O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
ARTICLE ABSTRACT Purpose: Verify factors that influence the oral health status of people living with HIV/AIDS (PLWHA) in Brazil. Method and materials: The study was cross-sectional and includes 177 HIV-positive individuals, who answered questionnaire on the sociodemographic conditions, HIV aspects, habits, and satisfaction with the service. The oral health data were collected by means of the decayed, missing, and filled teeth (DMFT) index, use and need of dentures, and the Community Periodontal Index. Results: Average number of the DMFT was 17.64. Most HIV-positive patients presented good periodontal status, 35.0% used dentures, 41.5% needed denture in the maxilla, and 62.0% in the mandible. In the multivariate analysis, older age and dissatisfaction with health care were associated with nonuse of dentures. The abandonment of the use of antiretroviral therapy increased the risk of PLWHA presenting more than three decayed teeth. Conclusion: Poor oral health of the PLWHA was mainly influenced by sociodemographic factors and use and satisfaction with service.
KEY WORDS: HIV, oral health, patient satisfaction
176 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 176
Oral health status of people living with HIV/AIDS attending a specialized service in Brazil Gabriella Barreto Soares, MSc;1* Cléa Adas Saliba Garbin, PhD;2 Suzely Adas Saliba Moimaz, PhD;3 Artênio José Ísper Garbin, PhD4 1Master
Programme in Preventive and Social Dentistry, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil; 2Coordinator of Postgraduate Programme in Preventive and Social Dentistry, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil; 3Full Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil; 4Associate Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(4): 176-184, 2014
Int r od uct ion
The epidemic of HIV/AIDS enters into its fourth decade, with epidemiological and clinical features different from those observed in its beginning. This happens due to advances in diagnosis and treatment, with emphasis on the introduction of highly active antiretroviral therapy (HAART) more effectively led to the increase in life expectancy of people living with the disease. This fact led to a greater demand for health services.1,2 Brazil has a free program that is a global benchmark for care of people living with HIV/AIDS (PLWHA), focusing on treatment and control of the epidemic, the service offers exams of the CD4 cell count, Specialized Assistance Services, Day Hospital, anonymous testing centers, Reference Center (RC) with the multidisciplinary team and Home Care, as well as the existence of special legislation for people living with the disease.3 The success of this program is due to this assistance and proper health care, because it contributes to improvement in the mortality, morbidity, and the quality of life of these people. A good way to evaluate the services is through patient satisfaction, and this information is essential to the needs and desires of those who are duly attended.4 Because of this, it stresses the importance of services
to provide quality care, because this way people infected do not feel discouraged to disclose their risk behavior, since the stigma becomes a factor less noted as a deterrent for seeking health care.5,6 At the beginning of the epidemic, associating the PLWHA to homosexuals, intravenous drug users, and sex workers, being popularly called the “gay plague” or “gay cancer” that together with the fear of population contamination, consequently brought a reinforcement in prejudice and discrimination against this part of the population.7 Even after so many years, many people still suffer discrimination, not only by society but also by health professionals. The duty of health professionals to provide comprehensive care for PLWHA has been debated since the beginning. The American Medical Association and
© 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12056
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
other associations determine that the health professionals they represent have an ethical obligation to administer care to these patients, since their needs fall into their areas of competence.8 Even considering all the ethical aspects, through the efforts of the Ministry of Health through the National sexually transmitted disease (STD)/AIDS Program, as well as the support of several nongovernmental organizations, there are still many episodes of discrimination.9 We observed many denials in the care of these people, particularly by the dentists, and the fear of becoming infected during a dental procedure, losing other patients, and lack of psychological preparation are key motives.10 In addition, more barriers are observed in the access to oral health care for PLWHA, including: socioeconomic inequalities, availability of social and financial resources, geographical distances, cultural differences between health professionals and patients, and fear or real experience of preconception.11,12 The patients with HIV allege fear of professional rejection, ethical breach of confidentiality by the dentist, and still think it unnecessary to inform about their HIV status because they perceive the presence of biosecurity measures in the dental office.13 In spite of these difficulties with oral health care, it was also observed that these people are more prone to oral diseases such as caries, periodontal disease, oral lesions, and xerostomia.14–16 This requires prompt treatment and continuous monitoring since the oral health can interfere with eating and the administration of medications, as well as the quality of life of these individuals.17 Given all the aspects related to PLWHA, the aim of this study is to investigate the association of the sociodemographic variables, HIV-related habits, and use of and satisfaction with health services with the oral health of PLWHA assisted in the public service reference in Brazil.
M ethodology
This is an exploratory quantitative crosssectional and analytical study carried out
Soares et al.
scd12056.indd 177
in the public health service offered to PLWHA, STD/AIDS-RC, which has operated since 1992 in the capital of Espírito Santo. The sample selection was carried out by randomly contacting the patients, in each examination day on a dental service, until we completed contacting the 177 subjects. We included patients with a confirmed diagnosis of HIV infection over 18 years of age, and who agreed to participate in the study. Data collection was carried out during four consecutive months in 2012, after a pilot study in which all the variables were tested. Individual interviews and clinical oral examinations were conducted in the dental clinic of the service. The data relating to the sociodemographic questions, issues related to HIV, habits, experienced discrimination, use and satisfaction with services were obtained through a structured questionnaire constructed specifically for this study. The sociodemographic variables included age, gender, color, marital status, education, link to employment, family income, and number of people living at home. Those factors related to HIV and habits are: viral load and CD4, date of HIV diagnosis, mode of infection, antiretroviral therapy, smoking habits, alcohol, drug use, and condom use before and after diagnosis. The data related to discrimination experienced in the health services include: by which professionals, in what kind of service, and the form of discrimination. For the issues in the use of services, there are: frequency of dental visits, difficulty to be serviced in the STD/AIDS-RC, time since the last dental visit, a place where the patient goes to dental treatment, the reason for not seeking the closest Basic Health Unit (BHU), reason for visit and reveal their HIV status to the dentist without being from the STD/AIDS-RC. Finally, the data of satisfaction with the service offered by the STD/AIDS-RC were evaluated through questions adapted by Melchior18 and Esperidião.19 Therefore, we created 11 indicators: physical structure, respect for user privacy, professional/patient
r elationship, opportunities given to the patient to make complaints, support offered by the service, timeliness of health professionals, received guidelines for the treatment, care, convenience of opening hours, availability of antiretroviral drugs and laboratory tests, ease of access to services. Each indicator has gradations ranging from 1 to 5 points, which correspond respectively to the following scores: poor (1 point), bad (2 points), fair (3 points), good (4 points), excellent (5 points), the lowest value being assigned to the sum of all indicators (11) and the maximum value (55) points. The oral health examination was conducted by a calibrated dentist (κ > .81 for all the collected variables), who used the probe recommended by the World Health Organization (WHO) and mouth mirrors. Condition of the teeth, gums, and the use and need of dentures were evaluated according to the codes and criteria for the epidemiological surveys of the WHO.20 For the condition of the teeth, the average number of decayed, missing, or filled teeth (DMFT) was used. The periodontal status was verified by the Community Periodontal Index (CPI), which evaluated the presence of bleeding, calculus, and periodontal pockets. The codes were: 0—healthy, 1—bleeding observed after probing, 2—presence of calculus, 3—pocket 4 to 5 mm, 4—pocket of 6 mm or more, X—excluded sextants (less than 2 teeth), 9—no information. The use of dentures was recorded as follows: 0—no use, 1—fixed bridge, 2—more than one fixed bridge, 3—a removable partial denture, 4—fixed + removable denture, 5—complete dentures, 9—no information. The need for dentures was also evaluated according to the following codes: 0—no need, 1—one denture element, 2—more than one element, 3—combination of dentures, 4—complete dentures, 9—no information.
Data analysis The descriptive analyses were performed to characterize the population through measures of central tendency (simple
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 177
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
frequencies, mean, and median) and measures of dispersion (standard deviation). The sample involved in the research set the normal distribution of probability, assessed by the Kolmogorov and Smirnov tests (p = .001) and the hypotheses were verified with the aid of parametric statistics. The reason for the rejection or not for any of these hypotheses considered a significance level of .05. The statistical analysis of variance (ANOVA) and multiple logistic regression (MLR) tests were conducted with elimination of the nonsignificant variables. The selection of independent variables for the MLR models was performed according to a stepwise model. After adjusting the MLR model with a confidence interval of 95% (CI), the odds ratio and p values were estimated. All statistical tests were performed using the SPSS for Windows version 17.0 program.
Ethical aspects All ethical issues related to the development of the research were met. The research was conducted with the understanding and written consent of each participant. The study protocol was approved by the Ethics Committee for Research with humans from the Paulista State University, School of Dentistry of Araçatuba.
Res u lts
The study included 177 HIV-positive patients, slightly more than half of the sample were women (53.1%) with a mean age of 42 years. Most participants (63.8%) had a monthly income of one to two minimum wages. Regarding family composition, respondents live, on average, with three people. Most were brown (61.6%) and were not in a stable relationship (48.6%). Regarding education, 53.1% had 8 years or less of schooling and 7.3% could not read and write. Upon completion of this study, 62.7% of the participants performed any professional activity, whereas 23.2% of them were unemployed. There are still those who reported receiving benefits from government agencies such as sickness (5.6%) and retirement (8.5%).
178 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 178
Regarding the laboratory data, it was observed that 78.2% had CD4 above 350 cells/mm3, whereas only 5.3% had values below 200 cells/mm3. In the analysis of the viral load, 61.6% were undetectable, whereas 25.0% had values above 10,000 copies/ml. As the time elapsed since the diagnosis of HIV infection, it was observed that 35% stated that there was more than 10 years, with 86.4% of the patients aged 20 to 50 years, when they received the result. The contamination by heterosexual relations was second, 55.9% and 53.1% of the respondents said they did not know who they contracted the virus from. At the time of the survey, 77.4% of the subjects were on the HAART. Patients had a mean DMFT of 17.64 (standard deviation [SD] = 7.786) (2.85 decayed teeth, SD = 3.58; 9.12 missing teeth, SD = 7.95; and 5.67 filled teeth, SD = 4.99). The majority of HIV-positive patients showed good periodontal status (56.6%) and 25.3% had a 4 to 5 mm periodontal pocket. Regarding the use of dentures, 35% of those surveyed used dentures. Among them, 1.69% used a fixed bridge, 18% partial removable dentures, and 10.7% complete dentures. Regarding the need for dentures, 41.5% needed dentures in the maxilla and 62% in the mandible. As for the dental care, 33.3% answered that they have never been to the dentist and 25.4% only when they had pain in a tooth, before the diagnosis of HIV. Of the majority of the interviewed, 75.7% said they sought dental care only in the STD/AIDS-RC, since 93.8% said they had no problems being examinated. Asked why they did not seek the BHU, 24.9% said they would prefer care in the RC, while 22.0% said they had no vacancies in the BHU. The main reasons for visiting a dentist were routine examination (30.5%) and cavities in the teeth (27.1%). A total of 29.9% of the patients said they did not in any way reveal their HIV status to another dentist and 14.1% responded only when asked. Of those who did not reveal, 20.3% said they were afraid of suffering discrimination. Only 16.4% of the interviewed were prejudiced against by health professionals,
the majority of cases by the dentist, followed by the doctor. As for the venue, 13.6% said they were in the public health service. And the refusal in attendance (7.9%), followed by lack of respect/ ignorance (5.6%) were described as ways in which they were discriminated. In the analysis of the 11 indicators used to assess the satisfaction with the health service, it was considered satisfactory by 63.8% of the surveyed, whereas only 36.2% assessed it as unsatisfactory. The dissatisfaction was prevalent in only two indicators: timeliness of professionals and physical structure of the service. In the bivariate analysis, with the CPI as the dependent variable, age, education, age at diagnosis, time of smoking, difficulty to be attend in STD/AIDS-RC, and the reason for the dental visit were associated with p < .05 (Table 1). In the MLR model, having a younger age proved to be less likely to produce periodontal problems (p = .04; Table 3). With the DMFT as the dependent variable, the analysis showed that age, marital status, employment relationship, age at diagnosis, mode of contamination, reason for the dental visit, and the reason why their HIV status was not revealed to other surgeon-dentists, were associated with p < .05 (Table 1). When decayed teeth were used as the dependent variable in the bivariate analysis, the reason for abandonment of the HAART, smoking habit, time of smoking, not having sought the BHU, reason for dental consultation, and revealing their HIV status to another dentist, were associated with p < .05 (Table 2). The multivariate model indicated that people who abandoned the use of the HAART were at risk of having more than three decayed teeth (Table 3). Regarding the filled teeth, the results of the bivariate analysis showed that age, sex, frequency of consultation with the dentist before HIV, local demand for dental care, not revealing their HIV status to another dentist, and service satisfaction were associated with p < .05 (Table 2). Among them, the frequency of visits to the dentist before the diagnosis of HIV was a risk indicator for the presence of a few filled teeth (Table 3).
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 1. Bivariate analysis of the CPI, DMFT, and denture use according to the independent variables of the participants of the study, Brazil, 2012. CPI
DMFT
≤2 n (%)
>2 n (%)
18 to 34
22 (22.0)
48 (62.3)
35 to 44
40 (40.0)
26 (33.8)
45 to 70
38 (38.0)
3 (3.9)
Single
50 (50.0)
36 (46.8)
Married/consensual union
36 (14.0)
13 (28.6)
3 (3.0)
10 (13.0)
11 (11.0)
Denture use
≤18
>18
38 (42.2)
3 (3.4)
26 (28.9)
40 (46.0)
26 (28.9)
44 (50.6)
44 (48.9)
42 (48.3)
34 (37.8)
24 (27.5)
2 (2.2)
11 (12.6)
9 (11.7)
10 (11.1)
6 (6.0)
7 (9.1)
years of schooling
16 (16.0)
3 (3.9)
Employed
54 (54.0)
31 (40.3)
Not employed
46 (46.0)
46 (59.7)
Independent variables
p Value
p Value
No
Yes
37 (29.4)
4 (7.8)
50 (39.7)
16 (31.4)
39 (31.0)
31 (60.8)
64 (50.8)
22 (43.1)
44 (34.9)
14 (27.5)
6 (4.8)
7 (13.7)
10 (11.5)
12 (9.5)
8 (15.7)
5 (5.6)
8 (9.2)
8 (6.3)
5 (9.8)
48 (53.3)
46 (52.9)
61 (48.4)
33 (64.7)
24 (26.7)
27 (31.0)
40 (31.7)
11 (21.6)
13 (14.4)
6 (6.9)
17 (13.5)
2 (3.9)
52 (57.8)
33 (37.9)
65 (51.6)
20 (39.2)
38 (42.2)
54 (62.1)
61 (48.4)
31 (60.8)
p Value
Age .000
.000
.000
Marital status
Widowed Separated/divorced
.058
.049
.157
Education Illiterate
.002
.320
.059
Link to employment .069
.008
.134
Age at diagnosis 20 years
5 (21.7)
9 (52.9)
3 (20.0)
11 (44.0)
11 (35.5)
3 (33.3)
>50 years old
.000
.012
.001
Contamination mode
Do not know
.188
.003
.550
Time of smoking .040
.115
.905
Frequency of dentist examination. before HIV When in pain
22 (22.0)
23 (29.9)
19 (21.1)
26 (29.9)
9 (15.0)
36 (30.8)
Never
36 (36.0)
29 (36.7)
42 (46.6)
23 (26.4)
53 (42.1)
12 (23.6)
Once a year
30 (30.0)
18 (23.4)
22 (24.4)
26 (29.9)
31 (24.6)
17 (33.3)
06 times in 06 months
12 (12.0)
7 (9.1)
7 (7.8)
12 (13.8)
13 (10.3)
6 (11.8)
When in pain
22 (22.0)
23 (29.9)
19 (21.1)
26 (29.9)
9 (15.0)
36 (30.8)
5 (5.6)
6 (6.9)
9 (7.1)
2 (3.9)
85 (94.4)
81 (93.1)
117 (92.9)
49 (96.1)
.577
.062
.049
Service difficulty with STD/AIDS-RC Yes
10 (10.0)
1 (1.3)
No
90 (90.0)
76 (98.7)
Soares et al.
scd12056.indd 179
.009
0.712
.685
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 179
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 1. Continued. CPI Independent variables
≤2 n (%)
DMFT >2 n (%)
p Value
Denture use
≤18
>18
27 (30.0)
26 (29.8)
15 (16.7)
17 (19.5) 44 (50.6)
p Value
No
Yes
45 (35.7)
8 (14.7)
18 (14.3)
14 (27.5)
63 (50.0)
0 (0.0)
p Value
Time elapsed since last consultation Less than 6 months
36 (36.0)
18 (23.4)
6 months to 1 year
17 (17.0)
15 (19.5)
More than 1 year
48 (48.0)
44 (57.1)
48 (53.3)
.359
0.812
.040
Reason for dental consultation Pain
10 (10.0)
6 (7.8)
10 (11.1)
6 (6.9)
12 (9.5)
4 (7.8)
Routine visit
33 (33.0)
21 (27.3)
32 (35.6)
22 (25.3)
42 (33.3)
12 (23.5)
9 (9.0)
15 (19.5)
13 (13.3)
12 (13.8)
34 (34.0)
14 (18.2)
28 (31.1)
20 (23)
Bleeding gums Cavities Oral lesions
.005
.001
15 (11.9)
9 (17.6)
35 (27.8)
13 (25.5)
1 (1.0)
0 (0.0)
1 (1.1)
0 (0.0)
1 (0.8)
0 (0.0)
Extraction
12 (12.0)
13 (16.9)
7 (7.8)
18 (20.7)
20 (15.9)
5 (9.8)
Dentures
1 (1.0)
8 (10.4)
0 (0.0)
9 (10.3)
1 (0.8)
8 (15.7)
26 (81.3)
10 (47.6)
30 (76.9)
6 (42.9)
.006
Reason for not revealing their HIV status to another dentist? Discrimination
26 (74.3)
10 (55.6)
Confidentiality
2 (5.7)
1 (5.6)
Link with professional
2 (5.7)
2 (11.1)
Did not think necessary
5 (14.3)
5 (27.8)
Satisfied
56 (56.0)
54 (70.1)
Unsatisfied
44 (44.0)
23 (29.9)
.541
1 (3.1)
2 (9.5)
2 (6.3)
2 (9.5)
3 (9.4)
7 (33.3)
51 (56.7)
59 (67.8)
39 (43.3)
28 (32.2)
.007
1 (2.6)
2 (14.3)
2 (5.1)
2 (14.3)
6 (15.4)
4 (28.6)
72 (57.1)
38 (74.5)
54 (42.9)
13 (25.5)
.115
Satisfaction with service
Finally, lost teeth were associated with age, education, link to employment, age at diagnosis, reason for the abandonment of the HAART, reason for dental consultation, and satisfaction with service with p < .05 (Table 2). The regression model showed that older age, lower education, and having as the reason for consultation, pain and cavities, were risk factors for the presence of missing teeth (Table 3).
D is cu s s io n
In Latin American countries, it is estimated that 1.4 million people are infected with HIV and nearly half of these individuals live in Brazil. The AIDS epidemic in Brazil is relatively stable, with an estimated prevalence of 0.6% adults, being mostly female, 25 to 49 years old, low income and education, as the data observed in this study.21 Many advances have been achieved by that
180 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 180
.053
third decade of the HIV epidemic with the National STD/AIDS-RC in Brazil, including dental care, however, few studies have been carried out to demonstrate this improvement, as well as surveys to assess the oral health status of Brazilian adults living with HIV/AIDS. With regard to tooth decay, the PLWHA had on average of 17.64 DMFT index. Comparing this result with the data from the Epidemiological Surveys of the 2010 National Oral Health, the average DMFT of Brazilian adults was 16.3, one can see a poorer dental status of the PLWHA Brazilians.22 The sociodemographic variables were able to identify the PLWHA with bad oral health conditions where respondents who had links to employment, more than 9 years of schooling, and were of younger age, were less likely to have high levels of DMFT. This is also observed in studies of the general population, in which the socioeconomic status is a determining factor in
.126
.028
health with improved access to information and demand for a healthier life.23–25 The abandonment of antiretroviral therapy for reasons of discouragement, not accepting the disease, use of drugs and alcohol, were also risk factors for decayed and missing teeth. One explanation for this is that with nonadherence to treatment, the viral load increases and CD4 cells decrease, which causes the decrease of immunity, which appear as a result of opportunistic diseases, including oral disorders.26 In addition, studies show that patients on HAART have a lower occurrence of carious surfaces than those that are not. This is because patients that tend to adhere to treatment are more likely to seek health care and therefore, more often visit the dentist and the dental treatment is performed completely.27–29 Historically, in Brazil, the adult population has been intended for emergency dental services, mostly caused by pain,
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 2. Bivariate analysis of decayed teeth, missing teeth, and filled teeth variables according to the independent variables of the participants of the study, Brazil, 2012. Decayed teeth Independent variables
≤6 n (%)
>6 n (%)
18 to 34
28 (23.0)
13 (23.6)
35 to 44
40 (32.8)
26 (47.3)
45 to 70
54 (44.3)
16 (29.1)
Female
63 (51.6)
31 (56.4)
Male
59 (48.4)
24 (43.6)
9 (7.4)
4 (7.3)
years of schooling
15 (12.3)
4 (7.3)
Employed
56 (45.9)
29 (52.7)
Not employed
66 (54.1)
26 (47.3)
8 (6.6)
3 (5.5)
20 to 50 years old
10 (84.4)
50 (90.9)
>50 years old
11 (9.0)
Filled teeth ≤6 n (%)
>6 n (%)
30 (26.8)
10 (16.1)
35 (31.3)
30 (48.4)
47 (42.0)
22 (35.5)
52 (46.4)
39 (62.9)
60 (53.6)
23 (37.1)
11 (9.8)
2 (3.2)
62 (55.4)
30 (48.8)
29 (25.9)
21 (33.9)
10 (8.9)
9 (14.5)
52 (46.4)
31 (50.0)
60 (53.6)
31 (50.0)
9 (8.0)
2 (3.2)
93 (83.0)
57 (91.9)
2 (3.6)
10 (8.9)
p Value
Missing teeth ≤9
>9
38 (35.2)
2 (3.0)
40 (37.0)
25 (37.9)
30 (27.8)
39 (59.1)
55 (50.9)
36 (54.5)
53 (49.1)
30 (45.5)
5 (4.6)
8 (12.1)
48 (44.4)
44 (66.7)
39 (36.1)
11 (16.7)
16 (14.8)
3 (4.5)
58 (53.7)
25 (37.9)
50 (46.3)
41 (62.1)
11 (10.2)
0 (0.0)
93 (86.1)
57 (84.6)
3 (4.8)
4 (3.7)
9 (13.6)
p Value
p Value
Age
.111
.063
.000
Sex .560
.036
.643
Education Illiterate
.704
.172
.001
Link to employment .400
.652
.001
Age at diagnosis 20 years
4 (19.0)
10 (52.6)
12 (44.4)
2 (16.7)
6 (27.3)
8 (47.1)
27 (24.1)
16 (25.8)
23 (21.3)
20 (30.3)
52 (45.4)
12 (19.3)
39 (36.1)
25 (37.8)
24 (21.4)
24 (38.7)
33 (30.6)
15 (22.7)
9 (8.0)
10 (16.1)
13 (12.0)
6 (9.1)
.034
.549
.037
Smoker .013
.468
.411
Time smoking .025
.083
.202
Consultation frequency at dentist before HIV When in pain
32 (26.2)
13 (23.6)
Never
42 (34.5)
23 (41.8)
Once a year
35 (28.7)
13 (23.6)
Every 6 months
13 (10.7)
6 (10.9)
Soares et al.
scd12056.indd 181
.798
.000
.375
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 181
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 2. Continued. Decayed teeth Independent variables
≤6 n (%)
>6 n (%)
Filled teeth
p Value
≤6 n (%)
>6 n (%)
Missing teeth
p Value
≤9
>9
p Value
Location that usually seeks dental services Health service near home
8 (6.6)
3 (5.5)
6 (5.4)
4 (6.5)
6 (5.6)
4 (6.1)
AIDS STD-RC
92 (75.6)
42 (76.4)
88 (78.6)
44 (71.0)
79 (73.1)
53 (80.3)
Private practice
17 (13.9)
8 (14.5)
15 (13.4)
10 (16.1)
16 (14.8)
9 (13.6)
Dental plan
4 (3.3)
0 (0.0)
.131
0 (0.0)
4 (6.5)
.042
4 (3.7)
0 (0.0)
No where
0 (0.0)
2 (3.6)
2 (1.8)
0 (0.0)
2 (1.9)
0 (0.0)
Bureaucracy
12 (10.4)
8 (14.4)
13 (13.1)
7 (12.1)
10 (9.8)
10 (15.9)
Discrimination/fear/secrecy
19 (16.5)
6 (11.5)
13 (12.2)
12 (20.7)
18 (17.6)
7 (11.2)
Did not take care of health
1 (0.9)
4 (7.7)
5 (4.7)
0 (0.0)
3 (2.9)
2 (3.2)
19 (16.5)
2 (3.8)
12 (11.2)
9 (15.5)
12 (11.8)
9 (14.3)
9 (7.8)
4 (7.7)
9 (8.4)
4 (6.9)
7 (6.9)
7 (11.1)
No vacancies
26 (22.6)
13 (25.0)
24 (22.4)
13 (22.4)
26 (25.5)
11 (17.5)
Preferred dentist attendance
29 (25.2)
15 (28.8)
31 (29.0)
13 (22.4)
28 (27.5)
16 (25.4)
8 (6.6)
8 (14.5)
8 (7.1)
6 (9.7)
10 (9.3)
4 (6.1)
Routine visit
44 (36.1)
10 (18.2)
33 (29.5)
20 (32.3)
37 (34.3)
16 (24.2)
Bleeding gums
23 (18.9)
1 (1.8)
14 (13.0)
10 (15.2)
Decayed teeth
27 (22.1)
21 (38.2)
33 (30.6)
15 (22.7)
Oral lesions
0 (0.0)
Tooth extraction Dentures
.220
Reason for not searching the BHU
Didnotneed Did not have a health service
.020
.453
.619
Reason for dental visit Pain
17 (15.2)
7 (11.3)
28 (25.0)
20 (32.3)
1 (1.8)
1 (0.9)
0 (0.0)
1 (0.9)
8 (12.1)
11 (9.0)
14 (25.5)
18 (16.1)
4 (11.3)
12 (11.1)
13 (19.7)
9 (7.4)
0 (0.0)
7 (6.3)
2 (3.2)
1 (0.9)
8 (12.1)
56 (51.9)
41 (62.1)
37 (34.3)
16 (24.2)
.000
.659
.013
Reveal their HIV status to the dentist without being from the STD/AIDS-RC Yes
59 (48.4)
40 (72.7)
No
42 (34.4)
11 (20.0)
64 (57.1)
33 (53.2)
33 (29.5)
20 (32.3)
Only if asked
21 (17.2)
4 (7.3)
15 (13.4)
9 (14.5)
15 (13.9)
9 (13.6)
Discrimination Confidentiality
29 (69.0)
7 (63.6)
25 (75.8)
11 (55.0)
28 (75.7)
8 (50.0)
2 (4.8)
1 (9.1)
0 (0.0)
3 (15.0)
2 (5.4)
1 (6.3)
Link with professional
3 (7.1)
1 (9.1)
4 (12.1)
0 (0.0)
1 (2.7)
3 (18.8)
Did not think neccesary
8 (19.0)
2 (18.2)
4 (12.1)
6 (30.0)
6 (16.2)
4 (25.0)
Satisfactory
77 (58.3)
33 (60.0)
68 (60.7)
39 (62.9)
62 (57.4)
45 (68.2)
Unsatisfactory
45 (41.7)
22 (40.0)
44 (39.3)
23 (37.1)
46 (42.6)
21 (31.8)
.008
.883
.172
Reason for not revealing
.952
.006
.172
Satisfaction with service
which usually results in missing teeth. Having searched the dentist for the reason of pain or tooth decay, increased the risk of PLWHA, having more than nine missing teeth in the mouth. This
182 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 182
.257
shows that the demand for dental care happens when the dental disease is already at an advanced stage, which causes irritation and pain. A direct consequence of this systematic exclusion of
.044
.047
services, extractions are outcomes that, in most cases, could be avoided.30 With regard to periodontal status, less than half of the interviewed presented alterations, and studies have
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 3. Multiple logistical regression for the PCI, DMFT, denture use, decayed teeth, filled teeth, and missing teeth in dependent variables of the participants of the study, Brazil, 2012. Odds ratio
Confidence interval
p Value
5.954
1.76–20.123
.004
2.472
0.788–7.755
.121
Older age
2.624
1.609–4.279
.000
Unsatisfied with service
2.656
1.262–5.588
.010
Abandonment of HAART because of discouragement
0.125
0.015–1.029
.050
Smoker
0.006
0.000–0.406
.017
Not reveal HIV status for dentist out of RC
66.223
66.223–0.394
.109
2.047
1.143–3.666
.016
Older age
2.974
1.771–4.997
.000
Lower education level
0.507
0.311–0.829
.007
Reason for pain and cavities in the teeth
1.254
1.021–1.541
.031
Variables CPI Older age DMFT Contamination via sex Denture use
number of decayed and missing teeth and the need for dentures characterizes the sample as a group in great need of dental care. This reflects the importance of providing adequate treatment and quality for the patient, with improvement in the implementation of oral (dental) rehabilitation strategies due to the large number of missing teeth, as well as the appreciation of the dentist in multi-RCs, and also the realization of educational programs for greater adherence to health care and dental care for these patients.
Decayed teeth
Filled teeth Little or no examination before HIV diagnosis Missing teeth
shown that patients with low levels of CD4 cells have a higher prevalence of periodontal disease, and the good condition of the participants may be explained by the high levels of CD4 cells.31,32 In relation to the use of dentures, it is observed that those with older age, greater missing teeth, and thus, use more dentures, increases the search for the dental services offered. However, access to free prosthetic treatment in Brazil is still complicated, there is a long waiting list for patients needing dentures and they do not have the financial means to afford a private service, because of that they give up the dental treatment.33 This fact is seen in this study with the high number of people who need dentures in the maxilla and mandible. Since 1990, Brazil offers free health assistance, specialized quality, and universal access for PLWHA, it reflects the results of the satisfaction of surveyed with the service offered by the STD/ AIDS-RC, and the few reports of dissatisfaction were mostly related to physical structure and timeliness of professionals,
Soares et al.
scd12056.indd 183
also observed in other studies.34,35 The fact that these patients were satisfied with the referral service, reflects the seeking of dental care, which was not very common before the diagnosis of HIV. This lack of oral care before the discovery of infection, caused the PLWHA of the study to present fewer restored teeth. After the discovery of serology, the majority of respondents sought dental care only in the STD/AIDS-RC, as it reported no problems obtaining consultation and the preference compared with the BHU in the neighborhood in which they live.One reason is that not disclosing the HIV status to the dentist who is not a referral service for fear of discrimination and suffering of others knowing their health condition. This preference for specialized services and even far from the places in which they live is also reported in other studies, with reasons related to the stigma of a society living with HIV/AIDS.9,36 Many people living with chronic diseases, such as HIV live with preventable and untreated dental problems. The
C oncl us ion
The poor oral health of PLWHA was mainly influenced by the sociodemographic factors, issues related to HIV, use and satisfaction with service.
References 1. Sepkowitz KA. AIDS: the first 20 years. N Engl J Med 2001;344:1764-72. 2. Porter K, Babiker A, Bhaskaran K, et al. Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet 2003;362:1267-74. 3. Campos TS, Ribeiro LCC. Perfil epidemiológico dos pacientes com HIV/AIDS no Alto Vale do Jequitinhonha, 1995–2008. Rev Med Minas Gerais 2011;21:14-8. 4. Jenkison C, Coulter A, Bruster S, Richards N, Chandola T. Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care 2002;11:335-9. 5. Solorio MR, Currier J, Cunningham W. HIV health care services for Mexican migrants. J Acquir Immune Defic Syndr 2004; 37:5240-51. 6. Rungsiyanont S, Lam-ubol A, Vacharotayangul P, Sappayatosok K. Thai dental practitioners’ knowledge and attitudes regarding patients with HIV. J Dent Educ 2013;77:1202-8. 7. Creel AH, Rimal RN, Mkandawire G, Boose K, Brown JW. Effects of a mass media intervention on HIV-related stigma: ‘Radio Diaries’ program in Malawi. Health Educ Res 2011;26:456-65. 8. Bryan CS. HIV/AIDS and bioethics: historical perspective, personal retrospective. Health Care Anal 2002;10:5-18.
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 183
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
9. Garbin CAS, Martins RJ, Garbin AJI, Lima DC, Prieto AKC. Percepção de paciente HIV-positivo de um centro de referência em relação a tratamento de saúde. DST—J Bras Doenças Sex Transm 2009;21:107-10. 10. Sheldon J, Murray E, Johnson A, Haines A. The involvement of general practitioners in the care of patients with human immunodeficiency virus infection: current practice and future implications. FamPract 1993;10:396-9. 11. Oliveira IBN. Acesso universal? Obstáculos ao acesso, continuidade do uso e gênero em um serviço especializado em HIV/AIDS em Salvador, Bahia, Brasil. Cad Saúde Pública 2009;25:259-68. 12. Marcus M, Maida CA, Coulter ID, et al. A longitudinal analysis of unmet need for oral treatment in a national sample of medical HIV patients. Am J Public Health 2005;95: 73-5. 13. Shiboski CH, Palacio H, Neuhaus JM, Greenblatt RM. Dental care access and use among HIV-infected women. Am J Public Health 1999;89:834-9. 14. Weinert M, Grimes RM, Lynch DP. Oral manifestations of HIV infection. Ann Intern Med 1996;125:485-96. 15. Petersen PE. Strengthening the prevention of HIV/AIDS-related oral disease: a global approach. Community Dent Oral Epidemiol 2004;32:399-401. 16. Petruzzi MN, Cherubini K, Salum FG, Figueiredo MA. Risk factors of HIV-related oral lesions in adults. Rev SaúdePública 2013; 47:52-9. 17. Dobalian A, Andersen RM, Stein JA, Hays RD, Cunningham WE, Marcus M. The impact of HIV onoral health and subsequent use of dental services. J Public Health Dent 2003;63:78-85. 18. Melchior R, Nemes MIB, Basso CR, et al. Avaliação da estrutura organizacional
184 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 184
da assistência ambulatorial em HIV/AIDS no Brasil. Rev Saúde Pública 2006;40: 143-51. 19. Esperidião MA, Trab LB. Avaliação de satisfação de usuários: considerações teórico-conceituais. Cad Saúde Pública 2006;22:1267-76. 20. World Health Organization. Oral health surveys: basic methods, 4th ed. Geneva: World Health Organization; 1997. 21. Programa Conjunto das Nações Unidas sobre HIV/Aids. A ONU e a resposta à AIDS no Brasil. Brasília: UNAIDS; 2010. 22. Brasil. Ministério da Saúde. Boletim epidemiológico Aids DST-briefing. Brasília: Ministério da Saúde; 2010. 23. Krustrup U, Petersen PE. Dental caries prevalence among adults in Denmark—the impact of sociodemographic factors and use of oral health services. Community Dent Health 2007;24:225-32. 24. Santo AE, Tagliaferro EP, Ambrosano GM, Meneghim MC, Pereira AC. Dental status of Portuguese HIV+ patients and related variables: a multivariate analysis. Oral Dis 2010;16:176-84. 25. Tobias CR, Lemay CA, Jeanty Y, UmezEronini AA, Reznik DA. Factors associated with preventive dental care-seeking behavior among people living with HIV. J Public Health Dent 2012;72:60-7. 26. Mukherjee JS, Ivers L, Leandre F, Farmer P, Behforouz H. Antiretroviral therapy in resource-poor settings decreasing barriers to access and promoting adherence. J Acquir Immune Defic Syndr 2006;43:s123-6. 27. Aleixo AP, Scherma G, Guimarães JR, Cortelli IR, Cortelli SC. DMFT index and oral mucosal lesions associated with HIV infection: cross-sectional study in Porto Velho, Amazonian region—Brazil. Braz Infect Dis 2010;14:449-56.
28. Bretz WA, Flaitz C, Moretti A, Corby P, Schneider LG, Nichols CM. Medication usage and dental caries outcome-related variables in HIV/AIDS patients. AIDS Patient Care STDS 2000;14:549-54. 29. Carey H, Ackerie A, Houtzager L, Purnomo J, Jeganathan S. Oral health referral trigger tools for people living with HIV. Spec Care Dentist 2012; doi: 10.1111/j.1754-4505.2012.00309.x 30. Nasir EF, Marthinussen MC, Åstrøm AN. HIV/AIDS-related attitudes and oral impacts on daily performances: a cross-sectional study of Sudanese adult dental patients. BMC Health Serv Res 2013;13:1-9. 31. Pedreira EN, Cardoso CL, Barroso EC, Santos JA, Fonseca FP, Taveira LA. Epidemiological and oral manifestations of HIV-positive patients in a specialized service in Brazil. J Appl Oral Sci 2008;16: 369-75. 32. Sy AA, Freed BA, Chau FK, Marcus M. National estimates of the characteristics of individuals infected with HIV who are likely to report and receive treatment for painful bleeding gums. Spec Care Dentist 2011;31: 162-9. 33. Engeland CG, Jang P, Alves M, Marucha PT, Califano J. HIV infection and tooth loss. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:321-6. 34. Galvão J. Access to antiretroviral drugs in Brazil. Lancet 2002;360:1862-5. 35. Stein MD, Fleischman J, Mor V, Dresser M. Factors associated with patient satisfaction among symptomatic HIV-infected persons. Med Care 1993;31:182-8. 36. Rungsiyanont S, Vacharotayangul P, Lam-ubol A, Ananworanich J, Phanuphak P, Phanuphak N. Perceived dental needs and attitudes toward dental treatments in HIV-infected Thais. AIDS Care 2012;24: 1584-90.
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
ARTICLE ABSTRACT Purpose: Verify factors that influence the oral health status of people living with HIV/AIDS (PLWHA) in Brazil. Method and materials: The study was cross-sectional and includes 177 HIV-positive individuals, who answered questionnaire on the sociodemographic conditions, HIV aspects, habits, and satisfaction with the service. The oral health data were collected by means of the decayed, missing, and filled teeth (DMFT) index, use and need of dentures, and the Community Periodontal Index. Results: Average number of the DMFT was 17.64. Most HIV-positive patients presented good periodontal status, 35.0% used dentures, 41.5% needed denture in the maxilla, and 62.0% in the mandible. In the multivariate analysis, older age and dissatisfaction with health care were associated with nonuse of dentures. The abandonment of the use of antiretroviral therapy increased the risk of PLWHA presenting more than three decayed teeth. Conclusion: Poor oral health of the PLWHA was mainly influenced by sociodemographic factors and use and satisfaction with service.
KEY WORDS: HIV, oral health, patient satisfaction
176 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 176
Oral health status of people living with HIV/AIDS attending a specialized service in Brazil Gabriella Barreto Soares, MSc;1* Cléa Adas Saliba Garbin, PhD;2 Suzely Adas Saliba Moimaz, PhD;3 Artênio José Ísper Garbin, PhD4 1Master
Programme in Preventive and Social Dentistry, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil; 2Coordinator of Postgraduate Programme in Preventive and Social Dentistry, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil; 3Full Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil; 4Associate Professor, Preventive and Social Dentistry Postgraduate Programme, Araçatuba Dental School, Estadual Paulista University, Unesp, Araçatuba, Brazil. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(4): 176-184, 2014
Int r od uct ion
The epidemic of HIV/AIDS enters into its fourth decade, with epidemiological and clinical features different from those observed in its beginning. This happens due to advances in diagnosis and treatment, with emphasis on the introduction of highly active antiretroviral therapy (HAART) more effectively led to the increase in life expectancy of people living with the disease. This fact led to a greater demand for health services.1,2 Brazil has a free program that is a global benchmark for care of people living with HIV/AIDS (PLWHA), focusing on treatment and control of the epidemic, the service offers exams of the CD4 cell count, Specialized Assistance Services, Day Hospital, anonymous testing centers, Reference Center (RC) with the multidisciplinary team and Home Care, as well as the existence of special legislation for people living with the disease.3 The success of this program is due to this assistance and proper health care, because it contributes to improvement in the mortality, morbidity, and the quality of life of these people. A good way to evaluate the services is through patient satisfaction, and this information is essential to the needs and desires of those who are duly attended.4 Because of this, it stresses the importance of services
to provide quality care, because this way people infected do not feel discouraged to disclose their risk behavior, since the stigma becomes a factor less noted as a deterrent for seeking health care.5,6 At the beginning of the epidemic, associating the PLWHA to homosexuals, intravenous drug users, and sex workers, being popularly called the “gay plague” or “gay cancer” that together with the fear of population contamination, consequently brought a reinforcement in prejudice and discrimination against this part of the population.7 Even after so many years, many people still suffer discrimination, not only by society but also by health professionals. The duty of health professionals to provide comprehensive care for PLWHA has been debated since the beginning. The American Medical Association and
© 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12056
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
other associations determine that the health professionals they represent have an ethical obligation to administer care to these patients, since their needs fall into their areas of competence.8 Even considering all the ethical aspects, through the efforts of the Ministry of Health through the National sexually transmitted disease (STD)/AIDS Program, as well as the support of several nongovernmental organizations, there are still many episodes of discrimination.9 We observed many denials in the care of these people, particularly by the dentists, and the fear of becoming infected during a dental procedure, losing other patients, and lack of psychological preparation are key motives.10 In addition, more barriers are observed in the access to oral health care for PLWHA, including: socioeconomic inequalities, availability of social and financial resources, geographical distances, cultural differences between health professionals and patients, and fear or real experience of preconception.11,12 The patients with HIV allege fear of professional rejection, ethical breach of confidentiality by the dentist, and still think it unnecessary to inform about their HIV status because they perceive the presence of biosecurity measures in the dental office.13 In spite of these difficulties with oral health care, it was also observed that these people are more prone to oral diseases such as caries, periodontal disease, oral lesions, and xerostomia.14–16 This requires prompt treatment and continuous monitoring since the oral health can interfere with eating and the administration of medications, as well as the quality of life of these individuals.17 Given all the aspects related to PLWHA, the aim of this study is to investigate the association of the sociodemographic variables, HIV-related habits, and use of and satisfaction with health services with the oral health of PLWHA assisted in the public service reference in Brazil.
M ethodology
This is an exploratory quantitative crosssectional and analytical study carried out
Soares et al.
scd12056.indd 177
in the public health service offered to PLWHA, STD/AIDS-RC, which has operated since 1992 in the capital of Espírito Santo. The sample selection was carried out by randomly contacting the patients, in each examination day on a dental service, until we completed contacting the 177 subjects. We included patients with a confirmed diagnosis of HIV infection over 18 years of age, and who agreed to participate in the study. Data collection was carried out during four consecutive months in 2012, after a pilot study in which all the variables were tested. Individual interviews and clinical oral examinations were conducted in the dental clinic of the service. The data relating to the sociodemographic questions, issues related to HIV, habits, experienced discrimination, use and satisfaction with services were obtained through a structured questionnaire constructed specifically for this study. The sociodemographic variables included age, gender, color, marital status, education, link to employment, family income, and number of people living at home. Those factors related to HIV and habits are: viral load and CD4, date of HIV diagnosis, mode of infection, antiretroviral therapy, smoking habits, alcohol, drug use, and condom use before and after diagnosis. The data related to discrimination experienced in the health services include: by which professionals, in what kind of service, and the form of discrimination. For the issues in the use of services, there are: frequency of dental visits, difficulty to be serviced in the STD/AIDS-RC, time since the last dental visit, a place where the patient goes to dental treatment, the reason for not seeking the closest Basic Health Unit (BHU), reason for visit and reveal their HIV status to the dentist without being from the STD/AIDS-RC. Finally, the data of satisfaction with the service offered by the STD/AIDS-RC were evaluated through questions adapted by Melchior18 and Esperidião.19 Therefore, we created 11 indicators: physical structure, respect for user privacy, professional/patient
r elationship, opportunities given to the patient to make complaints, support offered by the service, timeliness of health professionals, received guidelines for the treatment, care, convenience of opening hours, availability of antiretroviral drugs and laboratory tests, ease of access to services. Each indicator has gradations ranging from 1 to 5 points, which correspond respectively to the following scores: poor (1 point), bad (2 points), fair (3 points), good (4 points), excellent (5 points), the lowest value being assigned to the sum of all indicators (11) and the maximum value (55) points. The oral health examination was conducted by a calibrated dentist (κ > .81 for all the collected variables), who used the probe recommended by the World Health Organization (WHO) and mouth mirrors. Condition of the teeth, gums, and the use and need of dentures were evaluated according to the codes and criteria for the epidemiological surveys of the WHO.20 For the condition of the teeth, the average number of decayed, missing, or filled teeth (DMFT) was used. The periodontal status was verified by the Community Periodontal Index (CPI), which evaluated the presence of bleeding, calculus, and periodontal pockets. The codes were: 0—healthy, 1—bleeding observed after probing, 2—presence of calculus, 3—pocket 4 to 5 mm, 4—pocket of 6 mm or more, X—excluded sextants (less than 2 teeth), 9—no information. The use of dentures was recorded as follows: 0—no use, 1—fixed bridge, 2—more than one fixed bridge, 3—a removable partial denture, 4—fixed + removable denture, 5—complete dentures, 9—no information. The need for dentures was also evaluated according to the following codes: 0—no need, 1—one denture element, 2—more than one element, 3—combination of dentures, 4—complete dentures, 9—no information.
Data analysis The descriptive analyses were performed to characterize the population through measures of central tendency (simple
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 177
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
frequencies, mean, and median) and measures of dispersion (standard deviation). The sample involved in the research set the normal distribution of probability, assessed by the Kolmogorov and Smirnov tests (p = .001) and the hypotheses were verified with the aid of parametric statistics. The reason for the rejection or not for any of these hypotheses considered a significance level of .05. The statistical analysis of variance (ANOVA) and multiple logistic regression (MLR) tests were conducted with elimination of the nonsignificant variables. The selection of independent variables for the MLR models was performed according to a stepwise model. After adjusting the MLR model with a confidence interval of 95% (CI), the odds ratio and p values were estimated. All statistical tests were performed using the SPSS for Windows version 17.0 program.
Ethical aspects All ethical issues related to the development of the research were met. The research was conducted with the understanding and written consent of each participant. The study protocol was approved by the Ethics Committee for Research with humans from the Paulista State University, School of Dentistry of Araçatuba.
Res u lts
The study included 177 HIV-positive patients, slightly more than half of the sample were women (53.1%) with a mean age of 42 years. Most participants (63.8%) had a monthly income of one to two minimum wages. Regarding family composition, respondents live, on average, with three people. Most were brown (61.6%) and were not in a stable relationship (48.6%). Regarding education, 53.1% had 8 years or less of schooling and 7.3% could not read and write. Upon completion of this study, 62.7% of the participants performed any professional activity, whereas 23.2% of them were unemployed. There are still those who reported receiving benefits from government agencies such as sickness (5.6%) and retirement (8.5%).
178 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 178
Regarding the laboratory data, it was observed that 78.2% had CD4 above 350 cells/mm3, whereas only 5.3% had values below 200 cells/mm3. In the analysis of the viral load, 61.6% were undetectable, whereas 25.0% had values above 10,000 copies/ml. As the time elapsed since the diagnosis of HIV infection, it was observed that 35% stated that there was more than 10 years, with 86.4% of the patients aged 20 to 50 years, when they received the result. The contamination by heterosexual relations was second, 55.9% and 53.1% of the respondents said they did not know who they contracted the virus from. At the time of the survey, 77.4% of the subjects were on the HAART. Patients had a mean DMFT of 17.64 (standard deviation [SD] = 7.786) (2.85 decayed teeth, SD = 3.58; 9.12 missing teeth, SD = 7.95; and 5.67 filled teeth, SD = 4.99). The majority of HIV-positive patients showed good periodontal status (56.6%) and 25.3% had a 4 to 5 mm periodontal pocket. Regarding the use of dentures, 35% of those surveyed used dentures. Among them, 1.69% used a fixed bridge, 18% partial removable dentures, and 10.7% complete dentures. Regarding the need for dentures, 41.5% needed dentures in the maxilla and 62% in the mandible. As for the dental care, 33.3% answered that they have never been to the dentist and 25.4% only when they had pain in a tooth, before the diagnosis of HIV. Of the majority of the interviewed, 75.7% said they sought dental care only in the STD/AIDS-RC, since 93.8% said they had no problems being examinated. Asked why they did not seek the BHU, 24.9% said they would prefer care in the RC, while 22.0% said they had no vacancies in the BHU. The main reasons for visiting a dentist were routine examination (30.5%) and cavities in the teeth (27.1%). A total of 29.9% of the patients said they did not in any way reveal their HIV status to another dentist and 14.1% responded only when asked. Of those who did not reveal, 20.3% said they were afraid of suffering discrimination. Only 16.4% of the interviewed were prejudiced against by health professionals,
the majority of cases by the dentist, followed by the doctor. As for the venue, 13.6% said they were in the public health service. And the refusal in attendance (7.9%), followed by lack of respect/ ignorance (5.6%) were described as ways in which they were discriminated. In the analysis of the 11 indicators used to assess the satisfaction with the health service, it was considered satisfactory by 63.8% of the surveyed, whereas only 36.2% assessed it as unsatisfactory. The dissatisfaction was prevalent in only two indicators: timeliness of professionals and physical structure of the service. In the bivariate analysis, with the CPI as the dependent variable, age, education, age at diagnosis, time of smoking, difficulty to be attend in STD/AIDS-RC, and the reason for the dental visit were associated with p < .05 (Table 1). In the MLR model, having a younger age proved to be less likely to produce periodontal problems (p = .04; Table 3). With the DMFT as the dependent variable, the analysis showed that age, marital status, employment relationship, age at diagnosis, mode of contamination, reason for the dental visit, and the reason why their HIV status was not revealed to other surgeon-dentists, were associated with p < .05 (Table 1). When decayed teeth were used as the dependent variable in the bivariate analysis, the reason for abandonment of the HAART, smoking habit, time of smoking, not having sought the BHU, reason for dental consultation, and revealing their HIV status to another dentist, were associated with p < .05 (Table 2). The multivariate model indicated that people who abandoned the use of the HAART were at risk of having more than three decayed teeth (Table 3). Regarding the filled teeth, the results of the bivariate analysis showed that age, sex, frequency of consultation with the dentist before HIV, local demand for dental care, not revealing their HIV status to another dentist, and service satisfaction were associated with p < .05 (Table 2). Among them, the frequency of visits to the dentist before the diagnosis of HIV was a risk indicator for the presence of a few filled teeth (Table 3).
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 1. Bivariate analysis of the CPI, DMFT, and denture use according to the independent variables of the participants of the study, Brazil, 2012. CPI
DMFT
≤2 n (%)
>2 n (%)
18 to 34
22 (22.0)
48 (62.3)
35 to 44
40 (40.0)
26 (33.8)
45 to 70
38 (38.0)
3 (3.9)
Single
50 (50.0)
36 (46.8)
Married/consensual union
36 (14.0)
13 (28.6)
3 (3.0)
10 (13.0)
11 (11.0)
Denture use
≤18
>18
38 (42.2)
3 (3.4)
26 (28.9)
40 (46.0)
26 (28.9)
44 (50.6)
44 (48.9)
42 (48.3)
34 (37.8)
24 (27.5)
2 (2.2)
11 (12.6)
9 (11.7)
10 (11.1)
6 (6.0)
7 (9.1)
years of schooling
16 (16.0)
3 (3.9)
Employed
54 (54.0)
31 (40.3)
Not employed
46 (46.0)
46 (59.7)
Independent variables
p Value
p Value
No
Yes
37 (29.4)
4 (7.8)
50 (39.7)
16 (31.4)
39 (31.0)
31 (60.8)
64 (50.8)
22 (43.1)
44 (34.9)
14 (27.5)
6 (4.8)
7 (13.7)
10 (11.5)
12 (9.5)
8 (15.7)
5 (5.6)
8 (9.2)
8 (6.3)
5 (9.8)
48 (53.3)
46 (52.9)
61 (48.4)
33 (64.7)
24 (26.7)
27 (31.0)
40 (31.7)
11 (21.6)
13 (14.4)
6 (6.9)
17 (13.5)
2 (3.9)
52 (57.8)
33 (37.9)
65 (51.6)
20 (39.2)
38 (42.2)
54 (62.1)
61 (48.4)
31 (60.8)
p Value
Age .000
.000
.000
Marital status
Widowed Separated/divorced
.058
.049
.157
Education Illiterate
.002
.320
.059
Link to employment .069
.008
.134
Age at diagnosis 20 years
5 (21.7)
9 (52.9)
3 (20.0)
11 (44.0)
11 (35.5)
3 (33.3)
>50 years old
.000
.012
.001
Contamination mode
Do not know
.188
.003
.550
Time of smoking .040
.115
.905
Frequency of dentist examination. before HIV When in pain
22 (22.0)
23 (29.9)
19 (21.1)
26 (29.9)
9 (15.0)
36 (30.8)
Never
36 (36.0)
29 (36.7)
42 (46.6)
23 (26.4)
53 (42.1)
12 (23.6)
Once a year
30 (30.0)
18 (23.4)
22 (24.4)
26 (29.9)
31 (24.6)
17 (33.3)
06 times in 06 months
12 (12.0)
7 (9.1)
7 (7.8)
12 (13.8)
13 (10.3)
6 (11.8)
When in pain
22 (22.0)
23 (29.9)
19 (21.1)
26 (29.9)
9 (15.0)
36 (30.8)
5 (5.6)
6 (6.9)
9 (7.1)
2 (3.9)
85 (94.4)
81 (93.1)
117 (92.9)
49 (96.1)
.577
.062
.049
Service difficulty with STD/AIDS-RC Yes
10 (10.0)
1 (1.3)
No
90 (90.0)
76 (98.7)
Soares et al.
scd12056.indd 179
.009
0.712
.685
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 179
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 1. Continued. CPI Independent variables
≤2 n (%)
DMFT >2 n (%)
p Value
Denture use
≤18
>18
27 (30.0)
26 (29.8)
15 (16.7)
17 (19.5) 44 (50.6)
p Value
No
Yes
45 (35.7)
8 (14.7)
18 (14.3)
14 (27.5)
63 (50.0)
0 (0.0)
p Value
Time elapsed since last consultation Less than 6 months
36 (36.0)
18 (23.4)
6 months to 1 year
17 (17.0)
15 (19.5)
More than 1 year
48 (48.0)
44 (57.1)
48 (53.3)
.359
0.812
.040
Reason for dental consultation Pain
10 (10.0)
6 (7.8)
10 (11.1)
6 (6.9)
12 (9.5)
4 (7.8)
Routine visit
33 (33.0)
21 (27.3)
32 (35.6)
22 (25.3)
42 (33.3)
12 (23.5)
9 (9.0)
15 (19.5)
13 (13.3)
12 (13.8)
34 (34.0)
14 (18.2)
28 (31.1)
20 (23)
Bleeding gums Cavities Oral lesions
.005
.001
15 (11.9)
9 (17.6)
35 (27.8)
13 (25.5)
1 (1.0)
0 (0.0)
1 (1.1)
0 (0.0)
1 (0.8)
0 (0.0)
Extraction
12 (12.0)
13 (16.9)
7 (7.8)
18 (20.7)
20 (15.9)
5 (9.8)
Dentures
1 (1.0)
8 (10.4)
0 (0.0)
9 (10.3)
1 (0.8)
8 (15.7)
26 (81.3)
10 (47.6)
30 (76.9)
6 (42.9)
.006
Reason for not revealing their HIV status to another dentist? Discrimination
26 (74.3)
10 (55.6)
Confidentiality
2 (5.7)
1 (5.6)
Link with professional
2 (5.7)
2 (11.1)
Did not think necessary
5 (14.3)
5 (27.8)
Satisfied
56 (56.0)
54 (70.1)
Unsatisfied
44 (44.0)
23 (29.9)
.541
1 (3.1)
2 (9.5)
2 (6.3)
2 (9.5)
3 (9.4)
7 (33.3)
51 (56.7)
59 (67.8)
39 (43.3)
28 (32.2)
.007
1 (2.6)
2 (14.3)
2 (5.1)
2 (14.3)
6 (15.4)
4 (28.6)
72 (57.1)
38 (74.5)
54 (42.9)
13 (25.5)
.115
Satisfaction with service
Finally, lost teeth were associated with age, education, link to employment, age at diagnosis, reason for the abandonment of the HAART, reason for dental consultation, and satisfaction with service with p < .05 (Table 2). The regression model showed that older age, lower education, and having as the reason for consultation, pain and cavities, were risk factors for the presence of missing teeth (Table 3).
D is cu s s io n
In Latin American countries, it is estimated that 1.4 million people are infected with HIV and nearly half of these individuals live in Brazil. The AIDS epidemic in Brazil is relatively stable, with an estimated prevalence of 0.6% adults, being mostly female, 25 to 49 years old, low income and education, as the data observed in this study.21 Many advances have been achieved by that
180 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 180
.053
third decade of the HIV epidemic with the National STD/AIDS-RC in Brazil, including dental care, however, few studies have been carried out to demonstrate this improvement, as well as surveys to assess the oral health status of Brazilian adults living with HIV/AIDS. With regard to tooth decay, the PLWHA had on average of 17.64 DMFT index. Comparing this result with the data from the Epidemiological Surveys of the 2010 National Oral Health, the average DMFT of Brazilian adults was 16.3, one can see a poorer dental status of the PLWHA Brazilians.22 The sociodemographic variables were able to identify the PLWHA with bad oral health conditions where respondents who had links to employment, more than 9 years of schooling, and were of younger age, were less likely to have high levels of DMFT. This is also observed in studies of the general population, in which the socioeconomic status is a determining factor in
.126
.028
health with improved access to information and demand for a healthier life.23–25 The abandonment of antiretroviral therapy for reasons of discouragement, not accepting the disease, use of drugs and alcohol, were also risk factors for decayed and missing teeth. One explanation for this is that with nonadherence to treatment, the viral load increases and CD4 cells decrease, which causes the decrease of immunity, which appear as a result of opportunistic diseases, including oral disorders.26 In addition, studies show that patients on HAART have a lower occurrence of carious surfaces than those that are not. This is because patients that tend to adhere to treatment are more likely to seek health care and therefore, more often visit the dentist and the dental treatment is performed completely.27–29 Historically, in Brazil, the adult population has been intended for emergency dental services, mostly caused by pain,
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 2. Bivariate analysis of decayed teeth, missing teeth, and filled teeth variables according to the independent variables of the participants of the study, Brazil, 2012. Decayed teeth Independent variables
≤6 n (%)
>6 n (%)
18 to 34
28 (23.0)
13 (23.6)
35 to 44
40 (32.8)
26 (47.3)
45 to 70
54 (44.3)
16 (29.1)
Female
63 (51.6)
31 (56.4)
Male
59 (48.4)
24 (43.6)
9 (7.4)
4 (7.3)
years of schooling
15 (12.3)
4 (7.3)
Employed
56 (45.9)
29 (52.7)
Not employed
66 (54.1)
26 (47.3)
8 (6.6)
3 (5.5)
20 to 50 years old
10 (84.4)
50 (90.9)
>50 years old
11 (9.0)
Filled teeth ≤6 n (%)
>6 n (%)
30 (26.8)
10 (16.1)
35 (31.3)
30 (48.4)
47 (42.0)
22 (35.5)
52 (46.4)
39 (62.9)
60 (53.6)
23 (37.1)
11 (9.8)
2 (3.2)
62 (55.4)
30 (48.8)
29 (25.9)
21 (33.9)
10 (8.9)
9 (14.5)
52 (46.4)
31 (50.0)
60 (53.6)
31 (50.0)
9 (8.0)
2 (3.2)
93 (83.0)
57 (91.9)
2 (3.6)
10 (8.9)
p Value
Missing teeth ≤9
>9
38 (35.2)
2 (3.0)
40 (37.0)
25 (37.9)
30 (27.8)
39 (59.1)
55 (50.9)
36 (54.5)
53 (49.1)
30 (45.5)
5 (4.6)
8 (12.1)
48 (44.4)
44 (66.7)
39 (36.1)
11 (16.7)
16 (14.8)
3 (4.5)
58 (53.7)
25 (37.9)
50 (46.3)
41 (62.1)
11 (10.2)
0 (0.0)
93 (86.1)
57 (84.6)
3 (4.8)
4 (3.7)
9 (13.6)
p Value
p Value
Age
.111
.063
.000
Sex .560
.036
.643
Education Illiterate
.704
.172
.001
Link to employment .400
.652
.001
Age at diagnosis 20 years
4 (19.0)
10 (52.6)
12 (44.4)
2 (16.7)
6 (27.3)
8 (47.1)
27 (24.1)
16 (25.8)
23 (21.3)
20 (30.3)
52 (45.4)
12 (19.3)
39 (36.1)
25 (37.8)
24 (21.4)
24 (38.7)
33 (30.6)
15 (22.7)
9 (8.0)
10 (16.1)
13 (12.0)
6 (9.1)
.034
.549
.037
Smoker .013
.468
.411
Time smoking .025
.083
.202
Consultation frequency at dentist before HIV When in pain
32 (26.2)
13 (23.6)
Never
42 (34.5)
23 (41.8)
Once a year
35 (28.7)
13 (23.6)
Every 6 months
13 (10.7)
6 (10.9)
Soares et al.
scd12056.indd 181
.798
.000
.375
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 181
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 2. Continued. Decayed teeth Independent variables
≤6 n (%)
>6 n (%)
Filled teeth
p Value
≤6 n (%)
>6 n (%)
Missing teeth
p Value
≤9
>9
p Value
Location that usually seeks dental services Health service near home
8 (6.6)
3 (5.5)
6 (5.4)
4 (6.5)
6 (5.6)
4 (6.1)
AIDS STD-RC
92 (75.6)
42 (76.4)
88 (78.6)
44 (71.0)
79 (73.1)
53 (80.3)
Private practice
17 (13.9)
8 (14.5)
15 (13.4)
10 (16.1)
16 (14.8)
9 (13.6)
Dental plan
4 (3.3)
0 (0.0)
.131
0 (0.0)
4 (6.5)
.042
4 (3.7)
0 (0.0)
No where
0 (0.0)
2 (3.6)
2 (1.8)
0 (0.0)
2 (1.9)
0 (0.0)
Bureaucracy
12 (10.4)
8 (14.4)
13 (13.1)
7 (12.1)
10 (9.8)
10 (15.9)
Discrimination/fear/secrecy
19 (16.5)
6 (11.5)
13 (12.2)
12 (20.7)
18 (17.6)
7 (11.2)
Did not take care of health
1 (0.9)
4 (7.7)
5 (4.7)
0 (0.0)
3 (2.9)
2 (3.2)
19 (16.5)
2 (3.8)
12 (11.2)
9 (15.5)
12 (11.8)
9 (14.3)
9 (7.8)
4 (7.7)
9 (8.4)
4 (6.9)
7 (6.9)
7 (11.1)
No vacancies
26 (22.6)
13 (25.0)
24 (22.4)
13 (22.4)
26 (25.5)
11 (17.5)
Preferred dentist attendance
29 (25.2)
15 (28.8)
31 (29.0)
13 (22.4)
28 (27.5)
16 (25.4)
8 (6.6)
8 (14.5)
8 (7.1)
6 (9.7)
10 (9.3)
4 (6.1)
Routine visit
44 (36.1)
10 (18.2)
33 (29.5)
20 (32.3)
37 (34.3)
16 (24.2)
Bleeding gums
23 (18.9)
1 (1.8)
14 (13.0)
10 (15.2)
Decayed teeth
27 (22.1)
21 (38.2)
33 (30.6)
15 (22.7)
Oral lesions
0 (0.0)
Tooth extraction Dentures
.220
Reason for not searching the BHU
Didnotneed Did not have a health service
.020
.453
.619
Reason for dental visit Pain
17 (15.2)
7 (11.3)
28 (25.0)
20 (32.3)
1 (1.8)
1 (0.9)
0 (0.0)
1 (0.9)
8 (12.1)
11 (9.0)
14 (25.5)
18 (16.1)
4 (11.3)
12 (11.1)
13 (19.7)
9 (7.4)
0 (0.0)
7 (6.3)
2 (3.2)
1 (0.9)
8 (12.1)
56 (51.9)
41 (62.1)
37 (34.3)
16 (24.2)
.000
.659
.013
Reveal their HIV status to the dentist without being from the STD/AIDS-RC Yes
59 (48.4)
40 (72.7)
No
42 (34.4)
11 (20.0)
64 (57.1)
33 (53.2)
33 (29.5)
20 (32.3)
Only if asked
21 (17.2)
4 (7.3)
15 (13.4)
9 (14.5)
15 (13.9)
9 (13.6)
Discrimination Confidentiality
29 (69.0)
7 (63.6)
25 (75.8)
11 (55.0)
28 (75.7)
8 (50.0)
2 (4.8)
1 (9.1)
0 (0.0)
3 (15.0)
2 (5.4)
1 (6.3)
Link with professional
3 (7.1)
1 (9.1)
4 (12.1)
0 (0.0)
1 (2.7)
3 (18.8)
Did not think neccesary
8 (19.0)
2 (18.2)
4 (12.1)
6 (30.0)
6 (16.2)
4 (25.0)
Satisfactory
77 (58.3)
33 (60.0)
68 (60.7)
39 (62.9)
62 (57.4)
45 (68.2)
Unsatisfactory
45 (41.7)
22 (40.0)
44 (39.3)
23 (37.1)
46 (42.6)
21 (31.8)
.008
.883
.172
Reason for not revealing
.952
.006
.172
Satisfaction with service
which usually results in missing teeth. Having searched the dentist for the reason of pain or tooth decay, increased the risk of PLWHA, having more than nine missing teeth in the mouth. This
182 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 182
.257
shows that the demand for dental care happens when the dental disease is already at an advanced stage, which causes irritation and pain. A direct consequence of this systematic exclusion of
.044
.047
services, extractions are outcomes that, in most cases, could be avoided.30 With regard to periodontal status, less than half of the interviewed presented alterations, and studies have
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
Table 3. Multiple logistical regression for the PCI, DMFT, denture use, decayed teeth, filled teeth, and missing teeth in dependent variables of the participants of the study, Brazil, 2012. Odds ratio
Confidence interval
p Value
5.954
1.76–20.123
.004
2.472
0.788–7.755
.121
Older age
2.624
1.609–4.279
.000
Unsatisfied with service
2.656
1.262–5.588
.010
Abandonment of HAART because of discouragement
0.125
0.015–1.029
.050
Smoker
0.006
0.000–0.406
.017
Not reveal HIV status for dentist out of RC
66.223
66.223–0.394
.109
2.047
1.143–3.666
.016
Older age
2.974
1.771–4.997
.000
Lower education level
0.507
0.311–0.829
.007
Reason for pain and cavities in the teeth
1.254
1.021–1.541
.031
Variables CPI Older age DMFT Contamination via sex Denture use
number of decayed and missing teeth and the need for dentures characterizes the sample as a group in great need of dental care. This reflects the importance of providing adequate treatment and quality for the patient, with improvement in the implementation of oral (dental) rehabilitation strategies due to the large number of missing teeth, as well as the appreciation of the dentist in multi-RCs, and also the realization of educational programs for greater adherence to health care and dental care for these patients.
Decayed teeth
Filled teeth Little or no examination before HIV diagnosis Missing teeth
shown that patients with low levels of CD4 cells have a higher prevalence of periodontal disease, and the good condition of the participants may be explained by the high levels of CD4 cells.31,32 In relation to the use of dentures, it is observed that those with older age, greater missing teeth, and thus, use more dentures, increases the search for the dental services offered. However, access to free prosthetic treatment in Brazil is still complicated, there is a long waiting list for patients needing dentures and they do not have the financial means to afford a private service, because of that they give up the dental treatment.33 This fact is seen in this study with the high number of people who need dentures in the maxilla and mandible. Since 1990, Brazil offers free health assistance, specialized quality, and universal access for PLWHA, it reflects the results of the satisfaction of surveyed with the service offered by the STD/ AIDS-RC, and the few reports of dissatisfaction were mostly related to physical structure and timeliness of professionals,
Soares et al.
scd12056.indd 183
also observed in other studies.34,35 The fact that these patients were satisfied with the referral service, reflects the seeking of dental care, which was not very common before the diagnosis of HIV. This lack of oral care before the discovery of infection, caused the PLWHA of the study to present fewer restored teeth. After the discovery of serology, the majority of respondents sought dental care only in the STD/AIDS-RC, as it reported no problems obtaining consultation and the preference compared with the BHU in the neighborhood in which they live.One reason is that not disclosing the HIV status to the dentist who is not a referral service for fear of discrimination and suffering of others knowing their health condition. This preference for specialized services and even far from the places in which they live is also reported in other studies, with reasons related to the stigma of a society living with HIV/AIDS.9,36 Many people living with chronic diseases, such as HIV live with preventable and untreated dental problems. The
C oncl us ion
The poor oral health of PLWHA was mainly influenced by the sociodemographic factors, issues related to HIV, use and satisfaction with service.
References 1. Sepkowitz KA. AIDS: the first 20 years. N Engl J Med 2001;344:1764-72. 2. Porter K, Babiker A, Bhaskaran K, et al. Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet 2003;362:1267-74. 3. Campos TS, Ribeiro LCC. Perfil epidemiológico dos pacientes com HIV/AIDS no Alto Vale do Jequitinhonha, 1995–2008. Rev Med Minas Gerais 2011;21:14-8. 4. Jenkison C, Coulter A, Bruster S, Richards N, Chandola T. Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care. Qual Saf Health Care 2002;11:335-9. 5. Solorio MR, Currier J, Cunningham W. HIV health care services for Mexican migrants. J Acquir Immune Defic Syndr 2004; 37:5240-51. 6. Rungsiyanont S, Lam-ubol A, Vacharotayangul P, Sappayatosok K. Thai dental practitioners’ knowledge and attitudes regarding patients with HIV. J Dent Educ 2013;77:1202-8. 7. Creel AH, Rimal RN, Mkandawire G, Boose K, Brown JW. Effects of a mass media intervention on HIV-related stigma: ‘Radio Diaries’ program in Malawi. Health Educ Res 2011;26:456-65. 8. Bryan CS. HIV/AIDS and bioethics: historical perspective, personal retrospective. Health Care Anal 2002;10:5-18.
S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4 183
23/06/14 9:51 PM
O R A L H E A LT H S TAT U S O F P E O P L E L I V I N G W I T H H I V / A I D S
9. Garbin CAS, Martins RJ, Garbin AJI, Lima DC, Prieto AKC. Percepção de paciente HIV-positivo de um centro de referência em relação a tratamento de saúde. DST—J Bras Doenças Sex Transm 2009;21:107-10. 10. Sheldon J, Murray E, Johnson A, Haines A. The involvement of general practitioners in the care of patients with human immunodeficiency virus infection: current practice and future implications. FamPract 1993;10:396-9. 11. Oliveira IBN. Acesso universal? Obstáculos ao acesso, continuidade do uso e gênero em um serviço especializado em HIV/AIDS em Salvador, Bahia, Brasil. Cad Saúde Pública 2009;25:259-68. 12. Marcus M, Maida CA, Coulter ID, et al. A longitudinal analysis of unmet need for oral treatment in a national sample of medical HIV patients. Am J Public Health 2005;95: 73-5. 13. Shiboski CH, Palacio H, Neuhaus JM, Greenblatt RM. Dental care access and use among HIV-infected women. Am J Public Health 1999;89:834-9. 14. Weinert M, Grimes RM, Lynch DP. Oral manifestations of HIV infection. Ann Intern Med 1996;125:485-96. 15. Petersen PE. Strengthening the prevention of HIV/AIDS-related oral disease: a global approach. Community Dent Oral Epidemiol 2004;32:399-401. 16. Petruzzi MN, Cherubini K, Salum FG, Figueiredo MA. Risk factors of HIV-related oral lesions in adults. Rev SaúdePública 2013; 47:52-9. 17. Dobalian A, Andersen RM, Stein JA, Hays RD, Cunningham WE, Marcus M. The impact of HIV onoral health and subsequent use of dental services. J Public Health Dent 2003;63:78-85. 18. Melchior R, Nemes MIB, Basso CR, et al. Avaliação da estrutura organizacional
184 S p e c C a r e D e n t i s t 3 4 ( 4 ) 2 0 1 4
scd12056.indd 184
da assistência ambulatorial em HIV/AIDS no Brasil. Rev Saúde Pública 2006;40: 143-51. 19. Esperidião MA, Trab LB. Avaliação de satisfação de usuários: considerações teórico-conceituais. Cad Saúde Pública 2006;22:1267-76. 20. World Health Organization. Oral health surveys: basic methods, 4th ed. Geneva: World Health Organization; 1997. 21. Programa Conjunto das Nações Unidas sobre HIV/Aids. A ONU e a resposta à AIDS no Brasil. Brasília: UNAIDS; 2010. 22. Brasil. Ministério da Saúde. Boletim epidemiológico Aids DST-briefing. Brasília: Ministério da Saúde; 2010. 23. Krustrup U, Petersen PE. Dental caries prevalence among adults in Denmark—the impact of sociodemographic factors and use of oral health services. Community Dent Health 2007;24:225-32. 24. Santo AE, Tagliaferro EP, Ambrosano GM, Meneghim MC, Pereira AC. Dental status of Portuguese HIV+ patients and related variables: a multivariate analysis. Oral Dis 2010;16:176-84. 25. Tobias CR, Lemay CA, Jeanty Y, UmezEronini AA, Reznik DA. Factors associated with preventive dental care-seeking behavior among people living with HIV. J Public Health Dent 2012;72:60-7. 26. Mukherjee JS, Ivers L, Leandre F, Farmer P, Behforouz H. Antiretroviral therapy in resource-poor settings decreasing barriers to access and promoting adherence. J Acquir Immune Defic Syndr 2006;43:s123-6. 27. Aleixo AP, Scherma G, Guimarães JR, Cortelli IR, Cortelli SC. DMFT index and oral mucosal lesions associated with HIV infection: cross-sectional study in Porto Velho, Amazonian region—Brazil. Braz Infect Dis 2010;14:449-56.
28. Bretz WA, Flaitz C, Moretti A, Corby P, Schneider LG, Nichols CM. Medication usage and dental caries outcome-related variables in HIV/AIDS patients. AIDS Patient Care STDS 2000;14:549-54. 29. Carey H, Ackerie A, Houtzager L, Purnomo J, Jeganathan S. Oral health referral trigger tools for people living with HIV. Spec Care Dentist 2012; doi: 10.1111/j.1754-4505.2012.00309.x 30. Nasir EF, Marthinussen MC, Åstrøm AN. HIV/AIDS-related attitudes and oral impacts on daily performances: a cross-sectional study of Sudanese adult dental patients. BMC Health Serv Res 2013;13:1-9. 31. Pedreira EN, Cardoso CL, Barroso EC, Santos JA, Fonseca FP, Taveira LA. Epidemiological and oral manifestations of HIV-positive patients in a specialized service in Brazil. J Appl Oral Sci 2008;16: 369-75. 32. Sy AA, Freed BA, Chau FK, Marcus M. National estimates of the characteristics of individuals infected with HIV who are likely to report and receive treatment for painful bleeding gums. Spec Care Dentist 2011;31: 162-9. 33. Engeland CG, Jang P, Alves M, Marucha PT, Califano J. HIV infection and tooth loss. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:321-6. 34. Galvão J. Access to antiretroviral drugs in Brazil. Lancet 2002;360:1862-5. 35. Stein MD, Fleischman J, Mor V, Dresser M. Factors associated with patient satisfaction among symptomatic HIV-infected persons. Med Care 1993;31:182-8. 36. Rungsiyanont S, Vacharotayangul P, Lam-ubol A, Ananworanich J, Phanuphak P, Phanuphak N. Perceived dental needs and attitudes toward dental treatments in HIV-infected Thais. AIDS Care 2012;24: 1584-90.
Oral health status of people living with HIV/AIDS
23/06/14 9:51 PM
