Problems associated with providing dental care to patients with HIV-infected and AIDS patients John Hardie, BDS, MSc, FRCDC,” Vancouver, British Columbia, Canada

VANCOUVER GENERAL HOSPITAL

Numerous articles published during the last decade have discussed the significance of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) toward the practice of dentistry. However, only since 1987 have studies been undertaken on the attitudes and behavior of dentists toward HIV-positive patients. A detailed analysis of 15 such reports suggests that concerns regarding the perceived stigma of treating such patients, together with a fear that HIV is transmitted through dental treatment are major reasons why dentists are reluctant to care for HIV-positive and AIDS patients. Successful resolution of these concerns is time consuming and expensive but necessary if dentists are ,to satisfy their professional obligations to patients with HIV infection and AIDS. (ORAL SURC ORAL MED ORAL’ PATHOL 1992;73:231-5)

T here is no doubt that infection with the human immunodeficiency virus (HIV)1 has been the most significant disease to affect our society during the last decade. This infection, characterized by its evolution from an initial, often asymptomatic phase, through associated opportunistic symptomatic infections, to the terminal phase of the acquired immunodeficiency syndrome (AIDS), has had a dramatic influence on the practice of health care. The adoption of universal precautions has been the most visible evidence of this change. However, an equally significant result has been a reassessment of a health profession’s respon- sibility to treat victims of infectious but fatal illnesses, who often lead. different, high-risk life-styles.

The dental profession has not escaped from the problem. In some situations knowledge of a patient’s life-style and social and sexual activities may be per- tinent to dental treatment, but such enquiries are not common. Almost inevitably the diagnosis of an HIV infection categorizes the patient into a specific culture or life-style. This provides the dentist with informa- tion that would not normally be available and that may consciously or unconsciously influence the den- tist’s opinion to treat, refer, or abandon the patient.

“Head, Department of Dentistry.

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This conflict, together with the unusual situation of treating patients contemplating premature or immi- nenr death, may be why dentists have negative or am- bivalent feelings toward caring for HIV-positive pa- tients. Additional reasons for this reluctance may be confusion regarding HIV transmission, ignorance of the oral manifestations of HIV infection, inexperience with medically compromised patients, and the finan- cial status of ill, often unemployed, patients. Separately and together these factors may present problems in the provisions of oral health care to HIV-positive and AIDS patients. The purpose of this article is to validate whether these barriers are real or perceived, and to provide solutions that will permit their dismantling.

METHODS

The initial recognition of AIDS in the early 1980s spawned numerous articles in the dental literature on this syndrome and the associated HIV infection. However, these early articles and many subsequent ones tended to concentrate on the pathophysiology of the disease process, its effect on oral mucous mem- branes, and specific case reports. The first study con- cerning dentists’ attitudes and behavior toward pa- tients with AIDS (with the appreciation that these could adversely affect treatment) was published in

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232 Hardie ORAL SURG ORAL b!ihD QRAL PATHOL

February 1992

March 1987 by Gerbert.’ Subsequently approxi- mately 2 1 articles have reported on similar topics and their relationship to the provisions of care by North American and U.K. dentists. For the purposes of this report, 15 of these articles published between March 1987 and March 1990 were chosen at random and analyzed in detail.

The articles according to their subject matter were categorized as belonging to one of the following groups.

Group 1: Dentists’ attitudes, behavior, knowledge. A total of 11 articles were in group 1, relating to den- tists’ attitudes, behavior, and knowledge. Of these sevenI-7 were survey-type reports and were allocated to subgroup 1 a. One article8 used a unique approach to assessing dentists’ attitudes and was placed in sub- group lb. Another article9 indicating how dentists’ attitudes could be altered was assigned to subgroup lc. Two articleslo, I1 provided a comparison between specific groups of dentists. They were placed in sub- group Id.

Group 2: Attitudes of non-HIV-infected patients. Two articlest2, I3 belonged to group 2, on attitudes of non-HIV-infected patients.

Group 3: Dental experience of HIV-positive pa- tients. Two articlest4, t5 pertained to the dental expe- rience of HIV-positive patients and were classified into group 3.

RESULTS Group 1: Dentists’ attitudes, knowledge

Subgroup la: Survey reports (references I-7). Subgroup la addressed the following issues:

@ Do dentists have a responsibility to treat HIV- positive and AIDS patients?

This specific question was asked in three of the sur- veys.‘, 4. 6 Positive responses ranged from 50% to 70% [mean 62%).

o Would not accept but would refer HIV-positive and AIDS patients

This comment was identified in six surveys.‘-4, 6, 7 Positive responses ranged from 56% to 73% (mean 68%).

e Reasons for not treating These were listed in four surveys.2, 4, 6, 7 The most frequent reason cited for not treating HIV-positive and AIDS patients was the perceived stigma associ- ated with treating patients. The second most common reason was fear of transmission of HIV during dental procedures. Other reasons included lack of knowledge of the oral manifestations of HIV and AIDS; lack of necessary skills to provide safe, effective treatment; refusal of staff to treat HIV-positive and AIDS

patients; the expense of necessary infection control procedures; and the failure of HIV-positive patients to reveal their status.

l Satisfactory knowledge about AIDS regarding its transmission and the high-risk groups

This information was sought in a subjective manner in two articles’, 2 and objectively in a third.” Satisfac- tory responses ranged from 77% to 90% (mean 82%).

o Satisfactory knowledge of the oral manifesta- tions of HIV and AIDS

This was identified in four surveys.‘-3, 6 The responses ranged from 24% to 75% (mean 45%).

Subgroup I b: Assessment of dentists’ attitudes. -4 different approach to assessing dentists’ attitudes to members of high-risk life-styles was taken by Hazelkorn,* who employed a professional actor re- quiring dental care to pose as a heterosexual, a homo- sexual, and an intravenous drug abuser (IVDA). A total of 102 randomly selected, uninformed dentists were the subjects. The actor, portraying the role of a heterosexual, was examined by 33 dentists, for ‘34 dentists he played the role of a homosexual, and for 35 dentists he acted as an IVDA. The participating dentists were interviewed regarding their attitudes toward members of the high-risk groups.

One dentist refused to examine the actor on appre- ciating that he was an “IVDA,” and one dentist re- fused to make a treatment appointment for the “gay” actor. Of the 69 dentists who saw the actor as a mem- ber of a high-risk group for HIV infection and AIDS, 67 would have accepted him as a patient, despite the fact that Hazelkorn determined that 44% to 78% of the participating dentists were either uncomfortable or slightly uncomfortable with public displays of ho- mosexuality.

Subgroup 1 c: Alteration of dentists’ attitudes. The investigation’ assigned to this category demonstrated that by intensive comprehensive instruction during a h-month period it was possible to alter positively the attitudes, behaviors, and knowledge of a group of dentists toward HIV infection and AIDS and toward patients with such diseases.

Subgroup 1 d: Comparisons of specij?c groups. A study by Cothen and GracetO of dental faculty dem- onstrated that such dentists had negative attitudes toward AIDS patients and homosexuals and a general unwillingness to treat or work with such persons.

Samaranayake et al.’ 1 made a comparison of the attitudes toward AIDS patients as expressed by hos- pital dental staff and final-year dental students in both Los Angeles, Calif., and Glasgow, Scotland. Signifi- cant results were as follows:

o Who should treat HIV-positive and AIDS pa- tients?

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Approximately 100% of respondents stated that this should be done by dentists with special training and in special facilities. However, 18% to 88% of the re- spondents agreed that such patients could be treated by students, general practitioners, and recognized specialists.

l \Nould respondents treat HIV-positive and AIDS patients?

Among the hospital staff 13% to 16% and of dental students 15% to 48% would refuse to treat but would refer HIV-positive and AIDS patients.

l Attend dentist treating HIV-positive anld AIDS patients?

Although 80% to 84% of hospital dental staR would attend a dentist treating hepatitis B patients, 3% of this group in Los Angeles and 13% of the same group in Glasgow would not attend a dentist treating HIV- positive and AIDS patients. Among dental students, 60% to 68% w’ould be treated by a dentist caring for hepatitis B patients but only 50% would visit a den- tist attending HIV-positive and AIDS patients.

l Spread of HIV in dental environment? Among the Glaswegian respondents, 85% believed that spread of HIV in the dental environment was highly unlikely. However, in Los Angeles, 40% of the hospital dental staff and 28% of the students consid- ered it to be a likely or very likely occurrence.

l Adoption of extra precautions? When treating drug addicts, homosexuals, and he- mophiliacs, 82% to 100% of respondents would adopt special precautions.

l (Oral manifestations of HIV infection and AIDS? All the respondents identified the three most common oral manifestaltions of HIV infection/AIDS.

Group 2: Attitudes of non-HIV-infected patients

A survey of pati.ents revealed the following’2: l Patients were not afraid of contracting HIV in-

fection in the dental office. l Patients were reluctant to discuss AIDS and re-

lated topics with their dentists. l The infectious status of patients must remain

confidential. l Losing p,atients because of using infection con-

trol measures or because of treating HIV-posi- tive and AIDS patients were not justifiable fears of dentisls.

These results contrast with ai later study13 of many more adults and their attitudes toward AIDS and dentistry. In this survey

* 56% of respondents would attend dentists treat- ing HIV-infected patients

l 61% would change dentists if theirs was HIV positive

Dental care of HIV-infected and AIDS patients 233

l 50% of respondents believed HIV could be transmitted during treatment from an infected dentist

l 83% of all respondents wished to know the HIV status of their dentist

l 34% believed that they should be informed if their dentist was treating HIV-positive patients

l 87% of the adults would be comfortable discuss- ing AIDS with their dentist; only 13% had, with 80% of those initiating the conversation

l 82% believed that their dentist had treated someone with AIDS

l gloves were the barrier technique most endorsed by the respondents

Group 3: Dental experience of HIV-positive patients

A survey of the dental care experiences of HIV- positive patients revealed the following14:

l 1% to 3% of San Francisco men at high risk for AIDS were denied dental care during the past 3 years

e 8% to 10% of San Francisco men who were HIV positive or with AIDS were denied dental care, mainly because of HIV positivity

e 100% of IVDAs denied dental care believed it was because of their socioeconomic status

Somewhat similar experiences were obtained by another survey of HIV-positive men.15 The investiga- tors

e

e

e

found that 96% of the respondents had success in obtaining dental care of 26 dentists familiar with the patients’ status, only one refused to treat an infected patient although successful in obtaining treatment, the HIV-positive patients feared refusal because of their HIV status

DISCUSSION

During the last 7 years numerous investigators have established a distinct knowledge base regarding the relationship between HIV and oral disease. The sig- nificance of candidiasis, Kaposi’s sarcoma, hairy leu- koplakia, and HIV-associated gingivitis have been well documented in the dental literature. National dental associations in the United States, Britain, and Canada have recommended infection control tech- niques commensurate with current knowledge on how viral diseases are transmitted. In addition, these organizations have stated that dentists have a profes- sional obligation to treat HIV-positive patients who must not be denied care on the basis of their infection. A recent report16 suggested that for the most part, HIV-infected and AIDS patients may be offered the

234 Hardie ORALSLRGORAL M~DQRAL PATHOL February 1992

same treatment, delivered in the same manner and with the same experience and skiI!s as is necessary for non-HIV-infected patients. All these facts are signif- icant when it is considered that in North America there are more than 100,000 patients with AIDS and approximately 1.5 million HIV-infected persons, all of whom may require dental care. If such treatment is to be available, there must be no barriers to its ac- cess, but this review has indicated that obstacles to the delivery of care do exist. The problems appear to be most pronounced among dentists and to a lesser extent among their patients, whether or not they are infected with HIV.

Although a small majority (62%) of dentists believe that they have a responsibility to treat HIV-positive and AIDS patients, an almost equal percentage (68%) would prefer to refer such patients. This contrasts dramatically with Hazelkorn’s study,” in which only two dentists refused to provide treatment, and with the actual experiences of HIV-positive and AIDS pa- tients t4. l5 for whom obtaining dental treatment was not a ‘major problem. It may be that dentists respond differently to a patient than to a confidential ques- tionnaire. Therefore the reluctance to accept HIV- positive and AIDS patients may be more perceived than real. However, what cannot be ignored are the reasons given for this reluctance. The most common excuse cited is the stigma associated with treating in- fected patients, which would translate into a decrease in the numbers of noninfected patients seeking care. That this would be a genuine concern to dentists is supported by the finding that of 2000 adults surveyed across the United States,t3 only 56% would attend a dentist known to be treating HIV-infected patients. Presumably 44%, a substantial minority, would not. Further substantiation for this concern is provided by the fact that 50% of final-year dental students and 3% to 13% of hospital dental staff” would not attend +:tists treating HIV-positive and AIDS patients. The reason for this reluctance among both patients and dental personnel appears to be related to the fear of viral transmission during dental procedures. Al- though authorities have stated that dental treatment is not a route for HIV transmission, especially if rec- ommended precautions are adopted, it is surprising to note that 40% of the Los Angeles dental staff and 28% of their students’ 1 considered HIV transmission to be a likely occurrence during dental treatment. The re- cent albeit inconclusive report17 of a possible trans- mission from an HIV-positive dentist to a young fe- male patient is liable to raise further the concerns among patients and dental staff regarding the issue of HIV transmission.

Two additional obstacles to the delivery of oral care are interrelated. These are the belief that special knowledge and technical skills are necessary, and the less than satisfactory appreciation of the oral signs and symptoms of HIV infection and AIDS by general dentists. Barr et all6 indicated that HIV-positive and AIDS patients may be treated in the same manner as noninfected patients; however, the apparent igno- rance by dentists of the oral manifestations of these diseases may influence their decisions to treat such cases. Apart from the concerns voiced by IVDAs, financial considerations do not appear to be a signif- icant barrier to the provisions of care. No doubt den- tists have accepted that the costs of adopting recom- mended infection control procedures are an inevitable aspect of current dental practice.

The issues relating to HIV infection and AIDS are complex, and because of the life-styles of many afflicted patients, the subject of discrimination must be discussed. Dentists, like other persons, have per- sonal opinions on sex, morality, and behaviors that they may deem to be unacceptable. What has not been known is to what extent these feelings would influence their decisions to treat HIV-positive AIDS patients. The study by Hazelkorn indicates that dentists are decidedly homophobic but will accept as patients ho- mosexuals and IVDAs. This contrasts with the results obtained by Cohen and Grace,‘O which suggest that the unwillingness of dental faculty to treat AIDS pa- tients may be related to homophobia. The reason for this difference may be explained by the general reluc- tance of dentists to refuse treatment to patients whom they have examined. This may be a design fault of Hazelkorn’s study.* The issue of homophobia has been raised in surveys of other health care workers and probably deserves further investigation among dentists. The death anxiety that surrounds HIV and AIDS has negatively affected hospital personnel but does not appear to be a concern of dentists.18

An interesting parallel finding from four of the surveys 4-7 is that there is an inverse relationship be- tween dentists’ willingness to treat HIV-positive and AIDS patients and their age and years from gradua- tion. The acceptance of such patients by younger dentists might be a reflection of well-informed fac- ulty, but the findings of Cohen and GracelO tend to discount such a theory. Indeed, the hospital dental staff identified in Samaranayake’s study” would not be considered to be ideal role models. Perhaps the differences between younger and older dentists are related to busyness, established patient base; or developing as opposed to developed personal and pro- fessional opinions. The reasons for the apparent dif-

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ference in attitudes toward HIV-positive and AIDS patients among specific age groups of dentists are worthy of further investigations.

A significant finding of this review is the appreci- ation ,that the knowledge of, attitudes toward, and behavior of dentists toward the many issues associated with HIV infection and AIDS may be altered in a positive, beneficial manner.9 However, the investiga- tors readily admit that the methad employed is labor intensive and expensive, and may not be suitalble for all dentists. Nevertheless, the majority of surveys re- viewed stress the need for dental personnel to receive comprehensive education on all pertinent aspects re- lating to HIV infection and AIDS. There is unfortu- nately no consensus on the format of this educational exercise. Some investigators favor changing attitudes rather than knowledge,4 whereas others favor con- centrating on a target audience that is motivated to change.3 There is no agreement on whether such ed- ucation should be provided through referred -journal articles, continuing education courses, or formal postgraduate progra.ms.

CONCLUSIONS

This review was not based on a statistical analysis of previously published data; nevertheless, it dloes re- veal thlat the delivery of oral health care to HIV-pos- itive and AIDS patients is hampered by two signifi- cant obstacles. The first is the widely held belief (with some justification) aimong dentists that treatment of HIV-positive and AIDS patients will reduce the number of noninfected patients seeking their care. The second is the fear among dental staff and patients that the HIV may be transmitted during dental pro- cedures. Additional but less significant barriers are the perceived blelief among dentists that caring for HIV-positive and AIDS patients requires special dental skills and expertise, and the less than satisfac- tory knowledge dentists have of the oral manifesta- tions of HIV infection and AIDS. The willingness of dentisls to treat persons with life-styles with which they disagree is debatable but may be a significant factor in their reluctance to care for HIV-positive and AIDS patients.

It appears that properly designed scientific and clinical educational programs would assist in over- coming the first four obstacles. It may be much harder to provide a satisfactory solutiosn to the problem of homophobia. In fact, it may be naive to believe that even with the most skilled and empathetic teachers, dentists will not pass a life-style judgment on their HIV-infected and AIDS patients. However, this must

Dental care of HIV-infected and AIDS patients 235

not be viewed as an excuse for the dental profession to abrogate its moral, ethical, and legal responsibili- ties to care for the victims of the HIV.

REFERENCES

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Gerbert B. AIDS and infection control in dental practice: den- tists’ attitudes, knowledge, and behavior. J Am Dent Assoc 1987;114:311-4. Hardie J. Dentists’ attitudes towards AIDS: a survey. J Can Dent Assoc 1987;53:823-5. Atchison KA, Dolan TA, Meetz HK. Have dentists assimi- lated information about AIDS? J Dent Ed 1987;51:668-72. Gerbert B, Badner V, Maguire B. AIDS and dental practice. J Public Health Dent 1988;48:68-73. Verrusio AC, Neidle EA, Nash KD, Silverman S, Horowitz AM, Wagner KS. The dentist and infectious diseases: a national survey of attitudes and behavior. J Am Dent Assoc 1989;118:553-62. Dove SB, Cottone JA. Knowledge and attitudes of Texas den- tists concerning AIDS. Am J Dent 1990;3:5-8. Rydman RJ, Yale SW, Mullner RM, Whiteis D, Vaux K. Pre- ventive control of AIDS by the dental profession: a survey of practices in a large urban area. J Public Health Dent 1990; 50:7-12. Hazelkorn HM. The reaction of dentists to members of groups at risk of AIDS. J Am Dent Assoc 1989;119:612-9. Gerbert B, Maguire B, Badner V, et al. Changing dentists’ knowledge, attitudes and behaviors relating to AIDS: a controlled educational intervention. J Am Dent Assoc 1988; 116:851-4. Cohen LA, Grace EG. Attitude of dental faculty toward indi- viduals with AIDS. J Dent Educ 1989;53:199-202. Samaranayake LP, Figueiredo HMJ, Rowland CA, Aitchison K.. A comparison of the attitudes of hospital dentists and den- tal students in Glasgow, U.K., and Los Angeles, U.S.A., towards treatment of AIDS and hepatitis B patients. Am J Dent 1990;3:9-14. Gerbert B, Maguire B, Spitzer S, Henne J, Chamberlin K. A.ttitudes about AIDS. Calif Dent Asooc J 1988;16:42-4. Gerbert B, Maguire B, Spitzer S. Patients’ attitudes towards dentistry and AIDS. J Am Dent Assoc 1989;119(supp1):16S- 27s. Gerbert B, Sumser J, Chamberlin K, Maguire BT, Greenblatt R-M, McMaster JR. Dental care experience of HIV-positive patients. J Am Dent Assoc 1989;119:601-3. Jacobson JA, Stocking C, Gramelspacher G. Dental care ex- perience of HIV-infected men in Chicago. J Am Dent Assoc 1989;119: 605-8. Barr CE, Ruba-Dobles A, Puig N. Dental care for HIV-pos- itive patients. Spec Care Dent 1989;9:191-4. Centers for Disease Control. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. 1990;MMWR 39:489-93. Pomerance LM, Shields JJ. Hospital workers and AIDS: un- derstanding the importance of contact, knowledge, death anx- iety and homophobic attitudes [Abstract 91071. Fourth Inter- national Conference on AIDS; Stockholm; 1988.

Reprint requests. J. Hardie, BDS, MSc, FRCDC Department of Dentistry Vancouver General Hospital 855 W. 12th Ave. Vancouver, British Columbia Canada V5Z lM9