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Clinical Practice Guideline for an Infection Control/Exposure Control Program in the Oral Healthcare Setting
Medical Conditions and Work Restrictions

Course Author(s): Géza T. Terézhalmy, DDS, MA

Medical Conditions and Work Restrictions

Oral health care facilities shall have written policies to protect patients and OHCWs with latex allergies, to protect OHCWs who are susceptible to opportunistic infections, and to protect patients from OHCWs with transmissible infections.

  1. Background

    OHCPs and patients may become susceptible to latex-related adverse reactions, OHCPs may also develop acute or chronic conditions, which may predispose them to opportunistic infections, or OHCPs may acquire potentially transmissible infections. Such individuals should discuss the problem with their personal physician or other qualified authority to determine if the condition might affect their ability to safely perform their duties.

  2. Execution/ Compliance
    1. Minimize latex allergy-related health problems among OHCPs and patients.
      1. Reduce exposure to latex-containing materials by substituting non-latex products when appropriate and using appropriate work practice controls.
      2. Train and educate OHCPs to recognize signs and symptoms of latex-related adverse effects, i.e.,
        1. Allergic contact dermatitis
        2. Urticaria
        3. Angioedema
        4. Allergic rhinitis
        5. Anaphylaxis
      3. Monitor signs and symptoms of latex sensitivity among OHCWs and patients.
      4. Refer OHCP with signs and symptoms suggestive of latex allergy to a physician to confirm diagnosis.
    2. Minimize the exposure of OHCPs with acute or chronic diseases to patients who have been diagnosed with a transmissible infectious disease.
      1. Consult with personal physician
        1. Determine if condition(s) might affect ability to safely perform duties.
    3. Minimize the exposure of patients to OHCPs who have been exposed to or have been diagnosed with an infectious disease (Tables 1, 2, 3, and 4).
      1. Restriction criteria
        1. Mode of transmission.
        2. Period of infectivity.
        3. Level of circulating viral burden.
        4. Level of risk for the transmission of a pathogen in association with a procedure.
      2. Procedure-related risk for bloodborne pathogen transmission.
Oral healthcare-associated procedures according to
the level of risk for bloodborne pathogen transmission.
  • Category I: Procedures with minimal risk of bloodborne pathogen transmission
    • History-taking
    • Extraoral physical examination
    • Intraoral examination
      • Including the use of a tongue depressor, mirror, explorer, or a periodontal probe
    • Routine preventive dental procedures - not requiring the administration of local anesthesia
      • Application of sealants or topical fluoride
      • Prophylaxis – not to include subgingival scaling with a hand instrument
      • Orthodontic procedures
      • Prosthetic procedures
        • Fabrication of complete dentures
      • Hands-off supervision of surgical procedures
  • Category II: Procedures for which bloodborne pathogen transmission is theoretically possible but unlikely
    • Dental procedures requiring the administration of local anesthesia
      • Operative, endodontic, and prosthetic procedures and periodontal scaling and root planning
        • Use of ultrasonic instruments greatly reduce or eliminate the risk of percutaneous injury to the provider
        • If significant physical force with hand instruments is anticipated to be necessary, scaling and root planning and other Category II procedures could reasonably classified as Category III
      • Minor surgical procedures
        • Simple tooth extraction not requiring excessive force
        • Soft tissue flap procedures
        • Minor soft tissue biopsy
        • Incision and drainage of an abscess
    • Insertion of, maintenance of, and drug administration into arterial and central venous lines
  • Category III: Procedures for which there is a definite risk of bloodborne pathogen transmission or that have been classified as “exposure prone”
    • General oral surgery
      • Surgical extractions
        • Removal of an erupted or unerupted tooth requiring elevation of a mucoperiosteal flap, removal of bone, or sectioning of tooth and suturing
      • Apicoectomy and root amputation
      • Periodontal curettage, gingivectomy, and mucogingival and osseous surgery
      • Alveoplasty and alveoectomy
      • Endosseous implant surgery
    • Open extensive head and neck surgery involving bone
    • Trauma surgery, including open head injuries, facial fracture reductions, and extensive soft issue trauma
    • Any open surgical procedure with a duration of more than 3 hours, probably necessitating glove change
3. Criteria for recommended clinical privileges:
  1. No evidence of having transmitted infection to patients.
  2. Obtained advice from an Expert Review Panel about continued practice.
  3. Follow-up twice a year to demonstrate the maintenance of an acceptable viral burden.
  4. Follow-up by personal physician with expertise in the management of infections with bloodborne pathogens.
  5. Consulted with an expert about and strictly adhere to optimal infection control procedures.
  6. Agreed to and signed a contract or letter from the Expert Review Panel that characterizes responsibilities.
Table 1. Work Restrictions: HAV, HBV, HCV, and HIV Infections.
Infectious state Restrictions
HAV Acute infection Restrict from duty for seven days after onset of jaundice.
HBV and HCV
  • Circulating viral burden < 104GE/mL
    • Category I, II, and III procedures – no restrictions as long as the infected healthcare provider:
      • no evidence of having transmitted infection to patients
      • obtained advice from an Expert Review Panel about continued practice
      • follow-up twice a year to demonstrate the maintenance of a viral burden <104GE/mL
      • follow-up by a personal physician who has expertise in the management of HBV infection and who is allowed to communicate with the Expert Review Panel about the infected provider’s clinical status
      • consulted with an expert about optimal infection control procedures and strictly adheres to the recommended procedures
        • routine use of double gloving and frequent glove changes during procedures (particularly when performing tasks known to compromise glove integrity) for all instances in patient care for which gloving is recommended
        • agreed to and signs a contract or letter from the Expert Review Panel that characterizes the infected providers responsibilities
  • Circulating viral burden =104 GE/mL
    • Category I and II procedures – no restrictions as long as the infected provider meets the criteria noted above for infected providers with a viral burden of less than 104 GE/mL
      • Category III procedures – these procedures are permissible only when the viral burden is <104 GE/mL
HIV
  • Circulating viral burden <5 x 102GE/mL
    • Category I, II, and III procedures – no restrictions as long as the infected healthcare provider:
      • no evidence of having transmitted infection to patients
      • obtained advice from an Expert Review Panel about continued practice
      • follow-up twice a year to demonstrate the maintenance of a viral burden <5 x 102GE/mL
      • follow-up by a personal physician who has expertise in the management of HIV infection and who is allowed to communicate with the Expert Review Panel about the infected provider’s clinical status
      • consulted with an expert about optimal infection control procedures and strictly adheres to the recommended procedures
        • routine use of double gloving and frequent glove changes during procedures (particularly when performing tasks known to compromise glove integrity) for all instances in patient care for which gloving is recommended
      • agreed to and signs a contract or letter from the Expert Review Panel that characterizes the infected providers responsibilities
  • Circulating viral burden >=5 x 102GE/mL
    • Category I and II procedures – no restrictions as long as the infected provider meets the criteria noted above for infected providers with a viral burden of <5 x 102GE/mL
    • Category III procedures – these procedures are permissible only when the viral burden is <5 x 102GE/mL
Table 2. Work Restrictions: Measles, Mumps, and Rubella Infections.
Infectious state Restrictions
Measles

Post-exposure

Susceptible OHCP

 Exclude from duty from the 5thday after first exposure through the 21stday after last exposure
OR for 4 days after rash appears.
Acute infection Exclude from duty for 7 days after rash appears.
Mumps

Post-exposure

Susceptible OHCP

 Exclude from duty from the 12thday after first exposure through the 26thday after last exposure
OR for 9 days after onset of parotitis.
Acute infection Exclude from duty for 7 days after onset of parotitis.
Rubella

Post-exposure

Susceptible OHCP

 Exclude from duty from the 7thday after first exposure through the 21stday after last exposure.
Acute infection Exclude from duty for 5 days after rash appears.
Table 3. Work Restrictions: Herpes Simplex and Varicella Infections.
Infectious state Restrictions
Herpes simplex

Acute orofacial herpes

 Evaluate the need to restrict from the care of patients at high-risk until lesions heal.
Acute herpetic whitlow Exclude from duty until lesions heal.
Acute genital herpes No Restrictions
Varicella
(chicken pox)

Post-exposure

Susceptible OHCP

 Exclude from duty from the 10thday after first exposure through the 21stday after last exposure.
Acute infection Exclude from duty until all lesions dry and crust.
Varicella zoster
(shingles)

Post-exposure

Susceptible OHCP

 Exclude from patient care from the 5thday after first exposure through the 21stday after last exposure.
Acute infection
Healthy OHCP		 Cover lesions and restrict from the care of patients at high-risk until all lesions dry and crust.
Acute infection
Immunocompromised OHCP		 Restrict from patient care until all lesions dry and crust.
Table 4. Work Restrictions: Respiratory Tract Infections.
Infectious state Restrictions
Influenza and syncytial viruses Acute infection with fever Exclude from the care of patients at high-risk until acute symptoms resolve.

Group A

streptococci

 Acute infection Restrict from duty until 24 hours after treatment is initiated.
Mycobacterium tuberculosis PPD Positive No Restrictions
Acute infection Exclude from duty until proven non-infectious.
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