Responding to Occupational Exposures: 12 Questions from Our Learners

Is your dental team prepared for an occupational exposure?

When an occupational exposure occurs, uncertainty around protocols, testing, responsibilities, and follow-up can delay care for the person exposed and create added stress for both employers and team members.

That’s why CareQuest Institute and the Association for Dental Safety (ADS) hosted the webinar, “Occupational Exposures in Dental Settings: Protocols, Response, and Follow-Up,” to help dental teams build the knowledge and systems they need to prevent, recognize, and respond to occupational exposures.

During the webinar, Karen Gregory, RN, CDIPC, and Marie T. Fluent, DDS, FACD, CDIPC, shared practical guidance on exposure prevention, post-exposure protocols, employer responsibilities, and building an effective response plan.

More than 650 learners attended the webinar, moderated by Natasha Wiltshire, RDH, MPH, CHES, of the University of North Carolina at Chapel Hill Adams School of Dentistry. Attendees had several questions — What should you do immediately after an exposure? Who is responsible for testing? When is post-exposure prophylaxis (PEP) needed? — that the experts answered on the call and below:

 

1. In your experience, what are the most common gaps you see in dental practices’ occupational exposure plans?

Fluent: The biggest gap is not having a written policy in place. I’ve seen situations where the practice owner was away and an injury or exposure occurred, and everyone looked at each other and said, “Now what do we do?” Practices need a written protocol established in advance so everyone knows what steps to take.

Another major gap is not knowing where to go if an incident occurs. Employees may have different ideas about where they should seek care, so where to go for evaluation needs to be determined before an exposure occurs.

Gregory: Another common issue is not understanding the post-exposure process. I’ve heard people say an employee needs post-exposure testing for a year, even when that may not be necessary for their situation. Exposure incidents hopefully don’t happen frequently, but that can mean team members are less familiar with what to do. That’s why it’s so important to understand the process before an incident happens.

 

2. How can a minor scratch that does not break the skin or cause bleeding pose an exposure risk?

Gregory: An exposure occurs when blood or other potentially infectious material comes into contact with the eyes, mouth, mucous membranes, non-intact skin, or enters through the skin. If a scratch does not break the skin, it is not considered an exposure. The area should still be washed, and the event recorded as a near miss so the practice can determine what happened and how to prevent it from happening again.

If there is any question about a break in the skin, then always move forward and let a licensed health care provider make that determination.

 

3. Should you squeeze the injury while washing it?

Gregory: No. Do not squeeze the area, as this can cause bruising. Wash the area thoroughly with soap and water, document the exposure, and follow up with a licensed health care provider.

 

4. If you’re wearing contact lenses and get a chemical splash in your eyes, what should you do first?

Fluent: The first thing you should do is get to the eyewash station and begin flushing your eyes immediately. Don’t stop to remove your contact lenses before flushing. Once you’ve started flushing, you can remove the contacts and continue rinsing.

Ideally, another team member can retrieve the safety data sheet for the chemical while you remain at the eyewash station. The most important thing is to begin flushing immediately and then follow the appropriate protocol for the chemical involved.

 

5. Who is responsible for ordering the laboratory tests for the source patient?

Gregory: The employer is responsible for ensuring the exposed worker receives an immediate, confidential medical evaluation at no cost and that the source patient is tested for hepatitis B, hepatitis C, and HIV, with consent if required by state law. Because ordering these tests may be outside a dentist’s scope of practice, testing is typically ordered by a provider at a prearranged occupational medicine clinic or urgent care.

 

6. Is there a name for the post-exposure medication, and how effective is it?

Gregory: The treatment is called post-exposure prophylaxis (PEP). The “2025 US Public Health Service Guidelines” recommend a 28-day course of a three-drug antiretroviral regimen for people starting PEP. While the experts did not provide a specific efficacy rate, they noted that there have been no documented cases of seroconversion from an occupational exposure since 2008.

 

7. Would pharmacies be able to provide rapid testing or PEP?

Gregory: While there are some states allowing pharmacies to provide pre-exposure prophylaxis (PrEP) or PEP, this does not address the issue of testing and addressing prophylaxis for hepatitis B exposure.

 

8. If you’re vaccinated and have documented immunity, does that mean you don’t need PEP?

Fluent: It depends on what you were exposed to. Keep in mind that there is no vaccine for hepatitis C or HIV. If you are exposed to hepatitis B and have documented immunity, you would not need hepatitis B PEP. But an exposure could still require follow-up related to hepatitis C or HIV. That’s why evaluating the exposure and, when appropriate, testing the source patient are important for determining the necessary next steps.

Gregory: There is a high level of confidence in the hepatitis B vaccine and the testing used to document immunity:

According to the “Hepatitis B and Healthcare Personnel” featured in the webinar, health care professionals who completed the hepatitis B vaccine series and have a documented positive antibody response are considered immune and do not need additional routine testing or vaccination.

Of course, we’re talking about people with normal immune function. Individual circumstances can vary, particularly for people who are immunocompromised.

 

9. If hepatitis B antibody levels decline over time, how should a titer taken years after vaccination be interpreted?

Gregory: There is evidence that 8 to 10 years after you receive the vaccine, antibody levels can decline. I received the vaccine in the early 2000s, for example. If you drew a titer on me today, I might not show adequate antibody levels.

In that situation, you may receive one dose of the vaccine or repeat the vaccine series and then have another titer to determine whether you show immunity or are considered a non-responder. However, if you previously had a titer showing adequate antibody protection, there is evidence of long-term protection. That’s why you don’t want to just randomly get a titer years later. You may find that your measurable antibody levels have declined and end up repeating vaccination unnecessarily. Currently, there is no reason for serial titers once adequate immunity has been documented.

 

10. Will dormant antibodies be activated once exposed?

Gregory: According to “Hepatitis B and Healthcare Personnel,” hepatitis B antibody levels can decline over time, but the immune system retains memory of the vaccine. That means people who previously demonstrated adequate antibody levels (≥10 mIU/mL) are still considered protected even if those levels later fall below 10 mIU/mL. For health care professionals with normal immune function and documented protection, routine boosters or periodic antibody testing are not recommended.

 

11. What happens if an employee has had the hepatitis B series two times and did not convert?

Gregory: According to “Hepatitis B and Healthcare Personnel,” if someone still does not show adequate immunity after a second hepatitis B vaccine series, additional testing can help determine whether they are a vaccine non-responder or have evidence of a past or current hepatitis B infection. Those who are considered vaccine non-responders remain susceptible to hepatitis B and may need hepatitis B immune globulin (HBIG) following certain exposures. People whose results indicate a current infection should receive appropriate counseling and be referred for ongoing care.

 

12. For an exposed employee who is a known non-responder to the hepatitis B vaccine, would you immediately give a booster instead of testing?

Gregory: According to “Hepatitis B and Healthcare Personnel,” hepatitis B vaccine non-responders are still susceptible to infection. If they are exposed to blood that is positive for hepatitis B, or if the source patient’s hepatitis B status is unknown, they should receive hepatitis B immune globulin (HBIG) to help protect against infection.

 

Editor’s Note: View the full presentation — and download the accompanying slides — in CareQuest Institute’s webinar library.