OCCUPATIONAL HEALTH AND SAFETY IN DENTISTRY

Dr. ATTAULLAH

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Occupational Hazard

A working/job related condition that can lead to illness or death.

(Often, people in jobs which pose a high level of risk are paid more than similar but less risky jobs to compensate for the danger involved.)

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Recognition of Hazards

• Recognition is the duty of the Occupational Safety and Health Authorities and implementation of safety measures is usually via legislations/acts

• E.g. the US department of Labor has the Occupational Safety and Health Administration office www.osha.gov

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Occupational safety from hazards

This is ensured by:

Setting and enforcing standards e.g. Infection Control Protocols

Providing training and education e.g. ICP trainings

Establishing partnerships e.g. Mercury recycling companies

Encouraging continual improvement in workplace safety and health.

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Occupational Health and Safety (OHS) situation in Pakistan

• The main law governing OHS is the Factories Act 1934 Chapter 3.

• The Hazardous Occupation Rules of 1978 regulate certain occupations as hazardous, and contain special provisions to regulate the working conditions in those occupations.

• Each province has also enacted its own Rules within the mandate of the Factories Act.

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OHS Cont’

In addition there are other laws dealing with OHS:

The Mines Act 1923 Social Security Ordinance 1965 Workmen’s Compensation Act 1923 Shop and Establishment Ordinance 1969 Dock Laborer Act 1934

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OHS cont’

• However, these acts have not kept up with the rapid pace of the current technological advancement and need updating. This has led to the establishment of public and private organizations dealing solely with Occupational Health and safety e.g.:

Centre for the Improvement of Working Conditions and Environment , Lahore (CIWCE) www.ciwce.org.pk

Occupational Safety and Loss Prevention International (OSALP) www.osalp.com.pk

Occupational Training Institute (OTI) www.oti.com.pk Safety Info Inc www.safetyinfo.com.pk

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Occupational Hazards in Dentistry

Dental professionals are at risk for exposure to biological, chemical, environmental, physical, and psychological workplace hazards. These hazards include but are not limited to:

The spectrum of blood-borne pathogens,pharmaceuticals agentschemical agentsergonomic hazards noise workplace violence

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Safety Measures for the spectrum of Blood Borne Pathogens

These include: Prophylactic Hepatitis B vaccination of ALL dental

workers (dentists, DSA, Lab and dental radiology workers) within 10 days of employment.

Development and strict implementation of Infection Control Protocols .

Provision of and strict enforcement of use of Personal Protective Barriers (PPB) such as eye ear, masks, coats, gloves, lead coats etc

Needle stick injury prevention

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cont’

Needle-stick injury prevention: Safety measures include:

Train dental team in disposal of sharps Always hand sharp instruments with sharp end pointing

away Always recap needles after use; use recommended

techniques Remove burs, scaling tips, needles individually and

immediately after use Dispose of needles and sharps in recommended manner Use heavy duty gloves when cleaning instruments

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Ouch!! An accidental needle prick should be dealt in the

following steps:

1. Encourage full bleeding of site2. Wash with either 70% alcohol, antiseptic solution or soap/water. (Do

not scrub the site)3. Take the full history of the patient (If not taken earlier)

4. Explain (in a sensitive manner) to the patient about the needle prick, taken written consent of the patient and then withdraw two blood sample of patient to carry out tests for Hepatitis B&C and HIV/AIDS. (if patient refuses, then his/her medical practitioner may be contacted to find out if the patient has been tested for some other reason)

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Ouch Cont’

5. Meanwhile, assuming the precautionary principle, the risk of infection is assessed which depends on:

Type of injury – risk is higher if needle enters artery or vein (pre and/or post injury)

Degree of contamination: The dental needle bore is very thin and usually holds very little fluid but if the plunger is pushed during the injury, this increases the degree of contamination

Infectivity of material transferred: This varies with the disease, HIV/AIDS and Hepatitis

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Ouch Cont’

• HIV-positive patient: The main factor determining infectivity is the viral load. High load is high infectivity. Viral load is usually higher in the late stage of HIV and full blown AIDS. On an average, the risk is 0.3% with a needle stick injury. (Splashes of infected blood into the eye have 0.1%)

• Hepatitis B: It has a 30% risk – it is so infectious that degree of injury is immaterial. Presence of HBe antigen and antibodies to HBc antigen indicate high infectivity

• Hepatitis C: The risk is 3%. Presence of anti-hep C antibody indicate 85% of carrier state, so infectivity is assumed as high.

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Ouch cont’

6. Post-exposure prophylaxis has maximum effectiveness if administered within one hour of injury

HIV/AIDS: Antiretroviral drugs given. Regime changes with new advances.

Hepatitis B: Interferon injections Hepatitis C: No known active or passive

drug regime appears effective, however interferon injections are started immediately

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Moral of this aspect?

All students of this class must get hepatitis B vaccination before the beginning of 3rd yr clinical rotations.

The normal protocol of Hep B vaccination is three doses:– 2nd dose after one month– 3rd dose after 6 months– Booster dose after every 5 years

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Checklist of hazards in dentistry

The spectrum of blood-borne pathogens,pharmaceuticals agentschemical agentsergonomic hazards noise workplace violence

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Safety measures for Pharmaceutical agents

The main hazardous pharmaceutical agent in the dental office is the waste anesthetic gas – Nitrous oxide (N2O)

Chronic exposure to N2O causes decrease in mental performance, audiovisual ability, manual dexterity and adverse reproductive effects.

Chronic exposure occurs if the scavenging systems is inefficient and leaking. Scavenging systems are local exhaust ventilation that collect waste gases from anesthetic breathing systems and remove them from the workplace.

Control is more difficult in dental operatories because only the patient's nose is covered during anesthetic administration and scavenging, while both the nose and mouth are covered in general operating theaters.

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Cont’

Safety measures include

I. Staff should be trained and licensed to operate the machinery. Perform the following monitoring procedures at installation and every 3 months thereafter: Leak testing of equipment; Monitoring of air in the worker's personal breathing zone and environmental (room air) monitoring

II. Prevent leakage from the anesthetic delivery system through proper maintenance and inspection of equipment. Eliminate or replace loose-fitting connections, loosely assembled or deformed slip joints and threaded connections and defective or worn seals, gaskets, breathing bags, and hoses.

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Cont’

III. Control waste N2O with a well-designed scavenging system that include securely fitting masks, sufficient flow rates for the exhaust system and properly vented vacuum pumps

IV. Make sure that the room ventilation is effectively removing waste N2O. If concentrations of N2O are above 25 ppm, increase the airflow into the room and use supplemental local ventilation to capture N2O at the source.

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Checklist of hazards in dentistry

The spectrum of blood-borne pathogens,pharmaceuticals agentschemical agentsergonomic hazards noise workplace violence

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Safety measures for chemical agents

The main hazardous chemical agent are mercury from amalgam fillings; silica and beryllium in dental labs

Mercury in the dental office:

Hg is a neurotoxin and nephrotoxin; Exposure is via inhalation, ingestion and dermal contact

Points of Hg exposure in the dental office occur during the manipulation of amalgam and also depend on the dental office environment

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Cont’

Manipulation of amalgam

Accidental spills Inhalation during trituration; insertion & burnishing; removal of

old fillings use of pestle/mortar, squeeze cloths or capsules Autoclaving of instruments used for amalgam fillings

Dental Office environment

Ventilation Heating system

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Safety measures for Hg exposure

Safety measures are met by observing the Amalgam Waste Management Protocols

Amalgam waste is divided into two categories:

Contact Waste: Amalgam residue that has come in contact with body fluids. This includes the excess amalgam during filling, the sludge collected in the vacuum suction sieves and extracted teeth with amalgam restorations

Non-contact Waste: Amalgam residue not contaminated by body contact – excess triturated amalgam, used or expired capsules

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Cont’

Basically three foundation protocols are followed:

• Always use personal protective equipment e.g. gloves, masks, eyewear when manipulating amalgam

• Phase out use of elemental Hg and replace it with capsules; This single step addresses several points of exposure

• Use of tightly sealed labeled containers to collect and store contact and non-contact amalgam waste; Send to Hg recycling companies

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Chemical agents

Silica and Beryllium in dental labs:

Silicosis is a disabling, nonreversible and sometimes fatal lung disease caused by overexposure to respirable crystalline silica. Vulnerable population is the dental technician

Chronic Beryllium disease (CBD) is often mistaken for sarcoidosis, is a respiratory disorder characterized by shortness of breath, dry cough and lack of energy.

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Cont’

• The dental technician is the vulnerable.

Exposure to silica is during dust during porcelain work and exposure to beryllium is dust due to manipulation of dental alloy used in crown, bridge and cast denture-work.

Safety measures include limit use of alloys with beryllium, use PPB, installation of proper filter, exhaust and ventilation systems in the dental lab and place grinding machines away from main lab.

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Checklist of hazards in dentistry

The spectrum of blood-borne pathogens,pharmaceuticals agentschemical agentsergonomic hazards noise workplace violence

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Ergonomic Hazards

• Ergonomic hazards refer to workplace conditions that pose the risk of injury to the musculoskeletal system of the worker

• Ergonomic hazards include repetitive and forceful movements, vibration, temperature extremes, and awkward postures that arise from improper work methods and improperly designed workstations, tools, and equipment.

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Checklist of hazards in dentistry

The spectrum of blood-borne pathogens,pharmaceuticals agentschemical agentsergonomic hazards noise workplace violence

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Noise

Noise-induced hearing loss is one of the most common occupational illnesses; 100% preventable but once occurred, it is permanent

It is often ignored because there are no visible effects;

It usually develops over a long period of time, and, except in very rare cases, there is no pain. What does occur is a progressive loss of communication, socialization, and responsiveness to the environment.

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Cont’

• Workplace noise should ideally be below 85 decibels

• The noise level of a high speed hand-piece is 98 decibels

• Exposure to the hand-piece drill for > 30 minutes continuously can lead to hearing loss.

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Cont’

How to tell if a noise situation is too loud?

There are two rules: First, if you have to raise your voice to talk to someone

who is an arm's length away, then the noise is likely to be hazardous.

Second, if your ears are ringing or sounds seem dull or flat after leaving a noisy place, then you probably were expose to hazardous noise.

Safety measures is basically use of hearing protective wear e.g. foam and/or silicone ear plugs; ear muffs;

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Checklist of hazards in dentistry

The spectrum of blood-borne pathogens,pharmaceuticals agentschemical agentsergonomic hazards noise workplace violence

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Workplace violence

• In the US, homicide is the second leading cause of death on the job, second only to motor vehicle crashes.

• Homicide is the leading cause of workplace death among females. However, men are at three times higher risk of becoming victims of workplace homicides than women.

• 76% of all workplace homicides are committed with a firearm.

• The majority of workplace homicides are robbery related crimes (71%) with only 9% committed by coworkers or former coworkers.

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Cont’

• Most nonfatal workplace assaults occur in service settings such as hospitals, nursing homes, and social service agencies.

• 48% of nonfatal assaults in the workplace are committed by a health care patient.

• Nonfatal workplace assaults result in more than 876,000 lost workdays and $16 million in lost wages.

• Nonfatal assaults occur among men and women at an almost equal rates.

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Cont’

• No statistics on workplace violence specific to the dental profession.

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QUESTIONS?