EDlTORlAL J Oral Maxillofac Surg

47:437-439, 1999

Getting Rid of Bugs, Drugs, and Trash Hepatitis B is currently the major infectious oc-

cupational hazard in the health care delivery sys- tem. According to the Centers for Disease Control (CDC), there are over 300,000 new cases in the gen- eral public per year, and the incidence has been increasing dramatically. Thus, there is considerable risk for anyone involved in the care of patients who is exposed to blood, body fluids, or the possibility of being stuck with a needle. Studies have shown that between 10% and 40% of dental personnel have serologic evidence of past or present hepatitis B virus infection. This figure is probably even higher in those involved in the practice of oral and maxil- lofacial surgery.

Since it was first recognized in the United States in 1981, AIDS has also grown to be a major health hazard. It is estimated that 1.5 million people are carriers of the Human Immunodeficiency Virus, and, by 1991, there will be more than 270,000 per- sons with clinical manifestations of the disease. Al- though only a small number of cases have been re- ported in health care workers, the seriousness of the consequences and the lack of a protective vac- cine make AIDS potentially an even greater hazard than hepatitis B. It is logical, therefore, that the federal government, through the Occupational Safety and Health Administration (OSHA), should be concerned about proper protection of employees in the workplace against these diseases.

OSHA regulations now clearly specify the gen- eral infection control measures that must be imple- mented in the office. These include the use of per- sonal protective equipment in the form of gloves, gowns, masks, and eye protectors; use of proper sterilization, disinfection, and waste disposal tech- niques; and correct handling and disposal of needles and non-reusable sharp instruments. Personnel at risk must be offered the hepatitis B vaccine, and a documented educational program on infection con- trol is also required. The use of such universal pre- cautions obviously protects the public, as well as the doctor and the staff, and is well worth the added cost, time, and effort. However, in its zeal to pro- tect the public, the federal government has now also extended its influence into areas where, in certain instances, the end may not always justify the means.

A good example is the OSHA directive that now includes dental offices in the expanded hazard com- munications program involving users, as well as manufacturers, of hazardous chemicals. This pro-

gram, actually designed for industrial users, re- quires that all hazardous substances used in the of- fice be properly labeled and that all employees be provided with information and training on the han- dling of such materials. The new standard also re- quires that material safety data sheets be obtained from the manufacturer or supplier for any hazard- ous chemical used and that a list of these substances be posted. In addition, OSHA requires that their “Job Safety and Health Protection” notice be posted.

The impact that these regulations will have on the health of office employees is far less obvious than those relating to infection control. Many substances deemed dangerous are actually consumer products used for household purposes and familiar to the user, whereas others are already regulated by the Food and Drug Administration. Moreover, there does not seem to be any evidence of chemically related health problems occurring in oral surgery office personnel. The enforcement of the OSHA regulations appears to be an example of how sweep- ing governmental programs designed to deal with a problem in one area inadvertently penalize the guilty with the innocent.

Another example is the Environmental Protec- tion Agency’s (EPA) plan designed to deal with the problem of inappropriate disposal of medical waste. As a result of national attention to this issue brought about last summer by syringes and bloody vials washing up on East Coast beaches, the agency has now developed rules regarding the proper manage- ment of such waste. Included under these rules are tissues and body parts; needles and other dispos- able sharp instruments; surgical dressings, drapes, and gloves; and discarded equipment and parts that were possibly in contact with infectious agents. These wastes will have to be separated, packaged, and labeled, and a log book will have to be kept that must be signed by the hauler of the waste.

Again, we may be dealing with a costly and time- consuming solution to a non-problem. Even the CDC maintains that medical waste poses little health threat to society, that most hospital waste is no more infective than residential waste, and that there is no epidemiologic evidence that it has caused disease in the community as a result of im- proper disposal. Compared with hospitals and large clinics, the amount of infectious waste produced in the average oral surgery office is minuscule, and its disposal is already covered in the OSHA infection

437

EDITORIAL

control guidelines. If there is a problem, it is with the waste management companies and not with the health profession.

Since both the OSHA hazard communication program and the EPA waste disposal plan still re- main to be fully implemented, there may yet be time to seek exemptions or request modifications. In the meantime, however, we need to become thoroughly

familiar with the rules and be sure that we are in compliance. Whereas the basic concept of regula- tion may be distasteful, we still need to deal appro- priately with any potential health-related problems that may exist, so that such regulation will ulti- mately become unnecessary.

DANIEL M. LASKIN

LETTERS TO THE EDITOR J Oral Maxillofac Surg

47:436, 546-549. 1969

THE CURRENT STATUS OF TMJ ARTHROSCOPY

To the Editor:-1 was disappointed with the “counterpoint” positions on TMJ arthroscopy taken by Drs Nickerson and Blaustein at the recent Boston meet- ing. Instead of denouncing arthroscopy entirely, they would have been more effective by presenting a challenge to specific areas. For example, is repositioning the disc critical, or is retrodiscal remodeling the key to long-term satisfactory function, and, if so, then just what needs to be done in the joint? These, among others, were issues that needed to be raised and adroitly argued so a clearer sense of surgical direction could be gotten. Instead, they were barely and ineffectively touched upon during a dis- gruntled caII for a moratorium. Sure, there are questions, but they will only be answered with more arthroscopic surgery, not less.

Because neither disputed the successes reported, both obviously recognize that the procedure, even in its in- fancy, represents a relatively benign and effective step beyond nonsurgical treatment. The bottom line is that the procedure works. They should be thankful that we have the luxury of success even while we’re learning.

I think well-intentioned, but misdirected efforts such as these hurt more than they help. Publicly aired dissension that does not properly recognize the surgery’s already impressive record gives support to the erroneous claim that it is “experimental.” We ourselves have probably been an influencing factor in recent third party refusal to pay for the procedure. The result is that patients who would have been helped, while themselves helping with unanswered questions, may not get the chance for either.

MICHAEL FREEDUS, DDS Schenectady, New York

Reply:-Dr Michael Freedus’ recognition of unanswered questions supports my contention that further investiga-

Letters to the Editor are considered for publication (subject to editing and abridgment), provided that they are submitted in du- plicate, signed by all authors, typewritten in double spacing, and do not exceed 40 typewritten lines of manuscript text (excluding references). Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal article must be received within 6 weeks of the article’s publica- tion. Receipt of letters is not acknowledged; correspondents will be notified when a decision is made.

tion is needed. These questions will only begin to be an- swered by more arthroscopy, but only if such arthros- copy is performed under research protocols. I suggested that research on arthroscopy should be done and in no way was “denouncing arthroscopy entirely.” I ques- tioned the value of the reported successes published in the journals on the basis that the surgeons performing the procedure were also the primary evaluators of success or failure, the results were short-term, there have been no published reports on postarthroscopic joint imaging, the data have been largely subjective, and the results were not compared with untreated controls.

Dr Freedus admits that arthroscopy is in its infancy and that we are learning. These admissions support the con- tention that arthroscopy is investigational. It is not I, but he, who should be thankful for any perceived success with arthroscopy, because I am not performing it. I do not consider my efforts as having been misdirected or as hurt- ing anything. What hurts is when members of my profes- sion foist treatments on the public with claims of success when no strong evidence of success exists. This is mag- nified when the hierarchy of the AAOMS try to argue with the insurance industry using the scarce data that presently exist. Dr Freedus is correct that it is we who have influenced third party refusal to pay for arthros- copy; we have done so by not having a convincing data- base from which to argue.

I personally believe that arthroscopy of the temporo- mandibular joint will evolve to occupy a place in the di- agnosis and treatment of some specific types of TMJ af- flictions; however, just exactly what these will be will take some time to find out. While this time elapses, I suggest that Dr Freedus will have the time to read Claude Bernard’ and George Bernard Shaw.’

JAMES W. NICKERSON, JR, DMD Nashville, Tennessee

References

1. Bernard C: An Introduction to the Study of Experimental Medicine. New York, MacMillan, 1927

2. Shaw GB: The Doctor’s Dilemma. Middlesex, England, Penguin, 1946

Continued on page 546