/home/opencode/cpanel/stomaeduj_hacked/uploads/Article_7_3_5.pdf DENTAL PUBLIC HEALTH www.stomaeduj.com 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. Stoma Edu J. 2020;7(3): 191-196 pISSN 2360-2406; eISSN 2502-0285 191 Farias MA, et al. www.stomaeduj.com 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. 192 Stoma Edu J. 2020;7(3): 191-196 pISSN 2360-2406; eISSN 2502-0285 Dental health and HCV infection www.stomaeduj.com 30 Original Articles 15 14 25 13 20 12 15 % 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 Stoma Edu J. 2020;7(3): 191-196 pISSN 2360-2406; eISSN 2502-0285 193 Farias MA, et al. www.stomaeduj.com Original Articles 100 90 80 70 % of social impact 60 50 40 30 20 10 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 194 Stoma Edu J. 2020;7(3): 191-196 pISSN 2360-2406; eISSN 2502-0285 Dental health and HCV infection www.stomaeduj.com 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. REFERENCES 1. Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med. 9. 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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. 196 Stoma Edu J. 2020;7(3): 191-196 pISSN 2360-2406; eISSN 2502-0285