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Case

31

Ouch!

What would you do immediately?


Encourage bleeding at the injury site and wash it with soap
and water but without scrubbing. Antiseptics should not be
used as their effects on the local defence mechanisms are
unknown. Free bleeding should be encouraged.

What is the most urgent priority and why?


The most urgent priority is to assess whether there is a
significant risk of transmission of HIV infection. Postexposure
prophylaxis (PEP) with antiretroviral drugs can significantly
reduce the chance of transmission of HIV, but for maximum
effectiveness it is recommended that it is administered within
1 hour, and certainly within a few hours. The reduction in risk
may be as high as 81%. There is limited evidence that some
protection of transmission is still given if the administration of
the PEP is delayed, even by as much as 4872 hours.

How could you obtain postexposure prophylaxis if required?

SUMMARY
You sustain a substantial percutaneous injury to
your foot. What should you do?

The Health Act 2006 requires that every NHS employer has a
policy on the management of exposure to blood or other
bodily fluids. The policy must ensure that advice is available
24 hours a day.
PEP is only available following a formal risk assessment for
each individual injury. This involves determining the severity
of the injury and the risk that the patient is carrying HIV
infection.
The procedure for obtaining a formal risk assessment varies
with local circumstances. In hospitals, the infection control
consultant(s), hospital casualty or occupational health
department will perform the risk assessment and provide the
appropriate medication. Those in general practice must
contact their local hospital casualty department who will
follow their local guidelines. Each dental practitioner should
know the contact number and name/position of the
appropriate person.
When you phone you will be asked details of the injury and
patient. You will then be told whether or not the injury is
sufficient to carry a risk of transmission and whether a risk
assessment of the patient is required.

What is the risk of developing HIV infection following a


sharps injury?
The average risk for transmission of HIV is estimated at 3
infections per 1000 injuries.
Fig. 31.1 Murphys law in action. Nice shoes.

History
You are extracting a difficult tooth and have used a luxator
to loosen the tooth prior to elevation. While transferring the
luxator to the bracket table, you drop it. The luxator impales
itself in your foot.

What diseases of significance may be transferred by


the injury?
Most infectious diseases can be transmitted by a sharps injury
but the main concerns are hepatitis B, hepatitis C and human
immunodeficiency virus (HIV) infection.

What factors affect the risk of transmission?


An increased risk of occupationally acquired HIV infection is
associated with:
A deep injury
Visible blood on the device that caused the injury
Injury with a needle that has been in a blood vessel
A high viral load in the source patient.
The risk from a needlestick injury where the needle has been
used to administer a local analgesic is therefore lower as the
needle would not be expected to have been placed in a
blood vessel if an aspirating syringe was used. PEP is therefore often unnecessary for a needlestick injury from a dental
anaesthetic needle.

CASE

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146

Ouch!

Splashes of infected blood carry a low risk. Splashes on


to broken skin or mucous membranes, including the eye,
carry a risk of transmission estimated at being less than
0.1%. It is considered that there is no risk of transmission
from a splash of blood on to intact skin.
The viral load is a measure of the virus concentration in
the blood. It is higher during the primary infection (the
so-called window period), reduces with early infection
but then rises with symptomatic and late-stage infection
(acquired immunodeficiency syndrome: AIDS). It is reduced
with effective treatment.
Your injury is a deep injury by a sharp instrument
covered with blood and therefore there is a risk of transmission of HIV.

The patient has returned to the waiting room with your


nurse. What will you say and do?
You should explain to the patient exactly what has happened
and that there has been an accident involving a surgical
instrument and that there is a practice policy, derived from
national policy, that should be carried out when this happens.
Introducing the HIV assessment of the patient in this way
depersonalizes the incident and avoids making difficult
judgements, and discriminating against perceived high-risk
groups for HIV infection. If the policy is written and shown to
the patient then this can prevent the patient feeling
discriminated against.
The patient should be asked to give informed consent for
blood to be taken and tested for HIV, hepatitis B and hepatitis
C and for storage of serum. If infection is transmitted, it will
be necessary to compare the patients sample and the
sample of your blood for industrial injury benefit or insurance
purposes.
Lengthy pretest counselling is now no longer a requirement
prior to testing for HIV. It is only necessary to provide it if the
patient requests it or needs it. The benefits of testing to both
the dentist and the patient should be stressed. If the patient

has an undiagnosed HIV infection then an earlier diagnosis is


more likely to lead to effective treatment, and the dentist can
have the most effective prophylaxis to prevent transmission.
Most patients will be happy to give a sample of their blood
under these circumstances. If not, then the reason for the
refusal should be explored as sensitively as possible. It may be
that patients have an inaccurate idea that they have in some
way done something illegal or hold a false belief about the
virus itself.
The general population have little knowledge of hepatitis but
understand that it is a serious disease and may be aware that
it can be transmitted sexually. As a minimum, blood should
be obtained to store the serum in case testing is required at a
later date.
The dentist will most likely not have the facilities to take the
blood and the patient can be asked to go to his or her
general medical practitioner with a request or to attend the
local Accident and Emergency department. If the dentist
does carry out the test then the patient should collect the
results from the general medical practitioner.
The possibility that the patient might be HIV-positive will
have to be addressed in order to assess the risk of
transmission. This must be done in a sensitive manner,
preferably in a quiet room and with reassurance about the
confidentiality of any answers given. The questions should
not be asked by the recipient of the needlestick injury
because it is difficult to be objective if you are feeling
anxious or distressed. However, in dental practice there
may be no other person to handle this issue and you may
have to ask the questions yourself. As an alternative you could
consider asking the patient to speak on the phone to the
local casualty officer responsible for the PEP, sexual health
clinic medical staff, a sexual health counsellor or other
experienced person.
You should remember that it is not the risk factor that
denotes the risk of transmission but how the activity takes
place which dictates the relative risk (Table 31.1).

Table 31.1Risk factors for human immunodeficiency virus (HIV) infection


Type of risk

Risk factor

Relative risk

Parental infection

Transfusion

There is a small risk of infection to recipients of blood transfusion given between the middle 1970s and 1987.
Most of those exposed will already have developed the infection and there is a very small risk for those who are
not positive. Donor screening since 1987 has reduced this risk to a minimal level

Haemophilia

Recipients of factor VIII-containing blood products before 1985 had a high risk of infection almost 80%. Most
of those exposed will already have developed the infection and there is a very small risk for those who are not
positive. All UK factor VIII sources are now screened

Injecting drug users (IDUs)

The risk depends on whether the needle is shared and how much contamination occurs. Needle exchange
programmes have reduced the incidence of HIV in IDUs.
Prisoners who are IDUs without access to needle exchange programmes represent a high-risk group for
acquiring HIV

Sexually transmitted infection

Needlestick injury

The risk is 0.3%, but depends on the type of injury, volume of blood transmitted and the infectivity of the blood

Vaginal intercourse

A risk to both partners but greater for the female. Properly lubricated condoms offer good protection

Prostitution

Unprotected intercourse with a prostitute is a high-risk practice, but the risk varies greatly in different parts of
the world

Oral sex

Transmission has been documented but the risk is considered lower than for vaginal sex

Anal intercourse

The highest-risk sexual activity. Condoms reduce risk but failure is common. Prisoners may have consensual or
coerced sex and lack of access to condoms means they represent a high-risk group for acquiring HIV

Ouch!
What questions would you ask?
Are you a regular blood donor in the UK?
(Blood donations are screened for hepatitis B and C,
and HIV. The rate of new infections among repeat
blood donors in 2007 was 1 in 100 000 in the UK.)
Have you ever had a blood donation refused?
Have you ever been diagnosed with hepatitis B or C,
or HIV?
Have you ever lived in HIV high-prevalence areas such
as Africa or Asia?
Have you ever had a blood transfusion or surgery
abroad?
Have you ever had an injury when you have been
exposed to someone elses blood?
Have you ever injected drugs into a vein?
Have you ever been to prison?
Do you have sex without using a condom?
A positive answer to any of these questions requires further
questioning to understand the degree of risk of acquiring
HIV through the activity. In practice, asking these questions
does not usually constitute a problem as in almost all cases
there will be either no risk or a very low risk. Similarly, most
HIV-positive individuals will disclose the information
readily in this situation.

What are the risk factors for contracting HIV infection?


In the UK, in 2007, an estimated 55% of persons with a
new diagnosis of HIV infection acquired it through
heterosexual contact and 41% through men who have
sex with men (MSM). The number of diagnoses acquired
through injecting drug use and mother-to-child transmission
has remained low over the last 5 years. Of the heterosexualacquired infections, 77% were probably infected abroad
with the vast majority from contacts from sub-Saharan
Africa. However, of the MSM diagnoses, 82% probably
acquired their infection in the UK.

If the patient discloses that he or she is HIV-positive, what


information would you like to know? What is the
significance of the answers?
Answers and significance are shown in Table 31.2. The
answers to these questions would be invaluable to the
person making the risk assessment.

If the patient indicates that he or she is not HIV-positive


but agrees to an HIV test, can you carry it out?
Yes, UK National Guidelines for HIV Testing 2008 say that it
should be within the competence of any trained health care
worker to obtain consent and conduct an HIV test.
If you do not have the facilities to perform the test then you
can ask the patients general medical practitioner or the local
on-call health professional who has been designated to carry
out risk assessments, advice and provision of PEP. The result of
the test should be given back to the patent by a person
qualified to answer any initial questions that the patient
might have and who has knowledge of the local specialist
services for a prompt referral. This is often the patients
general medical practitioner.

31

Table 31.2Information from human immunodeficiency virus


(HIV)-positive patients and its significance
Information

Significance

Whether patients are generally well

Patients with asymptomatic HIV infection have


low viral load and lower infectivity

Their CD4 (T-helper cell) count

An indicator of immunosuppression, the stage


of disease and effectiveness of treatment

Their viral load and when it was last


checked

A direct measure of infectivity

The names of any medications they are


taking

The same drugs would be avoided for


postexposure prophylaxis if they are not being
effective in the patient

Whether their medication has changed


recently and why

Recent changes in medication may indicate


their strain of HIV becoming drug-resistant
and this must be taken into account in
choosing the drugs for postexposure
prophylaxis

The address of the patients HIV clinic

To contact for further information. Obtain


consent to do this and respect the patients
confidentiality

What is PEP? Why not simply take the drugs regardless of


the relative risk?
PEP is preventive treatment started immediately after
exposure to an agent that causes infection. The regimes for
PEP following HIV infection are complex. New drugs are being
developed and knowledge is continually acquired about
HIV and the emergence of drug-resistant strains. This, along
with the desire to reduce side-effects of PEP to increase
compliance, means that the regime for PEP is constantly
under review. At the time of writing (2009) the regime
includes a combination of tenofovir, emtricitabine, lopinavir
and ritonavir. This is continued for 4 weeks.
The side-effects of these drugs include nausea, diarrhoea,
dizziness, headache, muscle weakness and skin rash. These
effects can be debilitating and automatic prophylaxis for
every sharps injury cannot be advocated. Pregnancy is not a
contraindication for PEP but the evidence for its safe use is
limited.

What if the patient indicates a risk of HIV infection to you


but you cannot obtain a formal risk assessment within 1
hour?
You should not delay starting PEP while awaiting either a
formal risk assessment or the testing of the patients sample
of blood. PEP is at its most effective within the first few hours,
and preferably the first hour.

Do I have to give a blood sample for testing?


You will be asked to give a blood sample for storage of
serum. This is because you may need to prove that infection
was not present at the time of the injury. If the patient is
subsequently shown to have an infection, you will be asked
to provide a sample for testing 12 weeks (as a minimum) after
the injury, or cessation of PEP if it was prescribed.

What is the risk of transmission of hepatitis B by this injury?


This should be minimal. All members of the dental team
should be vaccinated against hepatitis B. Once they have

CASE

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CASE

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148

Ouch!
achieved a satisfactory antibody response of 100mIU/ml to
the vaccine, a single booster is given after 5 years. Nonresponders will receive anti-hepatitis B immunoglobulin on
an occupational exposure. If recent evidence of the
effectiveness of the recipients vaccination is not available,
the recipient should have his or her antibody titre checked.
If the recipient is not immune, the risk of transmission has
been estimated at 30% if the patient is e antigen-positive.
Infection can follow transmission of as little as 0.1ml of
blood. Hepatitis B is so infectious that the degree of injury is
almost immaterial. In the unlikely event that a nonimmunized individual receives a sharps injury, specific
hepatitis B immunoglobulin provides passive immunity
and can give immediate but temporary protection after
accidental inoculation or contamination with hepatitis
B-infected blood.

Does this mean I have to give blood even if I know that my


hepatitis B vaccination is successful?
Yes. Even if the patient is of very low risk for having HIV, you
must also ensure that your serum is stored, because you may
need to show that hepatitis infection was not present at the
time of injury.

How can you determine whether the patient is infectious for


hepatitis B?
Blood must be screened for hepatitis B antigens and
antibodies (Table 31.3).

What is the risk of contracting hepatitis C?


The risk of contracting hepatitis C through a needlestick
injury is 3% if the donor is infected. This risk is therefore
higher than for HIV infection but, as for HIV infection, is
dependent on the amount of virus present in the blood.
The consequences can be severe. As many as 75% of
individuals who become infected will become chronic
carriers. Of these, 20% will go on to develop cirrhosis, liver
cancer or liver failure.
It is estimated that 4 in 1000 individuals in England in the
1559-years age group is infected with hepatitis C. The
majority remain undiagnosed. The prevalence of hepatitis C in

intravenous drug users has been estimated to be between 3


and 42%.

Is prophylaxis against hepatitis C available?


No PEP is available. However, early treatment of acute
hepatitis C infection may prevent chronic hepatitis C
infection.

How may the risk of needlestick or sharps injury in the


dental setting be minimized?
Sharps injuries do not always result from needles. Burs, hand
instruments (as you have just found out) and other
contaminated sharps all constitute a risk. You should:

Ensure that all the dental team are trained in the disposal
of sharps.
Identify and dispose of needles and other sharps
immediately after use.
Always pass instruments with the sharp end pointing
away from any person.
Remove burs and ultrasonic tips from handpieces
immediately after use.
Pick up instruments individually.
Retract the patients cheek with a mirror while
administering local analgesia.
Never resheath a needle holding the sheath in a hand:
use a one-handed technique (Figure 31.2) or dispose of
the needle immediately.
Never ever place your finger, or your assistants finger, in
front of a sharp instrument, such as a scalpel or luxator.
Always use a firm finger rest while scaling.
Dispose of sharps into a solid container (approved to
BS 7320).
Ensure that sharps are disposed of by incineration and by
an authorized person registered to collect such waste.
Use heavy-duty gloves when cleaning instruments prior
to autoclaving.
Keep your working area well organized and uncluttered
with sharps in a separate area. Do not place waste
material such as swabs or tissues over instruments.

Table 31.3 Hepatitis B antigens and antibodies and their significance


Antigen or antibody

When found

Significance for infectivity

HBs (surface) antigen or Australia antigen

Becomes detectable in late incubation and is present during


acute hepatitis. Declines over 36 months but persists in carriers,
whether asymptomatic or with chronic active hepatitis

Indicates infectivity, though not necessarily a high infectivity

Antibody to HBs (surface) antigen

Seen in recovery, reflecting immunity against the virus. Also


found in those immunized against hepatitis B

Probably indicates no risk of infection. Denotes past


exposure and immunity (including by active vaccination) to
the virus and a possible need for further investigation to
determine infectivity

HBc (core) antigen

Only present in the liver; not used for determining infectivity

Antibody to HBc antigen

Found in acute disease, recovery and in carriers, whether


asymptomatic or with chronic active hepatitis

Indicates past infection but a high level indicates an


infection risk

HBe (envelope) antigen

Becomes detectable in late incubation and is present during


acute hepatitis. Persists in carriers with chronic active hepatitis
but not usually in asymptomatic carriers

Indicates acute infection or a carrier state of high infectivity

Antibody to HBe antigen

Develops as Hbe disappears. Sometimes persists in chronic


asymptomatic carriers

Indicates either recovery from acute infection or a carrier


state of low infectivity

Ouch!

31

Always wear appropriate masks, visors or protective eye


protection. Modern minimalist designer glasses offer little
protection.
Footwear should cover the top of the foot. You would
not have a problem today if you had worn footwear
appropriate for the dental surgery.

What is your last duty before you can turn your back on this
unfortunate episode?
You must remember to fill in an incident report as required
by law (the Reporting of Injuries, Disease and Dangerous
Occurrences Regulations 1995) and submit it to the Health
and Safety Executive. This will be important evidence for
industrial injury benefit or insurance purposes, together with
the records in your notes.

This injury has ruined your day. This has all proved so
complex that next time you might just wash the injury and
ignore it. Why not?

Fig. 31.2A simple needle sheath holder. The holder is not


intended to hold the syringe upright, only to hold the sheath
during resheathing.

The main reason is the worry that you might contract HIV
infection from an unsuspected carrier. The effectiveness of
PEP reducing the risk of transmission by over 80% cannot
be ignored. Also, it would be unethical for a dentist not to
follow up the possibility of developing an infection which
could jeopardize the wellbeing of his or her patients. There
would also be a risk of transmission to the dentists sexual
partner(s).

CASE

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