Dental Management of Adolescents and Young Adults Living with HIV/AIDS

Danny A. Kalash, D.M.D., M.P.H.; Kavita P. Ahluwalia, D.D.S., M.P.H.; Burton L. Edelstein, D.D.S., M.P.H.

ABSTRACT

HIV, both diagnosed and undiagnosed, remains a significant health problem among U.S. adolescents and young adults. Since HIV/AIDS increases the risk for various oral conditions, it is imperative that dentists become familiar with its presentation and clinical management within this unique population. This brief paper details the occurrence, elevated risk fororal diseases, and clinical management of HIV/AIDS among adolescents and young adults.

Epidemiology

The prevalence of HIV among U.S. children has declined, since vertical transmission at birth is now rare. Yet, HIV among adolescents and young adults remains persistently high: nearly one in-ten people living with HIV (8.6%) are under age 20, and an additional 29% of HIV-infected persons are ages 20 to 24. The Centers for Disease Control (CDC) also reports that among newly diagnosed HIV cases, one-in-five (21%) occurred between the ages of 13 and 24, with most (87%) in males. 1 Among adolescents and young adults, disease incidence is greatest among African-American and Latino males aged 19 to 24. 2

Oral Health

Adolescents and young adults living with HIV/AIDS present with unique oral health needs. They experience particularly high risk for dental caries, periodontal diseases, and oral soft-tissue pathologies due to compromised immunity and medication side effects that compound poor oral health behaviors. The specific oral effects of long-term, highly active antiretroviral therapy (“HAART”) remain unknown. However, early, as opposed to latelife initiation of antiretroviral therapy, predisposes this population group to greater susceptibility of any long-term systemic and oral side effects.

Dentist Engagement

Dentists play a leading role in the healthcare of young patients with and at-risk for HIV by providing services, from identification of possible HIV infection, to prevention, diagnosis and management of related oral diseases. The CDC reports that few at-risk youth have been tested for HIV (only 15% of male students who have sexual contact with other males have been tested), and youth with HIV are the least likely of any age group to obtain timely healthcare. 1 As adolescents may utilize dental care more frequently than medical care, and since early manifestations of HIV infection often occur in the mouth, dentists may be the first to suspect immunosuppression and be positioned to subsequently initiate referrals for appropriate medical care. 3

Section of Population Oral Health, College of Dental Medicine, Columbia University, New York, NY

According to the National Institute for Dental and Craniofacial Research (NIDCR), “Some of the most common oral problems for people with HIV/AIDS are: chronic dry mouth, gingivitis, bone loss around the teeth (periodontitis), canker sores, oral warts, fever blisters, oral candidiasis (thrush), hairy leukoplakia (which causes a rough, white patch on the tongue) and dental caries.” 4 Patients with HIV/AIDS can be safely and effectively treated by dentists using universal precautions. However, management of the HIV+ patient requires special consideration of its unique oral and soft-tissue disease sequela among this patient population.

Dental Management of Adolescents and Young Adults Living with HIV Antibiotic Therapy Well-managed HIV alone does not require antibiotic prophylaxis prior to dental care. However, advanced HIV status, reflected in CD4 counts under 500 (obtained from a complete blood count [CBC] test) may result in sustained immune suppression, necessitating antibiotic prophylaxis prior to dental treatment. Table 1 lists HIV stage and related dental considerations for antibiotic prophylaxis, according to the Dental Alliance for AIDS/HIV Care (DAAC) and the American Academy of Pediatric Dentistry (AAPD). 6,7

Salivary Function and Hard-Tissue Management HIV may result in increased risk for dental caries due to decreased salivary function, side effects of HIV drug therapy and disease-related decline in daily oral self-care. In addition to restorative therapy, dentists should provide targeted counseling regarding diet, oral health-related behaviors, and homecare. Table 2 lists salivary function and dental considerations, according to the DAAC. 7

Soft-Tissue Management Dentists should also be able to recognize, diagnose and manage soft-tissue lesions associated with HIV/AIDS. Table 3 lists the most common HIV-related mucosal conditions among adolescents and young adults, according to the New York State Department of Health AIDS Institute. 8

REFERENCES

1. HIV/AIDS. Centers for Disease Control and Prevention (CDC), 19 June 2019, http://www.cdc.gov/hiv/group/age/youth/index.html.

2. Diagnoses of HIV infection in the United States and dependent areas, 2017. HIV SurveillanceReport 2018;29.

3. Bloom B, Jones LI, Freeman G. Summary Health Statistics for U.S. Children: NationalHealth Interview Survey, 2012. National Center for Health Statistics. Vital Health Statistics.2013; 10(258).

4. HIV/AIDS Overview. National Institute of Dental and Craniofacial Research, U.S. Departmentof Health and Human Services, 19 June 2019, https://www.nidcr.nih.gov/healthinfo/hiv-aids.

5. Monitoring selected national HIV prevention and care objectives by using HIV surveillancedata—United States and 6 dependent areas—2016. HIV Surveillance SupplementalReport 2018;23(4).

6. Antibiotic Prophylaxis for Dental Patients at Risk for Infection. American Academy of PediatricDentistry (AAPD). Web. 19 July 2020. https://www.aapd.org/media/Policies_Guidelines/BP_Prophylaxis.pdf

7. Abel S, Croser D, Fischman S, Glick M, Phelan J. Principles of Oral Health Managementfor the HIV/AIDS Patient. Dental Alliance for AIDS/HIV Care, 2000. Web. 19 July 2019.https://aidsetc.org/sites/default/files/resources_files/Princ_Oral_Health_HIV.pdf

8. Oral Health Care for People With HIV Infection. New York State Department of HealthAIDS Institute. 2001. Web. 19 July 2019. https://aidsetc.org/sites/default/files/resources_files/oral_guidelines.pdf

Dr. Kalash

Danny A. Kalash, D.M.D., M.P.H., is a dental public health resident, Columbia University College of Dental Medicine, New York, NY.

Dr. Ahluwalia

Kavita P. Ahluwalia, D.D.S., M.P.H., is associate professor of dental medicine, Columbia University College of Dental Medicine, New York, NY.

Dr. Edelstein

Burton L. Edelstein, D.D.S., M.P.H., is professor of dental medicine and health policy, Columbia University College of Dental Medicine, New York, NY.