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South African Dental Journal

versão On-line ISSN 0375-1562
versão impressa ISSN 0011-8516

S. Afr. dent. j. vol.70 no.6 Johannesburg Jul. 2015



For common oral conditions found in HIV-infected and non-HIV infected patients, over two thirds of OHCW administer the same treatment with a slight difference in patients presenting with oral thrush where 22.8% (n=10) said they would not give the same treatment/advice.

Further correlations were performed between selected demographic characteristics (age, years of experience and employment sector) and selected questions on the knowledge, attitudes and practice sections. One question was considered for each of the KAP sections for correlations. The cross-tabulations were used to determine if there were any significant associations between the selected variables and the different KAP sections. The Fisher's exact test of association was applied to 2x2 contingency tables and the significance was set at p=0.05. The results are reported with the exact p-values.

Cross-tabulations were performed to determine the relationship between the age of OHCW and their knowledge of oral lesions associated with HIV with the purpose of determining whether age increased knowledge of HIV-associated lesions. The median age of 39 years old was used for this association instead of the mean due to the skewed nature of the data caused by the presence of outliers. OHCW were categorized in two groups of <39 and >39 years. The results show that the majority of the participants from both age groups who had previously seen oral candidiasis could correctly identify it. However, a greater proportion of participants above >39 years old (n=5) could not correctly identify angular cheilitis despite the fact that only one of them had not seen the lesion previously (p=0.021) as compared with the <39 year old group who all correctly identified the lesion. It was also observed that not all participants who had seen the lesions previously were able to correctly identify them. However, some who claimed they had not seen some lesions before were in fact able to identify them correctly. A correlation made between the two employment sectors of OHCWs (private and public) and their knowledge with regards to the ability to identify oral HIV lesions revealed several significant findings. OHCW in the public sector encounter patients presenting with oral manifestations of HIV more frequently than their counterparts in the private sector: candidiasis (n=34; p =0.048), oral hairy leukoplakia (n=28; p=0.023), herpetic gingivostomatitis (n=32; p=0.005) and herpes zoster (n=30; p=0.0149). In addition, public sector workers had a significantly better ability to correctly identity herpetic gin-givostomatitis (n=29; p = 0.030) and herpes zoster (n=31; p=0.0257) than those in the private sector (Table 6).



The present study sought to determine the knowledge, attitudes and practices of oral health care workers in Lesotho regarding the management of oral HIV/AIDS related lesions. All the participants consented and completed the questionnaires. While most countries legally permit dentists and dental therapists to perform invasive dental procedures such as dental extractions, minor dental surgeries and restorations, in Lesotho, due to the dire shortage of OHCW, oral hygienists, dental assistants, dental technologists as well as nurse assistants are also entrusted with clinical responsibilities.

The majority of the participants (44.4%) had a range of 1-10 years of experience and this may be due to the fact that most qualified dentists are emigrants who work in Lesotho immediately after they attain their dental degrees in their countries and often are on short-term contracts.

The results of the present study revealed that OHCW demonstrated a fair knowledge of oral manifestations of HIV with nearly all in agreement that oral lesions are a common finding in PLWHA and this concurs with the literature.13,19,20 This was also in agreement with the findings of other studies conducted in Lesotho confirming the high prevalence of oral lesions in PLWHA.14,21,22 The majority listed oral candidiasis as the most common oral lesion associated with HIV, which also highlights the high prevalence of this lesion in PLWHA in Lesotho. This result was similar to the findings of several studies.22,23,24,25,26

Oral lesions of HIV such as periodontal infections, herpes infections, Kaposi's sarcoma and Oral hairy leukoplakia are classified as lesions strongly associated with HIV.28 However, fewer than half of the OHCW listed these l esions as l ess common than documented in the literature. This result concurred with the results of another South African study where less than 50% of the participants named oral hairy leukoplakia, herpes infections and periodontal diseases as common lesions of HIV, with the exception of Kaposi's sarcoma.24 This was contrary to the findings in the Kenyan study where more than half of all the participants correctly identified periodontal infections, herpes infections, Kaposi's sarcoma and oral hairy leukoplakia as lesions strongly associated with HIV.23 This could be due to the fact that the study participants were all dentists.

The presence of Kaposi's sarcoma is indicative of disease progression and high mortality. A study conducted in PHC facilities in South Africa revealed the significance of early diagnosis and timely access to HAART and chemotherapy for patients with KS.29 Lack of adequate knowledge of this lesion by OHCW may lead to a delayed diagnosis resulting in detrimental effects, including morbidity and mortality.

Oral hairy leukoplakia is similarly strongly associated with HIV and its presence signposts progression to AIDS. A probable explanation for OHCW describing these lesions as uncommon may indicate that the lesions are not encountered as frequently as oral candidiasis and herpes infections, or may signify a lack of knowledge of these lesions and their association with HIV/AIDS. Regardless, these findings suggest that OHCWs require further training to prevent delayed diagnosis, which may lead to poor health and quality of life caused by discomfort, dysfunction and disability.18

While 84% of the participants reported to have received training in the diagnosis of oral lesions of HIV, less than a fifth perceived that they had comprehensive knowledge of oral HIV lesions. Just over a third felt their knowledge was 'better than average' and nearly all expressed the need for further training in this regard. In a study on South African dentists, 71% of the respondents thought they had adequate knowledge of HIV.24 This may be attributed to the fact that the study was conducted only on dentists as opposed to all other cadres of OHCW. There is a need for training and education in the management of PLWHA on a continuous basis and in the form of regular refresher courses.

Participants were asked to identify seven unlabelled photographic images depicting oral lesions strongly associated with HIV. The images correctly identified by the majority of participants were oral candidiasis, angular cheilitis herpes zoster and oral ulcerations respectively. Just over half of the participants correctly identified Kaposi's sarcoma and oral hairy leukoplakia, which are lesions strongly associated with HIV. Even though some of these lesions were listed by the participants in the questionnaire as less commonly associated with HIV, slightly higher proportions were able to identify them correctly when provided with the visual images. This result may be due to increased uptake of HAART therapy, which significantly reduces the prevalence of oral lesions of HIV.10,29-32 It may also indicate poor practical knowledge and perhaps a low appreciation of the significance of history taking in identifying specific oral lesions, because the onset of some conditions as expressed by patients will often aid the diagnosis. Nearly all participants in the present study correctly identified oral candidiasis as the most common oral HIV lesion and this finding is similar to other studies.23,24,33

Many of the correlations conducted showed statistically insignificant results and this may likely be attributed to the small sample population of the study (n=46), even though this was representative of the whole population of OHCW in Lesotho. There were statistically significant results between knowledge and employment sector suggesting that participants working in the public sector more frequently encountered common oral lesions associated with HIV and were more able of correctly identifying them than were their private practice colleagues. The association between knowledge and years of experience showed that the knowledge of HIV by OHCW increases with an increase in the number of years of experience, however, the results were not statistically significant.

In the current study, almost all participants showed a willingness to treat PLWHA, which may be explained by the current wealth of knowledge of HIV and its routes of transmission and the appropriate infection control measures. The high response rate on willingness to treat concurred with other studies.8,9,23,35,36 Furthermore, knowledge regarding the risk of transmission of HIV and the use of infection control measures has been identified by some as factors associated with a willingness to treat HIV/AIDS patients where the OHCW may otherwise have been fearful regarding cross-infection.7,9,36 The high willingness reported in the present study may indicate the fact that OHCW are cognizant of their ethical obligation in providing treatment to all patients. A South African study reported similar findings where 81.5% of the participants were willing to treat PLWHA based on their professional responsibility.26

While the vast majority of OHCW of Lesotho showed willingness to treat HIV/AIDS patients, a surprising 59% believed that the risk of contracting HIV in the dental clinic was high. This general misconception is consistent with other studies.9,23,37 More than two thirds reported that there was no need to treat HIV-positive patients differently while those who disagreed felt that on account of their immunocompromised state and prescribed drugs, special care was needed. Many of those who felt HIV-positive patients needed to be referred named public dental clinics and dedicated HIV clinics as facilities to which patients should be referred. This was also consistent with other findings where participants felt patients must be referred to dedicated clinics, academic hospitals and to dentists with special training.23,24

Though it is the responsibility of OHCW to effectively manage the oral health conditions of PLWHA just as they would for any other patient, the challenges with PLWHA are many, including possible neglect of oral hygiene due to pain and discomfort. This, however, does not justify poor management of PLWHA.32,38 Generally, one would not adapt the dental treatment of a patient merely based on their HIV status, however, certain considerations such as the referral of the patient for further management may be necessary due to the patient's immunocompromised state.

Participants were asked to rate their confidence levels in managing PLWHA and to specify if they would provide the same treatment options and/or advice for five common oral diseases/conditions, which may be found in PLWHA and HIV-negative patients. Nearly two thirds reported high levels of confidence in managing PLWHA. They stated that they would give the same treatment to both PLWHA and the HIV-negative patients presenting with the same oral diseases. For those who opted for different treatment/advised, the reasons mentioned were positively discriminatory towards PLWHA. For example, they would provide the patient with prophylactic antibiotic cover prior to dental extraction and they would spend more time emphasizing the importance of individual oral self-care because of increased susceptibility to infections.

It has been established that severe oral ulcerations may occur in HIV-infected patients, often characterized by pain and fever. These may range from recurrent aphthous ulcers, herpes infections, cytomegalovirus infections and Epstein-Barr virus infections.17 However, a South African study reported a small prevalence (2.9%) of oral ulcerations in a group of 600 HIV-positive patients and these findings were consistent with the findings of another study, conducted in India.16,39

As regards patients presenting with sores in the mouth, the vast majority of OHCW reported that they would offer the same treatment after taking a thorough medical examination to establish the aetiology, duration and frequency of the ulcers. Different treatments suggested included advice to HIV-negative patients to go for testing and counselling, referral for blood tests to establish the causes of ulcerations and if widespread, referral to a physician for further management.

Periodontal diseases such as linear gingival erythema, necro-tizing ulcerative gingivitis, necrotizing ulcerative periodontitis and necrotizing stomatitis have been reported to be highly predictive of the underlying HIV infection in individuals who may seem otherwise healthy. Associated symptoms include bleeding gums, tooth mobility and general discomfort in the mouth.12,40 Less than half of the participants in the present study listed periodontal diseases as common lesions of HIV and almost all reported that they would not give different treatment to patients presenting with painful gums. This finding may likely indicate lack of knowledge since periodontal diseases have been described as a common finding in PLWHA. A few participants reported that they would refer such patients for HIV testing and counselling and for CD4 cell count tests.

HIV-infection may lead to a reduction in the flow of saliva, which may be indicative of salivary gland dysfunction and a side-effect of long-term HAART therapy. Furthermore, dry-mouth in PLWHA has been found to be crucial in the HIV disease progression.30,41 The management of xerostomia in PLWHA is vital considering the discomfort it causes the patient and the inability to function adequately. An overwhelming majority of the OHCW reported that they would give the same treatment or advice to both HIV+/ HIV- patients presenting with xerostomia. Less than ten per cent stated that they would probe further into the medical history of the patient specifically regarding the medications taken by patients and advise accordingly. A possible explanation for this is that OHCW may not be aware of the association between xerostomia and HIV/AIDS, or that they do not frequently encounter patients presenting with xerostomia.

The majority of respondents reported that they would provide the same treatment to both categories of patients presenting with oral candidiasis. However, others suggested that they provided different treatment options for PLWHA presenting with oral thrush, including recommending for a CD4 count test and prescribing systemic antifungal medication instead of topical antifungals. They also stated that they would recommend HIV testing and counselling for HIV-negative patients or patients whose status is unknown, and who present with oral thrush. The management practices of OHCW are in line with the recommendations for treatment of oral candidiasis where systemic antifungals such as fluconazole are especially required in cases where a definitive HIV diagnosis has been made. OHCW also mentioned the use of topical antifungals such as amphotericin B and nystatin for mild cases of candida infections, which have also been reported to be effective.17



The present study has not only highlighted the pivotal role played by OHCW in the identification, diagnosis and management of oral manifestations of HIV/AIDS but has also provided some insight into the knowledge, attitudes and practices of OHCW in Lesotho regarding the management of oral lesions associated with HIV/AIDS. In resource-limited settings such as Lesotho, the value of their role cannot be overemphasised, especially considering the high prevalence of HIV coupled with the dire shortage of human resources in health management including OHCW. It further revealed that above average knowledge yields positive attitudes and good, acceptable practices. However, further training concerning risk in the dental clinic setting is required and this may help to dispel fears and lead to more positive attitudes and an increased willingness to treat patients. The present study focussed only on OHCW and it may be useful to investigate the knowledge, attitudes and practices of other cadres of healthcare workers (nurses, community health care workers etc.) regarding their KAP of the oral manifestations of HIV/AIDS. In view of the shortage of OHCWs, it is recommended that these health professionals also be trained in the diagnosis and management of oral lesions of HIV.



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15. Patton LL, Phelan JA, Ramos-Gomez FJ, Nittayananta W, Shiboski CH, Mbuguye TL. Prevalence and classification of HIV-associated oral lesions. Oral Dis. 2002; 8 (Suppl 2):98-109        [ Links ]

16. Arendorf TM, Bredekamp B, Cloete CAC, Sauer G. Oral manifestations of HIV infection in 600 South African patients. Journal of Oral Pathology and Medicine. 1998;27: 176-9        [ Links ]

17. Johnson NW, Glick M, Mbuguye TNL. Oral health and general health. Adv Dent Res. 2006; 19:118-21        [ Links ]

18. Yengopal V, Naidoo S. Do oral lesions associated with HIV affect quality of life? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(1): 66-73        [ Links ]

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20. Lim AA, Leo YS, Lee CC, Robinson AN. Oral manifestations of human immunodeficiency virus (HIV) - infected patients in Singapore. Annals of Academic Medicine in Singapore. 2002; 30: 600-6        [ Links ]

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22. Prithiviraj TG. Knowledge, attitudes and practice among Primary Health Care nurse practitioners regarding oral health and oral HIV lesions in QE II and Roma health service areas in Maseru Lesotho. Masters Thesis (MPH). University of the Witwatersrand 2012        [ Links ]

23. Gachigo JN, Naido S. HIV/AIDS: the knowledge, attitudes and behaviour of dentists in Nairobi, Kenya. South African Dental Journal. 2001; 56(12):587-91        [ Links ]

24. Darling M, Arendorf T, Samaranayake LP. Oral care of HIV infected patients: the knowledge and attitudes of South African Dentists. J Dent Assoc S Afric. 1992; 47(9):399-402        [ Links ]

25. Malele-Kolisa Y. Knowledge, attitudes and practices of caregivers about oral lesions in HIV positive patients in NGOs / CBOs in Region, Johannesburg, Gauteng. Thesis (MChD) University of the Wit-watersrand. South Africa 2009        [ Links ]

26. Rudolph MJ, Ogunbodede EO. HIV infection and oral health care in South Africa. South African Dental Journal. 1999; 54(12):594-601        [ Links ]

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28. Chu KM, Mahlangeni G, Swanne S, Ford NP, Boulle A, Van Cutsem G. AIDS-associated Kaposi's sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa. Journal of the International AIDS Society. 2010; 13(23):2-5        [ Links ]

29. Frezzini C, Leao JC, Porter S. Current trends of HIV disease of the mouth. J Oral Pathol Med. 2005; 34(9):513-31        [ Links ]

30. Scully C, Laskaris, Porter SR. Oral manifestations of HIV infection and their management. I. More common lesions. Oral Surg, Oral Med, Oral Pathol. 1991;71(2): 158-64        [ Links ]

31. Johnson NW. The mouth in HIV/AIDS: markers of disease status and management challenges for the dental profession. Australian Dental Journal. 2010; 55(1): 85-102        [ Links ]

32. Agbelusi GA, Wright AA. Oral lesions as indicators among routine dental patients in Lagos Nigeria. Oral Diseases. 2005; 11:370-3        [ Links ]

33. Kitaura H, Adachi K, Kobayashi K, Yamada T. Knowledge and attitudes of Japanese dental health care workers towards HIV related disease. Journal of Dentistry. 1997; 25(3-4): 279-83        [ Links ]

34. Bennett ME, Weyant RJ, Wallisch J, Green G. A national survey: Dentists' attitudes towards the treatment of HIV-positive patients. JADA. 1995;126: 509-14        [ Links ]

35. Bodhade A, Dive A, Khandekar S, Dhoble A, Moharil R, Gayakwad R, Tekade S. Factors associated with refusal to treat HIV-infected patients: national survey of Dentists in India, Science Journal of Public Health. 2013;1(2):51-5        [ Links ]

36. Kaste LM, Bednarshe H. The third decade of HIV/AIDS: A brief epi-demiologic update for Dentistry. Journal of Canadian Dental Association. 2007; 73(10): 941-44        [ Links ]

37. Diz-Dios P, Fernandez-Feijoo J, Vazquez-Garcia E. Tooth extraction in HIV sero-positive patients. Int Dent J. 1999; 49: 317-21        [ Links ]

38. Ranganathan K, Hemalatha R. Oral lesions in HIV infection in developing countries. An overview. Adv Dent Res. 2006; 19: 63-8        [ Links ]

39. Nokta M. Oral manifestations associated with HIV infection. The science of HIV medicine. Curr HIV / AIDS Rep. 2008; 5: 5-12        [ Links ]

40. Younai FS, Marcus M, Freed JR, Coulter ID, Cunningham W, Der-Martirosian C, Guzman-Bercerra, N, Shapiro M. Journal of Oral Surg, Oral Med, Oral Path. 2001; 2(6): 629-636        [ Links ]



S Naidoo
Faculty of Dentistry
University of the Western Cape
Private Bag X1 Tygerberg, 7505
Tel: 021 937 3095
Fax: 021 931 2287

^rND^sMcLean^nAT^rND^sWheeler^nEK^rND^sCameron^nS^rND^sBaker^nD^rND^sRobinson^nPG^rND^sMcCarthy^nGM^rND^sKoval^nJJ^rND^sMorin^nRJ^rND^sGodin^nG^rND^sNaccache^nH^rND^sBrodeur^nJM^rND^sAlary^nM^rND^sIrigoyen^nM^rND^sZepeda^nM^rND^sLopez-Camara^nV^rND^sChapple^nLC^rND^sHamburger^nJ^rND^sRamos-Gomez^nFJ^rND^sPetru^nA^rND^sHilton^nJF^rND^sCoogan^nMM^rND^sGreenspan^nJ^rND^sChallacombe^nSJ^rND^sSeacat^nJD^rND^sLitt^nMD^rND^sAdam^nS^rND^sDaniels^nMS^rND^sKamiru^nHN^rND^sNaidoo^nS^rND^sPatton^nLL^rND^sPhelan^nJA^rND^sRamos-Gomez^nFJ^rND^sNittayananta^nW^rND^sShiboski^nCH^rND^sMbuguye^nTL^rND^sArendorf^nTM^rND^sBredekamp^nB^rND^sCloete^nCAC^rND^sSauer^nG^rND^sJohnson^nNW^rND^sGlick^nM^rND^sMbuguye^nTNL^rND^sYengopal^nV^rND^sNaidoo^nS^rND^sNichols^nCM^rND^sFlaitz^nCM^rND^sHicks^nMJ^rND^sLim^nAA^rND^sLeo^nYS^rND^sLee^nCC^rND^sRobinson^nAN^rND^sWalid^nEI^rND^sNasir^nF^rND^sNaidoo^nS^rND^sGachigo^nJN^rND^sNaido^nS^rND^sDarling^nM^rND^sArendorf^nT^rND^sSamaranayake^nLP^rND^sRudolph^nMJ^rND^sOgunbodede^nEO^rND^sChu^nKM^rND^sMahlangeni^nG^rND^sSwanne^nS^rND^sFord^nNP^rND^sBoulle^nA^rND^sVan Cutsem^nG^rND^sFrezzini^nC^rND^sLeao^nJC^rND^sPorter^nS^rND^sScully^nC^rND^sLaskaris^rND^sPorter^nSR^rND^sJohnson^nNW^rND^sAgbelusi^nGA^rND^sWright^nAA^rND^sKitaura^nH^rND^sAdachi^nK^rND^sKobayashi^nK^rND^sYamada^nT^rND^sBennett^nME^rND^sWeyant^nRJ^rND^sWallisch^nJ^rND^sGreen^nG^rND^sBodhade^nA^rND^sDive^nA^rND^sKhandekar^nS^rND^sDhoble^nA^rND^sMoharil^nR^rND^sGayakwad^nR^rND^sTekade^nS^rND^sKaste^nLM^rND^sBednarshe^nH^rND^sDiz-Dios^nP^rND^sFernandez-Feijoo^nJ^rND^sVazquez-Garcia^nE^rND^sRanganathan^nK^rND^sHemalatha^nR^rND^sNokta^nM^rND^sYounai^nFS^rND^sMarcus^nM^rND^sFreed^nJR^rND^sCoulter^nID^rND^sCunningham^nW^rND^sDer-Martirosian^nC^rND^sGuzman-Bercerra^nN^rND^sShapiro^nM^rND^1A01^nS^sRanchod^rND^1A01^nDA^ssmit^rND^1A01^nJA^sMorkel^rND^1A01^nS^sRanchod^rND^1A01^nDA^ssmit^rND^1A01^nJA^sMorkel^rND^1A01^nS^sRanchod^rND^1A01^nDA^ssmit^rND^1A01^nJA^sMorkel



Substance abuse and maxillofacial injuries



S RanchodI; DA smitII; JA MorkelIII

IBChD (Steil), PDD (Oral Surg) (Western Cape). Dentist, Department of Maxillofacial and Oral Surgery, University of the Western Cape
IIBChD (Stell/Western Cape), MChD (Comm Dent) (Western Cape). Dentist, Department of Maxillofacial and Oral Surgery, University of the Western Cape
IIIBChD, MBChB, MChD (Stellenbosch). Head (Academic), Department of Maxillofacial and Oral Surgery, University of the Western Cape





Some of the major causes of maxillofacial injuries are assault/inter-personal violence (IPV), motor vehicle accidents (MVAs), work-related injuries, sporting accidents and falls. However, the epidemiological data for the different types of injury vary significantly and are influenced by geographic location, socioeconomic status, the time of year when patients are assessed and the type of facility where the study is conducted.1-5

The 2012 Statistics South Africa's release document on 'mortality and causes of death in South Africa' indicated that 9.8% of all deaths in South Africa were reported as non-natural. Transport accidents were the third most common (11.2%) reported cause of non-natural deaths followed by assaults at 10.2%.6 According to a number of international studies, the face is the most common site affected by assault-related trauma.7-10

Substance abuse is a major public health concern in South Africa and has also been rated as the leading health problem in the United States.11 Intoxication is also the most common denominator associated with violence and injury.12 In a Swiss study, Eggensperger found that almost a quarter of assault-related facial fractures were caused by people intoxicated with alcohol, illicit drugs or a combination thereof.13