Epidemiology of pediatric HIV infection

Introduction
WHO defines
Health as a state of
complete physical,
mental and social
well being, and not
merely the absence
of disease and
infirmity. 66th IDA Conference, 2013

 This state of well being has been guaranteed as a ‘human right’
through a number of international human rights treaties..
66th IDA Conference, 2013

 The rapid spread of HIV/AIDS has led to an infringement of the human rights of men, women
and children affected by the epidemic in various ways.
 The impact of HIV/AIDS has permeated the social, cultural and economic fabric of many a
nations.
 With no known cure, the disease has acquired pandemic proportions and countries are least
equipped to cope in the absence of a definitive strategy and treatment regime.

In providing dental
care, dentists fact
the challenge of
providing
optimum care and
respect for
patients while
minimizing any
health and safety
risks for
themselves and
others.
In the case of caring
for patients living
with HIV, this can
be a challenge66th IDA Conference, 2013

Aims &
Objectives
1. To discuss the considerations in the dental
management of children with HIV infection
2. To recognize the oral manifestation of pediatric
HIV infection: classification, clinical
characteristics, and treatment
recommendations
3. To discuss the need for integrating oral health
care into the management of children with HIV
infection
4. To discuss strategies for a safe and
empathetic
environment for child patients & Standard
infection control measures offering protection to
DHCP and their patients against these
infections.

EPIEDEMIOLOGY OF
PEDIATRIC HIV INFECTIONEPIDEMIOLOGY
OF PEDIATRIC
HIV INFECTION

Across the globe, AIDS is responsible for an increasing number
of deaths each year
2.5 million children globally living with HIV; 10,000 becoming
infected daily
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 earlier66th IDA Conference, 2013

Routes of Transmission of HIV,
India, 2011-12

Considerations in the
Dental Management of
Children with HIV Infection

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
Percentage
Age of patient and CD
count
Level of
Immunosuppress
ion
< 12 mths 1-5 yrs 6 –1yrs
> 25% >1499 >999 >500 No
15- 24% 740-1499 500-999 200-499 Moderate
< 15% <750 <500 <200 Severe

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

• 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

 Elective Dental Procedures
 Platelet count > 50,000/mm3
 no special precautions are necessary
Over-retained primary incisors
Over-retained primary incisors
in need of elective extractions
 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
Prevention of Hemorrhage

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
 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 66th IDA Conference, 2013

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

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

Oral Manifestations of Paediatric
HIV infection
 one of the earliest, most reliable Indicators of
paediatric HIV infections
 oral conditions most frequently occuring in
children :
 Oral Candidiasis
 Herpetic Gingivostomatitis
 Aphthous-like ulceration
 Necrotizing Ulcerative Gingivitis (NUG)
 HIV-related periodontal disease
 Hairy leukoplakia
 Oral hyperpigmentation
 Salivary gland disease
 Oral purpura
 Kaposi’s sarcoma
 Lymphomas

Considerations in the Management
of oral soft tissue manifestations of
pediatric HIV infection :
classification, clinical characteristics,
and treatment recommendations

Early detection of HIV-related oral lesions
can be used to:
1. Diagnose HIV infection
2. Elucidate the disease progression
3. Predict immune status
4. Provide timely therapeutic interventions

Orofacial lesions associated with pediatric HIV
infection
Group 1
Lesions commonly
associated with pediatric HIV
infections
Candidiasis: pseudomembranous, erythematous, angular
chelitis
Herpes simplex virus infection
Linear gingival erythema
Parotid enlargement
Recurrent apthous ulcers: minor, major, herpetiform
Group 2
Lesions less commonly
associated with pediatric HIV
infections
Bacterial infections of oral tissues
Periodontal diseases: ANUG, ANUP, necrotizing stomatitis
Seborrheic dermatitis
Viral infections: cytomegalovirus, human papillomavirus,
Moluscum contagiosum and varicella zoster virus (Herpes-zoster
and Varicella)
Xerostomia
Group 3
Lesions strongly associated
with pediatric HIV infections
but rare in children
Neoplasms: Kaposi’s sarcoma and non-Hodgkin’s lymphoma
Oral hairy leukoplakia
TB-related ulcers
Ramos-Gomez et al., J Clin Ped Dent 23(2): 86, 1999

Pseudomembranous candidiasis
 Candidiasis indicates severely depressed immune
system; first clinical manifestation of the disease
( marker of disease progression)
 CD4 lymphocyte count: <1000/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)

New York State Department of Health AIDS Institute's Clinical Guidelines Development ProgramAIDSinfo. U.S. Department of Health and Human Services (DHHS)

Oral candidiasis recommendations
1. Following oral hygiene instructions to
control oral Candida and delay candidiasis’
progression
2. Preventive measures to start at birth
3. Preventive measures include:
a) Cleaning food and medicine residue on teeth
and soft tissues (gingiva, oral mucosa)
b) Nutrition and medication management
4. Weaning from bottle to cup as early as
possible to reduce risk and frequency

LINEAR GINGIVAL
ERYTHEMA
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

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

HERPES SIMPLEX VIRUS INFECTION

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

Infection control in dental practice

Routes of transmission
 • Direct contact with blood, oral fluids (saliva) or other patient
material.
 • Indirect contact with contaminated objects, viz. instruments,
equipment,
or environmental surfaces.
 • Contact of conjunctiva, nasal, or oral mucosa with droplet
infection.
 • Inhalation of airborne particles.
 The risk of occupational exposure to bloodborne infections depends
on the following factors.
 • Prevalence of bloodborne viruses in patient population.
 • The nature and frequency of contact with blood and body
fluids through
percutaneous or permucosal exposures.
 • Inoculum size.

Infection control procedures to
be adopted by DHCP
 Environmental infection control
 Personal protection measures:
 Immunization:
 Protective clothing:
 Hand hygiene (washing):
 Hand gloves and their correct use:
 Masks, protective eyewear and face shields:
 Avoidance of occupational injuries:
 Health status of DHCP:

Patient procedures in infection
control
 Medical history: Thorough medical history clearly
identifies infective diseases ,for example,
HBV/HIV, tuberculosis, should be recorded.
 patients referred to relevant consultants for
investigations and opinion.
 Preprocedural mouth rinses: use of antimicrobial
rinses intended to reduce microorganisms that
patient might release via the aerosol or spatter
contaminating the equipment or the DHCP.
 Use of chlorhexidine gluconate, essential oils or
providone-iodine was found helpful.

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

The primary care clinician’s 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 patient’s 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

Nutshell
 These unique challenges must be recognized
and understood in order to provide
appropriate holistic management enabling
them to become productive citizens of
tomorrow.
 To address these multi-factorial issues, there
is an urgent need for a concerted, sustainable
and multipronged national and global
response.

Epidemiology of pediatric HIV infection

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (6)

Similar to Epidemiology of pediatric HIV infection

Similar to Epidemiology of pediatric HIV infection (20)

More from Dr. Roshni Maurya

More from Dr. Roshni Maurya (20)

Recently uploaded

Recently uploaded (20)

Epidemiology of pediatric HIV infection