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Dentistry and the Ethics of Infection Author(s): D. Shaw Source: Journal of Medical Ethics, Vol. 34, No. 3 (Mar., 2008), pp. 184-187 Published by: BMJ Stable URL: http://www.jstor.org/stable/27720037 . Accessed: 08/01/2014 22:23
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Law,

ethics

and medicine

Dentistry and the ethics of infection

D Shaw
Correspondence to: D Shaw, Dental School, Faculty of Medicine, University of Glasgow, 378 Sauchiehall Street, Glasgow, G2 3JZ; d.shaw@dental.gla.ac.uk Received 21 June 2007 Revised 18 October 2007 Accepted 24 October 2007 Published Online First

ABSTRACT

INFECTED DENTISTS

in "invasive77 about work 10% of doctors Currently,any dentist in the UKwho is HIV-seropositive Only are interventions must stop treating patients. This is despite the fact that but almost all dental specialities,6 as exposure-prone a classified can B-infected with dentists low viral load (EPPs) by hepatitis procedures are to continue the DH.5 Doctors allowed continue to practise, and the fact that HIV is 100 times normally less infectious than hepatitis B. Dentists are obliged to working with patients if they are diagnosed as as are not in involved treat HIV-positivepatients, but are obliged not to treat any HIV-positive, they routinely on the other EPPs. Dentists, the end of face are if themselves hand, Furthermore, patients they HIV-positive. careers are to be their if they found infected: prospective dental students are now screened for are "Dentists HIV are not allowed to enrol on positive diagnosed required [by hepatitis B and C and HIV,and to their normal immedi work Bachelor of Dental Surgery degrees if they are infectious DH protocol] stop carriers of these diseases.

This paperwill argue that: (i) the current restrictionon HIV-positivedentists is unethical, and unfair; (ii)dentists are more likelyto contract HIV from patients than vice versa, and this is not reflected by the current system; (iii) the screening of dental students for HIV is also unethical; a dentist transmission between and his patient (iv) the fact that dentists can continue to practise despite are followed. one when proper procedures Only B but infected students infection, hepatitis prospective ever been dentist to have has confirmed infected are denied matriculation, is unethical; and (v) that the current Department of Health protocols, as well as being patients with HIV. David Acer infected five in the late 1980s, in Florida and was very patients unfair, have further unethical effects, such as intrinsically not all necessary probably taking precautions: the waste of valuable resources on 'lookback'exercises and the even more damaging loss of present and future transmission to The of HIV from David Acer dentists. Regulation in this area seems to have been concern on focused Bergalis Kimberly public driven by institutionalfear of public fear of infection, rather not on how HIV was who transmitted HIV, than any scientific evidence or ethical reasoning. was transmitted. What feared was the
person? a dentist, and by extension all physicians and a other healthcare what practitioners?not did or do not do. dentist HIV Personalising infection techniques infection Defining a removing It isworth Association diverted and attention behaviours from that the particular can

or more six years and to sacrifice of training ately career and any future income in from their chosen to protect order their patients.773 The is whether restric such question, though, tions do protect is very There actually patients. little that evidence is any there real risk of HIV

It

is

obligations patients unethical

generally of infected

accepted dentists with

that require bloodborne

the them

professional to treat such as

viruses

HIV and hepatitis B and C (HBV and HCV): "It is

for the a dentist to refuse that other to the treat a on solely bloodborne or grounds virus or any with at least person transmissible patient has disease

spread to particular of people. groups as the makes persons problem the persons the obvious solution.7 here that noting states that "there the American is no significant Dental risk

infection."12

diagnosed patients,

However, must HBV

are who dentists any refrain from treating and dentists with temporarily,

of contracting 4
provision precautions procedures the risk of of and are

bloodborne
dental recommended routinely reaction

disease
when

through

the

HIV

or HCV
dental and HCV

face
for

losing
several

their
have years,

treatment

livelihood.3
screened recent with

universal control fact, the

infection In

Prospective for HBV

students

been

followed77.8

Department
mending Those allowed that who

of Health
HIV also

(DH) guidelines
be included will on not Bachelor in

recom

risk of contracting HIV from a dentist

a fatal to penicillin

is less than
or a general

screening.5

test positive to matriculate

be normally of Dental

anaesthetic: the risk of dying from the latter is 1/ 10 000, while the risk of catching HIV from a dentist is estimated at 1/200 000 to 1/2 000 000.9
(Some the have questioned "at whether the classification

courses.5 that (It is worth Surgery degree noting the guideline seems to go too far, as above quoted it would be unethical for a dentist to refuse hardly to treat a patient who had an infection such as

of most dental procedures as EPPs is really justified

by evidence: to dentistry the moment same the definition applied is the as that for a cardiac recesses

Ebola.)

This
current in current that dentists unfairly,

paper will
DH guidelines, protocols current and and infected also

examine
and and

the
identify

justification
inconsistencies It will both dental

for

surgeon working by touch of the body cavity77.3)

in the

invisible

Although
dentists infected once seem 184 with their strange,

UK regulations prohibit HIV-positive

continuing are allowed HBV is under that "The to practice, to return control. dentists to This practice

the

practices. treats system prospective

be argued infected students

from

infection given

disadvantages

patients.

might risk of transmission of

J Med Ethics 2008;34:184-187.

doi: 10.1136/jme.2007.021972

This content downloaded from 132.206.27.25 on Wed, 8 Jan 2014 22:23:26 PM All use subject to JSTOR Terms and Conditions

Law,
HIV a clinical care worker is approximately 100 times less of hepatitis are B77.10 However, the reason that they to return to work allowed is that "under control77 that implies are no in its transmissible the virus form, they longer carrying from than that same is not true indicate careers of as viral does not to end transmis dentist is an avoidable distinction risk are

ethics

and medicine
own as

HIV-positive belief,

infinitesimal should infinitesimal, not

risk. My be

irrelevant, status.

however, as both

is that types other final

this of

regarded and patients

should not be informed of their dentists7 HIV

(There "lookbacks77 in the are reasons section). for

having a viral load <103 copies per ml; it has been argued that the
HIV, necessarily dentists7 non-transmissibility.11 because they might transmission when undetectability But is it ethical be suppressed but

(orHBV or HCV)
patients; see

telling

Another
records positive, name him. if an

issue is that dentists

yet when as regarded it would was

are obliged
in the

to keep patient
as HIV interest77 to

sible and thus might

no evidence of

transmit HIV to a patient, given that there is

suitable precautions are in

confidential, it is often Of course,

a dentist being be in the not on

is diagnosed "public interest public

to reveal

place? (It has been argued10 that HIV and HBV pose a similar overall risk because, despite being 100 times less deadly, HBV is 100 times as infectious as HIV, although it is far from clear that
this is an accurate does risk not risk It certainly a vastly calculation.) seem fair. As of from It is already an mentioned, anaesthetic to there than insist and is of that at

HIV-positive

doctor

antiretroviral

medication

and was
necessary

exposing patients
are

to the risk of transmission,

taken, the dentist's the

but if the
status as a

precautions being be paramount, should patient necessitating status. of his medical

confidentiality

catching HIV-negative the same

greater HIV from

dying a dentist. must that It entails

inconsistent

INFECTED DENTAL STUDENTS

as to meet well academic and rigorous having personal are also screened the in dental students UK criteria, prospective a for bloodborne viral infections. Several there was ago years minor HBV the of for about introduction controversy screening As for medical draconian These and measure seem dental and with students, the beginning been warnings of a that this was slope.613 recently a

dentists time insist

patients, HIV-positive cannot dentists HIV-positive is true that dentists themselves have a to more

treat

treat profes

patients. HIV-negative that sional obligation and of HIV more dentists. that

do not patients is that dentists the matter from patients HIV-infected It is natural than

exposing a similar have

risk, but the fact obligation, more are at much risk of catching are as there far vice versa, obviously there to be are afraid HIV-infected of catching

worries

to have

justified, healthcare

slippery as the DH

than patients for patients the

published
should students first year to their be

new
carried

guidelines
out on

setting
new

out additional
workers, out EPPs add HIV

checks

that

HIV, but they should be reminded that HIV-negative

clearly protect patients, knowing directions: believe they precautions the virus from the risk of catching them HIV have of whom may many (possibly work of course, it). And precautions, are taken, measures if all recommended transmission protocol EPPs until for HBV. risk of would his HIV This would and protect is also vanishingly that take are

dentists
from

sufficient

students (dental at university).5 healthcare (EPPs), Additional

carry routinely These guidelines who will

including from their to the list

that already included HBV and HCV.

For new workers additional health procedures undertaken. health perform clearance means exposure-prone also should being be

without in the both risk of

clearance

non

patient-dentist A reasonable refrain is the from case

small. a dentist control, from to as any and

infectious
antigen

for HIV
or,

(antibody
if positive,

negative),
e-antigen

hepatitis
negative

B
with

(surface
a viral

oblige temporarily was under infection

is already the modus operandi in North America (although to state in the USA)11: "In the USA and policies vary from state
Canada, normal additional and A for once example, their viral that HIV levels dentists positive are controlled must control adopt can continue the as and with one

significant

infection

protect patients dentists7 livelihoods,

or less) and hepatitis C load of 103 genome equivalents/ml (antibody negative or, if positive, negative for hepatitis C RNA).
checks should to an be EPP completed as the post, that these before confirmation worker of will an be healthcare

negative

These

appointment In practice, not does school: of they to this

ineligible if found to be infectious.5

this means satisfy one school's infection to who any criteria prospective will be states be that dental refused "Those to enter student entry who to are

proviso recommended further question,

they infection however, that are

universal

precautions dentists

dental carriers unless

website will not

procedures77.4 is whether practising cannot all the

allowed

training

respond

treatment.7714

should be obliged to tell their patients

Some consent undergoing transmission, HIV-positive. have unless argued they treatment, patients But as patients aware of and have already that a

that they are infected.

fully give risks that they small the if their risk informed run of HIV is from in

All
asked

13 UK dental schools were

information students. Of about the

contacted
their that four

for this paper and

screening responded, All procedures one only tests were where

provide for prospective all screened out tests

however right

did not screen for HIV

and for carried HIV

(although

this policy
and HCV. at except and were

is under review),
one school

to know the

dentist

tuberculosis,

HBV

mentioned,

risk of dying of these

penicillin
known This need

or anaesthetic
clinicians there

is higher,
do not are

and (beyond checking

warn that such (There the

for
risks.

to matriculation, prior in 2007 were introduced One the

allergies)

that suggests to be informed shaking

routinely risks certain consenting, hand.7

to matriculation. reported, was found of students Despite rejected, advertise mandatory. students they will Although protection regardless but

of before the dentist's

do not patients as the risk of an is also the point

given result from one HCV-positive to matriculate was allowed student positive. No of schools any number that reported infection. of most

subsequent school was after this

to be

a false

incidences

earthquake was known

that patients would

probably

find a new dentist

if their own

of to be HIV-positive, regardless that we be objected it might risk.) However, an anaesthetic, needs If a patient of risk. two different types to see a dentist, needs if a patient she needs; is what that then an hand risk of his to run the she needs during shaking she does to see a dentist, needs if a patient But earthquake. and Anaesthetics dentist.12 to see an HIV-positive not need earthquakes J Med are necessary infinitesimal risks, while 185 visiting an

lack of any real are talking about

because rejected being low the apparently be remembered it should in their

students dental

being schools

is that fact the screening prospectuses that many it is possible prospective that because are from applying they know discouraged to matriculate. be denied test and permission positive seem to be an acceptable the current system might an unethical it is really for patients, practice, are affected. students of how many actually Therefore,

Ethics 2008;34:184-187.

doi:10.1136/jme.2007.021972

This content downloaded from 132.206.27.25 on Wed, 8 Jan 2014 22:23:26 PM All use subject to JSTOR Terms and Conditions

Law,

ethics

and medicine

First of all, it hardly seems fair to deprive young adults of their

chosen taken, career need pose simply no they risk to patients.14 because have an infection many that, if care is Secondly, prospective

patients that their This losing dentist's

some dentist on

distress, had to the

even to quit second

assuming because point.

that he was Losing

they

don't

know

leads

HIV-positive. one dentist

is also

dental students will only just have passed their 16th birthday; while adult dentists must take responsibility for avoiding these
infections, any these infections probably thirdly, have been as a child potential can hardly when children students be held the that To who have contracted as they contracted. were one most And will HIV of responsible, was infection some

a valuable

but informing of their former resource, patients can also lead to waste status of resources. HIV-positive has led to "lookback77 exercises which

The

climate of fear surrounding HIV, despite the lack of any

evidence, to establish costly to any viral transmission patients rarer than in the This make these are now might past). terms future and of against protecting litigation use of NHS resources but the for patients, continuing when they have from dentist not to one produced single is patient questionable: case of if there was

scientific attempt (although sense in

it is quite possible born with HIV. or from

exclude from

prospective who anyone becoming

students

their mother

acquired a dental student

would
fault not of

be doubly unethical:
their own, safely. dental the and practise Just as

they would
be no qualified

be infected through no
reason dentists why they not should could be

reassuring such exercises HIV

there would

transmission

prohibited from practising if their HIV infection is under control,

prospective tion, with before students that should their condition viral be granted loads deferred are fully current matricula suppressed

The guidance given by UKAP [theUnited Kingdom Advisory

Panel Viruses, for Healthcare which DH Workers healthcare does not Infected with Bloodborne on how to advises workers have

the course. they begin is another There unethical

facet

of

the

Qualified
infection excluded

dentists
under from

can be afforded the time to get their HBV

procedures.

to work, control before are but those who returning not get another school might chance entry to dental under the current to the due of getting system, impracticalities treatment in time for entry. the point about (Of course, having no fault of their own the virus also acquired through applies here.) There will also be those who to test continue for the surface positive antigen, possibly same criteria are but students, their infection until delaying entry to both the for several qualified years. dentists to will the Technically, and prospective return to work if be denied

which implement policy] is safe legally and is to The open completely challenge. legal are "lookback" exercises terms and in monetary both costly It is difficult to see how distress for patients. psychological lookbacks clinicians that Of they that apart from assuaging anything supervising are active and ensuring doing something are to UKAP adhering guidelines.16 they in the current climate of increasing criminalisation achieve

a risk assessment

course, HIV

of HIV
that that But

transmission,

and given
easily would

the widespread

public belief

applied dentists have is under

is extremely health authorities clear that

they do the same. a student allow to begin test them might require ethical

alternative whether want to take the risk. Given the that prospective they possibility students who are infected know are from they being discouraged under the current seem fairer to itwould applying system, change the advertised criteria and allow students the chance to get their HBV infection under control and then matriculate. unfair is to allow HIV system changed to practise, it will be a grave if HIV positive injustice dental students continue to be restricted positive prospective from to become dentists. If that we will have training happens, a situation where suffer from a disease no people who through fault of their own are denied to a where entry profession people with that disease to practise continue because there is no rightly relevant risk of its transmission to That would be patients. New dental students should be told in advance triply unethical. that be given the chance to control they will any infection, whether or that is discovered.15 hepatitis HIV, Finally, dentists if the current

be argued that itwould for a profession in which training to but it seems stop practising, to allow to decide students prospective

control, It might

opportunity while students

it is not

it is understandable transmitted, want to maintain trust. public are the best way lookbacks of doing this;

entry to be unfair a future the more

educating
much more Finally,

the public about the extremely

cost-effective in cases where measure prospective dental

low risk might

students

be a

are refused

entry to a BDS degree, it is likely that (slightly) less well qualified students will take their places. This is unlikely tomake
any significant unfair of effect difference the current to standards of care, but is another system.

CONCLUSION
In conclusion, allowed undetectable currently HIV-infected enter BDS to the current DH guidelines once restore are

be changed. Firstly, dentists diagnosed as HIV-positive

return levels. skewed to This practice would their some dentist viral equilibrium

unethical,

and

should

should be
loads reach to the

balance

prospective courses,

of patient and dental students the proviso

rights. Secondly, should be allowed to their viral loads are

again with

that

undetectable
be offered

(the same applies to students diagnosed during their studies). Thirdly, HBV-infected prospective students should also
delayed treatment matriculation, and avoid EPPs on until the they condition that they are non-infectious.

undergo resources

And finally, the implementation

of these suggestions would

loss of dentists lookback enter from exercises, dental school.

save

RELATED UNETHICAL EFFECTS

Quite current apart from the also the aforementioned have loss related of good by intrinsic unethical dentists, the health procedures three main effects: resources, qualified First, current and dentists. it is obvious that dentists good 20 minutes of are being lost under the the unfairness, effects. There the are

the wasteful by obviating reduce the need for (if any exists) that the candidates best-qualified of risk is not the same perception and they should become not be allowed unethical.

the NHS, and ensure Patient of it, that

the

acquisition

of squandering service of worse

thing to influence

as scientific policies

evidence extent

to the

Funding: The writing of this articlewas funded by a grant from the Philosophical Quarterly. Competing interests: None.

dentist

an HIV test, a undergoing livelihood.4 More importantly, perhaps, the public has lost access to a dentist. to have good may They which necessitate change practices, might going private, given the current of NHS dentists. This will also cause the shortage

system. Within can have lost his

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2. 3. 4. 5. Singh A. Professional duties of dentists. In:Lambden P, ed. Dental Law and Ethics. Abingdon: Radcliffe Medical Press: 21-32. Croser D. Written off. BDJ 2006;201:497-9. Hancocks S. Losing your livelihood just twenty minutes from now (editorial).Brit DentJ 2006:201:485. Department of Health. Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcareworkers. March 2007 http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_073132 (accessed 11 Dec 2007). Lever AML Hepatitis B and medical student admission (editorial).BritMed J 1994;308:870-1. Ozar DT, Sokol DJ. Dental Ethics at Chairside. Washington: Georgetown University Press, 2002. American Dental Association. Policy statement on bloodborne pathogens, infection control and the practice of dentistry. Chicago: ADA, 1999. 9. 10. 11. 12. 13. 14.

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Bayer R. Discrimination, informed consent, and the HIV infected clinician. BritMedJ 1997;314:915. Blatchford 0, O'Brien SJ, Blatchford M, etal. Infectious health care workers: should patients be told? J Med Ethics 2000;26:27-33. Bagg J, TumimW. Achieving balance (letter). Brit Dent J 2006,201:740-1. Iam indebted to Justine Shaw for pointing this out. De Wildt G, Sweeney H. Moving away from rationalmedicine? BritMed J 1996:312:1367. University of Glasgow. Bachelor of Dental Surgery admission: other requirements. (accessed 11 http://www.gla.ac.uk/schools/dental/bdsadmission/otherrequirements/ Dec 2007). Gauntlett R, Bailey M. Hepatitis B and admission to medical school (letter). Brit Meo'J1994;308:1161. Martin MV. Illogicalguidance (letter). Brit Dent J 2006,201:87.

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187
J Med Ethics 2008;34:184-187. doi:10.1136/jme.2007.021972

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