Germ Warfare

There has been a great deal of concern in the last few years about the possibilities of cross contamination and of infectious diseases that might be transmitted to patients in dental offices as well as other health care settings. The case of Dr. Acer, a Florida dentist who allegedly transmitted the AIDS virus to five of his patients several years ago, as well as a recent study, heavily reported in the media, indicating that the AIDS virus could conceivably be transmitted through dental handpieces (the high speed drills) and prophy angles (the device used to polish teeth at cleanings), have caused a great deal of legitimate concern and anxiety.

While the more frightening and sensational aspects of these issues get a big splash in the media when they occur, the follow up studies often do not. For instance, last spring the CDC issued a report that followed nearly 16,000 patients of 32 dentists and physicians infected with the AIDS virus and have found no patients (other than the five cases linked to Dr. Acer) infected during treatment. They go on to conclude that the risk for HIV transmission from an infected health-care worker to a patient is very low. Also CDC researchers and Florida health officials both reported that after two years of intensive investigation of the Dr. Acer case (the sole case of this type since the beginning of the epidemic) they still do not know how the disease was transmitted to his patients and are closing the case. They reported that they can only conclude that Dr. Acer directly infected his patients, rather than somehow passing the virus from another infected patient. There has even been speculation, corroborated by a close friend of Dr. Acer, that he may have infected those patients deliberately.

 

I've been asked, why treat HIV positive patients? First there is an ethical obligation to treat, second we're not always aware of someone's status (in spite of consistent updating of each patient's medical histories, sometimes patients don't know their status or won't admit it), and third the Federal government has ruled the disease is a handicap, and as such to refuse to treat someone because of their HIV status is illegal discrimination against the handicapped and can result in license loss and/or fines up to $10,000.

 

Modern dentistry has always been concerned with infection control. Frankly the main focus of infection control in health-care settings has always been Hepatitis B, a virus that is stronger, more common, and more difficult to kill than HIV. It is also highly virulent--a person is about 1000 times more likely to become Hepatitis B positive than HIV positive if their blood was exposed to both. Fortunately, due to the precautions taken in disinfection and sterilization, the spread of Hepatitis B in dental offices has been minuscule. The last case of Hepatitis B spread from dentist to patient was in 1985, and there has never been any spread by a dentist wearing gloves. The CDC has no cases of Hepatitis B spread from patient to patient at a dental office.
 

Does all this mean, however, that we can be complacent? Quite the contrary in recent years dentists have stepped up their infection control measures dramatically. We are constantly improving our abilities to achieve higher and higher levels of protection. Technology now exists, for example, for us to have handpieces that can be sterilized in an autoclave (an autoclave works by injecting superheated, pressurized steam into a chamber where the instruments to be sterilized are placed--no virus, bacteria or spore can live through this).

 

The good news is that contracting a disease in a dental office is highly unlikely. Additional good news is that by following what is called "universal precautions" (that means treating every patient and health-care worker as a potential source of infection) and following the recommendations, regulations and guidelines of the CDC, American Dental Association, OSHA, and the EPA, dental treatment can be made extraordinarily safe. The bad news may be that the cost of health-care is going up because of the additional measures being taken (it is estimated, that these additional costs are between $8-$14 per dental patient visit. At least a $4 billion yearly increase in dental health-care costs alone).

 

I'd like to list some of the types of sterilization and infection control procedures that should be used in dental offices (these are designed to protect the safety of patients and staff). The heart of any infection control program must be a high quality autoclave (ours, for instance, is computerized to self diagnose and alert us of any problem), the autoclave should be monitored routinely, for proper function either by the dental office or, preferably, by an independent lab. After each use all dental instruments, handpieces, prophy angles, etc. Should be cleaned manually or preferably in an ultrasonic cleaning machine (recently in our office we've been using an enzyme treatment, that has become available for use in the ultrasonic machine, which dissolves organic matter) and then autoclaved in a sealed pouch.

 

We use as many items as possible that can be disposed of after a single use, for instance needles, scalpels, gauze, suction tips, cotton products, etc. (In our office we even use single use disposable trays to place our instruments on) these need to be handled and disposed of in compliance with EPA, OSHA and local regulations to prevent accidental cuts or contamination. One of the most important, yet rarely mentioned, procedures is hand washing before every patient contact with an anti-microbial soap. A new pair of gloves must be used for every patient. Face protection must be worn when there is any aerosol created. All personnel should be vaccinated against Hepatitis B. Any surface likely to be touched, such as X-ray and chair switches, counter tops, X-ray machines, light handles, faucet handles, hoses, soap dispensers, etc. should have a disposable cover or be treated with two applications of a hospital-grade, tuberculocidal, EPA approved, surface disinfectant following stringent CDC guidelines, or modified to be non-hand operated.

 

Recently, there have been concerns about the water, that is emitted from dental apparatus waterlines. This potential problem area continues to be researched, and waterline safety technologies, continue to evolve. To deal with this issue, we have installed water delivery systems which supply water independent of, and unattached to the municipal water system.  The water supplied through this system is treated with anti-microbials.  Also the system is routinely treated and then flushed with anti-microbials--a regimen proven effective in research published in the Journal of the American Dental Association. 

 

You should feel comfortable to ask your dentist about his or her infection control measures. I think you will find that a great deal is being done for your protection.

-Richard B. Shapiro, D.D.S. (404)523-2514
Reprinted from The Bond Community