ORAL AND MAXILLOFACIAL SURGERY. Occupational blood exposure and HIV infection among oral and maxillofacial surgeons. Editor: Larry J

Vol. 85 No. 2 February 1998 ORAL AND MAXILLOFACIAL SURGERY Editor: Larry J. Peterson Occupational blood exposure and HIV infection among oral and m...
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Vol. 85 No. 2 February 1998

ORAL AND MAXILLOFACIAL SURGERY

Editor: Larry J. Peterson

Occupational blood exposure and HIV infection among oral and maxillofacial surgeons Barbara F. Gooch, DMD, MPH,' Chakwan Siew, PhD,b Jennifer L. Cleveland, DDS, MPH,c Stephen E. Gruninger, MS'd Stuart A. Lockwood, DMD, MPH,' and Edwin D. Joy, DDS,f Atlanta, Ga., Chicago, Ill., and Augusta, Ga. CENTERS FOR DISEASE CONTROL AND PREVENTION, AMERICAN DENTAL ASSOCIATION HEALTH FOUNDATION, AND MEDICAL COLLEGE OF GEORGIA

Objective. The purpose of this study was to examine occupational blood exposure and the seroprevalence of HIV infection among oral and maxillofacial surgeons. Study Design. Three hundred twenty-one oral and maxillofacial surgeons attending an annual meeting voluntarily and anonymously participated in an HIV serosurvey and completed a questionnaire assessing practice and demographic factors. Statistical tests included the Wilcoxon rank-sum test and the chi-squared test. Results. Eighty percent of those who completed the survey reported one or more blood-skin contacts within the previous month. The mean number of percutaneous injuries within the previous year was 2.36 ± 0.2. Wire was most commonly associated with percutaneous injuries. Oral and maxillofacial surgeons who reported three or more percutaneous. injuries performed more fracture reductions than oral and maxillofacial surgeons reporting no percutaneous injuries (p < 0.01). No participant was HIV positive; the upper limit of the 95%o confidence interval was 1.1 5%/. Conclusion.The findings suggest that the occupational risk for HIV infection in oral surgery is very low even though most oral and maxillofacial surgeons experienced blood contact. Associations of percutaneous injuries with fracture reductions and wire may assist in the development of new techniques and equipment to minimize blood exposures. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:128-34)

This study was supported by the American Associaition of Oral and Maxillofacial Suirgeons, the American Dental Association Health Foundation, and the Centers for Disease Control and Prevention. aDental Health Officer, Stirveillance, Investigations, and Research Branch, Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Ga. bDirector, Department of Toxicology, Research Institute, American Dental Association Health Foundation, Chicago, Ill. 'Dental Officer and Epidemiologist, Surveillance, Investiigations, and

Research Branch, Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control, Atlanta, Ga. dResearch Associate, Department of Toxicology. Research Institute. American Dental Association Health Foundatton. Chicago, Ill. eEpidemiologist, Surveillance, Investigations, and Research Branch, Division of Oral Health, National Center tor Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Ga. rProfessor and Chairman, Department of Oral and Maxillofacial Surgery, Medical College of Georgia, Augusta, Ga. Received for publication June 26, 1997: returned for revision Aug. 6, 1997, accepted for publication Sept. 10, 1997.

Copyright@' 1998 by Mosby, Inc. 1079-2104/98/$5.00 + 0 7/12/86266

Among dental workers, oral and maxillofacial surgeons (OMS) may be at the greatest risk of occupational exposure to blood and thus to bloodborne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. OMS have been more likely than general dentists to have serologic evidence of past infection with HBV, the bloodhome virus most commonly transmitted in health care settings. Serosurveys conducted before 1982, when hepatitis B vaccine became available commercially, indicated that approximately 26% of OMS and about 15% of general dentists had been previously infected with HBV. 1 -4 Determinants of the risk of transmission of bloodborne pathogens in health care settings include the type and frequency of blood contact, the prevalence of bloodborne pathogen infection among patients, and the risk of transmission after a single exposure to infected blood. 5 The type of blood contact may be skin or mucous membrane exposure and/or exposure resulting from a percutaneous injury (PT) with a needle or other sharp instrument that was used on the patient. The type

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Table 1.Distribution of demographic characteristics (%) of oral and maxillofacial surgeons participating in the 1992 HIV serosurvey and in the 1991 national survey of private dental practice Characteristic Age < 40 years :40 years Sex Male Female Location of practice* New England Middle Atlantic South Atlantic East South Central East North Central West North Central West South Central Mountain Pacific

HI-V serosurvey (n = 320)

National survey (n = 5188)

27.4 72.6

22.5 77.5

97.5 2.5

98.2 1.8

9.9 10.6 16.8 5.6 14.7 5.1 11.5 8.6 17.8

8.3 21.1 16.3 5.1 16.0 6.1 8.1 4.7 14.3

*Because of rounding, percentages may not add to 100,0%. Location of practice was taken from the HnviuCV serosurvey questionnaire (n = 321).

of blood exposure most likely to transmit a bloodborne infection is a percutaneous exposure. 6-9 Estimates of the risk of PIs among OMS have varied. The mean PI rate was 0.22 per month among 83 OMS participating in a prospective self-reported diary study among dentists in the United States in 1992.10 No Pls were observed during approximately 4000 outpatient oral surgery procedures (such as tooth extractions, alveoloplasties, and soft-tissue biopsies) in a prospective observational study among general dentistry and oral surgery residents in New York City in 1993.11t Similarly, no Pls were recorded during 521 outpatient procedures in a prospective self-reported study among oral surgery residents in Atlanta in 1995.12 In the latter study, the P1 rate during 362 operating room procedures was 1.1%. The rate for 105 trauma and infection procedures alone, which included fracture reductions, was 2.9%. Although these studies were limited by small numbers of participating OMS, clinical study sites, or complex procedures, findings suggest that oral surgeons continue to encounter opportunities for occupational blood exposure, particularly during complex operating room procedures. The last survey to assess the seroprevalence of bloodborne infection in a large sample of oral surgeons in the United States was conducted in 1981 and was limited to HBV.4 Since then, studies of dentists attending the Health Screening Program (HSP) at annual meetings of the American Dental Association have provided, along with other health information, important data on both

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Table II. Type and frequency of occupational exposures to patients' blood among HIV serosurvey participants Type and number of exposures to patients' blood Skin, in previous month* (n = 315) 0 1-4 5-9 >9 Mucous membrane, in previous month (n = 316) 0 1-4 >4 Percutaneous, in previous year (n = 295) 0 1 2 >2 Percutaneous, in previous month (n = 274) 0 159 >1

Number of responses

Distribution of responses (%)

69 181 37 28

21.9 57.5 11.5 8.9

263 47 6

83.2 14.9 1.9

80 70 62 83

27.1 23.7 21.0 28.1

199

72.6 21.5 5.8

16

*Percentages may not add to 100.0% because of rounding.

the seroprevalence of bloodborne pathogens-HBV, H-IV, and HCV-and the frequency of Pls. 13 -16 The number of oral surgeons participating in the HSP annually, however, has been small-generally fewer than 50. Because of the limitations of available data, a voluntary survey was conducted to examine occupational blood contact and seroprevalence of bloodborne infection among oral and maxillofacial surgeons. Data from this study on the seroprevalence of HCV and HBV were published in 1996.17 METHODS Of 1260 attendees at the 1992 annual meeting of the American Association of Oral and Maxillofacial Surgeons in Honolulu, Hawaii, 320 oral surgeons who practiced in the United States voluntarily and anonymously participated in the HIV serosurvey. A blood sample was collected from each of the participants who signed a consent formn and completed a 14-item questionnaire. The consent form did not ask for the participant's name or assign an identification number, and no participant could be linked with any completed questionnaire or blood sample. The questionnaire assessed occupational and nonoccupational risks for HIV infection. Occupational

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16 14

13.1

13.1

*0

12 a C C. C

Pls in past year (n=80)

D 3 Pls in past year (n=80)

10 8

C

C C

6 4 2.5

2.6

22

3.0

2 0

1.6ula Excision

Temporonia Dental implant

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Orthognathic surgery

Type of Procedure *Significantly

different between 0 and =3 Pis in past year: Wilcoxon rank sum = 5198.5; z =-2.58; p = 0.0097

Figure 1. Mean number of surgical procedures performed in a typical month by percutaneous injury (PI) rate Table Ill. Numbers and percentages of participants reporting specific devices associated with percutaneous injuries in the history of their practice Device

Orthodontic or surgical wire Syringe needle Suture needle Other sharp instrument Bur Scalpel blade

Intraoral procedures No. ()No.(%

Extraoral procedures

207 161 147 85 30 24

65 (20.2) 56(17.4) 80 (24.9) 47 (14.6) 13 (4.0) 27 (8.4)

(64.5) (50.2) (45.8) (26.5) (9.3) (7.5)

risks included having practiced in a location with a high prevalence of HIV/AIDS (Atlanta, Baltimore, Boston, Chicago, Dallas, Denver, Detroit, Ft. Lauderdale, Houston, Jersey City, Los Angeles, Miami, New Orleans, New York City, Newark, Oakland, Philadelphia, San Diego, San Francisco, San Juan, Seattle, Tampa, Washington D.C., West Palm Beach, Bergen-Passaic County, Nassau-Suffolk County, Africa, or the Caribbean) and having treated patients known to be infected or at risk for infection with HIV, as well as types and frequency of exposure to patients' blood. The three types of exposure were skin and mucous membrane exposure to patients' blood and P1, defined as an accidental parenteral skin puncture from a sharp instrument (e.g., needle, drill, scalpel, wire) that had been used on a patient. Non-occupational risks included having used drugs parenterally (intravenously or intracutaneously); having received blood transfusions, blood

products, organs, or tissues; having hemophilia; having had sex with anyone known to have AIDS or HIV infection; having had sex with a male (if the participant was male); and having had sex since 1975 with anyone known to have any of these risk factors. Participants were not asked to indicate which non -occupational risk applied to them. Methods of serosurvey assay have been described previously. 14 Most participants in the HIV serologic screening also voluntarily participated in serologic screening for markers of HBV and HCV infection or hepatitis B vaccination and completed a 2 1-item questionnaire addressing clinical practice and demographic characteristics. 17 In the current analysis some information (e.g., state of residence and specific devices associated with Pls) from the confidential questionnaire administered with the HBV/HCV serosurvey was used. Clinical and demographic factors associated with Pls and history of previous HIV testing were examined. Statistical tests of association included one-way analysis of variance (ANOVA), Wilcoxon rank-sum, and chi-squared. To assess representativeness of the study sample, the age, gender, and practice location of each study participant were compared with those of 5188 OMS in a 1991 national survey of dental practice conducted by the American Dental Association.' 8 The upper boundary of the 95% confidence interval for HIV seroprevalence rates was calculated by the binomial distribution. 19 RESULTS The age and gender distributions of OMS participat-

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ing in the HIV serosurvey and in a 1991 national survey of dental practice were similar (Table 1). Participants in the serosurvey were more likely than OMS in private practice to be from West South Central, Mountain, and Pacific states and less likely to be from Middle Atlantic states. Almost 60% of the participants reported one to four skin contacts within the previous month, and 20% reported five or more skin contacts (Table 11). Fewer than 20% of OMS reported a mucous membrane contact with blood in the previous month. Of those who did, almost all reported one to four such contacts. The mean number of PIs (± standard error) was 2.36 (± 0.2) for the previous year (range, 0-35) and 0.3 (± 0.04) for the previous month (range, 0-6). Seventy-three percent of OMS reported one or more PIs in the previous year, and 27% reported at least one PT in the previous month. Fifteen OMS (4.8%) reported that in the history of their practice they had experienced one or more PIs with a sharp instrument that had been used on a patient-known to have HIV infection or AIDS; eight reported that such an exposure had occurred in the previous year. Fifty-three percent of questionnaire respondents indicated that orthodontic or surgical wire was the device most commonly associated with PIS in the history of their practice. Other devices commonly associated with PIs were syringe needles (25%), suture needles (15%), and other sharp instruments (e.g., burs and scalpel hlades)(7%). Of the participating OMS, 92% and 86% reported having sustained PIs at least once while performing intraoral procedures or extraoral procedures, respectively, in the history of their practice. PIs from orthodontic or surgical wire, syringe needles, and suture needles during intraoral procedures were the most commonly reported PIs (Table 111). Respondents reported performing a mean of 11.6 surgical excisions (of inflammatory lesions, tumors, cysts, and neoplasms), 4.4 dental implants, 1.6 temporomandibular joint surgeries, 2.5 orthognathic surgeries, and 2.7 fracture reductions in a typical month. With respect to these surgical procedures, the number performed in a typical month was compared for those respondents who reported no PIs in the previous year and those who reported three or more PIs in the previous year. Each of these exposure groups included roughly 25% of the sample population; the two groups represented the extremes of the distribution of responses. The differences between the two exposure groups were statistically significant only for fracture reductions, which were performed more frequently among surgeons reporting at least three PIs in the previous year (Wilcoxon rank sum = 5198.5; z = -2.58; p = 0.0097) (Figure 1). When the two exposure groups were compared by age, mean number of practice years, and per-

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Table IV.Characteristics of all serosurvey participants and of those who reported having been previously tested for HIV antibody

Characteristic Age 20-39 years 40-49 years 50-69 years Years of practice 1-9 10-19 20-29 30 Have practiced in a location with a high prevalence of HI V/AIDSt Yes No Have treated patients known to be infected with HIV Yes No No. of HI V-infected patients treated in the previous year 0 No. of skin exposures to patients' blood in the previous month 0 >1 No. of mucous membrane exposures to patients' blood in the previous month 0 1l No. of occupational percutaneous injuries in the previous year

0 >1l

All participants No. ()No.

Those previously testedfor HIV antibody (%)

87 (27.4) 135 (42.5) 96 (30.2)

63 (72.4)* 106 (78.5)* 57 (59.4)

68(21.5) 126 (39.7) 89(28.1) 34 (10.7)

49 93 66 17

(72.1I)t (73.8)t ( 7 4 .2 )t (50.0)

79 (16.6) 218 (73.4)

61 (77.2) 148 (67.9)

281 (89.2) 34 (10.8)

205 (73.0)§ 18 (52.9)

48(16.4) 245 (83.6)

28 (58.3)1 180 (73.5)

69 (22.0) 246 (78.0)

41 (59.4)§ 181 (73.0)

263 (83.2) 53 (16.8)

189 (71.9) 35(66.0)

80(27.0) 215 (73.0)

49 (6I.3)§ 162 (75.0)

p< 0.01 versus 50-69 years lp < 0.05 versus >30 years t * ilanta, Baltimore, Boston, Chicago, Datlas, Denver, Detroit. Ft. Lauderdale, Houston, Jersey City, Los Angeles, Miami, New Orleans, New York City, Newark, Oakland, Philadelphia, San Diego, San Francisco. San Juan, Seattle, Tampa, Washington DC, West Palm Beach, Bergen-Passaic Counties, NassauSuffolk Counties, Africa, and the Canibbean. Op< 0.05 versus "No." lp < 0.05 versus >1

cent of surgery done in the hospital, there were no significant differences between the OMS reporting no PIs in the previous year and those reporting three or more PIs in the previous year. Seventy-one percent of the participants reported having received a previous HIV antibody test. Younger OMS (< 50 years of age or < 30 years of practice), those

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who had treated HIM-infected patients (either ever or within the previous year), and those reporting PIs in the previous year were more likely to have been previously tested for HIM infection than were other OMS (Table IV). Two of the five HIM serosurvey participants reporting a non-occupational risk for HIV infection had been previously tested. About 60% of those reporting a previous HIM test responded to the question about why they had been tested. The most frequently cited reasons were insurance requirements (80%), curiosity (42%), and blood donation (28%). Seventeen participants (11I%) indicated that a blood or body-fluid exposure to HIM was a reason for testing. Of the 320 OMS participating in the serosurvey none was HIV-seropositive (upper limit of the 95% confidence interval = 1. 15%).

DISCUSSION Our finding of no HIM seropositive survey participants is consistent with results of other voluntary seroprevalence studies, which have shown very low rates of HIM infection among dental workers' 4 2. 0 2'1 and orthopedic 22 and hospital-based surgeons. 23 For example, participants in the HSP at annual meetings of the American Dental Association have been offered voluntary, anonymous HIM testing since 1987. Of about 17,000 blood samples tested through 1996, three were positive for HIV antibody. 14-24 Of these, one was from a dentist who did not report behavioral or transfusion risks for HIV infection. Infection rates may be underestimated in voluntary surveys, however, because persons who suspect or know that they are infected with HIV may not volunteer to be tested. Among the OMS in this study 7 1%reported previous HIV antibody testing, most (80%) because of insurance requirements. Also, the extent of exposure to HIV (both occupational and non -occupational) among the workers tested often is unknown. Although more than 80% of participating OMS had treated one or more HIM-infected patients in the previous year, fewer than 5% reported a percutaneous exposure to HIMinfected blood in the history of their practice, and 73% did not practice in areas with high prevalence of HIM infection or AIDS cases. In contrast to the results of earlier serologic surveys of HBM infection, 14 our findings do not suggest a high prevalence of previously undetected HIM infection among participating OMS. Other findings in this study indicate that OMS had direct contact with patient blood and were at potential risk for bloodbomne infection. First, as reported elsewhere, 17 21.2% of participating OMS were found to have serologic evidence of previous or current infection with HBM. In comparison, seroprevalence rates among general dentists attending the HSP at annual sessions of

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Febritan 1998

the American Dental Association from 1989 to 1992 remained relatively constant at 9%.16 These findings suggest that OMS were much more likely than general dentists to have serologic evidence of previous infection, although percentages of OMS and general dentists reporting receipt of hepatitis B vaccination were similar at 8 1%25 and 85%, 16 respectively. However, rates among OMS and general dentists are higher than the rate for the general populace in the United States, which is estimated to be 5%.26 Most participants reported contact with patients' blood within the previous month. The most frequent type of contact reported was skin contact, which is consistent with the results of studies in other surgical services. 27-29 Information pertinent to future efforts to prevent skin contact, including information about anatomic sites of contact and the use and/or failure of barriers, was not collected here. In this study of OMS the mean PI rate was 0.3 per month, which is similar to estimates from self-reported and observational studies of US dentists. 10 11 The mean rate of self-reported PIs was slightly higher among orthopedic surgeons (0.6 per month) 22 and hospitalbased surgeons (0.5 per month). 23 Prospective studies, however, may provide more reliable estimates of blood contacts. In a prospective self-reported study of oral surgery residents, one PI occurred during 1.1% of all operating roomn procedures and during 2.9% of trauma and infection procedures that included fracture reductions. Observational studies among hospital-based surgical personnel have found at least one PI during 1% to 15% of procedures. 27 -33 More than one half of the OMS reported that wire was the device most prominently associated with PIs, followed by syringe needles and suture needles. Amnong all dentists, burs, followed by syringe needles and other sharp instruments, have been the most frequently cited device. 10 13 Among general surgeons, most PIs-up to 80% in one prospective study-were associated with suture needles. 5 30 Many participants in this study reported having sustained intraoral injuries with wire, syringe needles, and suture needles in the history of their practice. Such an injury may increase the risk of direct blood contact, inasmuch as the intraoral operative field and the associated device are likely to be visibly bloody. In some instances, the patient may be placed at risk for contact with the surgeon's blood when the contaminated device recontacts the patient. However, the volume of blood associated with solid-bore suture needles, 34 35 wire, and syringe needles of small gauge would likely be very small. Also, in laboratory studies the presence of glove material has been shown to decrease the size of the blood inoculum. 34 The association found in this study between PI rate

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Volume 85, Number 2

and number of fracture reductions performed in a typical month is consistent with findings among oral surgery residents that three of four PIs occurred-during fracture reductions. 12 This association may be due to the greater use of wire during fracture reductions in comparison with other surgical procedures, to the surgeon's technique (e.g., retraction of tissue using fingers instead of instruments in the presence of wire), or to the presence of sharp bone fragments or foreign bodies. Most participants in this study (711%) reported receipt of a previous HIV antibody test. This percentage is larger than those among 438 participating dentists in a

statewide survey (29%) in 198936 and among 71 dentists in a local survey (58%) in 1991.37 Although the proportion of OMS previously tested was higher among those who reported a percutaneous injury in the previous year (75%) than among those who did not (61%7), one quarter of OMS who reported a P1 in the previous year had not been tested. .Our study was limited to the extent that no information on the specific circumstances of recent blood contacts was gathered. For example, for PIs reported in the last month it would be useful to know the specific devices, procedures, and actions associated with the injuries, particularly when prevention strategies are being considered. Recall bias is an additional limitation; the frequency or circumstances of percutaneous exposures from the previous year or in the history of practice may not be accurately remembered. Also, in this survey

not all respondents answered all survey items. For example, almost 20% of participants did not reply to the question about PIS in the previous month. Finally, it is unlikely that findings from this small, self-selected sample of 320 OMS are generalizable to the more than 5000 oral surgeons practicing in the United States. The characterization of blood contacts is important because prevention of blood contact remains the primary strategy for minimizing the risk of occupational transmission of bloodborne pathogens. OMS should continue to adhere to universal precautions for mtnimizing blood contact, receive hepatitis B vaccination, and seek appropriate counseling and follow-up after occupational exposure to HIV or HBV.3 8 3, 9 Other strategies to prevent PIs in oral surgery could include the use of safer devices such as self-sheathing hollowbore needles and blunted suture needles .40 The findings in one British study4 ' suggest that the use of small plates instead of wires during surgical treatment of some mandibular fractures may reduce the risk of PIs. Manual palpation of suture needles and retraction of tissues by hand should be discouraged. Because most PIS in health care settings involve the fingers and hands, the use of thimbles and the continued development of puncture-resistant gloves may be indicated. One study

Gooch et al. 133

among oral surgeons performing outpatient procedures found that double gloving decreased the probability of inner glove puncture. 42 Once developed, preventive interventions should be evaluated to determine whether they reduce blood exposures without adversely affecting patient care. 5 In conclusion, our study findings indicate that although the risk of occupational transmission of HIV infection in oral surgery is very low, most OMS experience blood contact, including PIs, and are thus potentially at risk for occupationally acquired bloodborne infection. Skin contacts reportedly were most frequent. PIs may be associated with procedures that use wire, such as fracture reductions, but they were not associated with the surgeon's age or experience or with surgical setting. For their reviews of drafts of the manuscript, the authors thank Dr. Carl Russell, of the Office of Biostatistics at the Medical College of Georgia; Drs. Eugenio Beltrdn, Dolores Malvitz, and Donald Marianos, of the Division of Oral Health at the National Center for Chronic Disease Prevention and Health Promotion; and Dr. Denise Cardo, of the Hospital Infections Program at the National Center for Infectious Disease (Centers for Disease Control and Prevention, Atlanta). The authors also thank Ms. Darian White for her assistance with the preparation of the manuscript. REFERENCES I .Feldman

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