The Ethical Dilemma of Infectious Disease Disclosure for Dentists – usdentistsdirectory

In July 1990, the Florida Department of Health reported a possible transmission of HIV from a dentist to five of his patients.¹ While it was unclear whether actual transmission of the virus actually occurred, this incidence caused much controversy and concern within the dental community.^2.3

At the time, health care providers were required to follow the CDC’s “Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients,” which recommended that health care providers with HIV or Hepatitis B disclose their status to an expert review panel for consideration before the provider may continue to practice.⁴These guidelines have since been withdrawn by the CDC due to the fact that the risk of HIV or HBV transmission from healthcare provider to patient is minimal during exposure-sensitive procedures and does not affect non-invasive procedures.^5.6

The current CDC guideline makes no mention of patient exposure from dental care providers, as this is not a problem.⁶ However, several states have established their own standards and guidelines to deal with this situation.

Texas Administrative Code Line §108.25

Several states, including Texas, require HIV/HBV positive health care providers to disclose their status to a panel of experts before treating patients. But Texas is the only state that requires these providers to take additional measures, including informing patients individually.

The Texas Administrative Code Rule §108.25 states, “A dental care provider who is infected with HIV or HBV and is HBeAg positive must inform a prospective patient of the dental care provider’s status and obtain the patient’s consent before the patient undergoing an exposure procedure performed by the notifying healthcare practitioner.”⁷

The Texas State Board of Dental Examiners (TSBDE) states that disciplinary action for non-compliance with the disclosure of infectious diseases to patients can range from a verbal reprimand to suspension of the license.

It is safe to say that this rule is outdated and discriminatory as it can have serious consequences for providers. Mandatory disclosure to patients can have major consequences for the dentist, such as loss of practice, prejudice against the healthcare provider and reduced career and training opportunities.

The Impact of Advances in Antiviral Drugs on the Management of the Infected Health Professional

hiv

The development of one of the newer classes of antiretroviral drugs (integrase strand transfer inhibitors) has been an important step forward in the treatment of the disease. These drugs are currently considered optimal for initial therapy as they are highly effective in virological suppression and extremely well tolerated. Viral suppression can make the HIV viral load so low that it is no longer detectable in the bloodstream and thus cannot be transferred to another person.⁸

In 2012, the FDA approved the use of the drug Truvada as a pre-exposure prophylaxis (PrEP) for HIV-negative individuals at high risk of contracting HIV. Today there are two approved oral medications and 1 injectable treatment for use as PrEP.⁸

With the advances made in HIV treatment and prevention, we can safely say that the Texas Administrative Code Rule §108.25 is obsolete and contributes nothing to patient safety or public health.

Hepatitis B

The excellent protection provided by the Hepatitis B vaccine has been shown to provide protection that lasts for up to 30 years. This was the first important step in reducing the number of healthcare professionals infected with HBV and thereby reducing the risk of further transmission to patients.⁹ This contributes to the case where the Texas rule is outdated and unnecessary because the risk of hepatitis B transmission is low.

Looking forward

Looking at the situation in general, you could argue that following universal precautions alone makes the Texas rule obsolete and discriminatory. In addition, it is inconsistent that dentists should disclose personal health information just because it is HIV or HBV compared to other infectious diseases. The Texas State Board of Dental Examiners did not take the same stance when the virus in question was SARS-CoV-2.

According to the Texas Dental Association, the Texas State Board of Dental Examiners requires dentists and team members who test positive for COVID-19 and have had close contact with patients while they are positive to notify those patients. However, the dental team may also be required to protect the team member’s confidentiality under applicable privacy laws.¹⁰ Why wouldn’t the same laws apply if the dentist was positive for HIV or HBV instead? Especially when HIV and HBV transmission is much less likely in a dental setting. This is proof that Texas Administrative Code Rule §108.25 is discriminatory and should be abolished.

I hope we use the updated research to do away with rules like the outdated Texas Administrative Code Rule §108.25 so that all healthcare providers and students have an equal opportunity to treat patients without fear of prejudice or discrimination.

dr. Alex Barrera is a general dentist at Legacy Community Health in Houston, Texas. He graduated from the University of Texas School of Dentistry in Houston in 2017 and is a member of several organizations, including the American Dental Association, Hispanic Dental Association, Greater Houston Dental Association, and the Houston Equality Dental Network. He currently chairs the New Dentist Committee for the Hispanic Dental Association and serves on the ADA Council on Advocacy for Access and Prevention. dr. Barrera is the current president of the Houston Equality Dental Network, enabling him to be an advocate for LGBTQ+ care in dentistry. dr. Barrera is a certified yoga teacher and uses mindfulness and meditation to better treat patients with dental phobias. In his spare time he likes to read, cook and travel.

References:

1. “Guidelines for HIV-Positive Health Professionals, The Center for HIV Law & Policy (2008).” Guidelines for HIV Positive Health Professionals, The Center for HIV Law & Policy (2008) | The Center for HIV Law and Policy, Mar 1, 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. Accessed April 16, 2022.
3. Jaffe, Harold. “Lack of HIV Transmission in a Dentist’s Practice with AIDS.” Annals of Internal Medicine, vol. 121, no. 11, 1994, p. 855., https://doi.org/10.7326/0003-4819-121-11-199412010-00005. Accessed April 18, 2022.
4. “Recommendations for Preventing Human Immunodeficiency Virus and Hepatitis B Virus Transmission to Patients During Exposure-Sensitive Invasive Procedures.” MMWR. Recommendations and reports: Weekly report on morbidity and mortality. Recommendations and Reports, US National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/1648165/.
5. US Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during invasive procedures susceptible to exposure. MMWR Recommend Rep. 1991;40(RR08)::1–9.
6. “Summary of Infection Prevention Practices in Dental Facilities: Basic Expectations for Safe Care.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, Sept. 10, 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 on April 18. 2022.
8. “About PrEp.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, Apr 20, 2022, https://www.cdc.gov/hiv/basics/prep/about-prep.html.
9. Barrigar, Diana L, et al. “Hepatitis B Virus Infected Physicians and Patient Transmission Risk Disclosure: 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.