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Clinical and Legal Issues Impacting on Dental Care Australian Dental Journal The official journal of the Australian Dental Association Australian Dental Journal 2012; 57: 256–270 REVIEW doi: 10.1111/j.1834-7819.2012.01715.x HIV and dentistry in Australia: clinical and legal issues impacting on dental care AT McLean,* EK Wheeler, S Cameron, D Baker *St Vincent’s Hospital, Fitzroy, Victoria. Australasian Society for HIV Medicine, Darlinghurst, New South Wales. ABSTRACT The number of people in Australia living with HIV is growing. This reflects a consistent rate of new HIV infections combined with an increased life expectancy of people with HIV. Dentists are ideally positioned to identify, manage and treat HIV-associated oral manifestations and have a responsibility to themselves and to their patients to be up-to-date with the evolving area of HIV and related issues. Those issues include medico-legal implications associated with HIV diagnosis and treatment. This article provides a review of the current clinical and medico-legal aspects of HIV in Australia. The oral manifestations of HIV can be divided into five categories: microbiological infections (fungal, bacterial and viral); oral neoplasms; neurological conditions; other oral conditions that may be associated with HIV infection; and oral conditions associated with HIV treatment. Current treatment options in the scope of general dental practice are outlined. Medico-legal issues related to the management of patients with HIV are explored, including rights of the patient regarding disclosure of HIV status; an algorithm for the management of a patient with signs or symptoms indicating possible HIV infection, including referral pathways; and an algorithm for dealing with patient management and referral issues. Keywords: Bacterial, dental, fungal, HIV, legal. Abbreviations and acronyms: ADA = Australian Dental Association; AIDS = acquired immune deficiency syndrome; ASHM = Australasian Society for HIV Medicine; cART = combination antiretroviral therapy; CMV = cytomegalovirus; EBV = Epstein-Barr virus; HHV = human herpesvirus; HHV4 = human herpesvirus 4; HHV8 = human herpesvirus 8; HIV = human immunodeficiency virus; HSV = herpes simplex virus; HZ = herpes zoster; KS = Kaposi’s sarcoma; MCV2 = molluscum contagiosum virus 2; NHL = non-Hodgkin’s lymphoma; OHL = oral hairy leukoplakia; VZV = varicella zoster virus. (Accepted for publication 17 May 2012.) reflecting Bell’s estimate.5 HIV is present in saliva, INTRODUCTION however it is not considered a risk factor for transmis- Currently in Australia there are more than 21 300 sion because of the low levels of HIV and endogenous people living with human immunodeficiency virus antiviral factors present in saliva.6–8 There is no (HIV), with approximately 1000 people newly infected evidence that HIV can be transmitted by contact with each year.1 The number of people living with HIV tears, sweat, urine or faeces.3,4 infection continues to rise as improved antiretroviral Dentists can play a key part in the diagnosis and treatments mean people live longer, often for decades, management of patients with HIV. Research has following HIV infection.2 demonstrated that early identification of HIV is an HIV is transmitted by exposure to HIV-infected important factor in maximizing positive outcomes for bodily fluids or tissues by way of unprotected sex, individual patients and for preventing ongoing trans- re-using drug-injecting equipment and vertical mission.9 Unfortunately, indications for HIV testing are transmission from mother-to-child.3,4 In Australia, often missed.9 Dentists should not underestimate the male-to-male sex remains the dominant mode of contribution they can make in the diagnosis of HIV by transmission.1 Transmission via medical procedures is way of its oral manifestations. Due to the complexity of uncommon4 as the risk of HIV transmission after HIV infection and its associated complications, a team percutaneous exposure to HIV-infected blood is 0.3%, approach to the management of HIV is ideal, with 256 ª 2012 Australian Dental Association Clinical and legal issues impacting on dental care dentists as important contributors to this multidisci- Oral lesions may be present at all stages of HIV plinary approach. infection (Fig. 1). However, it should be emphasized The potential for dentists to play a proactive role in that HIV-associated oral lesions are not pathogno- HIV diagnoses and treatment is complicated by the monic as it is possible to find such conditions in significant patient, social and legal implications related immunocompetent people without HIV infection.11 to this particular disease. Such advice is based on Similar to systemic HIV-associated pathology, oral awareness that HIV based discrimination remains lesions presenting during HIV infection are more likely prevalent across health services. Notably HIV Futures to occur with a high viral load or a reduced CD4 cell 6 surveyed over 1000 HIV positive individuals and count.12–19 Oral manifestations of the seroconversion found 26% had experienced less favourable treatment illness may include oral ulcers, oral candidiasis, oral from their health services and 10% had experienced herpes and tonsillitis and, uncommonly, gingivitis and discrimination due to their HIV status.10 Thus, HIV stomatitis.20,21 Multiple factors such as the failure of service organizations advise HIV positive individuals to normal immune surveillance and HIV-related immuno- ‘think carefully’ before disclosing HIV status to dental suppression increase the risk of neoplasia throughout professionals. the course of HIV infection.22 It is illegal for dentists to discriminate on the basis of disease. HIV status should not affect the decision to Treatment of HIV infection provide treatment, however knowing the HIV status of a patient does allow the dentist to provide more The aim of treatment is to suppress HIV infection and comprehensive dental care as HIV and HIV-associated allow immune recovery to optimize health.23 Ulti- disease significantly impacts on oral health. It is mately, such treatment will prevent or lessen the important that Australian dentists do not become likelihood of HIV-related complications and may complacent about HIV and instead keep abreast of prevent advanced HIV disease or acquired immune current HIV medicine and wider issues to ensure deficiency syndrome (AIDS). Current treatments are optimal outcomes for their patients. usually very successful with current life expectancy from diagnosis of a young person projected to be almost 40 years.24 Oral pathophysiology of HIV infection Treatment of HIV infection involves the use of HIV infection causes an immunodeficient state by combinations of antiretroviral medications, currently gradually impairing humoral and cell-mediated immu- referred to as combination antiretroviral therapy nity. This allows new pathogens to more readily infect (cART). cART is instituted based on the monitoring and cause disease, and this disease is usually more of disease progression. Current guidelines recommend severe and widespread. Pre-existing or latent conditions starting treatment when an individual’s CD4 cell count held dormant by a functioning immune system can be declines to 350 cells ⁄ lL or there is a diagnosis of an re-activated. Also opportunistic infections may develop, AIDS-defining illness with treatment aiming to produce a process whereby normally non-pathogenic organisms an undetectable viral load of less than 20–75 HIV gain the ability to cause disease. copies ⁄ mL of plasma.25 KS = Kaposi’s sarcoma; PJP = pneumcystis jirovecii pneumonia; OHL = oral hairy leukoplakia; NHL = non-Hodgkin’s lymphoma; MAC = Mycobacterium avium complex; CMV = cytomegalovirus; TB = tuberculosis; NUP = necrotizing ulcerative periodontitis; HZ = Herpes zoster. Fig. 1 Natural history of HIV infection – the various stages of HIV infection depicting the development of different opportunistic infections with advanced immunodeficiency and the impact of antiretroviral therapy on CD4 cell count recovery. Adapted from: Sasadeusz J, Locarnini S, Kidd M, Bradford D, Danta M. HIV, HBV, HCV and STIs: Similarities and Differences. In: Bradford D, Hoy J, Matthews G, et al., eds. HIV, Viral Hepatitis and STIs: A Guide for Primary Care. Sydney: Australasian Society for HIV Medicine, 2008:18. ª 2012 Australian Dental Association 257 AT McLean et al. Impact of HIV treatment on oral conditions erythema is now classed as a periodontal condition of fungal origin.30 Oral manifestations may occur with the progression of Fungal infections may appear at any time throughout HIV infection in patients without medical treatment or HIV infection, however they are more prevalent when intervention, however most people with HIV infection the CD4 cell count falls to below 500 cells ⁄ lL.12,14,19,20 in Australia start a treatment regimen prior to signif- Ninety per cent of patients with advanced HIV disease icant immune impairment. The impact of cART are affected with oral candidiasis at some point during generally results in a marked reduction in viral load, their disease.28 However cART results in a significant which in turn enables the immune system to return reduction of oral candidiasis, such that rates range from to adequate surveillance of the oral environment with 0% to 16.7%.18,19 cART has changed the prevalence oral manifestations often resolving. Occasionally, some patterns of oral lesions associated with HIV infection, conditions such as aphthous ulceration may persist so candidiasis is no longer the most common condi- while HIV-related periodontal
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