Updating the Dental Occupational Exposure Plan
Brian C. Muzyka, DMD, MS, MBA
The United States Public Health Service (PHS) first published management guidelines for postexposure prophylaxis against human immunodeficiency virus (HIV) in 1998. Since the publication of these guidelines, much has occurred in the arena of medical management for HIV. As a direct result of research aimed primarily at treating HIV disease, many new drug therapies are available for HIV and other viral diseases. Some of these newer therapies work through inhibiting the replication of HIV and other viruses within a host.
With this in mind, the PHS released updated guidelines for the management of occupational exposures to hepatitis B (HBV), hepatitis C (HCV), and HIV. This update also includes postexposure prophylaxis (PEP) recommendations for these three diseases. The most effective method of preventing occupational exposure to blood-borne diseases in the dental setting is to avoid exposure to saliva and blood. Saliva is included simply because it is presumed to be contaminated with blood during dental procedures.
To reduce the risk of contraction, the Occupational Safety and Health Administration (OSHA) developed a standard (Occupational Exposure to Blood-borne Pathogens) that outlines ways in which an employer can reduce the risk of employee exposure to HIV and HBV. This standard mandates engineering controls (eg, sharps containers and personal protective devices), work practice controls (ensuring tasks are performed as safely as possible), and employee training. The standard has been generally well received and has been employed in healthcare settings across the United States since 1991.
In spite of the OSHA standards and practice recommendations, occupational exposure to blood-borne pathogens remains a concern of healthcare professionals. The risk of contracting HBV after exposure to an HBV-positive source during dental procedures has been well documented in the literature. This risk is virtually negated if the exposed individual has successfully completed the HBV vaccination series, which includes follow-up and measurement of protective antibody titers. In fact, this strategy has been so successful that the provision of HBV vaccines to at-risk employees is a part of the OSHA Blood-borne Standard (at no cost). Hepatitis C cannot be efficiently transmitted via occupational exposure to blood, and epidemiological data suggest that environmental contamination by HCV is not a significant risk in the healthcare setting, except perhaps in hemodialysis.
The risk of contracting HIV from percutaneous exposure to HIV-infected blood is 0.3%. Risk is increased with exposure to larger quantities of infected blood, which may occur following injury from a device that is visibly contaminated with blood, by a needle placed in an artery or vein, or by a deep injury. Although the risk of contracting HIV from a dental exposure is less documented, this occurrence may comprise a minimal portion of the aforementioned percutaneous risk.
When an occupational exposure does occur, immediate action and medical evaluation should be taken. Particularly with HIV, a brief window of opportunity exists in which postexposure antiretroviral intervention might modify or prevent viral replication. Theoretically, postexposure prophylaxis may limit or inhibit viral proliferation.
In an attempt to include the advances in chemotherapeutics, the PHS issued updated recommendations for occupational exposure to HIV. Additionally, the PHS also has included information regarding management of occupational exposure to HBV and HCV. This is the first time a single document comprehensively addresses management of occupational exposure to blood-borne pathogens and recommends postexposure prophylaxis regimes. It is with this in mind that every practicing clinician must develop an occupational exposure protocol and enable access to this protocol for all at-risk employees.