Dr Naomi Sutton explains how dental teams can be crucial when it comes to detecting symptoms of sexually transmitted infections.
I write this aware that as a sexual health consultant, I am very comfortable and practised at taking a sexual history. I have the advantage of patients expecting these questions and understanding why they are being asked. As a dental practitioner, I can imagine bringing up the subject of sex could be quite alien and is not something most dental patients would not be expecting.
What happens therefore if a sexually transmitted infection (STI) is suspected from a sign or symptom in the oral cavity? How do you broach this?
I want to illustrate that you do not need to go into the nitty gritty of a sexual history, even if you suspect an STI. If your differential diagnosis includes an STI, the person should be referred for testing regardless of everything else. Do not make a judgement of their sexual risk by what they wear, their gender, sexual orientation, age, race or religion. If you start making judgements of STI risk you will undoubtedly be wrong.
Encourage testing
Another way to illustrate this is by giving a different example. A patient presents to their GP with rectal bleeding suggestive of bowel cancer. Knowing if that patient ate red meat or smoked would not change the management of this patient who needs referral for investigations. A referral that would hopefully rule this diagnosis out.
This would be exactly the same with a lesion which may be suggestive of syphilis or HIV. This, of course, may not be the cause. But a simple blood test is all it takes to get the answer. We encourage anyone who is sexually active to have full STI testing whatever their perceived risk factors.
A sexual history will never give a fully accurate assessment of risk because it does not take into account the partner, or partner’s, risk factors. The patient may, or may not, be aware of these. I have some patients who are living with HIV who have only ever had sex with one person. Conversely, I see other patients who have had sex with hundreds of people and have never had an STI.
Reassure your patients
Don’t let the concern over bringing up the subject of sex be the stumbling block for suggesting testing. I would explain it as simply as possible: you have noticed a purple pigmented lesion on the hard palate. As part of your differential diagnosis you consider that this could represent Kaposi’s sarcoma (a HIV indicator disease).
You may want to say something like: ‘I have noticed a lesion in your mouth which concerns me. I am not 100% sure what this represents but I would like to refer you to X (if this is necessary for a biopsy for example) and for HIV testing. I can refer you to our local sexual health services for a simple blood test’.
At this point the patient will react to your advice in their own unique way and you have to be prepared. Some may just accept it and ask very few questions. Some may feel insulted or judged at the suggestion of having and STI. Should this happen I would explain that their care is your upmost priority and gently explore their feelings.
Indicator diseases
You could explore if they have ever had HIV testing before. Ensure they are aware this is not a judgement of them and that you would refer any person with the same symptoms regardless of demographics, if necessary, referring to the British HIV Association (BHIVA) guidelines (see below).
I would also reassure that all sexually transmitted infections can be cured or managed, including HIV.
There is a list of indicator diseases in the BHIVA 2008 Guidelines which should prompt HIV testing, some relating to conditions which could be identified by a dental practitioner.
Examples include Kaposi’s sarcoma, oral hairy leucoplakia, oral candidiasis, lymphadenopathy of unknown cause, chronic parotitis, lymphoepithelial parotid cysts and mononucleosis-like syndrome seen in primary HIV infection.
Refer to https://www.bhiva.org/HIV-testing-guidelines for more information.
HIV is now a manageable condition but it has to be tested for and diagnosed for us to treat it. There are still approximately 7,000 people undiagnosed in the UK. This means there is continued potential for inadvertent onward transmission, morbidity and death.
Oral symptoms of STIs
If diagnosed early, treatment can be started and patients can expect a normal and healthy life. One of the most important campaigns of the last couple of years is the U=U message (Undetectable = Untransmittable). It illustrates that the overwhelming data that patients taking effective antiretroviral medication are no longer infectious to their sexual partners. This also means transmission to others can be prevented.
Syphilis is another condition which can cause local and systemic disease presenting with symptoms in the oral cavity. There has been a substantial increase in the number of infectious syphilis diagnoses made in England over the last decade, with new diagnoses of syphilis increasing rapidly from 2013 to 2018.
Statistics show that 75% syphilis diagnoses are made in gay, bisexual and other men who have sex with men (MSM). But there has also been an increase in the number of diagnoses among heterosexuals as well as in cases of congenital syphilis. As with all STIs, there is an undiagnosed reservoir so testing and treatment is key to preventing onward transmission.
Syphilis, gonorrhoea and chlamydia
Syphilis can be transmitted via oral, anal or vaginal sex and is divided into primary, secondary and tertiary stages. All stages can present with oral symptoms. The primary non-painless chancre can easily be overlooked as traumatic ulceration or go completely unnoticed as it is most often painless.
The secondary symptoms represent haematogenous spread of the bacteria. Symptoms can include mucous patches and maculopapular lesions, although nodular lesions may arise.
In the tertiary stage the oral complications centre around gumma formation, usually of the hard palate and tongue, although it can give rise to syphilitic leucoplakia. Neurological complications can give rise to both unilateral and bilateral trigeminal neuropathy and facial nerve palsy.
Should any suspicious lesions be noted during an examination, the same rules should apply. Refer for testing, with no judgement made about the person sitting in the chair.
Some sexually transmitted infections affect the oral cavity transmitted directly via oral sex. Gonorrhoea and chlamydia can infect the throat, however this is usually asymptomatic so unlikely to cause any signs of symptoms.
Human Papilloma Virus (HPV), transmitted in the same way, describes a family of viruses, some of which can lead to cancerous changes. https://www.throatcancerfoundation.org/hpv/ is a good source of information to direct patients to who want to know more.
Refer, refer, refer
As a dental practice it would be very helpful to know where your local sexual health services are located. A letter accompanying the patient is always very helpful because it can detail any specific concerns. If preferred, a patient can self refer.
During their clinic visit, we would enquire about their sexual orientation, sexual practices, number of partners etc. This is never something we would expect to have in a referral so please do not feel you have to ask.
Learning points:
- Anyone who is, or has been, sexually active is potentially at risk of an STI
- Presume the majority of the adult population has had sex so is therefore potentially at risk
- Signs and symptoms of STIs can present in the oral cavity
- If an STI is suspected, testing should be arranged without the need for a sexual history. It will not change your management.
Dr Naomi Sutton is a consultant physician and doctor on the Channel 4 show The Sex Clinic. She can be found on Twitter and Instagram @drnaomisutton.
