by John A. Molinari, PhD
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Primary strategies for reducing occupational infections require avoiding exposure to blood and other potentially infectious body fluids.
Specific practices include using aseptic technique precautions, personal protective equipment, work practice controls, and receiving appropriate health-care providers' immunizations. Unfortunately, occupational exposures still occur despite the best efforts of health-care workers (HCW) to prevent them. Although precise numbers are not available, for the more than eight million HCW in the U.S., it has been estimated there may be as many as 600,000 annual percutaneous injuries. In addition, multiple retrospective studies suggest at least half of the accidents are not reported.
The Federal Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, published Dec. 6, 1991, was a major step aimed at substantially reducing the potential for occupational HCW injury and infection. When this series of regulations went into effect in the spring of 1992, HCW were required to use a combination of universal (now standard) precautions, administrative engineering (e.g., needle recapping devices, sharps containers), and work practice controls (e.g., not recapping needles using a two-handed technique) as the best means toward eliminating or minimizing occupational exposures.
Published CDC infection control guidelines for dentistry in 1993 and 2003 reinforced governmental regulations. This is illustrated by the following recommendations from the 2003 CDC Guidelines for Infection Control in Dental Health Care Settings:
- Use standard precautions (OSHA's bloodborne pathogens standard retains the term universal precautions) for patient encounters.
- Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries.
- Implement a written, comprehensive program designed to minimize and manage dental health-care personnel exposures to blood and body fluids.
Since implementation of the 1991 OSHA regulations, many safer versions of devices used in hospital settings have become available, and their impact on reducing injuries has been studied.
Aspirating anesthetic syringes that incorporate safety features have been developed for dentistry. The impact of safer medical devices in medical settings suggests that devices with engineered safety features could reduce percutaneous injuries in dental settings as well. When they occur, however, appropriate postexposure management is essential for reducing the risk of subsequent infection.
When evaluating occupational exposures to fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), blood and body fluids containing visible blood are considered infectious. During dental procedures, saliva is predictably contaminated with blood. It can still be present in limited quantities even when blood is not visible. Thus, saliva is considered a potentially infectious fluid by the CDC and OSHA.
Current data and knowledge indicate it is likely that only small quantities of blood are present in dental treatment settings, and the risks for transmission of HCV, and HIV are small. However, despite this low risk of transmission, a qualified health-care professional should evaluate any occupational exposure incident to saliva in dental settings, regardless of the presence of visible blood.
The logical question after 17 years of OSHA regulations to protect HCW is: Have the increased efforts and incurred expenses proven successful in lowering occupational bloodborne infection risks? The answer is an unequivocal “yes.”
Studies examining the incidence of accidental sharps injuries in medical and dental facilities have indicated a substantial decline as more HCW use safer practices (e.g., the single-handed scoop recapping technique for syringe needles), and utilize more protective engineering devices.
Using occupational HIV infections as an example, of 57 documented HIV infections that occurred between 1984 and 2006 (the infections occurred following accidental exposures), the overwhelming majority occurred before the OSHA Bloodborne Pathogens Standard went into effect.
Despite some early resistance against OSHA regulations and CDC guidelines, HCW took measures to improve the area of sharps handling. The ongoing issue is to remain compliant with practices and procedures that are designed to protect HCW.
Dr. John A. Molinari is professor and chairman of the Department of Biomedical Sciences at the University of Detroit Mercy School of Dentistry. Contact him at [email protected].