Editor's Note: I think it's safe to say that dentistry is a safer place because of Dr. Chris Miller. Since April 1989, his articles have helped RDH readers develop an excellent understanding of what it takes to practice dentistry safely. The column below is his last one for RDH. Thanks, Dr. Miller, for watching out for our safety. If readers wish to acknowledge how his column has affected them, you may contact him at [email protected].
Protection of the dental team against bloodborne pathogens carried by patients is the goal of the OSHA Bloodborne Pathogens Standard (BPS). The lack of specific procedures for protecting patients is not because OSHA doesn't care about patients, but because Con-gress has charged OSHA to protect the workers of America. Nevertheless, some of the BPS requirements do benefit patients indirectly, and some even protect patients from exposure to microorganisms. However, most of the patient-protection procedures come from state laws or rulings from state dental boards that are based on recommendations from the Centers for Disease Control and Prevention.
The BPS has seven major groups of rules that affect dental offices:
- Exposure control plan
- Methods of compliance
- Hepatitis B vaccination
- Post-exposure evaluation and follow-up
- Hazard communication
Let's look at these sections to see where some form of patient protection may be involved.
The exposure control plan is a written description of the tasks performed (and the job classification of those performing the tasks) that have a potential for occupational exposure of employees to patients' blood or saliva. The plan must also set forth the schedule for implementing the standard and specify procedures for evaluating employee-exposure incidents. It also describes the methods used to prevent the spread of microbes in the office. Since this plan is to be made available to employees, it clearly helps them to understand the standard and how they may become exposed.
Indirectly, the plan helps patients as well. While the plan was not designed for their benefit, it does describe the office's infection control program and is used in staff training. Knowing the plan (what to do and when) will reduce confusion among staff members about procedures and how they are performed. This makes infection control more efficient and less intrusive to patient care, an indirect benefit to patients.
The methods of compliance section mandates universal precautions, which indicates that infection control procedures are to be used with all patients. In addition to this obvious benefit, some specific methods reduce patients' exposure to microbes. For example, the OSHA rule for employees to wear gloves when there is a chance for contacting patient blood or saliva also protects patients from microbes that may be present on the staff member's hands. The OSHA rule that gloves are not to be reused on other patients also prevents cross-contamination between patients, a patient benefit. The OSHA rule to change gloves "as soon as feasible" if they become torn also benefits the patient by reducing chances for exposure to underlying skin microbes on the staff person's hands.
The use of masks to prevent contact with patient spatter and to reduce inhalation of dental aerosols also provides a little protection to the patients from respiratory microbes of the staff. Likewise, the protective clothing worn by the staff also may reduce the patient's contact with microbes on underlying street clothes. The significance of these kinds of contaminations would be low, but would be even further reduced by wearing the barriers.
Certainly, the OSHA rule of cleaning and disinfecting operatory surfaces that become contaminated with patient blood or saliva help prevent transfer of that material to subsequent patients treated in that operatory. Also, the option of using surface barriers to prevent contamination of surfaces helps prevent patient-to-patient cross-contamination.
The required OSHA training helps the team understand the nature and occurrence of bloodborne diseases, how they are spread, and how their spread in the office can be prevented. Since these diseases can be spread from health-care workers to patients under rare special circumstances, this training will help protect patients.
The training also involves how to select, use, remove, handle, decontaminate, and dispose of personal protective equipment, which clearly affects patient safety. Also, the OSHA requirement to offer hepatitis B vaccinations to the dental team will help patients by assuring that the dental team will be immune and will not spread the disease. Immunization not only prevents the disease in the immunized person, but also prevents that person from getting the disease and spreading it to others.
The post-exposure evaluation and follow-up that requires offering a medical evaluation and follow-up to exposed office staff is pretty much employee rather than patient protection. However, it does involve patients being asked to consent to testing for their HIV and hepatitis status free of charge.
The hazard communication part of the BPS requires identifying potentially infectious materials (items containing blood or saliva) by using color-coded containers or the biohazard symbol to identify the hazards. The OSHA precautions for handling sharps carefully and containerizing contaminated sharps and other wastes benefits everyone in the office by reducing chances for accidental contact with these materials. This indirectly benefits those "curious" patients who like to touch things in the office unless they are identified as hazardous.
The recordkeeping required by OSHA (employee training records, employee medical records) has little to do with patients, but they do document that proper training has occurred (and the training does benefit patients).
What is not addressed in the OSHA standard are the obvious protective procedures for patients, such as instrument and handpiece cleaning, packaging, and sterilization. Reusable instruments and handpieces should be cleaned, packaged, and sterilized before use on subsequent patients. These procedures are recommended by the CDC and ADA and reinforced by the states.
In summary, the OSHA Bloodborne Pathogens Standard does offer some protection to patients, even though it was designed to protect health-care workers.
Chris H. Miller, PhD, is professor of oral microbiology and executive associate dean at the Indiana University School of Dentistry.