1. Infection Control and Related Health and Safety in the Dental Office
Module 14
Infection Control and Related Health and Safety in the Dental Office
Part 1

2. Infection Control and Related Health and Safety
Kathy Eklund, RDH, MHP
The Forsyth Institute
Boston, Massachusetts

3. Objectives of an Infection Control Program
Reduce the available number of microorganisms
Interrupt the spread, break the cycle of cross-contamination
Treat all patients/clients and clinicians as if infected
Protect from exposure, infection and disease

4. Elements of an Effective Infection Control Program
Instrument Processing and Sterility Assurance of Patient Care Items
Environmental Management of Clinical Contact Surfaces
Housekeeping practices
environmental asepsis
waste
Hazard communication
Client assessment
Immunizations for HCW and Patients
Exposure incident prevention and management
Universal Precautions/ Standard Precautions
Personal Protective Equipment

5. Universal Precautions/ Standard Precautions
Treat every one as if infected with a pathogenic microorganism
Handle every contaminated item as if carrying a bloodborne infectious agent

6. System of infection control and related health and safety that is procedure specific, not based upon the known or unknown sero-status of client

7. Standard Precautions
Standard Precautions synthesize the major features of Universal (Blood and Body Fluid) Precautions (designed to reduce the risk of transmission of blood-borne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances) and applies them to all patients receiving care regardless of their diagnosis or presumed infection status.
Standard Precautions apply to (1) blood, (2) all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood, (3) non-intact skin, and (4) mucous membranes.
Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals [ Guideline for isolation precautions in hospitals Part II, Recommendations for isolation precautions in hospitals]

8. Spaulding’s Classification Items and Chemicals Summary
Critical - Penetrate Tissue
single use disposable, sterilize
Semi-critical - touch nonintact tissue/mucous membranes
sterilize preferred; high level disinfection
Non-critical – touch intact tissue
Clean and low-level disinfection

9. Spaulding’s Classification (con’t.)
Non-Critical Clinical Contact Surfaces
Clean and intermediate level disinfection (use a hospital level/tuberculocidal agent) or
Use Surface and Equipment Barriers/Covers

10. Topics for This Talk Instrument Processing and Sterility Assurance
Dental Handpieces and Aseptic Management
Dental Unit Water Quality

11. Instrument Reprocessing and Sterility Assurance

12. Goals Sterility assurance for patient protection
“all reusable instruments and handpieces are sterilized (rather than just disinfected) between use on patients”. Chris Miller, Ph.D
Achieve maximum efficiency in instrument processing
Provide safety for the worker and the patient throughout all aspects of the process

13. Objectives To have clear written policies To use safe procedures
To select cost effective products and equipment
To create a sound operational flow for processing instruments
To evaluate safety, efficiency and effectiveness

14. Instrument Reprocessing
Chairside Handling and Management
Transport of Contaminated Instruments
Holding (presoaking) ?????
Instrument Cleaning
Instrument Packaging
Sterilization
Sterilization Monitoring
Storage of Packaged Sterile Instruments

15. Chairside Handling and Management
Using Instruments/Sharps Safely
Debridement - pre-cleaning
Passing
Sharpening
Containment of Instruments for Transport

16. Principle
Prevent Sharps injuries by using safe products, devices, and practices.

17. Types of Occupational Exposures to Bloodborne Pathogens
Percutaneous injury (PI)
Mucous membrane
Non-intact skin
Human bites

18. Prevention Strategies
Engineering controls
Personal protective
equipment
Work practice controls

19. Prevent Percutaneous Injuries
Use medical devices with engineered safety features designed to prevent injuries and/or by using safer techniques
Self-sheathing needles/needles with engineered safety features
passive vs active
Do not recap needles by hand
Do not disengage needles from a reusable syringe by hand
Use disposable needle syringe systems
Dispose of needles in appropriate sharps disposal containers

20. Prevent Percutaneous Injuries (continued)
Avoid hand contact with sharps
Do not debride instruments on gauze by hand . Use a single-hand technique, such as:
Cotton rolls taped to the instrument tray
Use a commercial safe wipe device

21. Prevent Mucous Membrane and Skin Exposures
Avoid exposure to eyes, nose, mouth, or skin by using appropriate barriers
Gloves
Eye and face protection
Clinical attire

22. Safe Instrument Handling for Processing

23. Instrument Transport
Containment
The Container
PPE
Labeling

24. Contaminated Instruments
Wash and dry hands
Wear appropriate PPE, including puncture resistant gloves
Transport contaminated instruments in an appropriate container directly to the receiving area of the sterilization area
Do not rinse, scrub, or unnecessarily handle contaminated instruments in the operatory

25. Contaminated Instruments
Receive contaminated instruments in the “dirty” only area
Isolate contaminated items to be cleaned to prevent unnecessary exposures
Keep the area separated by “dirty”, “clean”, and “sterile” designations
terms/designation terminology may vary

26. Principle
Clean and package instruments and items as soon after use to eliminate the need for the presoak step.

27. Holding (presoaking) Indications for Presoaking Methods
Presoak Solution
Holding Container
Management
Hazard Communication/Labeling

28. Holding/Presoaking
Purpose is to keep bio-burden/debris moist until proper cleaning can occur.
Presoak solutions need only be water that contains a surfactant that is low in corrosion.
Disinfectants are not needed or indicated for presoaking

29. Instrument Cleaning Methods PPE Injury Prevention Strategies
Ultrasonic Cleaning
Thermal Disinfection
Instrument Washers
Manual Hand Scrubbing
PPE
Injury Prevention Strategies

30. Principle
Always clean before sterilization

31. Methods: Ultrasonic Cleaning
Current Technology
Management
Space Commitment
Infection Control and Safety Considerations
Hazard Communication Labeling
Follow Manufacturers Directions for Use

32. Methods: Thermal Disinfection/Instrument Washers
Current Technology
Management
Space Commitment
Infection Control and Safety Considerations
Hazard Communication Labeling
Follow Manufacturers Directions for Use

33. Methods: Handscrubbing
Infection Control and Safety Considerations
PPE
Injury Prevention

34. Instrument Packaging
Principle
Materials/products
Process
Labeling

35. Principle
Items should be packaged for sterilization and storage. Items should remain packaged to the point of use.

36. Selection of Packaging Materials
Criteria
compatibility with sterilization method
safety considerations
labeling requirements
appropriate for the items to be processed
storage requirements
FDA cleared for market

37. Compatibility with Sterilization Process
Steam Autoclave
Gravity Displacement (121°C/ 250°F – 132°C/ 273°F for 30 minutes)
Prevacuum Sterilizer (132°C 270 °F for 4 minutes)
Pouches/Tubing (paper, paper/plastic, nylon, polypropylene)
CSR Wrap (muslin, paper, polypropylene)

38. Compatibility with Sterilization Process
Dry Heat 320°F):
Pouches/Tubing (paper, paper/plastic, nylon)
Closed containers, paper CSR wrap
Dry Heat (Rapid Heat 375°F):
Pouches (heavy gauge nylon)

39. Compatibility with Sterilization Process
Unsaturated Chemical Vapor (273°F):
Pouches/Tubing (paper, paper/plastic)
CSR Wrap (paper)
Caution:
Maximum load size = 3.3 lbs.
No other packaging materials can be used!

40. Legal Reminder…
Packaging materials are considered CLASS II devices and must be cleared for market by the FDA or have pre-market clearance!

41. Packaging Process
Pouches/Tubing – use an instrument rack if available to aid sterilant contact and drying. Instruments in pouches lying flat should be in a single layer. Tape or heat seal per the Mfg.’s recommendation.
CSR wrap - should be double layered when packaging cassettes or instrument trays.

42. Labeling/Identification
Contents/ Type of set-up
Depend upon visibility through packaging material
Date, Sterililizer and Cycle number
Owner/operatory for items
Other ( e.g. BI monitoring cycle)

43. Sterilization Defined Principle Methods Selection Criteria
Infection Control and Safety Considerations
Space Considerations

44. Sterilization Defined
The process of killing all microbial life forms, including bacterial endospores

45. Principle “Don’t dunk it, cook it”. Walter Bond, CDC
Never disinfect when you can sterilize.

46. Methods Saturated Steam Saturated Chemical Vapor
Dry Heat - Rapid Heat Transfer
Dry Heat - Convection
EO Gas
Chemical Immersion
Other

47. Legal Reminder…
Sterilizers are considered CLASS II devices and must be cleared for market by the FDA or have pre-market clearance!

48. Selection Criteria Site specific selection criteria Size of practice
May need more than one method of sterilization
Size of practice
Instrument inventory
Types of instruments and materials to be sterilized
Space considerations

49. Sterilization Infection Control and Safety
PPE
Hazard Communication Labeling
Handling of Sterile Packaged Items

50. Follow Directions Use Item and Packaging Compatibility
Cycle Parameters
Unwrapped vs. wrapped
CI and BI Monitoring Requirements
Routine Maintenance
Warranty Requirements

51. Space Considerations and Flow
Efficiency in Instrument Processing

52. Sterilization Monitoring
Mechanical/Electronic
Chemical Indicators/Integrators
Biological Indicators (spore tests)

53. Mechanical/Electronic Controls
Observation of gauges, and indicators on the sterilization equipment. (cycle monitors)
Time
Temperature
Pressure
Etc.

54. Chemical Indicators Examples: FDA: Class 1 – 5 depending on quality!
Color change indicators printed directly onto packaging (i.e. pouches).
Indicator Tape
Indicator Strips
Indicator Labels
FDA: Class 1 – 5 depending on quality!

55. Biological Indicators
Processing nonpathogenic spore organisms impregnated on a strip or in a glass vial to verify sterility by killing bacterial endospores.

56. Biological Indicators (BI)
Bacillus stearothermophilus
Steam and chemical vapor sterilization
Bacillus subtilis
Dry heat and ethylene oxide sterilization

57. How to Spore Test
Select a BI that is FDA cleared for use with your sterilization process.
Unwrapped – place in the center of the load.
Wrapped – place inside a pack in the center of the load or over the drain of a large unit.
Do not put the control strip/vial in the sterilizer.

58. Types of BI Systems
In-Office
Vials
Incubator
Record book

59. Types of BI Systems Mail-In Service 3rd Party Verification
Dental School
Commercial Lab
3rd Party
Verification

60. Rapid Enzyme Indicators

61. CDC Guidelines state… “Proper functioning of sterilization
cycles should be verified by the
periodic use (at least weekly) of
biological indicators (i.e. spore tests).”
May 28, 1993

62. Causes of Sterilization Failure and Troubleshooting

63. Sterilization Failure
Improper Cleaning of Instruments
Improper Packaging Materials
Improper Loading of the Sterilizer
Improper Sterilization Parameters
Time
Temperature
And/or pressure
Improper Selection of Sterilization Method

64. What to do if there is a sterilization failure.

65. Positive Spore Test: Failure
Do not recall instruments, other than implantable devices, because a single positive spore test unless the sterilizer or sterilization procedure is obviously dedfective (e.g., incorrect mechanical or chemical indicator readings
Recall ( as far as possible) and reprocess all items from a suspect load(s) if a second spore test remains positive for bacterial growth

66. Handling and Transport of Processed Sterile Packages

67. Storage of Packaged Sterile Instruments

68. Considerations Location Environmental storage conditions Cool Dry
Clean

69. What is the shelf-life of a sterilized package of instruments?

70. “Event Related” Policy
Maintain integrity of the package as a barrier
Keep the package material dry
Do inventory checks for damaged packaging material
Repackage and re-sterilize damaged packages before use.

71. Events that Compromise the Packaging Material
Moisture
Wet packages out of sterilizer due to inadequate dry time
Moist storage conditions
Torn, ripped, punctured, crushed, rupture of seals and closures, opened packages
Handling and transport
Poor organization of storage area

72. Chairside Marketing of the Sterilization Program
Always open the package of sterile instruments in front of the patient.

73. Other Considerations?

74. Instrument Protection
Considerations and Recommendations

75. Dental Handpieces Considerations
Semi-critical dental devices that touch mucous membranes that are attached to the air and /or waterlines of the dental unit
Follow Manufacturers’ Directions

76. Dental Handpieces High speed handpieces Slow-speed handpieces
Prophy angles
Ultrasonic and sonic scaling tips
Air abrasion devices
Air and water syringe tips

77. Handpiece Infection Control
Clean and treat dental handpieces and other intraoral instruments, that can be removed from air and/or waterlines of dental units, with a sterilization process that uses heat
e.g., steam, dry heat, unsaturated chemical vapor
Sterilize between each patient
Follow manufacturer’s directions for maintenance and compatibility of the handpiece with sterilization method(s)
Also consult the manufacturer of the sterilizer and mechanical cleaning devices for compatibility with specific dental handpieces

78. Instrument Processing and Sterility Assurance
Cost Effective Product and Equipment Selection

79. Instrument Processing
Work Flow and Design for Safety and Efficiency
Choosing the Right Strategy for Your Practice
Following the principles of infection control and related health and safety

80. Sterility Assurance - Components of Instrument Processing
Biologic debridement
Cleaning, Packaging, Sterilization
Sterilization Monitoring
Appropriate Storage
Inventory Management
Personnel Management

81. Sterility Assurance
Adequate and properly functioning equipment and products
Properly trained personnel who behave in a manner consistent with policies, procedures and product directions
Adequate space, design and flow of the reprocessing area to facilitate efficiency and safety

82. Dental Unit Water Quality
What is in your water?
The Problem(s)
Solutions
Recommendations
Regulations?

83. Water Quality Potable water: Dental unit water 10k - 100k, ...CFU/ml
Less than 500 CFU per ml. of water and 0 coliforms
Dental unit water 10k - 100k, ...CFU/ml
Why?
The American Dental Association statement and challenge to industry
Develop methods to control biofilms in dental unit water systems
Goal : heterotrophic bacteria should not exceed 200 CFU/ml in unfiltered output

84. Sources of DUWL Contamination
Source water
Retracted oral fluids?
Biofilm formation in the dental unit waterline

85. Conditions that Facilitate Biofilm Formation in the DUWL
Low numbers of microbes continually enter the line/tubing
Nutrients are continually being supplied in the incoming water
Stagnation of the water in the tubing facilitate accumulation
The waters natural flow rate is low near the tubing walls

86. Conditions that Facilitate Biofilm Formation in the DUWL (con’t.)
Water in the tubing is now under high pressure
The tubing is not under high pressure
The tubing’s small diameter creates a large surface-to-volume ratio

87. Health Implications
No definable health risks (limited epidemiologic data) However, the the high CFU in DUWL is a sanitation concern at minimum

88. Dental Unit Water Quality
Centers for Disease Control and Prevention (CDC) recommendations
American Dental Association (ADA) recommendations
Office Safety and Asepsis Procedures (OSAP) Positions Paper
ISO standards
Other?......

89. Solutions and Currently Available Technology

90. Reduce the Microbial Contamination
Source Water:
Improve the quality of the incoming water
Waterlines:
Control the biofilm in the tubing
Output Water:
Control water quality as it leaves the tubing

91. Available Technology Independent reservoirs Chemical treatment
Continuous
Intermittent
Sterile water delivery systems
Filtration
Combined

92. Resource for Dental Unit Quality Information
Organization for Safety and Asepsis Procedures in Dentistry (OSAP)
Dental Unit Water Quality Focus
Complete resource of information, scientific literature, CDC and professional recommendations and available technology

93. From Policy to Practice
Site-specific application of policies
Standard operating procedures
Day -to- Day management of policies and procedures

94. Education and Training
Techniques
Tools
Centers for Disease Control and Prevention (CDC) Recommendations, OSHA Regulations others
Organization for Safety and Asepsis Procedures (OSAP)
Institutional Policies and SOP for each practice setting
Resources (related guidelines, standards, regulations and statutes)
Approaches ( talking vs teaching vs training)

95. Compliance Assessment / Evaluation
Feedback and Reflection
Assuming responsibility for health and safety of patients/clients, yourself and other staff
Ethical
Legal
Enforcement
Positive reinforcement
Negative reinforcement

96. Resources Recommendations
Centers for Disease Control and Prevention (CDC)
National Institutes of Occupational Safety and Health (NIOSH)
Professional Recommendations (
OSAP
ADA
ADHA
ADAA

97. Resources (continued)
Regulations/statutes
State Boards of Registration
State Departments of Public Health
State /local agencies who regulate waste
Biohazard, chemical, general

98. Kathy Eklund Motto for Infection Control and Health and Safety
Learn the concepts, keep current with the science and relevant standards
Believe that it is critical to healthcare delivery
Behave in a manner consistent with the above