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International Journal of Clinical Medicine Research
2019; 6(1): 1-5
http://www.aascit.org/journal/ijcmr
ISSN: 2375-3838
Knowledge of HIV and HIV Associated Oral Lesions
Among Nigerian Final Year Dental Students
Joan Emien Enabulele
1, *
, Mercy Okoh
2
1
Department of Restorative Dentistry, School of Dentistry, University of Benin, Benin City, Nigeria
2
Department of Oral Pathology and Medicine, School of Dentistry, University of Benin, Benin City, Nigeria
Email address
*
Corresponding author
Citation
Joan Emien Enabulele, Mercy Okoh. Knowledge of HIV and HIV Associated Oral Lesions Among Nigerian Final Year Dental Students.
International Journal of Clinical Medicine Research. Vol. 6, No. 1, 2019, pp. 1-5.
Received: February 1, 2019; Accepted: March 20, 2019; Published: April 9, 2019
Abstract: Providing proper dental care to HIV/AIDS patients necessitates good knowledge for recognition of the oral
lesions associated with the disease. This study was aimed at assessing the knowledge of HIV and HIV associated oral lesions
among final year dental students in Nigeria. This was a questionnaire-based cross-sectional study of final year dental students
in 4 Nigerian universities. The questionnaire consisted of 3 sections: Demographic characteristics of the respondents,
knowledge of transmission of HIV and oral lesions associated with HIV/AIDS. Data was analyzed using IBM SPSS version
21.0. Descriptive statistics, Chi square test, Fisher’s exact test and Students T-test were the analysis carried out with P set at
0.05. A total of 61 respondents participated in the study. The mean knowledge score of 26.18± 7.841. The knowledge score
obtained by the male respondents was 26.38±8.05 while the mean knowledge score obtained by female respondents was
25.82±7.63. There was no statistically significant difference in mean score across the dental schools and across gender. The
most commonly identified oral lesions: oral candidiasis (98.4%), Kaposi’s sarcoma (98.4%), periodontal disease (91.8%) and
Mycobacterium tuberculosis (82.0%). The least identified oral lesions; facial palsy (21.3%), drug reactions (ulcerative,
erythema multiforme, lichenoid) (27.9%), trigeminal neuralgia (32.8%). Nigerian dental students have a good knowledge of
HIV transmission and oral manifestations of HIV/AIDS. This is encouraging and should be translated to adequate oral health
care for patients living with HIV/AIDS.
Keywords: HIV/AIDS, Nigerian Dental Students, Oral Manifestation
1. Introduction
The possibility of HIV transmission in the oral health care
setting is very rare. Nonetheless, the oral health care setting
has become a helpful environment for the early detection of
HIV infection because most of its lesions present orally
during the first stages of the disease [1, 2]. As many as 40
oral manifestations of HIV have been reported [3-6].
Providing proper dental care to HIV/AIDS patients
necessitates good knowledge for recognition of the oral
lesions associated with the disease [1].
As the number of people with HIV/AIDS are increasing
worldwide, the need of infected individuals for medical and
dental care will increase. Dentists and other dental personnel
have a professional and ethical responsibility to provide
treatment to patients with HIV/AIDS [7]. Willingness to treat
HIV patients appears to be related to knowledge of the
disease process, recognition of oral manifestations, and
understanding the modes of its transmission [8]. Dental
practitioners should be required to enhance their knowledge
of the disease and its oral manifestations [1].
People living with HIV/AIDS are subject to a spectrum of
potentially painful and health-compromising oral conditions
with recent studies around the world indicating that oral
lesions tend to occur in as many as 50%–70% of all
HIV/AIDS cases [1].
A sound basis of knowledge about HIV infection and
AIDS is essential to allow students to develop as dentists
who undertake appropriate measures during clinical practice.
In addition, it is also likely that possessing appropriate
information may instil confidence in their own ability to
diagnose and then manage patients infected by HIV [2, 9].
2 Joan Emien Enabulele and Mercy Okoh: Knowledge of HIV and HIV Associated Oral Lesions
Among Nigerian Final Year Dental Students
Increased knowledge of HIV is believed to lead to an
increased willingness and confidence to treat HIV-positive
patients [10, 11]. Hence, it is essential to gain insight into
dental students’ knowledge of HIV. Several countries have
reported studies on the knowledge of dental students on
HIV/AIDS [12-17] with countries such as Brazil [12], Iran
[13], China [14] and Sudan [15] reporting that dental students
had insufficient knowledge about HIV, particularly in relation
to its transmission. However, there are only a few such
studies [18] in Nigeria hence this study which was aimed at
assessing the knowledge of HIV and HIV associated oral
lesions among final year dental students attending Nigerian
Universities.
2. Methods
A cross sectional study was carried out from October 2016
to February 2017 among final year dental students in 4
Nigerian dental schools. The dental schools used for this
study were picked using simple random sampling technique
(University of Benin, Obafemi Awolowo University Ile-Ife,
University of Port-Harcourt and University of Nigeria,
Nsukka). Taking into consideration the size of the final year
students all final year students who gave their consent to
participate in the study were recruited for the study.
The survey instrument was a self-administered
questionnaire which was adapted from a previous study [19].
The questionnaire consisted of 3 sections. The first section
focused on the socio-demographic characteristics of the
respondents’ in the form of age, gender, school and marital
status. The second section consisted of 15 closed ended
questions related to knowledge of transmission of HIV. Each
correct answer was awarded a score of one and each incorrect
answer was awarded a score of zero. A knowledge score was
obtained by adding all correct responses with the highest
possible score obtainable being 15 and the least score being
zero. The third section contained 29 questions about the oral
lesions associated with HIV/AIDS. A knowledge score was
computed by adding the correct responses given for the
yes/no questions with each correct answer scored 1 and
incorrect answer scored 0. A respondent’s total score could
range from 0 to 29. The scores from section 2 and 3 were
added together to give a total knowledge score which was
interpreted into four segments as done in a previous study
among dental students [1]:
1. < 25% - weak,
2. 25%–50% - moderate,
3. 51%–75% - good, and
4. 75% - excellent level of knowledge.
IBM SPSS version 21.0 software was used for statistical
analysis. Frequency and percentages were used to describe
the sociodemographic characteristics and response to
questions in sections 2 and 3. Descriptive statistics in the
form of mean and standard deviation were used to describe
quantitative data (age and knowledge scores). A Pearson Chi
square test was used to determine association between
categorical variables. Fisher’s exact test was used in areas
were expected cell count was <5. Students T-test was used to
determine difference in mean knowledge score across gender
of the respondents. P value was set at 0.05.
3. Results
A total of 70 questionnaires were administered but 62 were
filled and returned giving a response rate of 88.6% however,
only 61 were properly filled and used for the study. There
was a male preponderance (63.9%) and University of Benin
dental school made up 36.1% of the respondents and
Obafemi Awolowo University dental school made up 29.5%
of the respondents (Table 1). The age of the respondents
ranged from 21-31 years with a mean of 25.24±2.28 years.
Table 1. Demographic characteristics of the respondents.
Characteristics Frequency Percent
Dental school
University of Benin 22 36.1
University of Port-Harcourt 12 19.7
Obafemi Awolowo University 18 29.5
University of Nigeria 9 14.8
Gender
Male 39 63.9
Female 22 36.1
Marital status
Single 60 98.4
Married 1 1.6
Total 61 100.0
The knowledge score obtained in this study ranged from
11- 41 with a mean score of 26.18± 7.841. The knowledge
score obtained by the male respondents was 26.38±8.05
while the mean knowledge score obtained by female
respondents was 25.82±7.63. There was no statistically
significant difference in mean score across the dental schools
and across gender (p=0.428).
A higher proportion (42.6%) exhibited good knowledge
while no participant exhibited weak knowledge and 21.3%
exhibited excellent knowledge (Figure 1).
Figure 1. Knowledge of respondents regarding HIV and HIV associated oral
lesions.
There was no statistically significant association between
International Journal of Clinical Medicine Research 2019; 6(1): 1-5 3
knowledge and gender however, there was statistically
significant association between knowledge and the dental
school of the respondents (p=0.008), with a significantly
higher proportion (66.7%) of respondents from University of
Port-Harcourt Dental school exhibiting good knowledge and
the remaining 33.3% exhibiting moderate knowledge while
none exhibited excellent knowledge. In like manner, a higher
proportion (66.7%) of respondents from the University of
Nigeria Dental school exhibited moderate knowledge while
the remaining 21.3% exhibited excellent knowledge while
none exhibited good knowledge (Table 2).
Table 2. Association between knowledge, gender and dental school of the participants.
Characteristics
Knowledge Total
n (%)
Moderate Good Excellent
n (%) n (%) n (%)
Gender P=0.894
Male 14 (35.9) 16 (41.0) 9 (23.1) 39 (100.0)
Female 8 (36.4) 10 (45.5) 4 (18.2) 22 (100.0)
Dental school P=0.008
University of Benin 3 (13.6) 12 (54.5) 7 (31.8) 22 (100.0)
University of Port-Harcourt 4 (33.3) 8 (66.7) 0 (0.0) 12 (100.0)
Obafemi Awolowo University 9 (50.0) 6 (33.3) 3 (16.7) 18 (100.0)
University of Nigeria 6 (66.7) 0 (0.0) 3 (33.3) 9 (100.0)
Total 22 (36.1) 26 (42.6) 13 (21.3) 61 (100.0)
Table 3. Knowledge of oral lesions associated with HIV.
Oral lesions Frequency Percent
Oral candidiasis 60 98.4
Kaposi’s sarcoma 60 98.4
Non-Hodgkins lymphoma 37 60.7
Periodontal disease 56 91.8
Linear gingival erythema 38 62.3
Necrotizing ulcerative gingivitis 49 80.3
Necrotizing ulcerative periodontitis 49 80.3
Mycobacterium tuberculosis 50 82.0
Melanotic hyperpigmentation 23 37.7
Necrotizing ulcerative stomatitis 42 68.9
Salivary gland disease 24 39.3
Dry mouth due to decreased salivary flow 25 41.0
Unilateral or bilateral swelling of major
salivary gland 29 47.5
Thrombocytopenic purpura 21 34.4
Ulceration not otherwise specified 35 57.4
Herpes Simplex virus infection 43 70.5
Varicella Zoster virus infection 40 65.6
Human Papilloma virus infection (warty-
like lesions) 38 62.3
Focal epithelial hyperplasia 27 44.3
Verruca Vulgaris 22 36.1
Actinomyces Israeli 21 34.4
Drug reactions (ulcerative, erythema
multiforme, lichenoid) 17 27.9
Histoplasma capsulatum 26 42.6
Aspergillus flavus 25 41.0
Neurological disturbances 28 45.9
Facial palsy 13 21.3
Trigeminal neuralgia 20 32.8
Recurrent apthous stomatitis 40 65.6
Cytomegalovirus infection 42 68.9
Table 3 shows the most commonly identified oral lesions:
oral candidiasis (98.4%), Kaposi’s sarcoma (98.4%),
periodontal disease (91.8%), Mycobacterium tuberculosis
(82.0%), Necrotizing ulcerative periodontitis (80.3%),
Necrotizing ulcerative gingivitis (80.3%) and Herpes
Simplex Virus infection (70.5%) and the least identified oral
lesions; facial palsy (21.3%), drug reactions (ulcerative,
erythema multiforme, lichenoid) (27.9%), trigeminal
neuralgia (32.8%), thrombocytopenic purpura (34.4%),
Actinomyces Israeli infection (34.4%), Verruca vulgaris
infection (36.1%) and salivary gland disease (39.3%).
Table 4. Responses relating to transmission of HIV.
Frequency
Percent
Mother-to-child-transmission of HIV can occur
During pregnancy 2 3.3
During delivery 15 24.6
During breasting feeding 6 9.8
During all the above three stages 38 62.3
Groups in which HIV is prevalent
Drug abusers 28 45.9
Female sex workers 42 68.9
Male homosexuals 48 78.7
Survival of HIV outside the body
A few hours 51 83.6
A few days 4 6.6
A few weeks 1 1.6
No idea 5 8.2
Sterilization method effective for HIV
Regular disinfectant 5 8.2
Autoclaving 46 75.4
UV rays/gamma rays 10 16.4
Boiling water 0 0.0
Main target cells that HIV Infects and depletes
TCD4 lymphocytes 60 98.4
TCD8 lymphocytes 1 1.6
Red blood cells 0 0.0
Infection risk of HBV and HCV compared to
HIV
HBV higher 55 90.2
HBC higher 4 6.6
No idea 2 3.3
Body fluids that can transmit HIV
Blood 59 96.7
Semen 54 88.5
Vaginal fluid 50 82.0
Breast milk 46 75.4
Total 61 100.0
Table 4 depicts the response to questions regarding
transmission of HIV. Less than two-thirds (62.3%) of the
respondents were aware that mother-to-child HIV
4 Joan Emien Enabulele and Mercy Okoh: Knowledge of HIV and HIV Associated Oral Lesions
Among Nigerian Final Year Dental Students
transmission can occur in all three stages of pregnancy and
nursing (during pregnancy, during delivery and during
breastfeeding).
With regards to groups where HIV was prevalent 78.7%
claimed male homosexuals, 68.9% female sex workers and
45.9% drug abusers. Majority (83.6%) were of the opinion
that HIV can only survive for a few hours outside the body.
With regards to the best sterilization method for HIV 75.4%
felt autoclaving was the best. Almost all (98.4%) of the
respondents knew that the main target cells that HIV infects
and depletes were the TCD4 lymphocytes. Majority (90.2%)
were cognizant with the infection risk of HBV and HCV as
they reported a higher risk of HBV compared to HIV. The
respondents were knowledgeable about the body fluids that
could transmit HIV, with 96.7% affirming that blood could
transmit HIV, 88.5% agreed that semen could transmit HIV,
82.0% believed that Vaginal fluid could transmit HIV and
75.4% were of the opinion that breast milk could transmit
HIV.
4. Discussion
Oral care is vital to (HIV)-positive individuals. As future
dentists, it is pertinent that dental students have sufficient
knowledge and a positive approach toward this disease [14].
The mean age of respondents in this study was higher
(25.24±2.28 years) than that reported in a previous study
23.27 (SD = 1.01) years [1].
The mean score of 26.18± 7.841 (59.5%) observed in this
study was lower than that reported in a previous study [14]. It
was noticed that there was no statistically significant
difference in mean score across gender a finding similar to a
previous study that also found no significant difference
regarding sex [14].
Less than half (42.6%) of the respondents had good
knowledge score a finding far lower than the 72.7% reported
in a previous study [1] and also the 82.1% reported by
Sadeghi and Hakimi [13] and the 78.8% reported by
Aggarwal and Panat [8]. Less than a quarter of the
respondents exhibited excellent level of knowledge a finding
similar to a previous study that reported that more than half
of the respondents demonstrated a good level of knowledge,
although few exhibited an excellent level [9].
There was no statistically significant association between
knowledge and gender in this study, a finding contrary to that
reported in a previous study where there was statistically
significant association between knowledge and gender (P =
0.009), with a significantly high proportion (48%) of female
students having excellent knowledge [1].
Oral candidiasis, Kaposi Sarcoma and periodontal disease
were the three most commonly identified oral lesions by
respondents in this study. a finding similar to a previous
study that reported Kaposi’s sarcoma, oral candidiasis and
hairy leukoplakia, as three of the most common oral lesions
in HIV-positive patients [1, 20] and another study that
reported that most dental students were aware of the
association of hairy leukoplakia, oral Kaposi's sarcoma, oral
candidiasis as a whole, and thrush as one clinical variant,
with HIV infection [9].
There was a much lower level of knowledge of awareness
of the association of facial palsy, drug reactions (ulcerative,
erythema multiforme, lichenoid), trigeminal neuralgia,
thrombocytopenic purpura, actinomyces Israeli infection,
Verruca vulgaris infection and salivary gland disease with
HIV infection. A finding similar to a previous study where
there was a much lower level of knowledge of erythematous
candidiasis, HIV-associated salivary gland disease, oral
melanotic hyperpigmentation and idiopathic
thrombocytopenic purpura [9, 20].
Majority of the respondents were of the opinion that
infection Hepatitis B was more infectious than HIV. This is
contrary to a previous study in which about a third (33.1%)
of the study population claimed that HIV was more
infectious than any of the strains of hepatitis virus [7].
However, the students needed a broader knowledge of
lesions less strongly associated with HIV such as condyloma,
papilloma and xerostomia. Students should also be educated
that even the lesions strongly associated with HIV/AIDS are
not exclusive to HIV/AIDS. Kaposi’s sarcoma, oral
candidiasis, and hairy leukoplakia may also be seen in
patients not infected with HIV/AIDS [1].
5. Conclusion
Nigerian dental students tend to have a good knowledge
of HIV transmission and oral manifestations of HIV/AIDS
however, there is still room for improvement. This is
encouraging and should be translated to adequate oral
health care for patients living with HIV/AIDS. As future
dentist having good knowledge of HIV/AIDS will ensure a
high index of suspicion of HIV cases which will prompt
adequate diagnostic investigations for confirmation.
Furthermore, this will enable recognition and accurate
diagnosis of these oral lesions as well as early treatment
with ultimate reduction in morbidity and mortality of the
HIV infected patient.
Acknowledgements
The authors acknowledge all the students who agreed to
take part in this study as well as Drs N Okolo, C Aniagor and
I Ogbomwan who assisted with data collection. This study
was solely financed by the authors. The authors declare no
conflict of interest.
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