A guideline for the management of healthcare workers who are infected with the HBV, HCV, and HIV was developed by the Society of Healthcare Epidemiology of America (SHEA).3 It recommends that infected OHCP should not be totally prohibited from patient care solely on the basis of an infection with a bloodborne pathogen and that clinical privileges be graduated according to the level of risk for transmitting a bloodborne pathogen (i.e., HBV, HCV, and HIV) in association with a procedure (Table 4) and the level of circulating viral burden of the infected OHCP.3
Table 4. Oral Healthcare-associated Procedures According to the Level of Risk for Bloodborne Pathogen Transmission.3
- Category I procedures: minimal risk of bloodborne pathogen transmission
- History-taking
- Extraoral physical examination
- Intraoral examination
- Including the use of a tongue depressor, mirror, explorer, or a periodontal probe
- Routine preventive dental procedures - not requiring the administration of local anesthesia
- Application of sealants or topical fluoride
- Prophylaxis – not to include subgingival scaling with a hand instrument
- Orthodontic procedures
- Prosthetic procedures
- Fabrication of complete dentures
- Hands-off supervision of surgical procedures
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- Category II procedures: theoretical possibility of bloodborne pathogen transmission
- Dental procedures requiring the administration of local anesthesia
- Operative, endodontic, and prosthetic procedures and periodontal scaling and root planing
- Use of ultrasonic instruments greatly reduce or eliminate the risk of percutaneous injury to the provider
- If significant physical force with hand instruments is anticipated to be necessary, scaling and root planing and other Category II procedures could reasonably classified as Category III
- Minor surgical procedures
- Simple tooth extraction not requiring excessive force
- Soft tissue flap procedures
- Minor soft tissue biopsy
- Incision and drainage of an abscess
- Insertion of, maintenance of, and drug administration into arterial and central venous lines
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- Category III procedures: definite risk of bloodborne pathogen transmission
- General oral surgery
- Surgical extractions
- Removal of an erupted or unerupted tooth requiring elevation of a mucoperiosteal flap, removal of bone, or sectioning of tooth and suturing
- Apicoectomy and root amputation
- Periodontal curettage, gingivectomy, and mucogingival and osseous surgery
- Alveoplasty and alveolectomy
- Endosseous implant surgery
- Open extensive head and neck surgery involving bone
- Trauma surgery, including open head injuries, facial fracture reductions, and extensive soft issue trauma
- Any open surgical procedure with a duration of more than 3 hours, probably necessitating glove change
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This strategy encourages routine voluntary, confidential testing and emphasizes that clinicians who perform Category III procedures should know their immune or infection status, i.e., their relative viral load with respect to HBV, HCV, and HIV.3 Clinicians who are institutionally based and develop one of these infections are ethically bound to report it to their institution’s occupational medicine department. Private practitioners are ethically bound to report their infectious status to the local public health department.
These recommendations take into consideration evidence that (1) the HBeAg is not a sensitive marker for HBV infectivity (2) the availability of molecular tests that measure a patient’s circulating viral burden for hepatitis B, hepatitis C, and human immunodeficiency viruses with precision, and (3) the availability of antiviral agents for the treatment of chronic HBV infection, both acute and chronic HCV infection, and HIV infection.3 Table 5 lists recommended clinical privileges for healthcare providers with HBV, HCV, and HIV infection.3
Table 5. Recommended Clinical Privileges for Healthcare Providers with HBV or HCV Infection.3
| Pathogen | Circulating Viral Burden | Clinical Privileges |
|---|
| HBV and HCV | <104 GE/mL | Category I, II, and III procedures* |
| ≥104 GE/mL | Category I and II procedures* |
| HIV | <5 x 102 GE/mL | Category I, II, and III procedures* |
| ≥5 x 102 GE/mL | Category I and II procedures* |
*Clinical privileges predicated on the infected healthcare provider meeting the following requirements:
- No evidence of having transmitted infection to patients
- Obtained advice from an Expert Review Panel about continued practice
- Follow-up twice a year to determine viral burden
- Follow-up by a personal physician who has expertise in the management of infections with HBV, HCV, and HIV and who is allowed to communicate with the Expert Review Panel about the infected provider’s clinical status
- Consulted with an expert about optimal infection control procedures and strictly adheres to the recommended procedures
- Routine use of double gloving and frequent glove changes during procedures (particularly when performing tasks known to compromise glove integrity) for all instances in patient care for which gloving is recommended
- Agreed to and signs a contract or letter from the Expert Review Panel that characterizes the infected providers responsibilities
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