Access to oral health care for HIV patients in Nigeria: Role of attending physicians

O. O. Sofola, O. G. Uti, O. Emeka
Departments of Preventive Dentistry, College of Medicine/Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Summary

Objective: To assess the knowledge of attending physicians on oral manifestations of HIV infection and their attitude and practice towards dental referral for HIV patients. Method: A self-administered questionnaire survey of attending physicians in outpatient clinics of two teaching hospitals in Lagos and the National hospital, Abuja. Results: seventy-eight (78) doctors returned questionnaires. 16 of them (20.5%) could list correctly three oral lesions in HIV infection, 40 (51.3%) listed two, 18 (23.1%) listed one while 4 (5.1%) could not list any. In managing oral health complaints by patients, 59 (75.5%) agreed that their patients had complained of oral symptoms, of these, only 18 had ever referred a patient for dental care. Majority (84.6%) agreed that HIV patients should have regular dental check ups. Conclusion: The education of both patients and health providers in Nigeria on the importance of good oral health in the quality of life of the HIV patient is necessary. HIV patients in Nigeria should be referred for dental checkups and prophylaxis at least twice a year

Key words: Access, oral health, HIV, physician.

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Correspondence: Dr O.O.Sofola

Department of Preventive Dentistry, College of Medicine, University of Lagos, P.M.B.12003, Lagos, Nigeria. This email address is being protected from spambots. You need JavaScript enabled to view it. , Fax: 234-1-3453232

INTRODUCTION

The oral cavity is an important and frequently undervalued source of diagnostic and prognostic information in patients with HIV disease¹. A variety of conditions have been described affecting oral tissues in HIV infection ². These oral lesions may indicate HIV infection in previously undiagnosed cases thus making the dentist the first health care worker to detect the disease; they may be predictive of disease progression and may also be used in staging and classification of the disease.

Studies indicate that 70-90% of HIV patients will have at least one oral manifestation at some point during the course of the disease ^3,4 hence many HIV positive patients may require dental treatment at different times during the course of the disease. Oral lesions in HIV patients though often debilitating can be managed effectively with proper oral health care. Also the state of oral health can complicate the treatment of HIV positive patients by causing feeding discomfort and thus exacerbating nutritional problems. Oral health has been found to be significantly associated with both physical and mental health in a study measuring quality of life in HIV patients⁵.

The periodontal tissues in the mouth provide a potentially weak barrier through which bacteria and their factors can enter the connective tissues and systemic circulation. Therefore, maintaining a low microbial load within the mouth should be seen as an essential component of preventive treatment regimen in HIV positive patients ¹. This can be achieved through regular dental checkups and prophylaxis. A study of the impact of intensified dental care on outcomes in HIV infection concluded that "access to dental screening, prophylaxis and repair will significantly improve oral health, functioning and quality of life in persons with AIDS" ⁶. Therefore prophylactic oral health care is important even in the absence of oral lesions. Hence it is vitally important that HIV positive patients have easy access to oral health care.

Access to oral health care may be influenced by many factors including a lack of perception of the importance of oral health and an ignorance of existing services. While the authors have no knowledge of any study of the utilization of dental services by HIV positive patients in Nigeria, a previous Nigerian study reported a low level of utilization of oral health services amongst Nigerian households ⁷. Also most Nigerians are reported to attend the dental clinic mainly because of pain rather than for preventive practices ⁸

In an unpublished study on HIV patients in Nigeria, about 54% of them claimed they would complain to their attending physician in the haematology clinic of the teaching hospital where they attend regularly for antiretroviral therapy if they have any oral problem. This indicates that these physicians and others who consult in other medical outpatient and paediatric clinics may be the first port of call for the Nigerian HIV patient with oral lesions and thus have an important role to play in the ability of these patients to access oral health care, which may contribute to their total quality of life. These clinicians though working in tertiary hospitals may be regarded as primary care physicians for these patients because they see to the basic health needs of these patients in the Nigerian health care setting. They are therefore in a good position to advice their patients on regular dental care and indeed help the patient to easily access such care by referring them for regular dental checkups.

The objective of this study is to assess the knowledge of attending physicians on oral manifestations of HIV, their attitude towards referral of HIV positive patients for oral care and their present pattern of referral with a view to recommending ways of achieving better access to oral health care for HIV positive patients in Nigeria.

METHOD

The study was carried out by means of a self-administered questionnaire distributed to physicians and paediatricians who attend to HIV positive patients in various outpatient clinics at the Lagos University teaching hospital (LUTH), and also to doctors and heamatologists in HIV dedicated clinics of LUTH, Lagos State University teaching hospital (LASUTH) and the National hospital, Abuja, Federal capital territory. The questionnaire contained questions, both close- ended and open- ended addressing the demography of the doctors, their knowledge of oral lesions in HIV infection, the practices of doctors towards oral health complaint by their patients and their attitude towards dental referral for these patients.

RESULTS

Seventy-eight (78) doctors, 61(78.2%) males and 17 (21.8%) females participated.

Table 1 shows the distribution of doctors by age, years of experience and position. Their year of practice was normally distributed with a mean of 8.43 (sd 5.21), both median and mode were 8.00.

Knowledge of oral manifestations: All of them agreed that HIV infection has oral manifestations. However, when asked to list three (3) oral lesions in HIV infection, 16 (20.5%) of them got three correct answers, 40 (51.3%) got two correct answers, 18 (23.1%) got one correct answer while 4 (5.1%) could not list any correct answer. There was no significant association with year of practice, position or sex and number of correct answers. Pseudomembranous candidosis referred to as "thrush" by a lot of the respondents was the most commonly listed lesion by all the doctors.

Management of oral health problems: of the 78 respondents, 59 (75.6%) agreed that their patients had complained of oral problems to them at one point or the other. Of the 59, only 18 of them had ever referred a patient to the dentist while others claimed they examined and treated with medications.

Forty-six (58.9%) of them claimed to have carried out oral examination on their patients at sometime. Of this 46, 36 of them said they could identify some oral lesions while 10 said they could not identify any lesion. Again, pseudomembranous candidosis was the most commonly identified lesion. Only one respondent claimed to have identified oral hairy leukoplakia while four of them identified ulcers (unspecified).

Pattern of dental referral: 18 doctors had referred patients for dental care. More than half of these (55.6%) had referred less than five patients, 6 (33.3%) claimed to have referred between five to ten patients while 2 (11.1%) claimed to have referred more than ten patients. There was a significant difference between genders in dental referral (Fisher exact- 0.006). None of the female doctors had ever referred patients for dental care whereas 14 of them claimed that they have had oral health complaints from their patients and 15(88.2%) of them agreed that routine dental checkups should be part of the management for HIV patients.

Attitude towards dental referral: 66 (84.6%) of the doctors agreed that HIV patients should have routine dental check up as part of their management while 12 (15.4%) of them felt routine dental checkups was unnecessary because in their opinion, the oral manifestations are not severe enough to require specialist attention. There was no significant difference between genders and attitude towards dental referral.

DISCUSSION

The optimal oral health condition is essential for the general wellbeing of the HIV patient. It is important that physicians who primarily care for these patients be able to recognize important oral lesions in their patients both for diagnostic and prognostic reasons. In a country like Nigeria with poor dental visiting habit, these clinicians may be the first persons that HIV positive patients come in contact with. This study reveals an inadequate knowledge of oral lesions seen in HIV infection among the respondents. Only 16 (20.5%) of them could name three pertinent oral lesions seen in HIV infection. This may be an indication that they may not be able to identify these lesions. The EC clearing house on oral problems related to HIV infection ⁹ classified oral lesions associated with HIV into four groups with about eight lesions classed as lesions strongly associated with HIV. Of these lesions, the doctors in this study appear to be more familiar with pseudomembranuous candidosis mostly with oral hairy leukoplakia coming a very distant second and Kaposi?s sarcoma third. None of the other lesions strongly associated with HIV was mentioned by the doctors.

Oral ulcerations, herpes simplex infection and hyper pigmentation, which were listed by the doctors are classified as lesions commonly associated with HIV infection. Also while some of the doctors claimed they could identify some oral lesions, there was no way of objectively assessing this claim. There is a need for adequate training of physicians caring for HIV patients in Nigeria in recognition of these oral lesions. While the mouth can be easily examined by clinicians and some oral lesions such as pseudomembranous candidosis may be simply identified as shown in this study, other lesions may be misdiagnosed by the inexperienced eye. In a study of primary care physicians, only 26% were able to diagnose oral Kaposi sarcoma and 22% hairy leucoplakia ¹⁰. Another study revealed a sensitivity of 45.2% in the accuracy of recognition of oral lesions by medical clinicians after undergoing a 1-day- refresher course; however they were less able to describe such lesions accurately ¹¹.

In terms of attitude, while 66 (84.65%) of the respondents agreed that routine dental checkups is desirable as part of management of HIV, only 18(23.1%) of them had ever referred a patient for dental treatment. Also a considerable number-12 (15.4%) felt that regular dental checkup was unnecessary for HIV patients. This shows poor attitude in these doctors whose opinion may be a source of barrier to accessing oral health care for their patients. It is essential that both the patient and the health care provider be better informed of the importance of good oral health as it has an impact on their overall quality of life. Attending physicians in Nigeria needs to be educated so that they see the management of HIV patients in a more holistic way.

CONCLUSION AND RECOMMENDATIONS

In conclusion, an appreciation of the role of oral health care workers in diagnosis and treatment of HIV patients and indeed the adoption of a team approach involving physicians, dental surgeons, nursing staff and community care workers is very important in ensuring the best management of HIV patients. A formal training of attending physicians in Nigeria in the recognition and management of oral lesions in HIV is desirable. These doctors should be educated and encouraged to include regular dental checkups in their routine management of HIV positive patient. They should consciously refer their patients for regular screening and prophylaxis as part of their preventive management of HIV patients.

We also recommend that patients with HIV in Nigeria be referred to a dentist for routine checkups two times a year.

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