Oral candidiasis and AIDS

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J A D A devotes th is section to co m m en t by readers o n topics of c u rre n t interest to dentistry. T h e e ditor reserves th e rig h t to e d it a ll c o m m u n ic atio n s to fit a vailable space a n d req u ires th a t all letters be typed, d ouble-spaced, a n d signed. N o m ore th a n ten references sh o u ld be given w ith each letter. P rin ted c o m m u ­ n icatio n s do n o t necessarily reflect the o p in io n o r official policy o f the A ssociation. Y our p a rtic ip a tio n in th is section is invited.

P a y m en t for care □ In regard to the article by Drs. T ryfon B eazoglou, A lbert G uay , a n d D ennis Heffley (April), it should be pointed out that there is an o th er model of the fee-forservice system still used by m any of us today:

It is still ju st as acceptable to expect patients to pay for their dental care directly to the treating dentist as it is for grocers to expect direct paym ent at the end of our weekly sh o p p in g trips. T h e relatio n sh ip o u r patients have w ith their em ployers and any of n u m e ro u s th ird -p a rty insurers sh o u ld have n o th in g to do w ith the relatio n sh ip they have w ith their freely chosen dentist. T h ere are a nu m b er of p u re direct reim bursem ent plans aro u n d the country th at co n tinue to recognize the distinction between the doctor-patient relatio n sh ip an d the p a tie n t-th ird - p a r ty - e m p lo y e r relationship. C H A R L E S G . LEW IS. DDS M ULESHOE. TX

In su ran ce c o m p a n y p o lic ie s □ I w rite to you as a p h y s ic ia n , as a p atien t w ith his share of dental problem s, and as a p articip a n t in the dental plan of . . . insurance com pany to solicit your 818 ■ JADA, Vol. 116, June 1988

h e lp an d advice re g a rd in g a m a tte r of concern. I refer to a com p an y ’s req u ire­ m ent that all claim s for paym ent of dental expenses be accom panied by radiologic evidence that the w ork has indeed been com pleted. T h is req u irem en t forces the dentist to take costly, unnecessary, an d potentially hazardous radiographs. I su b m it th a t a lth o u g h the risk may be m in im a l even if c u m u la tiv e , th e ‘'m ax im u m safe dose” of ionizing ra d i­ ation is a statistical and n ot an absolute concept and th at, therefore, there is no excuse for ex p o su res o th e r th a n th o se dictated by professional judgm ent. T h u s, th e o n ly m o tiv a tio n s a p p e a r to be a s h o r tc u t to p a p e rw o rk a n d a d is tru s t of th e d e n tis t, th e p a tie n t, a n d th e ir records and statements. W hat is the p osition of the Am erican D ental A ssociation on the use an d abuse of ra d io g ra p h s ? W h a t ca n we d o to convince the insurance com pany to stop this practice? P IE R O P. FOA, MD. ScD W AYNE S T A T E U N IV ER SITY

□ C om m ent. T h e A m erican D ental Asso­ ciatio n ’s policy on the use of radiographs c o n ta in s 16 g u id e lin e s for th ird -p a rty payers and dentists. T h e p ertin en t g u id e­ lines include: 2. T h e use of rad io g rap h s sh o u ld be only for d eterm in in g the extent of lia b ility of th e p ro g ra m s a n d in n o case s h o u ld in f r in g e o n th e professional ju d g m en t of the dentist o r o n th e d e n tis t- p a tie n t r e la ­ tionship. 12. P a tie n ts s h o u ld be e x p o se d to radiation only w hen such exposure is clinically necessary as determ ined by th e a t te n d in g d e n tis t. R a d io ­ g r a p h s s h o u ld n ev er be ta k e n to satisfy the a d m in istra tiv e re q u ire ­ m ent of a third party. F or ex ten siv e d e n ta l tre a tm e n t, an d w hen in su ran ce co m p an ies an d service

co rp o ratio n s have q u alified dentists on sta ff, p r e tr e a tm e n t r a d io g r a p h s are regarded as a second o p in io n —a practice used frequently in m edicine. However, p o sttreatm en t rad io g rap h s co n stitu te a “ g u ilty u n til proved in n o c e n t” sta te­ m e n t o n th e p a r t of th e in s u r a n c e com pany. Fortunately, n ot all insurance c o m p a n ie s a re as lazy. It is o b v io u sly easier for the insurance com pany to treat all providers w ith suspicion th an to roll u p its sleeves a n d id e n tify th e few p ro v id e rs w h e re s u s p ic io n m ig h t be justified. T h is ca llo u s d isreg ard for the safety a n d w e lfa re o f p a tie n ts m ay w a r ra n t le g is la tiv e rem e d y , a n d th is ca n be explored by the ap p ro p riate agencies. M ARYE FELD M AN SECR ETA R Y C O U N C IL O N D E N T A L CA RE PR O G R A M S

O ral ca n d id ia sis and A ID S □ O ra l c a n d id ia s is (th ru s h ) is o n e of th e m o st c o m m o n m a n if e s ta tio n s of ac q u ired im m u n e deficiency syndrom e (AIDS) an d AIDS-associated co n d itio n s.1'2 It m ay be th e i n it ia l s y m p to m in an o th e rw is e h e a lth y in d iv id u a l w h o is s e ro p o s itiv e fo r h u m a n im m u n o d e f i­ ciency virus (HIV ) or may ap p e ar su b ­ sequently at different stages in patients w ith p e rsis te n t g en eralized ly m p h ad en o p ath y , A ID S-related com plex (ARC), an d full-blow n AIDS.3 T h is p ro s p e c tiv e stu d y in c lu d e d 89 h o m o - a n d b ise x u a l a d u lt m ales w h o are rec eiv in g a d o u b le -b lin d , placeboco n tro lled az id o th y m id in e p ro to co l for A ID S -associated K a p o si’s sarcom a. An o ra l e x a m in a tio n w as d o n e a t 4-w eek in te rv a ls by an o ra l p a th o lo g ist. O ral th ru sh was classified in to different types a c c o rd in g to its c lin ic a l a p p e a r a n c e .4 S m ears w ere ta k e n a n d s ta in e d w ith periodic acid-Schiff (PAS) technique and e x a m in e d m ic ro sc o p ic a lly to c o n firm th e c lin ic a l d ia g n o sis by th e presen ce

L e tte r s to E d it o r

NEW YORK U N IV ER SITY D E N T A L A N D M ED IC A L C E N T E R S NEW YO RK

the

of Candida albicans. In th is series, sm ears w ere taken of 79 patien ts an d were found positive for p s e u d o h y p h a e /s p o r e s in 43 p a tie n ts (59%). In 32 o f th e 43 p a tie n ts (74%), th ru s h a p p e a re d as a heav ily to m o d ­ erately co a te d to n g u e . A p se u d o m e m ­ b ran o u s type of th ru sh was noted in five p a tie n ts (9%). It w as c h a ra c te riz e d by a loose, n o n a d h e re n t, w h ite cheeselike m aterial freely flo atin g in the saliva and often deposited on different parts of the oral mucosa. In two patients (4%), thrush was of an ery th em ato u s/atro p h ic variety. T h e oral m ucosa was dry, red, an d shiny. T h e tongue show ed fissuring an d depap illa tio n and was often associated w ith u n ila te ra l o r b ilateral an g u la r cheilitis. T w o p a tie n ts (4%) h a d h y p e r tr o p h ic candidiasis, w hich appeared as adherent, le u k o p la k ia - lik e p la q u e o n th e o ra l m u c o sa o r to n g u e . In b o th cases, the lesion involved a large p art of the dorsum of the ton g ue an d extended over the lateral borders of the tongue on to the sublingual m u co sa. In o n e p a tie n t (2%), the o ral candidiasis sim ulated geographic tongue, a n d in a n o th e r , m e d ia n - r h o m b o id glossitis. In this study, the incidence of thrush was 59% in p a tie n ts w ith A ID S-related K aposi’s sarcom a as com pared w ith 90% in intravenous d ru g users a n d /o r h om o­ sex u al p a tie n ts w ith A ID S .1,5 F u rth e r­ m ore, th ru sh appeared m ore frequently in the form of a coated tongue am ong p a tie n ts w ith A ID S-associated K aposi’s sa rc o m a th a n th e p se u d o m e m b ra n o u s type of oral candidiasis, the latter being m ore com m only observed in acutely ill an d severely debilitated hospitalized AIDS p a tie n ts w h o w ere in tr a v e n o u s d ru g a b u s e rs a n d / o r h o m o se x u a ls an d h a d p re v io u s ly h a d re p e a te d e p iso d e s of o p p o rtu n istic infections, in particular, P neum ocystis carinii pneu m o n ia, often w ith o u t K a p o s i’s sa rc o m a ( a u th o r s ’ u n p u b lish ed data). T h ru s h m ay m asquerade in different clinical forms in AIDS-related conditions. A N A N D P. C H A U D H R Y . PhD ABRAHAM C H A C H O U A . MD BRIA N R. SALTZM A N , MD A LV IN FR IED M A N -K IEN , MD

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1. S ilv e rm a n , S., a n d o th e rs . O ra l fin d in g s in p e o p le w ith o r a t h ig h risk for AIDS: a study of 375 h o m osexual males. JADA 112(2): 187-192, 1986. 2. P h e la n , J .A ., a n d o th e rs . O ra l f in d in g s in p atien ts w ith acq u ired im m unodeficiency syndrom e. O ral S u rg O ral Med O ral P ath o l 64(l):50-56, 1987. 3. K le in , R .S ., a n d o th e rs. O ra l c a n d id ia s is in h ig h -risk p a tie n ts as the in itia l m a n ife statio n s of the acquired im m unodeficiency syndrom e. N E ngl J M ed 311:354-358, 1984. 4. L ah n er, T . C lassification and clin ico p ath o lo g ic features o f C an d ida infections in the m o u th . In W inner, J.J., a n d H urley, R., eds. Sym posium of C an d id a Infections, 1966, p p 119-137. 5. L ozada-N ur, F., and others. O ral m anifestations of tu m o r an d o p p o rtu n istic infections in the acquired im m u n o d e fic ie n c y sy n d ro m e (A ID S): fin d in g s in 53 h o m o sex u a l m en w ith K a p o si’s sarcom a. O ra l S urg O ral Med O ral P ath o l 56(4):491-494, 1983.

B o u n c in g m o n ey orders

rem oval of the old denture, w hich burned o u t the bearing of two handpieces. T h e technician came in on Saturday as a favor to m e to tediously fabricate the esthetic te m p o r a r y d e n tu re w h ile th e p a t ie n t reco v ered from a n e sth e sia . S a tu r d a y ’s treatm ent lasted nearly 4 hours. T h e p a tie n t k ep t h er a p p o in tm e n t T h u rs d a y , a n d m ade a n o th e r fo r S a t­ urday. W hen she did n ot keep Saturday’s ap p o in tm e n t, we attem pted to reach her by telep h o n e b u t could not. L ater that m o rn in g , a letter arrived from the bank w ith a stop paym ent on her m oney order. We re a c h e d h e r a t w o rk M o n d a y m o r n in g . U n a sh a m e d ly a n d a n n o y e d th at we called her at work, she inform ed my secretary th a t she h ad indeed been to th e d e n tis t on S a tu r d a y —a n o th e r dentist! “ S he c a n ’t s to p a m o n ey o r d e r ! ” I d e fia n tly assu red my secretary, “ w e’ll co n tac t the b a n k .” W ell, you can, and she did. We fo u n d o u t th a t it is easier to sto p a m oney order th an a certified check. I was angry; I felt like a virtuous w om an w ho was violated. Not only was my ex p ertise an d labor u su rp ed , b u t I h a d a h u g e la b o rato ry b ill for th e 12u n it bridge. I w anted to sue b u t my lawyer in fo rm ed me th at he w anted an in itia l reta in er or, “better yet, forget it—w rite it off as a business expense.” I decided n o t to forget it and pursued th is m a tte r th r o u g h th e sm a ll c laim s c o u rt. A b o u t 6 m o n th s la te r, I h a d a ju d g m en t, still uncollected, for $750. M oral: Sometimes su in g is for the birds. An ounce of prevention is w orth weeks in court. T re a t money orders as you treat personal checks.

□ F orty years ag o I b o u g h t a g en e ral p r a c tic e fro m a s u p e rb d e n tis t w h o b ec am e fa ta lly ill a m o n th a fte r o u r association. O n his final day, w ith his last breath, he w hispered: “ H arold, you m ust prom ise me two things . . . do the best dentistry that can be done, an d never accep t checks from new p a tie n ts. T h e dentistry you owe the patients; the bad checks w ill eat you u p alive.” I p ro m ise d , a n d I h o p e th a t I have lived u p to the good dentistry. I learned the second lesson w hen one day, a certain Ms. A w as referred to me. (T h is story is tru e ; o n ly th e n a m e is c h a n g e d to protect the guilty.) First came the clues th a t led me to suspect this patient: the referrin g d en tal g ro u p refused to send radiographs as they were never paid for; the p a tie n t stated she d id n ’t care w hat DR. H A R O L D H A M B U R G PA LM BEACH G A R D E N S, FL it cost to replace a 12-unit anterior fixed bridge; she in sisted trea tm e n t be co m ­ T h a n k s— for the o rth o d o n tics pleted in 2 weeks, and said she left her checkbook at hom e w hen we asked for □ T h a n k you for in c lu d in g the article o u r m o d e st e x a m in a tio n fee. A t th a t o n o r th o d o n tic s in th e A p ril issu e of p o in t, I realized I w asn’t ab o u t to accept T h e Jo urnal, “ Vertical ex tru sio n u sin g her check. H a s tily , I c a n c e lle d a ll S a tu rd a y a re m o v a b le o r th o d o n tic a p p l ia n c e ,” by Drs. Barbara Ries, G eorgia Jo h n so n , a p p o in tm e n ts to fit h er in for all-d ay resto ra tio n of several tw o-surfaced cav­ an d Lew is Nieberg. L et’s see more. JIM B O W LES, DDS ities, electrocautery gingivectom ies, an d JA C K SO N , WY the placem ent of the fixed denture. Ms. A was inform ed that half of the paym ent w ould be due before the treatm ent was A p p ly th e rubber dam perform ed in a certified check or money □ I have an an sw er for th e a u th o r of order. She did n ot object. Saturday arrived, an d so d id the patien t “ W h a t do I do n o w ?” (L e tte rs to th e w ith a m oney order b u t in an am o u n t E d ito r , A p ril). F irs t, he w as a “ w e t­ less th an we asked for, b u t en o u g h for fingered” dentist for 28 years, an d then us to a c c e p t h er. E v e ry th in g w e n t as he c a n ’t buy gloves for 11 m onths. Now p la n n e d ; th e o n ly d iffic u lty w as th e he is w o rrie d a b o u t “ le sio n s u n d e r