From the dentist’s chair, remembering how they cried wolf

“Snazzy safety glasses,” I said to the dental hygienist who was just about to ask me to open wide.   Something about the pink rims caught my eye and led me to a remark that showed my age:

“I remember when dentists didn’t wear gloves, or masks, or eye protection.”

I not only recall the bare hands of my dentist circa 1970-1980, I also remember the hullabaloo from dentists when new federal regulations were proposed in 1989 requiring them to provide such protection for their hygienists.   At the time, the term “AIDS’ was less than 10 years old, and exposure to HIV in the U.S. was considered a death sentence.

The OSHA proposal was based in part on guidelines from the Centers for Disease Control and Prevention (CDC) on methods to reduce healthcare workers’ exposure to bloodborne pathogens, such as HIV and Hepatitis B.  The guidelines embraced the concept of “universal precautions” to protect against exposure to blood and other body fluids.   The CDC noted that in dental settings, saliva should be considered a hazardous body fluid because it is likely to be contaminated with blood during typical dental procedures.  The dentists scoffed.  No, they did more than scoff.

The sky was falling, and it would be the end of dental care as we knew it.  Children would be frightened by hygienists in surgical masks.   Gloves would hinder a dentist’s fine motor skills.   The excuses went on and on.   The letters flooded OSHA’s offices.  I worked at OSHA during the time and remember it well.  We answered letter after letter from Members of Congress who were writing on behalf of the dentists in their districts.   Why was OSHA killing the tooth fairy?

It was ridiculous at the time, and looking back, still ridiculous.

The American Dental Association (ADA) was leading the charge against OSHA’s bloodborne pathogens rule.  The ADA argued, among other things, that there was little evidence to show that dentists or hygienists were at risk of exposure to bloodborne pathogens.  “I don’t have any hygienists who’ve developed AIDS or contracted hepatitis,” the dentists would say.   Even if they admitted that they or their employees were at risk of exposure to bloodborne pathogens, the ADA insisted that dentists were highly trained professionals.  They could decide for themselves and for their employees if, or when gloves, masks for goggles should be worn.  Dentists didn’t need the government telling them how to run their businesses.

The ADA pulled out all the stops to try to avoid the OSHA regulation.   They participated actively in the public rulemaking process, organized letter writing campaigns and sought Congressional intervention.  In an op-ed published in the New York Times on November 12, 1989, New Haven, CT periodontist Avrum Goldstein expressed his opposition this way:

“…these regulations will bring about changes in the dentist-patient relationship and make it more difficult to practice dentistry.  By its nature, dentistry is an intimate occupation.  The dentist works within an inch of a patient’s head, probing sensitive, often tender areas of the patient’s body.  The mouth embodies our ability to smile, kiss, talk and eat—all very emotional qualities.  Patients needs a warm and trusting relationship with their dentist to help overcome fears and make necessary dentistry possible.  It will be more difficult to establish this relationship when the dentist is gowned, shielded, and masked.  [These barriers] will have a profound effect on the relationship between the dentist and patient.”

But shielding against deadly viruses with common sense protections would eventually trump arguments about emotions.  When the rule was finalized in December 1991, the ADA exercised their right under the OSH Act to challenge the rule before the U.S. Court of Appeals.  The court didn’t buy their arguments either.   In January 1993, the OSHA rule was upheld and would apply to dental practices.

Seeing my dental hygienists snazzy eye protection and matching gloves, the ADA’s opposition to OSHA’s bloodborne pathogens rule now seems so ludicrous.  But their claims about the demise of dentistry because of OSHA were just another in a long list of over-reaction to proposed worker safety regulation.  Some can probably be attributed to innocent misunderstanding, but others are orchestrated campaigns that spread false information to rally opposition to a new public protection.   (One recent example of the latter was the Farm Bureau’s attack on the Labor Department’s rule to protect young workers employed on farms from certain hazardous tasks.   Sadly, even the Obama Administration caved to their false claims.)

The Cry Wolf Project has compiled loads of quotes from industry representatives and others who alleged the terrible harm that will come from regulating wages, auto emissions, pharmaceuticals and other hazards.   Some date back decades, others are more recent.  A few key themes emerge from all the wolf cries: regulations are burdensome, costly and unnecessary.

During my next visit to the dentist, I’m going to ask him flat out:  are the steps you take to protect yourself and your employees from bloodborne pathogens burdensome, costly or unnecessary?

 

Comments

  1. #1 mandas
    May 7, 2013

    Whether or not the gloves are needed to protect the dentist from diseases is one thing, but I am just as concerned about being protected from any diseases that he may stick in my mouth.

  2. #2 Hamish
    May 8, 2013

    It would be nice, and more accurate, if you qualified your assertion to reflect the fact that not all dentists in the US were against these measures.
    I was practicing dentistry during that era and was already using universal precautions and was in favor of making it mandatory. I was certainly not alone.
    Having said that, I wonder if you could cite a clinical trial from that era showing that gloves and masks reduce the transmission of AIDS or Hep B in a dental setting.

  3. Hamish,
    You are correct to point out that not all dentists were opposed to OSHA’s proposed rule. From someone on the inside of the agency at the time, however, comments from dentists in support of the regulation were rare. The ADA’s campaign against the rule certainly felt like the vast majority of dentists were opposed to the OSHA rule.

    I’ve not done a literature search for a study examining the association between personal protective equipment in dental settings and AIDS or hepatitis transmission. I could certainly do that. In the next few months, OSHA will be publishing a “lookback review” on its bloodborne pathogens standard and it may provide that kind of information.

  4. #4 Hamish
    May 9, 2013

    I recall a lengthy exchange of letters between editorial board members of the Journal of the Canadian Dental Association and a dentist from South Africa from that time period. The journal representative (possibly Joel Epstein) was advocating for universal precautions while the South African dentist was insisting that there was little or no science-based evidence to support the initiative. I remember being surprised that the journals academic representative was unable to counter his arguments very well.
    The little bit of searching I did suggested to me that gloves, masks, and eye protection for the dental setting was poorly researched and the rationales were extrapolated from medical research: specifically surgery. Advocates had little to support the initiative other than common sense.
    As I said I was an advocate but not based on specific science.

  5. #5 Judith Weinberg
    Washington, DC
    May 10, 2013

    The “OSHA Fee” that shows up on my dentist bills, that no one has ever been able to explain to me — is that to cover the gloves and gowns that dentists and their staff now use? Bad, Bad OSHA.

  6. Are you serious?? Your dentist includes a line item called “OSHA Fee”?? That’s like a restaurant adding a line item on your check called “sanitation fee” to cover the cost of the hot water and detergent to clean the dishes.

  7. #7 john smith
    May 11, 2013

    Dr Monforton, your 2-decades-old scorn for the evil dentists would be buttressed more by CDC statistics demonstrating a drop in dental-acquired infections after introducing the face masks. Just saying the CDC won and dentists are still practicing is hardly evidence that the cost of the measure has been translated into public health benefit. Medical professionals spend an ever-rising percentage of time and spend an ever-increasing proportion of health care dollars satisfying government mandates imposed by earnest, well-intentioned fools and busybodies who sit in offices and decide how doctors should practice.

    And hardly ever –EVER –is someone held accountable for demonstrating the benefit. So please spare us your scorn for the dentists’ resistance to one more example of this unless you can also show us the stats on infections prevented. And then maybe we’ll find your scorn persuasive.

  8. #8 Judith Weinberg
    Washington, DC
    May 13, 2013

    Celeste, unfortunately I am serious. And I’m not the only one seeing these “OSHA fees” on dentist bills. See, for example:
    http://answers.yahoo.com/question/index?qid=20070713105109AAwJNQ1

  9. #9 john smith
    May 14, 2013

    Dr Monfort, how about a real response to the real issue here? The dentists correctly recognized this requirement would add $5-10 to the cost of dental care. Ms. Weinberg’s dentist is making that explicit in her bill. I am sure you are aware that Medicaid dental fees were not raised to cover this no-trivial cost. One of the public health outcomes of a mandated increased fixed expense for providers was to increase the unprofitability of Medicaid patients, who then and now have difficulty finding dentists who will accept Medicaid reimbursement. How many dentists stopped accepting Medicaid at the time of this regulation? How many infections were prevented and at what dollar cost? Your expertise in public health demands you recognize the validity of these questions when you choose to write on this topic.

    Or maybe next year you can engineer a regulation that all doctors wear a fresh pair of gloves when touching any patient. That will only add a dollar or two to the cost of each health care visit and I am sure that somewhere, sometime that will prevent an infection as well. The only difference between the two measures is the magnitude of the cost per benefit. And since some doctors will be seeing some patients in ten years, you can crow about how the troglodyte doctors resisted the march of public health progress but civilization didnt collapse.

    Pardon my hyperbole, but the tone and gratuitous one-sidedness of this column was unworthy of you. Please respond.

  10. John Smith,
    I’m not sure the one-sided view of this column is “unworthy” of me because i write a lot of one-sided columns. Setting that aside, look for a follow-up post on this topic in the future.

  11. #11 john smith
    May 14, 2013

    Thanks. Will look forward to it.

  12. #12 Brandon McBride
    www.drjohnbaron.com/
    May 17, 2013

    I’m with Mandas on this one. The gloves serve to protect both parties.

  13. #13 Middle Man
    UK
    June 20, 2013

    You might enjoy this about the experience of visiting the dentist:

    http://caughtinthemiddleman.wordpress.com/2010/05/26/the-dentists-chair/

  14. #14 Christine
    June 24, 2014

    Dentist should use stuffs like gloves, or masks, or eye protection. Not just for their own protection but also for their patients.