WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Raja.K et al.

World Journal of Pharmacy and Pharmaceutical Sciences

SJIF Impact Factor 2.786

Volume 3, Issue 6, 397-415.

Review Article

ISSN 2278 – 4357

OCCUPATIONAL HAZARDS IN DENTISTRY AND ITS CONTROL MEASURES – A REVIEW Mr. Raja.K*, Dr. Auxilia Hemamalini Tilak Department of Microbiology, ASAN Memorial Dental College and Hospital, Asan Nagar, Oragadam Road, Keerapakkam Village, Chengalpet- 603105,Kancheepuram – Dt, Tamilnadu.

Article Received on 26 March 2014, Revised on 17 April 2014, Accepted on 8 May 2014

ABSTRACT Dentists, as well as other dental personnel are constantly exposed to a number of specific occupational hazards. These cause the appearance of various ailments, specific to the profession, which develop and intensify with years. In many cases they result in diseases and disease

*Correspondence for Author

complexes, some of which are regarded as occupational illnesses.

Raja.K Department of Microbiology,

Relying on relevant literature, the present paper discusses occupational

ASAN Memorial Dental

hazards like stressful situations, latex hypersensitivity, allergic

College and Hospital, Asan

reactions due to various dental materials, exposure to radiation

Nagar, Oragadam Road,

(ionizing and non-ionizing), percutaneous exposure incidents (PEI),

Keerapakkam Village,

hazard due to nitrous oxide gas, as well as factors leading to the

Chengalpet,Kancheepuram – Dt, Tamilnadu

musculoskeletal system diseases and diseases of the peripheral nervous system. Awareness regarding these occupational hazards and

implementation of preventive strategies can provide a safe working environment for all the dental personnel. There is also a need for continuing dental education programs in dentistry so that dentists can update themselves with the latest and newer techniques and materials. Keywords: Dental personnel, Hazards, Infectious Disease, Stress, Control measures INTRODUCTION Dentists are usually exposed to a number of occupational hazards during their professional work. These cause various ailments, specific to the profession, which develop and intensify with years. In many cases they result in diseases and disease complexes, some of which are regarded as occupational illnesses. Occupational hazards can be defined as a risk to a person usually arising out of employment. It can also refer to a work material, substance, process or situation that predisposes, or itself causes accidents or disease (1). Although modern dentistry www.wjpps.com

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has been cited as the least hazardous of the all the occupations, many risks still challenge the status of this occupation(2). Dental personnel are exposed to various occupational hazards like stress, allergic reactions, higher noise levels, accidental percutaneous exposure, radiation, musculoskeletal disorders, etc.. (3), Dental environment is also associated with a significant risk of exposure to various micro-organisms. Infectious agents may be present in blood or saliva, as a consequence of bacterimia or viremia associated with systemic infections. Dental patients and Dental Health Care Workers [DHCW] may be exposed to variety of microorganisms via blood or oral or respiratory secretions (4). These micro-organisms may include Cytomegalo virus ,Hepatitis B virus, Hepatitis C virus, Herpes simplex virus types 1 and 2, HIV ,Mycobacterium tuberculosis and other viruses and bacteria, especially those that infect the upper respiratory tract. Microorganisms can infect, through a cut on the skin of hand while performing a medical procedure, any dental procedure resulting in an accidental biting by the patient, or through a needle wound created while imparting anaesthesia. An indirect infection occurs when an infectious agent is transmitted into the dental care giver through the so-called carrier. The following are the main sources of indirect infection: aerosols of saliva, gingival fluid, natural organic dust particles (dental caries tissue) mixed with air and water, and accidental breakage of dental instruments and devices .during clinical practice exposes to variety of work related hazards(5). These occupational hazards can be classified into five types: “physical, chemical, biological, psychological and musculoskeletal disorders (6). The paper reviews various studies relating to occupational health hazards in dental profession, and its control measures. HAZARDS FROM PHYSICAL AGENTS Noise generated by dental equipments Dental personnel are exposed to noise of different sound levels while working in dental clinics or laboratories. Dental laboratory machine, dental hand piece, ultrasonic scalers, amalgamators, high speed evacuation devices and other items produce sound at different levels which is appreciable. As reported in an earlier study conducted among dentists and dental auxiliaries, 16.6% of subjects reported of tinnitus, 30% had difficult in speech discrimination and 30.8% had speech difficulty in a background noise(7) .The noise levels of modern dental equipment is below 85 db and up to this point the risk of hearing loss is negligible(8,9). But the risk is amplified while using older or faulty equipment. In dental practical classes, the acoustic environment is characterized by higher noise levels, in relation to other teaching areas, due to exaggerated noise produced by some of these devices and due

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to the use of a single dental equipment by many users at the same time. This situation is aggravated when the classrooms have hard surfaces which act as noise reflectors, as is usually the case(10). Therefore, it should be guaranteed that, in school buildings of this type sound levels are not detrimental to learning activities. Harmful effect is produced on the students and lecturers due to long exposure to higher noise levels. It is well known that higher sound levels have a negative effect on the extra-auditory systems with physical consequences (quickened pulse, increase in blood pressure, constriction of blood vessels, etc.) and psychical consequences (nervousness, mental fatigue and emotional frustration, low productivity etc) in some individuals. These effects occur especially with noise levels above 80db and are dependent on the intensity, the distance to the source, the total duration of the noise, the age of the individual and physical condition and sensitivity(8,9). Also, it is commonly known that exposure to noise can induce loss of hearing. It is therefore essential to control noise in learning environments, not forgetting that acoustic comfort depends not only on the control of the emitted sound levels but also on the acoustic characteristics of the classrooms. Ultrasonic scalers sometimes may be a potential hazard to the auditory system of both clinicians and patients. Damage to operator hearing is possible through air-borne subharmonics of the ultrasonic scaler. For the patient, damage can occur through the transmission of ultrasound through the tooth contact to the inner ear via the bones of the skull. This later hazard is possible during the scaling of molar teeth(11). Tinnitus is an early sign of hearing loss and may occur following ultrasonic scaling in some individuals. A small number of dentists have experienced tinnitus or numbness of the ear after the prolonged use of ultrasonic scaler, which indicates a small potential risk to hearing.(12). Kilpatrick(13) has listed the decibel ratings for various office instruments and equipment, which amount to70–92 dB for highspeed turbine hand pieces, 91 dB for ultrasonic cleaners, 86 dB for ultrasonic scalers, 84 dB for stone mixers and 74 dB for low-speed hand pieces. The noise levels generated during cutting were significantly higher than those of non cutting, which was proved in the course of the measurements. These demonstrate that the noise level for laboratory machines during cutting is 85.33 dB, without cutting – 77.51dB respectively, for the laboratory electromotor hand piece - 82.04 and 67.86, the angled-design turbine hand piece -78.98 and 66.84, the low-speed angled design hand piece 71.89–67.53. This may be attributed to the friction between the cutting material and cutting tools (14).

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EFFECTS OF NOISE Auditory effects  Auditory Fatigue (90dB or 4000 Hz)  Deafness- Temporary (4000-6000Hz)  Permanent (100dB) Non Auditory Effects  Interference with speech  Annoyance  Reduction in efficiency  Physiologic damage (increased intracranial pressure, increased heart rate, headache etc) (15) RADIATION Dental personnel are exposed to both ionizing and non ionizing type of radiations. Ionizing radiation is a well established risk factor for cancer(16). However, despite the fact that most dental offices and clinics have x-ray machines that are in frequent use [17], the exposure of dental workers to ionizing radiation and the associated potential cancer risk have been assessed in only a few studies. Dental staff should stand behind protective barriers and also use radiation monitoring badges to protect themselves. Non-ionizing radiation has become an important concern with the use of blue light and ultra-violet light to cure various dental materials. Exposure to the radiations emitted by these can cause damage to the various structures of the eye including the retina and the cornea (18).Use of safety glasses and appropriate shields can minimize or eliminate the radiations in this regard. A study conducted among Canadian dentists reported that occupational doses of ionizing radiation among dentists and dental workers have decreased markedly since the 1950s (19). The incidence of cancer among dental workers was lower than that for the Canadian population for all cancers except melanoma of the skin. Direct radiation injury has been virtually eliminated by improvements in radiologic equipment and methods and radioprotection measures.(20) However, the potential effects of whole-body doses remain of concern (21) with secondary radiation scattered from bones in the patient’s head now representing the greatest source of radiation received by dentists and dental workers.(22)

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PERCUTANEOUS EXPOSURE INCIDENTS [PEI] Percutaneous injuries are a frequent problem among dentists, who are among the healthcare professionals most involved in occupational accidents(23) particularly needle stick and sharp instrument injuries(24, 25). This exposure is related to the fact that dentists work in a limitedaccess and restricted- visibility field and frequently use sharp devices. Percutaneous exposure incidents facilitate transmission of blood borne pathogens such as human immunodeficiency virus [HIV], hepatitis C virus [HCV] and hepatitis B virus [HBV] (26). Estimates based on data from the Centers for Disease Control and Prevention, suggest that a healthcare provider’s risk of acquiring HIV infection as a result of percutaneous exposure to an HIVcontaminated device is 0.3%(27) According to a study the prevalence of needle stick and sharp instrument injuries in dentists was 19.2% within the previous six months(26). Burs represented the most common device as the cause of exposure in this study. Reports of another study carried out in Washington reveals that 66.7% of the percutaneous injuries are sustained by dentists (28) and most of the injuries (70%) occurred during administration of local anesthesia, recapping a needle and performing surgical procedures. According to a study carried out in UK, glove damage is reported in 2% of latex gloves and 5% of nitrile gloves which sustained punctures following routine clinical dental procedures(29). As already cited, the most common “sharps” injuries among dentists continue to rise from needles and drilling instruments, such as burs. Of concern in needle stick injuries, is the fact that they often occur while giving injections, when there is usually some residual bodily fluid in the needle from the punctured site. National and international guidelines, such as the Needle stick Safety Act in 2001 were developed to help minimize the risk of blood borne pathogen exposure to health care workers including dental settings.(30, 31) The infection risk after accidents involving contaminated blood contact depends on various factors, such as: type of exposure, inoculums size, host response, infectious material involved, and the amount of blood (32). In principle, any accident should be treated equally, regardless of the characteristics of the patient or the accident site. A careful evaluation is necessary to determine the need for post-exposure chemoprophylaxis. Moreover, analysis of the circumstances of the accidents can contribute to preventing other accidents.(33) CHEMICAL Dentists are exposed to various types of chemicals that are hazardous while providing care. They include mercury, beryllium, silica and powdered natural rubber latex (NRL). Most dangerous of these agents is mercury. These chemicals act by local action, inhalation and

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ingestion. Mercury use in dental amalgam has potential occupational exposure to dentists. The maximum level of exposure considered to be safe is 50 µg/ cc of air (34, 35). The active component in mercurial vapour has a particular affinity for brain tissue. Mercury poisoning can be characterized by tumours of the face, arms or legs and may be associated with progressive, tremulous illegible handwriting with slurred speech.(36,37) The exposure risks from mercury can be minimized by careful handling, collecting the waste part of amalgam in closed container and subjecting it to recycling, use of proper evacuation system and avoiding the direct physical contact. The research conducted at the University of Calgary Faculty of Medicine found that exposure to mercury caused the formation of "neurofibrillar tangles," which are one of the two diagnostic markers for Alzheimer's disease. In February, 1998, a group of the world's top mercury researchers announced that mercury from amalgam fillings can permanently damage the brain, kidneys, and immune system of children. Dental amalgam fillings have been found to affect DNA. This later can leads to cancer. Damage in human blood cells based on a number of studies in Sweden, the World Health Organization review of inorganic mercury in 1991 determined that mercury absorption is estimated to be approximately four times higher from amalgam fillings than from fish consumption.(37) Inhalation of dust containing free silica or silicon dioxide in ceramic laboratories leads to silicosis. Some of the dental alloys contain beryllium and if it inhaled while working on items such as dental crowns, bridges, and partial denture framework, they can cause chronic beryllium disease (CBD). As per Occupational Safety and Health Administration (OSHA) specification, employees cannot be exposed to more than 2 microorganisms of beryllium per cubic Meter of air for an 8 hour time weighted average(38). Formaldehyde is one of the chemical agents routinely used in the clinical set up mainly for disinfection of operatory area. Liquid and vapour forms of formaldehyde may cause severe abdominal pain, nausea, vomiting and eye irritation(39). Occupational Safety measures should be followed to minimize the side effects due to chemical agents. There are many potentially toxic materials that are used in dentistry that may pose a health hazard in the absence of appropriate precautionary measures. Most of the dental materials undergo an extensive range of tests both before and after use. Even so, some dental materials are aerosolized during high speed cutting and finishing and may thereby be inhaled by dental staff. Other dental materials are volatile and may give rise to dermatological and respiratory effects (40)The dangers of chronic exposure to mercury are well documented. On the contrary, it is now recognized that the health hazards of amalgam restorations is negligible with the exception of rare allergic reactions. The greatest exposure to mercury from dentists comes from handling amalgam and www.wjpps.com

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amalgam capsules for restorations and storage and disposal of amalgam also represent important sources of exposure(41). New filling materials have been developed to help reduce the dependence on mercury based substances, such as composite resins, although these may be less durable and clinically effective than mercury amalgam. Chemicals used in radiology can also lead to occasional health problems. Developing solutions are chemicals used in the reduction of silver bromide ions. These also contain chemicals that control the processing speed, a preservative and a hardening agent(42). Fixing solutions include a neutralizer, a clearing agent to remove underdeveloped silver bromide ions, a preservative and a hardening agent. There are a number of constituents that may cause health effects: acetic acid, diethyl glycol, glutaraldehyde, hydroquinone, potassium hydroxide etc. In medical imaging, glutaraldehyde is primarily used as a hardening agent to prevent films from sticking together. Skin sensitization and allergic contact dermatitis after occasional exposure have been documented in case of glutaraldehyde. Mixing of processor chemical components also causes the release of sulphur-dio-oxide from decomposition of sulphite. Chronic exposure may result in bronchospasm. Ammonia, a highly soluble respiratory irritant, is another potential byproduct released from the breakdown of processing chemicals. Another source of vapor release is the silver recovery unit. It is important that the lid be tightly secured and only opened in a well-ventilated area(42) MUSCULOSKELETAL DISORDER Muskuloskeletal disorders are common health problems reported among dentists. Its prevalence reported to be between 38-82%. Musculoskeletal disorders are a group of conditions that involves: Nerves , Tendons , Muscles and supporting structures such as intervertabral discs. (43) It has been reported that young and less experienced dentists experience more musculoskeletal disorders compared to older and experienced ones(44). Common musculoskeletal problems are, low back pain, shoulder pain, headache, hand and wrist pain. Low back pain is more prevalent than other types. The cause of musculoskeletal problem is due to, repeated unidirectional twisting of the trunks, working in one position, prolonged static periods and operators flexibility.(44,45,46) At work, the dentist assumes a strained posture (both while standing and sitting close to a patient who remains in a sitting or lying position), which causes an overstress of the spine and limbs. Back pain syndromes diagnosed in dental workers originate from spine degeneration in its different phases. The posture of the

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dentist at work, with the neck bent and twisted, an arm abducted, repetitive and precise movements of the hand are frequent cause of the neck syndrome and of pain within the shoulder and upper extremities(47). Puriene A et al (48)reported Fatigue and back pain as most common prevalent and chronic physical complaints among Lithinium dentists. The dentist makes constant monotonous movements, which stress the wrist and elbow joints. Also of consequence are mechanical vibrations. A number of dental doctors suffer from a defect of the median nerve and of the cubital nerve. A consequence of the defected median nerve in the carpal canal is the so-called tunnel syndrome. Its early phase is dominated by paroxysmal paraesthesiae of the thumb and index finger, which occur almost without exception at night and which are accompanied by sensomotor disorders of the thumb and index finger(49). Pains of the epicondylus, appearing at first during strain and special movements, gradually intensifying and radiating along the forearm, point to an inflammation of the epicondylus of the humeral bone. Operations carried out during extractions stress not only the elbow joint and the wrist joint but may result in chronic tendon sheath inflammation. (50)Prevention includes maintaining correct body posture while treating patients, taking adequate rest, doing some exercises. Prevention includes maintaining correct body posture while treating patients, taking adequate rest, doing some exercises. Common musculoskeletal disorders occurring among dentists. Following are the classification of some of the musculoskeletal disorders seen commonly among dental practitioners.(50,51)

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THE BIOLOGICAL HAZARDS The biological hazards are constituted by infectious agents of human origin and include viruses, bacteria and fungi. Transmissible diseases currently of greatest concern to the dental professional are HIV, HBV, HCV and Mycobacterium tuberculosis. A dentist can become infected either directly or indirectly, i.e by a cut or wound, needle stick injury, aerosols of saliva, gingival fluid and natural organic dust particles. The following are the main entry points of infection epidermis of hands, oral epithelium, nasal epithelium, epithelium of upper airways, bronchial tubes, alveoli and conjunctival epithelium. In order to overcome from the infection spread, a thorough knowledge about the infection, mode of transmission and safety measures is necessary. During many dental procedures, the use of a rubber dam will eliminate virtually all contamination arising from saliva or blood.(52) All members of the dental include hepatitis A virus (HAV), HBV, and hepatitis C. In a study done by Watt HIV/AIDS was believed to be very similar to eye injury and mercurial poisoning in terms of rate of concern amongst dental personnel team are at risk of exposure to Hepatitis B virus (HBV), HIV infection, and other types of communicable infections(53).In the United Kingdom for example, the carrier rate HBV in the general population is 0.5%, while dentists have a carrier rate of approximately 1.6%.Several of the common viral agents that can cause hepatitis have been detected in body fluids including saliva and blood. The viruses most commonly implicated. The risk of HIV transmissions to healthcare workers approximately range from 0.2 to 0.3% for parenteral exposures and 0.1% or less for mucosal exposures. A report published by the Centers for disease control and prevention (CDC) studied the 208 dental exposures (percutaneous, mucous membrane, and prolonged skin exposures) reported to the CDC from 1995 to 2001, 13% had HIV-positive source patients and did not lead to a seroconversion (75% of exposed individuals took the three-drug PEP regimen for variable lengths of time). Percutaneous exposure to HBV containing transmission risk about 2% for HBe Ag-negative and about 30% for HBe Ag positive blood.[14] Despite reducing the risk for HBV transmission among healthcare workers by effective HBV vaccination programs, measuring of anti-HBs antibody response after HBV vaccination is essential for all vaccinated individuals with high-risk professions(54,55,56) HCV transmission risk is 1.8% and is the most serious viral hepatitis infection because of its ability to produce chronic infection in as many as 85% of those infected. The U.S. Public Health Service recommendations for HCV exposures implicate precise follow-up of the exposed practitioners and referral for appropriate therapy if an infection occurs. (57)

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PSYCHOLOGICAL HAZARDS a. Stress Dentists encounter numerous sources of professional stress, beginning in the dental clinic. Stress can be defined as the biological reaction to any adverse internal or external stimulus physical, mental or emotional that tends to disturb the organism’s homeostasis. Dentists perceive dentistry as being more stressful than other occupations. Coping with difficult or uncooperative patients, over workload, constant drive for technical perfection, underuse of skills, low self-esteem and challenging environment are important factors contributing to stress among dentist. Dunlap J and Stewart J in their survey on 3,500 dentists found that 38 percent were frequently worried or anxious, 34 percent of the respondents felt physically or emotionally exhausted, and 26 percent said they always or frequently had headaches or backaches(43, 58,59) b. Professional burnout One of the possible consequences of chronic occupational stress is professional burnout. Meslach and Jackson (1986) define burn out as: “A syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who do people work of some kind.” Burnout is best described as a gradual erosion of the person .Prolonged experience of burn out may lead to depression, so early recognition of the symptom is important(59). In a study of three dental specialities Humphris et al reported that general dentists and Oral surgeons had the highest levels of burnout and that orthodontists had the lowest levels of burnout can grow progressively worse if not treated (60). Two common and potentially overlapping anxiety disorders are panic disorder and generalized anxiety disorder, or GAD. In panic disorder, feelings of extreme fear and dread strike unexpectedly and repeatedly for no apparent reason They are accompanied by intense physical symptoms like feeling sweaty, weak, faint, dizzy, flushed or chilled; having nausea, chest pain, smothering sensations, or a tingly or numb feeling in the hands. GAD is characterized by chronic exaggerated worry and tension, even though little or nothing has provoked it.(59) Depressive disorder often occurs with anxiety disorders and substance abuse. Major depression is an illness that involves the body, mood and thoughts. It affects the way people eat, sleep, feel about themselves and think about things. Studies have indicated that both anxiety and depressive disorders are observed frequently in dentists.(60)

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CONTROL MEASURES Dentist has to upgrade his existing knowledge by participating in continuing dental education. Universal precaution has to be taken while practicing to prevent occupational hazards. Dental clinic design has to be made with, sufficient lighting, ventilation, engineering control measure and equipped with appropriate personal protective. ROUTINE PRECAUTIONS Transmission of infection within the setting of dentistry may occur from the dentalhealth care worker to the patient, from the patient to the health care worker or frompatient to patient. Cases have been documented in which human immunodeficiency virus(HIV) or hepatitis B virus (HBV) was transmitted from dental health care workers totheir patients and vice versa. Patient to patient transmission, although being reportedonly in medical settings so far, may potentially occur in dental practices.The major documented routes of transmission of HIV and HBV in dental settings are (i) precutaneous inoculation and (ii) contact with an open wound, non-intact (e.g. chapped, abraded, weeping or dermatitic) skin, or mucous membranes to blood, blood contaminated body fluids or concentrated viruses. Blood is the single most important source of HIV and HBV in dental practice. Protective measures against HIV and HBV should focus primarily on preventing these types of exposures to blood as well as ondelivery of Hb vaccination .Since it is now known that persons carrying blood-borne viruses, including both health care workers and patients, may not have been identified and are thus not aware oftheir own condition, it follows that procedures adopted routinely for ALL practices mustbe adequate to prevent cross-infection. Under current technology, it is recognized that the risks of accidental percutaneous injury during dental procedures cannot be reduced to zero. While the risk of HBV transmission could be eliminated by immunization, the risk of exposure to the blood ofHIV infected individual is a special concern to dental health care workers. It isconsidered justifiable to apply additional infection control measures when performing invasive procedures on individuals with known HIV infection. Dental health care workers who consider themselves at increased risk of HIV infection should arrange confidential testing. Those who are infected must seek appropriate medical advice to ensure they pose no risk to patients (please refer to Advisory Council on AIDS published document “HIV infection and the health careworkers – recommended guidelines. Protection can be achieved by a combination of immunisation procedures, use of barrier techniques and strict adherence to routine infection control procedures.

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(i) Immunisation All dental health care workers are advised to be immunized against HBV unless immunity from natural infection or previous immunization had been documented (ii) Protective coverings  Uniforms Uniforms should be changed regularly and whenever soiled. Gowns or aprons should be worn during procedures that are likely to cause spattering or splashing of blood

 Hand protection Gloves must be worn for procedures involving contact with blood, saliva o rmucous membrane. A new pair of gloves should be used for each patient. If a glove is damaged, it must be replaced immediately. Hands should be washed thoroughly with a proprietary disinfectant liquid soap prior to and immediately after the use of gloves. Disposable paper towels are recommended for drying of hands. Any cuts or abrasions on the hands or wrists should be covered with adhesive water proof dressings at all times.  Protective glasses, masks or face shields Protective glasses, masks or face shields should be worn by operators and close-support dental surgery assistants to protect the eyes against the spatter and aerosols which may occur during cavity preparation, scaling and the cleaning of instruments. (iii)Sharp instruments and needles Sharp instruments and needle should be handled with great care to prevent unintentional injury. Needles should never be recapped by using both hands indirect contact or by any other technique that involves moving the point of a used needle towards any part of the body. The needle can be recapped by laying the capon the tray, placing the cap in a reheathing device or holding the cap with forceps before guiding the needle into the cap. (iv) First aid and inoculation injuries In the event of a skin puncture by a contaminated instrument, the wound should be encouraged to bleed and washed thoroughly with running water All incidents should be reported to the officer i/c of the clinic. Where there is reason to be concerned about the possible transmission of infection, advice on appropriate serologic testing, medical evaluation and follow-up could be sought from Accident, and the address and contact telephone of the

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patient concerned should be recorded. INSTRUMENT STERILIZATION All instruments should be cleaned thoroughly before sterilization by rinsing and scrubbing with detergent and water. Splashing of water should be avoided. Heavy duty gloves and, where appropriate, face protection shield, should be worn .Items which will penetrate tissues must be sterilized in an autoclave or hot air steriliser. Items which will touch mucous membrane but not penetrate tissues should similarly be sterilized by heat, or, if not possible, disinfected, e.g., by immersion in 2%glutaraldehyde solution in a closed container according to the manufacturer instructions. All chemical residues must then be removed by thorough rinsing before use or storage. Handpieces, ultrasonic scaler inserts/tips and air-water syringe tips where detachable should be flushed for 30 seconds, dismantled, cleaned, oiled where required,

and autoclaved between patients. (Hand pieces, etc. left overnight should be

allowed to discharge water for two minutes at the beginning of the day). Hand pieces which cannot be autoclaved are disinfected with an appropriate virucidal agent .Following sterilization, all instruments should be stored in clean containers to prevent recontamination. Surgical and endodontic instruments should be kept in closed containers. It may be necessary to re-sterilize them immediately before they are used and care should be taken to ensure the instruments are cool prior to use. Aspiration and ventilation The use of high volume aspiration will reduce any risk of cross-infection from aerosols. The risk is further reduced by good ventilaton. The tubings of high volume aspirators and saliva ejectors should be flushed with water between patients and with disinfectant (sodium hypochlorite, 0.1%) regularly or according to the manufacturer’s instructions. DISPOSAL OF WASTE Sharp items including needles and scalpels and local anaesthetic cartridges, should be placed into puncture proof containers which should be securely sealed. These together with all medical waste must be disposed of in red bags, securely fastened. Red plastic bags are to be picked up by a special collection service for hospitals and clinics. Non infective waste should be disposed of in thick black plastic bags securely fastened .Liquid waste should be carefully poured into a drain and then flushed with water .Spatter and splash should be avoided.

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Laboratory items Impressions and appliances should be rinsed thoroughly to remove all visible blood and debris. Gloves should be worn when handling impressions and pouring models .Certain types of impression material (silicone, polysulphur) can be disinfected by totally immersion in glutaraldehyde (2%) or sodium hypochlorite (0.1%). Other materials(alginate, polyether) may be disinfected by submerging for several seconds in sodium hypochlorite (0.1%), which should then be wrapped in a hypochlorite saturated paper towel and kept in a closed container for the recommended disinfectant time. Additional precautions to be taken when performing invasive procedures on HIV infected individuals (a) If possible, schedule the patient surgery at the end of the list. (b) The team should be limited to essential members of staff and the procedures should be performed by experienced, fully trained staff. (c) The operator should wear two pairs of gloves. Plastic gown, cap mask and protective eye wear should be worn. (d) All procedures should be performed in a way which minimizes the formation of droplets, spatter and aerosols, utilizing high volume vacuum aspirators,

rubber dams where

appropriate and proper patient positioning. Ultrasonic scalers should be avoided (e) Avoid the use of instruments which cannot be easily decontaminated .Instruments and tools used should be handled and cleansed by experienced staff before autoclaving (f) After the operation, all surfaces inside the surgery and equipment should be cleaned and decontaminated with appropriate disinfectants. CONCLUSION As this review shows, many occupational health problems remain in modern dentistry. In order to be a protective professional one must be healthy. One thing should kept in mind that every technology, no matter how beneficial, can exert a negative impact on some members of the population. Immunization against various infectious diseases like HIV, HBV etc. is very essential for every Dental Health Care Worker. Dentists should control their working hours, pace of work, be aware of occupational hazards and observe their mental health. Strategies

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for improving mental health and reducing the effects of occupational hazards should be developed and implemented in order to secure the well being of dentists. Serious infectious due to percutaneous exposure incidents(PEI) can be avoided by use of appropriate barrier techniques and high level sterilization. Dental personnel should be familiar with the major signs and symptoms of allergic reactions, including anaphylaxis in the case that an allergic emergency should arise during a consultation. Various continuing dental education programs should be organized so that dental professionals can gain knowledge about various newer methods and developments. REFERENCE 1. Pelka, M., Distler, W., Petschelt, A.: Elution parameters and HPLC-detetction of single components from resin composite, Clinical Oral Investigations., Vol. 3, pp. 194-200, 1999 2. Leggat PA, Kedjarune U ( 2001) occupational risk of modern dentistry; a review. J occup Health Saf (Aus Nz) 17, 279-86 3. Al-Khatib IA, Ishtayeh M, Barghouty H, Akkawi B. Dentists’ perceptions of occupational hazards and preventive measures in East Jerusalem. East Mediterr Health J 2006; 12: 15360. 4. Adebola FA, Owotade FJ. Occupational hazards among clinical dental staff. J Contemp Dent Pract 2004; 5: 134-52. 5. Jolanta Scymanska. Occupational hazards of dentistry. Ann Agric Environ Med 1999, 6, 13-9. 6. Prashant Babaji et al Occupational Hazards Among Dentists ; Journal of International Dental and Medical Research Volume ∙ 4 ∙ Number ∙ 2 ∙ 2011 7. Caballero AJ, Palencia IP, Cardenas SD. Ergonomic factors that cause the presence of pain muscle in students of dentistry. Med Oral Patol Oral Cir Bucal 2010; 15 : e906-11. 8. Bahannan S, el-Hamid AA, Bahnassy A. Noise level of dental handpieces and laboratory engines. J Prosthet Dent 1993; 70: 356- 60. 9. Setcos JC, Mahyuddin J. Noise levels encountered in dental clinical and laboratory practice. Int J Prosthodont 1998; 11: 150-7. 10. Sampio Fernandes JCS, Carvalho APO, Gallas M, Vaz P, MatosPA. Noise levels in dental schools, Eur J Dent Educ 2006; 10: 32-7. 11. Trenter SC, Walmsley AD. Ultrasonic dental scaler: associated hazards. J Clin Periodontol 2003; 30: 95-101

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