Chris Miller, PHD
What is an exposure incident?
An exposure incident is an event that causes one to be contaminated with material that is known to contain (or could contain) potentially pathogenic microbes. Examples of such incidents in the dental office are:
- Sprays or splashes of contaminants (saliva and/or blood, for example) into the eyes, mucous membranes of the nose or mouth or onto non-intact skin.
- Cuts, punctures, or abrasions of the skin with a contaminated scaler, needle, wire, bur, scalpel blade, file, or other sharp instrument or item.
How do exposures occur in the office?
Sprays of contaminants will occur with the intraoral use of a prophy cup, air-water syringe, ultrasonic scaler, and high-speed handpiece. Occasionally, and unpredictably, when patients just open their mouths a squirt of saliva occurs. Sprays of contaminants also may occur when polishing, grinding, or using rotary laboratory equipment on contaminated appliances, temporary crowns, or other items.
Splashes of contaminants may occur if contaminated instruments are scrubbed with a brush or are carelessly dropped into the used ultrasonic detergent in the cleaner chamber. Splashing or spraying also may occur when contaminated detergent is being rinsed off the processed instruments under tap water.
Cuts, punctures, or abrasions may occur on the fingers or hands when working in a patient`s mouth. They also may occur when:
- Reaching for contaminated instruments or returning them to the bracket table, cassette, or tray at chairside.
- When manipulating contaminated appliances or sharp instruments or grinding burs in the laboratory.
- When sharpening contaminated instruments.
- When removing contaminated burs from a handpiece.
- When trying to pick up a sharp item using your fingers and not tongs.
- When trimming with a knife.
- When handling or disposing of contaminated sharps.
What should be done after an exposure?
The exposed person should immediately report to the person in charge and obtain any first aid necessary, depending on the nature of any injury. A post-exposure medical evaluation should be obtained.
The OSHA Bloodborne Pathogens Standard requires that an employer make immediately available to any exposed employee (at no cost to this person) a medical evaluation and follow-up that includes at least the items described below. In general, the exposed person and source individual are sent to a medical facility for testing and medical evaluation in regard to the possible spread and exposure to the bloodborne disease agents HIV and HBV.
1. Document the route of exposure and how the exposure occurred. This can be accomplished by completing an exposure incident form that allows for a description of the surrounding circumstances.
This documentation helps in two ways. Since a copy is given to the health-care professional who is evaluating the exposed person, it helps to plan for the medical care. Also, it helps the employer to clearly understand the incident so that efforts can be made to prevent its recurrence.
2. Inform the evaluating health-care professional of the circumstances. The health-care professional evaluating the employee after an exposure is to be given:
- A description of the exposed person`s job duties relevant to the exposure incident.
- Documentation of the route(s) of exposure and circumstances of exposure as mentioned above.
- All relevant medical records including the exposed person`s HBV vaccination status.
- The results of the source individual`s blood tests as described below.
3. Identify and document the source individual. This should happen unless the employer can establish that identification is not possible or prohibited by state or local law. Identifying the source individual will facilitate the medical evaluation of the exposed person.
4. Test the source individual. With consent, the source individual should be tested for HBV and HIV infectivity unless the person already is known to be infected. This information helps in the medical evaluation of the exposed person. This individual may be sent to the same health-care professional that is evaluating the exposed person or may be tested through his own physician and medical-care facility.
5. Inform the exposed person of the source individual`s test results. The employer must make sure that the exposed person is informed of the source individual`s test results. However, the employer does not have the right to know the test results. These results are to be directed to the health-care professional evaluating the exposed person, who will inform the exposed person and describe the confidential nature of the source individual`s identity and test results.
6. Collect and test the blood from the exposed person. With consent, collect the exposed person`s blood as soon as feasible after the exposure incident and test for HIV and HBV serological status. This is referred to as baseline testing.
Since HIV infection after exposure usually takes six to 12 weeks for detection, and HBV infection frequently longer, this baseline testing cannot determine if the exposure incident resulted in infection. It simply determines the HIV and HBV status of the exposed at the time of exposure and provides epidemiological information should the exposed person seroconvert (become positive).
If the employee gives consent for blood collection, but does not consent to HIV testing at that time, the blood sample must be preserved for 90 days should the exposed person later give consent. If consent is given later, the testing is to be conducted as soon as feasible.
7. Provide care following current recommendations of the U.S. Public Health Service. The HBV and HIV serological testing, counseling and safe and effective post-exposure prophylaxis are to be performed by accredited testing laboratories and by the evaluating health-care professional following current recommendations from the U.S. Public Health Service including CDC.
8. Provide a written opinion to the employee. The employer is to obtain a written opinion from the evaluating health-care professional within 15 days of the completion of the evaluation. The opinion is to be given to the employee and a copy maintained in the medical records file. The opinion is to be limited to the following information:
* The results of the evaluation.
* Any medical conditions resulting from the exposure, which may require further evaluation or treatment.
9. Recordkeeping. An employer must maintain a confidential medical record of occupational exposures that includes the employee?s name and Social Security number, results of examinations, post-exposure evaluations and follow-up procedures along with the health-care professional?s written opinion, and a copy of the information provided to the health-care professional. The medical record also is to contain the information on the employee?s hepatitis B vaccination status and records (written opinions) to the employee?s ability to receive vaccinations. These medical records are to be kept for the duration of employment plus 30 years.
The Bloodborne Pathogens Standard is designed to prevent occupational exposure to blood and saliva. However, if exposure does occur, the standard also attempts to ensure that the proper medical evaluation will be given to the exposed person.
Chris Miller is director of Infection Control Research and Services and professor of oral biology at Indiana University.