Integrating Oral Health Care for Pediatric HIV: Models for Interdisciplinary Care

1. Integrating Oral Health Care into the Management of Children With HIV Infection: Models of Interdisciplinary Care

2. Pediatric HIVOral Health Care OBJECTIVES With the completion of this module participants will be able to: • Understand barriers to routine dental care for children living with HIV infection • Identify the components of successfully integrated HIV and dental care for pediatric HIV infection

3. Pediatric HIVOral Health Care OBJECTIVES (continued) • Describe four models of integrated HIV and dental care • Discuss treatment and follow-up issues including communication among the pediatric dental care provider, HIV care team and anesthesiologist

4. Pediatric HIV Oral Health Care Why are integrated HIV and dental care services important? Many patients living with HIV infection • Experience multiple complex problems associated with poverty, racism and substance abuse, etc. • Lack access to preventive dental services • Seek only emergency dental care for painful or debilitating problems • Are at-risk for potentially serious consequences from oral disease The integration of medical and dental services for children living with HIV infection is critical to support the attainment and maintenance overall health

5. Pediatric HIVOral Health Care Oral Health Care Concerns • Dental caries • Systemic infections • Abscesses • Pain • Weight loss • Dehydration • Morbidity/Mortality

6. Pediatric HIV Oral Health Care Barriers to Routine Oral Health Care • Lack of available and accessible services • Preventive care -- low priority for patient • Lack of dental provider education regarding the specific needs of children with HIV infection • Lack of dental provider education concerning the risk of HIV transmission between patient and provider

7. Pediatric HIVOral Health Care Barriers to Routine Oral Health Care (continued) • Fear of contracting an illness because of invasive nature of dental care • Social stigma • Quality of past experience • Fear of dentist

8. Pediatric HIV Oral Health Care Components of comprehensive oral healthcare • Partnership between the HIV care team and the pediatric dental provider • Pediatric dental provider participation in the HIV care team • Cross-training for HIV care team and dental providers

9. Pediatric HIVOral Health Care Successful Partnerships Involve • HIV care providers who are educated about dental problems • HIV care providers who are advocates for dental care • Dental care providers who are educated about HIV immunology, biology and therapeutic regimens • Both HIV and dental care providers trained in HIV-specific psychosocial issues

10. Pediatric HIVOral Health Care Successful Partnerships Involve (continued) • Face-to-face interaction between HIV care team and pediatric dental provider • Co-located or closely coordinated HIV care and dental services • Coordinated scheduling of appointments to minimize required office visits • Protocol for communication and sharing of examination results between HIV care team and pediatric dental provider

11. Pediatric HIV Oral Health Care Integrated Care Models • Care Model 1 Co-located HIV care and dental services • Care Model 2 Coordinated HIV care and on-site dental services • Care Model 3 Coordinated HIV care and community-based dental services • Care Model 4 Mobile dental care program

12. Pediatric HIV Oral Health Care • Care Model 1 Co-located HIV Care and Dental Services • Dental Screening • Dental screening by a pediatric dental provider in the HIV clinic-- an environment familiar to the child and family. Emergent care must be referred to dental clinic. • Oral Examination • Oral examination in an on-site dental clinic • Pediatric dental provider participates in post-clinic case conference with multidisciplinary HIV care team --physician, nurse practitioner, social worker and case manager

13. Pediatric HIV Oral Health Care • Care Model 2 Coordinated HIV Care and On-Site Dental Services Not co-located so environment is unfamiliar to child • Dental Screening and Oral Examination • HIV care team • Coordinates with on-site pediatric dental service • Conducts screening examination every three months in HIV care clinic • Ensures prompt referral and priority appointment for dental problems at on-site pediatric dental service • Refers child to on-site pediatric dental service for dental examination every six months

14. Pediatric HIV Oral Health Care • Care Model 3 Coordinated HIV Care and Community- Based Dental Services • Dental Screening and Oral Examination • HIV care team • Identifies community-based pediatric dental provider trained in HIV clinical and psychosocial issues • Ensures referrals to community-based dental provider • Develops protocol for communication and sharing of examination results between HIV care providers and pediatric dental provider. Lack of information exchange may have an impact on quality of care.

15. Pediatric HIVOral Health Care • Care Model 4 Mobile Dental Care Program • Dental Screening and Oral Examination • HIV care team identifies and develops linkages with community-based organizations serving at-risk and HIV-infected populations • Portable equipment is stationed at each site • HIV dental team (program director, primary care dentist, clinical coordinator, dental assistant and primary care postdoctoral trainees) travels to sites four days/week. This requires careful attention to continuity and follow-up.

16. Pediatric HIVOral Health Care Treatment Issues Children living with HIV infection often require general anesthesia for treatment toallow extensive treatment in a single session and minimize demands on family time and resources for healthcare appointments Vital Linkage • HIV care team • Pediatric dental provider • Anesthesiologist HIV care team support for pediatric dental provider is essential for consultation with anesthesiology

17. Pediatric HIVOral Health Care Treatment Issues (continued) Anesthesiology Concerns • Multiple health problems such as lymphoid interstitial pneumonitis (LIP) and chronic respiratory diseases pose additional risk Response • HIV care team provides consultation to anesthesiologist. Medical leadership is essential to effectively address anesthesiology and other health concerns.

18. Pediatric HIVOral Health Care Treatment Issues (continued) • Pediatric dental provider coordinates follow-up after treatment • HIV care team provides continual patient and family education about oral health

19. Pediatric HIV Oral Health Care Summary • Coordinated HIV care and dental care is essential for children living with HIV infection • To overcome the barriers to dental care • To ensure routine dental care • To avoid serious health consequences • Successful care models involve • Face-to-face partnership, coordination, cross-training and communication

20. Pediatric HIV Oral Health Care Summary (continued) • Care models vary by environment • Co-located, coordinated on-site and community-based, mobile care • Treatment Issues • Pediatric dental provider and HIV care team serve as consultants to anesthesiology to support treatment and provide follow-up