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UNMET DENTAL TREATMENT NEED IMPAIRS QUALITY OF

Original Articles
LIFE IN HEPATITIS C VIRUS-INFECTED PATIENTS
Miguel Angel Farias1a , Silvia Andrea Medici2,3b , Aldo Fabián Squassi2,3c* , Gabriel Antonio Sánchez1,2d
1
Cátedra de Biofísica y Bioestadística, Facultad de Odontología, Universidad de Buenos Aires, Buenos Aires, Argentina
2
Clínica para la Atención de Pacientes de Alto Riesgo I, Facultad de Odontología, Universidad de Buenos Aires, Buenos Aires, Argentina
3
Cátedra de Odontología Preventiva y Comunitaria, Facultad de Odontología, Universidad de Buenos Aires, Buenos Aires, Argentina

a
DDS, Senior Faculty; e-mail: miguel.farias@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0002-3881-0258
b
DDS, Assistant Professor; e-mail: silvia.medici@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0001-5370-2709
c
DDS, MSc, PhD, Head Professor; e-mail: aldo.squassi@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0001-7687-5805
d
DDS, MD, MSc, PhD, Head Professor; e-mail: gabriel.sanchez@odontologia.uba.ar; ORCIDiD: https://orcid.org/0000-0002-2358-4622

ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(3).art.5

Introduction The hepatitis C virus (HCV) infection is a health condition affecting 3% of the world population,
which oral manifestations and associated factors interest both physicians and dentists. The aim of this work
was to describe the dental treatment need and the impact of the perception of the oral component of health
on the quality of life in HCV+ patients.
Methodology Descriptive study on a convenience sample. 45 HCV+ patients (46±5 y.o.) completed
the OHIP-14 questionnaire, which consists of 14 questions grouped in 7 domains (D1 functional
limitation, D2 physical pain, D3 psychological discomfort, D4 physical disability, D5 psychological
disability, D6 social disability and D7 general disability). The participants indicated their responses
using a Likert-type frequency scale. The Community Caries Index of Treatment Need (CCITN) was
determined for each patient. The proportion and CI95% of the social impact on the quality of life
were calculated. The association between CCITN and the quality of life was assessed by Chi2 (p<0.05).
Results The CCITN was 11 (8-14). The overall social impact was 38% (24-52%). The increasing order
relationship of the impact on each of the domains was D1, D7, D6, D4, D5, D2, D3. A significant association
between oral health-related quality of life and CCITN was observed (Chi2 = 7.57, p = 0.006), showing greater
impairment of the quality of life as the treatment need increased.
Conclusion The association between CCITN and quality of life becomes evident using OHIP-14 during dental
appointments. The results suggest the need for comprehensive interventions during the provision of oral
health care to HCV+ patients.

KEYWORDS
Dental Care; Hepatitis C; Medical Risk; Oral Medicine; Quality of Life.

1. INTRODUCTION the incidence of hepatocellular carcinoma, one of
the main indications of liver transplant, is 3-5% per
The hepatitis C (HCV) viral infection affects 175 year [3]. In Latin America and the Caribbean region
million subjects over the world, that is, 3% of its HCV infected patients are estimated at 7.8 million
population; and, three millions of new infections [4]. In Argentina HCV is considered a low prevalence
are reported each year [1]. Chronic liver pathology infection, with an approximate value of 1.2%, which
consequent to HCV has been reported in eighty increases in overcrowded dwelling conditions
percent of the infected patients. If no treatment is up to 3.6%. Males (3.4%) are more affected than
administered, close to 25% of patients progresses to females (2.5%) [5]. The infection risk rate has also
liver cirrhosis [2]. Once cirrhosis has been diagnosed, been studied in South American countries. The

OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Farias MA, Medici SA, Squassi AF, Sánchez GA. Unmet dental treatment need impairs quality of life in Hepatitis C Virus-infected patients.
Stoma Edu J. 2020;7(3):191-196.
Received: May 08, 2020; Revised: July 13, 2020; Accepted: August 06, 2020; Published: August 07, 2020
*Corresponding author: Professor Aldo Fabián Squassi; Cátedra de Odontología Preventiva y Comunitaria, Facultad de Odontología, Universidad de
Buenos Aires; MT de Alvear 2142, 5th floor, Suite B; CP 1122, Buenos Aires, Argentina
Tel:. / Fax: +54 11 5287 6253, e-mail: aldo.squassi@odontologia.uba.ar
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.

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Original Articles Table 1. Description of the Community Caries Index of Treatment Need (CCITN).

Health condition Score Needed treatment
Healthy mouth with preventive
00 No treatment needed
treatment
Healthy mouth without preventive
01 Basic preventive plan
treatment
Healthy mouth with dental white Additional preventive plan including the sealing of dental
02
spots/ deep grooves grooved and fissures
Amelo-dentinal tooth decay in 1
03 Additional preventive plan + restorative treatment in 1 quadrant
quadrant of the mouth
Amelo-dentinal tooth decay in 2 Additional preventive plan + restorative treatment in 2
04
quadrant of the mouth quadrants
Amelo-dentinal tooth decay in 3 Additional preventive plan + restorative treatment in 3
05
quadrant of the mouth quadrants
Amelo-dentinal tooth decay in 4 Additional preventive plan + restorative treatment in 4
06
quadrant of the mouth quadrants
Pulp disease in 1 quadrant of the Additional preventive plan + pulp treatment in 1 quadrant of the
07
mouth mouth + restorations
Pulp disease in 2 quadrants of the Additional preventive plan + pulp treatment in 2 quadrants of
08
mouth the mouth + restorations
Pulp disease in 3 quadrants of the Additional preventive plan + pulp treatment in 3 quadrants of
09
mouth the mouth + restorations
Pulp disease in 4 quadrants of the Additional preventive plan + pulp treatment in 4 quadrants of
10
mouth the mouth + restorations
Missed teeth in 1 quadrant of the Additional preventive plan + pulp treatment + tooth removal +
11
mouth prosthesis rehabilitation in 1 quadrant of the mouth
Missed teeth in 2 quadrants of the Additional preventive plan + pulp treatment + tooth removal +
12
mouth prosthesis rehabilitation in 2 quadrant of the mouth
Missed teeth in 3 quadrants of the Additional preventive plan + pulp treatment + tooth removal +
13
mouth prosthesis rehabilitation in 3 quadrant of the mouth
Missed teeth in 4 quadrants of the Additional preventive plan + pulp treatment + tooth removal +
14
mouth prosthesis rehabilitation in 4 quadrant of the mouth

nosocomial infection risk was the highest (45.3%), In this regard, the affected oral status described
followed by sexual transmission (18.8%), unknown above may result in predisposing conditions for
causes (12.5%), use of intravenous drugs (4.7%) and the development of periodontal disease and oral
occupational exposure (4.7%) [6]. carcinogenesis. For this reason, the existence of an
Extra hepatic manifestations of HCV infection immunological link between HCV and periodontal
include depression (25%) and diabetes (15%) as health is being studied [12].
the most frequent ones, along with chronic renal The health care of HCV infected patients is a matter
disease, B-cells lymphoma, cutaneous porphyria and of concern of both, physicians and dentists. The
rheumatoid arthritis [7]. The oral manifestations of inclusion of the dental examination and treatment
hepatic dysfunction include oral mucosa jaundice in the routine medical health care protocol for these
and petechiae, blood coagulation disorders, gingi- patients has been proposed and the interdisciplinary
vitis and gum bleeding, perioral rash, atrophic collaboration between physicians and dentists has
tongue and hepatic halitosis. Xerostomia has been also been pointed out as mandatory [13]. However,
reported as a frequent symptom of HCV infection little is known about the oral component of health
and Sjögren disease, and sialadenitis and oral lichen in HCV patients.
planus are more likely to occur [8,9]. Dry eye and This lack of updated knowledge motivated this
mouth symptoms have been reported in 20-30% investigation aimed at determining the need for
of HCV infected patients. However, less than 5% of dental treatment in HCV positive patients and the
Sjögren patients are also HCV patients [10]. As for social perception they have of the oral component
the periodontal conditions of patients suffering of health on their quality of life. Our hypothesis
from hepatic diseases, there are no updated reports states that oral health conditions derived from HCV
focused on their association, but the development infection impair the quality of life of the affected
of specific research lines has been encouraged [11]. subjects.

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Original Articles
15

14 25

13
20

%
11
CCITN value

10
10

9 5

8
0
8 9 10 11 12 13 14
CCITN value
7
Figure 2. HCV+ patients need for dental treatment. Bar chart of the
percent distribution of patients according to CCITN values (n = 45).
6

5 CETICAFOUBA20020120100324BA/13). The need
Figure 1. CCITN in HCV+ patients. Box plot of the distribution of the for dental treatment was assessed through the
index obtained values showing median and range of the need for dental Community Caries Index of Treatment Need (CCITN)
treatment in a sample of 45 infected subjects.
[14] during the clinical routine examination of the
oral cavity performed by three previously calibrated
2. METHODOLOGY operators (Kappa's coefficient=0.92). The CCITN was
designed to determine the oral health condition
The investigation was planned as a descriptive of populations in terms of health and disease. It
observational study including some preliminary indicates the recommended treatment to achieve
analytical work regarding the prevalence of the a healthy oral condition, and it also estimates
need for dental treatment and its associated social the amount of appropriate resources to provide
impact on the quality of life of HCV+ patients. From the corresponding oral health care. The index is
this study population, a sample consisting of 45 determined within an ordinal number scale from 0
patients was obtained through the non-probabilistic to 14 following the criteria shown in the Table 1.
convenience sampling method. Thirty patients were The social impact of the oral health condition on
males and 15 were females, with a mean age of 46±5 the quality of life was measured using the validated
y.o. Participants were recruited from patients with questionnaire Oral Health Impact Profile (OHIP-14)
chronic moderate HCV infection referred to this Unit [15], which consists of 14 questions grouped in 7
by their treating hepatologists for oral check-up. domains; namely, D1: functional limitation, D2: phy-
The reported time course of the infection was for sical pain, D3: psychological discomfort, D4: physical
all of them three years and the drug therapy they disability, D5: psychological disability, D6: social
had received was interferon and rivabirin. All of the disability and D7: general disability. Participants indi-
referred patients had health insurance, a formal cated their responses using a Likert-type frequency
employment, middle income and were high school scale: never, hardly ever, sometimes, frequently and
graduates. very frequently, coded as 0, 1, 2, 3 and 4 respectively.
Patients coinfected with HIV, users of nasal drugs, The total score was obtained as the sum of the coded
smokers and users of intravenous drugs (except for score numbers given to each of the questions. This
those rehabilitated five years prior to recruitment) procedure allows the calculation of 0 as the minimal
were not included in this study. Recruitment was score and 56 as the maximal one, indicating greater
done at the High Risk Patients Dental Care Unit impact as the score value increases.
(CLAPAR I), an oral health care clinic at the Dental The descriptive statistical data analysis included
School of the University of Buenos Aires, between the calculation of median and range for the CCITN
April 2014 and July 2015. All participants gave their and the frequency distribution determination for
written informed consent for free and voluntary each category of the index. The assessment of
participation in the study. the social impact included the calculation of the
The research protocol was reviewed and approved percent proportion of the impact along with the
by the Ethics Committee of the Dental School of 95% confidence interval. The inferential statistical
the University of Buenos Aires (Acceptance number: analysis evaluated through Chi2 test the association

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Original Articles 100

70
% of social impact

0
1 2 3 4 5 6 7 8
OHIP-14 domain

Figure 3. Social impact of the oral component of health in HCV+ pa- Figure 4. Association between Community Caries Index of Treatment
tients. Box plot of the distribution of the social impact expressed as %. The Need (CCITN) values and Oral Health Impact Profile (OHIP-14) score.
proportion and CI95% obtained in 45 patients are shown. The numbers on Bar plot of the distribution of HCV+ patients (n = 45) grouped according
the x axis indicate the OHIP-14 domains: 1 functional limitation, 2 physical median CCITN and mean % of social impact reported through OHIP-14.
pain, 3 psychological discomfort, 4 physical disability, 5 psychological
disability, 6 social disability and 7 general disability. Number 8 indicates the
overall impact value.

between CCITN score and OHIP-14 percent of impact significant association between those two variables
distributions according to their corresponding me- (Chi²=7.57, p=0.006).
dian and mean values, respectively. The level of
significance used to determine the association was 4. DISCUSION
p<0.05.
This is the first study investigating the need for
3. RESULTS dental treatment in HCV+ subjects in association
with the quality of life of this patient population. The
The need for dental treatment found in HCV+ results reported herein interest both physicians and
patients in this investigation was great. The obtained dentists and provide new evidence for the successful
median value of CCITN was 11 and its range was 8-14, interdisciplinary approach of this viral infection. Up
as shown in Fig. 1 and Fig. 2. There were no patients to now, most studies have focused exclusively on the
with healthy oral conditions and no patients with oral manifestations of the HCV infection and on the
only amelo-dentinal tooth decay either. In all cases, haemostatic associated complications. For instance,
tooth decay involved dental pulp in different extent. oral lichen planus is clinically diagnosed by dentists
The frequency distribution of CCITN values found in [16] and it has been reported as involved in oral
male patients was not significantly (Chi²=0.21, p= carcinogenesis [17].
0.96) different from those determined for female Another well-known systemic disorder of HCV
patients (data not shown). infection involves haemostatic complications lead-
The social impact of the oral component of health ing to oral bleeding during dental procedures [8],
self-reported through the use of OHIP-14 revealed especially in the acute stage of the disease, but fewer
a 38% of impact (CI95%: 24-52%) in HCV+ patients complications have been reported in asymptomatic
included in the convenience sample studied in the chronic patients [18]. It is also known that the viral
present research and no significant differences (Chi² infection may alter the metabolism of certain drugs.
=0.34, p=0.88) were found between male and female That is why the current clinical challenge includes
patients (data not shown). the prediction and treatment of hemorrhage and
Fig. 3 shows this finding along with the differential the careful evaluation of drugs interactions in HCV
impact recorded for each single domain of the infected patients [19].
questionnaire. The social impact showed the The results reported in this study show a clear social
increasing order D1 < D 7 < D4 < D5 < D6 < D2 < impact of the oral component of health which impairs
D3, being D3 (78%, IC95 90-66%) and D2 (62%, IC95 the quality of life of the studied HCV+ patients, who
48-76%), the domains revealing the highest social mainly experience physical pain and psychological
impact of the oral component of health on the discomfort because of their dental status consequent
quality of life. to the course of the liver disease as we hypothesize.
To assess the association between CCITN and OHIP- Given that the study design used herein lacks a
14, the distribution of patients was determined in control group studied in parallel, data of CCITN and
two categories according to the value of 11 for the OHIP-14 previously reported in other groups of pati-
dental treatment need, and according to the value ents may be useful for a comparative discussion.
of 38% for the social impact. Fig. 4 shows 52% of the Compared to non-medically compromised patients,
HCV+ patients reporting social impact above 38% the CCITN largely exceed the reported value of 6
if their CCITN value is found above 11, revealing a [20] in healthy subjects and the social impact on

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the quality of life regarded as intermediate [21]. As 5. CONCLUSION

Original Articles
compared to other viral infections, HIV+ patients
showed also social impact of the oral conditions on On the basis of the features of this convenience
the quality of life with similar percentage (36%) and sample showing moderate chronic viral infection,
similar CCITN values [14]. it can be concluded that the need for dental
These results are in line with previous findings of treatment in HCV+ patients is high and impairs
hepatologists, surgeons and psychologists reporting the quality of life of the subjects, a fact detectable
that HCV infection negatively changes the patients' during the routine dental visit through the use of
quality of life in the analysis of the psychological the OHIP-14 Questionnaire. Our results suggest
component of health [22]. Increased levels of anxiety that oral preventive measures should be necessarily
and depression have been reported to impair the reinforced in the oral health care of this group of
quality of live [23]. patients.
The results obtained in this investigation provide
evidence to support the early referral to oral health CONFLICT OF INTEREST
care of HCV+ patients, which will benefit the patients The authors declare no conflict of interest.
since the beginning of the medical treatment if they
are referred to the dentist during the first medical AUTHOR CONTRIBUTIONS
visit, a professional decision that we strongly reco-
mmend. MF: participated in the research goal proposal, research protocol
Although the sample size we analyzed may appear design, and scientific writing of the manuscript. SM: participated
small, it was large enough to perform the planned in the clinical examinations and data collection procedures.
statistical analysis meeting the criteria of optimal AS: participated in the research plan design and critical revision
sample size. of the manuscript. GS: participated in the clinical examinations,
The future perspective of this research includes data collection, statistical analysis and scientific writing of the
the extension of the study variables such as the manuscript.
Community Periodontal Index, dental plaque index,
HCV viral load in blood, routine hepatic enzymes ACKNOWLEDGMENTS
laboratory values and the time course of the viral
infections which will be interesting to perform a This research work was performed with a grant from the
multivariate analysis of factors. Universidad de Buenos Aires, Grant UBACyT 20020120100324BA.

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[Full text link]

Miguel Angel FARIAS
DDS, Senior Faculty
Cátedra de Biofísica y Bioestadística
Facultad de Odontología
Universidad de Buenos Aires
Buenos Aires, Argentina

CV
Miguel Angel Farias, DDS specialized in periodontics, is currently a PhD fellow at the University of Buenos Aires. His research work
in the field of Preventive Dentistry and Dentistry for medically compromised patients has been recognized by scientific research
associations both locally and regionally (Argentine Divison of the International Association for Dental Research –IADR- and the
Brazilian Division of said world association). He was also presented with Research Awards as an undergraduate research fellow of
the University of Buenos Aires, such as the Argentine Dental Schools Association Award. He is an active participant and presenter
of IADR Divisional meetings and he has published seven abstracts of his research oral communications in the last five years in the
widely known online version of the abstracts date base of the Journal of Dental Research.

Questions
1. Which of the following oral manifestations could be found in HCV infected patients?
qa. Mucosa jaundice and petechiae, blood coagulation disorders;
qb. Gingivitis and gum bleeding, perioral rash, atrophic tongue and hepatic halitosis;
qc. Xerostomia;
qd. All of them are correct.

2. What is the ideal dental treatment approach for HCV positive patients?
qa. Interdisciplinary approach;
qb. No specific approach;
qc. Approach does not matter if patients receive medical treatment;
qd. Interdisciplinary approach is not required.

3. What is the need for dental treatment in HCV infected patients?
qa. No need;
qb. Low;
qc. Moderate;
qd. High.

4. What it the relationship between unmet oral health care needs and the quality of life in
HCV positive patients?
qa. Impairs quality of life;
qb. Improves quality of life;
qc. Quality of life is not affected;
qd. There is no relation between oral health and quality of life.

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