A Test for the Profession?
A growing amount of media attention is focusing on the potential for an AIDS-infected physician or dentist to transmit the disease to patients. There have been instances in both professions of alleged transmissions of the human immunodeficiency virus (HIV), and we will undoubtedly be hearing more about such cases.
Questions are being raised about what the appropriate action of a physician or dentist who tests positive for HIV ought to be. Should the individual inform all of his or her patients? Should the individual immediately stop practicing any invasive procedures? Should the individual stop practicing altogether?
Should a physician or dentist who has engaged in no high-risk behavior, and has no reason to believe he or she has AIDS, voluntarily submit to periodic testing and inform patients that he or she has tested negative for HIV? Should such testing be mandatory? Is the public entitled to know a health-care worker's medical and personal history? Does protection of a professional person against the potentially career-destroying effect of the announcement of a positive HIV status outweigh the public's "right to know"?
Then we have the other side of the coin. Should patients about to undergo invasive procedures be tested for HIV? Should all patients be tested? If a physician or dentist performs procedures that involve bleeding by the patient and potential puncture wounds to the professional person, can that professional person be required to treat known HIV-positive patients?
The Centers for Disease Control have published guidelines that recommend voluntary testing for health-care workers involved in "exposure-prone procedures", which are defined to include "digital palpation of a needle tip in a body cavity or the simultaneous presence of the health-care worker's fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic site''.1 The CDC considers mandatory testing of health-care workers to be too expensive, given the minimal risk of infection.
Both organized medicine and organized dentistry have concurred with the CDC guidelines. The most recent information from the ADA reasserts this position and the previous ADA policy that "HIV-infected dentists should refrain from performing invasive procedures or should disclose their seropositive status". The ADA further stated, "The Association continues to support the use of proper infection control procedures. As long as these protocols are followed, the risk to the patients, dentists, and staff are infinitesmal."2 On Aug. 7, the ADA Board of Trustees added a statement that encourages dentists who believe they are at risk of HIV infection to seek testing.
Since much of the public discussion about AIDS deals with occurrences in dental offices--both general practice and orthodontic--something more needs to be done by the organized profession and by individual practitioners to bolster public trust. Dentists should not be viewed as a self-serving group more interested in their own welfare than in the public's. The profession should advocate handling the AIDS epidemic as what it is: an epidemic of a potentially fatal communicable disease. It is absurd to treat it as a political question.
With regard to testing, although current techniques are not 100 percent effective, an initial mandatory, reportable nationwide testing of health-care workers would at least screen the professions for those who are HIV-positive at the time the test is given. There would be some value in that in terms of public confidence. A second test a year later might suffice for mandatory testing of present health-care workers.
In the end, however, the question of testing may well be decided not by the professions, but by insurance companies and the courts. The prevalence of the right to privacy over the reportability of a communicable disease is beginning to break down.
A Pennsylvania appeals court--in a decision that is being appealed to the state supreme court--recently ruled that although the risk of transmission from doctor to patient is very low, it is significant enough to warrant reporting. In this case, the infected physician's name was not disclosed to the patient, but the fact of the infection was. The court also mentioned that informed consent requires physicians to inform patients of the risks involved in any procedure. The core of the judges' decision: "Surely it is no consolation to the one or two individuals who become infected after innocently consenting to medical care by an unhealthy doctor that they were part of a rare statistic."
Even if the professions end up with no say on the question of confidentiality, they are entitled to determine what precautions would protect the health and welfare of doctors, staff members, and their families. The dilemma, of course, is that neither the professional person nor the patient can know for certain who has AIDS. Even a carrier may not know. Still, it is reasonable for a professional person to include questions on HIV status in a medical history, even though some people may withhold the information, some may not be aware of their condition, and some may become infected in the middle of treatment. Considering that the possibility of a health-care worker contracting AIDS from a patient may be greater than that of a patient contracting AIDS from a health-care worker, it is preposterous to suggest, for example, that an orthodontist should be required to treat a known HIV-positive patient.
Orthodontics is not generally thought of as involving "invasive" or "exposure-prone" procedures. Yet, in a survey published in the January 1988 issue of JCO, Georgia orthodontists reported that they or their chairside assistants experienced an average of 1.26 puncture wounds a week, or 65 a year, and that they observed blood in patients' mouths an average of 14.9 times a week.3 What are the odds that these two events would occur simultaneously and that one party or the other would be HIV positive? The odds of infection may be "infinitesimal" overall, but they are 100 percent for the one time the coincidence does occur.
A great deal of media attention has been paid to the apparently poor sterilization and barrier procedures in at least two of the dental offices involved in alleged transmission of AIDS to patients. In one office, cold sterilization was being used. Emphasis may soon shift from reports of transmission from health-care worker to patient, and from patient to health-care worker, to the possibility of patient-to-patient transmission because of improperly sterilized instruments and improper use of barrier devices.
The public is becoming aware of the role of these procedures, and professionals would do well to have state-of-the-art sterilization and barrier programs in their offices, and to be sure that their patients are aware of the programs. The ADA may be confident that "when health-care workers adhere to recommended infection-control procedures, the risk of transmitting HIV [hepatitis B virus] from an infected health-care worker to a patient is small, and the risk of transmitting HIV is likely to be even smaller". But I would not care to risk my life on the presumption that 100 percent of dental offices have 100-percent-effective sterilization procedures.
There are, in summary, some positive steps that can be taken in the individual orthodontic practice:
1. Obtain thorough medical histories.
2. Delay elective orthodontic procedures for known HIV-positive patients.
3. Expand informed consent to include the results of possible periodic HIV testing.
4. Employ proper barrier procedures, including the routine wearing of gloves.
5. Use state-of-the-art sterilization and disinfection procedures.
6. Conduct an ongoing staff training and awareness program on communicable diseases.
All physicians and dentists ought to be more supportive of the concerns of all parties, and get strongly behind efforts to find a cure for this dread disease. A cure offers the only good prospect that the jeopardy and the anxiety of both professional people and the public can be relieved.