Dental BranchDental Branch

2008 Annual Clinic Update2008 Annual Clinic Update

Presented by: Environmental Health & Presented by: Environmental Health & SafetySafety

Bloodborne Pathogens Bloodborne Pathogens & Infection Control& Infection Control

ObjectivesObjectives

Bloodborne PathogensBloodborne Pathogens Preventive MeasuresPreventive Measures Spill, Injury/Potential ExposureSpill, Injury/Potential Exposure TB, MRSA, FluTB, MRSA, Flu Water Lines & QualityWater Lines & Quality General Safety (drills, physical, x-ray, General Safety (drills, physical, x-ray,

laser) laser)

Regulations & GuidelinesRegulations & Guidelines

Occupational Safety & Health Occupational Safety & Health Administration (OSHA) Administration (OSHA)

Centers for Disease Control & Centers for Disease Control & Prevention (CDC)Prevention (CDC)

American Dental Association (ADA)American Dental Association (ADA) Texas Department of State Health Texas Department of State Health

Services (DHSH)Services (DHSH) Texas Commission on Environmental Texas Commission on Environmental

Quality (TCEQ)Quality (TCEQ)

Training RequirementsTraining Requirements

All health care workers with potential All health care workers with potential for exposure to blood or other body for exposure to blood or other body fluids must receive training:fluids must receive training:

At time of initial assignmentAt time of initial assignment

AnnuallyAnnually

Bloodborne PathogensBloodborne PathogensOSHA 1910.1030OSHA 1910.1030

Definition:Definition: Any pathogenic microorganism Any pathogenic microorganism

that is present in human blood or that is present in human blood or other potentially infectious other potentially infectious materials (OPIM), and can infect materials (OPIM), and can infect and cause disease in humans. and cause disease in humans.

BloodborneBloodborne Pathogens (BBP)Pathogens (BBP)

Examples:Examples: HIV HIV HBV HBV HCVHCV T. pallidumT. pallidum Herpes VirusHerpes Virus M. tuberculosis M. tuberculosis (typically an aerosol (typically an aerosol

hazard)hazard) Human T-Lymphotropic Virus Type I Human T-Lymphotropic Virus Type I

(HTLV-I)(HTLV-I)

Bloodborne Bloodborne Pathogens (BBP)Pathogens (BBP)

Body fluids that can harbor BBP:Body fluids that can harbor BBP: BloodBlood Semen and vaginal secretionsSemen and vaginal secretions Saliva involved in dental proceduresSaliva involved in dental procedures Synovial fluidSynovial fluid Cerebrospinal fluidCerebrospinal fluid Human tissue and cell culturesHuman tissue and cell cultures All body fluids containing bloodAll body fluids containing blood

Occupational ExposureOccupational Exposure**

Mucous membrane contactMucous membrane contact Splash to the eyes, nose or mouthSplash to the eyes, nose or mouth

Percutaneous inoculationPercutaneous inoculation Misuse of sharps (broken glass, needles, Misuse of sharps (broken glass, needles,

scalpels, dental bur, knife)scalpels, dental bur, knife)

Exposure to broken/damaged skinExposure to broken/damaged skin Risk increases if contact involves a large area Risk increases if contact involves a large area

of broken/damaged skin or if contact is of broken/damaged skin or if contact is prolongedprolonged

* * Risk increases with high titer levels in the sourceRisk increases with high titer levels in the source

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

Both patients & dental health care Both patients & dental health care personnel (DHCP) can be exposed to personnel (DHCP) can be exposed to pathogenspathogens

Contact with blood, oral & respiratory Contact with blood, oral & respiratory secretions, & contaminated equipment secretions, & contaminated equipment occursoccurs

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

Potential Routes of TransmissionPotential Routes of Transmission

PatientPatient DHCPDHCP

DHCPDHCP PatientPatient

PatientPatient PatientPatient

PathogenPathogen

SourceSource

ModeModeEntryEntry

Susceptible HostSusceptible Host

Preventive MeasuresPreventive Measures

Risk of exposure can be minimized or Risk of exposure can be minimized or eliminated by using the following eliminated by using the following controls:controls:

Engineering controlsEngineering controls

Personal protective equipment (PPE)Personal protective equipment (PPE)

Administrative controlsAdministrative controls

Work place practicesWork place practices

Engineering ControlsEngineering Controls

Leakproof containersLeakproof containers Use for storage & transportation of Use for storage & transportation of ALLALL

bloodborne pathogen materialbloodborne pathogen material

Sharps containersSharps containers Fill no greater than ¾ fullFill no greater than ¾ full

Needleless devicesNeedleless devices Use retractable syringes, self-sheathing Use retractable syringes, self-sheathing

needles (if possible)needles (if possible)

Personal Protective Equipment (PPE)Personal Protective Equipment (PPE)

Consider that all patients are Consider that all patients are infectious infectious

Wear personal protective equipmentWear personal protective equipment GownsGowns GlovesGloves MasksMasks Protective EyewearProtective Eyewear

Clinic GownClinic Gown

The official protective gown for The official protective gown for use in all Dental Branch clinics is use in all Dental Branch clinics is the the Clinic Gown:Clinic Gown:

WhiteWhite for faculty for faculty BlueBlue for students for students

Laboratory GownLaboratory Gown

Working in a clinical Working in a clinical dental laboratory:dental laboratory:

YellowYellow gown gown should be used should be used

Vinyl, nitrile, or latex examination Vinyl, nitrile, or latex examination gloves must be worn when treating gloves must be worn when treating nonsurgical patientsnonsurgical patients

Nonsurgical GlovesNonsurgical Gloves

Surgical GlovesSurgical Gloves

Sterile Sterile disposable disposable gloves must be gloves must be worn during all worn during all surgical surgical proceduresprocedures

Utility GlovesUtility Gloves

Each student must have Each student must have a pair of a pair of heavy-duty utility heavy-duty utility glovesgloves for break down for break down after patient treatment after patient treatment

Must be washed with Must be washed with antimicrobial soap, antimicrobial soap, rinsed & driedrinsed & dried

Stored in plastic bag in Stored in plastic bag in lockerlocker

Masks must be worn to protect: Masks must be worn to protect: FaceFace Oral & nasal mucosa Oral & nasal mucosa

MasksMasks

MasksMasks

Masks must be changed if they Masks must be changed if they become damp become damp

The mask must be changed for The mask must be changed for each new patient,each new patient, except for except for short exams!short exams!

If a face shield is worn it must be If a face shield is worn it must be worn at the same time as a worn at the same time as a surgical masksurgical mask

Special MasksSpecial Masks

A laser plume A laser plume face mask face mask must be worn must be worn during a laser during a laser or or electrosurgery electrosurgery procedure!procedure!

Protective EyewearProtective Eyewear

Must be worn to protect from aerosol & Must be worn to protect from aerosol & spatterspatter

Regular eyewear must have side shieldsRegular eyewear must have side shields Side shields must be securely attached Side shields must be securely attached

to the eyewear frame, abutting the to the eyewear frame, abutting the lenses & free of vents or openingslenses & free of vents or openings

Special protective eyewear for laser Special protective eyewear for laser proceduresprocedures

Administrative ControlsAdministrative Controls

Medical surveillanceMedical surveillance TB skin (PPD) or Quantiferon test, baseline TB skin (PPD) or Quantiferon test, baseline

serumserum

ImmunizationsImmunizations Hepatitis B seriesHepatitis B series

TrainingTraining BBP, infection control, hazard communicationBBP, infection control, hazard communication

Management of staff Management of staff SOP complianceSOP compliance

Background checksBackground checks

Hepatitis B VaccinationHepatitis B Vaccination

Available at no cost to employeesAvailable at no cost to employees

All health care workers must have All health care workers must have vaccinationvaccination

Employees can decline vaccination, Employees can decline vaccination, but must sign a declination but must sign a declination statementstatement

Good Work Place PracticesGood Work Place Practices

Universal/Standard precautionsUniversal/Standard precautions A standard of care designed to protect A standard of care designed to protect

health care providers & patients from health care providers & patients from pathogens that can spread by blood & other pathogens that can spread by blood & other body fluidsbody fluids

Treat all human blood & body fluids as if known to Treat all human blood & body fluids as if known to be infectious for HIV, HBV or other BBPbe infectious for HIV, HBV or other BBP

ALL BLOOD AND BODY FLUIDS ALL BLOOD AND BODY FLUIDS ARE CONSIDERED TO BE ARE CONSIDERED TO BE INFECTIOUS !INFECTIOUS !

Good Work Place Practices (cont.)Good Work Place Practices (cont.)

Follow SOPsFollow SOPs NEVERNEVER recap needles with two hands! recap needles with two hands! Establish & maintain clean & dirty zonesEstablish & maintain clean & dirty zones Decontaminate work surfacesDecontaminate work surfaces

At start & end of proceduresAt start & end of procedures Immediately after spillImmediately after spill Before removal of equipmentBefore removal of equipment

Survey work areaSurvey work area Note locations of all necessary equipment, waste Note locations of all necessary equipment, waste

containers, disinfectants, soapscontainers, disinfectants, soaps

Good Work Place Practices (cont.)Good Work Place Practices (cont.)

Wash hands frequently, always between Wash hands frequently, always between patients & always before leaving work area!patients & always before leaving work area!

DO NOT eat, drink, or apply cosmetics in DO NOT eat, drink, or apply cosmetics in the work areathe work area

Practice proper personal hygiene for the Practice proper personal hygiene for the dental clinic settingdental clinic setting

Label containers - hazard communicationLabel containers - hazard communication Chemical & biological working stocksChemical & biological working stocks

Dispose of waste properlyDispose of waste properly

Exposure Control PlanExposure Control Plan Written plan to eliminate exposure to Written plan to eliminate exposure to

blood & body fluidsblood & body fluids Exposure determinationExposure determination Plan must be accessiblePlan must be accessible Compliance Compliance

UTHSC-H Dental School Clinic ManualUTHSC-H Dental School Clinic Manual www.db.uth.tmc.edu/clinicpat/Documents/Clini

c_Manual.pdf UTHSC-H Biological Safety ManualUTHSC-H Biological Safety Manual

www.uth.tmc.edu/safety

Injury PreventionInjury Prevention Remove burs from handpiece immediately Remove burs from handpiece immediately

after completion of dental procedureafter completion of dental procedure

Recap anesthetic needles using proper Recap anesthetic needles using proper techniquetechnique

Restrict use of fingers in tissue retraction or Restrict use of fingers in tissue retraction or palpation during suturing or administration palpation during suturing or administration of anesthesiaof anesthesia

Avoid uncontrolled movements of dental Avoid uncontrolled movements of dental instruments. THINK BEFORE MOVING AN instruments. THINK BEFORE MOVING AN INSTRUMENT!INSTRUMENT!

Injury Prevention (cont.)Injury Prevention (cont.)

Burs

Must be removed from handpiece immediately upon completion of patient treatment

Recapping Anesthetic NeedlesRecapping Anesthetic Needles

Use the needle Use the needle recapper to recapper to recap anesthetic recap anesthetic needlesneedles

NEVER use two NEVER use two hands!hands!

Recapping Anesthetic NeedlesRecapping Anesthetic Needles

Use the “Use the “one-one-handed scoophanded scoop” ” technique to recap technique to recap if a recapper is not if a recapper is not availableavailable

NEVER use two NEVER use two hands!hands!

SharpsSharps

Handle carefullyHandle carefully Do not recap Do not recap

with two handswith two hands Discard in sharps Discard in sharps

containercontainer Do not bend or Do not bend or

break needlesbreak needles Report all injuriesReport all injuries

SharpsSharps

Discard in sharps containersDiscard in sharps containers Used needlesUsed needles Blades, scalpelsBlades, scalpels BursBurs Anesthetic cartridgesAnesthetic cartridges Broken glassBroken glass

Sharps – Red Handled Lab KnifeSharps – Red Handled Lab Knife

USE OF SHARP INSTRUMENTSUSE OF SHARP INSTRUMENTS To prevent accidental exposure To prevent accidental exposure

injuries related to injuries related to trimming trimming wax wax with a with a red handled lab red handled lab knifeknife at chair-side, DISINFECT at chair-side, DISINFECT when possible and…when possible and…

BE EXTREMELY CAREFUL WHEN BE EXTREMELY CAREFUL WHEN USING THE RED HANDLED LAB USING THE RED HANDLED LAB KNIFE!KNIFE!

Policy 2.39Policy 2.39

Maintain the Clinical WorksiteMaintain the Clinical Worksite

Worksite must be maintained in a clean & Worksite must be maintained in a clean & sanitary conditionsanitary condition

Equipment & work surfaces must be cleaned Equipment & work surfaces must be cleaned & disinfected before & after procedures, & & disinfected before & after procedures, & after any contact with blood or OPIMafter any contact with blood or OPIM

Protective covering must be used to cover Protective covering must be used to cover equipment and work surfacesequipment and work surfaces

Biological waste & contaminated materials Biological waste & contaminated materials must be disposed of in appropriate must be disposed of in appropriate biological waste containersbiological waste containers

Contact SurfacesContact Surfaces

Clinical Contact SurfacesClinical Contact Surfaces

Risk of transmitting Risk of transmitting infections greater for infections greater for clinical contact surfaces clinical contact surfaces than for general than for general housekeeping surfaceshousekeeping surfaces

Clean & disinfect surfacesClean & disinfect surfaces

Apply barriersApply barriers

Routine Surface DecontaminationRoutine Surface Decontamination

Sani-Cloth Plus Sani-Cloth Plus DisinfectantDisinfectant

EPA registeredEPA registered Meets OSHA & CDC guidelines Meets OSHA & CDC guidelines Double ammonium chloride & Double ammonium chloride &

alcoholalcohol Tuberculocidal, bactericidal & Tuberculocidal, bactericidal &

virucidal virucidal Use on surfaces in dental Use on surfaces in dental

operatoriesoperatories

Sani-Cloth Plus DisinfectantSani-Cloth Plus Disinfectant

Effective against:Effective against: Methicillin Resistant Methicillin Resistant Staphylococcus aureus Staphylococcus aureus (MRSA) (MRSA) Vancomycin Resistant Enterococci (VRE)Vancomycin Resistant Enterococci (VRE) Mycobacterium tuberculosisMycobacterium tuberculosis Flu VirusesFlu Viruses RSV (Respiratory Syncytial Virus) RSV (Respiratory Syncytial Virus) Pseudomonas Pseudomonas sp.sp. Hepatitis B & C Viruses (HBV, HCV) Hepatitis B & C Viruses (HBV, HCV) Herpes Simplex Virus (HSV)Herpes Simplex Virus (HSV) Human Immunodeficiency Virus (HIV)Human Immunodeficiency Virus (HIV) OthersOthers

Routine Surface DecontaminationRoutine Surface Decontamination

Sani-Cloth Plus DisinfectantSani-Cloth Plus Disinfectant

The disinfecting process is a The disinfecting process is a two-step process:two-step process:

Wipe to clean the surface & Wipe to clean the surface & remove bioburdenremove bioburden

Wipe a second time to disinfectWipe a second time to disinfect

All disinfectants must be used All disinfectants must be used correctly to be effective!correctly to be effective!

Surface CoversSurface Covers

Handles, Handles, handpieces & handpieces & similar surfaces similar surfaces that may be that may be contaminated by contaminated by blood, saliva or blood, saliva or OPIM must be OPIM must be wrapped with wrapped with clear plastic wrapclear plastic wrap

Rubber DamRubber Dam

Provides Provides protection protection from from aerosols aerosols and and spattersspatters

Clinical Computer EquipmentClinical Computer Equipment

Procedures should be followed to Procedures should be followed to avoid contamination of electronic avoid contamination of electronic equipment when possibleequipment when possible

If it will be necessary to enter data If it will be necessary to enter data while a patient is in the operatory, while a patient is in the operatory, barrier protection for equipment barrier protection for equipment must be utilized & high touch areas must be utilized & high touch areas must be disinfectedmust be disinfected

Follow established guidelinesFollow established guidelines

Electronic Equipment BarriersElectronic Equipment Barriers

Apply two lengths of Apply two lengths of plastic wrap to cover plastic wrap to cover entire keyboard & tuck entire keyboard & tuck in on all sidesin on all sides

Use Sani-Cloth Plus Use Sani-Cloth Plus Disinfectant Disinfectant

Disinfect daily, or if Disinfect daily, or if contaminated or visibly contaminated or visibly soiledsoiled

Touch monitor screen Touch monitor screen with cotton tipped with cotton tipped applicator only (no Sani-applicator only (no Sani-Cloth Plus on the Cloth Plus on the monitor screen)monitor screen)

Hand HygieneHand Hygiene

Source: Hand Hygiene Resource Center Source: Hand Hygiene Resource Center http://www.handhygiene.org/

On average only On average only 40% 40% of health care workers of health care workers regularly wash their handsregularly wash their hands

Hospital acquired infections result in Hospital acquired infections result in transmission of:transmission of: MRSAMRSA – Methicillin resistant – Methicillin resistant S. aureusS. aureus VREVRE – Vancomycin resistant Enterococci – Vancomycin resistant Enterococci

Methods for contaminationMethods for contamination Moving patientsMoving patients Taking blood pressureTaking blood pressure Touching bedrails Touching bedrails

Hand Hygiene (cont.)Hand Hygiene (cont.)Proper hand washing is VITAL to infection prevention!Proper hand washing is VITAL to infection prevention!

You may not realize you have germs on your hands!You may not realize you have germs on your hands!

Wash your hands, even if gloves have been worn…Wash your hands, even if gloves have been worn… Before patient contact, including between different patients Before patient contact, including between different patients After contact with anything contaminated After contact with anything contaminated During patient care:During patient care:

Before & after invasive procedure Before & after invasive procedure Before & after contact with wound Before & after contact with wound Between procedures on different parts of same patientBetween procedures on different parts of same patient Between glove changesBetween glove changes Immediately if skin is contaminated or an injury occurs Immediately if skin is contaminated or an injury occurs

Proper Hand WashingProper Hand Washing

Wet hands with warm (not hot) waterWet hands with warm (not hot) water Apply soap on handsApply soap on hands

Liquid soap is better (germs can live on wet soap bars)Liquid soap is better (germs can live on wet soap bars) Rub hands together for at least 15 secondsRub hands together for at least 15 seconds

Wash longer if there is visible dirt on handsWash longer if there is visible dirt on hands Cover all surfaces of hands & fingers - including Cover all surfaces of hands & fingers - including

between fingers, backs of hands, thumbs, under between fingers, backs of hands, thumbs, under fingernails fingernails

Rinse hands thoroughly with warm water Rinse hands thoroughly with warm water Dry hands thoroughly Dry hands thoroughly

If using air dryer, push button with elbowIf using air dryer, push button with elbow If available, use towel to turn off waterIf available, use towel to turn off water

What song is about 15 seconds long…. What song is about 15 seconds long…. Source: Hand Hygiene Resource Center http://www.handhygiene.org/Source: Hand Hygiene Resource Center http://www.handhygiene.org/

Where do we miss?Where do we miss?

Hand Hygiene (cont.)Hand Hygiene (cont.) Alcohol sanitizersAlcohol sanitizers

62% ethyl alcohol62% ethyl alcohol Accepted as effective under Accepted as effective under certaincertain

conditionsconditions Should not be used when there is Should not be used when there is

visible dirt or grime!visible dirt or grime!

Good Work Place Practices (cont.)Good Work Place Practices (cont.)

Eating & Eating & drinking drinking prohibited in all prohibited in all clinical areasclinical areas

Do not wear Do not wear jewelry in clinic jewelry in clinic areasareas

HairHair

Hair should be short & well-Hair should be short & well-managedmanaged

Long hair should be pulled back or Long hair should be pulled back or completely covered with a surgical completely covered with a surgical cap to minimize the possibility of cap to minimize the possibility of contamination contamination

Beards, mustaches, or other facial Beards, mustaches, or other facial hair must be neatly trimmed to fit hair must be neatly trimmed to fit under the maskunder the mask

FingernailsFingernails

Fingernails must be short to help Fingernails must be short to help prevent collections of microbes & prevent collections of microbes & tears in glovestears in gloves

CCoolloorreedd nail polish is prohibited nail polish is prohibited May obscure soil under the nailsMay obscure soil under the nails

False fingernails are prohibitedFalse fingernails are prohibited

Blood (or OPIM) Spill Clean upBlood (or OPIM) Spill Clean up Wear appropriate PPE & clean up all blood (or Wear appropriate PPE & clean up all blood (or

OPIM) spills with a 10% bleach solution or another OPIM) spills with a 10% bleach solution or another EPA-approved disinfectantEPA-approved disinfectant

Apply disinfectant to perimeter of spillApply disinfectant to perimeter of spill Slowly proceed inwardsSlowly proceed inwards

Allow at least 15 minutes of disinfectant contact Allow at least 15 minutes of disinfectant contact timetime

Be careful of sharps! Remove any sharps from Be careful of sharps! Remove any sharps from the spill (after disinfectant contact time) using the spill (after disinfectant contact time) using forceps & discard in sharps containerforceps & discard in sharps container

Slowly wipe up spill, working from the perimeter Slowly wipe up spill, working from the perimeter of the spill inwards; clean area with disinfectant of the spill inwards; clean area with disinfectant againagain

Materials used to clean up the spill (e.g., towels) Materials used to clean up the spill (e.g., towels) should be disposed in biohazard containershould be disposed in biohazard container

Biological Waste DisposalBiological Waste Disposal

Blood, saliva or OPIM Blood, saliva or OPIM saturated items must be saturated items must be discarded in biohazard discarded in biohazard bags at chairsidebags at chairside

Biohazard bags must be Biohazard bags must be maintained in hard-maintained in hard-walled, leakproof, walled, leakproof, secondary containmentsecondary containment

Small biohazard bags Small biohazard bags must be discarded in must be discarded in larger biohazard bags (at larger biohazard bags (at the dispensary)the dispensary)

Biological Waste DisposalBiological Waste Disposal

Place sharps in Place sharps in appropriate hard-appropriate hard-walled, leakproof walled, leakproof sharps containersharps container

Do not overfill (no more Do not overfill (no more than ¾ full), see “fill than ¾ full), see “fill line”line”

Call for pickup – UTHSC-Call for pickup – UTHSC-H Waste Line 713-500-H Waste Line 713-500-58375837

Regulated Medical WasteRegulated Medical Waste

Contaminated Contaminated waste disposalwaste disposal

Sharps disposalSharps disposal

In compliance In compliance with OSHA, with OSHA, DSHS & TCEQDSHS & TCEQ

Injury/Potential ExposureInjury/Potential Exposure Stop procedureStop procedure Apply routine first aid immediatelyApply routine first aid immediately

Clean site of injury with soap or antiseptic Clean site of injury with soap or antiseptic & flush with warm water for at least 15 & flush with warm water for at least 15 minutesminutes

Flush mucous membranes with water or Flush mucous membranes with water or saline for at least 15 minutessaline for at least 15 minutes

DO NOT dismiss patientDO NOT dismiss patient Report incident to nearest dispensaryReport incident to nearest dispensary

Notify supervisorNotify supervisor Complete “Supervisor’s First Report of Complete “Supervisor’s First Report of

Injury” formInjury” form Seek medical attentionSeek medical attention

Injury/Potential ExposureInjury/Potential Exposure

REMEMBER!REMEMBER!

If you have received a puncture or If you have received a puncture or laceration injury from a laceration injury from a contaminated needle or instrument…contaminated needle or instrument…

REMOVE THE ANESTHETIC SYRINGE REMOVE THE ANESTHETIC SYRINGE OR INSTRUMENT FROM CASSETTE – OR INSTRUMENT FROM CASSETTE – DO NOT REUSE INSTRUMENT !DO NOT REUSE INSTRUMENT !

Injury/Potential ExposureInjury/Potential Exposure““Please wait Please wait

here for a few here for a few minutes”minutes”

DO DO NOTNOT

DISMISSDISMISS

THETHE

PATIENT!PATIENT!

Medical SurveillanceMedical Surveillance Baseline LabsBaseline Labs

HIV antibody (with consent)HIV antibody (with consent) RPR (Syphilis)RPR (Syphilis) Hepatitis B surface antibodyHepatitis B surface antibody HCV antibodyHCV antibody

If source is known to be Hepatitis CIf source is known to be Hepatitis C++, also , also obtain a liver function & HCV RNA testsobtain a liver function & HCV RNA tests

CBC with differential & platelets, chemistry CBC with differential & platelets, chemistry profile, urine pregnancy test if source is known profile, urine pregnancy test if source is known HIVHIV++ and if exposed personnel chooses to utilize and if exposed personnel chooses to utilize post-exposure prophylaxispost-exposure prophylaxis

Hepatitis B VaccinationHepatitis B Vaccination Tuberculin skin test, Quantiferon testTuberculin skin test, Quantiferon test

Rights Rights In the event of a potential exposure In the event of a potential exposure to BBP, the person is entitled to:to BBP, the person is entitled to: Confidential medical evaluation & follow-upConfidential medical evaluation & follow-up

UT Student or Employee Health Services ClinicUT Student or Employee Health Services Clinic Documentation of routes of exposureDocumentation of routes of exposure Identification, documentation, testing & Identification, documentation, testing &

results of the source individualresults of the source individual Source blood draw for testingSource blood draw for testing

CounselingCounseling Evaluation of reported illnessEvaluation of reported illness

Record KeepingRecord Keeping

Medical records related to Medical records related to exposure incidents must be exposure incidents must be retained for duration of retained for duration of employment plus 30 yearsemployment plus 30 years

Training records must be Training records must be maintained for three years maintained for three years

TuberculosisTuberculosis

Caused by Caused by Mycobacterium Mycobacterium tuberculosistuberculosis

Spread by airborne droplets – Spread by airborne droplets – coughing, sneezing, speakingcoughing, sneezing, speaking

Also considered to be bloodborneAlso considered to be bloodborne

Patient Assessment for Risk of Patient Assessment for Risk of Tuberculosis Tuberculosis

Routinely ask all patients:Routinely ask all patients:

Do you have a history of TB disease?Do you have a history of TB disease?

Do you have symptoms suggestive of Do you have symptoms suggestive of TB?TB?

TB Presentation & IsolationTB Presentation & Isolation

CoughCough Chest PainChest Pain Coughing up bloodCoughing up blood WeaknessWeakness Fever or night sweatsFever or night sweats Weight lossWeight loss

Patients with History or Symptoms Patients with History or Symptoms of Undiagnosed TBof Undiagnosed TB

Should be referred promptly for medical Should be referred promptly for medical evaluation of possible infection evaluation of possible infection

Should not remain in the dental facility Should not remain in the dental facility any longer than required to arrange a any longer than required to arrange a referralreferral

Should wear surgical mask while in the Should wear surgical mask while in the dental facilitydental facility

Should have urgent dental care provided Should have urgent dental care provided in areas that can provide TB isolationin areas that can provide TB isolation

Patients with History or Symptoms Patients with History or Symptoms of Undiagnosed TB (cont.)of Undiagnosed TB (cont.)

Should have elective dental Should have elective dental treatment deferred until a physician treatment deferred until a physician confirms that the patient does not confirms that the patient does not have infectious TBhave infectious TB

If diagnosed as having active TB, If diagnosed as having active TB, elective dental treatment should be elective dental treatment should be deferred until no longer infectiousdeferred until no longer infectious

Methicillin Resistant Methicillin Resistant Staphylococcus aureus Staphylococcus aureus (MRSA)(MRSA)

Responsible for “difficult-to-treat Responsible for “difficult-to-treat infections”infections”

Multiple- or multidrug-resistant (MRSA), Multiple- or multidrug-resistant (MRSA), or oxacillin-resistant (ORSA) bacteriaor oxacillin-resistant (ORSA) bacteria

Resistant to beta-lactam antibiotics:Resistant to beta-lactam antibiotics: MethicillinMethicillin DicloxacillilnDicloxacilliln NafcillinNafcillin OxacillinOxacillin

Methicillin Resistant Methicillin Resistant Staphylococcus aureus Staphylococcus aureus (MRSA)(MRSA)

According to CDC, each year:According to CDC, each year:

Over 94,000 people develop a serious Over 94,000 people develop a serious MRSA infectionMRSA infection

Nearly 19,000 die from serious MRSA Nearly 19,000 die from serious MRSA infections infections

StaphylococcusStaphylococcus (Staph.) Bacteria (Staph.) Bacteria

Most common cause of skin infectionsMost common cause of skin infections MostMost are minor (pimples, boils) are minor (pimples, boils) SomeSome can be serious (surgical wound can be serious (surgical wound

infections, blood stream infections, & infections, blood stream infections, & pneumonia)pneumonia)

Nose colonization in 25 - 30% of Nose colonization in 25 - 30% of populationpopulation

MRSA colonization in ~ 1% of populationMRSA colonization in ~ 1% of population

Staph. Skin Infection WoundsStaph. Skin Infection Wounds

What Does “Colonized with MRSA” What Does “Colonized with MRSA” Mean?Mean?

MRSA is present in or on the body, but is MRSA is present in or on the body, but is not causing infection not causing infection

Colonized individuals are the main source Colonized individuals are the main source of infection for susceptible individuals of infection for susceptible individuals

TransmissionTransmission

Most common sourceMost common source Individuals who have MRSA but do not Individuals who have MRSA but do not

have symptoms (i.e., colonized with have symptoms (i.e., colonized with MRSA)MRSA)

Main mode of transmissionMain mode of transmission Through Through human hands human hands (especially (especially

health care workers hands)health care workers hands)

Who Gets Serious MRSA Infections? Who Gets Serious MRSA Infections?

Individuals with compromised immune Individuals with compromised immune systems are susceptible to serious MRSA systems are susceptible to serious MRSA infectionsinfections

Colonized individuals can be the source of Colonized individuals can be the source of MRSA for immunocompromised patients in MRSA for immunocompromised patients in the dental officethe dental office

MRSA in Dentistry - MRSA in Dentistry - What is Our Responsibility?What is Our Responsibility?

Prevent transmission of MRSA in dental Prevent transmission of MRSA in dental settingssettings

Frequent handwashingFrequent handwashing

Sterilization of instrumentationSterilization of instrumentation

Appropriate use of disinfectants & barriersAppropriate use of disinfectants & barriers

Prescribe responsiblyPrescribe responsibly

Seasonal or Pandemic Flu Seasonal or Pandemic Flu Person to person transmission by:Person to person transmission by:

Coughing, sneezing, spittingCoughing, sneezing, spitting Droplets from infected person on Droplets from infected person on

HandsHands Environmental surfacesEnvironmental surfaces

Table tops, door knobs, handrails, phonesTable tops, door knobs, handrails, phones Droplets reach uninfected personDroplets reach uninfected person

Directly from coughing, sneezing, spittingDirectly from coughing, sneezing, spitting Hand shakesHand shakes Touching contaminated environmental Touching contaminated environmental

surfacessurfaces

Help Prevent Flu TransmissionHelp Prevent Flu Transmission

Cover your mouth & nose with a tissue Cover your mouth & nose with a tissue when you cough or sneeze when you cough or sneeze

Cover your mouth & nose with your upper Cover your mouth & nose with your upper sleeve (not your hands), if you do not have sleeve (not your hands), if you do not have a tissue & need to cough or sneeze a tissue & need to cough or sneeze

Wash your hands as soon as possible after Wash your hands as soon as possible after coughing, sneezing, or blowing your nosecoughing, sneezing, or blowing your nose

Practice social distancing during flu season Practice social distancing during flu season or a flu pandemicor a flu pandemic

Help Prevent Flu Transmission Help Prevent Flu Transmission (cont.)(cont.)

Keep surfaces touched by more than one Keep surfaces touched by more than one person clean & disinfected (door knobs, person clean & disinfected (door knobs, handrails)handrails)

Remember to clean first & then disinfectRemember to clean first & then disinfect Wash your hands frequently & always before Wash your hands frequently & always before

eating eating Carry alcohol-based (60 – 95%), sanitizing hand Carry alcohol-based (60 – 95%), sanitizing hand

wipes or gel with you to disinfect your handswipes or gel with you to disinfect your hands Teach your children to practice good hand Teach your children to practice good hand

hygienehygiene Flu is often transmitted at schoolFlu is often transmitted at school

Pandemic PreparednessPandemic Preparedness

UTHSC-H has an UTHSC-H has an appointed Task Force appointed Task Force that includes input from:that includes input from:

Harris County Health Harris County Health Dept.Dept.

City of Houston Health City of Houston Health Dept.Dept.

TMCTMC Memorial Hermann Memorial Hermann

HospitalHospital

Pandemic Preparedness: Pandemic Preparedness: How to protect yourself How to protect yourself

Get vaccinated for seasonal fluGet vaccinated for seasonal flu Wash hands frequentlyWash hands frequently Practice & teach cough etiquette Practice & teach cough etiquette Practice social distancingPractice social distancing

Avoid close contact with sick peopleAvoid close contact with sick people Avoid close contact if sickAvoid close contact if sick Stay home if sick!Stay home if sick!

Dental Unit Waterlines & BiofilmDental Unit Waterlines & Biofilm

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

Biofilms serve as a Biofilms serve as a microbial reservoirmicrobial reservoir

Primary source of Primary source of microorganisms is microorganisms is municipal water municipal water supplysupply

Dental Unit Water QualityDental Unit Water Quality

Using water of uncertain quality is Using water of uncertain quality is inconsistent with infection control inconsistent with infection control principlesprinciples

Microbial counts in water from Microbial counts in water from untreated systems can exceed untreated systems can exceed 1,000,0001,000,000 CFU/mL (CFU/mL (CFU = colony CFU = colony forming unit)forming unit)

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

Dental Unit Water Quality (cont.)Dental Unit Water Quality (cont.)

For routine dental For routine dental treatment, meet treatment, meet regulatory standards for regulatory standards for drinking water:drinking water:

< 500 CFU/mL of < 500 CFU/mL of heterotrophic water bacteriaheterotrophic water bacteria

ADA standards:ADA standards:

< 200 CFU/mL of < 200 CFU/mL of heterotrophic bacteriaheterotrophic bacteria

Dental Unit Water Quality Dental Unit Water Quality (cont.)(cont.)

ICX TabletsICX Tablets

Available on Available on gray cabinets at gray cabinets at the back of the the back of the baysbays

Instructions Instructions posted in each posted in each cubiclecubicle

ICX TabletsICX Tablets Rinse empty water bottle with tap Rinse empty water bottle with tap

waterwater Prior to rinsing, make sure the water Prior to rinsing, make sure the water

from tap has run for at least 30 from tap has run for at least 30 seconds or until clearseconds or until clear

Add one tablet of ICX to empty water Add one tablet of ICX to empty water bottle – bottle – avoid touching the tabletavoid touching the tablet

Fill bottle with tap waterFill bottle with tap water Wait 60 seconds for tablet to fully Wait 60 seconds for tablet to fully

dissolvedissolve

Dental Unit Water Quality (cont.)Dental Unit Water Quality (cont.)

Fire Alarm DesignFire Alarm Design

Stop patient procedureStop patient procedure Send one person to Send one person to

emergency exit to listen to emergency exit to listen to announcement, & ask that announcement, & ask that person to tell you if there is a person to tell you if there is a need to evacuateneed to evacuate

Alarm sounds on involved Alarm sounds on involved floor, & floor immediately floor, & floor immediately above & belowabove & below

If fire discovered, alarm will If fire discovered, alarm will sound in entire buildingsound in entire building

If you see smoke or fire, If you see smoke or fire, evacuate immediately using evacuate immediately using the nearest stairwell exit the nearest stairwell exit

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Safe Handling & ErgonomicsSafe Handling & Ergonomics SquatSquat down, bending at the hips & knees only. down, bending at the hips & knees only. PressPress your chest straight forward. This helps keep your upper back your chest straight forward. This helps keep your upper back

straight while maintaining a slight arch in your lower back. straight while maintaining a slight arch in your lower back. Slowly liftSlowly lift by straightening your hip & knee joints (not your back). by straightening your hip & knee joints (not your back). HoldHold the load as close to your body as possible, at naval level of your the load as close to your body as possible, at naval level of your

navel. navel. Set downSet down your load carefully, squatting with the knees & hips only. your load carefully, squatting with the knees & hips only. Do not Do not attempt to lift or set down by bending forward at the waist. attempt to lift or set down by bending forward at the waist. Avoid turning or twisting Avoid turning or twisting your body while holding a heavy object.your body while holding a heavy object. Work with objects at a surface near waist high, Work with objects at a surface near waist high, rather than rather than

bending to the items on the floor. bending to the items on the floor.

X-Ray & Laser SafetyX-Ray & Laser Safety

Special training is Special training is available for personnel available for personnel that will use X-Rays & that will use X-Rays & LasersLasers

Programs are available Programs are available for individuals who are for individuals who are pregnant pregnant

Contact InformationContact Information

General safety concerns, General safety concerns, emergency response (including emergency response (including after hours)after hours) Ext. 5832Ext. 5832

Hazardous wasteHazardous waste Ext. 5837Ext. 5837

Environmental Health & SafetyEnvironmental Health & Safety Ext. 8100 (Main number)Ext. 8100 (Main number)

ResourcesResources

UTHSC-H Dental School Clinic ManualUTHSC-H Dental School Clinic Manual www.db.uth.tmc.edu/clinicpat/Documents/Cl

inic_Manual.pdf

UTHSC-H Biological Safety ManualUTHSC-H Biological Safety Manual www.uth.tmc.edu/safety

OSHAOSHA www.osha.gov

CDCCDC www.cdc.gov

Resources (cont.)Resources (cont.)

ADAADA www.ada.org

DSHSDSHS www.dshs.state.tx.us

TCEQTCEQ www.tceq.state.tx.us

Questions??