HIV positive children have been reported to suffer a higher prevalence of dental caries [3, 4], candidiasis, leukoplakia, herpetic lesions, lymphadenopathy and parotiditis than other children [10, 11]. The clinical status of children participating in this study, as obtained from the dental examination, was reported in another study . However, little is known about the functional, emotional and social consequences of poor oral health among these children . Having assessed the self-perception of paediatric patients with AIDS, this study reported socio-demographic, behavioural and clinical factors that are associated with a higher impact on OHR-QoL. These are the main results of this study, and they may instruct programmes that are undertaken to monitor the oral health of children who have AIDS.
General questions about self-perceived health are a useful resource that is commonly used in surveys. Endorsed by the World Health Organization , this strategy permits the production of health indices that are related to several variables and contribute to an assessment of the demand and effective use of healthcare services. This proposition highlights the importance of including overall indices of oral health and well being in the questionnaire used in this study. Oddly, discrepant results were obtained by questions 1 and 2. Question 1 (on the overall perception of oral health) revealed a higher prejudicial impact than question 2 (on how much oral health affects life overall). Furthermore, answers to question 1 were related to socio-demographic and behavioural factors, whereas answers to question 2 did not.
The comparative analysis of subscale rates showed oral symptoms as the QoL domain that was most affected in children examined in this study. This conclusion is consistent with previous studies that report the prejudicial impact of oral lesions on the OHR-QoL of adults who were affected  and unaffected  by the HIV infection. Fostering the importance of this observation, we observe that dental caries, soft tissue lesions and infections in the oral cavity are acknowledged to be frequent manifestations in paediatric patients with AIDS [3, 4, 10–12].
Methodological tools that systematize how children assess their own oral health are relatively recent and, as yet, no reference averages for CPQ11-14 rates have been established for the overall population. Indeed, conflicting conclusions were observed from the comparison of our data with those of previous studies that assessed OHR-QoL in Brazilian children. Currently assessed averages for subscale and overall rates ranked higher than those reported for 114 children without AIDS and free of caries, and live in another Brazilian city (Belo Horizonte) . However, the results for 55 children enrolled in public schools in Piracicaba (State of São Paulo) , who have not AIDS and were free of caries, were similar to those reported in this study.
In regards to the identification of associated factors, it is noteworthy that tooth brush frequency was virtually indicative of protection against prejudicial impacts on OHR-QoL. This observation is in agreement with the hypothesis that a simple, although effective resource of oral health promotion can contribute to improve QoL. However, as this study exclusively assessed cross-sectional information, one cannot rule out a reverse causality, hypothesizing that children with AIDS who feel a higher impact of poor oral health may have greater difficulty to maintain a desirable tooth brushing frequency.
This study also highlights the importance, for these children, of having their own mothers as caregivers. This also reinforces the importance of home monitoring as an effective resource in oral health promotion, which is in agreement with the observation of household crowding as an additional factor that impacts on OHR-QoL. Household overcrowding has been used as a proxy for socioeconomic status in epidemiological studies assessing dental disease , because poorer subjects in Brazil tend to live in more crowded households.
Viral load was the most relevant clinical indicator in the assessment of OHR-QoL. This is relevant for healthcare units that attend children with AIDS, and must be taken into consideration in the planning of both medical and dental services for this group of patients. Children who presented an advanced stage of HIV infection (more than 10,000 HIV-RNA copies per millilitre of plasma) ranked poorer in OHR-QoL overall scale and in the four subscales. This information should be taken into consideration when planning dental services, to anticipate interventions that potentially result in QoL improvements for these patients.
The OHR-QoL questionnaire was originally designed for children of ages 11 to 14 years; but the current study included 10- and 15-year-old patients in order to recruit a higher number of participants and to improve the assessment of associated factors. Self-perception of oral health, however, has been described as dependent on age , and the enlargement of the age range may have modified the profile of answers. However, a regression analysis that is adjusted for age may have controlled, at least in part, the effect of age variation on the identification of factors that modify OHR-QoL.
In spite of having expanded the intended age range of respondents for the questionnaire (from 11-14 to 10-15 years old), the sample size (88 children) was still reduced, and may have had an insufficient number of participants to assess other factors that eventually associate with the study outcome. In addition, the study group corresponds to one paediatric hospital, and cannot be considered to be representative of children with AIDS in the Brazilian context. Sampling design - restricted to a single hospital and with a relatively reduced number of participants - is acknowledged as the main study limitation. Therefore, this study strongly advocates the realization of further studies on OHR-QoL, with broader and more representative samples of children with AIDS.
Participating children completed the questionnaire in a separate room of the medical setting, immediately after they had their clinical consultation. We wonder whether they would have answered differently if they have been assessed in their homes or schools, and we are unaware of evidence on this issue. Assessing these children in the medical facility that they attend was a methodological option that facilitated the access to eligible participants; although this option may entail an additional study limitation.
The assessment of OHR-QoL is an important adjunct to the establishment of priorities and planning of healthcare programs. Since the 1980 s, patients have been invited to report their perception of health in evaluations of therapeutic and prophylactic resources, and in the clinical decision making . However, the specific questionnaire used in this study was only proposed in 2002 , and is recognized as the first survey instrument specifically designed to assess self-perceived oral health in children .
The perspective of assessing children's perception of oral health is even more recent in Brazil. This questionnaire was translated and validated in 2008 [8, 9]. To our knowledge, the current study was the first one to assess OHR-QoL in children with AIDS in the Brazilian context . Assessing the magnitude of prejudicial impacts of oral health on QoL, and reporting associated factors may relevantly contribute to the planning of appropriate programs of dental services to children who have AIDS, thus contributing to an improvement of their oral and systemic health.