1. Module 5 Pediatric HIV and AIDS Oral Health Considerations Pediatric HIV and AIDS Oral Health Considerations

2. Pediatric HIV and AIDS Oral Health Considerations Harold S. Goodman, D.M.D., M.P.H. Associate Professor Department of Pediatric Dentistry University of Maryland Dental School Baltimore, Maryland Harold S. Goodman, D.M.D., M.P.H. Associate Professor Department of Pediatric Dentistry University of Maryland Dental School Baltimore, Maryland

3. HIV Infected Children 12-13 7 th leading cause of death among children in US In 50 percent infected, oral manifestations are the earliest clinical signs and are evident before 1 st birthday More susceptible to many opportunistic infections, soft tissue lesions and neoplasms HIV infection progresses more rapidly than adults  Immune system still not fully developed  Rapid growth of body organs 7 th leading cause of death among children in US In 50 percent infected, oral manifestations are the earliest clinical signs and are evident before 1 st birthday More susceptible to many opportunistic infections, soft tissue lesions and neoplasms HIV infection progresses more rapidly than adults  Immune system still not fully developed  Rapid growth of body organs

4. Pediatric AIDS 12-13 Most infants with congenital HIV normal at birth Clinical problems develop during first year  Oral complications first sign in 50 percent children 50 percent of children infected perinatally diagnosed before 1 st birthday Early AIDS-related problems in children  Weight loss  Failure to thrive  Pneumonia  Lymphadenopathy  Chronic diarrhea  Abnormal enlargement of liver or spleen  Bacterial infections Most infants with congenital HIV normal at birth Clinical problems develop during first year  Oral complications first sign in 50 percent children 50 percent of children infected perinatally diagnosed before 1 st birthday Early AIDS-related problems in children  Weight loss  Failure to thrive  Pneumonia  Lymphadenopathy  Chronic diarrhea  Abnormal enlargement of liver or spleen  Bacterial infections

5. Pediatric HIV/AIDS Epidemiology 3 Percent of AIDS cases (through June 2001) United States (by sex and race, 0-19 years age) Sex: 1 percent of all males (~7100 cases) 4 percent of all females (~6100 cases) Race (percent of all pediatric cases): White-21 percent African-American - 56 percent Hispanic-22 percent Other- 1 percent Sex: 1 percent of all males (~7100 cases) 4 percent of all females (~6100 cases) Race (percent of all pediatric cases): White-21 percent African-American - 56 percent Hispanic-22 percent Other- 1 percent

6. Pediatric HIV/AIDS Epidemiology 3 Percent HIV infection cases* (through June 2001) United States (by sex and race, 0-19 years age) Sex: 3 percent of all males 11 percent of all females Race (percent of all pediatric cases): White-26 percent African-American - 65 percent Hispanic- 8 percent Other- 1 percent *from 36 areas with confidential HIV reporting Sex: 3 percent of all males 11 percent of all females Race (percent of all pediatric cases): White-26 percent African-American - 65 percent Hispanic- 8 percent Other- 1 percent *from 36 areas with confidential HIV reporting

7. Pediatric HIV/AIDS Epidemiology 3 United States Transmission – through June 2001 87-91% of infected infants through vertical transmission (mother to infant)  During utero development  During labor and delivery  Postpartum transmission by breastmilk Other transmission routes  Blood transfusion (2-4%)  Hemophilia/coagulation disorder (3-5%)  Risk not reported or identified (2-6%) Large decline in AIDS cases in infants and children since 1992 Transmission – through June 2001 87-91% of infected infants through vertical transmission (mother to infant)  During utero development  During labor and delivery  Postpartum transmission by breastmilk Other transmission routes  Blood transfusion (2-4%)  Hemophilia/coagulation disorder (3-5%)  Risk not reported or identified (2-6%) Large decline in AIDS cases in infants and children since 1992

8. Oral Manifestations of HIV Infected Children 1,5,11,15,17 Soft tissue lesions Cervical lymphadenopathy Chronic swelling of salivary glands  predominately the parotid gland (parotitis) Long-lasting oral ulcers Linear gingival erythema Necrotizing ulcerative periodontitis/necrotizing ulcerative gingivititis (adolescents only) Dental caries  Medications  Xerostomia due to salivary dysfunction  Poor dietary choices due to HIV-related problems Delayed tooth development Soft tissue lesions Cervical lymphadenopathy Chronic swelling of salivary glands  predominately the parotid gland (parotitis) Long-lasting oral ulcers Linear gingival erythema Necrotizing ulcerative periodontitis/necrotizing ulcerative gingivititis (adolescents only) Dental caries  Medications  Xerostomia due to salivary dysfunction  Poor dietary choices due to HIV-related problems Delayed tooth development

9. Soft Tissue Lesions 5,9,11,15 HIV Infected Children Candidiasis  Most common  Fungal infection  Angular cheilitis Hairy Leukoplakia  Rarely found in young children; more common in older children or adolescents  Etiologic agent is Epstein-Barr virus Kaposi’s sarcoma  Very rare in children Viral lesions of different etiologies  Herpes  Cytomegalovirus Candidiasis  Most common  Fungal infection  Angular cheilitis Hairy Leukoplakia  Rarely found in young children; more common in older children or adolescents  Etiologic agent is Epstein-Barr virus Kaposi’s sarcoma  Very rare in children Viral lesions of different etiologies  Herpes  Cytomegalovirus

10. Oral Lesions 1,4-6,9,11,15 HIV Infected Children Candidiasis  Most common (72 percent HIV infected children)  Suspect HIV infection in infants only when candidiasis is persistent, recurrent or severe  Suspect HIV infection in children older than 1 year old when present  Associated with lower CD4 counts (<1000/sq. mm)  Initial clinical marker of AIDS predictor of further opportunistic infections  AIDS-defining illness Rapid progression of disease Candidiasis  Most common (72 percent HIV infected children)  Suspect HIV infection in infants only when candidiasis is persistent, recurrent or severe  Suspect HIV infection in children older than 1 year old when present  Associated with lower CD4 counts (<1000/sq. mm)  Initial clinical marker of AIDS predictor of further opportunistic infections  AIDS-defining illness Rapid progression of disease

11. Candidiasis 2,5,11,15 HIV Infected Children Pseudomembranous most common form  White and yellow areas easily removed with gauze leaving raw and bleeding surface Also presents in erythematous form or as angular cheilitis Pathogenic species  Candida albicans – most common  Candida krusei  Candida glabrata  Candida dubliniensis Pseudomembranous most common form  White and yellow areas easily removed with gauze leaving raw and bleeding surface Also presents in erythematous form or as angular cheilitis Pathogenic species  Candida albicans – most common  Candida krusei  Candida glabrata  Candida dubliniensis

12. Candidiasis Treatment 5,9,11,15 HIV Infected Children Less severe cases Topical applications of nystatin or clotrimazole troches Angular cheilitis  Nystatin or triamcinolone ointment Widespread or resistant to treatment cases Topical amphotericin Systemic therapy  Fluconazole one to two times per week Less severe cases Topical applications of nystatin or clotrimazole troches Angular cheilitis  Nystatin or triamcinolone ointment Widespread or resistant to treatment cases Topical amphotericin Systemic therapy  Fluconazole one to two times per week

13. Cervical Lymphadenopathy 4,5,9,11,15 HIV Infected Children Early finding Swelling in lymph nodes  Submandibular  Mental  Parotid Persistent and found in the absence of infection and medications affecting lymph nodes Nodes generally larger than 1cm diameter Multiple sites are found Decline in CD4 type of T4 helper cells Positive sign for long-term survival Early finding Swelling in lymph nodes  Submandibular  Mental  Parotid Persistent and found in the absence of infection and medications affecting lymph nodes Nodes generally larger than 1cm diameter Multiple sites are found Decline in CD4 type of T4 helper cells Positive sign for long-term survival

14. Salivary Gland Enlargement 5,9,11,15 HIV Infected Children Can affect all major salivary glands Parotid gland most common  Usually bilateral and asymptomatic  Persistent, chronic swelling  Not a marker of poor outcomes  Prevalence up to 30 percent in this population  Often associated with: Hepatomegaly Splenomegaly Lymphadenopathy  Causes xerostomia Can affect all major salivary glands Parotid gland most common  Usually bilateral and asymptomatic  Persistent, chronic swelling  Not a marker of poor outcomes  Prevalence up to 30 percent in this population  Often associated with: Hepatomegaly Splenomegaly Lymphadenopathy  Causes xerostomia

15. Oral Ulcers 5,11,15 HIV Infected Children Differential and early diagnosis is critical Often persistent – last longer Can be more painful Size and location may be atypical Often interfere with oral intake  Dehydration  Weight loss Most common:  Apthous ulcers  Herpes simplex virus lesions  Cytomegalovirus ulcerations  Ulcerations from HIV medications Differential and early diagnosis is critical Often persistent – last longer Can be more painful Size and location may be atypical Often interfere with oral intake  Dehydration  Weight loss Most common:  Apthous ulcers  Herpes simplex virus lesions  Cytomegalovirus ulcerations  Ulcerations from HIV medications

16. Gingival and Periodontal Problems 5,11,14-15 HIV Infected Children Gingiva: At higher risk for gingivitis  Changes in saliva/xerostomia  Poor oral hygiene due to low socioeconomic status Linear Gingival Erythema – frequently observed  Once known as HIV associated gingivitis  Red gingival band 1-3mm wide  Maxillary/mandibular anterior dentition  Does not respond to traditional treatment – not associated w/plaque accumulation or periodontal disease progression Necrotizing ulcerative gingivitis  Possible precursor to necrotizing ulcerative periodontitis  Rare in US children but adolescents at higher risk Gingiva: At higher risk for gingivitis  Changes in saliva/xerostomia  Poor oral hygiene due to low socioeconomic status Linear Gingival Erythema – frequently observed  Once known as HIV associated gingivitis  Red gingival band 1-3mm wide  Maxillary/mandibular anterior dentition  Does not respond to traditional treatment – not associated w/plaque accumulation or periodontal disease progression Necrotizing ulcerative gingivitis  Possible precursor to necrotizing ulcerative periodontitis  Rare in US children but adolescents at higher risk

17. Gingival and Periodontal Problems 5,11,15 HIV Infected Children Periodontal Necrotizing ulcerative periodontitis  Once known as HIV associated periodontitis  Very rare in US children but adolescents at high risk Has been observed in some preadolescents whose HIV infection was undiagnosed and untreated  Pain, interproximal gingival necrosis, cratered soft tissues  Localized, isolated lesions  Rapid and extensive loss of supporting periodontal attachment and bone  May be associated with low CD4 count (<200 cells/mm 3 ) Periodontal Necrotizing ulcerative periodontitis  Once known as HIV associated periodontitis  Very rare in US children but adolescents at high risk Has been observed in some preadolescents whose HIV infection was undiagnosed and untreated  Pain, interproximal gingival necrosis, cratered soft tissues  Localized, isolated lesions  Rapid and extensive loss of supporting periodontal attachment and bone  May be associated with low CD4 count (<200 cells/mm 3 )

18. Principles of Gingival and Periodontal Treatment HIV Infected Infants, Children, and Adolescents 11 Application of appropriate risk and age-based preventive strategies Removal of plaque Debridement of necrotic tissues (if indicated) Appropriate use of antibiotics and antimicrobial rinses (if indicated) New York State Department of Health AIDS Institute ’s Clinical Guidelines Development Program. Copyright New York State Department of Health AIDS Institute, 2000-2002. All rights reserved. Application of appropriate risk and age-based preventive strategies Removal of plaque Debridement of necrotic tissues (if indicated) Appropriate use of antibiotics and antimicrobial rinses (if indicated) New York State Department of Health AIDS Institute ’s Clinical Guidelines Development Program. Copyright New York State Department of Health AIDS Institute, 2000-2002. All rights reserved.

19. Gingival and Periodontal Treatment 5,11,15 HIV Infected Children Linear gingival erythema No known treatment Necrotizing ulcerative periodontitis & necrotizing ulcerative gingivititis Similar treatment since similar pathologic process Systemic antibiotics (e.g., metronidazole, clindamycin, amoxicillin) with debridement  Consider antifungal agents if candidiasis occurs as result of systemic antibiotic therapy Chlorhexidine oral rinses Frequent appointments and recalls Linear gingival erythema No known treatment Necrotizing ulcerative periodontitis & necrotizing ulcerative gingivititis Similar treatment since similar pathologic process Systemic antibiotics (e.g., metronidazole, clindamycin, amoxicillin) with debridement  Consider antifungal agents if candidiasis occurs as result of systemic antibiotic therapy Chlorhexidine oral rinses Frequent appointments and recalls

20. Dental Caries 5,10-11,15-16 HIV Infected Children Higher rate in primary and permanent dentitions  Increases with decreasing CD4 status and moderate to severe immune suppression  But likely not linked to reduced immune efficiency Caries-free status lower than non-HIV child population Higher caries rates likely due to  Poor dietary choices - need to maintain weight and caloric intake  Low socioeconomic status  Oral anti-fungal medications – cariogenic (sugar)  HIV treatment medications – decreased saliva xerostomia Higher rate in primary and permanent dentitions  Increases with decreasing CD4 status and moderate to severe immune suppression  But likely not linked to reduced immune efficiency Caries-free status lower than non-HIV child population Higher caries rates likely due to  Poor dietary choices - need to maintain weight and caloric intake  Low socioeconomic status  Oral anti-fungal medications – cariogenic (sugar)  HIV treatment medications – decreased saliva xerostomia

21. Delayed Tooth Eruption (DTE) 7,17 HIV Infected Children Has been observed but few studies to date Valdez et al (1994) found 31 percent of this population with DTE  Not correlated with skeletal development Hauk et al (2001) found statistical association between DTE and severity of clinical symptoms  No statistical association with CD4 depletion  Concluded that the onset of HIV related oral symptoms and not HIV itself associated with DTE Has been observed but few studies to date Valdez et al (1994) found 31 percent of this population with DTE  Not correlated with skeletal development Hauk et al (2001) found statistical association between DTE and severity of clinical symptoms  No statistical association with CD4 depletion  Concluded that the onset of HIV related oral symptoms and not HIV itself associated with DTE

22. Dental Management and Approach 5,9,11,15 General Principles HIV Infected Children Follow the American Academy of Pediatric Dentistry guidelines for anticipatory guidance Dental treatment should be based on patients’ ability to undergo procedures, not their HIV status These patients are at high risk for oral disease in both soft and hard tissues Use of medications for HIV treatment/HIV oral complications place patients at further risk for oral diseases Behavioral management techniques such as use of sedation or general anesthesia may be required The best treatment strategy should consider medical status, frequency of visits and preventive strategy Follow the American Academy of Pediatric Dentistry guidelines for anticipatory guidance Dental treatment should be based on patients’ ability to undergo procedures, not their HIV status These patients are at high risk for oral disease in both soft and hard tissues Use of medications for HIV treatment/HIV oral complications place patients at further risk for oral diseases Behavioral management techniques such as use of sedation or general anesthesia may be required The best treatment strategy should consider medical status, frequency of visits and preventive strategy

23. Dental Management and Approach 5,9,11,15 HIV Infected Children Preventive oral health education – start in prenatal period  Medical and dental providers should both be involved and be part of primary health care network and team Preventive oral health care begins with the infant Determine oral health risk – ask about:  Health status  Medication management  Nutritional demands/feeding behaviors  Oral health/hygiene behaviors  Family and psychosocial issues Frequent oral exams/recalls/health history reevaluation (every 3-6 months) depending on HIV status/severity oral symptoms Preventive oral health education – start in prenatal period  Medical and dental providers should both be involved and be part of primary health care network and team Preventive oral health care begins with the infant Determine oral health risk – ask about:  Health status  Medication management  Nutritional demands/feeding behaviors  Oral health/hygiene behaviors  Family and psychosocial issues Frequent oral exams/recalls/health history reevaluation (every 3-6 months) depending on HIV status/severity oral symptoms

24. Oral Health HIV Preventive Strategies by Age 11 Age GroupPreventive Strategy Infants -Supervised use of bottle -Manage cariogenic medication -Oral health education -Dental visits - Fluoride varnish applications -Brush teeth with fluoridated toothpaste Children - Dental sealants - Optimal systemic/topical fluorides -Manage nutrition/carbohydrate intake -Brush teeth with fluoridated toothpaste -Manage medications - Medical hx./status evaluation -Frequent dental visits Adolescents - Chlorhexidine use - Frequent dental visits -Brush teeth w/fluoridated toothpaste -Oral health education - Assess oral hygiene -Manage medications - Medical hx./status evaluation -Optimal topical fluorides - Manage nutrition Adapted from: New York State Department of Health AIDS Institute’s Clinical Guidelines Development Program. Copyright New York State Department of Health AIDS Institute, 2000-2002. All rights reserved.

25. References 1.Barasch A, Safford M, Catalanotto FA, Fine DH, Katz RV. Oral soft tissue manifestations in HIV-positive vs. HIV-negative children from an inner city population: a two-year observational study. Pediatr Dent 2000;22:215-220. 2.Brown DM, Jabra-Rizk MA, Falkler WA, Baqui AAMA, Meiller TF. Identification of Candida dubliniensis in a study of HIV-seropositive pediatric dental patients. Pediatr Dent 2000;22:234-238. http://www.cdc.gov/hiv/stats http://www.cdc.gov/hiv/stats 3.Centers for Disease Control and Prevention. Surv. Report vol. 13, no. 1. National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention, 2002. http://www.cdc.gov/hiv/stats.http://www.cdc.gov/hiv/stats 4.Del Toro A, Berkowitz R, Meyerowitz C, Frenkel LM. Oral findings in asymptomatic (P-1) and symptomatic (P-2) HIV-infected children. Pediatr Dent 1996;18:114-116. 5.Ferguson, FS, Nachman S, Berentsen B. Implications and management of oral diseases in children and adolescents with HIV infection. HIVDENT, 2002. http://www.HIVdent.org.http://www.HIVdent.org 1.Barasch A, Safford M, Catalanotto FA, Fine DH, Katz RV. Oral soft tissue manifestations in HIV-positive vs. HIV-negative children from an inner city population: a two-year observational study. Pediatr Dent 2000;22:215-220. 2.Brown DM, Jabra-Rizk MA, Falkler WA, Baqui AAMA, Meiller TF. Identification of Candida dubliniensis in a study of HIV-seropositive pediatric dental patients. Pediatr Dent 2000;22:234-238. http://www.cdc.gov/hiv/stats http://www.cdc.gov/hiv/stats 3.Centers for Disease Control and Prevention. Surv. Report vol. 13, no. 1. National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention, 2002. http://www.cdc.gov/hiv/stats.http://www.cdc.gov/hiv/stats 4.Del Toro A, Berkowitz R, Meyerowitz C, Frenkel LM. Oral findings in asymptomatic (P-1) and symptomatic (P-2) HIV-infected children. Pediatr Dent 1996;18:114-116. 5.Ferguson, FS, Nachman S, Berentsen B. Implications and management of oral diseases in children and adolescents with HIV infection. HIVDENT, 2002. http://www.HIVdent.org.http://www.HIVdent.org

26. References 6.Flanagan MA, Barasch A, Koenigsberg SR, Fine D, Houpt M. Prevalence of oral soft tissue lesions in HIV-infected minority children treated with highly active antiretroviral therapies. Pediatr Dent 2000;22:287-291. 7.Hauk MJ, Moss ME, Weinberg GA, Berkowitz RJ. Delayed tooth eruption: association with severity of HIV infection. Pediatr Dent 2001;23:260-262. 8.Hicks MJ, Flaitz CM, Carter AB, Cron SG, Rossmann SN, Simon CL,Demmler GJ, Kline MW. Dental caries in HIV-infected children: a longitudinal study. Pediatr Dent 2000;22:359-364. 9.Little JW, Falace DA, Miller CS, Rhodus, NL. AIDS and related conditions. In: Little JW, Falace DA, Miller CS, Rhodus, NL. Dental management of the medically compromised patient, 6 th ed. St. Louis, MO:Mosby, Inc; 2002: DM22-DM24, 221-247. 10. Madigan A, Murray PA, Houpt M, Catalanotto F, Feuerman M. Caries experience and cariogenic markers in HIV-positive children and their siblings. Pediatr Dent 1996;18:129-136. 6.Flanagan MA, Barasch A, Koenigsberg SR, Fine D, Houpt M. Prevalence of oral soft tissue lesions in HIV-infected minority children treated with highly active antiretroviral therapies. Pediatr Dent 2000;22:287-291. 7.Hauk MJ, Moss ME, Weinberg GA, Berkowitz RJ. Delayed tooth eruption: association with severity of HIV infection. Pediatr Dent 2001;23:260-262. 8.Hicks MJ, Flaitz CM, Carter AB, Cron SG, Rossmann SN, Simon CL,Demmler GJ, Kline MW. Dental caries in HIV-infected children: a longitudinal study. Pediatr Dent 2000;22:359-364. 9.Little JW, Falace DA, Miller CS, Rhodus, NL. AIDS and related conditions. In: Little JW, Falace DA, Miller CS, Rhodus, NL. Dental management of the medically compromised patient, 6 th ed. St. Louis, MO:Mosby, Inc; 2002: DM22-DM24, 221-247. 10. Madigan A, Murray PA, Houpt M, Catalanotto F, Feuerman M. Caries experience and cariogenic markers in HIV-positive children and their siblings. Pediatr Dent 1996;18:129-136.

27. References 11.New York State Department of Health AIDS Institute ’s Clinical Guidelines Development Program. Oral health care for people with HIV infection. New York State Department of Health AIDS Institute, 2000. http://www.hivguidelines.org.http://www.hivguidelines.org 12.Ramos-Gomez FJ. Oral aspects of HIV infection in children. Oral Dis 1997;3(Suppl 1):S31-S35. 13.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. Collaborative Workgroup on Oral Manifestations of Pediatric HIV Infection. J Clin Pediatr Dent 1999 Winter;23(2) 85- 96. 14.Schoen DH, Murray PA, Nelson E, Catalanotto FA, Katz RV, Fine DH. A comparison of periodontal disease in HIV-infected children and household peers: a two year report. Pediatr Dent 2000;22:365-369. 15.State of New York, Department of Health. Oral health care for infants and children. HIVDENT, 2002. http://www.HIVdent.org.http://www.HIVdent.org 11.New York State Department of Health AIDS Institute ’s Clinical Guidelines Development Program. Oral health care for people with HIV infection. New York State Department of Health AIDS Institute, 2000. http://www.hivguidelines.org.http://www.hivguidelines.org 12.Ramos-Gomez FJ. Oral aspects of HIV infection in children. Oral Dis 1997;3(Suppl 1):S31-S35. 13.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. Collaborative Workgroup on Oral Manifestations of Pediatric HIV Infection. J Clin Pediatr Dent 1999 Winter;23(2) 85- 96. 14.Schoen DH, Murray PA, Nelson E, Catalanotto FA, Katz RV, Fine DH. A comparison of periodontal disease in HIV-infected children and household peers: a two year report. Pediatr Dent 2000;22:365-369. 15.State of New York, Department of Health. Oral health care for infants and children. HIVDENT, 2002. http://www.HIVdent.org.http://www.HIVdent.org

28. References 16.Tofsky N, Nelson EM, Lopez RN, Catalanotto FA, Fine DH, Katz RV. Dental caries in HIV-infected children versus household peers: two-year findings. Pediatr Dent 2000;22:207-214. 17.Valdez IH, Pizzo PA, Atkinson JC. Oral health of pediatric AIDS patients: a hospital-based study. J Dent Child 1994 Mar- Apr;61:114-118. 16.Tofsky N, Nelson EM, Lopez RN, Catalanotto FA, Fine DH, Katz RV. Dental caries in HIV-infected children versus household peers: two-year findings. Pediatr Dent 2000;22:207-214. 17.Valdez IH, Pizzo PA, Atkinson JC. Oral health of pediatric AIDS patients: a hospital-based study. J Dent Child 1994 Mar- Apr;61:114-118.