Managing Dental Caries Risk in Young Children with HIV Infection: The Rationale for Early Recognition and Prevention by the Primary Care Team

Why Target Specific Populations? Early Childhood Caries (ECC) is extraordinarily predictable, based upon:Early Childhood Caries (ECC) is extraordinarily predictable, based upon:  Race  Socio-economic status (SES)  Feeding Habits  Oral hygiene practices ECC is easily diagnosed or is amenable to population screeningsECC is easily diagnosed or is amenable to population screenings ECC is easily preventedECC is easily prevented ECC is easily treated in its early stages, andECC is easily treated in its early stages, and ECC adversely impacts upon quality of life if left untreatedECC adversely impacts upon quality of life if left untreated

Why Target the Pediatric HIV Population? Survival rates of children with HIV infection continue to riseSurvival rates of children with HIV infection continue to rise The pediatric HIV population shares risk factors observed in ECC populationsThe pediatric HIV population shares risk factors observed in ECC populations  85% of HIV infected children are either African-American or Hispanic  Vertically transmitted HIV is a disease observed most commonly in low SES populations  HIV infected children have a higher decay rate than their uninfected siblings  HIV infected children carry a larger oral burden of lactobacilli and streptococcus mutans  Dental infections may be life threatening

Biology of Dental Caries

Etiology of Dental Caries Demineralization Remineralization Frequent carbohydrate intake Frequent exposure to acids Plaque presence Decreased salivary flow Exposure to fluoride Removal of plaque Balanced diet Limited exposure to carbohydrates

What Factors Contribute to Additional Risk in the Pediatric HIV Population? Increased caries susceptibilityIncreased caries susceptibility  High carbohydrate diet supplementation Effects on salivary pHEffects on salivary pH  Frequent intake of sugar containing medications Effects on salivary function and oral floraEffects on salivary function and oral flora  Compromised immunological status Increased mutans streptococci and lactobacilli levelsIncreased mutans streptococci and lactobacilli levels Increased systemic risk in face of infectionIncreased systemic risk in face of infection Compliance is poor among HIV infected children with unmet dental needsCompliance is poor among HIV infected children with unmet dental needs

Untreated Dental Caries Pain Eating difficulties Sleep disturbance Growth and development affected Risk of systemic infection

First Dental Visit - Anticipatory Guidance The American Academy of Pediatric Dentistry recommends a dental consultation shortly after the eruption of the first primary tooth and no later than 12 months of age. The American Academy of Pediatric Dentistry recommends a dental consultation shortly after the eruption of the first primary tooth and no later than 12 months of age.

Streptococcus mutans Transmission “Window of infectivity” -- transmission of cariogenic bacteria from caregiver to infant-- as early as 6 to 12 months Karn T et al J Pub Health Dent 58: , 1998

Early Childhood Caries (ECC) Dental caries can occur at any age after teeth erupt ECC is particularly damaging 25% of US children have 80% of the dental caries

Objectives of Dental Screening Examination Identify abnormal vs normal dental findingsIdentify abnormal vs normal dental findings Perform visual dental exams in infants and toddlersPerform visual dental exams in infants and toddlers  Check for abnormalities of tooth eruption and soft tissues  Determine whether plaque is present on teeth  Check teeth for “white spots” and cavitation (cavities)

Dental Screening Examination of Infants and Toddlers Knee to Knee Examination Position

Clinical Pictures of Early Childhood Caries (ECC)

ECC Distinguishing Features Associated with prolonged bottle-feeding and breastfeeding*Associated with prolonged bottle-feeding and breastfeeding* Develops rapidly--progressing from white spot lesions (subsurface decalcification) to frank cavitationDevelops rapidly--progressing from white spot lesions (subsurface decalcification) to frank cavitation Affects the upper incisor primary teeth firstAffects the upper incisor primary teeth first Primary molars are secondarily affectedPrimary molars are secondarily affected Mandibular incisors affected when disease has become very severeMandibular incisors affected when disease has become very severe *Breastfeeding is contraindicated in HIV infected children

Dental Screening Examination Findings Pointing out plaque to child’s caretaker

Dental Screening Examination Findings Decalcification and early cavitation Decalcification Cavitation

Dental Screening Examination Findings Decalcification and cavitation

Dental Screening Examination Findings Hypoplastic enamel (no decay)

Early Diagnosed Dental Caries May be managed easily and painlessly with preventive and restorative therapyMay be managed easily and painlessly with preventive and restorative therapy

Objectives of Assessment of Caries Risk Provide preventive recommendations to parentProvide preventive recommendations to parent Provide preventive treatmentProvide preventive treatment Refer to dentist for necessary preventive and restorative treatmentRefer to dentist for necessary preventive and restorative treatment

Dietary Risks for ECC Bottle-feeding after 12 months Sleeping with the bottle Bottle-feeding sugar-containing substances Breastfeeding ad lib* Using pacifiers dipped in sweeteners Snacking > 3 times per day Snacking on cariogenic foods and drinks Milgrom and Weinstein, 1999 *Breastfeeding is contraindicated for HIV infected children and HIV infected mothers.

Sleep Time Habits Cariogenic effects of night-time bottle feeding is due to:  Continuous feeding of sugars to cariogenic bacteria  Decreased buffering of acids  Low salivary flow rate

Medications Be aware of sucrose content Evaluate medications taken for chronic conditions

Reducing Risk of ECC Motivate parents to change specific parenting practicesMotivate parents to change specific parenting practices  Modifying faulty feeding practices Be sensitive to cultural influenceBe sensitive to cultural influence No night-time bottle use and ad-lib bottleNo night-time bottle use and ad-lib bottle No juice or soda in bottleNo juice or soda in bottle Encourage parent to use cup at an early ageEncourage parent to use cup at an early age Recommend reducing number (frequency) of sweet snacks or drinksRecommend reducing number (frequency) of sweet snacks or drinks Limit sweets to mealtimesLimit sweets to mealtimes

Inadequate Oral Hygiene as Risk for ECC Parents not brushing their children’s teethParents not brushing their children’s teeth Quality of cleaning is more important than frequencyQuality of cleaning is more important than frequency Plaque on labial surfaces of incisors - best predictor of future development of ECC (Alaluusua, et al, 1994)

Reducing Risk of ECC Motivate parents to change specific parenting practicesMotivate parents to change specific parenting practices  Teeth cleaning Be flexible and give simple instructionsBe flexible and give simple instructions Recommend toothpaste - demonstrate amountRecommend toothpaste - demonstrate amount Fluoride supplementsFluoride supplements Professional fluoride treatmentsProfessional fluoride treatments  Fluoride varnish application

Tooth-brushing a Young Child Should begin with the eruption of the first toothShould begin with the eruption of the first tooth Should be supervised until age 7Should be supervised until age 7 Only pea-sized amount of toothpaste is neededOnly pea-sized amount of toothpaste is needed

ADA Recommended Supplemental Fluoride Dosage Schedule

Fluoride Varnish Developed in the late 1960s and early 1970s By 1980s were widely used in European countries In US, FDA approved as cavity liners and for treatment of hypersensitivity Effective in reducing caries in permanent dentition but few studies have been done on the primary dentition.

Which Child under Three is at High Risk for ECC? Does the child sleep with a bottle, or has the child slept with a bottle after 12 months of age?Does the child sleep with a bottle, or has the child slept with a bottle after 12 months of age? Does the child have frequent (3 or more/day) cariogenic snacks?Does the child have frequent (3 or more/day) cariogenic snacks? Does the child have visible plaque on upper incisors? Do parents neglect to brush?Does the child have visible plaque on upper incisors? Do parents neglect to brush? Does the family, especially older siblings, have dental caries?Does the family, especially older siblings, have dental caries? Does the child drink water with less than optimal fluoride content?Does the child drink water with less than optimal fluoride content? The more “yes” answers, the greater the risk for ECC. Milgrom and Weinstein, 1999

Oral Health Recommendations for the Child with HIV Infection Primary dental and oral care of children with HIV infection should include a careful oral examination at regular intervals, with an emphasis on oral health promotion, prevention and early intervention.Primary dental and oral care of children with HIV infection should include a careful oral examination at regular intervals, with an emphasis on oral health promotion, prevention and early intervention. Dental evaluations should begin shortly after emergence of the first of the primary teethDental evaluations should begin shortly after emergence of the first of the primary teeth Pediatricians, nurse practitioners, physician assistants, dentists or hygienists may be directly involved in the early screening of patients for identification of risk factorsPediatricians, nurse practitioners, physician assistants, dentists or hygienists may be directly involved in the early screening of patients for identification of risk factors