1.0  Introduction
Nutrition is the main factor in diet which directly correlates with oral health; certain infections in the mouth are easily rejected when the diet is high in foods that contain the appropriate nutrients the body needs for good general health (Moynihan & Petersen, 2004). Negative impacts on oral health are also caused by different forms of drug intake for example medications related to disease, vitamins and minerals and the use of recreational drugs (Sebastian, 2004). A clinician has been presented with a case of an individual requiring the provision of an appliance, however there are several factors to be considered that are affecting the nutrition, oral and general health of the patient. The clinician is dealing with an individual who is malnourished due to high sugar intake and suffering from HIV (Human Immunodeficiency Virus) and xerostomia. This can potentially affect the choice of an appliance for example the HIV can have a great influence on one’s oral health due to lack of saliva in the mouth and an increase in dental caries. This can then potentially affect their diet and overall general health, because the body will lack the pivotal nutrients necessary.

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2.0  Nutrition (High intake of sugar)
A well balanced diet allows the body to intake the necessary nutrients needed to live a good, healthy lifestyle. The mouth is prone to infections when the body is in nutrient deficit, which can potentially contribute towards the rapid progression of periodontal disease and other oral diseases (Moynihan & Petersen, 2004). Nevertheless, the most important influence of poor nutrition comes from the local action of diet in an individual’s mouth, resulting in an increase of enamel erosion and cavities. Cavities are formed when plaque acids attack the enamel of the tooth when consuming a diet high in Carbohydrates, Sugars and Starches (Scardina et al, 2011).

Decay can extend into the internal part of the tooth which can eventually lead to nerve pain if left untreated. Visible symptoms of decay involve a white spot that is usually seen on the tooth affected that will ultimately darken into a brown colour. Other signs include: halitosis, tooth discoloration, sensitivity or pain in one or more teeth (Sheetal et al, 2013). The main factor affecting the progression of caries is the frequency of an individual’s sugar intake from foods such as chocolates, cakes, sweets and fizzy drinks. Sugar is a sweet substance obtained from various plants like sugar cane and sugar beet; it has a crystal-like appearance and can be brown or white (Moynihan & Petersen, 2004). Pure sugar will be white and highly refined, as less refined sugar becomes brown in colour. There are two forms of sugars some are healthy and others harmful. Food products like fruits and vegetables (oranges and lettuce) contain good sugars which are pivotal nutrients that the human body needs to function.
On the other hand, sugars that are man-made and manufactured in the laboratories/factories offer no nutritional value and are harmful for the human body (Sebastian, 2004).

Individuals must control their daily intake and diet, nutrition is a factor which can highly affect the success and health of dental implants. A dental implant can be described as a titanium screw used to help restore missing teeth caused by disease, infections or trauma. “Osseointegration” is a known procedure that involves fusing an implant to the bone then joining it with an abutment which is the support system for the crown (Karen et al, 2012). Dentures and bridges often cause damage to the real teeth that are useful to preserve the jawbone. Non-removable bridges require the trimming of neighboring teeth and partial dentures are held in place by adjacent teeth, the chewing forces have adverse effects on the teeth and they can become severely weakened. A bridge has a durability of five to ten years; however, the teeth that support a partial denture or bridge show a high failure rate of 30 percent which is a negative indication. Full dentures on the contrary do not rely on any neighboring teeth which means at times they can slip and hinder the patient from eating certain foods (Sheetal et al, 2013).
The American Academy of implant dentistry stated that the “long-term success rate of dental implants is 97 percent”; mainly due to the fact that dental implants stabilize the jawbone without harming other teeth and patients can eat any type of food. The success of dental implants does not solely rely on how well they are placed; it depends on how healthy an individual’s oral tissues are, because the tissues are the foundation of any dental implants. A lack of essential nutrients can damage the oral tissues; once they become unhealthy it will be nearly impossible for the dental implants to be successful (Chandki et al, 2012).

There are various differences between a natural tooth and a dental implant; implants do not have a dental pulp which helps to indicate early stages of infections, they are not prone to cavities and do not have a periodontal membrane (Chandki et al, 2012). On the other hand, it is not advisable to place a dental bridge in an individual that has a diet highly ridged on sugar and sweets as they can potentially develop decay. If the decay is in between the teeth or inside the supporting tooth, the only way to access the area would be from removing the bridge. The clinician must ensure that all fillings are restored before placing the appliance into the patient’s mouth.
3.0  Oral Health (Xerostomia)
Normal salivation is important because it stops food gathering around the tooth and gum line, saliva also neutralizes the acids produced by plaque which harm the enamel of the tooth, increasing the risk of tooth decay triggered by a condition called Xerostomia (Rodriguez et al, 2017). Saliva contains important enzymes which allow the breakdown of food, increase the ability to taste food and aid good digestion. The secretion of saliva is important as it keeps oral tissues lubricated, cleans the oral cavity and starts the process of digestion as food is being broken down and chewed. The colloquial term for Xerostomia is “dry mouth” which is frequently found in patients treated by radiotherapy, it is also likely in patients taking medications such as; anti-depressants, vitamins and minerals, anti-inflammatories and antiretroviral drugs. Other factors causing xerostomia include immunological diseases, connective tissue disorders, depression and malnourishment (Isidor et al, 1999). A clinician should provide careful consideration when choosing the appropriate appliance for an individual with Xerostomia.

Research has shown that there is a direct correlation between a decrease in saliva production and patients having a higher amount of caries in the mouth (Rodriguez et al, 2017). Unfortunately, considering a dental bridge as an option for a patient suffering with dry mouth wouldn’t be ideal due to possible decay developing from the supported tooth.
Equally, additional research identified that xerostomia can cause difficulties wearing dentures and can trigger the development of caries and candidiasis (Guggenheimer, 2003). (Ravisankar, 2013) concluded that Xerostomia can cause sores, irritations and infections and may also result in the loosening of the denture, which has a negative effect on the oral functionality and satisfaction when wearing removable dentures. On the other hand, in the past three decades the use of implantology as treatment has been extensive; as has the research into the durability of dental implants. Longitudinal study results identified a 90 to 95 percent success rate with survival 5 to 10 years after treatment completion (Rodriguez et al, 2017). Research conducted in patients with a smaller follow up period of 4 years presented an 84 percent survival rate. (Isidor et al, 1999) Similarly, follow ups after two years have shown success rates of up to 88 percent. (Payne et al, 1997) The implications of xerostomia are significant; in severe cases the development of caries can result in a loss of teeth where prosthetic rehabilitation would be necessary.

Dental implants are a favorable option for patients with xerostomia as the low saliva levels have a minute effect on the materials used, although the demands of hygiene are increased in the individual with reduced saliva (Sciubba, J.J, 2012). This information is applicable to clinicians when trying to identify the causes of Xerostomia and research has strongly highlighted that dental implants are a favorable option and offer much more success rate in the long run in comparison to dentures and dental bridges.

Nonetheless under good clinical provision and strict adherence to the daily maintenance of the implants, a patient suffering from xerostomia can be relieved with the use of this appliance as the success does not depend on oral moisture (Payne et al, 1997). Given all the research it can be concluded that dental implants are a viable method of treatment for patients suffering with this condition.
4.0  General Health (HIV- Human immunodeficiency virus)
(World Health Organisation, 1946) defined the term ‘Health’ as a relative state in which an individual is managing well physically, mentally and socially and not only the absence of disease or physical or mental weakness. An individual’s general health can be affected by HIV virus which attacks a particular form of T cell called CD4 cells. The T cells are significant to an individual’s immune system in order for the body to fight off any potential infections. A person is prone to cancers and infections when the functions of the immune system deteriorate causing an illness known as AIDS. This type of virus can be transmitted from one body to another through fluids coming into contact with blood, damaged tissue and mucous membranes. According to (World Health Organization, 2013) early HIV can be treated with ARV (Antiretroviral) medication. This treatment is given to infected HIV patients to help fight the infection and lessen the chance of the virus spreading.
An individual suffering from HIV should be given the appropriate recommended appliance from the clinician, to ensure their general health is not affected. It has been documented that patients who use complete custom conventional dentures in the mandible commonly have issues adapting to the appliance. There is increasing evidence showing that two-implant and mandibular overdentures provide a better support and retention than conventional dentures (Stevenson et al, 2007). The use of implant overdentures can improve stability, comfort, chewing effectiveness and function. Patients who get two-implant mandibular dentures have reported a positive change in their quality of life when comparing to the previous use of the conventional denture (Stevenson et al, 2007). Many HIV infected patients who wear dentures are now requesting the use of dental implants as an alternative means of treatment (Stevenson et al, 2007).

In the year 1998 the first successful single root form implant placement into a HIV positive patient was reported by (Rajnay et al, 1998). In addition, another case of a patient who had twelve implants placed; six in the maxilla and six in the mandible there was complete recovery and success despite being infected with HIV and Hepatitis B and C (Baron et al, 2004). Above all, it seems pertinent for the clinician to consider dental implants as an option for healthy individuals to increase their oral health quality of life.

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5.0  Drugs related to disease (HIV medication- antiretroviral drugs)
In order to treat, prevent and cure many diseases and medical conditions, drugs and other forms of medicine are generally used. Medications are chemicals and compounds which operate in the body in different ways (Ouanounou et al, 2016). They can fight off microorganisms that attack your body, substitute when vitamins and hormones in the body are scarce, terminate abnormal cells that lead to cancer and alter the way the cells operate within the body. Drugs come from various sources; many were extracted from natural resources for example plants. Medications can also be produced in laboratories by mixing chemicals and compounds; however other medications (penicillin) are byproducts of organisms for example fungus (Ouanounou et al, 2016). Some medications need to create a certain substance in order to be effective and therefore are biologically engineered by injecting genes into bacteria. Medications can be administered in several ways such as swallowing liquids/tablets, applying creams, gels and patches or through injections (Achong et al, 2006).

When a patient is diagnosed with early HIV, antiretroviral treatment is essential to managing the HIV infection. Individuals suffering from HIV also experience many difficulties such as thrush, white lesions, ulcers, lack of saliva and canker sores (Lemos et al, 2018). Dental mouth problems involving HIV can cause pain which will affect the ability of an individual to be able to chew or swallow.

Antiretroviral side-affects can contribute to the flow of saliva, which can potentially cause dry mouth. An individual who lacks saliva production would have to become accustomed to a new diet as foods like meat become difficult to chew and taste. Overtime, the body can lack the nutrients needed to maintain a healthy lifestyle which can have a negative impact on one’s weight and oral health. Sometimes the individual will stop taking the antiretroviral medication which can also result in lack of nutrients as they have difficulty eating. A compromised digestive system can affect the intake of antiretroviral treatment. A study on prosthodontics placed in HIV infected patients taking antiretroviral medication revealed that individuals that were given complete or partial dentures had several issues with mastication, speech, swallowing food and soreness (Nagaraj, 2013). Additionally, a reduced flow of saliva and resultant impediments were found in elderly patients infected by HIV due to both the contribution of age and virus. Placing full dentures in the elderly patients can be a challenge because stability and retention are difficult to accomplish. Whereas, (Lemos et al, 2018) found that the life expectancy of patients with infected HIV taking antiretroviral medication has increased, due to the immune system developing great defenses to fight the infection. (Achong et al, 2006) documented the successfulness of implant therapy in patients affected with HIV, in which 2 patients were taking antiretroviral medication. The results showed that dental implants do not indicate any high risks to the HIV patient when the viral load is particularly low. Furthermore, during surgery it was reported that the CD4 cells level had no effect on the success rate of dental implants (Nagaraj et al, 2013).
This is led to more patients seeking dental implant surgery for oral rehabilitation.

6.0  Conclusion
There is evidence that a provision of an appliance can be affected by oral health, nutrition, general health and any drugs consumed due to disease. An individual who is affected with cavities due to high sugar intake should not be recommended with a dental bridge because of possible decay. It is clear to say that dental implants is a more advantageous appliance to be used as it cannot form cavities and helps to preserve the bone structure. Whereas, denture were seen to cause damage to the natural tooth and have an adverse effect on the structure of the jaw bone. Research concluded that Xerostomia was another cause of distress in patients suffering from HIV. Dental implants were shown to be the best solution for patients with dry mouth as the survival rate is high. On the other hand, dentures that have a negative effect on the functionality were shown to be less successful. This is significant and highlights the reasons why dental implants offer a long term successful solution for missing teeth in patients with these conditions. Individuals suffering from dry mouth, HIV and high sugar intake usually consume fewer nutrients which can make the oral tissue more friable. If a patient is prescribed with a denture they are more likely to stop using it which can affect their oral health due to weight loss. This will then lead to a poor general health, which is why it is more ideal to offer the patient a dental implant because it doesn’t have any effect on the oral moisture. The clinician must take careful consideration when recommending the dental implant as patient compliance is the key to success in implants. Correct guidance and health advice must also be provided to the patient in order to achieve the best results.



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