Risk Assessment
HIV Risk Assessment: Building on Dentistry’s History of Promoting Health
Roseann Mulligan, DDS, MS, and Sue A. Lemme MA
Copyright 2001 Journal of the California Dental Association.
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Dentists have demonstrated a willingness to look beyond the mouth and consider the patient’s overall presentation in a number of health-related areas. The HIV pandemic is another opportunity to involve the dentist in overall health issues through identification of those individuals at risk for acquiring HIV. This risk assessment activity can be facilitated through the use of a structured risk assessment algorithm that is presented in detail. The purpose of this algorithm is to encourage dentists -- when they notice specific conditions or become aware of risky behaviors -- to talk with their patients about HIV/AIDS and how the patient may be at risk. The historic success dentists have achieved in conveying information about the prevention of disease and promotion of health should bolster their resolve to expand their discussions with patients to include an HIV risk assessment.
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The application of disease prevention by the dental profession to systemic conditions was first noted in the literature of the 1960s when a complete medical history review1 and examination of the head and neck2 area by the dentist prior to initiation of treatment and especially before giving injections of local anesthetics was called for by various authors.3,4 The 1970s saw efforts to expand the dentist’s role in physical evaluation5 and observation of deviations from normal in the patient’s gait, skin, sclera or mucosal appearance, presence of edema, appearance of swollen joints, and breathing irregularities.6 Dental education programs were noted to contain curricula to assess systemic health status and refer to physicians as appropriate.7 Taking blood pressure readings as part of a dental visit was described as an "opportunity for dentists to show their commitment to total health care."8
Today dentists include in their health promotion activities counseling against tobacco use in all of its guises;9-12 recognizing and reporting child abuse and/or neglect,13,14 elder abuse,15 and domestic violence;16 and encouraging the use of mouthguards during sports and play activities.17,18 They continue to be concerned about human immunodeficiency virus as they have been since the first appearance of HIV.
Dentistry and HIV/AIDS
For most of the past two decades, the HIV pandemic has been a focus of concern. In the beginning of the epidemic, specific intraoral lesions and symptom clusters that were unique to this infection were identified.19-22 Patients who sought dental care for oral symptoms typically represented a particular demographic profile and were already diagnosed with the HIV infection, and many had already progressed to the full-blown stage of AIDS.23 Their life spans were considerably shortened, and much of the oral care provided was palliative.
An HIV patient seen today may come from a variety of racial/ethnic backgrounds, be of any age, gender, or sexual preference and may not know that he or she has been infected with HIV.24 Since oral lesions may be the first manifestations of HIV infection,25 and since typical dental patients seek out dental care when they are feeling healthy,26,27 the dentist may be the first health care practitioner who becomes aware of the possibility of a patient being infected with this life-threatening virus.
Intervention opportunities for talking with patients can occur when the oral health clinician discovers a possible manifestation of HIV.28 After detecting an intraoral lesion, the dentist will need specific past medical history, behavioral activities, and additional symptomatology from the patient to add to the clinical appearance of the lesion in order to weigh the risks of possible HIV infection. There may be other signs including tattooing or piercing of various body parts indicating that patients are involved in unsafe behaviors. Such indicators warrant discussion and risk assessment by the dentist. Off-the-cuff conversations or other comments by the patient about health or relationship issues may also trigger concerns about the patient’s HIV risk.
Structuring the Risk Assessment
In adults, HIV is transmitted in three ways: blood or blood products; shared needles, typically with other drug users; and unprotected sexual activities with an infected partner.29 As has been true of the physician,30 the dentist is often uncomfortable obtaining the necessary information since two of the risk factors -- use of needles and unprotected sex -- relate to topics that are taboo and not easily discussed in U.S. society. There is however a method that can be used by the dentist to systematically elicit information from the patient relative to his or her risk of HIV while encouraging the patient to feel comfortable in divulging the information and the dentist to engage in nonjudgmental inquiry into the patient’s risk-taking behaviors.
The presence of a suspicious intraoral lesion or unsafe behavior should prompt a discussion that brings to the patient’s conscious level his or her personal risk for HIV/AIDS. How to achieve such an understanding without precipitating panic is one of the constructs of the structured risk assessment protocol. With recent advances in HIV treatment, being tested for the virus and, if positive, receiving appropriate care as early as possible have become increasingly important. Conveying this message to the patient is another of dentistry’s risk assessment goals.
Risk Assessment Algorithm
To help structure the patient interview, the authors use an HIV risk assessment algorithm developed by Richard Call, DMD, at the Mountain-Plains Regional AIDS Education and Training Center at the University of Colorado. This algorithm addresses the three basic routes of HIV transmission: blood, shared needle use, and sex.31 The branching algorithm, updated as more has been learned about HIV and the behavior that places a person at risk for acquiring the infection, provides structure to the interview (Figure 1). Whenever a risk behavior is identified, more complete questions are asked about that behavior before going on to the next risk area. This approach helps the health care professional structure an interview to obtain as much information as possible to assess accurately the patient’s overall HIV exposure. In the training program provided as part of the Pacific AIDS Education and Training Center program for dental providers, the authors subscribe to this model by having dentist trainees role-play the interview with a standardized patient.
Assessing a Patient’s Risk for HIV
To demonstrate the algorithm, an interview model will be described that builds on the finding of a suspicious intraoral lesion. In this case, the practitioner starts by showing the patient the area that is of concern, posing the typical questions asked whenever a lesion is discovered such as: Is it painful? Is the patient aware of it? How long has it been there? Before actually beginning the questions from the algorithm, the dentist is encouraged to explain to the patient the reason for the questioning, i.e., an attempt to determine the causative factor for the oral finding, and why the dentist will be asking personal and sensitive questions. As with other diagnoses, the patient should be provided with a range of possibilities for the oral lesion, including in the differential benign explanations such as simple trauma (biting the side of the mouth, etc.), to other more systemic underlying causes. As appropriate, these could include conditions such as a drug reaction, diabetes, and sexually transmitted diseases, including HIV among other possible causes.
The patient should understand that at no time is the dentist diagnosing HIV, for that would be beyond the scope of the practice of dentistry. Rather, the goal is to collect information that may be helpful in considering the patient’s relative risk for HIV. In order to facilitate open communication very early on, the dentist must reassure the patient that what is discussed will be completely confidential and that this information will help the dentist understand the oral problem and thus be able to provide better care. Reassuring the patient of the intention to be his or her dentist regardless of the outcome of the interview is also important because discrimination against HIV-positive individuals by dental practitioners is still a concern to many. Throughout the risk assessment, the dentist should use nonjudgmental language and assiduously avoid any appearance of labeling or judging the patient.
Blood Risks
In questioning the patient about HIV risk, it is usually helpful to begin with the least sensitive issues, usually blood-related risks, and move to those in more sensitive areas, such as needle sharing and sexual risks. As questions are asked about blood transfusions, needle use, and sexual activity, the patient’s behavior as well as the behavior of past and present sexual partners32 is explored. Since HIV is spread by sexual contact, sexual partners’ risk behaviors are also relevant. If risky behavior is discovered, follow-up questions are asked.
Blood transfusions in the early 1980s prior to 1985 when the blood supply was routinely checked in the United States for the HIV virus would increase the risk of having acquired the infection.33 Asking where a transfusion occurred is necessary as other countries did not check their blood supplies until some years later. Similar questions should be asked relative to any sexual partners of the patient. Additionally, individuals sometimes forget that major surgeries or accidents require blood transfusions. Therefore, follow-up questions about the patient and the patient’s sexual partners are asked concerning whether the individuals have had surgery or been in a major accident.
Shared Needles Risk
The questions about needles are asked in such a way as to include all possible uses of shared needles, not just those dealing with street drugs. Sharing of needles to take medications including vitamins occurs in some cultural and/or socioeconomic strata. Cleaning needles with bleach has been shown to have some effect in disinfecting needles; however, cleaning needles is not as safe as using sterile needles obtained through a needle exchange program.34 Again, follow-up questions regarding the sexual partners’ sharing of needles is pursued. Additional questions relating to needle use to take medications or vitamins or for body piercing or tattooing may further trigger memories of risky behaviors. Body piercing or tattooing are included in the algorithm due to the possibility of shared needles and improper cleaning between uses.35,36 A history of alcohol and other drug use is also of concern since studies show that individuals participating in sex under the influence are more likely to engage in risky behaviors.37,38
Sexual Risks
The final series of questions deals with the sexual behavior itself. Eliciting information on whether the patient is or has been sexually active and consistently applies safe sex behaviors is relevant. To determine sexual orientation without labeling, the question, "Do you have sex with men, women or both?" is asked. Questions regarding the number of sexual partners and type of sexual activities are also raised. These questions are important because the number of different sexual partners39 and the type of sexual activity relate to relative risk of HIV infection with some sexual activities having a higher risk of potential infectivity than others (anal has a greater risk than vaginal, which has a greater risk than oral).40 The inconsistent use of condoms, particularly with higher risk sexual activity, puts individuals at greater possibility of acquiring the disease.41 Condoms should be used with every sexual activity.42 Patients should be asked if HIV testing has been performed in the past as this is often an action taken by patients who realize that they have engaged in unsafe behavior.43 Determining that the patient has contracted a sexually transmitted disease other than HIV indicates a breakdown in following safe sex practices.
Pursuing a detailed HIV risk assessment not only provides information to the practitioner on the patient’s relative HIV risk, it also helps patients understand how they may have put themselves at risk. Even if early in the interview the dentist determines that a patient is in danger of having acquired HIV, the dentist should continue with the entire assessment. Additional risk information is often revealed and, perhaps more importantly, the patient may learn more about his or her own behavior relative to HIV risk and be motivated to be tested.
The dentist should also be knowledgeable regarding types of HIV testing as well as testing sites so that he or she can refer the patient appropriately.44 Referral to the patient’s physician or to confidential or anonymous testing sites will ensure that state of California mandated counseling does occur as part of the HIV testing process. Generally keeping up with the latest information relative to the success of new medications,45 the populations where the epidemic is advancing the most,46-48 and issues of transmission risk during pregnancy45 will help the dentist provide the patient with facts rather than myths.
Acceptance of the Risk Assessment Model by Dentists
This risk assessment approach has been used as one segment of the authors’ multiple-module HIV Training Program for Dentists for a number of years. Although dentist trainees initially have some reluctance to pursue these questions, role-play simulations using a standardized patient portraying a real patient story quickly affirm the value to the dentist interviewer of this model of inquiry. Thirty-eight dentists trainees were asked to rate the usefulness of the knowledge or skills received in this segment of the training program. A five-point Likert scale was used with a 1 rating being "Not Useful" and 5 rating being considered "Very Useful." The Risk Assessment Workshop received an average rating of 4.5. In response to the open-ended query about the most positive experience each dentist trainee had during the entire training program, enthusiastic feedback about the Risk Assessment Workshop was received: "very useful information on a very delicate subject;" "could have used more of this," and "the risk assessment and standardized patient segments provided the most-needed areas of training."
The Dentist’s Role in Primary Care
Today’s dentists routinely perform medical history reviews and physical evaluations. In addition to conveying the traditional messages about oral problems induced by the presence of plaque, they counsel their patients about the use of tobacco49,50 or alcohol,49 good nutrition principles,27,51 the hazards of self-induced vomiting,52 body piercing,53 and the importance of using protective gear such as mouthguards, helmets, and seat belts during activities at high risk for injury to the orofacial complex.18 Dentists often diagnose and manage intraoral side effects of medications taken for systemic diseases54 or facilitate referrals of patients to physicians for diagnosis7 or better control of suspected medical problems. They counsel pregnant women, or women planning on becoming pregnant, about the need for specific minerals in the diet to aid in the development of sound teeth in utero,27 the capability of vitamins such as folic acid to reduce the incidence of cleft lip/cleft palate and neural tube defects in the embryo,55 and the impact of the mother’s periodontal disease on the birth weight of the baby.56 The elderly patient is frequently advised to increase his or her intake of calcium to 1,200 mg per day to maintain bone mass, including alveolar bone.27 Dentists routine advise patients of the side effects to medications they prescribe for managing oral disease such as the disruption of the normal flora of the gut and/or the vagina during the use of antibiotics,57 the thinning of the blood during the use of aspirin-based products,54 or the constipation that results from codeine-containing medications.54
Dentistry and HIV Prevention
Although a sensitive area to broach, the prevention and control of sexually transmitted disease is a public health opportunity for all health care practitioners. Two of the five STD prevention and control concepts published in the CDC’s 1998 Guidelines for Treatment of Sexually Transmitted Diseases are particularly opportune for incorporation into the dental practice: Detection of asymptomatically infected people and symptomatic people unlikely to seek diagnostic and treatment services and education of those at risk in ways to decrease the possibility of becoming infected.58 The dentist is in a unique position to identify and counsel patients who are unaware that they may have been infected by the HIV virus, for dentists see 62 percent of the population annually and 75 percent of individuals age 5 to 17.59 Since most American males and females have had intercourse by the time they reach 16 to 18 years of age and the majority of young adults age 18 to 24 have multiple serial sex partners,60 the dentist may in fact be the only health care professional regularly interacting with this younger age group who are at increasing risk of acquiring HIV.61 In addition, the dentist spends more time with each patient than the median 12 minutes spent by the physician62 thereby further allowing an opportunity to take note of and educate patients who are at risk for HIV.
Conclusion
The faculty of the Pacific AIDS Education and Training Center encourage dentists to talk with their patients about HIV/AIDS and about possible risks for HIV transmission whenever patients present with an oral sign or symptom suggestive of immunologic deficiency or there are other indications of involvement in hazardous behavior. The historic success the authors have achieved in conveying information about the prevention of disease and the importance of oral health should bolster dentists’ resolve to expand their preventive discussions with their patients to include preventing disease and promoting the health of the entire person. HIV infection provides dentists with the opportunity to do just that.
Authors
Roseann Mulligan, DDS, MS, is a professor and associate dean for community health programs at the University of Southern California School of Dentistry. She is also the dental director of the Pacific AIDS Education and Training Center.
Sue A. Lemme, MA, is a clinical assistant professor in the Department of Family Medicine at the USC School of Medicine. She is also co-director of the USC satellite of the Pacific AIDS Education and Training Center.
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To request a printed copy of this article, please contact/ Roseann Mulligan, DDS, MS, USC School of Dentistry, 925 W. 34th St., Room 4338, Los Angeles, CA 90089-0641 or at mulligan@hsc.usc.edu.
Pacific AIDS Education and Training Center,
University of Southern California
HIV Risk Assessment Algorithm
Because the first physical manifestations of HIV may occur orally, the Pacific AIDS Education and Training Center encourages dental practitioners to talk with their patients about HIV/AIDS and risks for transmission when patients present with an oral sign suggestive of immunology deficiency or other indications that the patient is involved in unsafe behavior.
Blood Related Issues Algorithm
Have you ever had a blood transfusion or used a blood product to control a bleeding disorder?
NO YES
Explore Possibilities
Why did you need the product?
When did you receive it?
Where were you living?
To your knowledge, have any of your sexual partners ever had a blood transfusion or used a blood product?
NO YES
Explore Possibilities
Why did they need the product?
When did they receive it?
Where were they living?
Have you ever had surgery or been in a major accident?
NO YES
Explore Possibilities
When did this occur?
Where did this occur?
Might you have received blood?
To your knowledge, have any of your sexual partners ever had surgery or been in a major accident?
NO YES
Explore Possibilities
When did this occur?
Where did this occur?
Might they have received blood?
Shared Needle and Drug Algorithm
Have you ever shared needles to take anything:
NO YES
Explore Possibilities
What did you take by using needles?
Did you clean any of the needles or syringes?
How did you clean your equipment?
Do you participate in a needle exchange program?
To your knowledge, have any of your sexual partners ever shared needles to take anything?
NO YES
Explore Possibilities
What did they take by using needles?
Did they clean any of the needles or syringes?
How did they clean their equipment?
Did they participate in a needle exchange program?
Have you used needles to take medications or vitamins?
NO YES
Explore Possibilities
Have You Had Body Piercing or Tattooing?
NO YES
Explore Possibilities
Do you use alcohol or take drugs without needles?
NO YES
Explore Possibilities
Do you ever have sex while under the influence of drugs, including alcohol?
NO YES
Explore Possibilities
Sexual Issues Algorithm
Are you sexually active? (or have you been sexually active)
Do you have sex with men, women, or both?
How many sexual partners have you had:
In the last 12 months?
In the last 5 years?
Lifetime?
What type of sexual activities do you engage in?
Oral
Anal
Vaginal
When you have sex, do you use condoms?
NO YES
Explore Possibilities
How often do you use condoms?
Always
Sometimes
Never
With what sexual activity?
Have you ever been tested for HIV?
NO YES
EXPLORE POSSIBILITIES
When were you tested?
What were the results?
Why did you get tested?
To your knowledge, have any of your sexual partners ever been tested for HIV?
NO YES
Explore Possibilities
When were they tested?
What were the results?
Why did they get tested?
Have you ever had a sexually transmitted disease?
NO YES
Explore Possibilities
When?
What?
Treatment?
To your knowledge, have any of your sexual partners ever had a sexually transmitted disease?
NO YES
Explore Possibilities
When?
What?
Treatment?
Adapted from an HIV risk assessment algorithm originally developed by Richard L. Call, DMD, for the Mountain-Plains AIDS Education and Training Center at the University of Colorado Health Sciences Center.
