Gonzalez, Cesar D.

Pruhs, Ronald J.

Sampson, Elise

English

epublications@Marquette

Marquette Universitye-Publications@MarquetteSchool of Dentistry Faculty Research andPublications Dentistry, School of3-1-1994Clinical Occupational Bloodborne Exposure in aDental SchoolCesar D. GonzalezMarquette University, cesar.gonzalez@marquette.eduRonald J. PruhsMarquette UniversityElise SampsonMarquette UniversityPublished version. Journal of Dental Education, Vol. 58, No. 3 (March 1994): 217-220. Publisher link.© 1994 American Dental Education Association. Used with permission.Clinical Occupational Bloodborne Exposure in a Dental School Cesar D. Gonzalez, D.D.S., M.S.; Ronald J. Pruhs, D.D.S., M.S.; Elise Sampson , L.D.S., R .C.S. Drs. GonzalezandPrullsare 111 dre DepartmerztofDeveJopmentaJSctences and Community Heallh. and Dr. Sampson is In the Departmenl of Diagnostic Sciences aO at Marquette University, School of Dentistry. Please setJd C01Tespont:lena and reprintreqtii!Ststo:Cesarn Gonzalez,D.D.S.,MS.,DepartmentofDevelopmentaJSclena!sandCommunltyHeaJJh,Marquette University, School of Dentistry, 604 N 16th Stree( MUUXII.Ikee, W153202. I n recent years, infection control procedures designed to minimize the risk of transmission of infection between health care workers (HCWs) and patients have received increased attention. Of particular concern to dental health care w o rkers ace the pathogens human im-munodeficiency virus (HIV) and the hepatitis B virus (HBV). Both ace bloodbome pathogens also found in saliva, and other body fluids.1-6 Because of the invasive nature of many dental p rocedures, the use of sharp instruments, and the potential for blood contact, particularly parenteral b lood contact, dental providers, dental students, andsta.ffarepotentiallyatriskofbecominginfected with a bloodboroe pathogen such as mv or HBV via an occupational exposure. A recent study of dentists at the health screening program of an American Dental Association annual session esti-mated the annual occupation related injury rate among these dentists to be 3.21 injuries per year.' Although similarities between modes of trans-mission ofHIV and HBV have been recognized, the risk of acquiring HBV infection i.s greater. Follow-ing a percutaneous exposure to HBV, the risk of acquirin_g the infection ranges from 6 percent to 30 percenttf·9 while a percutaneous exposure to HIV results in a 0 .36 percent risk of acquiring the infec-tion.10 Few data exist regarding bloodborne occupa-tional exposures among dental care providers in a dental school. The objective of this stUdy is to describe the frequency, type, and distribution of clinical occupatio nal exposures among dental stu· dents, dental hygiene students, dental staff, and faculty at Marquette University School of Dentistry in the academic years 1989·90, 1990-91, and 1991-92. MErnons -------Exposure inddents at the dental school are reported to the Clinic Director and/or to the Infec-tion Control Officer and an incident report i.s com-pleted Information for this study was taken from the exposure incident reports for the 1989-90, 1990-91, and 1991-92 academic years. Each inci-dent report included the following information: type of worker exposed (e.g., dental student, dental hygiene stu<knt, etc.), gender, date of exposure, operatory site of exposure, type of exposure, health information of the patient involved, and exposed person medical follow-up. Additional open-ended information was solicited and docu-mented on some of the reports; for example, when and row the exposure occurred. For this report occupational exposures ace defined by the Occupational Safety and Health Act (OSHA) standard, which is "skin, eye, mucous membrane, or _parenteral contact with blood or other potentially infectious materials that may re-sult from the performance of an employee's du-ties. •It Three types of exposures were recorded: percutaneous exposure (needlestick or other in-jury with sharp instrument), cutaneous exposure (prolonged skin contact with blood/bOdy fluids or VOL. 58/NO. 3/ 1994 • j OURNAL OF D ENTAL EDUCATION ---------- 217 Table 1. Reported Occupational Exposures at Marquette University by Type of Worker, 1989-92 (Fisher's Exact Test at level P <0.05) . Type of Worker Dental Students (OS) Dental Hygiene Srudents (DHS) Clinical Staff Clinical Faculty 1989·90 n• (total) %s 4 (263)•• 1.5 1 (26l 3.8 •Number of reported exposures per group, per academic year. Academic Year 199().91 n• (total) %s 18 (231).. 7.7 2 (30).. 6.6 2 (23)* 8.6 1 (256). 0.4 1991·92 n• <total) %s 19 (195).. 9.7 1 (36)•• 2.7 3 (22)* 13.6 •'Total number of sophomores, juniors, and seniors enrolled ln pre-clinical and c llnlcal work (DS) and (DHS). ~Percem of reported exposures per group, per academlc year. Total number of clinical staff and clinical flculty (fulJ. and part-time). contact of broken skin with blood/body fluids), and mucous membrane or corneal exposure (splashes to mouth, eyes or other mucous mem· branes). Distributions were compared for signifi· cance using the Fisher's Exact Test at< 0.05. RESULTS--------· A total of 51 occupational exposures were reponed to the Clinic Director or Infection Control Office during the period of the study. Five expo-sures were reported in the 89·90 academic year. Occupational exposure reports increased signifi· cantly (p < 0.05) with 23 exposure reports in each of the last two academic years of the study (1990-91 and 1991-92). Dental students reported 41 occupational ex-posures (80 percent). Dental staff reported six ex-posures (12 percent). Dental hygiene students reported three exposures (6 percent) and faculty reported one exposure (2 percent) (Table 1). Sophomore dental students reported one labora-tory related exposure (2 percent). Junior dental students were responsible for most of the exposure reports with 23 ( 45 percent) while senior dental students reponed 17 exposures (33 percent). The difference between the number of exposures re-ported by junior and senior dental students was not significant (p < 0.05). Of the 51 occupational exposures reported, 50 exposures (98 percent) were percutaneous in· juries. Only one exposure (2 percent), a corneal injury, was not percutaneous. Of the 50 percutane-ous injuries, needlesticks were the most common with I8 injuries reported (36 percent). Nine ex-plorer injuries accounted for 18 percent of reports. Seven scaler injuries accounted for 14 percent. Seven laboratory rclated injuries also accounted for 14 percent. Four dental bur injuries accounted for 8 percent. Other instruments accounted for the remaining I 0 percent including crown removers with two exposures and elevators, blades, and cavitron tips with one exposure each. More than half of the occupational exposures (28) occurred in restorative clinics (operative, fixed prosthodontics, removable prosthodontics, and endodontics). In these clinics, needles ac-counted for 13 exposures. Explorers accounted for siX exposures, dental burs four exposures, scalers two exposures and other instruments (crown re-tooVer, cavitron tip) three exposures. Five expo-sures (10 percent) occurred in the periodontal clinic and three exposures (6 percent) occurred in the dental hygiene clinic. In these clinics scalers were the most common cause with five exposures. Needles accounted for two exposures and there was one corneal exposure. Seven exposures (I 4 percent) occurred in the laboratory. Five exposures (10 percent) occurred in oral surgery. Needles accounted for three exposures, explorers one ex· posure, and other instruments (elevator) one expo-sure. Two exposures ( 4 percent) occurred in the patient screening room and one exposure (2 per· cent) in the locker room. Dlsa.JSSION------~ In a retrospective analysis at Marquette Uni· versity School of Dentistry, the frequency, type, and distribution of clinical bloodbome occupational exposures in three academic years were studied The number of reported exposures increased al· most five times in the second academic year and stayed the same in the third. The authors believe the reason for the increased number of occupa-tional exposure reports in the last two academic years was a result of increased awareness among dental students, faculty, and staff of the possible consequences of bloodborne disease exposures in their workplace and a better knowledge of the school's Infection Control ProtocoL A prior study involving practidng dentists reponed that a~. ex~erience, and skill were not related to injury rate. The data from the present study support this finding since no significant dif· ference was found in the number of exposure ind-dent reports between juniors and seniors in the three years of the study. Comparison between stu-218 JOURNAL OF DENTAL EDUCATION • VOL. 58/NO. 3/ 1994 dent and faculty exposures was not possible be-cause of limited faculty/ patient contact. The results of this study show that among dental students at Marquette University, needlestick injuries were the most common form of occupa-tional exposure_ This finding is different from a study performed at the University of Texas Health Science Center at San Antonio, Dental Scbool12 where lacerations were the most common form of occupational exposure and needlestick injuries were second. A recent survey of dentist partici-pants and non-participants in the health screening program at the American Dental Association's an-nualsession ( l987through 1991),7 reported dental burs as the most common source of injury (37 percent), followed by syringe needles (30 percent). A retrospective analysis of occupational injuries at Bristol Dental Hospital between 1980 and 1988 found sharps injuries to be the most common type of occupational ex:rosures with 55 percent of all recorded injuries. 1 A study of 144 Scottish general practitioners w ho were questioned about the number of needles-tick injuries received over a three-year period, re-ported 80 percent receiving at least a single injury.14 This compares with 60 percent of 543 Irish dentists15 and 71 percent of 325 Malaysian dentists t6 who received such injuries within simi· 1ar time spans. These findings are similar to studies of medical pecsonnel. 17-20 Junior and seniordentalstudentsat Marquette University School of Dentistry spend approxi-mately 80 percent of their clinical time performing restorative procedures. As a result, the majority of exposures occurred in restorative clinics. This re-sult is similar to findings reported in a previous study of practicing dentists? The open-ended portion of the incident re-ports indicated that DL'l11Y of the needlestick expo-sures occurred because of improper needle recapping and disposal techniques. In addition, some injuries also occurred at clean-up time. Heavy dUty gloves, required bytheschool's lnfection Con-trol Protocol were used only sporadically. The use of needle disposal units in clinic areas as well as information given to students and staff regarding correct ways to recap needles (e.g. , scoop method) are preventive measures that were implemented and reinforced subsequent to this report. The effect of these preventive measures, implemented at the Marquene University School of Dentistry, is yet to be investigated. Some controVersy e:xists concern-ing whether or not adherence to Universal Precau-tions (UPs) reduces the risk of occupational exposures. A few studies have reporterl that UPs alone are not sufftcient to reduce the risk of nee-dJestick or other sharps injuries.2 1•22 However, Wong et al,23 reported a 62 percent reduction in the frequency of needlestic k injuries after the im-plementation of UPs. Other studies that have fo-cused on the epidemiology of needlestick injuries suggest that placement of puncture-resistant nee-dle disposal units at the site of use can prevent certain types of needlestick injuries, especially those due to recapping, transport of uncaf:rsoo needles, and improper disposal techniques. 2 • 5 1be one occupational exposure that was not percutaneous is worth special notice. A student had removed his safety glasses and was exposed to a mixture of local anesthetic and aspirated blood by being squirted in the face when a faculty member placed the anesthetic syringe onto the bracket table after injecting the patient for the student. This study serves to identify high riSk clinical procedures and clinical areas for bloodbome occu-pational exposures at a dental schooL It under· scores the frequency of risk encountered by students, staff, and faculty and emphasizes the need for increased diligence in seeking to reduce this risk. References 1. Heathcote J, Cameron CH, Dane OJ. Hepatitis B antigen ln saliva and semen. Uocet 1974; 1:71·3. 2 . GroopmanJB, Salahuddln SZ, Sarogadharan MG, et at. HfL v .m ln saliva of people with AIDS related complex and healthy homosexual men at risk for AIDS. Science 1984;226:447·9 . 3. Ho 0 0 , Byington RE, Schooley RT, Flynn T, Rota TR, Hirsch MS. lofrequeocyoflsobtlon ofH'nV-m virus from saliva to AIDS. N EoglJ Med 1985;3 13:1606. 4. <Ailo RC, Salahuddln SZ, Popovic M, et at. Frequent detection and lsobtloo of cytopathic retrovirus (till. V·ITI) from pat ients with AIDS and at risk for AIDS. Science 1984;224:5ro3. 5. Brodersen M, Stegmann S, Klein KH, TrulzccU 0, Rensch P. Salivary HBAg detected by radioimmunoassay. Uocet 1974; 1:675-6. 6. VUiarejos VM, Vtsona KA, Gutierrez A, Rodriguez A. Role of sallv2, urine, and feces In the transmission of rype Bhepatllls. N EogJJ Med 1974;291:1375-8. 7. Slew C, Chang S, Grulolnger SB, et at . Self-reported percutaneous Injuries to dentists: Implications for HBV, HJV transmission risk. J Am De nt Assoc, 1992 ; 123:3744. 8. Seem LB, Wright EC, Zimmerman tU, et at. Type B hepatitis after needlestlck exposure: Preveolloo with hepatitis B lmmunoglobuUo. Ann Intern Med 1978;88:285-93. 9. Gr.ldy GF, Lee VA, Prince AM, e t at. Hepatitis B lmmuooglobulln for accldentlll exposures among medical personnel: Float report or a multicenter controlled trial . J Infect Dis 1978; 138:625-38 . 10. Tok:ars Jl , Marcus R, Culver DH, et at. Survey of HJV lofectJoo and ZJdovudloe use among health care workers after occupat io oat exposure to HJV.Jofected blood. Ann l.tt Med 1993; 118:9 13-9. 11. Occupational exposure to bloodbome pathogens. Pioal Rule, 29CI'R part 1910. 1030 Federal Register 1991 ;56:64175-82. 12. CononeJA, O!Uard RL, Dove SB. Frequency of percutaneoos Injuries to dental care providers.} Dent Educ 1992;56:34, 114. V OL. 58/NO. 3/ 1994 • jOU RNAL OF D ENTAL EDUCATION 219 13. ~rter KM, Scully C, PorterS, Theyer Y. Needlestlc.lc injuriesto dental staff. BrDentJ 1989;167:265-6. 14. SamaraoayakeLP, Lamey PJ, Mcfarlaoe TW, Glass GWJ. Attitudes of general de ntal practitioners towards the hepatitis B vaccine. Comm Dent Oral Epidemlol 1987; 15: 125·7. 15. McCartan BE, Samaraoayalce LP. Awareness and acceptance of hepatitis B vaccine by Irish denl.a.l practitioners. J Ir Dent Assoc 1987;33:3~. 16. Yaacob HB, Sama.ra.oa.ya.lce LP. Awareness and acceptance of the hepatitis B vaccine by denl.a.l practitione rs in Ma.la.ysia. ) Oral Pathol Med 1989; 18:236-9. 17. Wormsen GP, Rabkin CS, Jollne C. Frequency of nosocomial transmission of HIV Infection among health care workers. N F.oglJ Med 1988;319:307·8. 18. Jagger J , Hunt EH, Brand·FllnagganJ , Pearson RD. Rates of needlestick injury caused by various devices In a unlversity hospil.a.l. N EoglJ Med i988;319:2848. 19. Marcus R, CDC Cooperative Needlestlck SurveUlaoce Group. Surveillance of health care workers exposed to blood from patients infected with the human Immunodefic iency virus. N Eng!] Med 1988;319: 1118·23. 20. To.lcars]I, Bell DM, Culver DH, et al. Percutaneous injuries durtog surgical procedures. JAMA 1992;267:2899-904. 21. Krasiosld K, LaCouture R, Holzman RS. Effect of changing needle disposal systems on needle puncture Injuries. Infect Control 1987;8:59-62. 22. Linnemann CL, Cannon C, DeRonde M, Lanphear B. Effect on educational programs, rigid sharps containers, and unlversal precautions on reported needlestlc.lc injuries l.o health care workers. Infect Control Hosp Eptdemlol 1991;12:214·9. 23. Wong ES, Stot.lca]L, Chtnchlill VM, Williams OS, Stuart GC, Markowitz SM. Are unlversal precautions effective in reducing the number of occupational exposures among health care workers? JAMA 1991 ;265:1123-8. 24. Rlboer BS, Landry MN, Gholson GL, Linden LA. Impact of a rigid, punctUre resistant container system upon needlestlck Injuries. Infect Control 1987;8:6~. 25. Bee .leer MH, Janz NK, Band J, Bartley), Snyder P, Gaynes RP. NoocompUance with universal precautions pollcy: Why do physicians and nurses recap needles? Am] Infect Control 1990; 18:232-9. 220 }OURNAL OP DENTAL EDUCATION • VOL. 58/NO. 3/ 1994 

Clinical Occupational Bloodborne Exposure in a Dental School

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Clinical Occupational Bloodborne Exposure in a Dental School

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