Principles of Oral Health Management for the HIV/AIDS Patient

1. Principles of Oral HealthManagement for the HIV/AIDS Patient A Course of Training for the Oral Health Professional Made possible from a grant to the New York State Department of Health AIDS Institute from the HIV/AIDS Bureau, Division of Community Based Programs, Health Resources and Services Administration, DHHS

2. Module 1 Occupational Exposures to Bloodborne Pathogens: Risk, Prevention, and Management Jennifer L. Cleveland, DDS, MPH Barbara F. Gooch, DMD, MPH Denise Cardo, MD Helene Bednarsh, RDH, MPH Kathy J. Eklund, RDH, MHP

3. Summary • Risk for transmission is low • Preventing exposures is primary goal • Prompt reporting and management is essential • PEP may be effective in preventing HIV

4. Objectives • Documented vs. possible case of HIV infection • Risk factors for HIV transmission • Characteristics of PIs in dentistry • Three categories of prevention strategies • Considerations for PEP • Qualifications of a health care provider

5. Objectives • Need for prompt medical evaluation • Dentist/employer role • Elements of an exposure report • Importance of counseling • Issues of confidentiality • Ethical and legal considerations

6. Determinants of Risk • Prevalence of infection in patients • Risk of infection after single blood contact • Nature and frequency of blood contacts

7. Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS Infection CDC Database as of June 1999 Documented Possible Dental Worker 0 6 (*) Lab Tech, clinical 16 16 Physician, nonsurgical 6 12 Lab Tech, nonclinical 3 – Nurse 23 34 Other 7 68 Total 55 136 (*) 3 dentists, 1 oral surgeon, 2 assistants

8. HIV Seroprevalence, U.S. Dentists Author Flynn Klein ADA News Siew No. Pos.(%) 0 (0) 1 (0.09) 2 (<0.01) 0 (0) No. Tested 89 1132* >18,000 321 Location Sacramento,1987 ADA meeting and New York City,1986 ADA meetings, 1987–1998 AAOMS** meeting, 1992 * Community risk excluded ** American Association of Oral and Maxillofacial Surgeons

9. Average Risk of HIV Infection to HCWs by Exposure Route (%) • Percutaneous 0.3 • Mucous membrane 0.1 • Non-intact skin <0.1

10. Average Risk of Transmissionafter Percutaneous Exposure to Blood HIV Hepatitis C Hepatitis B (only HBeAg) Source Risk (%) 0.3 1.8 30.0

11. Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood CDC Case-Control Study Risk Factor Adjusted OR ratio (95% CI) Deep injury 15.0 (6.0-41) Visible blood on device 6.2 (2.2-21) Procedure involving needle 4.3 (1.7-12) placed in artery or vein Terminal illness in source patient 5.6 (2.0-16) Postexposure use of zidovudine 0.19 (0.06-0.52) Cardo et al., NEJM;1997;337:1485-90

12. Annual Number ofPercutaneous Injuries*1987–1993 Number 11.4 12 10 8.8 8 6.2 5.4 6 3.5 4 2.9 2.2 2 0 1987 1988 1989 1990 1991 1992 1993 *ADA Health Screening, per dentist

13. Characteristics of Percutaneous Injuries DentistsOral Surgeons – burs– wires – extraoral– fracture reductions – hands/fingers

14. Percutaneous Injuries AmongDental Workers (n=19) inCDC Needlestick Study, 1995 • One third of instruments visibly bloody at time of injury • Hollow-bore needles of smaller gauge (>18 gauge) • No deep puncture wounds

15. Prevention Strategies Categories • Engineering controls • Work practice controls • Personal protective equipment

16. Prevention Strategies Engineering Controls • Remove the hazard from the worker • Technology based, safer design of instruments

17. Prevention Strategies Work Practice Controls • Behavior based • Change the manner in which the task is performed

18. Prevention Strategies Personal Protective Equipment • Gloves, masks, protective eyewear • Puncture-resistant gloves and thimbles • Double gloves

19. Prevention Strategies Worker Education and Training • Strategies to prevent occupational exposure to blood • Importance of reporting exposure incidents

20. Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis (PEP) MMWR , May 15, 1998;47(No. RR-7) • Provide scientific rationale • Emphasize consultation with HIV Expert

21. Efficacy of PEP • Biologically plausible • Animal studies • Human studies • case-control • perinatal transmission

22. “in the absence of visible blood in the saliva, exposure to saliva from a person infected with HIV is not considered a risk for HIV transmission” MMWR 1998/Vol. 47/No. RR-7

23. Risk of Transmission Risk of Adverse Effects PEP

24. Unknown HIV Status of Source • Assess epidemiologically • Review medical records • Modify PEP if new information becomes available

25. Basic regimen For exposures with recognized risk of HIV transmission Drugs ZDV 3TC Expanded regimen For exposures with increased risk of HIV transmission Drugs Basic regimen PLUS Indinavir OR Nelfinavir PEP Regimens

26. Initiation of PEP • Start PEP as soon as possible after exposure • Hours rather than days • Regard as an urgent medical concern • Duration 4 weeks

27. PEP Safety and Toxicity • Monitor blood, renal, liver function • Subjective symptoms (nausea, fatigue, malaise) are frequent • 30%–50% cases stopped treatment

28. Possible Reasons for PEP Failures • Exposure to ZDV-resistant strain of HIV • High titer or large inoculum • Delayed initiation or short duration of PEP • Host factors, e.g., diminished immune response

29. Postexposure Management and Follow-up • Policy statement • Staff education and training • Identification of a health care professional

30. Policy Statement • Promote prompt reporting • Facilitate access to care • Ensure confidentiality • Consistent with OSHA and PHS

31. Staff Education and Training • Prevention strategies • Principles of postexposure management • PEP efficacy and toxicity • Importance of prompt reporting

32. The Health Care Professional • Qualified to manage, counsel, provide medical follow-up • Selected before exposure incident • Familiar with dental aspects of risk assessment and management

33. Wound Care • Clean wounds with soap and water • Flush mucous membranes with water • Avoid use of bleach and other caustic agents

34. Reporting System • Facilitate prompt and confidential reporting • Provide timely access to PEP • Designate knowledgeable personnel to • evaluate exposure • initiate referral to HCP • complete forms

35. Information Provided to HCP • Copy of the Standard • Description of the employee’s job duties • Report of the specific exposure incident • Route(s)/Circumstances • Results of source blood testing, if available • Relevant employee medical records

36. Elements of an Exposure Report • Date and time of exposure • Procedure details… where, when, how, with what device • Exposure details...route ,body substance involved, volume/duration of contact • Information about source patient • Exposure management details

37. Source Patient Identification and Testing • Document source in writing, unless • not feasible or prohibited by law • Contact source for consent for HIV testing and disclosure of results to exposed person • Maintain confidentiality

38. Testing of Exposed Worker • Baseline, 6 and 12 weeks, 6 months • Extending to 12 months optional • HCP will notify employee of results

39. Counseling • Employee’s infectious status • Potential risk of infection • Considerations for PEP • Results of and interpretation of tests

40. Education • Seek medical evaluation for acute illness (e.g., fever, rash, flu-like illness) • Prevent secondary transmission • no blood/tissue donation • no breast feeding • use sexual abstinence or condoms

41. Management of Exposures to HBV Need for postexposure prophylaxis and/or vaccination depends on: • HBsAg status of source • Immunization status of exposed person

42. Management of Exposures to HCV • Baseline testing for anti-HCV • Follow-up testing for anti-HCV and liver enzyme activity • No prophylaxis with IG or antiviral agents • Education on risk and prevention

43. Legal Issues Ethical Considerations Confidentiality

44. Summary • Risk for transmission is low • Preventing exposures is primary goal • Promptly report and manage exposures • PEP may be effective in preventing HIV

45. Sources of Additional Information • CDC Hospital Infections Program Home Page: http://www.cdc.gov/ncidod/hip/ • PEPline: toll-free 888-448-4911 • National Prevention Information Network: 800-458-5231

46. STEP 1:Determine theExposure Code(EC) Is the source material blood, bloody fluid, other potentially infectious material (OPIM), or an instrument contaminated with one of these substances? Yes No No PEP needed OPIM Blood or bloody fluid What type of exposure has occurred? Mucous membrane or skin, integrity compromised Percutaneous exposure Intact skin only No PEP needed Volume? Severity? Small(e.g., few drops, short duration) Large(e.g., several drops, major blood splash and/or longer duration) Less Severe(e.g., solid needle, superficial scratch) More Severe(e.g., large-bore hollow needle, deep puncture, visible blood on device, needle used in source patient’s artery or vein) EC 1 EC 2 EC 2 EC 3

47. STEP 2:Determine theHIV Status Code(HIV SC) What is the HIV Status of the Exposure Source? HIV negative Status unknown Source unknown HIV positive No PEP needed HIV SC Unknown Higher titer HIV exposure, e.g., advanced AIDS, primary HIV infection, high or increasing viral load or low CD4 count Lower titer exposure, e.g., asymptomatic and high CD4 count HIV SC 1 HIV SC 2

48. STEP 3: Determine the PEP Recommendation EC 1 1 2 2 3 2 or 3 HIV SC 1 2 1 2 1 or 2 Unknown PEP recommendation PEP may not be warranted Consider basic regimen Recommend basic regimen Recommend expanded regimen Recommend expanded regimen Consider basic regimenif setting suggests risk for HIV exposure