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The ethical dilemma of infectious disease disclosure for dentists – New Dentist Blog

In July 1990, five of Florida’s patients were exposed to HIV by a dentist.1It was not known if actual transmission occurred but this caused great concern within the dental community.2,3

Dr. Barrera

At the time, health care providers were to follow the CDC’s “Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients,” which recommended that providers with HIV or Hepatitis B must disclose their status to an expert review panel for consideration before the provider may continue to practice.4The CDC has since removed these guidelines. This is because the risk of HIV or HBV transmission from provider to patient during exposure-prone procedures is very low and noninvasive procedures are not as dangerous.5,6

Current CDC guidance doesn’t mention patient exposure by dental health care providers, as it is a nonissue.6However, there are many states that have their own standards and guidelines for dealing with this issue.

Texas Administrative Code Rule §108.25

Texas is one of several states that require HIV/HBV-positive healthcare providers to inform an expert panel about their status before they can treat patients. Texas is the only state that requires providers to notify patients individually.

The Texas Administrative Code Rule §108.25 states, “A dental health care worker who is infected with HIV or HBV and is HbeAg positive shall notify a prospective patient of the dental health care worker’s status and obtain the patient’s consent before the patient undergoes an exposure-prone procedure performed by the notifying dental health care worker.”7

Figure 1. Figure 1. Source: The Center for HIV Law and Policy. Guidelines for HIV-Positive Care Workers, The Center for HIV Law and Policy. Publited March 2008. Last updated June 2017. Melanie E. Patterson (RDH, BSDH) and Kimberlynn N. Patzold (RDH, BSDH) provided this information.

According to the Texas State Board of Dental Examiners, disciplinary actions for not disclosing infectious diseases to patients can range from a verbal reprimand up to license suspension.

We can safely say that this rule has become outdated and discriminatory. It could also have serious consequences for providers. Mandatory disclosure to patients can have serious repercussions on the dentist. This could include loss of practice and prejudice towards the provider as well as fewer career opportunities and educational opportunities.

How advances in antiviral drugs have impacted the management of infected health workers

HIV

One of the more recent classes of antiretroviral medications (integrase-strand transfer inhibitor agents), has been a huge step forward in managing the disease. These drugs are ideal for initial therapy, as they are highly effective in suppressing virological activity and can be tolerated well. Viral suppression may reduce HIV viral load enough to make it inaccessible in the bloodstream. This can prevent HIV from being transmitted to other people.8

Truvada, a Pre-exposure Prophylaxis (PrEP), was approved by FDA in 2012. It is for HIV-negative people who are at high risk of developing HIV. There are currently two approved oral medications, and one injectable treatment that can be used as PrEP.8

With the progress that has been made towards HIV treatment & prevention, it is safe to say that the Texas Administrative Code Rule §108.25 is antiquated and does nothing to further patient safety or public health.

Hepatitis B

Hepatitis B vaccine provides outstanding protection that can last for as long as 30 years. This was the first step to reducing the HBV-infected health care workers, and thus reducing the risk of transmission to patients.9This further supports the argument that the Texas Rule, which is outdated and ineffective due to the low risk of Hepatitis-B transmission, is unnecessary.

Looking ahead

One could argue that Texas’s rule is obsolete and discriminatory if we examine the entire situation. It is also inconsistent that dentists must disclose personal health information because HIV/HBV is more prevalent than other infectious diseases. When the virus was SARS-CoV-2, the Texas State Board of Dental Examiners didn’t take the same position.

According to the Texas Dental Association’s, dentists and other team members must notify patients if they test positive for COVID-19. However, the dental team may also be required to protect the team member’s confidentiality under applicable privacy laws.10These laws would not apply if the dentist is positive for HIV/HBV. This is especially true when HIV/HBV transmission is less likely in a dental setting. This is evidence that the Texas Administrative Code Rule §108.25 is discriminatory and should be abolished.

My hope is that we use the updated research to abolish rules like the outdated Texas Administrative Code Rule §108.25 so that all health care providers and students have an equal opportunity to treat patients without fear of prejudice or discrimination.

Dr. Alex Barrera works as a general dentist at Legacy Community Health, Houston, Texas. He graduated from the University of Texas School of Dentistry at Houston in 2017. He is also a member of several organizations, including the American Dental Association and Hispanic Dental Association. He is currently the chair of Hispanic Dental Association’s New Dentist Committee and a member of the ADA Council on Advocacy for Access and Prevention. Dr. Barrera serves as the president of Houston Equality Dental Network. This allows him to advocate for LGBTQ+ dentistry. Dr. Barrera is a yoga teacher certified in mindfulness and meditation. He uses these techniques to better treat dental phobias. He enjoys reading, cooking, and traveling in his spare time.

 

References:

  1. “Guidelines for HIV-Positive Health Care Workers, the Center for HIV Law & Policy (2008).” Guidelines for HIV-Positive Health Care Workers, The Center for HIV Law & Policy (2008) | The Center for HIV Law and Policy, 1 Mar. 1970, https://www.hivlawandpolicy.org/resources/guidelines-hiv-positive-health-care-workers-center-hiv-law-policy-2008.
  2. Brown, David. “The 1990 Florida Dental Investigation: Theory and Fact.” Annals of Internal Medicine, vol. 124, no. 2, 1996, p. 255., https://doi.org/10.7326/0003-4819-124-2-199601150-00010. Retrieved 16 April. 2022.
  3. Jaffe, Harold. “Lack of HIV Transmission in the Practice of a Dentist with AIDS.” Annals of Internal Medicine, vol. 121, no. 11, 1994, p. 855., https://doi.org/10.7326/0003-4819-121-11-199412010-00005. Retrieved 18 April. 2022.
  4. “Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients during Exposure-Prone Invasive Procedures.” MMWR. Recommendations & Reports – Morbidity & Mortality Weekly Report. Recommendations and Reports, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/1648165/.
  5. United States Centers for Disease Control and Prevention. Recommendations for the prevention of transmission of the human immunodeficiency and hepatitis B to patients during exposure-prone procedures. MMWR Recomm Rep. 1991;40(RR08):1–9.
  6. “Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 10 Sept. 2021, https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/index.html.
  7. Texas Administrative Code, 22 Tex. Admin. Code § 110.11, 2010, https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=5&ch=108&rl=25. Accessed 18 April. 2022.
  8. “About PrEp.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Apr. 2022, https://www.cdc.gov/hiv/basics/prep/about-prep.html.
  9. Barrigar, Diana L, et al. “Hepatitis B Virus Infected Physicians and Disclosure of Transmission Risks to Patients: A Critical Analysis.” BMC Medical Ethics, vol. 2, no. 1, 2001, https://doi.org/10.1186/1472-6939-2-4.
  10. Tsbde Covid-19 Emergency Rule, https://www.tda.org/covid-19/tsbde-covid-19-emergency-rule.

 


The ethical dilemma of infectious disease disclosure for dentists – New Dentist Blog

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