Percutaneous injuries amongst Greek

endodontists: a national questionnaire survey

T. Zarra & T. Lambrianidis
Department of Endodontology, Dental School, Aristotle University of Thessaloniki, Thessaloniki, Greece
Abstract
Zarra T, Lambrianidis T. Percutaneous injuries amongst
Greek endodontists: a national questionnaire survey.
International Endodontic Journal, 46, 264274, 2013.
Aim To investigate amongst Greek endodontists the
incidence of percutaneous injuries, the circumstances
associated with them, the therapeutic measures taken
after the injuries and their compliance with infection
control measures.
Methodology One hundred and forty-seven end-
odontists met the inclusion criteria and were invited
to participate in the survey. Personal and professional
data, information on percutaneous injuries in the past
5 years and on infection control practices were gath-
ered through interviews based on a questionnaire.
Data were analysed using chi-square test, independent
samples t-test, one-way ANOVA and Pearsons correla-
tion coefcient. The level of signicance was set at
P = 0.05.
Results The response rate was 84%. The injury
rate was estimated at 1.35 per endodontist per year.
Endodontic les were associated with 37% of the
injuries and ngers were injured in 75% of the
most recent cases. Medical assistance was sought in
36% of the most recent injuries. Endodontists who
always or usually practiced 4-handed endodontics
(P = 0.007) as well as those not performing surgical
endodontics (P = 0.007) reported signicantly fewer
injuries. In 91% of the participants, a complete hepa-
titis B virus vaccination was reported. Gloves, masks,
rubber dam isolation and puncture-resistant contain-
ers for disposal of sharp instruments were always
used by 98%, 94%, 100% and 81% of the respon-
dents, respectively.
Conclusions The injury rate was low. The practice
of four-handed endodontics was associated with a
reduced number of percutaneous injuries; the perfor-
mance of surgical endodontics increased their inci-
dence. Greek endodontists showed a high level of
compliance with infection control measures.
Keywords: endodontics, hepatitis B virus vaccina-
tion, infection control measures, occupational hazard,
percutaneous injuries.
Received 28 May 2012; accepted 3 August 2012
Introduction
Occupational hazard has been dened as any risk of
injury or disease peculiar to the specic occupation or
place of employment that arises during normal work
(Websters New World Law Dictionarys 2010). In
dentistry, these hazards comprise contamination with
biological uids, exposure to ionizing radiation, aller-
gic reactions, dermatitis, acoustic and respiratory
problems/irritations, burns or scalds and progressive
development of acquired diseases such as musculo-
skeletal disorders and ocular problems.
Dentists can be exposed to biological uids through
skin and mucous membranes or through percutane-
ous injuries, with the latter being the most common
(Thomas et al. 1996, McCarthy et al. 1999, Cleveland
et al. 2002, Duffy et al. 2004). Percutaneous injuries
are inherent to the working conditions of dentists.
These conditions involve close proximity to patients,
use of sharp instruments under limited or indirect
Correspondence: Theodora Zarra, Ellis Labeti 16, Nea Politeia,
Larissa, PC 41335, Greece (Tel.: 00302410615555,
00302311202806, 00306944340591; e-mail: theozarra@
gmail.com).
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013
doi:10.1111/j.1365-2591.2012.02126.x
264
visual contact and frequent patient movement.
Overall percutaneous injuries pose the greatest risk
of bloodborne pathogen transmission (Centers for
Disease Control & Prevention 1997, Kotelchuck et al.
2004).
Dentists are, apparently, at a greater risk of acquir-
ing the hepatitis B virus (HBV) infection than the
general population (Nagao et al. 2008, Mahboobi
et al. 2010, Alavian et al. 2011). This was more pre-
valent prior to the development of the HBV vaccine
(Panlillio et al. 2004).
Published data on percutaneous injuries amongst
dental personnel include surveys (Verrusio et al.
1989, Adegboye et al. 1994, Gore et al. 1994, Gers-
hon et al. 1998, McCarthy et al. 1999, Duffy et al.
2004, Kotelchuck et al. 2004, Stewardson et al.
2004, Venoresi et al. 2004, Wood et al. 2006, Mach-
ado-Carvalhais et al. 2008, Martins et al. 2010,
Wicker & Rabenau 2010), observational (Cleveland
et al. 1995, Duffy et al. 2004), retrospective (McDon-
ald et al. 1997, Panagakos & Silverstein 1997, You-
nai et al. 2001, Shah et al. 2006) and prospective
(Siew et al. 1995, Ramos-Gomez et al. 1997) studies.
Studies on occupational exposure amongst oral sur-
geons (Carlton et al. 1997, Gooch et al. 1998) and
orthodontists (Woo et al. 1992, Bagramian & McNa-
mara 1998) have also been published. A search of
the literature (PubMed and MEDLINE Database, Coch-
rane Library) revealed no study concerning exposure
of endodontists to biological uids. Endodontists per-
form only a proportion of the procedures operated by
general dental practitioners and utilize specialized
endodontic equipment. These may account for a vari-
ance on the incidence of percutaneous injuries
between endodontists and general dentists or other
dental specialists. One study investigated the injury
rate of general dentists during endodontic procedures
(Cleveland et al. 1995) and two studies, in which
endodontists comprised a low proportion of the study
population, referred to the impact of dental specialties
(including endodontics) on the number of percutane-
ous injuries (Siew et al. 1995, McCarthy et al. 1999).
The latter provided no details for the circumstances
associated with injuries sustained by endodontists.
This study aims to investigate (i) the incidence of
percutaneous injuries amongst Greek endodontists
and the circumstances associated with them, (ii) the
therapeutic measures taken after the injuries accord-
ing to the dental patients health status, iii) the com-
pliance of Greek endodontists with infection control
measures.
Materials and methods
A survey on occupational hazards in endodontics was
conducted from July 2011 to March 2012 amongst
members of the Hellenic Society of Endodontics and/
or dentists who completed a postgraduate program in
endodontics and practice in Greece. The study was
approved by the Ethical Committee of the Dental
School of Aristotle University of Thessaloniki, Greece.
Participation was voluntary and all participants were
assured of condentiality. Data were gathered
through interviews based on a questionnaire, which
consisted mainly of closed-ended but also some open-
ended questions. The rst part of the questionnaire,
analysed in this study, focused on percutaneous
injuries and included:
Personal data (age, gender and dominant hand).
Education and professional data (year of gradua-
tion, years of clinical experience, information on
postgraduate studies and participation in contin-
uing education programs or ESE/AAE congresses,
as well as information on the working conditions,
type of employment (private/public sector) and
cooperation with a dental assistant).
Information on the events of percutaneous injuries
experienced during endodontic procedures in the
past 5 years, the type of instruments associated
with the injuries and the number of them accom-
panied by bleeding. Those endodontists who
reported such injuries were further asked for
details on the most recent of the injuries reported
in the past 5 years and the associated circum-
stances including the affected body part and the
subsequent handling procedures.
Information on infection control practices, that is,
HBV vaccination, use of personal protective equip-
ment, hand washing and disposal of sharp instru-
ments.
An earlier pilot study amongst 20 general dentists
not included in the main study was conducted to
standardize questions and to estimate the time needed
for each interview. The participants were asked to
express their opinion on the clarity and understand-
ing of the questions. Their remarks were discussed by
the two investigators and the questionnaire was mod-
ied accordingly.
The questionnaire and a cover letter were mailed to
174 endodontists (study population), who were, sub-
sequently, contacted by the same investigator (T.Z.)
for the arrangement of a personal interview. Amongst
them, four had retired, four did not practice dentistry,
Zarra & Lambrianidis Percutaneous injuries: a survey
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 265
nine practiced dental specialties other than endodon-
tics, two had taken days off owing to illness, eight
could not be contacted (three attempts were made)
and 24 refused to participate in the survey, resulting
in 123 participants.
Throughout interviews, the questions were addressed
to endodontists by the same investigator exactly as they
were formulated in the questionnaire without giving
additional clarication.
Percutaneous injury was dened according to
Cleveland et al. (1995) and Siew et al. (1995) as any
breach in the integrity of the skin of the endodontist
in the dental operatory, regardless of presence or
absence of bleeding.
The reliability of the data was evaluated prior to
the survey using a testretest model to assess answer
variations by the same respondent at different times.
Twenty-four randomly selected endodontists were
interviewed by the same investigator for a second
time (approximately 68 weeks after the rst inter-
view) and the agreement between responses on the
two occasions was measured by the kappa (k) coef-
cient. Only close-ended questions were evaluated.
Values for kappa coefcient that exceeds 0.7 indicate
an almost perfect agreement between participants
responses on the two occasions (Krippendorff 1980).
The responses of the participants were analysed using
the Statistical Package for the Social Sciences (IBM
SPSS Statistics v.19, New York, NY, USA). Data anal-
ysis included descriptive statistics by analysing
observed values and frequencies. Association between
categorical variables was tested for statistical signi-
cance using the chi-square test and the correlation
between two continuous variables using the Pearsons
correlation coefcient. KolmogorovSmirnov test was
employed to evaluate the normal distribution of con-
tinuous variables within each group and Levenes test
to verify the equality of variances assumption. Hence,
means were compared by using parametric tests. The
independent samples t-test was used for two-level
independent variables and one-way ANOVA for multi-
ple-level independent variables. In the latter cases,
Bonferroni correction was used for multiple compari-
sons amongst the groups. The level of signicance
was set in all cases at P = 0.05.
Results
Results were classied in the following categories:
response rate, personal and professional data, information
on percutaneous injuries and compliance with infection
control measures. Kappa values obtained ranged from
0.71 to 1, indicating an almost perfect agreement
between the participants responses on the two occasions.
Response rate
The response rate was 84%. The statistical analysis
was based on 120 endodontists as three more were
excluded, having reported endodontic work of <50%
of their overall clinical practice.
Personal and professional data
Personal and professional data are presented in
Table 1. The age of endodontists ranged from 26 to
63 years old with a mean of 40.6 years. Participants
worked a mean of 7.45 h per day and 1626 h per
year, a mean of 46 weeks per year and treated a
mean of eight patients per day.
Percutaneous injuries
One hundred and seven practitioners (89% of the
sample) reported having 838 injuries in the past
5 years. Based on the sample of 120 endodontists,
the injury rate was 1.35 per year per endodontist.
Table 2 presents the number and percentage of inju-
ries that occurred by sterile and used instruments.
One endodontist reported an injury of his index n-
ger by the sharp edges of a temporary crown whilst
removing it to perform endodontic treatment of the
abutment teeth. Two injuries caused by human bites
were also reported, one during a patients epileptic
seizure and one during access cavity preparation on a
child. Of 838 injuries, 435 (54%) were accompanied
by bleeding. Figure 1 presents the percentage of the
most recent injuries caused by instruments (sterile,
used, both) in various body parts.
Table 3 presents the circumstances associated with
the most recent injuries by each type of instrument,
either sterile or used.
Only 2% of the involved injuries occurred intraoral-
ly. Overall, 30% of endodontists adopted specic safety
protocols or individual protective measures, that is,
immediate removal of burs/ultrasonic tips/Gates-Glid-
den drills from handpiece after their use, single-hand
recapping of the anaesthetic needle, to avoid injuries.
Regarding their post-incident actions (Fig. 2), medi-
cal assistance was not sought in 82% of the most recent
injuries (98% of the injuries by sterile instruments and
71% of the injuries by used instruments). Injured
Percutaneous injuries: a survey Zarra & Lambrianidis
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 266
endodontists were content to self-treat or not to treat.
Amongst those having sought medical assistance, one
needed surgical removal of a fractured instrument from
the soft tissues of his elbow and one needed suturing of
a wound caused by a sterile scalpel blade.
It should be noted that only 6% of the source
patients were known HIV/HBV/hepatitis C virus
(HCV) carriers at the time of the injury.
The reasons for carrying out serologic tests after the
most recent injuries by used instruments are summarized
in Fig. 3. No serologic tests were reported to have been
carried out after injuries by sterile instruments.
Table 1 shows the relationship between categorical
variables and the number of injuries. There was a signif-
icant association between performing surgical endodon-
tics [t(118) = 2.739, P = 0.007] and the number of
injuries. Endodontists who performed surgical end-
odontics reported more accidents (M = 9.03,
SD = 8.343) compared with those who did not
(M = 5.45, SD = 5.841). In addition, there was a signif-
icant difference amongst those practicing or not four-
handed endodontics. Bonferroni correction showed that
endodontists who always or usually practiced four-
handed endodontics reported signicantly fewer injuries
compared with those who did it rarely or never
(P = 0.007); there was no signicant difference
amongst the other groups. Owing to the small sample
size of left-handed and ambidextrous endodontists, the
impact of dominant hand on the incidence of percutane-
ous injuries was not analysed. There was no signicant
correlation between age (r = 0.065, P = 0.483), work
Table 1 Personal and professional data of participants in
the study by number () and percentage (%) of the respon-
dents. Relationship between categorical variables and the
number of percutaneous injuries (mean number of injuries
and P-values)
Personal and
professional data N (%)
Mean
number
of injuries P-value
Gender
a
Male 56 (46.7) 7.48 0.634
b
Female 64 (53.3) 6.84
Dominant hand
a
Left handed 5 (4.2)
Right handed 114 (95)
Ambidextrous 1 (0.8)
Years of clinical practice since graduation
a
>20 33 (27.5) 7.10 0.976
c
1120 37 (30.8) 7.41
10 50 (41.6) 7.06
Postgraduate studies
a
Yes 108 (90)
No 12 (10)
Duration of the postgraduate program
d
1 year 3 (2.7)
18 months 2 (1.9)
2 years 41 (38)
3 years 62 (57.4)
Years since completion of the postgraduate program
d
>20 13 (12) 7.33 0.865
c
1120 19 (17.6) 6.47
10 76 (70.4) 7.85
Participation in continuing education programs/ESE/AAE
congresses
a
Yes 116 (96.7) 7.08 0.398
b
No 4 (3.3) 10.25
Practice limited to endodontics
a
Yes 89 (74.2) 7.10 0.837
b
No 31 (25.8) 7.42
Work load (days per week)
a
2 days 1 (0.8)
3 days 4 (3.3)
4 days 24 (20)
5 days 90 (75)
6 days 1 (0.8)
Type of employment
a
Private practice 99 (82.5) 6.88 0.327
b
Public sector 7 (5.8)
Both 14 (11.7)
8.62
Surgical endodontics
a
Yes 58 (48.3) 9.03 0.007
b
No 62 (51.7) 5.45
Mean length of appointments (min)
a
3045 34 (28.3) 7.76 0.777
c
4560 67 (55.8) 7.15
>60 19 (15.8) 6.26
Working with a dental assistant
a
Yes 76 (63.3) 7.54 0.488
b
No 44 (36.7) 6.57
Table 1 Continued
Personal and
professional data N (%)
Mean
number
of injuries P-value
Four-handed dentistry
a
Never 58 (48.3) 0.002
b
Rarely 14 (11.7)
8.81
Often 16 (13.3) 6
Usually 20 (16.7)
Always 12 (10)
4.13
Instrument cleaning
a
Yes 53 (44.2) 8.09 0.229
b
No 67 (55.8) 6.46
a
Percentages have been calculated with respect to the total
number of participants.
b
t-test.
c
One-way ANOVA.
d
Percentages have been calculated with respect to the number
of participants having attended a postgraduate program in
endodontics.
Zarra & Lambrianidis Percutaneous injuries: a survey
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 267
load (hours per day) (r = 0.071, P = 0.444), work load
(hours per year) (r = 0.069, P = 0.455) as well as
number of patients treated per day (r = 0.053,
P = 0.565) and the number of injuries.
Compliance with infection control measures
HBV vaccination status
Amongst the participants, 91% reported having
received the recommended three doses of the HBV
vaccine and 5% had acquired immunity to HBV as a
consequence of previous exposure.
When they were asked if they had checked their
immunization status or had performed a post-vaccina-
tion test, 7% of the respondents reported checking their
anti-HBsAg titre in specic time intervals, 23% every
year, 28% every 23 years, 23% every 45 years.
Seven point two per cent reported having checked it at
least once and only 20% had never taken the test.
Use of personal protective equipment, disposal of sharp
instruments and hand washing
Table 4 shows endodontists compliance with infection
control measures. In addition, one respondent reported
the use of latex kitchen gloves during instrument clean-
ing procedures. There was a signicant association
between the use of long sleeve coats [t(118) = 2.589,
P = 0.011] and the sum of injuries by sterile and used
burs/Gates-Glidden drills, ultrasonic tips and endodontic
les. Forty-eight endodontists (40%) reported washing
their hands before or after each appointment, 38.3%
both before and after each patient, 14% every time they
changed their gloves and 2% washed their hands only at
the end of the day. Liquid soap and water was used by
93%, whilst 22% combined it with an alcohol-containing
antiseptic. There was no signicant association between
age (F = 0.574, P = 0.682), gender (v
2
= 3.606,
P = 0.462), years of clinical practice (v
2
= 7.500,
P = 0.484) and the frequency of hand washing.
Discussion
This survey was the rst attempt to thoroughly inves-
tigate percutaneous injuries amongst endodontists. As
the response rate was high (84%), the results of the
present study should be considered representative of
the population. The data were gathered through inter-
views, which constitute a widely accepted method of
Table 2 Number (N) and percentage (%)
a
of injuries that occurred by sterile (A) and used (B) instruments
Instrument
Injuries by sterile
instruments (A)
Injuries by used
instruments (B) A + B
N (%) N (%) N (%)
Anaesthetic needles 131 (15.6) 123 (14.7) 254 (30.3)
Suture needles 3 (0.4) 12 (1.4) 15 (1.8)
Burs/Gates-Glidden drills 22 (2.6) 97 (11.6) 119 (14.2)
Endodontic les 140 (16.7) 173 (20.6) 313 (37.3)
Ultrasonic tips 8 (1) 24 (2.9) 32 (3.9)
Endodontic probes 22 (2.6) 53 (6.3) 75 (8.9)
Other
b
9 (1.1) 21 (2.5) 30 (3.6)
Total 335 (40) 503 (60) 838 (100)
a
Percentages have been calculated with respect to the total number of injuries.
b
Other: dam clamp, dental elevators, irrigation needles, scalpel blades, dental probes, sharp edges of a metal ceramic bridge and
human bites.
Figure 1 Percentage (%) of the
most recent injuries by sterile (A)
and used (B) instruments in rela-
tion to injured body part.
Percutaneous injuries: a survey Zarra & Lambrianidis
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 268
Table 3 Number () and percentage (%) of the most recent percutaneous injuries caused by sterile and used instruments
in relation to the circumstances associated with the injuries
a
Instrument
Circumstances associated with percutaneous injuries
Sterile N (%) Used N (%)
Anaesthetic needles Needle cap removal 16 (32.7) Recapping of the needle 43 (79.6)
Palpation of the retromolar area
with nger
13 (26.5) Unexpected patients movement 4 (7.4)
Adjusting needle to carpule syringe 6 (12.2) Palpation of the retromolar area
with the nger
2 (3.7)
Unexpected patients movement 6 (12.2) Needle disposal 2 (3.7)
Recapping of the needle 4 (8.2) Not remember 2 (3.7)
Needle disassembly 1 (2) Needle disassembly 1 (1.9)
Not remember 3 (2.5) Not remember 2 (3.7)
Total 49 (100) Total 54 (100)
Suture needles Removal from package 1 (50) Left on the bracket table 2 (66.7)
Placement in suture needles holder 1 (50) During suturing 1 (33.3)
Total 2 (100) Total 3 (100)
Burs Left in handpiece 5 (62.5) Left in handpiece 34 (94.4)
During placement in handpiece 2 (25) Unexpected patients movement 1 (2.8)
During opening the sterile package 1 (12.5) Removal from the bracket table 1 (2.8)
Total 8 (100) Total 36 (100)
Files Placement on stand 9 (25) Left on the bracket table 12 (26.7)
During prebending 6 (16.7) Instrument cleaning 9 (20)
Left on the bracket table 5 (13.9) Left in handpiece 8 (17.8)
Removal from the sterile package 4 (11.1) Placement on stand 3 (6.7)
Puncture of the sterilized package 2 (5.6) Pick up from the stand 3 (6.7)
During organizing the bracket table 2 (5.6) Pick up from the bracket table 3 (6.7)
Other
b
6 (16.8) Other
b
5 (11.1)
Not remember 2 (5.6) Not remember 2 (4.4)
Total 36 (100) Total 45 (100)
Ultrasonic tips Left in handpiece 4 (100) Left in handpiece 9 (90)
Whilst collecting fallen tip from
the oor
1 (10)
Total 4 (100) Total 10 (100)
Endodontic probes Puncture during collection from
the sterilized package
4 (66.7) Instrument cleaning 5 (45.5)
Left on the bracket table 2 (33.3) Left on the bracket table 4 (36.4)
Other
b
2 (18.2)
Total 6 (100) Total 11 (100)
Dam clamp Dental clamp positioned around
the tooth fractured during
manipulations to slide rubber
sheet below it. Parts catapulted
under tension, perforated gloves
and caused a percutaneous injury
to the index nger
1 (100)
Total 0 Total 1 (100)
Dental probe Left on the bracket table 1 (50) Left on the bracket table 1 (50)
Puncture at collection from the
sterilized package
1 (50) Instrument cleaning 1 (50)
Total 2 (100) Total 2 (100)
Irrigation needle Left on the bracket table 1 (100)
Total 0 Total 1 (100)
Scalpel blade Finger held attachment of the blade to
the scalpel handle
3 (100) Scalpel blade had been left to the bracket
table. Injury occurred during collecting
the instruments.
1 (100)
Total 3 (100) Total 1 (100)
Zarra & Lambrianidis Percutaneous injuries: a survey
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 269
data collection in studies dealing with occupational
hazards (Maupome et al. 2000, Al Wazzan et al.
2001, Venoresi et al. 2004). To prevent possible bias
owing to this process, all interviews were conducted
by the same investigator whilst no additional clarica-
tions were given. It must be emphasized, though, that
studies based on selective memory have inherent limi-
tations as data are gathered retrospectively. The fre-
quency or circumstances associated with
percutaneous injuries during the past 5 years may not
be accurately recalled. Additionally, the reliability of
these studies depends on the honesty of the partici-
pants responses. Although participants are assured of
condentiality, the answers may be biased in favour of
those being socially desirable. To compensate for these
limitations in the present study, the repeatability of
the answers was assessed by estimating the kappa
coefcient, and the obtained results indicated a strong
agreement between the collected responses for the cat-
egorical variables (see Krippendorff 1980).
In the present study, the percutaneous injury rate
was calculated 1.35 per year per person. This is lower
than the corresponding gures reported for dentists
(Gore et al. 1994, Cleveland et al. 1995, Siew et al.
1995, Bellissimo-Rodrigues et al. 2006), endodontists
(McCarthy et al. 1999), dental students (Machado-
Carvalhais et al. 2008) and oral surgeons (Adegboye
et al. 1994, Gooch et al. 1998), which are 1.73.6,
1.73, 1.78 and 2.3 per year per person, respectively.
It is higher, though, than the 0.99 per year per per-
son reported for orthodontists (Bagramian & McNa-
mara 1998) and the 0.190.53 per year per person
for dental students in other studies (Stewardson et al.
2002, Kotelchuck et al. 2004).
he variations in methods for data reporting lead to
inherent difculties for direct quantitative comparisons.
The number, circumstances and handling of percuta-
neous injuries by sterile instruments were also
recorded. This was based on the assumption that they
may also pose a risk of pathogen transmission depend-
ing on the circumstances associated with the injury,
for example, percutaneous injury with sterile instru-
ment through bloody/contaminated gloves. In this
study, details were recorded only for the most recent
Table 3 Continued
Instrument
Circumstances associated with percutaneous injuries
Sterile N (%) Used N (%)
Dental elevator Surgical endodontics (Hemisection of
mandibular molar)
1 (100)
Total 0 Total 1 (100)
a
Percentages have been calculated with respect to the total number of injuries that occurred by each type of sterile or used instru-
ment.
b
Others include a variety of conditions, each one reported to be associated with only one injury.
Figure 2 Endodontists post-expo-
sure behaviour (antiseptics include
povidone iodine, sodium hypochlo-
rite).
Percutaneous injuries: a survey Zarra & Lambrianidis
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 270
injuries. It was considered impossible to record infor-
mation on all injuries that occurred in the past 5 years
whilst it was regarded easier for the endodontists to
recall accurate information on the most recent ones.
In the present study, the instruments most fre-
quently associated with injuries were endodontic les
(38%). In previous studies amongst dentists, injuries
caused by hollow bore needles (Porter et al. 1990,
Adegboye et al. 1994, Younai et al. 2001, Do et al.
2003, Callan et al. 2006, Shah et al. 2006, Cleveland
et al. 2007) and burs (Gore et al. 1994, Cleveland
et al. 1995, Siew et al. 1995, McDonald et al. 1997,
McCarthy et al. 1999, Martins et al. 2010) were the
most prevalent. This difference can be attributed to
the fact that no other study has investigated exclu-
sively endodontists who use les more frequently than
general practitioners.
Human bites were also recorded, as they can cause
transmission of HCV, HIV and HBV (Dusheiko et al.
1990). The lower incidence of this type of exposure
in this survey (0.2%) compared with previous ones
(0.53.6%) (Ramos-Gomez et al. 1997, Trape-Cardoso
& Schenck 2004, Wicker & Rabenau 2010) can be
attributed to the use of rubber dam isolation in most
stages of endodontic treatment.
The signicant association between the number of
percutaneous injuries and the performance of surgical
endodontics can be attributed to the fact that surgical
procedures may favour the incidence of injuries. This is in
accordance with earlier ndings reported by Thomas
et al. (1996) amongst participants at the Annual Meeting
of the American Dental Association in 1992, in which
more oral surgeons had experienced at least one percuta-
neous injury compared with general dental practitioners.
Endodontists who always or usually practiced four-
handed endodontics reported signicantly fewer inju-
ries compared with those who did it rarely or never.
Other studies amongst orthodontists (Bagramian &
McNamara 1998) and dental students (Stewardson
et al. 2002, 2004) also revealed that dentists working
with an assistant are less prone to percutaneous inju-
ries compared with those working alone.
Patients noncontributory medical history was the
most frequently reported reason for not seeking
medical assistance after percutaneous injuries. This
(a)
(b)
Figure 3 Factors that inuenced endodontists decision (a)
to carry out serologic tests by percentage (%) of the most
recent injuries by used instruments, (b) not to carry out
serologic tests by percentage (%) of the most recent injuries
by used instruments.
Table 4 Number (N) and percentage (%) of respondents conforming to infection control measures
Infection control measures
Often
Always Usually N (%) Rarely Never
Use of gloves 118 (98.3) 1 (0.8) 0 1 (0.8) 0
Glove change between patients 120 (100) 0 0 0 0
Use of oronasal masks 113 (94.2) 3 (2.5) 1 (0.8) 3 (2.5) 0
Use of rubber dam isolation 120 (100) 0 0 0 0
Use of double gloving 4 (3.3) 0 12 (10) 75 (62.5) 29 (24.2)
Single-hand recapping of the anaesthetic needle 32 (26.7) 10 (8.3) 9 (7.5) 5 (4.2) 64 (53.3)
Retraction of soft tissues with instruments rather than ngers 82 (68.3) 19 (15.8) 15 (12.5) 2 (1.7) 2 (1.7)
Long sleeve coats 33 (27.5) 6 (5) 28 (23.3) 14 (11.7) 39 (32.5)
Disposal of sharp instruments in puncture-resistant boxes 97 (80.8) 2 (1.7) 3 (2.5) 0 18 (15)
Double gloving when cleaning instruments 12 (19) 8 (12.7) 6 (9.5) 3 (4.8) 34 (54)
Shoes that entirely cover the feet 109 (90.8) 1 (0.8) 5 (4.2) 1 (0.8) 4 (3.3)
Skin cuts and abrasions covered with waterproof dressings 59 (49.2) 11 (9.2) 10 (8.3) 5 (4.2) 35 (29.2)
Zarra & Lambrianidis Percutaneous injuries: a survey
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 271
highlights an underestimation by the participants of
how accurately self-reported medical histories may
represent a patients health status (McDaniel et al.
1995, Cohen et al. 1997).
Furthermore, many endodontists were content to
self-treat, because the trauma was considered minor.
This nding highlights that even trained specialists
underestimate the infectious potential of injuries not
involving blood. In the present study, all endodontists
washed the exposed site with soap and tap water or
normal saline immediately after the accident and
applied an antiseptic solution. This should be consid-
ered with caution, as procedures increasing the exposed
area and the application of caustic agents are not indi-
cated. Furthermore, 43% of endodontists pressed the
exposed area to facilitate spontaneous bleeding. How-
ever, there is no support for this procedure in the litera-
ture (Centers for Disease Control Update 2001).
Only 10% of the needlestick injuries were deemed
unavoidable owing to the patients unexpected move-
ment. The remaining 90% were thought preventable,
had appropriate measures been adopted. In particular,
15% of those injuries could have been avoided if the
affected endodontists had withdrawn their nger after
palpation of the retromolar area and 46% had
avoided recapping the needle or had adopted the sin-
gle-hand recapping technique. This technique was
used by only 27% of the respondents.
Similarly, 90% of injuries caused by used ultrasonic
tips, 94% by used burs/Gates-Glidden drills and 18% by
used endodontic les could have been prevented by their
immediate removal from their handpiece after use or
through changes in handpiece delivery system design.
Vaccination is the most effective way to prevent
HBV infection (Chen & Gluud 2005, Nagao et al.
2008). Optimal and long-term protection against
HBV is ensured only after the third dose (Jilg et al.
1988). For this reason, it was decided to record as
vaccinated only the endodontists who had completed
the HBV vaccination series. In Greece, there is no
legislation requiring HBV vaccination by dental
health care providers. In the present study, 91% of
the respondents reported the completion of the HBV
vaccination series, whilst a further 5% had antibod-
ies to HBV as a consequence of previous exposure.
Cohen et al. (1997) found a much higher percentage
(19%) of natural immunization, possibly because
their study was conducted 15 years earlier, when
HBV vaccination was less widespread.
As many people do not respond to HBV vaccine,
every dentist should have a post-vaccination test after
completion of the HBV vaccination series (Di Giuseppe
et al. 2007). The present study revealed that 81% of
the respondents had a post-vaccination test.
Routine use of gloves reduces the amount of inocu-
lated microbial material in cases of percutaneous
injuries and, consequently, the risk of infection (Mast
et al. 1993). Endodontists reported a very high per-
centage of glove use (98%). Double gloving seems to
be more efcient than single gloving in protecting
from occupational exposures (Schwimmer et al.
1994). In this study, most endodontists (63%) rarely
wore double gloves during dental procedures and only
3% were always using them regardless of the patients
medical history. This low percentage increased to
19% when they were asked for double glove use dur-
ing instrument cleaning. One endodontist reported
using latex kitchen gloves during the procedure.
These ndings may reect the higher risk perception
amongst dentists, regarding injuries during cleaning
procedures (Machado-Carvalhais et al. 2008).
Hand washing is a basic infection control measure
and is recommended between patients to enhance the
degree of achieved asepsis (Otis & Cottone 1989).
Hands should also be washed after touching objects
likely to be contaminated by patient uids (Sofola &
Savage 2003). In this study, 78% of the endodontists
washed their hands before and/or after each patient,
in accordance with the ndings of Venoresi et al.
(2004) (68%) and Bellissimo-Rodrigues et al. (2006)
(86.7%) amongst general dental practitioners. On the
contrary, Gershon et al. (1998) and Qudeimat et al.
(2006) indicated that the majority of dentists washed
their hands more frequently and always after glove
removal.
Uncovered parts of the body may increase the risk
of percutaneous injuries by sharp instruments. In the
present study, participants wearing long sleeve coats
reported fewer injuries by burs/ultrasonic tips/Gates-
Glidden drills compared with those who did not.
A possible correlation between gloves, masks, dis-
posal of sharp instruments in puncture-resistant con-
tainers, shoes that entirely covered the feet or their
combination and the number of percutaneous injuries
could not be investigated in this study owing to the
adoption of them by the majority of the participants.
Conclusions
The injury rate of Greek endodontists was low. An
association was found between the performance of
surgical endodontics as well as the practice of
Percutaneous injuries: a survey Zarra & Lambrianidis
2012 International Endodontic Journal International Endodontic Journal, 46, 264274, 2013 272
four-handed endodontics and the number of percuta-
neous injuries. Greek endodontists had a high level of
compliance with infection control measures. low
percentage of them were tested for bloodborne patho-
gen transmission after the injuries by used instru-
ments.
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