Transcript Considerations in the Dental Management of Children with HIV

Considerations in the Dental
Management of Children with
HIV Infection
Pediatric HIV infection
• 85-90% of cases are vertically acquired
• Approximately 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
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Oropharyngeal Candidiasis (OPC)
Linear Gingival Erythema (LGE)
Salivary gland enlargement
Herpes simplex viral infection
Recurrent apthous stomatitis
Recurrent apthous stomatitis
Cervical lymphadenopathy
• As children with HIV infection have increased
survival, they are at risk for additional oral
burdens, such as lymphoma
Fungal Infections
• Candidiasis
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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
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Herpes simplex
Herpes zoster
Cytomegalovirus
Human Papillomavirus
Epstein-Barr virus
Herpes simplex
 Hairy leukoplakia
• Molluscum contagiosum
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/mm3, prophylactic
antibiotics are not necessary
 If ANC is between 500 and 1000/mm3, elective treatment may
proceed, following antibiotic prophylaxis
 If ANC is < 500/mm3 or WBC < 2000/mm3, 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/mm3
no special precautions are
necessary
• Platelet count < 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 < 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/mm3
no special precautions are
necessary
• Platelet count < 50,000/mm3
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
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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
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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/mm3 and platelet count >
20,000/mm3
 Dental hygiene efforts with moist gauze or toothette only
when ANC < 500/mm3 or platelet count < 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
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