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Oral Health Management in Children and Adolescents With HIV Infection

Free Online CME: HIV and Oral Health Care

Updated December 2001 — Currently Under Revision

I. INTRODUCTION

With the introduction of successful antiretroviral therapy (ARV), oral health care providers are now more likely to encounter children and adolescents who live longer with HIV/AIDS. Although some of these children may appear healthy, others may have past or present indicators of HIV infection. Early identification of HIV infection can result in timely access to health care for the child and supportive therapy for the family or caregiver.

HIV disease varies considerably in children. Among those infected perinatally, some experience few or no symptoms for years, whereas others progress rapidly. The sequelae of HIV infection in children include potential chronic progressive illness with acute episodes, hospitalizations, failure to thrive, poor weight gain, multiple and long-term medication regimens, and developmental delay. Poor general health of children and caregivers can interfere with appropriate and consistent oral health behaviors and access to preventive care. Oral function can be impaired by infections of the teeth, mucosa, and gingival and periodontal tissues. Children with untreated or poorly controlled HIV may suffer from poor nutrition because of an inability to chew properly as a result of a decayed and painful dentition or because of untreated soft-tissue problems, such as oral ulcers and gingival and periodontal diseases.

Neurological involvement and developmental delay can be complications found in children with HIV infection.1 Behavior management of these children can create obstacles to the delivery of dental therapy.

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II. THE ORAL HEALTH CARE PROVIDER’S ROLE IN THE PRIMARY CARE TEAM

Recommendations:

Because of the variety of oral health problems associated with HIV disease, the oral health care provider should be involved in the initial management and be a participant of the primary care team for pediatric patients.

The oral health care provider should inform the appropriate primary care team members of the patient’s oral health needs and concerns, the patient’s role in oral health maintenance, and the oral health care provider’s ability to deliver specialized preventive and restorative treatment and recall care.

Because of the unpredictable nature of acute and chronic illnesses associated with HIV infection, the oral health care provider should always strive to prevent oral problems. Understanding the psychosocial, medical, and family issues that can be associated with HIV illness, obtaining a detailed medical and social history of the child, performing an oral-facial-dental evaluation at each visit, and establishing an appropriate recall interval for assessment of the patient’s oral health status are key to the preventive strategy. Recall intervals should be based on each patient’s caries history, plaque and debris index, and treatment adherence.

As part of the primary care team, the oral health care provider should discuss with the pediatrician dental preventive and restorative strategies for the child, work collaboratively to resolve questions of contraindications to dental procedures, and coordinate medical procedure appointments with dental procedure appointments.

Oral health care providers should request that the pediatrician or team members keep them informed of important changes in the patient’s status. The oral health care provider should be furnished with current information that may influence dental treatment, including staging of the patient’s disease, medications, nutritional status, and blood serum laboratory tests (e.g., recent CD4/CD8 counts, viral load, and platelet count).

As the oral health care provider may be the first health professional to suspect HIV infection in the pediatric patient, the oral health care provider should know the findings suggestive of HIV infection (see Table 5-1). Identified findings should be reported to the child’s pediatrician.

The oral health care provider should understand the psychosocial issues that confront HIV-infected children and adolescents.

Oral health care providers should make every effort to avoid disruption or discontinuation of a patient’s treatment that may result from family-related problems. Problems related to treatment adherence should be discussed with the primary care team to solve what may be a complicated issue(s).

Table 5-1: Findings Suggestive of HIV Infection in Pediatric Patients
  • Uncommon, unusual, or frequent oral infections or lesions
  • Delay in age-appropriate neurological development (e.g., speech, fine and gross motor skills)
  • Delay in age-appropriate weight and height gain
  • Respiratory distress (past and present)
  • Recurrent infections (e.g., pneumonia) or hospitalizations
  • Chronic low-grade fevers, chronic diarrhea (i.e., more than 3 stools per day for 2 weeks)
* Used for multiple ulcers or ulcers not easily accessible for topical application.



The oral health care provider should teach and empower patients and caregivers by giving them the knowledge necessary to provide consistent and appropriate oral, dietary, or medication guidance. For example, prolonged and unsupervised use of a bottle for feeding or pacification, improper delivery of medications, or failure to give medications are significant concerns.

Social workers, nurses, and other auxiliaries should be involved in the care plan to help patients who have trouble keeping appointments. They can also help the family by making referrals to the medical-dental team or the primary care team. This collaborative effort offers the child and the family the most comprehensive and compassionate support.

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III. FAMILY ISSUES

Recommendation:

Oral health care providers should make every effort to avoid disruption or discontinuation of a patient’s treatment as a result of family-related problems.

Families may present with problems that affect dental treatment and outcomes. Problems related to poverty, substance use, physical or sexual abuse, homelessness, mental illness, and parental HIV infection can contribute to missed appointments, non-adherence with routine personal dental care, and discontinuation of treatment.

Every effort should be made to avoid disruption or discontinuation of treatment. Social workers, nurses, and child development staff can help address family issues. For example, if parents or caregivers report that they are changing dentists, the oral health care provider should follow up with a call to the new clinician or ask an assistant, social worker, or nurse to do so. Willful failure of a parent or guardian to seek and follow through with treatment may be reported as neglect. If necessary, parents may be legally forced to bring a child for treatment, and intervention by child protective services may be required.

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IV. INITIAL INTAKE VISIT

Recommendations:

The oral health care provider should consider HIV counseling and testing of children whose birth parents’ medical or social histories are suggestive of HIV.

If the child’s HIV status has not been disclosed or if HIV infection is strongly suspected:

  • The medical history should be re-evaluated with questions about risk factors for HIV infection in the family.
  • The patient’s or caregiver’s consent should be obtained in order to attain the patient’s HIV medical information.

The dental provider should be sensitive to and respect the caregiver’s willingness to discuss HIV status with the child and should try to ascertain whether the child has been informed of his/her HIV status, even if the subject has not been discussed.

When information regarding the birth parents’ health status, medical and psychosocial history, history of drug and/or alcohol use, information concerning adoption or foster care, or history of blood transfusions are suggestive of HIV, the oral health care provider should consider HIV counseling and testing.

If a caregiver resists discussing specific issues and the dental provider suspects that the patient is HIV infected, the dental provider should ask the caregiver general questions, such as:

  • Does the child go to any clinic or doctor other than his/her usual pediatrician?
  • Has the child or any family member had any unusual or persistent infections? How have they been treated?

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V. CONSIDERATIONS FOR PREVENTION AND TREATMENT PLANNING

Recommendations:

The oral health care provider should follow the American Association of Pediatric Dentistry (AAPD) guidelines for anticipatory guidance.2

Treatment modifications for children and adolescents should be based on the patient’s medical status rather than HIV status.

Oral health care providers should be aware that children with HIV infection might experience an increased risk of oral disease, including soft-tissue and hard-tissue pathology.

The oral health care provider should let the caregiver know that all health-related information is essential for the safe treatment of the child and will be kept confidential.

The oral health care provider should review the treatment plan with the family or caregivers and set dates of treatment. It is important that families are provided with a clear idea of what is expected regarding their involvement in the care plan. The oral health care provider should supply caregivers with necessary oral, dietary, or medication knowledge.

The following indicators should be considered in devising the best treatment strategy for each patient:

  • Medical status – The patient’s medical status should be updated at each visit to accurately track progression of disease and changes in medication protocols.
  • Frequency of visits – Visits should be scheduled according to the needs and caries risk factors of each patient.
  • Preventive strategy – Early and aggressive preventive therapy (e.g., sealants) and reinforcement of good oral hygiene at home can help avoid or minimize caries (see Table 5-2).



Table 5-2: Oral Health Preventive Strategies by Age
Age Group Preventive Strategies
Infants Supervised use of bottles for feeding or pacification, management of cariogenic medication
Children Dental sealants, optimal systemic and topical fluoride, fluoride varnish supplementation, management of nutrition and medication, low frequency and chronicity of fermentable carbohydrate intake (e.g., juices, milk, dietary supplements)
Adolescents Removing residue of food and medicine through rinsing with water or mechanical cleansing, management of nutrition and medication, addressing barriers that prevent adolescents from accessing care



HIV infection does not necessitate changes in the treatment plan for a child or adolescent. However, effects of HIV infection on the pediatric patient and the patient’s family may alter the oral health care provider’s approach to treatment. Updating of medical and psychosocial summaries is an important part of treatment of chronically ill patients and should be performed at recall visits.

Preventive measures provided by the child’s caregiver and the medical-dental team are especially critical for the child with HIV infection. Dental sealants, optimal systemic and topical fluoride, and fluoride varnish supplementation are keys to preventive strategy. Dental therapy based on effective home care and management of nutrition and medication can give a sense of accomplishment to caregivers who may feel ineffective in combating the child’s illness. The patient’s oral hygiene and the condition of the soft tissues usually reflect the degree of the caregiver’s and the patient’s ability to adhere to the specified home care regimen.

In the overall health care management of the patient, the oral health care provider should give restorative care and develop a suitable prevention program tailored to the profile of the individual child. HIV status in itself is not a reason to alter a treatment plan.

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VI. ORAL LESIONS AND PERIDONTAL DISEASE IN THE PEDIATRIC PATIENT

Recommendation:

Oral health care providers should be prepared to recognize, identify, and manage oral lesions in children with HIV infection.

Oral health care providers should refer to the primary medical care provider for diagnoses, observation, and management of any lesions that disrupt the integrity of the oral mucosa in children.

Several studies have described oral lesions in the pediatric population with HIV infection. In 1994, the Centers for Disease Control and Prevention (CDC) revised the classification system for HIV infection in children <13 years of age to include oral lesions as markers of severity of HIV infection.3 Oral health care providers should review this information.

Although it is common for children to present with palpable lymph nodes of the cervical and submandibular chain, the oral health care provider should interpret these findings in the context of the patient’s total profile (see Chapter 2: Diagnosis and Management of Soft-Tissue Lesions). HIV-infected children whose disease is well controlled by medications will commonly show no signs of oral lesions. Untreated or undiagnosed children will be more likely to develop lesions.

Oral lesions associated with HIV infection cause pain and discomfort, compromise function, interfere with oral hygiene, and may negatively influence the patient’s general health. Potential causes of lesions include herpes simplex, coxsackievirus, and ARV drugs. Fluocinonide ointment 0.05% and hydrocortisone acetate oral paste can be used to provide pain relief. Because nutrition often plays a role in the prevention of these lesions, maintaining and increasing caloric intake is very important.

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A. Oral Candidiasis

Recommendations:

Oral rinsing, nutritional and medication management, and cleansing the entire mucosal and gingival tissue area beginning at birth may help control oral Candida and delay the progression of oral candidiasis.

Oral hygiene instructions should be given to patients and caregivers, and, for young children, the caregiver’s role in the oral hygiene process should be stressed. Residue of food and medicine on the oral tissues (mucosa, gingiva) and on the teeth should be removed by the caregivers of young children and independently by older children through rinsing with water or mechanical cleansing.

The most common soft-tissue lesion in children with HIV infection is pseudomembranous oral candidiasis (reported in approximately 75% of cases).4 Erythematous candidiasis and angular cheilitis are also commonly observed in children with HIV infection (see Appendix 5-A for photographic examples). A number of factors may influence the risk for candidiasis in children. Feeding behaviors and nutritional requirements that increase the frequency of fermentable carbohydrates intake (e.g., formula, juices, milk, dietary supplements), especially when delivered with bottles, support the growth of candidiasis.

Oral rinsing, nutritional and medication management, and cleansing the entire mucosal and gingival tissue area beginning at birth may help control oral Candida and delay the progression of oral candidiasis. In infants and small children, candidal lesions can be treated by swabbing with nystatin. Antifungal medications may also be required (see Table 5-3 for topical and systemic medications).

Evidence is growing that prolonged and chronic use of antifungal medications has limitations, such as resistant strains, toxicity, and deleterious effects on immature organ systems. Furthermore, both the sucrose in some antifungal preparations and the juice or milk that may be added to ensure adherence will increase the risk of caries. Elimination of the feeding bottle by weaning to a cup as early as possible may reduce candidiasis risk and frequency.

Table 5-3: Topical and Systemic Antifungal Medications for Pediatric Populations With Oral Candidiasis*
Agent Dosage

Topical

- Oral nystatin suspension

- Clotrimazole troches

 

- 2 to 5 mL, 4 to 6 times/day

- 10-mg tablet, 3 to 5 times/day

Systemic

- Fluconazole

- Itraconazole


- Ketoconazole

 

- 3 to 5 mg/kg once daily

- 100 mg/day orally for children

>3 years of age

- 5 to 10 mg/kg/day

* Five to seven days of therapy is often sufficient to clear oral candidiasis.

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B. Angular Cheilitis

Recommendation:

As angular cheilitis may represent poor diet and poor feeding in addition to fungal infection, the oral health care provider should assess the diet, oral habits, and/or HIV status of a child with angular cheilitis.5 Consultation should occur with the primary care team regarding nutritional support and vitamin supplementation, which may improve this condition in children.

Angular cheilitis appears as cracks or fissures at the commissures of the lips. This oral environment frequently accompanies intra-oral candidiasis (see Appendix 5-A for photographic example).

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C. Parotid Swelling

Parotid swelling is the second most commonly reported oral lesion, with a prevalence of up to 30%. It is usually asymptomatic and bilateral and spontaneously resolves and recurs. The reason for the swelling is not well understood, and medication side effects have been offered as a possible explanation. In contrast to candidiasis, parotid swelling does not seem to be a marker of poor outcome (see Appendix 5-A for photographic example).

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D. Caries and Gingivitis

Recommendation:

Extensive caries or chronic demineralization should be treated definitively with comprehensive restorative care.

The dental literature suggests that children with HIV infection are at greater risk for dental caries and gingivitis than children without HIV infection. The increased risk is due, in part, to baby-bottle tooth decay, progressive immunodeficiency, effects of medications on salivary flow and oral flora, developmental delay, and/or failure to thrive. Extrinsic factors such as diet, inadequate oral hygiene, socioeconomic status, lack of caregiver knowledge, and frequent use of the bottle while going to sleep may be additional risk factors. HIV infection, changes in saliva, and xerostomia contribute to the severity of plaque-related diseases.

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E. Xerostomia

Recommendation:

Sugarless gum and frequent consumption of water or highly diluted fruit juices should be used to alleviate xerostomia.

Xerostomia has been observed in pediatric patients. The frequency is unknown, and the etiology is not clear. The administration of gamma globulin and didanosine (ddI) has been suggested as a possible cause for xerostomia in some children. Although increased caries have been observed in some children with HIV infection, the relationship between xerostomia and dental caries has not been demonstrated in clinical studies of children with HIV infection. Symptoms include dry stools, low urine volume, high fluid consumption, eating of “watery, loose” foods, and complaints of dry mouth.

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F. Aphthous Ulcers

Recommendation:

Topical corticosteroids should be used to manage aphthous ulcers (see Chapter 2: Diagnosis and Management of Soft-Tissue Lesions).

Aphthous ulcers in children with HIV (estimated prevalence, <10%) can present serious problems, such as pain and impaired ability to eat. In addition to prolonged course, size and location may be atypical. ARV therapy with zalcitabine (ddC) has been suggested as an etiologic factor (see Appendix 5-A for photographic example).

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G. Herpetic Stomatitis

Recommendation:

Supportive therapies, such as topical applications of medicaments, should be used to encourage hydration and the intake of food (see Chapter 2: Diagnosis and Management of Soft-Tissue Lesions).

Herpetic stomatitis is a common viral infection in the pediatric population, regardless of HIV status (see Appendix 5-A to view photographic example). This lesion, however, can be especially severe in children with HIV infection. The course of an infection may be longer than normally observed (10-14 days); the lesions may be more aggressive and may recur more frequently.

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H. Hairy Leukoplakia

Hairy leukoplakia has been reported in HIV-infected children, but it is rare.6,7 It appears to resolve spontaneously, and its prognostic significance is unknown (see Appendix 5-A to view photographic example).

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I. Kaposi’s Sarcoma

Kaposi’s sarcoma and other neoplasms are rarely found in children who have AIDS.

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J. Linear Gingival Erythema

Linear gingival erythema (LGE), most commonly associated with the upper and lower anterior dentition, has been observed in pediatric patients (see Appendix 5-A for photographic example). Based on clinical experience, it has been determined that approximately 10% of children have this condition. These lesions usually do not cause clinical problems or interfere with nutrition. Necrotizing ulcerative periodontitis (NUP) and other destructive diseases of the periodontium [e.g., atypical necrotizing ulcerative gingivitis (ANUG)] are rarely described in studies of children in the United States. There may be a higher risk of these diseases in adolescents with HIV infection (see Chapter 3: Clinical Manifestations and Management of HIV-Related Periodontal Disease).

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VII. ADOLESCENCE AND HIV INFECTION

Recommendations:

Oral health care providers should be aware of the direct and indirect factors that place adolescents at risk for acquiring HIV infection.8

Oral health care providers should strive to gain the trust of adolescent patients at the outset of the professional relationship.

To care adequately for adolescents with HIV infection, oral health care providers should first address the barriers that prevent adolescents from accessing care, including payment, consent, and confidentiality.

Adolescents with HIV infection not already in care should be referred for immediate consultation with an appropriate health care center AIDS team or HIV Specialist.

Adolescence is defined not only by chronological age but also by hormonal changes of puberty, rapid somatic growth, development of personal autonomy and identity, feelings of immortality, and exploration of sexual activity and substance use. Certain behaviors and circumstances, including history of substance use and alcohol use, sexual orientation, history of mental illness, and trading sex for food, shelter, or money, are recognized as predictors for risk of HIV infection among adolescents.

Adolescents with early HIV infection present unique treatment issues for any clinician. These include differences in the epidemiology of HIV infection among youth, barriers to HIV care, and specific features of the progression of HIV infection during adolescence. Additional pediatric and adolescent clinical guidelines developed by the New York State Department of Health AIDS Institute can be reviewed and downloaded at http://www.hivguidelines.org.9

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REFERENCES

1. Belman AL, Diamond G, Dickson D, Horoupian D, Llena J, Lantos G, et al. Pediatric acquired immunodeficiency syndrome: Neurologic syndromes. Am J Dis Child 1988;142:29-35.

2. American Academy of Pediatric Dentistry. AAPD Reference Manual 2000-2001. Available at: http://www.aapd.org

3. Centers for Disease Control and Prevention. Revised classification of HIV infection in children (birth-13 yrs.). MMWR Morb Mortal Wkly Rep 1994;43(RR-12).

4. Scully C, el-Kabir M, Samaranayake LP. Candida and oral candidosis: A review. Crit Rev Oral Biol Med 1994;5:125-157.

5. Nizel AE. Nutrition in Clinical Dentistry. 3rd ed. Philadelphia, PA: Saunders; 1989.

6. Ferguson FS, Archard H, Nuovo G, Nachman S. Hairy leukoplakia in a child with AIDS: A rare symptom case. Am J Pediatr Dent 1993;15:280-281.

7. Greenspan JS, Mastrucci MT, Leggott PJ, Freese UK, DeSouza YG, Scott GB, et al. Hairy leukoplakia in a child. AIDS 1988;2:143.

8. Hein K, Dell R, Futterman D, Rotheram-Borus MJ, Shaffer N. Comparison of HIV+ and HIV– adolescents: Risk factors and psycho-social determinants. Pediatrics 1995;95:96-103.

9. Committee for the Care of Children and Adolescents With HIV Infection. Criteria for the Medical Care of Children and Adolescents With HIV Infection. 4th ed. New York, NY: New York State Department of Health AIDS Institute; 2001. Available at: http://www.hivguidelines.org

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FURTHER READING

Asher RS, McDowell J, Acs G, Belanger G. Pediatric infection with the human immunodeficiency virus (HIV): Head, neck, and oral manifestations. Special Car Dent 1993;13:113-116.

Bykov VL. Velocity and Candida albicans invasion into host tissues. Mycoses 1991;34:293-296.

Ferguson FS, Berentsen B, Nachman S. Experiences of a pediatric dental program for HIV positive children: Oral Manifestations and Dental Diseases Observed in 58 children. In Greenspan JS, Greenspan D, eds. Oral Manifestations of HIV Infection: Proceedings of the Second International Workshop on the Oral Manifestations of HIV Infection, January 31-February 3, 1993; San Francisco, California. Chicago, IL: Quintessence Publishing Co; 1995.

Ferguson FS, Nachman S, Berentsen B. Implications and management of oral diseases in children and adolescents with HIV infection. N Y State Dent J 1997;63:46-50.

Ketcham L, Berkowitz R, McIlveen L, et al. Oral findings in HIV- seropositive children. Pediatr Dent 1990;12:143.

Leggott P. Oral manifestations of HIV infection in children. Oral Surg Oral Med Oral Pathol 1992;73:187-192.

Moniaci D, Cavallari M, Greco D, Bruatto M, Raiteri R, Palomba E, et al. Oral lesions in children born to HIV-1 positive women. J Oral Pathol Med 1993;22:8-11.

Ramos-Gomez FJ, Greenspan D, Greenspan JS. Orofacial manifestations and management of HIV-infected children. Oral Maxillofac Surg Child Adolesc 1994;6:37-47.

Rosenberg PS, Biggar RJ, Goedert JJ. Declining age at HIV infection in the United States [letter]. N Engl J Med 1994;330:789-790.

Sherwood J, Gow NAR, Gooday GW, Gregory DW, Marshall D. Contact sensing in Candida albicans: A possible aid to epithelial penetration. J Med Vet Mycol 1992;30:461-469.

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APPENDIX 5-A

ORAL HEALTH MANAGEMENT IN CHILDREN AND ADOLESCENTS WITH HIV INFECTION

Figure 5A-1: Illustrations of Pediatric Oral Lesions Associated With HIV Infection
d-peds-fa5-1.jpg

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