Terri L.

Deal

Center for Disease Control updated in 2003

Previously released in 1986, 1993 Consolidates recommendations for : Preventing infectious diseases Managing personnel health and safety Updates previous CDC recommendations Incorporates relevant infection control measures Discusses concerns not previously mentioned

General recommendations
Develop a written program

Policies Procedures Education and training guidelines Immunizations

 Exposure prevention
Post-exposure management Medical conditions Work restrictions Contact dermatitis, latex sensitivity Maintenance of records, data management and confidentiality

Establish referral arrangements

Education and training

Provide to new employees When new tasks or procedures affect employees

exposure Provided annually re: exposure to potentially infectious agents and infection control procedures Provide educational information appropriate in content, vocabulary for the health care provider

Immunization
List of all required and recommended

immunizations Refer employee to prearranged health care provider or their own health care provider

Exposure Prevention and Post-exposure Management

Develop post-exposure management and medical

follow up program

Medical conditions, work-related illness, and work restrictions

Develop written policies re: work restriction and

exclusion and who can implement Policies for preventive and curative care and reporting illnesses. Dont penalize with loss of wages, benefits or job status Policies for evaluation, diagnosis and management of occupational contact dermatitis Definitive diagnosis of suspected latex allergy, work restrictions and accommodations

Records Maintenance, data management and confidentiality

Establish and maintain confidential medical

records for all dental health care providers Ensure compliance of federal, state and local laws re: medical recordkeeping and confidentiality

Occupational exposure:
reasonably anticipated skin, eye, mucous

membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employees duties

Occupational exposure occurs when your ..

Skin Eyes

Mucous membrane
Blood

Come into contact with

Blood or saliva from a patient Contaminated instruments Equipment of laundry contaminated by blood or

saliva from a patient

Who is potentially infectious?

all human blood and certain human body fluids are treated as if known to be infectious

Transmission of infectious diseases from patient to health care workers usually involves patients who do not know they have an infectious disease.

Category I Routinely exposed to blood, saliva or both Examples: Dentist, Hygienist, Assistant, Infection Control/Sterilization Assistant, Lab Technician Category II May on occasion be exposed to blood, saliva or both

Every dental office should have an infection control program designed to prevent the transmission of disease from: Patient to dental team Dental team to patient Patient to patient Dental office to community (includes dental teams family) Community to patient

Health care workers must

Consider blood and saliva from all patients as

potentially infectious
Take precautions to protect themselves from

exposure

Employer must educate employees. Employer must offer the vaccine within 10 working days and pay for the vaccine. Employee can decline, but must sign declination statement.

Employer must:
Document exposure and circumstances Document source individual Source individuals blood tested If source is known to be infected, blood test is not

necessary.

Employees blood is tested. If employee refuses HIV testing, then blood is stored at least 90 days. Confidential medical evaluation When indicated use post-exposure prophylaxis which will prevent HIV infection

Blood or saliva mixed with blood

Items that release blood or saliva-blood if compressed or during handling

Pathological waste
Teeth Tissue

Contaminated sharps

Landfills Private pick-up services Hospitals On-site

Items that do not release blood and/or saliva when compressed or handled do NOT need special disposal.

A reservoir of pathogen A pathogen of sufficient infectivity and number A mode of escape from the host A mode of spread to the new host A portal of entry A susceptible host

Preventing Transmission of Blood borne Pathogens

HBV vaccination Preventing exposure to Blood and

OPIM (other potentially infectious material)

Use standard precautions for all patients

 Consider sharp items contaminated with blood and saliva as potentially infective Implement written program to minimize exposures

Destruction of all microorganisms including bacterial spores Should be used for all instruments which come in contact with blood or saliva

Destroys most microorganisms but not bacterial spores Used for surfaces and impressions

Disinfectants are chemicals that are applied to inanimate surfaces (such as countertops and dental equipment). Antiseptics are antimicrobial agents that are applied to living tissue. Disinfectants and antiseptics should never be used interchangeably because tissue toxicity and damage to equipment can result.

If there were an ideal surface disinfectant, it would have a rapid kill of a broad spectrum of bacteria, have residual activity, minimal toxicity, and would not damage surfaces to be treated. In addition, it would be odorless, inexpensive, work on surfaces with remaining bio-burden, and be simple to use.

Unfortunately, no single disinfectant product on the market today meets all these criteria.

When selecting a surface disinfectant, you must carefully consider the advantages and disadvantages of various products. Often the manufacturers of dental equipment will recommend the type of surface disinfectant that is most appropriate for their dental chairs and units.

Iodophors are EPA-registered intermediatelevel hospital disinfectants with tuberculocidal action. Because iodophors contain iodine, they may corrode or discolor certain metals and may temporarily cause reddish or yellow stains on clothing and other surfaces.

Synthetic phenol compounds are EPAregistered intermediate-level hospital disinfectants with broad-spectrum disinfecting action. Phenols can be used on metal, glass, rubber, or plastic. They also may be used as a holding solution for instruments; however, phenols leave a residual film on treated surfaces. Synthetic phenol compound is prepared daily.

Sodium hypochlorite (household bleach) is a fast-acting, economic, and broad-spectrum intermediate-level disinfectant (1:100 dilution for surface decontamination).

Disadvantages: It is unstable and must be

prepared daily, has a strong odor and is corrosive to some metals. It is also destructive to fabrics and irritating to the eyes and skin; it may eventually cause plastic chair covers to crack.

Alcohols are not effective in the presence of blood and saliva. They evaporate quickly and are damaging to certain materials such as plastics and vinyl.

The American Dental Association (ADA), CDC, and

the Office of Safety and Asepsis Procedures Research Foundation (OSAP) do not recommend alcohol as an environmental surface disinfectant.

Instruments and equipment are divided into three classifications: Critical Semi-critical Non-critical The classifications are used to determine the minimal type of post-treatment processing.

Utility gloves Protective eyewear and mask or face shield Protective gown

Use PPE for preparation and use of disinfectants Use an EPA-registered, ADA-accepted disinfectant for cleaning and disinfecting Follow manufacturers directions on the disinfectant label Use water if dilution is required

Spray, Wipe, SprayWipe

Spray and wipe to clean surface Spray again and leave disinfectant on surface long

enough to be tuberculocidal (usually 10 min.)

Do not pre-saturate gauze squares with disinfectant

Surfaces that are difficult to disinfect may be wrapped with water-impervious material that is changed between patients.

There is a wide variety of surface barriers available on the market today. All should be resistant to fluids to keep microorganisms in saliva, blood or other liquids from soaking through to contact the surface underneath.

Some plastic bags are designed especially to the shape of items such as the dental chair, air-water syringe, hoses, pens, light handles, etc.

Plastic-barrier sticky tape is frequently used to protect smooth surfaces such as touch pads on equipment, electrical switches on chairs, or x-ray equipment. Aluminum foil can also be used because it is easily formed around any shape.

Something is contaminated if:

You touch it with your bare skin You touch it after you touch the patient You touch it after you touch a contaminated item

Use over-gloves Use clean towel or paper towel

Hand hygiene Wash hands:

When visibly soiled After barehanded touching likely contaminated objects

(by blood, saliva or respiratory secretions) BEFORE and AFTER treating each patient Before putting on gloves Immediately after removing gloves Liquid hand care products stored in containers that can be washed and dried. Dont top off

Special hand considerations

Use hand lotions to prevent skin dryness Avoid lotions with petroleum or other oil

emollients Fingernails short

 No artificial nails or extenders or polish No jewelry -it compromises the fit and integrity

of the glove

Microorganisms thrive around rough cuticles

and enter through break in the skin

PPE (personal protective equipment)

OSHA requires employer to provide employees

with appropriate PPE at no charge Masks, Eyewear and Face shields

Solid side shields on eyewear protects mucous membranes of eyes, nose and mouth

 eyewear and face-shield should be disinfected Change masks between patients or if mask gets wet or is visibly soiled Touch masks only on side Mask should not contact the mouth Mask with 95% filtration for particles 3-5mm in diameter

Face shields
Chin-length shield replaces eyewear but not

mask. Doesnt protect against inhaling aerosols Patient eyewear Protect from Handpeice splatter Spilled or splashed materials Airborne bits of acrylic or tooth fragments

 Protective clothing-covers area likely to be soiled with blood, saliva or OPIM Change if soiled Remove PPE when leaving work area

Gloves New pair each pt. Remove if torn, cut or punctured Do not wash gloves before use-may be rinsed to remove excess powder Wash hands before re-gloving Proper fit

 Double gloving-effectiveness in preventing

disease transmission has NOT been demonstrated. Over-gloves-not acceptable alone as hand barrier Sterile gloves-invasive procedures

Latex Hypersensitivity Educate staff to signs, symptoms and diagnosis of skin reaction

Three types of allergic reactions to latex

1. Irritant dermatitis, non-immunologic process

involves only surface irritation. Chemical substance causes irritation. Red, dry, irritated and sometimes cracked. 2.Type IV most common, involves immune system. Delayed contact reaction. 48-72 hrs. Limited to areas of contact. Caused by chemicals used to process latex

 3. Type I MOST dangerous. Can cause death.

Reaction to latex protein. Occurs 2-3 minutes after contact.

Remember:
When one employee in the dental office has been

diagnosed as having a latex allergy, all staff members should use practices to minimize the use of latex-containing products. These practices include the wearing of powder-free gloves by all dental staff members to minimize the risk of airborne latex particles.

Dental health care workers are exposed to Legionella bacteria at a much higher rate than the general public. Dental personnel are exposed to contaminated dental unit waterlines by inhaling the aerosol generated by the hand piece and the air-water syringe.

There is at least one suspected fatality of a dentist from legionellosis. Case reports have been published of immunocompromised patients who developed postoperative infections caused by contaminated dental water.

The primary source of microorganisms in dental waterlines is the public water supply. It is possible that saliva may be retracted back into the waterlines during treatment. This process is also called suck back.

Anti-retraction valves on dental units and thorough flushing of the dental lines between patients minimize the chance of this occurring. Entering public water source has a colony forming units (CFU) count of less than 500; once that water enters the dental waterlines and colonizes within the bio-film, the CFU count skyrockets.

There are two communities of bacteria in dental unit waterlines: One bacterial community exists in the water itself and is referred to as planktonic (free floating). The other exists in the bio-film attached to the walls of the waterlines.

Bio-film exists in all places where moisture and a suitable solid surface exist. Bio-film consists of bacterial cells and other microbes that adhere to surfaces and form a protective slime layer. Bio-film can contain many types of bacteria, as well as fungi, algae, and protozoa. Viruses, such as the human immunodeficiency virus (HIV), cannot multiply in the dental unit waterline.

It is not yet possible to totally eliminate biofilm, but it can be minimized by: Self-contained water reservoirs Chemical treatment regimens Micro-filtration Daily draining and drying of lines

These systems supply air pressure to the water bottle (reservoir).

The air pressure in the bottle forces the water from the bottle up into the dental unit water lines (DUWL) and out to the hand piece and air-water syringe.

Self-contained water systems have two advantages:

The dental personnel can select the quality of water

to be used, such as distilled, tap, or sterile. Maintenance of the water system (between the reservoir bottle and the hand pieces and syringes) is under the control of the dentist and staff.

A disposable inline micro-filtration cartridge also can dramatically reduce the bacterial contamination in the dental unit water.

This device must be inserted as close to the hand piece or air-water syringe as possible. It should be replaced at least daily on each line. The use of filtration cartridges combined with water reservoirs can ensure improved water quality.

Chemicals can be used to help control biofilm in two ways: Periodic or shock treatment with bio-cidal levels (levels that will kill microorganisms) of chemicals. Continuous application of chemicals to the system (at the level to kill the microorganisms but not harm humans).

Always check with the manufacturer of the dental equipment to determine which chemical product and maintenance protocol they recommend.

Dental unit water should not be used as an irrigant for surgery involving the exposure of bone. Only use sterile water from special sterile water delivery systems or hand irrigation using sterile water in a sterile disposable syringe.

All dental waterlines and hand pieces should be flushed in the mornings and between patients. Although this will not remove bio-films from the lines, it may temporarily reduce the microbial count in the water.

It will help clean the hand piece waterlines of materials that may have entered from the patients mouth. Flushing also brings a fresh supply of chlorinated water from the main waterlines into the dental unit.

Always use the high-volume evacuator when using the high-speed hand piece, ultrasonic scaler, and air-water syringe. The high-volume evacuation may also reduce exposure of the patient to these waterborne microorganisms.

The dental dam greatly reduces direct contact. The dam also greatly reduces the aerosolizing and spattering of the patients oral microorganisms onto the dental team. Protective barriers, including masks, eyewear, and face shields, also serve as barriers for the dental team.

Several government agencies and professional organizations have a direct influence on dentistry, infection control, and other health care safety issues. In addition to issuing recommendations and regulations some have regulatory roles and others are advisory. These agencies can serve as an excellent resource for information and educational materials.

Recommendations are made by individuals, groups, or agencies that are advisory and have no authority for enforcement.

Regulations are made by groups or agencies that do have the authority to enforce compliance with the regulations. Enforcement penalties may include fines, imprisonment, or suspension or revocation of licenses. Recommendations may be made by anyone, but regulations are made by governmental groups or licensing boards in towns, cities, counties, and states.

The American Dental Association (ADA) is the professional organization for dentists. The ADA periodically updates its infection control recommendations as new scientific information becomes available.

The Organization for Safety and Asepsis Procedures (OSAP) is a not-for-profit organization composed of dentists, hygienists, dental assistants, government representatives, dental manufacturers, university professors, researchers, and dental consultants. This organization is an excellent resource for information on infection control, injury prevention, and occupational health issues.

Associations and Organizations- contd

State and local dental societies can be helpful to you in complying with regulatory issues in your specific area. National, state, and local dental assisting societies can often answer questions and provide opportunities for continuing dental education.

Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) Occupational Safety and Health Administration (OSHA) National Institute for Occupational Safety and Health (NIOSH)

The CDC is recognized as the lead federal agency for protecting the health and safety of people at home and abroad. The CDC bases its public health recommendations on the highest quality scientific data.

The FDA is a regulatory agency and is part of the United States Department of Health and Human Services.

The FDA regulates the manufacturing and labeling of medical devices (such as sterilizers, biologic and chemical indicators, ultrasonic cleaners and cleaning solutions, liquid sterilants, gloves, masks, protective eyewear, dental handpieces and instruments, dental chairs, and dental unit lights). It also regulates antimicrobial handwashing products and mouth rinses.

The EPA is a regulatory agency. It ensures the safety and effectiveness of disinfectants.

Manufacturers of disinfectants must submit information about the safety and effectiveness of the product. If the claims meet the EPA criteria, the product receives an EPA registration number that must appear on the product label. The EPA regulates discharge and final treatment of waste materials (i.e., chemicals), as well as medical waste, after it leaves the dental office.

OSHA is a regulatory agency. It protects workers against physical, chemical, or infectious hazards in the workplace.

It establishes protective standards, enforces those standards, and offers technical assistance and consultation programs. OSHA is a federal agency, but 22 states administer their own state-operated OSHA programs. In states that administer their own OSHA programs, the state standards must be equivalent to, or more stringent, than those of the federal agency.

NIOSH does not have regulatory authority. It is responsible for conducting research and making recommendations for the prevention of work-related disease and injury.

NIOSH makes recommendations and disseminates information on preventing workplace disease, injury, and disability. It provides training to occupational safety and health professionals.

Outbreaks of waterborne disease have occurred in a broad range of facilities. Although there is no evidence of a widespread public health problem, published reports have associated illness with exposure to water from dental units. The fact that there are bacteria capable of causing disease in humans found in dental unit waterlines is reason for concern.

In community water, the number of waterborne bacteria is kept below 500 colony-forming units (CFU) per milliliter. The water from air-water syringes and dental hand pieces frequently has bacteria levels that are hundreds or thousands of times greater than is permissible in drinking water. The types of bacteria that are found in dental unit water are frequently the same types as those found in community water, but the levels of bacteria found in the dental units are almost always higher.

www.engenderhealth.org/ ip/sharps/nsm3.html www.ada.org www.fda.gov www.osha.gov www.cdc.gov