General and Oral Health Related Behaviors among HIV Positive and the Background Adult Tanzanian Population

Febronia Kokulengya Kahabuka^1*, Poul Erik Petersen², Hawa Shariff Mbawala¹ and Nanna Jürgensen²

¹Department of Orthodontics, Paedodontics & Community Dentistry, Muhimbili University of Health and Allied Sciences, School of Dentistry, Dar es Salaam, Tanzania

²Department for Global Oral Health and Community Dentistry, Faculty of Health Sciences, Centre for Health and Society, School of Dentistry, University of Copenhagen, Copenhagen , Denmark

*Corresponding Author:

Febronia K. Kahabuka
Department of Orthodontics
Paedodontics & Community Dentistry
School of Dentistry, Dar es Salaam, Tanzania
Tel: 255 22 215 11 35
Fax: 255 22 215 04 56
E-mail: fkahabuka@muhas.ac.tz, kokukahabuka@yahoo.com

Received Date: August 19, 2014; Accepted Date: September 09, 2014; Published Date: September 15, 2014

Citation: Kahabuka FK, Petersen PE, Mbawala HS, Jürgensen N (2014) General and Oral Health Related Behaviors among HIV Positive and the Background Adult Tanzanian Population. J Oral Hyg Health 2:162. doi:10.4172/2332-0702.1000162

Copyright: © 2014 Kahabuka FK, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objectives: To assess the general and oral health related behaviors among HIV positive adults and the background population.

Methods: A case-control study utilizing a structured questionnaire to collect data. Cross tabulations and Chisquare statistics were conducted for bivariate analyses and simple logistic regression was used for multivariate analyses

Results: 898 individuals aged 15-80 years participated in the study of whom 66.8% were females. Slightly more than half (51.2%) self-reported to be living with HIV/AIDS. Of the health behaviors investigated, positive behaviors frequently reported were: hand washing, eating fresh fruits, eating green vegetables, infrequent snacking or consumption of sweetened soft drinks, not smoking or consuming alcohol. Behaviors seldom reported were; tooth brushing (twice a day), use of fluoride toothpaste and regular dental visits. The OR for reporting hand washing before eating among people living with HIV/AIDS was 0.5 (0.3, 0.9). People living with HIV/AIDS had significantly higher odds for daily eating of fresh fruits and vegetables, OR 2.2 (1.6, 3.1) and 1.7 (1.2, 2.3), respectively. They were as well less likely to smoke and consume alcohol than the comparative general population. They were significantly less likely to use sweetened soft drinks (OR 0.6 CI (0.4, 0.8) but more likely than the general population. to have not used fluoridated toothpaste.

Conclusion: From the findings of this study, we conclude that most HIV positive individuals had better general health behaviors than the background population but only a few (18%) had good oral health behaviors (using fluoridated toothpaste and dental visit due to oral problem). HIV positive individuals should be encouraged to maintain positive health behaviors and be facilitated to practice the positive behaviors currently reported by few.

Keywords

Oral health; Health behavior; Oral health behavior; HIV, People living with HIV/AIDS; Case control study; Tanzania

Introduction

Conner and Norman [1] defined health behavior as any activity undertaken for the purpose of preventing or detecting disease or for maintaining health and well-being. Health related behaviors can be grouped into positive and negative health behaviors. Examples of positive or ‘health-enhancing’ health behaviors include participation in regular leisure-time physical activity, body and hand hygiene, annual health checks-ups, vaccination, screening for high blood pressure and high cholesterol, consumption of fruits and vegetables, and condom use in response to the threats from sexually transmitted diseases [2]. Whereas, negative or ‘health-impairing’ health behaviors include: tobacco use, drinking heavily, driving too fast, and eating a diet high in saturated fat [2]. Correspondingly, positive oral health behaviors are proper tooth brushing, fluoride use and dental consultation [3] while negative oral health behaviors include tobacco use and frequent in between meals and sugar consumption [4,5].

There is sufficient information on association between healthrelated behaviors and diseases, as well health-related behaviors and health status. For instance, morbidity and mortality from coronary heart disease(CHD), oral cancer, development and progression of periodontal disease are known to increase among smokers [6-10]. Likewise, excessive alcohol consumption is a known risk factor for periodontal diseases [7] and oral cancer [11]. Inadequate physical activity, especially when coupled with consumption of excess calories, lead to obesity [12] which is a risk factor for periodontal disease [13]. Frequent consumption of sugars, especially when taken in between meals, is associated with increased risk of dental caries [4]. Recently, Liang et al.; [14] reported that obesity-related behaviors, such as increased food intake, dis-inhibited eating, and less physical activity are associated with executive dysfunction in children and adolescents. Galanti et al.; [15] reported, among adolescents, that tobacco and oral snuff use were significantly associated with a number of problematic behaviors such as drinking and driving, unsafe sex, and school truancy.

Positive behaviors like body & hand hygiene, physical examination, vaccination, screening for high blood pressure and high cholesterol, consumption of fruits and vegetables at least five portions a day promote good health [16]. Likewise, tooth brushing twice a day in the morning and before retiring to bed, use of fluoride and regular dental consultation promote good oral health as well as prevent dental caries [17].

In disease causation models, agent factors comprise characteristics that include the immunological state of the individual. Immune- challenged individuals have an increased likelihood for occurrence of diseases or bad health conditions. HIV/AIDS, diabetes, transplant patients and some forms of neoplasms (e.g. leukemia) are health conditions that may result into immunologic challenges and hence increased risk for disease occurrences including opportunistic infections [18]. General and oral health enhancing behaviors on the other hand tend to lower the likelihood of occurrence of diseases and conditions thus it is the arm of the disease causation model that public health can alter.

It rewards positively for an individual to live positive or ‘healthenhancing’ health behaviors thus leading to good health, appreciable quality of life, delaying the onset of chronic disease and extending active lifespan. Patients with chronic diseases/conditions such as coronary heart disease, hypertension, arthritis, diabetes, and musculoskeletal pain would be expected to be in the forefront in observing positive or ‘health-enhancing’ health behaviors. In their study Munir et al.; [19] stated that there were differences in diet and exercise activities among younger and older workers managing the same chronic illness while Kurpas et al.; [20] concluded that the quality of life in patients with chronic respiratory diseases was significantly shaped by their health behaviors. Furthermore, Li-Ching Ma [21] reported a significant positive correlation between health promoting behavior and resilience in all study subjects with chronic kidney disease. Likewise, HIV infected individuals would be expected to observe most positive behaviors. Unfortunately, they face a number of challenges as they attempt to observe positive health behavior. For instance, Njuki et al.; [22] reported low socioeconomic status, poor knowledge and clear understanding of AIDS related illness, distance to facility and transportation costs, medical pluralism, stigma, low HIV risk perception, lack of family support and health care system barriers as factors contributing to delays/constraints in seeking care. Ritte and Kessy [23] stated that “people living with HIV/AIDS (PLWHA)” attending care and treatment clinics had problems with their nutrition, underweight being common. It has been observed that HIV-positive people tend to seek preventive care when it was offered at no cost and Tobias et al.; [24] stated that people with HIV may be more likely to seek preventive dental care if financial barriers to care were removed. As such, it is not known whether Tanzanian HIV-positive individuals perform health enhancing behaviors or not. This study was, therefore, conducted to assess the general and oral health behavior among PLWHA and compare them with the background population. The study will identify general as well as oral health positive and negative health behaviors among HIV positive individuals then form the basis for the behaviors to be reinforced and those to be encouraged and emphasized ultimately contribute in improving PLWHA’s quality of life.

Study Population and Methodology

Study population

The targeted study population was 840 people comprising of 420 PLWHA and the same number of the background population. Three regions, Dar-es-Salaam, Iringa and Mbeya were conveniently chosen on the basis of HIV/AIDS prevalence according to the recent National Surveillance report [25]. According to the 2006 surveillance report, the estimated number of people living with HIV infection in Mainland Tanzania was 2,246,341 out of whom 27.3% were enrolled in HIV care programme. Regions that were enrolling many infected people were Dar es Salaam (15.3%), Iringa (11.9%), Mbeya (11.2%), and Mwanza (10.2%). Multistage cluster sampling was applied whereby adult participants from urban and peri-urban settings were chosen. The sample size was calculated from precision level ±5% and prevalence rate of 45% HIV/AIDS oral affection using the following formula: n = (Z²× P(1 – P))/e².

This was a case-control study, where PLWHA were cases and the background population being the controls. PLWA participants were recruited from care and treatment centres. All urban care and treatment centres available in the three focal points Dar es Salaam, Mbeya and Iringa were included in the study and all clinic attendants were invited to participate. The controls were obtained from the same socio-demographic background as the cases (PLWHA participants). A one stage cluster sampling design was used, where villages located in vicinity to the participated care and treatment facilities were randomly selected to participate. At the village level the participants were recruited at household level and all those who were eligible and present during the day of interview and could avail themselves for intra-oral examination were invited to participate in the study. Both the cases (PLWHA participants) and the control (background participants) responded to a questionnaire through interview and as well underwent intra-oral examination. This article reports only the interview part.

Inclusion criteria

For the cases the participants were to be known HIV positive individuals aged 15 years or older while the matched controls were to be aged 15 years or older from the same location with the cases

Exclusion criteria

The cases excluded the bedridden HIV positive individuals and the controls were not to be known to have any form of terminal disease conditions.

Methodology

Participants were interviewed using a structured questionnaire to collect information about general and oral health-related behavior namely; hygiene practices (washing hands before eating and after using toilet, tooth brushing, use of fluoride toothpaste), use of formal health services (visiting a dentist), alcohol consumption, and current and previous tobacco use. The questionnaire also inquired on dietary habits such as use of fresh fruits and green vegetables, sugary soft drinks and in between meals snacking, educational background, number of bedrooms and number of family members. Statistical Package for the Social Sciences (SPSS) version 19 was used for data analysis. Bivariate analyses of the behavior under study were conducted using cross-tabulations and χ2 statistics. Multivariate variable analyses were conducted using standardized logistic regression with odds ratios and 95% Confidence Intervals (CI). The difference in general and oral healthrelated behavioral practices among cases (PLWHA) and background participants was examined. To examine whether the differences in practicing the behaviors was a true difference between the two diverse groups (case vs. control), all statistically significant variables in bivariate analysis were considered in the multivariate analysis.

Results

Sample profile

The study sample comprised 898 participants aged 15 years and above with mean age 38.3 years and Standard Deviation 11.8. The study was a population based in a country where the exact number of family members is not known to local authorities which were assisting in enrollment. Consequently all family members who consented and came to examination sites on the day of study were recruited for the study. Females constituted the majority (66.8%) of the sample. Slightly more than half (51.2%) of the participants self-reported as living with HIV/AIDS.

Socio-demographically, participants who reported to be living with HIV/AIDS differed statistically significantly from the background population. Higher proportions of females, people aged 25-44 years, persons with low educational level (primary school education or less), persons living in a family of less than six people, and those who had fewer bedrooms were reported among persons living with HIV/AIDS more often than among the background population (Table 1).

Table 1: Socio-demographic characteristics of the study population.

General health related behaviors

Hand washing before eating and after using toilet was reported by 90.9% and 84.0%, respectively of the 898 participants regardless of their HIV status. As shown in Table 2 the proportions were 89.6% and 82.6% for HIV positive participants. There were no statistical significant differences in hand washing practices between persons living with HIV/AIDS and the background population. Daily eating of fresh fruits and vegetables was reported by 47.2% and 76.1% of the PLWHA respectively. These results differed significantly from those of the background population which were 28.3% and 60.0%, respectively (Table 2). Among participants living with HIV/AIDS, 4.4% and 13.9% reported to be smoking and consuming alcohol on their daily basis whereas 8.4% and 31.5% of the background population reported to do so and the differences were statistically significant (p value = 0.012, p = 0.001respectively); (Table 2). In multivariate analysis, people living with HIV/AIDS were significantly different from the background population in that the OR for reporting wash hand before eating was 0.5 (0.3, 0.9), (Table 3). People living with HIV/AIDS had significantly higher odds for daily eating of fresh fruits and vegetables, OR 2.2 (1.6, 3.1) and 1.7 (1.2, 2.3), respectively. They were also less likely to smoke and consume alcohol than the comparative background population (Table 3).

Table 2: Participants of PLWHA and of the background population who reported certain general health related behaviors.

Table 3: The association of living with HIV/AIDS with general health related behaviors adjusted for socio-demographic variables, as measured by ORs (95% CI).

Oral health related behaviors

Significantly higher proportion of participants living with HIV/ AIDS reported to perform tooth brushing irregularly compared with participants of the background population (p = 0.036). Among participants living with HIV/AIDS only 18% reported to use fluoridated toothpaste on a regular basis against 7.8% in the comparison group and the difference in use of fluoridated toothpaste was significant (p = 0.001). In the two groups about one fifth reported to have been to a dentist due to oral health problems. It was a much common behavior for the general population to take sugary soft drinks than for the participants living with HIV/AIDS (Table 4). This difference was significant (p = 0.002).

Table 4: Participants of PLWHA and of the background population who reported certain oral health related behaviors.

Table 5 presents the socio-demographically adjusted analysis for association of living with HIV/AIDS and oral health related behavior, where by living with HIV/AIDS is significantly associated with use of fluoridated tooth paste and use of sweetened soft drinks. People living with HIV/AIDS were significantly less likely to use sweetened soft drinks OR 0.6 CI (0.4, 0.8) and were more likely to report not to have used fluoridated toothpaste than the background population.

Table 5: The association of living with HIV/AIDS with oral health related behaviors adjusted for socio-demographic variables, as measured by ORs (95% CI).

Discussion

Interpretation of these findings should bear in mind that HIV infected individuals were not tested for their HIV status by the current researchers. Instead, a trust was made that all registered with treatment and care centers for HIV infected individuals have been previously confirmed of their serostatus. Besides, in the background population there may be HIV infected individuals whose serostatus was not yet known or who did not want to disclose their serostatus.

More HIV positive females participated in this study, similar to previous reports [26]. Apparently, in Tanzania most HIV positive women cannot afford the treatment cost at private sectors, hence they seek medical care from public facilities. Three quarters of HIV positive participants and consequently more than half of the general population were aged 25-44 years. This age group is the most HIVaffected age since they are more sexually active though some may have been affected at earlier age through other routes including mother to child. Regarding level of education, most participants were in the lowest level (had primary/elementary school education). This is in line with the general national picture which shows that only 19.1% of Tanzanians who complete elementary education enroll to secondary education [27]. HIV positive participants significantly had fewer family members and less number of bedrooms probably due to their lower income but maybe also due to less demand from the society for HIV positive families to support members of extended families.

Larger proportions of HIV positive participants compared to the background population reported positive general health behavior; use of fresh fruits, eating green vegetables, not smoking or consuming alcohol. This impressive finding is likely to be a result of efforts from various stake holders in Tanzania who educate HIV positive individuals to observe certain behaviors in order to maintain their health and prolong their lives. Even if the general population is also advised to practice health behavior in order to maintain good health, it is possibly easier for someone whose health is already jeopardized to adhere to the advice than otherwise. Our findings closely match those reported on patients with other chronic diseases [19-21] where health promoting behaviors were reported to be frequent among individuals with chronic diseases. Washing of hands before eating or after using the toilet was reported by over 80% of participants from both groups with no statistical significant differences between the groups. Probably, promotion of hand washing has received good coverage among Tanzanians despite their HIV status. Besides, the practice is easy to perform and goes hand in hand with cultural as well as religious norms.

Smaller proportions of HIV positive participants reported, contrary to the positive general health behaviors, positive oral health behaviors including tooth brushing, use of fluoridated toothpaste and dental visit. The HIV infected participants were less likely to have used fluoridated toothpaste. Although Kahabuka et al.; [26] had previously recommended that oral health professionals should provide sound oral health information to HIV infected individuals; it appears that such communication seldom has been done. Additionally, high cost of some dental products, less priority placed on oral health in the Tanzanian society and minimal involvement of dental professionin the care of HIV infected individuals may explain these findings. In attempting to follow health promoting behaviors, HIV infected individuals face a number of challenges including cost, distance to health facilities, availability of services and stigma [24]. For instance treatment cost has been reported to be a barrier to accessing oral health care by the Tanzanian general population [28], and by other underserved communities [29-31]. HIV infected individuals in underserved communities are likely to find cost as a main barrier to accessing dental services since they have many other requirements to meet. The World Health Organization strongly advocates affordable primary oral health care be established urgently to meet the needs of underprivileged and disadvantaged population groups, including HIV infected people [32].

In order for this group to have good oral healthpractices; brush their teeth twice a day (in the morning and after breakfast), use fluoride tooth paste, and visit a dentist regularly; they need to be empowered economically and educationally but also be constantly motivated. Adequate oral hygiene is important to HIV infected people as it has a chance of decreasing the presence and impact of oral lesions [33] ultimately contributing to increasing their quality of life.

HIV infected participants were less likely to consume sweetened soft drinks and in between meals snacks. Apparently these two dietary habits put an individual at risk of developing dental caries which may compound the already oral health problems HIV infected individuals may be having. Thanks to campaigns that discourage HIV positive people to use processed over home-made drinks. Furthermore, unavailability and inaccessibility to snacks may also contribute to this finding.

Earlier on, Petersen et al.; [3] suggested that several approaches and multiple methods should be applied in oral health education in order to modify behaviors that affect oral health of adolescents in the general population. Such actions may be prudent for HIV infected individuals. Accordingly, a need for strategies that focus on the importance of oral health [34] and developing effective educational methodologies to empower HIV infected patients with knowledge that may translate to positive attitudes and practices [35] have been recommended.

Conclusion and Recommendations

From the findings of this study, we conclude that most HIV positive individuals reported to have good general health behaviors but only a few had good oral health behaviors. The well-practiced positive health behaviors (hand washing, use of fresh fruits, eating green vegetables, infrequent snacking or consumption of sweetened soft drinks, not smoking or consuming alcohol) should be encouraged while emphasis should be placed on behaviors reported by few participants (tooth brushing twice a day, use of fluoride toothpaste and dental visits). Oral health professionals should take charge and educate HIV positive individuals to facilitate betterment of their own general and oral health.

Acknowledgements

We are grateful to DANIDA Danish Ministry of Foreign Affairs UM j.no. 104. DAN.8-917 for funding the study and to the participants for accepting to take part in the study.

Grants

The study was funded by the Danish Ministry of Foreign Affairs UM j.no. 104

References

1. Conner M, Norman P (1996) Predicting Health Behavior. Buckingham, UK: Open University Press.
2. Sutton S (2004) Determinants of Health-Related Behaviors: Theoretical and Methodological Issues in Sutton S, Baum A, Johnston M (Eds)The Sage Handbook of Health Psychology. Sage Publications Ltd. London,1st Edition; 94-126.
3. Petersen PE, Jiang H, Peng B, Tai BJ, Bian Z (2008) Oral and general health behaviours among Chinese urban adolescents. Dent Oral Epidemiol 36: 76-84.
4. Sanders TA (2004) Diet and general health: dietary counselling. Caries Res 38 Suppl 1: 3-8.
5. Warnakulasuriya S, Dietrich T, Bornstein MM, Casals Peidró E, Preshaw PM, et al. (2010) Oral health risks of tobacco use and effects of cessation. Int Dent J 60: 7-30.
6. Doll R, Peto R, Wheatley K, Gray R, Sutherland I (1994) Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 309: 901–911.
7. Wickholm S, Galanti MR, Söder B, Gilljam H (2003) Cigarette smoking, snuff use and alcohol drinking: coexisting risk behaviours for oral health in young males. Community Dent Oral Epidemiol 31: 269-274.
8. Bergström J, Preber H (1994) Tobacco use as a risk factor. J Periodontol 65: 545-550.
9. Johnson GK, Slach NA (2001) Impact of tobacco use on periodontal status. J Dent Educ 65: 313-321.
10. Winn DM (2001) Tobacco use and oral disease. J Dent Educ 65: 306-312.
11. Franceschi S, Talamini R, Barra S, Barón AE, Negri E, et al. (1990) Smoking and drinking in relation to cancers of the oral cavity, pharynx, larynx, and esophagus in northern Italy. Cancer Res 50: 6502-6507.
12. Giovannucci E, Colditz GA, Stampfer MJ, Willett WC (1996) Physical activity, obesity, and risk of colorectal adenoma in women (United States). Cancer Causes Control 7: 253-263.
13. Saito T, Shimazaki Y, Kiyohara Y, Kato I, Kubo M, et al. (2005) Relationship between obesity, glucose tolerance, and periodontal disease in Japanese women: the Hisayama study. J Periodontal Res 40: 346-353.
14. Liang J, Matheson BE, Kaye WH, Boutelle KN (2014) Neurocognitive correlates of obesity and obesity-related behaviors in children and adolescents. Int J Obes (Lond) 38: 494-506.
15. Galanti MR, Wickholm S, Gilljam H (2001) Between harm and dangers. Oral snuff use, cigarette smoking and problem behaviours in a survey of Swedish male adolescents. Eur J Public Health 11: 340-345.
16. Macera CA (2003) Promoting healthy eating and physical activity for a healthier nation. In Centers for Disease Control and Prevention. Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for Action. Atlanta, GA: Department of Health and Human Services, 7-1 – 7-22.
17. Petersen PE (2007) Inequalities in oral health: the social context for oral health. In: Pine C, Harris R, eds. Community oral health. 2nd ed. London: Quintessence, 31-58.
18. Chinen J, Shearer WT (2010) Secondary immunodeficiencies, including HIV infection. J Allergy ClinImmunol 125: S195-203.
19. Munir F, Khan HTA, Yarker J, Haslam C, Bains M, et al. (2009). Health behaviors among older and younger workers with chronic illness. Oxford Institute of Ageing Working Papers Working paper 109.
20. Kurpas D, Mroczek B, Jasinska M, Bielska D, Nitsch-Osuch A, et al. (2013) Health behaviors and quality of life among patients with chronic respiratory disease. AdvExp Med Biol 788: 401-406.
21. Li-Ching Ma, Hong-Jer Chang, Yueh-Min Liu, Hsiang-Li Hsieh, Lan Lo, et al. (2013) The Relationship between Health-Promoting Behaviors and Resilience in Patients with Chronic Kidney Disease. ScientificWorldJournaldoi: 10.1155/2013/124973.
22. NjukiR., Kimani J, Obare F, Warren C (2013) Using Verbal and Social Autopsies to Explore Health-Seeking Behavior among HIV Positive Women in Kenya: A Retrospective Study.
23. Ritte SA, Kessy AT (2012) Social factors and lifestyle attributes associated with nutritional status of people living with HIV/AIDS attending care and treatment clinics in Ilala District, Dar Es Salaam. East Afr J Public Health 9: 33-38.
24. Tobias CR, Lemay CA, Jeanty Y, Umez-Eronini AA, Reznik DA (2012) Factors associated with preventive dental care-seeking behavior among people living with HIV. J Public Health Dent 72: 60-67.
25. The United Republic of Tanzania, Ministry of Health Tanzania mainland, National AIDS Control Programme HIV/AIDS/STI Surveillance Report January – December 2006.
26. Kahabuka FK, Fabian F, Petersen PE, Nguvumali H (2007) Awareness of HIV/AIDS and oral manifestations among people living with HIV/AIDS in Dar es Salaam, Tanzania. Afr J AIDS Res 6:91-95.
27. Ministry of Education and Culture The United Republic of Tanzania. Secondary Education Master Plan.
28. Kikwilu EN, Masalu JR, Kahabuka FK, Senkoro AR (2008) Prevalence of oral pain and barriers to use of emergency oral care facilities among adult Tanzanians. BMC Oral Health 8: 28.
29. Zittel-Palamara K, Fabiano JA, Davis EL, Waldrop DP, Wysocki JA, et al. (2005) Improving patient retention and access to oral health care: the CARES program. J Dent Educ 69: 912-918.
30. Varenne B, Petersen PE, Fournet F, Msellati P, Gary J, et al. (2006) Illness-related behaviour and utilization of oral health services among adult city-dwellers in Burkina Faso: evidence from a household survey. BMC Health Serv Res 6: 164.
31. Ajayi DM, Arigbede AO (2012) Barriers to oral health care utilization in Ibadan, South West Nigeria. Afr Health Sci 12: 507-513.
32. Jones J, Mofidi M, Bednarsh H, Gambrell A, Tobias CR (2012) Increasing access to oral health care for people living with HIV/AIDS in rural Oregon. Public Health Rep 127 Suppl 2: 65-72.
33. Ponnam SR, Srivastava G, Theruru K (2012) Oral manifestations of human immunodeficiency virus in children: An institutional study at highly active antiretroviral therapy centre in India. Journal of Oral and Maxillofacial Pathology JOMFP 16:195-202.
34. Rajabiun S, Fox JE, McCluskey A, Guevara E, Verdecias N, et al. (2012) Patient perspectives on improving oral health-care practices among people living with HIV/AIDS. Public Health Rep 127 Suppl 2: 73-81.
35. Khan SA, Moorthy J, Omar H, Hasan SS (2012) People living with HIV/AIDS (PLWHA) and HIV/AIDS associated oral lesions; a study in Malaysia.BMC Public Health 12: 850.

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