Proper Prevention and Response to an Eye Incident in Your Operatory

She went to her general dentist and in the process of passing the anesthetic syringe, the assistant or the dentist dropped the syringe and the contaminated needle perforated her right eye, went to the emergency room. They admitted her to the hospital at the end of the week. They could not get the infection under control and they had to remove her right eye. Welcome to the Phil Klein Dental Podcast. In today's episode, we're focusing on eye protection, a crucial yet often overlooked aspect of dental safety. Whether it's protecting against debris from high-speed instrumentation, exposure to harmful chemicals, or accidental splashes, safeguarding the eyes of both dentists and patients is a non-negotiable part of clinical care. In this episode, we'll be breaking down the protocols for proper eye protection, including the types of eyewear needed for both practitioners and patients, the correct setup of an eyewash station and how to ensure it meets ANSI and OSHA-compliant standards. We'll be talking about the prevention measures that every dental office should follow to minimize risk, and most importantly, what to do in the event of an eye incident in your practice. Ensuring compliance and best practices for eye safety isn't just about avoiding fines. It's about protecting the health and well-being of your team and your patients. So stay with us as we dive into the essential steps every dental professional needs to take. to keep their eyes on safety. Our guest today is Dr. Marie Fluent. Dr. Fluent's dental career spans over 35 years and includes all roles within the dental practice. She is passionate and deeply committed to improving dental infection control and patient safety. Through her writing, webinars, and invited lectures, she has educated thousands of dental professionals and students nationally and internationally. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Fluent, it's a pleasure to have you on the show. Thanks, Phil. Thanks for having me. Delighted to be here. So generally speaking, Dr. Fluent, dentistry is a fairly safe profession. It got a bad rap during COVID for obvious reasons. We were on the front lines of the aerosol and so forth. There is still a risk that we have to be keenly aware of regarding eye safety. And, you know, things are flying around the office, small particles, aerosols that can go in the eye. It's something we have to be, as I mentioned, very aware of and very protective of because we only have two eyes and we need them very desperately to do our dentistry and function in life. So tell us what the ocular risk is for a dentist and dental staff person who's in that operatory every day. Well, we've got stuff coming at us from every which direction, and that's my generic term. We have chemicals, we have blood-borne pathogens, we've got dental materials. How many times have you removed an amalgam restoration and have been hit in the face with a chunk of amalgam? Then on top of that, we are exposed to eye strain because we're using digital computer, digital devices, and exposed to blue light left and right. And then we've got the blue light hazard. And some of us use lasers in laser dentistry as well. So we won't really address that today. But we've got lots of debris coming at us. And it comes at us pretty fast and at a short distance. So yeah, we've got lots of risks that happen in dentistry. Right, chemicals as well. As far as the particles, the speed in which it hits the surface of the eye, that could be, what, 50 miles per hour? Yeah, there's one study that shows it comes at us at 60 miles an hour. And my focal distance, I remember when I was practicing dentistry, and by the way, I'm not because of my eye of all things. My focal distance between my loops and the field of vision was about 17 inches. So if you've got debris flying at you 60 miles an hour at a 17 inch distance, you don't have time to duck. shield your eyes, move, get out of the way, et cetera. You simply must rely on your personal protective equipment and it better be in place and it better be impact resistant. We'll be getting back to Dr. Fluent in a moment, but first. With countless dental composites on the market today, choosing the right one can be overwhelming, yet a few products rise above the rest, and Voco composites lead the way. For over a decade, Grandioso's tooth-like physical properties have remained unmatched by any other restorative material. 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Well, ironically, CDC doesn't have enough information in my humble opinion, but the American Dental Association does. The ADA has a great page dedicated to eye safety and dentistry and gives you the run through on what to do depending. on the type of injury, illness, or exposure you would be exposed to. So let's start off with the scariest first. The scariest would be a penetrating injury where you've got something actually stuck in to the sclera or cornea of your eye. And if you have a penetrating injury, you assess and then immediate referral to hopefully ophthalmology. So urgent care, but ophthalmology would be ideal for treatment. And in that scenario, if you have a penetrating injury, you don't rinse out, you don't flush, you don't rub because you don't want to push that foreign object in deeper into your eye. So immediate referral if you have a penetrating injury. Yeah, let me just ask you one question about that. How do you detect or how do you confirm that it is a penetrating incident when... there might be just something on the surface that just flew into your eye. And that's kind of hard to determine sometimes. In the case of a penetrating injury, I would think it would be fairly obvious where you have something stuck in your eye and you can physically see it. And hopefully you've got a team member who can look at your eye and say, yeah, you've got a big problem here. Or, hey, it's an exposure incident. Let's see if we can rinse that out. And if unsure, medical referral. If you're torn at all, medical referral right away. So if you see something in the eye that's a particle that's sitting on the surface and the person is blinking a little bit, but it's not moving. So it's kind of stuck in its place. You're saying not to go to an eyewash at that point. Well, if it's sitting on the surface, yes, absolutely an eyewash. If it's sticking in your eye, that's the distinction. Then you've got a big problem on your hands and you need an emergent medical referral right away. But if it's just simply on the surface of your eye or a chemical that's been splashed into your eye or a bloodborne pathogen that's been exposed to your eye, those are. exposure incidents that require an eyewash station. So we talked about the penetrating injury to the eye. Let's talk about chemical exposure. What happens when the eye is exposed to a chemical agent? Okay, we'll do. And I'll lump chemical exposures in with any other type of exposure incident as well. For instance, exposure to a bloodborne pathogen, which is an exposure incident, just as we think of an exposure incident in dentistry. So if you have such an incident, what you would need to do is assess the situation and then head to your eyewash station and flush your eye out for a solid 15 minutes, which seems like a forever amount of... time. When we look at the literature and injuries that have occurred in dentistry, we see that people who have had an exposure incident, they rinsed, quote unquote, a couple of times or a little bit, but that's really not enough. It really needs to be a full 15 minutes. And then the situation is assessed. If it's a bloodborne pathogen or a chemical, then immediate referral for further evaluation. it's a chemical of course you would take your safety data sheet your SDS sheet with you so that your provider will know what you've been exposed to and know how to treat you and if it's been the exposure incident was a blood-borne pathogen then they will assess and determine if any type of post exposure treatment or prophylaxis would be indicated. Then, of course, there's an incident report. There's documentation and record keeping. There is follow-up and medical care if needed, post-exposure prophylaxis if needed. And then, of course, you return to work with an increased awareness of safety and an awareness on how to prevent this injury from happening again. So that's the basic outline on what you do if you've been exposed. either a bloodborne pathogen or a chemical or debris that's on the surface of your eye. So that's where we're at right now. Can you get into more specifics about what the responsibility is of the dental practice owner, the employer, regarding documenting an incident like an eye injury that we're talking about today? Well, now we are into an OSHA phenomenon. And with regard to record keeping and medical records of employees, all employees are to have their own medical record within the facility. Not just their dental record that can be either pulled from the shelf or downloaded digitally on the dental software management system within your office, but this is separate. This is your private medical information that's to be kept private. The only people who should have access to it include you as the employee, your employer dentist, and possibly the infection control coordinator as well. So all of us have to have a medical record. record at our office including that includes any type of exposure or illness that occurs on the job or exposure incident and of course our vaccination history and anything medical related to us and related to our employment history. So that is part of our medical record. And then in addition to that, you have the documentation that goes with you to the health care provider, including the safety data sheet, if applicable. And then your medical provider will look at that and help determine what the next step should be. In occupational medicine, they're trained to treat crazy illnesses and injuries and exposure incidents that have occurred and make the determination on what should be done next. And so the detailed form should have as much much detail as possible, what happened, how it happened, what PPE was being worn at the time, and how much of whatever were you exposed to. So that is part of that, that form of a copy of it is maintained in your medical record in the facility. And then the duplicate form goes with you to your healthcare provider to determine what happens next. So what's your recommendation, Dr. Fluent, when an employee has an eye incident and it's determined that it's not a penetrating injury, they go to the eye wash, wash it out, they feel better, and they're ready to go back to work, whether they're going to go see the same patient they were seeing or maybe that patient left and they start a new patient in the schedule. What's your recommendation regarding resuming work after an eye incident? I can't make a blanket statement generically. I guess it would depend on the scenario. For instance, I had a patient who was exposed to acid etch, the etch gel that's used for like this 35% phosphoric acid that's used in any type of bonding procedure in the dental office. And my dental assistant was, they had a clogged cannula. So she pounded on the edge end of it to release that clog. And of course, etchant gel splashed up into her eye and asked the practicing dentist. uh at the end of her eye wash she said i'm fine i'm fine i'm ready to go back to work and i went this goes against my better judgment no i'm not fine i think you need follow-up care and we'll let the medical professionals determine if you are indeed okay or not fortunately knock on wood i'm here to say she was fine immediately afterwards and had no sequela no long-term damages as a result of this but it sure made my heart skip a beat and i was uncomfortable with that. Now, if you had a little particle of dust and it was removed thoroughly and the employee felt comfortable, that's a different scenario. So I would determine that on a case-by-case basis. But to be on the safe side, if you, in your best judgment, think that it could be more than a mild injury, a chemical injury, for example, and the eye is bloodshot and 10 minutes have passed, 15 minutes have passed after the eye wash and the eye is pretty bloodshot, at that point, you don't want that employee going back to work, right? You want them to, you want to get them checked out at it. Absolutely. And if the employee was exposed to a bloodborne pathogen, then absolutely they need follow-up. That is an exposure incident as well. So yes, absolutely. Do you think, we're going to talk about eyewash station now, but do you think that most dental practices at this point, especially after COVID, have the proper PPE? in their office and the employees and the dentists themselves that own the practice are using PPE properly where this is not a big issue anymore? Eye injuries? No, I think it is a big issue and a lot of us are unprotected. A lot of the... Well, I'll just give you a for example. I was in... purchasing my own personal eyeglasses recently at the optical shop, just personal prescriptive lenses. And they had a full wall of what was called safety glasses. And I looked at these and I thought, holy cow, the dental personnel, if they were standing in front of this display, they would be totally duped at thinking all of these would be appropriate to use in the dental setting because they're not. And as I look at them, some of the lenses were very, very small. Some had large gaps around the perimeter, particularly the lower rim area. Most of them had zero side protection. And I thought, you know what? You would not be safe wearing any of these in the dental practice. And some of them looked very protective. So I think it's a case of buyer beware and know what you want. were indeed looking for. So we see a lot of loop manufacturers today who are making loops that enhance the field of vision and provide illumination to your field of vision as well. But are they safety glasses? Do they provide adequate protection? In many scenarios, no, and you better be aware of what you're looking for. We'll be getting back to our guest in a second, but first, are you looking for an air-driven handpiece that rivals the power and torque of electric? Well, I have good news. It's finally here. It's called the TMacZ and it's from NSK, a company we all know and trust as a world leader in dental handpieces. In addition to being lightweight and ergonomic, this revolutionary air-driven handpiece delivers unprecedented 44 watts of power, allowing it to cut through tough zirconia smoothly and quickly. In fact, the TMac-Z reduces overall cutting time by 30%. That means less chair time, reducing the burden on you and your patient. Take a test drive of the TMAX Z air-driven handpiece from NSK. For a free 10-day trial, go to nskdental.com and find your local rep to inquire. Experience the power and excitement of the TMAX Z series. On top of that, we have a compliance problem where people don't wear their PPE all of the time. So both are considerations. You need adequate protection and you better be wearing it. So when you're buying loops that are mounted on the glasses that come with the system, they may be impact proof, but they're not necessarily protective glasses. No. And they do not provide adequate coverage. They may be a safety lens that has ANSI standards for impact resistance. But if it's a lens the size of a half dollar, that's not going to provide adequate protection for you. You need full coverage. Right. And on the bottom too, you need that little lip where the top of the mask meets the under part of the glasses, right? Exactly, exactly. And that's another area that's relatively new in dentistry that's called the bottom gap. And it is a like the way that the eyeglasses or the eye protection fit together with the mask. It's kind of like a gap in our modern PPE combination, if you will, where when we put on our protective eyewear and our mask, you can actually slip a finger underneath between the lower rim and the top portion of your mask. and a lot of debris can fly through that bottom gap and cause injury from a lower trajectory, if you will, from your vantage point in the dental chair. So you actually need to look at the top bottom side coverage of your PPE to make sure you have adequate coverage. In addition to that, impact resistant as well. So every dental office has to have an eyewash station. That's a mandate by OSHA. Tell us about the eyewash station and some of the protocol that needs to be adhered to in order to stay compliant with OSHA. Will do. Now, there's two sets of standards I want you to be aware of, Phil. The first comes to us from OSHA. And ironically, the OSHA standards are a little bit more vague than the second set of standards that come to us from ANSI, American National Standards Institute. So let's start off with OSHA. OSHA says that we have to have eyewash equipment for emergency use where your eyes may be exposed to injurious corrosive materials. Number two, you need to flush for a minimum of 15 minutes and then seek medical help. Number three, the temperature should be tolerated, meaning not too hot, not too cold, but OSHA doesn't really specify exactly what temperature they're talking about there. The next bullet point is that the eyewash station should be installed 10 seconds from the hazard. And that's a 10 second walk on the same floor as where the hazard may have occurred. And then finally, the eyewash equipment is required to be inspected annually. So that's kind of vague. So ANSI has taken it a step further and quantified all of the above. So they say that when you activate the eyewash station, it should be in a controlled low velocity flow for both eyes and not injurious to the user. So think of your air water syringe in your dental office. You can turn on the water portion only and have it trickle out, or you can press on the air in water combined and have it blasted out. So we want obviously a low velocity, more in the simple flush range where you're not going to cause more damage to the eye. They recommend that we keep the heads of the eyewash station protected from airborne contaminants. In other words, keep a lid on when not in use. Then they quantify what the speed of delivery of the water should be, and that's 0.4 gallons of water per minute. And then they quantify how this should be operated, hands-free, open valve that operates and activates within one second of time or less. the 10-second phenomena that translates to 55 feet from the hazard. It should be on the same floor. It should be an unobstructive path. And the water should be between 60 and 100 degrees Fahrenheit. People need to be trained how to use this. And not only should it be inspected annually, but it should be activated weekly. And that's kind of important, Phil, because one office where I was consulting it, I went into the eyewash station and I said, okay, let's turn that on. And the first interesting thing was nobody knew how to activate that. It's kind of scary. Let's figure this out together. And then when we did activate it, the water that came out was rusty in appearance. It actually had a rust color sediment in it. And I thought, I would not want my eyes in that. That's kind of scary. So I think that leads us right into training. People really need to be trained and have practice sections. role-playing. My eyes are injured. Where do I go? What do I do? How do I activate this thing? And let's role-play it on out rather than just looking at it and saying, yep, there it is. I inspected it. Let's move on. Because that eyewash station is there for a purpose and 99.99% of the time you don't need it. But when you do need it, it better be there and it better be working. So you mentioned 0.4 gallons per minute. And if it's 15 minutes, we're looking, let's say 0.5 gallons. So you're looking at seven and a half gallons of water. Is there an option to have a container with that water in it of seven and a half or eight gallons? It would be a big container. But if you had one, would that obviate the need to have it plumbed? Because it seems like it would be a lot easier to install in a hallway that's 10 seconds away from where an incident might happen. Well, I have never seen a container that can deliver, and by the way, your math is very quick. I commend you on that. Thank you. But seven and a half gallons, if you think about a gallon jug of water that you would purchase from the grocery store, imagine seven of those. I have never seen an eyewash station that has that much water incorporated into it. What I have seen are smaller quart size or soda pop bottle size of eyewash stations to flush. your eye out and those are not plumbed and obviously they do not and cannot deliver enough water to make your flush completely effective. So people have said to me, can I just use one of these little eyewash stations with a bottle that I purchased from my medical supplier? And the answer is, well, if it can deliver seven and a half gallons of water over 15 minutes of time, sure. But if it can't, then no, you can't. So it ought to be plumbed in. Yeah. So if you buy an existing practice that I don't know when this law came into place, but I don't think they have anything that's grandfathered. We're an older practice that. has an office that doesn't have plumbing access at the areas that you're talking about, which is 55 feet from an operatory, you're going to have to go through the walls and get a plumber to do that, I assume, right? Yes. When it comes to OSHA, there's no such thing as a grandfather law. In OSHA, there's the general duty clause, and that is if you recognize a hazard, you must address it. So if it's not plumbed in, you have to figure out a way to make that happen. Today's episode is sponsored by Sunstar, makers of gum products. Gum's premium line of interdental cleaners, soft picks, and toothbrushes offers innovative, easy-to-use solutions for better oral care. Introduce your patients to gum, the tools they need to maintain healthier smiles. Learn more today by visiting sunstargum.com. So if you have an inspection, whether it's scheduled or not, it could be a surprise inspection. I don't think they have that many surprise inspections anymore based on... people I've been talking to that are in this business, if OSHA shows up and they inspect your eyewash and it's not capable of doing what you just described, which is 15 minutes sounds like an eternity to me to be sitting there flowing water on your eye, 15 minutes, it's just a long, long time. But anyway, if you don't have that set up, then you are eligible or vulnerable to being fined from OSHA. Correct. So in your experience, Dr. Fluent, how compliant is the dentist that's out there, generally speaking, when it comes to an eyewash? I know most offices have eyewashes, but how compliant are they where if they got an inspection, they would pass it? Most offices have an eyewash station, but I don't believe that it's inspected on a regular basis. I don't believe it's flushed out on a regular basis. And a lot of offices where I've gone to consult at, I've seen lots of violations. For instance, one office had a great eyewash station, but to get to it, you had to walk through the sterilization room, enter a big steel door into the supply closet, trip over boxes. to get to another steel door and into a utility room around the corner to get to the eyewash station. And guess what? There were more boxes stored in there, that room as well, right in front of the eyewash station. So if I were in panic mode and in a hurry, I'd be tripping and falling all over these boxes and may not be able to navigate the big heavy steel doors. So, you know, if they have an eyewash, I think most offices have an eyewash station. But it's generally not to the standards that I just mentioned. Yeah. So let's talk about eye protection. Could you go over the CDC guidelines, which I know aren't comprehensive at best. They don't really cover it very precisely, CDC, on what the eye protection guidelines are. But let's begin with the patient themselves. What are we looking to do for protection for the patient? Well, the CDC, it's interesting, when you read the guidelines, they have the science behind the guidelines and the description behind the guidelines, and then they give the guidelines themselves. So the description behind the guidelines says, protective eyewear for patients shields their eyes from spatter or debris generated during dental procedures. But then during the section on the actual guidelines themselves, there's no recommendation for the patient, which is... crazy. And I do not understand why. So having said that, your best practice would be whatever level of protection that you are wearing as dental personnel in the room, that the patient should be provided the same level of protection. In other words, if you're wearing eyewear that protects against impact resistance, then that's what your patient should be wearing. If you're wearing eyewear that protects against light irradiation, and we'll talk about that in upcoming podcasts, then that's the level your patient should be wearing as well. And then the American Dental Association goes on to say that the caveat or the paradigm would be first on last off. So the first thing you do when the patient is seated in the chair is put on their protective eyewear. And the last thing they remove upon dismissal would be their protective eyewear. And that way accidents or injuries cannot happen. then CDC does not provide specifics on personal eyeglasses for the patient. But if personal eyeglasses are not adequate for the dental provider, they're not adequate for the patient. So I think the best practice is the same level, the same coverage of protection for the dental personnel for the patient, and first on, last off. Yeah, so what happens if a patient says, no thanks, I have my own glasses, or they... decline when you offer them the eye protection glasses. What do you do? That shouldn't even be an option. When the patient sits in the dental chair, the first thing provided to them should be your protective eyewear. And it might be a case of, do you prefer to wear this pair or this pair? And both that meet those standards. And here, these are your options. And if the patient refuses, then not a good scene. There have been lawsuits related to lack of patient eyewear. dental procedures and it's pretty darn scary. So I would be a little bit more, well I would absolutely have a policy on eye protection in my office, make sure all of my employees understand the policy. role-play communication with the patients in the case scenario that that should happen. And hopefully, once you have a well-established policy and patients return for their re-care appointments, that they understand this is the expectation and this is what I'm going to be wearing when I sit down in that dental chair. Right. So even if it's just an exam, whatever they do in that operatory, you suggest that the patient should be wearing eye protection of some kind. Absolutely. Absolutely. Crazy stuff happens. You could drop an explorer or a periodontal probe upon passing instruments between the assistant and the dentist, and it can penetrate right into the patient's eye. Yeah. There's actually a very well-known, famous case, unfortunately, of a patient who had a severe eye injury, a horrific eye injury during her dental visit. She's actually done a webinar on VivaLearning.com about it. Tell us about that, Dr. Fluent. Sure. There's a patient, her name was Jen, and she was a victim of an eye injury. And she's now a patient advocate for eye protection in the dental office. She went to her general dentist and had a root canal procedure performed on a lower molar. And in the process of passing the anesthetic syringe, the assistant or the dentist, I forget who, dropped the syringe and the contaminated needle perforated her right eye. And the dentist gave her... a warm compress and told her that she would just be fine and he proceeded to finish the root canal procedure well that night Jen was not fine. She was in excruciating pain in her right eye, went to the emergency room, and of course, the emergency room personnel were appalled at what happened. They admitted her to the hospital, put her on numerous rounds of antibiotics to fight off any infection, and at the end of the week, they could not get the infection under control, and they had to enucleate her eye, which means, of course, remove. her right eye. So Jen now wears a prosthesis in her right eye. And as you might imagine, there was a lawsuit. And interestingly enough, if everybody was sitting in front of me, I would say, who would you think won the lawsuit? And people would raise their hand and anticipate it was Jen. But actually, The dentist won the lawsuit because our CDC guidelines are not descriptive enough saying that the patient is required to wear protective eyewear. And the dentist said there was nothing to prevent her from going out to her car and getting her sunglasses anyway. So there wasn't great regulation for patient eyewear. And so it was a horrible, horrible scenario. Hopefully we can learn from Jen and not let this happen in our offices. Her YouTube site was up. I think it's still available. And if you have an opportunity to watch it, I encourage you to do so because it really is compelling and a yucky story. Yeah, no, it's a sad story. I'm a little surprised that even though there was no mandate for eye protection for the patient, what actually happened in reality was that the dental office dropped a syringe in the patient's eyes. I don't really see why the dental office would be completely exonerated from that liability. I'm not really understanding that. Agree. And in my humble opinion, I think Jen needed a better attorney, but that's another story for another day. Yeah. Yeah. Very sad. All right. Well, listen, the moral of the story is eye protection, eye protection, eye protection. There's something that's certainly a priority for our PPE considerations. And the eye protection is not equal for every company that sells it. Like you said, you went to the optometrist or Optimal, wherever they were selling glasses and they... were marketing eye protection and you were looking at it probably shocked at how inadequate that eye protection was. So you have to really look at what you're buying. Like you say, buyer beware. And it's something that's very, very important. So we thank you for your insight very much. And Dr. Fluent, and we look forward to having you on future programs. Thank you so much, Phil. Thanks for the opportunity to be here today. Appreciate it.