Inoculation Injuries

An Inoculation Injury includes all instances where:

A object or substance contaminated by blood or other body fluids (e.g. saliva).
Either:
o Breaches the integrity of the skin or mucosa (e.g. puncture wounds or
lacerations), or
o Comes into contact with the eyes.

The nature of dentistry places the dental team at risk of inoculation injuries from
many sources including:
Needles, sharp-edged instruments, broken glassware, or spicules of bone or teeth.

The major hazard associated with inocualtion injuries is the transmission of Blood-
borne Viruses (BBVs), and in particular:
Hepatitis B.
Hepatitis C.
HIV.

Potentially there may be other BBVs of clinical significance:

There have been recent concerns about possible transmission of Hepatitis G (also
known as GBV-C) in the dental surgery.
The significance of this virus to human health and whether transmission does
occur during dental treatment remains unclear.

Reducing Inoculation Injuries

With due care and good working practices, the risk of experiencing an
inoculation injury can be reduced considerably.
The majority of inoculation injuries sustained in the dental environment are
avoidable. For example:
o Do not re-sheath local anaesthetic needles manually unless:
A device is available that allows this to be done with one hand.
The barrel of the syringe is held in one hand and the needle cap is
scooped up from a flat, hard surface. Only when the needle is
covered by the cap should the second hand be used to complete the
re-sheathing and secure the needle cap.
o Cover existing wounds, skin lesions and all breaks in exposed skin with
waterproof dressings.
Remember that gloves cannot be relied upon to form an intact
barrier. The longer that gloves are worn, the more likely that:
The number and size of holes in gloves will increase as a
consequence of physical trauma.
Latex gloves become porous due to hydration of latex.
Accordingly, it is essential that:
Gloves are changed:

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 Between patients.
During long procedures.
When damaged.
The hands are washed properly each time before gloves are
worn.
o Avoid sharps usage where possible.
o When sharps have to be used, exercise particular care in handling and
disposal.
Each member of the team should understand in advance what
tasks they are to perform.
This requires training and planning.
Use approved sharps containers that conform to standards for off-
site disposal.
Place sharps containers:
Out of the reach of children (i.e. not on the floor).
As close as is practical to the point of use.
Place all disposable sharps in sharps containers immediately after
use.
Discard disposable items as a single unit where possible, rather
than dismantling them into their components.
Do not overfill sharps containers.
Secure the lids of sharps containers prior to transfer to a licenced
authority for subsequent incineration.
Replace full sharps containers promptly.
o Avoid wearing open footwear in situations where blood may be spilt or
where sharp instruments or needles are handled.
o Clear up spillage of blood promptly and disinfect surfaces.
o Wear gloves:
Where contact with blood or other body fluids (e.g. saliva) is
anticipated.
To clean equipment prior to sterilisation or disinfection.
When handling disinfection fluid.
When cleaning up spillages.
o Wear safety glasses.
Keep yourself updated about best practices.

What to do Following an Innoculation Injury

DO NOT PANIC.
Follow the local procedures:
o Be familiar with these before the innoculation injury occurs!
o These procedures take account of the interests of both the HCW and the
patient.
In most, but not all instances, the HCW will be the recipient and
the patient the source.

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 Do not place others at risk:
o For example, do not leave sharps where they might result in a second
inoculation injury.
Immediately after exposure:
o Liberally wash the wound or non-intact skin with soap and water.
Do not scrub the wound.
Do not suck on the wound, but gently encourage any free bleeding
from the wound.
o Involved mucous membranes (including the eyes) should be irrigated
copiously with water (after removing any contact lenses).
Do not swallow the irrigant when used in the mouth.
Then report the incident to the nominated person so that urgent advice can be
obtained on further management.
o Know who this is in advance.
o Accident and emergency departments are open 24 hours a day and will be
able to offer advice over the telephone.
The designated doctor will:
o Need, where possible, to obtain information about, or from the source
about possible indicators of BBV infection including:
Risk factors.
Results of previous tests (if any) for HIV and Hepatitis B and
Hepatitis C.
Medical history suggestive of previous infection.
Current and previous anti-viral treatment in patients known to be
HIV positive.
o When indicated, to counsel and then ask the source to consent for testing
for BBVs.
o Evaluate whether the recipient should receive post-exposure prophylaxis:
For Hepatitis B this may involve
Immediate initiation of immunization in those not
previously immunized.
A booster dose in those successfully immunized in the past.
For HIV this may involve immediate prescription, ideally within
one hour, of anti-retroviral drugs.
There is no effective prophylaxis against Hepatitis C infection.
There are inevitable delays before the results of any serology testing (of the donor
and recipient) are known. When transmission has occurred, 95% of BBVs will be
detectable within 6 months. During this period of uncertainty
o It is acceptable for the clinician to keep working:
The risk of the HCW having become infected occupationally with
a BBV is low.
Even if the HCW had been occupationally infected, the chances of
then passing on that infection in the workplace to either a patient or
work colleague are remote.
o Safer sex should be practiced.
o The recipient should not donate blood.

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 It is a requirement to report the incident under the
o Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations (RIDDOR) 1995.
The circumstances surrounding the innoculation injury should be investigated
and changes implemented to reduce the likelihood of future, similar events.
o The majority of inoculation injuries are avoidable.
If a HCW has contracted a BBV in the workplace:
o The appropriate guidelines should be followed to:
Optimise the care of the infected individual.
Limit the risk of further spread of infection. This does not
necessarily mean that the infected HCW will have to cease
working, but modifications to working practices may be required.
o Compensation may be due from the NHS Injury Benefits Scheme.