Dr Simon Parsons, dentolegal adviser at Dental Protection, looks at what is changing for dental practitioners as they renew registration with AHPRA
When renewing your registration with AHPRA, due by 30 November, dental practitioners will notice some changes to the declarations you make. This is due to the recent endorsement by the Australian Health Ministers’ Advisory Council (AHMAC) of guidelines developed by the Communicable Diseases Network Australia (CDNA).
The guidelines, Australian national guidelines for the management of healthcare workers living with blood borne viruses and healthcare workers who perform exposure prone procedures at risk of exposure to blood borne viruses, apply to all healthcare workers (HCWs), including dental practitioners and dental students.
The CDNA guidelines have also been endorsed by the Dental Board of Australia, consistent with the Board’s primary role of protecting the public and preserving public safety during dental treatment.
In implementing these guidelines, the Dental Board of Australia is proposing an additional set of complementary guidelines, which will be in the submissions phase until 1 November 2019, and released sometime after that.
Rationale for changes
Given that all healthcare practitioners have a professional and ethical responsibility of primum non nocere (first, do no harm), there is an implicit expectation that we prevent the transmission of blood-borne viruses from ourselves to our patients and co-workers. The CDNA guidelines are of particular relevance to:
- • Dental practitioners and students living with a blood-borne virus, specifically, Hepatitis B (HBV), Hepatitis C (HCV) and HIV
- • Dental practitioners and students who perform exposure-prone procedures
- • Medical practitioners involved in the ongoing care of the above practitioners and students.
The risk of transmission of a blood-borne virus (BBV) from an HCW to a patient or co-worker is very small, and there is a paucity of evidence in the literature demonstrating known transmission of BBVs from dental practitioners to their patients. Nevertheless, some risk exists, particularly when performing procedures where the gloved or ungloved hands of a dental practitioner could sustain an injury, resulting in transmission of the HCW’s blood and BBV into an open wound in a patient. Such procedures are defined as exposure prone procedures (EPPs).
As there is also a risk of an HCW contracting a BBV from exposure to a patient’s blood during treatment, the CDNA guidelines recommend that all HCWs are vaccinated against HBV and have this immunity assessed post-vaccination.
What are the implications of these changes at the time of registration renewal?
When applying for or renewing one’s professional registration, it is already a requirement that we declare any known impairment that might detrimentally affect our safe practice of dentistry. While a BBV on its own is not considered an impairment, a dental practitioner or student infected with HBV, HCV or HIV falls under this category as not complying with the CDNA guidelines and may pose a risk to public safety.
Notably, it will not be necessary to specify the nature of any BBV when renewing one’s registration, nor provide any evidence of blood test results (either positive or negative to BBVs). Practitioners will be required to indicate if they have complied with CDNA guidelines in the previous registration period and that they are committed to doing so going forwards. Accordingly, practitioners and students must take reasonable steps to know their own BBV status and should be tested at least once every three years, or more often if known to already be infected.
It is proposed under the draft Board guidelines that, in accordance with existing national law, the Board take action if a practitioner makes a false declaration. It is therefore recommended that practitioners have blood tests as suggested so that any declaration made is based on blood test evidence obtained within a compliant timeframe. Blood tests should also be performed to detect BBV after the occurrence of any actual or potential occupational exposure incident.
The CDNA guidelines specifically note that it is not a requirement for HCWs to disclose their BBV status to their employers. However, consistent with the guidelines, a dental practitioner who is not permitted to perform EPPs would be wise to explain this to colleagues and/or an employer, given the restriction this places on the scope of procedures able to be performed.
What do these new guidelines mean to everyday dental practice?
Practically, these guidelines have implications to dental practitioners and students.
Dental practitioners and students are able to practise dentistry and continue in any course of study while living with a blood-borne virus, subject to them complying with CDNA guidelines. There is no blanket restriction on practising if infected with HBV, HCV or HIV, but there are situations where a practitioner may not be able to practise specific procedures, or be prevented from practising more broadly (see the following points).
The CDNA guidelines do not restrict practitioners and students from performing non-EPPs, such as routine oral examinations using gloved hands and a mirror, due to the low likelihood of incurring the risk of exposures. This assumes that routine infection control measures are in place at all times.
However, it is conceivable that most dental practitioners and dental students will be performing clinical procedures that involve the use of sharp instruments and/or exposure to sharp tissues within the oral cavity. Unless one is performing a very limited scope of practice, it is likely that EPPs will be part of a HCW’s activities in the practice of dentistry.
EPPs in the dental setting include any procedures where one’s hands may be in contact with sharp instruments, needle tips or sharp tissues (such as spicules of bone or teeth). Examples mentioned by the CDNA include oral surgical and maxillofacial procedures (excluding highly mobile or exfoliating teeth), periodontal surgery, endodontic surgery, and implant surgery. Further examples, such as restorative dentistry, have not been specified in the guidelines, but might nevertheless fall into the broad definition of this category in some circumstances, such as where sharp metal matrices and burs are manipulated by hand.
When first diagnosed with a BBV, a dental practitioner or student must cease performing EPPs immediately and then seek appropriate medical care. Once the HCW’s viral load and infectious status are known, the medical practitioner overseeing the HCW’s management will advise if the HCW is able to practise EPPs, in accordance with the guidelines. There is no need for an infected dental practitioner or student to notify AHPRA if they are following their medical practitioner’s advice and are complying with the CDNA guidelines.
HCWs known to be infected with HBV, HCV or HIV must have regular and appropriate medical care to monitor their viral loads. The CDNA guidelines provide specific information on the frequency of blood tests necessary for infected HCWs and the viral loads at which practitioners will be unable to perform EPPs. Where an infected practitioner fails to attend for relevant medical care, refuses to have testing for viral load, or continues to perform EPPs when known to be excluded from performing EPPs according to the guidelines, the medical practitioner is required to notify AHPRA. The Dental Board may then choose an appropriate course of action to determine if the HCW poses a risk to the public. Should the practitioner be deemed to pose such a risk, the Board may elect to take further action such as suspension of registration, imposition of conditions, attendance at hearings or referral to a tribunal.
• Dental practitioners and dental students have a professional and ethical duty to prevent the transmission of blood-borne diseases to those in their care and their co-workers. They are expected to know if they pose a risk to others through periodic blood testing, with mandated testing requirements if known to be infected with HBV, HCV or HIV.
• Under CDNA guidelines, infected HCWs who do not perform exposure prone procedures may continue to provide clinical care to patients, provided routine infection control measures are in place at all times.
• Some practitioners should not perform exposure prone procedures, due to the risks their BBV status poses to the safety of others. These practitioners need to determine their compliance in consultation with their appropriately qualified medical practitioner.
• When applying for or renewing registration with AHPRA, practitioners are required to make a truthful declaration as to whether they have an impairment, including any arising from advice to not perform exposure prone procedures. Penalties may apply to those practitioners who perform these procedures when not permitted to do so under these guidelines, or who knowingly make a false declaration as to any impairment at the time of registration renewal.