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Introduction
The purpose of this manual is to assist dental societies and associations in establishing some mechanism for support of dentists with infectious diseases. The chapters may be utilized individually for training purposes or, as a whole, as a comprehensive resource. When all levels of state programs are using this as a primary framework, consistency will be established throughout the country.
The emergence of new infectious diseases and the re-emergence of diseases, once thought to be under control, now challenge the practices of all health care professionals. Strains of bacteria which were once susceptible to antibiotics have become resistant. Tuberculosis has returned, often in a multi-drug resistant form. Viral diseases which were unknown twenty years ago must now be recognized and responded to in an aggressive and timely manner.
Organized dentistry continues to meet these challenges. Dental school curricula continuously evolve, as does the scope and content of continuing education for those already in practice. Both of these educational efforts reflect sound scientific information regarding infectious diseases. Dentistry is at the forefront of infection control procedures, which confirms the fact that patients' health and well being are primary concerns. The procedures and practices that have now become standard in dentistry have served as models for other health care providers. Dentistry has played, and continues to play, a major role in establishing state-of-the-art infection control protocols for the small office environment.
The leadership role that dentistry has played in the prevention of infectious diseases continues with this manual. A resource document for health care providers with infectious diseases has, up to now, not been available for any of the health professions. General issues and needs arise whenever any person becomes ill, but for infected health care providers unique challenges are presented.
Preventing disease before it has a chance to occur has been the traditional definition of primary prevention in public health. The chapters that follow will discuss the implications of primary prevention as it relates to dentists with infectious diseases. Universal precautions and strict infection control guidelines also fall under the category of primary prevention. Both patients and staff are being protected from infection.
Secondary prevention of disease is defined as its early detection and prompt treatment. Diagnosis of infection, especially of those infections with long asymptomatic periods, is crucial for both the health of the individual dentist and the agencies responsible for assessing the provider's ability to provide care. Prompt treatment through the use of medications, alterations in lifestyle, stress reduction, emotional and psychological support, have all been shown to increase the quality of life of those with chronic illnesses. The need for regular medical care and monitoring cannot be overemphasized.
The tertiary component of prevention is rehabilitation and limitation of disability. It is best described as a period of transition. Alternatives to clinical practice along with retraining may be important for dentists who can no longer perform direct patient care. Restrictions on practice may also be obligatory by state statute. The financial consequences for those with inadequate disability or health insurance can be devastating. This manual will address these challenging issues and provide pertinent resources for finding assistance and information.
Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) infection, hepatitis (HBV), and tuberculosis (TB), along with its latest permutation, multi-drug resistant tuberculosis (MDRTB), are the triad of disease entities this monograph will address. Using this triad as a paradigm, modifications, alternatives and resources may also be identified for other infections which impact the dentist. All infectious diseases impacting the dentist raise significant concerns; however, at this writing, HIV disease has well established resources, treatments and supportive services. For this reason, the manual will draw heavily upon HIV/AIDS as a model for adaptation with other infectious diseases.
A certain sense of unity in dealing with infected dentists emerges when one studies the literature on HIV/AIDS, HBV and TB. At the same time, HIV/AIDS is unique in the response it has elicited from both the public and the profession. Since 1982, more than 440,000 Americans have been diagnosed with AIDS, yet outside of the Florida dentist's cluster, no other cases of transmission from health care provider to patient have been documented. To date, of the 22,101 patients treated by 51 HIV positive HCWs (25 of whom were dentists and four of whom were dental students), no other cases of transmission from HCWs have been documented. Despite the unique singularity of the Florida case, the concerns regarding transmission have been enormously publicized and scrutinized, making HIV/AIDS unique for dentists who are infected. Some states, for example, have passed laws mandating that infected providers limit their practices until the Board enters an order delineating the scope of practice. Others have allowed infected providers to continue practicing provided they adhere to universal precautions and are followed regularly by a personal physician. Some states require that dentists who are HIV infected inform their patients of their HIV status.
Regardless of the existing recommendations and laws, infected dentists, physicians and/or their estates have been involved in litigation involving care provision while infected. The public feels it has a right to know the HIV status of their dentists; to facilitate proper treatment, dentists want to know the health status of their patients. Certainly the circumstances and issues surrounding disclosure by the infected dentist can be volatile, at best.
What does having an infectious disease truly mean to practicing dentists? Whom do they inform and when? What resources are available to assist with the decision making process? How do they determine whether and how to find legal counsel? How do they go about informing the expert review panel, if necessary, in their state? How to maintain confidentiality when filing for benefits? The questions are endless but answers are available.
Offering problem solving strategies is the purpose of this manual: to help the infected dentist begin the process of accessing the information needed to make decisions. A theme that will recur throughout the manual is that of informed decision making. No two providers will ever be confronted with the same set of issues. Their age, sex, geographic location, disease, stage in the disease process, support networks, economic position and point in career path will influence the decision model they choose. What becomes crucial is the need for a resource base to acquire the knowledge necessary for an informed decision.
Infected dentists can be well served by being aware of the facts and the arguments and then assessing what is appropriate action for their unique situation. Because of the complexity of the issues involved, a specific bibliography for further study is available at the end of each section of this manual. Some sections also list resources that may be of particular interest to dentists and their caregivers. The ADA does not necessarily endorse the non-ADA resources that appear on those lists, and makes no representations or warranties about the services those resources may provide. However, it is hoped that some of the contact agencies will be of assistance to their families, caregivers, colleagues or anyone else wishing to learn more about the general concerns of people living with chronic infectious diseases, particularly HIV/AIDS.
These materials are a start - they are neither comprehensive nor definitive. Throughout the text, one disease, HIV/AIDS, has been used as a primary focus and, whenever possible, other infectious diseases are addressed. What is provided should be seen as a groundwork for further study toward informed decision making. Dentists must rely on their personal physicians and attorneys for medical and legal advice.
The American Dental Association will continue to provide leadership and resources to states developing programs for dentists with infectious disease and provide updated information when it becomes available.
Bibliography
Centers for Disease Control and Prevention HIV/AIDS Surveillance Report 6(2); 1994.
Robert, L.M., et al. Investigation of patients of health care workers infected with HIV. Centers for Disease Control and Prevention Data Base. Annals of Internal Medicine 1995; 122:653.
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