1. Infection Control in Dental Health-Care Settings
Terri L. Deal

2. Infection Control 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

3. Infection Control General recommendations Develop a written program
Policies
Procedures
Education and training guidelines
Immunizations

4. Infection Control Exposure prevention Establish referral arrangements
Post-exposure management
Medical conditions
Work restrictions
Contact dermatitis, latex sensitivity
Maintenance of records, data management and confidentiality
Establish referral arrangements

5. Infection Control 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

6. Infection Control 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

7. Infection Control
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. Don’t 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

8. Infection Control
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

9. Infection Control 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 employee’s duties”

10. Infection Control Occupational exposure occurs when your ..
Skin
Eyes
Mucous membrane
Blood

11. Infection Control Come into contact with…
Blood or saliva from a patient
Contaminated instruments
Equipment of laundry contaminated by blood or saliva from a patient

12. Infection Control
Who is potentially infectious?

13. Universal Precautions:
“…all human blood and certain human body fluids are treated as if known to be infectious…”

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

15. Occupational Exposure Determination
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

16. Disease Transmission in the Dental Office
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 team’s family)
Community to patient

17. Therefore… Health care workers must…
Consider blood and saliva from all patients as potentially infectious
Take precautions to protect themselves from exposure

18. Hepatitis B Vaccine 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.

19. Post-Exposure Evaluation and Follow-up
Employer must:
Document exposure and circumstances
Document source individual
Source individual’s blood tested
If source is known to be infected, blood test is not necessary.

20. Post-Exposure Evaluation and Follow-up
Employee’s 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

21. Medical Waste
Blood or saliva mixed with blood

22. Medical Waste:
Items that release blood or saliva-blood if compressed or during handling

23. Medical Waste:
Pathological waste
Teeth
Tissue
Contaminated sharps

24. Disposal of regulated Waste:
Landfills
Private pick-up services
Hospitals
On-site

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

26. Requirements for Transmission of Infection
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

27. Infection Control Preventing Transmission of Blood borne Pathogens
HBV vaccination
Preventing exposure to Blood and OPIM (other potentially infectious material)
Use standard precautions for all patients

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

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

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

31. Disinfectants Versus Antiseptics
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.

32. Disinfectants Versus Antiseptics
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.

33. The “Perfect Disinfectant?”
Unfortunately, no single disinfectant product on the market today meets all these criteria.

34. The “Perfect Disinfectant?”
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.

35. Types of Chemical Disinfectants
Iodophors are EPA-registered intermediate-level 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.

36. Types of Chemical Disinfectants
Synthetic phenol compounds are EPA-registered 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.

37. Types of Chemical Disinfectants- cont’d
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.

38. Types of Chemical Disinfectants- cont’d
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.

39. Classification of Instruments and Equipment
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.

40. PPEs Utility gloves Protective eyewear and mask or face shield
Protective gown

41. Surface Disinfection Use PPE for preparation and use of disinfectants
Use an EPA-registered, ADA-accepted disinfectant for cleaning and disinfecting
Follow manufacturer’s directions on the disinfectant label
Use water if dilution is required

42. Surface Disinfection Spray, Wipe, Spray……………Wipe
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

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

44. Types of Surface Barriers
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.

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

46. 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.

47. Cross-Contamination 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

48. To avoid cross-contamination
Use over-gloves
Use clean towel or paper towel

49. Infection Control 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. Don’t top off

50. Infection Control Special hand considerations
Use hand lotions to prevent skin dryness
Avoid lotions with petroleum or other oil emollients
Fingernails short

51. Infection Control 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

52. Infection Control 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

53. Infection Control 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

54. Infection Control Face shields
Chin-length shield replaces eyewear but not mask.
Doesn’t protect against inhaling aerosols
Patient eyewear
Protect from
Handpeice splatter
Spilled or splashed materials
Airborne bits of acrylic or tooth fragments

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

56. 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

57. Infection Control
Double gloving-effectiveness in preventing disease transmission has NOT been demonstrated.
Over-gloves-not acceptable alone as hand barrier
Sterile gloves-invasive procedures

58. Infection Control Latex Hypersensitivity
Educate staff to signs, symptoms and diagnosis of skin reaction

59. Infection Control 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 hrs. Limited to areas of contact. Caused by chemicals used to process latex

60. Infection Control
3. Type I –MOST dangerous. Can cause death. Reaction to latex protein. Occurs 2-3 minutes after contact.

61. Infection Control 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.

62. Background
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.

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

64. Microorganisms in Waterlines
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.”

65. Microorganisms in Waterlines
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.

66. Communities of Bacteria
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.

67. Bio-film
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.

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

69. Self-Contained Water Reservoirs
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.

70. Self-Contained Water Reservoirs
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.

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

72. Micro-filtration Cartridge
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.

73. Chemical Agents
Chemicals can be used to help control bio-film 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).

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

75. Water for Surgical Procedures
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.

76. Flushing Waterlines
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.

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

78. Minimize Aerosol
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.

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

80. 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.

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

82. Recommendations and Regulations
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.

83. Associations and Organizations
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.

84. Associations and Organizations
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.

85. Associations and Organizations- cont’d
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.

86. Governmental Agencies
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)

87. Centers for Disease Control and Prevention (CDC)
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.

88. Food and Drug Administration (FDA)
The FDA is a regulatory agency and is part of the United States Department of Health and Human Services.

89. Food and Drug Administration (FDA)
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.

90. Environmental Protection Agency
The EPA is a regulatory agency.
It ensures the safety and effectiveness of disinfectants.

91. Environmental Protection Agency
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.

92. Occupational Safety and Health Administration (OSHA)
OSHA is a regulatory agency.
It protects workers’ against physical, chemical, or infectious hazards in the workplace.

93. Occupational Safety and Health Administration (OSHA)
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.

94. National Institute for Occupational Safety and Health (NIOSH)
NIOSH does not have regulatory authority.
It is responsible for conducting research and making recommendations for the prevention of work-related disease and injury.

95. National Institute for Occupational Safety and Health (NIOSH)
NIOSH makes recommendations and disseminates information on preventing workplace disease, injury, and disability.
It provides training to occupational safety and health professionals.

96. 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.

97. 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.

98. Websites www.engenderhealth.org/ ip/sharps/nsm3.html www.ada.org