By Eve Cuny, RDA, MS
Needlesticks and other blood and body fluid exposures are rare events for most dental offices, but when they do occur, it is important to have a plan in place for appropriate and swift response. Exposures to blood may occur in dentistry when personnel accidentally stick themselves with a used sharp instrument or needle, experience a splash to the eyes, nose or mouth during patient treatment, or come into barehanded contact with contaminated equipment and surfaces. There are no confirmed cases of Human Immunodeficiency Virus (HIV) transmission from dental patient to dental personnel. However, the Centers for Disease Control and Prevention (CDC) identified six dental workers possibly infected occupationally.
Because there are no confirmed cases of occupationally acquired HIV in dentistry, we can assume the risk is quite low. This does not eliminate the need to collect information about the exposure, discuss the incident with the patient and seek appropriate medical follow-up. In addition to the risk of HIV, blood exposures also carry a risk of transmitting hepatitis B virus (HBV), hepatitis C virus (HCV) and any other bloodborne disease.
The Occupational Safety and Health Administration (OSHA) has very specific rules within the Bloodborne Pathogens Standard regarding the steps to follow if an exposure occurs. In order to comply with these requirements, the dental office must be prepared to respond before an exposure happens. It is extremely important to seek medical follow-up as soon as possible after the exposure occurs and this does require preplanning. Preparation includes:
- having a designated person within the office to whom the exposed worker reports the incident;
- providing immediate first aid, including antiseptic and eyewash stations for splashes to the eyes;
- having a form on which to collect the OSHA-required information (Page 1 on the .PDF);
- contacting a qualified health-care professional that understands the proper treatment for exposure incidents; and,
- contacting the office worker’s compensation insurance carrier to determine if they cover exposure incidents.
The designated responder is the person that everyone knows to go to if there is an exposure incident. This person should collect information to assist the evaluating health-care professional in assessing the exposure (Page 1 on the .PDF), and interview the source patient, if the patient is available. OSHA requires that the employer request the patient submit to testing for bloodborne diseases. The testing is at the expense of the employer and the patient does have the option of refusing testing. The test results are specifically for the evaluation of the risk the exposure may carry, and is not for the patient’s dental record. The test results should go only to the evaluating health-care professional that the exposed worker sees for postexposure counseling. There should also be at least one other person trained to respond to blood exposures in case the primary designated responder is not in the office at the time of an exposure incident.
If the exposure is a blood or body fluid splash to the eyes, thoroughly rinse the eyes with running water. The best method of delivering running water is by installing an eyewash station. These may be freestanding or attach to an existing water faucet (page 2 on the .PDF). Activate the eyewash station and holding eyelids open with finger, allow the water to have direct contact with the eyes.
If the exposure is a stick with a contaminated needle or instrument, first remove the item from the instrument tray to ensure no one reuses it on the patient. Next, remove gloves and wash the wound with soap and water. If desired, apply an antiseptic such as Betadine. Do not use disinfectants or bleach on skin. Do not try to “milk” the wound since this has no beneficial effects and will simply aggravate the skin around the wound.
Qualified Health-care Professional
The person to provide counseling and medical follow-up is the qualified health-care professional. The appropriate provider for exposure incidents is an occupational health physician or occupational health nurse. Often, hospitals have occupational health or occupational injury clinics where dental personnel can go for follow-up of exposure incidents. It is important to locate a health-care professional before an exposure occurs to determine if they accept referrals and obtain instructions regarding information they require, if they will perform testing on the patient, if they accept insurance, and their hours of operation. Ask the health-care professional if they follow the latest CDC guidelines for postexposure management and if there is an alternative referral for after-hours exposure incidents.
The CDC guidelines provide comprehensive, yet complex instructions to the health-care provider that manages the medical follow-up for exposed workers. The CDC guidelines include recommendations for management of exposures to Human Immunodeficiency Virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV), and assist in making decisions concerning the use of postexposure prophylaxis (PEP). In September 2005, the CDC updated the guidelines for HIV exposure management. The 2005 guidelines modify and expand the recommendations for antiretroviral drugs, emphasize the need for prompt management of occupational exposures to blood and body fluids, distinguish between types of exposures, discuss issues of drug regimens, drug interactions, and consultation with experts, and HIV rapid testing, counseling and follow-up of exposed health-care workers.
Most significant to remember is that an occupational exposure to blood or other potentially infectious materials is an urgent medical concern for which the exposed worker should receive immediate appropriate medical attention. For HBV, postexposure management depends on whether or not the exposed worker is immune to HBV. Workers with immunity to HBV, either through vaccination or past infection, will not require additional treatment.
There is no vaccination or effective postexposure treatment available for HCV. It is still important to establish whether the source patient is positive for HCV. This information will determine the medical follow-up, testing and counseling. The only treatment available for HCV infection is to treat early disease if it occurs after an exposure to blood known to contain hepatitis C.
Management of an HIV exposure includes an assessment of the risk of disease transmission. The depth of the injury, the amount of blood involved and the nature of the source patient’s HIV status affect the risk. The same antiretroviral medications prescribed to treat HIV disease are also useful for postexposure management. Only a qualified health-care professional can determine which medications, if any, are appropriate for a given exposure incident.
While prevention of exposure remains the primary strategy to prevent transmission of bloodborne pathogens, prompt reporting and appropriate medical follow-up are essential to managing an exposure should one occur. A rapid HIV test gives preliminary results in about 20 minutes. This rapid result allows the evaluating health-care professional to make a decision as to whether or not to offer medications or further testing. Certainly, if the patient is not HIV positive there is no indication for the medications.
As you can see, the management of exposures to blood is a complex issue that requires preplanning and the assistance of medical personnel. The best defense is to take steps to prevent exposures by using appropriate protective attire, handling sharp instruments carefully and instituting safety devices where available.
Eve Cuny, RDA, MS is the Director of Environmental Health and Safety and Assistant Professor in the department of Pathology and Medicine at the University of the Pacific School of Dentistry. Ms. Cuny is a consultant to the ADA Council on Scientific Affairs. She is a nationally recognized expert in infection control in dentistry, publishing and lecturing widely throughout North America. She acts as an advisor for numerous agencies including the Centers for Disease Control and Prevention, Cal/OSHA, and the California Dental Board. She is past chairperson of the Organization for Safety and Asepsis Procedures (OSAP).