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Prevalence of Orodental Findings in HIV-Infected Romanian Children

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Prevalence of Orodental Findings in HIV-Infected Romanian Children Scientific Article Prevalence of orodental findings in HIV-infected Romanian children Catherine Flaitz, DDS, MS Blake Wullbrandt, DDS John Sexton, DDS Timothy Bourdon, DDS John Hicks, DDS, MS, PhD, MD Dr. Flaitz is professor, Division of Oral and Maxillofacial Pathology, Departments of Stomatology and Pediatric Dentistry and Dr. Wullbrandt is a pediatric dentistry resident, Department of Pediatric Dentistry, University of Texas-Houston Health Science Center, Dental Branch; Dr. Sexton is in pediatric dentistry private practice, Lakewood, CO; Dr. Bourdon is in general dentistry private practice, Arvada, CO; and Dr. Hicks is associate professor, Department of Pathology, Texas Children’s Hospital and Baylor College of Medicine and Adjunct Professor, Department of Pediatric Dentistry, University of Texas-Houston Health Science Center, Dental Branch. Correspond with Dr. Flaitz at [email protected] Abstract Background: Romania, the pediatric AIDS capital of the ing age and are capable of transmitting this virus vertically to world, has tremendous unmet dental care needs for children and their offspring. In 1999 alone, 2.3 million women became in- adolescents with HIV infection. The purpose of this study was to fected, many of whom may have been unaware of their HIV assess the prevalence of orodental conditions in symptomatic HIV- status. Just as tragic are the more than 13.2 million children positive children from Constanta, Romania. who have been orphaned due to the AIDS pandemic. This sce- Methods: The children underwent dental examinations and nario increases the risk that a child will live in extreme poverty, treatment at Constanta Municipal Hospital by a volunteer team drop out of school and continue the cycle of HIV infection. of dental healthcare professionals from the United States. Oral One of the highest concentrations of children living with lesions and dental caries were recorded during an 8-day period HIV is in Romania, with 1999 estimates reporting up to prior to initiating comprehensive dental care. 5,300 children infected in a country with a population of 23 Results: The study population consisted of 173 children (88 million.4-10 The absolute number of children with HIV is simi- males; 85 females) with a mean age of 8.8 years (range 6 to 12 lar to the total HIV-infected pediatric population in the United years). The primary HIV risk factor was contaminated needle re- States with 270 million inhabitants. Unlike other countries use and/or blood products (88%). The most common oral and where HIV-infected children are in the minority, children rep- perioral lesions included: candidiasis (29%), ulcers (15%), sali- resent about 90% of all AIDS cases in Romania.4-6,8 Most were vary gland disease (9%), necrotizing ulcerative gingivitis/ not infected by vertical HIV transmission, but rather from periodontitis (5%), linear gingival erythema (4%), labial mol- HIV-contaminated blood products. The practice of luscum contagiosum (3%), oral warts (2%), hairy leukoplakia microtransfusions for neonates and reuse of contaminated (2%), and herpes zoster (1%). One or more oral/perioral lesions needles in hospitals and orphanages account for the high HIV occurred in 55% of the children. Severe dental caries was noted infection rate in Romanian children. HIV subtype F is found in the majority of children (dfs/dft 16.9/3.7 and DMFS/DMFT predominately with minimal viral genetic variation from one 8.1/3.1). Over-retention of primary teeth (25%) and delayed erup- child to the next, supporting the fact that these children were tion (42%) were common. Postoperative complications included infected through HIV-contaminated blood products obtained delayed clotting (common) and thrombocytopenia-induced bleed- from adults.11 Tragically, many of the children have been aban- ing disorders (4%). doned and placed in orphanages or group homes, where these Conclusions: The oral healthcare needs of Romanian HIV- children are at risk for opportunistic infections, including tu- infected children are considerable, with the majority living with berculosis (TB), and bloodborne pathogens, such as hepatitis persistent, symptomatic oral diseases. (Pediatr Dent 23:44-50, B and C viral infections.12 2001) The purpose of this study was to assess the prevalence of orodental conditions in symptomatic HIV-positive Romanian lobally in 1999, there were 620,000 new human im- children who received dental care from a volunteer American munodeficiency virus (HIV) pediatric cases and over dental team at the Municipal Hospital in Constanta, Roma- G1.3 million children living with this viral infection.1-3 nia. In addition, the type of dental care rendered and any In that same year, 500,000 children died from complications treatment complications were documented. associated with AIDS. The World Health Organization (WHO) estimates that there are 1,600 babies born each day Methods with HIV, while 7,000 youths between 10 to 24 years of age The study population consisted of 173 consecutive HIV-in- are infected on a daily basis. Of particular concern are the 15.7 fected children who received dental care during an 8-day period million HIV-infected women, many of whom are of child-bear- at Municipal Hospital in Constanta, Romania. Priority of care Received January 26, 2000 Revision November 27, 2000 44 American Academy of Pediatric Dentistry Pediatric Dentistry – 23:1. 2001 Fig 1. Pseudomembranous candidiasis with diffuse palatal involvement. Fig 3. Diffuse perioral herpes simplex viral infection. Fig 2. Necrotizing ulcer of lateral border of tongue. was given to those children who lived in orphanages, includ- Oral and perioral lesions were diagnosed using the classifi- ing the hospital, and who were under the direct medical cation and diagnostic criteria for HIV-associated lesions in supervision of the director of the pediatric AIDS clinic. Medi- children, as described by the Collaborative Workgroup on the cal histories were reviewed by the local medical staff and Oral Manifestations of Pediatric HIV Infection.19 In addition, screened for the need of antibiotic prophylaxis based on severe cutaneous lesions involving the head and neck region and ex- neutropenia or for the prevention of subacute bacterial en- tremities were recorded in consultation with the attending docarditis. In addition, the most recent hematologic laboratory pediatricians. All treatment and postoperative complications studies were reviewed when available. Excluded from patient that were attributable to the dental care of these children were care were those children who were significantly moribund or documented. When serious postsurgical bleeding complications who had active tuberculosis disease. A comprehensive oral ex- arose, appropriate laboratory studies were ordered in consul- amination, excluding radiographs, was completed in tation with the attending physicians. All dental care was consultation with an oral and maxillofacial pathologist. All performed under the supervision of the pediatric AIDS medi- examinations were performed, using portable dental chairs, cal director at the Constanta Municipal Hospital. artificial light, and dental explorers. All oral and perioral le- All data were analyzed using description statistics, includ- sions, selected cutaneous lesions, permanent tooth eruption ing mean, range, and percent baseline prevalence. patterns, and primary and permanent dentition caries (dfs/dft, DMFS/DMFT) were recorded onto individual forms. Diag- Results nosis was performed by 4 dentists, who were calibrated using The study population consisted of 173 children (88 males, 85 the WHO criteria13 for caries diagnosis and were assisted by females), ranging in age from 6 to 12 years with a mean age of 18 auxiliaries. An estimate of the chronologic development of 8.8 years. The majority (75%) were orphans who lived in the the permanent teeth was assessed clinically, using the year of hospital or in group homes. Nosocomial HIV transmission by eruption age range that was developed by Logan and microtransfusion or contaminated needle reuse was the risk Kronfield14 and modified by Schour and Massler.15 The erup- factor for HIV infection in 88%. Approximately 30% of the tion of the teeth was broadly divided into delayed, accelerated, children were receiving some type of antiretroviral drug or normal eruption, based on these clinically determined therapy. The vast majority of children had no prior dental ex- norms. Over-retention of the primary teeth was defined as those perience and did not speak English. teeth, which had not exfoliated by the age ranges as determined A wide variety of HIV-associated oral and perioral lesions by the same chronologic development studies.14,15 was present in this group of children. The most common mani- festations included candidal infections (29%), oral and perioral Pediatric Dentistry – 23:1, 2001 American Academy of Pediatric Dentistry 45 Table 1. Caries Status in HIV-Infected Romanian Children Mean Primary Dentition dfs 16.9 male 21.4 female 11.9 dft 3.7 male 4.5 female 2.8 Caries-Free 10% Fig 4. Parotid enlargement. male 7% female 14% Permanent Dentition DMFS 8.1 male 8.3 female 7.9 DMFT 3.1 male 3.1 female 3.1 Caries-Free 18% male 16% Fig 5. Necrotizing ulcerative periodontitis. female 21% Both Dentitions Caries-Free 10% ulcers (15%), salivary gland enlargement (9%), necrotizing ul- cerative gingivitis/periodontitis (5%) and linear gingival erythema (4%). Viral-associated lesions such as labial mollus- cum contagiosum (3%), oral warts (2%), hairy leukoplakia (2%), and herpes zoster (1%) were documented less frequently. One or more oral/perioral lesions were found in 55% of chil- dren (Figs 1-7). Many of the children also had cutaneous diseases that were florid due to their immunocompromised status. These included impetigo, scabies, molluscum contagiosum, pediculosis capitus (lice), tinea corporis and capitus, verruca plana and vulgaris, HIV-induced psoriasis, seborrheic dermatitis, and vitiligo. Sev- eral of these diseases are contagious and especially transmittable Fig 6. Linear gingival erythema. from child to child within an orphanage or group home living conditions. Dental caries in both the permanent and primary teeth were considerable (Table 1).
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