeSH Terms] OR ("hiv"[All Fields] AND "infections"[All Fields]) OR "hiv infections"[All Fields] OR
AIDS ("hiv"[All Fields] AND "infection"[All Fields]) OR "hiv infection"[All Fields])) OR ("acquired immunodeficiency
HIV infection syndrome"[MeSH Terms] OR ("acquired"[All Fields] AND "immunodeficiency"[All Fields] AND "syndrome"[All Fields]) OR
HIV Coinfections "acquired immunodeficiency syndrome"[All Fields] OR "aids"[All Fields])) OR "medically compromised"[All Fields]) OR
("hiv infections"[MeSH Terms] OR ("hiv"[All Fields] AND "infections"[All Fields]) OR "hiv infections"[All Fields] OR ("hiv"[All
Fields] AND "coinfections"[All Fields]) OR "hiv coinfections"[All Fields]))
Intervention Dental implants #2 ("dental implants"[MeSH Terms] OR ("dental"[All Fields] AND "implants"[All Fields]) OR "dental implants"[All Fields] OR
("dental"[All Fields] AND "implant"[All Fields]) OR "dental implant"[All Fields])) OR "oral implants"[All Fields]))
Comparison HIV-negative patients #3 ("hiv"[MeSH Terms] OR "hiv"[All Fields]) AND negative[All Fields] AND ("patients"[MeSH Terms] OR "patients"[All
Fields])
Outcome Success, survival #4 ((("survival"[All Fields] OR "survival"[MeSH Terms]) OR ("survival rate"[MeSH Terms] OR ("survival"[All Fields] AND
"rate"[All Fields]) OR "survival rate"[All Fields])) OR success[All Fields]) OR success[All Fields] AND ("dental
implants"[MeSH Terms] OR ("dental"[All Fields] AND "implants"[All Fields]) OR "dental implants"[All Fields])
Databases d 1. PubMed
2. Cochrane registry, CENTRAL
3. Clinicaltrails.gov, Google scholar, journal database (Wiley, Elsevier, Quintessence Publishing)
Search strategy d Database 1: 1,2,3,4
Database 2,3: “HIV infection,” “AIDS,” “HIV coinfections,” “dental implants,” “oral implants,” “HIV
negative,” “survival,” “success”
Filters d None
Journals searched d Journal of Prosthetic Dentistry, International Journal of Prosthodontics, Clinical Oral Implants Research, Clinical Implant
through journal Dentistry and Related Research, Journal of Periodontology, International Journal of Oral and Maxillofacial Implants,
database Journal of Oral Implantology and Journal of Prosthodontics.

statistics. When the I-squared value was more than 75%,
substantial heterogeneity was determined, and accord-
ingly, a random-effects model meta-analysis was
preferred.52
RESULTS
Three hundred ninety-one publications were obtained
from the electronic search and 3 records from hand
searching. Ninety-one records were obtained after the
removal of duplicates. Screening the titles and abstracts
excluded 65 records, making 26 records eligible for full-
text screening. After full-text assessment, 18 records
were excluded because they were case reports, systematic
reviews, multiple publications of the same pool of par-
ticipants, conference presentations, or letters to the
editor. Eight studies40-47 were subjected to qualitative
synthesis and meta-analysis (Fig. 1). Inter-reviewer
agreement was found to be good to excellent (k=0.96,
95% confidence interval [CI]: 0.94 to 0.98).
Detailed descriptive data of the included studies are
listed in Supplementary Table 1, available online. Of the
8 included studies, 5 were prospective,40,41,43,46,47 and 3
were retrospective.42,44,45 No randomized clinical studies
were identified. The year of publication of the included
studies ranged from 2007 to 2019. The mean follow-up
period was 2.8 years. Four hundred eleven patients
with HIV received 1109 implants. Nevertheless, 29 pa-
tients had diabetes, and 146 patients had a history of
smoking, although 2 studies excluded smokers. The CD4
cell count was reported to range from 141.24 cells/mm3 to
726.3 cells/mm3, and viral load was lower than 50 copies/
mL. Most studies reported a specific type of HAART
undertaken by the patients with HIV, with the most
common drug being PI and nucleoside/nucleotide
reverse transcriptase inhibitors (NNRTI). Amoxicillin was
the drug of choice for most authors as a postoperative
antibiotic, although 2 studies40,46 noted a preference for
amoxicillin plus clavulanic acid.
Most of the included studies used the criteria of
Albrektsson et al53 for measuring implant success, except
for one study44 that did not describe the criteria for
measuring the study outcome (Table 3). Of the 1109
implants, 51 implants failed, and the most common
reason for failure was peri-implantitis (15 implants),
followed by primary infection (7 implants) and osseoin-
tegration failure (2 implants). The common complication
that the studies encountered included either peri-
implantitis or prosthesis failure. The marginal bone
loss levels ranged from 0.06 mm to 2.5 mm, and the
weighted mean values for marginal bone loss based on
the patient number and implant number was 0.88 mm
and 1.02 mm, respectively. The implant survival rate
ranged between 90.9% and 100%, and the weighted
mean values for implant survival, based on the patient
number and the implant number, were 95.54% and
95.39%, respectively. The success rate of the included
studies ranged between 68.4% and 100%.
The assessment revealed “fair” quality for 4 studies
and “poor” quality for the remaining 4 studies (Table 4).
The studies did not explain the rationale for choosing the
participant numbers and failed to calculate the sample
size, possibly indicating that the studies lacked adequate
size and effect. Statistical analysis to control the potential
confounding variables which were not of interest was
measured in 4 of the included studies.40,41,44,46 Unlike

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Identification
391 records identified through 3 additional records identified
database searching through other sources

91 records after
duplicates removed
Screening

91 records screened 65 records excluded

26 full-text articles
Eligibility

assessed for eligibility
8 studies included in
qualitative synthesis
Included
18 full-text articles
excluded
12- case reports
3- systematic reviews
1-same pool of patients
2-conference
presentation/letter to the
editor

8 studies included in
quantitative synthesis
(meta-analysis)

Figure 1. Flow diagram of study selection according to PRISMA statement. PRISMA, Preferred Reporting Items for Systematic Reviews and
Meta-Analyses.

randomized controlled trials, cohort studies need to pay
more attention to controlling the confounding factors
with robust statistical analysis. The overall quality of the
included studies was rated as fair to poor with a mod-
erate risk of bias. Eight studies contributed data to the
meta-analysis. Each study had reported the implant
survival rate ranging from 90% to 99%.40-47 After pooling
all the data from the 8 studies, a forest plot was gener-
ated, which revealed a pooled estimate of 95% of implant
survival rate with 95% CI (92% to 96%). Heterogeneity
across the 8 studies was measured by using the I-squared
statistics of 41% with moderate true variability (Fig. 2).
DISCUSSION
Three systematic reviews30-32 concerning the survival of
dental implants in patients with HIV have been pub-
lished. The articles studied the survival of dental implants
in patients with HIV but also included case reports, case
series, and letters to the editor in the qualitative analysis.
Although the results demonstrated the suitability of
dental implants for patients with HIV, they were unable
to justify it quantitatively through meta-analysis. In the
current review, the heterogeneity was at a moderate
level, with the survival rate ranging from 90% to 99%. As
the heterogeneity did not arise because of studies with
different survival rates, the data were pooled in a meta-
analysis to estimate overall survival. Because no ran-
domized controlled trials have been published, other
study designs, including cohort studies and retrospective
studies, were included for the review, based on the
presumption that a better internal validity could be
found.54 The quality assessment tool used in this study
was intended to assess specifically the nature of the
relationship between exposure and outcome and
examine the strength of the study design.51
The criteria of Albrektsson et al 53 for evaluating the
success of dental implants was adopted in most of the
research because of its simplicity and reliability. The
question related to outcome measures in the assess-
ment tool is an important attribute that determines the
quality of the studies. Accordingly, 1 study was rated
poor. The meta-analysis in the present study showed
the pooled estimate of the survival rate for implants in
patients with HIV to be 95% with 95% CI (92% to
96%) with a mean 2.8-year follow-up. These meta-
analysis results are comparable with those of a recent
systematic review that reported that the survival of
implants in a healthy population was 96.4%.10 The
survival rate was slightly lower for patients with HIV
than that of a healthy population.

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Table 3. Outcomes of included studies

Criteria for Peri-Implant Follow- Implant Implant Prosthesis Survival
Assessment of No. of Failed Bone Loss up Rate Survival Rate Success Rate/Failure Rate
Study Implant Success Implants (mm) Complication (%) (%) Rate (%) (%)
Rubinstein Albrektsson et al 0 Mesial bone Crown in hyperocclusion 100 100 90% Not specified
et al (2019)45 loss e 0.7 Mesial bone loss e 5.3 mm,
Distal bone distal e 6mm, overall close to
loss e 0.4 50% loss
Sabbah et al No defined criteria to 27 Not specified Not specified 100 94.4 Not Not specified
(2019)44 measure outcome specified
May et al Defined their own 3 Not specified Not specified 100 90.9 Not Not specified
(2016)47 criteria to measure (1 e Infection specified
outcome 2 e Osseo
integration
failure)
Gherlone Buser et al 15 1.19 ±0.87 7 e Peri-implantitis 100 92.1 92.1 Prosthesis failure
et al (2016)40 (5 e Infection 2 e Prosthetic failure rate e 2.9
10 e Peri-
implantitis)
Oliveira et al Roos et al 0 0.49 - 0.47 None 100 100 Not Not specified
(2011)41 Albrektsson et al. specified
Stevenson Albrektsson et al 0 0.06 None 75 100 100 Not specified
et al (2007)43
Gay-Escoda Albrektsson et al 1 e Peri- 2.5 ±1.9 22.2% e Mucositis 100 98.3 68.4 Not specified
et al (2016)42 implantitis 44.4% e Peri-implantitis
Gastaldi et al Defined their own 5 Maxilla e 3.7 % e Peri-implantitis 100 95.37 Not 96.3
(2017)46 criteria to measure (4 e Peri- 0.98 ±0.21 7.42% e Fracture of provisional specified
outcome implantitis Mandible prosthesis
1 e Primary e0.88 ±0.32
infection)
Total d 51 Weighted d d Weighted mean d d
(Peri-implantitis e mean value value (P) e
15 (P) e 0.88 95.54
Infection e 7 (I)-1.02 (I)-95.39
Osseointegration
failure e 2)

I, implant number; P, patient number.

Osteoporosis and osteopenia are noted as long-term
complications of HIV infection and the HAART
regimen.34-38 However, the recent integrase
inhibitors dolutegravir and tenofovir alafenamide have
been reported to have lesser effects on bone mineral
density.25-27 However, reports on the use of these newer
drugs in patients with HIV with dental implants are
lacking. In addition, the presence of osteoporosis may
not be a definitive condition to contraindicate dental
implant treatment.9,55 The placement of dental implants
with a high degree of clinical acuity addressing
methodical treatment planning tactics and choosing
appropriate implant geometry and surface treatment is
the key to successful osseointegration even in morbid
conditions.
Viral load is used as a surrogate marker of disease
progression because a significant association has been
reported between decreased viral load and clinical out-
comes.22,23 A rise in viral load is often followed by a
decrease in the CD4 count and subsequent illness. Hence,
knowing the type of HAART regimen, viral load level, and
CD4 cell count before the start of implant therapy is
important for successful implant-supported restorations.
In the current review, 5 of the 8 included studies recorded
the viral load (˂50 copies/mL),41,42,44,46,47 CD4 cell count
(range 141 to 726 cells/mm3), and specific type of HAART
drugs41,42,44,45,47 undertaken by the study group. Sabbah
et al44 reported a significant increase in implant failure
rate when preplacement, the CD4 was  20% (the
count is under 200 cells/mm3). However, others did not
report any significant correlation between implant suc-
cess and CD4 cell count or viral load.40,41
Sabbah et al44 reported a high implant failure rate in
patients who received PI with a 4.4% risk of failure at 1
year and 8.9% at 3 and 5 years than patients who fol-
lowed another HAART regimen. The study by Oliveira et
al41 was the only study which tried to analyze whether
the HAART drug might affect implant success by
recording the baseline levels of bone resorption
markers pyridinoline and deoxypyridinoline. Higher
levels of pyridinoline and deoxypyridinoline were asso-
ciated with lower bone mineral density and higher risk of
fracture. Among patients with HIV, a majority (68%) had
pyridinoline and deoxypyridinoline levels higher than
normal limits, indicating increased bone resorption.
However, the authors concluded that the higher levels of
bone resorption markers did not contribute to implant
failure after 12 months of follow-up.41 The effects of
higher levels of bone resorption markers on implant
success could only be reflected in long-term

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Table 4. Quality assessment using quality assessment tool for observational cohort and cross-sectional studies
Gay-
May Gherlone Oliveira Stevenson Escoda Gastaldi Sabbah Rubinstein
et al et al et al et al et al et al et al et al
47
Criteria (2016) (2016)40 (2011)41 (2007)43 (2016)42 (2017)46 (2019)44 (2019)45
Was research question or objective in article clearly stated? d d d d d d d d
Was study population clearly specified and defined? d d d d d d d d
Was participation rate of eligible persons at least 50%? d d d d d d d d
Were all participants selected or recruited from same or similar d d d d x d x x
populations (including the same time period)? Were inclusion and
exclusion criteria for being in study prespecified and applied uniformly to
all participants?
Was sample size justification, power description, or variance and effect x x x x x x x x
estimates provided?
For analyses in this article, were exposure(s) of interest measured before d d d d d d d d
outcome(s) being measured?
Was timeframe sufficient so that one could reasonably expect to see d d d x d d d d
association between exposure and outcome if it existed?
For exposures that can vary in amount or level, did study examine NA NA NA NA NA NA NA NA
different levels of exposure as related to outcome (such as categories of
exposure or exposure measured as continuous variable)?
Were exposure measures (independent variables) clearly defined, valid, d d d d d d d d
reliable, and implemented consistently across all study participants?
Was exposure(s) assessed more than once over time? NA NA NA NA NA NA NA NA
Were outcome measures (dependent variables) clearly defined, valid, d d d d d d x d
reliable, and implemented consistently across all study participants?
Were outcome assessors blinded to exposure status of participants? NA NA NA NA NA NA NA NA
Was loss to follow-up after baseline 20% or less? d d d d d d d d
Were key potential confounding variables measured and adjusted x d d x x d d x
statistically for their impact on relationship between exposure(s) and
outcome(s)?
Quality rating Fair Fair Fair Poor Poor Fair Poor Poor

-, yes; x-, no, CD, cannot determine; NA, not applicable; NC, not recorded.

observations, as the patients with HIV receive HAART
drugs for their lifetime.
Peri-implantitis is a common complication occurring
after implant therapy. It could result in bone loss around
dental implants and lead to implant failure.2 The prev-
alence of peri-implantitis in a healthy population was
analyzed in a recent systematic review that reported
about 9.25% and 19.83% at 95% CI for implant-based
and participant-based peri-implantitis, respectively.3
The current systematic review noted a failure of 15
implants because of peri-implantitis and 7 implants
because of infection. In the study by Gherlone et al40,
peri-implantitis and primary infection contributed to
implant failure of about 5.2% (10 of 190 implants) and
2.7% (5 of 190 implants). The authors linked the
immunologic status in patients with HIV to the occur-
rence of infection. Gay-Escoda et al42 reported peri-
implant disease at 66.6% in 77 months of mean
follow-up, but the researchers failed to rectify the con-
dition. This contributed to an implant success rate
of 68.4%, which is quite low and which implicated
the relationship between implant success and peri-
implantitis. May et al47 reported a slightly higher
failure rate of 10% in patients with HIV than healthy
patients at 5% to 7%. Sabbah et al44 reported 27 implant
failures, though no reason was given.
Smoking is another important patient-related factor
that has been attributed to implant failure.4 Various trials
and cohort studies reported a range of 6.5% to 20%
failure rate of endosseous implants in patients who
smoked compared with nonsmokers.5-7 Smoking indi-
rectly affected the stability and integrity of the dental
implants because of marginal bone loss and peri-
implantitis. Smoking in patients with HIV increases
susceptibility to oral infections, including candidiasis, and
compromises the capillary blood flow.8 Five of the 8
studies in the current systematic review included 146
patients with smoking habits who experienced a higher
number of implant failures (41.6% at 1-year follow-up
and 10.1% at 5-year follow-up) than nonsmokers or
occasional smokers.40,42-44,46 Furthermore, they had a
higher incidence of peri-implantitis, pus, and pain.
A follow-up period is important to ensure a conse-
quential assessment of the relationship between a dental
implant and its survival rate in patients with HIV. Clinical
researchers in implant dentistry have reported that a
minimum mean of 5-year follow-up period allows for
optimal scientific deliberation in research related to
dental implants.56 In the current systematic review, only
2 included studies had a follow-up period of 5 years or
more.42,47 The follow-up rate of the studies was 75% to
100%. Short follow-up periods and loss to follow-up

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Implant Survival Rate

Study Name Statistics for Each Study Event Rate and 95% CI
Event Lower Upper
Rate Limit Limit Z-Value P
Rubinstein et al, 2019 0.997 0.947 1.000 3.990 <.001
Sabbah et al, 2019 0.944 0.920 0.961 14.283 <.001
May et al, 2016 0.909 0.753 0.970 3.803 <.001
Gherlone et al, 2016 0.921 0.873 0.952 9.132 <.001
Oliveira et al, 2011 0.992 0.882 0.999 3.377 .001
Stevenson et al, 2007 0.992 0.879 0.999 3.353 .001
Gay-Escoda et al, 2016 0.982 0.886 0.998 3.990 <.001
Gastaldi et al, 2017 0.954 0.894 0.981 6.606 <.001
0.950 0.922 0.969 11.919 <.001

–1.00 –0.50 0.00 0.50 1.00

Survival Rate

Figure 2. Meta-analysis of included studies (95% confidence interval [CI]).

could undermine the validity of any study. Participants
who were lost to follow-up could have a different
prognosis than those who complete the study. With an
implant survival rate of about 96% at 10-year follow-up
in healthy individuals, it is imperative to study the
survival of dental implants in immunocompromised
conditions such as HIV infection with longer follow-up
terms. In addition, prosthesis-related factors including
overload, suboptimal implant design, and improper
prosthetic designs could contribute to implant failure. In
the current review, 2 studies observed the prosthesis-
related failure rate to be 2.9% and 3.7%, but other
studies failed to report or did not observe prosthesis
related failures.40,46 The disease status of HIV infection,
risk of coinfections (hepatitis C virus, hepatitis B virus,
myocardial infarction, long-term liver diseases, long-
term kidney diseases, and fracture of bone),48,49 adverse
effects of HAART drugs in the long term, and compli-
cations associated with implant therapy could influence
the success of implant therapy.
HIV can change into a new form or subtype every
time it infects a cell. At present, there are more than 100
subtypes of HIV.57 The genetic difference between the
HIV subtypes among infected patients may account for
about 35%. HIV in the developed world is subtype B,
which accounts for only 12% of the global HIV popula-
tion.58 Some of the more aggressive subtypes, including
subtype AE and subtype C, are predominant in devel-
oping countries.59 Because of the genetic differences in
the subtypes, the behavior of the virus may transform to
become more drug resistant and progress to acquired
immune deficiency syndrome faster.60 Most of the
research on the effect of HIV infection and dental im-
plants has been conducted in developed countries, and
the research must be expanded to intercontinental set-
tings. Furthermore, with the emergence of newer less-
toxic HAART regimens, their effects on the survival of
dental implants in the long term should be studied.33
Conducting randomized controlled trials with dental
implants in patients with HIV is difficult. However, well-
designed prospective trials with larger sample sizes and
longer follow-up periods could add more patient-
centered evidence to implant therapy.
CONCLUSIONS
Based on the findings of this systematic review and
meta-analysis, the following conclusions were drawn:
1. Short-term evaluation suggests that HIV infection
does not pose a serious threat to implant survival.
However, the evidence is relatively weak.
2. Methodologically sound clinical trials controlling for
confounding factors including complications of drug
therapy, the status of HIV infection, and HIV co-
infection are required to provide higher levels of
evidence.
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Corresponding author:
Dr Indumathi Sivakumar
Faculty of Dentistry
SEGi University
No. 9, Jalan Teknologi
Taman Sains Selangor
Kota Damansara PJU 5, 47810 Petaling Jaya
Selangor Darul Ehsan
MALAYSIA
Email: cherub2008@gmail.com
CRediT authorship contribution statement
Indumathi Sivakumar: Conceptualization, Methodology, Writing - original
draft, Investigation. Sivakumar Arunachalam: Writing - original draft, Investi-
gation, Formal analysis. Suchismita Choudhary: Writing - review & editing.
Muaiyed Mahmoud Buzayan: Writing - review & editing.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.04.001
Sivakumar et al