THE IMPACT OF TRANSMISSIBLE DISEASE IN THE PRACTICE OF DENTISTRY

1. THE IMPACT OF TRANSMISSIBLE DISEASE IN THE PRACTICE OF DENTISTRY dr shabeel pn

2. INTRODUCTION • Many diseases are encountered in dental practice. • The most common infectious disease we may encounter or give importance to in dental practice are bloodborne diseases or diseases that need transfer of body fluids such as blood or serum from the infected to the recipient.

3. INFECTIOUS DISEASES COMMONLY ENCOUNTERED IN DENTISTRY

13. ORAL LESIONS ASSOCIATED WITH INFECTIOUS DISEASE

14. HEPATITIS • Viral hepatitis refers to a primary infection of the liver. • Caused by any of the heterogenous group of ‘hepatitis viruses’ which currently consists of types A, B, C, D, E and G. • All the hepatitis viruses are RNA virus. • Except type B which is DNA virus. • HBV and HCV commonly causes occupational spread of infection. • Hepatitis mainly transmitted through Fecal-Oral route Transfer of body fluids either parenterally/sexual contact.

15. Diagnosis -detection for Ag- *IEM *ELISA *Isolation -detection for Ab- *IgM indicates recent infection * IgG -recent/remote infection and immunity. • Treatment • General Preventive Measures • Health education • Improvement of personal hygiene • Strict attention to sterility • Immunisation • Passive Immunisation • Active Immunisation • Plasma Derived Vaccine • Recombinant yeast hepatitis B

16. HEPATITIS C LESION HEPATITIS VIRUS

17. COMPARISON OF HEPATITIS VIRUSES

20. India with a population of approximately 1 billion stills harbors approximately 30 million HBV carriers. • HBV is responsible for about 68% of cirrhosis of liver and 80% of hepatocellular carcinoma in India.

21. HUMAN IMMUNODEFICIENCY VIRUS • NOT single factor has affected the practice of dentistry since the early 1980’s more than acquired immunodeficiency syndrome. • HIV is a condition where transmission occurs through contact with blood and other body fluids. • This disease was identified in June 1981 and has been the plague of the 20th century. • Initially seen among homosexuals later in all parts of society- heterosexuals, females and children.

23. The initial HIV infection progresses into a more severe and debilitating condition where it is associated with a variety of other infections and is called Acquired Immuno Deficiency Syndrome (AIDS) • In the EARLY stages- infection - may not be noticeable and may be accompanied by symptoms such as weakness, arthralgias or - even totally asymptomatic. • On progression- infection - may be associated with a variety of conditions.

24. HAIRY LEUKOPLAKIA ORAL CANDIDIASIS

25. Some of the ORAL LESIONS associated with HIV infection and AIDS – Hairy Leukoplakia, Kaposi’s, Sarcoma, Candidiasis, etc. • Systemic conditions associated with AIDS- protozoal, fungal, other viral and myobacterial infection. • Diagnosis • Detection of Ag • Test for p24 core Ag- represent acute/sero conversion • Detection of Ab • Screening test- ELISA • Confirmatory test- Western blotting

26. EXTENSIVE KAPOSIS SARCOMA KAPOSIS SARCOMA

27. Treatment • General Management • Treatment and prophylaxis of oppurtunistic infections and tumours • Immunorestorative Measures • Antiviral therapy • India is among the highest caseload of HIV infected people with about half the population in sexually active stage .i.e.15 years and above(0.3%). • Population of India is 1 billion and the population with HIV is 2.4 million.

29. First HIV case was detected in 1986 by Dr S. Solomon. • The spread of HIV in India has been diverse with much of India having a low rate of infection and the epidemic being more prevalent in the southern region and the far north-east. • Highest HIV prevalence rate in India • Far north-east i.e. Manipur, Nagaland- due to unsafe injection drug use, sex workers. • Southern states i.e. Tamil Nadu, Andhra Pradesh, Karnataka- due to sexual contact • West i.e. Maharashtra, Gujarat

30. In 2000 Larry Kramer, the co-founder of the AIDS Coalition to Unleash Power, reminded the world that AIDS crisis is more devastating than ever. • “Even if we were to find a cure tomorrow, millions and millions of people will die. You were all told this before it was too late. Now it is too late. So sit back and watch the destruction of world.” • Dealing with the HIV and its consequences may prove to be the greatest challenge ever faced by the dental profession. • The manner in which dentistry responds to this challenge may, to a large degree, shape dentistry’s FUTURE.

31. TUBERCULOSIS • Tuberculosis is one of the oldest infectious diseases known to humans. • Causative organism- M.tuberculosis • Transmission by inhalation of infective droplets expelled through cough by an infectious patient with active pulmonary disease. • Mostly affects lungs • But can virtually affect every organ system in the body. • TB is able to produce acute to latent chronic disease

32. TUBERCULOUSLUNGS ORAL TUBERCULOUS LESION

33. Diagnosis • Sputum AFB • Gastric lavage • BAL • Trans Bronchial Biopsy • PCR • Culture • ESR • Mantoux test • Treatment • Rifampicin • INH • Ethambutol • Pyrazinamide

34. Tuberculosis has been and continues to be taking a terrible toll on the Indian population. • Causes 3,64,000 deaths annually. • There were more than 1.8 million new TB cases in India in 2004. • It represents 1/5th of all TB cases worldwide. ORAL TUBERCULOUS LESION

35. RISK TO THE PATIENT • Health care workers; primarily physicians and dentists, have a 3 fold to 5 fold higher prevalence of HBV than the general population does. • HBV transmission had been well documented from dentists to patients. • Since the early 1970’s when serologic testing became available for HBV, the CDC had reported on 20 clusters of HBV transmission to more than 300 patient from infected health care workers. • In 12 of the clusters the health care worker did not routinely use gloves, and some reported skin lesions that could have promoted the transmission. • Nine of these clusters were linked to dentists or oral surgeons.

36. Most of the reports were before the acceptance of Universal Precautions. • The CDC suggested that “the limited no .of reports of HBV transmission from HCWs to patients in recent years may reflect the adoption of Universal Precautions and increased use of HBV vaccine. • Recent reports of HBV transmission from a health care worker to patients during performance of invasive, exposure-prone procedures are not among dentists, but refer to a surgeon who is HBeAg +ve and had not been vaccinated against HBV. • Factors of transmission were more likely related to irritations on the surgeon’s fingers and virus which may have escaped through tiny holes in the gloves was found in the glove washings.

37. However transmission from HIV infected dental health care workers to patients had not yet been reported. • HERPES transmission occur mostly from from dental hygienists to patients. • HCV transmission in health care facilities has also been documented. • Simultaneous transmission of HIV and HCV to a health care worker who sustained a deep needlestick injury from an HIV/HCV infected source patient in 1990 was reported. • Use of zidovudine was declined. • Researchers at the International Conference on Emerging Diseases convened in 2000 reported that Health Care Workers had a 20 to 40 times greater risk of contracting HCV from an accidental needlestick than HIV.

38. RISK TO DENTAL HEALTH CARE WORKERS • The first case of occupationally aquired HIV infection, by needlestick, was reported in Africa in 1984. • As of December 31, 1999, 56 health care workers had been reported to CDC as having a documented occupational transmission of HIV. • Among the documented cases • 48 reported percutaneous exposure. • 5 blood splashes to eyes, nose or mouth. • 2 percutaneous + mucocutaneous exposure • 1 reported an unknown route.

39. Reporting occupational incidents to agencies is important in tracking not just seroconversion but the routes and circumstances of injury as well. • CDC has 2 programs for voluntary reporting: • Incidents related to Known HIV infected source individuals reported to – The National Studies for Infectious Disease. • Documented HIV seroconversion reported to – local/state health department, which further reports to CDC. • Reports of medical device failures that may facilitate the injury should go to the FDA Medwatch program.

40. In February 1995, OSHA issued a guide to dental employer obligations as a follow-up to the bloodborne pathogens std in regard to occupational exposure. • The employer is obligated to provide, not perform, a confidential medical evaluation and follow-up by a licensed health care professional at no cost to the employee. • The medical services that the employee must be offered are counseling, collection and testing of the employees blood, post exposure prophylaxis and evaluation of reported illness. • The employer is obligated to pay the cost of treating the incident and not the cost of the subsequent disease should seroconversion occur. • The current U.S. Public Health Service recommendation is that health care workers who are exposed to HIV on the job should, in many cases, take zidovudine and other antiretroviral drugs after exposure to reduce their risk of becoming infected.

41. Most percutaneous injuries occurred outside the patient’s mouth, most on the hands of the dentist. Burs were the most common source(37%), followed by syringe needles(30%), sharp instruments(21%) and orthodontic wires(6%). • The best estimates of risk to health care workers: • 0.3% for HIV transmission from percutaneous exposures and 0.09% for mucous membrane exposures • 3-10% for HCV • 30% for HBV transmission from after percutaneous injury from an infected patient.

42. PREVENTION & INFECTION CONTROL • Even if cure is available, protection from the untoward effects and discomforts of each disease would be desirable. • Because many diseases can go undetected for long periods of time, the focus must be on preventing disease transmission from providers to patients, vice versa and between patient and family.

43. Methods for the prevention and infection control includes: • Medical history • Vaccinations • Protective Attire and Barrier Techniques • Handwashing and Care of Hands • Use and Care of Sharp Instruments and Needles

44. Disinfection in the Dental Laboratory • Use and Care of Handpieces, Antiretraction Valves, and Other Intraoral Dental Devices Attached to Air and Water Lines of Dental Units • Single-Use Disposable Instruments

45. Sterilization and Disinfection of Instruments • Cleaning and Disinfection of Dental unit and Environmental Surfaces • Use of Extracted Teeth in Dental Education Settings • Disposal of Waste Materials • Boil Water Advisories • Dental Unit Water Quality • Infection Control in Public Health Settings

46. WHEN CAN INFECTED CLINICIAN RETURN TO WORK?

50. LEGISLATION AND LITIGATION • Refusals to treat people with HIV/AIDS by dentists and other health care professionals may well be the most common and blatant form of discrimination against people with HIV today.