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1. Guidelines for Infection Control in Dental Health-Care Settings2003 SIUC Dental Hygiene IC Training Part One CDC. MMWR 2003;52(No. RR-17)
http://www.cdc.gov/oralhealth/
infectioncontrol/guidelines/index.htm
2. Additional slides for each section of the document will be developed and may be used in conjunction with the core slides. This presentation and supplemental slides may be broken into separate sections, depending on the trainees level of experience and knowledge, previous training, level of interest in specific topics, and the amount of time available.
Additional slides for each section of the document will be developed and may be used in conjunction with the core slides. This presentation and supplemental slides may be broken into separate sections, depending on the trainees level of experience and knowledge, previous training, level of interest in specific topics, and the amount of time available.
3. CDC Recommendations Improve effectiveness and impact of public health interventions
Inform clinicians, public health practitioners, and the public
Developed by advisory committees, ad hoc groups, and CDC staff
Based on a range of rationale, from systematic reviews to expert opinions
CDC develops a broad range of guidelines which are intended to improve the effectiveness and impact of public health interventions and inform key audiences, most often clinicians, public health practitioners, and the public.
Guidelines can be developed by formal advisory committees, ad hoc work groups, and CDC staff. Development processes can vary, depending on topic, available scientific data, urgency, resources, etc. and are based on a range of rationale, depending on the availability of scientific evidence.
This Guideline identifies infection control practices that CDC recommends for all settings where dental treatment is provided. Although CDC recommendations are not regulatory, some practices are mandated by federal, state, or local regulations. These are identified in the Recommendations Section of the CDC Guideline.CDC develops a broad range of guidelines which are intended to improve the effectiveness and impact of public health interventions and inform key audiences, most often clinicians, public health practitioners, and the public.
Guidelines can be developed by formal advisory committees, ad hoc work groups, and CDC staff. Development processes can vary, depending on topic, available scientific data, urgency, resources, etc. and are based on a range of rationale, depending on the availability of scientific evidence.
This Guideline identifies infection control practices that CDC recommends for all settings where dental treatment is provided. Although CDC recommendations are not regulatory, some practices are mandated by federal, state, or local regulations. These are identified in the Recommendations Section of the CDC Guideline.
4. Background
5. Why Is Infection Control Important in Dentistry? Both patients and dental health care personnel (DHCP) can be exposed to pathogens
Contact with blood, oral and respiratory secretions, and contaminated equipment occurs
Proper procedures can prevent transmission of infections among patients and DHCP During the provision of dental treatment, both patients and dental health care personnel (DHCP) can be exposed to pathogens through contact with blood, oral and respiratory secretions, and contaminated equipment.
Following recommended infection control procedures can prevent transmission of infectious organisms among patients and dental health care personnel.
During the provision of dental treatment, both patients and dental health care personnel (DHCP) can be exposed to pathogens through contact with blood, oral and respiratory secretions, and contaminated equipment.
Following recommended infection control procedures can prevent transmission of infectious organisms among patients and dental health care personnel.
6. Modes of Transmission Direct contact with blood or body fluids
Indirect contact with a contaminated instrument or surface
Contact of mucosa of the eyes, nose, or mouth with droplets or spatter
Inhalation of airborne microorganisms Dental patients and DHCP may be exposed to a variety of disease-causing microorganisms that are present in the mouth and respiratory tract. These organisms may be transmitted in dental settings through several routes, including:
Intact or non-intact skin in direct contact with blood, oral fluids, or other potentially infectious patient materials.
Indirect contact with a contaminated object (e.g., instruments, operatory equipment, or environmental surfaces).
Contact of mucous membranes of the eyes, nose, or mouth with droplets (e.g., spatter) containing microorganisms generated (e.g., coughing, sneezing, talking) from an infected person and propelled a short distance.
Inhalation of airborne microorganisms that can remain suspended in the air for long periods of time.Dental patients and DHCP may be exposed to a variety of disease-causing microorganisms that are present in the mouth and respiratory tract. These organisms may be transmitted in dental settings through several routes, including:
Intact or non-intact skin in direct contact with blood, oral fluids, or other potentially infectious patient materials.
Indirect contact with a contaminated object (e.g., instruments, operatory equipment, or environmental surfaces).
Contact of mucous membranes of the eyes, nose, or mouth with droplets (e.g., spatter) containing microorganisms generated (e.g., coughing, sneezing, talking) from an infected person and propelled a short distance.
Inhalation of airborne microorganisms that can remain suspended in the air for long periods of time.
7. Infection through any of these routes requires that all of the following conditions be present:
An adequate number of pathogens, or disease-causing organisms, to cause disease.
A reservoir or source that allows the pathogen to survive and multiply (e.g., blood).
A mode of transmission from the source to the host.
An entrance through which the pathogen may enter the host.
A susceptible host (i.e., one who is not immune).
The occurrence of all these events is considered the chain of infection. Effective infection control strategies prevent disease transmission by interrupting one or more links in the chain of infection.Infection through any of these routes requires that all of the following conditions be present:
An adequate number of pathogens, or disease-causing organisms, to cause disease.
A reservoir or source that allows the pathogen to survive and multiply (e.g., blood).
A mode of transmission from the source to the host.
An entrance through which the pathogen may enter the host.
A susceptible host (i.e., one who is not immune).
The occurrence of all these events is considered the chain of infection. Effective infection control strategies prevent disease transmission by interrupting one or more links in the chain of infection.
8. Standard Precautions Apply to all patients
Integrate and expand Universal Precautions to include organisms spread by blood and also
Body fluids, secretions, and excretions except sweat, whether or not they contain blood
Non-intact (broken) skin
Mucous membranes Previous CDC recommendations on infection control for dentistry (1986, 1993) focused on the use of Universal Precautions to prevent transmission of bloodborne pathogens. Universal Precautions were based on the concept that all blood and certain body fluids should be treated as infectious because it is impossible to know who may be carrying a bloodborne virus. Thus, Universal Precautions should apply to all patients.
The relevance of Universal Precautions applied to other potentially infectious materials was recognized, and in 1996, CDC replaced Universal Precautions with Standard Precautions. Standard Precautions integrate and expand Universal Precautions to include organisms spread by:
Blood.
All body fluids, secretions, and excretions except sweat, regardless of whether they contain blood.
Non-intact skin.
Mucous membranes.
Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions.
Previous CDC recommendations on infection control for dentistry (1986, 1993) focused on the use of Universal Precautions to prevent transmission of bloodborne pathogens. Universal Precautions were based on the concept that all blood and certain body fluids should be treated as infectious because it is impossible to know who may be carrying a bloodborne virus. Thus, Universal Precautions should apply to all patients.
The relevance of Universal Precautions applied to other potentially infectious materials was recognized, and in 1996, CDC replaced Universal Precautions with Standard Precautions. Standard Precautions integrate and expand Universal Precautions to include organisms spread by:
Blood.
All body fluids, secretions, and excretions except sweat, regardless of whether they contain blood.
Non-intact skin.
Mucous membranes.
Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions.
9. Elements of Standard Precautions Handwashing
Use of gloves, masks, eye protection, and gowns
Patient care equipment
Environmental surfaces
Injury prevention
Standard Precautions include:
Handwashing.
The use of personal protective equipment, such as gloves, masks, eye protection, and gowns, that are intended to prevent the exposure of skin and mucous membranes to blood and other potentially infectious materials.
Proper cleaning and decontamination of patient care equipment.
Cleaning and disinfection of environmental surfaces.
Injury prevention through engineering controls or safer work practices.
Note: OSHA retains the use of the term Universal Precautions because they are concerned primarily with transmission of bloodborne pathogens.
Standard Precautions include:
Handwashing.
The use of personal protective equipment, such as gloves, masks, eye protection, and gowns, that are intended to prevent the exposure of skin and mucous membranes to blood and other potentially infectious materials.
Proper cleaning and decontamination of patient care equipment.
Cleaning and disinfection of environmental surfaces.
Injury prevention through engineering controls or safer work practices.
Note: OSHA retains the use of the term Universal Precautions because they are concerned primarily with transmission of bloodborne pathogens.
10. Bloodborne Pathogens
11. Preventing Transmission of Bloodborne Pathogens Are transmissible in health care settings
Can produce chronic infection
Are often carried by persons unaware of their infection
Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are of concern to dental health care personnel (DHCP). These viruses:
Can be transmitted to patients and health care personnel (HCP) in health care settings.
Can produce chronic infection.
Are often carried by persons unaware of their infection.
Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) are of concern to dental health care personnel (DHCP). These viruses:
Can be transmitted to patients and health care personnel (HCP) in health care settings.
Can produce chronic infection.
Are often carried by persons unaware of their infection.
12. Potential Routes of Transmission of Bloodborne Pathogens Theoretically, transmission of bloodborne pathogens may occur from patient to DHCP, from DHCP to patient, and from patient to patient.
Because DHCP frequently are exposed to blood and blood-contaminated saliva during dental procedures, they are at greater risk of infection by a bloodborne pathogen than are patients. Theoretically, transmission of bloodborne pathogens may occur from patient to DHCP, from DHCP to patient, and from patient to patient.
Because DHCP frequently are exposed to blood and blood-contaminated saliva during dental procedures, they are at greater risk of infection by a bloodborne pathogen than are patients.
13. Factors Influencing Occupational Risk of Bloodborne Virus Infection Frequency of infection among patients
Risk of transmission after a blood exposure (i.e., type of virus)
Type and frequency of blood contact
The risk of infection with a bloodborne virus is largely determined by:
Its prevalence, or frequency, in the patient population.
The risk of transmission after an exposure to blood (risk varies by type of virus).
The type and frequency of blood contacts. If health care personnel are frequently exposed to blood, especially if they are working with sharp objects such as needles, their risk of exposure to a bloodborne virus would be higher than if they rarely come into contact with blood.
The risk of infection with a bloodborne virus is largely determined by:
Its prevalence, or frequency, in the patient population.
The risk of transmission after an exposure to blood (risk varies by type of virus).
The type and frequency of blood contacts. If health care personnel are frequently exposed to blood, especially if they are working with sharp objects such as needles, their risk of exposure to a bloodborne virus would be higher than if they rarely come into contact with blood.
14. Average Risk of Bloodborne Virus Transmission after Needlestick This slide shows the average risk of transmission after a single needlestick from an infected patient by type of bloodborne virus. As shown here, risk varies greatly by type of virus.
For instance, the risk of HBV transmission after a percutaneous exposure (e.g., needlestick) to HBV-infected blood varies from 1% 62%, depending on the hepatitis B e-antigen (HBeAg) status of the source patient. If the source patients blood is positive for HBeAg (a marker of increased infectivity), the risk of transmission can be as high as 62%. If the patients blood is hepatitis B surface antigen (HBsAg) positive but HBeAg negative, the risk varies from 1% 37%.
The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%.
The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%. To put this in perspective, 1 in 3 needlesticks from an HBeAg+ source patient would result in infection compared to only 1 in 300 needlesticks from an HIV-infected patient. This slide shows the average risk of transmission after a single needlestick from an infected patient by type of bloodborne virus. As shown here, risk varies greatly by type of virus.
For instance, the risk of HBV transmission after a percutaneous exposure (e.g., needlestick) to HBV-infected blood varies from 1% 62%, depending on the hepatitis B e-antigen (HBeAg) status of the source patient. If the source patients blood is positive for HBeAg (a marker of increased infectivity), the risk of transmission can be as high as 62%. If the patients blood is hepatitis B surface antigen (HBsAg) positive but HBeAg negative, the risk varies from 1% 37%.
The average risk of HCV transmission after a percutaneous exposure to HCV-infected blood is 1.8%.
The average risk of HIV infection after a percutaneous exposure to HIV-infected blood is 0.3%. To put this in perspective, 1 in 3 needlesticks from an HBeAg+ source patient would result in infection compared to only 1 in 300 needlesticks from an HIV-infected patient.
15. Concentration of HBV in Body Fluids High Moderate Low/Not Detectable
Blood Semen Urine
Serum Vaginal Fluid Feces
Wound exudates Saliva Sweat
Tears
Breast Milk As mentioned earlier, one factor to consider in assessing the risk of infection is the type of body substances to which DHCP are exposed. This slide shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus.
Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat. Saliva alone, without blood, has a moderate concentration of virus.As mentioned earlier, one factor to consider in assessing the risk of infection is the type of body substances to which DHCP are exposed. This slide shows the concentration of HBV in various body fluids. On the left, in red, are the fluids with the highest concentration of virus.
Moving from the left to the right side, the concentration decreases. Blood, for instance, has a higher virus concentration than urine or sweat. Saliva alone, without blood, has a moderate concentration of virus.
16. Estimated Incidence of HBV Infections Among HCP and General Population, United States, 1985-1999 In the early to mid-1980s, health care personnel (HCP) had a much higher incidence (i.e., the number of new infections each year) of HBV infection than the general population. By the early 1990s, however, the incidence among health care personnel had dropped below that found in the general population. This decrease likely is the result of increased use of Universal Precautions and the hepatitis vaccine.In the early to mid-1980s, health care personnel (HCP) had a much higher incidence (i.e., the number of new infections each year) of HBV infection than the general population. By the early 1990s, however, the incidence among health care personnel had dropped below that found in the general population. This decrease likely is the result of increased use of Universal Precautions and the hepatitis vaccine.
17. Hepatitis B Vaccine Vaccinate all DHCP who are at risk of exposure to blood
Provide access to qualified health care professionals for administration and follow-up testing
Test for anti-HBs 1 to 2 months after 3rd dose
Both Occupational Safety & Health Administration (OSHA) regulations and CDC recommendations state that hepatitis B vaccine should be made available to all DHCP who are exposed to blood or other potentially infectious materials.
Employers should provide easy access to a qualified health care professional who can administer the vaccine and provide appropriate follow-up testing.
Post-vaccination testing for antibody to hepatitis B surface antigen (anti-HBs) response is indicated for DHCP who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks. Post-vaccination testing should be completed one to two months after the 3rd vaccine dose. Knowledge of antibody response should guide appropriate postexposure prophylaxis.
Both Occupational Safety & Health Administration (OSHA) regulations and CDC recommendations state that hepatitis B vaccine should be made available to all DHCP who are exposed to blood or other potentially infectious materials.
Employers should provide easy access to a qualified health care professional who can administer the vaccine and provide appropriate follow-up testing.
Post-vaccination testing for antibody to hepatitis B surface antigen (anti-HBs) response is indicated for DHCP who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks. Post-vaccination testing should be completed one to two months after the 3rd vaccine dose. Knowledge of antibody response should guide appropriate postexposure prophylaxis.
18. HCV Infection in Dental Health Care Settings Prevalence of HCV infection among dentists similar to that of general population (~ 1%-2%)
No reports of HCV transmission from infected DHCP to patients or from patient to patient
Risk of HCV transmission appears very low
Currently, there is little information from which to estimate the occupational risk of HCV infection in dentistry. However, most studies suggest that the prevalence (frequency) of HCV infection among dentists, surgeons, and hospital-based HCP is ~1%2%, similar to that among the general population.
There have been no reports of an HCV transmission from an infected DHCP to a patient or of patient-to-patient transmission of HCV in a dental health care setting.
Based on this information, the risk of HCV transmission in dentistry appears very low.
Currently, there is little information from which to estimate the occupational risk of HCV infection in dentistry. However, most studies suggest that the prevalence (frequency) of HCV infection among dentists, surgeons, and hospital-based HCP is ~1%2%, similar to that among the general population.
There have been no reports of an HCV transmission from an infected DHCP to a patient or of patient-to-patient transmission of HCV in a dental health care setting.
Based on this information, the risk of HCV transmission in dentistry appears very low.
19. Transmission of HIV from Infected Dentists to Patients Only one documented case of HIV transmission from an infected dentist to patients
No transmissions documented in the investigation of 63 HIV-infected HCP (including 33 dentists or dental students) To date, transmission of HIV from infected HCP to patients has been documented in only one practice. Investigation of the patients of a Florida dentist with AIDS strongly suggested that HIV was transmitted during dental care to 6 of approximately 1,100 patients tested.
Additional evidence supporting the very small risk of HIV transmission to patients comes from investigations conducted in the early 1990s of patients of other HIV-infected HCP. Test results of more than 22,000 patients of 63 HIV-infected HCP, including 33 dentists or dental students, failed to identify any additional cases of transmission. To date, transmission of HIV from infected HCP to patients has been documented in only one practice. Investigation of the patients of a Florida dentist with AIDS strongly suggested that HIV was transmitted during dental care to 6 of approximately 1,100 patients tested.
Additional evidence supporting the very small risk of HIV transmission to patients comes from investigations conducted in the early 1990s of patients of other HIV-infected HCP. Test results of more than 22,000 patients of 63 HIV-infected HCP, including 33 dentists or dental students, failed to identify any additional cases of transmission.
20. As of December 2002, there were no DHCP among the 57 U.S. HCP with documented HIV transmission following a specific exposure to a known HIV-infected source.
CDC also has received reports of 139 other HCP considered to have possible occupational HIV transmission; of these, only 6 were DHCP. For each of the 139 persons, no other risk for infection could be identified during follow-up investigation.
* Each of the 6 DHCP reported a history of occupational percutaneous or mucous membrane exposure to blood or body fluids in the dental setting, but HIV transmission could not be linked to a specific exposure. As of December 2002, there were no DHCP among the 57 U.S. HCP with documented HIV transmission following a specific exposure to a known HIV-infected source.
CDC also has received reports of 139 other HCP considered to have possible occupational HIV transmission; of these, only 6 were DHCP. For each of the 139 persons, no other risk for infection could be identified during follow-up investigation.
* Each of the 6 DHCP reported a history of occupational percutaneous or mucous membrane exposure to blood or body fluids in the dental setting, but HIV transmission could not be linked to a specific exposure.
21. Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood CDC Case-Control Study Deep injury
Visible blood on device
Needle placed in artery or vein
Terminal illness in source patient
Source: Cardo, et al., N England J Medicine 1997;337:1485-90. Several factors affect the risk of HIV transmission after an occupational exposure.
In a study of health care personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a relatively large quantity of blood as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein.
The risk was also increased if the exposure was to blood from patients with terminal illness, possibly reflecting the higher titer of HIV in late-stage AIDS. Several factors affect the risk of HIV transmission after an occupational exposure.
In a study of health care personnel who had percutaneous exposure to HIV-infected blood, an increased risk for HIV infection was associated with exposure to a relatively large quantity of blood as indicated by deep injury, visible blood on the device, or a procedure involving a needle placed in an artery or vein.
The risk was also increased if the exposure was to blood from patients with terminal illness, possibly reflecting the higher titer of HIV in late-stage AIDS.
22. Characteristics of Percutaneous Injuries Among DHCP Reported frequency among general dentists has declined
Caused by burs, syringe needles, other sharps
Occur outside the patients mouth
Involve small amounts of blood
Among oral surgeons, occur more frequently during fracture reductions and procedures involving wire Available information indicates that percutaneous injuries among dentists declined from an average rate of 11 injuries per year in 1987 to <3 injuries per year in 1993.
In general, most injuries among general dentists were caused by burs, followed by syringe needles and other sharp instruments. Injuries most often occur while the dentists hands are outside the patients mouth. Most injuries involve small, rather than large, amounts of blood.
The frequency of percutaneous injuries among oral surgeons is similar to that reported among U.S. dentists. Injuries among oral surgeons may occur more frequently during procedures using surgical wire, such as during fracture reductions. Available information indicates that percutaneous injuries among dentists declined from an average rate of 11 injuries per year in 1987 to <3 injuries per year in 1993.
In general, most injuries among general dentists were caused by burs, followed by syringe needles and other sharp instruments. Injuries most often occur while the dentists hands are outside the patients mouth. Most injuries involve small, rather than large, amounts of blood.
The frequency of percutaneous injuries among oral surgeons is similar to that reported among U.S. dentists. Injuries among oral surgeons may occur more frequently during procedures using surgical wire, such as during fracture reductions.
23. Wound management
Exposure reporting
Assessment of infection risk
Type and severity of exposure
Bloodborne status of source person
Susceptibility of exposed person Post-exposure Management The key elements of post-exposure management include wound management and exposure reporting.
The evaluating health care professional should assess the risk of infection by examining the type and severity of exposure, the bloodborne status of the source person, and the susceptibility (immune status) of the exposed person. All of these factors should be considered in assessing the risk of infection and the need for further follow-up (e.g., PEP).
The key elements of post-exposure management include wound management and exposure reporting.
The evaluating health care professional should assess the risk of infection by examining the type and severity of exposure, the bloodborne status of the source person, and the susceptibility (immune status) of the exposed person. All of these factors should be considered in assessing the risk of infection and the need for further follow-up (e.g., PEP).
24. Hand Hygiene
25. Why Is Hand Hygiene Important? Hands are the most common mode of pathogen transmission
Reduce spread of antimicrobial resistance
Prevent health care-associated infections
Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings?
First, hands are the most common mode of pathogen transmission.
Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections.
[Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]
Next we turn to the subject of Hand Hygiene. So, is hand hygiene the single most important factor in preventing the spread of pathogens in health care settings?
First, hands are the most common mode of pathogen transmission.
Hand washing can reduce the spread of antibiotic resistance in health care settings and the likelihood of health care-associated infections.
[Additional comments: CDC estimates that each year nearly 2 million patients in the United States acquire infections in hospitals, and about 90,000 of these patients die as a result.]
26. Hands Need to be Cleaned When Visibly dirty
After touching contaminated objects with bare hands
Before and after patient treatment (before glove placement and after glove removal) CDC recommends that hands be cleaned:
When they are visibly dirty.
After touching contaminated objects with bare hands.
Before and after patient treatment, that is, before glove placement and immediately after glove removal.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.CDC recommends that hands be cleaned:
When they are visibly dirty.
After touching contaminated objects with bare hands.
Before and after patient treatment, that is, before glove placement and immediately after glove removal.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.
27. Hand Hygiene Definitions
Handwashing
Washing hands with plain soap and water
Antiseptic handwash
Washing hands with water and soap or other detergents containing an antiseptic agent
Alcohol-based handrub
Rubbing hands with an alcohol-containing preparation
Surgical antisepsis
Handwashing with an antiseptic soap or an alcohol-based handrub before operations by surgical personnel
Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.
Handwashing refers to washing hands with plain soap and water.
Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent, such as triclosan or chlorhexidine.
Using a waterless agent containing 60%95% ethanol or isopropanol alcohol-containing preparation is referred to as an alcohol handrub. These agents are a new addition to the dental guidelines and have become more frequently used in the United States to improve compliance with handwashing in hospitals. In dental practices, however, sinks are readily available and the need for alcohol preparations is not as great.
Surgical antisepsis refers to an antiseptic handwash or alcohol-based handrub* performed preoperatively by surgical personnel to eliminate microorganisms on hands. Antiseptic preparations for surgical hand hygiene should have persistent (long-lasting) antimicrobial activity.
* If using an alcohol-based handrub the hands should first be washed with soap and water.
Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.
Handwashing refers to washing hands with plain soap and water.
Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent, such as triclosan or chlorhexidine.
Using a waterless agent containing 60%95% ethanol or isopropanol alcohol-containing preparation is referred to as an alcohol handrub. These agents are a new addition to the dental guidelines and have become more frequently used in the United States to improve compliance with handwashing in hospitals. In dental practices, however, sinks are readily available and the need for alcohol preparations is not as great.
Surgical antisepsis refers to an antiseptic handwash or alcohol-based handrub* performed preoperatively by surgical personnel to eliminate microorganisms on hands. Antiseptic preparations for surgical hand hygiene should have persistent (long-lasting) antimicrobial activity.
* If using an alcohol-based handrub the hands should first be washed with soap and water.
28. Efficacy of Hand Hygiene Preparations in Reduction of Bacteria Plain soap is good for reducing bacterial counts, but antimicrobial soap is better and alcohol-based handrubs are the best, providing activity that prevents or inhibits survival of microorganisms after the product is applied. Plain soap is good for reducing bacterial counts, but antimicrobial soap is better and alcohol-based handrubs are the best, providing activity that prevents or inhibits survival of microorganisms after the product is applied.
29. Alcohol-based Preparations Rapid and effective antimicrobial action
Improved skin condition
More accessible than sinks Cannot be used if hands are visibly soiled
Store away from high temperatures or flames
Hand softeners and glove powders may build-up
This slide lists the benefits and limitations of alcohol-based preparations.
Alcohol handrubs have a rapid and effective antimicrobial action when applied to the skin but must contain other ingredients, such as chlorhexidine or triclosan, to achieve persistent (long-lasting) activity.
When combined with emollients, or skin softeners, they can improve skin condition.
In hospital settings, they are often more accessible than sinks.
However,
Alcohol is not a good cleaning agent, so these products cannot be used if hands are visibly soiled.
Because of their flammable nature, they must be stored away from high temperatures or flames.
In addition, there is some concern that hand softeners and glove powders might build up on the hands after repeated use. Hands should be washed occasionally with soap and water.
This slide lists the benefits and limitations of alcohol-based preparations.
Alcohol handrubs have a rapid and effective antimicrobial action when applied to the skin but must contain other ingredients, such as chlorhexidine or triclosan, to achieve persistent (long-lasting) activity.
When combined with emollients, or skin softeners, they can improve skin condition.
In hospital settings, they are often more accessible than sinks.
However,
Alcohol is not a good cleaning agent, so these products cannot be used if hands are visibly soiled.
Because of their flammable nature, they must be stored away from high temperatures or flames.
In addition, there is some concern that hand softeners and glove powders might build up on the hands after repeated use. Hands should be washed occasionally with soap and water.
30. Special Hand Hygiene Considerations Use hand lotions to prevent skin dryness
Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may cause early glove failure)
Keep fingernails short
Avoid artificial nails
Avoid hand jewelry that may tear gloves Hand lotions can prevent skin dryness associated with hand washing. However, its important to consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves when selecting and using them.
Short nails allow thorough cleaning of nails and may reduce premature glove tearing. Artificial nails can harbor pathogensthus, their use should be avoided.
During surgical procedures, hand or arm jewelry can harbor microorganisms or increase risk of glove failure. If worn during non-surgical procedures, hand or arm jewelry can affect glove placement, fit, or durability.
Hand lotions can prevent skin dryness associated with hand washing. However, its important to consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves when selecting and using them.
Short nails allow thorough cleaning of nails and may reduce premature glove tearing. Artificial nails can harbor pathogensthus, their use should be avoided.
During surgical procedures, hand or arm jewelry can harbor microorganisms or increase risk of glove failure. If worn during non-surgical procedures, hand or arm jewelry can affect glove placement, fit, or durability.
31. Personal Protective Equipment
32. Personal Protective Equipment A major component of Standard Precautions
Protects the skin and mucous membranes from exposure to infectious materials in spray or spatter
Should be removed when leaving treatment areas
Personal protective equipment (PPE), or barrier precautions, are a major component of Standard Precautions. Use of rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers) and air-water syringes creates a visible spray that contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a short distance and settles out quickly, landing either on the floor, operatory surfaces, dental health care personnel (DHCP), or the patient.
PPE is essential to protect the skin and the mucous membranes of DHCP from exposure to infectious or potentially infectious materials. PPE should be worn whenever there is potential for contact with spray or spatter and should be removed when leaving treatment areas.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
Personal protective equipment (PPE), or barrier precautions, are a major component of Standard Precautions. Use of rotary dental and surgical instruments (e.g., handpieces, ultrasonic scalers) and air-water syringes creates a visible spray that contains primarily large-particle droplets of water, saliva, blood, microorganisms, and other debris. This spatter travels only a short distance and settles out quickly, landing either on the floor, operatory surfaces, dental health care personnel (DHCP), or the patient.
PPE is essential to protect the skin and the mucous membranes of DHCP from exposure to infectious or potentially infectious materials. PPE should be worn whenever there is potential for contact with spray or spatter and should be removed when leaving treatment areas.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
33. Masks, Protective Eyewear, Face Shields Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth
Change masks between patients
Clean reusable face protection between patients; if visibly soiled, clean and disinfect A standard surgical mask that covers the nose and mouth is worn to protect the mucous membranes from spatter generated during dental procedures. Eye protection with solid side shields or a face shield should also be worn.
A mask should be changed between patients or if it becomes wet during patient treatment.
Clean reusable face protection with soap and water between patients; if visibly soiled, clean and disinfect. A standard surgical mask that covers the nose and mouth is worn to protect the mucous membranes from spatter generated during dental procedures. Eye protection with solid side shields or a face shield should also be worn.
A mask should be changed between patients or if it becomes wet during patient treatment.
Clean reusable face protection with soap and water between patients; if visibly soiled, clean and disinfect.
34. Protective Clothing Wear gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material
Change if visibly soiled
Remove all barriers before leaving the work area DHCP should wear long-sleeved disposable or reusable gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material (e.g., when spatter and spray of blood, saliva, or other potentially infectious material to the forearms might occur).
DHCP should change protective clothing when it becomes visibly soiled or as soon as possible if penetrated by blood or other potentially infectious fluids.
All protective clothing should be removed before leaving patient care or laboratory areas.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
DHCP should wear long-sleeved disposable or reusable gowns, lab coats, or uniforms that cover skin and personal clothing likely to become soiled with blood, saliva, or infectious material (e.g., when spatter and spray of blood, saliva, or other potentially infectious material to the forearms might occur).
DHCP should change protective clothing when it becomes visibly soiled or as soon as possible if penetrated by blood or other potentially infectious fluids.
All protective clothing should be removed before leaving patient care or laboratory areas.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
35. Gloves Minimize the risk of health care personnel acquiring infections from patients
Prevent microbial flora from being transmitted from health care personnel to patients
Reduce contamination of the hands of health care personnel by microbial flora that can be transmitted from one patient to another
Are not a substitute for handwashing!
Gloves are worn for three reasons:
To minimize the risk of health care personnel acquiring infections from patients.
To prevent pathogenic organisms from being transmitted from health care personnel to patients.
To reduce contamination of health care personnel's hands by organisms that can be transmitted from one patient to another.
Wearing gloves does not eliminate or replace the need for hand washing. Hand hygiene should be performed immediately prior to putting on and after removal of gloves. Gloves might have small holes or tears that are not noticeable, or hands can become contaminated as gloves are removed. Such circumstances increase the risk of wound contamination and exposure of the DHCPs hands to microorganisms from patients.Gloves are worn for three reasons:
To minimize the risk of health care personnel acquiring infections from patients.
To prevent pathogenic organisms from being transmitted from health care personnel to patients.
To reduce contamination of health care personnel's hands by organisms that can be transmitted from one patient to another.
Wearing gloves does not eliminate or replace the need for hand washing. Hand hygiene should be performed immediately prior to putting on and after removal of gloves. Gloves might have small holes or tears that are not noticeable, or hands can become contaminated as gloves are removed. Such circumstances increase the risk of wound contamination and exposure of the DHCPs hands to microorganisms from patients.
36. Recommendations for Gloving Wear gloves when contact with blood, saliva, and mucous membranes is possible
Remove gloves after patient care
Wear a new pair of gloves for each patient
For the protection of DHCP and patients, gloves should always be worn when contact with blood, saliva, and mucous membranes is possible.
Gloves should be removed after patient care and hands should be immediately washed. Hands should also be washed before putting gloves on.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GAFor the protection of DHCP and patients, gloves should always be worn when contact with blood, saliva, and mucous membranes is possible.
Gloves should be removed after patient care and hands should be immediately washed. Hands should also be washed before putting gloves on.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GA
37. Latex Hypersensitivity and Contact Dermatitis Occupationally-related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals, and glove use. Occupationally-related contact dermatitis can develop from frequent and repeated use of hand hygiene products, exposure to chemicals, and glove use.
38. Latex Allergy Type I hypersensitivity to natural rubber latex proteins
Reactions may include nose, eye, and skin reactions
More serious reactions may include respiratory distressrarely shock or death
Latex allergy is a Type I or an immediate hypersensitivity reaction to the proteins found in natural rubber latex. These proteins can attach to the powder in gloves which, in turn, causes more latex protein to reach the skin.
This reaction is generally a more severe and immediate systemic reaction than contact dermatitis. Common reactions include runny nose, itchy eyes, hives, and burning skin sensations.
More severe reactions are characterized by breathing difficulty and, rarely, anaphylaxis (shock) or death.
Photo credit: Arto Lahti, MD, Department of Dermatology, University of Oulu, Finland. Latex allergy is a Type I or an immediate hypersensitivity reaction to the proteins found in natural rubber latex. These proteins can attach to the powder in gloves which, in turn, causes more latex protein to reach the skin.
This reaction is generally a more severe and immediate systemic reaction than contact dermatitis. Common reactions include runny nose, itchy eyes, hives, and burning skin sensations.
More severe reactions are characterized by breathing difficulty and, rarely, anaphylaxis (shock) or death.
Photo credit: Arto Lahti, MD, Department of Dermatology, University of Oulu, Finland.
39. Contact Dermatitis Irritant contact dermatitis
Not an allergy
Dry, itchy, irritated areas
Allergic contact dermatitis
Type IV delayed hypersensitivity
May result from allergy to chemicals used in glove manufacturing Not all skin reactions are due to an allergic reaction to latex rubber. Most skin reactions are attributed to an irritant or allergic contact dermatitis.
Irritant contact dermatitis develops as dry, itchy, irritated areas on the skin around the contact area. It is commonly associated with frequent handwashing and is not an allergic reaction.
The second type of contact dermatitis is a type IV or delayed hypersensitivity or allergic reaction due to contact with a chemical allergen (e.g., accelerators and other chemicals used in the manufacture of patient-care gloves). Reactions are generally localized to the contact area and occur slowly, over a period of 1248 hours.
Not all skin reactions are due to an allergic reaction to latex rubber. Most skin reactions are attributed to an irritant or allergic contact dermatitis.
Irritant contact dermatitis develops as dry, itchy, irritated areas on the skin around the contact area. It is commonly associated with frequent handwashing and is not an allergic reaction.
The second type of contact dermatitis is a type IV or delayed hypersensitivity or allergic reaction due to contact with a chemical allergen (e.g., accelerators and other chemicals used in the manufacture of patient-care gloves). Reactions are generally localized to the contact area and occur slowly, over a period of 1248 hours.
40. General Recommendations Contact Dermatitis and Latex Allergy Educate DHCP about reactions associated with frequent hand hygiene and glove use
Get a medical diagnosis
Screen patients for latex allergy
Ensure a latex-safe environment
Have latex-free kits available (dental and emergency) Other recommendations can minimize the risk of contact dermatitis and latex hypersensitivity:
Educate DHCP workers about reactions associated with frequent hand hygiene and glove use.
Staff that have dermatologic problems should get a diagnosis from a qualified medical provider before making changes in gloves or hand hygiene agents.
Screen patients and DHCP for latex allergy in your medical histories.
DHCP and dental patients with latex allergy should not have direct contact with latex-containing materials and should be in a latex-safe environment with all latex-containing products removed from their vicinity.
Have both dental and medical emergency latex-free products available at all times.
Other recommendations can minimize the risk of contact dermatitis and latex hypersensitivity:
Educate DHCP workers about reactions associated with frequent hand hygiene and glove use.
Staff that have dermatologic problems should get a diagnosis from a qualified medical provider before making changes in gloves or hand hygiene agents.
Screen patients and DHCP for latex allergy in your medical histories.
DHCP and dental patients with latex allergy should not have direct contact with latex-containing materials and should be in a latex-safe environment with all latex-containing products removed from their vicinity.
Have both dental and medical emergency latex-free products available at all times.
41. Sterilization and Disinfection of Patient Care Items
42. Critical Instruments Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile tissues (of the mouth)
Heat sterilize between uses or use sterile single-use, disposable devices
Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental burs There are three categories of patient-care items depending on their intended use and the potential risk of disease transmission.
Critical items penetrate soft tissue or contact bone, the bloodstream, or other normally sterile tissues of the mouth. They have the highest risk of transmitting infection and should be heat-sterilized between patient uses. Alternatively, use sterile, single-use disposable devices.
Examples include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs.There are three categories of patient-care items depending on their intended use and the potential risk of disease transmission.
Critical items penetrate soft tissue or contact bone, the bloodstream, or other normally sterile tissues of the mouth. They have the highest risk of transmitting infection and should be heat-sterilized between patient uses. Alternatively, use sterile, single-use disposable devices.
Examples include surgical instruments, periodontal scalers, scalpel blades, and surgical dental burs.
43. Semi-critical Instruments Contact mucous membranes but do not penetrate soft tissue
Heat sterilize or high-level disinfect
Examples: Dental mouth mirrors, amalgam condensers, and dental handpieces Semi-critical items contact only mucous membranes and do not penetrate soft tissues. As such, they have a lower risk of transmission.
Because most items in this category are heat-tolerant, they should be heat sterilized between patient uses. For heat-sensitive instruments, high-level disinfection is appropriate.
Examples of semi-critical instruments include dental mouth mirrors, amalgam condensers, and impression trays. Dental handpieces are a special case. Even though they do not penetrate soft tissue, it is difficult for chemical germicides to reach the internal parts of handpieces. For this reason, they should be heat sterilized using a steam autoclave or chemical vapor sterilizer.
Semi-critical items contact only mucous membranes and do not penetrate soft tissues. As such, they have a lower risk of transmission.
Because most items in this category are heat-tolerant, they should be heat sterilized between patient uses. For heat-sensitive instruments, high-level disinfection is appropriate.
Examples of semi-critical instruments include dental mouth mirrors, amalgam condensers, and impression trays. Dental handpieces are a special case. Even though they do not penetrate soft tissue, it is difficult for chemical germicides to reach the internal parts of handpieces. For this reason, they should be heat sterilized using a steam autoclave or chemical vapor sterilizer.
44. Noncritical Instruments and Devices Contact intact skin
Clean and disinfect using a low to intermediate level disinfectant
Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuff Noncritical instruments and devices only contact intact (unbroken) skin, which serves as an effective barrier to microorganisms.
These items carry such a low risk of transmitting infections that they usually require only cleaning and low-level disinfection. If using a low-level disinfectant, according to OSHA, it must have a label claim for killing HIV and HBV. However, if an item is visibly bloody, it should be cleaned and disinfected using an intermediate-level disinfectant before use on another patient.
Examples of instruments in this category include X-ray head/cones, facebows, pulse oximeter, and blood pressure cuff.
Noncritical instruments and devices only contact intact (unbroken) skin, which serves as an effective barrier to microorganisms.
These items carry such a low risk of transmitting infections that they usually require only cleaning and low-level disinfection. If using a low-level disinfectant, according to OSHA, it must have a label claim for killing HIV and HBV. However, if an item is visibly bloody, it should be cleaned and disinfected using an intermediate-level disinfectant before use on another patient.
Examples of instruments in this category include X-ray head/cones, facebows, pulse oximeter, and blood pressure cuff.
45. Sterilization Monitoring Types of Indicators Mechanical
Measure time, temperature, pressure
Chemical
Change in color when physical parameter is reached
Biological (spore tests)
Use biological spores to assess the sterilization process directly
Proper monitoring of sterilization procedures should include a combination of process indicators, including the following:
Mechanicalinvolves assessment of cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer.
Chemicaluses sensitive chemicals that change color when a given parameter is reached (e.g., heat-sensitive external tape, internal chemical indicator strip).
Biologicalthis method is the most valid method for monitoring the sterilization process because it assesses the process directly. It does so by using the most heat-resistant microorganisms and not by using indicators that only test the physical and chemical conditions necessary for sterilization.
Mechanical and chemical indicators should be assessed with each load. If either mechanical indicators or internal or external chemical indicators indicate inadequate processing, items in the load should not be used until reprocessed.
Biological indicators should be assessed at least once a week.Proper monitoring of sterilization procedures should include a combination of process indicators, including the following:
Mechanicalinvolves assessment of cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer.
Chemicaluses sensitive chemicals that change color when a given parameter is reached (e.g., heat-sensitive external tape, internal chemical indicator strip).
Biologicalthis method is the most valid method for monitoring the sterilization process because it assesses the process directly. It does so by using the most heat-resistant microorganisms and not by using indicators that only test the physical and chemical conditions necessary for sterilization.
Mechanical and chemical indicators should be assessed with each load. If either mechanical indicators or internal or external chemical indicators indicate inadequate processing, items in the load should not be used until reprocessed.
Biological indicators should be assessed at least once a week.
46. Storage of Sterile and Clean Items and Supplies Use date- or event-related shelf-life practices
Examine wrapped items carefully prior to use
When packaging of sterile items is damaged, re-clean, re-wrap, and re-sterilize
Store clean items in dry, closed, or covered containment DHCP have a choice about how they maintain their instrument storage area either date- or event-related shelf-life practices. In date-related packing, every sterilized package is expiration-dated and the instruments are used on a first in, first out basis. In event-related practice, the contents of a sterilized package should remain sterile indefinitely unless some event, for example, torn or wet packaging material, causes it to become potentially contaminated. It is still useful to place the date of sterilization and identify the sterilizer used if multiple sterilizers are utilized in the office. In case of sterilization failure, this information would facilitate retrieval of processed items.
Examine each package. If it is damaged in any way, items should be re-cleaned, re-wrapped, and re-sterilized. Even if an event-related approach is used, all packages should be labeled with the date of sterilization and which sterilizer was used, should a sterilization failure occur.
Store all sterile and clean items and supplies in dry, closed, or covered cabinets.DHCP have a choice about how they maintain their instrument storage area either date- or event-related shelf-life practices. In date-related packing, every sterilized package is expiration-dated and the instruments are used on a first in, first out basis. In event-related practice, the contents of a sterilized package should remain sterile indefinitely unless some event, for example, torn or wet packaging material, causes it to become potentially contaminated. It is still useful to place the date of sterilization and identify the sterilizer used if multiple sterilizers are utilized in the office. In case of sterilization failure, this information would facilitate retrieval of processed items.
Examine each package. If it is damaged in any way, items should be re-cleaned, re-wrapped, and re-sterilized. Even if an event-related approach is used, all packages should be labeled with the date of sterilization and which sterilizer was used, should a sterilization failure occur.
Store all sterile and clean items and supplies in dry, closed, or covered cabinets.
47. Environmental Infection Control
48. Environmental Surfaces May become contaminated
Not directly involved in infectious disease transmission
Do not require as stringent decontamination procedures Environmental surfaces can become contaminated with microorganisms during patient care, although they have not been associated directly with disease transmission to patients or DHCP.
Environmental surfaces do not require decontamination procedures as stringent as those used on patient care items.
Environmental surfaces can become contaminated with microorganisms during patient care, although they have not been associated directly with disease transmission to patients or DHCP.
Environmental surfaces do not require decontamination procedures as stringent as those used on patient care items.
49. Categories of Environmental Surfaces Clinical contact surfaces
High potential for direct contamination from spray or spatter or by contact with DHCPs gloved hand
Housekeeping surfaces
Do not come into contact with patients or devices
Limited risk of disease transmission There are two categories of environmental surfaces.
Clinical contact surfaces have a high potential for direct contamination from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCPs gloved hand. These surfaces can later contaminate other instruments, devices, hands, or gloves.
Housekeeping surfaces do not come into contact with patients or devices used in dental procedures. Therefore, they have a limited risk of disease transmission.
There are two categories of environmental surfaces.
Clinical contact surfaces have a high potential for direct contamination from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCPs gloved hand. These surfaces can later contaminate other instruments, devices, hands, or gloves.
Housekeeping surfaces do not come into contact with patients or devices used in dental procedures. Therefore, they have a limited risk of disease transmission.
50. Clinical Contact Surfaces This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows).
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
This slide shows some examples of clinical contact surfaces, including a light handle, countertop, bracket tray, dental chair, and door handle (shown by arrows).
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
51. Housekeeping Surfaces Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows).
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
Examples of housekeeping surfaces are walls, sinks, and floors (shown by arrows).
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
52. General Cleaning Recommendations Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and disinfecting environmental surfaces
Physical removal of microorganisms by cleaning is as important as the disinfection process
Follow manufacturers instructions for proper use of EPA-registered hospital disinfectants
Do not use sterilant/high-level disinfectants on environmental surfaces
Use appropriate protective barriers such as heavy-duty utility gloves, masks, and protective eyewear when cleaning and disinfecting surfaces.
In general, cleaning and removal of microorganisms is as important as the disinfection process itself. Blood or other patient materials left on surfaces can interfere with the disinfecting process. Follow the manufacturers instructions for proper storage, dilution, and use of hospital disinfectants.
Because of their toxic nature, the use of sterilants or high-level disinfectants on environmental surfaces is NOT recommended.
Use appropriate protective barriers such as heavy-duty utility gloves, masks, and protective eyewear when cleaning and disinfecting surfaces.
In general, cleaning and removal of microorganisms is as important as the disinfection process itself. Blood or other patient materials left on surfaces can interfere with the disinfecting process. Follow the manufacturers instructions for proper storage, dilution, and use of hospital disinfectants.
Because of their toxic nature, the use of sterilants or high-level disinfectants on environmental surfaces is NOT recommended.
53. Cleaning Clinical Contact Surfaces Risk of transmitting infections greater than for housekeeping surfaces
Surface barriers can be used and changed between patients
OR
Clean then disinfect using an EPA-registered low- (HIV/HBV claim) to intermediate-level (tuberculocidal claim) hospital disinfectant Because clinical contact surfaces come into direct contact with contaminated gloves, instruments, spray or spatter, their risk of transmitting infection is greater than for housekeeping surfaces. These surfaces can subsequently contaminate other instruments, devices, hands, or gloves.
Surface barriers can be used to protect clinical contact surfaces and changed between patients. Surface barriers are particularly useful for surfaces that are hard to clean, such as switches on dental chairs. This practice will also reduce exposure to harmful chemical disinfectants.
If surface barriers cannot be used, clean and then disinfect the surface with an EPA-registered hospital disinfectant effective against HIV and HBV (low-level disinfectant). If the surface is visibly contaminated with blood or other patient material, clean and then disinfect the surface with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant).Because clinical contact surfaces come into direct contact with contaminated gloves, instruments, spray or spatter, their risk of transmitting infection is greater than for housekeeping surfaces. These surfaces can subsequently contaminate other instruments, devices, hands, or gloves.
Surface barriers can be used to protect clinical contact surfaces and changed between patients. Surface barriers are particularly useful for surfaces that are hard to clean, such as switches on dental chairs. This practice will also reduce exposure to harmful chemical disinfectants.
If surface barriers cannot be used, clean and then disinfect the surface with an EPA-registered hospital disinfectant effective against HIV and HBV (low-level disinfectant). If the surface is visibly contaminated with blood or other patient material, clean and then disinfect the surface with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant).
54. Medical Waste Medical Waste: Not considered infectious, thus can be discarded in regular trash Regulated Medical Waste: Poses a potential risk of infection during handling and disposal There is no evidence that traditional medical waste management has contributed to increased levels of disease in the community or among health care personnel.
The majority of waste generated in a medical or dental office (~98%99%) is not considered infectious and can be discarded in the regular trash. Examples include used gloves, masks, and lightly bloodied gauze.
Some waste, such as used needles, extracted teeth, and gauze soaked in blood, may pose a potential risk of infection, however, and warrants special precautions during handling and disposal. Follow federal, state, and local regulations for proper treatment and disposal.
There is no evidence that traditional medical waste management has contributed to increased levels of disease in the community or among health care personnel.
The majority of waste generated in a medical or dental office (~98%99%) is not considered infectious and can be discarded in the regular trash. Examples include used gloves, masks, and lightly bloodied gauze.
Some waste, such as used needles, extracted teeth, and gauze soaked in blood, may pose a potential risk of infection, however, and warrants special precautions during handling and disposal. Follow federal, state, and local regulations for proper treatment and disposal.
55. Regulated Medical Waste Management Properly labeled containment to prevent injuries and leakage
Medical wastes are treated in accordance with state and local EPA regulations
Processes for regulated waste include autoclaving and incineration Regulated medical waste requires careful containment for treatment or disposal. A single leak-resistant biohazard bag is usually adequate to contain non-sharp, regulated medical waste. Puncture-resistant containers with a biohazard label, such as sharps containers, are used as containment for scalpel blades, needles, syringes, and unused sterile sharps.
Medical waste, both nonregulated and regulated, should be stored and disposed of in accordance with federal, state, and local EPA regulations.
Treatment of regulated waste can involve on-site or off-site autoclaving and incineration. Never include extracted teeth with amalgam in regulated waste when disposed by one of these methods.
Photo credit: NIOSH Web site.Regulated medical waste requires careful containment for treatment or disposal. A single leak-resistant biohazard bag is usually adequate to contain non-sharp, regulated medical waste. Puncture-resistant containers with a biohazard label, such as sharps containers, are used as containment for scalpel blades, needles, syringes, and unused sterile sharps.
Medical waste, both nonregulated and regulated, should be stored and disposed of in accordance with federal, state, and local EPA regulations.
Treatment of regulated waste can involve on-site or off-site autoclaving and incineration. Never include extracted teeth with amalgam in regulated waste when disposed by one of these methods.
Photo credit: NIOSH Web site.
56. Dental Unit Waterlines, Biofilm, and Water Quality
Dental Unit Waterlines (DUWL), Biofilm, and Water Quality.Dental Unit Waterlines (DUWL), Biofilm, and Water Quality.
57. Dental Unit Waterlines and Biofilm Microbial biofilms form in small bore tubing of dental units
Biofilms serve as a microbial reservoir
Primary source of microorganisms is municipal water supply Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment.
Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented.
Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor. Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.Studies have shown that colonies of microorganisms, or biofilms, can form on the inside of the small-bore plastic tubing that transports water within the dental unit to handpieces and air-water syringes. Once formed, a biofilm serves as a reservoir that may dramatically increase the number of free-floating microorganisms in water used for dental treatment.
Most organisms isolated from dental water systems originate from the public water supply and do not pose a high risk of disease for healthy persons. Although a few pathogenic organisms, such as Legionella spp. and Pseudomonas sp., have been found, adverse public health threats have not been documented.
Photo credit, top: CDC Image library. This Scanning Electron Micrograph depicts an E. coli (ATCC 11775) biofilm grown on PC (polycarbonate) coupons using a CDC biofilm reactor.Photo credit, bottom: Illustration from the Center for Biofilm Engineering, Bozeman MT.
58. Dental Unit Water Quality Using water of uncertain quality is inconsistent with infection control principles
Colony counts in water from untreated systems can exceed 1,000,000 CFU/mL
CFU=colony forming unit
Untreated dental units cannot reliably produce water that meets drinking water standards
Despite a lack of documented adverse health effects, using water of uncertain microbiological quality is inconsistent with infection control principles. Levels of contamination in water from untreated systems can exceed 1 million colony forming units per milliliter (mL) of water.
Untreated dental units cannot reliably produce water that meets drinking water standards (fewer than 500 CFU/mL of heterotrophic water bacteria). Even using source water containing =500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in a self-contained system will not eliminate bacterial contamination in treatment water if biofilms in the water system are not controlled. Removal or inactivation of dental waterline biofilms requires use of chemical germicides.
Despite a lack of documented adverse health effects, using water of uncertain microbiological quality is inconsistent with infection control principles. Levels of contamination in water from untreated systems can exceed 1 million colony forming units per milliliter (mL) of water.
Untreated dental units cannot reliably produce water that meets drinking water standards (fewer than 500 CFU/mL of heterotrophic water bacteria). Even using source water containing =500 CFU/mL of bacteria (e.g., tap, distilled, or sterile water) in a self-contained system will not eliminate bacterial contamination in treatment water if biofilms in the water system are not controlled. Removal or inactivation of dental waterline biofilms requires use of chemical germicides.
59. Dental Water Quality For routine dental treatment, meet regulatory standards for drinking water.*
* <500 CFU/mL of heterotrophic water bacteria
For this reason, CDC recommends that water used for routine dental treatment meet regulatory standards for drinking water (fewer than 500 CFU/mL of heterotrophic water bacteria).
For this reason, CDC recommends that water used for routine dental treatment meet regulatory standards for drinking water (fewer than 500 CFU/mL of heterotrophic water bacteria).
60. Dental Handpieces and Other Devices Attached to Air and Waterlines Clean and heat sterilize intraoral devices that can be removed from air and waterlines
Follow manufacturers instructions for cleaning, lubrication, and sterilization
Do not use liquid germicides or ethylene oxide
Any removable device that is attached to the air or waterlines should be heat sterilized to ensure that internal components have been sterilized.
It is very important to follow the manufacturers instructions for cleaning and lubrication. These protocols can ensure the effectiveness of the process and contribute to the life of the device.
Surface disinfection or liquid chemical germicide immersion are not acceptable. In addition, the use of ethylene oxide is not recommended because it cannot reliably penetrate the internal components.
Any removable device that is attached to the air or waterlines should be heat sterilized to ensure that internal components have been sterilized.
It is very important to follow the manufacturers instructions for cleaning and lubrication. These protocols can ensure the effectiveness of the process and contribute to the life of the device.
Surface disinfection or liquid chemical germicide immersion are not acceptable. In addition, the use of ethylene oxide is not recommended because it cannot reliably penetrate the internal components.
61. Components of Devices Permanently Attached to Air and Waterlines Do not enter patients mouth but may become contaminated
Use barriers and change between uses
Clean and intermediate-level disinfect the surface of devices if visibly contaminated Some parts of dental instruments are permanently attached to dental unit waterlines. These items do not enter the patients mouth but are likely to become contaminated with oral fluids during treatment procedures. Some examples include handles or dental unit attachments of saliva ejectors, high-speed air evacuators, and air/water syringes.
These components should be covered with waterproof barriers and changed after each use.
If the item becomes visibly contaminated during use, clean and disinfect with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant) before using it with the next patient. Some parts of dental instruments are permanently attached to dental unit waterlines. These items do not enter the patients mouth but are likely to become contaminated with oral fluids during treatment procedures. Some examples include handles or dental unit attachments of saliva ejectors, high-speed air evacuators, and air/water syringes.
These components should be covered with waterproof barriers and changed after each use.
If the item becomes visibly contaminated during use, clean and disinfect with an EPA-registered hospital disinfectant with a tuberculocidal claim (intermediate-level disinfectant) before using it with the next patient.
62. Saliva Ejectors Previously suctioned fluids might be retracted into the patients mouth when a seal is created
Do not advise patients to close their lips tightly around the tip of the saliva ejector
Backflow, meaning reverse flow, can occur when there is more negative pressure in the patients mouth than in the evacuator tubing, for example, when the patient uses the saliva ejector as a straw. When this happens, material from the mouth of a previous patient might remain in the vacuum line of the saliva ejector and be aspirated into the mouth of the next patient being treated.
Although there have been no reports of any adverse health issues, patients should not be instructed to close their lips tightly around the saliva ejector tip during use.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
Backflow, meaning reverse flow, can occur when there is more negative pressure in the patients mouth than in the evacuator tubing, for example, when the patient uses the saliva ejector as a straw. When this happens, material from the mouth of a previous patient might remain in the vacuum line of the saliva ejector and be aspirated into the mouth of the next patient being treated.
Although there have been no reports of any adverse health issues, patients should not be instructed to close their lips tightly around the saliva ejector tip during use.
Photo credit: Lt. Col. Jennifer Harte, U.S.A.F. Dental Investigation Service, Great Lakes, IL.
63. Dental Radiology Wear gloves and other appropriate personal protective equipment as necessary
Heat sterilize heat-tolerant radiographic accessories
Transport and handle exposed radiographs so that they will not become contaminated
Avoid contamination of developing equipment When taking or processing radiographs:
Wear gloves and other appropriate personal protective equipment as necessary.
Heat sterilize heat-tolerant radiographic accessories.
Transport and handle exposed radiographs so as to prevent cross-contamination.
Avoid contamination of developing equipment.
When taking or processing radiographs:
Wear gloves and other appropriate personal protective equipment as necessary.
Heat sterilize heat-tolerant radiographic accessories.
Transport and handle exposed radiographs so as to prevent cross-contamination.
Avoid contamination of developing equipment.
64. Preprocedural Mouth Rinses Antimicrobial mouth rinses prior to a dental procedure
Reduce number of microorganisms in aerosols/spatter
Decrease the number of microorganisms introduced into the bloodstream
Unresolved issueno evidence that infections are prevented
Preprocedural mouth rinsing is the use of an antimicrobial mouth rinse by the patient prior to a dental procedure. These mouth rinses can contain, for example, chlorhexidine gluconate, essential oils, and povidine-iodine.
Studies have shown that preprocedural mouth rinses can reduce the number of aerosolized bacteria, and in some cases, the number of bacteria introduced into the bloodstream. However, there is no scientific evidence that this practice can prevent clinical infections among patients or DHCP.
Although there is no harm in using preprocedural mouth rinses because of the lack of evidence that clinical infections are prevented, no recommendation is made.Preprocedural mouth rinsing is the use of an antimicrobial mouth rinse by the patient prior to a dental procedure. These mouth rinses can contain, for example, chlorhexidine gluconate, essential oils, and povidine-iodine.
Studies have shown that preprocedural mouth rinses can reduce the number of aerosolized bacteria, and in some cases, the number of bacteria introduced into the bloodstream. However, there is no scientific evidence that this practice can prevent clinical infections among patients or DHCP.
Although there is no harm in using preprocedural mouth rinses because of the lack of evidence that clinical infections are prevented, no recommendation is made.
65. Transmission of Mycobacterium tuberculosis Spread by droplet nuclei
Immune system usually prevents spread
Bacteria can remain alive in the lungs for many years (latent TB infection)
Mycobacterium tuberculosis (TB) is spread from person to person through the air. When a person with pulmonary or laryngeal TB coughs or sneezes, tiny particles, known as droplet nuclei, are expelled into the air. The particles are an estimated 1-5 m in size, and normal air currents can keep them airborne for prolonged periods of time and spread them throughout a room or building. Infection may occur when a person inhales droplet nuclei containing TB organisms.
During the first few weeks after infection, organisms can spread from the initial location in the lungs to the lymph nodes in the center of the chest and then to other parts of the body by way of the bloodstream. Within 2 to 12 weeks, the body's immune system usually prevents further multiplication and spread, although they can remain alive in the lungs for years. This condition is referred to as latent TB infection.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.
Mycobacterium tuberculosis (TB) is spread from person to person through the air. When a person with pulmonary or laryngeal TB coughs or sneezes, tiny particles, known as droplet nuclei, are expelled into the air. The particles are an estimated 1-5 m in size, and normal air currents can keep them airborne for prolonged periods of time and spread them throughout a room or building. Infection may occur when a person inhales droplet nuclei containing TB organisms.
During the first few weeks after infection, organisms can spread from the initial location in the lungs to the lymph nodes in the center of the chest and then to other parts of the body by way of the bloodstream. Within 2 to 12 weeks, the body's immune system usually prevents further multiplication and spread, although they can remain alive in the lungs for years. This condition is referred to as latent TB infection.
Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.
66. Risk of TB Transmission in Dentistry Risk in dental settings is low
Only one documented case of transmission
Tuberculin skin test conversions among DHP are rare Overall, the risk for transmission of TB in most dental settings is quite low.
There has been only one case report of transmission of tuberculosis bacteria from an infected dentist to patients, reportedly transmitted by direct inoculation of extraction sites through the dentist's fingers (Smith WH, Davies D, Mason KD, Onions JP: Intraoral and pulmonary tuberculosis following dental treatment. Lancet 1982;1:842-4).
In addition, tuberculin skin test conversions among DHCP are rare, even among populations of dentists at high risk for exposure to TB patients.Overall, the risk for transmission of TB in most dental settings is quite low.
There has been only one case report of transmission of tuberculosis bacteria from an infected dentist to patients, reportedly transmitted by direct inoculation of extraction sites through the dentist's fingers (Smith WH, Davies D, Mason KD, Onions JP: Intraoral and pulmonary tuberculosis following dental treatment. Lancet 1982;1:842-4).
In addition, tuberculin skin test conversions among DHCP are rare, even among populations of dentists at high risk for exposure to TB patients.
67. Preventing Transmission of TB in Dental Settings Assess patients for history of TB
Defer elective dental treatment
If patient must be treated:
DHCP should wear face mask
Separate patient from others/mask/tissue
Refer to facility with proper TB infection control precautions Periodic updates of medical histories should include questions concerning history of TB exposure, infection or (current or past) treatment for active TB, and symptoms consistent with TB.
Elective dental treatment should be deferred for any patient suspected or known to have active TB until they have been evaluated by medical personnel.
DHCP should wear a face mask (surgical) or N-95 respirator for all patient contact. Any patient with suspected or possible infectious TB should be separated from other patients or DHCP, given a surgical mask to wear, and provided with tissues for coughing or sneezing. Refer the patient to a facility with proper TB infection control precautions for medical evaluation or urgent dental treatment.
If you are in an office or facility that will provide dental treatment for patients with TB, additional precautions are necessary. Refer to CDC Guidelines for Preventing the Transmission of MTB in Health-care Facilities. MMWR 1994;43(No. RR-13)
Photo credit: Centers for Disease Control and Prevention.
Periodic updates of medical histories should include questions concerning history of TB exposure, infection or (current or past) treatment for active TB, and symptoms consistent with TB.
Elective dental treatment should be deferred for any patient suspected or known to have active TB until they have been evaluated by medical personnel.
DHCP should wear a face mask (surgical) or N-95 respirator for all patient contact. Any patient with suspected or possible infectious TB should be separated from other patients or DHCP, given a surgical mask to wear, and provided with tissues for coughing or sneezing. Refer the patient to a facility with proper TB infection control precautions for medical evaluation or urgent dental treatment.
If you are in an office or facility that will provide dental treatment for patients with TB, additional precautions are necessary. Refer to CDC Guidelines for Preventing the Transmission of MTB in Health-care Facilities. MMWR 1994;43(No. RR-13)
Photo credit: Centers for Disease Control and Prevention.
68. Infection Control Program Goals Provide a safe working environment
Reduce health care-associated infections
Reduce occupational exposures
The goal of an infection control program is to provide a safe working environment for DHCP and their patients.
We can accomplish this by adopting measures that will reduce health care-associated infections among patients and occupational exposures among DHCP.
The goal of an infection control program is to provide a safe working environment for DHCP and their patients.
We can accomplish this by adopting measures that will reduce health care-associated infections among patients and occupational exposures among DHCP.
