Volume 7 • 2020 • Issue 4

“The recommendations have been developed to aid those involved in assessing and managing health care workers infected with these bloodborne viruses,” says Dr. Cleghorn. “This could include regulatory bodies, treating physicians or expert review panels that could be tasked to assess individual situations. It provides guidance with respect to the scope of practice for infected health care workers.” What are the recommendations? All health care workers should adhere to Routine Practices, a set of infection control strategies and standards designed to protect patients from exposure to potential sources of infectious diseases, at all times and in all settings. Failure to do so can result in the transmission of bloodborne viruses. If infected health care workers adhere to Routine Practices, the risk of transmission of bloodborne viruses from an infected health care worker to a patient is negligible, except in the case of exposure-prone procedures. If an infected health care worker is performing exposure- prone procedures, risk is increased, though it remains minimal. Exposure-prone procedures are defined as invasive procedures where there is a risk that injury to the health care worker may result in the exposure of the patient’s open tissues to the blood of the health care worker. Exposure‑prone procedures in dentistry include cutting or removal of any oral or perioral tissue, during which the patient’s open tissues may be exposed to the blood of an injured health care worker. One example is a surgical extraction of a third molar. All health care workers who perform exposure-prone procedures should know their own serological status with respect to HIV, Hepatitis B and Hepatitis C. “The guideline states that transmission has been documented with several surgical and dental procedures, but evidence is lacking to definitively categorize specific medical and dental procedures with respect to transmission risk,” says Dr. Cleghorn. Transmission risk for different procedures has been developed based on expert consensus rather than numerical evidence, so the guideline does not provide a detailed list of procedures that should be categorized as exposure-prone. “Instead, it provides criteria for exposure-prone procedures and suggests that experts in the appropriate specialties determine which procedures meet the criteria.” What does this look like in practice? “When we established our updated policy on infected health care workers at Dalhousie, we formed a committee, that included representation from dental hygiene, periodontics, and oral and maxillofacial surgery, to develop our definition of exposure-prone procedures based on a review of the literature,” says Dr. Cleghorn. If the situation were to arise that a student was infected with a bloodborne virus, Dalhousie defined which procedures the student would not be able to perform until their viral infection had been appropriately medically-managed. “Once we had defined our list of exposure-prone procedures, we would be able to act quickly and modify a student’s clinical program until their condition was medically managed,” says Dr. Cleghorn. The guideline emphasizes the importance of training and education in preventing injuries in any health care setting. “It’s impossible for there to be zero risk of transmission of bloodborne viruses,” says Dr. Cleghorn, “But the good news is that there are vaccines that provide immunity to Hepatitis B and there are very effective treatment modalities for Hepatitis C and HIV, which can bring down the viral load to undetectable levels. So, in fact, the risk of transmission can be rendered negligible.” The New Guideline’s Takeaways for Dentists • Adhere to Routine Practices. Every time. • Get vaccinated for Hepatitis B. • Make sure everyone on the team, including yourself, have the appropriate training to prevent and manage percutaneous injuries that can create risk of acquiring Hepatitis B, Hepatitis C and HIV. • All health care workers should know their own serological status, especially those performing exposure-prone procedures. • Health care workers who are infected with HIV, Hepatitis B and/or Hepatitis C that do not perform exposure-prone procedures should have no practice restrictions. • Health care workers who are infected and who perform exposure-prone procedures should follow these recommendations: a) They must be under the care of a physician that has expertise in the management of their particular bloodborne virus. b) They must be medically managed according to the current recommendations for their bloodborne disease. c) Those with Hepatitis B should be restricted from performing exposure- prone procedures until they have an HBV DNA level below 103 IU/ml (5 x 103 GE/ ml). In addition, they should have their HBV DNA level monitored and assessed regularly, every 3 to 6 months. d)Those with Hepatitis C should be restricted from performing exposure‑prone procedures until they have an undetectable viral load, at least 12 weeks post-treatment. e) Those with HIV should be restricted from performing exposure-prone procedures until they are either have an undetectable viral load due to effective antiretroviral therapy or being diagnosed as an elite controller. S upporting Y our P ractice 22 | 2020 | Issue 4