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What every dental professional needs to know about contracting STDs in the dental practice.
Many dental professionals think that if they refrain from unprotected sex with an infected person at the dental office, they are safe from contracting a sexually transmitted disease (STD) there. But they are wrong.
The fact is you could contract a number of STDs at your office without engaging in sexual contact, including:
· Hepatitis B (HBV)
· Hepatitis C (HCV)
· Herpes Simplex 2 (HSV2)
· Human Immunodeficiency virus (HIV)
· Human Papilloma Virus (HPV)
Infections can occur through exposure to an infected person’s blood, which can occur through splashes to unprotected eyes, nose or mouth, as well as percutaneous injuries. In the case of HSV2 and HPV, infections can occur through exposure to an infected person’s saliva. In addition, you could sustain exposure to many viruses including the other human herpes viruses (there are eight in all), influenza and Epstein-Barr. You could even end up exposed to diseases like measles, mumps, rubella and polio-and this list is far from comprehensive.
The fact is you could be exposed to all kinds of bacterium, viruses and other microorganisms that cause disease in the dental office.
Or you could be exposed if you don’t take the universal precautions as specified by the Occupational Safety and Health Administration (OSHA) or the standard precautions by the Centers for Disease Control (CDC).
Dr. David Reznik, DDS, is the founder and President of HIVdent, a nonprofit organization assuring that people living with HIV disease have access to quality dental care. Per Dr. Reznik, OSHA’s universal precautions (or standard precautions per the CDC) provide all the protection you need from these dangerous and contagious diseases people bring into the operatory.
“Unless you sleep with the patient without any protection, you're not going to get syphilis or gonorrhea or HIV or any of those diseases that can be sexually transmitted. So, it's a matter of following the safest dental visit practices,” Dr. Reznik says.
However, the concerns for exposure to these conditions doesn’t stop in the operatory. Dental laboratories should also employ OSHA’s universal precautions to protect themselves from contracting STDs in the lab.
“The dental laboratory owner must protect his workers by using universal precautions. The same processes and equipment would be used in the manufacture of the dental device regardless of the patient’s medical condition,” explains Mary Borg-Bartlett, President of SafeLink Consulting Inc., a regulatory compliance consulting firm that helps clients meet safety requirements set forth by OSHA.
Next: Why you should practice as if all patients are infectious...
Dr. Reznik said most medical history forms patients fill out include questions about sexually transmitted diseases they might have. Upon seeing that a patient has a sexually transmitted disease, some dental professionals might think they need to take additional precautions. However, in the case of patients with HIV, which is a protected disability, taking extra precautions can be a violation of the Americans with Disabilities Act. “You have to do what you do for everybody else. So, your standards, which are easily found on OSAP, are what you need to follow and make sure you're following the checklist,” he says.
“There should not be a difference in how one patient is treated over another. You have to presume they are all infectious,” Borg-Bartlett says.
Universal precautions protect dental professionals and employees from exposure to diseases patients might not know they have, Borg-Bartlett explained. Some infections like the hepatitis and HIV can be asymptomatic in some patients. Unless they have had a blood test informing them otherwise, patients won’t disclose that information because they don’t know themselves. “You could live a lifetime and not ever know. So, that's why universal precautions and standard precautions must be practiced presuming every patient has a disease,” she explains.
In the cases where the patient might not yet know they have contracted an STD, Dr. Reznik feels that dentists should be able to recognize how some of these diseases present orally and refer them to the appropriate medical personnel. Also, dentists should screen for certain conditions and refer the patient as necessary. “We're healthcare professionals, and people are going to come in with a variety of illnesses. It could be diabetes that's uncontrolled. Or it could be so many different things. I feel very strongly that since oral health is a component of primary care that it's our job to identify these and refer as necessary,” he says.
In some cases, Borg-Bartlett said patients might not disclose their condition for fear of not being treated. Dr. Reznik agrees, remembering his private practice days in the 80s when the dental profession was scared. When no one in Atlanta would treat patients with an HIV diagnosis, Dr. Reznik would and did, usually for free.
“My mom was a Holocaust survivor. I'm Jewish and have multicultural influences in my life. Ever since I was a small child, I've felt discrimination in any form is wrong in my mind,” Dr. Reznik says. “And so I couldn't see turning away people based on a medical disease. So that's why I was getting all the patients. The patients felt comfortable, and I wasn't worried about catching the disease because I didn't plan on having relations in the dental chair.”
After five years of advocating for and treating these patients for free, Dr. Reznik joined Grady Health System, the fifth largest public health system in the U.S. Dr. Reznik is now the Chief of the Dental Service for the Grady Health System. Since then, he feels that dental professionals have done an excellent job of communicating appropriate information regarding transmission of HIV and other STDs in the dental setting.
Next: Why practices AND labs must both be vigilant...
In the dental lab, the risk for exposure continues, particularly in those diseases that can live outside the body, such as HBV and HCV. Impressions and implant components could have saliva and blood present. If the lab worker isn’t in compliance with the universal precautions, it can lead to an infection. Borg-Bartlett cites the universal precautions as the best defense against these types of exposures, starting at the dental practice. “Prior to packaging items that have saliva and blood on them, the dental staff should remove the blood and disinfect the items,” she says, then explains that the lab should also rinse and disinfect the items before proceeding with any manufacturing, per OSHA’s requirements in the Bloodborne Pathogen Standard and the recommendations by the CDC.
In states where dental technicians can perform chairside services in the operatory, the technicians should also use personal protective equipment (PPE). PPE includes gloves, mask, safety eyewear or face shield, and gown. If the PPE isn’t provided by the lab, then the practice must provide them. “Dental technicians must abide by all state and federal regulations regarding participation in procedures such as All-on-4’s,” Borg-Bartlett says. The State Dental Board for each state will have guidelines on the legality of these types of relationships in the dental operatory.
One additional consideration pertaining to HIV exposure Dr. Reznik would add is for dental professionals to be aware of post-exposure prophylaxis, a short-term antiretroviral treatment to reduce the likelihood of HIV infection, and know how to get the treatment within two hours of the potential exposure. “You want to get that as soon as possible, preferably within two hours. We have no data for effectiveness after that, but the sooner, the better,” Dr. Reznik says. “They should have protocols in place. Whether it's corporate offices or private offices, you should have a protocol if there is a needle stick.”
In 2016, the CDC released a summary that reviewed the practices in place and made recommendations to improve infection control practices. Borg-Bartlett explains that one of the new recommendations pertained to safety when administering anesthesia through a needle. The CDC recommended reducing the risk of a needle stick by looking for safer devices.
The CDC also recommended that each facility, dental practice or dental laboratory, needs to appoint an Infection Prevention Coordinator. “The CDC gives a good checklist in that summary. So appoint someone who is responsible for infection prevention,” Borg-Bartlett says.
Both experts contend that when the dental practice or the lab follows the universal or standard precautions, there is no risk of contracting STDs and other serious diseases in the dental practice-at least not from dental work.
“Both dental practices and dental laboratories must practice universal precautions as required by OSHA. This is for the protection of the employees in those organizations. To the best of my knowledge using universal precautions will protect these employees from STDs,” Borg-Bartlett says.
“Be familiar with the CDC recommendations for standard precautions, truly be familiar with the OSAP's CDC checklist on how to follow them and what steps should be taken,” Dr. Reznik says. “And then there's nothing to worry about.”