ADVANCED POWER DRIVEN SCALERS ULTRASONIC INSTRUMENTATION Presented by Tammy Maahs, RDH, BSDH DH 220...

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 18-42 thousand cycles per second (cps). Piezoelectric Ultrasonic Scaler: activated by dimensional changes in quartz or crystal transducers (25-50K). Sonic Scaler: air-driven; only 2000-6300 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 ( 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 movementincreasing the ability to remove deposits. OPTIMUM frequency is 18-32 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. The higher the frequency, the shorter the active tip area.

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).

Care & Maintenance of Inserts 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.

Care & Maintenance of Inserts 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 thatmagnetostrictive (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. ~http://www.crdha.ca/portals/0/newletters/InTouch_Jan06.pdf

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

Protg Ultrasonics by Discus Dental Protg 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 SofTip TM 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 ObliqueOblique/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

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 unitknown 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 tappingstrokes 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.

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

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

Periodontal Therapy Options 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

Root Morphology/ Instrumentation 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

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

Root Morphology/ Instrumentation 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

Root Morphology/ Instrumentation 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 molars distal root The Gracey 13/14 can access the distal of the maxillary first molars 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.

Dentinal Hypersensitivity 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.

Dentinal Hypersensitivity 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)

Brnnstrms 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 Tomes 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 authors (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 productpotassium 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

NUPRO Sensodyne Prophylaxis Paste with Novamin Made by Dentsply (makers of NuPro prophy paste) Desensitizing ingredient is NovaMin (calcium sodium phophosilicateinduces the formation of new hydroxyapatite) Low in abrasion Available in stain removal and polishing grits

NUPRO Sensodyne Prophylaxis Paste with Novamin (Formerly NUSolutions)

NUPRO Sensodyne Prophylaxis Paste with Novamin 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 phophosilicateinduces 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: dont 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 employees 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 persons 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 defensemust 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 clinicians 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

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 individuals 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 ones 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) http://www.cdc.gov/oralhealth/ 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. 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 Guidelines for Infection Control in Dental Health- Care Settings2003. MMWR 2003; Vol. 52, No. RR-17. 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

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

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

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

Chain of Infection Pathogen Source ModeEntry Susceptible Host

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

Elements of Standard Precautions Handwashing Use of gloves, masks, eye protection, and gowns Patient care equipment Environmental surfaces Injury prevention

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

Bloodborne Pathogens

Preventing Transmission of Bloodborne Pathogens 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)

Potential Routes of Transmission of Bloodborne Pathogens Patient DHCP 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

Average Risk of Bloodborne Virus Transmission after Needlestick SourceRisk 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)

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

Estimated Incidence of HBV Infections Among HCP and General Population, United States, 1985-1999 Health Care Personnel General U.S. Population

Source: Cleveland et al., JADA 1996;127:1385-90. Personal communication ADA, Chakwan Siew, PhD, 2005. Percent HBV Infection Among U.S. Dentists Yea r

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 3rd dose

Transmission of HBV from Infected DHCP to Patients Nine clusters of transmission from dentists and oral surgeons to patients, 19701987 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

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 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

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)

Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS CDC Database as of December 2002 * 3 dentists, 1 oral surgeon, 2 dental assistants DocumentedPossible Dental Worker 0 6 * Nurse24 35 Lab Tech, clinical16 17 Physician, nonsurgical 6 12 Lab Tech, nonclinical 3 Other 8 69 Total57139

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;337:1485-90.

Characteristics of Percutaneous Injuries Among DHCP Reported frequency among general dentists has declined Caused by burs, syringe needles, other sharps Occur outside the patients mouth Involve small amounts of blood Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire

Exposure Prevention Strategies Engineering controls Work practice controls Administrative controls

Engineering Controls Isolate or remove the hazard Examples: Sharps container Medical devices with injury protection features (e.g., self-sheathing needles)

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

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)

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

Wound management Exposure reporting Assessment of infection risk Type and severity of exposure Bloodborne status of source person Susceptibility of exposed person Post-exposure Management

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

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)

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

Efficacy of Hand Hygiene Preparations in Reduction of Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub Source: http://www.cdc.gov/handhygiene/materials.htm

Alcohol-based Preparations 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 BenefitsLimitations

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

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

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

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

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!

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

Recommendations for Gloving Remove gloves that are torn, cut or punctured Do not wash, disinfect or sterilize gloves for reuse

Latex Hypersensitivity and Contact Dermatitis

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

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

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)

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

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

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

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

Automated Cleaning Ultrasonic cleaner Instrument washer Washer-disinfector

Manual Cleaning Soak until ready to clean Wear heavy-duty utility gloves, mask, eyewear, and protective clothing

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

Heat-Based Sterilization Steam under pressure (autoclaving) Gravity displacement Pre-vacuum Dry heat Unsaturated chemical vapor

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

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

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

Environmental Infection Control

Environmental Surfaces May become contaminated Not directly involved in infectious disease transmission Do not require as stringent decontamination procedures

Categories of Environmental Surfaces Clinical contact surfaces High potential for direct contamination from spray or spatter or by contact with DHCPs gloved hand Housekeeping surfaces Do not come into contact with patients or devices Limited risk of disease transmission

Clinical Contact Surfaces

Housekeeping Surfaces

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 manufacturers instructions for proper use of EPA-registered hospital disinfectants Do not use sterilant/high-level disinfectants on environmental surfaces

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

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

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

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

Dental Unit Waterlines, 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

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

Dental Water Quality For routine dental treatment, meet regulatory standards for drinking water.* *

Available DUWL Technology Independent reservoirs Chemical treatment Filtration Combinations Sterile water delivery systems

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

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

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 manufacturers instructions for cleaning, lubrication, and sterilization Do not use liquid germicides or ethylene oxide

Components of Devices Permanently Attached to Air and Waterlines Do not enter patients mouth but may become contaminated Use barriers and change between uses Clean and intermediate-level disinfect the surface of devices if visibly contaminated

Saliva Ejectors Previously suctioned fluids might be retracted into the patients mouth when a seal is created Do not advise patients to close their lips tightly around the tip of the saliva ejector

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

Parenteral Medications Definition: Medications that are injected into the body Cases of disease transmission have been reported Handle safely to prevent transmission of infections

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

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

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 issueno evidence that infections are prevented

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

Precautions for Surgical Procedures Sterile Irrigating Solutions Sterile Surgeons Gloves Surgical Scrub

Handling Biopsy Specimens Place biopsy in sturdy, leakproof container Avoid contaminating the outside of the container Label with a biohazard symbol

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

Handling Extracted Teeth in Educational Settings Remove visible blood and debris Maintain hydration Autoclave (teeth with no amalgam) Use Standard Precautions

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

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 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

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)

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

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

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

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

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 134C for 18 minutes Do not use flash sterilization

Program Evaluation 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

Infection Control Program Goals Provide a safe working environment Reduce health care-associated infections Reduce occupational exposures

Program Evaluation Strategies and Tools Periodic observational assessments Checklists to document procedures Routine review of occupational exposures to bloodborne pathogens

Program evaluation provides an opportunity to identify and change inappropriate practices, thereby improving the effectiveness of your infection control program.

ADVANCED POWER DRIVEN SCALERS ULTRASONIC INSTRUMENTATION Presented by Tammy Maahs, RDH, BSDH DH 220...

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