Ethical dilemma: Dental patient with HIV

Sir,

We read with great interest the article by Sheriff and Sheriff¹ regarding a dental case scenario with HIV infection. Although this report reveals useful information, there are some areas for discussion upon which we would like to expand.

First, the authors discussed about the difficulties in HIV testing and counseling the patient presenting with chronic painful tooth infection. The oral medicine specialist played a role in diagnosing and referring the patient to appropriate management: Endodontic or oral surgical treatment. A clinical-ethical question arises: “Should the oral medicine specialist do HIV testing for the patient?” The answer may be “No.” Studies have shown the success of root canal treatment in HIV-positive patients, regardless of the symptomatic clinical presentation, antiretroviral drug therapy, and viral load.²,³ Hence, if the patient will be referred to endodontic treatment, HIV testing may not be necessary (whatever requested by the oral medicine specialist or the endodontist). There is little evidence of complications from dental procedures among healthy-looking individuals affected by HIV/AIDS. The HIV test may be done when the patient will be treated surgically; and the oral surgeon should be the person who requires the test “only if” HIV status is important for the treatment given, such as in cases with a bleeding disorder or severe immune deficiency.⁴ By this way, the healthcare provider who will know the patient's HIV status is the treating oral surgeon “only,” not all two or three dentists.

In general, once HIV becomes part of the differential diagnosis, prompt referral to the patient's primary care physician for additional evaluation is essential. During the primary care provider's assessment, a thorough physical examination will be performed to evaluate for the development of opportunistic diseases associated with an advanced stage of infection, including pre- and post-HIV testing counseling.⁴ This is not a duty of dentists to manage all health care alone.

Second, the authors applied an ethical approach based on the four principles of “principlism”: Autonomy, beneficence, non-malfeasance, and distributive justice.⁵ However, the authors did not emphasize the importance of distributive justice (equitable distribution of healthcare resources). This principle is aimed at minimizing disparities between treating practitioners or between healthcare centers. One solution is to develop and follow a continual audit and a clinical practice guideline.⁵ In Germany, where Institute of Dentistry (a dental faculty) is usually affiliated with a medical school or a university hospital, almost all oral-maxillofacial surgical departments have the same approach for dental infection patients with suspected or proven HIV infection. All questions mentioned by Sheriff and Sheriff¹ can be easily solved by clear and effective practice guidelines of national professional associations (available at http://www.dagnae.de/fachthemen/stellungnahmen/hiv-zahnmedizin/; http://www.daignet.de/site-content/hiv-therapie/leitlinien-1; http://www.leitlinien.de/leitlinie/odontogene-infektionen-und-abszesse).

Lastly, it should be borne in mind that there are several ethical approaches to clinical practice, such as utilitarianism, casuistry, deontology (Kantianism), and virtue theory. Each approach has its own strength, weakness, and limitations. For details on weakness and limitations of principlism, we refer interested readers to our recent publication.⁵