DENTAL CARIES EXPERIENCE AMONG HIV POSITIVE 6-

12 YEARS CHILDREN, ATTENDING COMPREHENSIVE:

CARE CENTRE, KENYATTA NATIONAL HOSPITAL,

NAIROBI, KENYA.

A commumty Dentistry Project Proposal, Submitted in partial fulfillment of the

Degree of Bachelor of Dental Science at the University of Nairobi.

Investigator: Tafa CC BDS III-V28/8324/03

SUPERVISORS

INTERNAL: Dr. B. N. Mua (BDS, MPH, Pg Dip STI)

Department of Periodontology, Community and Preventive

Dentistry, School of Dental Sciences

University of Nairobi.

EXTERNAL: Dr. E. A. O. Dimba .BDS, PhD

Department of Oral maxilo-facial Surgery, Oral Pathology and Oral

Medicine, School of Dental Sciences

University of Nairobi.

11

TABLE OF CONTENTS

SUPERVISORS ii

TABLE OF CONTENTS 111

LIST OF ABBREVIATIONS. IV

ABSTRACT.. .. . 1

1.0 IT--rTRODUCTION 2

2.0 LITERATURE REVIEW 4

3.0 STATEMENT OF PROBLEM 6

4.0 JUSTIFICATION OF THE STUDy 6

') () (}BJEC'TIVES. . . .. . .. 6

5.1 GENERAL OBJECTIVES 6

5.2 SPECIFIC OBJECTIVES 6

6.0 METHODOLOGY 7

6.1 STUDY AREA 7

6.2 STUDY POPULATION 7

6.3 STUDY DESIGN 7

6.4 STUDY VARIABLES 7

6.4.1 INDEPENDENT VARIABLES 7

6.4.2 DEPENDENT VARIABLES 8

6.5 SAMPLING 8

6.6 DATA COLLECTION METHOD 9

6.7 INCLUSION CRITERIA 9

6.8 EXCLUSION CRITERIA 9

6.9 ETHICAL CONSIDERATION 10

MINIMIZING ERRORS 10

6.11 DATA ANALYSIS % PRESENTATION 10

7.0 BUDGET 11

REFERENCES 12

APPENDIX 1 13

APPENDIX 2 14

III

LIST OF ABBREVIATIONS

1. HIV - Human Immunodeficiency Virus

2. ARV - Anti retro viral

3. KNH - Kenyatta National Hospital

4. BDS - Bachelor of Dental Surgery

5. Kshs - Kenya Shillings

6. WHO - World Health Organization

7. DMFT - Decayed Missing Filled Teeth (permanent dentition)

8. dmft-decayed missing filled teeth (deciduous dentition)

9. AIDS - Acquired Immune Deficiency Syndrome

10. UON - University of Nairobi

11. USA - United States of America

12. HAART - Highly Active Antiretroviral Therapy

IV

ABSTRACT

Human Immunodeficiency Virus (HIV) infection is a major global public health

problem. More than 95% of HIV -infected people live in developing countries;

hence management of the infection has become one of the priority health issues

in developing countries. The management includes ARV therapy and treatment

of opportunistic infections. These medications have adverse effects on salivary

flow, oral flora resulting in an increase in the Decayed Missing Filled Teeth.

This will be a descriptive cross-sectional study aimed at determining caries

experience among 78 HIV positive children aged between 6 and 12 years. It will

be conducted at the Comprehensive Care Center in Kenyatta National Hospital

(KNH). Data will be recorded in a clinical examination form and DMFT and dmft

indices will be used to assess caries experience for permanent and deciduous

teeth respectively

The information form this study will form a baseline for further studies. It could

also be used for planning for oral health programmes aimed at improving oral

health status of this children which will translate to better quality of life.

1

1.0. INTRODUCTION

Dental caries is a multi-factorial disease related to people's lifestyle; therefore,

control and prevention are intimately linked to changes in daily habits and

attitudes, which should be started early on, within the family circle. The desired

changes are associated with alterations of dietary and oral hygiene habits as well

as the use of fluorides. (1, Dental caries is still a major oral health problem in most

industrialized countries affecting 60 - 90% of school going children but it appears

to be less common and less severe in most African countries. However, it is

expected that the incidence of dental caries will increase in the near future in

many developing countries of Africa, particularly as a result of growing sugar

consumption and inadequate exposure to fluorides. (2) The goals of prevention

as set by the World Health Organization (WHO) for the year 2000 were: At 5 - 6

years of age 50% should be caries free. At 12 years of age Decayed Missing

Filled Teeth (DMFT) should be less than three.

By international standards, caries experienced in Kenyan population is low;

DMFT for 12 year olds has been reported to be 1.8. ( 92000). There is an indirect

link between dental caries and Human Immunodeficiency Virus (HIV) as well as

Anti Retro Viral drugs (ARV). Increased caries susceptibility in HIV-infected

children may be due to several different factors. Many of the children experience

failure to thrive and more frequent feedings with carbohydrates and sucrose rich

foods may be necessary to maintain the body weight. It has been shown that

increased frequency of carbohydrate intake in HIV infection is associated with

increased caries prevalence and cariogenic microbes.

Researchers have shown that topical treatments for mild to moderate cases of

both erythematous and pseudombembranous candidiasis include clotrimazole

troches, nystatin oral suspension. It should be noted that common nystatin and

oral suspension contains 50% sucrose, which is cariogenic. (3) Human

immunodeficiency virus (HIV) infection is a major global health problem. By the

2

end of 2003, there were around 46 million HIV infected people in the world

(UNAIDS, 2004). More than 95% of HIV-infected live in the developing countries,

therefore given these figures, management of HIV infection has become one of

the priority issues in developing countries.

ARV therapy is the main mode of treatment for HIV or AIDS. The treatment

consists of drugs that have to be taken everyday for the rest of someone's life. It

is not a cure, but it prolongs life of the infected individual. Literature suggests that

HIV -infected children are at risk of dental caries in most cases, ARV with

Zalcitabine (ddc). In addition to increased frequency of carbohydrates, many of

the medications essential for ARV therapy contain relatively high sweeteners

levels. The fact that these medications need to be taken on a frequent basis

increases the child's exposure to cariogenic substances.

The aim of the study is thus to determining dental caries experience among HIV

positive children aged between 6 and 12 years The information form this study

will form a baseline data for further studies. It could also be used for planning for

oral health programmes aimed at improving oral health status of this children

which will translate to better quality of life.

3

2.0 LITERATURE REVIEW

Dental caries is the demineralization of the inorganic structure of the tooth and

the destruction of the organic component by acid produced from metabolism of

carbohydrates mostly sucrose by dental plaque bacteria. A study showed that

caries usually result from prolonged dental imbalance between those factors

producing demineralization and factors promoting remineralization. It further

highlighted that in the presence of a consistent exposure of fluoride together with

normal levels of saliva, most patients are able to maintain the remineralization

balance; however the frequency of carbohydrate ingestion results in a prolonged

high concentration of acid at the tooth surface, the ability of the saliva and

fluoride ion balance can be lost", This might be the case in children who are

bottle fed due to the fact that they cannot be breastfed because of their mother's

HIV status, or apparently due to the effects of medications on salivary flow, oral

flora as revealed by some researchers. A study on gingival status of HIV-positive

children and the correlation with caries incidences and immunologic profile by

some researchers showed that children with greater caries experience showed

more gingival inflammation and in addition, a greater immunological deficiency

might indicate a greater caries in children (6)

In another study, association of HIV viral load with oral diseases as measured by

DMFT, periodontal assessment and oral candidal colonization, it showed that

among the high viral load patients 69.2% and DMFT >20. It was then concluded

that elevated viral load levels correlated well with oral disease prevalence.'

Oral diseases and conditions affect every race worldwide. The prevalence has

been found to vary from region to region. The prevalence and severity of these

diseases and conditions have been found to be higher among people infected

with HIV. However, a study investigating oral conditions and their social impact

among HIV dental patients, revealed that the DMFT index and its components

did not differ significantly between HIV and the general patients. (8)

4

association with effects of medications like Didanosine or the proliferation of

CD8+ cells in the major salivary glands, changes in the quantity and quality of

saliva including diminished antimicrobial properties, lead to rapidly advancing

dental decay. (9)

In yet another study it was noted that a reduction of oral lesions from 46.6% pre-

potent ARV therapy to 37.5% during the potent ARV therapy era. Overall there

appeared to be a reduced incidence of candidiasis, Kaposi sarcoma, hairy

leukoplakia and necrotizing ulcerative periodontitis (NUP), an increase in salivary

gland disease, oral warts and dental caries in form of "brittle teeth syndrome." (10)

5

3.0 STATEMENT OF PROBLEM

A study revealed that there is a strong evidence of a decline in dental caries

occurrence within the Australian population especially for school going children,

indicating that most children have a good dental health. This could be the

opposite for HIV positive children taking ARV drugs due to compromised immune

system, bottle-feeding and effects of drugs on salivary flow resulting in a turn of

events for dental caries prevalence. (11)

4.0 JUSTIFICATION OF THE STUDY

Although there are many studies evaluating oral soft tissue manifestations of

HIV/AIDS in children, there are relatively few clinical investigations into caries

experience in primary and permanent dentition, therefore this study seeks to

establish level of caries experience in HIV - positive children on ARV therapy,

and provide services for caries control in the affected group of children.

5.0. OBJECTIVES

5.1 GENERAL OBJECTIVES

To determine the caries experience, among HIV positive children.

5.2 SPECIFIC OBJECTIVES

1) To establish the prevalence of dental caries among children who are HIV

positive

2) To determine the proportion of children with filled teeth among the

children.

3) To determine the percentage of children with missing teeth due to caries

4) To determine relationship between DMFT and the CD4 count.

6

6.0 METHODOLOGY

6.1 STUDY AREA

The study will be conducted at KNH, Comprehensive Care Centre. Nairobi is

capital city of Kenya, East Africa. KNH is the largest referral hospital in Kenya.

The Comprehensive Care Centre for HIV positive patients is under the

department of internal medicine. Patients seen in the clinic are drawn from the

wards, voluntary counseling and testing centre and referrals from other health

facilities. The departments of laboratory medicine and diagnostic radiology

provide investigation for CCC.

6.2 STUDY POPULATION

Children who are HIV positive and on ARV therapy aged 6 - 12 years, at the

Comprehensive Care Centre, KNH, Nairobi.

6.3 STUDY DESIGNThis will be a descriptive, cross-sectional study.

6.4 STUDY VARIABLES

6.4.1 INDEPENDENT VARIABLES

1) Type of drug

2) Other sugar-containing medications (ARV)

3) Formulation of medication

4) Age

5) Gender

6) Viral load

7) Frequency of intake of ARV

8) Duration of ARV therapy

7

;.4.2 DEPENDENT VARIABLESCaries experience

1) Decayed teeth

2) Missing teeth

3) Filled teeth

6.5 SAMPLING

Systematic random sampling will be used to select the sample. Every second

patient will be included in the study.

6.5.1 SAMPLE SIZE

n= Z2 x P(1 -P)

C2

n = (1.962)2 xO.8 x 0.2

(0.05) 2

Where n = Sample size

P = prevalence

C = confidence interval

Z value = 1.96

N = study population

n= 246

nf=n

1+ n

N nf = study pop< 10 000

Therefore nf = 78

6.5.2 SAMPLING UNIT

HIV positive child, at the comprehensive care center in KNH, Nairobi.

8

6.6 DATA COLLECTION METHOD

DMFT index

Diagnostic instruments, dental mirrors and dental explorers under natural light

will be used. Gauze will be used to dry the tooth surface and the child will be

seated on an ordinary chair during dental examination.

1) Medical Records

Child's medical files will be obtained from the staff and reviewed to get the

relevant information.

6.7 INCLUSION CRITERIA

• All HIV positive children, on ARV therapy, at the Comprehensive Care Centre,

KNH.

• Children whose parents consent to the study

• Children who assent to the study

• Children aged 6 to 12 years old

6.8 EXCLUSION CRITERIA

• Children below 6 years, and above 12years old at the Comprehensive Care

Centre, KNH.

• Children whose parents do not consent to the study

• Children who do not assent to the study

9

6.9 ETHICAL CONSIDERATIONS

The proposal will be submitted to the ethical committee, Kenyatta National

Hospital for approval. The purpose of the study, expected benefits and risks will

be explained to the participants' parents/guardians clearly. Written informed

consent will be sought and obtained to join the study and publish data arising

from the participants. Each subject meeting the inclusion criteria will have an

equal chance of being included in the study. The participants will be at liberty to

terminate participation at any time without victimization. All information collected

will be treated confidentially.

MINIMIZING ERRORS

In order to ensure the study is acceptable and provides a true picture of the

actual situation, the following measures will be taken.

1. A study sample large enough to represent the entire population will be taken.

Errors will be minimized by calibration of the examiners; the intra-examiner

reliability will be conducted.

2. Correct and appropriate examination instruments will be used.

6.11 ANALYSIS AND PRESENTATION OF DATAComputer will be used for analyzing data, using Standard Package for Social

Scientist (SPSS) Programme. The mean, median and frequency will be used to

describe the data. XL test will be used to assess the relationship between

categorical variables.

Data will be presented in the form of text, tables, graphs and pie charts.

10

7.0 BUDGET

Proposal

Development Phase

Number Item Amount in

Kenya

Shillings

1. Internet use (3x) @ 5/6 4500

mins

2. Purchase research 5000

textbooks

3. Statistic textbook 2000

4. Photocopying 3ksh./page x 210

70

5. Printing 15 Kshs/page x 15 225

6. Subtotal 11 935

Report Writing Phase

1. Photocopying 5kshs./page x 50

10

2. Binding 100

3. Stationery 1500

4. Storage Device (flash disc 3000

1GB)

5. Airtime for appointments 2000

6. Data Analysis (Statistician 1500

services)

8. Contingency 2500

9. Subtotal 10650

10. Grand Total 23000

] 1

REFERENCES

1) Krasse B, Biesbrock AR, Dental caries prevalence among 12 year old

children in Guguletu, South Africa J. African 2001: 35; 45-46

2) Mosby D and colleagues, Dental health and dietary habits in 6 year olds in

a primary school in Sweden, J Swedish Dental 2006: 15: 67 - 68.

3) Cartledge JD, Midgley J Gazzard BG: Non-albicans oral candidosis in

HIV-positive patients J Antimicrob chemother. 1999: 43: 419 - 422.

4) Rangnathan K, Hemalathan R, J Advanced dental research 2006, 19; 63-

68.

5) Greenspan D, Ganchola AJ, Macphail LA, Sheikh B,Greenspan JS : Effect

of HAART, ARV on frequency of oral warts J. Br, 2001. 357: 1411-1412

6) Viera AR et al: New concepts regarding the pathogenesis of periodontal

disease in HIV infection, J Periodontology 1994: 65: 393 -397

7) Baqui and colleagues, Oral manifestation of HIV in 600 South African

patients, J oral pathol med. 1998: 27: 176 - 179.

8) Coates and colleagues, HIV infection and periodontal disease, J Am Dent

Assoc, 2001; 132: 368 - 376.

9) Younai FS, Marcus M, Fred JR et al: Self-reported dryness and HIV

disease in a national sample of patients receiving medical care, J Oral

surgery, oral medicine, oral pathology, oral radiology, endo, 2001: 92:629-

636.

10) Patton LL, Mckaig R, Strauss R et ai, the effect of ARV therapy on the

prevalence of oral manifestations of HIV-infected patients, J infectious

diseases 2001: 92:623 - 628.

11) Aguirre JM, Echebarria MA, Ocina E, Pabacoba Let al: Reduction of HIV

associated oral lesions after HAART, J Acquired Immune Defic Syndr

1999,88: 114 - 115.

12

APPENDIX 1.

1.2.3.

Serial No:Sex MaleDate of Birth: Day

Initial

FemaleMonth Year Age

Current4. Viral Load

5. ARV Therapy

Drug Information Frequency of intakeDrugs Syrup Suspension TabletName

5. Other sugar containing medications6. Duration patient has been on ARV therapy7. Foods which are cariogenic

DENTITION STATUS

(40)(56)

55 54 53 52 51 61 62 63 64 6518 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Crown

ITIIIIIIJ ITIIIIIIJ (55)ITIIIIIIJ ITIIIIIIJ (71)Root

Primaryteeth

CrownABCDE

Permanentteeth

Crown/Rooto 01 I2 23 34

5

85 84 83 82 81 71 72 73 74 7548 47 46 45 44 43 42 41 31 32 33 34 35Crown

(72) ITIIIIIIJ ITIIIIIIJ (87)(88) ITIIIIIIJ ITIIIIIIJ (103)

Root

36 37 38FG

67 7

StatusSoundDecayedFilled, with decayFilled, no decayMissing, as aresult of cariesMissing, any othe

reasonFissure sealantBridge abutment,special crown orvaneerlimplantUnerupted tooth,(crown )/unexposerootTrauma (fracture)Not recorded

8 8

T T9 9

13

APPENDIX 2

CONSENT FORM

Dear Parent/Guardian

I am an undergraduate student at the University of Nairobi Dental School. I wish

to request for your permission for your child to participate in a study that will form

part of my degree work. The study will involve examination of your child's mouth

which will be done by me.

This will be recorded and analyzed for research purposes only. Should any

problem be detected in your child then they will be referred to a dentist or

advised accordingly. No invasive procedure will be performed on your child

during the study. I would therefore appreciate your consent by signing below.

TAFA CHOBUYA COLLEEN (BDS III)

I, Parent/Guardian of

........................................................ of do hereby freely

consent/do not consent to my child participation in the current study.

I. have explained what is required of the child. I

understand that no harm will be caused and that the child can withdraw at any

time without any adverse consequences to him/her. I also guarantee that all the

information about the child shall be treated confidentially.

Signed .

PARENT OR GUARDIAN

Witnessed by. .

Date .

14