ADVANCED POWER DRIVEN SCALERS ULTRASONIC INSTRUMENTATION

ADVANCED POWER DRIVEN SCALERS ULTRASONIC INSTRUMENTATION
Presented by Tammy Maahs, RDH, BSDH DH 220 Fall Term 2014

Types of Power Driven Scaling Devices
Magnetostrictive Ultrasonic Scaler: converts high frequency electrical current into rapid mechanical vibrations; operates at thousand cycles per second (cps). Piezoelectric Ultrasonic Scaler: activated by dimensional changes in quartz or crystal transducers (25-50K). Sonic Scaler: air-driven; only cps.

Magnetostrictive Ultrasonic Scaler
Tip movement is elliptical; all sides of the working end are active. Frequency (cycles per second = cps) is described in kilohertz (1 kHz = 1000 cps). Manual-tuned or auto-tuned units. Most common.

Magnetostrictive Cavitron Handpiece
Electrical energy is applied to coils of copper wire in the handpiece and magnetically changes the dimension of the stack to produce vibrations in the tip.

Magnetostrictive Technology
ELLIPTICAL TIP MOVEMENT

Piezoelectric Ultrasonic Scaler
Used widely in Europe and Asia Growing popularity in the U.S. Tip movement is linear; only 2 sides (lateral borders) are active

Piezoelectric Ultrasonic Scalers

Sonic Scaler Uses compressed air to produce vibrations
Tip movement elliptical or orbital Technique is pressure sensitive Frequency much less powerful than with ultrasonic scalers (2,000-6,300 cps)

Sonic Scalers * *This example has a protective sheath for
use around implants

MAGNETOSTRICTIVE ULTRASONIC SCALERS
Manual Tuned Units Automatic Tuned Units

Manual Tuning Units: 3 controls
Power control (amplitude) Tuning control (frequency) Water control (amount)

USI Manual-Tuned Unit Holbrook Technique “favorite” for low power and frequency; less sensitivity for the patient.

“Old” Dentsply Cavitron Manual Tuned Unit

Power Control (Amplitude)
Stroke: maximum distance the tip moves during ONE (back and forth) cycle. Amplitude: Tip displacement; the length of the stroke (½ the stroke). The higher the power the longer the stroke. More energy created by a longer stroke. Longer stroke = increased ability to remove dense/tenacious calculus deposits

More Efficient “Chipping” Action

Tuning Control (Frequency)
The number of times per second the tip completes one back and forth cycle. 1 kHz (kilohertz) = 1000 cycles per second (cps). The higher the frequency, the faster the tip movement—increasing the ability to remove deposits. OPTIMUM frequency is cps. Affects the speed of the movement of the tip.

Water Control (amount)
Used to cool the stack and tip. Cavitation: the resulting water spray on the vibrating tip (bubbles collapse and lyse bacterial cell walls). Acoustic Turbulence or Microstreaming: hydrodynamic wave around oscillating tip disrupts bacteria. Functions as a lavage (flushes debris from the area, removes LPS, removes attached plaque and loosely adherent plaque).

Water Coolant

Automatic Tuning Units
Frequency is pre-set (controlled automatically by the system): automatically changes as load conditions change 25K or 30K Two controls: Power Control (amplitude) Water Control (amount)

Dentsply Automatic Units
Cavitron Bobcat, Bobcat Pro, SPS, Plus, and Select

Parkell Turbo Sensor Can use 25K and 30K tips
Burnett thin power tip can be used on high power

LOAD Definition: the resistance on an insert when it is place against a deposit or the tooth/root surface. With an auto-tuned unit, the insert maintains the [pre-set] frequency even though pressure is being applied to the tip, therefore scaling efficiency is not compromised.

Parts of an Insert System
Stacks Connecting Body O-ring Insert Tip: the working end of the insert

Parts of an Insert System

Stacks Energy source for insert
Move by elongation and contraction in a horizontal plane Should be straight for peak performance

Connecting Body (Grip/Handle/Finger Grasp)
Can be metal or plastic ‘Experts’ (Anna Pattison, S.N. Bhaskar) prefer the all metal inserts (i.e., metal grip) for more power and efficiency

O-Ring Stops water from flowing outside the handpiece
Should be wet prior to inserting the insert into the handpiece

Insert Tip The WORKING END of the insert

Dentsply Inserts 25K & 30K

Active Tip Area The portion of the tip that is capable of doing work.
Affected by the frequency. The higher the frequency, the shorter the active tip area. The power to remove calculus is concentrated in the last 2-4 mm of the length of the tip.

Ultrasonic Tip Power Power concentrated in the TIP

Care & Maintenance of Inserts
Do not submerge in glutaraldehyde or use surface disinfectants (e.g., Birex); VOIDS THE WARRANTY. Do not put in ultrasonic bath (solutions are not able to be rinsed well from the stacks). Rinse ,or scrub tip and grip gently with a brush/soap/water and rinse well, and place in individual packaging (sterilization pouches or cassettes especially made for ultrasonic tips).

Check periodically for wear: replace if too short. Replace O-ring if water leaking or insert is loose in handpiece. Place on the top of the load if using pouches, take care not to bend the tip or water conduit.

When using pouches, must be all paper or combination paper/plastic pouches; paper side down in a steam autoclave or Statim. “In a steam sterilizer, if paper/poly packages must be placed flat in a single layer, place them paper side down. Placing paper/poly packaging plastic side down may cause condensate to pool inside the pouch resulting in a wet pack, which must then be considered contaminated.” ~Confirm Monitoring Systems

Sterilization Pouches
It is important to place inserts in pouches TIP(s) to the bottom of the package and fold the top (seal) properly (arrows lined up). TIP(s) down allows view of which tips are in the package; sealing the package often covers the tip if it is placed tip to top. Package STRAIGHT tips separately, and be sure to package the CURVED PAIR of right/left inserts together correctly (a right and left, not 2 rights or 2 lefts!).

Sterilization Pouches: prepared for sterilization

Sterilization Pouches: Curved Tips Sterile

Hu-Friedy IMS Cassette for Ultrasonic Tips
Are in your student issue for sterilization and storage of the set of inserts purchased

Variables for Replacement
Efficiency indicator template: use to check for wear in tip length. Literature suggests that inserts with 2 mm of wear lose about 50% scaling efficiency. Condition of stacks: replace if stack is so bent or splayed that energy is no longer being delivered to the tip.

Efficiency Indicator Template

Asepsis & Infection Control
Operator: PPE including face shield Client: protective lenses, cloth towel Ultrasonic unit: drape unit with plastic wrap to cover the controls that may be touched when adjusting during treatment! Handpiece: small barrier with sticky to hold in place. Bleed the handpiece for 1 minute to remove contaminants.

Asepsis & Infection Control
Pre-procedural rinse to reduce microorganisms the patient might release in the form of aerosol Water spray: external water source tends to have less aerosol

Infection Control (continued)
Water Evacuation: High-volume if working with an assistant; saliva ejector or hygoformic saliva ejector if working without an assistant.

Advantages of Ultrasonic Scalers
Water lavage: clears area of debris & bacteria Lyses bacterial cell walls Removes attached and loosely adherent plaque Gram– bacteria most susceptible to lavage Less trauma to soft tissue than curettes Increased client comfort (usually) Decreased operator fatigue

Advantages (continued)
MAY require less treatment time. BETTER (excellent!) access to deep, narrow pockets and furcation areas (with slimline inserts). No sharpening of inserts and less sharpening of curettes Reduces lateral pressure Less tissue distention

Disadvantages of Ultrasonic Scalers
Decreased tactile sensitivity (improves with experience!). Requires water evacuation. Produces contaminated aerosol. Possible effects of noise/vibrations Potential for damaging certain restorative materials. Handpiece sterilization.

Contraindications: Pacemakers
Pacemaker or implanted defibrillator (with magnetostrictive) "Although all modern pacemakers are shielded, care must be taken if magnetostrictive ultrasonics or ultrasonic cleaning devices are used that generate a magnetic field that might interfere with certain types of cardiac pacemakers." (Bennett, Contemporary Oral Hygiene, June 2007). Dentsply Cavitron (directions for use): recommend that the handpiece and cables be kept at least 6-9 inches away from any device and their leads.

Pacemakers In Touch, January 2006: Clients with Cardiac Pacemakers: “Most dental hygiene/dental procedures do not involve strong electromagnetic signals and are unlikely to interfere with a shielded pacemaker or ICD. Those considered safe are [dental] radiographs, handpieces, composite curing lights, sonic scalers and piezoelectric scalers. There is some evidence that…magnetostrictive (Cavitron) scalers, ultrasonic cleaning baths, and electrosurgical units can cause marked interference with cardiac implant devices when tested in-vitro setting and placed at close proximity.” ~

Contraindications: Other Implanted Medical Devices
Implanted Cardiac Defibrillators Spinal Cord Stimulators Vagus Nerve Stimulators Insulin Pumps It has been recommended not to use magnetostrictive ultrasonics for patients with these devices or use a lead apron.

Pacemakers: LCC Policy
Our policy for patients with a cardiac pacemaker, implanted defibrillator , or other implanted devices: the piezo electric unit should be used. NOTE: when calling physicians for other implanted devices as listed in previous slide, recommendation is to NOT use the magnetostrictive ultrasonic scaler.

Contraindications Active communicable or infectious diseases transmissible by aerosols Pulmonary or respiratory disease Gagging or problems swallowing Metal inserts on dental implants Lack of consent of therapy

Ultrasonic Tip Design Water source external or internal
Gross Debridement (standard diameter) Tip Assorted Specialty Tips Slimline inserts Straight Paired (curved left and right)

External Water Source

Gross Debridement Tip Higher power setting can be used
“Chips” away at heavy deposits Once accomplished, power should be reduced to medium or low

Gross Debridement Heavy Calculus

Loose tissue will accommodate larger tips

Assorted Specialty Tips
Dentsply DiamondCoat Tip Implant Tips For perio surgery only (must have visibility!)

Hu-Friedy Inserts Furcation Insert After-Five (Slim) Inserts
(curved & straight) Triple Bend Insert

Hu-Friedy Swivel Inserts
Allows for single-handed adjustment

Protégé Ultrasonics by Discus Dental
Protégé™ LED Ultrasonic insert: has a unique grip has a built-in light emitting diode (LED) that illuminates the working surface.

Sonic and Ultrasonic Scalers with Specialized Tips
Remove plaque and calculus from titanium surface without damaging titanium. It was noted previously that the sonic or ultrasonic vibrations might have the potential to adversely affect the connective tissue adherence. However, the consensus is with the specialized tips used on LOW POWER; this is an effective method for debriding implants. (Samuel B. Low, DDS, MS, MEd)

Dentsply Ultrasonic SofTipTM Insert
Disposable prophy tip is for single-use only

Piezo Electric Scaler with Peek® [Composite] Tip

Piezo Electric Scaler with Peek® Tip
This tip is fabulous and I use it regularly for debriding implants and other porcelain and gold types of restorations! Autoclavable and durable tip; however once the tip wears down, it must be disposed of and replaced. Use only on a lower power!

Thin Design Ultrasonic Tips

Dentsply FSI Slimline Inserts

Curved Inserts Paired: Left and Right

Curved Inserts Angles [curves] are important for access with ultrasonics. Curved inserts not only access deeper pockets and furcations better, but these also provide better access when posterior teeth have bulbous crowns.

Curved Inserts Adapt to concave root anatomy

Instrumentation Technique
Grasp: feather-light, writing pen grasp. Drape cord over arm to decrease pull on handpiece.

Cord Management

Fulcrum Calculus removal: intraoral or extraoral fulcrum.
Biofilm disruption and removal (deplaquing): extraoral fulcrum will help the clinician to use lighter pressure.

Strokes Multiple, rapid, multi-directional, erasing, or sweeping strokes. Keep tip moving at all times. The lighter the pressure, the more effective the vibrations.

Strokes

Insertion Insert tip parallel to the long axis of the tooth/root
For CEJ areas, insertion is approximately 90°

Insertion Parallel Oblique Oblique/Proximal

Adaptation Use lateral side or rounded back of tip
Adapt side of tip to tooth surface; tip/face to tooth angulation near zero degrees. Keep tip moving continuously and submarginally on root surface. Clean several surfaces at a time; do not continuously start and stop.

Adaptation

Pocket Negotiation Enter pocket using the lateral side or back surface; keeping the [side of] tip in contact [and parallel] with the tooth/root surface. Negotiate to the apical extent using short, overlapping strokes.

Adaptation for Piezo Scalers

Adaptation for Piezo Scalers
Adapt the lateral surface of the tip for optimal performance Maintain tip angulation near ZERO degrees (parallel to the tooth surface) NEVER adapt tip at a 90◦ angle to avoid tooth/root damage Use minimal or no lateral pressure; let the tip do the work for you

Tip Design for Piezo Scalers
The variety of tip designs offers more options They offer thin designs and contra-bend bladed curettes HuFriedy: “Clinicians love this tip because looks and functions like their bladed hand instruments”

Piezo Scaler for Stain Removal
View the You-Tube Video on Moodle

Techniques to Avoid Sensitivity
Decrease power. Decrease frequency (if manual tuned unit—known as “detuning” or tuning “out of phase”). Increase water flow. Always keep the tip moving at all times, maintain constant water flow. Determine the source of sensitivity; either avoid instrumenting sensitive tooth surface(s) [debride with alternate methods] or consider using desensitizing agents or topical (Oraqix).

NUPRO® Sensodyne® Prophylaxis Paste with Novamin

Colgate® Sensitive Pro-Relief™ Desensitizing Polishing Paste
With Pro-Argin™ Used to be marketed by Ortek as Proclude; Colgate then distributed Proclude, then repackaged (same ingredient)

Oraqix® lidocaine/prilocaine gel intra-pocket anesthetic

Calculus Deposit Removal
The type, amount, and tenacity of calculus must be considered for proper tip selection.

Calculus Deposit Removal
Adapt appropriate insert using the anterior 1/3 of the working end (active tip area). Engage the most coronal portion of the deposit with the insert tip. Use light, intermittent “tapping”strokes against the deposit. Continue the strokes in a lateral and apical direction until the deposit is removed.

Tapping Strokes

Summary Can remove deposits from any direction.
Can instrument coronally to apically on the root surface (unlike hand/manual instrumentation). It is not necessary to place the instrument beneath the deposit in order to remove it.

Gross Debridement

Slimline Inserts/Tips
A low (narrow stroke width) power setting recommended. A maximum of medium power should be used for moderate calculus removal during root scaling. Use of high power setting has been associated with breaking the slimline tips.

The thinner the ultrasonic tip, the lower the power setting.
BASIC PRINCIPLE The thinner the ultrasonic tip, the lower the power setting.

Combination/Blended Approach to Debridement
Dense/hard/tenacious deposits generally require ultrasonics and the manual use of curettes to ensure complete debridement. Scaling with curettes for final finishing should always follow the use of ultrasonics (when removing calculus OR biofilm). Following hand scaling with ultrasonics is also efficient in additional irrigation/lavage and cleanliness.

Biofilm Removal and Disruption (i.e. deplaquing)
Use short, overlapping brush-like strokes Keep the side of the tip (active tip area) in contact with the tooth/root surface while moving with a series of gentle erasing motions The instrument must touch every square mm of the tooth surface to remove biofilm

Complementary Methods for Debridement
Anna Pattison, RDH, MS

Words of Wisdom “Experienced clinicians appreciate the synergy that occurs when power-driven instrumentation and manual [curettes] are used in conjunction with one another.” ~Technology & Ultrasonic Debridement, Low, S.B.

“The best results are probably obtained by combining sonic/ultrasonic instruments with manual scaling.” ~ Charles M. Cobb, DDS, MS, PhD

Clinical Application of Root Morphology
DH 220 A Prepared by Leslie Clark, RDH, M.Ed

Objectives Understand relationship of tooth support and root morphology Identify relationship of root anatomy and anomalies on periodontal disease Identify periodontal therapy options

Terminology Review Periodontium: gingiva, cementum, PDL, alveolar and supporting bone, alveolar mucosa Gingivitis: inflammation (disease) of the gingiva Periodontitis: inflammation (disease) of the supporting tissues of the teeth, usually resulting in progressive destruction of those tissues

Terminology Review Periodontal disease: pathologic processes affecting the periodontium, most often gingivitis and periodontitis Dental biofilm: layer containing microorganisms that adhere to teeth; contributes to the development of gingival and periodontal disease and caries

Terminology Review Calculus: hard concretion that forms on the teeth (or dental protheses) through calcification of bacterial biofilm

Furcation Involvement
As periodontal disease progresses attachment loss increases Bone loss may reach a furcation area These areas are difficult for the patient to clean Furcation areas readily accumulate biofilm and calculus mineralization

Furcation Location Maxillary Molars: Mid-buccal
Mesial (accessed from lingual) Distal (accessed from lingual)

Furcation Location Mandibular Molars: Mid-buccal Mid-lingual

Furcation Location Maxillary Premolars: (with buccal and lingual roots) middle of mesial middle of distal

Furcation Location Key points Where Type (type I, II or III)
Accessibility Radiographs ARE an important tool

Gingival Recession Loss of gingival tissue resulting in the exposure of more root surface The gingival margin is apical to the cementoenamel margin The papillae may be blunted or rounded, and no longer fill the interproximal embrasure

Gingival Recession Contributing Factors: plaque biofilm
poorly aligned teeth lack of attached gingiva aggressive tooth brushing abnormal tooth and root prominence

Gingival Recession Key Points: Deviations of general characteristics
CEJ configuration Root sensitivity Oral Hygiene Instruction

Other Factors Other factors that affect periodontal health: Mobility
CAL Bleeding

Tooth Support and Root Morphology
Root attachment is primary importance to stability of tooth Root attachment depends on length of root, number of roots, presence or absence of concavities and curvatures

In Health Connective tissue fibers insert into cementum on entire root surface gingival fibers (supracrestal) PDL

In Health Long roots and wide roots increase support
Concavities and root curvatures increase support in two ways: augment (increase) total surface area concave configuration provides multi-directional fiber orientation

In Health: Generally: (based on root surface area)
Maxillary canines most stable single rooted teeth Mandibular incisors least stable single rooted teeth

In Health Generally: Maxillary 1st molar (3 divergent roots) more stable than 3rd molars (frequent fused roots)

Additional Factors Presence or absence of periodontal disease
Excessive occlusal forces Density and structure of supporting bone

Root Anomalies and Periodontal Disease
Enamel extension on mandibular molar and enamel pearls on maxillary molars prevent normal connective tissue attachment may channel disease into furcation area

Root Anomalies and Periodontal Disease
Palatal gingival grooves occur on maxillary incisors; readily collect and retain plaque biofilm, which can lead to periodontal destruction Root fractures predispose periodontal destruction along fracture line

Other Root Anomalies Concrescence: fusion of two teeth at the root
Fusion: formation of a single tooth from the union of two adjacent tooth buds Hypercementosis: excessive formation of cementum around the root after the tooth has erupted

Accessory roots: extra roots that form on teeth after birth
Dwarfed roots: abnormally short roots with normal-sized crowns Dilaceration: distortion of the root and crown from their normal vertical position Flexion: sharp bend or curvature of a root that only affects the root portion of the tooth

Importance of Root Anomalies
Identify what is different or unique about the tooth and root structure Provide instrumentation with a purpose Provide Oral Hygiene Instruction based on anomalies

Periodontal Therapy Options
Non-surgical Periodontal Therapy may include: Effective debridement and root planing Oral Hygiene Instructions Antimicrobial agents

Surgical Therapy: Correct results of periodontal disease Removal of soft and hard tissue components of pocket wall

Gingivectomy Root resection Periodontal flaps Osseous surgery Regenerative periodontal surgery Bone grafting

Root Morphology/ Instrumentation
Identify unique characteristics of individual root anatomy explorer periodontal probe radiographic evaluation

CEJ Anterior teeth: arc interproximally making it difficult to instrument due to limited accessibility and close proximity or adjacent teeth Improper instrument adaptation results in incomplete scaling

CEJ: Molars are generally easy to follow with explorer CEJ: generally feels smooth, may have slight groove based on anatomy

Furcations: Identify number and location of roots Furcations are generally narrow and difficult to reach Clinician must picture roots from facial, lingual, distal and mesial perspectives and identify specific characteristics

Instrument Selection: Visualize root surface to be treated using assessment tools including radiographs

Consider root surfaces of multi-rooted teeth as independent areas to be instrumented
EXAMPLES: The Gracey 11/12 can access the mesial surface of the mandibular molar’s distal root The Gracey 13/14 can access the distal of the maxillary first molar’s mesiobuccal root

Instrumentation After-Five Curettes: terminal shank elongated to allow access to deep pockets and adaptation to root surfaces Mini-Five Curettes: modification of after-five design. Length of blade is reduced to allow ease of instrumentation and improved adaptation for difficult to instrument areas

Clinical Application Clinician must use a variety of tools to identify effective instrumentation techniques Instrument selection is based on the anatomy of the area being treated Knowing what is ‘usual’ root morphology aids the clinician in modifying traditional instrumentation techniques to provide quality periodontal therapy

Dentinal Hypersensitivity
Presented by Tammy Maahs, RDH, EP, BSDH DH 220A Fall 2014

Dentinal Hypersensitivity defined:
Pain arising from exposed dentin in response to a stimulus or stimuli, which cannot be explained as arising from any other form, dental defect, or pathology. A variety of treatment interventions have been developed to treat hypersensitivity, but no single therapy has been found to solve the problem.

A “unique entity” apart from other sources of dental pain. Represents a transient type of pain. NOT all exposed dentin is hypersensitive. No consensus on what causes it and how to best manage it.

Can occur at any site on any tooth. More commonly buccal or lingual surfaces at the gingival margin. Pain is sporadic and can range over time from being localized, sharp or intense, to generalized with varying degrees of pain. Symptoms are individual and episodic. Usually described as a short, sharp pain as a response to stimuli such as cold, hot, sweet, or air.

First Step Behavioral Modification
Eliminating or reducing personal habits that encourage tooth sensitivity is the first step in controlling hypersensitivity Even though hypersensitivity is associated with exposed dentin, not ALL exposed dentin is hypersensitive

Stimuli That Elicit Pain Response:
Mechanical (touch): 29% of clients Thermal (temperature): 75% of clients (primarily cold) Chemical (usually acids): can elicit pain response or may be the cause Osmotic (sugar or salt solution) Evaporative (drying)

Causes and Locations for Dentin Exposure
Most frequently found at CEJ. Usually facial/buccal surfaces of most teeth. Canines and first premolars show the highest incidence.

Enamel Loss: Cementum/Dentin Exposure
Exposed cementum and/or dentin are readily abraded when compared with enamel. Dentin abrades 25 times faster than enamel. Cementum abrades 35 times faster than enamel.

Causes and Locations: Recession: observed with normal aging.
Tooth apposition also may predispose a tooth to gingival tissue loss since the buccal alveolar plate may be thin. Abrasion: mechanical wear. Erosion (chemical): acidic foods and drinks. Attrition: occlusal or incisal wear. Scaling and Root Planing (periodontal treatment). Abfraction

Abfraction defined: Biomechanical wearing of tooth structure through occlusal loading; causing stress, fatique, deformation and fracture of dentin and enamel. Causes wedge-shaped notches at the CEJ. This is caused by tensile and compressive forces during tooth flexure.

Abfraction

Differential Diagnosis
A differential diagnosis to rule out other conditions must be established before treating for hypersensitivity. Need a radiographic examination and clinical examination (e.g., percussion test, occlusal evaluation) to rule out other possible causes.

Dental Conditions That Mimic Dentinal Hypersensitivity
Caries or demineralization Fractured restorations Cracked tooth syndrome Post-restorative sensitivity Teeth in “hyperfunction” Tooth Slooth (for detecting cusp fractures)

Brännström’s Hydrodynamic Theory
Dentin is permeable Lymphatic fluid present in the dentinal tubules transmit stimuli Odontoblasts and their processes act as receptors and transmitters of sensory stimuli Stimuli create movement of fluids, causing nerve endings at the pulpal wall to be stimulated Fluid movement can be caused by pressure, desiccation, heat, cold, and hypertonic solutions

Hydrodynamic Theory The number of tubules varies
There can be as many as 30,000 tubules in a square millimeter of dentin Tome’s fibers extend from the odontoblasts into the tubules These fibers are what communicate to the pulp

Hydrodynamic Theory Fluid movement within tubules transmits a signal to the nerves in the pulp chamber.

Hydrodynamic Theory The fluid movement stimulates the small, myelinated A-delta fibers These nerve fibers transmit to the brain Results in the sensation of a localized, sharp pain [that is associated with dentinal hypersensitivity].

Hydrodynamic Theory Odontoblastic processes are stimulated (excited) due to ion exchange.

Smear Layer: An organic matrix of hard tissue composed of cementum, dentin, and calculus particles. Remains over the dentin surface after instrumentation or restorative procedures. Acts as a natural desensitizer (barrier) for a short period until removed by toothbrushing, plaque acids, or acid-etching.

How Plaque Affects Dentinal Hypersensitivity:
Invades open tubules; implicated as a pain provoking stimulus. PLAQUE EXACERBATES SENSITIVITY! More sensitivity occurs with poor plaque control. Brushing technique (Bass Technique) important! Stress no “scrubbing”, which abrades the gingiva and possibly(?) susceptible tooth surface(s).

Sulcular Brushing

Some Newer Research on Plaque/Biofilm
Information from Terri Tilliss, RDH, MS, MA, PhD: “There is not a correlation between teeth with plaque biofilm and teeth with hypersensitivity. In fact, teeth with less biofilm have more sensitivity.” NOTE: it is still this author’s (me!) opinion and experience that acidic bacterial plaque can exacerbate sensitivity; and plaque removal is important!

Etiology of the Reduction of Dentin Sensitivity Over Time
Natural desensitization: Natural formation of secondary, reparative, tertiary, or sclerotic dentin. (Explains why hypersensitivity generally diminishes over time and with aging). The creation of a smear layer and calculus formation on the dentin surface. Deposition of minerals in the tubule openings (usually from fluoride) or from other salivary minerals.

TREATMENT STRATEGIES:
The ideal desensitizing agent does not exist! Clinicians must use a systematic trial and error approach based on available evidence and professional experience. One decision-making component as to which product to use is if the sensitivity is LOCALIZED or GENERALIZED.

Treatment Strategies Oxalates Cavity Varnish Bonding Agents Fluorides
Laser Treatment Connective Tissue Grafts Corticosteroids Others

Oxalates Protect (Butler): potassium oxalate
Sensodyne Sealant Dentin Desensitizing Kit: ferric oxalate D/Sense Crystal (Centrix): potassium binoxalate BisBlock: oxalate Super Seal: potassium oxalate ADVANTAGE of oxalates: Tissue friendly!!!!

Cavity Varnish (Solution Liners)
Copalite Varnal Barrier Dentin Sealant Cavi-Line Handi-Liner 90% solvent mixture and 10% copal resin A chemical barrier that reduces permeability of the dentinal tubules

Bonding Agents Glass Ionomers: have been used for class V restorations. Releases fluoride and chemically bonds to the tooth surface. Composite Restorations: work well (and can be placed with a glass ionomer base) if greater than 1 mm depth of abrasion or erosion.

Primers (used prior to placing restorations or as chemical desensitizing agents alone)
Gluma Primer/Desensitizer Does not leave a film layer on the tooth. Acts within the tubules. Gluteraldehyde reacts with the organics in the tubules and seals the “ends” [openings] by “clotting” the organic liquid. Acqua Seal A gluteraldehyde formula combined with fluoride.

More Primers HurriSeal: same ingredients as the new formulation of Acquaseal (benefit is no gluteraldehyde) Isodan: combination product—potassium nitrate, sodium fluoride, HEMA and excipients, also used prior to placement of restorations Pain Free: self-cure primer

Fluorides Varnish: 5% Neutral Sodium Fluoride
DURAPHAT (Colgate), DURAFLOR (Medicom), CAVITY SHIELD (Omnii), FLUORIDEX LONG-LASTING DEFENSE (Discus Dental). FDA approved for sensitivity; ADA approved for caries prevention.

Fluorides Gel-Kam Dentin Bloc: an aqueous solution of sodium fluoride, stannous fluoride, and hydrogen fluoride available in unit doses with a foam applicator; applied for 1 minute. Other in-office methods: a four-minute NSF or APF fluoride tray placed prior to scaling (for generalized sensitivity) or localized placement with cotton-tipped applicator.

Iontophoresis Desensitron (Parkell): Uses an electric current to create a positively charged tooth surface, which attracts negatively charged fluoride ions and imbeds them into dentin tubules.

Laser Treatment Coalesces the tooth structure (tubules).
Can be used in conjunction with sodium fluoride varnish or a stannous fluoride gel.

Connective Tissue Grafts
For root coverage; a physical barrier. Outcomes unpredictable. Before After

Colgate® Sensitive Pro-Relief™
Pro-Argin technology Contains calcium carbonate and arginine (same ingredient in Proclude) Dispensed in a 3 oz. tube or 60 unit dose cups Recommended for pre-polishing/ desensitizing prior to scaling

Colgate® Sensitive Pro-Relief™

Made by Dentsply (makers of NuPro prophy paste) Desensitizing ingredient is NovaMin (calcium sodium phophosilicate—induces the formation of new hydroxyapatite) Low in abrasion Available in “stain removal” and “polishing” grits

(Formerly NUSolutions)

Remember that this product also enhances remineralization! Also available as a 5000ppm fluoride prescription toothpaste with NovaMin for sensitivity relief, caries prevention and superior remineralization. Can be used as a daily treatment in place of regular toothpaste.

OTC Products for Client Application
Desensitizing Dentifrices: containing strontium chloride, potassium nitrate* (*most contain), sodium citrate. Sensitivity Protection Crest Crest Pro-Health (contains stannous fluoride) Colgate Sensitive Sensodyne Mouthrinses (Avoid mouthrinses with an acidic pH) ACT fluoride rinse (.05% sodium fluoride), or other fluoride rinses

Sensodyne Pronamel “Protects your teeth from sensitivity and the effects of acid wear. Everyday foods such as fruit, sodas, orange juice and wine contain acids that soften the enamel surface which is then more easily worn away by brushing. As the enamel layer becomes thinner, teeth can become visibly less white and older looking.”

Dentifrices Continued:
Sodium Bicarbonate dentifrices play an important role; they neutralize acids and are low in abrasion. New “combination” dentifrices (of calcium & phosphate) that may help remineralize the teeth offer protection by continually abating the erosion process. (Arm & Hammer EnamelCare and Mentadent Replenishing White toothpastes), both with “liquid calcium”.

Liquid Calcium

Prescription Products for Client Application
Fluoride Products (pastes and gels are OTC) Stannous Fluoride Gel .4% (Gel Kam, Gel Tin, Stop, Omnii Gel, Fluoridex Daily Renewal) 1.1% Sodium Fluoride (Prevident, Fluoridex) Mouthrinses .12% CHX followed by .2% sodium fluoride rinse (Hodges) Stannous Fluoride Rinse .63%: Gel Kam (Colgate), PerioMed (Omnii) [rinses require Rx]

More “Others”: “At Home” (prescription/patient applied) Therapies
SootheRx (Omnii): also utilizes Novamin (calcium sodium phophosilicate—induces the formation of new hydroxyapatite). Recaldent: PROSPEC MI Paste (GC America, Inc.): calcium phosphate combination (marketed as a remineralizing agent but also cited as reducing dentinal hypersensitivity by occluding dentinal tubules).

Whitening Considerations
Recommend (ALWAYS provide!) desensitizing toothpaste during whitening procedures. Ultradent (Opalescence) adds fluoride and potassium nitrate to some of their bleaching products and have a separate product (UltraEZ—3% sodium nitrate and .11% fluoride ion in a gel form) for use in the custom tray for desensitizing.

Behavioral Modification
Dietary Counseling Patients may need to consider some lifestyle changes, such as altering their diet/habits Caution patients NOT to brush directly after eating acidic foods

Treatment Tips from Practicing Clinician
That would be me…

For Generalized Root Exposure/ Dentin Sensitivity
PRE-POLISH with NovaMin based prophy paste: don’t bother with “polish” vs. “stain removal” formulas; I only use the ‘polish’ formula for general full mouth polishing for root sensitivity.

For Generalized Root Exposure/ Dentin Sensitivity (continued)
If a patient “feels” (reports sensitivity) it on the first application (touch/tactile), re-polish that surface a second time with NUPRO Sensodyne polish. Be sure to leave on the teeth for several minutes (do not rinse immediately). Proceed with debridement procedures (ultrasonic and/or hand instrumentation).

For Localized Root Exposure/ Dentin Sensitivity
Purchase the Colgate Sensitive Pro Relief in TUBE form

For Localized Root Exposure/ Dentin Sensitivity (continued)
Put a “dab” (pea-size) on top of your regular prophy paste; I prefer Enamel Pro with ACP coarse for heavier plaque and/or stain removal.

For Localized Root Exposure/ Dentin Sensitivity (continued)
Again PRE-POLISH the sensitive areas and do not rinse immediately Continue with generalized polishing with “regular” prophy paste to remove plaque biofilm and stain

A little “dab” will do ya!

INFECTION CONTROL/ BLOODBORNE PATHOGENS REVIEW
DH 220A presented by Tammy Maahs, RDH, BSDH

OSHA Occupational Safety & Health Administration
Created in 1970 by the U.S. Department of Labor Purpose is to protect the health and safety of ALL workers

EXPOSURE CONTROL To identify and manage the prevention of exposure to workplace hazards in order to reduce or eliminate harm to the employee or patient NOT the same as INFECTION CONTROL

Components of Exposure Control
Infection Control Policy and Practice Physical Precautions Chemical Safety Warning Signs and Labels Waste Management Record Keeping

Exposure Control Manual
Contain written health and safety plans Contain post-exposure management plan Centrally located in the office with access to all employees Maintain record keeping for employee

Employee Records: Must be kept private and contain:
Job description with Exposure Risk Determination Accident/Incident reports (injuries, exposures) Training Records Basic medical information Hepatitis B record

OCCUPATIONAL EXPOSURE
Physical, chemical, or infectious hazards

Physical Exposure (Hazards)
Exposure to equipment Exposure to sharps Exposure to dental waste

Chemical Exposure Hazardous Communication Standard: Regulates and establishes a standard for hazards associated with the production, transportation, usage, storage and disposal of chemicals

MSDS Material Safety Data Sheets
Used to communicate the hazard of a product

Infectious Exposure Exposure to bloodborne pathogens
BLOODBORNE PATHOGENS STANDARD: deals with infectious disease exposure control to prevent transmission of bloodborne diseases

HAZARD ABATEMENT Exposure control
The use of certain controls to reduce the probability of occupational exposure

Standard Precautions Method of exposure control that treats all patients and materials as potentially infectious New term is Body Substance Isolation (BSI) Used to be called ‘Universal Precautions’

Principles of BSI Provide a barrier between yourself and the blood/body fluid of another person Treat all blood/body fluid as if it is infectious

Work Practice Controls
Methods that reduce the chance of exposure incident (e.g., handwashing, one handed needle recapping)

Engineering Controls Use of devices that isolate and promote safety (e.g., instrument cassettes, recapping devices) Sharps or biomedical waste containers within easy reach to dispose of infectious materials

Personal Protective Equipment (PPE)
Gloves: first line of defense ALWAYS wash hands as soon as possible after removing gloves! CHANGE if torn or soiled Masks Protective eyewear with side shields Face shields Lab coats

Housekeeping (Regulated Waste Disposal)
Safe handling of waste and laundry Cleanliness of environment and clothing Sharps containers do not go into regular trash

INFECTIOUS DISEASE PROCESS
Causative agent: microorganism capable of causing disease Susceptible host: lacks effective resistance to a particular agent Mode of Transmission: Direct contact Indirect contact Airborne inhaled droplets

Occupational Exposure to Pathogens
As defined by OSHA: “A specific eye, mouth, mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials as a result of performing employee’s duties.”

Exposure Access Parenteral exposure: piercing of the skin with a needle or sharp instrument Contact with mucous membrane Contact with a wound or abrasions in the skin (non-intact skin)

NOT all exposures result in infection
Infection depends upon: Route of transmission Dosage of the virus Host susceptibility Volume of the infectious fluid Infection = increased virulence of agent + decreased host resistance + the amount of the agent

Exposure Risk Determination Categories
Category I: employees who perform tasks that involve exposure to blood or potentially infectious materials Category II: employees who do not perform tasks involving exposure during work, but may be called upon to do so Uncategorized: administrative employees who have no risk

Exposure Protocol Treat injury Notify exposure control manager
Evaluate situation Document incident Testing if indicated (informed consent) Baseline testing for HIV, HBV, and HCV as close to time of exposure as possible Follow up--CONFIDENTIAL

Post-exposure Prophylaxis
Evidence for post-exposure prophylaxis is great enough to support the use of highly active anti-retroviral therapy [HAART] agents to prevent HIV infection. Post-exposure prophylaxis is not 100% effective but can alter the course of the disease if given early enough.

Post-exposure Prophylaxis to HIV Considerations
Type of exposure (needle stick or puncture wound highest risk) Source person’s medical history Toxicity of the prophylactic drugs (AZT, and 3TC, possibly IDV)—risk vs. benefit!

Other Infectious Diseases
Hepatitis A Hepatitis B Hepatitis C (highly virulent) Tuberculosis Meningitis Staphylococcus Aureus MRSA (Healthcare associated and community associated)

BARRIERS Provide protection from workplace hazards; either chemical or infectious and encompasses standard precautions. Two types: Biological (immunizations) Physical: second line of defense—must be between the person and the agent

Personal Hygiene: Handwashing
Two types of microflora on hands: Resident: survive and multiply on the skin. Many are not highly infectious but may cause infection Transient: recent contaminants that can survive on the skin only a limited period of time (e.g., HBV)

Thorough Handwashing Requires time
Use liquid antimicrobial soap with residual effect 3% PCMX (parachlorometaxylenol) 4% CHX (chlorhexidine) NO bar soap

Proper Handwashing Technique (SOP)
Remove jewelry (rings, watches, bracelets) Wet hands, wrists, forearms with cool water Dispense soap and work gently into all areas (minimum 15 seconds) Rinse thoroughly and pat dry with disposable paper towel If no foot control or hands-free control, turn off with paper towel and then throw away towel

More Hand Hygiene Soap used for hand washing
Antimicrobial/alcohol hand sanitizers are the main method on unsoiled hands Use EPA approved healthcare products DO BOTH THROUGHOUT THE DAY Wash hands with soap and water to remove contaminants Use alcohol hand rub to kill most organisms

GLOVES: protect the clinician and the patient!
Types: Latex Nitrile or vinyl Over-gloves Utility gloves Heat resistant oven mitts

More on Gloves GLOVES FAIL
Organisms grow under gloves, doubling every 12 minutes

Protective Eyewear Belong over the clinician’s EYES, not worn on top of his/her head! Put on before donning treatment gloves

Protective Eyewear (continued)
Shatter resistant goggle with side shields or prescription personal eyewear with removable side shields Must be worn (over the eyes!) to protect from spatter of blood and saliva or injury from foreign particles Clean eyewear between patients with soap and water Recommended that patients also wear protective eyewear

Masks Protect face and mucous membranes of nose and mouth from spatter
Should cover nose, mouth, and most of cheek and skin Fit snugly against the face Change when wet or contaminated between patients Never leave dangling from one ear or around neck Never touch with gloved hands

Face Shields Should be worn when aerosols are generated
Can be worn instead of goggles with a mask

Clinical Attire Launderable lab coats or disposable
Not worn outside the office Employer is responsible for laundering lab coats

KEY TERMS (in alphabetical order)
INFECTION CONTROL KEY TERMS (in alphabetical order)

AEROSOLIZATION Spray generated by dental devices that can transfer microorganisms through the air. Infection may result in direct transmission from air or indirect transmission via fomites.

AIDS Acquired Immune Deficiency Syndrome caused by the Human Immunodeficiency Virus (HIV); a bloodborne virus that affects the immune system.

ANTIMICROBIAL An agent that prevents microbial growth

ANTISEPTIC A chemical agent applied to living tissue to reduce the amount of microorganisms

ASEPSIS The absence of disease producing microorganisms

ASEPTIC TECHNIQUE A procedure that reduces or eliminates pathogens through disinfecting or sterilizing of instruments and surfaces to avoid contamination of the patient.

BACTERICIDAL Capable of killing bacteria

BARRIER A means of protection from a workplace hazard either chemical or infectious

BIO-BURDEN Biologically contaminated debris found on instruments; MUST be removed before sterilization

BLOOD-BORNE Microorganisms within the bloodstream that are able to be transmitted to other via blood

CAUSATIVE AGENT Microorganism capable of causing a disease

CENTERS FOR DISEASE CONTROL (CDC)
A governmental agency responsible for the epidemiological study of a disease. It is not a regulatory agency, but provides information and advises.

CROSS-CONTAMINATION Contamination as a result of transfer of a microorganism from one source to another, (i.e., person to person, OR person to object to another person).

CROSS-INFECTION Infection as a result of transfer of microorganisms between people

DIRECT CONTACT Transmission via blood to an individual

DISINFECTANT A chemical agent applied to inanimate objects or surfaces to reduce the risk of infection by reducing the number of microorganisms present

ENGINEERING CONTROL An abatement or device that removes or isolates a workplace hazard

ENVIRONMENTAL PROTECTION AGENCY (EPA)
A governmental agency responsible for regulating items than impact the environment, such as chemicals and waste

ETIOLOGY The cause of a disease, finding an etiological agent which is responsible microbe for a specific infectious disease

FOOD & DRUG ADMINISTRATION (FDA)
A governmental agency responsible for regulating that which impacts living tissue (e.g., food, drugs, and medical services).

FOMITES Inanimate, potentially contaminated objects that serve as agents of disease transmission

FUNGICIDAL Capable of killing fungi

GERMICIDE A chemical agent capable of destroying bacteria

HAZARD ABATEMENT Those procedures which reduce your risk of occupational exposure to bloodborne diseases and hazardous chemical usage in the workplace

HAZARDOUS WASTE Waste that poses a threat to people

HBIG: Hepatitis B Immune Globulin
HBV: Hepatitis B Virus (bloodborne virus that affects the liver) HCV: Hepatitis C Virus HIV: Human Immunodeficiency virus (bloodborne virus that affects the immune system and can ultimately lead to AIDS)

INDIRECT CONTACT Transmission via a contaminated object

INFECTIOUS DISEASE A disease induced by microorganisms that can be transmitted from one host to another via an infectious process

INFECTIOUS WASTE Waste capable of causing infection

MSDS Material Data Safety Sheets

MICROBIAL DOSE LOAD The dose level of microbes present in a specific area

MICROORGANISM A microscopic form of life

MODE OF TRANSMISSION A method by which a disease is transmitted

OCCUPATIONAL EXPOSURE
Contact with infectious material at an individual’s workplace that puts him or her at risk of harm or contacting a disease

OSHA Occupational Safety & Health Administration: a federal regulatory agency responsible for ensuring workplace safety and health

PATHOGENIC The inherent ability of a microorganism to cause disease

PERSONAL PROTECTIVE EQUIPMENT (PPE)
Personal attire worn by the health care worker to protect them from an infectious or chemical hazard

SANITIZATION The process by which the number of organisms on inanimate objects is reduced to a “safe” level. Helps to reduce the cleaning process.

SEPSIS The presence of disease producing organisms

SPORICIDAL Capable of killing spores

STANDARD PRECAUTIONS The method of infection control that treats all patients and all materials as potentially infectious Current terminology is Body Substance Isolation (BSI) OLD term was Universal Precautions

STATIC AGENTS Chemicals that inhibit the growth of microorganisms, but do NOT kill them

STERILIZATION The process by which all life forms are destroyed by physical or chemical means

SURFACE DISINFECTION The process of killing some types of microorganisms on environmental surfaces

SUSCEPTIBLE HOST A host (person) who lacks effective resistance to a particular agent

VIRUCIDAL Capable of killing viruses

VIRULENCE The ability of pathogens to cause infectious disease due to its strength, and ability to reproduce and organize

WORK PRACTICE CONTROLS
Method of performing one’s duties in a manner that reduces or eliminates risk of an exposure incident

Guidelines for Infection Control in Dental Health-Care Settings—2003
CDC. MMWR 2003;52(No. RR-17) infectioncontrol/guidelines/index.htm

This slide set “Guidelines for Infection Control in Dental Health-Care Settings- Core” and accompanying speaker notes provide an overview of many of the basic principles of infection control that form the basis for the CDC Guidelines for Infection Control in Dental Health-Care Settings — 2003. Additional slides for each section of the document will be developed and may be used in conjunction with the core slides. This presentation and supplemental slides may be broken into separate sections, depending on the trainees’ level of experience and knowledge, previous training, level of interest in specific topics, and the amount of time available. This slide set can be used for education and training of infection control coordinators, educators, consultants, and dental staff (initial and periodic training) at all levels of education.

Infection Control in Dental Health-Care Settings: An Overview
Background Personnel Health Elements Bloodborne Pathogens Hand Hygiene Personal Protective Equipment Latex Hypersensitivity/Contact Dermatitis Sterilization and Disinfection Environmental Infection Control Dental Unit Waterlines Special Considerations Program Evaluation The information in this slide set provides some of the available scientific rationale for performing infection control practices for which recommendations are made. These practices are broken into the broad categories listed on this slide. Guidelines for Infection Control in Dental Health-Care Settings— MMWR 2003; Vol. 52, No. RR-17.

CDC Recommendations Improve effectiveness and impact of public health interventions Inform clinicians, public health practitioners, and the public Developed by advisory committees, ad hoc groups, and CDC staff Based on a range of rationale, from systematic reviews to expert opinions CDC develops a broad range of guidelines which are intended to improve the effectiveness and impact of public health interventions and inform key audiences, most often clinicians, public health practitioners, and the public. Guidelines can be developed by formal advisory committees, ad hoc work groups, and CDC staff. Development processes can vary, depending on topic, available scientific data, urgency, resources, etc. and are based on a range of rationale, depending on the availability of scientific evidence. This Guideline identifies infection control practices that CDC recommends for all settings where dental treatment is provided. Although CDC recommendations are not regulatory, some practices are mandated by federal, state, or local regulations. These are identified in the Recommendations Section of the CDC Guideline.

Background

Why Is Infection Control Important in Dentistry?
Both patients and dental health care personnel (DHCP) can be exposed to pathogens Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Proper procedures can prevent transmission of infections among patients and DHCP During the provision of dental treatment, both patients and dental health care personnel (DHCP) can be exposed to pathogens through contact with blood, oral and respiratory secretions, and contaminated equipment. Following recommended infection control procedures can prevent transmission of infectious organisms among patients and dental health care personnel.

Modes of Transmission Direct contact with blood or body fluids
Indirect contact with a contaminated instrument or surface Contact of mucosa of the eyes, nose, or mouth with droplets or spatter Inhalation of airborne microorganisms Dental patients and DHCP may be exposed to a variety of disease-causing microorganisms that are present in the mouth and respiratory tract. These organisms may be transmitted in dental settings through several routes, including: Intact or non-intact skin in direct contact with blood, oral fluids, or other potentially infectious patient materials. Indirect contact with a contaminated object (e.g., instruments, operatory equipment, or environmental surfaces). Contact of mucous membranes of the eyes, nose, or mouth with droplets (e.g., spatter) containing microorganisms generated (e.g., coughing, sneezing, talking) from an infected person and propelled a short distance. Inhalation of airborne microorganisms that can remain suspended in the air for long periods of time.

Chain of Infection Pathogen Susceptible Host Source Entry Mode
Infection through any of these routes requires that all of the following conditions be present: An adequate number of pathogens, or disease-causing organisms, to cause disease. A reservoir or source that allows the pathogen to survive and multiply (e.g., blood). A mode of transmission from the source to the host. An entrance through which the pathogen may enter the host. A susceptible host (i.e., one who is not immune). The occurrence of all these events is considered the “chain” of infection. Effective infection control strategies prevent disease transmission by interrupting one or more links in the chain of infection. Entry Mode

Standard Precautions Apply to all patients
Integrate and expand Universal Precautions to include organisms spread by blood and also Body fluids, secretions, and excretions except sweat, whether or not they contain blood Non-intact (broken) skin Mucous membranes Previous CDC recommendations on infection control for dentistry (1986, 1993) focused on the use of Universal Precautions to prevent transmission of bloodborne pathogens. Universal Precautions were based on the concept that all blood and certain body fluids should be treated as infectious because it is impossible to know who may be carrying a bloodborne virus. Thus, Universal Precautions should apply to all patients. The relevance of Universal Precautions applied to other potentially infectious materials was recognized, and in 1996, CDC replaced Universal Precautions with Standard Precautions. Standard Precautions integrate and expand Universal Precautions to include organisms spread by: Blood. All body fluids, secretions, and excretions except sweat, regardless of whether they contain blood. Non-intact skin. Mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions.

Elements of Standard Precautions
Handwashing Use of gloves, masks, eye protection, and gowns Patient care equipment Environmental surfaces Injury prevention Standard Precautions include: Handwashing. The use of personal protective equipment, such as gloves, masks, eye protection, and gowns, that are intended to prevent the exposure of skin and mucous membranes to blood and other potentially infectious materials. Proper cleaning and decontamination of patient care equipment. Cleaning and disinfection of environmental surfaces. Injury prevention through engineering controls or safer work practices. Note: OSHA retains the use of the term “Universal Precautions” because they are concerned primarily with transmission of bloodborne pathogens.

Personnel Health Elements

Personnel Health Elements of an Infection Control Program
Education and training Immunizations Exposure prevention and postexposure management Medical condition management and work-related illnesses and restrictions Health record maintenance Each dental office should have a written plan for an infection control program that includes elements to protect personnel. These elements include: Education programs for staff members. Immunization plan for vaccine preventable diseases. Exposure prevention and postexposure management, with follow-up of staff exposed to infectious organisms or potentially harmful materials. Medical condition management and work-related illnesses and restrictions. Maintenance of health records in accordance with all applicable state and federal laws.

Bloodborne Pathogens

Preventing Transmission of Bloodborne Pathogens
Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) Are transmissible in health care settings Can produce chronic infection Are often carried by persons unaware of their infection Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are of concern to dental health care personnel (DHCP). These viruses: Can be transmitted to patients and health care personnel (HCP) in health care settings. Can produce chronic infection. Are often carried by persons unaware of their infection.

Potential Routes of Transmission of Bloodborne Pathogens
Patient DHCP Patient DHCP Theoretically, transmission of bloodborne pathogens may occur from patient to DHCP, from DHCP to patient, and from patient to patient. Because DHCP frequently are exposed to blood and blood-contaminated saliva during dental procedures, they are at greater risk of infection by a bloodborne pathogen than are patients. Patient Patient

Factors Influencing Occupational Risk of Bloodborne Virus Infection
Frequency of infection among patients Risk of transmission after a blood exposure (i.e., type of virus) Type and frequency of blood contact The risk of infection with a bloodborne virus is largely determined by: Its prevalence, or frequency, in the patient population. The risk of transmission after an exposure to blood (risk varies by type of virus). The type and frequency of blood contacts. If health care personnel are frequently exposed to blood, especially if they are working with sharp objects such as needles, their risk of exposure to a bloodborne virus would be higher than if they rarely come into contact with blood.

Average Risk of Bloodborne Virus Transmission after Needlestick
Source Risk HBV HBsAg+ and HBeAg+ 22.0%-31.0% clinical hepatitis; 37%-62% serological evidence of HBV infection HBsAg+ and HBeAg- 1.0%-6.0% clinical hepatitis; 23%-37% serological evidence of HBV infection HCV 1.8% (0%-7% range) HIV 0.3% (0.2%-0.5% range) This slide shows the average risk of transmission after a single needlestick from an infected patient by type of bloodborne virus. As shown here, risk varies greatly by type of virus. For instance, the risk of HBV transmission after a percutaneous exposure (e.g., needlestick) to HBV-infected blood varies from 1%– 62%, depending on the hepatitis B e-antigen (HBeAg) status of the source patient. If the source patient’s blood is positive for HBeAg (a marker of increased infectivity), the risk of transmission can be as high as 62%. If the patient’s blood is hepatitis B surface antigen (HBsAg) positive but HBeAg negative, the risk varies from 1%– 37%. The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%. The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%. To put this in perspective, 1 in 3 needlesticks from an HBeAg+ source patient would result in infection compared to only 1 in 300 needlesticks from an HIV-infected patient.

Concentration of HBV in Body Fluids
High Moderate Low/Not Detectable Blood Semen Urine Serum Vaginal Fluid Feces Wound exudates Saliva Sweat Tears Breast Milk As mentioned earlier, one factor to consider in assessing the risk of infection is the type of body substances to which DHCP are exposed. This slide shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus. Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat. Saliva alone, without blood, has a moderate concentration of virus.

Estimated Incidence of HBV Infections Among HCP and General Population, United States, 1985-1999
Health Care Personnel General U.S. Population In the early to mid-1980s, health care personnel (HCP) had a much higher incidence (i.e., the number of new infections each year) of HBV infection than the general population. By the early 1990s, however, the incidence among health care personnel had dropped below that found in the general population. This decrease likely is the result of increased use of Universal Precautions and the hepatitis vaccine.

HBV Infection Among U.S. Dentists
Percent Among U.S. dentists, evidence of past HBV infection decreased from prevaccine levels of 14% in 1972 to ~9% in Since then, levels have remained relatively unchanged. This is because the prevalence (proportion) of HBV infection among all dentists should gradually decrease as older dentists (who are more likely to be infected and unvaccinated than younger dentists) retire. Year Source: Cleveland et al., JADA 1996;127: Personal communication ADA, Chakwan Siew, PhD, 2005.

Hepatitis B Vaccine Vaccinate all DHCP who are at risk of exposure to blood Provide access to qualified health care professionals for administration and follow-up testing Test for anti-HBs 1 to 2 months after rd dose Both Occupational Safety & Health Administration (OSHA) regulations and CDC recommendations state that hepatitis B vaccine should be made available to all DHCP who are exposed to blood or other potentially infectious materials. Employers should provide easy access to a qualified health care professional who can administer the vaccine and provide appropriate follow-up testing. Post-vaccination testing for antibody to hepatitis B surface antigen (anti-HBs) response is indicated for DHCP who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks. Post-vaccination testing should be completed one to two months after the 3rd vaccine dose. Knowledge of antibody response should guide appropriate postexposure prophylaxis.

Transmission of HBV from Infected DHCP to Patients
Nine clusters of transmission from dentists and oral surgeons to patients, 1970–1987 Eight dentists tested for HBeAg were positive Lack of documented transmissions since 1987 may reflect increased use of gloves and vaccine One case of patient-to-patient transmission, 2003 Since the early 1970s, nine clusters involving more than 300 cases of HBV transmission from infected DHCP to patients have been reported. Eight (8) providers tested for hepatitis B e-antigen were positive. Since 1987, however, no cases of DHCP-to-patient transmission of HBV have been reported, probably the result of increased use of Universal or Standard Precautions and increased use of the hepatitis B vaccine. In 2003, the first and only case of patient-to-patient transmission of HBV in a dental office was reported. A later investigation of office procedures indicated that proper infection control precautions were being followed and the exact mechanism of transmission could not be identified.

Occupational Risk of HCV Transmission among HCP
Inefficiently transmitted by occupational exposures Three reports of transmission from blood splash to the eye Report of simultaneous transmission of HIV and HCV after non-intact skin exposure HCV appears not to be efficiently transmitted through occupational exposures. Transmission of HCV generally has been associated with hollow-bore needles and not other sharp instruments. Although studies have not documented transmission associated with mucous membrane or non-intact skin exposure, at least two cases of transmission of HCV from a blood splash to the conjunctiva of the eye have been reported. In 2003, there was a report of simultaneous transmission of HIV and HCV from a nursing home patient to a health care worker. This transmission is thought to have occurred through a non-intact skin exposure. The investigation concluded that consistent use of barrier precautions might have prevented this transmission.

HCV Infection in Dental Health Care Settings
Prevalence of HCV infection among dentists similar to that of general population (~ 1%-2%) No reports of HCV transmission from infected DHCP to patients or from patient to patient Risk of HCV transmission appears very low Currently, there is little information from which to estimate the occupational risk of HCV infection in dentistry. However, most studies suggest that the prevalence (frequency) of HCV infection among dentists, surgeons, and hospital-based HCP is ~1%–2%, similar to that among the general population. There have been no reports of an HCV transmission from an infected DHCP to a patient or of patient-to-patient transmission of HCV in a dental health care setting. Based on this information, the risk of HCV transmission in dentistry appears very low.

Transmission of HIV from Infected Dentists to Patients
Only one documented case of HIV transmission from an infected dentist to patients No transmissions documented in the investigation of 63 HIV-infected HCP (including 33 dentists or dental students) To date, transmission of HIV from infected HCP to patients has been documented in only one practice. Investigation of the patients of a Florida dentist with AIDS strongly suggested that HIV was transmitted during dental care to 6 of approximately 1,100 patients tested. Additional evidence supporting the very small risk of HIV transmission to patients comes from investigations conducted in the early 1990s of patients of other HIV-infected HCP. Test results of more than 22,000 patients of 63 HIV-infected HCP, including 33 dentists or dental students, failed to identify any additional cases of transmission.

CDC Database as of December 2002
Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS CDC Database as of December 2002 Documented Possible Dental Worker * Nurse Lab Tech, clinical Physician, nonsurgical Lab Tech, nonclinical – Other Total As of December 2002, there were no DHCP among the 57 U.S. HCP with documented HIV transmission following a specific exposure to a known HIV-infected source. CDC also has received reports of 139 other HCP considered to have possible occupational HIV transmission; of these, only 6 were DHCP. For each of the 139 persons, no other risk for infection could be identified during follow-up investigation. * Each of the 6 DHCP reported a history of occupational percutaneous or mucous membrane exposure to blood or body fluids in the dental setting, but HIV transmission could not be linked to a specific exposure. * 3 dentists, 1 oral surgeon, 2 dental assistants

Visible blood on device Needle placed in artery or vein
Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood CDC Case-Control Study Deep injury Visible blood on device Needle placed in artery or vein Terminal illness in source patient Source: Cardo, et al., N England J Medicine 1997;337: Several factors affect the risk of HIV transmission after an occupational exposure. In a study of health care personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a relatively large quantity of blood as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein. The risk was also increased if the exposure was to blood from patients with terminal illness, possibly reflecting the higher titer of HIV in late-stage AIDS.

Characteristics of Percutaneous Injuries Among DHCP
Reported frequency among general dentists has declined Caused by burs, syringe needles, other sharps Occur outside the patient’s mouth Involve small amounts of blood Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire Available information indicates that percutaneous injuries among dentists declined from an average rate of 11 injuries per year in 1987 to <3 injuries per year in 1993. In general, most injuries among general dentists were caused by burs, followed by syringe needles and other sharp instruments. Injuries most often occur while the dentist’s hands are outside the patient’s mouth. Most injuries involve small, rather than large, amounts of blood. The frequency of percutaneous injuries among oral surgeons is similar to that reported among U.S. dentists. Injuries among oral surgeons may occur more frequently during procedures using surgical wire, such as during fracture reductions.

Exposure Prevention Strategies
Engineering controls Work practice controls Administrative controls Primary methods used to prevent occupational exposures to blood in health care settings include Standard Precautions, engineering controls, work practice controls, and administrative controls. Engineering controls that eliminate or isolate the hazard are the primary strategies for protecting DHCP and patients. Where engineering controls are not available or appropriate, work practice controls that result in safer behavior and personal protective equipment (PPE) can prevent exposure. Administrative controls are policies and procedures that reduce the risk of exposure to certain diseases, such as TB.

Engineering Controls Isolate or remove the hazard Examples:
Sharps container Medical devices with injury protection features (e.g., self-sheathing needles) Engineering controls reduce exposure either by removing, eliminating, or isolating the hazard from the worker. These controls are frequently technology based and often incorporate safer designs of instruments and devices. Examples include the following: Sharps containers. Medical devices with injury protection features, such as self-sheathing needles and scalpels.

Work Practice Controls
Change the manner of performing tasks Examples include: Using instruments instead of fingers to retract or palpate tissue One-handed needle recapping Work practice controls are behavior based and are intended to reduce the risk of blood exposure by changing the manner in which a task is performed. Examples include the following: Using instruments instead of fingers to retract or palpate tissue during suturing and administration of anesthesia. One-handed needle recapping. Not passing an unsheathed needle to another DHCP.

Administrative Controls
Policies, procedures, and enforcement measures Placement in the hierarchy varies by the problem being addressed Placed before engineering controls for airborne precautions (e.g., TB) Administrative controls include policies, procedures, and enforcement measures to prevent exposure to disease-causing organisms. The placement of administrative controls in the hierarchy of control measures varies by the problem or disease being addressed. For example, for airborne organisms such as Mycobacterium tuberculosis, these controls rank before engineering controls. In this example, the early identification and referral of dental patients suspected of having TB is the most important prevention strategy.

Post-exposure Management Program
Clear policies and procedures Education of dental health care personnel (DHCP) Rapid access to Clinical care Post-exposure prophylaxis (PEP) Testing of source patients/HCP Despite our best efforts, blood exposures will likely continue to occur. Post-exposure management remains an important component of a complete program to prevent infection following exposure to blood. Elements of an effective post-exposure management program include: Policies and procedures that clearly state how to manage exposures. Education of dental health care personnel in prevention strategies (including evaluation of safety devices), principles of post-exposure management, the importance of prompt reporting, and PEP efficacy and toxicity. Resources for rapid access to clinical care, post-exposure prophylaxis, as well as testing of both source patients and exposed health care personnel (preferably with a rapid HIV test). [Comments: Except for institutional settings, coordination with off-site infection control or occupational health services likely will be necessary. A health care professional who is qualified to manage, counsel, and provide medical follow-up should be selected before staff are placed at risk. Ensure that this person is familiar with the dental application of risk assessment and management.]

Post-exposure Management
Wound management Exposure reporting Assessment of infection risk Type and severity of exposure Bloodborne status of source person Susceptibility of exposed person The key elements of post-exposure management include wound management and exposure reporting. The evaluating health care professional should assess the risk of infection by examining the type and severity of exposure, the bloodborne status of the source person, and the susceptibility (immune status) of the exposed person. All of these factors should be considered in assessing the risk of infection and the need for further follow-up (e.g., PEP).

Hand Hygiene

Why Is Hand Hygiene Important?
Hands are the most common mode of pathogen transmission Reduce spread of antimicrobial resistance Prevent health care-associated infections Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings? First, hands are the most common mode of pathogen transmission. Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections. [Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]

Hands Need to be Cleaned When
Visibly dirty After touching contaminated objects with bare hands Before and after patient treatment (before glove placement and after glove removal) CDC recommends that hands be cleaned: When they are visibly dirty. After touching contaminated objects with bare hands. Before and after patient treatment, that is, before glove placement and immediately after glove removal. Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.

Hand Hygiene Definitions
Handwashing Washing hands with plain soap and water Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub Rubbing hands with an alcohol-containing preparation Surgical antisepsis Handwashing with an antiseptic soap or an alcohol-based handrub before operations by surgical personnel Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis. Handwashing refers to washing hands with plain soap and water. Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent, such as triclosan or chlorhexidine. Using a waterless agent containing 60%–95% ethanol or isopropanol alcohol-containing preparation is referred to as an alcohol handrub. These agents are a new addition to the dental guidelines and have become more frequently used in the United States to improve compliance with handwashing in hospitals. In dental practices, however, sinks are readily available and the need for alcohol preparations is not as great. Surgical antisepsis refers to an antiseptic handwash or alcohol-based handrub* performed preoperatively by surgical personnel to eliminate microorganisms on hands. Antiseptic preparations for surgical hand hygiene should have persistent (long-lasting) antimicrobial activity. * If using an alcohol-based handrub the hands should first be washed with soap and water.

Efficacy of Hand Hygiene Preparations in Reduction of Bacteria
Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub Plain soap is good for reducing bacterial counts, but antimicrobial soap is better and alcohol-based handrubs are the best, providing activity that prevents or inhibits survival of microorganisms after the product is applied. Source:

Alcohol-based Preparations
Benefits Limitations Rapid and effective antimicrobial action Improved skin condition More accessible than sinks Cannot be used if hands are visibly soiled Store away from high temperatures or flames Hand softeners and glove powders may “build-up” This slide lists the benefits and limitations of alcohol-based preparations. Alcohol handrubs have a rapid and effective antimicrobial action when applied to the skin but must contain other ingredients, such as chlorhexidine or triclosan, to achieve persistent (long-lasting) activity. When combined with emollients, or skin softeners, they can improve skin condition. In hospital settings, they are often more accessible than sinks. However, Alcohol is not a good cleaning agent, so these products cannot be used if hands are visibly soiled. Because of their flammable nature, they must be stored away from high temperatures or flames. In addition, there is some concern that hand softeners and glove powders might build up on the hands after repeated use. Hands should be washed occasionally with soap and water.

Special Hand Hygiene Considerations
Use hand lotions to prevent skin dryness Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may cause early glove failure) Keep fingernails short Avoid artificial nails Avoid hand jewelry that may tear gloves Hand lotions can prevent skin dryness associated with hand washing. However, it’s important to consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves when selecting and using them. Short nails allow thorough cleaning of nails and may reduce premature glove tearing. Artificial nails can harbor pathogens—thus, their use should be avoided. During surgical procedures, hand or arm jewelry can harbor microorganisms or increase risk of glove failure. If worn during non-surgical procedures, hand or arm jewelry can affect glove placement, fit, or durability.

Personal Protective Equipment

Personal Protective Equipment
A major component of Standard Precautions Protects the skin and mucous membranes from exposure to infectious materials in spray or spatter Should be removed when leaving treatment areas Personal protective equipment (PPE), or barrier precautions, are a major component of Standard Precautions. Use of rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers) and air-water syringes creates a visible spray that contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a short distance and settles out quickly, landing either on the floor, operatory surfaces, dental health care personnel (DHCP), or the patient. PPE is essential to protect the skin and the mucous membranes of DHCP from exposure to infectious or potentially infectious materials. PPE should be worn whenever there is potential for contact with spray or spatter and should be removed when leaving treatment areas. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Masks, Protective Eyewear, Face Shields
Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth Change masks between patients Clean reusable face protection between patients; if visibly soiled, clean and disinfect A standard surgical mask that covers the nose and mouth is worn to protect the mucous membranes from spatter generated during dental procedures. Eye protection with solid side shields or a face shield should also be worn. A mask should be changed between patients or if it becomes wet during patient treatment. Clean reusable face protection with soap and water between patients; if visibly soiled, clean and disinfect.

Protective Clothing Wear gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material Change if visibly soiled Remove all barriers before leaving the work area DHCP should wear long-sleeved disposable or reusable gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material (e.g., when spatter and spray of blood, saliva, or other potentially infectious material to the forearms might occur). DHCP should change protective clothing when it becomes visibly soiled or as soon as possible if penetrated by blood or other potentially infectious fluids. All protective clothing should be removed before leaving patient care or laboratory areas. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Gloves Minimize the risk of health care personnel acquiring infections from patients Prevent microbial flora from being transmitted from health care personnel to patients Reduce contamination of the hands of health care personnel by microbial flora that can be transmitted from one patient to another Are not a substitute for handwashing! Gloves are worn for three reasons: To minimize the risk of health care personnel acquiring infections from patients. To prevent pathogenic organisms from being transmitted from health care personnel to patients. To reduce contamination of health care personnel's hands by organisms that can be transmitted from one patient to another. Wearing gloves does not eliminate or replace the need for hand washing. Hand hygiene should be performed immediately prior to putting on and after removal of gloves. Gloves might have small holes or tears that are not noticeable, or hands can become contaminated as gloves are removed. Such circumstances increase the risk of wound contamination and exposure of the DHCP’s hands to microorganisms from patients.

Recommendations for Gloving
Wear gloves when contact with blood, saliva, and mucous membranes is possible Remove gloves after patient care Wear a new pair of gloves for each patient For the protection of DHCP and patients, gloves should always be worn when contact with blood, saliva, and mucous membranes is possible. Gloves should be removed after patient care and hands should be immediately washed. Hands should also be washed before putting gloves on. Photo credit: Centers for Disease Control and Prevention, Atlanta, GA

Recommendations for Gloving
Remove gloves that are torn, cut or punctured If the integrity of a glove is compromised by tears, cuts, or punctures, it should be changed as soon as possible. Surgical or examination gloves should not be washed before use, nor should they be washed, disinfected, or sterilized for reuse. Washing of gloves can cause a condition known as “wicking,” or penetration of liquids through undetected holes in the gloves. These circumstances may increase the risk of wound contamination and exposure of the DHCP’s hands to microorganisms from patients. Disinfecting agents, oils, certain oil-based lotions, and heat treatments such as autoclaving may result in deterioration of gloves. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL. Do not wash, disinfect or sterilize gloves for reuse

Latex Hypersensitivity and Contact Dermatitis
Occupationally-related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals, and glove use.

Latex Allergy Type I hypersensitivity to natural rubber latex proteins
Reactions may include nose, eye, and skin reactions More serious reactions may include respiratory distress–rarely shock or death Latex allergy is a Type I or an immediate hypersensitivity reaction to the proteins found in natural rubber latex. These proteins can attach to the powder in gloves which, in turn, causes more latex protein to reach the skin. This reaction is generally a more severe and immediate systemic reaction than contact dermatitis. Common reactions include runny nose, itchy eyes, hives, and burning skin sensations. More severe reactions are characterized by breathing difficulty and, rarely, anaphylaxis (shock) or death. Photo credit: Arto Lahti, MD, Department of Dermatology, University of Oulu, Finland.

Contact Dermatitis Irritant contact dermatitis
Not an allergy Dry, itchy, irritated areas Allergic contact dermatitis Type IV delayed hypersensitivity May result from allergy to chemicals used in glove manufacturing Not all skin reactions are due to an allergic reaction to latex rubber. Most skin reactions are attributed to an irritant or allergic contact dermatitis. Irritant contact dermatitis develops as dry, itchy, irritated areas on the skin around the contact area. It is commonly associated with frequent handwashing and is not an allergic reaction. The second type of contact dermatitis is a type IV or delayed hypersensitivity or allergic reaction due to contact with a chemical allergen (e.g., accelerators and other chemicals used in the manufacture of patient-care gloves). Reactions are generally localized to the contact area and occur slowly, over a period of 12–48 hours.

General Recommendations Contact Dermatitis and Latex Allergy
Educate DHCP about reactions associated with frequent hand hygiene and glove use Get a medical diagnosis Screen patients for latex allergy Ensure a latex-safe environment Have latex-free kits available (dental and emergency) Other recommendations can minimize the risk of contact dermatitis and latex hypersensitivity: Educate DHCP workers about reactions associated with frequent hand hygiene and glove use. Staff that have dermatologic problems should get a diagnosis from a qualified medical provider before making changes in gloves or hand hygiene agents. Screen patients and DHCP for latex allergy in your medical histories. DHCP and dental patients with latex allergy should not have direct contact with latex-containing materials and should be in a latex-safe environment with all latex-containing products removed from their vicinity. Have both dental and medical emergency latex-free products available at all times.

Sterilization and Disinfection of Patient Care Items

Critical Instruments Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth) Heat sterilize between uses or use sterile single-use, disposable devices Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs There are three categories of patient-care items depending on their intended use and the potential risk of disease transmission. Critical items penetrate soft tissue or contact bone, the bloodstream, or other normally sterile tissues of the mouth. They have the highest risk of transmitting infection and should be heat-sterilized between patient uses. Alternatively, use sterile, single-use disposable devices. Examples include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs.

Semi-critical Instruments
Contact mucous membranes but do not penetrate soft tissue Heat sterilize or high-level disinfect Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces Semi-critical items contact only mucous membranes and do not penetrate soft tissues. As such, they have a lower risk of transmission. Because most items in this category are heat-tolerant, they should be heat sterilized between patient uses. For heat-sensitive instruments, high-level disinfection is appropriate. Examples of semi-critical instruments include dental mouth mirrors, amalgam condensers, and impression trays. Dental handpieces are a special case. Even though they do not penetrate soft tissue, it is difficult for chemical germicides to reach the internal parts of handpieces. For this reason, they should be heat sterilized using a steam autoclave or chemical vapor sterilizer.

Noncritical Instruments and Devices
Contact intact skin Clean and disinfect using a low to intermediate level disinfectant Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuff Noncritical instruments and devices only contact intact (unbroken) skin, which serves as an effective barrier to microorganisms. These items carry such a low risk of transmitting infections that they usually require only cleaning and low-level disinfection. If using a low-level disinfectant, according to OSHA, it must have a label claim for killing HIV and HBV. However, if an item is visibly bloody, it should be cleaned and disinfected using an intermediate-level disinfectant before use on another patient. Examples of instruments in this category include X-ray head/cones, facebows, pulse oximeter, and blood pressure cuff.

Instrument Processing Area
Use a designated processing area to control quality and ensure safety Divide processing area into work areas Receiving, cleaning, and decontamination Preparation and packaging Sterilization Storage Most instrument cleaning, disinfecting, and sterilization should occur in a designated central processing area to control both quality and personnel safety. To prevent cross-contamination, the instrument processing area should be physically or spatially divided into regions for cleaning, packaging, sterilization, and storage. In the cleaning area, reusable contaminated instruments are received, sorted, and cleaned. The packaging area is for inspecting, assembling, and packaging clean instruments in preparation for final sterilization. The sterilization and storage area contains the sterilizers and related supplies, incubators for analyzing spore tests (if performed in office—although some states require using a testing service), and can contain enclosed storage for sterile items and disposable (single-use) items.

Automated Cleaning Ultrasonic cleaner Instrument washer
Washer-disinfector Cleaning is the basic first step in all decontamination processes. Cleaning involves the physical removal of debris and reduces the number of microorganisms on an instrument or device. If visible debris or organic matter is not removed, it can interfere with the disinfection or sterilization process. Automated or mechanical cleaning equipment, such as ultrasonic cleaners, instrument washers, and washer-disinfectors, are commonly used to clean dental instruments. Automated cleaners increase the efficiency of the cleaning process and reduce the handling of sharp instruments. After cleaning, instruments should be rinsed with water to remove chemical or detergent residue. Photo credit: Chris Miller, PhD, Indiana University School of Dentistry.

Manual Cleaning Soak until ready to clean
Wear heavy-duty utility gloves, mask, eyewear, and protective clothing If manual cleaning is necessary, soak instruments in a rigid container filled with detergent, disinfectant/detergent, or an enzymatic cleaner. This step prevents drying of patient material and makes cleaning easier and less time consuming. Do not use high-level disinfectants/sterilants (e.g., glutaraldehyde) as instrument-holding solutions. To avoid injury from sharp instruments, personnel should wear puncture-resistant, heavy-duty, utility gloves (i.e., not patient care gloves) when handling or manually cleaning contaminated instruments and devices. To protect against splashes, a facemask, eye protection or face shield, and a gown or jacket should be worn. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Preparation and Packaging
Critical and semi-critical items that will be stored should be wrapped or placed in containers before heat sterilization Hinged instruments opened and unlocked Place a chemical indicator inside the pack Wear heavy-duty, puncture-resistant utility gloves After thorough cleaning and drying of instruments, critical and semi-critical instruments that will be stored before use should be wrapped or placed into container systems prior to heat sterilization. This step protects items from contamination after the sterilization cycle and during storage. Open or unlock hinged instruments so that all surfaces are exposed. Place a chemical indicator inside each wrapped package. If the indicator cannot be seen from the outside, place another indicator (e.g., indicator tape) on the outside of the package. Always wear heavy-duty, puncture-resistant utility gloves while inspecting and packaging instruments.

Heat-Based Sterilization
Steam under pressure (autoclaving) Gravity displacement Pre-vacuum Dry heat Unsaturated chemical vapor There are three types of heat sterilization methods commonly used in dentistry. Steam under pressure (autoclaving). There are two types of tabletop steam autoclaves: In most commonly used gravity displacement sterilizers, steam enters the chamber and unsaturated air is forced out of the chamber through a vent in the chamber wall. In contrast, pre-vacuum sterilizers are fitted with a vacuum pump to create a vacuum in the chamber and ensure air removal from the sterilizing chamber and load before the chamber is pressurized with steam. This method improves the speed and efficiency of the sterilization process. Dry heat sterilizers are either static air (convection or FDA-approved oven type) or forced air (rapid heat-transfer). Unsaturated chemical vapor sterilizers use a proprietary formula of alcohol/formaldehyde. With all of these methods, always use FDA-approved devices and closely follow the manufacturer’s instructions for proper use.

Liquid Chemical Sterilant/Disinfectants
Only for heat-sensitive critical and semi-critical devices Powerful, toxic chemicals raise safety concerns Heat tolerant or disposable alternatives are available Heat-sensitive instruments can be sterilized or high-level disinfected by soaking them in a liquid chemical germicide cleared by the FDA. However, exposure to these powerful and toxic chemicals can be harmful to DHCP and patients if the manufacturer’s instructions for use and safety precautions are not followed precisely. For these reasons, CDC encourages the use of heat-tolerant or disposable alternatives. Photo credit: Col. Shannon Mills, United States Air Force.

Sterilization Monitoring Types of Indicators
Mechanical Measure time, temperature, pressure Chemical Change in color when physical parameter is reached Biological (spore tests) Use biological spores to assess the sterilization process directly Proper monitoring of sterilization procedures should include a combination of process indicators, including the following: Mechanical—involves assessment of cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer. Chemical—uses sensitive chemicals that change color when a given parameter is reached (e.g., heat-sensitive external tape, internal chemical indicator strip). Biological—this method is the most valid method for monitoring the sterilization process because it assesses the process directly. It does so by using the most heat-resistant microorganisms and not by using indicators that only test the physical and chemical conditions necessary for sterilization. Mechanical and chemical indicators should be assessed with each load. If either mechanical indicators or internal or external chemical indicators indicate inadequate processing, items in the load should not be used until reprocessed. Biological indicators should be assessed at least once a week.

Storage of Sterile and Clean Items and Supplies
Use date- or event-related shelf-life practices Examine wrapped items carefully prior to use When packaging of sterile items is damaged, re-clean, re-wrap, and re-sterilize Store clean items in dry, closed, or covered containment DHCP have a choice about how they maintain their instrument storage area — either date- or event-related shelf-life practices. In date-related packing, every sterilized package is expiration-dated and the instruments are used on a “first in, first out” basis. In event-related practice, the contents of a sterilized package should remain sterile indefinitely unless some event, for example, torn or wet packaging material, causes it to become potentially contaminated. It is still useful to place the date of sterilization and identify the sterilizer used if multiple sterilizers are utilized in the office. In case of sterilization failure, this information would facilitate retrieval of processed items. Examine each package. If it is damaged in any way, items should be re-cleaned, re-wrapped, and re-sterilized. Even if an event-related approach is used, all packages should be labeled with the date of sterilization and which sterilizer was used, should a sterilization failure occur. Store all sterile and clean items and supplies in dry, closed, or covered cabinets.

Environmental Infection Control

Environmental Surfaces
May become contaminated Not directly involved in infectious disease transmission Do not require as stringent decontamination procedures Environmental surfaces can become contaminated with microorganisms during patient care, although they have not been associated directly with disease transmission to patients or DHCP. Environmental surfaces do not require decontamination procedures as stringent as those used on patient care items.

Categories of Environmental Surfaces
Clinical contact surfaces High potential for direct contamination from spray or spatter or by contact with DHCP’s gloved hand Housekeeping surfaces Do not come into contact with patients or devices Limited risk of disease transmission There are two categories of environmental surfaces. Clinical contact surfaces have a high potential for direct contamination from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCP’s gloved hand. These surfaces can later contaminate other instruments, devices, hands, or gloves. Housekeeping surfaces do not come into contact with patients or devices used in dental procedures. Therefore, they have a limited risk of disease transmission.

Clinical Contact Surfaces
This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows). Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Housekeeping Surfaces
Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows). Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

General Cleaning Recommendations
Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and disinfecting environmental surfaces Physical removal of microorganisms by cleaning is as important as the disinfection process Follow manufacturer’s instructions for proper use of EPA-registered hospital disinfectants Do not use sterilant/high-level disinfectants on environmental surfaces Use appropriate protective barriers such as heavy-duty utility gloves, masks, and protective eyewear when cleaning and disinfecting surfaces. In general, cleaning and removal of microorganisms is as important as the disinfection process itself. Blood or other patient materials left on surfaces can interfere with the disinfecting process. Follow the manufacturer’s instructions for proper storage, dilution, and use of hospital disinfectants. Because of their toxic nature, the use of sterilants or high-level disinfectants on environmental surfaces is NOT recommended.

Cleaning Clinical Contact Surfaces
Risk of transmitting infections greater than for housekeeping surfaces Surface barriers can be used and changed between patients OR Clean then disinfect using an EPA-registered low- (HIV/HBV claim) to intermediate-level (tuberculocidal claim) hospital disinfectant Because clinical contact surfaces come into direct contact with contaminated gloves, instruments, spray or spatter, their risk of transmitting infection is greater than for housekeeping surfaces. These surfaces can subsequently contaminate other instruments, devices, hands, or gloves. Surface barriers can be used to protect clinical contact surfaces and changed between patients. Surface barriers are particularly useful for surfaces that are hard to clean, such as switches on dental chairs. This practice will also reduce exposure to harmful chemical disinfectants. If surface barriers cannot be used, clean and then disinfect the surface with an EPA-registered hospital disinfectant effective against HIV and HBV (low-level disinfectant). If the surface is visibly contaminated with blood or other patient material, clean and then disinfect the surface with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant).

Cleaning Housekeeping Surfaces
Routinely clean with soap and water or an EPA-registered detergent/hospital disinfectant routinely Clean mops and cloths and allow to dry thoroughly before re-using Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendations Housekeeping surfaces carry the least risk for transmitting infections in dental settings. On a routine basis, these surfaces should be either cleaned with soap and water or an EPA-registered detergent/hospital disinfectant. Wet mops and cloths may become contaminated with microorganisms, so clean the mop and cloths after use and allow them to dry thoroughly before re-using. Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendations.

Medical Waste Medical Waste: Not considered infectious, thus can be discarded in regular trash Regulated Medical Waste: Poses a potential risk of infection during handling and disposal There is no evidence that traditional medical waste management has contributed to increased levels of disease in the community or among health care personnel. The majority of waste generated in a medical or dental office (~98%–99%) is not considered infectious and can be discarded in the regular trash. Examples include used gloves, masks, and lightly bloodied gauze. Some waste, such as used needles, extracted teeth, and gauze soaked in blood, may pose a potential risk of infection, however, and warrants special precautions during handling and disposal. Follow federal, state, and local regulations for proper treatment and disposal.

Regulated Medical Waste Management
Properly labeled containment to prevent injuries and leakage Medical wastes are “treated” in accordance with state and local EPA regulations Processes for regulated waste include autoclaving and incineration Regulated medical waste requires careful containment for treatment or disposal. A single leak-resistant biohazard bag is usually adequate to contain non-sharp, regulated medical waste. Puncture-resistant containers with a biohazard label, such as sharps containers, are used as containment for scalpel blades, needles, syringes, and unused sterile sharps. Medical waste, both nonregulated and regulated, should be stored and disposed of in accordance with federal, state, and local EPA regulations. Treatment of regulated waste can involve on-site or off-site autoclaving and incineration. Never include extracted teeth with amalgam in regulated waste when disposed by one of these methods. Photo credit: NIOSH Web site.

Dental Unit Waterlines, Biofilm, and Water Quality
Dental Unit Waterlines (DUWL), Biofilm, and Water Quality.

Dental Unit Waterlines and Biofilm
Microbial biofilms form in small bore tubing of dental units Biofilms serve as a microbial reservoir Primary source of microorganisms is municipal water supply Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment. Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented. Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor. Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.

Dental Unit Water Quality
Using water of uncertain quality is inconsistent with infection control principles Colony counts in water from untreated systems can exceed 1,000,000 CFU/mL CFU=colony forming unit Untreated dental units cannot reliably produce water that meets drinking water standards Despite a lack of documented adverse health effects, using water of uncertain microbiological quality is inconsistent with infection control principles. Levels of contamination in water from untreated systems can exceed 1 million colony forming units per milliliter (mL) of water. Untreated dental units cannot reliably produce water that meets drinking water standards (fewer than 500 CFU/mL of heterotrophic water bacteria). Even using source water containing ≤500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in a self-contained system will not eliminate bacterial contamination in treatment water if biofilms in the water system are not controlled. Removal or inactivation of dental waterline biofilms requires use of chemical germicides.

Dental Water Quality For routine dental treatment, meet regulatory standards for drinking water.* * <500 CFU/mL of heterotrophic water bacteria For this reason, CDC recommends that water used for routine dental treatment meet regulatory standards for drinking water (fewer than 500 CFU/mL of heterotrophic water bacteria).

Available DUWL Technology
Independent reservoirs Chemical treatment Filtration Combinations Sterile water delivery systems In recent years, commercial devices and procedures designed to improve the quality of water used in dental treatment have become widely available. Examples of methods shown to be effective include the following: Self-contained water systems combined with intermittent or continuous chemical treatment. In-line microfilters. Combinations of these treatments. Another alternative is to bypass the conventional dental water delivery system entirely and use either autoclavable or disposable pathways, such as sterile water delivery systems. As with any dental equipment, always consult with the dental unit manufacturer for appropriate methods to maintain the recommended quality of dental water.

Monitoring Options Water testing laboratory
In-office testing with self-contained kits Follow recommendations provided by the manufacturer of the dental unit or waterline treatment product for monitoring water quality Monitoring of dental water quality may be performed using commercial self-contained test kits or commercial water-testing laboratories. In-office water-testing systems are available that work at room temperature using small paddles or plates of culture medium to reveal bacterial colonies after 72 or more hours. Dentists should consult with the manufacturer of their dental unit or water delivery system to determine the best method for maintaining acceptable water quality (i.e., <500 CFU/mL) and the recommended frequency of monitoring.

Sterile Irrigating Solutions
Use sterile saline or sterile water as a coolant/irrigator when performing surgical procedures Use devices designed for the delivery of sterile irrigating fluids During oral surgical procedures, microorganisms may enter the bloodstream and other normally sterile areas of the oral cavity (e.g., bone or subcutaneous tissue). For this reason, sterile solutions (e.g., sterile saline or sterile water) should be used as a coolant/irrigator when performing surgical procedures. Because the tubing cannot be reliably sterilized, conventional dental units cannot reliably deliver sterile water even when equipped with independent water reservoirs. Sterile water delivery devices, such as sterile irrigating syringes, shown here, or bulb syringes should be used to deliver sterile water. Sterile water systems, such as those used with surgical handpieces, bypass the dental unit and use sterile disposable or autoclavable tubing. Photo credit, top: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL. Photo credit, bottom: Eve Cuny, University of the Pacific School of Dentistry, San Francisco, CA.

Special Considerations
Dental handpieces and other devices attached to air and waterlines Dental radiology Aseptic technique for parenteral medications Single-use (disposable) Devices Preprocedural mouth rinses Oral surgical procedures Handling biopsy specimens Handling extracted teeth Laser/electrosurgery plumes or surgical smoke Dental laboratory Mycobacterium tuberculosis Creutzfeldt-Jacob Disease (CJD) and other prion-related diseases

Dental Handpieces and Other Devices Attached to Air and Waterlines
Clean and heat sterilize intraoral devices that can be removed from air and waterlines Follow manufacturer’s instructions for cleaning, lubrication, and sterilization Do not use liquid germicides or ethylene oxide Any removable device that is attached to the air or waterlines should be heat sterilized to ensure that internal components have been sterilized. It is very important to follow the manufacturer’s instructions for cleaning and lubrication. These protocols can ensure the effectiveness of the process and contribute to the life of the device. Surface disinfection or liquid chemical germicide immersion are not acceptable. In addition, the use of ethylene oxide is not recommended because it cannot reliably penetrate the internal components.

Components of Devices Permanently Attached to Air and Waterlines
Do not enter patient’s mouth but may become contaminated Use barriers and change between uses Clean and intermediate-level disinfect the surface of devices if visibly contaminated Some parts of dental instruments are permanently attached to dental unit waterlines. These items do not enter the patient’s mouth but are likely to become contaminated with oral fluids during treatment procedures. Some examples include handles or dental unit attachments of saliva ejectors, high-speed air evacuators, and air/water syringes. These components should be covered with waterproof barriers and changed after each use. If the item becomes visibly contaminated during use, clean and disinfect with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant) before using it with the next patient.

Saliva Ejectors Previously suctioned fluids might be retracted into the patient’s mouth when a seal is created Do not advise patients to close their lips tightly around the tip of the saliva ejector Backflow, meaning reverse flow, can occur when there is more negative pressure in the patient’s mouth than in the evacuator tubing, for example, when the patient uses the saliva ejector as a straw. When this happens, material from the mouth of a previous patient might remain in the vacuum line of the saliva ejector and be aspirated into the mouth of the next patient being treated. Although there have been no reports of any adverse health issues, patients should not be instructed to close their lips tightly around the saliva ejector tip during use. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Dental Radiology Wear gloves and other appropriate personal protective equipment as necessary Heat sterilize heat-tolerant radiographic accessories Transport and handle exposed radiographs so that they will not become contaminated Avoid contamination of developing equipment When taking or processing radiographs: Wear gloves and other appropriate personal protective equipment as necessary. Heat sterilize heat-tolerant radiographic accessories. Transport and handle exposed radiographs so as to prevent cross-contamination. Avoid contamination of developing equipment.

Parenteral Medications
Definition: Medications that are injected into the body Cases of disease transmission have been reported Handle safely to prevent transmission of infections Parenteral medications are medications that are injected into the body. Cases of disease transmission following improper administration of parenteral medications have been reported in medical settings. For this reason it is critical that DHCP handle parenteral medications safely and use special precautions to prevent infection transmission.

Precautions for Parenteral Medications
IV tubings, bags, connections, needles, and syringes are single-use, disposable Single dose vials Do not administer to multiple patients even if the needle on the syringe is changed Do not combine leftover contents for later use Precautions to prevent disease transmission associated with the use of parenteral medications include: Treat fluid infusion and administration sets, including IV tubings, bags, connections, needles, and syringes as single-patient, disposable. Regarding single-dose vials: Do not administer to multiple patients even if the needle on the syringe is changed. Use single-dose instead of multi-dose vials whenever possible. Do not combine leftover contents for later use. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Single-Use (Disposable) Devices
Intended for use on one patient during a single procedure Usually not heat-tolerant Cannot be reliably cleaned Examples: Syringe needles, prophylaxis cups, and plastic orthodontic brackets A single-use device, also referred to as a disposable device, is intended for use on one patient. It was never intended to be cleaned, disinfected, or sterilized and used on another patient. Single-use devices used in dentistry are usually not heat tolerant and cannot be reliably cleaned. Examples of such items include syringe needles, prophylaxis cups and brushes, and plastic orthodontic brackets.

Preprocedural Mouth Rinses
Antimicrobial mouth rinses prior to a dental procedure Reduce number of microorganisms in aerosols/spatter Decrease the number of microorganisms introduced into the bloodstream Unresolved issue–no evidence that infections are prevented Preprocedural mouth rinsing is the use of an antimicrobial mouth rinse by the patient prior to a dental procedure. These mouth rinses can contain, for example, chlorhexidine gluconate, essential oils, and povidine-iodine. Studies have shown that preprocedural mouth rinses can reduce the number of aerosolized bacteria, and in some cases, the number of bacteria introduced into the bloodstream. However, there is no scientific evidence that this practice can prevent clinical infections among patients or DHCP. Although there is no harm in using preprocedural mouth rinses because of the lack of evidence that clinical infections are prevented, no recommendation is made.

Oral Surgical Procedures
Present a risk for microorganisms to enter the body Involve the incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity Examples include biopsy, periodontal surgery, implant surgery, apical surgery, and surgical extractions of teeth The oral cavity is colonized by many types and large numbers of microorganisms. Surgical procedures present an opportunity for these microorganisms to enter the bloodstream and other normally sterile areas of the mouth. Entry of microorganisms into bone and subcutaneous tissue may increase the potential for localized or systemic infection. CDC recommendations define oral surgical procedures as those that “involve the incision, excision, or reflection of tissue that exposes normally sterile areas of the oral cavity.” Examples include biopsy, periodontal surgery, implant surgery, apical surgery, and surgical extractions of teeth, defined as the removal of erupted or nonerupted teeth requiring elevation of mucoperiosteal flap, removal of bone, or sectioning of teeth and suturing if needed.

Precautions for Surgical Procedures
Sterile Surgeon’s Gloves Surgical Scrub A higher level of infection control is warranted when performing surgical procedures and includes the following: Surgical handscrub using an antimicrobial agent. Use of sterile surgeon’s gloves. Use of sterile irrigating solutions. The latter includes delivery systems that bypass the dental unit, such as sterile bulb syringes or sterile injection syringes. Photo credit (top left and at right): U.S.A.F. Dental Investigation Service, Great Lakes, IL. Photo credit (center): Eve Cuny, University of the Pacific School of Dentistry, San Francisco, CA.. Sterile Irrigating Solutions

Handling Biopsy Specimens
Place biopsy in sturdy, leakproof container Avoid contaminating the outside of the container Label with a biohazard symbol To protect the people handling and transporting biopsy specimens, each specimen must be placed in a sturdy, leakproof container with a secure lid to prevent leakage during transport. Care should be taken when collecting the specimen to avoid contaminating the outside of the container. If the outside of the container becomes visibly contaminated, it should be cleaned and disinfected or placed in an leakproof bag. The container also must be labeled with a biohazard symbol. Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.

Extracted Teeth Considered regulated medical waste
Do not incinerate extracted teeth containing amalgam Clean and disinfect before sending to lab for shade comparison Can be given back to patient Extracted teeth that are being discarded are considered infectious and should be treated as regulated medical waste. Extracted teeth containing amalgam should not be placed in a medical waste container that uses an incinerator for final disposal. State and local regulations should be consulted regarding disposal of amalgam. Extracted teeth used for shade comparison should be cleaned and the surface disinfected with an intermediate-level EPA-registered hospital grade disinfectant before sending to the laboratory. If patients request their own extracted teeth, the tooth fairy wins: OSHA regulations no longer apply once the tooth has been returned to the patient. However, for the safety of others who may come into contact with the tooth, it should be cleaned and disinfected before it is returned to the patient.

Handling Extracted Teeth in Educational Settings
Remove visible blood and debris Maintain hydration Autoclave (teeth with no amalgam) Use Standard Precautions Extracted teeth are occasionally collected and used for preclinical educational training. Extracted teeth should be cleaned of visible blood and debris and kept hydrated in tap water or saline. Be sure to use a sturdy, leakproof container if transporting and label the container with a biohazard symbol. Using teeth without amalgam is preferred because teeth can be safely autoclaved. If extracted teeth that contain amalgam must be used, DO NOT heat sterilize since this will produce harmful mercury vapors. Instead, immerse in 10% formalin for 2 weeks before use. Even though the inside of the pulp chamber is now safe to touch, CDC suggests that students use Standard Precautions, because preclinical exercises should simulate clinical practice.

Laser/Electrosurgery Plumes and Surgical Smoke
Destruction of tissue creates smoke that may contain harmful by-products Infectious materials (HSV, HPV) may contact mucous membranes of nose No evidence of HIV/HBV transmission Need further studies Lasers or electrosurgical units can cause thermal destruction of tissue and create a smoke by-product containing toxic gases and vapors such as benzene; dead and live cellular material (including blood fragments), and viruses. One concern is that aerosolized infectious material, such as herpes simplex virus (HSV) and human papillomavirus (HPV) in the laser plume may contact the nasal mucosa of the laser operator and nearby DHCP. No evidence exists that HIV or HBV have been transmitted via aerosolization and inhalation. Until studies have fully evaluated the risk for DHCP from exposure to laser plumes and electrosurgery smoke, it might be practical to follow National Institute of Occupational Safety and Health (NIOSH) recommendations (see guidelines). Use of precautions beyond Standard Precautions is an unresolved issue in dentistry.

Dental Laboratory Dental prostheses, appliances, and items used in their making are potential sources of contamination Handle in a manner that protects patients and DHCP from exposure to microorganisms Dental prostheses, such as crowns, full and partial dentures, orthodontic appliances, and items used in their fabrication are potential sources of contamination in the dental laboratory. As such, they should be handled in a manner that protects patients and DHCP from exposure to microorganisms.

Dental Laboratory Clean and disinfect prostheses and impressions
Wear appropriate PPE until disinfection has been completed Clean and heat sterilize heat-tolerant items used in the mouth Communicate specific information about disinfection procedures Prostheses, orthodontic appliances, and impressions should be cleaned, disinfected with an intermediate-level disinfectant, and rinsed before and after being manipulated. Wear gloves and other appropriate personal protective equipment (PPE) until disinfection has been completed. Clean and heat sterilize heat-tolerant items used in the mouth. Communicate specific information about disinfection procedures; personnel in both the dental office and the laboratory should ensure that the other knows what has occurred.

Transmission of Mycobacterium tuberculosis
Spread by droplet nuclei Immune system usually prevents spread Bacteria can remain alive in the lungs for many years (latent TB infection) Mycobacterium tuberculosis (TB) is spread from person to person through the air. When a person with pulmonary or laryngeal TB coughs or sneezes, tiny particles, known as droplet nuclei, are expelled into the air. The particles are an estimated 1-5 μm in size, and normal air currents can keep them airborne for prolonged periods of time and spread them throughout a room or building. Infection may occur when a person inhales droplet nuclei containing TB organisms. During the first few weeks after infection, organisms can spread from the initial location in the lungs to the lymph nodes in the center of the chest and then to other parts of the body by way of the bloodstream. Within 2 to 12 weeks, the body's immune system usually prevents further multiplication and spread, although they can remain alive in the lungs for years. This condition is referred to as latent TB infection. Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.

Risk of TB Transmission in Dentistry
Risk in dental settings is low Only one documented case of transmission Tuberculin skin test conversions among DHP are rare Overall, the risk for transmission of TB in most dental settings is quite low. There has been only one case report of transmission of tuberculosis bacteria from an infected dentist to patients, reportedly transmitted by direct inoculation of extraction sites through the dentist's fingers (Smith WH, Davies D, Mason KD, Onions JP: Intraoral and pulmonary tuberculosis following dental treatment. Lancet 1982;1:842-4). In addition, tuberculin skin test conversions among DHCP are rare, even among populations of dentists at high risk for exposure to TB patients.

Preventing Transmission of TB in Dental Settings
Assess patients for history of TB Defer elective dental treatment If patient must be treated: DHCP should wear face mask Separate patient from others/mask/tissue Refer to facility with proper TB infection control precautions Periodic updates of medical histories should include questions concerning history of TB exposure, infection or (current or past) treatment for active TB, and symptoms consistent with TB. Elective dental treatment should be deferred for any patient suspected or known to have active TB until they have been evaluated by medical personnel. DHCP should wear a face mask (surgical) or N-95 respirator for all patient contact. Any patient with suspected or possible infectious TB should be separated from other patients or DHCP, given a surgical mask to wear, and provided with tissues for coughing or sneezing. Refer the patient to a facility with proper TB infection control precautions for medical evaluation or urgent dental treatment. If you are in an office or facility that will provide dental treatment for patients with TB, additional precautions are necessary. Refer to CDC Guidelines for Preventing the Transmission of MTB in Health-care Facilities. MMWR 1994;43(No. RR-13) Photo credit: Centers for Disease Control and Prevention.

Creutzfeldt-Jakob Disease (CJD) and other Prion Diseases
A type of a fatal degenerative disease of central nervous system Caused by abnormal “prion” protein Human and animal forms Long incubation period One case per million population worldwide Creutzfeldt-Jacob Disease (CJD) is a rare, fatal disease of the central nervous system characterized by rapid, progressive dementia and other sensory and motor disturbances. CJD is thought to be caused by small, proteinaceous agents referred to as prions. Prions occur naturally in mammals and birds but turn destructive when they become folded in a way that changes how they react with other brain chemicals. CJD has an extremely long incubation period and is fairly rare–only one case per million worldwide.

New Variant CJD (vCJD) Variant CJD (vCJD) is the human version of Bovine Spongiform Encephalopathy (BSE) Case reports in the UK, Italy, France, Ireland, Hong Kong, Canada One case report in the United States – former UK resident A new form of CJD, known as variant CJD, was reported in 1996 in the United Kingdom (UK) where an outbreak of BSE had been occurring among cattle since the early 1980s. Laboratory tests have shown a strong similarity between the prions causing BSE and vCJD. Although specific foods have not been identified, transmission is believed to occur primarily by processed food items that contain infectious bovine tissues such as brain or spinal cord. Most cases of vCJD have been reported from the UK, as well as a few cases from Italy, France, Ireland, Hong Kong, and Canada. One case has been reported from the U.S. in The patient had grown up in the UK when the BSE outbreak was increasing and when the risk for human exposure to BSE was probably at its peak.

Infection Control for Known CJD or vCJD Dental Patients
Use single-use disposable items and equipment Consider items difficult to clean (e.g., endodontic files, broaches) as single-use disposable Keep instruments moist until cleaned Clean and autoclave at 134°C for 18 minutes Do not use flash sterilization Until additional scientific information is available regarding the transmissibility of CJD or vCJD, special precautions in addition to Standard Precautions, may be indicated when treating the known CJD or vCJD patient. A list of such precautions is provided for consideration without recommendation. Use single-use disposable items and equipment. Consider items that are difficult to clean (e.g., endodontic files, broaches, carbide and diamond burs) as single-use, disposable and discard after one use. Keep instruments moist until cleaned and decontaminated. Clean thoroughly and steam autoclave in a prevacuum sterilizer at 134°C for 18 minutes. This is the least stringent of a list of sterilization methods offered by WHO. Do not use flash sterilization for reprocessing instruments or devices.

Program Evaluation Develop standard operating procedures
“Systematic way to improve (infection control) procedures so they are useful, feasible, ethical, and accurate” Develop standard operating procedures Evaluate infection control practices Document adverse outcomes Document work-related illnesses Monitor health care-associated infections Program evaluation is an essential component of an infection control program. The CDC Guidelines describe program evaluation as a “systematic way to ensure that infection control procedures are useful, feasible, ethical, and accurate.” A successful infection-control program depends on: Developing standard operating procedures. Evaluating practices. Routinely documenting adverse outcomes (e.g., occupational exposures to blood) and work-related illnesses in DHCP. Monitoring health care–associated infections in patients.

Infection Control Program Goals
Provide a safe working environment Reduce health care-associated infections Reduce occupational exposures The goal of an infection control program is to provide a safe working environment for DHCP and their patients. We can accomplish this by adopting measures that will reduce health care-associated infections among patients and occupational exposures among DHCP.

Program Evaluation Strategies and Tools
Periodic observational assessments Checklists to document procedures Routine review of occupational exposures to bloodborne pathogens Strategies and tools to evaluate the infection control program can include the following: Periodic observational assessments. Checklists to document procedures. Routine review of occupational exposures to bloodborne pathogens. Constructive review and feedback to staff.

“Program evaluation provides an opportunity to identify and change inappropriate practices, thereby improving the effectiveness of your infection control program.” END Check back periodically on the CDC Oral Health Web site for updates, additional materials, and other useful oral health information. Thank you for visiting this site.

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