During dental procedures, saliva is predictably contaminated with blood. Even when blood is not visible, it can still be present in limited quantities and therefore is considered a potentially infectious material by the Occupational Safety and Health Administration (OSHA).
After an occupational blood exposure, first aid should be administered as necessary. Puncture wounds and other injuries to the skin should be washed with soap and water; mucous membranes should be flushed with water. No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, use of antiseptics is not contraindicated. Exposed DHCP should immediately report the exposure to the infection-control coordinator or other designated person, who should initiate referral to the qualified healthcare professional and complete necessary reports.
Because multiple factors contribute to the risk of infection after an occupational exposure to blood, the following information should be included in the exposure report, recorded in the exposed person’s confidential medical record, and provided to the qualified healthcare professional:
• Date and time of exposure.
• Details of the procedure being performed, including where and how the exposure occurred and whether the exposure involved a sharp device, the type and brand of device, and how and when during its handling the exposure occurred.
• Details of the exposure, including its severity and the type and amount of fluid or material. For a percutaneous injury, severity might be measured by the depth of the wound, gauge of the needle, and whether fluid was injected; for a skin or mucous membrane exposure, the estimated volume of material, duration of contact, and the condition of the skin (eg, chapped, abraded or intact) should be noted.
• Details regarding whether the source material was known to contain HIV or other blood-borne pathogens, and, if the source was infected with HIV, the stage of disease, history of antiretroviral therapy, and viral load, if known.
• Details regarding the exposed person (eg, hepatitis B vaccination and vaccine response status).
• Details regarding counseling, post-exposure management and follow-up.
DHCP, including students, should have principles of post-exposure management, including PEP options, as part of their job orientation and training. Each occupational exposure should be evaluated individually for its potential to transmit HBV, HCV and HIV, based on the following:
• The type and amount of body substance involved.
• The type of exposure (eg, percutaneous injury, mucous membrane or non intact skin exposure, or bites resulting in blood exposure to either person involved).
• The infection status of the source person (eg, HIV positive or terminal AIDS).
• The susceptibility of the exposed person.
All of these factors should be considered in assessing the risk for infection and the need for further follow-up (eg, PEP).
Public Health Services of the United States (PHS) published guidelines for PEP and other management of healthcare worker exposures to HBV, HCV or HIV. In 2001, these recommendations were updated and consolidated into one set of PHS guidelines. The new guidelines reflect the availability of new antiretroviral agents, new information regarding the use and safety of HIV PEP, and considerations regarding employing HIV PEP when resistance of the source patient’s virus to antiretroviral agents is known or suspected. In addition, the 2001 guidelines provide guidance to clinicians and exposed HCP regarding when to consider HIV PEP and recommendations for PEP regimens.
1. Post exposure management and prophylaxis
• Follow Department of Health recommendations after percutaneous, mucous membrane, or non intact skin exposure to blood or other potentially infectious material.
• Follow PHS guidelines for PEP and other management of DHCP exposure to HBV, HCV or HIV.
Hand hygiene (eg, handwashing, hand antisepsis or surgical hand antisepsis) substantially reduces potential pathogens on the hands and is considered the single most critical measure for reducing the risk of transmitting organisms to patients and DHCP.
Transient and resident flora can colonize the skin. Transient flora are usually acquired during contact with patients and contaminated environmental surfaces. These are usually the cause of healthcare associated infections. Being superficial, they are easier to remove by routine handwashing. Resident flora are attached to deeper layers of the skin and are more difficult to remove. They are, however, less likely to be associated with such infections.
The preferred method of hand hygiene will depend on:
• The type of procedure to be done (invasive or non-invasive)
• The degree of contamination
• Substantivity of the antimicrobial agent
For routine dental examinations and nonsurgical procedures, handwashing and hand antisepsis is achieved by using either plain or antimicrobial soap and water. If the hands are not visibly soiled, an alcohol-based hand rub is adequate.
For surgical procedures, antisepsis is directed toward elimination of transient flora and reduction of resident flora to prevent introduction of the organisms into the operative site. The soap used should be antimicrobial. Skin bacteria can rapidly multiply under surgical gloves if hands are washed with soap that is not antimicrobial.
Selection of Antiseptic Agents
The choice of an antiseptic agent for the hands must consider several factors. Obviously the most important factors in selection are the spectrum, substantivity and rapidity of action. Delivery system, cost per use and availability of the product must also be considered. Other factors that cannot be ignored are the possibility of producing chemical allergies, effect on skin integrity after repeated use, compatibility with hand lotions and offensive ingredients that may impart a disagreeable scent, for instance.
Storage and Dispensing of Hand Care Products
Keep in mind that even handwashing products can become contaminated and even support the growth of microorganisms.
Liquid products should be stored in closed containers and dispensed from either disposable containers or containers that are washed and dried thoroughly before refilling. Soap should not be added to a partially empty dispenser, because this practice of topping off might lead to bacterial contamination. Store and dispense products according to manufacturer’s directions.
The primary defense against infection and transmission of pathogens is healthy, unbroken skin. The potential of detergents to cause skin irritation varies considerably, but can be reduced by adding emollients. Lotions are often recommended to ease the dryness resulting from frequent handwashing and to prevent dermatitis from glove use.
However, petroleum-based lotion formulations can weaken latex gloves and increase permeability. For that reason, lotions that contain petroleum or other oil emollients should only be used at the end of the work day.
Fingernails and Artificial Nails
Microorganisms can accumulate under the fingernails. Logically, the longer the nails, the greater the possibility for accumulation of microorganisms. Fingernails should be short enough for the DHCP to clean under and around the fingernails.
Fingernails can also be a source of injury to the patient’s tissues and glove failure. Long nails, whether natural or artificial, make donning of gloves more difficult and can cause the gloves to tear. Nail polish, particularly if they are chipped, can harbor additional bacteria.
Studies have demonstrated that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings. However, two other studies on wearing rings reported that increased likelihood of transmitting a pathogen is unknown; further studies are needed to establish whether rings result in higher transmission of pathogens in healthcare settings.
However, rings and decorative nail jewelry can make donning gloves more difficult and cause gloves to tear more readily. Thus, jewelry should not interfere with glove use (eg, impair ability to wear the correct-sized glove or alter glove integrity).
a. Perform hand hygiene with either a non-antimicrobial or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer’s instructions.
b. Indications for hand hygiene include:
i. When hands are visibly soiled
ii. After barehanded touching of inanimate objects likely to be contaminated
by blood, saliva, or respiratory secretions
iii. Before and after treating each patient
iv. Before donning gloves
v. Immediately after removing gloves
c. For oral surgical procedures, perform surgical hand antisepsis before donning sterile surgeon’s gloves. Follow the manufacturer’s instructions by using either an antimicrobial soap and water, or soap and water followed by drying hands and application of an alcohol-based surgical handscrub product with persistent activity.
d. Store liquid hand-care products in either disposable closed containers or closed containers that can be washed and dried before refilling. Do not add soap or lotion to (ie, top off) a partially empty dispenser.
2. Special Considerations for Hand Hygiene and Glove Use:
a. Use hand lotions to prevent skin dryness associated with handwashing.
b. Consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves during procedures.
c. Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears.
d. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (eg, those in intensive care units or operating rooms).
e. Use of artificial fingernails is usually not recommended.
f. Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integrity of the glove.