- Email: [email protected]
FACING UP TO PHOBIA
The only thing we have to fear is
I Fear has not been an acceptable legal defense for failing to teat the NIV-positive patient But anxiety and uncontrollable fear are legitimate psychiatric disorders.
...
fear itself -Franklin Delano Roosevelt
Uhe evidence continues to grow that universal precautions and barrier techniques have reduced to nearly zero the risk of transmitting the HIV bloodborne pathogen from patient to dentist. Those who question this statement need only examine the outcomes of health worker exposures to the AIDS virus. According to the Centers for Disease Control and Prevention, the risk of seroconversion in health care workers exposed to HIV-infected blood through the percutaneous route (needlesticks or cuts) is 0.3 percent. For those exposed by contact with mucocutaneous tissues, the risk is 0.09 percent. The risk is even less for skin contacts. What's more, of the 49 health care workers who have seroconverted to HIV after occupational exposure, none was a dentist. While its statistics may not be all-inclusive, the CDC surveillance system covers sufficient numbers within the dental universe to allow it to testify in a court of law that "treating HIV positive patients ... in a dental office does not pose a direct threat to the health and safety of others." That includes dentists and members of their dental office teams. Risks for patients visiting a dental office also are negligible; only in the mystifying Acer case has HIV transmission from an infected dentist to a patient been recorded. The mode of transmission in that case still has not been established.
E D I T O FR I A L
LAWRENCE H. MESKIN, D.D.S. EDITOR
E-mail: [email protected] 1450 JADA, Vol. 127, October 1996
Acting on CDC treatment recommendations and scientific information, the ADA has declared the dental office safe for all participants. The strength of that commitment can be noted in the ADA's Principles of Ethics and Code of Professional Conduct, which includes the following: "A dentist should not refuse to treat a patient whose condition is within the dentist's current realm of competency solely because the patient is HIV infected." While earlier surveys indicated a reluctance by some dentists to treat HIV-infected patients, recent assessments indicate that most dentists are adhering to the tenets of the ADA's ethical code. Compliance, however, has not been universal, and more than
~VIE[WS one dentist has found that a reluctance to treat can subject him or her to court actions and substantial fines. Since HIV infection has been labeled a disability under the Americans with Disabilities Act, legal encounters have centered on federal courts. To date, no legal argument has prevailed that questioned the classification of HIV infection as a disability. And no argument has prevailed that implied that HIV-infected patients pose a direct threat to the health and safety of others. Attempts to discredit the effectiveness of universal precautions and barrier techniques have gained little credence. Inevitably, such arguments collapse under the huge body of evidence that dental procedures are safe, that the risk is infinitesimal.
I concur with the CDC and ADA positions. The science supporting universal precautions and barrier techniques is irrefutable. However, I would like to advance a proposition for those dentists experiencing excessive mental stress when called on to treat the HIV-infected patient. Please note that I limit my proposal to dentists who are sincerely fearful of the consequences of treating the AIDS patient, even though they are aware the risk is small. Excluded are dentists who would deny care due to certain
prejudices. On several occasions, dentists have confided to me that their fears of infectivity make it difficult-even impossible-to carry out an effective treatment plan. Forcing them to treat could cause damage to both pa-
tient and dentist. As one who finds it difficult to stand on a six-foot ladder without dizziness, I am sympathetic. How many dentists fall into this category? I don't know. There may be only those few who have spoken or written to me. Or there could be hundreds more too fearful to speak out. I would predict that most of these dentists, knowing the career-damaging consequences of their fears, would willingly offer treatment if they could control their anxieties. For dentists in this phobic state, chances are that many are mid-career. They entered the profession with no thought that they would ever be in a situation-no matter how small the risk-where they might contract a fatal disease. For such dentists, the profession should offer programs to help them
Only NSKeces control patient vector cross-infection at the source...IN _
following patient, thus nullifying the most rigorous autoclaving of the handpiece. ANSWR: NSK invented the Clean Head System to prevent such cross-infection. It consists of a labyrinth of air passages at the
OCLEANHEAD head of the p handpiece and a FACT: All conventional dental handpieces draw fluids and contaminants into
duckbill valve in the water spray tube of the
handpiece.
heads, couplings, hoses and dental units.
Research has confirmed the effectiveness of the NSK Clean Head System.'
Infective materials may enter the water tubing beyond the handpiece only to be blown back into the mouth of a
The labyrinth prevents the sucking back of materials, including viral matter, into
_
the turbine chamber and the duckbill prevents flowback of contaminated water from the handpiece into the water supply tube. The NSK Clean Head System is also available on NSK low speed handpieces, attachments and clinical motors. Every NSK clinical product is autoclavable. The NSK Clean Head System takes your professional precautions against cross-infection another step forward. Copies of the University Studies on the NSK Clean Head System are available on request from your nearest NSK distributor. NSK's Clean Head system limits internal contamination to the turbine labyrinth, expelling contaminated fluids immediately they enter the head. NSK's anti-water-retraction valve prevents contaminants from entering the water lines and dental unit.'
Distributed in America by:
NSK AMERICA CORPORATION
IAK
IAKANISHI INC.
700B Cooper Court, Schaumburg, Illinois 60173 USA Telephone: 847-843-7664 Facsimile: 847-843-7622 NSK009M2
1I LLI CTTEDQ ILOQ s s~; ^a^gb ^11;^~~~~~~~~~~ Wiwik I~~~~~~~~~~.
~~~~~~~~I.,.
~
!~ ~
I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~ ~ ~ ~
.WMF
~
wm
i
deal with their fears. Fear has not been an acceptable legal defense for failing to treat the HIV-positive patient. But anxiety and uncontrollable fear are legitimate psychiatric disorders. Unwarranted, illogical fear of a situation can, on the one hand, manifest itself in simple curtailment of normal function. On the other hand, it can produce extreme panic leading to illness or bodily injury. This editorial does not suggest that dentists who refuse to treat AIDS patients be allowed to use fear as a legal argument. What it does recommend is that the two, 20 or 200 dentists who legitimately are not in total control of their professional skills, hamstrung by their fears of HIV, be treated as phobic. Such treatment is available and often successful; 90 percent of phobias respond to therapy. Programs using accepted therapies-desensitization, behavior modification, visualization-can assist needy dentists, not punish them. Just as peer boards have been established to support the HIVinfected dentists, so should professional boards be created to assist those dentists who have nothing to fear but fear itself.
*ADA welcomes letters from readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be typed, double-spaced and signed. The views expressed are those of the letter writer and do not necessarily reflect the opini
I Fear has not been an acceptable legal defense for failing to teat the NIV-positive patient But anxiety and uncontrollable fear are legitimate psychiatric disorders.
...
fear itself -Franklin Delano Roosevelt
Uhe evidence continues to grow that universal precautions and barrier techniques have reduced to nearly zero the risk of transmitting the HIV bloodborne pathogen from patient to dentist. Those who question this statement need only examine the outcomes of health worker exposures to the AIDS virus. According to the Centers for Disease Control and Prevention, the risk of seroconversion in health care workers exposed to HIV-infected blood through the percutaneous route (needlesticks or cuts) is 0.3 percent. For those exposed by contact with mucocutaneous tissues, the risk is 0.09 percent. The risk is even less for skin contacts. What's more, of the 49 health care workers who have seroconverted to HIV after occupational exposure, none was a dentist. While its statistics may not be all-inclusive, the CDC surveillance system covers sufficient numbers within the dental universe to allow it to testify in a court of law that "treating HIV positive patients ... in a dental office does not pose a direct threat to the health and safety of others." That includes dentists and members of their dental office teams. Risks for patients visiting a dental office also are negligible; only in the mystifying Acer case has HIV transmission from an infected dentist to a patient been recorded. The mode of transmission in that case still has not been established.
E D I T O FR I A L
LAWRENCE H. MESKIN, D.D.S. EDITOR
E-mail: [email protected] 1450 JADA, Vol. 127, October 1996
Acting on CDC treatment recommendations and scientific information, the ADA has declared the dental office safe for all participants. The strength of that commitment can be noted in the ADA's Principles of Ethics and Code of Professional Conduct, which includes the following: "A dentist should not refuse to treat a patient whose condition is within the dentist's current realm of competency solely because the patient is HIV infected." While earlier surveys indicated a reluctance by some dentists to treat HIV-infected patients, recent assessments indicate that most dentists are adhering to the tenets of the ADA's ethical code. Compliance, however, has not been universal, and more than
~VIE[WS one dentist has found that a reluctance to treat can subject him or her to court actions and substantial fines. Since HIV infection has been labeled a disability under the Americans with Disabilities Act, legal encounters have centered on federal courts. To date, no legal argument has prevailed that questioned the classification of HIV infection as a disability. And no argument has prevailed that implied that HIV-infected patients pose a direct threat to the health and safety of others. Attempts to discredit the effectiveness of universal precautions and barrier techniques have gained little credence. Inevitably, such arguments collapse under the huge body of evidence that dental procedures are safe, that the risk is infinitesimal.
I concur with the CDC and ADA positions. The science supporting universal precautions and barrier techniques is irrefutable. However, I would like to advance a proposition for those dentists experiencing excessive mental stress when called on to treat the HIV-infected patient. Please note that I limit my proposal to dentists who are sincerely fearful of the consequences of treating the AIDS patient, even though they are aware the risk is small. Excluded are dentists who would deny care due to certain
prejudices. On several occasions, dentists have confided to me that their fears of infectivity make it difficult-even impossible-to carry out an effective treatment plan. Forcing them to treat could cause damage to both pa-
tient and dentist. As one who finds it difficult to stand on a six-foot ladder without dizziness, I am sympathetic. How many dentists fall into this category? I don't know. There may be only those few who have spoken or written to me. Or there could be hundreds more too fearful to speak out. I would predict that most of these dentists, knowing the career-damaging consequences of their fears, would willingly offer treatment if they could control their anxieties. For dentists in this phobic state, chances are that many are mid-career. They entered the profession with no thought that they would ever be in a situation-no matter how small the risk-where they might contract a fatal disease. For such dentists, the profession should offer programs to help them
Only NSKeces control patient vector cross-infection at the source...IN _
following patient, thus nullifying the most rigorous autoclaving of the handpiece. ANSWR: NSK invented the Clean Head System to prevent such cross-infection. It consists of a labyrinth of air passages at the
OCLEANHEAD head of the p handpiece and a FACT: All conventional dental handpieces draw fluids and contaminants into
duckbill valve in the water spray tube of the
handpiece.
heads, couplings, hoses and dental units.
Research has confirmed the effectiveness of the NSK Clean Head System.'
Infective materials may enter the water tubing beyond the handpiece only to be blown back into the mouth of a
The labyrinth prevents the sucking back of materials, including viral matter, into
_
the turbine chamber and the duckbill prevents flowback of contaminated water from the handpiece into the water supply tube. The NSK Clean Head System is also available on NSK low speed handpieces, attachments and clinical motors. Every NSK clinical product is autoclavable. The NSK Clean Head System takes your professional precautions against cross-infection another step forward. Copies of the University Studies on the NSK Clean Head System are available on request from your nearest NSK distributor. NSK's Clean Head system limits internal contamination to the turbine labyrinth, expelling contaminated fluids immediately they enter the head. NSK's anti-water-retraction valve prevents contaminants from entering the water lines and dental unit.'
Distributed in America by:
NSK AMERICA CORPORATION
IAK
IAKANISHI INC.
700B Cooper Court, Schaumburg, Illinois 60173 USA Telephone: 847-843-7664 Facsimile: 847-843-7622 NSK009M2
1I LLI CTTEDQ ILOQ s s~; ^a^gb ^11;^~~~~~~~~~~ Wiwik I~~~~~~~~~~.
~~~~~~~~I.,.
~
!~ ~
I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~ ~ ~ ~
.WMF
~
wm
i
deal with their fears. Fear has not been an acceptable legal defense for failing to treat the HIV-positive patient. But anxiety and uncontrollable fear are legitimate psychiatric disorders. Unwarranted, illogical fear of a situation can, on the one hand, manifest itself in simple curtailment of normal function. On the other hand, it can produce extreme panic leading to illness or bodily injury. This editorial does not suggest that dentists who refuse to treat AIDS patients be allowed to use fear as a legal argument. What it does recommend is that the two, 20 or 200 dentists who legitimately are not in total control of their professional skills, hamstrung by their fears of HIV, be treated as phobic. Such treatment is available and often successful; 90 percent of phobias respond to therapy. Programs using accepted therapies-desensitization, behavior modification, visualization-can assist needy dentists, not punish them. Just as peer boards have been established to support the HIVinfected dentists, so should professional boards be created to assist those dentists who have nothing to fear but fear itself.
*ADA welcomes letters from readers on topics of current interest in dentistry. The Journal reserves the right to edit all communications and requires that all letters be typed, double-spaced and signed. The views expressed are those of the letter writer and do not necessarily reflect the opini