Oral Health Management of the HIV Infected Child

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Oral Health Management of the HIV Infected Child

• Romer A. Ocanto, DDS, MSPH, MEd
• Associate Professor and Chair
• Department of Pediatric Dentistry
• Nova Southeastern University College of Dental
  Medicine

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• Disclosure of Financial Relationships
• This speaker has no significant financial
  relationships with commercial entities to
  disclose
• This slide set has been peer-reviewed to ensure
  that there are no conflict of interest
  represented in the presentation

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• Objectives
• To discuss the considerations in the dental
  management of children with HIV infection
• To recognize the oral manifestation of pediatric
  HIV infection classification, clinical
  characteristics, and treatment recommendations
• To discuss the need for integrating oral health
  care into the management of children with HIV
  infection

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• Acknowledgments
• New York State Department of Health AIDS
  Institute's Clinical Guidelines Development
  ProgramAIDSinfo. U.S. Department of Health and
  Human Services (DHHS)
• U.S. Public Health Service (USPHS) and Infectious
  Diseases Society of America (IDSA)
• Dr. Stephen Abel (NSU-CDM)

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REFERENCES
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2
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• U.S. Public Health Service (USPHS) and Infectious
  Diseases Society of America (IDSA) 2001
  USPHS/IDSA Guidelines for the Prevention of
  Opportunistic Infections in Persons Infected with
  HIV November 2001
• Abel SN, Acs GC, Flaitz CM, Jandinski JJ, Ng MW.
  Principles of Oral Health Management for the
  Pediatric HIV/AIDS Patient A Course of Training
  for the Oral Health Professional. June 2002
• AIDSinfo. US Department of Health and Human
  Services. http//www.aidsinfo.nih.gov
• Church JA. HIV disease in Children. Postgraduate
  Medicine. 107(4), April 2000
• Ramos-Gomez FJ, Flaitz C, Catapano P, Murray P,
  Milnes AR, Dorenbaum A. Classification,
  diagnostic criteria and treatment recommendations
  for orofacial manifestations in HIV-infected
  pediatric patients. J Clin Ped Dent. 23(2)85-95,
  1999
• NYSDOH AI. Criteria for the Medical Care of
  Children and Adolescents with HIV Infection Oral
  Health Care, July 2004
• American Academy of Pediatric Dentistry.
  Anticipatory Guidance Guidelines, 2005
  (http//www.aapd.org/media/Policies_Guidelines/G_P
  eriodicity.pdf)

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Introduction
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• EPIDEMIOLOGY OF PEDIATRIC HIV INFECTION
• Across the globe, AIDS is responsible for an
  increasing number of deaths each year
• 2.3 million children globally living with HIV
  700,000 new cases in 2005
• In the US, 9,300 children living with AIDS
• MTCT accounts for the vast majority of HIV
  infected children
• PCR nearly all infants during the first month of
  life
• Highly variable disease course, but more rapid
  progression than in adults
• 20 of HIV infected children are clinically
  symptomatic within the first year of life
• 50 have AIDS by age 5
• Mean survival is 10 years and increasing with
  HAART
• Short incubation period and oral manifestations
  occur earlier than in adults

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85-90 of cases are vertically acquired
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lt2 to 6 transmission rate with antiretroviral
therapy
Number of cases
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More susceptible to bacterial infections than
adults
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Disproportionably high rates among some ethnic
groups
Rate per 100,000
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Considerations in the Dental Management of
Children with HIV Infection
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• Children with HIV infection have
• Higher rates of dental caries
• Higher incidence of periodontal disease
• Higher incidence of soft tissue lesions
  including bacterial, viral and fungal infections
• Decreased access to dental care
• Increased risk of enamel hypoplasia

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Pathophysiology

• Most human cells can be infected by HIV, but most
  commonly the T-helper lymphocytes (CD4 cells) are
  involved
• Decreased CD4 counts appear to be associated
  with increasing clinical manifestations and
  progression of disease
• In young children, the CD4 is a more accurate
  reflection of immune suppression
• CD4 gt 25 No immune suppression
• CD4 15-24 Moderate immune suppression
  
  
• CD4 lt 15 Severe immune suppression

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Hematologic Guidelines for Dental Management of
Patients with HIV Infection

• Prevention of Infection
• Antibiotic Prophylaxis
• Elective Dental Procedures (not presenting as
  imminent sources of infection)
• If Absolute Neutrophil Count (ANC) is gt 1000/mm3,
  prophylactic antibiotics are not necessary
• If ANC is between 500 and 1000/mm3, elective
  treatment may proceed, following antibiotic
  prophylaxis
• If ANC is lt 500/mm3 or WBC lt 2000/mm3, elective
  procedures should be deferred.
• If CD4 lt 200 prophylactic antibiotics may be
  considered
• Emergency Dental Procedures
• Any procedure which needs to be performed in
  order to remove an imminent source of infection
  may be performed following consultation with
  physician, and appropriate selection of
  antibiotics and/or replacement of platelets

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• Children not allergic to penicillin
• Amoxicillin 50 mg/kg (maximum 2 grams) orally 1
  hour prior to dental procedure
• Children not allergic to penicillin, but unable
  to take oral medications
• Ampicillin 50 mg/kg (maximum 2 grams) IV or IM
  within 30 minutes before dental procedure
• Children allergic to penicillin
• Clindamycin 20 mg/kg (maximum 600 mg) orally 1
  hour before dental procedure
• Children allergic to penicillin and unable to
  take oral medications
• Clindamycin 20 mg/kg (maximum 600 mg) IV or IM

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• Prevention of Hemorrhage
• Elective Dental Procedures
• Platelet count gt 50,000/mm3
• no special precautions are necessary
• Platelet count lt 50,000/mm3
• defer treatment, unless imminent or near term
  odontogenic infection would ensue or if a biopsy
  is required for diagnosis and treatment of an
  oral lesion
• Anemia - Hemoglobin lt 8 gm/dl
• defer treatment, unless imminent or near term
  odontogenic infection would ensue

Over-retained primary incisors in need of
elective extractions
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• Prevention of Hemorrhage
• Emergency Dental Procedures for the control of
  pain, infection or biopsy procedure in order to
  establish a diagnosis
• Platelet count gt 50,000/mm3
• no special precautions are necessary
• Platelet count lt 50,000/mm3
• consider platelet replacement
• Anemia - Hemoglobin lt 8 gm/dl
• consider transfusion

Painful and infected primary incisors
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• Risk Factors for Dental Caries in Children
• with HIV Infection
• High lactobacilli and mutans streptococci burdens
• Increased plaque indices
• High carbohydrate dietary supplements
• Frequent intake of juices, milk and other
  sweetened beverages to prevent dehydration
• Cariogenic effects of oral medications
• Decreased salivary flow associated with
  medications
• Oral dysfunction/developmental delay/failure to
  thrive
• Poor clearance of foods/medications

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• Dental Caries Prevention in Children with HIV
  Infection
• Frequent diagnostic visits
• Aggressive use of fluorides
• Systemic, if necessary (as per CDC guidelines)
• High potency, operator applied
• High potency, daily use
• Low potency rinses
• Fluoride varnishes
• Promote prevention and oral hygiene measures
• Aggressive plaque control measures
• Chlorhexidine rinses
• Education of caretakers
• Pit and Fissure Sealants

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• Dental Caries Management in Children with HIV
  Infection
• Aggressive use of preventive and minimally
  invasive restorative strategies
• Dictated by the age of the patient, extent of the
  caries, and previous history of caries
• Preventive resin restorations
• Adherence to pulpal therapy guidelines
• Aggressive treatment of non-vital primary teeth
• Restrictive criteria for assessing pulpal
  vitality
• Well contoured restorations
• Appropriate use of prophylactic antibiotics
• Platelet supplementation

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• Miscellaneous Treatment Considerations in the
  Oral Health
• Management of Children with HIV Infection
• Nitrous Oxide
• Evaluate pulmonary function and ability to
  breathe through the nose
• Conscious Sedation
• Evaluate size of tonsils and pulmonary function
• Potential for drug interaction with HIV
  medications and midazolam and meperidine
• General Anesthesia
• Consult with pediatrician and anesthesiologist

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• Miscellaneous Treatment Considerations in the
  Oral Health
• Management of Children with HIV Infection
• Life Expectancy
• Duration of treatment
• Prognosis of treatment
• Psychosocial
• Image enhancement
• Normalcy

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• Miscellaneous Treatment Considerations in the
  Oral Health
• Management of Children with HIV Infection
• Orthodontics
• Chlorhexidine rinses
• Fluoride supplementation
• Fastidious Oral Hygiene
• Meticulous care of retainers and appliances
• Endodontics
• No contraindication with appropriate diagnosis

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• Oral Hygiene Considerations in the Management of
• Children with HIV Infection
• Hematologic Considerations
• Daily tooth brushing, deplaquing of the tongue
  and flossing when ANC gt 500/mm3 and platelet
  count gt 20,000/mm3
• Dental hygiene efforts with moist gauze or
  toothette only when ANC lt 500/mm3 or platelet
  count lt 20,000/mm3
• Chlorhexidine Rinses
• Potential adjunct in the management of
  Conventional Gingivitis (CG)
• Effective adjunct for necrotizing periodontal
  diseases
• May be beneficial for decreasing halitosis

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Considerations in the Management of oral soft
tissue manifestations of pediatric HIV infection
classification, clinical characteristics, and
treatment recommendations
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• Early detection of HIV-related oral lesions
• can be used to
• Diagnose HIV infection
• Elucidate the disease progression
• Predict immune status
• Provide timely therapeutic interventions

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Orofacial lesions associated with pediatric HIV
infection
Ramos-Gomez et al., J Clin Ped Dent 23(2) 86,
1999
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• Pseudomembranous candidiasis
• Candidiasis indicates severely depressed immune
  system first clinical manifestation of the
  disease (marker of disease progression)
• CD4 lymphocyte count lt1000/sq. mm
• Multifocal, non-adherent creamy white papules or
  plaques that can be wiped off with minimal
  pressure, leaving an erythematous surface
• Petechial bleeding after removal of white coating
  in some cases
• Anywhere in oropharyngeal area
• Response to antifungal therapy is defining
  diagnostic criterion (prolonged used of
  antifungals ? increased resistance)

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New York State Department of Health AIDS
Institute's Clinical Guidelines Development
ProgramAIDSinfo. U.S. Department of Health and
Human Services (DHHS)
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• Oral candidiasis recommendations
• Following oral hygiene instructions to control
  oral Candida and delay candidiasis progression
• Preventive measures to start at birth
• Preventive measures include
• Cleaning food and medicine residue on teeth and
  soft tissues (gingiva, oral mucosa)
• Nutrition and medication management
• Weaning from bottle to cup as early as possible
  to reduce risk and frequency

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• Linear gingival erythema
• Most common form of HIV-associated periodontal
  disease
• Fiery red, linear band 2-3mm wide on the marginal
  gingiva accompanied by diffuse red lesions on the
  attached gingiva or oral mucosa
• Pain rarely associated
• Mostly on buccal from canine to canine
• Resists conventional plaque-removal therapies

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• Parotid enlargement (parotitis)
• Occurs in 10-30
• Late in the course of HIV
• Associated with slower progression of AIDS
• Unilateral or bilateral diffuse soft-tissue
  swelling may be accompanied by pain
• Lymphoid intersticial pneumonitis may be
  associated
• Always with hepatomegaly, splenomegaly and
  lymphadenopathy
• Both lymphadenopathy and parotitis are good signs
  ? long-term survival

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• Herpes Simplex Virus Infection
• Not specifically related to HIV status
• Fever malaise, swollen and tender cervical nodes
  intra and extraoral
• Lesions on ginviva, hard palate, lips vermillion
  border
• Vesicles ? irregular ulcers
• Severe and may require hospitalization in some
  cases
• Recurrent cases present with extensive lesions
• Topical anesthetics to encourage hydration and
  food intake

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• Recurrent aphthous ulcers
• More common in children than adults
• Drug-induced
• Minor ulcers are less than 5mm covered with a
  pseudomembrane
• A prompt response to steroid treatment confirms
  the diagnosis (differential DX with candidiasis)
• Major ulcers are larger in diameter (1-2cm) and
  persists for weeks
• Very painful interfere with eating and
  swallowing. Also drug related (ddC or
  zalcitabine)
• Herpetiform appears in clusters and also responds
  to topical steroids and anesthetics

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• Summary
• Life expectancies of children with HIV infection
  are rising
• Children with HIV infection are at greater risk
  for oral and dental diseases
• Consultation with the medical community is
  required in order to assess risk/benefit
  associated with treatment
• Aggressive dental management is indicated in an
  effort to prevent or manage oral and dental
  disease

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• Summary
• The primary care clinicians role in oral health
• care
• Should perform an initial dental screening at
  approximately 12 months
• Anticipatory guidance giving to parents bottle
  feeding, eruption sequence and infant oral
  hygiene (follow AAPD guidelines for anticipatory
  guidance)
• Refer child to oral health care provider as
  necessary and supply documentation on patients
  medical status, meds, nutritional status, lab
  tests (recent CD4/CD8 counts, viral load,
  platelet count)
• Discuss preventive and restorative dental
  treatment plans with primary oral health care
  provider
• Coordinate medical and dental appointments

http//www.aapd.org/media/Policies_Guidelines/G_
Periodicity.pdf
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• Questions?

Thank you
rocanto_at_nova.edu