Risky Business or Playing It Safe

Nov. 1, 2007
Rather than focus on cumulative trauma disorders or issues covered under OSHA-mandated blood-borne pathogen guidelines, it’s time to look at situations that foster workplace accidents and injuries.

by Anne Nugent Guignon, RDH, MPH

Rather than focus on cumulative trauma disorders or issues covered under OSHA-mandated blood-borne pathogen guidelines, it’s time to look at situations that foster workplace accidents and injuries.

Fifteen years ago, my primary clinical time was spent as a temporary dental hygienist, going from office to office, week after week. Over the course of five years, I witnessed and experienced some of the most amazing breaches of workplace safety imaginable. Unfortunately, unsafe working conditions still exist.

Every year when the cold and flu season comes around, patients and co-workers come in with hacking coughs, drippy noses, sore throats, and elevated temperatures. No one wants a decrease in production, and no one wants to get sick either. Mistakes come easy and good work is hard to do when you feel lousy. Patients deserve our best care, which we can’t give when distracted by illness. If any team members are contagious or obviously sick, they should be asked to go home! Every office needs a policy on this delicate subject. Knowingly putting your co-workers and patients at risk is not appropriate and shouldn’t be tolerated. Guidelines should be listed in the office manual and may include fever, epidermal outbreaks, expressed bodily fluids, or highly contagious children at home. To help defray costs for staying home, put fifty dollars into a special savings account every pay period to cover time off from illness.

Other dangers lurk inside and out of the dental office. Watch where you walk. Along with looking unsightly, loose, torn carpet or uneven floor surfaces can trip up an unsuspecting pedestrian, resulting in a nasty fall that can have dramatic consequences. Unsecured floor mats shift. The backing on a floor mat is designed for specific types of flooring. Using the right one for different applications is a basic tenet for choosing a mat. Adhering well regardless of the weather challenges is an important concern.

Wet floors, fluid spills, or damp, slick surfaces are an obvious recipe for disaster. Clean up the mess and dry the surface as quickly as possible using the appropriate mop or towel, and make sure you’re covered appropriately too. Moisture from rain or snow can be hard to control. Keep walkways as dry as possible by switching out mats often, and use a hazard cone as a visual alert.

“I work in an office that has EVERY cord and wire above ground. The operatories are very small and I am always running into the patient to take an X-ray. Last week I scooted around the chair toward the door to push the X-ray button. I tripped over a cord, fell straight down on my knees onto a hard floor. The week before I had started on Coumadin, so you can imagine what my knee looked like. Very maddening. Totally avoidable.” - Anonymous in Virginia

Have you ever counted the total number of cords and footswitches on the floor - slow speed, high speed, ultrasonic scaler, chair control, intraoral camera, just to name a few? Add in electrical plug-ins, surge suppressor strips, and extension cords. Don’t forget fans and view boxes. Then top it off with multiple handpiece cords, evacuation hoses, air/water syringes, cords from curing lights and fiber-optic headlights, and wired digital X-ray leads. Is it a treatment room or a spaghetti bowl? It’s really easy to get tangled up or trip over a mass of dangling cords or even a lone cord misplaced on the floor.

“All of the tubing was too long in this office. I was moving quickly, caught my foot in the tubing, and landed flat on my face! My arm underneath me took the fall. Ouch! A broken arm and wrist. After a few weeks, I was able to get back to work but for shorter days. The hardest part was paying the bills for the daily physiotherapy visits and the stress of wondering if there would be long-term problems” - Melinda Ferguson, RDH, British Columbia

Replace frayed electrical cords or worn connections immediately. Overloaded electrical outlets, extension cords, or surge protectors are a potential fire hazard. Devices are rated for how many watts they can support. Ignoring their capacity can severely tax an office’s wiring system, risking a fire. Does your office have a fire extinguisher and does everyone know how to use it properly? When was the fire marshal there last to check the unit, making sure it was charged properly?

Adequate indoor and outdoor lighting is a must. As one gets older, illumination becomes more and more important. The average baby boomer needs four times more light than a first-year college student does. Sufficient lighting in the parking lot is critical, especially in the winter when people go home in the dark and arrive in the dark, which, of course, brings up the topic of chemical ice removal.

The actual physical layout of the office is important. Have a direct traffic flow. Less agile patients appreciate seating that is easy to get in and out of, with stationary arms, and that isn’t too low to the ground. Keep the hallways free of boxes and cords, brooms and chairs, people, and clutter. Put storage boxes, water coolers, and dental equipment out of areas with people traffic.

Dental office storage is another amazing topic fraught with potential dangers. While dental office real estate is expensive, who wants their face masks and gloves stored in the bathroom? Designated storage areas should be easy to navigate, well lit, and organized so that heavy lifting is kept to a minimum. Well-constructed shelves designed to bear significant weight are a must. If supplies are stored on high shelves, a sturdy step stool is critical; a discarded operator stool is a hazardous option. No one wants to get bonked in the head by a falling box of dental materials.

“I opened the cabinet door to get the office oral pathology atlas and a computer monitor fell on my face! Blood everywhere! I fell back and hit my head on the door frame to the lab before I crashed to the floor, along with the computer monitor. The doctor, who had put the monitor on the top shelf, wondered why I didn’t look up before I opened the door. I couldn’t see straight and I had an exploding headache, but my nose wasn’t broken. Although the doctor expressed concern, he didn’t seem impressed that I left for the day. The next couple of days were excruciating. I was popping pain pills like a madwoman and couldn’t move my shoulders or neck very well. At a minimum, I had hoped he would cover my physiotherapy bills, but that was a no-go.” Cate Grater, RDH - Pickering, Ontario, Canada

It’s easy to put off needed repairs, but it’s hard to stay calm when an overhead light or renegade X-ray machine hits a team member or patient in the head or shoulder. An exam light, X-ray arm or head, or a computer screen that comes loose from its moorings can create an even bigger headache. These heavy devices need to be properly secured to the wall or ceiling and checked monthly.

Operator stools are also a potential source of injury. A binding chair caster full of dental floss and bits of gauze can cause a dangerous fall or jarring injury to knee and hip joints. If the casters can’t be cleaned out, replace them immediately. Wobbly stools or unsecured lumbar supports are also dangerous. Retire the chair if it’s impossible to repair. Products that make vinyl surfaces look slick and shiny are dangerous. Why risk a nasty tumble to the floor?

“Seventeen years ago, the floors in the office had just gotten a high-shine wax like a bowling alley. I seated my first patient and started to sit on my chair. It slipped out from under me and I landed on my back. I was out of work for three weeks and paid for my own physical therapy. I was young and stupid, but this episode taught me to hold on to my chair.” Millie Thaw, RDH - Deer Park, N.Y.

Personal protective equipment can pose a variety of problems. It is difficult to hold an object safely if your gloves are too big, and jackets that are too large pose additional concerns snagging onto doorknobs or handles. Worse is catching on a piece of office equipment and pulling it to the floor. Loose fabrics can get caught on a protrusion or get entangled in a rotating device.

A properly fitted face mask, rated for a particular type of activity, is critical. For example, ultrasonic scaling requires a mask that has high fluid resistance; however, it is also important to consider the particle size and filtration rate. The best face mask in the world can only provide so much protection. Face mask effectiveness diminishes dramatically if it does not cover the nose and the mouth completely, with all edges of the mask molded directly to the face.

Ultrasonic scaling is not the only procedure that produces contaminated aerosol. Consider the contaminated particulate generated by the air/water syringe, high-speed handpiece, air polisher, or an air abrasion unit. Do you want to inhale these particles into your lungs? A number of hygienists, especially those who are sensitive to dust, mold, seasonal pollens, and poor air quality, report more frequent respiratory illnesses or compromised breathing with regular use of air polishers. Preprocedural rinsing is paramount in reducing the bacterial load, but rinsing won’t reduce the particulate matter. One must consider if temporary stain reduction is worth compromised respiration.

“I used to use the Prophy-Jet on 80 percent of my patients, but I kept coming down with respiratory illnesses every couple of months. These episodes would not heal on their own so I ended up taking antibiotics every time for two weeks before I was back to normal. I believe the aerosol from the Prophy Jet was making me sick. Now I only use the Prophy Jet very selectively on patients who have tons of stain.” Shirley Cross, RDH, BS - Sugarland, Texas

While a slow-speed, aerosol-reduction device can reduce aerosols, a high-volume suction device captures even more. Sonic and ultrasonic devices, as well as air polishers, generate contaminated aerosols that can be inhaled by both the clinician and the patient. Unless a high-volume evacuation device collects the airborne aerosols immediately, they can travel from the point source throughout an office, contaminating multiple respiratory systems and operatory surfaces in their pathway, putting everyone in the office at risk. These aerosols are not short-lived. They have been found in the air for 30 minutes after treatment has ended.

Do you know if your gloves or face mask are clean right out of the box? Some products are manufactured in plants that do not adhere to high cleanliness and come loaded with unseen irritants and potential pathogens. Other companies go to great lengths to make sure their products are made in clean factories.

There are manufacturers that sanitize their prophy angles and saliva ejectors prior to final packaging. Sanitizing does not mean sterile, but rather cleaned by some process before being encased in a unit-dose cellophane wrapper. If you don’t know the answer, then you are subjecting both yourself and your patients to more than you might imagine, especially if either of you has an open portal of entry like a hangnail, paper cut, sinus infection, respiratory challenge, or any type of gingival inflammation. It can be difficult to find out this information. Dental supply sales personnel may not have this information. Contact a manufacturer’s customer service department directly.

Exposure to chemicals, through both inhalation and direct dermal contact, brings forth another set of concerns. Studies have linked nitrous oxide sedation with a variety of health disorders including miscarriages. A scavenger unit, in good working order, is necessary to contain potentially harmful gasses.

While more and more practices are converting to digital imaging, traditional film radiography is still widespread. Chemicals used to process traditional film radiographs have also been under attack as suspected contributors to a variety of health-related concerns. Isolate wet chemical radiograph processing units in a specially ventilated room to remove noxious fumes out of the physical confines of the dental office.

Contact dermatitis, especially on the hands, is a common problem experienced by dental health-care workers. Initially, latex gloves were implicated as the culprit, but in hindsight, relatively few dental health-care workers are actually sensitive to natural rubber latex proteins. While this may be the current case, it is prudent to consider wearing a synthetic glove that does not pose this risk. Today’s new nitrile formulations stretch better and have improved tactile sensitivity, plus they do not have the allergic potential of natural rubber latex. In addition, nitrile is more puncture-resistant than latex.

Other factors can contribute to contact dermatitis: glove powder, chemicals used to finish gloves, and hand-washing preparations. Powdered gloves are easier to don, but powder dries out skin. Some gloves use talc and others use cornstarch. Some glove manufacturers use chemicals in the final stages of manufacturing, which can be irritating to certain individuals.

Hand cleansing preparations are another source of irritation. A recent study indicated that there was no advantage to using an antibacterial soap, which some find irritating, over a plain hand soap using a minimum 20-second hand-washing protocol. The CDC recommends conventional hand washing at the beginning and end of the day or when hands become visibly soiled. Hand washing should be supplemented by alcohol-based hand rubs after removal and prior to donning new gloves. According to the CDC, alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast-acting, and cause less skin irritation, unless fake fingernails are in place. Fake fingernails harbor bacteria and fungus and can lead to a systemic infection and strain glove fingertips.

Are you wearing gloves that are suited for the task? For example, latex gloves are not appropriate for instrument cleaning and disinfection, cleaning the X-ray processor, or turning a room around. Elbow-length nitrile gloves, that are highly resistant to both chemicals and punctures, are perfect for cleaning and disinfecting a treatment room or handling contaminated instruments.

“A few weeks before I got married, I was cleaning a partial denture in the ultrasonic cleaner. When I picked up the beaker, the tartar and stain remover solution spilled. I was leaning against the counter and my uniform and lab coat got soaked with the chemicals, which I rinsed off immediately. By that night, I had developed a chemical burn the size of a half dollar on my stomach. It was sore, oozed a bit, and I had to keep it bandaged until it healed.” Karen Sonneborn, RDH - Mastic Beach, N.Y.

Inhaling the fumes from chemical disinfectants or nonwater-based sterilization units can have negative effects on respiratory systems. While solutions vary, the chemicals can pose significant risks. One sterilizer solution clearly lists formaldehyde as a key ingredient.

Never, ever agree to treat a patient without at least one other person in the office. Medical emergencies or an inappropriate advance are just the tip of the iceberg. There will never be enough compensation for an unexpected event that could severely impact your career or threaten your personal safety.

Getting distracted or lack of adequate time are key contributors to accidents on the job. Slow down and learn to pace yourself, otherwise you might find yourself with plenty of time to play the “If only” or “I should have” tapes over and over in your head.

If you find yourself alone, make sure the office doors are securely locked. Call a loved one or friend when you arrive or leave, especially if you are working alone. Unfortunately, parking lots, especially those that are poorly lit or unattended, can pose hazards. Try to leave in pairs and make sure everyone’s car starts before heading for home.

Obviously if you’re reading this in the comfort of your home or you’ve made it safely through another busy day, please take time to assess your workplace risks with a fresh set of eyes designed to ensure that you continue to practice in the comfort zone. Along with reevaluating your office, remember to either purchase or update your personal disability coverage. In a split second, your future can change dramatically, so it’s important to play it safe to stay in the comfort zone.

Stay safe and enjoy your holiday season!

About the Author

Anne Nugent Guignon, RDH, MPH, is the senior consulting editor for RDH magazine. She is an international speaker who has published numerous articles and authored several textbook chapters. Her popular programs include ergonomics, patient comfort, burnout, and advanced diagnostics and therapeutics. Recipient of the 2004 Mentor of the Year Award, Anne is an ADHA member and has practiced clinical dental hygiene in Houston since 1971. You can reach her at [email protected] or (832) 971-4540, and her Web site is www.anneguignon.com.