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Géza T. Terézhalmy, D.D.S.,M.A.Géza T. Terézhalmy, D.D.S.,M.A.
Professor and Dean EmeritusProfessor and Dean Emeritus
School of Dental MedicineSchool of Dental Medicine
Case Western Reserve UniversityCase Western Reserve University
Cleveland, OhioCleveland, Ohio
[email protected]@case.edu
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Preprocedural antimicrobial rinses Procedures shall be performed in such a
manner as to minimize splash, spattering, and aerosols Patients MAY rinse with chlorhexidine gluconate-, or
an essential oil-, or povidone iodine-containing mouthwash
01/01/2010 Terezhalmy 2
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01/01/2010 Terezhalmy 3
0.12% Chlorhexidine gluconate
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01/01/2010 Terezhalmy 4
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01/01/2010 Terezhalmy 5
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01/01/2010 Terezhalmy 6
Disposition of reusable patient-care items Critical
Penetrate soft tissue and bone during their intended use
Semi-critical Touch mucous membranes or non-intact skin during
their intended use
Non-critical Contact only intact skin during their intended use
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01/01/2010 Terezhalmy 7
Critical and semi-critical items MUST be cleaned and MUST be heat sterilized Heat-sensitive items MUST be cleaned and
MUST be sterilized using Ethylene oxide OR FDA-registered sterilants
e.g., glutaraldehyde, glutaraldehyde with phenol, hydrogen peroxide, or hydrogen peroxide with peracetic acid
http://www.epa.gov/oppad001/chemregindex.htmhttp://www.epa.gov/oppad001/chemregindex.htm
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01/01/2010 Terezhalmy 8
Central instrument processing area Receiving and cleaning
Clean instruments using an ultrasonic system with a strainer type basket
Visually inspect instruments are for residual debris and damage
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01/01/2010 Terezhalmy 9
Preparation and packaging Assemble cassettes, tray sets, or packs with hinged
instruments unlocked and open Place an internal or an external chemical indicator
in or on each cassette, tray set, or pack Date all cassettes, tray sets, or wrapped packs
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01/01/2010 Terezhalmy 10
Sterilization MUST use an FDA cleared sterilizer
Load cassettes, tray sets, or packs according to manufacturer’s recommendations
Set cycle time, temperature, and pressure according to manufacturer’s recommendation
Allow packages to cool and dry before removing from the sterilizer
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01/01/2010 Terezhalmy 11
Storage MUST be a clean, enclosed, and dry area
Cassettes, tray sets, or packs remain sterile indefinitely
Instruments in compromised cassettes, tray sets, or packs MUST be re-cleaned, re-wrapped, and re-sterilized
Cassettes, tray sets, or packs MUST be delivered to the operatories in a manner that maintains sterility until instruments are used
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01/01/2010 Terezhalmy 12
Monitoring the sterilization process Mechanical: each load
Assess the cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer
Chemical: each load Use time- and temperature-sensitive internal or
external indicators to assess physical conditions during the sterilization process
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01/01/2010 Terezhalmy 13
Biological: weekly Place a spore strip or vial inside one of the
cassettes, tray sets, or packs Place the cassette, tray set, or pack in the center of
the load A strip or vial, which is not heat processed, is used
as a control Maintain a record of the weekly results
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01/01/2010 Terezhalmy 14
Quality assurance procedures following mechanical, chemical, or biological failure Secure sterilizer Make log entry Take corrective action Retest sterilizer using a biological monitor Suspect loads dating back to the last
negative biological test MUST be re-called, re-wrapped, and re-sterilized
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01/01/2010 Terezhalmy 15
Non-critical items MUST be cleaned MUST be disinfected
EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim e.g., chlorine-containing products, quaternary
ammonium compounds with alcohol, phenolics, or iodophors
http://www.epa.gov/oppad001/chemregindex.htmhttp://www.epa.gov/oppad001/chemregindex.htm
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01/01/2010 Terezhalmy 16
Disposition of single-use patient-care items Disposable sharps
MUST be removed from cassettes, tray sets, or packs in the patient treatment area
MUST be placed in a puncture-resistant, leak-proof, labeled/color-coded container in the patient treatment area
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01/01/2010 Terezhalmy 17
Other contaminated single-use items Blood- or saliva-soaked cotton rolls, gauze, pellets,
tissue coverings (packs) MUST be placed in small biohazard bag
Disposed of into a centralized Regulated Waste Receptacle after each appointment
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Handpieces MUST be
sterilized between patients
Clean, sterilize, and maintain each handpiece according to manufacturer’s recommendations
01/01/2010 Terezhalmy 18
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Saliva ejectors Backflow with low-volume suction
Do not place any portion of the suction tubing holding the tip above the patient’s mouth
Do not use simultaneously with high-volume evacuation
Do not have patient create a seal around the saliva ejector
01/01/2010 Terezhalmy 19
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Dental radiography Cover clinical contact areas with protective
barrier Hand hygiene and PPE before initiating the
radiographic process Use disposable or heat-sterilized film-holding
and positioning devices Use FDA-cleared film barrier pouches Remove film packet from pouch and place in a
clean container Remove gloves, wash hands, and transport
the exposed films to the dark room01/01/2010 Terezhalmy 20
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Panoramic radiography Place disposable plastic cover over bite
guide before the patient is positioned in the machine
If no barrier is used, use a sterile bite guard Digital radiography sensors and other
high-technology instruments Should be cleaned and sterilized according
to manufacturer’s recommendations
01/01/2010 Terezhalmy 21
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Oral surgical procedures Perform surgical hand antisepsis Don sterile surgeon’s gloves Use only sterile saline or sterile water as a
coolant or irrigant Laser plumes or surgical smoke may contain
aerosolized infectious material Follow standard precautions
01/01/2010 Terezhalmy 22
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Biopsy Place specimen in leak-proof, puncture-
resistant, closed container with a secure lid for storage and transportation If container becomes visibly contaminated, clean it,
disinfect it, or placed in an impervious bag Label with the biohazard symbol
01/01/2010 Terezhalmy 23
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Extracted teeth If sent to the laboratory for shade and size
comparison Clean and disinfect with an EPA-registered,
intermediate-level hospital disinfectant claiming tuberculocidal activity, e.g., chlorine-containing products, quaternary
ammonium compounds with alcohol, phenolics, or iodophors
With dental amalgams Consult state and local regulations regarding
disposal of amalgam
01/01/2010 Terezhalmy 24
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Extracted teeth returned to the patient Clean and disinfect
Extracted teeth in educational settings Cleaned of visible blood and gross debris and
maintained in a hydrated state (e.g., water or saline) in a well constructed closed container
The teeth are heat-sterilized (autoclave cycle for 40 minutes) before clinical exercises or study
Teeth with amalgam restorations are disinfected by immersion in 10% formalin solution for 2 weeks
01/01/2010 Terezhalmy 25
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Laboratory asepsis Environmental surfaces
Barrier-protected or cleaned and disinfected
Use PPE when handling items in the laboratory until they have been disinfected
Impressions, prostheses, and other devices Rinsed under running tap water an disinfected with
EPA-registered intermediate level disinfectant with tuberculocidal claim
01/01/2010 Terezhalmy 26
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Burs, polishing points, rag wheels, and laboratory knives Cleaned and then heat-sterilized or disinfected
following manufacturer’s recommendations or discarded
Metal impression trays and face bow forks Cleaned and heat sterilized
Articulators, case pans, and water pans Cleaned and disinfected according to
manufacturer’s recommendations
01/01/2010 Terezhalmy 27
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Dental unit waterlines Must meet the regulatory standard for safe
drinking water <500 CFU/mL
Self-contained water systems in combination with a chemical germicide Follow the recommendations for monitoring water
quality provided by the manufacturer of the unit or waterline treatment product
Dental devices connected to the water system Operated for 20-30 seconds after each patient to
discharge water and air
01/01/2010 Terezhalmy 28
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Boil-water advisory Do not deliver water from the public water system For hand hygiene use an alcohol-based hand rub or
bottled water When the boil-water advisory is lifted disinfect
dental waterlines according to manufacturer’s recommendations
01/01/2010 Terezhalmy 29
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Dental records Charts are notated and radiographs viewed
Before gloving After the gloves are removed and the hands are
washed While wearing cover gloves
01/01/2010 Terezhalmy 30
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01/01/2010 Terezhalmy 31
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01/01/2010 Terezhalmy 32
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01/01/2010 Terezhalmy 33
Environmental infection control Provides for a safer work environment
Environmental surfaces Clinical contact surfaces
May serve as reservoirs for microbial contamination
Housekeeping surfaces Do not contribute to significant cross-
contamination
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01/01/2010 Terezhalmy 34
Clinical contact surfaces Cover with materials impervious to moisture Coverings are removed and discarded
between patients Surfaces are examined for visible soil Soiled surfaces are cleaned and disinfected
with an EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim
General cleaning and disinfection is performed at the end of daily work activities regardless of barrier protection
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01/01/2010 Terezhalmy 35
Housekeeping surfaces Walls, window drapes, and other vertical
surfaces Unless visibly clean, cleaning is unnecessary
Floors and sinks Clean regularly with a detergent and water OR An EPA-registered hospital disinfectant/detergent
designed for general housekeeping
Carpeting and cloth furnishing Cannot be reliably disinfected
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01/01/2010 Terezhalmy 36
Spills and spatter of blood or OPIM Visible organic material is removed using
disposable paper towels Discard in a leak-proof, biohazard-labeled
container Contaminated surface is cleaned with a
detergent and water AND Disinfected with an EPA-registered
intermediate-level hospital disinfectant with tuberculocidal claim
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01/01/2010 Terezhalmy 37
Biohazard communication Labels
Fluorescent orange or orange red, with lettering or symbols or a contrasting color
Affixed to containers or regulated waste by string, wire, adhesive, or other methods
Red bags or red containers may be substituted for labels
Decontaminated regulated waste is not labeled or color-coded
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01/01/2010 Terezhalmy 38
Post-exposure management and follow-up Establishes policies and practices to
reduce the risk of post-exposure infection
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01/01/2010 Terezhalmy 39
Post-exposure protocol Immediately after an exposure incident
Wash area of injury with soap and water Report the exposure incident immediately Complete the Uniform Needlestick and Sharp Object
Injury Report Form
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01/01/2010 Terezhalmy 40
Within 2 hours of an exposure incident Arrange for a post-exposure evaluation by a
physician A copy of the employee’s medical record A copy of the Uniform Needlestick and Sharp
Object Injury Report Any information available about the source
individual
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01/01/2010 Terezhalmy 41
As soon as feasible after an exposure incident If the source person can be identified and with
his/her consent The source person’s blood is tested for HBV, HCV,
and HIV Results are made available to the employee Applicable privacy laws and regulations apply
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01/01/2010 Terezhalmy 42
Post-exposure management and prophylaxis According to latest CDC recommendations
A written report from the consultant physician is obtained within 15 days of the post-exposure evaluation
Written report becomes part of the OHCW’s medical record
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01/01/2010 Terezhalmy 43
Medical record Maintained on all personnel
Name and SSN Documentation of vaccination status
A copy of the Mandatory Hepatitis B Vaccination Declination Form (if applicable)
A copy of all results of examinations, medical tests, and other post-exposure follow-up data
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01/01/2010 Terezhalmy 44
The medical record is confidential Its content is not disclosed except as required by
law
The medical record is made available to the OHCW for examination A copy is provided upon request
The medical record is maintained for at least the duration of employment plus 30 years
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01/01/2010 Terezhalmy 45
Administrative controls Establish exclusion policies from work
and patient care
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01/01/2010 Terezhalmy 46
Minimize latex-related health problems among OHCWs and patients Reduce exposure to latex-containing
materials Train and educate OHCWs to recognize signs
and symptoms of latex-related adverse effects Monitor signs and symptoms of latex-related
adverse effects among OHCWs and patient
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01/01/2010 Terezhalmy 47
Minimize the exposure of OHCWs with acute or chronic diseases to patients i.e., to patients who have been diagnosed
with a transmissible infectious disease OHCWs shall consult with their personal physician
Determine if their condition(s) might affect their ability to safely perform their duties
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01/01/2010 Terezhalmy 48
Minimize the exposure of patients to OHCWs i.e., to OHCWs who have been exposed to or
have been diagnosed with an infectious disease Restrictions based on the mode of transmission and
the period of infectivity of the pathogen
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Infectious state Restrictions
HBV
OHCWs with acute or chronic HBsAg who do
not perform exposure-prone
procedures
No restrictions
OHCWs with acute or chronic
HBeAg who perform
exposure-prone procedures
Do not perform exposure-prone procedures until counsel from a review panel has been sought
(State Dental Board)
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Infectious state Restrictions
HCVAcute or chronic infection
No restrictions
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Infectious state Restrictions
HIV HIV infection AIDS
Do not perform exposure-prone procedures until
counsel from a review panel has been sought
(State Dental Board)
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SUMMARYSUMMARYGood structureGood structure
Increases the likelihood of a good process
Good process Good process Increases the likelihood of a good outcome
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References1.Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64004-64182.2.CDC. Guidelines for infection control in dental health-care settings-2003. MMWR 2003;52(No. RR-17):1-68.3.Terezhalmy GT. Clinical practice guidelines for an infection control/exposure control program in the oral healthcare setting. Access PDF file at dentalcare.com 4.Huber MA, Terezhalmy GT. Hepatotropic viruses: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com
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5. Huber MA, Terezhalmy GT. HIV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com
6. Huber MA, Terezhalmy GT. Measles, mumps, rubella: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com
7. Huber MA, Terezhalmy GT: HSV and VZV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com
8. Porteous NB, Terezhalmy GT: Tuberculosis: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com
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9. Huber MA, Terezhalmy GT: Mandated and highly recommended and highly recommended vaccines for oral health care. Access PDF file at dentalcare.com
10. Huber MA, Terezhalmy GT. Adverse reactions to latex products: preventive and therapeutic strategies. Access PDF file at dentalcare.com
11. Terezhalmy GT, Huber MA. Hand hygiene: infection control/exposure control issues for oral healthcare setting. Access PDF file at dentalcare.com
12. Terezhalmy GT, Huber MA. Environmental infection control in oral healthcare settings. Access PDF file at dentalcare.com