Guidelines for Infection Guidelines for Infection Control in Dental Health-Care Control in Dental Health-Care

SettingsSettings

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 Infection Control in Dental Health-Care Settings: An OverviewHealth-Care Settings: An Overview

Guidelines for Infection Control in Dental Health-Care Settings—2003. 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 RecommendationsCDC Recommendations

Improve effectiveness and impact of public health Improve effectiveness and impact of public health interventionsinterventions

Inform clinicians, public health practitioners, and the Inform clinicians, public health practitioners, and the publicpublic

Developed by advisory committees, ad hoc groups, Developed by advisory committees, ad hoc groups, and CDC staffand CDC staff

Based on a range of rationale, from systematic reviews Based on a range of rationale, from systematic reviews to expert opinionsto expert opinions

BackgroundBackground

Why Is Infection Control Important Why Is Infection Control Important in Dentistry?in Dentistry?

Both patients and dental health care personnel Both patients and dental health care personnel (DHCP) can be exposed to pathogens(DHCP) can be exposed to pathogens

Contact with blood, oral and respiratory secretions, Contact with blood, oral and respiratory secretions, and contaminated equipment occursand contaminated equipment occurs

Proper procedures can prevent transmission of Proper procedures can prevent transmission of infections among patients and DHCPinfections among patients and DHCP

Modes of TransmissionModes of Transmission

Direct contact with blood or body fluidsDirect contact with blood or body fluids

Indirect contact with a contaminated Indirect contact with a contaminated instrument or surfaceinstrument or surface

Contact of mucosa of the eyes, nose, or mouth Contact of mucosa of the eyes, nose, or mouth with droplets or spatterwith droplets or spatter

Inhalation of airborne microorganismsInhalation of airborne microorganisms

Chain of InfectionChain of Infection

Pathogen

Source

ModeEntry

Susceptible Host

Standard PrecautionsStandard Precautions

Apply to Apply to allall patients patients

Integrate and expand Universal Precautions Integrate and expand Universal Precautions to include organisms spread by blood and to include organisms spread by blood and also also

• Body fluids, secretions, and excretions except Body fluids, secretions, and excretions except sweat, whether or not they contain bloodsweat, whether or not they contain blood

• Non-intact (broken) skinNon-intact (broken) skin

• Mucous membranesMucous membranes

Elements of Standard PrecautionsElements of Standard Precautions

HandwashingHandwashing

Use of gloves, masks, eye protection, and Use of gloves, masks, eye protection, and gownsgowns

Patient care equipmentPatient care equipment

Environmental surfacesEnvironmental surfaces

Injury preventionInjury prevention

Personnel Health Personnel Health ElementsElements

Personnel Health Elements of an Personnel Health Elements of an Infection Control ProgramInfection Control Program

Education and trainingEducation and training

ImmunizationsImmunizations

Exposure prevention and postexposure managementExposure prevention and postexposure management

Medical condition management and work-related Medical condition management and work-related illnesses and restrictionsillnesses and restrictions

Health record maintenanceHealth record maintenance

Bloodborne PathogensBloodborne Pathogens

Preventing Transmission of Preventing Transmission of Bloodborne PathogensBloodborne Pathogens

Are transmissible in health care settingsAre transmissible in health care settings

Can produce chronic infectionCan produce chronic infection

Are often carried by persons unaware of their Are often carried by persons unaware of their infectioninfection

Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)

Potential Routes of Transmission Potential Routes of Transmission of Bloodborne Pathogensof Bloodborne Pathogens

Patient DHCP

DHCP Patient

Patient Patient

Factors Influencing Occupational Factors Influencing Occupational Risk of Bloodborne Virus InfectionRisk of Bloodborne Virus Infection

Frequency of infection among patientsFrequency of infection among patients

Risk of transmission after a blood Risk of transmission after a blood exposure (i.e., type of virus)exposure (i.e., type of virus)

Type and frequency of blood contactType and frequency of blood contact

Average Risk of Bloodborne Virus Average Risk of Bloodborne Virus Transmission after NeedlestickTransmission after Needlestick

SourceSource RiskRisk

HBVHBVHBsAgHBsAg++ and HBeAg and HBeAg++ 22.0%-31.0% clinical hepatitis; 37%-62% 22.0%-31.0% clinical hepatitis; 37%-62%

serological evidence of HBV infectionserological evidence of HBV infection

HBsAgHBsAg++ and HBeAg and HBeAg-- 1.0%-6.0% clinical hepatitis; 23%-37% 1.0%-6.0% clinical hepatitis; 23%-37% serological evidence of HBV infectionserological evidence of HBV infection

HCVHCV 1.8% (0%-7% range)1.8% (0%-7% range)

HIVHIV 0.3% (0.2%-0.5% range)0.3% (0.2%-0.5% range)

Concentration of HBV in Body FluidsConcentration of HBV in Body Fluids

HighHigh ModerateModerate Low/Not DetectableLow/Not Detectable

BloodBlood SemenSemen UrineUrine

SerumSerum Vaginal FluidVaginal Fluid FecesFeces

Wound exudatesWound exudates SalivaSaliva SweatSweat

TearsTears

Breast MilkBreast Milk

Estimated Incidence of HBV Infections Among Estimated Incidence of HBV Infections Among HCP and General Population, HCP and General Population,

United States, 1985-1999United States, 1985-1999

0

50

100

150

200

250

300

350

1985 1987 1989 1991 1993 1995 1997 1999

Year

Inci

den

ce p

er 1

00,0

00

Health Care Personnel

General U.S. Population

Source: Cleveland et al., JADA 1996;127:1385-90. Personal communication ADA, Chakwan Siew, PhD, 2005.

Per

cen

tHBV Infection Among U.S. DentistsHBV Infection Among U.S. Dentists

Year

0

2

4

6

8

10

12

14

16

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

Hepatitis B VaccineHepatitis B Vaccine

Vaccinate all DHCP who are at risk of Vaccinate all DHCP who are at risk of exposure to bloodexposure to blood

Provide access to qualified health care Provide access to qualified health care professionals for administration and professionals for administration and follow-up testingfollow-up testing

Test for anti-HBs 1 to 2 months after Test for anti-HBs 1 to 2 months after 3rd dose3rd dose

Transmission of HBV from Infected Transmission of HBV from Infected DHCP to PatientsDHCP to Patients

Nine clusters of transmission from dentists and oral Nine clusters of transmission from dentists and oral surgeons to patients, 1970–1987surgeons to patients, 1970–1987

Eight dentists tested for HBeAg were positiveEight dentists tested for HBeAg were positive

Lack of documented transmissions since 1987 may Lack of documented transmissions since 1987 may reflect increased use of gloves and vaccinereflect increased use of gloves and vaccine

One case of patient-to-patient transmission, 2003One case of patient-to-patient transmission, 2003

Occupational Risk of HCV Occupational Risk of HCV Transmission among HCPTransmission among HCP

Inefficiently transmitted by occupational Inefficiently transmitted by occupational exposuresexposures

Three reports of transmission from blood Three reports of transmission from blood splash to the eye splash to the eye

Report of simultaneous transmission of HIV Report of simultaneous transmission of HIV and HCV after non-intact skin exposureand HCV after non-intact skin exposure

HCV Infection in HCV Infection in Dental Health Care SettingsDental Health Care Settings

Prevalence of HCV infection among Prevalence of HCV infection among dentists similar to that of general population dentists similar to that of general population (~ 1%-2%) (~ 1%-2%)

No reports of HCV transmission from No reports of HCV transmission from infected DHCP to patients or from patient infected DHCP to patients or from patient to patient to patient

Risk of HCV transmission appears very lowRisk of HCV transmission appears very low

Transmission of HIV from Infected Transmission of HIV from Infected Dentists to PatientsDentists to Patients

Only one documented case of HIV Only one documented case of HIV transmission from an infected dentist to transmission from an infected dentist to patientspatients

No transmissions documented in the No transmissions documented in the investigation of 63 HIV-infected HCP investigation of 63 HIV-infected HCP (including 33 dentists or dental students)(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

Documented Possible

Dental Worker 0 6 *

Nurse 24 35

Lab Tech, clinical 16 17

Physician, nonsurgical 6 12

Lab Tech, nonclinical 3 –

Other 8 69

Total 57 139

Risk Factors for HIV Transmission after Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood Percutaneous Exposure to HIV-Infected Blood

CDC Case-Control StudyCDC Case-Control Study

Deep injuryDeep injury

Visible blood on deviceVisible blood on device

Needle placed in artery or veinNeedle placed in artery or vein

Terminal illness in source patientTerminal illness in source patient

Source: Cardo, et al., Source: Cardo, et al., N England J Medicine N England J Medicine 1997;337:1485-90.1997;337:1485-90.

Characteristics of Percutaneous Characteristics of Percutaneous Injuries Among DHCPInjuries Among DHCP

Reported frequency among general dentists has Reported frequency among general dentists has declineddeclined

Caused by burs, syringe needles, other sharps Caused by burs, syringe needles, other sharps

Occur outside the patient’s mouthOccur outside the patient’s mouth

Involve small amounts of bloodInvolve small amounts of blood

Among oral surgeons, occur more frequently Among oral surgeons, occur more frequently during fracture reductions and procedures during fracture reductions and procedures involving wireinvolving wire

Exposure Prevention StrategiesExposure Prevention Strategies

Engineering controlsEngineering controls Work practice controlsWork practice controls Administrative controlsAdministrative controls

Engineering ControlsEngineering Controls

Isolate or remove the hazard Isolate or remove the hazard

Examples:Examples:

• Sharps containerSharps container

• Medical devices with injury protection Medical devices with injury protection features (e.g., self-sheathing needles)features (e.g., self-sheathing needles)

Work Practice ControlsWork Practice Controls

Change the manner of performing tasksChange the manner of performing tasks

Examples include:Examples include:

• Using instruments instead of fingers to Using instruments instead of fingers to retract or palpate tissueretract or palpate tissue

• One-handed needle recappingOne-handed needle recapping

Administrative ControlsAdministrative Controls

Policies, procedures, and enforcement Policies, procedures, and enforcement measuresmeasures

Placement in the hierarchy varies by the Placement in the hierarchy varies by the problem being addressedproblem being addressed

• Placed before engineering controls for Placed before engineering controls for airborne precautions (e.g., TB) airborne precautions (e.g., TB)

Post-exposure Management Post-exposure Management ProgramProgram

Clear policies and proceduresClear policies and procedures

Education of dental health care personnel Education of dental health care personnel (DHCP) (DHCP)

Rapid access toRapid access to

• Clinical careClinical care

• Post-exposure prophylaxis (PEP)Post-exposure prophylaxis (PEP)

• Testing of source patients/HCPTesting of source patients/HCP

Wound managementWound management Exposure reportingExposure reporting Assessment of infection riskAssessment of infection risk

• Type and severity of exposureType and severity of exposure

• Bloodborne status of source personBloodborne status of source person

• Susceptibility of exposed personSusceptibility of exposed person

Post-exposure ManagementPost-exposure Management

Hand HygieneHand Hygiene

Why Is Hand Hygiene Important?Why Is Hand Hygiene Important?

Hands are the most common mode of Hands are the most common mode of

pathogen transmissionpathogen transmission

Reduce spread of antimicrobial resistanceReduce spread of antimicrobial resistance

Prevent health care-associated infectionsPrevent health care-associated infections

Hands Need to be Cleaned WhenHands Need to be Cleaned When

Visibly dirtyVisibly dirty

After touching contaminated After touching contaminated objects with bare handsobjects with bare hands

Before and after patient Before and after patient treatment (before glove treatment (before glove placement and after glove placement and after glove removal)removal)

Hand Hygiene DefinitionsHand Hygiene Definitions

HandwashingHandwashing• Washing hands with plain soap and waterWashing hands with plain soap and water

Antiseptic handwashAntiseptic handwash• Washing hands with water and soap or other detergents Washing hands with water and soap or other detergents

containing an antiseptic agentcontaining an antiseptic agent

Alcohol-based handrubAlcohol-based handrub• Rubbing hands with an alcohol-containing preparationRubbing hands with an alcohol-containing preparation

Surgical antisepsisSurgical antisepsis• Handwashing with an antiseptic soap or an alcohol-based Handwashing with an antiseptic soap or an alcohol-based

handrub before operations by surgical personnelhandrub before operations by surgical personnel

Efficacy of Hand Hygiene Efficacy of Hand Hygiene Preparations in Reduction of BacteriaPreparations in Reduction of Bacteria

Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

Source: http://www.cdc.gov/handhygiene/materials.htm

Alcohol-based PreparationsAlcohol-based Preparations

Rapid and effective Rapid and effective antimicrobial actionantimicrobial action

Improved skin conditionImproved skin condition

More accessible than More accessible than sinkssinks

Cannot be used if hands Cannot be used if hands are visibly soiledare visibly soiled

Store away from high Store away from high temperatures or flamestemperatures or flames

Hand softeners and Hand softeners and glove powders may glove powders may “build-up”“build-up”

Benefits Limitations

Special Hand Hygiene ConsiderationsSpecial Hand Hygiene Considerations

Use hand lotions to prevent skin dryness Use hand lotions to prevent skin dryness

Consider compatibility of hand care products with Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may gloves (e.g., mineral oils and petroleum bases may cause early glove failure)cause early glove failure)

Keep fingernails shortKeep fingernails short

Avoid artificial nails Avoid artificial nails

Avoid hand jewelry that may tear glovesAvoid hand jewelry that may tear gloves

Personal Protective Personal Protective EquipmentEquipment

Personal Personal Protective Protective EquipmentEquipment

A major component of Standard PrecautionsA major component of Standard Precautions

Protects the skin and mucous membranes Protects the skin and mucous membranes from exposure to infectious materials in spray from exposure to infectious materials in spray or spatter or spatter

Should be removed when leaving treatment Should be removed when leaving treatment areasareas

Masks, Protective Eyewear, Face ShieldsMasks, Protective Eyewear, Face Shields

Wear a surgical mask and either eye protection with Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouthmembranes of the eyes, nose, and mouth

Change masks between patientsChange masks between patients

Clean reusable face protection between patients; if Clean reusable face protection between patients; if visibly soiled, clean and disinfectvisibly soiled, clean and disinfect

Protective ClothingProtective Clothing

Wear gowns, lab coats, or Wear gowns, lab coats, or uniforms that cover skin and uniforms that cover skin and personal clothing likely to become personal clothing likely to become soiled with blood, saliva, or soiled with blood, saliva, or infectious materialinfectious material

Change if visibly soiledChange if visibly soiled

Remove all barriers before leaving Remove all barriers before leaving the work areathe work area

GlovesGloves

Minimize the risk of health care personnel Minimize the risk of health care personnel acquiring infections from patientsacquiring infections from patients

Prevent microbial flora from being transmitted Prevent microbial flora from being transmitted from health care personnel to patientsfrom health care personnel to patients

Reduce contamination of the hands of health Reduce contamination of the hands of health care personnel by microbial flora that can be care personnel by microbial flora that can be transmitted from one patient to anothertransmitted from one patient to another

Are not a substitute for handwashing!Are not a substitute for handwashing!

Recommendations for GlovingRecommendations for Gloving

Wear gloves when contact with Wear gloves when contact with blood, saliva, and mucous blood, saliva, and mucous membranes is possiblemembranes is possible

Remove gloves after patient care Remove gloves after patient care

Wear a new pair of gloves for Wear a new pair of gloves for each patienteach patient

Recommendations for GlovingRecommendations for Gloving

Remove gloves that are torn, cut or punctured

Do not wash, disinfect or sterilize gloves for reuse

Latex Hypersensitivity Latex Hypersensitivity and Contact Dermatitisand Contact Dermatitis

Latex AllergyLatex Allergy

Type I hypersensitivity to natural Type I hypersensitivity to natural rubber latex proteinsrubber latex proteins

Reactions may include nose, eye, Reactions may include nose, eye, and skin reactionsand skin reactions

More serious reactions may More serious reactions may include respiratory distress–rarely include respiratory distress–rarely shock or deathshock or death

Contact DermatitisContact Dermatitis

Irritant contact dermatitisIrritant contact dermatitis

• Not an allergyNot an allergy

• Dry, itchy, irritated areasDry, itchy, irritated areas

Allergic contact dermatitis Allergic contact dermatitis

• Type IV delayed hypersensitivityType IV delayed hypersensitivity

• May result from allergy to chemicals used in glove May result from allergy to chemicals used in glove manufacturingmanufacturing

General RecommendationsGeneral RecommendationsContact Dermatitis and Latex AllergyContact Dermatitis and Latex Allergy

Educate DHCP about reactions associated with Educate DHCP about reactions associated with frequent hand hygiene and glove use frequent hand hygiene and glove use

Get a medical diagnosisGet a medical diagnosis

Screen patients for latex allergyScreen patients for latex allergy

Ensure a latex-safe environmentEnsure a latex-safe environment

Have latex-free kits available (dental and Have latex-free kits available (dental and emergency)emergency)

Sterilization and Disinfection Sterilization and Disinfection of Patient Care Itemsof Patient Care Items

Critical InstrumentsCritical Instruments

Penetrate mucous membranes or contact bone, Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile the bloodstream, or other normally sterile tissues (of the mouth)tissues (of the mouth)

Heat sterilize between uses or use sterile single-Heat sterilize between uses or use sterile single-use, disposable devicesuse, disposable devices

Examples include surgical instruments, scalpel Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental blades, periodontal scalers, and surgical dental bursburs

Semi-critical InstrumentsSemi-critical Instruments

Contact mucous membranes but do not Contact mucous membranes but do not penetrate soft tissue penetrate soft tissue

Heat sterilize or high-level disinfect Heat sterilize or high-level disinfect

Examples: Dental mouth mirrors, Examples: Dental mouth mirrors, amalgam condensers, and dental amalgam condensers, and dental handpieceshandpieces

Noncritical Instruments Noncritical Instruments and Devicesand Devices

Contact intact skinContact intact skin

Clean and disinfect using a low to intermediate Clean and disinfect using a low to intermediate level disinfectantlevel disinfectant

Examples: X-ray heads, facebows, pulse Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuffoximeter, blood pressure cuff

Instrument Processing AreaInstrument Processing Area

Use a designated processing area to control quality Use a designated processing area to control quality and ensure safetyand ensure safety

Divide processing area into work areasDivide processing area into work areas

• Receiving, cleaning, and decontaminationReceiving, cleaning, and decontamination

• Preparation and packaging Preparation and packaging

• Sterilization Sterilization

• StorageStorage

Automated Cleaning Automated Cleaning

Ultrasonic cleanerUltrasonic cleaner

Instrument washerInstrument washer

Washer-disinfectorWasher-disinfector

Manual CleaningManual Cleaning

Soak until ready to cleanSoak until ready to clean

Wear heavy-duty utility Wear heavy-duty utility gloves, mask, eyewear, gloves, mask, eyewear, and protective clothingand protective clothing

Preparation and PackagingPreparation and Packaging

Critical and semi-critical items that will be Critical and semi-critical items that will be stored should be wrapped or placed in stored should be wrapped or placed in containers before heat sterilizationcontainers before heat sterilization

Hinged instruments opened and unlockedHinged instruments opened and unlocked

Place a chemical indicator inside the packPlace a chemical indicator inside the pack

Wear heavy-duty, puncture-resistant utility Wear heavy-duty, puncture-resistant utility glovesgloves

Heat-Based SterilizationHeat-Based Sterilization

Steam under pressure (autoclaving)Steam under pressure (autoclaving)

• Gravity displacementGravity displacement

• Pre-vacuum Pre-vacuum

Dry heatDry heat

Unsaturated chemical vaporUnsaturated chemical vapor

Liquid Chemical Liquid Chemical Sterilant/DisinfectantsSterilant/Disinfectants

Only for heat-sensitive critical Only for heat-sensitive critical and semi-critical devicesand semi-critical devices

Powerful, toxic chemicals Powerful, toxic chemicals raise safety concernsraise safety concerns

Heat tolerant or disposable Heat tolerant or disposable alternatives are availablealternatives are available

Sterilization Monitoring Sterilization Monitoring Types of IndicatorsTypes of Indicators

Mechanical Mechanical

• Measure time, temperature, pressureMeasure time, temperature, pressure

Chemical Chemical

• Change in color when physical parameter is Change in color when physical parameter is reachedreached

Biological (spore tests)Biological (spore tests)

• Use biological spores to assess the sterilization Use biological spores to assess the sterilization process directlyprocess directly

Storage of Sterile and Storage of Sterile and Clean Items and SuppliesClean Items and Supplies

Use date- or event-related shelf-life practicesUse date- or event-related shelf-life practices

Examine wrapped items carefully prior to useExamine wrapped items carefully prior to use

When packaging of sterile items is damaged, When packaging of sterile items is damaged, re-clean, re-wrap, and re-sterilizere-clean, re-wrap, and re-sterilize

Store clean items in dry, closed, or covered Store clean items in dry, closed, or covered containmentcontainment

Environmental Infection Environmental Infection ControlControl

Environmental SurfacesEnvironmental Surfaces

May become contaminated May become contaminated

Not directly involved in infectious disease Not directly involved in infectious disease transmissiontransmission

Do not require as stringent decontamination Do not require as stringent decontamination proceduresprocedures

Categories of Environmental SurfacesCategories of Environmental Surfaces

Clinical contact surfacesClinical contact surfaces

• High potential for direct contamination from High potential for direct contamination from spray or spatter or by contact with DHCP’s spray or spatter or by contact with DHCP’s gloved handgloved hand

Housekeeping surfacesHousekeeping surfaces

• Do not come into contact with patients or Do not come into contact with patients or devicesdevices

• Limited risk of disease transmissionLimited risk of disease transmission

Clinical Contact SurfacesClinical Contact Surfaces

Housekeeping SurfacesHousekeeping Surfaces

General Cleaning RecommendationsGeneral Cleaning Recommendations

Use barrier precautions (e.g., heavy-duty utility gloves, Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and masks, protective eyewear) when cleaning and disinfecting environmental surfacesdisinfecting environmental surfaces

Physical removal of microorganisms by cleaning is as Physical removal of microorganisms by cleaning is as important as the disinfection processimportant as the disinfection process

Follow manufacturer’s instructions for proper use of Follow manufacturer’s instructions for proper use of EPA-registered hospital disinfectantsEPA-registered hospital disinfectants

Do not use sterilant/high-level disinfectants on Do not use sterilant/high-level disinfectants on environmental surfacesenvironmental surfaces

Cleaning Clinical Contact SurfacesCleaning Clinical Contact Surfaces

Risk of transmitting infections greater Risk of transmitting infections greater than for housekeeping surfacesthan for housekeeping surfaces

Surface barriers can be used and Surface barriers can be used and changed between patientschanged between patients

OROR

Clean then disinfect using an EPA-Clean then disinfect using an EPA-registered low- (HIV/HBV claim) to registered low- (HIV/HBV claim) to intermediate-level (tuberculocidal intermediate-level (tuberculocidal claim) hospital disinfectantclaim) hospital disinfectant

Cleaning Housekeeping SurfacesCleaning Housekeeping Surfaces

Routinely clean with soap and water or an EPA-Routinely clean with soap and water or an EPA-registered detergent/hospital disinfectant routinelyregistered detergent/hospital disinfectant routinely

Clean mops and cloths and allow to dry thoroughly Clean mops and cloths and allow to dry thoroughly before re-usingbefore re-using

Prepare fresh cleaning and disinfecting solutions Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendationsdaily and per manufacturer recommendations

Medical WasteMedical Waste

Medical Waste: Medical Waste: Not considered infectious, Not considered infectious, thus can be discarded in regular trashthus can be discarded in regular trash

Regulated Medical Waste: Regulated Medical Waste: Poses a Poses a potential risk of infection during handling potential risk of infection during handling and disposaland disposal

Regulated Medical Waste ManagementRegulated Medical Waste Management

Properly labeled containment to Properly labeled containment to prevent injuries and leakage prevent injuries and leakage

Medical wastes are “treated” in Medical wastes are “treated” in accordance with state and local EPA accordance with state and local EPA regulations regulations

Processes for regulated waste include Processes for regulated waste include autoclaving and incinerationautoclaving and incineration

Dental Unit Waterlines, Dental Unit Waterlines, Biofilm, Biofilm,

and Water Qualityand Water Quality

Dental Unit Waterlines Dental Unit Waterlines and Biofilmand Biofilm

Microbial biofilms form in Microbial biofilms form in small bore tubing of dental small bore tubing of dental units units

Biofilms serve as a microbial Biofilms serve as a microbial reservoirreservoir

Primary source of Primary source of microorganisms is municipal microorganisms is municipal water supplywater supply

Dental Unit Water QualityDental Unit Water Quality

Using water of uncertain quality is inconsistent Using water of uncertain quality is inconsistent with infection control principleswith infection control principles

Colony counts in water from untreated systems Colony counts in water from untreated systems can exceed 1,000,000can exceed 1,000,000 CFU/mL CFU/mL

CFU=colony forming unitCFU=colony forming unit

Untreated dental units cannot reliably produce Untreated dental units cannot reliably produce water that meets drinking water standards water that meets drinking water standards

Dental Water QualityDental Water Quality

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

** <500 CFU/mL of heterotrophic water <500 CFU/mL of heterotrophic water bacteriabacteria

Available DUWL TechnologyAvailable DUWL Technology

Independent reservoirsIndependent reservoirs

Chemical treatmentChemical treatment

FiltrationFiltration

CombinationsCombinations

Sterile water delivery systemsSterile water delivery systems

Monitoring OptionsMonitoring Options

Water testing laboratoryWater testing laboratory

In-office testing with self-contained kitsIn-office testing with self-contained kits

Follow recommendations provided by the Follow recommendations provided by the manufacturer of the dental unit or waterline manufacturer of the dental unit or waterline treatment product for monitoring water qualitytreatment product for monitoring water quality

Sterile Irrigating SolutionsSterile Irrigating Solutions

Use sterile saline or sterile water Use sterile saline or sterile water as a coolant/irrigator when as a coolant/irrigator when performing surgical proceduresperforming surgical procedures

Use devices designed for the Use devices designed for the delivery of sterile irrigating fluidsdelivery of sterile irrigating fluids

Special ConsiderationsSpecial Considerations Dental handpieces and other Dental handpieces and other

devices attached to air and devices attached to air and waterlineswaterlines

Dental radiologyDental radiology

Aseptic technique for Aseptic technique for parenteral medicationsparenteral medications

Single-use (disposable) Single-use (disposable) DevicesDevices

Preprocedural mouth rinsesPreprocedural mouth rinses

Oral surgical proceduresOral surgical procedures

Handling biopsy specimensHandling biopsy specimens

Handling extracted teethHandling extracted teeth

Laser/electrosurgery Laser/electrosurgery plumes or surgical smokeplumes or surgical smoke

Dental laboratoryDental laboratory

Mycobacterium Mycobacterium tuberculosistuberculosis

Creutzfeldt-Jacob Disease Creutzfeldt-Jacob Disease (CJD) and other prion-(CJD) and other prion-related diseasesrelated diseases

Dental Handpieces and Other Devices Dental Handpieces and Other Devices Attached to Air and WaterlinesAttached to Air and Waterlines

Clean and heat sterilize intraoral devices Clean and heat sterilize intraoral devices that can be removed from air and that can be removed from air and waterlineswaterlines

Follow manufacturer’s instructions for Follow manufacturer’s instructions for cleaning, lubrication, and sterilizationcleaning, lubrication, and sterilization

Do not use liquid germicides or ethylene Do not use liquid germicides or ethylene oxideoxide

Components of Devices Permanently Components of Devices Permanently Attached to Air and WaterlinesAttached to Air and Waterlines

Do not enter patient’s mouth but may Do not enter patient’s mouth but may become contaminatedbecome contaminated

Use barriers and change between usesUse barriers and change between uses Clean and intermediate-level disinfect the Clean and intermediate-level disinfect the

surface of devices if visibly contaminatedsurface of devices if visibly contaminated

Saliva EjectorsSaliva Ejectors

Previously suctioned fluids Previously suctioned fluids might be retracted into the might be retracted into the patient’s mouth when a seal is patient’s mouth when a seal is createdcreated

Do not advise patients to close Do not advise patients to close their lips tightly around the tip their lips tightly around the tip of the saliva ejectorof the saliva ejector

DentalDental RadiologyRadiology

Wear gloves and other appropriate personal Wear gloves and other appropriate personal protective equipment as necessaryprotective equipment as necessary

Heat sterilize heat-tolerant radiographic Heat sterilize heat-tolerant radiographic accessories accessories

Transport and handle exposed radiographs so Transport and handle exposed radiographs so that they will not become contaminatedthat they will not become contaminated

Avoid contamination of developing equipmentAvoid contamination of developing equipment

ParenteralParenteral MedicationsMedications

Definition: Medications that are injected into the Definition: Medications that are injected into the bodybody

Cases of disease transmission have been Cases of disease transmission have been reportedreported

Handle safely to prevent transmission of Handle safely to prevent transmission of infectionsinfections

Precautions for ParenteralPrecautions for Parenteral MedicationsMedications

IV tubings, bags, connections, IV tubings, bags, connections, needles, and syringes are single-needles, and syringes are single-use, disposableuse, disposable

Single dose vialsSingle dose vials

• Do not administer to multiple Do not administer to multiple patients even if the needle on the patients even if the needle on the syringe is changedsyringe is changed

• Do not combine leftover contents Do not combine leftover contents for later usefor later use

Single-Use (Disposable) DevicesSingle-Use (Disposable) Devices

Intended for use on one patient during a single Intended for use on one patient during a single procedureprocedure

Usually not heat-tolerantUsually not heat-tolerant

Cannot be reliably cleanedCannot be reliably cleaned

Examples: Syringe needles, prophylaxis cups, and Examples: Syringe needles, prophylaxis cups, and plastic orthodontic brackets plastic orthodontic brackets

Preprocedural Mouth RinsesPreprocedural Mouth Rinses

Antimicrobial mouth rinses prior to a dental Antimicrobial mouth rinses prior to a dental procedure procedure

• Reduce number of microorganisms in aerosols/spatterReduce number of microorganisms in aerosols/spatter

• Decrease the number of microorganisms introduced Decrease the number of microorganisms introduced into the bloodstreaminto the bloodstream

Unresolved issueUnresolved issue–no evidence that infections –no evidence that infections are preventedare prevented

Oral Surgical ProceduresOral Surgical Procedures

Present a risk for microorganisms to enter the bodyPresent a risk for microorganisms to enter the body

Involve the incision, excision, or reflection of tissue Involve the incision, excision, or reflection of tissue that exposes normally sterile areas of the oral that exposes normally sterile areas of the oral cavitycavity

Examples include biopsy, periodontal surgery, Examples include biopsy, periodontal surgery, implant surgery, apical surgery, and surgical implant surgery, apical surgery, and surgical extractions of teethextractions of teeth

Precautions for Surgical ProceduresPrecautions for Surgical Procedures

Sterile Irrigating Solutions

Sterile Surgeon’s Gloves

Surgical Scrub

Handling Biopsy SpecimensHandling Biopsy Specimens

Place biopsy in sturdy, Place biopsy in sturdy, leakproof containerleakproof container

Avoid contaminating the Avoid contaminating the outside of the containeroutside of the container

Label with a biohazard Label with a biohazard symbolsymbol

Considered regulated medical Considered regulated medical wastewaste• Do not incinerate extracted teeth Do not incinerate extracted teeth

containing amalgamcontaining amalgam

• Clean and disinfect before sending to Clean and disinfect before sending to lab for shade comparisonlab for shade comparison

Can be given back to patientCan be given back to patient

Extracted TeethExtracted Teeth

Handling Extracted TeethHandling Extracted Teethin Educational Settingsin Educational Settings

Remove visible blood and debris Remove visible blood and debris

Maintain hydrationMaintain hydration

Autoclave (teeth with no amalgam)Autoclave (teeth with no amalgam)

Use Standard PrecautionsUse Standard Precautions

Laser/Electrosurgery Plumes and Laser/Electrosurgery Plumes and Surgical SmokeSurgical Smoke

Destruction of tissue creates smoke that may Destruction of tissue creates smoke that may contain harmful by-productscontain harmful by-products

Infectious materials (HSV, HPV) may contact Infectious materials (HSV, HPV) may contact mucous membranes of nosemucous membranes of nose

No evidence of HIV/HBV transmissionNo evidence of HIV/HBV transmission

Need further studiesNeed further studies

Dental LaboratoryDental Laboratory

Dental prostheses, appliances, and items Dental prostheses, appliances, and items used in their making are potential sources used in their making are potential sources of contaminationof contamination

Handle in a manner that protects patients Handle in a manner that protects patients and DHCP from exposure to and DHCP from exposure to microorganismsmicroorganisms

Dental LaboratoryDental Laboratory

Clean and disinfect prostheses and impressions Clean and disinfect prostheses and impressions

Wear appropriate PPE until disinfection has been Wear appropriate PPE until disinfection has been completed completed

Clean and heat sterilize heat-tolerant items used Clean and heat sterilize heat-tolerant items used in the mouthin the mouth

Communicate specific information about Communicate specific information about disinfection proceduresdisinfection procedures

Transmission ofTransmission of Mycobacterium tuberculosisMycobacterium tuberculosis

Spread by droplet nucleiSpread by droplet nuclei

Immune system usually prevents spreadImmune system usually prevents spread

Bacteria can remain alive in the lungs for many years Bacteria can remain alive in the lungs for many years (latent TB infection)(latent TB infection)

Risk of TB Transmission in DentistryRisk of TB Transmission in Dentistry

Risk in dental settings is lowRisk in dental settings is low

Only one documented case of transmission Only one documented case of transmission

Tuberculin skin test conversions among Tuberculin skin test conversions among

DHP are rareDHP are rare

Preventing Transmission of TB in Preventing Transmission of TB in Dental SettingsDental Settings

Assess patients for history of TBAssess patients for history of TB

Defer elective dental treatmentDefer elective dental treatment

If patient must be treated:If patient must be treated:

• DHCP should wear face maskDHCP should wear face mask

• Separate patient from others/mask/tissueSeparate patient from others/mask/tissue

• Refer to facility with proper TB infection control Refer to facility with proper TB infection control precautionsprecautions

Creutzfeldt-Jakob Disease (CJD)Creutzfeldt-Jakob Disease (CJD)and other Prion Diseasesand other Prion Diseases

A type of a fatal degenerative disease of central A type of a fatal degenerative disease of central nervous system nervous system

Caused by abnormal “prion” protein Caused by abnormal “prion” protein

Human and animal formsHuman and animal forms

Long incubation periodLong incubation period

One case per million population worldwideOne case per million population worldwide

New Variant CJD (vCJD)New Variant CJD (vCJD)

Variant CJD (vCJD) is the human version of Variant CJD (vCJD) is the human version of Bovine Spongiform Encephalopathy (BSE) Bovine Spongiform Encephalopathy (BSE)

Case reports in the UK, Italy, France, Case reports in the UK, Italy, France, Ireland, Hong Kong, CanadaIreland, Hong Kong, Canada

One case report in the United States – One case report in the United States – former UK residentformer UK resident

Infection Control for Known CJD or Infection Control for Known CJD or vCJD Dental PatientsvCJD Dental Patients

Use single-use disposable items and equipment Use single-use disposable items and equipment

Consider items difficult to clean (e.g., endodontic Consider items difficult to clean (e.g., endodontic files, broaches) as single-use disposable files, broaches) as single-use disposable

Keep instruments moist until cleaned Keep instruments moist until cleaned

Clean and autoclave at 134°C for 18 minutes Clean and autoclave at 134°C for 18 minutes

Do not use flash sterilization Do not use flash sterilization

Program EvaluationProgram Evaluation

““Systematic way to improve (infection control) Systematic way to improve (infection control) procedures so they are useful, feasible, ethical, procedures so they are useful, feasible, ethical, and accurate”and accurate”

• Develop standard operating proceduresDevelop standard operating procedures

• Evaluate infection control practicesEvaluate infection control practices

• Document adverse outcomesDocument adverse outcomes

• Document work-related illnessesDocument work-related illnesses

• Monitor health care-associated infectionsMonitor health care-associated infections

Infection Control Program GoalsInfection Control Program Goals

Provide a safe working Provide a safe working environmentenvironment

• Reduce health care-associated Reduce health care-associated infections infections

• Reduce occupational Reduce occupational exposuresexposures

Program EvaluationProgram Evaluation

Strategies and ToolsStrategies and Tools

• Periodic observational Periodic observational assessmentsassessments

• Checklists to document Checklists to document proceduresprocedures

• Routine review of Routine review of occupational exposures to occupational exposures to bloodborne pathogensbloodborne pathogens

“ “Program evaluation provides an Program evaluation provides an

opportunity to identify and change opportunity to identify and change

inappropriate practices, thereby inappropriate practices, thereby

improving the effectiveness of your improving the effectiveness of your

infection control program.”infection control program.”