Oral Manifestations of Pediatric Oral Manifestations of Pediatric HIV Infection: HIV Infection:

Clinical Characteristics, Clinical Characteristics, Diagnosis, Treatment Diagnosis, Treatment

Recommendations and Disease Recommendations and Disease SignificanceSignificance

Disease Pattern Differences in Disease Pattern Differences in Pediatric and Adult HIV Infection Pediatric and Adult HIV Infection

• Narrower spectrum of infectious diseases in childrenNarrower spectrum of infectious diseases in children• More vulnerable to recurrent bacterial infectionsMore vulnerable to recurrent bacterial infections• More susceptible to central nervous system disordersMore susceptible to central nervous system disorders• Increased risk for HIV-lymphoproliferation Increased risk for HIV-lymphoproliferation • Decreased risk for malignanciesDecreased risk for malignancies• Endocrine and metabolic impact on growth and Endocrine and metabolic impact on growth and

developmentdevelopment• Behavioral and emotional problems due to chronic Behavioral and emotional problems due to chronic

illnessillness

Diagnosis of Pediatric HIV Oral LesionsDiagnosis of Pediatric HIV Oral Lesions

• Clinical examination is important because Clinical examination is important because history is often unknown or incompletehistory is often unknown or incomplete

• Rely on noninvasive procedures for initial Rely on noninvasive procedures for initial diagnosis and treatmentdiagnosis and treatment

• Treatment often requires modification and Treatment often requires modification and individual customization individual customization

• Successful management necessitates care Successful management necessitates care giver involvement and understanding giver involvement and understanding

• Diagnosis should be re-evaluated, if treatment is Diagnosis should be re-evaluated, if treatment is not effectivenot effective

Oral Manifestations of Pediatric HIV InfectionOral Manifestations of Pediatric HIV Infection• Most children will have at least one oral lesionMost children will have at least one oral lesion

• Infectious diseases: bacterial, viral and fungalInfectious diseases: bacterial, viral and fungal

• Most neoplasms are EBV driven: lymphoma, Most neoplasms are EBV driven: lymphoma, leiomyoma and leiomyosarcoma leiomyoma and leiomyosarcoma

• Immunologic disorders: aphthous ulcers, parotitis, Immunologic disorders: aphthous ulcers, parotitis, lymphadenopathy, thrombocytopenia and allergic lymphadenopathy, thrombocytopenia and allergic reactions reactions

• Iatrogenic diseases are caused by drug side effects Iatrogenic diseases are caused by drug side effects

• Dental diseases: Dental caries, enamel hypoplasia, Dental diseases: Dental caries, enamel hypoplasia, over-retained teeth, delayed eruption of teethover-retained teeth, delayed eruption of teeth

Oral Candidiasis in ChildrenOral Candidiasis in Children• Common opportunistic fungal infection, affecting up to Common opportunistic fungal infection, affecting up to

72% of HIV infected children72% of HIV infected children

• Cause: Cause: Candida speciesCandida species, usually , usually Candida albicansCandida albicans

• Contributing factors: Immune suppression, xerostomia Contributing factors: Immune suppression, xerostomia medications, oral appliances, poor oral hygienemedications, oral appliances, poor oral hygiene

• Forms: Pseudomembranous, erythematous & Forms: Pseudomembranous, erythematous & hyperplastic candidiasis, angular cheilitis, median hyperplastic candidiasis, angular cheilitis, median rhomboid glossitis, cheilocandidiasisrhomboid glossitis, cheilocandidiasis

• Site: Lips and oropharyngeal mucosaSite: Lips and oropharyngeal mucosa

• Signs & Symptoms: Red or white patches, erosions, Signs & Symptoms: Red or white patches, erosions, burning sensation, sore throat, taste alterationsburning sensation, sore throat, taste alterations

• Diagnosis: Clinical findings, culture, cytology, biopsyDiagnosis: Clinical findings, culture, cytology, biopsy

Oral Candidiasis in ChildrenOral Candidiasis in Children

Rx: Oropharyngeal CandidiasisRx: Oropharyngeal Candidiasis

• Nystatin susp: 100,000-500,000 U 4 times daily for Nystatin susp: 100,000-500,000 U 4 times daily for 14-21 days14-21 days

• Clotrimazole susp, troche: 10 mg 4-5 times daily for Clotrimazole susp, troche: 10 mg 4-5 times daily for 14-21 days14-21 days

• Fluconazole susp, tab: 3-6 mg/kg daily for 14-21 daysFluconazole susp, tab: 3-6 mg/kg daily for 14-21 days

• Ketoconazole susp, tab: 5-10 mg/kg in 1 or 2 doses Ketoconazole susp, tab: 5-10 mg/kg in 1 or 2 doses for 14-21 daysfor 14-21 days

• Itraconazole susp: 2-5 mg/kg daily for 14-21 daysItraconazole susp: 2-5 mg/kg daily for 14-21 days

• Amphotericin IV: 0.5-1.0 mg/kg/dAmphotericin IV: 0.5-1.0 mg/kg/d

• Antifungal ointment or cream for lips, if neededAntifungal ointment or cream for lips, if needed

Parotitis in ChildrenParotitis in Children• Lymphocyte-mediated salivary gland disease observed Lymphocyte-mediated salivary gland disease observed

observed in about 30% of childrenobserved in about 30% of children

• Cause: CD8+ infiltrate; HIV, EBV; genetic predisposition Cause: CD8+ infiltrate; HIV, EBV; genetic predisposition

• Median age of onset: 5.4 yearsMedian age of onset: 5.4 years

• Site: Parotid and submandibular glands; may affect lungs Site: Parotid and submandibular glands; may affect lungs and other organsand other organs

• Signs & Symptoms: Diffuse facial swelling, may be Signs & Symptoms: Diffuse facial swelling, may be tender, xerostomia, cervical lymphadenopathy, enlarged tender, xerostomia, cervical lymphadenopathy, enlarged palatine tonsilspalatine tonsils

• Diagnosis: Clinical findings, advanced imaging, aspiration Diagnosis: Clinical findings, advanced imaging, aspiration or labial lip biopsyor labial lip biopsy

• Complication: Bacterial sialadenitis, lymphomaComplication: Bacterial sialadenitis, lymphoma

Parotitis in ChildrenParotitis in Children

Treatment of ParotitisTreatment of Parotitis

• Caries and gingivitis prevention: Topical fluorides, Caries and gingivitis prevention: Topical fluorides, clorhexidine gluconate oral rinseclorhexidine gluconate oral rinse

• Pain management: Nonsteroidal anti-inflammatory Pain management: Nonsteroidal anti-inflammatory drugs (NSAIDS)drugs (NSAIDS)

Ibuprofen: 5-10 mg/kg q 4-6 h (max = 40 mg/kg/d)Ibuprofen: 5-10 mg/kg q 4-6 h (max = 40 mg/kg/d)

Naproxen: 5-10 mg/kg q 8 h (max = 1500 mg/d) Naproxen: 5-10 mg/kg q 8 h (max = 1500 mg/d)

• Saliva stimulants: Pilocarpine, cevimeline hydrochloride Saliva stimulants: Pilocarpine, cevimeline hydrochloride

• Severe facial swelling: Prednisone; surgery, if large Severe facial swelling: Prednisone; surgery, if large cystic lesions are presentcystic lesions are present

• Bacterial sialadenitis: Antibiotics - clindamycinBacterial sialadenitis: Antibiotics - clindamycin

Herpes Simplex Infection in ChildrenHerpes Simplex Infection in Children• Common viral infection affecting up to 24% of children Common viral infection affecting up to 24% of children

• Transmission: Direct contact, asymptomatic viral Transmission: Direct contact, asymptomatic viral shedding in genital fluids and salivashedding in genital fluids and saliva

• Median age of onset: 5 yearsMedian age of onset: 5 years

• Site: Orofacial, nasal and esophageal regionSite: Orofacial, nasal and esophageal region

• Signs & Symptoms: Painful gingivitis, recurrent Signs & Symptoms: Painful gingivitis, recurrent persistent ulcers intraorally; vesicles and crusted ulcers persistent ulcers intraorally; vesicles and crusted ulcers on lips and skin on lips and skin

• Non-nutritive sucking habits increase risk for ocular and Non-nutritive sucking habits increase risk for ocular and digital infectiondigital infection

• Diagnosis: Clinical, culture, PCR, cytology, biopsyDiagnosis: Clinical, culture, PCR, cytology, biopsy

Herpes Simplex Infection in ChildrenHerpes Simplex Infection in Children

Treatment of HSV InfectionTreatment of HSV Infection

• Systemic Antiviral MedicationsSystemic Antiviral Medications Zovirax, generic (acyclovir): 15 mg/kg, 5 times/day Zovirax, generic (acyclovir): 15 mg/kg, 5 times/day Famvir (famciclovir): Not approved for pediatric useFamvir (famciclovir): Not approved for pediatric use Valtrex (valacyclovir): Not approved for pediatric useValtrex (valacyclovir): Not approved for pediatric use Foscavir (foscarnet), if resistant (6.4% HIV) - IV Foscavir (foscarnet), if resistant (6.4% HIV) - IV

• Topical Antiviral Agents: Not usually recommendedTopical Antiviral Agents: Not usually recommended Denavir (penciclovir) 1% creamDenavir (penciclovir) 1% cream Zovirax (acyclovir) 5% ointmentZovirax (acyclovir) 5% ointment Abreva (docosanol) 10% cream (OTC)Abreva (docosanol) 10% cream (OTC)

Cytomegalovirus Infection in ChildrenCytomegalovirus Infection in Children

• Congenital Infection: 4.5 - 21% of HIV-exposed infantsCongenital Infection: 4.5 - 21% of HIV-exposed infants

• Transmission: Viral shedding in genital fluids, breast Transmission: Viral shedding in genital fluids, breast milk, urine and saliva; blood, organsmilk, urine and saliva; blood, organs

• CMV disease: 8-18%; retinitis, pneumonitis, colitis, CMV disease: 8-18%; retinitis, pneumonitis, colitis, mucocutaneous ulcers, neuropathy, encephalopathymucocutaneous ulcers, neuropathy, encephalopathy

• Site: Oral and esophageal regions, salivary glands Site: Oral and esophageal regions, salivary glands

• Oral S/S: Persistent ulcers, gingivitis, pyogenic Oral S/S: Persistent ulcers, gingivitis, pyogenic granuloma; enamel hypoplasia - congenital diseasegranuloma; enamel hypoplasia - congenital disease

• Diagnosis: Culture, PCR, biopsyDiagnosis: Culture, PCR, biopsy

• Treatment: Ganciclovir, foscarnet, cidofovirTreatment: Ganciclovir, foscarnet, cidofovir

Cytomegalovirus Infection in ChildrenCytomegalovirus Infection in Children

Herpes Zoster in ChildrenHerpes Zoster in Children • Prevalence: 2-6% HIV infected childrenPrevalence: 2-6% HIV infected children• Cause: Reactivation of varicella-zoster virus Cause: Reactivation of varicella-zoster virus • Median age: 7.6 yrs but common under 5 yrsMedian age: 7.6 yrs but common under 5 yrs• Site: 5% in the head & neck region; CN5 & CN7Site: 5% in the head & neck region; CN5 & CN7• Signs & Symptoms: Vesicles, coalescing ulcers, Signs & Symptoms: Vesicles, coalescing ulcers,

thick crust on skin, follow dermatome and stop at thick crust on skin, follow dermatome and stop at midline; pain, fever and headache; 4% are bilateralmidline; pain, fever and headache; 4% are bilateral

• Diagnosis: Clinical, culture, cytologyDiagnosis: Clinical, culture, cytology• TX: Acyclovir, valacyclovir, famciclovir, foscarnet TX: Acyclovir, valacyclovir, famciclovir, foscarnet • Complication: Scarring, blindness, secondary Complication: Scarring, blindness, secondary

infection, disseminated diseaseinfection, disseminated disease

Herpes Zoster in ChildrenHerpes Zoster in ChildrenWRONG PICTURE !WRONG PICTURE !

Aphthous Stomatitis in ChildrenAphthous Stomatitis in Children

• Pediatric prevalence: Up to 16%; common oral lesion Pediatric prevalence: Up to 16%; common oral lesion

• Cause: Localized immune dysfunctionCause: Localized immune dysfunction

• Predisposing factors: Trauma, hematologic disorders, Predisposing factors: Trauma, hematologic disorders, nutritional deficiencies, allergies, oral appliancesnutritional deficiencies, allergies, oral appliances

• Variants: Minor, major and herpetiformVariants: Minor, major and herpetiform

• Site: Primarily affects nonkeratinized oropharyngeal Site: Primarily affects nonkeratinized oropharyngeal mucosa, esophagusmucosa, esophagus

• S/S: Painful recurrent ulcers, multifocal pattern, S/S: Painful recurrent ulcers, multifocal pattern, increase in the major variant, may result in scarring increase in the major variant, may result in scarring

• Diagnosis: Clinical; culture and biopsy, if persistentDiagnosis: Clinical; culture and biopsy, if persistent

Aphthous Stomatitis in ChildrenAphthous Stomatitis in Children

Treatment of Aphthous UlcersTreatment of Aphthous Ulcers

• Pain management: Topical anesthetics and coating Pain management: Topical anesthetics and coating agents, systemic analgesics agents, systemic analgesics

• Ulcer management:Ulcer management: Kenalog (triamcinolone) in Orabase 0.1%Kenalog (triamcinolone) in Orabase 0.1% Fluocinonide gel or ointment 0.05%Fluocinonide gel or ointment 0.05% Clobetasol gel or ointment 0.05%Clobetasol gel or ointment 0.05% Dexamethasone elixir 0.5 mg/5 mLDexamethasone elixir 0.5 mg/5 mL Beclomethasone dipropionate:1-2 puffs/3X/dBeclomethasone dipropionate:1-2 puffs/3X/d Prednisone (2mg/kg/d or 20 - 60 mg): 5-7 d Prednisone (2mg/kg/d or 20 - 60 mg): 5-7 d Thalidomide (50 - 200 mg/d)Thalidomide (50 - 200 mg/d)

Molluscum Contagiosum in ChildrenMolluscum Contagiosum in Children• Common skin infection caused by the poxvirusCommon skin infection caused by the poxvirus

• Associated with low CD4+ countsAssociated with low CD4+ counts

• Predisposing factors: Trauma and dermatitisPredisposing factors: Trauma and dermatitis

• Transmission: Direct contactTransmission: Direct contact

• Site: Facial skin and genital regionSite: Facial skin and genital region

• Signs & Symptoms: Multiple, pearly-white nodules Signs & Symptoms: Multiple, pearly-white nodules with umbilicated center and erythematous borderwith umbilicated center and erythematous border

• Diagnosis: Clinical, cytology, biopsyDiagnosis: Clinical, cytology, biopsy

• TX: Surgical - curettage, cryotherapy, excisionTX: Surgical - curettage, cryotherapy, excision Topical – cantharidin, cidofovir, imiquimodTopical – cantharidin, cidofovir, imiquimod

Molluscum Contagiosum in ChildrenMolluscum Contagiosum in Children

Periodontal Diseases in ChildrenPeriodontal Diseases in Children

Disease Classification and PrevalenceDisease Classification and Prevalence• Linear gingival erythema (LGE): 0 - 38%Linear gingival erythema (LGE): 0 - 38%

• Necrotizing ulcerative gingivitis (NUG): 0 - 5%Necrotizing ulcerative gingivitis (NUG): 0 - 5%

• Necrotizing ulcerative periodontitis (NUP): 0 - 5% Necrotizing ulcerative periodontitis (NUP): 0 - 5% (most common oral lesion in Africa)(most common oral lesion in Africa)

• Necrotizing stomatitis (NS): UnknownNecrotizing stomatitis (NS): Unknown

• Conventional gingivitis: 50 - 97%Conventional gingivitis: 50 - 97%

• Periodontitis modified by systemic disease: Periodontitis modified by systemic disease: UnknownUnknown

Linear Gingival Erythema in ChildrenLinear Gingival Erythema in Children

• Pediatric prevalence: Up to 38%; common oral lesionPediatric prevalence: Up to 38%; common oral lesion

• Cause: Unknown but Cause: Unknown but Candida Candida sp, especially sp, especially C. C. albicansalbicans, , C. dublinienesisC. dublinienesis has been implicated has been implicated

• Site: Usually multiple teeth but may be localizedSite: Usually multiple teeth but may be localized

• Signs & Symptoms: Fiery red band 2-3 mm wide on Signs & Symptoms: Fiery red band 2-3 mm wide on marginal gingiva; petechiae or diffuse erythema on marginal gingiva; petechiae or diffuse erythema on adjacent mucosa; bleeding is uncommon; pain is rareadjacent mucosa; bleeding is uncommon; pain is rare

• Note: Erythema is disproportional to amount of plaqueNote: Erythema is disproportional to amount of plaque

• Diagnosis: Clinical; nonresponsive to oral hygieneDiagnosis: Clinical; nonresponsive to oral hygiene

• TX: Plaque and caries control; antifungal medicationsTX: Plaque and caries control; antifungal medications

Linear Gingival Erythema in ChildrenLinear Gingival Erythema in Children

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

• Pediatric prevalence: 0 - 5%; uncommon oral lesionPediatric prevalence: 0 - 5%; uncommon oral lesion

• Cause: Fusiform-spirochete bacteria; Gram-negativeCause: Fusiform-spirochete bacteria; Gram-negative

• Predisposing factors: Stress, immune suppression, Predisposing factors: Stress, immune suppression, smoking, malnutrition, pre-existing gingivitissmoking, malnutrition, pre-existing gingivitis

• Age: Adolescents in US; young children in developing Age: Adolescents in US; young children in developing countries, especially Africacountries, especially Africa

• Site: Anterior gingiva to widespreadSite: Anterior gingiva to widespread

• Signs & Symptoms: Punched out, ulcerated papillae, Signs & Symptoms: Punched out, ulcerated papillae, bleeding, pain, lymphadenopathy, fetid odor, feverbleeding, pain, lymphadenopathy, fetid odor, fever

• Diagnosis: Clinical, biopsy of persistent lesionsDiagnosis: Clinical, biopsy of persistent lesions

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Necrotizing Ulcerative PeriodontitisNecrotizing Ulcerative Periodontitis

• Pediatric prevalence: 0 - 5%; uncommon oral lesionPediatric prevalence: 0 - 5%; uncommon oral lesion

• Cause: Fusiform-spirochete bacteria; Gram-negative Cause: Fusiform-spirochete bacteria; Gram-negative

• Predisposing factors: Immune suppression, smoking, Predisposing factors: Immune suppression, smoking, malnutrition, stress, pre-existing periodontitismalnutrition, stress, pre-existing periodontitis

• Age: Usually adolescents Age: Usually adolescents

• Site: Lower anterior gingiva to widespreadSite: Lower anterior gingiva to widespread

• S/S: Features of NUG, rapid bone loss, necrosis and S/S: Features of NUG, rapid bone loss, necrosis and sequestration, tooth losssequestration, tooth loss

• Diagnosis: Clinical and radiographic, biopsy, if Diagnosis: Clinical and radiographic, biopsy, if persistent lesionspersistent lesions

Necrotizing Ulcerative PeriodontitisNecrotizing Ulcerative Periodontitis

Necrotizing Stomatitis in ChildrenNecrotizing Stomatitis in Children

• Pediatric prevalence: Uncommon oral diseasePediatric prevalence: Uncommon oral disease

• Cause: Multifactorial including bacterial, fungal, viralCause: Multifactorial including bacterial, fungal, viral

• Predisposing factors: Severe immune suppression, Predisposing factors: Severe immune suppression, neutropenia, malnutritionneutropenia, malnutrition

• Site: Often contiguous with gingival lesions but may Site: Often contiguous with gingival lesions but may occur at any mucosal siteoccur at any mucosal site

• Signs & Symptoms: Persistent, destructive ulcers Signs & Symptoms: Persistent, destructive ulcers with thick, tenacious pseudomembrane; single or with thick, tenacious pseudomembrane; single or multiple; very painfulmultiple; very painful

• Diagnosis: Clinical, culture, biopsy, if persistent Diagnosis: Clinical, culture, biopsy, if persistent

• Complication: Weight loss and wasting diseaseComplication: Weight loss and wasting disease

Necrotizing Stomatitis in ChildrenNecrotizing Stomatitis in Children

Necrotizing Periodontal Diseases Necrotizing Periodontal Diseases ManagementManagement

• NUG/NUP: Debridement, 10% povidone-iodine, NUG/NUP: Debridement, 10% povidone-iodine, extraction of involved primary teeth, extraction of involved primary teeth, chlorhexidine oral rinse, antifungal and antibiotic chlorhexidine oral rinse, antifungal and antibiotic therapy therapy

• Antibiotics: Clindamycin 20-30 mg/kg/d or Antibiotics: Clindamycin 20-30 mg/kg/d or penicillin VK 25-50 mg/kg/d plus metronidazole penicillin VK 25-50 mg/kg/d plus metronidazole 30 mg/kg/d or amoxicillin + clavulanate 40 30 mg/kg/d or amoxicillin + clavulanate 40 mg/kg mg/kg

• Systemic analgesics for painSystemic analgesics for pain

• Periodic dental visits: Every 3-4 monthsPeriodic dental visits: Every 3-4 months

Conventional Gingivitis in ChildrenConventional Gingivitis in Children• Conventional gingivitis mimics LGEConventional gingivitis mimics LGE

• Decreased gingival health is associated with advanced HIV Decreased gingival health is associated with advanced HIV disease and decreased CD4 percentagesdisease and decreased CD4 percentages

• Higher plaque and gingival indices associated with candidiasisHigher plaque and gingival indices associated with candidiasis

• Leukopenia and anemia mask the clinical signs of erythema Leukopenia and anemia mask the clinical signs of erythema

Lymphadenopathy in ChildrenLymphadenopathy in Children• Prevalence: Cervical lymphadenopathy > 50%Prevalence: Cervical lymphadenopathy > 50%

• Cause: HIV and EBV lymphoid replicationCause: HIV and EBV lymphoid replication

• Site: Generalized; submandibular, cervical and Site: Generalized; submandibular, cervical and pharyngeal tonsilspharyngeal tonsils

• S/S: Bilateral, persistent, diffuse enlargement; S/S: Bilateral, persistent, diffuse enlargement; nontender; no erythema of the skin; nontender; no erythema of the skin; >> 0.5 cm at more 0.5 cm at more than one sitethan one site

• Significance: Positive predictor of HIV survivalSignificance: Positive predictor of HIV survival

• Mimics viral, bacterial infection, lymphomaMimics viral, bacterial infection, lymphoma

• Treatment: None required; aspiration biopsy and Treatment: None required; aspiration biopsy and advanced imaging with significant enlargementadvanced imaging with significant enlargement

Lymphadenopathy in ChildrenLymphadenopathy in Children

Hairy Leukoplakia in ChildrenHairy Leukoplakia in Children

• Pediatric prevalence: 2 - 3%; uncommon oral lesionPediatric prevalence: 2 - 3%; uncommon oral lesion

• Cause: Replicating and latent EBV, multiple strains Cause: Replicating and latent EBV, multiple strains and recombinant variantsand recombinant variants

• Site: Primarily lateral border of the tongueSite: Primarily lateral border of the tongue

• Signs & Symptoms: Filmy to shaggy adherent white Signs & Symptoms: Filmy to shaggy adherent white plaques, asymptomatic, taste abnormalities, burning plaques, asymptomatic, taste abnormalities, burning sensation; lesion waxes and wanessensation; lesion waxes and wanes

• Concurrent disease: CandidiasisConcurrent disease: Candidiasis

• Diagnosis: Clinical, cytology, biopsy, PCR or Diagnosis: Clinical, cytology, biopsy, PCR or in situin situ hybridizationhybridization

Hairy Leukoplakia in ChildrenHairy Leukoplakia in Children

Oral Warts in ChildrenOral Warts in Children

• Skin lesions are common but oral warts are rare (<1%)Skin lesions are common but oral warts are rare (<1%)

• Cause: Human papillomavirus (HPV)Cause: Human papillomavirus (HPV)

• Transmission: Direct contact, vertical infectionTransmission: Direct contact, vertical infection

• Predisposing factor: Inflammatory skin disordersPredisposing factor: Inflammatory skin disorders

• Site: Perioral skin, vermilion, oral and nasal mucosa Site: Perioral skin, vermilion, oral and nasal mucosa

• S/S: Spiky or flat, papillary or stippled, white papules and S/S: Spiky or flat, papillary or stippled, white papules and nodules; usually multiple or florid in numbernodules; usually multiple or florid in number

• Diagnosis: Clinical, biopsy, HPV-typing Diagnosis: Clinical, biopsy, HPV-typing

• TX: Excision, laser ablation, cryotherapy when localizedTX: Excision, laser ablation, cryotherapy when localized

Oral Warts in ChildrenOral Warts in Children

Thrombocytopenia in ChildrenThrombocytopenia in Children

• Pediatric prevalence: Up to 18% during disease course Pediatric prevalence: Up to 18% during disease course

• Cause: Antibody-mediated, bone marrow failureCause: Antibody-mediated, bone marrow failure

• Site: Oropharyngeal and nasal mucosa, skin Site: Oropharyngeal and nasal mucosa, skin

• S/S: Gingival bleeding, petechiae, purpura, hematoma; S/S: Gingival bleeding, petechiae, purpura, hematoma; nosebleednosebleed

• Diagnosis: Complete blood count, including platelet Diagnosis: Complete blood count, including platelet count, thrombopoietincount, thrombopoietin

• TX: HAART regimens, interferon-TX: HAART regimens, interferon-, steroids, IVIG, , steroids, IVIG, transfusion transfusion

Thrombocytopenia in ChildrenThrombocytopenia in Children

Cancer in ChildrenCancer in Children • Prevalence: 2% of HIV infected childrenPrevalence: 2% of HIV infected children• Cause: Viral-associated, EBV, HHV-8, HPVCause: Viral-associated, EBV, HHV-8, HPV• Median age: 4.3 years - vertical; 13.4 years - blood Median age: 4.3 years - vertical; 13.4 years - blood • Types from Children’s Cancer Group (1982-97):Types from Children’s Cancer Group (1982-97):

Non-Hodgkin’s lymphoma (65%)Non-Hodgkin’s lymphoma (65%) Leiomyosarcomas, leiomyomas (17%)Leiomyosarcomas, leiomyomas (17%) Leukemia, lymphoblastic and myeloid (8%)Leukemia, lymphoblastic and myeloid (8%) Kaposi’s sarcoma (5%)Kaposi’s sarcoma (5%) Hodgkin’s lymphoma (3%)Hodgkin’s lymphoma (3%) Vaginal carcinoma, tracheal neuroendocrine (2%)Vaginal carcinoma, tracheal neuroendocrine (2%)

Lymphoma in ChildrenLymphoma in Children• Prevalence: < 2%; most common malignancyPrevalence: < 2%; most common malignancy

• Type: Most are high-grade non-Hodgkin’s lymphoma Type: Most are high-grade non-Hodgkin’s lymphoma

• Cause: EBV, HHV-8 and immunosuppressionCause: EBV, HHV-8 and immunosuppression

• Median age: 5.5 years (1.1-19.4 yrs)Median age: 5.5 years (1.1-19.4 yrs)

• Site: 80% are extranodal; GI and CNSSite: 80% are extranodal; GI and CNS

• Oral site: Tonsils, palate and gingivaOral site: Tonsils, palate and gingiva

• S/S: Rapid growth, diffuse pink to red mass, S/S: Rapid growth, diffuse pink to red mass, ulceration; pain & paresthesia; tooth mobility and ulceration; pain & paresthesia; tooth mobility and displacement; bone lossdisplacement; bone loss

• Diagnosis: Biopsy, advanced imaging, tumor staging Diagnosis: Biopsy, advanced imaging, tumor staging

• TX: Multiagent chemotherapy +/- radiation TX: Multiagent chemotherapy +/- radiation

Lymphoma in ChildrenLymphoma in Children

Kaposi’s Sarcoma in ChildrenKaposi’s Sarcoma in Children• Pediatric prevalence: Rare except for Africa Pediatric prevalence: Rare except for Africa

• Cause: HHV-8 and immune suppressionCause: HHV-8 and immune suppression

• Rare vertical transmission, except AfricaRare vertical transmission, except Africa

• Form: Lymphadenopathic type with or without diffuse Form: Lymphadenopathic type with or without diffuse skin lesions; rare oral involvementskin lesions; rare oral involvement

• Oral site: Palate and gingivaOral site: Palate and gingiva

• S/S: Red to purple macule or nodule; single or S/S: Red to purple macule or nodule; single or multiple, usually asymptomaticmultiple, usually asymptomatic

• Diagnosis: Biopsy and tumor stagingDiagnosis: Biopsy and tumor staging

• TX: HAART regimens, chemotherapyTX: HAART regimens, chemotherapy

Kaposi’s Sarcoma in ChildrenKaposi’s Sarcoma in Children

Cutaneous Lesions in ChildrenCutaneous Lesions in Children

• Prevalence: > 80% of HIV infected children will have Prevalence: > 80% of HIV infected children will have at least one mucocutaneous lesionat least one mucocutaneous lesion Infectious diseases account for 66%Infectious diseases account for 66% Inflammatory disorders account for 33%Inflammatory disorders account for 33%

• Similar prevalence as oral lesions in these childrenSimilar prevalence as oral lesions in these children

• Besides herpetic infections, several lesions are Besides herpetic infections, several lesions are potentially contagious to the health care providerpotentially contagious to the health care provider ImpetigoImpetigo Tinea corporisTinea corporis ScabiesScabies

Impetigo in ChildrenImpetigo in Children

• Type: Contagious, superficial bacterial infectionType: Contagious, superficial bacterial infection

• Cause: Cause: Staphylococcus aureus, streptococciStaphylococcus aureus, streptococci

• Transmission: Direct contactTransmission: Direct contact

• Site: Usually the face but any body surfaceSite: Usually the face but any body surface

• Signs & Symptoms: Vesicles, pustules or bullae with Signs & Symptoms: Vesicles, pustules or bullae with a red base and covered by honey-colored sticky crust; a red base and covered by honey-colored sticky crust; lymphadenopathy; may become hyperpigmentedlymphadenopathy; may become hyperpigmented

• Diagnosis: Clinical, cultureDiagnosis: Clinical, culture

• TX: Mupirocin (Bactroban) ointment for isolated TX: Mupirocin (Bactroban) ointment for isolated lesions; systemic antibiotics if widespread lesions; systemic antibiotics if widespread

Impetigo in ChildrenImpetigo in Children

Tinea Infections in ChildrenTinea Infections in Children

• Type: Superficial fungal infection (ringworm)Type: Superficial fungal infection (ringworm)

• Cause: DermatophytesCause: Dermatophytes and immune defectand immune defect

• Distribution: Tinea pedis (feet); tinea corporis (face, Distribution: Tinea pedis (feet); tinea corporis (face, body, limbs); tinea capitus (scalp); tinea cruris (groin) body, limbs); tinea capitus (scalp); tinea cruris (groin)

• Signs & Symptoms: Annular lesions with red, scaly, Signs & Symptoms: Annular lesions with red, scaly, advancing front; alopecia when scalp is involvedadvancing front; alopecia when scalp is involved

• Diagnosis: Clinical, cytologyDiagnosis: Clinical, cytology

• Significance: Severe and persistent infectionSignificance: Severe and persistent infection

• TX: Topical or systemic antifungal medications; refer to TX: Topical or systemic antifungal medications; refer to pediatrician or dermatologist pediatrician or dermatologist

Tinea Infections in Children Tinea Infections in Children

Antiretroviral Regimens in ChildrenAntiretroviral Regimens in Children

• HAART: 2 nucleoside analogue reverse transcriptase HAART: 2 nucleoside analogue reverse transcriptase inhibitors (NRTI) + 1-2 protease inhibitor (PI) or 1non-inhibitors (NRTI) + 1-2 protease inhibitor (PI) or 1non-nucleoside reverse transcriptase inhibitor (NNRTI)nucleoside reverse transcriptase inhibitor (NNRTI)

• NRTI oral side effects: Oral ulcers (ddC), sore throat NRTI oral side effects: Oral ulcers (ddC), sore throat (ABC), xerostomia (ddI), anemia, neutropenia (AZT)(ABC), xerostomia (ddI), anemia, neutropenia (AZT)

• PI oral side effects: Taste perversions, xerostomia, PI oral side effects: Taste perversions, xerostomia, exfoliative cheilitis, circumoral paresthesia, exfoliative cheilitis, circumoral paresthesia, thrombocytopeniathrombocytopenia

• NNRTI oral side effects: Lichenoid reaction, erythema NNRTI oral side effects: Lichenoid reaction, erythema multiforme majormultiforme major

• Drug Interactions and dentistry: Midazolam, triazolam, Drug Interactions and dentistry: Midazolam, triazolam, metronidazole, meperidinemetronidazole, meperidine

Antiretroviral Regimens in ChildrenAntiretroviral Regimens in Children

Dental Considerations in ChildrenDental Considerations in Children

• Poor compliance with therapies Poor compliance with therapies

• Oral effects of medications: dry mouth, vomiting, taste Oral effects of medications: dry mouth, vomiting, taste alterations, sucrose and alcohol contentalterations, sucrose and alcohol content

• Symptomatic orofacial lesionsSymptomatic orofacial lesions

• Referred pain: Sinusitis, otitis media, neuropathiesReferred pain: Sinusitis, otitis media, neuropathies

• Compromised airway and pulmonary functionCompromised airway and pulmonary function

• Poor motor skills: neuropathy, encephalopathyPoor motor skills: neuropathy, encephalopathy

• Hematologic disorders: CytopeniasHematologic disorders: Cytopenias

• HAART regimens & potential drug interactionsHAART regimens & potential drug interactions

• Exposure to a variety of infectious diseasesExposure to a variety of infectious diseases