Research Paper

5/8/2023
Dental Workers exposure to occupational health
hazards; physical, chemical, and biological hazards

California State University of San Bernardino

Christina Marie Marquez
Spring MPH Program: HSCI 6230
Professor Swat Kethireddy
Research topic: Dental Workers exposure to occupational health hazards, physical, chemical,
and biological hazards.

Abstract

Dental workers risk their health daily by caring for and treating patients’ oral health.
Having proper personal protective equipment is essential to prevent the risk of a severe chronic
illness or even a common cold. There are multiple routes of skin exposure (eyes, puncture),
mouth (eating), and nose (breathing). Exposure to physical hazards daily, ionizing radiation.
Chemical hazards in liquid, metal, or gas; silica dust, mercury, nitrous oxide beryllium, and
disinfectants. Biological hazards include viruses (HIV, Covid -19, hepatitis) and bacteria
(whooping cough, tuberculosis). Many of these occupational hazards cannot be seen with the
naked eye or cause harm the same day it can be caused by chronic exposure. Ensuring the
workplace is taking proper precautions pertaining to Occupational Safety and Health
Administration guidelines could significantly reduce this risk.

Introduction

There are around 750,000 Dental Occupations in the United States, including dental
assistants, technicians, dentists, dental hygienists, etc. (Elka, 2020). The first thing that comes
to mind of a healthcare worker and the dangers of it is doctors and nurses; however, dental
workers also have to deal with and be exposed to chemical, biological, and physical hazards
daily. Dental workers are trained to understand the ways of transmissions and have more
significant concerns about biological hazard more than physical or chemical ones. Covid -19 just
heightened the concern among dental workers because having to contact a patient without their
mask very closely shows the risk dental workers take to treat oral needs. Some dental workers
must expose themselves daily by taking x-rays of patients' teeth, mouths, or jaw. Ionizing
radiation is a concern most patients are informed about the harm to an unborn fetus or the
reproductive system. Other hazards dental workers will be exposed to are harmful chemicals
used in the workplace that are considered dangerous according to CA Prop 65; mercury is used
in the amalgam to fix most cavities. OSHA provides the limits or amount on which employees
should be exposed to daily hazards. The Centers Control for Diseases explains the harm a
chemical can have upon a human being. A dental office should have access to proper
resources and equipment to take precautions to protect the employees.

PPE- Personal Protective Equipment

OSHA - Occupational Safety and Health Administration
CDC- Center for Disease Control and Prevention
PEL - Permissible Exposure Limits
FDA – US Food and Drug Administration
NIOSH – National Institute for Occupational Safety and Health
EPA – Environmental Protection Agency
HVS- Hand-Arm Vibration syndrome
LMP-Liters per minute

1
Chemical

Chemical Hazards could come in the forms of liquid, metal, or gas.

Mercury is used in the amalgam to fix most cavities. In Dentistry, the use of amalgam is mixed
with a liquid and powder form of two metals; 5% mercury and other elements; silver, copper,
and tin (FDA, 2021).
Beryllium is one of the materials or metals dental technicians use to make or fix crowns,
bridges, and dental plates in labs. Dangerous of using this are being exposed to dust by
inhalation or skin contact could cause Chronic Beryllium Disease (CBD), lung disease, or
cancer (OSHA).
Dental technicians work with silica dust but use an enclosed workspace so that it does
not go up in the air when working with dental casting. Silicosis is a lung disease with coughing,
wheezing, sharp pain, fever, and weight loss symptoms (American Lung Association, 2022). It
usually contains crystalline silica dust in the sand, rocks, and quartz. OSHA (PEL) is 50
micrograms per cubic meter of air in an 8-hour shift (Stoltzfus, C. 2020). The dust while working
with material containing silica is dangerous to inhale. A person usually gets sick with years of
exposure. Other health outcomes can be lung cancer, bronchitis, and kidney disease. Around
2.3 million people in Unite states are exposed to silica, and only some treatments are available
and effective (American Lung Association, 2022).
Nitrous Oxide (N2O) is an anesthetic gas used to light sedate a patient, commonly
known as laughing gas. It helps them with anxiety and is used during a lengthy procedure. This
is a safer alternative than full sedation to fill cavities. It is Hazardous because it can reduce
oxygen in the air through leaks and ventilation issues. Another reason is that if a person is left
too long with the nitrous oxide mask, it can be deadly, reducing oxygen to that person. The
recommended airflow rate of 45 LPM to protect workers and patients; (NIOSH) created the
requirement for ventilation (CDC, 2014). Over time Serious side effects include seizures, loss of
consciousness, irregular heartbeat, can overdose issues, and Long-term effects; Memory loss,
vitamin B 12 deficiency, ringing in ears, limb spasms, numbness of hands and feet, congenital
disabilities, weak immune system. (Alcohol and Drug Foundation, 2023). Other dangerous effect
of being exposed focusing on women who are pregnant and very young child; high exposure to
N2O can affect pulmonary function (Tulchinsky, pg.511). Woman in dentistry occupations who
are mostly around N2O are more likely to take longer to get pregnant than someone who
doesn’t causing fertility issues (Tulchinsky, pg.546).
It is essential to disinfect harmful bacteria and viruses in the room or on instruments
used for procedures; dental workers use harsh chemicals to disinfect. Glutaraldehyde can be
used to sterilize instruments that cannot be exposed to heat. It has a strong odor and usually is
diluted down; workers must take precautions to be exposed because it can cause symptoms
that affect the eye, lungs, skin, and nose. Depending on the time of exposure, a serious harmful
effect is difficulty breathing, wheezing, and lung irritation (CDC, 2019).

2
Biological

Biological hazards are microorganisms that may be transmitted to a human, virus, or

toxin. Many biological hazards go unspoken in the dentistry field. The familiar environment that
comes to mind when healthcare workers are in contact with infectious disease comes from
hospitals or doctor's offices. The dentistry field is as damages because they work with a human
mouth, which has fluid like blood and saliva that can transmit a disease to the worker if either
gets an accidental puncture by a needle or an instrument. Micrograms or chemicals, including
the nose, mouth, eyes, and skin, can enter the body. Also known as the Route of exposure
through inhalation, ingestion, skin contact, and injections (Tulchinsky, T. H, pg.115). An
example, in the dentist's office, an accidental puncture through a needle can expose a person to
HIV. Another example is inhaling bacteria that can spread tuberculosis and whooping cough.
Tetanus is a bacteria known as Clostridium tetani; it cannot be spread through contact
with a person but lives with the person; it originated through dirt and fertilizer (CDC,2022). It is
expected to get exposure but this bacterium through puncture wounds or already had an
existing injury open. Symptoms include seizures, jaw locking, muscle spasms, stiffness, trouble
swallowing, fever, regulation of blood and heart rate, and a serious can be pulmonary embolism
(CDC, 2022). Having a dental infection increases the risk, and having surgical treatments is
anything open up for bacteria to enter.
Many viruses are around today, including Covid-19; during the pandemic, many dental
workers fear getting infected because the job description is working with an open mouth. In
2020 there was a survey to collect data on dental workers (dental hygienists and dentists); their
anxiety; 28% of dental hygienists and 17% of dentists had anxiety symptoms (Eldridge, 2022).
However, the most concerning viruses for dental workers are Hepatitis C/B and HIV
(CDC,2020). It can be spread by accidental puncture but also as airborne. Using an instrument
with high speeds (ultrasonic scaler) can increase airborne pathogens in the air that contain
blood and saliva or are turned into an aerosol that may stay in the air and be inhaled
(CDC,2020). The reason an infection like Hepatitis C/B is hazardous is because it can affect the
body long-term. Hepatitis B can cause cancer and liver damage, and Hepatitis C can cause
Cirrhosis or liver cancer (CDC, 2023). There is a vaccination for B but not for C, and a dental
worker is at higher risk because of daily exposure to blood. The scary thing about Hepatitis C is
there are usually no symptoms, and if not tested regularly can be symptomatic when it turns into
a fatal disease like cancer or liver failure. Hepatitis B symptoms can include fatigue, poor
appetite, stomach pain, nausea, and jaundice, but in children can be more severe and have
long-term damage (CDC, 2023).
Many other exposures can affect the health of a dental worker, common colds, influenza,
measles, strep throat, norovirus, and many more. Training in appropriate precautions can
reduce the spread to family, employees, friends, and other patients. Another way they can be at
risk is not wearing the proper personal protective equipment or taking home clothes worn in the
office. Some measures to be practiced regularly are that dentists or dental office managers
should ensure that sterilization is done, and proper disinfectants are available (Avatollahi, J.
2012). Other office protocols are cleaning the water lines in the dental office are at high risk of
growing bacteria and biofilms. Also using sterilized filtered water for patients to avoid
contamination in open wounds in mouth.

Physical and some Ergonomic

Physical and some ergonomic occupational hazards can be a person lifting, posture for
long periods, the environment's temperature, repetitive movements (vibrations), noise, and

3
radiation. Dental workers working on patients must sit with their heads and back bent down for
long periods. Most of the time, they use their wrist to treat patients. Around 62% of dentists in
Greece mention having issues or symptoms in at least one part of the body, including joints,
bones, and muscles (Avatollahi, J. 2012).
Some common disorders are back pain, carpal tunnel, arthritis, neck and shoulder pain.
Some repetitive movement: vibration from the instruments has created a concern this may be
causing vibration syndrome that affects upper limbs and vascular, neurological, and damage to
the cartilage of hands/arms, a form of arthritis (Avatollahi, J. 2012). Women are more likely to
work in dental occupations and are at higher risk of developing arthritis, rheumatoid arthritis,
and osteoarthritis (CDC, 2021). Arthritis can affect a person's joints in the long term and can
prevent them from using the full function of their hand. Some symptoms of rheumatoid arthritis
and osteoarthritis include stiffness, pain, weight loss, fever, fatigue, unable to use in particular
motion or loss of flexibility (CDC, 2019).
The more extended period working in the dentistry field, for dentists and dental
hygienists that use tools with vibration increases the chances of disorders and vibration
syndrome or Raynaud's phenomenon. About 1.2 million people in the United States may work
with tools exposing them to vibration in their hands; NIOSH recommends medical surveillance
monitor health (CDC, 2014). Symptoms include tingling, numbness, blanching pain, flushing, or
blanches in different temp, hot /cold (CDC,2014). The reason for that is the vibration I
hazardous in a dental setting because of the use of ultrasonic handpieces or drills, amplitudes
at high speed for dental workers to be more accurate and speedier in many procedures (Banga
H.K., 2021). These tools are used throughout the day for an extended period. A recent study
suggested anything over 2.5 m/s2 harms dental work due to high-frequency vibration that
mainly affects the hand, palm, and fingers depending on the person's grip on the instrument
(Banga H.K., 2021).there are some techniques and new ways to apply pressure and also have
same accuracy while using the tools, using a nondominant hand or more considerable arm
muscle and pacing some of the weight on the patient's cheek, jaw, or chin (Aubreé, 2014).
Radiation is another concern among dental workers; ionizing radiation comes from X-
rays. Usually, in a dental office, they will place a lead apron that protects the neck down. Most
dental assistants oversee X-rays; they usually leave the room to take the X-ray or hide behind a
wall, leaving uncertainty if they are some exposures because this can be a daily task. Ionizing
radiation is dangerous to reproductive health; employees should take precautions and practice
safety protocols to reduce exposure to radiation, time, distance, and shielding (OSHA,2014).
Another type of non-ionizing radiation they use in dentistry is UV light to cure the dental
composite to a tooth or glue a brace. UV radiation has no symptoms, and it has the same type
of radiation as the sun; it can hurt the eyes (OSHA,2014). Today, they use more of a blue curing
light, mostly like a LED light, to avoid damage to the eyes.

4
Preventive / Safety Precautions

Preventive care to reduce workplace injuries could be standards placed by federal and state
agencies to protect people from future harm. Other approaches towards preventive measures
are practicing health behaviors like being physically active, eating nutritious foods, and
training/practicing regularly. 
OSHA compliance checklist is recommended to avoid penalties and reduce workplace
hazards depending on the state; it can be state or federally regulated. A list does not pertain to
every site; the checklist can be altered/ varies and changes in different occupations. 1. general
environment; an example is knowing the machinery, items used in sites, hazards in the room,
and how to dispose of them, and knowledge on ergonomic preventive care. 2. keeping logs; an
example is having health agencies' phone numbers, records/reporting to OSHA of exposures,
and hospital admission or testing after exposure.3—radiation, pathogens standards; for
example, daily reminders on safety precautions with signs up on walls and proper materials like
sterilization machines or lead apron shield. Preventive measures could be as simple as asking
women if they are pregnant before placing them on or near an X-ray machine. However, there
can be some training involved when working with blood or risk of pathogen exposures; The
Needlestick Safety and Prevention Act is a train that should be provided by job for free to
update workers in proper handling and disposal of needles (HIPAA, 2023). 
CDC has guidelines and standards for dental work sites with detailed descriptions of
safety protocols called Guidelines for Infection Control in Dental Health Settings. 
Training is essential to learn the signs and symptoms of exposures, to take the proper steps to
immediate action if exposed, medical testing, blood testing, or even get treatments if needed or
available. These guidelines go from details on how to use PPE, clean waterlines, education
training in infection control, and information on risk assessment to personal-patient care practice
and standard safety precautions. 
CDC Guidelines for preventive care in a dental environment example, use equipment
like handpieces that use water to operate. An example of the information provided is a standard
for office waterlines is essential to flow the (EPA) required to have equal or less than < 500 CFU
/ ML of heterotrophic water bacteria in waterlines (CDC,2021). Disinfecting the water line is
essential even though they use sterile water with saline or filtered sterilized clean water. A build-
up in the line can occur like Biofilms. Biofilms can be hard to remove if not regularly cleaned the
lines because it is a thin, slim bacteria that stick to the lines; common bacteria found in dental
water lines; are Pseudomonas aeruginosa and Legionella (CDC, 2021). Things can be done by
adding antibacterial solutions through the lines to clean it. 
Some education training is preventive measures and training on using the hand in a
particular position to avoid getting arthritis, carpal tunnel, or any pain. An example is called
Intraoral and extraoral fulcrum techniques combined for stability and precision (CDC,2021). 
PPE is used to protect dental workers; Surgical masks (FDA after one use or if wet during a
procedure), Shields, Disposable Gowns or reusable Lab coats, Gloves, protective eyewear
(even over glasses), long sleeves, and clothing should be changed at the office when leaving.
Most dental offices should have a washer machine to wash scrubs because using a personal
washer machine exposes the whole family to biological hazards. Another precaution is removing
the PPE to avoid contamination to self and surface areas; remove it at the work site, not at
home (CDC,2021).
CDC: Some preventive care suggestions to avoid getting infectious diseases or viruses,
Hepatitis B/C, Influenza, Covid-19, measles, and tetanus, are getting Vaccinated because the
risk is higher in a dental setting. Other Preventatives can be stretching techniques from yoga or
visiting an occupational therapist to help ease the strain of daily repetitive movement. Also,
eating a balanced diet and staying physically active; consult with a doctor if a concern is having
daily repetitive positions or what other precautions can be in place. 

5
 Resources

American Lung Assication (2022). Learn about Silicosis. Lung Health and dieases.
https://www.lung.org/lung-health-diseases/lung-disease-lookup/silicosis/learn-about-
silicosis.

Alcohol and Drug Foundation. (2023). Insights. Nitrous Oxide – Uses, impacts, and risks.
https://adf.org.au/insights/nitrous-oxide/.

Ayatollahi, J., Ayatollahi, F., Ardekani, A. M., Bahrololoomi, R., Ayatollahi, J., Ayatollahi, A., &
Owlia, M. B. (2012). Dental research journal, 9(1), 2–7. Occupational hazards to dental
staff.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3283973/.

Aubreé M. Chismark, , Diane Millar, (2014). Scaling and exercise strategies to prevent hand,
wrist, and arm injuries. RDH magazine.
https://www.rdhmag.com/career-profession/article/16404259/scaling-and-exercise-
strategies- to-prevent-hand-wrist-and-arm-injuries.

Banga, H. K., Goel, P., Kumar, R., Kumar, V., Kalra, P., Singh, S., Singh, S., Prakash, C., &
Pruncu, C. (2021). International journal of environmental research and public
health, 18(8), 4084. Vibration Exposure and Transmissibility on Dentist's Anatomy: A
Study of Micro Motors and Air-Turbines. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8069559/.

CDC. (2019). The National Institute for Occupational Safety and Health (NIOSH).
Glutaraldehyde.
https://www.cdc.gov/niosh/topics/glutaraldehyde/default.html#:~:text=Glutaraldehyde
%2C%20C5H8O2%20or%20OCH(CH₂,%2C%20burning%20eyes%2C%20and
%20conjunctivitis.

CDC. (2014). The National Institute for Occupational Safety and Health (NIOSH). Vibration
Syndrome. https://www.cdc.gov/niosh/docs/83-110/default.html.

CDC. (2019). Arthritis. Arthritis types, rheumatoid arthritis, osteoarthritis.

https://www.cdc.gov/arthritis/basics/types.html.

CDC. (2016). Recommended Vaccines for healthcare workers. Vaccine information for adults.
https://www.cdc.gov/vaccines/adults/rec-vac/hcw.html.

CDC. (2021). Arthritis; Arthritis Basics. Risk Factors.

https://www.cdc.gov/arthritis/basics/risk-factors.htm.

CDC. Tetanus. Causes and How it Spreads, Symptoms & complications.

https://www.cdc.gov/tetanus/about/causes-transmission.html.

CDC. (2014) The National Institute for Occupational Safety and Health (NIOSH). Control of
Nitrous Oxide in Dental Operations.
https://www.cdc.gov/niosh/docs/hazardcontrol/hc3.html.

6
CDC. (2022). Oral Health. Bloodborne Pathogens & Aerosols.
https://www.cdc.gov/oralhealth/infectioncontrol/faqs/bloodborne-
exposures.html#:~:text=In%20dentistry%2C%20the%20diseases%20we,human
%20immunodeficiency%20virus%20(HIV).

CDC. (2023) Virial Hepatitis. Frequently Asked Question for the Public, Hepatitis B, C.
https://www.cdc.gov/hepatitis/hbv/bfaq.htm#:~:text=Hepatitis%20B%20is%20a
%20liver,known%20as%20chronic%20hepatitis%20B..

CDC. (2020). Oral Health. Personal Protective Equipment

https://www.cdc.gov/oralhealth/infectioncontrol/faqs/personal-protective-equipment.html

CDC. (2021). Oral Health. Dental Unit Water Quality. Summary of infection prevention practices
in dental settings.
https://www.cdc.gov/oralhealth/infectioncontrol/summary-infection-prevention-practices/
dental-unit-water-quality.html.

Elka Torpey. (March 2020). U.S. Bureau of Labor Statistics. Dental Work Careers in Oral Care.
https://www.bls.gov/careeroutlook/2020/article/dental-careers.htm.

Eldridge LA, Estrich CG, Gurenlian JR, Battrell A, Lynch A, Vujicic M. (2022). J Am Dent Assoc.
Aug;153(8):740-749. US dental health care workers' mental health during the COVID-19
pandemic. doi: 10.1016/j.adaj.2022.02.011. PMID: 35902154; PMCID: PMC9310057.

FDA.(2021). Dental Amalgm Fillings.

https://www.fda.gov/medical-devices/dental-devices/dental-amalgam-fillings.

HIPAA Journal. (2023). The HIPAA Journal Reader Offer. OSHA Compliance Checklist.
https://www.hipaajournal.com/osha-compliance-checklist/.

OSHA. Safety and Health Topics; Dentistry. Hazard recognition, control, and prevention.
https://www.osha.gov/dentistry/hazard-control-prevention.

OSHA. United States Department of Labor; Occupational Safety and Health Administration.
Ionizing Radiation, NON- Ionizing Radiation.
https://www.osha.gov/ionizing-radiation/standards.

OSHA.OSHA Fact Sheet. OSHA’s Respirable Crystalline Silica Standard for General Industry
and Maritime.
https://www.osha.gov/sites/default/files/publications/OSHA3682.pdf.

Praveen BN, Shubhasini AR, Bhanushree R, Sumsum PS, Sushma CN. (2013). J Contemp
Dent Pract. Jan 1;14(1):143-8.). Radiation in Dental Practice: Awareness, Protection,
and Recommendations. https://www.thejcdp.com/doi/pdf/10.5005/jp-journals-10024-
1289.

Torbica, N., & Krstev, S. (2006). World at work: Dental laboratory technicians. Occupational and
environmental medicine, 63(2), 145–148. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078071/.

7
Tulchinsky, T. H., & Varavikova, E. A. (2014). Environmental and Occupational
Health. The New Public Health, 471–533.  Doi: 10.1016/B978-0-12-415766-
8.00009-4

Upendran A, Gupta R, Geiger Z. (2022). In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; Dental Infection Control.
https://www.ncbi.nlm.nih.gov/books/NBK470356/.