ARTÍCULOS ORIGINALES

Impact of oral health care needs on health-related quality of life in adult HIV+ patients

 

Gabriel A. Sánchez^1,2,3, Luciana R. D’Eramo^1,3, Rodolfo Lecumberri¹, Aldo F. Squassi^1,3,4

¹ High Risk Patients Dental Care Unit (CLAPAR I), School of Dentistry, University of Buenos Aires. Argentina.
² Biophysics Department, School of Dentistry, University of Buenos Aires, Argentina.
³ Institute for Public Health Research, University of Buenos Aires, Argentina.
⁴ Community and Preventive Dentistry Department, School of Dentistry, University of Buenos Aires, Argentina.

CORRESPONDENCE Gabriel A. Sanchez, CLAPAR 1, Facultad de Odontologia Universidad de Buenos Aires, M T de Alvear 2142, 5o piso, Sector A (C1122AAH) Buenos Aires ARGENTINA e-mail: gabriel@odon.uba.ar

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ABSTRACT

The aim of this work was to determine the social impact of oral conditions on health-related quality of life in adult HIV+ patients and create a predictive model. The oral health impact profile questionnaire OHIP-49 was randomly administered to 200 HIV+ adults patients of any age and either sex at the High Risk Patients Dental Care Unit (CLAPAR I), School of Dentistry, University of Buenos Aires. Argentina. For each of the 49 items, participants indicated their responses on a five point Likert-type frequency scale ranging from “never” to “very often”. Oral health needs were assessed through the CCITN (Community Caries Index of Treatment Need) and CPITN (Community Periodontal Index of Treatment Need). The Mann- Whitney test was used to compare the OHIP-49 score between male and female respondents. The Kruskal-Wallis test was used to assess score differences among the OHIP-49 domains. Altogether, 50% of the respondents were male and 50% were female, aged 36.45 ± 0.70 years and 38.03 ± 0.78 years respectively. The assessment of oral health care needs revealed a great need for treatment. Mean CCITN was 11.15 ± 0.35 and CPITN was 2.41 ± 0.12. The average total OHIP-49 score (83) revealed a high level of social impact, which was higher for female compared to male respondents (Z(T) = 2.08, p = 0.037). The domains concerning functional limitation (domain 1), physical pain (domain 2) and psychological discomfort (domain 3) showed higher levels of social impact (H = 395.06, p < 0.0001). The social impact observed in these domains was higher for female compared to male patients. In the correlation analysis, oral conditions, age, gender and social impact were significantly associated. These results demonstrate that unmet oral health care need impairs the quality of life of HIV+ patients and suggest the need of comprehensive oral health care interventions.

Key words: HIV; Oral health; Social impact; Quality of life; Health behavior.

RESUMEN

Impacto de la necesidad de tratamiento odontológico sobre la calidad de vida de los pacientes adultos VIH+

El proposito de este trabajo fue determinar el impacto social del estado de la salud bucal sobre la calidad de vida de los pacientes VIH+ y establecer un modelo predictivo. El cuestionario correspondiente al perfil del impacto social de la salud bucal, OHIP-49, se administro aleatoriamente a 200 pacientes adultos VIH+ de ambos generos en la Clinica para la Atencion de Pacientes de Alto Riesgo I (CLAPAR I) de la Facultad de Odontologia de la Universidad de Buenos Aires, Argentina. Los pacientes indicaron su respuesta a cada una de las 49 preguntas del cuestionario en una escala de frecuencia tipo Likert (nunca, casi nunca, a veces, casi siempre, siempre). La necesidad de tratamiento odontologico se determino haciendo uso del Indice de Necesidad de Tratamiento de Caries (INTC) y del Indice de Necesidad de Tratamiento Periodontal (INTP). La prueba de Mann-Whitney se utilizo para analizar la diferencia del puntaje global del OHIP-49 entre hombres y mujeres. La prueba de Kruskal- Wallis se empleo para evaluar las diferencias de los puntajes observados entre los diferentes dominios del OHIP-49. La influencia de la necesidad de tratamiento odontologico, la edad y el genero sobre la calidad de vida de los pacientes VHI+ se analizo a traves de un modelo de regresion multivariado, donde el puntaje obtenido en el OHIP-49 fue la variable dependiente y la necesidad de tratamiento odontologico, la edad y el genero se desempenaron como variables independientes. El 50% de los pacientes fueron de sexo masculino con una edad promedio de 36.45 ± 0.70 anos y el otro 50% correspondio a pacientes de sexo femenino con una edad promedio de 38.03 ± 0.78 anos. La evaluacion del estado bucodental evidencio una alta necesidad de tratamiento odontologico. El valor medio del INTC fue 11.15 ± 0.35 y el del INTPC fue 2.41 ± 0.12. La media del puntaje registrado en el OHIP-49 (83) revelo un alto nivel de impacto social de las condiciones de salud bucal, siendo dicho impacto mayor en mujeres que en hombres (Z(T) = 2.08, p = 0.037). Los dominios relativos a la limitacion funcional (dominio 1), al dolor fisico (dominio 2) y al disconfort psicologico (dominio 3) mostraron mayores niveles de impacto social (H = 395.06, p < 0.0001). El impacto observado en dichos dominios resulto incluso mayor para el caso de las mujeres. El analisis de correlacion revelo que las necesidades de tratamiento odontologico, la edad, el genero y el impacto social del componente bucal de la salud se encuentran asociados de manera significativa. Nuestros resultados indican que las necesidades de atencion odontologica insatisfechas menoscaban la calidad de vida de los pacientes VIH+ y sugieren la necesidad de brindar atencion de salud bucal integral a este grupo de pacientes.

Palabras clave: VIH; Salud bucal; Impacto social; Calidad de vida; Conducta de salud.

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INTRODUCTION

HIV+ patients are considered a dental caries risk group^1,2. Several authors have reported a significantly higher need for dental and periodontal treatment in HIV+ patients^{3- 6} and dental care has been described as the most frequently unmet health need⁷. The use of the highly aggressive antiretroviral therapy (HAART) has been effective enough in turning the viral infection into a chronic disease⁸. Consequently, the life expectancy of the infected patients has become longer⁹. In view of this background, public health policies should be addressed to provide optimal quality of life to these patients¹⁰. In this respect, surveys and questionnaire-based research of oral health are useful to provide valuable data of oral disease and its determinants, its effect on dental services utilization and the behaviors and attitudes that influence oral health^11,12. We have recently reported on erroneous dental beliefs concerning oral self-care and its influence on the demand for dental treatment in Argentine HIV+ adult patients¹³. However, little is known about the social impact of their oral care needs.
The OHIP-49 (Oral health impact profile) questionnaire was developed by Slade & Spencer¹⁴ to assess the social impact of oral disorders. Since then, multilingual versions^15-17, including Spanish¹⁸, have been validated. The questionnaire contains 49 questions regarding impacts attributed to oral conditions. The 49 impact items are grouped in seven domains, namely: functional limitations (e.g., difficulty chewing foods), physical pain (e.g., toothache), psychological discomfort (e.g., uncomfortable appearance), physical disability (e.g., unclear speech), psychological disability (e.g., concentration affected), social disability (e.g., difficulty doing jobs) and handicap (e.g., life less satisfying). The dimensions were ranked to reflect increasingly complex impacts. The first three domains comprise impacts apparent primarily to the individual, while questions in the disability and handicap dimensions are more likely to represent impacts on everyday activities and social roles. Since research on the oral conditions and its impact on the quality of life of HIV+ patients will help improve the oral health care planning, we decided to undertake this study to provide new background in this field. The aim of this work was to determine the social impact of oral conditions on health-related quality of life in adult HIV+ patients and estimate the direction and strength of their association. We tested the hypothesis that poor oral condition impairs oral health-related quality of life.

MATERIALS AND METHODS

Study population
Participants were 200 HIV+ randomly selected adult patients of any age and either sex. Subjects were recruited from March 2007 through November 2010 at the High Risk Patients Dental Care Unit (CLAPAR I), School of Dentistry, University of Buenos Aires, Argentina. The research was conducted as a descriptive cross-sectional study. All of the patients had been diagnosed with positive serology for HIV at least 5 years prior to the study and were under antiretroviral drug therapy. Patients suffering from HIV-non-related systemic diseases were excluded. Each patient signed the informed written consent prior to enrollment. Oral health care needs assessment Dental and periodontal treatment needs were assessed through the CCITN¹⁹ (Community Caries Index of Treatment Need) and CPITN20 (Community Periodontal Index of Treatment Need) respectively. Oral examinations were performed by three previously calibrated dental examiners.

Social impact of oral conditions assessment
The Spanish validated version¹⁸ of the OHIP-49 questionnaire was used. For each of the 49 questions, participants indicated their responses on a five point Likert-type frequency scale ranging from “never” to “very often”. Patients who left 10 or more individual questions blank were excluded from the study. The questionnaire was administered to patients prior to oral examination.

Data analysis
Mean values and SEM were calculated for age, CCITN and CPITN and tested for statistical significance between female and male respondents by Student’s t test. To analyze the overall levels of social impact, the responses to individual questions of the seven OHIP-49 domains were standardized and summed to produce a single summary score. The method has been described previously¹⁴ and involved the multiplication of coded responses for individual questions (coded 0 for “never” through 4 for “very often”). A Mann-Whitney test was used to compare the OHIP-49 score between male and female respondents. A Kruskal-Wallis test, with Dunn’s post hoc test for multiple comparisons, was used to assess score differences among the OHIP- 49 domains. The level of significance used was p < 0.05. Multivariate non-parametric correlation was used to determine the association among OHIP-49, CCITN and CPITN scores, age and gender. A Rho Spearman coefficient was used to estimate the direction and strength of the associations.

RESULTS

Altogether, 50% of the respondents were male and 50% were female, aged 36.45 ± 0.70 y and 38.03 ± 0.78 y, respectively. The difference in age did not reach statistical significance (t(198) = 1.49, p = 0.13). Oral health care needs assessment revealed a great need of treatment. Altogether 56% (CI 95% = 49.12 - 62.88) of the sample needed dental prosthetic treatment and 43 % (CI 95% =36.14 – 49.86) needed tooth removal or endodontic treatment. Mean CCITN was 11.15 ± 0.35. Differences in mean CCITN between male (11.48 ± 0.29) and female (10.82 ± 0.42) patients were not significant (t(198) = 1.29, p = 0.19). Periodontal conditions revealed supragingival tartar in 69% (CI 95% = 62.59 – 75.41) of the sample, whereas 25% (CI 95% = 19.0 – 31.0) showed 4-5-mm periodontal pockets. The remaining 6% (CI 95% = 2.71 – 9.29) showed 6-mm pathological pockets. The mean CPITN was 2.41 ± 0.12. Differences in mean CPITN between male (2.48 ± 0.06) and female (2.34 ± 0.10) patients were not significant (t(198) = 1.20, p = 0.23).
Fig. 1 shows the social impact of oral conditions. The average total OHIP-49 score was 83, i.e., 43% of the maximal recordable value (Fig. 1A). The Kruskal- Wallis test revealed statistically significant differences (H = 395.06, p < 0.0001) among domains (Fig. 1B). Dunn’s post hoc test for multiple comparisons revealed higher social impact in domains 1, 2 and 3. Fig. 2 shows the influence of gender on the social impact of oral conditions. The total score for male and female patients was 80 and 85 respectively. The Mann- Whitney test revealed a significantly higher (Z(T) = 2.08, p = 0.037) social impact of oral conditions in females. The domains 1, 2 and 3 showed significantly higher score values for both male (H = 372.01, p < 0.0001) and female (H = 401.5, p < 0.0001) respondents. For domains 1 and 3, the social impact was higher in females than in males (Domain 1: Z(T) = 2.35, p = 0.021; Domain 3: Z(T) = 2.24, p = 0.027).

Fig. 1. Social impact of oral health. OHIP-49 scores recorded for each domain. OHIP-49 domains are 1: Functional limitation, 2: Physical pain, 3: Psychological discomfort, 4: Physical disability, 5: Psychological disability, 6: Social disability, 7: Handicap.

Fig. 2. Influence of gender on the social impact of oral health. OHIP-49 scores recorded for each domain in (A) male and (B) female respondents. OHIP-49 domains are 1: Functional limitation, 2: Physical pain, 3: Psychological discomfort, 4: Physical disability, 5: Psychological disability, 6: Social disability, 7: Handicap.

Table 1 shows the matrix correlation for the multivariate non-parametric correlation analysis among oral conditions, age, gender and the social impact of oral health. The coefficient estimates were positive, indicating that higher levels of social impact were associated with higher CCITN and CPITN values, increasing age and female gender. The strength of the significant association of each studied variable with the perception of the social impact of oral health followed the order CCITN, age, gender, CPITN. The association found was moderate for CCITN, age and gender but low for CPITN.

Table 1: Correlation among OHIP-49 score, oral health care needs, age and gender.

DISCUSSION

Employing CCITN and CPITN, this study revealed a great unmet need for dental and periodontal treatment in HIV+ adult patients, as previously reported by several authors^{3-6, 13, 21} and found evidence that poor oral conditions impaired their wellbeing. Few studies have demonstrated that oral health status affect the oral health-related quality of life in HIV+ patients^22-24. Yengopal & Naidoo²⁴ reported that patients with oral lesions associated with HIV infection appeared to be more affected in terms of their functional limitation, physical pain and psychological discomfort. Our results agree with this previous report but in a larger HIV population. Moreover, we included the assessment of variables regarding dental and periodontal status.
Coates et al.²² found a significant positive correlation between DMFT and CPITN with oral health-related quality of life. However, we believe that indices of need for oral treatment are more appropriate to assess the oral-health-related quality of life than the indicators of dental caries experience. Furthermore, the indices of need for treatment allow the assessment of the existence of barriers in the access to oral health care, another factor that could affect the social impact of oral health. In this respect, further studies should be conducted to identify those barriers. Although OHIP has been used previously²³ to describe the social impact of oral condition in HIV+ patients, this is the first report of its kind in Argentine HIV+ populations. Moreover, not only is the social impact of oral health reported here, but it is also analyzed according to gender. The OHIP-14 Spanish validated version²⁵ has been reported as a useful tool to assess the impact of oral status on the quality of life. In this work, the OHIP-49 Spanish validated version was used because the Spanish version of the OHIP-14 was not available at the beginning of the study. In addition, in medically compromised patients it might be more appropriate to use the full OHIP version to guarantee greater accuracy in social impact self-reporting. The study of the scores of the individual OHIP-49 domains allows the analysis of the partial contributions to the total score. Therefore, in this study we report score descriptive statistics for each domain. Participants reported high levels of social impact in domains regarding functional limitation, physical pain and psychological discomfort, while lower impact was reported for the remaining domains. This result could be explained on the basis that the later domains concern the dimensions most distal to the disease status in the Locker²⁶ model on which the OHIP instrument is based.
Research shows that oral health is a function of gender and that oral health-related quality of life depends on a person’s gender²⁷. Most of the studies do not report comparative results of the social impact of oral health between male and female HIV+ individuals^{22, 23}. This study originally hypothesized that scores on OHIP-49 would be higher for female patients, which is why data from male and female patients were compared. As females might show different psychosocial and/ or emotional features able to improve the perception of the social impact of oral health, as previously reported²⁸, a higher OHIP-49 score was expected in this group. Our results showed a trend this direction. Our findings suggest that oral health-related quality of life measurements can be useful in order to identify people with unmet needs for dental treatment, especially in non-dental environments, such as general hospitals or primary care centers. Therefore, developing and applying instruments able to measure the social impact of oral health would allow appropriate patient referral and improvement of resource planning. This assumption is in agreement with the conclusion reported by Santo et al.²⁹ who considered OHIP-14 as a risk indicator of dental caries. However, these authors suggested that oral health problems of HIV+ patients caused a mild impact on their wellbeing. In conclusion, this study identified clinical indicators in which dental professionals should intervene to improve the oral health-related quality of life of HIV-infected patients. In this regard, the impact of oral health care programs on the oral health-related quality of life should be assessed, and oral health care should be included as one of the components of the medical health care programs for HIV+ patients.

ACKNOWLEDGEMENT

This work was supported by a grant from the University of Buenos Aires (Grant UBACyT 0800).

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