This cross-sectional study evaluated the oral health status of HIV-infected patients living in Shiraz and factors affecting their status. Although half of the patients had 15 or more missed teeth and about one third of them were edentulous, only about 14% of them were wearing partial or complete denture. Furthermore, half of the patients had a DMFT score of more than 21. The oral heath indices were worse in men, older patients, and those with longer duration of HIV infection. Also, the patients with high risk behaviors such as smokers, alcoholics, addicts, and those with a previous history of imprisonment had poorer oral health status.
The high DMFT score found in the present study was very similar to that of another Iranian study (DMFT = 19.8) (3). The higher DMFT score in HIV-infected patients as compared with that in Iranian general population (DMFT = 7.33) (15) highlights the severity of dental problems in this group. The mean DMFT score in HIV-infected patients was similarly higher than that in non-infected ones in an Indian study as well (22). Furthermore, in the present study, similar to another Iranian study (3), the number of missed teeth (mean = 17.10) was more than the number of filled (mean = 2.06) and decayed (mean = 2.71) teeth. The high number of missed teeth in the present study as compared to others (3, 8, 13, 23) might be because of the number of older patients. Furthermore, extraction was reported as most frequent service that HIV-infected patients received because these patients tended to attend emergency dental visits where mainly led to tooth extraction instead of restorative treatments (3). Another reason might be the poor oral hygiene among these patients. In the present study, only 45.5% of the dentate patients declared that they brushed their teeth daily. Therefore, to improve the situation, we recommend policymakers to develop and implement educational programs to promote tooth brushing and other preventive modalities among this population. Furthermore, the high number of missed teeth might be because of patients’ socioeconomic status, which forced them to decide to extract treatable teeth. Therefore, educational programs are recommended to highlight the importance of preserving teeth and potential consequences of losing natural teeth. In addition, because of patients’ socioeconomic status and their fear of rejection by dental providers, dental clinics dedicated to HIV-infected patients, where the patients can be treated at a subsidized cost are needed. A dental clinic in Shiraz and similar clinics in other large cities in Iran are dedicated to HIV-infected patients. However, the high score of DMFT index and low percentage of patients wearing denture in the present study indicate that the provided services are inadequate or there may be some other barriers preventing these patients from receiving the offered services. Further qualitative research is warranted to explore these barriers from patient’s perspective.
Patients’ PI in the present study (PI = 1.11) was very similar to that in Indian studies with the same population [PI = 1.17 (24) & 1.40 (25)]. However, a south African study reported a much higher PI [PI = 2.55 (26)]. Furthermore, using CPI, we found healthy gingiva in about 40% of the patients. In contrast, in another Iranian study, only 1.5% of the patients had a healthy periodontium (3). An Indian study also reported healthy gingiva in 21.2% of HIV-infected patients (27) while in two other Indian studies, only 2% (13) and 0.8% (22) of the patients had healthy gingiva. The discrepancy in findings of these studies might be the result of the participants' oral hygiene because a significant association was confirmed between oral hygiene habits and periodontal status in HIV-infected patients (26). In a study conducted in Brazil, 85% of the HIV-infected patients cleaned their teeth once a day and about 84% of them had healthy gingiva (28). Overall, researchers found poorer periodontal status in patients with HIV as compared to non-HIV patients (22). Periodontal problems might be the first sign of HIV infection in oral cavity because immune suppression could create the change in oral tissue and micro flora that could lead to periodontal disease. Furthermore, side effects of the drugs used for the patients, poor oral hygiene, and smoking could deteriorate the periodontal status (27). Therefore, practical guidelines should be established for improving home care of these patients. In addition, regular periodontal check-ups, early and appropriate treatment of periodontal disease, and smoking cessation programs should be facilitated for them through public clinics.
All oral heath indices evaluated in the present study were worse in men than women. Another Iranian study also found that missing teeth was more prevalent in male individuals than female ones. However, after controlling the confounding factors such as smoking, the researchers could not find the association between sex and missing tooth (29). Therefore, poor oral health indices in men might be the effects of other health behaviors such as smoking, which was more prevalent in men. Furthermore, in the present study, similar to other studies (23, 8), by increasing the participants' age, their DMFT indices and the percentage of edentulous patients increased. Older HIV-infected patients suffered from more comorbidities than younger ones and patients with comorbidities had higher DMFT indices (8). Furthermore, poor oral health indices in older patients could be explained by more dental extractions due to caries, and periodontal diseases (29). Therefore, we should consider male and older patients as vulnerable groups, and implement more intensive preventive measures for these groups.
The present study showed a significant association between some oral health indices and indicators of socioeconomic status. For example, similar to other studies (3, 9, 30), we found unemployed patients or those with a temporary job to have the worst oral health indices. Patients with permanent job had more income and more access to dental services. Furthermore, they might have dental insurance; therefore, they were more likely to use dental care services including dental check-ups regularly (31). We also found a significant association between patient’s education and some of oral health indices, which is similar to other reports (23, 9). Less educated people may experience poor oral health because of lack of knowledge about oral hygiene (32, 33). Furthermore, in the present study and other studies (3, 9), oral health indices were significantly associated with patients' marital status. The relationship between the oral health indices and socioeconomic factors emphasized on the fact that high cost of oral health care services was one of the most important factors that limited the utilization of dental services among HIV-infected patients. Therefore, providing appropriate health insurance and essential facilities for these patients is an effective intervention in promoting their oral health status.
In the present study, the patients' oral health indices were significantly associated to factors related to HIV infection including duration of HIV infection and route of HIV transmission. In the present study, similar to another study (23), oral health status was worse in patients suffering from HIV infection for a longer period. Likewise, more unmet dental needs (18) and more prosthetic need (30) were found in HIV-infected patients with more years since being diagnosed. Other studies also showed the association between poor oral health indices in the patients and other related factors of HIV infection, i.e. high viral load (34) and advanced stages of HIV infection (3). The results indicated that better oral health was dependent on better HIV control and confirmed the association between general and oral health. Therefore, to promote the patients' oral health, policymakers should design programs for better control of their HIV infection. Moreover, HIV-infected patients were from groups with different levels of high risk behaviors. Some of them, such as IV drug abusers and those with multi-sexual partners, committed several high-risk behaviors. However, other groups, such as those that HIV transmitted to them from their spouse or newborns infected by mothers, might not experience any high-risk behaviors. The present study showed better oral health indices of the latter group in comparison with the former one. For example, the probability of being edentulous was 5.67 times more in the participants that HIV transmitted to them via an illegal sexual contact than those transmitted to them from their spouse. Other studies also showed a significant association between route of HIV transmission and some oral health indices such as number of missing teeth (23) and DMFT index (9). The result highlights the importance of establishing educational and supportive programs for HIV-infected patients with high-risk behaviors.
In the present study, similar to other studies (9, 29, 30), patients' oral health indices were significantly worse in those who smoked cigarette or hookah than in the non-smokers. This might be because of low PH (35) and inadequate buffering capacity of smokers' saliva (36). In addition, compared with non- alcoholic patients, alcoholic ones, in the present study and other studies (1, 37), had worse oral health indices. Gupta and coworkers (38) showed lower salivary flow rate and PH in alcoholics than non-alcoholics, which could be the reason for their poor oral health. Furthermore, similar to santo and coworkes' study (30), the present study showed worse oral health indices in patients addicted to smoked or injected illegal drugs. The result was predictable because previous studies also showed serious oral health problems including generalized dental caries, periodontal diseases, and tooth loss in drug abused individuals who are not infected by HIV (39). Moreover, in the present study, the oral health indices were worse in patients with a previous history of imprisonment, which was similar to what Vainionpää and coworkers reported. They found poor oral health status in prisoners so that 80% of them had the need for restorative treatment. In their study, the mean DMFT score of prisoners was 17 and no one had healthy periodontium (40). Prisoners had harmful oral health-related behaviors (40), which leaded to poor oral health (41). They also had high level of unmet dental need because of physical, financial, or cultural barriers to dental care (41). Furthermore, their personal knowledge, attitude, and behavior regarding seeking and maintaining oral health could aggravate the problem (41). Therefore, we recommend policymakers to consider prisoners or persons with a history of imprisonment as a vulnerable group. To meet the unmet needs of vulnerable groups such as cigarette smokers, alcoholics, drug addicts, and prisoners, policymakers should establish health promotion programs.
Although we tried our best to conduct a well-designed study, there were some limitations that need to be acknowledge. First, the study was cross-sectional so all limitations of this type of study should be considered. The most important was about the casual inferences between the variables, which was questionable. Therefore, to determine factors affecting oral health status of HIV-infected patients accurately, a prospective cohort study would be more appropriate. The second limitation was selection of participants from a single VCT center, which was the only referral center for HIV-infected patients in Shiraz. It was a national requirement that all HIV-infected patients were referred to a VCT center. However, some patients did not comply to attend the center; therefore, we did not have access to them. It is possible that patients refusing regular follow-up care experienced worse health status than those being under the care. Therefore, the oral health status of all HIV-infected patients in Shiraz might be worse than what we report. For better evaluation, a community-based study is recommended.