Download Infection Control in Dental Health-Care Settings

Infection Control in Dental
Health-Care Settings
Terri L. Deal
Infection Control
 Center for Disease Control updated in 2003
– Previously released in 1986, 1993
– Consolidates recommendations for :
 Preventing infectious diseases
 Managing personnel health and safety
– Updates previous CDC recommendations
– Incorporates relevant infection control measures
– Discusses concerns not previously mentioned
Infection Control
 General recommendations
– Develop a written program
 Policies
 Procedures
 Education and training guidelines
 Immunizations
Infection Control
 Exposure prevention
 Post-exposure management
 Medical conditions
 Work restrictions
 Contact dermatitis, latex sensitivity
 Maintenance of records, data management and
confidentiality
– Establish referral arrangements
Infection Control
 Education and training
– Provide to new employees
– When new tasks or procedures affect
employees exposure
– Provided annually re: exposure to potentially
infectious agents and infection control
procedures
– Provide educational information appropriate in
content, vocabulary for the health care provider
Infection Control
 Immunization
– List of all required and recommended
immunizations
– Refer employee to prearranged health care
provider or their own health care provider
 Exposure Prevention and Post-exposure
Management
– Develop post-exposure management and
medical follow up program
Infection Control
 Medical conditions, work-related illness, and
work restrictions
– Develop written policies re: work restriction and
exclusion and who can implement
– Policies for preventive and curative care and
reporting illnesses. Don’t penalize with loss of
wages, benefits or job status
– Policies for evaluation, diagnosis and
management of occupational contact dermatitis
– Definitive diagnosis of suspected latex allergy,
work restrictions and accommodations
Infection Control
 Records Maintenance, data management
and confidentiality
– Establish and maintain confidential medical
records for all dental health care providers
– Ensure compliance of federal, state and local
laws re: medical recordkeeping and
confidentiality
Infection Control
 Occupational exposure:
– “reasonably anticipated skin, eye, mucous
membrane, or parenteral contact with blood or
other potentially infectious materials that may
result from the performance of an employee’s
duties”
Infection Control
 Occupational exposure occurs when your ..
– Skin
– Eyes
 Mucous membrane
– Blood
Infection Control
 Come into contact with…
– Blood or saliva from a patient
– Contaminated instruments
– Equipment of laundry contaminated by blood or
saliva from a patient
Infection Control
 Who is potentially infectious?
Universal Precautions:
 “…all human blood and certain human body
fluids are treated as if known to be
infectious…”
Universal Precautions
 Transmission of infectious diseases from
patient to health care workers usually
involves patients who do not know they
have an infectious disease.
Occupational Exposure
Determination
 Category I – Routinely exposed to blood,
saliva or both
Examples: Dentist, Hygienist, Assistant,
Infection Control/Sterilization Assistant, Lab
Technician
 Category II – May on occasion be exposed
to blood, saliva or both
Disease Transmission in the
Dental Office
 Every dental office should have an infection
control program designed to prevent the
transmission of disease from:
• Patient to dental team
• Dental team to patient
• Patient to patient
• Dental office to community (includes
dental team’s family)
• Community to patient
Therefore…
 Health care workers must…
– Consider blood and saliva from all patients as
potentially infectious
– Take precautions to protect themselves from
exposure
Hepatitis B Vaccine
 Employer must educate employees.
 Employer must offer the vaccine within 10
working days and pay for the vaccine.
 Employee can decline, but must sign
declination statement.
Post-Exposure Evaluation and
Follow-up
 Employer must:
– Document exposure and circumstances
– Document source individual
– Source individual’s blood tested
– If source is known to be infected, blood test is
not necessary.
Post-Exposure Evaluation and
Follow-up
 Employee’s blood is tested.
 If employee refuses HIV testing, then
blood is stored at least 90 days.
 Confidential medical evaluation
 When indicated use post-exposure
prophylaxis which will prevent HIV
infection
Medical Waste
 Blood or saliva mixed with blood
Medical Waste:
 Items that release blood or saliva-blood if
compressed or during handling
Medical Waste:
 Pathological waste
– Teeth
– Tissue
 Contaminated sharps
Disposal of regulated Waste:




Landfills
Private pick-up services
Hospitals
On-site
Remember:
 Items that do not release blood and/or saliva
when compressed or handled do NOT need
special disposal.
Requirements for Transmission of
Infection
 A reservoir of pathogen
 A pathogen of sufficient infectivity and
number
 A mode of escape from the host
 A mode of spread to the new host
 A portal of entry
 A susceptible host
Infection Control
 Preventing Transmission of Blood
borne Pathogens
– HBV vaccination
– Preventing exposure to Blood and
OPIM (other potentially infectious
material)
 Use standard precautions for all
patients
Infection Control
 Consider sharp items contaminated with
blood and saliva as potentially infective
 Implement written program to minimize
exposures
Sterilization
 Destruction of all microorganisms including
bacterial spores
 Should be used for all instruments which
come in contact with blood or saliva
Disinfection
 Destroys most microorganisms but not
bacterial spores
 Used for surfaces and impressions
Disinfectants Versus
Antiseptics
 Disinfectants are chemicals that are
applied to inanimate surfaces (such as
countertops and dental equipment).
 Antiseptics are antimicrobial agents that
are applied to living tissue.
 Disinfectants and antiseptics should never
be used interchangeably because tissue
toxicity and damage to equipment can
result.
Disinfectants Versus
Antiseptics
 If there were an ideal surface
disinfectant, it would have a rapid kill of a
broad spectrum of bacteria, have
residual activity, minimal toxicity, and
would not damage surfaces to be
treated. In addition, it would be odorless,
inexpensive, work on surfaces with
remaining bio-burden, and be simple to
use.
The “Perfect Disinfectant?”
 Unfortunately, no single disinfectant
product on the market today meets all
these criteria.
The “Perfect Disinfectant?”
 When selecting a surface disinfectant, you
must carefully consider the advantages and
disadvantages of various products.
 Often the manufacturers of dental
equipment will recommend the type of
surface disinfectant that is most appropriate
for their dental chairs and units.
Types of Chemical
Disinfectants
 Iodophors are EPA-registered
intermediate-level hospital disinfectants with
tuberculocidal action. Because iodophors
contain iodine, they may corrode or discolor
certain metals and may temporarily cause
reddish or yellow stains on clothing and other
surfaces.
Types of Chemical
Disinfectants
 Synthetic phenol compounds are EPAregistered intermediate-level hospital
disinfectants with broad-spectrum disinfecting
action. Phenols can be used on metal, glass,
rubber, or plastic. They also may be used as a
holding solution for instruments; however,
phenols leave a residual film on treated
surfaces. Synthetic phenol compound is
prepared daily.
Types of Chemical
Disinfectants- cont’d
 Sodium hypochlorite (household bleach) is a fast-acting,
economic, and broad-spectrum intermediate-level
disinfectant (1:100 dilution for surface decontamination).
• Disadvantages: It is unstable and must be
prepared daily, has a strong odor and is
corrosive to some metals. It is also destructive
to fabrics and irritating to the eyes and skin; it
may eventually cause plastic chair covers to
crack.
Types of Chemical Disinfectantscont’d
 Alcohols are not effective in the presence of blood and
saliva. They evaporate quickly and are damaging to
certain materials such as plastics and vinyl.
• The American Dental Association (ADA), CDC,
and the Office of Safety and Asepsis
Procedures Research Foundation (OSAP) do
not recommend alcohol as an environmental
surface disinfectant.
Classification of Instruments and
Equipment
 Instruments and equipment are divided into
three classifications:
• Critical
• Semi-critical
• Non-critical
 The classifications are used to determine
the minimal type of post-treatment
processing.
PPEs
 Utility gloves
 Protective eyewear and mask or face shield
 Protective gown
Surface Disinfection
 Use PPE for preparation and use of
disinfectants
 Use an EPA-registered, ADA-accepted
disinfectant for cleaning and disinfecting
 Follow manufacturer’s directions on the
disinfectant label
 Use water if dilution is required
Surface Disinfection
 Spray, Wipe, Spray……………Wipe
– Spray and wipe to clean surface
– Spray again and leave disinfectant on surface
long enough to be tuberculocidal (usually 10
min.)
 Do not pre-saturate gauze squares with
disinfectant
Surface Barriers
 Surfaces that are difficult to disinfect may be
wrapped with water-impervious material that
is changed between patients.
Types of Surface Barriers
 There is a wide variety of surface barriers
available on the market today.
 All should be resistant to fluids to keep
microorganisms in saliva, blood or other
liquids from soaking through to contact the
surface underneath.
Types of Surface Barriers
 Some plastic bags are designed especially
to the shape of items such as the dental
chair, air-water syringe, hoses, pens, light
handles, etc.
 Plastic-barrier sticky tape is frequently used
to protect smooth surfaces such as touch
pads on equipment, electrical switches on
chairs, or x-ray equipment. Aluminum foil
can also be used because it is easily formed
around any shape.
Cross-Contamination
 Something is contaminated if:
– You touch it with your bare skin
– You touch it after you touch the patient
– You touch it after you touch a contaminated
item
To avoid cross-contamination
 Use over-gloves
 Use clean towel or paper towel
Infection Control
 Hand hygiene
 Wash hands:
– When visibly soiled
– After barehanded touching likely contaminated
objects (by blood, saliva or respiratory
secretions)
BEFORE and AFTER treating each patient
– Before putting on gloves
– Immediately after removing gloves
– Liquid hand care products stored in containers
that can be washed and dried. Don’t top off
Infection Control
 Special hand considerations
– Use hand lotions to prevent skin dryness
– Avoid lotions with petroleum or other oil
emollients
– Fingernails short
Infection Control
– No artificial nails or extenders or polish
– No jewelry -it compromises the fit and
integrity of the glove
– Microorganisms thrive around rough
cuticles and enter through break in the skin
Infection Control
 PPE (personal protective equipment)
– OSHA requires employer to provide employees
with appropriate PPE at no charge
– Masks, Eyewear and Face shields
 Solid side shields on eyewear protects mucous
membranes of eyes, nose and mouth
Infection Control
 eyewear and face-shield should be
disinfected
 Change masks between patients or if mask
gets wet or is visibly soiled
 Touch masks only on side
 Mask should not contact the mouth
 Mask with 95% filtration for particles 3-5mm
in diameter
Infection Control
 Face shields
– Chin-length shield replaces eyewear but not
mask.
– Doesn’t protect against inhaling aerosols
– Patient eyewear
 Protect from
–Handpeice splatter
–Spilled or splashed materials
–Airborne bits of acrylic or tooth fragments
Infection Control
 Protective clothing-covers area likely to be
soiled with blood, saliva or OPIM
–Change if soiled
–Remove PPE when leaving work area
 Gloves
– New pair each pt.
– Remove if torn, cut or punctured
– Do not wash gloves before use-may be rinsed
to remove excess powder
– Wash hands before re-gloving
– Proper fit
Infection Control
– Double gloving-effectiveness in
preventing disease transmission has NOT
been demonstrated.
– Over-gloves-not acceptable alone as
hand barrier
– Sterile gloves-invasive procedures
Infection Control
 Latex Hypersensitivity
– Educate staff to signs, symptoms and
diagnosis of skin reaction
Infection Control
 Three types of allergic reactions to latex
– 1. Irritant dermatitis, non-immunologic
process involves only surface irritation.
Chemical substance causes irritation. Red,
dry, irritated and sometimes cracked.
– 2.Type IV –most common, involves immune
system. Delayed contact reaction. 48-72 hrs.
Limited to areas of contact. Caused by
chemicals used to process latex
Infection Control
– 3. Type I –MOST dangerous. Can cause death.
Reaction to latex protein. Occurs 2-3 minutes
after contact.
Infection Control
 Remember:
– When one employee in the dental office has
been diagnosed as having a latex allergy, all
staff members should use practices to minimize
the use of latex-containing products. These
practices include the wearing of powder-free
gloves by all dental staff members to minimize
the risk of airborne latex particles.
Background
 Dental health care workers are exposed to
Legionella bacteria at a much higher rate than
the general public.
 Dental personnel are exposed to contaminated
dental unit waterlines by inhaling the aerosol
generated by the hand piece and the air-water
syringe.
Background
 There is at least one suspected fatality of a
dentist from legionellosis.
 Case reports have been published of immunocompromised patients who developed
postoperative infections caused by
contaminated dental water.
Microorganisms in
Waterlines
 The primary source of microorganisms in
dental waterlines is the public water supply.
 It is possible that saliva may be retracted back
into the waterlines during treatment. This
process is also called “suck back.”
Microorganisms in Waterlines
 Anti-retraction valves on dental units and
thorough flushing of the dental lines between
patients minimize the chance of this occurring.
 Entering public water source has a colony
forming units (CFU) count of less than 500;
once that water enters the dental waterlines
and colonizes within the bio-film, the CFU
count skyrockets.
Communities of Bacteria
 There are two “communities” of bacteria in
dental unit waterlines:
• One bacterial community exists in the
water itself and is referred to as
planktonic (free floating).
• The other exists in the bio-film attached
to the walls of the waterlines.
Bio-film
 Bio-film exists in all places where moisture
and a suitable solid surface exist.
 Bio-film consists of bacterial cells and other
microbes that adhere to surfaces and form a
protective slime layer.
 Bio-film can contain many types of bacteria,
as well as fungi, algae, and protozoa.
 Viruses, such as the human
immunodeficiency virus (HIV), cannot
multiply in the dental unit waterline.
Methods to Reduce
Contamination
 It is not yet possible to totally eliminate biofilm, but it can be minimized by:
• Self-contained water reservoirs
• Chemical treatment regimens
• Micro-filtration
• Daily draining and drying of lines
Self-Contained Water
Reservoirs
 These systems supply air pressure to the
water bottle (reservoir).
 The air pressure in the bottle forces the
water from the bottle up into the dental unit
water lines (DUWL) and out to the hand
piece and air-water syringe.
Self-Contained Water
Reservoirs
 Self-contained water systems have two
advantages:
• The dental personnel can select the quality of
water to be used, such as distilled, tap, or
sterile.
• Maintenance of the water system (between the
reservoir bottle and the hand pieces and
syringes) is under the control of the dentist and
staff.
Micro-filtration Cartridge
 A disposable inline micro-filtration cartridge
also can dramatically reduce the bacterial
contamination in the dental unit water.
Micro-filtration Cartridge
 This device must be inserted as close to
the hand piece or air-water syringe as
possible.
 It should be replaced at least daily on each
line. The use of filtration cartridges
combined with water reservoirs can ensure
improved water quality.
Chemical Agents
 Chemicals can be used to help control biofilm in two ways:
• Periodic or “shock” treatment with biocidal levels (levels that will kill
microorganisms) of chemicals.
• Continuous application of chemicals to the
system (at the level to kill the
microorganisms but not harm humans).
Chemical Agents
 Always check with the manufacturer of the
dental equipment to determine which
chemical product and maintenance protocol
they recommend.
Water for Surgical Procedures
 Dental unit water should not be used as an
irrigant for surgery involving the exposure of
bone.
 Only use sterile water from special sterile
water delivery systems or hand irrigation
using sterile water in a sterile disposable
syringe.
Flushing Waterlines
 All dental waterlines and hand pieces
should be flushed in the mornings and
between patients.
 Although this will not remove bio-films from
the lines, it may temporarily reduce the
microbial count in the water.
Flushing Waterlines
 It will help clean the hand piece waterlines
of materials that may have entered from
the patient’s mouth.
 Flushing also brings a fresh supply of
chlorinated water from the main waterlines
into the dental unit.
Minimize Aerosol
 Always use the high-volume evacuator
when using the high-speed hand piece,
ultrasonic scaler, and air-water syringe.
 The high-volume evacuation may also
reduce exposure of the patient to these
waterborne microorganisms.
Use Protective Barriers
 The dental dam greatly reduces direct
contact.
 The dam also greatly reduces the
aerosolizing and spattering of the patient’s
oral microorganisms onto the dental team.
 Protective barriers, including masks,
eyewear, and face shields, also serve as
barriers for the dental team.
Several government agencies and
professional organizations have a direct
influence on dentistry, infection control, and
other health care safety issues.
In addition to issuing recommendations
and regulations some have regulatory
roles and others are advisory.
These agencies can serve as an excellent
resource for information and educational
materials.
Recommendations and
Regulations
 Recommendations are made by
individuals, groups, or agencies that are
advisory and have no authority for
enforcement.
Recommendations and
Regulations
 Regulations are made by groups or
agencies that do have the authority to
enforce compliance with the regulations.
Enforcement penalties may include fines,
imprisonment, or suspension or
revocation of licenses.
 Recommendations may be made by
anyone, but regulations are made by
governmental groups or licensing boards
in towns, cities, counties, and states.
Associations and
Organizations
 The American Dental Association (ADA) is
the professional organization for dentists. The
ADA periodically updates its infection control
recommendations as new scientific information
becomes available.
Associations and
Organizations
 The Organization for Safety and Asepsis
Procedures (OSAP) is a not-for-profit
organization composed of dentists,
hygienists, dental assistants, government
representatives, dental manufacturers,
university professors, researchers, and dental
consultants. This organization is an excellent
resource for information on infection control,
injury prevention, and occupational health
issues.
Associations and Organizations- cont’d
 State and local dental societies can be
helpful to you in complying with regulatory
issues in your specific area.
 National, state, and local dental assisting
societies can often answer questions and
provide opportunities for continuing dental
education.
Governmental Agencies
 Centers for Disease Control and Prevention
(CDC)
 Food and Drug Administration (FDA)
 Occupational Safety and Health
Administration (OSHA)
 National Institute for Occupational Safety
and Health (NIOSH)
Centers for Disease Control
and Prevention (CDC)
 The CDC is recognized as the lead federal
agency for protecting the health and safety of
people at home and abroad.
 The CDC bases its public health
recommendations on the highest quality
scientific data.
Food and Drug
Administration (FDA)
 The FDA is a regulatory agency and is
part of the United States Department of
Health and Human Services.
Food and Drug Administration
(FDA)
 The FDA regulates the manufacturing
and labeling of medical devices (such as
sterilizers, biologic and chemical
indicators, ultrasonic cleaners and
cleaning solutions, liquid sterilants,
gloves, masks, protective eyewear, dental
handpieces and instruments, dental
chairs, and dental unit lights).
 It also regulates antimicrobial
handwashing products and mouth rinses.
Environmental Protection
Agency
 The EPA is a regulatory agency.
 It ensures the safety and effectiveness of
disinfectants.
Environmental Protection
Agency
 Manufacturers of disinfectants must submit
information about the safety and
effectiveness of the product.
 If the claims meet the EPA criteria, the
product receives an EPA registration number
that must appear on the product label.
 The EPA regulates discharge and final
treatment of waste materials (i.e., chemicals),
as well as medical waste, after it leaves the
dental office.
Occupational Safety and Health
Administration (OSHA)
 OSHA is a regulatory agency.
 It protects workers’ against physical,
chemical, or infectious hazards in the
workplace.
Occupational Safety and Health
Administration (OSHA)
 It establishes protective standards,
enforces those standards, and offers
technical assistance and consultation
programs.
 OSHA is a federal agency, but 22 states
administer their own state-operated OSHA
programs.
 In states that administer their own OSHA
programs, the state standards must be
equivalent to, or more stringent, than those
of the federal agency.
National Institute for Occupational
Safety and Health (NIOSH)
 NIOSH does not have regulatory authority.
 It is responsible for conducting research and
making recommendations for the prevention
of work-related disease and injury.
National Institute for Occupational
Safety and Health (NIOSH)
 NIOSH makes recommendations and
disseminates information on preventing
workplace disease, injury, and disability.
 It provides training to occupational safety
and health professionals.
Outbreaks of waterborne disease have
occurred in a broad range of facilities.
Although there is no evidence of a
widespread public health problem,
published reports have associated illness
with exposure to water from dental units.
The fact that there are bacteria capable of
causing disease in humans found in dental
unit waterlines is reason for concern.
 In community water, the number of waterborne
bacteria is kept below 500 colony-forming units
(CFU) per milliliter.
 The water from air-water syringes and dental
hand pieces frequently has bacteria levels that
are hundreds or thousands of times greater than
is permissible in drinking water.
 The types of bacteria that are found in dental
unit water are frequently the same types as
those found in community water, but the levels
of bacteria found in the dental units are almost
always higher.
Websites
www.engenderhealth.org/
ip/sharps/nsm3.html
www.ada.org
www.fda.gov
www.osha.gov
www.cdc.gov