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By acting proactively, dentists are in a unique position to help stop the spread of sexually transmitted infections. By Kerryn Ramsey
According to the World Health Organization, rates of sexually transmitted infections (STIs) are rising globally with over one million curable STIs acquired every day for people between the ages of 18 and 49. A number of these infections can present orally, putting dentists on the frontline of detection and referral.
Not only do dentists need to be able to identify the signs and symptoms of infection, they need to find a way to initiate a sometimes difficult conversation with affected patients.
Dr Amanda Phoon Nguyen, a dentist and oral medicine specialist in Perth, Western Australia, has been addressing this subject through lecturing, teaching and her social media accounts. She recently appeared on the Australian Dental Association Dental Files podcast in an episode called STIs and Oral Health.
“The problem is more widespread than most people believe,” Dr Nguyen told Bite. “When I was a dental student, I was taught syphilis was pretty much eradicated in Australia. We were told that it was likely none of us would ever see a case. Unfortunately, syphilis rates have increased over the past few years and cases occasionally present. The reason why is complicated—probably a combination of changing sexual practices and an increase in unprotected behaviours.”
Early detection
Dentists are in a unique position because they have a direct line of sight into the patient’s mouth. They may be the first person to pick up on an STI, often before the patient is aware. Unfortunately, many dentists are not even thinking about STIs during an oral examination.
“Dentists need to be open to the possibility that the ulcer they’ve spotted in a patient’s mouth may not be trauma or a recurrent aphthous ulcer,” Dr Nguyen says. “It may, in fact, be syphilis. If awareness of STIs is under-appreciated, the possibility of misdiagnoses or overlooking the problem increases.”
The human papillomavirus (HPV) is implicated in causing cases of oropharyngeal carcinoma. Common STIs that can be seen in the oral cavity are often related to HPV. There can be benign forms that look like warts, such as squamous papilloma and verruca vulgaris.
“Some flags associated with carcinoma are difficulty swallowing, unexplained pain, raised lymph nodes, and any sort of lesions that don’t heal,” Dr Nguyen says.
Dentists are well versed in asking about smoking, alcohol, medications, and recreational drugs but sexual history can be confronting. I believe the subject of sexual history should only be discussed if a potential problem has been identified in the mouth.
Dr Amanda Phoon Nguyen, dentist and oral medicine specialis
“Cases of syphilis and gonorrhoea in the mouth are difficult to diagnose because syphilis is called the great mimic, presenting in lots of different forms. Any of these presentations should be referred to an appropriate specialist to be evaluated properly.”
Social history
Dr Phoon Nguyen graduated from the University of Melbourne with a Bachelor of Dental Science, working in the Royal Australian Navy and as a general dentist in private and public practice. She completed her specialty training in oral medicine at the University of Western Australia in 2019 and has been an oral medicine specialist since then. Presently, she is a consultant at the Perth Children’s Hospital and an adjunct senior lecturer at the University of Western Australia and Curtin University. She also works in private practice at the Perth Oral Medicine and Dental Sleep Centre.
“While it’s common for dentists to take a full medical history of patients, a social history can be a little more problematic,” she says. “Dentists are well versed in asking about smoking, alcohol, medications, and recreational drugs but sexual history can be confronting. I believe the subject of sexual history should only be discussed if a potential problem has been identified in the mouth. It’s not warranted for every patient.”
How you approach the subject with the patient is key. It’s important to be sensitive but remain clinical in your approach. “You don’t want details,” Dr Nguyen says. “You don’t want to know who they’re seeing. You don’t want to know how they’ve acquired it. You just want to know whether they think there’s a possibility it could be an STI. The dentist isn’t the person to diagnose and treat it. The patient should be encouraged to see their GP or visit their local sexual health centre if this is the case.”
It’s important to explain that the questions are asked routinely of every patient with similar presentations in their mouth. It’s also essential to document it correctly. Being aware of the possibility of STIs, responding appropriately, and discussing it with the patient, are all part of a professional oral health assessment.
Managing denial
A further complication arises when patients with likely presentations refuse the possibility that it’s caused by an STI. This can be for any number of reasons but the dentist can proceed gently with an end goal of referral to a specialist. “There are few ways to approach this situation,” Dr Nguyen says. “You can say, ‘I don’t see these types of lesions often, but there are specialists who do and I think it should be looked at’, or ‘I think this lesion needs a second opinion’. Possibly ‘I would recommend seeing a specialist to ascertain exactly what this is’.
“At the end of the day, the most important thing is that the patient is informed and a pathway offered for a follow-up.”
To bring down the rate of STIs, a combined effort by all health professionals is required, with dentists playing a key role in being instrumental in early detection. Dr Nguyen insists that being aware of the problem, becoming educated about presentations, and referring when necessary are the most effective ways to slow the spread of STIs.
Dr Nguyen’s ADA podcast, STIs and Oral Health, is available for ADA members: subscribers.transistor.fm/112cfe1520af67
