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The Occupational Safety and Health Administration (OSHA) published the Bloodborne Pathogen Standard (BPS) (OSHA 29 CFR 1910.1030)1 to protect healthcare workers from exposure to blood and other potentially infectious items. The scope and application state that it applies to all occupational exposure to blood or other potentially infectious materials.2 Knowledge of this standard will help employers determine the procedures and practices that need to be in place to protect workers. Therefore, this article will review the Bloodborne Pathogen Standard by citing the language in the standard and then explaining how that section applies to infection control in the commercial dental laboratory. However, a dental laboratory in a clinical environment could face greater infectious risks than those concerning the commercial dental laboratory.
The following are some of the definitions shown in that section and information on where these terms apply in the development of a health and safety program for a dental laboratory.
BPS states: “Bloodborne Pathogen means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).”
Laboratory application: All items that have been in a patient’s mouth could contain bloodborne pathogens as defined above. This could include impressions, bites, models, dentures, and implant components.
BPS states: “Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.”
Laboratory application: All items that have been in a patient’s mouth are considered contaminated.
BPS states: “Contaminated laundry means laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.”
Laboratory application: When items that have been in a patient’s mouth arrive in the dental laboratory, a best practice is to rinse them to remove any blood or saliva plus any possible chemical used at the dental office to disinfect. During this rinsing, spray or splatter can occur; therefore, the worker must wear protective equipment to protect street clothes. This protective clothing must not be worn home and must be handled by the employer. The employer can accomplish this by providing a disposable gown or a reusable fabric gown, which should be washed onsite or cleaned by a licensed laundry service.
BPS states: “Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.”
Laboratory application: Items that have been in a patient’s mouth come from the dental office. Therefore, they must be decontaminated before they are handled without adequate personal protective equipment (PPE).3 In a dental laboratory, this usually occurs in the receiving area, where the worker uses an intermediate-level, EPA-registered, hospital-grade disinfectant to disinfect all items that have been in a patient’s mouth. The Centers for Disease Control and Prevention (CDC) established the disinfection guidelines and recommends following the product label indicating the time required for destroying the bacterium, mycobacterium tuberculosis.
BPS states: “Engineering controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.”
Laboratory application: With the correct procedures in place, a dental laboratory should not create biohazard sharps. Any used sharp burs or blades should be deposited into a sharps container to prevent injury to someone else. However, they would not be considered to be biohazard sharps unless they contained body fluids, and in that case, those sharps could be disinfected prior to disposal. A guard or shield on a lathe that is used for polishing or grinding on a denture repair or on a clinically poured model would be an appropriate engineering control in the dental laboratory.
BPS states: “Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.”
Laboratory application: Employers must identify the risk areas for where exposure incidents could occur and then implement controls to minimize or eliminate the hazard. The common opportunities for exposure risks in a dental laboratory can include:
• Pickup of cases at the dental office by the dental laboratory’s employees.
• Unpacking and disinfecting the case components upon receipt at the dental laboratory.
• Trimming back an overextended border on an impression.
• Trimming and grinding on models that were clinically poured.
• Grinding on denture repairs.
• Shade verifications and other interactions with patients.
BPS states: “Hand washing facilities means a facility providing an adequate supply of running potable water, soap, and single-use towels or air-drying machines.”
Laboratory application: Not only is this requirement in the BPS, but similar standards also exist for the number of facilities depending on the amount of employees. Employees working in any of the risk areas mentioned above must have immediate access to hand-washing facilities to prevent contamination to other areas. Certified Dental Laboratories are required to have a sink in the receiving area, so this is the basis for that requirement.
BPS states: “HBV means hepatitis B virus.”
Laboratory application: All employees who work in risk areas must have the option of receiving vaccination for HBV at no charge to them. This is a three-series vaccine that should be followed up with a titer test to determine if the employee received sufficient antibodies for protection. After an employer educates the employee about the risks for infection, the employer offers the vaccine. If the employee declines, then the employer must document the refusal.4 If at a later date the employee requests the vaccine, then the employer must provide it. Because this virus can live up to 7 days outside the body,5 HBV is a serious concern in the dental laboratory work environment. The 29 CFR 1910.1030(f) section details the employer’s responsibilities in regard to offering the HBV vaccine and also the postexposure evaluation and follow-up procedure.
BPS states: “Occupational Exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.”
Laboratory application: The typical opportunities for exposure risks in a dental laboratory were discussed earlier in this article. An exposure that the employee encounters in the laboratory would be referred to as an occupational exposure. If this type of exposure occurs, then the employer must use the Post-Exposure Evaluation and Follow-up procedure that OSHA established. The 29 CFR 1910.1030(f)(3) section details that procedure, including offering blood testing free of charge to the employee and source individual (patient). This procedure requires documentation by the employer and confidential retention of testing results.
BPS states: “Other Potentially Infectious Materials means
a. The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
b. Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
c. HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.”
Laboratory application: The BPS refers to blood and other potentially infectious materials. Note in the description above that the BPS specifies saliva in dental procedures and any body fluid that is visibly contaminated with blood.
BPS states: “Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.”
Laboratory application: The employer must identify the opportunities for when a needlestick, cut, or abrasion could occur. Dental laboratories typically do not use needles, but if they do, then the employer must provide a sharps disposal container and safety training for the individuals using the needles. A cut or abrasion could occur in the model department when a technician is grinding on a clinically poured model, die trimming a clinically poured model, or trimming back an overextended border on an impression (Figure 1). The primary protection for the employee when performing those tasks is receiving PPE and proper training on the safe methods for performing the tasks so injuries do not occur.
BPS states: “Personal Protective Equipment is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.”
Laboratory application: PPE that is provided to minimize or eliminate hazards in risk areas includes an outer garment to protect work clothes and street clothes, safety eyewear or a face shield, mask, and gloves. The employer must evaluate the procedures being performed to ensure that the PPE does not create a greater hazard that could result in injury to the employee. The employer must provide the PPE to the employee at no cost. Also, the employee must receive training on how to use and dispose of the PPE and whom to notify when additional PPE is needed. The 29 CFR 1910.1030(d)(3) section details the use of PPE in risk areas (Figure 2). This includes the requirement that the PPE be removed prior to leaving the work area and not be taken home for laundering.
BPS states: “Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.”
Laboratory application: Typically a commercial dental laboratory does not generate regulated waste as described above. Laboratories should rinse a case component that contains visible blood in order to remove the blood prior to disinfection. Most disinfectants state that the chemical should be placed on a clean surface.
BPS states: “Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.”
Laboratory application: If an employee receives a cut from a contaminated item, then the responsible person at the dental laboratory must ask the dentist to contact the patient regarding the exposure and testing. If the dentist refuses, then the dental laboratory should obtain a letter from the dentist to document the refusal. If the patient declines to undergo blood testing, then that should be documented on the post-exposure evaluation and follow-up form. The dental laboratory employee also can refuse to receive blood testing, but the rest of the procedure should be continued. Any testing results will be kept confidential and shared only with the affected employee.
BPS states: “Sterilize means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.”
Laboratory application: Sterilization more commonly occurs in the dental office. If a commercial dental laboratory uses sterilization equipment, then it must implement procedures to test the equipment to ensure that it is operating correctly. Typically a weekly spore culture monitoring is performed and sent to a testing laboratory to ensure that the equipment is in good operating condition.6
BPS states: “Universal Precautions7 is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.”
Laboratory application: Laboratories must handle the case components arriving from a dental practice by using Universal Precautions or Standard Precautions. This means that the laboratory presumes that the patient is infected with a disease. This system must be in place in all healthcare environments where patients are treated. If a patient does not disclose his or her complete medical condition to the healthcare professional, then the healthcare professional could be at risk for infection if Universal Precautions are not practiced. The CDC publishes information on the number of Americans it believes are at risk for having HBV, hepatitis C, and HIV.8
BPS states: “Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).”
Laboratory application: After an employer identifies a hazard, the laboratory must take steps to minimize or eliminate the risk.9 The first step is to implement Administrative Controls, including changes in the method used to perform the task. This would be prior to requiring the use of PPE. In many cases, work-practice controls and engineering controls do not minimize or eliminate the hazard; therefore, employing PPE is necessary. An example of a work-practice control in a commercial dental laboratory would be the task of trimming back the overextended border on an impression. The use of a utility knife could cause an injury, but the utilization of scissors could minimize this risk (Figure 3). Of course, employees should wear gloves when performing this procedure because it would require rinsing the item after trimming and disinfecting it.
Written Exposure Control Plan
The 29 CFR 1910.1030(c) section requires the employer who has any occupational exposures defined in this standard to establish a written Exposure Control Plan.10 The Exposure Control Plan would contain at least the following items:
• The exposure determination. This is a list of all job classifications in which all or some employees have occupational exposure. In a commercial dental laboratory, it is simpler to list the tasks that could involve possible exposure because job titles or classifications may not be easily identifiable to all employees.
• The schedule and method of implementation. This would include the Methods of Compliance, HBV vaccination, Post-Exposure Evaluation and Follow-up, communication of hazards to employees, and recordkeeping.
• The procedure for evaluation of circumstances surrounding exposure incidents.
The employer must make the written plan available to workers and must review it annually (Figure 4). The review has to be documented and reflect new or recently modified tasks and procedures that could affect occupational exposure. This would include any new technology in place to eliminate or reduce exposure to bloodborne pathogens.
Methods of compliance are described in 29 CFR 1910.1030(d)(1)-(4). This section covers eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses. It states that these actions are prohibited in work areas where a hazardous risk is present. Also, food and drink are not to be kept in refrigerators, freezers, shelves, or cabinets, or on countertops or benchtops where blood or other potentially infectious materials are present.
Communication of Hazards
The employer must communicate the hazards to the employees through labels and signs such as the biohazard emblem, when appropriate. Communication also includes training each employee who has occupational exposure when they are initially assigned and tasks for which occupational exposure can occur, and thereafter at least annually. Annual training must occur within 1 year from the previous training date.
Recordkeeping
Recordkeeping includes retention of medical records in accordance with 29 CFR 1910.1020,11 which addresses access to employee exposure and medical records. Medical records referred to in the BPS must be retained for at least the duration of employment plus 30 years. OSHA updated the reporting and recordkeeping rules as of January 1, 2015.12
Training records must be documented and include the following:
• Date of the training sessions
• Contents or summary of the training sessions
• Names and qualifications of persons conducting the training
• Names and job titles of all persons attending the training sessions
These training records must be retained for a minimum of 3 years from the date on which the training occurred.
Conclusion
The BPS is relevant to dental laboratories in numerous ways. In order to protect employees, all dental laboratories should be familiar with the BPS and develop a program based on it.
References
1. United States Department of Labor. Occupational Safety and Health Standards: Bloodborne Pathogens. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Published December 6, 1992. Accessed January 29, 2014.
2. United States Department of Labor. OSHA FactSheet: OSHA’s Bloodborne Pathogens Standard. https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact01.pdf. Published January 2011. Accessed January 29, 2014.
3. Centers for Disease Control and Prevention. Hepatitis B Virus Transmission in a Dental Office. http://www.cdc.gov/OralHealth/infectioncontrol/factsheets/hepB.htm. Updated October 22, 2013. Accessed January 27, 2014.
4. United States Department of Labor. Health Care Professionals Hepatitis B Declination Statement. https://www.osha.gov/SLTC/etools/hospital/hazards/bbp/declination.html. Accessed January 29, 2014.
5. Centers for Disease Control and Prevention. Hepatitis B Information for Health Professionals. http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm#overview. Updated March 6, 2015. Accessed April 23, 2015.
6. Centers for Disease Control and Prevention. Frequently Asked Questions – Sterilization – Monitoring. http://www.cdc.gov/OralHealth/infectioncontrol/faq/sterilization_monitoring.htm. Updated July 10, 2013. Accessed April 23, 2015.
7. United States Department of Labor. OSHA interpretation letter. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=27008. Published February 27, 2009. Accessed April 23, 2015.
8. Centers for Disease Control and Prevention. Viral Hepatitis Statistics and Surveillance. http://www.cdc.gov/hepatitis/Statistics/index.htm. Updated March 4, 2015. Accessed April 23, 2015.
9. United States Department of Labor. Safety & Health Management Systems eTool: Hazard Prevention and Control. https://www.osha.gov/SLTC/etools/safetyhealth/comp3.html. Accessed January 29, 2014.
10. United States Department of Labor. OSHA Appendix D, Model Exposure Control Plan. https://www.osha.gov/OshDoc/Directive_pdf/CPL_2-2_69_APPD.pdf. Accessed January 29, 2014.
11. United States Department of Labor. Access to Medical and Exposure Records. https://www.osha.gov/Publications/pub3110text.html. Accessed April 23, 2015.
12. United States Department of Labor. OSHA FactSheet: Updates to OSHA’s Reporting and Recordkeeping Rule: An Overview. https://www.osha.gov/recordkeeping2014/OSHA3744.pdf. Published September 2014. Accessed April 23, 2015.
About the Author
Mary A. Borg-Bartlett
President and cofounder
SafeLink Consulting, Inc.
Cumming, Georgia
