Case Report

Root Coverage in an HIV-Positive Individual: CombinedUse of a Lateral Sliding Flap and Resin-Modified GlassIonomer for the Management of an Isolated SevereRecession Defect

Shilpa Kolhatkar,* Shaziya A. Haque,* James R. Winkler,* and Monish Bhola*

Background: Gingival recession is a frequent clin-ical finding in the general population. Exposed rootsurfaces are more likely to develop root sensitivityand root caries and pose esthetic concerns for the pa-tient. Most root coverage procedures have been de-scribed on non-restored root surfaces. Limited dataare available that describe root coverage procedureson restored root surfaces. To our knowledge, this isthe first case report in which a severe recession defectand its associated carious lesion were managed usingthe combination of a lateral sliding flap and a resin-modified glass ionomer restoration in an HIV-positiveindividual.

Methods: A 53-year-old male patient with a 25-yearhistory of HIV infection presented for comprehensivecare. The facial surface of tooth #22 had a fracturedcomposite restoration, recurrent decay, and a MillerClass III recession defect. The lesion was restored withresin-modified glass ionomer and root coverage wasobtained by a lateral sliding flap mobilized from theadjacent edentulous ridge. After 8 weeks, surgicalaccess was used to correct a previously undetectedvoid in the restoration.

Results: Uneventful healing was observed at the1-, 4-, 8-, 10-, 12-, and 24-week postoperative visits.Root coverage of 5 mm along with a 2-mm band ofkeratinized tissue was obtained at 24 weeks. The gin-giva displayed no signs of inflammation and wastightly adapted to the root surface with minimal prob-ing depths circumferentially.

Conclusion: Successful root coverage was ob-tained on a resin-modified glass ionomer-restoredsurface in an HIV-positive individual. J Periodontol2010;81:632-640.

KEY WORDS

Gingival recession; glass ionomer; HIV; root caries.

HIV-positive individuals have experienced sig-nificantly increased life expectancy since thewidespread use of highly active antiretroviral

therapy (HAART).1,2 There has been a dramatic de-crease in HIV-related opportunistic infections, whichinclude a wide spectrum of oral lesions.3-11 HIV cannow be considered a chronic disease and this hasresulted in an increased demand for routine healthcare by HIV-infected individuals.12,13 Although earlystudies expressed concerns that HIV-associated im-mune suppression could lead to an increased risk ofcomplications,14,15 increasing amounts of evidencenow suggest that surgical procedures in HIV-positivepatients do not pose an increased risk for complica-tions.16-20 Reports of surgical procedures performedon HIV-positive patients include extractions,18 implantplacement,21-26 and vestibuloplasty using palatal softtissue grafts.27 Based on increased life expectancyand a desire for an improved quality of life,28 we canexpect HIV-positive individuals to seek routine dentalcare including the treatment of gingival recession.

Gingival recession is a fairly common clinical find-ing.29 Several etiologic factors have been associatedwith gingival recession, including abnormal tooth po-sition;30 frenal pull;31,32 pathology related to peri-odontal disease;30 factitial injuries;33-35 mechanicaltrauma caused by tooth brushing;36 and iatrogenicfactors, such as faulty restorations30 or uncontrolledorthodontic movement of teeth.37,38 Untoward effectsof gingival recession can be hypersensitivity, rootcaries, esthetic concerns, and inadequate gingivalwidth.39,40 Over the years, various periodontal plasticsurgical procedures have evolved to correct thesemucogingival deformities. The choice of which tech-nique to use is based on site-specific characteristicsand in some instances dictated by the patient.41

The lateral sliding flap (LSF) technique was first de-scribed by Grupe and Warren in 195642 for the treat-ment of localized recession defects on mandibular

* Department of Periodontology and Dental Hygiene, School of Dentistry,University of Detroit Mercy, Detroit, MI.indicates supplementary video in the online Journal of Periodontology. doi: 10.1902/jop.2009.090616

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incisors. Most studies documenting the success ofLSF procedures have been done on non-restored rootsurfaces.41-47 Limited information is available whenroot coverage is attempted on surfaces restored withresin-modifiedglass ionomer (RMGI) restorations.48-51

RMGI restorations have shown epithelial and connec-tive tissue adherence,52,53 which is an ideal propertyfor the subgingival environment. Other uses of RMGIinclude repair of root resorption defects,54,55 repairof a cracked tooth,56 and treatment of furcation de-fects.57,58

There is a single report of a connective tissue graftperformed in a hemophiliac HIV-positive patient thatresulted in significant morbidity and economic com-plications.59 In contrast, in this report we describethe successful use of LSF and RMGI for the manage-ment of hard and soft tissue loss associated with re-cession and root caries in an HIV-positive individual.We observed uneventful healing at all postoperative(PO) visits with a remarkable lack of morbidity. Toour knowledge this is the first such report.

CASE DESCRIPTION AND RESULTS

In September 2008, a 53-year-old African Americanman presented to the School of Dentistry, Universityof Detroit Mercy, Detroit, Michigan, for an emergencyexamination. His chief complaint was extreme sensi-tivity in the lower left jaw. The patient initially pre-sented to the School of Dentistry in 2004. A reviewof his medical history revealed a diagnosis of HIV in-fection (1984) and cold-induced asthma for whichhe is regularly seen by his physician. No conditionsindicative of AIDS were detected during the initial ex-amination and at subsequent intraoral and periodon-tal examinations. His current medications includedalbuterol sulfate inhaler and antiretroviral therapy(lopinavir/ritonavir, abacavir, lamivudine, and zido-vudine). The patient wore a maxillary complete den-ture and a mandibular removable partial denture(RPD). The patient was a former smoker and had ahistory of heroin addiction for which he has beensuccessfully treated. He has since adopted a positivechange in his lifestyle and was very motivated tomaintain his remaining dentition.

An intraoral examination revealed the presence ofa fractured Class V composite restoration; recurrentdecay; and a deep, narrow recession on the labial sur-face of the mandibular left canine. The presence oftwo small clefts in the apical region was observedalong with inflamed, edematous, and erythematousmarginal gingiva (Fig. 1A). Plaque and food debriswere present in the cavitated area on tooth #22 (toothnumbering according to the Universal System). Thetooth was immobile and tested normal to cold stim-ulus.† Circumferential probing depths were 2 to 4 mmand no radiographic periapical abnormalities were

detected (Fig. 1B). The recession defect was cate-gorized as a Miller Class III defect.60 Because the ce-mento-enamel junction (CEJ) could not be identified,a measurement of the gingival margin position wasmade using the incisal edge as a reference point.The distance from the incisal edge to the CEJ was18 mm. During the examination we noted that hehad bilaterally tense oral musculature. We believedthis finding could affect our ability to retract his cheekfor visualization, caries excavation, and future surgi-cal therapy. We repeatedly urged him to relax hisfacial muscles and to practice facial relaxation tech-niques at home.

A periodontal maintenance treatment was com-pleted in December 2008. Several treatment optionswere presented to the patient. The final treatment planincluded the use of LSF to obtain root coverage andplacement of RMGI restoration to manage the cariouslesion. The patient gave written consent to proceedwith this treatment option.

Presurgical laboratory values were CD4+ T-lym-phocyte count 642 cells/mm,3 viral load 150 cop-ies/ml, total white blood cell count 6.8 · 103/mL,absolute neutrophils count 3.5 · 103/mL, plateletcount 181,000/ml, hematocrit 45.1%, and hemoglo-bin 15.3 g/dl. In 2003, prior to becoming a patientof record at the School of Dentistry, the patient’sCD4+ T lymphocyte count was 198 cells/mm3 be-cause ofnon-compliancewithHAARTregimen formorethan 6 months. Since then, his CD4+ T-lymphocyte

Figure 1.A) Preoperative view of tooth #22. A fractured Class V compositerestoration (a), recurrent carious lesion (b), and two small clefts (blackarrows) are seen. The gingival tissue is inflamed, edematous, anderythematous with rolled and bulbous margins. There is presence ofplaque and debris in the carious lesion. B) Pretreatment periapicalradiograph shows no periapical pathology. Composite restoration (a)and recurrent carious lesion (b) are noted on the radiograph.

† Hygienic, Akron, OH.

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count has consistently remained above 200 cells/mm.3

Profound anesthesia was achieved.‡ The existingcomposite restoration was removed using a flame-shaped bur (Fig. 2A) (see supplementary video in on-line Journal of Periodontology).§ The same bur wasthen used to remove any soft dentin or cementum.Scaling and root planing was performed to removesoft and hard deposits and to smooth any irregulari-ties. The mesial and distal borders of the recessiondefect were de-epithelialized (Fig. 2B). A partial-thickness recipient site was prepared by making avertical incision approximately 4 mm from the mesialborder of the recession in an apico-coronal direction.It was joined to a horizontal incision at the level of the

CEJ in the mesial interdental area. The epitheliumwas removed using sharp dissection and the underly-ing connective tissue bed was exposed (Fig. 2C).The carious lesion measured 9 mm in length, 6 mmin width, and about 3 mm at its deepest area (Fig.2D). A partial-thickness pedicle flap was harvestedby making a crestal incision on the adjacent edentu-lous area followed by an oblique incision extendingbeyond the mucogingival junction. A small cutbackincision was made at the base of the flap and muscularattachments were removed to ensure passive flap ad-aptation (Fig. 2E).

Figure 2.A) The fractured composite restoration was removed using a flame-shaped bur. B) The mesial and distal margins of tooth #22 were de-epithelialized.C) The preparation of the partial-thickness recipient site included a vertical incision approximately 4 mm from the mesial border of the recession in anapico-coronal direction. This was connected to a horizontal incision at the level of CEJ in the mesial interdental area. D) The defect measured 9 mm inheight, 6 mm in width, and about 3 mm at its deepest area. E) The partial-thickness pedicle flap was obtained from the adjacent edentulous ridge.F) The pedicle flap was sutured using 4.0 polyglactin 910 and chromic gut sutures.

‡ Benco Dental Supply, Wilkes-Barre, PA.§ 7406; BRASSELER USA, Savannah, GA.

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Rubber dam isolation was not feasible because ofthe extensive nature of the defect. Therefore, to en-sure isolation and to control moisture contamination,cotton rolls were placed on the lingual and facial sur-faces. The root surface was then prepared for RMGIrestoration. The RMGI materiali was placed in incre-ments, contoured, and cured. The restoration waspolished. The LSF was stabilized and sutured with4.0 polyglactin 910 sutures.¶ The mesial border ofthe flap partially overlaid the recipient site. The alve-olar mucosa was sutured with multiple 4.0 chromicgut sutures (Fig. 2F).# No periodontal dressing wasplaced. PO instructions included recommendationsfor limited facial movements and no brushing or floss-ing around the surgical site for 14 days. The patientwas advised to rinse gently with 0.12% chlorhexidinegluconate rinse** twice daily for 2 weeks. PO painwas managed with analgesic.††

At the 1-week PO visit, the patient reported littlediscomfort and the surgical site had minimal swellingand erythema. The patient missed the 2-week PO visit.Sutures were removed at the 4-week PO follow-up.Uneventful healing of the donor site was observed.The marginal gingiva appeared pink and firm. On de-tailed examination a previously undetected void wasnoted on the distal surface of the restoration (Fig.3). Good root coverage and color match was seen de-spite the presence of the void. The patient was advisedof this findingandan informed consent wasobtained toreplace the restoration using surgical access.

Eight weeks later a full-thickness flap was raisedand the RMGI restoration was replaced. The designfor the flap included a sulcular incision and vertical in-cisions at the mesial and distal line angles (Fig. 4A).The flap was raised beyond the mucogingival junctionand the previously placed RMGI restoration was re-moved (Fig. 4B). A new RMGI restoration was placed(Fig. 4C) and absence of voids was ensured. The flapwas coronally advanced and sutured with 4.0 chro-mic gut sutures (Fig. 4D).‡‡ PO care similar to thefirst surgical procedure was reinforced. At day 10PO after the second surgery, sutures were removedand a thick band of keratinized tissue was seen overthe restored surface. The patient reported minimaldiscomfort and was satisfied with the results. Tissuesdisplayed good color match with a broad band of ker-atinized tissue at the 4-week PO follow-up (Fig. 4E).Our patient demonstrated good oral hygiene. Nosigns of inflammation or bleeding on probing werenoted during the PO visit. The gingival tissues aroundthe recipient and the donor sites had optimal colormatch at the 24-week PO visit. There were no signsof inflammation or bleeding on probing around thedonor site (Fig. 5A).The distance from the incisaledge to the CEJ was measured again and was foundto be reduced from 18 to 13 mm. The midfacial prob-

ing depth reduced from 3 (preoperatively) to 1 mm(Fig. 5B). The gingiva was tightly adapted to the rootsurface and a 2-mm band of keratinized tissue wasseen (Fig. 5C). The gingival tissues displayed goodcolor match and the patient was satisfied with the re-sults. The vitality of the tooth was tested again and itresponded normally to cold stimulus.§§ The patientwas advised to brush using a toothpaste with a highfluoride content,ii and oral hygiene instructions werereinforced. Further dental treatment includes the fab-rication of a new RPD and the recommendation fora full-coverage crown on #22.

DISCUSSION

Since the beginning of the AIDS epidemic a key ques-tion has been whether dental procedures pose anincreased risk of complications in HIV-positive pa-tients. Dental health care providers have hesitatedto perform invasive procedures, such as periodontalsurgery, in this population because of the presumedrisk of opportunistic infections, bleeding, delayedwound healing, and other similar complications.Some early studies14,15 suggested an increase in POcomplications at extraction sites compared to the

Figure 3.At the 4-week follow-up, uneventful healing of the donor site wasobserved. The marginal gingiva appeared pink and firm. A previouslyunobserved distal void that extended subgingivally (black arrow) wasnoted. Despite the presence of the void, good root coverage and colormatch were seen.

i Dent Mat, Santa Maria, CA.¶ Ethicon, Somerville, NJ.# Ethicon.** 0.12% chlorhexdine gluconate, 3M ESPE, St. Paul, MN.†† Tylenol 3 (acetaminophen 325 mg and codeine 7.5 mg), McNeil

Consumer Healthcare, Fort Washington, PA.‡‡ Ethicon.§§ Hygienic.ii Prevident 5000+ toothpaste, Colgate Oral Pharmaceuticals, New York, NY.

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general population. However, little scientific evidenceexists to corroborate these anecdotal findings. Thisconcern is not surprising because of the dramatic ef-fects that HIV infection has on the patient’s immuno-regulation. In fact, opportunistic infections have beena hallmark of HIV infections and are well described inthe literature.3-11

Many studies18-20 demonstrated a good responseto infectious diseases even before the advent ofHAART therapy. For example, treatment of periodon-tal disease in HIV-positive patients can be accom-plished using routine dental treatment.17 Since thewidespread use of HAART therapy, the medical anddental literature is replete with reports18-27 of surgicalprocedures performed in the HIV-positive populationwith no significantly increased number of complica-tions. In fact, numerous case reports have reporteda remarkable lack of complications directly attribut-able to HIV infection following simple and surgical ex-tractions,18 implant placement,21-26 vestibuloplastyusing palatal soft tissue grafts,27 and endodontictreatment.61 In the only report59 of a root coverageprocedure attempted in an HIV-positive individual,the complications were primarily caused by the con-comitant presence of hemophilia. In our case report,despite the presence ofHIV infection,wehadapositiveoutcome with no complications and a normal post-surgical healing pattern.

Gingival recession can pose an esthetic andfunctional problem for the patient. Various surgicalprocedures are available to correct these defects. Re-gardless of the surgical technique used, the goal is toaugment thedimensionsof thegingival tissues, improveesthetic concerns of the patient, obtain predictable rootcoverage, and provide a resistant band of keratinizedtissue for clasp placement.62,63 Since the first descrip-tion of LSF for root coverage, numerous reports havedescribed their success.41 Advantages of LSF are goodvascularity, favorable root coverage,43,45,47,64 goodcolor blend,41 and a single surgical site.65

In our patient a surgical approach was necessaryto obtain adequate access to the apical extent ofthe carious lesion. The restorative prognosis of thetooth would be hopeless and require extraction ifthe carious lesion was not properly excavated. Thepatient wanted to use any available option to retaintooth #22. The final restorative treatment plan in-cluded fabrication of a new RPD using tooth #22 asan abutment. Consequently, the presence of an ade-quate zone of keratinized tissue surrounding tooth#22 was required for prosthetic reasons.63 Becauseof the dimensions of the defect and the fact that wewere attempting to achieve root coverage on a re-stored root surface, we were primarily concerned withthe nourishment of the graft. An LSF was used be-cause it provided good vascularity to the pedicle flap.

Figure 4.A) A full-thickness flap was raised using sulcular and vertical incisionsplaced at the mesial and distal line angles. B) The old RMGIrestoration was removed. C) A new RMGI restoration was placed.D) The flap was coronally advanced and sutured with interrupted 4.0chromic gut sutures. E) At the 4-week PO visit, tissues displayed goodcolor match with a broad band of keratinized tissue. The patientmaintained good oral hygiene.

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The distal donor site was ideal because of the pres-ence of a wide band of keratinized tissue.

Procedures to obtain coverage on non-restoredroot surfaces have been reported to be very success-ful, ranging from 86% to 94% root coverage.43,44,47,66

However, the question remained if similar resultscould be obtained on restored root surfaces. Matter,67

in 1979, first reported on this subject. Since then onlya few studies50,51,68,70 have investigated root cover-age on restored root surfaces. Fourel68 attempted rootcoverage on carious surfaces on the mandibular leftcentral and lateral incisors using coronally positionedflaps. The teeth were restored with composite resto-rations. The study concluded that 4 years postopera-tively, stable soft tissue coverage and a 4-mm gain inclinical attachment level were maintained. In a similarstudy, Goldstein et al.69 treated carious and non-car-ious gingival recessions with subepithelial connectivetissue grafts. This study demonstrated no statisticaldifference in the percentage of root coverage, in thegain of clinical attachment, or in the reduction ofprobing depth between intact and carious root sur-faces.

RMGI restorations in conjunction with root cover-age procedures have not shown any detrimentaleffects on the periodontal apparatus,48 have showna greater reduction in dentin hypersensitivity,50 and

demonstrated a significant gainin clinical attachment and softtissue coverage.51 The two stud-ies by Santamaria et al.50,51 re-ported no statistical differencein the treatment of non-cariouscervical lesions by coronallyadvanced flaps (CAF) or com-bination of CAF with RMGIrestorations. The average rootcoverage obtained with CAFranged from 83% to 88%,whereas the combination ofCAF-RMGI restoration showedroot coverage ranging from

80% to 97%. These results are similar to those byAlkan et al.70 who used a subepithelial connectivetissue graft in conjunction with RMGI restoration inthe treatment of a carious root surface. They reportedan overall reduction in probing depths, a 5.5-mmgain in root coverage, and a 7.5-mm gain in clinicalattachment. These studies demonstrated that softtissue grafting procedures on carious root surfacescan be performed successfully and predictably. Sim-ilar clinical findings were seen in our case. We founda 2-mm reduction in probing depth, a 5-mm gainin clinical attachment level, and the presence of a2-mm wide band of keratinized tissue over therestored root surface. A measurement of the relativeclinical attachment from the incisal edge to the gin-gival margin of the defect was used to determine thechange in gingival position (Table 1) because theCEJ could not be identified. Our inability to locatethe CEJ for gingival recession measurement is a fre-quent finding. This is addressed by Zucchelli et al.71

who commented that a common pitfall in the treat-ment of recession defects is the proper identificationof the anatomic CEJ, which can be detected only30% of the time.

CONCLUSIONS

This case report illustrates that soft tissue grafting isa viable treatment procedure for root coverage in anHIV-infected individual. Although root coverage isroutinely reported to be successful on non-restoredroot surfaces, this case study demonstrates thatthe use of combined periodontal and restorativetreatment can provide optimal results when treatingcarious root surfaces with associated gingival reces-sion. Importantly, in this case, the presence of anRMGI restoration did not appear to impede the attach-ment of soft tissue to the restored root surface.

A thorough understanding of the patient’s medicalhistory is critical, but the presence of HIV infectionshould not exclude these patients from receiving sur-gical treatment. In the HIV-positive population, the

Table 1.

Clinical Parameters of Tooth #22

Clinical Parameters Preoperative 24 Weeks

PD (mm) 3 1

RCAL (mm) 18 13

KT (mm) <1 2

BOP + -PD = probing depth; RCAL = relative clinical attachment level; KT =keratinized tissue; BOP = bleeding on probing; + = BOP present; - = BOPabsent.

Figure 5.A) At the 24-week PO visit, the gingival tissues around the recipient and the donor sites had optimalcolor match. There were no signs of inflammation or bleeding on probing around the donor site. B) Aminimal probing depth of 1 mm was noted on the midbuccal surface at the 24-week PO visit. C) Athick, well-adapted 2-mm band of keratinized gingiva was seen.

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combination of good surgical techniques and appro-priate case selection can have the same favorableoutcome as seen in the general population. It is hopedthat case reports like this will encourage cliniciansto broaden the scope of surgical dental treatmentprovided to the HIV-positive population.

ACKNOWLEDGMENTS

The authors thank Mr. Eric Jacobs, Media Specialist,School of Dentistry, University of Detroit Mercy,Detroit, Michigan, for his assistance with videotapingand photography for this case. The authors report nofinancial relationship to any commercial firm. The au-thors report no conflict of interest related to this casereport.

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Correspondence: Dr. Shilpa Kolhatkar, 2700 Martin LutherKing Jr. Blvd., Detroit, MI 48208–2576. Fax: 313/494-6666; e-mail: kolhatsh@udmercy.edu.

Submitted November 3, 2009; accepted December 14,2009.

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