|Year : 2019 | Volume
| Issue : 14 | Page : 84-90
Pattern of utilization of dental services and oral self-care practices of people living with HIV/AIDS in two tertiary health institutions in Nigeria
Kehinde Adesola Umeizudike1, Opeyemi Daramola2, Babatope Bamidele Osagbemiro3, Titilope Adenike Adeyemo4
1 Department of Preventive Dentistry, Faculty of Dental Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
2 Department of Preventive Dentistry, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Preventive Dentistry, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
4 Department of Haematology and Blood Transfusion, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
|Date of Submission||01-Sep-2018|
|Date of Acceptance||01-Mar-2019|
|Date of Web Publication||04-Oct-2019|
Dr. Kehinde Adesola Umeizudike
Department of Preventive Dentistry, Faculty of Dental Sciences, College of Medicine, University of Lagos, P.M.B. 12003, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: People living with HIV/AIDS (PLWHA) have a high risk of oral health problems. However, little is known about their utilization of oral health services in Nigeria. Objectives: The aims of this study were to determine utilization of dental services and oral hygiene practices among PLWHA attending two tertiary health institutions. Materials and Methods: This was a descriptive, cross-sectional study among PLWHA attending HIV clinics in two teaching hospitals in South West and South South Nigeria. Information obtained using self-administered structured questionnaires included questions on pattern of dental services' utilization and oral hygiene behavior. P < 0.05 was considered as statistically significant. Results: Three hundred and fifty-two (352) PLWHA participated. Mean age was 42.5 ± 9.4 years, 64.2% were females, and 36.9% were of middle socioeconomic status (SES). Previous dental visits (36.9%) were associated with perception of dental need, center of study, and SES (P < 0.05). Odds of utilizing dental health services were higher among those who perceived they needed dental care (odds ratio: 4.12; 95% confidence interval: 2.13–7.96). Eighty-eight (25%) had visited the dentist in the preceding 12 months and received dental treatment in the form of extraction (64.4%), routine dental check (13.8%), and scaling and polishing (5.8%). Lack of perceived dental need and financial limitations were the main barriers for lack of dental visits. Twice daily tooth brushing was practiced by 40.1% of the respondents. Conclusion: Utilization of the dental services among PLWHA was low and influenced by self-perception of dental need, study center, and higher SES. Oral hygiene practices were less than optimal.
Keywords: Dental services, Nigeria, oral hygiene, people living with HIV/AIDS, utilization
|How to cite this article:|
Umeizudike KA, Daramola O, Osagbemiro BB, Adeyemo TA. Pattern of utilization of dental services and oral self-care practices of people living with HIV/AIDS in two tertiary health institutions in Nigeria. N Niger J Clin Res 2019;8:84-90
|How to cite this URL:|
Umeizudike KA, Daramola O, Osagbemiro BB, Adeyemo TA. Pattern of utilization of dental services and oral self-care practices of people living with HIV/AIDS in two tertiary health institutions in Nigeria. N Niger J Clin Res [serial online] 2019 [cited 2019 Dec 5];8:84-90. Available from: http://www.mdcan-uath.org/text.asp?2019/8/14/84/268533
| Introduction|| |
People living with HIV/AIDS (PLWHA) have a high risk of developing oral health problems which adversely impact their quality of life. In resource-restricted countries such as Nigeria, this negative impact may have more severe consequences, particularly when these oral health conditions are unattended to. Unmet dental care needs may occur in up to 50% of HIV-infected persons. According to a national oral health survey among 7630 adult Nigerians, only 26.4% (n = 2014) of the respondents had visited the dentist at least once before the survey. This implies that an estimated 78 million adolescents and adults are not utilizing oral health services. This population could also include PLWHA. Infection with HIV/AIDS remains a serious health challenge in Nigeria, considering the 3.2 million people estimated to be affected, representing the second largest HIV disease burden globally next to South Africa, with more than 600,000 currently receiving antiretroviral therapy (ART).
ART has gradually changed HIV infection from a previously progressive fatal infection to a chronic disease that persists for several years and a more manageable, illness. It is not unexpected therefore for PLWHA to manifest more chronic oral diseases, increasing the oral disease burden. In a study among a group of PLWHA in Nigeria, chronic periodontitis was observed to be more severe among HIV-positive persons compared to HIV-negative individuals. The morbidity associated with periodontitis and other atypical oral lesions in PLWHA merits paying more attention to their oral health. This includes abscess formation, necrotizing periodontal diseases, and ultimately tooth loss.
The utilization of dental services by PLWHA has been limited to treatment for HIV-associated oral lesions, oral opportunistic infections, and dental emergencies. Most dental visits in Nigeria are prompted by toothache and are symptom oriented rather than for preventive purposes.,, In a study among Nigerian physicians managing HIV patients, a significant proportion of the physicians encountered oral health complaints from their patients, however less than a third referred the patients for dental care. This was despite most of them (84.6%) agreeing that HIV patients should have regular dental checkups.
Poor oral hygiene can limit the adherence of PLWHA to their required nutrition/medication regimens and also contribute to the formation of opportunistic infections. Poorer oral hygiene was associated with low dental visits among PLWHA in a dedicated HIV clinic. Furthermore, the immunocompromised state in HIV infection makes the management of their oral diseases difficult to handle.
Meticulous oral self-care practices and professional prophylaxis will therefore ensure that inflammatory periodontal diseases do not progress to more severe conditions such as necrotizing stomatitis, cancrum oris, or in a worst-case scenario, tooth loss. PLWHA represent a vulnerable group of people. According to Jeanty et al., vulnerable populations may encounter more barriers to accessing oral health care either due to inability to pay for dental care or poor awareness about the importance of oral health care. This is likely to further escalate their oral disease burden. It is therefore expedient for the early detection and prevention of oral disease conditions through regular dental visits. Steinhart et al. suggested that PLWHA should receive oral health care every 4–6 months. Regular utilization of dental care services is essential in achieving a good oral health, which is an integral component of general health.,
Adedigba et al. reported that 92% of PLWHA in their study had not visited a dentist after contracting the disease. Their study was however limited to 3 care centers in southwestern Nigeria. Discrimination, fear of being treated differently, and concerns about confidentiality have been shown to be the major barriers in seeking dental care among PLWHA.,,, Moreover, the low utilization of dental services in developing countries has been attributed to socioeconomic status (SES), inaccessibility, cost, dental fear, and poor attitudes toward dental care., Few other barriers to dental service utilization are lack of knowledge of available dental services and self-perceptional factors.
Furthermore, previous studies among PLWHA in Nigeria had reported a low utilization of dental services., Their study showed that toothbrush and toothpaste were the predominant tooth cleaning aids used, and most participants cleaned their teeth once daily. None of the study participants had used dental floss. There are limited studies on the utilization of dental services among PLWHA in Nigeria. Hence, the objective of this study was therefore to determine the utilization of dental services and oral self-care practices among PLWHA attending HIV clinics at two tertiary health institutions in Nigeria.
| Materials and Methods|| |
This study was part of a larger project on PLWHA in two teaching hospitals in Nigeria. It was a descriptive, cross-sectional study among PLWHA attending HIV-dedicated clinics in two tertiary health institutions in two zones in Nigeria; South West: Lagos University Teaching Hospital (LUTH) and South South: University of Port Harcourt Teaching Hospital (UPTH), Nigeria. Ethical approval had been obtained from the Health Research and Ethics Committee of both teaching hospitals before the commencement of the study. Inclusion criteria were HIV-positive patients diagnosed at least 1 year before the study who presented for their scheduled outpatient appointment at the HIV clinic. Information was obtained using self-administered structured questionnaires on sociodemography, history of past dental visits, self-reported oral health problems, dental treatments received, hindrances to dental service utilization, and oral hygiene behavior. Socioeconomic class of the patients was determined by modified occupational strata.
Data analysis was performed with Statistical Package for Social Statistics Version 21.0 (SPSS Inc., Chicago Illinois, USA), and results were presented as frequencies and percentages. The figures and charts were generated using Microsoft Excel software. Associations between demographics and dental visits were determined using Chi-squared tests. A logistic regression was done to identify factors that were strongly associated with utilization of dental services. Level of significance was set at P < 0.05.
| Results|| |
A total of three hundred and fifty-two (352) PLWHA participated in the study (LUTH-254; UPTH-98). The mean age of the respondents was 42.5 ± 9.4 years (age range 17–73 years) and was significantly higher among respondents in LUTH (43.9 ± 9.1 years) than UPTH (38.7 ± 9.1 years) (P< 0.001). About two-thirds (64.2%) were females and 36.9% were of the middle SES. Majority (81.2%) of the respondents had more than primary level of education. Most (46.0%) of the participants in both centers were from the south-east zone of Nigeria, and this was found to be statistically significant [Table 1].
|Table 1: Sociodemographic characteristics of People living with HIV/AIDS by the hospital HIV clinics attended|
Click here to view
Pattern of dental service utilization
One hundred and thirty (36.9%) respondents had visited the dentist previously, which was significantly associated with center of study (P< 0.001), older age (P = 0.016), and higher SES (P = 0.037). Self-reported oral problems in the last 12 months included holes in their teeth (22.4%), toothache (21.3%), tooth sensitivity (13.6%), and bleeding gums (12.2%). Only 88 (25%) had however visited the dentist in the last 12 months, more being from LUTH (29.5%) than UPTH (13.3%) (P = 0.003). Dental treatments received in the last 12 months included extraction (64.4%), routine dental check (13.8%), and scaling and polishing (5.8%) as shown in [Table 2]. Only 27 (7.7%) of the respondents had ever had oral prophylaxis in the form of scaling and polishing done.
|Table 2: Pattern of dental service utilization and oral self-care behavior of the people living with HIV/AIDS|
Click here to view
Self-reported oral hygiene practices
Regarding their oral hygiene practices, 141 (40.1%) of the respondents cleaned their teeth twice daily, with 73.0% and 13.4% using the scrub and roll brushing techniques, respectively. Majority (84.6%) used toothbrush and fluoridated toothpaste to clean. More than one half (52.3%) of the respondents replace their toothbrush within 3 months of use as shown in [Table 2]. Lack of perceived dental need and financial limitations were the main reasons given by respondents for having never visited a dentist [Figure 1].
Predictors of dental service utilization
Ordinal logistic regression modeling identified three independent variables to be significantly associated with the use of the dental services. Respondent's perception of need for dental treatment had higher odds of predicting utilization of dental services compared to the other variables (Odds Ratio 4.12; 95% confidence interval: 2.13–7.96) as shown in [Table 3].
|Table 3: Logistic regression of independent variables with the utilization of dental services|
Click here to view
| Discussion|| |
Infection with HIV/AIDS has gradually entered a more chronic disease phase following the widespread use of highly active ART in both high- and low-income countries. Although the therapy has made HIV/AIDS a more manageable illness, inadequate oral health care can undermine the success of treatment by exacerbating existing medical conditions, compromising adherence to an antiretroviral treatment regimen, and ultimately diminishing the quality of life. Access to and utilization of dental care is important to HIV-positive persons because, according to some estimates, over 90% of HIV-positive persons will have at least one oral manifestation of HIV disease during the course of their infection. The present study was predicated on the need to assess the pattern of utilization of dental services and oral self-care practices of PLWHA in Nigeria considering the low utilization pattern among the presumably HIV-negative population. Although a previous Nigerian study reported the utilization level in PLWHA in 3 centers, their study was restricted to the southwestern zone of Nigeria. Our study included two tertiary health institutions from the South West and South South Nigeria. The LUTH study center had a significantly wider distribution of respondents from all the zones in Nigeria than the UPTH center, which is not unexpected considering the location of this center which is Lagos state. Lagos state is the commercial nerve hub of Nigeria and is home to people with different ethnic backgrounds.
Most of the respondents in the present study were 40 years and above, which differs from the younger age group that has been consistently reported among HIV-positive persons in earlier studies., According to the National Agency for the Control of Aids Country Progress Report (2012), HIV prevalence in Nigeria is reported as being highest among those aged 35–39 years. This could stem from the fact that this younger age group is among the most economically productive. The older age in our study may however be a reflection of the increasing life expectancy and more chronic phase of the infection in PLWHA with the widespread availability of ART. The higher frequency of older subjects observed at the LUTH APIN center supports our assertion of the beneficial influence of long term ART treatment on the life expectancy of PLWHA. This is facilitated by the heavily subsidized ART therapy.
Dental care utilization statistics is traditionally based on an individual reporting “at least one dental visit in the past year''. Regular dental visits are essential in achieving good oral health., This will thus provide an opportunity for oral health professionals to promptly diagnose illness, provide primary preventive services, and treat diseases in HIV-positive patients. Unfortunately, the level of oral healthcare utilization by the PLWHA in the present study was low, as only 36.9% (n = 130) reported ever visiting a dentist, while 25% (n = 88) had visited in the last 1 year before the study. This may be due to low oral health awareness, with a resultant effect on the health-seeking behavior and subsequent underutilization of oral health facilities. Besides, these patients might also be unaware of the possible link between their HIV status and oral complications and therefore be ignorant of the need for prompt diagnosis and early intervention.
The proportion of respondents who accessed dental services in our study far exceeds the utilization levels reported in other studies in Nigeria and Africa. It is higher than the 7%–8% reported among PLWHA in another Nigerian study which considered dental visits before and after HIV diagnosis as well as the 7.3% from another specialist hospital in Abeokuta, Nigeria. It is also higher than a Tanzanian study that documented 18.5% as the proportion of PLWHA that had visited the dentist, albeit due to oral problems. The slightly higher proportion in our study particularly the LUTH center may be attributed to a more positive attitude of the individuals toward their oral health as this population had been actively involved in oral health research in the past. The significantly higher number of individuals with self-reported dental visits at the LUTH center can attest to this assertion. In comparison, however to PLWHA in more developed countries, the utilization level in our study appeared inconsequential in comparison to an US-based study that reported 52.4% as having not seen a dentist in over 2 years. Regular dental care is more frequent in these climes and entrenched in their healthcare system coupled with the higher awareness levels among the populace unlike this environment where awareness is low and health insurance is only just gradually becoming more established.
Factors predictive of dental visits in our study included a higher SES, center of study, and self-perceived need for dental treatment. The influence of improved living standards on dental care service utilization has been documented. The odds of seeing a dentist in the preceding 2 years were greater for respondents with stable housing among low-income HIV-positive persons receiving primary care in South Florida. Despite the low utilization of oral health care services, 61.4% (n = 216) of the respondents reported a perceived need for dental treatment. Indeed, the logistic regression demonstrated that PLWHA who had a perceived need for dental care were four times more likely to seek dental services. This begs the question: if several people had such dental needs, why were they not visiting the dental clinic? The answer may be associated with the possible psychosocial impact of living with HIV/AIDS as well as the need to avoid the social stigma associated with the disease and conceal one's status from the dental health practitioner. This was previously highlighted by some researchers,, although stigmatization was not a barrier in the present study. Rather, lack of oral symptoms and high cost of dental treatment were the main limitations to dental visits in our study. Quite frankly on the other hand, should this be surprising? It could still be a reflection of the poor attitudes and ignorance to preventive dental care among Nigerians and may not be too different among PLWHA. The sources of the barriers that patients experience in relation to accessing oral health care are said to arise from their life experiences and psychosocial factors. These factors include but are not limited to age, gender, education, perception of need, dental anxiety, cost of treatment, and the adequacy of dental workforce. The self-reported barrier to dental service utilization for most of the respondents in this study was the lack of perceived need for dental treatment. This was highlighted in a review in which a lack of perception of the importance of oral health and an ignorance of existing services were emphasized. This low motivation for seeking care may be due to the competing need of a physical condition (HIV/AIDS) that is considered more serious and should be given more attention and priority.
Although most (64.2%) of the respondents in the present study were women which is in agreement with the study carried out in Ife-Ijesa, South West Nigeria (63.6%), this did not significantly influence their utilization of dental service. The higher prevalence of women in this study is probably a reflection of the overall higher prevalence of HIV in women in Nigeria. Of the respondents who reported a dental visit within the last year, 63.6% (n = 56) had tooth extractions done. This finding highlights a problem-oriented rather than preventive-oriented dental visit behavior in which people generally visit a dentist only when there is a severe oral condition requiring immediate attention. Thus, extractions are carried out due to late presentation by individuals at a time when little or nothing can be done to conserve the tooth. Besides, the cost of conserving a tooth is many times higher than extraction, and as many people still pay out of their pockets, it may have a direct influence on their ultimate choice to conserve or remove the tooth.
Studies have shown that PLWHA who receive oral hygiene education and preventive dental care are less likely to require complex procedures and treatment., This is because the two most prevalent oral diseases (dental caries and periodontal diseases) can be prevented through oral health education, regular dental checkups, and preventive care in the form of scaling and polishing. Sadly, the results of this study showed that only 27 (7.7%) of the respondents had ever had professional prophylaxis (scaling and polishing) done. The importance of regular dental checkups and oral prophylaxis (scaling and polishing) in PLWHA cannot be overemphasized enough in view of the increased prevalence of HIV salivary gland disease manifested by xerostomia (dry mouth), a frequent side effect of some HIV medications. The effect of salivary changes could increase their dental problems such as tooth decay and periodontal disease.
Tooth brushing is the most important tool for oral hygiene care. However, it is sometimes overlooked in dental health education. Generally, dentists recommend twice daily toothbrushing with a fluoride toothpaste usually the last thing at night (bedtime) and in the morning, preferably after breakfast. This facilitates application of fluoride on teeth and reduces bacterial plaque, ultimately reducing dental caries and periodontal diseases. The majority (84.6%) of the respondents cleaned their teeth with toothbrush and toothpaste, although less than half brushed twice daily (40.1%). This result is comparable to those obtained from other studies among PLWHA and the general population of Nigerians. Toothbrush and toothpaste in recent times have been widely advertised, made available, accessible, and affordable to the majority of Nigerians. It is important to emphasize twice daily cleaning practices through using the media.
In spite of the optimal level of toothbrush and toothpaste usage, majority of the respondents (73.0%) used the scrub brushing technique, which has been noted to be detrimental to oral health due to the possibility of causing tooth wear lesions such as cervical abrasions as well as gingival recession. One hundred and eighty-four (52.3%) respondents reported changing their toothbrushes every 3 months. This is an important oral health practice to prevent fraying of toothbrush bristles. Frayed toothbrushes do not clean the teeth as efficiently as new ones and thus predispose the teeth to retention of plaque and subsequent growth of harmful microorganisms leading to oral disease.
| Conclusion and Recommendations|| |
In conclusion, the utilization of the dental services among the PLWHA in this study was low and largely influenced by their self-perception of dental need. Paradoxically, the major barriers to their use of the dental services included their lack of perceived oral problem and finances. Their oral hygiene practices were less than optimal. It is important to drive and encourage regular dental visits by PLWHA with the assistance of their managing physicians who should be well educated and encouraged to refer these patients for regular dental checkups. Their role as oral health promoters should be highlighted to them in ensuring overall well-being of their patients.
Financial support and sponsorship
The study was partly supported by APIN (AIDS Prevention Initiative in Nigeria).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Levett T, Slide C, Mallick F, Lau R. Access to dental care for HIV patients: Does it matter and does discrimination exist? Int J STD AIDS 2009;20:782-4.
Jeanty Y, Cardenas G, Fox JE, Pereyra M, Diaz C, Bednarsh H, et al.
Correlates of unmet dental care need among HIV-positive people since being diagnosed with HIV. Public Health Rep 2012;127 Suppl 2:17-24.
Olusile AO, Adeniyi AA, Orebanjo O. Self-rated oral health status, oral health service utilization, and oral hygiene practices among adult Nigerians. BMC Oral Health 2014;14:140.
Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet 2013;382:1525-33.
Umeizudike KA, Ayanbadejo PO, Savage KO, Nwhator SO, Akanmu AS, Ogunleye O. Comparative periodontal status of human immunodeficiency virus-positive patients and controls in a dedicated human immunodeficiency virus clinic in Nigeria. Niger J Clin Pract 2016;19:35-40.
] [Full text]
Sourabha KG, Puranik MP, Uma SR, Biradar A, Puttaswamy P. Barriers in utilization of dental services among human immunodeficiency virus patients. Int J Adv Health Sci 2015;2:23-9.
Akaji EA, Chukwuneke FN, Okeke UF. Attendance pattern amongst patients at the dental clinic of the university of Nigeria teaching hospital, Enugu, Nigeria. Niger J Med 2012;21:74-7.
Ogbebor O, Azodo C. Reasons for seeking dental healthcare services in a Nigerian missionary hospital. Sahel Med J 2016;19:38-43. [Full text]
Umeizudike K, Ayanbadejo P, Taiwo O, Savage K, Alade G. Utilization of dental services by administrative workers in a tertiary health institution in Lagos, Nigeria – A pilot study. Niger Q J Hosp Med 2014;24:86-90.
Sofola OO, Uti OG, Emeka O. Access to oral health care for HIV patients in Nigeria: Role of attending physicians. Afr J Oral Health 2004;1:37-41.
Pereyra M, Metsch LR, Tomar S, Valverde E, Jeanty Y, Messinger S, et al.
Utilization of dental care services among low-income HIV-positive persons receiving primary care in South Florida. AIDS Care 2011;23:98-106.
Umeizudike KA, Ayanbadejo PO, Savage KO, Akanmu AS. Relationship of oral hygiene status and practices with oral lesions in a group of HIV positive patients. Nig Dent J 2012;20:31-6.
Steinhart C, Orrick J, Simpson K. HIV/AIDS Primary Care Guide. Florida AIDS Education and Training Center, University of Florida; 2002.
Rohn EJ, Sankar A, Hoelscher DC, Luborsky M, Parise MH. How do social-psychological concerns impede the delivery of care to people with HIV? Issues for dental education. J Dent Educ 2006;70:1038-42.
Adedigba MA, Adekanmbi VT, Asa S, Fakande I. Pattern of utilisation of dental health care among HIV-positive adult Nigerians. Oral Health Prev Dent 2016;14:215-25.
Quadri FA, Jafari FA, Albeshri AT, Zailai AM. Factors influencing patients' utilization of dental health services in Jazan, Kingdom of Saudi Arabia. Int J Clin Pediatr Dent 2018;11:29-33.
Ajayi DM, Arigbede AO. Barriers to oral health care utilization in Ibadan, south west Nigeria. Afr Health Sci 2012;12:507-13.
Campbell PC, Sheriff D. Awareness and method of oral health care among people living with human immunodeficiency virus infection and acquired immune deficiency syndrome attending federal medical centre, Abeokuta, Nigeria. J Oral Health Oral Epidemiol 2016;5:24-33.
Hima BA, Naga AP. Adverse effects of highly active anti-retroviral therapy (HAART). J Antivir Antiretrovir 2011;3:60-4.
Soares GB, Garbin CA, Rovida TA, Garbin AJ. Oral health associated with quality of life of people living with HIV/AIDS in Brazil. Health Qual Life Outcomes 2014;12:28.
Parish C, Siegel K, Pereyra M, Liguori T, Metsch L. Barriers and facilitators to dental care among HIV-infected adults. Spec Care Dentist 2015;35:294-302.
Umeizudike KA, Ayanbadejo PO, Savage KO, Akanmu AS, Nwhator SO, Emeka CI. Prevalence and determinants of chronic periodontitis in HIV positive patients in Nigeria. Asian Pac J Trop Dis 2014;4:306-12.
Wall TP, Vujicic M, Nasseh K. Recent trends in the utilization of dental care in the United States. J Dent Educ 2012;76:1020-7.
Kahabuka FK, Petersen PE, Mbawala HS, Jürgensen N. General and oral health related behaviors among HIV positive and the background adult Tanzanian population. J Oral Hyg Health 2014;2:1-6.
Fox JE, Tobias CR, Bachman SS, Reznik DA, Rajabiun S, Verdecias N, et al.
Increasing access to oral health care for people living with HIV/AIDS in the U.S. Baseline evaluation results of the innovations in oral health care initiative. Public Health Rep 2012;127 Suppl 2:5-16.
Hastreiter RJ, Jiang P. Do regular dental visits affect the oral health care provided to people with HIV? J Am Dent Assoc 2002;133:1343-50.
Patton LL, Strauss RP, McKaig RG, Porter DR, Eron JJ Jr. Perceived oral health status, unmet needs, and barriers to dental care among HIV/AIDS patients in a North Carolina cohort: Impacts of race. J Public Health Dent 2003;63:86-91.
Reznik DA. Oral manifestations of HIV disease. Top HIV Med 2005;13:143-8.
[Table 1], [Table 2], [Table 3]