People are used to feeling uncomfortable at the dentist, whether its suffering the drill or trying to make conversation with a gloved finger in your mouth. Given this baseline, perhaps the dentists’ office is the perfect place for another awkward experience: testing for HIV. This intriguing proposal has been made by public health advocates since the 2004 FDA approval of the rapid saliva HIV test, which produces reliable results in less than 20 minutes. Combining that convenient test with a check-up that’s a yearly tradition for most people — one that offers no shortage of saliva — could help spot HIV cases earlier and more often. But there’s a cognitive dissonance to the idea of sexually transmitted disease testing in the dental office that’s weird for more than just the patients, as a recent survey of dentists discovered.
The medical role of the dentist has expanded in recent years, as many dentists go beyond your standard tooth-cleaning and cavity-filling to screening for oral cancers, high blood pressure, and diabetes. Would adding an HIV test to their repertoire be feasible? That’s what a team of researchers from around the country, including the University of Chicago’s Harold Pollack, asked 40 dentists in phone interviews in a paper for the American Journal of Public Health. The study found that many dentists saw the value of helping potentially infected patients discover their disease status, and thus start treatment earlier than they might have otherwise. But there were also several objections raised about offering the HIV test alongside teeth-whitening in their offices.
Surprisingly, only 1 of the 40 dentists had even heard about the rapid saliva test before the phone call. Alongside the concerns about the test’s accuracy and reimbursement for the time it takes, the dentists voiced concerns that reflect the still-touchy topic of HIV. Many said that they wouldn’t feel comfortable talking to patients about the test or its results, worrying that older or more conservative patients would be offended by even offering an HIV test. “I think most of my patients would feel insulted or that I was overstepping my bounds,” said one dentist.
If the test should come back positive, some interviewees said they were nervous about being “the bearer of bad news” in disclosing the result before referring the patient to a medical doctor. A primary care physician might be better equipped to handle both the clinical questions and emotional fallout that could result from a positive HIV test.
“This is only my opinion, but it would seem very odd for the first person to tell the patient they were HIV positive would be the dentist,” one respondent said.
Some dentists even said that offering the test could produce a backlash among their patients, who might fear that the offer of an HIV test signaled that the clinic served a high-risk population. While the risk of patient-to-dentist or dentist-to-patient HIV transmission has receded into urban legend, dentists that served an older or more rural patient base said that there was still a lot of fear about the disease.
“They might be more concerned about the safety or even simple sterility or cleanliness or spread of HIV in the practice,” one subject told the interviewers.
To counter these dental doubts, the authors suggest a campaign of education and cultural change. For concerns about accuracy, the rapid HIV test has been proven over 99 percent sensitive and specific, with miniscule false positive and negative rates. Dentists can also be taught the same pre- and post-test counseling methods for patients that primary care physicians use in their own practice, hopefully lessening some of the awkwardness of the discussion. Older dentists may be more resistant to new education or new duties, but the authors suggest that this instruction could take place in dental school, preparing the next generation of dentists to assist the public health battle against undetected HIV.
“Altering the ethos of dental care to more fully embrace prevention would provide major opportunities for public health,” the authors conclude.
Siegel K, Abel SN, Pereyra M, Liguori T, Pollack HA, & Metsch LR (2012). Rapid HIV Testing in Dental Practices. American journal of public health, 102 (4), 625-632 PMID: 22397342