More than 8 million US health care workers may be exposed
to blood or other body fluids through the following types
of contact (NIOSH, 2004):
- Percutaneous injuries (injuries through the skin) with
contaminated sharp instruments such as needles, explorers,
scalers and scalpels (82%).
- Contact with mucous membranes of the eyes, nose, or mouth
- Exposure of broken or abraded skin (3%).
- Human bites (1%) Up to 800,000 percutaneous injuries
may occur annually among all U.S. healthcare workers (both
hospital-based workers and those in other health care settings).
After percutaneous injury with a contaminated sharp instrument,
the average risk of infection is 0.3% for HIV and ranges from
6% to 30% for hepatitis B (NIOSH, 2004).
Avoiding exposure is the best method for the prevention of
occupational exposure to bloodborne pathogens. There are a
number of different preventive practices that dental professionals
can utilize to protect themselves and their patients from
the threat of exposure.
Dental professionals need to become familiar with the hierarchy
of controls that categorize and prioritize prevention strategies.
The hierarchy of safety and health controls include (CDC,
- Legal and regulatory controls.
- Administrative and Training controls.
- Engineering controls.
- Work practice controls.
Legal and Regulatory controls are those instituted
by federal, state and local laws. Federal laws include those
of the Occupational Safety and Health Administration (OSHA)
Occupational Safety and Health Act of 1970, General Duty Clause
requires that each employer:
- Shall furnish to each of his employees employment and
a place of employment which are free from recognized hazards
that are causing or are likely to cause death or serious
physical harm to employees;
- Shall comply with occupational safety and health standards
promulgated under this Act. And each employee shall comply
with occupational safety and health standards and all rules,
regulations, and orders issued pursuant to this Act which
are applicable to his own actions and conduct.
In 1991 OSHA promulgated the Occupational Exposure to Bloodborne
Pathogens Standard. This standard was designed to protect
millions of healthcare workers and related occupations from
the risk of exposure to bloodborne pathogens, such as the
Human Immunodeficiency Virus (HIV) and the Hepatitis B Virus
Legal and Regulatory controls also include the component
of the Dental Practice Act in California that requires dental
professionals to utilize proper infection control procedures.
The failure to do so can include charges of professional misconduct.
Administrative and training controls include policies,
procedures, and enforcement measures to prevent exposure to
disease-causing organisms. Each healthcare facility must provide
such administrative control to their employees, outlining
the policies and procedures related to any issue in the occupational
setting in which the employee is to utilize proper infection
control practices. The training of employees regarding infection
control issues are also a component of administrative controls,
as each facility determines the need for training.
Each dental office should have a written plan for an Infection
Control Program that includes elements to protect personnel.
The objectives are to educate dental professionals regarding
the principles of infection control, identify work-related
infection risks, institute preventive measures, and ensure
prompt exposure management and medical follow-up. Elements
of the plan should include:
- Education programs for staff members - Personnel
are more likely to comply with an Infection Control Program
and Exposure Control Plan if they understand its rationale.
Clearly written policies, procedures, and guidelines can
help ensure consistency, efficiency, and effective coordination
of activities. Personnel subject to occupational exposure
are mandated receive infection control training on initial
assignment, when new tasks or procedures affect their occupational
exposure, and at a minimum, annually.
Education and training should be appropriate to the assigned
duties of specific dental professional (e.g., techniques
to prevent cross-contamination or instrument sterilization).
For dental professionals who perform tasks or procedures
likely to result in occupational exposure to infectious
agents, training should include:
- A description of their exposure risks;
- Review of prevention strategies and infection-control
policies and procedures;
- Discussion regarding how to manage work-related illness
and injuries, including PEP (Post Exposure Prophylaxis);
- Review of work restrictions for the exposure or infection.
Inclusion of dental staff with minimal exposure risks
(e.g., administrative employees) in education and training
programs will enhance facility wide understanding of
infection control principles and the importance of the
program (CDC, 2003).
- Immunization plan of vaccines for preventable diseases
- Immunizations are an essential part of prevention and
infection control programs for dental professionals, and
a comprehensive immunization policy should be implemented
for all dental health care facilities. Immunizations substantially
reduce both the number of dental professionals susceptible
to vaccine preventable diseases and the potential for disease
transmission to other healthcare professionals and patients.
Thus, The Advisory Committee on Immunization Practices (ACIP)
provides national guidelines for immunization of healthcare
providers, which includes dental providers (See Appendix
On the basis of documented healthcare associated transmission,
healthcare providers are considered to be at substantial
risk for acquiring or transmitting hepatitis B, influenza,
measles, mumps, rubella, and varicella. All of these diseases
are vaccine-preventable. ACIP recommends that all HCP
be vaccinated or have documented immunity to these diseases.
ACIP does not recommend routine immunization of healthcare
providers against TB (i.e., inoculation with bacille Calmette-Guérin
vaccine) or hepatitis A. No vaccine exists for HCV. ACIP
guidelines also provide recommendations regarding immunization
of healthcare providers with special conditions (e.g.,
pregnancy, HIV infection, or diabetes) (CDC, 1997).
OSHA requires that employers make hepatitis B vaccination
available to all employees who have potential contact
with blood or other potentially infectious material (OPIM).
Employers are also required to follow CDC recommendations
for vaccinations, evaluation, and follow-up procedures.
Non-patient care staff (e.g., administrative or housekeeping)
might be included, depending on their potential risk of
coming into contact with blood or OPIM. Employers are
also required to ensure that employees who decline to
accept hepatitis B vaccination sign an appropriate declination
statement (CDC, 2003) to be kept on file.
- Medical condition management and work-related illnesses
Dental programs in institutional settings, (e.g., hospitals,
health centers, and educational institutions) can coordinate
with departments that provide personnel health services.
The majority of dental practices are in ambulatory, private
settings that do not have licensed medical staff and facilities
to provide complete on-site health service programs. In
such settings, the infection-control coordinator should
establish programs that arrange for site-specific infection
control services from external health care facilities
and providers before dental health care personnel are
placed at risk for exposure. Referral arrangements can
be made with qualified healthcare professionals in an
occupational health program of a hospital, with educational
institutions, or with healthcare facilities that offer
personnel health services.
This is particularly needed in the case of occupational
exposure to bloodborne pathogens (post-exposure prophylaxis
will be discussed later in this course).
Maintenance of health records in accordance with all
applicable state and federal laws.
- Exposure prevention and post exposure management,
with follow-up of staff exposed to infectious organisms
or potentially harmful materials - Despite the hierarchy
of controls in the avoiding exposure to blood and OPIM,
occupational exposures can still occur. Written policies
and procedures to facilitate prompt reporting, evaluation,
counseling, treatment, and medical follow-up of all occupational
exposures should be available to all dental professionals.
Written policies and procedures should be consistent with
federal, state, and local requirements addressing education
and training, post exposure management, and exposure reporting.
The CDC has guidelines for the post-exposure management
of occupational exposure to blood and OPIM (CDC, 2005).
These guidelines can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm.
The infection control program should identify an infection
control coordinator (a dentist or other dental health care
professional) knowledgeable or willing to be trained who is
assigned responsibility for coordinating the program. The
effectiveness of the infection control program should be evaluated
on a regular basis.
It is important to remember that some training controls
are also a legal control, for example, this course is a legislated
requirement for dental professionals in the state of California.
Engineering controls eliminate, isolate or reduce
exposure to a threat such as a pathogenic organism or physical
hazard through the use or substitution of engineered machinery
or equipment. Such controls are often technology based, incorporating
a safer design to necessary equipment.
Examples include needleless syringes, needle recapping devices,
N2O2 scavenging devices, sharps disposal containers, positive
pressure ventilation patient rooms, dilution ventilation,
high-efficiency particulate air (HEPA) filtration, ultraviolet
lights, ventilation systems, sound-dampening materials to
reduce noise levels, safety interlocks, and radiation shielding.
Well designed engineering controls eliminate human error.
The dental professional has greater protection from the hazard
because it is either eliminated or reduced through no additional
effort on the part of the healthcare worker.
Where engineering controls are not available or appropriate,
work practice controls must be used. Work practice controls
result in safer behavior that is aimed at reducing the risk
of exposure by changing the way a task is performed. Examples
include using instruments rather than fingers to retract or
palpate tissue during suturing and administration of anesthesia,
not passing an unsheathed needle to another healthcare provider.
The utilization of barriers such as personal protective equipment
(PPE) when coming in contact with potentially infectious materials
is also a work practice control (this will be explained in
detail later in this course).
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