How safe is your dentist?

It was a tragic picture. How could a vibrant young girl be struck down by the HIV virus? The nation was mesmerized as the story of 22-year-old Kimberly Bergalis' battle with AIDS unfolded. AIDS (acquired immune deficiency syndrome) had long conjured up images of drug addicts in seedy alleys or of homosexual embraces in public bathhouses. And as transmission rates, steadily increased, authorities on AIDS continued to stress the following high-risk factors:

* Unsafe sex practices

* Intravenous drug use 

* Contaminated blood transfusions

But Kimberly Bergalis did not fit into any of these categories; she was not a drug user, had not had a blood transfusion, and had never had sex. When Kimberly and her parents accused her dentist, Dr. David Acer, of transmitting the HIV virus during a root canal procedure, the medical community was shocked. HIV was not supposed to be transmitted this way.

At a news conference at the National Press Club in August 1991, former U.S. surgeon general C. Everett Koop assured the public, "When standard infection control precautions are followed, the risk of a health-care provider transmitting HIV to a patient is zero for most routine medical and dental procedures."

Dr. Koop added, "AIDS is not easy to catch. You still have to do something risky to get it."

Studies have shown, however, that under certain laboratory conditions HIV is recoverable from environmental surfaces one to three days after drying, and the CDC has advised "dental personnel [to] assume that where blood and saliva are mixed there is a potential for transmission of HIV."

The fear of contracting AIDS during a dental procedure has prompted many to clamor for AIDS testing for health-care workers and for dentists to include negative HIV tests in theft business ads. But one problem with AIDS testing is that it tends to instill a false sense of security. The tests are accurate only at the time they are taken and do not reveal the health-care worker's HIV status a week, two weeks, or two months later. HIV antibodies are usually present within 6 to 12 weeks of infection, but a person may be capable of transmitting the virus before antibodies are detected.

"The problem is not solved by testing," says Dr. Phillip Ashiku, a dentist in northern California. "Rather, the concern of all consumers and healthcare workers should be adequate infection control. Without this, there is no guarantee that a blood-borne disease such as AIDS or hepatitis cannot be transmitted in the dental office."

The best prevention of transmission is precaution. The American Dental Association (ADA) and the Centers for Disease Control and Prevention (CDC) have long established guidelines for the use of barrier techniques in the dental office. But the reality is that these recommended procedures are not applied across the board.

Responsibility falls on consumers to help ensure that a visit to the dental office encounters as minimal risk as possible.

Many patients don't ask questions because they don't know what to look for or because they feel embarrassed to question their health-care practitioner.

Protective garments such as masks, gloves, face shields, eye wear, etc., are the most basic and obvious barrier techniques and should be the minimum barrier techniques. The Journal of the American Dental Association suggests the following precautions:

* The dentist should not conduct treatment in street clothes. A dental gown or smock should be worn and is to be changed at least once a day or when it becomes visibly soiled. Spatter from the use of rotary instruments can easily contaminate clinical attire. Long-sleeved gowns are preferable, as all exposed skin surfaces should be covered.

* Protective eyeglasses prevent infection. A disposable face mask should also be worn. Dr. Phillip Ashiku also recommends dental shields for added protection against spatter that could contaminate any open wounds on the dentist's face. Needless to say, the more your dentist is protected, the more protected you will be.

* In addition to handwashing before and after treatment, the dentist should wear disposable latex gloves. Antibacterial soap can remove surface microbes, but will not prevent the transmission of other more resistant viruses. The gloves should be discarded after each patient. Glove-- washing is not acceptable. To ensure that your dentist is wearing new gloves when working with you, you can request to have him or her put on the gloves in front of you.

"What many patients should also be aware of," says Dr. Elizabeth Ashiku, "is that when the dentist is gloved, he should not touch everything in sight, then put his hands in your mouth. This is a great way to transfer any germs from objects in the operatory to the patient."

Dr. Gordon J. Christensen, founder and senior consultant of Clinical Research Associates and a well-known lecturer in the clinical practice of dentistry, calls for foot controls on the sinks instead of hand-operated faucets to prevent "contaminating contacts with bare hands or gloved hands hundreds of times a day."

During the course of a work day, the dentist will probably have to readjust the light, open cabinets and drawers, and turn lights on and off many times. If he touches these objects then reaches back into the patient's mouth, cross-contamination is possible. The dental staff should wrap handles of light switches, doors, cabinets, and other objects they are likely to touch in wrapping that can be replaced after each patient.

* Dental hand pieces should be sterilized between each patient. Many dental offices attempt to disinfect the hand piece by cleaning the exterior and then soaking it in a surface disinfectant for 10 minutes. This is not sufficient as it does not disinfect the interior portion of the hand piece where blood and other debris often collect. Heat sterilization is the most effective and reliable way of sterilizing dental instruments. The burs (sharp drill bits) on the hand piece should also be sterilized.

"All noninvasive instruments that cannot be heat sterilized and are not disposable should be chemically sterilized," says Dr. Elizabeth Ashiku. "A minimum of 10 hours is needed for this. If your dentist says 10 minutes is enough, Forget it! However, instruments that puncture bone and gums must be heat sterilized."

The issue of AIDS transmission in the dental office has prompted more stringent guidelines from the Centers for Disease Control and Prevention, American Dental Association, and the Organization of Safety and Health Association (OSHA). In response to the AIDS issue, OSHA put out new standards that call for employers to have an "exposure control plan" that would inform employees of occupational risks of exposure and devise a procedure of dealing with incidents of exposure. In addition there should be "methods of compliance" that mandate the use of universal precautions, minimize exposure risks, and provide employees with adequate protective equipment. Employees should be offered free hepatitis vaccinations. Employers should incorporate information and training in dental offices, and postexposure evaluations and follow-ups that include testing, medical examinations, and counseling. This would increase health-care workers' awareness of infection control and self-protection.

The CDC also issued new guidelines that stress the use of mandatory barrier techniques in dental offices and emphasize the identification of infected health-care workers who practice inadequate infection control.

"The patient has the fight to a safe health-care environment," says Dr. Phillip Ashiku. "Patients should not be shy about asking detailed questions of their dentist."

The more informed and aware patients are, the greater their ability to insist upon effective infection control in not only dental offices, but in other health-care facilities.