Are you protected?

How often have you de-gloved after a patient only to realise you have obtained the smallest scratch mark on your hand? What do you do? Give it a thorough washing and think nothing more of it? Does your practice have a protocol in place if a needle-stick injury occurs?

In September of last year Dr Will Coulter spoke to all VDPs on the topic of cross infection control as part of our day release programme. More recently, Dr Martin Fulford spoke at the IDA conference held in Wexford on the same topic. Both were equally informative and thought-provoking.

At undergraduate level, in Cork Dental School and Hospital, our training in cross infection control was second to none. Every surface area of our assigned units was decontaminated before and after each patient: burs, suction tips, matrix bands, polishing cups and brushes, as well as endodontic hand files, were all limited to single use and disposed of thereafter. All instrumentation underwent stringent cleaning and sterilisation by CSSD staff and could be traced back to source if necessary. In dental practice today, is this the norm or the exception?

As healthcare workers (HCW), dentists, hygienists and dental nurses are all at risk from acquiring diseases that are of microbial origin. How seriously do we take this risk? And what are the risks that we expose our patients to if we do not practise proper cross-infection control?

Up to June 2006, there were 4,623 people on the island of Ireland diagnosed with the HIV virus. By June 2007, there were 204 newly diagnosed cases. Of those diagnosed, 53.9% were male. Fifty-two per cent of those cases diagnosed between June 2006 and June 2007 acquired the virus heterosexually. The mean age at diagnosis was 32.8 years. Of the 204 cases, in only 121 cases was the geographic origin known, with 39.7% being born in Ireland and 42.1% being from Sub-Saharan Africa.

As a dentist, the risk of contracting the HIV virus from a needle-stick injury, which can include a stab from a probe, or a laceration associated with a matrix band or having polishing paste splashed in the eye is one in 319.

The above statistics refer to the number of known cases. But how many people attend a surgery on any given day blissfully unaware that they may be HIV positive or those who know but withhold that information?

It may appear that I advocate this from the perspective of protecting us as dentists from contracting the HIV virus, but also, unless patients inform us of their HIV status, we cannot adequately monitor or manage the oral manifestations of the HIV virus such as HIV-associated periodontal disease, hairy leukoplakia, Kaposi’s sarcoma, etc.

Currently, any dentist in the UK who is HIV seropositive must stop treating patients. Dentists are obliged to treat HIV positive patients, but are obliged not to treat any patients if they themselves are HIV positive. Furthermore, prospective dental students are now screened for hepatitis B and C and HIV, and are not allowed to enrol in Bachelor of Dental Surgery degrees if they are infectious carriers of these diseases. Is this just? The risk of contracting hepatitis B and C via the aforementioned routes is somewhere in the vicinity of one in three to 30. Fortunately, there exists a vaccine for hepatitis B and each member of staff should have regular monitoring of their antibody levels to ensure they are adequately protected. In contrast to HIV positive dentists, dentists in the UK who have acquired hepatitis B and who have a low viral load are still allowed to practise.

Ongoing studies by Perrett and Jeffries (reported to DH Decontamination Research Group, 2 July 2002) report visible residue on dental files and reamers after cleaning in both general dental practice and hospital Sterile Services Departments (SSDs). Using fluoroluminescence methods to measure residual protein, they report an average of 10 micrograms (10-5g) dry weight of protein adhering to dental instruments after decontamination. However the amount adhering was subject to high variability, with instruments from general dental practice being more highly contaminated than those from hospitals, carrying up to around 50 micrograms of dry weight. Such research was carried out in relation to the possibility of instrumentation of the dental pulp during endodontic procedures being a mode of transmission for vCJD. vCJD infectivity in tissues encountered in dentistry – e.g. dental pulp – is implied by some animal models. Though such infectivity has not so far been detected in humans, the possibility cannot be ruled out. In the UK, all endodontic files are now limited to single use and must be disposed of thereafter.

While I have been accused of being an alarmist on more than one occasion, the nature of the article is not to send every healthcare worker into a frenzy but rather to raise awareness of the potential but very real health risks that our profession is exposed to on a daily basis. Gloves, masks and protective eyewear should be seen as a necessity and not as an added expense, as should the disposal of the aforementioned instruments.

I leave you with one final question: how willing are you to be the next patient in your own dental chair?

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