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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 78-82

A cross-sectional pilot survey of sharp injuries among dental students in a tertiary care dental hospital in Lucknow, India


1 Department of Conservative Dentistry and Endodontics, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Periodontology, Saraswati Dental College, Lucknow, Uttar Pradesh, India
3 Department of Community Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication4-Mar-2019

Correspondence Address:
Dr. Rhythm Bains
House No. 1317, Sector 16, Indira Nagar, Lucknow - 226 016, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_22_18

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  Abstract 


Aim: This study aims to estimate the frequency of sharp injuries among the post-graduate and undergraduate dental students and evaluate their knowledge regarding the needle-stick/sharp injuries, proper handling and disposal of sharp waste.
Methodology: A written questionnaire containing questions regarding frequency of sharps injury, source of injury, status of immunisation and knowledge regarding handling and disposal of sharps waste was personally distributed to the participants and collected on the same day. Informed consent was obtained from the participants, and the purpose of the study was explained to them. The data obtained was statistically analysed. Percentage distribution of responses for Bachelor of Dental Surgery (BDS) and Master of Dental Surgery (MDS) students was recorded. Furthermore, the comparison of responses for BDS and MDS was analysed using the t-test. Chi-square test was used to find the significance difference between responses by BDS and MDS students.
Results: The results of the present questionnaire study revealed that 38.5% (10/26) post-graduate students and 37.2% (16/42) undergraduate respondents had a history of sharps injury (P = 0.917). Most common reason for the injury among post-graduates was recapping of needles 84.6% (22/26) followed by endodontic instruments 11.5% (3/26) and use of probes/explorer 3% (1/26). Among the undergraduates, the most common source of injury was again recapping of needles 97.7% (42/43), followed by endodontic instruments 2.3% (1/43).
Conclusion: Both undergraduates and post-graduates reported with history of sharps injury, though the difference among them was not significant. Needle-stick or sharps injury can prove to be fatal, and as dental students have an early clinical exposure, they should be trained early in their curriculum regarding correct disposal and handling of sharps.

Keywords: Needle-stick, occupational hazard, sharps


How to cite this article:
Bains R, Bains VK, Kumari R. A cross-sectional pilot survey of sharp injuries among dental students in a tertiary care dental hospital in Lucknow, India. J Patient Saf Infect Control 2018;6:78-82

How to cite this URL:
Bains R, Bains VK, Kumari R. A cross-sectional pilot survey of sharp injuries among dental students in a tertiary care dental hospital in Lucknow, India. J Patient Saf Infect Control [serial online] 2018 [cited 2019 Mar 23];6:78-82. Available from: http://www.jpsiconline.com/text.asp?2018/6/3/78/253387




  Introduction Top


Healthcare workers are at a high risk of encountering biological hazards such as airborne and bloodborne pathogens, exposure to harmful chemicals and carcinogens, radiation exposure and ergonomic hazards. Among the various occupational hazards faced by healthcare workers and providers, sharps or needle-stick injuries are of a major concern as they carry the risk of transmitting about 20 bloodborne pathogens out of which hepatitis B (HBV), hepatitis C (HPC) and human immunodeficiency virus are most threatening.[1] The term 'sharps injury' applies to any incident where a needle, blade (such as a scalpel) or other sharp instrument or object causes injury by penetrating the skin. This can include a cut, stab or graze.[2] The healthcare workers include doctors, dentists, dental auxiliary staff, nurses, lab technicians and staff involved in handling and management of healthcare waste.[3] Occupational exposure may occur due to percutaneous or mucocutaneous injury. Percutaneous exposure refers to a penetrating injury from a needle-stick or other contaminated sharp object leading to bleeding or visible skin puncture. High-risk body fluids include blood, body fluid visibly stained with blood, exudates, unfixed tissue specimens, semen, vaginal discharge, synovial fluid, peritoneal fluid, pleural fluid, pericardial fluid, amniotic fluid, blood-stained saliva and human breast milk.[4] A bite also carries a significant risk if there was blood in the oral cavity. On the other hand, mucocutaneous injury refers to the contamination of the conjunctiva or a mucous membrane. Percutaneous exposures carry a much higher risk of transmission than mucocutaneous exposure and exposure to blood is more serious than exposure to other body fluids.[5]

Dental surgeons, hygienists and nurses also carry a risk of acquiring these bloodborne pathogens by occupational injuries due to sharps and needle-sticks. In this profession, early clinical exposure to the students begins as early as in the 3rd year of their curriculum and preclinical handling of instruments starts in the 2nd year.[6] Sharp objects in a dental clinic which may lead to such injuries are needles, dental probes/explorers, dental scalers, endodontic files, endodontic broaches, rotary cutting instruments such as burs and broken glass. Dental personnel is exposed to blood and saliva while performing dental treatment procedures. Moreover, they are at risk because of use of the above-mentioned sharp object for various procedures such as diagnosis, oral prophylaxis, restorative procedures, performing intra-oral nerve blocks and tooth extractions.[7]

Although the risk of sharps injuries faced by dental professionals is very high, many studies have highlighted that the knowledge and compliance among dental students is inadequate.[8] Moreover, the dental students are not very careful about their immunisations and negligent of their antibody titres. In addition, many dental students are careless about obtaining a detailed medical history from the patients, thus increasing the hazard of transmission of blood borne pathogens. They also lack adequate guidance and training about proper handling of used needles and other sharps.[9]

Thus, keeping in view the above-mentioned factors, this study was designed to estimate the frequency of sharp injuries among the post-graduate and undergraduate dental students and evaluate their knowledge regarding the needle-stick/sharp injuries, proper handling and disposal of sharp waste.


  Methodology Top


This cross-sectional study was carried out in the Department of Conservative Dentistry and Endodontics among the undergraduate dental interns and post-graduate dental students. A written questionnaire containing questions regarding frequency of sharps injury, source of injury, status of immunisation and knowledge regarding handling and disposal of sharps waste was personally distributed to the participants and collected on the same day. Informed consent was obtained from the participants, and the purpose of the study was explained to them. Confidentiality of the student's data was assured, and no personal identification such as student's name or roll number was recorded on the questionnaire.

The criterion for measuring the prevalence of sharps injury was inoculation in the body of healthcare worker, during the performance of his/her duties, with blood or potentially infectious material by a sharp instrument.

The questions were divided into two types:

  • Those relating to the frequency, source and knowledge of sharps injuries
  • Those relating to knowledge and practices about the handling of sharps.


The data obtained were statistically analysed. Percentage distribution of responses for Bachelor of Dental Surgery (BDS) and Master of Dental Surgery (MDS) students was recorded. Furthermore, the comparison of responses for BDS and MDS was analysed using the t-test. Chi-square test was used to find the significance difference between responses by BDS and MDS students.


  Results Top


The results of the present questionnaire study revealed that 38.5% (10/26) post-graduate students and 37.2% (16/43) undergraduate respondents had a history of sharps injury [Table 1]. The difference in the frequency among the undergraduates and post-graduates was not statistically significant (P = 0.917). Most common reason for the injury among post-graduates was recapping of needles 84.6% (22/26) followed by endodontic instruments 11.5% (3/26) and use of probes/explorer 3% (1/26). Among the undergraduates, the most common source of injury was again recapping of needles 97.7% (42/43), followed by endodontic instruments 2.3% (1/43). Regarding the knowledge about reporting of the injuries among post-graduates, 30.8% (8/26) reported that it should be reported to post-exposure prophylaxis (PEP) unit, 23.1% (6/26) responded that it should be reported to the head of the department, 19.2% (5/26) replied that it should be reported to the University Environment Cell, 15.4% did not report it and 11.5% did not reply (3/26). Among the undergraduates, the responses were as follows: 44.2% (22/43) to the head of the department, 30.2% (13/43) PEP unit, 11.6% (5/43) to University Environment Cell and 7% (3/43) said it should not be reported. Among the post-graduates, the most common reason for not reporting the injury was ignoring it as a minor injury 88.5% (23/26) followed by fear of stigma 3% (1/26) and lack of awareness regarding reporting 3% (1/26). For the undergraduate students, the most common cause for not reporting was ignoring it as a minor injury 76.7% (33/43), 16.3% (7/43) due to fear of stigma and 7% (3/43) due to lack of awareness regarding reporting.
Table 1: Knowledge of dental students on sharp injuries

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The questionnaire also assessed the knowledge and practice of the post-graduate and undergraduate students regarding handling and disposal of the sharps waste [Table 2]. Among the MDS students regarding the disposal of syringes for intra-oral injections, 76.9% (20/26) replied needle cutter plus plastic proof container should be used, 15.4% (4/26) said needle cutter should be utilised and 7.7% (2/26) said needle cutter followed by disposal in the red bin should be done. Among the undergraduates, 39.5% (17/43) responded that it should be disposed in the red bin, 30.2% (13/43) replied needle cutter followed by disposal in red bin should be done, 14% (6/43) responded that needle cutter followed by disposal in plastic proof container should be done, 9.3%(4/43) replied needle cutter alone should be used and 7% (3/43) replied that puncture-proof container alone should be employed.
Table 2: Knowledge of students about disposal of sharps

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The knowledge about sterilisation of the endodontic files was also checked. Among the post-graduates, 38.5% (10/26) responded that glass bead steriliser alone should be used, 26.9% (7/26) glass bead plus autoclave, 23.1% (6/26) autoclave and 7.7% (2/26) cold sterilisation. Among the undergraduates, 65.15% (28/43) replied that glass bead steriliser alone 18.6% (8/43) cold sterilisation should be used, 11.6% (5/43) replied that autoclaving is required and 4.7% (2/43) replied glass bead plus autoclaving should be done.


  Discussion Top


In the previous past studies done in dental schools, prevalence rates of sharp injuries ranging from 23% to 75.4% have been reported.[10] In the present study, the incidence of sharps injury among post-graduates was 38.5% and among undergraduates was 37.2%. There was no statistical difference among the undergraduates and post-graduates regarding the incidence of sharps injury. Overall, the incidence of sharps injury was 37.5%. The incidence for the present study was lower than reported by Osman among the dental students in Sudan who reported an incidence of 69%.[7] The most common reason for sharp injury among both post-graduates and undergraduates was recapping of syringes, which is agreement with the previous studies among dental students.[8],[9],[10] Recapping and using the local anaesthetic syringe are the two largest reported causes of sharps injury among dental students. In dental practice, especially endodontics, multiple injections are required in treatment modalities such as restorations and root canal treatment. These activities make dental professionals vulnerable to needle-stick injuries. Dental students usually recap needles with an intention to perform safe practice and decrease the risk of injury. Recapping is identified as 'a habitual behaviour, based on the desire to remove a sharp, and potentially dangerous object, from the immediate environment'.[11] It is during the process of recapping and disposing of the needles that most of the sharps injuries occur. Sharp injuries can be significantly reduced by providing proper guidelines and protocols to the students during theory classes and demonstration of the 'one-handed “scoop” technique for recapping' during their clinical hours.[12] Moreover, they should be trained not to pass syringes to each other by hand and pass them in an instrument tray instead.

Endodontic instruments such as files and broaches come in contact with patient's blood, saliva and canal exudates and also have sharp ends, posing a risk of sharps injury to the operator. In the present study, endodontic instruments were the second most important cause of injury among both undergraduates and post-graduates. Students need to be trained about proper handling of instruments both during instrumentation and cleaning. Apart from files and broaches, Gates Glidden drills, Peeso Reamers and suture needles also carry a risk of injury and should be used very carefully.[13] Knowledge regarding reporting of injuries was also evaluated and among the post-graduates and undergraduates was also assessed and it was seen that only 30% of the post-graduates and 11% of the undergraduates knew that it should be reported to the PEP unit. Earlier surveys have also hinted towards significant under-reporting of sharps/needle-stick injuries among medical professionals.[14],[15] The present survey also explored the reasons for not reporting these types of injuries. Among the undergraduates and the post-graduates, the most common cause of not reporting was ignoring it as a minor injury, followed by fear of social stigma. The students have to be trained and motivated to report these injuries and assured that their reports and the incident will be kept confidential.

The awareness regarding reporting of the sharp injuries should be discussed with the students in the lectures and during clinical teaching time. Prompt and correct action has to be taken if any such type of injury occurs. Hence, a knowledge of 'what to do' in such circumstances is essential. In the present study, among the undergraduates, maximum responses to what should be done after injury were that the site of injury should be scrubbed with disinfectant while post-graduates replied that it should be pressed to ooze the blood out. Continuous training and education should be provided with reinforcement regarding the action plan after injury, so that the student/operator does not panic, has a clear mind and can take a correct action for this challenge. Avoiding scrubbing or sucking the affected area and reporting immediately to PEP unit is desirable in such situations, written Standard Operating Protocols should be displayed in the clinics or working area with the contact numbers of concerned in charge who can handle the situation.[16] Time is a major factor in starting prophylactic regimen, so every effort should be made to save time, and clear, written instructions are helpful in doing so.

The status of immunisation of the students against hepatitis was also checked. Among the undergraduates, 83.5% undergraduates and 93.2% postgraduates responded that they were immunised against Hepatitis B. In dentistry, the students have an early clinical exposure. They start working on patients in 3rd year itself. Moreover, they work on extracted human teeth in their 2nd-year pre-clinical laboratory. Thus, emphasis should be made on getting them immunised against viral diseases such as hepatitis to reduce the risk of disease transmission, and 6%–30% of unvaccinated individuals carry the danger of being infected by hepatitis B.[17] According to this survey, the percentage of immunised students was quite high, though a 100% immunisation should be targeted.

The present study also tried to evaluate the knowledge and practice of the dental students regarding the handling and disposal of the sharp waste. The results showed that most of the undergraduates were lacking in knowledge regarding the correct disposal of the sharp waste. Most of the undergraduates responded that used syringes and endodontic instruments should be disposed of in the red bin and were not aware of the use of needle cutter. The post-graduates displayed a better level of knowledge, citing needle cutter and puncture proof container as the best method to dispose of syringes and endodontic instruments. Furthermore, the post-graduate had significantly better understanding of sterilising endodontic instruments responding that autoclave should be used for this purpose. The undergraduates mostly replied that glass bead steriliser or cold chemical sterilisation is enough for sterilising the root canal instruments.


  Conclusion Top


The present study demonstrates that the dental students lack in their knowledge regarding handling and disposal of sharps and needles. Although post-graduates scored a little better, the difference between the undergraduates and post-graduates was not significant. Steps should be taken to increase awareness among the dental students. This can be done by including the topics relating to handling and disposal in their BDS curriculum and reinforcing the instructions when they are working in the clinics. Students should be motivated to report them and not to ignore or hide them. Proper work environment with clearly labelled areas for disposal of sharps should be assigned in the clinics or laboratories. Needle-stick or sharps injury can prove to be fatal, thus clear instructions regarding what should be done should be posted in the working area, and it should be a collective responsibility of faculty, students, resident and support staff to make sure that these injuries are avoided, and in case they happen, should be handled properly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prüss-Üstün A, Rapiti E, Hutin Y. Sharps Injuries: Global Burden of Disease from Sharps Injuries to Health-Care Workers. WHO Environmental Burden of Disease Series. Geneva: World Health Organization; 2003. p. 3.  Back to cited text no. 1
    
2.
UNISON Centre. Managing and Preventing Sharps Injuries: A UNISON Guide for Safety Reps UNISON Communications. NW1 2AY. London: 2013.  Back to cited text no. 2
    
3.
Ministry of Health. SHARPS Injury Surveillance Occupational Health Unit Manual. Disease Control Division. 1st ed. Malaysia: Ministry of Health; 2007.  Back to cited text no. 3
    
4.
American Nurses Association. American Nurses Association's Needlestick Prevention Guide. American Nurses Association; 2002.  Back to cited text no. 4
    
5.
NHS Employers. Managing the Risks of Sharps Injuries. London: NHS Employers; 2015.  Back to cited text no. 5
    
6.
Gaballah K, Warbuton D, Sihmbly K, Renton T. Needle stick injuries among dental students: Risk factors and recommendations for prevention. Libyan J Med 2012;7:10.3402/ljm.v7i0.17507.  Back to cited text no. 6
    
7.
Osman T. Epidemiology of sharp instruments injuries at a dental school in Sudan. Int J Infect Control 2014;10:i4.  Back to cited text no. 7
    
8.
Yoshikawa T, Wada K, Lee JJ, Mitsuda T, Kidouchi K, Kurosu H, et al. Incidence rate of needlestick and sharps injuries in 67 Japanese hospitals: A national surveillance study. PLoS One 2013;8:e77524.  Back to cited text no. 8
    
9.
Perry J, Jagger J, Parker G, Phillips EK, Gomaa A. Disposal of sharps medical waste in the United States: Impact of recommendations and regulations, 1987-2007. Am J Infect Control 2012;40:354-8.  Back to cited text no. 9
    
10.
Askarian M, Malekmakan L, Memish ZA, Assadian O. Prevalence of needle stick injuries among dental, nursing and midwifery students in Shiraz, Iran. GMS Krankenhhyg Interdiszip 2012;7:Doc05.  Back to cited text no. 10
    
11.
Jaber MA. A survey of needle sticks and other sharp injuries among dental undergraduate students. Int J Infect Control 2011;7:i3.  Back to cited text no. 11
    
12.
Froom P, Kristal-Boneh E, Melamed S, Shalom A, Ribak J. Prevention of needle-stick injury by the scooping-resheathing method. Am J Ind Med 1998;34:15-9.  Back to cited text no. 12
    
13.
Cleveland JL, Lockwood SA, Gooch BF, Mendelson MH, Chamberland ME, Valauri DV, et al. Percutaneous injuries in dentistry: An observational study. J Am Dent Assoc 1995;126:745-51.  Back to cited text no. 13
    
14.
Shiao JS, McLaws ML, Huang KY, Ko WC, Guo YL. Prevalence of nonreporting behavior of sharps injuries in Taiwanese health care workers. Am J Infect Control 1999;27:254-7.  Back to cited text no. 14
    
15.
Smith, AJ, Cameron, SO, Bagg J, Kennedy D. Management of needlestick injuries in general dental practice. Br Dent J 2001;190:645-50.  Back to cited text no. 15
    
16.
Waterman J, Jankowski R, Madan I. Under-reporting of needlestick injuries by medical students. J Hosp Infect 1994;26:149-50.  Back to cited text no. 16
    
17.
Hanrahan A, Reutter L. A critical review of the literature on sharps injuries: Epidemiology, management of exposures and prevention. J Adv Nurs 1997;25:144-54.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2]



 

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