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Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 10-15

A primary care approach for oral health promotion among HIV patients: An interventional study

1 Department of Prosthodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Community Medicine, PSG Institute of Medical Sciences, Coimbatore, Tamil Nadu, India
3 Department of Public Health Dentistry, Coorg Institute of Dental Sciences, Coorg, Karnataka, India

Date of Submission03-Feb-2020
Date of Decision28-Feb-2020
Date of Acceptance20-Feb-2021
Date of Web Publication31-Mar-2021

Correspondence Address:
Anisha Rodrigues
Department of Prosthodontics, AJ Institute of Dental Sciences, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_22_20

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Background: HIV-positive patients are at a greater risk for developing oral health problems, making them potentially susceptible to nutritional deficiencies, decreased adherence to treatment, and failure of highly active antiretroviral therapy. Their oral health needs are unmet due to a lack of awareness, social stigma, and other factors. The primary care workers (PCWs) are the first point of contact for health issues of these patients. Aim: The aim of the study was to assess the effectiveness of the educational intervention for the PCWs on oral health. Materials and Methods: This interventional pilot study was conducted at two residential centers for HIV patients in Mangalore. The participants included 15 PCWs working at these centers. An educational module was prepared as the intervention that included dental conditions that could compromise oral health, oral manifestations of HIV, and oral health care. A structured questionnaire was administered to the PCWs before the intervention, immediately after the intervention, and at 3 months. The PCWs were required to routinely examine the HIV patients for any dental or oral health problems and refer them to the dental hospital for treatment. The Statistical Package for the Social Sciences 20.0 software (Chicago. IL, USA) was used for analysis. p < 0.05 was considered statistically significant. Repeated measures analysis of variance and Chi-squared test were used for data analysis. Results: 73% of the caretakers had no training in oral health care. Analysis of the mean scores revealed a statistically significant improvement (p < 0.05) in their knowledge and skills from 2.53 ± 1.3 to 7.57 ± 1.2. There was also a statistically significant increase in the number of referrals to the dental hospital. Conclusion: Educating the PCWs showed positive outcomes enabling patients' access to regular professional oral health care, thus improving their quality of life.

Keywords: HIV, oral health, primary care workers

How to cite this article:
Rodrigues A, Kannappan S, Sadhu B. A primary care approach for oral health promotion among HIV patients: An interventional study. J Indian Assoc Public Health Dent 2021;19:10-5

How to cite this URL:
Rodrigues A, Kannappan S, Sadhu B. A primary care approach for oral health promotion among HIV patients: An interventional study. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Dec 5];19:10-5. Available from: https://www.jiaphd.org/text.asp?2021/19/1/10/312640

  Introduction Top

HIV-related oral lesions are found in 30%–80% of HIV-infected individuals, and most often are the first clinical sign of the infection. While the presence of certain oral lesions might suggest an HIV infection, a few others might even signal the progression of the disease.[1] The oral manifestations of HIV are xerostomia, salivary gland disorders, oropharyngeal candidiasis, hairy leukoplakia, Kaposi's sarcoma, warts, recurrent aphthous ulcers, neutropenic ulcers, etc.[2] The dental conditions include dental caries, periodontal diseases, and tooth loss.[3],[4] With the introduction of highly active antiretroviral therapy (HAART), there has been a significant decrease in the occurrence of the more severe types of oral lesions, but there is also an increase in frequency of the more common lesions such as candidiasis and periodontitis as compared to the noninfected individuals. Studies have shown that HIV patients are more susceptible to oral lesions and harmful dental conditions than otherwise healthy individuals.[5] These conditions are a risk factor for nutritional deficiencies as they affect mastication, swallowing, and other oral functions. They are also a potential barrier to adherence to treatment and have been shown to be associated with an increased risk of progression of HIV disease, severe immune deterioration that could lead to increased mortality.[6] These conditions have a physical, social, and psychological impact on the patients which is detrimental to their well-being and impairs their quality of life.[7] The oral and dental needs are unmet in HIV patients due to a lack of awareness on oral health and available services, late diagnosis, social stigma, and poverty.[8] Oral health is most often neglected as it is not given utmost priority. It is therefore vital that the oral health status of these patients is regularly monitored and treatment guaranteed.

Collaborations with various professions are the need of the hour in the current health care scenario to improve health outcomes. With regard to people living with HIV, an interprofessional teamwork has the potential to bring about a significant change in their overall health and well–being, leading to a better quality of life. The dental professionals primarily work to prevent and treat oral and dental diseases. However, the HIV patients might not be able to avail of their services due to their perceived barriers. The primary care workers (PCWs) play a crucial role by complementing the health-care system. They generally are at ideal positions and the first point of contact for health issues of patients and therefore can play a pivotal role in oral health promotion. The PCWs comprise doctors, nurses, pharmacists, counselors, and care takers who regularly tend to the patients. However, in order to facilitate oral health promotion, they themselves need to have adequate knowledge about the oral manifestations of HIV and its management. The primary objective of this study was to develop an oral health-care module and evaluate its effectiveness among the PCWs in promoting oral health among HIV patients. The secondary objective was to explore if this training model led to an increase in the number of patients seeking oral health care. Althrough this project, we strived to enable HIV patients overcome their barriers and ensure accessibility to oral health care by educating the PCWs.

  Materials and Methods Top

This educational interventional study was carried out as a pilot initiative among PCWs of two HIV residential centers of Mangalore, housing 75 HIV-positive individuals. The PCW team included nurses, counselors, pharmacist, caretakers, and volunteers. The study was approved by the Institutional Human Ethics Committee (DCGI Reg. No. ECR/348/Inst/KA/2013). The study was explained to the participants, and written informed consent was obtained from them.

Module development and validation

A team comprising dental professionals (prosthodontists and dental public health Specialists) and physicians was formed to prepare the module for the intervention. The team together finalized the topics to be included in the module. Key areas included normal anatomy of oral cavity, general oral health, oral manifestations of HIV, early recognition of the lesions, harmful dental conditions, their management, documentation of cases, and diet. The module was tailor-made for ease of use for the PCWs that included illustrations using simple language. This was also translated to Kannada, which is the local language. The topics and content of the module were reviewed by five subject experts and a consensus was arrived at.

Health education of primary care workers and HIV patients

A training session was conducted for the PCWs by interactive lectures aided by video projector and demonstrations. A PowerPoint presentation was prepared to facilitate the intervention. It contained simplified text and images of lesions such as oropharyngeal candidiasis, linear gingival erythema, salivary gland enlargement, aphthous stomatits, oral hairy leukoplakia, and dental conditions such as dental caries, missing teeth, periodontitis, and dental fluorosis. They were also taught oral hygiene procedures and diet recommendations. The interventions were carried out both in English and in Kannada.

Following the training, the PCWs were expected to periodically conduct oral examinations of the patients, refer them for treatment, ensure that they are under the care of dental professionals, and also encourage them to follow dentist's recommendations. Referral cards were provided to the PCWs for referrals to the dentist.

A health education session was also conducted for the HIV-positive patients to enable them to perform self-examinations and identify the lesions in their oral cavity so as to report them to the PCWs.

Data collection and analysis

A preintervention baseline assessment was done for the PCWs, using a structured questionnaire. The questionnaire included sociodemographic information of the PCWs (age, gender, educational qualifications and employment status, years of experience, and past training in oral health), as well as their knowledge on oral health such as symptoms and clinical appearance of the lesions, preventive measures, and diet. There were eight questions on sociodemographic characteristics, nine questions on knowledge, and four questions on beliefs. The questionnaire was administered in English as well as Kannada to facilitate the workers who were not fluent in English. The PCWs were given an opportunity to clarify any doubts with the questionnaire. The participants completed the questionnaire in 30 min, following which the educational intervention was performed.

Posttest questionnaire was administered immediately after the intervention and after 3 months. Referrals were assessed by the number of patients visiting the dental hospital, confirmed by clinical data mentioned on the referral cards. Data were analyzed using the SPSS software, Version 20.0 (Chicago. IL, USA). The changes in the mean score pre- and post-intervention were assessed using the repeated measures analysis of variance.

  Results Top

Fifteen PCWs completed the questionnaire. All of them were females between the age group of 20–65 years. A majority of them (80%) were educated beyond the 12th grade. Nearly 73% of the workers had not received any previous training on oral health care. All the PCWs believed that oral health is important for HIV patients. They also agreed that regular screening is necessary, and it is important to seek dental treatment for dental problems. However, 20% did not believe that poor oral health could compromise nutrition. The responses showed that they had poor baseline knowledge. The pretest showed a mean knowledge score of 2.5 ± 1.3. The mean score immediately after intervention was 5.8 ± 1.2 and after 3 months was 7.2 ± 1.2. Repeated measures analysis of variance showed a statistically significant difference between the scores (p < 0.05), [Table 1].
Table 1: Pre- and post- intervention mean scores

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There was a 36% increase in the number of patients diagnosed and referred to the dental hospital pre- and post-intervention at 3 months. This increase was statistically significant as shown by the Chi-squared test [Table 2].
Table 2: Number of referrals made by the primary care workers-pre- and post- intervention (3 months)

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  Discussion Top

Oral diseases cause pain, discomfort, altered taste, and a burning sensation. Dental conditions such as decay, periodontitis, and loss of teeth can affect mastication, swallowing, and speech.[9] Although the overall incidence of oral lesions has significantly reduced due to HAART, the prevalence is still high in patients in developing countries and vulnerable age groups due to the various risk factors involved.[6]

The current study aimed to improve the oral health-related outcomes of HIV-positive patients through an educational intervention targeted at improving the knowledge and competencies of the PCWs. Before the study, discussions with the PCWs and also with a few patients had revealed that patients suffered from stigma associated with their illness, which along with a lack of awareness and low socioeconomic status, prevented them from seeking dental treatment. They also disclosed the problems they faced regarding accessibility to oral health care.

This study helped to empower the PCWs with knowledge related to oral health and also improve their skills in educating patients to ensure that their oral health care needs are met. Kolisa and Ayo-Yusuf[7] in their study have stated that the nontrained care givers are less likely to provide advice on oral hygiene. Educational interventions do improve the caregivers' knowledge of oral lesions and their beliefs about oral care. Therefore, they can efficiently complement the health-care system.

This study was conducted at two residential centers for HIV patients. Most of the patients were school-going children below the age of 18 years. A majority of the children were orphans and completely dependent on the PCWs for all their needs. It was seen that there was not much of an emphasis on oral health due to ignorance as well as inaccessibility to oral health-care facilities.

The PCWs who took part in the study were co-operative and willing to conduct periodic oral examinations. Regular visits and telephone reminders by the dentists also motivated them to perform their duties. The model proved to be an effective method for oral health-care promotion. It improved the knowledge of the PCWs significantly. Ever since this model has been introduced at the HIV centers, there has been a regular stream of HIV patients visiting the dental hospital to avail dental treatment. This study shows results similar to a study that had been conducted by Koyio et al.[10] on the community and professional health-care workers in Nairobi. They too showed that the training programs significantly increased the primary and community health workers' knowledge, recognition, and management of oral lesions in HIV patients.

This is a pilot study, and the sample is limited to 15 PCWs. However, the positive outcome with this study shows that this model can be implemented on a larger scale so as to benefit a wider population of the HIV patients.

  Conclusion Top

Despite the limitations of the study, this model shows that this model has the potential to benefit a larger number of HIV patients through its implementation to a larger group of PCWs in other centers. The PCWs have shown improved competencies with regard to diagnosing harmful oral and dental conditions and timely referrals to the dental hospital, therefore leading to an increased awareness among HIV patients about their oral health status. The patients can overcome the stigma in seeking treatment and improve their oral health-related quality of life. The study also suggests that an effective interprofessional collaboration can be developed between the dentists and the PCWs for the benefit of the patients.


The authors would like to thank the faculty of the Manipal University-FAIMER International Institute for Leadership in Interprofessional Education Fellowship Program for their support and guidance.

Financial support and sponsorship

The study was funded by the Rotary Club, Mangalore North.

Conflicts of interest

There are no conflicts of interest.

  Questionnaire Top




Educational qualification:

<12th Std

>12th std


Post graduate

1. Have you received any training in oral health care



2. Do you know the oral screening/examination procedures for children

  1. No knowledge
  2. Partial knowledge
  3. Complete knowledge

  4. 3. Oral health care is important for HIV patients

  5. Strongly agree
  6. Agree
  7. Neither
  8. Disagree
  9. Strongly disagree

4. HIV patients are at a high risk for

  1. Dental caries
  2. Gum disease
  3. Dry mouth
  4. All of the above

5. Do you think poor oral health can compromise nutrition

  1. Strongly agree
  2. Agree
  3. Disagree
  4. Strongly disagree

6. Which of the following is true about oral lesions:

  1. Predict HIV progression
  2. Signal failure of antiretroviral treatment
  3. Causes pain, discomfort
  4. All of the above

7. The most common oral lesion in HIV patients is

  1. Hairy leukoplakia
  2. Candidiasis
  3. Acute necrotizing periodontitis
  4. Oral cancer

8. What does oral thrush/candidiasis look like

9. Identify healthy gingiva (gums)

10. Most important cause of dental caries in HIV patients is

  1. Tooth grinding
  2. Avoiding dentist
  3. Dry mouth
  4. Genetics

11. Signs of periodontal disease are

  1. Red, swollen gums
  2. Bleeding while brushing
  3. Teeth looking longer than before
  4. All of the above

12. Do you think it is important to seek dental treatment for dental problems (dental caries, gingival inflammation)

  1. Strongly agree
  2. Agree
  3. Disagree
  4. Strongly disagree

13. Regular oral screening for HIV patients is necessary

  1. Strongly agree
  2. Agree
  3. Disagree
  4. Strongly disagree

14. Home care for periodontal disease includes

  1. Antibacterial mouthwash
  2. Proper nutrition
  3. Pain killers
  4. All of the above

15. Which of the following is not true regarding nutrition

  1. HIV patients must eat diet high in vegetables, fruits, and whole grains
  2. Eat small amount of fats and sugars
  3. Do not need higher daily calorie intake
  4. Eat smaller meals more often

16. Do you know the referral procedures for the patients

  1. No knowledge
  2. Partial knowledge
  3. Complete knowledge

17. Have you previously referred patients for dental/oral care to the doctor

  1. Yes
  2. No

18. If yes

  1. How many
  2. Reasons

  References Top

Grando LJ, Yurgel LS, Machado DC, Nachman S, Ferguson F, Berentsen B, et al. The association between oral manifestations and the socioeconomic and cultural characteristics of HIV-infected children in Brazil and in the United States of America. Rev Panam Salud Publica 2003;14:112-8.  Back to cited text no. 1
Reznik DA. Oral manifestations of HIV disease. Top HIV Med 2005;13:143-8.  Back to cited text no. 2
Leao JC, Ribeiro CM, Carvalho AA, Frezzini C, Porter S. Oral complications of HIV disease. Clinics (Sao Paulo) 2009;64:459-70.  Back to cited text no. 3
Navazesh M, Mulligan R, Komaroff E, Redford M, Greenspan D, Phelan J. The prevalence of xerostomia and salivary gland hypofunction in a cohort of HIV-positive and at-risk women. J Dent Res 2000;79:1502-7.  Back to cited text no. 4
Cavasin Filho JC, Giovani EM. Xerostomy, dental caries and periodontal disease in HIV+ patients. Braz J Infect Dis 2009;13:13-7.  Back to cited text no. 5
Ottria L, Lauritano D, Oberti L, Candotto V, Cura F, Tagliabue A, et al. Prevalence of HIV-related oral manifestations and their association with HAART and CD4+ T cell count: A review. J Biol Regul Homeost Agents 2018;32:51-9.  Back to cited text no. 6
Kolisa Y, Ayo-Yusuf O. Evaluation of caregivers' knowledge, beliefs and practices regarding oral lesions in HIV-patients: A pilot study. Health SA Gesondheid 2018;18:1-8.  Back to cited text no. 7
Saini R. Oral lesions: A true clinical indicator in human immunodeficiency virus. J Nat Sci Biol Med 2011;2:145-50.  Back to cited text no. 8
Mohamed N, Saddki N, Yusoff A, Mat Jelani A. Association among oral symptoms, oral health-related quality of life, and health-related quality of life in a sample of adults living with HIV/AIDS in Malaysia. BMC Oral Health 2017;17:119.  Back to cited text no. 9
Koyio LN, Sanden WJ, Dimba E, Mulder J, Creugers NH, Merkx MA, et al. Oral health training programs for community and professional health care workers in Nairobi East District increases identification of HIV-infected patients. PLoS One 2014;9:e90927.  Back to cited text no. 10


  [Table 1], [Table 2]


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