Upload
dr-roshni-maurya
View
765
Download
0
Embed Size (px)
Citation preview
66th IDA Conference, 2013
BREAKING BARRIERS
66th IDA Conference, 2013
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.
66th IDA Conference, 2013
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.
66th IDA Conference, 2013
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.
66th IDA Conference, 2013
EPIEDEMIOLOGY OF PEDIATRIC HIV INFECTION EPIDEMIOLOGY OF PEDIATRIC HIV INFECTION
66th IDA Conference, 2013
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
66th IDA Conference, 2013
Routes of Transmission of HIV, India, 2011-12
66th IDA Conference, 2013
66th IDA Conference, 2013
Considerations in the Dental Management of Children with HIV Infection
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
Hematologic Guidelines for Dental Management of Patients with HIV Infection
66th IDA Conference, 2013
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
66th IDA Conference, 2013
• 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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
Considerations in the Management of oral soft tissue manifestations ofpediatric HIV infection : classification, clinical characteristics, and treatment recommendations
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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)
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
Infection control in dental practice
66th IDA Conference, 2013
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.
66th IDA Conference, 2013
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:
66th IDA Conference, 2013
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.
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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
66th IDA Conference, 2013
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.
66th IDA Conference, 2013