JIDAM

REVIEW ARTICLE

eISSN 2582 - 0559
―An Official Journal of IDA - Madras Branch‖©2019.
Available online

JIDAM/Volume:7/Issue:1/Pages 15 - 21/January - March 2020

POST EXPOSURE PROPHYLAXIS IN DENTAL

CLINICS- A REVIEW

Dr.J.Selvakumar,

M.Rojadarshini

Department of Periodontology,

Madha Dental College and Hospital, Kundrathur, Chennai, Tamilnadu, India.

To access & cite this article

Website: jidam.idamadras.com

DOI:10.37841/jidam_2020_v7_i1_03

Address for correspondence:
Dr.J.Selvakumar., MDS.,
Professor and Head, Department of Periodontology,
Madha Dental College and Hospital, Kundrathur, Chennai,
Tamilnadu, India
Email id: dr.selvakumar@hotmail.com

Received – 20.12.2019

Accepted – 17.02.2020

Published – 27.03.2020

ABSTRACT

  Occupational  exposures  are  common  among  dentists,
physicians and other health care professionals as they are in
direct  connection  with  blood  and  other  body  fluids.
Accidental  exposure  to  the  blood  borne  pathogens  Human
Immunodeficiency  Virus  (HIV),  Hepatitis  B  Virus  (HBV)
and  Hepatitis  C  Virus  (HCV)  may  occur  through  injury  by
sharp  instruments  and  needles  and  exposure  of  mucous
membrane  to  blood  and  other  potentially  infectious  body
secretions.  This  article  deals  about  those  who  are  at  risk,
factors  that  influence  their  risk,  do’s  and  don’ts  of  the
exposed, their management and medications.

KEYWORDS

: HIV, HBV, HCV, exposure, risk.

JIDAM/Volume: 7/Issue: 1/Pages 15 - 21/January - March 2020

Selvakumar et al: Post exposure Prophylaxis in Dental Clinics

INTRODUCTION

Post occupational exposure of health care workers to

some blood-borne viral pathogens (HIV, HBV and HCV) is
more common; occurrence and ways of minimizing/
preventing such exposures; and the need for Post Exposure
Prophylaxis (PEP) after such exposure have been elaborated
briefly.

In the occupational settings, there is a risk that health

care professionals will be exposed to blood borne pathogens
like Human Immunodeficiency Virus (HIV), Hepatitis-B
Virus (HBV) and Hepatitis-C Virus (HCV) during working
hours.

An exposure that may place a Health Care

Professional at risk of blood-borne pathogens are mostly due
to:

 A percutaneous injury (eg; needle stick or cut with

a sharp instrument)

 Contact with mucous membrane of the eye or

mouth

 Contact with non-intact skin (particularly when the

exposed skin is chapped, abraded, afflicted with
dermatitis)

 Contact with the intact skin when the contact

duration is prolonged (eg: several minutes or more)

 With blood or other potentially infectious body

fluids.

1,2

WHO ARE AT RISK?

Professionals with frequent blood exposures include

dentists, nursing staff and students, physicians, surgeons,
emergency care providers, labor and delivery room
personnel, laboratory technicians and health facility cleaning
staff.

Fluids such as blood, semen, vaginal secretions,

cerebrospinal  fluid,  synovial  fluid,  pleural  fluid,  peritoneal
fluid,  pericardial  fluid,  amniotic  fluid  or  other  body  fluids
that  are  contaminated  with  visible  blood  are  at  risk  of
exposure  to  the  virus  more  frequently.  Faeces,  nasal
secretions, saliva, sputum, sweat, urine, tears and vomits are
not  potentially  infectious,  unless  visibly  contaminated  with
blood.

1,2,3

Transmission through intact skin contact are not yet

documented. Any direct contact of virus without any barrier
requires clinical evaluation.

FACTORS

THAT

INFLUENCE

RISK

INFECTION:

Various studies have shown that the risk of infection

varies with the type of exposure:

 Type of needle (hollow bore vs solid)
 Device visibly contaminated with patient’s blood
 Depth of injury
 Amount of blood involved in the exposure

 Amount of virus in the exposed blood or fluid at the

time of exposure

 Timely (< 2 hrs and upto 72hrs) availability and

efficacy of the Post exposure prophylaxis.

On an average, among dentists, prevalence rate of HIV
infection is low compared to HBV and HCV

infection.

2,3,4,5

COMMON ROUTES OF EXPOSURE ARE:

6,7,8,9,10,15,16

NOTE: Needle-stick exposure for HBV is 9-30% and for
HCV is 1-10%

17,18

EXPOSURE ROUTE

HIV

Blood transfusion

90-95%

Perinatal

20 - 40%

Sexual intercourse

0.1% - 10%

Vaginal

0.05%-0.1%

Anal

0.065%-0.5%

Oral

0.005%-0.01%

Injecting drugs use

0.67%

Needle stick exposure

0.3%

Mucous membrane splash to
eye, oral and nose

0.09%

DO’S and DONT’S for the exposed individuals:
DO’S:

 Stay calm
 Remove gloves, if appropriate
 Wash exposed site thoroughly with running water,

if splashes have gone into the eyes or mouth

 Consult

the

designated

physician/personnel

immediately as per institutional guidelines, for the
management of the occupational exposure

DONT’S:

 Do not panic


Do not contact the wound



Do not squeeze blood from wound



Do not use bleach, alcohol, iodine, antiseptic.

1,2

Reduction of the risk of infection:

   Guidelines  formulated/published  by  the  CDC  (Centre
for  Disease  Control),  known  as  the  standard  precautions
(1996;  formerly  universal  precautions,1987)  should  be
followed  for  handling  blood  and  body  fluids  including  all
secretions  and  excretions  (serum,  semen,  vaginal  secretion)
by  all  health  care  professionals  at  all  times.  As  the
prevention  of  exposure  to  virus  remains  the  mainstay  of
occupational  infection  prevention,  some  of  these  simple
procedures  can  limit  its  exposure  and  reduce  the  risk  of
infection.

3,11

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Selvakumar et al: Post exposure Prophylaxis in Dental Clinics



Handle hollow bore needles with care as it may

lead to deep injuries



Never recap needles

 Never break/bend needles by hand

 Needles/sharp instruments should not be left on

trolleys and bedside tables and must be disposed off
immediately

 Never pass used sharp instruments from one person

to another directly

 Dispose sharp instruments in a puncture resistant

container

containing

one

percent

sodium

hypochlorite solution

 Wash hands with water and soap after removing

gloves, handling infectious materials, before
leaving the laboratory area, and immediately after
any contamination of skin surfaces.



Work surfaces should be decontaminated with 0.1

percent sodium hypochlorite solution.

 Laboratory personnel should refrain from mouth

pipetting, eating, drinking, or smoking in the work
area.

 Access to the laboratory should be limited to

trained personnel only. Food and drink must be
stored in refrigerators in areas other than the work
area.



All Health Care Professionals must be immunized

against HBV

POST EXPOSURE MANAGEMENT

Steps to be followed the accidental exposure to
blood/other potentially infectious materials:
1. First aid

2. Risk assessment
3. Informed consent and counselling
4. Decision on prophylactic treatment for HIV and HBV
5. Monitoring and follow-up of HIV, HBV, and HCV status
6. Documentation of exposure

12,13,14,16

1. FIRST AID

Management of Exposed Site

For skin: If the skin is broken by a prick from needle stick
or sharp instrument, immediately wash the wound and
surrounding skin with water and soap, and rinse.

•

Do not scrub.

•

Do not use antiseptics or skin washes (e.g., bleach,
chlorine, alcohol).

•

Wash the area immediately after a splash of blood
or bodily fluid on unbroken skin.

For the eye: Immediately irrigate the exposed eye
thoroughly with water or normal saline.

•

If wearing contact lenses, leave them in place

while irrigating.

•

Once the eye is cleaned, remove the contact lens
and clean them in a normal manner.

•

Do not use soap or disinfectant on the eye.

For mouth: Spit fluid out immediately. Rinse the mouth

thoroughly using water or saline and spit again.

•

Repeat the process several times.

•

Do not use soap or disinfectant in the mouth.

*The exposure must be reported immediately to the
concerned authority.

2. ASSESSMENT OF RISK

•

A designated person/trained doctor must assess the
risk of HIV and HBV transmission following an
accidental exposure to blood (AEB).

•

This

assessment

must

quick

start

treatment/prophylaxis without any delay.

•

After an AEB (for percutaneous exposure), an HIV
seroconversion rate of 0.3 percent is an average rate.

•

The risk of infection transmission is proportional to
the amount of HIV transmitted, which depends on the
nature of exposure and the status of the source patient.

12,13,14,16

ASSESSING THE NATURE OF RISK:

CATEGORY

DEFINITION

AND

EXAMPLE

MILD EXPOSURE

Mucus  membrane/non-intact
skin with small volume, e.g.,
a  superficial  wound  (erosion
of  the  epidermis)  with  a
plain  or  low  caliber  needle;
contact  with  the  eyes  or
mucous

membranes;

subcutaneous

injection

following small bore needles

MODERATE EXPOSURE

Mucus membrane/non-intact
skin with large volumes or
percutaneous

superficial

exposure with solid needle
(e.g., a cut or needle stick
injury penetrating gloves).

SEVERE EXPOSURE

Percutaneous with large
volume,

e.g.,

accident with wide bore
needle (>18G) visibly
contaminated

with

blood; a deep wound
(haemorrhagic

wound

and/or very painful);
transmission

significant  volume  of
blood;  an  accidental
injury  with  material,
which  has  previously
been used intravenously
or intra-arterially

ASSESSING THE STATUS OF RISK:
Assessing the status of the patient or object

12,13,14,16

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Selvakumar et al: Post exposure Prophylaxis in Dental Clinics

HIV STATUS

DEFINITION

HIV NEGATIVE

Source is not HIV infected
(but consider HBV and
HCV)

LOW RISK

HIV positive and clinically
asymptomatic

HIGH RISK

HIV positive and clinically
symptomatic

UNKNOWN RISK

Status  of  the  patient  is
unknown  and  neither  the
patient  nor  his/her  blood  is
available for testing

3. INFORMED CONSENT AND COUNSELLING

Almost  every  person  feels  anxious  after  exposure.
They should be counselled, and psychological support must
be  provided.  They  should  be  informed  about  the  Post
Exposure Prophylaxis.
  Exposed

persons

should

receive

appropriate

information  about  the  risks  and  benefits  of  Post  Exposure
Prophylaxis  medications.  It  should  be  clear  that  Post
Exposure  Prophylaxis  is  not  mandatory.  Exposed  persons
should, however, be made to understand that a few cases of
transmission have been seen in cases given prophylaxis.
Documentation  of  exposure  is  essential.  For  prophylactic
treatment  the  exposed  person  must  sign  a  consent  form.
Informed consent also means that if exposed, the person has
been advised on Post Exposure Prophylaxis. If the individual
refuse  to  initiate  Post  Exposure  Prophylaxis,  it  should  be
documented.  The  designated  officer  for  Post  Exposure
Prophylaxis  should  keep  this  document.  An  information
sheet  covering  the  Post  Exposure  Prophylaxis  and  the
biological  follow-up  after  any  AEB  must  be  given  to  the
person under treatment.

4. DECISION ON PROPHYLACTIC TREATMENT
FOR HIV AND HBV

Medications and regimens:
Because Post Exposure Prophylaxis has its greatest effect if
started  within  2  hours  of  exposure  it  is  essential  to  act
immediately.  Ideally,  therapy  should  be  started  within  2
hours  and  or  atleast  within  72  hours  of  exposure.  Never
delay  the  treatment.  Re-evaluation  is  to  be  done  after  72
hours  of  the  exposure.  If  the  risk  is  known  to  be
insignificant,  Post  Exposure  Prophylaxis  should  be
discontinued,  if  the  medication  is  already  started.  People
who  are  known  to  be  HIV  positive  should  not  receive  Post
Exposure Prophylaxis. Type of exposure and the HIV status
of the exposed individual decides the type of regimen to be
started (given in table below)

Dosages of the drugs for post exposure prophylaxis

for  adults  and  adolescents-  Fixed  Dose  Combination  of
Tenofovir (TDF) 300 mg plus Lamivudine (3TC) 300 mg
plus  Efavirenz  (EFV)  600  mg  once  daily  for  4  weeks.  If
the  person  is  already  on  Antiretroviral  Therapy,  start
the  exposed  person  the  above-mentioned  regimen  at  the

earliest with proper counselling and then refer for an
expert opinion

9,10,13,19

EXPOSURE

HIV+

AND

ASYMPTOM
ATIC

HIV+

AND

CLINICALLY
SYMPTOMATIC

HIV STATUS
UNKNOWN

MILD

Consider 2-
drug

Post

Exposure
Prophylaxis

Start

2-drug

Post

Exposure

Prophylaxis

Consider 2-
drug

Post

Exposure
Prophylaxis
OR
No

Post

Exposure
Prophylaxis

MODERATE

Start 2-drug
Post
Exposure
Prophylaxis

Start

3-drug

Post

Exposure

Prophylaxis

Consider 2-
drug

Post

Exposure
Prophylaxis
or No Post
Exposure
Prophylaxis

SEVERE

Start 3-drug
Post
Exposure
Prophylaxis

Start

3-drug

Post

Exposure

Prophylaxis

Consider 2-
drug

Post

Exposure
Prophylaxis
or No Post
Exposure
Prophylaxis

An expert or physician opinion is to be seeked in case if
there is any delay in reporting the exposure., if the source is
unknown. If the person is known or suspected to be pregnant
or the breastfeeding mothers (initiate PEP) or if the source
patient is on Anti Retroviral Therapies or if the source is
toxic to Post Exposure Prophylaxis.

IF SOURCE PATIENT IS ON ART the physician

should consider the risk by the exposure; history of the
source and clinical response to ARTs; decreased CD4 count;
viral load measurement and the current stage of the disease.
If the source is known to be drug resistant (drugs considered
for PEP regimen) then an alternative drug regimen is to be
prescribed as per expert’s opinion.

PREGNANCY

AND

POST

EXPOSURE

PROPHYLAXIS: If the exposed individual is known to be
pregnant or suspected to be, at the time of exposure then she
must get the regimen primarily as of non-pregnant
individuals.

They

are

given

antiretroviral

chemoprophylaxis,  if  needed.  The  authority  must  be
consulted  about  the  use  of  ARTs  for  the  post  exposure
management  of  the  individual.  For  all  the  female
considering  post  exposure  prophylaxis,  pregnancy  test  is
recommended in case of doubt.

SIDE  EFFECTS  AND  ADHERENCE  TO  POST
EXPOSURE PROPHYLAXIS: Side effects most commonly
like  nausea  and  fatigue  are  more  commonly  indicated  in
Health Care Professionals taking Post Exposure Prophylaxis
than  People  Living  with  HIV/AIDS  taking  ARTs.  Side

JIDAM/Volume: 7/Issue: 1/Pages 15 - 21/January - March 2020

Selvakumar et al: Post exposure Prophylaxis in Dental Clinics

effects are more common at the initial stage of treatment and
includes  nausea,  fatigue  and  muscular  pain.  The  respective
individual  under  treatment  is  to  be  informed  about  the  side
effects  caused  and  to  be  dissuaded  from  stopping  the
treatment. Anaemia/ leukopenia/thrombocytopenia may also
occur. Side effects are mild and transient.

Adherence information and psychological support are

essential.  More  than  95%  adherence  is  important  to
maximize  the  efficacy  of  the  medication  in  Post  Exposure
Prophylaxis.  Side  effects  can  be  treated  by  medications.
Complete  blood  count  test  and  liver  function  test  are  to  be
performed  at  the  beginning  of  the  treatment  and  after  4
weeks

9,10,13,19

POST EXPOSURE PROPHYLAXIS (PEP) FOR HBV
AND HCV INDIVIDUALS:

PEP regimen against HBV individual depends upon

the HBV status, type of exposure and the previous
immunization status of the individual.

MANAGEMENT

POST

EXPOSURE

PROPHYLAXIS FOR HBV AND HCV INDIVIDUALS:

There is no specific PEP regimen for HCV exposed

individuals. For HBV individuals, the response of the person
depends on his or her immune status and are determined by
the history of the HBV vaccine and its response.

14,17,18,19

HBV Post Exposure Prophylaxis is safe for pregnant ladies
and breast-feeding mothers

5. MONITORING AND FOLLOW-UP OF HIV, HBV
AND HCV STATUS

Follow up of exposed HCPs:
Long term follow up, counselling, and education

14,17,18,19

 Testing for at least 6 months after exposure (6

weeks, 12 weeks and 6 months)

 If PEP is used: drug toxicity monitoring at base line

and after 2 weeks.

Specific steps taken to reduce the risk of infection for
HBV individual are:

HBV IMMUNE STATUS

POST

EXPOSURE

PROPHYLAXIS

Unvaccinated

HBV vaccination and HbIg

Previously

vaccinated,

known

responder

(Anti-

hepatitis B surface antigen
positive)

None

Previously

vaccinated,

known non-responder

HBV vaccination and HbIg

Antibody response unknown
: Test; if antibody response
is < 10 IU/ml,

HBV vaccination and HbIg

•

Pre-test counselling is to be provided and Post Exposure
Prophylaxis should be started as mentioned above.,

Before  starting  PEP,  3-5ml  of  the  person’s  baseline
blood  sample  is  to  be  taken  and  sent  to  lab  for  testing
and storage. Serum sample is to be collected as soon as
possible  after  exposure  for  HIV  testing.  Otherwise,  it
may be difficult to attribute the infection acquired.  The
first sample for HIV testing is collected immediately
after exposure, the 2

at 6weeks, the 3

at 12 weeks,

and the last at 6 months after exposure.

•

During  the  follow-up  period,  especially  the  first  6-12
weeks, the following measures are to be adopted by the
Health  Care  Professionals:  refraining  from  blood,
semen,  organ  donation  and  abstinence  from  sexual
intercourse.

•

In case, sexual intercourse is undertaken, a latex

condom must be used to reduce the risk of HIV
transmission. Women should not breast feed their
infants.

•

The exposed person is advised to seek medical
evaluation for any febrile illness that occurs within 12
weeks of exposure.

14,17,18,19

6. DOCUMENTATION OF EXPOSURE

The exposure report details should include:

•

Date, time, and place of exposure

•

Type of procedure done

•

Type of exposure: percutaneous, mucus membrane,
etc.

•

Duration of exposure: Exposure source and
volume; type of specimen involved

14,17,18,19

All persons must be informed about the immediate exposure
to initiate the preventive care in time to be effective and
casual approach may lead to casualty.

CONCLUSION

If transmission of a blood-borne infection occurs after

occupational  exposure,  it  should  be  documented,  and  the
Health  Care  Professionals  should  be  treated.  If  exposure
occurs,  immediate  care  for  the  exposed  part  and  the  person
is  to  be  done  and  it  should  be  documented  and  reported.
Then,  the  appropriate  PEP  medication  regimens  after  the
proper  assessment  of  such  exposure  must  be  started.
Counseling  is  to  be  given,  if  indicated  as  per  the  national
guidelines and subsequent follow-up would be beneficial.
For  the  management  of  such  occupational  exposures,  each
hospital\clinic  should  have  an  infection  control  team  and
policy arrangements for the prompt and uninterrupted (round
the  clock)  supply  of  PEP  drugs  as  per  national  guidelines.
All  Health  Care  Professionals  should  be  vaccinated  against
Hepatitis B.

Such exposures can be minimized by Health Care

Professionals following standard precautions at all times; by
treating  all  patients/specimens  as  potentially  infectious;  by
avoiding  unnecessary  invasive  intervention  wherever
possible;  by  using  appropriate  barriers  and  Personal
Protection Equipment to prevent exposure to blood and body
fluids;  through  the  safe  handling  of  sharps  and  their  proper
disposal to avoid injuries; by thoroughly washing hands after

JIDAM/Volume: 7/Issue: 1/Pages 15 - 21/January - March 2020

Selvakumar et al: Post exposure Prophylaxis in Dental Clinics

removing gloves; and by properly disinfecting work places
and sterilizing used up articles, etc.

FINANCIAL SUPPORT AND
SPONSORSHIP:

Nil

CONFLICTS OF INTEREST:

There are no conflicts of interest.

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