Learn more about the Canadian Dental Care Plan
Sedation and Anesthesia

Prevention and management of percutaneous injuries

Originally appeared in the February/March 2016 issue of Dispatch

Needle-stick and other percutaneous injuries pose the greatest risk of transmission of bloodborne pathogens e.g. HBV, HCV and HIV. Mucosal (eyes, nose and mouth) and cutaneous (non-intact skin) exposures may also transmit these pathogens. While the risk of transmission is small, the majority of exposures are preventable by following routine practices. This includes the need for immunizations, e.g. against Hepatitis B, which can substantially reduce susceptibility to infection. Some individuals, however, are non-responders to the HBV vaccine, and all oral health care workers should know their personal immunization status and ensure that it is up-to-date.

Best practices to prevent percutaneous injuries include the following:

  • Always use extreme caution when passing sharps during four-handed dentistry.
  • Needles should remain capped prior to use and not be left uncapped or unattended.
  • Needles should not be bent, recapped or otherwise manipulated by using both hands. They should be recapped as soon as possible, using a one-handed scoop technique or commercial recapping device.
  • When suturing, tissues should be retracted with an instrument, rather than fingers.
  • Burs should be removed from handpieces immediately following a procedure.
  • Sharps should be identified and carefully removed from trays before cleaning instruments. They should be discarded in clearly labelled puncture-resistant containers.
  • When cleaning contaminated instruments by hand, heavy duty utility gloves, appropriate clothing and long-handled brushes should be used. Consideration may be given to the use of ultrasonic cleaners and/or instrument washers.

The Needle Safety Regulation 474/07, made under the Occupational Health and Safety Act (OHSA), makes the use of safety-engineered needles (SENs) mandatory, subject to certain exemptions. The regulation allows for exceptions on a case-by-case basis where the use of a SEN will result in a risk of harm to a person or worker, or where a SEN is not available. Although SENs are not in common use for administration of local anesthetic, there are reasonable alternatives for the administration of parenteral sedation and anesthesia, including SENs for intravenous and intramuscular procedures. Dentists using these techniques should investigate available options.

When a percutaneous injury does occur, it can be quite alarming. All oral health care workers (OHCW) should receive training that includes information about their exposure risks, strategies to reduce these risks and the management of such injuries. Training should be supplemented whenever necessary and reviewed at least annually.

The management of a percutaneous injury should include the following:

  • Allow the wound to bleed briefly and freely. Gently wash the wound with soap and water, and bandage as needed.
  • In all cases of significant exposure, the dentist should assess the source patient’s status and risk for blood-borne illness by reviewing the medical history and, if necessary, asking the patient additional questions.
  • If the source patient’s status is unknown or the patient presents with known risk factors, then their cooperation should be sought to clarify information and/or provide consent to be tested. If it is the dentist who has sustained the percutaneous injury, it may be helpful to have another OHCW assist in speaking with the patient. Given that a decision regarding the source patient’s status is best made quickly, referring the patient to a hospital emergency department may be prudent. The source patient may then be tested for HBs Ag, HBc Ab, HCV Ab and HIV Ab.
  • The injured OHCW should be given the option of attending for a medical consultation with the nearest hospital emergency department for counselling, possible baseline blood tests (for HBs Ab, HCV Ab, HIV Ab and ALT) and consideration for post-exposure prophylaxis (PEP). When necessary, PEP should be administered as soon as possible (within hours).
  • The OHCW who may be exposed to HBV and has demonstrated immunity does not require either a HBV vaccine booster or HB Immune Globulin (HBIG). For non-responders or those who are not immune, the OHCW may receive HBIG and possibly the HBV vaccine series.
  • For the OHCW who may be exposed to HIV, PEP consists of specific antiretroviral medications, usually taken for up to 28 days.
  • Currently there is no PEP available following exposure to HCV. Infection with this virus may spontaneously clear, but early diagnosis and management will increase the likelihood of clearance.
  • Following a significant exposure, follow up medical evaluation should include repeat serologic testing of the OHCW at 6, 12 and 24 weeks to determine if they have become infected. Those taking HIV PEP must also be monitored for potential side effects and/or toxicity.

The OHSA states that “an employer shall…take every precaution reasonable in the circumstances for the protection of a worker.” This includes preparation and review of an occupational health and safety policy, and a written percutaneous injury protocol covering prevention, management and follow-up. It is also reasonable to have an appropriate first aid kit in the office and have staff trained in first aid.

The OHSA also mandates that employers document and investigate all workplace incidents and hazards. With respect to a significant percutaneous exposure, the report should include:

  • name of the OHCW and their vaccination status;
  • date and time of the exposure;
  • nature and extent of the exposure, the dental procedure and the action taken;
  • name of the source and details of the risk assessment;
  • details regarding follow up. 

If a dentist has voluntarily enrolled their staff in the insurance plan administered by the Workplace Safety and Insurance Board, it may be necessary to report a percutaneous injury. Similarly, if coverage exists under any other insurance plan, there may be reporting obligations.

Exposure to blood-borne pathogens is a risk for every OHCW. Appropriate knowledge, protocols and training are important prerequisites in the management of this risk.