May 1, 2001
by R.A.Clappison, DDS, FRCD(C), FACD
This Viewpoint was scheduled to be authored for the February 2001 issue of Oral Health, when Dr. Neiburger’s, article would have been fresh in readers’ minds. Due to a formidable personal matter it was not possible until this issue, therefore I have taken the liberty to put in italics some of the statements made by Dr. Neiburger in the article.RAC
In the reprinted article “Quantifiable Risk in Dentistry — A Letter to the Profession,” published in the January 2001 issue of Oral Health, Dr. E. J. Neiburger takes imprecise aim at “questionable and ineffective infection control measures”.
The author takes aim at issues, organizations or persons with which he disagrees and attempts to denigrate them; the “aggressive” Centers for Disease Control and Prevention (CDC); “the clinician making money on the lecture circuit”; ” the researcher in need of another grant”; the AIDS disease as “29 separate, immuno-suppression diseases classified and redefined (three times) as AIDS”, a pseudo-scientific opinion that has the author at odds with most of the rest of the world.
South African Prime Minister Thabo Mbeki drew worldwide criticism for the same opinion on the cause of AIDS in spite of the fact that South Africa has one of the fastest increases in the AIDS rate in the world. Dr. Neiburger bemires the infection control waters with this thesis. The “redefinition” of AIDS by the CDC and the “use of ineffective barriers” (UP’s – Universal Precautions), “expensive, dangerous, and ineffective government-mandated infection control rituals,” or “cooking handpieces” display his mind set.
According to a Health Canada study new infections of AIDS increased 91 percent between 1996 and 1999 in Canadian aboriginal people and 50,000 Canadians are HIV positive or have AIDS in 1999 and that is due to “29 separate immuno-suppression diseases”?
The author uses data from the berated Centers for Disease Control and Prevention (the CDC) that states that “there are no documented cases of occupational HIV/AIDS transmission in Dentistry”. That’s notable but how do you isolate dentistry from the rest of the healthcare system?
There were 319 reports of occupationally-acquired HIV among healthcare workers worldwide as of June 1999. Nurses, clinical laboratory workers, and doctor/medical students account for the major number of possible or confirmed cases of occupational transmission of HIV (119, 39, 37, cases respectively). 102 cases of these were confirmed. Nine of the 217 possible or probable cases were dental workers. However, I agree with Neiburger that there have been no confirmed reports of occupational transmission of HIV to any dental workers.1 Are they just plain lucky or do they practice Universal Precautions? Variation in viral load can be one factor and the smaller bore of dental needles another.
Critics of Standard Precautions (formerly UP) often quote the above fact that there have no confirmed reports of occupational transmission of HIV to any dental workers. However we are part of the healthcare profession. It is lamentable to note that 8.2% of nurses reported occupational exposures to HIV.2 All the more distressing is that 20 nurses in Ontario receive compensation from the Worker’s Compensation Board for occupationally acquired HIV (1999). The difference in the numbers being because persons are often reticent to report exposure to HIV and the dubiety of the serostatus of the source.
The denigrated CDC also advises to AVOID CONTACT WITH BLOOD AND SALIVA.3 It is rather difficult to do so without gloves. Blood borne exposure routes are either percutaneous (sharps cut or needle stick) or mucocutaneous (splash or splatter to eyes or mucous membranes). Gloves can’t stop you from a sharps or needle stick accidents but masks and glasses can reduce mucocutaneous ones. Here, you just need a little common sense and you don’t need to be an infection control expert.
The “cause celebre” of the “group” is Universal Precautions and according to Neiburger “UPs have their place, but they should not be mandated for every patient contact. Instead they should be used on a case-by-case basis as determined by the practitioner – not by a government bureaucrat or self anointed lecture circuit ‘expert’.” Also, FRAIDS was partially to blame for dentists being “required to wear gloves, masks and eyeglasses while practicing on patients.” Molinari in the JADC, Sept. 1999 disagrees, for he states that historical advances in microbiology and hospital asepsis provided the progress in dental preventive practice.
Neiburger hopes that most patients are healthy and not immune compromised. This is an assumption unless a thorough medical examination is performed, which is not within the prerogative of dentistry, so how does the dental practitioner know the status of the patient? The patient often does not know their own status or can be unwilling to impart the information for fear of information insecurity. The result is that you are ignorant of the infection status of the patient in your chair — so you do need Standard Precautions. Universal Precautions was updated by the CDC in 1996 to include not only blood-borne pathogens and/or blood contaminated saliva but to include body substance isolation precautions (all body fluids) and is known as Standard Precautions.
Just in case you need reinforcement of your desire not to abandon Standard Precautions, Dr. Neil Heywood, Director of Immigration and Health policy at the selection branch of Immigration Canada states that 53 percent of Canada’s 250,000 yearly immigrants head to Toronto. Stationed all over the world, Medical Officers of Health Immigration Canada often note an infection in an immigrant. The noted infection is encoded on the landing card alerting the officials in Canada that the person is to receive medical surveillance. In a case of Tuberculosis, the person agrees to have a chest X-ray within 30 days of arrival and the provincial and municipal authorities are notified. Toronto receives 3,000 to 4,000 surveillance notifications. With only 52 staff and $3.2 million from the province and the city, Toronto’s TB program has difficulty monitoring the 400 people in the city with ACTIVE TB according to Manager Sharon Police.4 If infected newcomers are not treated within five years, 10% of them can develop active TB due to depressed immune systems associated with immigration and refugee problems.
In one year, Toronto loses contact with about one-third of the immigrants on the notified list. If the cases go active, think of the explosion of the number of cases! To be controlled, the TB patients need DOT — Direct Observed Therapy, and only 25-30% are getting it. This means that they are observed each time they take their medication in order to prove complicity.
The objective of the government is not to keep people out of Canada, but if they test positive they are to be followed up and treated. “Dentists in normal practice should consider the risk insignificant” according to Neiburger. His MMWR reference to “targeted precautions” is slightly off the point. Patch testing proves or disproves the presence of contact with the disease but Standard Precautions are still required. In this situation, would not common sense tell you that the routine wearing of a mask is beneficial? That brings up the subject of masks.
“This [UPs] required dentists to wear gloves (usually latex), masks, and eyeglasses while practicing on patients. These preventive measures are essentially useless against viruses unless one has large portals of entry…” However, a recent study found that dentists who regularly wore masks and eye protection reported much fewer splashes of blood and blood contaminated saliva to the mouth, nose and eyes. Don’t you feel better protected by a mask (even though it has only 95% filtration efficiency) and gloves that will mostly protect you from blood and saliva?
A published study by Hardt stated that ultrasonic scalers have been found to produce blood contaminate aerosols during sub-gingival scaling. Ultrasonic scalers produce more bacterial aerosol contamination that any other dental instrument.6 That pair of glasses, with all the spatters on them at the end of the morning tells you something. All you need is some common sense and you don’t need to be a wizard.
Michael John, MB, c.h.., FRCP(C) in the November 2000 issue of the JCDA states that S. Aureus including the methicillin resistant S. Aureus (MRSA) are the common cause of hospital and now community acquired infections since Shaun and others have discovered it in a number of children in a Toronto daycare center. The mouth and nose are natural habitat for S. Aureus and dental workers who are nasally colonized with MRSA may, through shedding from their noses or via their hands, transmit the organism to susceptible patients. Asymptomatic carriers can transmit disease by droplet spread and Dr. John states that during the winter months 10%-20% of all persons may be asymptomatic carriers. The route of transmission can be cut by wearing a mask and washing or disinfecting hands. Bacteria spread in this manner include: Group A. streptococci, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Cornybacterium diphtheriae and Bordetella pertusis. Diseases rank from pneumonia, to “strep throat”, to meningitis. Dr. John states that the transmission to other patients and family members ranks as a significant health risk.
Another reason for wearing a mask is the scrumptious lingering aroma from that succulent dinner last night at your favourite garlic-laden Italian restaurant.
Some dentists may dislike wearing gloves but occult blood and fecal bacteria have been identified under fingernails. Proper hand disinfection by washing and scrubbing is a tedious and time-consuming procedure and hospital surgical standards are not met in daily dental practice. Gloving is a simpler and better method of hand sanitation in spite of all the unfortunate experiences with latex allergies and sensitization and irritant contact dermatitis. Bad mouthing latex, other than for significant past faults, should be a thing of the past since glove fabrication now includes compounds such as Nitrile and Elastyren and others that significantly reduce the problems. New hand cleansing procedures involving alcohol based products containing emollients can cut down the time for hand disinfection by as much as 25% and hold great promise for better skin health.7 Skin dryness and irritation are reduced by some alcohol based products.8 The soap scrub is required when there is significant contamination of the hands by blood or body fluids.
In the section titled, “Dental infection control…Where do we stand?” Dr. Neiburger states, “UPs do not protect you from the virus (Herpes Simplex Virus -HSV)…” “HSV is another insignificant risk”. The herpes viruses are shed in saliva and as Neiburger states a large proportion of the public are infected with the virus but acquiring the disease is not insignificant. Contacts with patients make antibody levels higher in dentists and clinical dental students than in preclinical dental students.9 Transmission from patients to healthcare workers has been substantiated10-12 and from dental workers to patients.13 Gloves were absent in a situation where 20 of 46 patients treated by a hygienist with herpetic whitlow developed HSV-1 gingivostomatis.14 Neiburger feels that is insignificant?
The CDC reported that bacteria found under the long fingernails of two medical nurses may have contributed to the deaths of 16 sickly babies. An association was found between the bacteria and the exposure to the two nurses with long fingernails.
The author states that gloves do not protect oral surgeons and that billions of oral surgery treatments are performed without risk. HBV vaccine acceptance by OMFS’s is a large factor in that statement. If a surgeon has an “accident” resulting in severe intrusion or cuts into his/her tissues then there are no gloves in the world that will stop the resulting problem. We cannot allow the use of this extreme example to blur our vision of correct infection control features. The quality of gloves surgeons and OMF Surgeons use can protect them from viruses (Elastyren etc.) under normal circumstances.
The astute observations of a nurse health inspector, upon discovering a cluster of cases of hepatitis B,15,16 found that it was transmitted to 75 (confirmed) cases in two electroencephalogram laboratories. The technician, with a high viral load, testing positive (HbsAg) and (HBeAg), was responsible for inserting intradermal electrodes into the scalp of patients. A high viral load in the technician, and inadequate infection control practices in the clinic, were responsible for probably the largest documented case of hepatitis B in a healthcare setting. Dentists are a part of the healthcare system and we should not be smug about “only nine clusters (dental) over the last 20 years”. Outbreaks (and individual cases) can go undetected unless someone makes the right connections and the fact that we fail to see an outbreak may simply mean that we did not look.
Dentists are concerned about “doing no harm” to patients and also protecting themselves, their staff and family. Some very intriguing information came from a study of outpatient facilities, which included dentists and chiropractors, utilizing:
1) a MEDLINE search for the period 1996 – 1989
2) a manual review of selected infectious disease and biomedical journals for the period 1980 through 1990 and:
3) search of records of over 2900 epidemiological field investigations conducted by the CDC stationed all over the world and state health departments from 1946 to 1989.17
Dentist’s offices and clinics were involved in transmission and transmission in 13 reports. In 12 of the reports, investigation suggested that one or more patients had been infected by an infected dentist or dental healthcare worker. HBV accounted for nine of the reports and herpes simplex and M. tuberculosis were also reported.
In the opinion of this author (RAC), the dental profession sometimes benefits from the fact that if there is a transfer of disease it is not related to the dentist because of the incubation period of some organisms. Weeks and longer can pass and patients do not relate their problem with a dental appointment.
If the author erroneously feels that ‘FRAIDS’ caused the mandating of Universal Precautions, which it did not, I for one am pleased that there has been a spill over of the benefits of proper infection control that has been be applied to other diseases. I am not so concerned about the ‘FRAIDS’ (fear of AIDS as described in the article) as I am about another “FRAIDS”, Frivolous Rhetoric About Infection in Dental Surroundings, and the possible acceptance of the dilution of standards that will reduce proper infection control measures to patients, staff, dentists and staff and dentists families.
The dental profession has earned a reputation for its efforts in infection control for which it should be proud. Why destroy a reputation in order to promote an agenda that is “dumbing down” the science of infection control and the prevention of cross-contamination?OH
Dr. Robert Clappison is Oral Health’s Infection Control and Health Issues board member.
Oral Health welcomes this original article.
1. Ippolito et al 1999,PHLS, 1999
2. Occupational Exposures to HIV Infections among Dentists, Surgeons and Nurses in Canada. McCarthy GM, Harris KA, Koval JJ, MacDonald JK, John, MA/: Oral Disease
3. Tullner, John, DDS, USAF SAM/AFD Brooks AFB TX
4. Torstar News Service – not exactly scientific but accurate
5. McCarthy G M , Koval JJ, MacDonald JK. Occupational injuries and exposures among Canadian dentists: the results of a national survey. Infect Control Hosp. Epidemiol 1999,,20,3312-6
6. The Presence of Blood in Aerosols Produced by Ultrasonic Scalers. Hardt, SK, Baylor College of Dentistry AADR Abstract# 9710
7. Voss A, Wimer AF, No time for handwashing? Handwashing versus alcoholic rub. Can we afford 100% compliance? Infect Control Hosp. Epidemiol. 1997; 18:205-8
8. Boyce JM, Kelliher S. Villande N. Skin irritation and dryness associated with two hand hygiene regimens,: soap- and- water hand washing versus hand antisepsis with an alcoholic hand gel. Infect Control Hosp Edpidern iol 2000: 21 :442-8
9. Herbier t AM, Bagg J, Walker DM, Davies KJ, Westmoreland D., Serioepiderniologgy of virus infections among dental personnel. J. Dent 1995, 23: 339-42
10. Recommendations for Infection Control procedures: Canadian Dental Association Board of Governors.J Can Dent Assoc 1995; 61: 509
11. McCarthy GM, Koval JJ, MacDonald JK Compliance with recommended infection control procedures among Canadian dentists: results of a national survey: Am J lnf Control 1999:27.-377-84
12. Lewis DL, Boe RK Cross infection risks associated with current procedures for using high -speed dental handpieces J Clin Micriobiol 1992:30:401-6
13. Epstein, JB, Rea G, Sibau L, Sherlock CH, Le ND Assessing viral retention and elimination in dental handpieces J Am Dent Assoc 1995: 126:87-9214. ibid
15. Risk Management, Practical Considerations, Margaret Fearon, MB, FRCP(C) J Can Dent Assoc 2000:66:542
16. An outbreak of Hepatitis B associated with reusable subdermal electroencephalogram electrodes. CMAJ 2000;162:1227-31
17. JAMA, May 8,1991 -Vol. 265, NO 18