29 May 2017
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Two Types of Dentists

Two Types of Dentists
In December, TeethGeek asked me to write about my experiences with the MFDS and MJDF. After a few months, the numbers of you reading that article rapidly approached 2,000. I am humbled by this response, appreciative of your interest and grateful for the opportunity to be asked for another serving of my experiences in dentistry.

On reflection and after several years, with some certainty, I might state there are at any given time only two types of dentist:

Those who have had a sharps injury and those who will get a sharps injury.*

Have you had a sharps injury?

My first was a few years ago using a blunt instrument and my last one was a few weeks ago… using a blunt instrument. Clearly, I have not learned anything about the sharp risks inherent in using blunt instruments and please note: Any blunt instrument needs more force than a sharp one to produce the same result and so a blunt instrument is more likely to cause a sharp injury than a sharp instrument will.

 The last injury was cutting cold wax (and my finger), while the first injury was cutting cold cadaver (and my finger). In between these two traumas, there were punctured gloves, patients (numb) gums, tongues and lips being variously and vigorously; scored, sliced then sutured and patients (not so numb) gums, tongues and lips about to be inadvertently numbed.  In essence; revise your regional anatomy, remember where your needle is pointed and don’t forget where the patient’s nerves are to be found. The accidental  trans-digital, intra-glossal  ID block is fraught with more risk to you and your patient, than an orthodox and intentional ipsilateral approach to the same ID nerve using a mirror or tongue retractor, rather than your finger as a needle guide!

The point about sharp injuries are they can equally affect our patients and our colleagues too. Please do not forget this: Either in the clinic or in your exams. One recurring nightmare OSCE is the dental nurse with a sharp injury.  It recurs with unfailing frequency in your exams, because it occurs with unfailing frequency in real life. The blunt truth is the sharp injury will happen to you, a colleague or a patient in equal measure.

What does not occur in equal measure is the transmission risk from the three main blood borne viruses: HIV, HCV and HBV. One set of figures you will have to remember in your exams are the average estimated seroconversion risks and these are widely reported as:

0.3% for percutaneous exposure to HIV-infected blood.

0.1% for mucocutaneous exposure to HIV-infected blood.

0.5-1.8% for percutaneous exposure to HCV-infected blood with detectable RNA.

30% for percutaneous exposure of a non-immune individual to an HBV e Antigen .

Today UK dental students must undergo vaccination, and then demonstrate absence of and immunity from Hepatitis B before being admitted to the clinical environment. Please note: Vaccination does not mean Immunisation. Vaccination is merely the administration of an agent. Whereas Immunisation is the detectable and demonstrable evidence the body has raised a specific protective antibody. With Hepatitis B: Immunisation is demonstrating a Hepatitis B Surface Antibody titre  in excess of 100 mIU /ml. Anything less than 10 mIU/ml is a non-response and  between 10 and 100 mIU/ml is a poor response. With non-responders and poor-responders, an Occupational Health Consultant will determine what if any additional regimen or monitoring is necessary to ensure safe working practices.

With immunity to HBV, from the figures above we can see the real risk from sharps injury comes from Hepatitis C and to a lesser extent from HIV.  We have all treated patient carrying viruses starting with H and ending in V. Some of our patients will know and confirm this in their medical histories, whereas others although displaying the clinical signs; will maintain an ignorance of their clinical symptoms, adamant they are in good health.

 As Dr James Wise, the Royal College of Surgeons of England Faculty tutor eloquently stated, when specifically addressing HIV:

“Your patients won’t die from it, but they will die with it.”

I think consideration of this is important when we incur any sharps injury. It will not be the end of us and with the advent of the 2013 General Dental Council Guidelines, nor will it be the end of our dental careers. This does not mean we should be any less vigilant either with ourselves or when caring for our patients. As noted above; in my years of practice I have had countless sharps injuries and I am still very much alive and healthy, (albeit still a little clumsy). Bearing all of this in mind, this knowledge might make the psychological trauma of a needle stick injury less painful and the impact of dealing with Occupational Health more bearable when we report our sharps injuries.

With any sharps injury, there are five things we need to do, or in an OSCE: Demonstrate knowledge of doing:

1. Gloves off and encourage the wound to bleed under running water.

2. Don’t scrub or suck the wound (strange but true the NHS Choices Web site reminds us not to!)

3. Dry and Dress the wound.

4. Report to your Senior Colleague for them to continue the patient care, as you Attend A and E, then Occupational Health.

5. Complete the Mandatory Paperwork documenting your incident and attend Follow Up appointments.

Perhaps the most important aspect of any untoward incident, but especially the sharps injury is to learn from it and so prevent or minimise the risk of its recurrence. In addition to the General Dental Council Guidelines, in the UK and Europe, we are now moving away from a culture of Risk Reduction to one of Risk Elimination. This means new management, new measures and new materials, the aim of which is to move the sharps injury and its consequences away from being a doom-laden spectre hanging over us to the status of a Never Event. That is something that can be reported upon and learned from without fear, stress or undue punishment.

In your dental studies, you will unfortunately have to memorise various facts and figures, such as those noted above on the transmissibility of various viruses and their sero-conversion risks. This is a hugely interesting and a somewhat experimental area, given the large number of sharps injuries but the small numbers of those being injured contracting an illness. Again, this fact does not mean we should be less vigilant, nor does it mean we should not continually develop knowledge from the evidence as it is gathered and presented to us. Beyond the numbers you have to learn, there is still one truth: With regard to this aspect of cross infection control, there are only two types of dentist:

Those who have had a sharps injury and those who will get a sharps injury.*

Until a time in the future with less risk or even no risk, the only real safety we have is in our education. We will explore this subject and cross infection control in a further article, until then; take care of your patients and yourselves.

*OK, I accept there might be another variety, these are Public Health Dentists. In treating populations and not patients, they are less prone to sharps injuries than clinically active dentists. Unless we consider their tetanus risk from a paper cut thumbing through their conspirational surveys looking for something inspirational  to report to our managers, I think we can ignore them (for the purposes of this article).