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Table of Contents   
ORIGINAL RESEARCH  
Year : 2021  |  Volume : 32  |  Issue : 3  |  Page : 305-309
Occupational exposures to bloodborne pathogens and its underreporting in dental teaching environment in an Indian dental school


1 Department of Periodontology, Bharati Vidyapeeth Deemed to be University Dental College and Hospital, Navi Mumbai, Maharashtra, India
2 Department of Periodontology, D. Y. Patil University School of Medicine, Navi Mumbai, Maharashtra, India

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Date of Submission24-Feb-2020
Date of Decision28-Apr-2021
Date of Acceptance11-Nov-2021
Date of Web Publication23-Feb-2022
 

   Abstract 


Introduction: The aims of this study were 1) to find out the prevalence of occupational exposures to contaminated biological material among undergraduate students and interns; 2) to find out how many cases of occupational exposures to bloodborne pathogens are reported; and 3) to know the reasons for non-reporting of occupational exposures. Materials and Methods: The study was conducted in a Dental School in Navi-Mumbai, India. An anonymous self-administered questionnaire was formulated. 210 dental students were given a questionnaire out of which 150 students attending clinical postings in their third year, final year, and internship responded. Approval was obtained from the Institutional Ethical Committee. Results: The study revealed a very high prevalence (66.7%) of exposures among the students. Only 12% of the students reported the exposures to the staff. Students from III year and final year BDS (Bachelor of Dental Surgery) had mean exposure of 2.40 as compared to 1.94 among interns. 46% of the students stated that they did not report about the exposure because they thought that injury was of minor nature. Conclusion: There is a very high prevalence of occupational exposures among students which are not reported. There is a need for the development of a post exposure protocol which has to be strictly implemented. The principle of infection control has to be emphasised to the students periodically and they should be encouraged to report incidences of exposures to biological material.

Keywords: Dental students, infection control, occupational exposure, post exposure protocol

How to cite this article:
Joshi NV, Joshi M, Rathod V, Langde D. Occupational exposures to bloodborne pathogens and its underreporting in dental teaching environment in an Indian dental school. Indian J Dent Res 2021;32:305-9

How to cite this URL:
Joshi NV, Joshi M, Rathod V, Langde D. Occupational exposures to bloodborne pathogens and its underreporting in dental teaching environment in an Indian dental school. Indian J Dent Res [serial online] 2021 [cited 2022 May 26];32:305-9. Available from: https://www.ijdr.in/text.asp?2021/32/3/305/338119



   Introduction Top


Healthcare workers are at a risk of exposure to bloodborne pathogens by the way of injury through needles, sharp instruments or mucosal contamination. Dental procedures are performed in close contact between dentist and the patient and require considerable skill in the use of sharp instruments. Dental students are involved in patient investigations and treatment during their clinical training. During this period they lack the experience and skill in performing dental procedures, which makes them more vulnerable to injuries.[1]

The dental schools not only have the responsibility of protecting the patients but also providing reasonable safety measures for the students who have not yet mastered the technical skills necessary for their profession and yet are engaged in patient-related activities.

Occupational exposures are defined as[2] that which are associated with the risk of transmission and spread of highly lethal pathogens like hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency viruses (HIV). These bloodborne viruses have serious consequences including long term illness, morbidity and death.[2]

For healthcare workers worldwide, the prevalence for percutaneous occupational exposure to HBV, HCV and HIV are 37%, 39% and 4.4%, respectively.[3]

The possibility of infection from a single exposure is low; however, it is potentially very dangerous. Such injuries have a serious emotional impact and distress on the students.[4] A vast number of blood borne exposures go unreported and undocumented. The dental teaching institutions should have a post exposure program (PEP) for the management of blood borne exposures and exposures to biological materials during training period. According to one study over the past one or two decades, several publications have raised serious concerns over the individual risks and institutional liabilities related to occupational blood borne exposures during clinical medical training.[5],[6],[7] Now that dental students have more clinical training on patients than their medical counterparts, the dental schools must realise their responsibility for ensuring student safety even more than medical schools. Gatto et al.[8] in their thirteen year surveillance study concluded that their results may serve as a benchmark for dental schools. Several studies worldwide have reported that there is underreporting of such bloodborne exposures (BBEs) in dental schools.[2],[4],[5],[9],[10],[11],[12],[13],[14],[15],[16] Cuny et al.[10] in their study concluded that students should be reminded about the importance of reporting BBEs throughout their curriculum.

National Institute for Occupational Safety and Health (NIOSH) in United States has published guidelines for Preventing Injuries in Healthcare Settings in year 1999.[3] Dental schools should have a protocol for reporting such events and a PEP should also be in place to deal with such events. Such PEP should be explained to the students during their clinical orientation just before beginning the clinical patient contact. PEP should be based on the Centre for Disease Control (CDC) guidelines. CDC has described dental healthcare personnel safety for dental settings which includes recommendations for qualified health care professional as well as educational institutions.[17]

It is essential therefore to gather the data from dental schools about the occupational BBEs. In order to do this, a questionnaire-based study was planned with the following aims and objectives.

  1. To find out the prevalence of occupational exposures to contaminated biological material among undergraduate students and interns
  2. To find out how many cases of occupational exposures to bloodborne pathogens are reported
  3. To know the reasons for non-reporting of occupational exposures.



   Materials and Methods Top


Epidemiological data is necessary to assess any problem and to plan a solution for the problem. Occupational exposures are defined as any contact of non-intact skin, eye, mucous membrane or parenteral contact (laceration or puncture with a needle or other sharp instrument) with blood or other potentially infectious material (such as saliva) which occurs during diagnosis and treatment of patients or when handling orally soiled impressions and prosthetic devices as well as during disposal of needles, burs or other sharp instruments.[2] Hence, an effort was made to gather the data about such exposures and their underreporting among dental students attending clinical postings in their third year, final year and internship. A study was conducted in a dental school in Navi-Mumbai, India. A questionnaire was formulated for this purpose and was validated. The questionnaire was given to the students at the end of academic year. The identity of the students was kept confidential. Before filling the questionnaire the students were told what an occupational exposure means. They were made to understand that it includes not only needle prick injuries but also handling of soiled dental impressions, dental X-ray films, cotton swabs, extracted teeth, aerosols generated by dental drills, etc., and exposures that might occur during cleaning and washing of instruments. The questionnaire asked whether they experienced any such exposures and if yes whether it was once or more than once, and whether they reported these incidences to the staff. Further, the questionnaire also asked the reasons for non-reporting of exposures. Approval was obtained from the Institutional Ethical Committee (072/2015). All the subjects were informed about the study and only those who were willing to participate in the study were enrolled. A verbal consent was obtained from the willing students.

The data was gathered and tabulated on MS Excel spreadsheet. Statistical evaluation was done using Stata Version 13.1' Copyright 1985-2013 Stata Corp LP, 4905 Lakeway Drive, College Station, Texas 77845, USA (http://www.stata.com).


   Results Top


The questionnaire was given to 210 students, out of which 150 subjects responded. Out of those who responded, 100 subjects had experienced blood borne occupational exposures (66.66%) of which 78 were female and 22 were male subjects. This difference in representation between male and female students is due to the reason that more girls are opting for dental graduation course than boys according to the All India Survey on Higher Education 2015-2016-Ministry of Human Resource Development Department of Higher Education, New Delhi.[18] From the III year BDS, 9 responded to the questionnaire out of which 5 (55.6%) experienced the exposures. From the IV year BDS, 76 students responded to the questionnaire out of which 57 (75.0%) experienced occupational exposures. From the interns, 65 students responded to the questionnaire out of which 38 (58.5%) had an experience of exposure to bloodborne pathogens. The BDS course consists of four years of study and one year of compulsory internship (total five years) [Table 1].
Table 1: Year of course and sex wise distribution

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[Table 2] tells about the number of exposures in a year. Among the final year BDS students the mean number exposure was highest, i.e., 2.40, whereas among the interns, it was least, i.e., 1.94. This shows that as the students gain more experience in handling instruments and performing the dental procedures the exposure rate is reduced though it was not statistically significant.
Table 2: Year of course and sex wise distribution with test of significance

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[Graph 1] tells us about the department wise distribution of exposures experienced by the students. According to these results, maximum exposure was seen in Periodontology (42.7%) followed by Conservative Dentistry and Endodontics (38%). The least exposure was seen in Public Health Dentistry and Pedodontics (0%).



[Graph 2] shows that only 12% of students reported the incidence of occupational exposures to the staff. The students were asked whether they reported the incidence of exposure to staff whether it was once or more than once on different occasions. This shows that overall reporting rate was 12%, from this 12% it was 7.6% of students who reported the incidence of exposure every time even if there was more than one exposure.



The subjects were asked the reasons for not reporting of the occupational exposures that they have encountered. 46% of the subjects said that they thought that the injury was minor, and 27% of subjects said that they did not think that it will cause any harm. 13% of subjects did not report as they thought that the item was unused, 10% did not report fearing staff's reaction, 8% did not report as they did not know how or whom to report, whereas 7% did not do so as they were busy [Graph 3].




   Discussion Top


Blood borne exposures like needle stick injuries, handling of soiled dental impressions, injury while washing and cleaning endodontic files and bur is common during dental education in dental colleges. However, traditionally there is poor reporting of such incidences by the students across the globe.[2],[3],[4],[6],[7],[8],[9],[11],[12] In our study, we found that only 12% of the subjects reported about such incidences, whereas 82% of them did not report. This is much more than the results found in previous similar studies. Machado-Carvalhais reported 71.9% of underreporting.[3] Kotelchuck et al. also reported that 70% of the respondents did not report occupational exposure.[5] In our study, the percentage of underreporting was significantly higher; this could be because the students think that such exposures are minor in nature as seen in the reasons for underreporting. Many of these exposures occur during non-clinical work like disposing of soiled impressions, used X-ray films, washing of instruments, etc., and the students might think that these are not significant.

Students who accidentally expose themselves to needle stick injuries have a fear of contracting blood borne infections like HIV. This causes tremendous mental stress and low self-esteem. Hence, we need to educate the students regarding infection control and post exposure protocols. A constant repetition of the infection control measures and post exposure protocol can be effective strategies to improve the compliance.[10]

In our study, we found that maximum exposure to sharp instruments was in Periodontology department (64%) followed by department of Conservative Dentistry and Endodontics (57%). In a study conducted by Jaber,[12] it was found that scaling was found to be the second most common procedure causing injuries, most common being capping of needles. In a study conducted by Sedky, it was found that dental burs were the most common cause of injury.[11] In our study, we found that mean number of exposure was less in interns as compared to the third and final year students though the difference was not statistically significant. This suggests that as the students gain experience they become less vulnerable to exposures. Similar results were seen in study conducted by Younai et al.[16] On the contrary, Sedkey reported that accidental exposures were more among senior students, this could be because they do more number of procedures as compared to junior students.[9]

One important finding of our study was that many students experienced multiple exposures (46%). This is because dental students need to work in a very constrained area close to the patient. It also requires considerable amount of skill, manual dexterity and expertise to perform dental procedures.

When the students were asked about the reasons for not reporting of exposures, the most common reason that they gave was that they thought that the injury was minor (46%). This is very important finding as it tells us that students are doing their own risk assessment and they do not think that the injury is significant. A similar finding was noted by Jaber.[12]

The dental schools should have an in-house post exposure protocol to address this issue.[3],[8] Lack of a post exposure protocol makes the students clueless as to what is to be done in case of exposure to sharp instruments of bloodborne pathogens. For every such exposure, documentation should be done followed by post exposure serologic testing. Multicentre trials can be done in future to find the reasons for not reporting of exposures and formulating post exposure protocol.

CDC has given guidelines on post exposure protocols for health workers who are at a risk of exposing themselves to blood borne products during handling of clinical material.[14] It is alarming that majority of the students did not report to their staff about the exposure. If they are made aware about the seriousness of the incident and the post exposure protocol, there could be an improvement in the situation. Once such a protocol is made, the staff/faculty should promote it for better compliance from the students.


   Conclusion Top


Based on the findings from this study, it can be concluded that dental students are at a great risk of accidental exposures during their clinical training. The third and fourth year students had more number of exposures compared to interns. Students had most exposures in Department of Periodontology followed by Conservative Dentistry and Endodontics. Majority of students failed to report the incident of exposures to the staff. The most common reason cited that the injury was minor and hence they did not report.

It is prudent to have a post exposure protocol for the safety of students. CDC guidelines can be helpful in formulating such a protocol. Given the limitations of a questionnaire-based study, the data gathered nevertheless can prove to be an important step in the direction of safety of students in healthcare profession.

Declaration of patient consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

I would like to thank Dr Aardra Patil (MDS) for helping in manuscript editing and proof reading of the prepared manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Jaber MA. A survey of needle sticks and other sharp injuries among dental undergraduate students. Int J Infect Control 2011;7:1-10.  Back to cited text no. 12
    
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Hashemipour M, Sadeghi A. Needlestick injuries among medical and dental students at the University of Kerman. A questionnaire study. J Dent Tehran Univ Med Sci 2008;5:71-6.  Back to cited text no. 15
    
16.
Younai FS, Murphy DC, Kotelchuck D. Occupational exposures to blood in a dental teaching environment: Results of a ten-year surveillance study. J Dent Educ 2001;65:436-48.  Back to cited text no. 16
    
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Kohn WG, Harte JA, Malvitz DM, Collins AS, Cleveland JL, Eklund KJ, et al. Guidelines for infection control in dental health care settings--2003. J Am Dent Assoc. 2004;135:33-47.  Back to cited text no. 17
    
18.
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Correspondence Address:
Dr. Nilesh V Joshi
103, Ascot, Raheja Gardens, Opp- TipTop Plaza, LBS Road, Thane West - 400 604, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_172_20

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