Donald W. Marianos

Transmission of Human Immunodeficiency Virus in a Dental Practice

OBJECTIVE To determine if patients of a dentist with the acquired immunodeficiency syndrome (AIDS) became infected with human immunodeficiency virus (HIV) during their dental care and, if so, to identify possible mechanisms of transmission. DESIGN Retrospective epidemiologic follow-up of the dentist, his office practice, and his former patients. SETTING The practice of a dentist with AIDS in Florida. PARTICIPANTS A dentist with AIDS, his health care providers and employees, and former patients of the dentist, including eight HIV-infected patients. MEASUREMENTS Identification of risks for HIV transmission (if present), degree of genetic relatedness of the viruses, and identification of infection control and other office practices. RESULTS Five of the eight HIV-infected patients had no confirmed exposures to HIV other than the dental practice and were infected with HIV strains that were closely related to those of the dentist. Each of the five had invasive dental procedures, done by the dentist after he was diagnosed with AIDS. Four of these five patients shared visit days (P greater than 0.2). Breaches in infection control and other dental office practices to explain these transmissions could not be identified. CONCLUSION Although the specific incident that resulted in HIV transmission to these patients remains uncertain, the epidemiologic evidence supports direct dentist-to-patient transmission rather than a patient-to-patient route.

No Visible Dental Staining in Children Treated with Doxycycline for Suspected Rocky Mountain Spotted Fever

OBJECTIVE To evaluate whether cosmetically relevant dental effects occurred among children who had received doxycycline for treatment of suspected Rocky Mountain spotted fever (RMSF). STUDY DESIGN Children who lived on an American Indian reservation with high incidence of RMSF were classified as exposed or unexposed to doxycycline, based on medical and pharmacy record abstraction. Licensed, trained dentists examined each childs teeth and evaluated visible staining patterns and enamel hypoplasia. Objective tooth color was evaluated with a spectrophotometer. RESULTS Fifty-eight children who received an average of 1.8 courses of doxycycline before 8 years of age and who now had exposed permanent teeth erupted were compared with 213 children who had never received doxycycline. No tetracycline-like staining was observed in any of the exposed childrens teeth (0/58, 95% CI 0%-5%), and no significant difference in tooth shade (P=.20) or hypoplasia (P=1.0) was found between the 2 groups. CONCLUSIONS This study failed to demonstrate dental staining, enamel hypoplasia, or tooth color differences among children who received short-term courses of doxycycline at <8 years of age. Healthcare provider confidence in use of doxycycline for suspected RMSF in children may be improved by modifying the drugs label.

Multidrug-resistant Mycobacterium tuberculosis in an HIV dental clinic.

OBJECTIVE To investigate possible transmission of multidrug-resistant tuberculosis (MDR-TB) in a dental setting. DESIGN A retrospective, descriptive study of dental workers (DWs), patients, and practice characteristics. PATIENTS Two dental workers (DW1 and DW2) with acquired immunodeficiency syndrome and MDR-TB. SETTING A hospital-based (Hospital X) human immunodeficiency virus (HIV) dental clinic in New York City. METHODS To identify dental patients with tuberculosis (TB), patients treated in the dental clinic at Hospital X during 1990 were cross-matched with those listed in the New York City Department of Health Tuberculosis Registry. Mycobacterium tuberculosis isolates from both DWs and from dental patients with TB were tested for antimicrobial susceptibility and typed by restriction fragment length polymorphism (RFLP) analysis. Infection control practices were reviewed. RESULTS M tuberculosis isolates infecting DW1 and DW2 were resistant to isoniazid and rifampin and had identical RFLP patterns. DW1 and DW2 worked in close proximity to each other in a small HIV dental clinic in Hospital X during 1990. Of 472 patients treated in the dental clinic in 1990, 41 (8.7%) had culture-proven M tuberculosis infection. Of these 41, 5 had isolates with resistance patterns similar to both DWs; however, for four available isolates, the RFLP patterns were different from the patterns of the DWs. Sixteen of the 41 patients received dental treatment while potentially infectious. Dental patients were not routinely questioned about TB by dental staff, nor were all dental staff screened routinely for TB. No supplemental environmental measures for TB were employed in the dental clinic in 1990. CONCLUSIONS Our investigation suggests that MDR-TB transmission may have occurred between two DWs in an HIV dental clinic. Opportunities for transmission of TB among dental staff and patients were identified. TB surveillance programs for DWs and appropriate infection control strategies, including worker education, are needed to monitor and minimize exposure to TB in dental settings providing care to patients at risk for TB.

Transmission of HIV from infected health-care workers to patients.

The five patients of the Florida dentist remain the only cases in which HIV transmission from an infected health-care worker to patients during invasive procedures had been reported by 1991. In this instance, neither the precise mode of HIV transmission to these patients nor the reasons for transmission to multiple patients are known. However, even in the HBV outbreaks that have been investigated, the causes of increased transmissibility by the health-care worker are not always clear, and may include variations in the procedures performed, surgical or dental techniques used, infection control precautions taken, titer of the infecting agent, and the susceptibility of the patients to infection. The investigation of the Florida dentists practice is ongoing. Additional studies of the patients of other infected health-care workers are being conducted in an attempt to answer some of the remaining questions about the risk and circumstances which allow the transmission of HIV from infected health-care workers to patients.

State oral health infrastructure and capacity: lessons learned from other states

This paper discusses some preliminary findings from the Infrastructure Enhancement Project conducted by the Association of State and Territorial Dental Directors (ASTDD), which focuses on state oral health programs and their roles in addressing core public health functions and essential public health services. Findings from analysis of state data since 2000, surveys, reports, and key informant interviews substantiate the value of the following: a) state oral health surveillance; b) oral health improvement plans; c) collaborations and coalitions; d) evidence-based practices and evaluation; e) diversified funding; f) placement and authority of the programs and directors; and g) competencies versus staffing formulas. No single program model fits all the unique populations and political and economic variations among states. Each state is encouraged to use the many tools, resources, and best practices/lessons learned available through ASTDD, federal agencies, and national organizations to design effective and sustainable programs.