Considerations in the Dental Management of Children with HIV Infection

Pediatric HIV infection 85-90% of cases are vertically acquired interventionApproximately 30% transmission rate without intervention <2% to 6% transmission rate with antiretroviral therapy Expression of infection may reflect timing in transmission Highly variable disease course, but more rapid progression than in adults More susceptible to bacterial infections than 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

HIV Infection in Children: Its Effects on Oral Health 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

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% > 25% No immune suppression  CD4% 15-24% Moderate immune suppression  CD4% < 15% Severe immune suppression

Oral Manifestations of Pediatric HIV Over 70% of HIV patients have oral lesions Lesions commonly associated with pediatric HIV  Oropharyngeal Candidiasis (OPC)  Linear Gingival Erythema (LGE)  Salivary gland enlargement  Herpes simplex viral infection  Recurrent apthous stomatitis  Cervical lymphadenopathy As children with HIV infection have increased survival, they are at risk for additional oral burdens, such as lymphoma Recurrent apthous stomatitis

Fungal Infections Candidiasis  Pseudomembranous/thrush  Erythematous  Hyperplastic  Angular Cheilitis  Median Rhomboid Glossitis Histoplasmosis Cryptococcosis Geotrichosis Pseudomembranous Candidiasis

HIV Associated Periodontal Disease Linear gingival erythema Periodontitis modified by systemic factors Necrotizing ulcerative gingivitis Necrotizing ulcerative periodontitis Necrotizing stomatitis Linear Gingival Erythema Periodontitis modified by systemic factors

Viral Infections Herpes simplex Herpes zoster Cytomegalovirus Human Papillomavirus Epstein-Barr virus  Hairy leukoplakia Molluscum contagiosum Herpes simplex Cytomegalovirus

Patient Management Objectives in the Oral Health Care of Children with HIV Infection Decrease the morbidity and mortality due to infection Decrease the morbidity due to hemorrhage Facilitate the patient’s nutritional status Improve the patient’s comfort Promote self esteem and socialization through the maintenance or restoration of a healthy smile Increase the education of the patient, family and physician relative to the importance of maintaining oral health and the methods to achieve it Monitor HIV disease progression through identification of orofacial lesions

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 > 1000/mm 3, prophylactic antibiotics are not necessary  If ANC is between 500 and 1000/mm3, elective treatment may proceed, following antibiotic prophylaxis  If ANC is < 500/mm 3 or WBC < 2000/mm 3, elective procedures should be deferred.  If CD4 < 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

Hematologic Guidelines for Dental Management of Patients with HIV Infection Antibiotic Prophylaxis  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

Hematologic Guidelines for Dental Management of Patients with HIV Infection Prevention of Hemorrhage  Elective Dental Procedures Platelet count > 50,000/mm 3  no special precautions are necessary Platelet count < 50,000/mm 3  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 < 8 gm/dl  defer treatment, unless imminent or near term odontogenic infection would ensue Over-retained primary incisors in need of elective extractions

Hematologic Guidelines for Dental Management of Patients with HIV Infection Prevention of Hemorrhage  Emergency Dental Procedures for the control of pain, infection or biopsy procedure in order to establish a diagnosis  Platelet count > 50,000/mm 3  no special precautions are necessary Platelet count < 50,000/mm 3  consider platelet replacement Anemia - Hemoglobin < 8 gm/dl  consider transfusion Painful and infected primary incisors

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

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

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

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

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  Discontinuation of elective or image enhancing procedures

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

Oral Hygiene Considerations in the Management of Children with HIV Infection Hematologic Considerations  Daily tooth brushing, deplaquing of the tongue and flossing when ANC > 500/mm 3 and platelet count > 20,000/mm 3  Dental hygiene efforts with moist gauze or toothette only when ANC < 500/mm 3 or platelet count < 20,000/mm 3 Chlorhexidine Rinses  Potential adjunct in the management of Conventional Gingivitis (CG)  Effective adjunct for necrotizing periodontal diseases  May be beneficial for decreasing halitosis

Considerations in the Dental Management of Children with HIV Infection: 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