I read with great interest "Avoiding Malpractice for Nondental Conditions: The Example of Human Immunodeficiency Virus" by Dr. Richard Grimes and colleagues (April JADA). I should like to comment from my perspective as a retired teacher of oral pathology and oral medicine.
My comments relate to candidiasis and its relation to HIV. I have always taught that candidiasis is "disease of the diseased." I have instructed my students that a diagnosis of oral candidiasis is not complete without establishing the underlying etiologic factor.
As the authors note, "The appearance of these lesions should raise the suspicion of HIV infection unless the patient has other risk factors for candidiasis." A diligent search should be conducted in the anamnesis for these factors. Many of the conditions would require diagnosis by a physician.
In my opinion, the "HIV Information Form" on page 506 is inappropriate. I would suggest that it is the professional obligation of the dentist to make a referral to a physician, describing oral candidiasis and certainly listing the differential underlying diagnosis. HIV disease should appear on this diagnostic list, as well as diabetes mellitus, blood dyscrasias and so on.
At the time of referral to the physician, the patient should be counseled and advised that his oral candidiasis may be a sign of an underlying medical condition. The astute dentist would, of course, include HIV in the list of underlying etiologic factors. The results of the medical consultation should be reported to the referring dentist.
In my opinion, the information on the HIV Information Form suggesting that the patient has HIV is quite presumptive. It might alarm, and even insult, the patient who has undetected diabetes or blood dyscrasia.
The authors would probably agree that it would be illogical to ask a patient to sign a statement indicating that dietary sugar intake should be closely monitored, exercise patterns be adjusted and precautions taken against having hypoglycemia while driving an automobile. I believe the authors would agree that the incidence of diabetes mellitus exceeds that of HIV in a typical American dental patient population. Many of the "precautions" on the form should only be recommended after a competent medical evaluation.
It is the dentist’s duty to diagnose and treat oral candidiasis. It is also the dentist’s duty, by careful anamnesis, to attempt to elucidate the underlying cause for this disease. It is not within the practice of dentistry to diagnose HIV, nor, for that matter, diabetes.
