Implement Administrative Controls

The Society of Healthcare Epidemiology of America (SHEA) emphasizes the importance of Standard and Transmission-based Precautions to minimize HIV transmission and states that infected providers should not be totally prohibited from providing patient care solely on the basis of HIV infection.36 SHEA recommends that clinical privileges be graduated according to the provider’s viral load and the likelihood of procedure-related provider-to-patient transmission of the HIV (Table 5).36,42

Table 5. The level of risk for the transmission of bloodborne pathogens associated oral healthcare procedures.
  • Category I: Procedures with 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
  • Category II: Procedures for which bloodborne pathogen transmission is theoretically possible but unlikely
    • Dental procedures requiring the administration of local anesthesia
      • Operative, endodontic, and prosthetic procedures and periodontal scaling and root planning
        • 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 planning 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
  • Category III: Procedures for which there is a definite risk of bloodborne pathogen transmission or that have been classified as “exposure prone”
    • 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

HCP have the ethical and moral duty to ensure patient safety. Routine, voluntary, confidential testing of oral HCP is encouraged, emphasizing that those who perform Category III procedures should know their immune or infectious status not only with respect to the HIV, but HB and HCV.36 HIV-infected clinicians are legally and ethically bound to so inform the local or state public health authorities. Table 6 lists recommended clinical privileges for healthcare providers with HIV infection.36

Table 6. Recommended clinical privileges for healthcare providers with HBV or HCV infection.36
  • Circulating viral burden <5 x 102 GE/mL
    • Category I, II, and III procedures – no restrictions as long as the infected healthcare provider:
      • no evidence of having transmitted infection to patients
      • obtained advice from an Expert Review Panel about continued practice
      • follow-up twice a year to demonstrate the maintenance of a viral burden <5 x 102GE/mL
      • follow-up by a personal physician who has expertise in the management of HIV infection 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
  • Circulating viral burden ≥5 x 102 GE/mL
    • Category I and II procedures – no restrictions as long as the infected provider meets the criteria noted above for infected providers with a viral burden of <5 x 102 GE/mL
    • Category III procedures – these procedures are permissible only when the viral burden is <5 x 102 GE/mL