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Géza T. Terézhalmy, D.D.S.,M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio

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Presentation on theme: "Géza T. Terézhalmy, D.D.S.,M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio"— Presentation transcript:

1 Géza T. Terézhalmy, D.D.S.,M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio gtt2@case.edu

2 Preprocedural antimicrobial rinses Procedures shall be performed in such a manner as to minimize splash, spattering, and aerosols Patients MAY rinse with chlorhexidine gluconate-, or an essential oil-, or povidone iodine-containing mouthwash 01/01/2010Terezhalmy2

3 01/01/2010Terezhalmy3 0.12% Chlorhexidine gluconate

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6 01/01/2010Terezhalmy6 Disposition of reusable patient-care items Critical Penetrate soft tissue and bone during their intended use Semi-critical Touch mucous membranes or non-intact skin during their intended use Non-critical Contact only intact skin during their intended use

7 01/01/2010Terezhalmy7 Critical and semi-critical items MUST be cleaned and MUST be heat sterilized Heat-sensitive items MUST be cleaned and MUST be sterilized using Ethylene oxide OR FDA-registered sterilants e.g., glutaraldehyde, glutaraldehyde with phenol, hydrogen peroxide, or hydrogen peroxide with peracetic acidhttp://www.epa.gov/oppad001/chemregindex.htm

8 01/01/2010Terezhalmy8 Central instrument processing area Receiving and cleaning Clean instruments using an ultrasonic system with a strainer type basket Visually inspect instruments are for residual debris and damage

9 01/01/2010Terezhalmy9 Preparation and packaging Assemble cassettes, tray sets, or packs with hinged instruments unlocked and open Place an internal or an external chemical indicator in or on each cassette, tray set, or pack Date all cassettes, tray sets, or wrapped packs

10 01/01/2010Terezhalmy10 Sterilization MUST use an FDA cleared sterilizer Load cassettes, tray sets, or packs according to manufacturers recommendations Set cycle time, temperature, and pressure according to manufacturers recommendation Allow packages to cool and dry before removing from the sterilizer

11 01/01/2010Terezhalmy11 Storage MUST be a clean, enclosed, and dry area Cassettes, tray sets, or packs remain sterile indefinitely Instruments in compromised cassettes, tray sets, or packs MUST be re-cleaned, re-wrapped, and re-sterilized Cassettes, tray sets, or packs MUST be delivered to the operatories in a manner that maintains sterility until instruments are used

12 01/01/2010Terezhalmy12 Monitoring the sterilization process Mechanical: each load Assess the cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer Chemical: each load Use time- and temperature-sensitive internal or external indicators to assess physical conditions during the sterilization process

13 01/01/2010Terezhalmy13 Biological: weekly Place a spore strip or vial inside one of the cassettes, tray sets, or packs Place the cassette, tray set, or pack in the center of the load A strip or vial, which is not heat processed, is used as a control Maintain a record of the weekly results

14 01/01/2010Terezhalmy14 Quality assurance procedures following mechanical, chemical, or biological failure Secure sterilizer Make log entry Take corrective action Retest sterilizer using a biological monitor Suspect loads dating back to the last negative biological test MUST be re-called, re-wrapped, and re-sterilized

15 01/01/2010Terezhalmy15 Non-critical items MUST be cleaned MUST be disinfected EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim e.g., chlorine-containing products, quaternary ammonium compounds with alcohol, phenolics, or iodophorshttp://www.epa.gov/oppad001/chemregindex.htm

16 01/01/2010Terezhalmy16 Disposition of single-use patient-care items Disposable sharps MUST be removed from cassettes, tray sets, or packs in the patient treatment area MUST be placed in a puncture-resistant, leak-proof, labeled/color-coded container in the patient treatment area

17 01/01/2010Terezhalmy17 Other contaminated single-use items Blood- or saliva-soaked cotton rolls, gauze, pellets, tissue coverings (packs) MUST be placed in small biohazard bag Disposed of into a centralized Regulated Waste Receptacle after each appointment

18 Handpieces MUST be sterilized between patients Clean, sterilize, and maintain each handpiece according to manufacturers recommendations 01/01/2010Terezhalmy18

19 Saliva ejectors Backflow with low-volume suction Do not place any portion of the suction tubing holding the tip above the patients mouth Do not use simultaneously with high-volume evacuation Do not have patient create a seal around the saliva ejector 01/01/2010Terezhalmy19

20 Dental radiography Cover clinical contact areas with protective barrier Hand hygiene and PPE before initiating the radiographic process Use disposable or heat-sterilized film-holding and positioning devices Use FDA-cleared film barrier pouches Remove film packet from pouch and place in a clean container Remove gloves, wash hands, and transport the exposed films to the dark room 01/01/2010Terezhalmy20

21 Panoramic radiography Place disposable plastic cover over bite guide before the patient is positioned in the machine If no barrier is used, use a sterile bite guard Digital radiography sensors and other high- technology instruments Should be cleaned and sterilized according to manufacturers recommendations 01/01/2010Terezhalmy21

22 Oral surgical procedures Perform surgical hand antisepsis Don sterile surgeons gloves Use only sterile saline or sterile water as a coolant or irrigant Laser plumes or surgical smoke may contain aerosolized infectious material Follow standard precautions 01/01/2010Terezhalmy22

23 Biopsy Place specimen in leak-proof, puncture-resistant, closed container with a secure lid for storage and transportation If container becomes visibly contaminated, clean it, disinfect it, or placed in an impervious bag Label with the biohazard symbol 01/01/2010Terezhalmy23

24 Extracted teeth If sent to the laboratory for shade and size comparison Clean and disinfect with an EPA-registered, intermediate- level hospital disinfectant claiming tuberculocidal activity, e.g., chlorine-containing products, quaternary ammonium compounds with alcohol, phenolics, or iodophors With dental amalgams Consult state and local regulations regarding disposal of amalgam 01/01/2010Terezhalmy24

25 Extracted teeth returned to the patient Clean and disinfect Extracted teeth in educational settings Cleaned of visible blood and gross debris and maintained in a hydrated state (e.g., water or saline) in a well constructed closed container The teeth are heat-sterilized (autoclave cycle for 40 minutes) before clinical exercises or study Teeth with amalgam restorations are disinfected by immersion in 10% formalin solution for 2 weeks 01/01/2010Terezhalmy25

26 Laboratory asepsis Environmental surfaces Barrier-protected or cleaned and disinfected Use PPE when handling items in the laboratory until they have been disinfected Impressions, prostheses, and other devices Rinsed under running tap water an disinfected with EPA- registered intermediate level disinfectant with tuberculocidal claim 01/01/2010Terezhalmy26

27 Burs, polishing points, rag wheels, and laboratory knives Cleaned and then heat-sterilized or disinfected following manufacturers recommendations or discarded Metal impression trays and face bow forks Cleaned and heat sterilized Articulators, case pans, and water pans Cleaned and disinfected according to manufacturers recommendations 01/01/2010Terezhalmy27

28 Dental unit waterlines Must meet the regulatory standard for safe drinking water <500 CFU/mL Self-contained water systems in combination with a chemical germicide Follow the recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product Dental devices connected to the water system Operated for 20-30 seconds after each patient to discharge water and air 01/01/2010Terezhalmy28

29 Boil-water advisory Do not deliver water from the public water system For hand hygiene use an alcohol-based hand rub or bottled water When the boil-water advisory is lifted disinfect dental waterlines according to manufacturers recommendations 01/01/2010Terezhalmy29

30 Dental records Charts are notated and radiographs viewed Before gloving After the gloves are removed and the hands are washed While wearing cover gloves 01/01/2010Terezhalmy30

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33 01/01/2010Terezhalmy33 Environmental infection control Provides for a safer work environment Environmental surfaces Clinical contact surfaces May serve as reservoirs for microbial contamination Housekeeping surfaces Do not contribute to significant cross-contamination

34 01/01/2010Terezhalmy34 Clinical contact surfaces Cover with materials impervious to moisture Coverings are removed and discarded between patients Surfaces are examined for visible soil Soiled surfaces are cleaned and disinfected with an EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim General cleaning and disinfection is performed at the end of daily work activities regardless of barrier protection

35 01/01/2010Terezhalmy35 Housekeeping surfaces Walls, window drapes, and other vertical surfaces Unless visibly clean, cleaning is unnecessary Floors and sinks Clean regularly with a detergent and water OR An EPA-registered hospital disinfectant/detergent designed for general housekeeping Carpeting and cloth furnishing Cannot be reliably disinfected

36 01/01/2010Terezhalmy36 Spills and spatter of blood or OPIM Visible organic material is removed using disposable paper towels Discard in a leak-proof, biohazard-labeled container Contaminated surface is cleaned with a detergent and water AND Disinfected with an EPA-registered intermediate- level hospital disinfectant with tuberculocidal claim

37 01/01/2010Terezhalmy37 Biohazard communication Labels Fluorescent orange or orange red, with lettering or symbols or a contrasting color Affixed to containers or regulated waste by string, wire, adhesive, or other methods Red bags or red containers may be substituted for labels Decontaminated regulated waste is not labeled or color-coded

38 01/01/2010Terezhalmy38 Post-exposure management and follow- up Establishes policies and practices to reduce the risk of post-exposure infection

39 01/01/2010Terezhalmy39 Post-exposure protocol Immediately after an exposure incident Wash area of injury with soap and water Report the exposure incident immediately Complete the Uniform Needlestick and Sharp Object Injury Report Form

40 01/01/2010Terezhalmy40 Within 2 hours of an exposure incident Arrange for a post-exposure evaluation by a physician A copy of the employees medical record A copy of the Uniform Needlestick and Sharp Object Injury Report Any information available about the source individual

41 01/01/2010Terezhalmy41 As soon as feasible after an exposure incident If the source person can be identified and with his/her consent The source persons blood is tested for HBV, HCV, and HIV Results are made available to the employee Applicable privacy laws and regulations apply

42 01/01/2010Terezhalmy42 Post-exposure management and prophylaxis According to latest CDC recommendations A written report from the consultant physician is obtained within 15 days of the post-exposure evaluation Written report becomes part of the OHCWs medical record

43 01/01/2010Terezhalmy43 Medical record Maintained on all personnel Name and SSN Documentation of vaccination status A copy of the Mandatory Hepatitis B Vaccination Declination Form (if applicable) A copy of all results of examinations, medical tests, and other post-exposure follow-up data

44 01/01/2010Terezhalmy44 The medical record is confidential Its content is not disclosed except as required by law The medical record is made available to the OHCW for examination A copy is provided upon request The medical record is maintained for at least the duration of employment plus 30 years

45 01/01/2010Terezhalmy45 Administrative controls Establish exclusion policies from work and patient care

46 01/01/2010Terezhalmy46 Minimize latex-related health problems among OHCWs and patients Reduce exposure to latex-containing materials Train and educate OHCWs to recognize signs and symptoms of latex-related adverse effects Monitor signs and symptoms of latex-related adverse effects among OHCWs and patient

47 01/01/2010Terezhalmy47 Minimize the exposure of OHCWs with acute or chronic diseases to patients i.e., to patients who have been diagnosed with a transmissible infectious disease OHCWs shall consult with their personal physician Determine if their condition(s) might affect their ability to safely perform their duties

48 01/01/2010Terezhalmy48 Minimize the exposure of patients to OHCWs i.e., to OHCWs who have been exposed to or have been diagnosed with an infectious disease Restrictions based on the mode of transmission and the period of infectivity of the pathogen

49 Infectious stateRestrictions HBV OHCWs with acute or chronic HBsAg who do not perform exposure-prone procedures No restrictions OHCWs with acute or chronic HBeAg who perform exposure-prone procedures Do not perform exposure-prone procedures until counsel from a review panel has been sought (State Dental Board) 01/01/2010Terezhalmy49

50 Infectious stateRestrictions HCV Acute or chronic infection No restrictions 01/01/2010Terezhalmy50

51 Infectious stateRestrictions HIV HIV infection AIDS Do not perform exposure- prone procedures until counsel from a review panel has been sought (State Dental Board) 01/01/2010Terezhalmy51

52 01/01/2010Terezhalmy52 AgentInfectious stateRestrictions Measles (Rubella) Post exposure Susceptible OHCW Exclude from duty from 5 th day after first exposure THROUGH 21 st day after last exposure OR 4 days after rash appears Acute infection Exclude from duty for 7 days after rash appears

53 01/01/2010Terezhalmy53 AgentInfectious stateRestrictions Mumps (Infectious parotitis) Post exposure Susceptible OHCW Exclude from duty from 12 th day after first exposure THROUGH 26 st day after last exposure OR 9 days after onset of parotitis Acute infection Exclude from duty for 9 days after onset of parotitis

54 01/01/2010Terezhalmy54 AgentInfectious stateRestrictions Rubella (German measles) Post exposure Susceptible OHCW Exclude from duty from 7 th day after first exposure THROUGH 21 st day after last exposure Acute infection Exclude from duty for 5 days after rash appears Exclude from duty for 5 days after rash appears

55 01/01/2010Terezhalmy55 AgentInfectious stateRestrictions HSV-1 and HSV-2 Acute orolabial herpes Restrict from care of patients at high risk until lesions heal Acute herpetic whitlow Exclude from duty until lesions heal Acute genital herpesNo restrictions

56 01/01/2010Terezhalmy56 AgentInfectious stateRestrictions VZV (Chicken pox) Post-exposure Susceptible OHCW Exclude from duty from the 10 th day after first exposure THROUGH 21 st day after last exposure Acute infection Exclude from duty until all lesions dry and crust

57 01/01/2010Terezhalmy57 AgentInfectious stateRestrictions VZV (Shingles) Post-exposure Susceptible OHCW Exclude from patient care from the 5 th day after first exposure THROUGH 21 st day after last exposure Acute infection Healthy OHCW Restrict from the care of patients at high-risk until lesions dry and crust Acute infection Immunocompromised OHCW Restrict from patient care until lesions dry and crust

58 01/01/2010Terezhalmy58 AgentInfectious stateRestrictions Influenza and syncytial viruses Acute infection with fever Exclude from the care of patients at high-risk until cute symptoms resolve TB PPD positiveNo restrictions Infectious TB disease Exclude from duty until proven non-infectious

59 01/01/2010Terezhalmy59 SUMMARY Good structure Increases the likelihood of a good process Good process Increases the likelihood of a good outcome

60 01/01/2010Terezhalmy60 References 1. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64004-64182. 2. CDC. Guidelines for infection control in dental health-care settings-2003. MMWR 2003;52(No. RR-17):1-68. 3. Terezhalmy GT. Clinical practice guidelines for an infection control/exposure control program in the oral healthcare setting. Access PDF file at dentalcare.com 4. Huber MA, Terezhalmy GT. Hepatotropic viruses: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com

61 01/01/2010Terezhalmy61 5. Huber MA, Terezhalmy GT. HIV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com 6. Huber MA, Terezhalmy GT. Measles, mumps, rubella: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com 7. Huber MA, Terezhalmy GT: HSV and VZV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com 8. Porteous NB, Terezhalmy GT: Tuberculosis: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com

62 01/01/2010Terezhalmy62 9. Huber MA, Terezhalmy GT: Mandated and highly recommended and highly recommended vaccines for oral health care. Access PDF file at dentalcare.com 10. Huber MA, Terezhalmy GT. Adverse reactions to latex products: preventive and therapeutic strategies. Access PDF file at dentalcare.com 11. Terezhalmy GT, Huber MA. Hand hygiene: infection control/exposure control issues for oral healthcare setting. Access PDF file at dentalcare.com 12. Terezhalmy GT, Huber MA. Environmental infection control in oral healthcare settings. Access PDF file at dentalcare.com


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