This cross-sectional study evaluated OHRQoL and its risk factors in patients living in Shiraz and infected with HIV. They declared that in the last 4 weeks, they satisfied from averagely 70% of asked items of OHRQoL. The worst and best satisfactions were from their concern about mouth problems and frequency of medication use, respectively. After controlling the confounding factors, we found that the patients wearing partial or complete denture had better OHRQoL than those not wearing.
In our study, the patients infected with HIV acquired more than two third of OHRQoL scores. Various studies had used different instrument for evaluating OHRQoL in patients with HIV; therefore, the comparison of their results was so difficult. However, the studies revealed that patients infected with HIV experienced a significantly worst OHRQoL for total and every dimension than general population. This difference was evident even though the groups were similar in their socioeconomic backgrounds and health behavior risk factors (6, 9, 12, 13). The patients' OHRQoL was reported poorer than those suffering from other diseases such as phobic dental anxiety, dentofacial deformity, and xerostomia (9). Studies also revealed that the patients' OHRQoL improved over time (10, 12). Therefore, positive changes happened in oral health access and coverage over time. It maybe because of decreasing in stigma and discrimination historically associated with HIV, and greater willingness of dental practitioners to provide dental care (10). A previous study also showed that participants with oral symptoms had poorer OHRQoL than those without the symptoms (6). Therefore, poor results of OHRQoL in patients with HIV reported from several studies (8, 14, 15) supported the hypothesis that the patients had significant oral health needs. In addition, studies showed that patients living with HIV in the United States and Malaysia had much better OHRQoL than the patients in our study (6, 10). The finding highlighted the importance of establishing programs to improve oral health access for the patients in Iran. A study provided evidence of an important link between oral health and general health. This finding highlighted the importance of collaboration between medical and dental professionals to improve the delivery of oral health care services to patients with HIV (6).
We found the worst OHRQoL scores in psychological category. The participants reported that in about half of the times in the last 4 weeks, they were worried or concerned about problems with their mouth. Mohamed and his coworkers also found that the most affected OHRQoL category in adults living with HIV/AIDS in Malaysia was psychological discomfort. "Discomfort due to food getting stuck between teeth or dentures" was the item within the psychological discomfort category that had the highest impact on OHRQoL (6). We also found the best OHRQoL scores in pain category and then social category. Most of our participants reported that in the last 4 weeks, they did not use or use a little medication to relieve pain or discomfort with their mouth. In contrast, Parish and coworkers found the highest impact on OHRQoL for the items assessing the presence of painful aching in the mouth and discomfort while eating (10). Similar to our study, Mohamed and his coworkers study, also, showed the lowest oral impact was for social disability so that no participant reported having impacts of ‘fairly often’ or ‘very often’ for “avoided going out” (6). In Adeniyi and coworkers study and Massarente and coworkers study, oral symptoms was identified as one of the most affected categories of OHRQoL (16, 17). There were some reasons for the different result of the studies. Different cultures of people living in different countries, establishing different health promotion programs for patients with HIV, and using various instruments for evaluation of OHRQoL in different studies were some of the reasons.
In our study, similar to other studies (5, 8, 16, 17), there was not a significant difference between female and male individuals' OHRQoL. Nevertheless, in Tomar and coworkers study, women had worse OHRQoL than men (15). Although we found a significantly positive correlation between patients' age and their OHRQoL, the correlation was not confirmed in regression analysis. Also, we found a controversy in this regard in literature. Some studies revealed that older age was associated with worse OHRQoL (8, 10). Nevertheless, other study could not show a significant association between the patients' age and their OHRQoL (16).
Evaluating socioeconomic factors, we could not show any association between OHRQoL and factors such as the patient's marriage status and education, and the number of children in the family. Furthermore, although a significant association between the patients' job and their OHRQoL was shown in univariate analysis, it was not confirmed in regression analysis. Other studies also could not show a significant association between the patients' OHRQoL and the following socioeconomic factors: income per capita (8), number of people residing in the family home (8, 17), education level (8), children's height-for-age ratio (2), household ownership (17). In contrast, studies showed worse OHRQoL for the unemployed (4, 7, 15), brown or black people (4), and those with lower education level (7) and lower personal monthly income (6, 7, 9, 10, 18). Also, studies showed that the patients with HIV that had adequate social support experienced better OHRQoL (10, 17). For example, the children having their own mother as caretaker had better OHRQoL (17). In addition, the patients with low social support that had symptoms of anxiety, depression, and loneliness experienced lower OHRQoL than those without the symptoms (10).
In our study, similar to other studies (8, 15) the patients' OHRQoL was not significantly associated to duration of disease. Also, we could not show a significant association between the patients' OHRQoL and their rout of HIV transmission. In contrast, Coulter and coworkers found that among patients infected with HIV, homosexual men had better OHRQOL than intravenous drug abusers (7). While a study explained that no HIV-related variables predicted OHRQoL (18), other studies showed that factors such as viral load (4, 17), CD4 cell counts (9), and AIDS diagnosis (7) that indicated severity of HIV infection were significantly associated with the patients' OHRQoL. Also, use or not use of antiretroviral therapy (4) and duration of the use (9) were found to be related to the patients' OHRQoL.
Although several other studies (7, 9, 10, 15, 18) showed significant association between cigarette smoking and OHRQoL in patients with HIV, our study could not confirm the association. Low OHRQoL in cigarette smokers is likely due to the direct dental problems such as tooth loss and mucosal inflammation caused by smoking. In addition, we could not show that the patients' OHRQoL was significantly associated to alcohol drinking. However, other studies showed that alcohol consumption had a negative impact on OHRQoL of people with HIV (4, 9). Also, our study could not show a significant association between the patients' OHRQoL and history of being in prison. In contrast, Tomar and coworkers showed poorer OHRQoL for those living in temporary housing, prison, or other institutional settings (15). The observed differences between the results might be because of different design of the studies and evaluation of different confounding factors in the studies.
In our study, the edentulous patients had significantly better OHRQoL than those had at least one tooth in their mouth in univariate analysis. However, we could not confirm the association after controlling the confounding factors in multiple regression analysis. In contrast, Mulligan and coworkers showed that total number of teeth was significantly related to OHRQoL so that each additional tooth was associated with a 1% improvement in OHRQoL scores (9). In addition, in our study, those wearing denture had significantly better OHRQoL than those not wearing. Also, the wearing denture was the only factor with significant association with OHRQoL in multiple regression analysis. In contrast, Jeganathan and coworkers study found that the patients wearing a removable denture had worse OHRQoL than those with natural dentition (18). The difference between the results of these studies and our findings might be because of the high proportion of decayed and bad quality teeth in our patients' mouth that led to oral symptoms. Mohamed and his coworkers showed that a cavitated tooth and toothache were significantly associated with reduced OHRQOL (6). In addition, the difference might be because of high proportion of patients that needed denture but could not buy it. Soares and coworkers found an association between need for dentures and worse OHRQoL (4). Parish and coworkers showed that unmet dental needs had the strongest positive association with poor OHRQoL and the fulfillment of dental needs could have a positive impact on the OHRQoL (10). Rovaris and coworkers study showed that the children living with HIV had high dental treatment need and as a result poor OHRQoL (8). Therefore, although the care of the patients living with HIV significantly improves recently, there are still important challenges regarding their management and treatment. This highlights the need for establishment of multidisciplinary interventions in this regard.
To improve OHRQoL in patients living with HIV, we recommend authorities to design health programs to improve the knowledge of caregivers on the importance of oral health in the patients. For better health outcomes, dentists should also be included in the team managing the patients. Dentists should implement OHRQoL assessments in their management of the care of patients with HIV to identify those who had significant oral health impacts (9). Public healthcare programs should establish for better prevention and treatment of dental and oral problems in this vulnerable population. Regarding high proportion of edentulous patients in this population, authorities should consider denture as an unmet need in the patients and provide facilities to help the patients to become denture owners. A study showed that there was a significant positive association between OHRQoL and general HRQoL (7). Therefore, improving the patients' OHRQoL can improve their general HRQoL and as a result can lead to health promotion.