Epidemiology of pediatric HIV infection

66th IDA Conference, 2013

BREAKING BARRIERS


Introduction

WHO defines Health as a state of complete physical, mental and social well being, and not merely the absence of disease and infirmity.


This state of well being has been guaranteed as a ‘human right’ through a number of international human rights treaties..


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 dentalcare, dentists factthe 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 challenge fraught with many

questions and concern.


Aims & Objectives1. 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 INFECTION EPIDEMIOLOGY OF PEDIATRIC HIV INFECTION


Across the globe, AIDS is responsible for an increasing number of deaths each year2.5 million children globally living with HIV; 10,000 becoming infected dailyMTCT accounts for the vast majority of HIV infected childrenPCR: nearly all infants during the first month of lifeHighly variable disease course, but more rapid progression than in adults20% of HIV infected children are clinically symptomatic within the first year of life50% have AIDS by age 5Mean survival is 10 years and increasing with HAARTShort incubation period and oral manifestations occur earlier than in adults


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 ofImmunosuppression

< 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 ProphylaxisElective Dental Procedures (not presenting as imminent sources of infection)

If Absolute Neutrophil Count (ANC) is > 1000/mm3,

prophylactic antibiotics are not necessaryIf 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


Prev en tio n o f He mo rrha ge

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 Childrenwith 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



• Life Expectancy Duration of treatment Prognosis of treatment

• Psychosocial Image enhancement Normalcy



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 ofpediatric HIV infection : classification, clinical characteristics, and treatment recommendations


Early detection of HIV-related oral lesions

can be used to:

1. Diagnose HIV infection2. Elucidate the disease progression3. Predict immune status4. Provide timely therapeutic

interventions


Orofacial lesions associated with pediatric HIV infection

Group 1Lesions commonly associated with pediatric HIV infections

Candidiasis: pseudomembranous, erythematous, angular chelitisHerpes simplex virus infectionLinear gingival erythemaParotid enlargementRecurrent apthous ulcers: minor, major, herpetiform

Group 2Lesions less commonly associated with pediatric HIV infections

Bacterial infections of oral tissuesPeriodontal diseases: ANUG, ANUP, necrotizing stomatitisSeborrheic dermatitisViral infections: cytomegalovirus, human papillomavirus, Moluscum contagiosum and varicella zoster virus (Herpes-zoster and Varicella)Xerostomia

Group 3Lesions strongly associated with pediatric HIV infections but rare in children

Neoplasms: Kaposi’s sarcoma and non-Hodgkin’s lymphomaOral hairy leukoplakiaTB-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)

66th IDA Conference, 2013New York State Department of Health AIDS Institute's Clinical Guidelines Development ProgramAIDSinfo. U.S. Department of Health and Human Services (DHHS)


Oral candidiasis recommendations1. Following oral hygiene instructions

to control oral Candida and delay candidiasis’ progression

2. Preventive measures to start at birth3. Preventive measures include:

a) Cleaning food and medicine residue on teeth and soft tissues (gingiva, oral mucosa)

b) Nutrition and medication management4. 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


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

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 risingChildren with HIV infection are at greater risk for oral and dental diseasesConsultation 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 monthsAnticipatory 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 providerCoordinate 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

Healthcare

Transcript of Epidemiology of pediatric HIV infection