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DENTAL HYGIENE PROGRAM
Clinic and Policies Manual
2015 - 2016
The purpose of this manual is to
provide students and faculty with information
regarding policies and procedures of the
Dental Hygiene Program and Dental Hygiene Clinic.
Indiana University South Bend
DENTAL HYGIENE PROGRAM
FACULTY and STAFF
Kimberly DeOrto, RDH, MSEd
Interim Program Director, Dental Education
Carmen Dielman, RDH, MLS
Clinical Lecturer in Dental Education
David Douglas, DDS
Clinical Assistant Professor in Dental Education
Supervising Dentist
Kathy Doerscher, RDH, MLS
Clinical Lecturer in Dental Education
Diane Lemanski, RDH, BSDH
Visiting Clinical Lecturer in Dental Education
Sandra Peek, RDH, MPA
Clinical Lecturer in Dental Education
Sue Szczypka
Secretary, Programs in Dental Education
Ashley Zielinski
Receptionist and Clinic Manager
Dental Hygiene Program
CLINIC and POLICIES MANUAL
TABLE OF CONTENTS
Clinic Policies
Section 1
Clinical Routines
Section 2
Patient Care Policies and Procedures
Section 3
Infection Control Protocols
Section 4
Radiology Policies and Procedures
Section 5
Radiology Guidelines
Appendix A
Infection Control Guidelines
Appendix B
Quick Reference Guides
Appendix C
Record Documentation
Clinic Process and Procedures
Section 1
Clinic Policies and Information
A. Clinic Information
 Clinic Fees and Collection
 Insurance/Medicaid Payment
 Parking
 Directions to the clinic
 Weather cancellation
B. Program Information and Policies
 Dress Code for Clinic and Laboratory
 Professionalism
 Management of Patient Records
 Appointing Patients
 Recare System
 Clinic Attendance
 Communications
 Use of Phones and Computers in Clinic
 Answering the Clinic Telephone
 Smoking Policies
C. Duties of the Student Hygienist
 General Duties
D. Duties of the Clinic Assistant
 Goals
 Evaluation
 Duties
E. Duties of the Class Representatives
F. Instrument Ordering, Replacement, Re-tipping, Sharpening
G. General Policies Related to Clinical Evaluation
H. Outline of Clinical Evaluation
I. Clinic Mentor Meetings
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A.
Clinic Fees and Collection
IU SOUTH BEND
PROGRAMS IN DENTAL EDUCATION
CLINIC FEES 2014-2015 revised 8/13
Dental Hygiene Treatment (Fees are for complete care, regardless of the number of appts.)
Adults
$30.00
Children (12 and under)
$15.00
IU South Bend Students
$15.00 (see exception below regarding DE students)
IU South Bend Faculty and Staff
$15.00
Seniors (over 62 yrs)
$15.00
Sealants (each)
$ 5.00
If, for premedication purposes, a patient forgets to take an antibiotic pre-medication prior to
their appointment, there will be a fee of $5.00 for the supervising DDS to dispense antibiotics for
the initiation and continuation of treatment that day.
Insurance:
 The policy for patients with insurance is for them to pay for services at the beginning of
treatment. The patient is responsible for filing and designating on the insurance form
that reimbursement should be sent to them, not to the clinic.
Radiographs
The fee for bitewing radiographs will be included in the treatment fees for all patients.
• .Radiographs will be determined as necessary by a DDS using the guidelines established
by the American Dental Association.
Patients needing bitewings, but no other treatment, AND patients requesting DUPLICATE will
be charged the fee of $5.00.
If, for diagnostic purposes, a dentist requests radiographs more than 1 time per year, there will
also be a fee of $5.00.
Bite Wing radiographs
$ 5.00
1-3 Periapical radiographs $ 5.00
Full Mouth Series*
$ 10.00
Panoramic radiograph*
$ 10.00
Cash, checks, and credit cards (Visa, MasterCard, Discover, and American Express) are accepted.
Checks must be made payable to IU South Bend DH Clinic.
Dental Hygiene Students actively enrolled in the Programs in Dental Education may request
services in the Dental Hygiene Clinic at no charge within the following parameters:
•
1 cleaning as needed according to recare schedule*
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1 FMX or Pano: only allowable within the recommended time frame of 3-5 years since a
previous series was taken
Bitewing films: every twelve (12) months
Sealants
Fluoride/Fluoride Varnish
* Dental hygiene students may treat one fellow dental hygiene student each clinical semester
as long as the student is due for their recare treatment.
No clinic fees will be waived for Dental Hygiene family members.
Each student enrolled will receive eight total coupons to be spent to cover clinic fees for
services up to a $30.00 value. Coupons can be carried over to subsequent clinical semesters.
Parking
Patient Parking:
 Patients use designated areas near the faculty/staff parking lot.
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Patients must register their car license plate at the reception desk before their
appointment.
Register car by writing date, name, time of arrival and car license plate number on
registration form.
Failure to register this information will result in a parking ticket from the campus
security officers.
Student Parking:
 Students who have a valid university parking stickers are permitted to park in
designated student areas and other sites on campus.
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These designated areas are marked "Student Parking". Students who park in areas
designated for faculty and patients will be ticketed by IU South Bend campus security.
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Directions to the IU South Bend Dental Hygiene Clinic
Address of Arts and Education Building
Dental Hygiene Clinic 574/520-4156
1002 S. Esther Street
Indiana University South Bend (IUSB)
Dental Education Office 574/520-4158
(Secretary’s phone)
From INDIANA 933 (Michigan Street going north, or Main Street going south, in South Bend)
Turn EAST onto Sample St. (S.R. 23). Watch for IUSB signs. After turning right onto Sample, stay
in right-hand lane, look straight ahead for a green/white sign that says “33 S- Lincolnway E Mishawaka” and take this exit.
Proceed on Sample, crossing Lincolnway East. At the signal, cross the bridge over the St. Joseph
River, turn right onto W. Mishawaka Ave. Turn Right onto Esther Street.
The Education and Arts building is on your left behind the Administration Building. Clinic
patients may park in the DENTAL PATIENT PARKING area and enter license plate number on the
roster at the reception desk in the Dental Hygiene Clinic.
Education & Arts Bldg
1002 S. Esther St.
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IU SOUTH BEND Weather and Cancellation Policies
Under IU SOUTH BEND winter-weather snow alert plan, the decision to close the campus and to
cancel classes is made by the Chancellor or Vice Chancellor. Before making this decision, the
administration consults with public safety and facilities management officials and
representatives of other area educational institutions. In accordance with longstanding
traditions, Elkhart and Plymouth off-campus program classes are cancelled when Elkhart and
Plymouth public school classes are canceled.
Announcements of weather-related cancellations will be made to the local media and through
IU Notify. Students, faculty and staff should listen to the radio or watch local television updates
for information about closings and cancellations. Students should update their contact
information through www.onestart.iu.edu, linking to IU Notify.
In the event that the campus is not closed, but inclement weather makes travel dangerous for
some individuals, employees should contact their supervisors, and students are encouraged to
contact their professors, about individual issues of safety and weather-related absenteeism.
IUSB DENTAL CLINIC: 574/520-4156
B.
PROGRAM INFORMATION AND POLICIES
Dress Codes for Clinic and Lab
 Lab jackets with name tag, gloves, mask and eyeglasses with side shields are required
when treating patients. The lab jacket is worn over accepted clinical attire.* Magnetic
name tags should be placed on the left side of the jacket.
* Accepted clinical attire:
 Full uniform for students includes clean, pressed color designated scrub tops and
pants and/or plain white scrub tops and pants. Plain white tops may be layered
beneath scrub tops.
 Plain clean white shoes designated for clinic use only and must remain in the
building. No open toed shoes are to be worn in clinic. Clean white socks are
appropriate for clinic.
 A colored designated lab jacket is required when in direct patient contact in all
clinic sessions, lab courses, and while performing clinic assistant duties.
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Treatment gloves are not to be worn outside dental hygiene chairside clinic treatment
areas, except when carrying sterile or contaminated instruments/items within the clinic.
Dispose of masks and gloves in the clinic trash containers.
Hair must be neat and clean. Hair must be secured and pulled back away from the face
so that it does not fall forward and interfere with sterile technique, vision or safety of
procedures. Styles must prevent hair from falling forward in the operator's face and/or
operating field. All hair clasps or headbands worn in clinic should be washable,
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disposable or capable of being disinfected after exposure to contaminated aerosols in
the treatment area.
Fingernails shall be kept short and even with the pad of the finger so that when viewed from
the palm side of the hand the fingernails cannot be seen. Only sheer or pastel nail color will be
allowed and should not be chipped or worn.
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Hair and beards must be clean and neatly trimmed.
Due to infection control standards, only one or two small pairs of simple stud earrings
may be worn. No other jewelry (necklaces, bracelets, watches, rings) is to be worn with
clinic uniforms and/or under gloves. Other visible body piercings and/or visible tattoos
are not appropriate for clinic. Oral and facial piercings are considered unprofessional
and are not considered part of accepted clinical attire.
Professionalism
 Eating, drinking, toothbrushing or personal grooming is not allowed in the clinic area.
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Make-up should be used in moderation and appropriate for a clinical setting.
Students should dress in business casual attire when representing the IU South Bend
Dental Hygiene Program at community and professional meetings.
o Refer to Program Handbook Chapters 1 and 2
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Gum is not to be chewed when in clinic or laboratory.
Management of Patient Records
 Each patient has an electronic medical record and returning patients have a
manila folder to hold their records. Patient records are legal documents.
Therefore, they must be treated with confidentiality and any data cannot be
removed from the clinic.
Appointing Patients
Students are responsible for appointing their own patients.
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All appointments including patient name and phone number should be entered in
Dentrix Enterprise as soon as possible to avoid double booking.
Appointment cards are available in the clinic. Complete a card for those patients who
make appointments in person or who are being reappointed.
Students may share patients, but the patient must first be notified and give
permission/consent. Students must also obtain faculty permission and let the clinic
manager know what is happening. It is suggested students check with their
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coordinators to find out how grading and patient count will be done.
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Always request the patient give 48-hour notice if any changes are needed in the
appointment. If an appointment is made over the telephone, be sure to repeat before
the end of the conversation, the day, date, and time of the appointment.
Student Clinicians should confirm the appointment and discuss any medical history
concerns 24 hours prior to the appointment. All patient contact should be documented
in the patient’s chart. Prior to the confirmation call, student clinicians should review the
patient’s medical history for potential complications that may affect treatment. Due to
the increasing use of Caller-ID, students are strongly urged to make all calls to patients
from the clinic phones.
If students are ill and will not be in clinic, it is the student’s responsibility to notify and
cancel patients for that clinic.
Patients cannot be seated in the clinic until an instructor is present. If the faculty
hygienist is present and the dentist is not, students may review the patient's medical
history and take blood pressure. No treatment can be initiated until the medical history
is reviewed and signed by the dentist.
Children are not allowed in the reception room unattended or in the clinic unless they
have an appointment. Students should provide this information to parents when
confirming appointments. Parents will be asked to reschedule if proper childcare has
not been arranged during their appointment.
Recare System
 Upon completion of each patient, the student should make a recommendation for the
patient's next treatment according to their oral health condition. When possible,
patients should be reappointed chair side for recare when their treatment is complete.
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Students should maintain their own patient recare information and update it after every
patient appointment.
Clinic Attendance
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The Commission on Dental Accreditation (CODA) (Standard 2-14) requires junior (firstyear) dental hygiene students to be in clinic treating patients 8-12 hours a week and
senior (second-year) dental hygiene students to be in clinic treating patients 12-16
hours a week.
o In order to meet the CODA standard, clinicians may leave no earlier than ONE
HOUR before the end of the clinic session.
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Student Clinicians must be set up and ready to seat patients at the beginning of each
session. It is required that students arrive at least 30 minutes prior to the beginning of
each session. Students will be considered ABSENT if they arrive later than 15 minutes
before the beginning of the clinic session.
The Clinic Assistant (CA) is required to be in the clinic at least 30 minutes prior to the
beginning of the clinic session (see Duties of the Clinic Assistant).
Students may switch clinics with another student clinician IF:
o It is within one week of the clinic (switches done in less time than one week will
NOT be allowed or approved)
o Both students are in agreement of the switch
o The clinic change form is emailed to the clinic manager, clinic coordinators, and
includes both students involved in the switch. This serves as documentation of
the switch and agreement of both students.
o Approval is given by the clinic manager as well as clinic coordinators
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Each student (CA and clinicians) must sign the clinic attendance book with their time
in and out.
All absences from clinic must be reported to the assigned clinic coordinator(s) and
the clinic manager prior to the beginning of clinic and arrangements must be made to
make up the missed clinic time. A clinic change form must be utilized.
Excessive absences will result in a final clinic grade point reduction at the discretion of
the coordinator(s). Absences include (for further information refer to course syllabi):
1. Absence which is not reported or documented properly.
2. Leaving an assigned clinic without permission or prior to one hour before the
end of clinic.
3. When classes remain open on the South Bend campus under adverse weather
conditions students are urged to "exercise discretion" in determining whether it
is safe to travel to the university. No one is expected to risk injury to attend
class/clinic. However, if a student is absent from clinic, the hours must be made
up.
a. It is important to consider there are a limited number of additional
treatment chairs for missed clinical hours. All requests for extra clinic time
may not be approved.
Communications
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Each student is to have an email account. IU South Bend lists email as the official
form of campus communication. If an email address changes, notify department
secretary immediately. IUSB email is the primary way appointments and
announcements to students are made. Students are expected to check email daily.
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See www.iusb.edu/uits/ to have IUSB email forwarded to a frequently checked nonIUSB account.
Use of the Phones and Computers in the clinic
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Due to the increasing use of Caller-ID, students are strongly urged to make all calls
to patients from the clinic phones.
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Confirmation calls will be made from the clinic manager’s office or storage alcove.
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Patients should be asked/reminded to silence their cell phones during treatment.
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Students may use the computer attached to the scanner in the clinic manager’s
office, but not the clinic manager’s computer.
Answering the Telephone
When patients call for an appointment:
 Find out if the patient is assigned to a student--check the patient’s file.
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If the patient has not been assigned to a student, patients may be scheduled in the
first open appointment available. It is the students’ responsibility to check the
appointment book regularly for filled appointments.
Students are not allowed to make unauthorized changes in the clinic appointment
book (i.e. appointments, canceling scheduled appointments, etc.). Tampering with
other student’s appointments and/or unnecessary rescheduling of patients is
professionalism issues and will be disciplined accordingly.
Professional dialog and information gathering is important when answering the
phone in the IU South Bend Dental Hygiene Clinic. The following prompts will be
helpful in providing and gathering information.

“Thank you for calling the IU South Bend Dental Hygiene Clinic. If you have a
few minutes, I need to get some information (name, home phone, work and
cell phone)”.
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“Have you been seen in the IU South Bend Dental Hygiene Clinic before?” If
yes, “when?”
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“The IU South Bend Dental Hygiene Clinic takes longer than a visit in private
dental practice. Appointments may be up to FOUR hours long and you must
be prepared for multiple visits to complete your dental cleaning if needed.”
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“Our policy is to take a full series of diagnostic x-rays on all patients. The fee
for these films is $10 in addition to the cleaning charge. If you would like
duplicate films sent to your dentist there is a $5.00 charge. If you have
current x-rays contact your dentist to have a copy made and have them sent
or bring these films to your 1st appointment; otherwise x-rays will be taken
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to assist in your treatment.”
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“Only the patient receiving treatment will be allowed in the clinic. Children
cannot be left unattended in the reception area. Please make arrangements
for their supervision while you are receiving care in the clinic”
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“The IU South Bend requires minimally a 48 hour notice of cancelled
appointments.”
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Directions to the clinic… “The IU South Bend Clinic is located in the Education
and Arts Building. The address is 1002 S. Esther Street. It is located behind
the Administration Building off of Mishawaka Ave.”
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“Clinic patients may park in the DENTAL PATIENT PARKING area in front of
the clinic and enter the license plate number at the reception desk.”
Smoking
 Clothing, body and hair must be free of smoke odor when in the dental education clinical
or laboratory settings.
The IUSB Clean Air/Smoking Policy is as follows:
 Smoking is not permitted on campus except in personal automobiles.
 Enforcement: The Office of Safety and Security as represented by the Safety Officer will be
responsible for enforcing these regulations.
C.
Duties of the Student Hygienist
General Duties
 When setting up the dental unit at the start of clinic, check the cleanliness of the entire
area as well as the unit and dental light. Prepare the unit according to clinic procedures for
cleanliness and sterilization. Units should be prepared at least 15 minutes prior to the
appointment time.
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Students should stay at their unit until the arrival of their patient.
Once informed, patients should be politely greeted in the reception area and escorted to
the chair. Patient records are to be kept at units in order to maintain confidentiality.
Address all adult patients by their surname. Courtesy and consideration of the patient
must prevail at all times. Greeting and seating patients within 5 minutes of their arrival
and/or the start of clinic is important. Give patients undivided attention as soon as they
arrive to the building.
If a patient fails to show on time for their appointment, students should attempt
contacting their patient to verify if they plan to keep their appointment. 15 minutes after
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the start of the clinic, if the patient has failed to show, the student should initiate their
back up plan/patient.
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Patient fees are collected at the beginning of the appointment by the clinic manager and
assistant. The clinic manager will mark the patient route slip with a paid stamp once the
fees are collected. Student clinicians may not take a patient to the chair until fees are
collected and the route slip is placed in the vertical file near the check-out window.
Assessment of the patient’s medical record should be completed at the beginning of each
appointment.
The student clinician should notify the dentist by signing up on the board to check the
patient’s medical history and prescribe radiographs.
After completing the patient assessment and all necessary charting, the student should
sign up for check in indicating they are ready for their zone instructor to grade the
assessment.
If a student is in need of a progress check, they should sign up on the board, but should
continue to work. The zone instructor will come to the student as time allows.
Students sign up on the board when they are ready for the final check out or
reappointment.
All grading paper work and electronic records must be complete and accurate. Patient
folders are returned to the clinic manager at the end of the clinic period. Students are
ethically and legally responsible to protect patient confidentiality.
Students are responsible for the proper cleaning and care of the units. Most maintenance
and sanitary procedures are done after each patient or daily. Record any necessary repairs
in the Clinic Maintenance/Repair Log binder in the manager’s office. Students are
responsible for:
o Checking the unit/chair for cleanliness at end of clinic.
o Bases of chairs being free of debris, dust, and stains.
o Unit and arms being dust free.
o Chair and light being in the proper position.
o Rheostat and wires coiled up and in position on the base of the chair.
o Restocking and organizing the units.
o Checking/cleaning ledges around units for dust and debris.
o Running HVE cleaner through suction lines.
D.
Duties of the Clinic Assistant
Goals of the Clinic Assistant
 Each student will be assigned 4-6 half days per semester as Clinic Assistant. This
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assignment will be in addition to regularly scheduled clinics.
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The overall goal of the assignment is to give the student experience in the
managerial and business aspects of the practice of dental hygiene. The Clinic
Assistant (CA) role involves clinic assisting duties and other duties as assigned.
Evaluation of the Clinic Assistant
The CA is expected to comply with the clinic dress code and carry out all general and
specific duties outlined for the role. For each assigned duty, the Clinic Assistant will
present a clinic assistant skill assessment to the clinic manager for evaluation. If it is
determined that a function was not satisfactorily completed, points (-2) will be deducted
from the student’s final clinical grade.
Duties of the Student as a Clinic Assistant
START OF THE CLINIC SESSION
 Arrive 30 minutes before the start of clinic
 Turn on the vacuum and compressed air in clinic located at unit 1 along the north wall
 Mix solution; fill ultrasonic cleaning tank (prosthetic and sterilization room)
 Assist the clinic manager; notify students when patients arrive
 Monitor flow of x-ray rooms
 Change and monitor laundry; hang outside student lockers on hooks
 Check M3 water bottles (follow Clinic Procedures Manual)
 Check water levels in autoclaves (follow Clinic Procedures Manual)
 Check water bottles at each unit; refill as needed and use enzymatic tablet at each refill
DURING THE CLINIC SESSION
 Check CA calendar, identify task for the session, initial calendar when completed
 Check supplies at each unit (sealants, disposables, hand sanitizer, soap, paper towels,
patient cups)
 Identify supplies needed from main storage area (Room 1234)
 Replenish clinic supplies in storage alcove (1224), sterilization room, and individual
units
 Wipe down sterilization countertops and x-ray suite countertops
 Refill cups, paper towels and faculty gloves
 Straighten and organize reception area
 Put away sterilized instruments in student drawers; check bags for color change to
insure sterilization
END OF THE CLINIC SESSION
Check HVE cleaning solutions at each unit; refill as needed
 Drain and clean both ultrasonic tanks
 X-ray rooms lights and computers are off or in sleep mode
 X-ray machines off in radiology rooms
 All items away in appropriate cabinets
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Sinks and countertops are clean and dry
Autoclaves off in front; switch off on back
Each Dental Unit checked
Vacuum and compressed air off
Lights off; Main clinic, sterilization room, storage alcove, reception area
Digital x-ray sensors returned to holders
Doors closed: Main clinic doors, Storage alcove.
E.
Duties of the Class Representative
Each class elects class representatives near the end of the first semester.
The following duties have been suggested.
Representative 1: Class President/ADHA Representative
 Serves as a school representative in the ADHA (must be a member both years)
•
Attends the IDHA annual session and the Mega Issues Forum for students
 Serves as a liaison between faculty and class members.
 Oversees class functions such as fund raisers, class trips to professional meetings, etc.
 Assists and oversees other representatives in carrying out their duties.
 Represents the class in meeting with faculty.
Representative 2: Vice President/Community Outreach Coordinator
 Serves as the contact person for the class on any community outreach activities
o Career Fairs, IUSB orientations, screening events, health fairs, etc.
 Publicizes clinic through media.
o As a minimum each semester a notice will be placed in the IUSB Preface and/or
the Daily Titan electronic newsletter at https://dt.iusb.edu/
 Serves as a liaison between class and other representatives.
Representative 3: Treasurer/Secretary
 Maintains class funds by collecting and depositing funds and manages class accounting
records.
o Signs checks, deposit slips, etc.
o Collects funds from fund raiser or for class dues, etc.
o Requests an account statement for reconciliation in:
 August for the year start up
 December to reconcile prior to the incoming class beginning fundraising
efforts
 Responsible for ordering, replacement, and re-tipping of instruments from various
manufacturers.
 Liaison between class and other representatives.
 Responsible for assembling meeting agenda, taking minutes, disseminating minutes to
faculty and other class reps for accuracy, and finally sending to the entire class for
inclusion in decisions and discussion.
 Present the entire time for class pictures (typically in February of second year)
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F.
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Instrument Ordering, Sharpening and Replacement
It is recommended that students engrave all instruments with their name or initials, and
use the assigned colors for color-coding all items in their instrument kit.
New instruments purchases and instrument replacements are handled through the
designated class representative. The following policies have been developed for efficient
processing of instrument orders.
Students may purchase new instruments at dental supply companies such as Midway or
Patterson or work with the class representative to receive a discount from manufacturers
as outlined below. If orders are made from a supply company, students should mention
they are an IUSB dental hygiene student.
INSTRUMENT REORDERS -- HU-FRIEDY SCHOOL POLICY
In normal use, curets and scalers are resharpened much more than other instrument types.
All scalers and curets originally purchased as part of a student kit may be exchanged for
identical new instruments at reduced cost.
1.
2.
3.
4.
5.
The cost to trade-in old instruments for new instruments is about half the cost to
ordering new instruments without a trade-in. Replacement/new instrument order
procedure: Payment must accompany all orders (see #5). You do not need to
return your old instruments until you receive your replacement/trade-in
instruments.
Checks should be made out to your representative when you order. Keep a list of
the instrument item # and quantity ordered. Class liaison will compile one list of all
items and quantities needed.
Allow two weeks for delivery. When the liaison receives orders, students should
bag, label and sterilize trade-in instruments in order to receive new instruments.
Class liaison will work with faculty member to complete orders. The company will
only accept credit cards, so all orders must be paid in advance to the class liaison.
Mailing address: Hu-Friedy Student Return
3232 N. Rockwell
Chicago, Ill 60618-5935
Telephone:
Hu-Friedy Customer Service for Price Quote: 1 (877) 321-4333
Credit Card Payment: Fax form to 1-800-729-1299
Instrument Sharpening
 Students are responsible for maintaining the sharpness and integrity of all instruments
used in patient care. Properly maintained instruments last longer needing fewer
replacements. Instruments sharpening techniques are taught in H219 Clinical Practice
II and reviewed in subsequent clinical courses to competency.
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G.
Professional sharpening is available through two local sharpening companies, T-SHARP
and Rx Honing. For more information on this service visit T-SHARP’s web site at
www.tsharp.com or call toll-free at (877) 487-4277. For more information on Rx
Honing, visit http://www.rxhoning.com/default.asp or call toll-free at (800)346-6464.
General Policies Related to Clinical Requirements
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To receive credit for clinical requirements, procedures must be completed on clinic
patients. Procedures may be practiced and evaluated on dental hygiene students.
Students may be treated each clinical semester for credit, if treatment on the student is
needed and justified.
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All clinical requirements, including radiographs, must be completed during scheduled clinic
periods. It is recommended all radiographs be taken during patient assessment. Students
cannot treat patients or practice on manikins (DXTTR) without clinical supervision by
faculty.
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On reappointed patients, after getting the dentist’s signature on the health history, students may begin
treatment after completing reassessment paperwork, and requesting faculty check-in.
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Patient credit for H219, H300, H301 and H302
When all patient experience requirements have been completed during the clinical
semester, students are required to continue treating patients. Up to half of the next
semester’s requirement of Perio II, III, IV and/or Calculus Levels II, III in excess of the
current semester’s requirements can be carried forward into the next semester if they are
completed at the next semester’s grade level. See course syllabi for grade levels.
•
Higher Perio and Calculus Levels may count for lower Perio and Calculus Levels.
•
Patient count will be rewarded in the semester they are completed. If a student completes
the maximum patient treatment requirements and skill assessments they may check out
early and begin working on the next semester’s requirements. This ensures students will
continue to build their clinical skills each semester by treating patients and using clinic time
wisely.
•
Credit for Calc Level III
Recommended treatment planning for Calculus Level III is at least two appointments of
non-surgical periodontal therapy with a 4-6 week re-evaluation. Exceptions to this can be
made by clinic faculty. It is recommended that these patients, due to active disease, return
after treatment is completed within 4-6 weeks to evaluate tissue response, complete a full
assessment and prophylaxis. The 4-6 week re-evaluation appointment will count for full
credit.
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•
Excess sealants done can only be carried forward if they are on an additional patient
(Example: if the clinic requirement is 8 sealants on 2 patients and a student completes
additional sealants on a 3rd patient those may be carried forward to the next semester).
Only half of the next semester’s requirements may carry forward to subsequent semesters.
H.
Outline of Clinical Evaluation
The final letter grade for clinical practice is based on clinical, professional and didactic performance in the
completion of requirements. Depending on the semester, the value and number of requirements is varied
to reflect the student’s abilities and clinical development. Professionalism in the practice, interpersonal
relationships, and personal conduct is also evaluated and weighed when assigning grades. A detailed
explanation of the course requirements is in the course syllabi.
Passing Level:
H219
Points
Deducted Grade
0
100
1
98
2
96
3
94
4
92
5
90
6
88
7
86
8
84
9
82
10
80
11
78
12
76
H300
Points
Deducted Grade
0
100
1
98
2
95
3
93
4
90
5
88
6
85
7
83
8
80
9
78
10
75
H301
Points
Deducted
0
1
2
3
4
5
6
7
Grade
100
97
93
89
86
82
79
75
H302
Points
Grade
Deducted
0
100
1
95
2
90
3
85
4
80
5
75
GRADING PROCEDURES AND POLICIES:
1.
Intentional misrepresentation: 0 for the patient. Action is grounds for dismissal from the
program and includes acts such as falsification of records, forging of instructor’s name.
2.
Critical error (such as a breach in infection control or a major infraction that puts the patient at risk):
Provision of patient treatment is unacceptable. Critical errors may result in failure of the
patient in which case no credit will be given.
3.
Re-attempt of patient treatment: If a student fails a patient, see course syllabi for
instructions/possibility of receiving credit for retreatment of the patient.
4.
Faculty Signatures:
When any phase of treatment is evaluated, faculty members are required to sign the
corresponding area on the evaluation sheet.
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a.
b.
c.
If the entire treatment segment is completed without errors, instructors will indicate
no errors with a (-0) and sign their name on the Student Grade Sheet.
If errors occur in a segment/quadrant, instructors will indicate the number of errors and sign
their name on the appropriate area of the quadrant evaluated.
When instructors give a progress check, it is recommended students note the areas.
5.
Use and Purposes of Clinical Alert
The goal of the Clinical Alert policy is to alert students as early as possible when their
clinical dental hygiene competence is not consistent with their clinical standing. When
faculty members identify students with clinical problems, they will complete a Clinic Alert
form. The faculty will provide the student with detailed information on clinical weaknesses
and make specific recommendations for improvement. The completed form is then given
to the faculty clinical coordinator who will share the information with the student; and the
original is given to the director of the program.
4.
Instructors will assist students in correcting errors by giving suggestions/demonstrations of
proper technique. If a student receives two or more clinic and/or academic alerts in a
semester, the student will meet with the faculty and director to determine how the
student will proceed in developing necessary skills, a Learning Contract or Professional
Improvement Plan will be issued outlining the issue, the necessary remediation, and the
outcome if the student is not successful at the end of remediation. Two or more alerts at
any time in the program may be grounds for dismissal from the program. See Section 2 on
Academic Policies.
I.
Clinic Mentor Meetings
Each student will have a minimum of 2 conferences (1 during summer session) each semester with
an assigned faculty mentor. The purpose of this is to enhance communication between students,
associate faculty, and full time faculty members. Conferences will be arranged on an individual
basis, but should follow the time frame given below.
1.
Fall semester meetings will be held by the end of September and before
Thanksgiving break.
2.
Spring semester meetings will be held by the end of February and by the
end of the first week of April.
3.
Summer semester meetings will be held by mid June.
More time may be arranged by either the student or the faculty member.
It is the student’s responsibility to contact their assigned faculty mentor. Students should bring
their clinic evaluation sheets, arranged in numerical order, and their patient record/recare list with
them to each conference, so that the faculty may discuss specifics with them about patient
treatment, technique, and professionalism. These meetings are to take place in an area which
insures privacy and confidentiality.
Notes from each meeting will be documented and signed by both the student and mentor.
200
Section 2
Clinical Routines
A. Outline of Dental Hygiene Treatment Procedures
B. General Preparation in Dental Hygiene Treatment
• Operator Preparation
• Unit/Tray Preparation
• Paperwork Preparation
C. Steps in the Dental Hygiene Process of Care
• Patient ASSESSment
• Patient Dental Hygiene DIAGNOSIS
• Dental Hygiene Care PLAN
• Treatment IMPLEMENTation
• Treatment EVALUATION
D. Grading
201
206
206
208
209
210
211
213
214
215
215
217
E. Process of Care Explained
• Medical and Dental History Evaluation
• Vital Signs
• Oral Inspection
• Guidelines for Recording findings
• Extra Oral Examination
• Classification of Occlusion
• Intraoral Examination
• Periodontal Probing
• Classification of Home Care/Plaque Index
• Classification of Case Type
• Dental Charting
F. Progress Notes Documentation
217
219
224
224
224
224
228
230
232
239
240
240
243
G. Patient Counseling and Education
243
H. Topical Fluoride Application
247
I. Instrument Breakage
248
J. Implant Care
248
201
A. Outline of Dental Hygiene Treatment Procedures DENTAL HYGIENE APPOINTMENT CHECKLIST
Prior to the patient’s appointment (unless patient is new to clinic).
1. Verify that the most recent medical history has been scanned into the patient’s Document Center
in Dentrix. If not, see the Clinic Manager.
2. Review medical history to determine the possible need for any premedications and/or medical
consultations.
On the day of appointment
1. Pull the patient’s paper chart, return to unit and open Dentrix.
2. Locate the patient’s digital chart and open the Document Center in Dentrix.
3. Review the previous Medical/Dental Histories in paper or Dentrix.
a) Any positive medical conditions that require a medical alert should be noted in Dentrix
with a red cross.
b) If the patient is a new patient, a new medical history should be filled out with the
patient signing and scanned into the patient’s Document Center in Dentrix by the Clinic
Manager. If the patient is returning, they may verify their medical conditions using the
previous document, but each student clinician should enter this information into the
patient’s Medical History Review.
4. Once the patient has arrived, the status bar will change color.
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a. Status bar color will change again when patient is ready to be brought back for
treatment.
b. Prior to leaving chairside to retrieve patient, achieve HIPAA compliance by selecting on
the keyboard the Windows key and L key simultaneously.
5. Pick up routing slip from vertical file in clinic manager’s office and verify the patient has paid
(indicated by the paid stamp and clinic manager’s initials).
6. Bring the patient back to the operatory and open patient chart in Dentrix.
7. Review Med/Dental History with patient.
8. Assess blood pressure; enter “Patient Health Assessment” and click ‘add’. Document BP on
Plaque Index/Caries Risk worksheet. This will be given to the patient at the end of treatment.
9. Perform cursory oral screening for radiographs.
10. Recommend radiographs needed and obtain verbal consent (written consent will be obtained in
the treatment plan). Verify procedure and fees are on the route slip. If the procedure is not on
the route slip, enter treatment into the appointment book and obtain a new route slip and collect
payment.
11. Confirm findings on Med/Dental History and radiographs recommended with hygiene zone
faculty. Zone faculty will begin the grading for the patient.
a. Items needed: entire patient record/folder
b. Med/Dental History
c. Grade sheet
d. White patient record/recare list
12. Seek dentist’s approval of Med/Dental History by signing up with a red marker on the board.
a. Dentist will come to each student, but students may begin the intra and extra oral
examination (except probing and exploring) on patients IF they have checked in with a
zone faculty.
13. Expose radiographs if needed; CAs or zone faculty will notify clinicians when a room is ready.
203
14. Intra/ Extraoral Exam:
a. New patients and annually: Open the File Folder –DentrixShare (E) –DentrixShare and
obtain the Intra/Extra Oral Exam sheet. Open the writable pdf and fill out the form and
when complete click on File – Print – Send to Dentrix Document Center – Print. DO NOT
SAVE THE FILE TO THE GENERAL DOC CENTER. BE SURE IT IS PRINTED IN THE
PATIENT’S FILE.
b. Recare/reappoint: Perform and record Extra Oral Exam in clinical notes only, refer to
previous exam in patient’s Document Center. NOTE: by noting ‘no changes’ for the
intra/extraoral exam, clinicians are agreeing with the previous findings. If faculty find a
discrepancy, it will be considered an error. If there are several changes students are to
open a new intra/extra exam and complete.
15. Occlusion Classification (Right and Left Molar or Canine) ; Overbite, Overjet, other
malpositionings
a. Cross bites are to be indicated by tooth relationship in the Maxillary & Mandibular
arches. (i.e. posterior crossbite between tooth numbers #3 & #30) it the relationship
between the 1st molars or canines can be determined the student is to indicate this in the
correct classification area.
b. The canine classification is to be used only if the molar relationship cannot be
determined (i.e. missing posterior tooth between #27 & #30) and must be indicated on
the form.
16. Dental Charting:
a. Mark out all missing teeth; zone faculty must approve prior to probing
b. Record all restorations
17. Periodontal Exam: Probing , BOP , recession, furcations, mobility, clinical attachment level,
suppuration/exudate.
18. Determine amount of Plaque, Calculus and Stain 0=none, 1=light, 2=moderate, 3= heavy
19. Click on Diagnostics.
204
a. Describe gingival tissue color, consistency, contour, generalized vs. localized
b. Disclose and calculate Plaque Index; note in Miscellaneous in Perio Chart/Perio Clinical
Notes.
c. Determine Periodontal Case Type (Periodontal Level)
d. Click on “Copy to Clipboard” then press “ok” (to be pasted in clinical notes later)
20. Perform Caries Risk Assessment utilizing current methodology and clinic forms to determine need
for fluoride. Patient will leave with this form. Document Caries Risk in Clinical notes.
21. Patient Education: Show patient areas of plaque, disease. Educate on the disease process.
Recommendations and demonstration of brushing and flossing. (Patient only gets one hygiene kit
per recare appointment. There will be designated toothbrushes for re-appoint patients).
22. Treatment/Care Plan: Use assessment data to develop dental hygiene diagnosis. Determine # of
appointments needed to complete treatment. Enter in Treatment Planner.
(Utilize laminated Parameters of Care document to help create an individualized treatment plan
and goals.)
205
23. Case Presentation: Discuss Care Plan with patient and stress patient’s role in treatment.
24. Informed Consent: Answer patient questions; be sure procedure codes and treatment are
entered properly; seek informed consent signature using e-pad. Do not have patient sign consent
until after zone faculty has approved of Treatment /Care plan.
CHECK IN: Indicate readiness for check in by signing up on the board. Make sure all assessment data
is complete.
1. Review treatment plan; determine with instructor what can be done at this appt.
2. Patient will sign consent form.
3. Zone Faculty will grade the Extra/Intra Oral through the Preventative and Supportive sections of
the grade sheet.
4. Enter Periodontal Level and Calculus Class coding in patient appointment.
 This is done for new, 4-6week re-evaluation, and recare patients for tracking individual
patient degree of difficulty classifications.
DEPOSIT REMOVAL:
5. Ultrasonic/Hand Scale; Explore to check for calculus removal.
 Progress check: indicate need for a “Progress Check” by signing up on the board.
6. Polish remaining stain and plaque
7. Floss
8. Disclose and use air to self-evaluate removal of all deposits. Go back and remove anything
missed. Re-disclose if unsure about removal.
9. Complete all progress notes by completing the prompts in Dentrix (PP, CC, HH, RXr, DD, TXR, RR
and NV) Recare (month/year) if patient is completed.
10. Use Hygiene prompt at every appointment to complete clinical notes unless the patient is
returning for SRP, otherwise the Periodontics prompt should be selected.
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11.
CHECK OUT: Indicate need for final instructor evaluation by signing up on the board.
Fluoride: This may be prepared and waiting for administration once check out is complete.
 Make arrangements with patient for next appointment (reappt. or recare). Have them call
the clinic if you do not have an appointment at that time.
 Walk patient to reception area.
 Verify all procedures, fees, and codes are on routing slip, initial, and return routing slip to
clinic manager.
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General Preparation for Dental Hygiene Treatment

Students may bring only their instrument kit, clinic manual and personal appointment book to
clinic sessions. All items must be stored in unit cabinets. All other personal items must be left in
the assigned locker. Do not bring other books, notebooks, book bags or purses into the clinic.
The following items are permitted in clinic:
1.
2 Clip Boards
2.
Treatment gloves
3.
Eye glasses with side shields for operator, eye protection for patients
4.
Face masks
5.
Infection control record barrier
6.
Patient education materials (typodont, sample dental aids)
7.
Utility Gloves
Operator Preparation
Personal Protection: It is the policy of Indiana University South Bend Dental Hygiene Program to
provide oral health care to all patients seeking treatment in the clinic. Since it is not possible to
accurately detect infectious and potentially infectious patients, IU South Bend Dental Hygiene Clinic
adheres to the concepts of universal precautions as defined by OSHA’s Bloodborne Pathogens
Standard (www.OSHA.gov). Emphasis is on the critical role each dental team member plays in
maintaining a clean and safe environment.
The policies and procedures outlined here are in place to protect students, staff, faculty and patients
from the spread of disease and to maintain a safe work environment.
Personal protection is one of the most important aspects of preventing infectious diseases. IU South
Bend enforces the following policies and procedures.
Immunizations (see Program Handbook pages 43-45)
 All students, faculty and staff who have direct patient care contact are required to obtain the
vaccination (or present evidence of immunity) against Hepatitis B infection, or formally decline
the vaccination.
 Students who decline to be vaccinated will be required to sign a formal declination waiver form.
 All students must provide evidence of a completed immunization record as a condition of entry
into the dental hygiene program.
Recommended immunizations of health care workers
• Rubella (German measles)
• Rubeola (Measles)
• Mumps
• Poliomyelitis
• Hepatitis B (HB)
• Influenza
• Tetanus-Diphtheria
• Mantoux (Tb) test yearly
Barrier Protection
Gloves
• Gloves must be worn for all intraoral procedures as well as extraoral examinations
o Must be changed between patients
o Damaged gloves must be changed immediately, and gloves must be discarded at the
end of each treatment session.
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o
o
Treatment gloves must not be worn outside the treatment unit area. In the event a
supply is needed from clinic drawers or the sterilization area, or in the instance of
using the flag system, the student must have clean bare hands.
Nitrile utility gloves must be worn for the handling of instruments. Carefully remove
utility gloves without touch the outside of gloves. Sterilizing utility gloves in one
load is recommended, and indicator tape may be placed on the metal sterilization
tray. Nitrile utility gloves must be replaced if they are peeling, cracked, discolored,
punctured, torn or display signs of deterioration.
Face Masks
• Masks must be worn to protect oral and nasal mucosa from splatter of blood, saliva, and
aerosols
o must be worn for all clinical procedures and must cover nose and mouth
o must be replaced between patients or when the mask becomes wet
o must not be placed on a contaminated surface and then placed on the face
Protective Eyewear
• Eyes (clinician and patient) must be covered with protective glasses or face shields
(operator) to guard against splatter of blood, saliva, aerosols and sprays.
o must be worn for all clinical procedures
o must consist of eyeglasses with side shields or chin-length plastic face shield worn
with face masks
o must be washed and sanitized between patients with antibacterial soap and water
Clinical Attire
• Lab coat and scrubs must be worn during all patient treatment. Lab coats must not be worn
into restrooms or outside the clinic building.
• Soiled lab coats should be handled as little as possible and placed in the appropriate laundry
bins in the clinic storage alcove Room 1224.
• Lab coats can be worn in the pre-clinic and laboratory facilities.
Hands
• The dental hygiene student should take particular care of their hands.
o Nails must be short and neatly manicured
o Only sheer or pastel nail color will be allowed and should not be chipped or worn.
o Artificial or acrylic nails are not allowed
o No rings or other wrist jewelry is to be worn
Handwashing
Every student will wash hands:
o Before setting up for a clinical procedures
o Before and after glove use
o Before leaving the designated clinical area
o Before and after sterilization and disinfection procedures
o After the removal of torn, cut or punctured gloves
Method of handwashing ~ Routine Handwash (Wilkins p. 66, 11th edition)
o Wet hands, apply soap; avoid hot water
o Rub hands together for at least 15 seconds; cover all surfaces of fingers, hands, and
wrists
o Interlace fingers and rub to cover all surfaces
209
o Rinse under running water; dry thoroughly with disposable towels.
o Don gloves
Antiseptic Hand Rub
o Alcohol-based hand rub should be used after patient treatment and before leaving
the clinic to decontaminate hands, may be used between glove changes if hands are
not soiled (no food consumption, no restroom usage, etc)
o Apply the product to the palm of one hand, and rub hands together
o Rub hands vigorously, covering all surfaces of fingers and hands, until they are dry.
Unit Preparation
Units within the Dental Hygiene Clinic are numbered 1-20 and clustered in units of 5 within
4 different zones (Purple #1-5; Red #6-10; Green#11-15; Blue #16-20); see diagram below.
Unit 1
Unit 6
Unit 11
Unit 16
Unit 2
Unit 7
Unit 12
Unit 17
Unit 3
Unit 8
Unit 4
Unit 5
Unit 13
Unit 18
Unit 9
Unit 14
Unit 19
Unit 10
Unit 15
Unit 20
Before preparing the unit, wash hands thoroughly and put on heavy utility gloves, mask, protective
eyewear and protective clothing when pre-cleaning and disinfecting the unit.
1.
Turn on master switch located on the bracket tray.
2.
Dental Chair and Light
 Thoroughly wipe the chair, handle and switch of the dental light with disinfectant wipe using
the two wipe method.
 Place chair in the patient reception position.
 Bracket tray
 Water syringes and all handpieces
 HVE/saliva ejector holder, base, and cord
 Any items that may be touched during procedures (i.e. pens, clipboard)
 Countertops
3.
Fill mechanical scaler handpiece with water by depressing the foot pedal.
IMPORTANT NOTE on cleaning the dental light
NOTE: DO NOT USE DISINFECTANT ON ANY EXTERNAL SURFACE OF THE LIGHT OTHER THAN THE
LIGHT SWITCH/ HANDLES
210
INSTRUMENT TRAY SET – UPS
Basic ASSESSMENT tray set-up
1.
mirror
2.
explorer (EXD 11/12)
3.
probe/explorer combination
4.
3 gauze squares
5.
2 cotton tip applicators
6.
disclosing solution in dappen dish (dispense only what is needed)
7.
saliva ejector tip
8.
air/water syringe tip
* basic assessment instruments (mirror, explorer, probe are always placed on the left side of the tray)
*instruments should not be unwrapped until the patient is seated and can witness the clean sterile
instruments being unwrapped in their presence.
Basic TREATMENT tray set-up
Include all of the above and add:
1. instruments of removal
2. ultrasonic insert(s)
3. polishing supplies (prophy angle, cup, brush, paste) (if treatment is to be completed)
*Upon completion of treatment, fluoride treatment is recommended if the patient is at a moderate to
high risk of caries. Do not set fluoride supplies on the bracket tray until you are ready to use them.
** Have the sharpening stone and test stick available chair side during treatment.
Paperwork Preparation
Gather and complete all necessary forms before seating the patient.
Student Forms:
1. Patient Record/Recare
2. Grade sheet
3. Skill assessment forms (as needed)
Good record management requires that ONLY forms/charts for the patient being treated should be
available.
Radiographs
 Review patient needs for new/updated radiographs. (Bitewings are recommended annually;
FMX/Panorex every 3-5 years) IUSB Dental Hygiene Clinic follows the ADA recommended
guidelines for exposing films. The ALARA concept should be followed at all times. Refer to
211

Radiology Clinic Manual (Section 7).
When presenting the patient record for medical history evaluation to the supervising dentist,
obtain approval and obtain needed radiographs.
Have most recent radiographs on monitor at every appointment.
Patient Arrival
 The clinic manager and clinic assistant will check in patients, accept payment, and give receipts.
 Student clinicians should remain at their unit until notified that their patient has arrived.
 Students should have the appointment book pulled up in their operatory watching the
appointment status indicator to change color signifying their patient is ready to be taken back.
Greeting and Preparing the Patient
 Put the patient at ease with a friendly greeting. Use first or last name of patient when calling
from reception area.
 Introduce yourself to the patient. Ask how the patient would like to be addressed.
 Observe the physical characteristics of the patient as you are directing him/her to the dental
unit. Move bracket tray or other obstacles out of the way of the dental chair.
 Seat patient in upright position making sure the headrest is in a comfortable position.
C. Steps in the Dental Hygiene Process of Care
Source Wilkins; 9th Edition, p6
ASSESSMENT
Medical and Dental History (Patients may complete or update their health history at the unit.)
• The medical/dental history paper form is completed, the clinic manager will scan the paper form
212
•
•
•
into the patient’s document center.
Verify the patient's name, address, phone number.
Review the medical/dental history with patient.
An explanation must be entered for any positive medical conditions; a medical alert
clinical note may need to be added for significant medical findings.
Any allergy or treatment-altering condition must include a medical alert in Dentrix and
approved by a faculty member.
ALTERATIONS IN TREATMENT ARE REQUIRED (but not limited to) THE FOLLOWING
CONDITIONS: See Sections 5 and 6 for treatment policies and protocols when treating patients
with:
o Artificial heart valves: Premedication indicated; consult physician.
o Heart trouble or stroke: Consult physician for clearance.
o Tuberculosis
o Upper respiratory or breathing difficulties
o Asthma
o Some prescription medications or surgeries
Medical Alerts are conditions revealed in the medical history which require direct attention and
heightened need for clinicians’ notification. The following are conditions (not an inclusive list)
which would require medical alerts with an explanation.
 Uncontrolled high blood pressure
 Heart valve or other cardiac conditions that would require preventive medications to be
present with the patient (angina pectoris for example)
 Diabetes (controlled or uncontrolled)
 Uncontrolled thyroid disorders
 Asthma (reference should be given to where the patient keeps their inhaler)
 Allergies (if medically relevant)
 End stage liver disorders
 Lung disorders
 Active cancer (patient undergoing chemotherapy or radiation therapy)
 End stage kidney disorders
Failure to recognize these factors when prescribing treatment may seriously affect treatment
and the patient’s health.
•
•
•
•
•
If patient is under 18 years of age, parent/guardian must complete and sign forms before
treatment can proceed.
At reappointment/recare appointment, review history with patient by asking if there have been
changes in his or her health.
Patient acknowledges updates to the health history at each appointment whether there are
changes or not. Changes are noted in chart and dated.
If it has been several years since your patient's last visit to the clinic, review health history
carefully with patient using interviewing technique.
Take and record blood pressure on all patients 18 years and older.
Extra and Intra Oral Inspections
• New patient:
o Record all observations.
213
Include observations of structures and tissues that are not pathological yet
are not found in every mouth. This includes observations such as: linea
alba, pigmentation, tissue tags, Fordyce Spots.
 Include observations of all structures that are pathological and include a
description of the lesion/structure.
 Use accepted medical/dental terminology in describing observations.
Include color, size, form, texture, location.
Re-appoint patient
o Do not record on the oral exam sheet. If any changes are noticed record in progress
notes.
Recare patients:
o A new intra/extra oral exam sheet is completed annually or if there are changes
from the previous record.

•
•
Hard Tissue Evaluation/Dental Charting
Restorative Charting
• Record all missing teeth on chart.
• Record all existing restorations using guidelines in Section 4 Dental Charting.
• Explore and examine for hard tissue deviations such as decalcification, attrition, etc. Record
findings.
Caries Detection
• Use current radiographs.
• All suspicious lesions should be addressed with the attending dentist at the time of the patient’s
caries check.
Periodontal Evaluation
Refer to Appendices for an example of Periodontal Evaluation charting and Patient Assessment Guide
Probing: Refer to page 436 for detailed procedures on periodontal probing, Appendix C for patient
paper charting, and Appendix D for Dentrix charting.
• Permanent dentition: probe all permanent teeth.
• Mixed dentition: probe only fully erupted permanent teeth.
• Deciduous dentition: no probing required.
Recording Measurements:
A full probe, including recession and clinical attachment loss, is recorded once a year. Faculty may
require a full probe if warranted due to patient disease status.
• New patient: Probe entire dentition and record all measurements. These should include
recession measurements and clinical attachment loss.
• Reappointed patient: Do not re-probe; do not record.
• 4-6 week re-evaluation patient: Re-probe all areas and record all measurements of 4mm or
more including all changes in recession and clinical attachment loss.
•
Recare patient: Probe all areas and record measurements of 4 mm and above.
Recording Bleeding Points (BOP)
214
Bleeding upon gentle probing generally is an indication of active disease.
• Indicate bleeding above the tooth number on chart where bleeding occurs; a red dot will appear
above the tooth/site in Dentrix.
Suppuration/exudate (pus)
Suppuration/exudate is an indication of active disease.
• Indicate suppuration/exudate above the tooth number on chart where it occurs; a yellow dot
will appear above the tooth/site in Dentrix.
Mobility
Suspect mobility when alveolar bone loss exists-refer to x-rays and evaluate probe depths.
• Indicate Class I, II, III mobility
Furcation
Suspect furcation involvement on multirooted teeth when pocket measurements are 4 or more
millimeters.
• Classify as I, II, or III
Plaque, Calculus and Stain Evaluation
Explore for removable roughness and indicate amounts in the calculus section of periodontal charting
(refer to page 403 #19).
• If dental stains are present, record the amount
• A plaque index is completed at each appointment and is recorded in the patient's treatment
record under miscellaneous. This should also be recorded on the patient’s plaque index
worksheet.
Evaluation of Patient Assessment
• For new and recare, all areas of oral inspection are reviewed and reassessed; changes are
recorded in appropriate area on clinical chart and dated, before treatment begins.
Patient Counseling
• Plaque Index is completed at this time and used as a basis of information and motivation in
patient counseling and education.
• Use the Plaque Index Score in this section to compute the score. Share changes in scores with
the patient, and make recommendations based on patient’s response, abilities, and interest.
DENTAL HYGIENE DIAGNOSIS
Developing a Diagnosis
• Once all the assessment phases of care have been completed, the data from each of these
procedures is analyzed carefully and synthesized into a comprehensive picture of the individual
needs of the patient. Use the laminated form as a guide.
o Determine patient’s chief concern(s)
Evaluate:
o Assessment findings
o Caries Risk
o Periodontal Risk
o Oral Cancer Risk
o Plaque Score
o Bleeding on Probing
215
o
o
o
o
Periodontal Index
Stain and Calculus
Tissue Description: Contour, color and consistency
Radiographic findings
Determine Patient Degree of Difficulty (Perio Level/Calculus Level) based on degree of difficulty
• *Use the criteria for each Perio Level and Calculus Level Classification evaluating patient’s tissue,
deposit, and pocket description to determine patient Degree of Difficulty (Perio Level 0, I, II, III
or IV and Calculus Level 0, I, II, III)
• Record the Dental Hygiene Diagnosis as evidenced by periodontal findings
• Discuss with the patient oral health signs and symptoms. Routines are discussed and treatment
is planned.
• Inform patient of the dental hygiene diagnosis
PLAN - Develop DENTAL HYGIENE CARE PLAN
• Determine number of appointments needed (full mouth, arch/side or quadrant scaling) to
complete treatment
• Record each appointment in the appropriate boxes and what treatment will be performed
• Make necessary referrals for additional treatment and care
• Develop treatment and home care goals cooperatively with the patient
Case Presentation
• Discuss with patient the entire care plan including home care recommendations and home care
goals.
• Answer questions and advise patient of treatment needs; inform patient of oral ramifications if
they fail to comply with recommendations.
• Seek patient consent (informed consent) and signature to proceed with care.
Assessment CHECK IN for new and recare patients
• Occurs prior to instrumentation procedures
• Introduce your patient to your instructor
• Stand to the side of the dental chair
• Be attentive: Watch instructor so she/he may point out things to you
• Record on the patient grade sheet observations of instructor which you did not observe; enter it
into Dentrix after check in
• Discuss your appointment and treatment plan with instructor.
Assessment CHECK IN for a Reappointed Patient
• Seat the patient
• Review the medical history with the patient. If there is a change, record it. The patient signs and
dates the form when the review is completed
• Review the chartings for any significant changes. Perform plaque index using the worksheet and
formulate home care procedures with patient
• Students may begin instrumentation if waiting for faculty occurs
• Introduce patient to instructor
• Discuss with instructor what treatment was completed at last appointment and what treatment
you have planned for this appointment, using your written treatment plan as a guide
• After instructor evaluation of your patient and your charting, begin instrumentation
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IMPLEMENT TREATMENT
Instrumentation
• Assist patient with two 30-second pre-procedural rinses before treatment. Debride the teeth
beginning with tooth #1, distal-facial-mesial, if treating the entire mouth, or treat the
designated quadrant.
• Ultrasonic scalers are available at each unit.
• Remove all plaque and stain from teeth. Use the least abrasive polishing agent needed for
effective removal.
• Floss all teeth.
TREATMENT EVALUATION
Self Evaluation
• Evaluate your work for thoroughness in deposit removal and tooth surface smoothness. Use
compressed air to remove saliva, loose debris to help locate any remaining hard deposits or
tooth surface roughness.
• Use a disclosing agent to locate any remaining soft deposits. Remove any remaining plaque,
stains, and hard deposits.
Topical Fluoride Application
• Patient fluoride is based on Caries Risk. If a patient is low caries risk (at any age) no fluoride is
recommended. If a patient is less than 6 years of age and has moderate to high caries risk,
fluoride varnish is appropriate. If a patient older than six to adult is moderate caries risk either
fluoride gel (ACP) OR fluoride varnish may be applied. A patient greater than six to adult with
high caries risk should receive fluoride varnish. If a patient refuses a fluoride treatment,
document their informed refusal in the progress notes.
• Select the appropriate fluoride (Neutral Sodium varnish, and Premier EnamelPro (ACP) are
available)
• Apply after final evaluation depending on time available before instructor evaluation.
Final Instructor Evaluation/CHECK OUT
Prior to final evaluation.
• Complete all forms before the end of clinic.
• Complete progress notes
• Use appropriate terminology when entering information.
• Use tooth numbers to indicate treatment area.
• Entries should be specific and with detail.
• When prompted while entering the clinical notes, enter full name.
• Have final evaluation form and your patient records complete and ready for the instructor
evaluation.
Final Evaluation for Completed Patients.
• Clean your tray and mouth mirror and put everything in its proper place on tray.
• 45 minutes before the end of the clinic session. The instructor who gave the initial check-in
should give you the final check, unless time and instructor availability do not permit.
• Disclosing solution will be applied for final evaluation.
• Stand on the opposite side of chair with final evaluation form and a pen.
• On final evaluation form record deposits and tissue trauma by code number on the sheet as
217
•
•
•
•
instructor indicates them to you.
Watch instructor so she/he may point things out to you visually.
Remove all soft and/or hard deposits remaining.
Have instructor evaluate any areas that were remaining.
Dismiss patient.
Reappointment Evaluation for Incomplete Treatment Patients
• Clean your tray and mouth mirror and put everything in its proper place on tray.
• 45 minutes before end of the clinic session.
• Explain to instructor what areas were treated and what you plan to complete at the next
appointment.
o At this time, the instructor will evaluate your progress with the patient.
o Patients not completed must be inspected by instructor before patient is dismissed from
the clinic.
FOLLOWING PATIENT DISMISSAL
1. If your patient has been reappointed, keep your evaluation grade forms and file the record.
2. Be sure to ask your instructor if you have any questions regarding this patient.
3. Promptly document all clinical notes in Dentrix.
4. Wearing heavy utility gloves, thoroughly clean, dry and package instruments for
autoclaving.
5. Cleaning/Sanitizing/Disinfecting Units
 Remove polishing angle, ultrasonic insert, and syringe tip and place on tray.
 Decontaminate chairs, handpieces, hoses, syringe handle, bracket tray and arm,
all holders, telescoping arm, ultrasonic unit, and all switches with disinfecting
solution.
 Bring all instruments to sterilization room enclosed in the cassettes.
 Re-wipe chairs, handpieces, hoses, syringe handle, bracket tray and arm, all
holders, telescoping arm, ultrasonic unit, and all switches with disinfecting
solution
 Place chair, operator stool, rheostat, bracket tray, and light in proper position.
 Inspect the unit area, including the floor around the unit. Place all foot controls
on the base of the chair.
 Flush HVE lines at the end of each clinic.
6.
Make sure unit countertops are clean and disinfected at the end of clinic.
7.
Restock any needed supplies at your unit.
The clinic must be spotless at end of clinic period.
IMPORTANT NOTE on HVE SYSTEM/Suction Motor
• Vacuum pumps and compressed air switches are located at unit 1 along the north wall
• Pumps should be turned off when clinic is not in use.
D. Grading
Students are evaluated using clinical grade sheets. When a student is being checked in or out the
instructor will inform them of the errors made. The instructor will mark the errors on the grade sheet
218
and may give an explanation for why the error was made. The grade sheets are turned in to the clinic
manager after each clinic so they may be entered in the student’s grade book. At the mentor meetings
students will receive a statement of their clinical grades so they may check them for accuracy. If any
discrepancies are noted, the clinic coordinator will correct any issues.
Each semester the passing level for patient treatment changes and becomes more rigorous. In H219
passing is -12, H300 -10, H301 -7, and H302 -5. Grading is based on 50 points possible for the patient.
These scores reflect competency levels of 75%, 80%, 85%, and 90% respectively. NOTE: one critical error
may be worth 5 points (see grade sheet for further explanation).
Grading of Oral Inspection
• Students are to record any oral condition found by instructor at check-in which have not been
observed and/or recorded by the student.
• Each missed observation is considered an error in the oral inspection.
Grading of Probing
• A difference of 1 mm between student's reading and instructor's reading is acceptable.
• A difference of 2 mm or more between student's reading and instructor's probing is considered
an error in probing.
E. Process of Care Explained
Medical and Dental History Evaluation
Patient treatment begins by gathering all pertinent data in a comprehensive health history. Information
recorded in the health history of the patient provides not only a summary of the patient's health
background, but also valuable insight into potential health problem or clinical manifestations that might
be detected during the head and neck exam, as well as during treatment.
Evaluation of the history assists in determining if treatment should be altered or delayed. Detailed
information on patient care policies specific to Indiana University South Bend Dental Hygiene Clinic is
found in Section 5.
Prescription Drug Information
If a patient is taking medication(s), ask if the patient is complying with the physician’s instructions for
use of the medication. This is done at each appointment and the information is recorded in the
treatment record whether medications were taken.
If a patient has not complied with prescribed drug regimes, the faculty dentist will make the decision to
treat patient.
Patients on Anticoagulants
Dental hygiene procedures may be performed only after consultation with and permission from the
patient’s physician. The patient must have clotting times within the recommended range in order to be
seen for dental hygiene treatment. The supervising dentist will need to know the clotting (PT/INR) times
prior to signing the medical history. This information should be obtained from the patient or their
health care provider prior to commencing treatment. It should then be recorded in the treatment
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record. The INR value should be less than of 2.0-3.5 for safe treatment within the month of treatment.
Clinic Policy for Antibiotic Prophylaxis/Decision to Treat
The purpose of this policy is to assist faculty and students in determining when to premedicate patients
at risk of developing bacterial endocarditis as a result of procedures to be performed in the IUSB Dental
Hygiene Clinic and in managing patients on an anticoagulant therapy. It is not possible to make
recommendations in every clinical case.
The current protocol of the American Heart Association (AHA) for prophylactic antibiotic administration
for patient at risk should be observed. The following can be found at http://www.ada.org/2157.aspx
The guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer
need them include people with:
•
•
•
•
•
mitral valve prolapse
rheumatic heart disease
bicuspid valve disease
calcified aortic stenosis
congenital heart conditions such as ventricular septal defect, atrial septal defect and
hypertrophic cardiomyopathy.
The new guidelines are aimed at patients who would have the greatest danger of a bad outcome if they
developed a heart infection.
Preventive antibiotics prior to a dental procedure are advised for patients with:
1. artificial heart valves
2. a history of infective endocarditis
3. certain specific, serious congenital (present from birth) heart conditions, including
o unrepaired or incompletely repaired cyanotic congenital heart disease, including those
with palliative shunts and conduits
o a completely repaired congenital heart defect with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the first six months after
the procedure
o any repaired congenital heart defect with residual defect at the site or adjacent to the
site of a prosthetic patch or a prosthetic device
4. a cardiac transplant that develops a problem in a heart valve.
5. Patients with prosthetic joint replacements: In 2014, a panel of experts convened by the
American Dental Association Council on Scientific Affairs developed an evidenced-based clinical
practice guideline (CPG) on the use of prophylactic antibiotics in patients with prosthetic joints
who are undergoing dental procedures. The panel based the current CPG on literature search
results and direct evidence contained in the comprehensive systemic review published by a
2012 panel of experts from the American Dental Association Council on Scientific Affairs and the
American Academy of Orthopaedic Surgeons. The results of the 2014 panel, which are inscribed
below, were published in the February, 2014 Journal of the American Dental Association (JADA).
Clinical Recommendation: In general, for patients with prosthetic joint implants, prophylactic
antibiotics are not recommended prior to dental procedures to prevent prosthetic joint
220
infection. For patients with a history of complications associated with their joint replacement
surgery who are undergoing dental procedures that include gingival manipulation or mucosal
incision, prophylactic antibiotics should only be considered after consultation with the patient
and orthopaedic surgeon.* To assess a patient’s medical status, a complete health history is
always recommended when making final decisions regarding the need for antibiotic
prophylaxis.
Clinical Reasoning for the Recommendation:
-There is evidence that dental procedures are not associated with prosthetic joint implant
infections.
-There is evidence that antibiotics provided before oral care do not prevent prosthetic joint
infections.
-There are potential harms of antibiotics including risk for anaphylaxis, antibiotic resistance,
and opportunistic infections like Clostridium difficile.
-The individual patient’s circumstances and preferences should be considered when deciding
whether to prescribe prophylactic antibiotics prior to dental procedures.
*In cases where antibiotics are deemed necessary, it is most appropriate that the orthopaedic
surgeon recommend the appropriate antibiotic regimen and when reasonable write the
prescription.
Vital Signs
Recording vital signs contributes to systemic evaluation of patients and information is used in
conjunction with the medical history.
The vital signs are:
 body temperature
 pulse
 respiratory rate
 blood pressure
*taken from Kwik Klip Enterprises
Determination of vital signs is important to appointment procedures and planning, and essential during
emergency treatment. Abnormal vital signs must be regarded with suspicion since they may indicate
previously undetected systemic problems. Most people visit their dentist on a more regular basis than
their physician.
A person in "good health" may not have seen his physician in many years; therefore, the dental office is
an excellent setting to provide this service for patients.
When the vital signs are not within a normal range, the patient should be informed and the finding
discussed with their physician before proceeding with treatment.
Body Temperature
A temperature above the normal range indicates the presence of infection. Patients can have an
elevated body temperature due to oral causes such as an apical or periodontal abscess, pericoronitis, or
acute necrotizing ulcerative gingivitis. Determination of the temperature of a patient with an oral
infection may be necessary for diagnosis and treatment planning.
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It is also important to detect the presence of a systemic or contagious condition. When a definite
increase in temperature is found the patient can be dismissed by the dentist to prevent further
contamination of the clinic, and advised to consult a physician.
Normal Temperature is 98.6 F. (37 C.)
Technique:
The digital thermometer should be turned on and allowed to clear. Once it reads L or 0.0 it is ready to
use. The thermometer must be disinfected and covered with a disposable shield. Place the
thermometer under the tongue, gently resting on sublingual mucosa. Instruct patient to lower tongue
and close lips. Leave thermometer in position for a minimum of 3 minutes or until the thermometer
beeps indicating the temperature reading is complete. Remove from mouth. Discard disposable shield.
Read thermometer. Disinfect thermometer with EPA-approved disinfectant according to instructions.
When the temperature is to be taken along with the other vital signs, the pulse and respiratory rates are
determined concurrently while the thermometer is in the patient's mouth.
Pulse
The pulse is an intermittent throbbing sensation felt when fingers are pressed against an artery. The
pulse rate is the count of the heartbeats. Irregularities of the quality (thready or weak), the rate (rapid
or slow), and the rhythm (skips or maturities) should be noted while counting the pulse rate.
The normal pulse rate ranges from 60 to 80 beats per minute.
During moments of stress or anxiety, (i.e. prior to a dental procedure) the pulse may be elevated to as
many as 100 beats per minute.
Technique:
The pulse may be palpated with the index and middle fingers at:
 the radial artery, the thumb side of the wrist
 the carotid artery, the anterior border of the sternocleidomastoid muscle
 the superficial temporal artery, anterior to the ear over the zygomatic arch
Measure (count) the rate for 15 seconds, multiply by four to identify beats per minute.
The pulse should be evaluated for:
 quality -- full, strong, poor or weak
 rate -- rapid or slow
 rhythm -- skips, irregular, regular
Respiration
The function of respiration is to supply oxygen to the tissues and to eliminate carbon dioxide. Variations
in normal respiration may be shown by characteristics such as the rate, rhythm, depth, and quality and
may be symptomatic of disease or emergency states.
Normal respiration rate for children is from 20 to 25 breaths per minute. The normal adult respiration
rate varies between 14-20 breaths per minute.
Technique:
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Observe the depth of inspiration and monitor the thoracic and
abdominal movements. Abdominal respiration is deep; the abdominal
wall expands and contracts. Costal respiration is shallow; the thorax
expands and contracts.
Count inhalation/exhalation rates for one-half minute and multiply by
two to obtain respiration rate.
Blood Pressure
Information about the patient's blood pressure is essential during dental
and dental hygiene appointments, since special adaptations may be
needed. Screening for blood pressure in dental offices has been shown
to be an effective health service.
Clinical Measurement of Blood Pressure:
Taken from Wilkins 9th ed.
Blood pressure is the force or pressure in arteries as a result of the pumping action of the heart.
Pressure is highest when the heart contracts, lowest when it relaxes. It is measured indirectly by a
sphygmomanometer and stethoscope. An artery is compressed, interrupting blood flow. When
stethoscope is placed over the artery, characteristic sounds (Korotkoff) can be heard as the
compressed artery returns to its original diameter. The first sound is systolic pressure, and the point
when the last sound is heard is diastolic.
Components of Aneroid Manometer:
 inflatable bladder within a cuff
 rubber bulb (pump)
 pressure control valve
 manometer with gauge
Technique:
Blood pressure is taken at the initial appointment and every subsequent recare appointment. If blood
pressure is in a treatable, but elevated level at initial appointment, it should be retaken at the
reappointment within the next month (see chart).
1.
Place cuff snuggly around upper arm with lower edge of cuff an inch above antecubital fossa.
Arrow should be over brachial artery. If arrow not present, center of bladder should be over
artery.
2.
Artery should be at heart level.
3.
Palpate brachial artery medial to antecubital
fossa and place diaphragm of stethoscope over artery.
4.
Close pressure valve, inflate rapidly to 200 mm
on adult, and release at rate of 2-3 mm per second.
5.
Deflate cuff completely.
6.
If a second measurement is to be taken, wait 2 minutes before making the second
determination. The average of the two readings is entered in the treatment record.
Errors to Avoid:
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










Improper cuff selection.
Cuff applied over clothing.
Center of bladder not over brachial artery.
Cuff too loose or too tight.
Arm not at heart level.
Stethoscope applied with too much pressure.
Bladder inflated too slowly (inflation rate).
Failure to note auscultatory gap.
Bladder deflated too fast or too slowly (deflation rate).
Failure to wait 1-2 minutes before making another determination.
Inaccurate manometer.
Taking and Evaluating Blood Pressure Measurements
 Blood pressure is measured on patients 18 and over at the first appointment and every
subsequent recare appointment. Blood pressure is not taken on "reappoint" patients unless the
first appointment measurement is elevated.
 Classification of blood pressure and recommendations for follow-up of the elevated reading are
in accordance with the 5th report of the Joint National Committee (JNC V). Refer to Section 6 of
this manual for further information, and Dental Management of the Adult Hypertensive
segment on Kwik Klipboard.
 Patient on physician -prescribed anti-hypertensive drugs:
 Students are instructed to monitor patient compliance at each appointment and to
record in the treatment record whether the prescribed medication was taken.
Note: In cases of noncompliance with high blood pressure medication the decision to treat is made by
the faculty dentist on a case-by-case basis, et. if a patient has not taken his/her medication, the decision
would depend on the duration of noncompliance and evaluation of the patient's blood pressure at the
time of the dental hygiene visit.
*Refer patients without a physician to Indiana Health Centers or Sister Maura Brannick for follow-up
Chart 1: taken from American Heart Association and modified with Kwik Klip Enterprises Dental
Management Chart
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Blood Pressure
Category
Systolic
mm Hg
(upper #)
Diastolic
mm Hg
(lower #)
Treatment Plan
Normal
less than
120
and
less than
80
No restrictions; recheck BP
in 2 years
Prehypertension
120 – 139
or
80 – 89
No restrictions; recheck BP
in 1 year
High Blood Pressure
(Hypertension) Stage 1
140 – 159
or
90 – 99
No restrictions; recheck in 2
months
High Blood Pressure
(Hypertension) Stage 2
160 or
higher
or
100 or
higher
No restrictions; refer to MD
w/in 1 month
High Blood Pressure
(Hypertension) Stage 3
180-209
or
110-119
Urgent care only; avoid use
of vasoconstrictors; refer to
MD w/in 1 week
High Blood Pressure
(Hypertension) Stage
IV
> 210
> 120
Palliation only; avoid use of
vasoconstrictors; refer to MD
immediately
ASA Classification: Assessment of Patient’s Overall Physical Health Status
The American Society of Anesthesiologists’ (ASA) Classification System is a systematic approach to
determining treatment modifications beneficial in providing patient care in the health care setting.
[These guidelines were originally developed to determine modifications necessary to provide general
anesthetic to patients during surgical procedures].
The extent of a patient’s medical, physical, and psychological risk determines modifications which are
needed for patient comfort and care. Patient positioning, sequence and timing of treatment can be
modified in prevention of medical complications during patient care.
The following table is helpful in ASSESSING the physical status of patients and IMPLEMENTING dental
treatment considerations (Wilkins, p. 342 11thed.)
Table 23-1 ASA* Physical Status Classification System
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Examples of Physical or Psychosocial
Manifestations
ASA Classification
Dental Hygiene Treatment Considerations
ASA I
Without systemic disease;
a normal, healthy patient
with little or no dental
anxiety
Able to walk one flight of stairs
with no distress
ADL/IADL level = 0
No modifications necessary
ASA II
Mild systemic disease or
extreme dental anxiety
Must stop after walking one
flight of stairs because of distress
Well-controlled chronic
conditions
Upper respiratory infections
Healthy pregnant woman
Allergies
ADL/IADL level = 1
Minimal risk; minor modifications to
treatment and/or patient education may
be necessary
ASA III
Systemic disease that
limits activity but is not
incapacitating
Must stop en route walking one
flight of stairs
Chronic cardiovascular
conditions
Controlled insulin-dependent
diabetes
Chronic pulmonary diseases
Elevated blood pressure
ADL/IADL level = 2 or 3
Elective treatment is not
contraindicated, but serious
consideration of treatment and/or
patient/caregiver education
modifications may be necessary
ASA IV
Incapacitating disease
that is a constant threat
to life
Unable to walk up one flight of
stairs
Unstable cardiovascular
conditions
Extremely elevated blood
pressure
Uncontrolled epilepsy
Uncontrolled insulin-dependent
diabetes
Conservative, noninvasive management
of emergency dental conditions; more
complex dental intervention may
require hospitalization during
treatment; caregiver training for daily
oral care may be necessary
ASA V
Patient is moribund and
not expected to survive
End-stage renal, hepatic,
infectious disease, or terminal
cancer
Only palliative treatment is delivered;
caregiver training for daily oral care may
be necessary.
*American Society of Anesthesiologists
Adapted from: Malamed, S. F.: Medical Emergencies in the Dental Office, 5th ed. St. Louis, Mosby, 2000, pp. 41–44.
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Oral Inspection
Guidelines for Recording findings during the Oral Inspection:
The role of the dental hygienist in the oral inspection is to:
 recognize normal and when a deviation from the normal is present.
 record accurately the deviation
 report the findings to the dentist
All findings from the visual inspection, either normal or abnormal, should be recorded with complete
descriptions of their color, size, location, morphology, and history.
The procedure for recording findings of the oral cavity is made easier if a systematic method of
describing lesions is used. The following methodology is adapted from an article by McCann and Wesley
of the University of Detroit.
Include the following in a complete and accurate description of a lesion:
Size
 include 2 dimensions, length and width.
 may require height if adequate elevation present
 measure in millimeters with probe
Color



state simply; such as, red, white, etc
include multiple colors when apparent
most common colors: blue, purple, gray, yellow, black, brown.
Location
 be specific as possible
 cite anatomical structures in close proximity
 use proper terminology: i.e. maxillary, mandibular, right, left, etc.
History



includes patient assessment and evaluation
duration
symptoms, such as, pain, swelling, etc.
Morphology
 most difficult aspect of recording
 use system which divides lesions into 3 morphological types:
 flat,
 elevated, or
 depressed
Extra Oral Examination
Visual Inspection
Patient should be seated in an upright position with operator facing the patient. Examine the following,
recognizing either normal or abnormal tissues/structures, etc. Record any suspicious lesions, including
complete description of their appearance. Include location, size, duration, texture, color, consistency,
outline, border, and depth
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









Location:
 mand/max,
 tooth number where appropriate,
 right/left.
Size: use probe, state in mm.
Duration: record how long it has been present with information from patient
Appearance: use appropriate terms when warranted:
 Vesicle, macule, papule, nodule, tumor, wheal, pustule, bulla, ulcer, atrophy, plaque
Texture:
 Smooth, papillary, fissured, crusted, indurated, irregular, verrucous, corrugated,
cratered
Color:
 White, blue, gray, black, red, purple, yellow, brown
Consistency:
 Soft, fluctuant, firm, hard, indurated, mobile
Outline:
 Regular or irregular
Border:
 Flat or raised
Depth:
 Superficial or deep (>3mm)
Areas to be assessed through Extra Oral Examination:
 General Appraisal
 Hair - note texture, amount and distribution and scalp lesions.
 Eyes - note sclera, pupils, eyelids and conjunctiva.
 Face - examine for symmetry, form and profile.
 Observe the Skin of the face for abnormal pigmentation, hair, texture, scars or lesions.
 Nose - observe form, symmetry and obstructions.
 Lymph nodes and TMJ
 Skin of the neck, ears - examine for pigmentation, texture, scars, or lesions
 Ears - should be examined for form, symmetry and color.
 Lips - examine for symmetry, form, texture, color, and habits. Note signs of
irritation, chapping or breaks in the skin, especially at the corners.
Extraoral Palpation
One of the following methods is indicated for each structure. Palpate soft tissue structures against a
harder structure such as bone, other fingers or hands. Gloves should be worn during the extraoral
examination.
Digital palpation: the use of a finger to examine tissues.
 Bi-digital palpation: the use of one or more fingers and the thumb by grasping the tissue
between thumb and fingers.
 Manual palpation: the use of all fingers of one hand to examine tissues.
 Bi-manual palpation: the use of both hands by grasping tissues between them for examination.
 Bilateral palpation: examination of structures on both sides of the face or neck simultaneously
to detect differences between the two sides.
 Circular compression: moving the fingertips in a circular pattern over a structure while
228
simultaneously applying pressure to the tissue.
Sequencing the Palpation
 MENTALIS MUSCLE: attaches to the lower lip and inserts into the symphysis of the mandible.
Use digital compression, rolling the tissue over the mandible. Observe the function of this
muscle in swallowing.

ANTERIOR BORDER OF THE MANDIBLE: From a position behind the patient use bi-digital
compression, and circular movement on the soft tissues, starting at the symphysis of the
mandible and moving back along the borders of the mandible.

OCCIPITAL LYMPH NODES: are located at the base of the skull at the back of the head. The
palpation should begin at the back of the neck and extend horizontally to the
sternocleidomastoid (SCM) muscle.

AURICULAR LYMPH NODES: located beneath and in front of the ears. The palpation should be
done bilaterally to the inferior auricular nodes and the anterior auricular nodes located anterior
to the tragus of the ear.

TEMPOROMANDIBULAR JOINT: is palpated bilaterally by placing index fingers of each hand just
anterior to outer meatus of the ear and asking the patient to slowly open and close his/her
mouth several times.

PAROTID GLAND: is bilaterally palpated by digital compression and circular movement. Begin
anterior to the tragus of the ear, and extend inferiorly to the angle of the mandible.

MASSETER MUSCLE: is palpated by placing the fingers of each over the angle of the mandible
and extending the hand up onto the cheek. The patient is then asked to clench the teeth
together several times and the muscle is examined bilaterally for size, function and deviation.

TEMPORALIS MUSCLE: examine by placing the hands bilaterally across the muscle on the
patient's temples and asking the patient to clench his/her teeth together several times.

SUBMENTAL REGION: is examined with digital compression and circular motion behind and
beneath the symphysis of the mandible.

SUBMANDIBULAR REGION: is palpated with bi-digital compression and circular movements.
Starting at the anterior border of the mandible, push the tissue from the left submandibular
area over to the right and grasp it with the finger tip of the right hand.

STERNOCLEIDOMASTOID MUSCLE: ask the patient to turn head to the left and lower the chin.
Begin bidigital palpation, starting from behind ear and extending all the way down the muscle
until you ranch the clavicle on the right side. Repeat the exam on the left side of the neck.

SUPERFICIAL CERVICAL LYMPH NODES: are located anterior and posterior to the
sternocleidomastoid muscle. Digital compression and circular movement should be applied to
this area, extending from the angle of the mandible in a downward direction along the anterior
and posterior aspects of this muscle.
229

DEEP CERVICAL LYMPH NODES: are located along and behind the sternocleidomastoid muscle.
The technique is the same as for the anterior cervical lymph nodes.

THYROID GLAND: it is located vertically between the crico-thyroid ligament and fourth tracheal
ring and horizontally between the sternocleidomastoid muscle and the trachea. With one hand,
place the fingers on one side of the trachea and gently displace the thyroid tissue over to other
side of the neck. With the opposite hand, apply gentle circular digital compression to the tissue.

LARYNX: should be examined by placing fingertips of one hand bilaterally over the larynx and
applying alternate pressure in a medial direction against the structure. A normal larynx should
be freely movable and should ascend and descend during the process of swallowing.

HYOID BONE: is located at the midline of the neck above the thyroid cartilage. In normal
function the hyoid bone will ascend and descend in the act of swallowing. It serves as the
attachment for many muscles, but cannot be palpated.
Recordings of Findings:
All significant findings should be described and recorded in the patient's chart. Summarize findings from
the palpation as follows:

BONY STRUCTURES: record abnormal anatomy, growths, fractures, crepitus and pain.

MUSCLES: record hyper or hypo function, deviations between the two sides, swellings, masses,
indurations and tenderness.

GLANDS: record abnormal swellings, tenderness and hard masses.

LYMPH NODES: record palpable nodes, describe size, (measure diameter), firmness (hard or
soft), mobility (fixed or freely movable), tenderness (sensitive or painless), length of time
present.
230
Occlusion
Evaluation of occlusion involves observing and recording the occlusal classification, measuring and
recording overjet and overbite, and observation and recording of other malpositionings. Record
malposed teeth in the “other malpositioning” segment of oral exam sheet, next to Angle’s classification.
It is also important to look at the profile of the person. This can be an important clue as to what
occlusion the patient has. (picture from Wilkins 11th ed. Pg. 274)
Steps in Classifying Occlusion:
1. Use molar relationship to determine classification. Record the classification by circling the
appropriate number on the evaluation sheet.
2. If molar relationship differs on the right and left, record both classes. Circle the class for the
right and write the word "right" after it. Do the same for the left side.
3. If any permanent 1st molars or premolars are missing, use the canines to determine
classification and indicate this on the chart.
Angle’s Classification of Occlusion: (pictures from Wilkins 11th ed. Pg 277)
The molar relationship in normal occlusion is such that the mesiobuccal cusp of the maxillary first
permanent molar occludes with the buccal groove of the mandibular first permanent molar.
Normal Ideal Occlusion
Molars: Mesiobuccal cusp of maxillary
First permanent molar occludes with
buccal groove of mandibular first
permanent molar.
Canines: Maxillary permanent canine
Occludes with distal half of mandibular
Canine and mesial half of mandibular first
Premolar.
Class I Malocclusion
Molar and canine relationship are
similar to normal
One or more may be present:
- crowded alignment of anterior teeth
- protruded or retruded maxillary
incisors
-Anterior or posterior crossbite
-Mesial drift of molars
231
Class II Division 1
Mandible is retruded and all maxillary
incisors are protruded.
Class II Division 2
Mandible is retruded and one or
more maxillary incisors are retruded.
For both Divisions of Class II:
Molars: Buccal groove of mandibular first permanent molar is distal to mesiobuccal cusp of maxillary
first permanent molar
Canines: Distal surface of mandibular canine is distal to mesial surface of maxillary canine.
Class III Occlusion
Molars: Buccal groove of the mandibular first permanent molar is mesial to the mesiobuccal cusp of the
maxillary first permanent molar.
Canines: Distal surface of mandibular canine is mesial to mesial surface of maxillary canine.
*Note: any deviation from Normal/Class I molar relationship is considered abnormal and is classified
as either II/III in the IUSB DH Clinic.
*Crossbite relationships that cannot adequately determine the Angles Classification will be
documented per tooth relationship (i.e. posterior crossbite teeth #’s 4, 5 & 28,29).
Primary Occlusion
Flush terminal plane: primary maxillary and mandibular second molars are in an end‑to‑end
relationship. This may allow a normal molar relationship to occur in the permanent dentition.
Mesial step: mandibular second molar is mesial to the maxillary molar. This will most likely allow a
normal molar relationship to occur in the permanent dentition.
Distal step: primary mandibular second molar distal to the maxillary second molar. This is not a
beneficial molar relationship because it will not usually result in a normal molar relationship in the
permanent dentition when it erupts and the primary teeth are shed. (picture from Fehrenbach 3rd ed. Pg
281)
Measurement of Overbite and Overjet
Overbite (vertical dimension)
When a patient has an overbite a relative measure should be recorded on the patient's chart to describe
232
the relationship. Following clinical examination with the posterior teeth closed together and lips
retracted, describe the overbite according to the following
categories. (picture from Wilkins 10th ed. Pg 286)
Incisal 1/3:
Normal/slight overbite: the incisal
edges of the maxillary teeth are
within the incisal third of the facial
surfaces of the mandibular teeth.
Middle 1/3:
Moderate overbite: the incisal edges
or the maxillary teeth are within the
middle third of the facial surfaces of
the mandibular teeth.
Cervical 1/3:
Severe overbite: the incisal edges of the
maxillary teeth are within the cervical third
of the facial surfaces of the mandibular teeth.
Overjet
When a patient has an overjet, the amount of overjet should be measured and recorded on the patient's
chart. To measure the amount of overjet, place the tip of a probe on the labial surface of a mandibular
incisor closest to the midline. If one of the maxillary centrals is more protruded than the other, measure
and record the one with the greatest overjet. Rest the probe horizontally against the incisal edge of the
maxillary tooth, read the distance between the maxillary and mandibular tooth in millimeters.
(Taken from Wilkins 11h ed. Pg 275)
Other Considerations with occlusion and tooth positioning:
 When individual teeth are malposed, they should be noted by tooth number and position (i.e.
linguoversion, torsiversion, etc.) under "other malpositioning". If more than 2 teeth in a sextant
are involved the term "generalized crowding" and the area noted (i.e. generalized crowding "2226").

Diastemas should be noted by the teeth involved, and recorded in the area designated for
“other malpositioning”.
Intraoral Examination
First start with at cursory screening to examine the intraoral tissues with the mouth mirror or a tongue
blade. This screening is to determine whether or not there are lesions/conditions which would alter the
treatment plan. The operator should briefly inspect the following structures:
 lips
 labial mucosa
233





hard palate
soft palate
tongue
floor of mouth
alveolar ridges
Also check the throat for signs of severe sore throat or other manifestations that would suggest that the
patient should be seen by a physician. Note breath and saliva characteristics.
Inspection and Palpation of All Intraoral Structures
 LIPS - skin should be intact and have semi-moist, firm texture. They should be free of all lesions,
discolorations, growths or swellings.

LABIAL MUCOSA - Check for moist red surface that does not demonstrate any abnormal lesions,
masses, or color deviations. Tissue should be palpated using bilateral, bi-digital compression
feeling the tissues between the thumb and fingers.

BUCCAL MUCOSA - retract the buccal mucosa out and slightly away from the teeth so that its
surface can be inspected from the labial mucosa back to the retromolar area. Examine the
tissues for swelling, lesions, breaks in the mucosa or abnormal color changes, including white or
red patches. The tissue should be palpated between the two hands from the front of the mouth
all the abnormal swellings, masses or tenderness noted. Common findings may include:
 Fordyce's granules
 xerostomia
 scarring
 cheek biting
 linea alba

FLOOR OF THE MOUTH - Ask the patient to lift the tongue to the roof of the mouth. This area
should appear moist and extremely vascular.
Examine the following:
 lingual vein
 sublingual caruncle
 plica fimbriata
 sublingual folds
 lingual frenum
 plica lingualis
Palpate by placing the right hand intraorally and left hand extraorally, feeling the tissue between the
two hands.

HARD PALATE - A normal palate surface will appear light pink and have the following anatomic
structures:
 incisive papilla
 median palatal raphe
 palatal rugae
 palatine fovea
The palate is palpated by digital compression of one or two fingers against the palatal surface.
234
Palpate for swellings or hard masses, tenderness and continuity of underlying bone.

SOFT PALATE AND PALATINE UVULA - observe for deviations in form or color. To examine the
oral pharynx, place a mouth mirror on the middle third of the tongue and ask the patient to say
"Ah." Observe the uvula noting any deviation of movement to either the right or left. Note any
redness, signs of exudation, lesions or tenderness of the following:
 posterior wall of the pharynx
 posterior pillars
 palatine tonsils
 anterior pillars

TONGUE - the dorsal surface is examined first for color, lesions, symmetry, and form. The
normal structures include:
 filiform papilla
 fungiform papillae
 circumvallate papillae
 foliate papillae
Retract the tongue from the mouth with gauze, inspect the lateral borders by turning tongue slightly
on its side. This area should be examined carefully for abnormal redness, white patches, swelling,
ulcerations or masses. The lateral borders are palpated by bi-digital compression beginning at
posterior borders.

MAXILLARY TUBEROSITY/RETROMOLAR AREA - these areas should be palpated with digital
compression. Common findings may include scarring from third molar extractions, overgrowth
of tissue, inflammation and tenderness due to erupting third molars.

ALVEOLAR RIDGES - should be examined for signs of redness, color deviations, swellings or
lesions.

HARD TISSUES - should be examined for signs of redness, color deviations, swelling or lesions.

OTHER - areas which deviate from normal and do not appear to be related to structures listed
above, should be noted here.
Periodontal Evaluation
Periodontal evaluation is the most critical part in determining presence and progression of disease. It
allows the clinician to have a detailed description of the gingival structures at each appointment. This
allows for proper treatment planning and prognosis of the patients case.
Clinical periodontal assessment includes the observation & recording of:
 soft tissue/gingival appearance
 periodontal probing depths
 bleeding points
 clinical attachment loss
 furcation involvement
 tooth mobility
235
The following Table is taken from Wilkins 11th edition page 217-18.
Table 14-1 Examination of the Gingival Clinical Markers
APPEARANCE IN HEALTH
Color
CHANGES IN DISEASE
CLINICAL APPEARANCE
CAUSES FOR CHANGES
Uniformly pale pink or coral
pink
Acute: bright red
Inflammation
Capillary dilation
Increased blood flow
Variations in pigmentation
related to complexion, race
Chronic: bluish pink,
bluish red
Vessels engorged
Blood flow sluggish
Venous return impaired
Anoxemia
Increased fibrosis
Attached gingiva: color
change may extend to
the mucogingival line
Deepening of pocket,
mucogingival
involvement
Size
Not enlarged
Fits snugly around the tooth
Enlarged
Edematous:
inflammatory fluid,
cellular exudate,
vascular engorgement,
hemorrhage
Fibrotic: new collagen
fibers
Shape
(contour)
Marginal gingiva: knife-edged,
flat, follows a curved line
about the tooth
Marginal gingiva:
rounded rolled
Inflammatory changes:
edematous or fibrous
Papillae:
(1)normal contact: papilla is
pointed and pyramidal; fills
the interproximal area
Papillae:
bulbous
flattened
blunted
cratered
Bulbous with gingival
enlargement (see
edematous and fibrotic,
above)
(2)space (diastema) between
teeth; gingiva is flat or saddle
Cratered in necrotizing
ulcerative gingivitis
236
shaped
Consistency
Soft, spongy: dents
readily when pressed
with probe
Associated with red
color, smooth shiny
surface, loss of stippling,
bleeding on probing
Edematous: fluid
between cells in
connective tissue
Firm, hard: resists probe
pressure Associated with
pink color, stippling,
bleeding only in depth of
pocket
Fibrotic: collagen fibers
Free gingiva: smooth
Acute condition: smooth,
shiny gingiva
Inflammatory changes
in the connective tissue;
edema, cellular
infiltration
Attached gingiva: stippled
Chronic: hard, firm, with
stippling, sometimes
heavier than normal
Fibrosis
Position of
Gingival Margin
Fully erupted tooth: margin is
1–2 mm above
cementoenamel junction, at or
slightly below the enamel
contour
Enlarged gingiva: margin
is higher on the tooth,
above normal, pocket
deepened
Recession: margin is
more apical; root surface
is exposed
Edematous or fibrotic
Junctional epithelium
has migrated along the
root; gingival margin
follows
Position of
Junctional
Epithelium
During eruption along the
enamel surface (Figure 14-7)
Fully erupted tooth: the
junctional epithelium is at the
cementoenamel junction
Position determined by
use of probe, is on the
root surface
Apical migration of the
epithelium along the
root
Mucogingival
Make clear demarcation
No attached gingiva:
Apical migration of the
Surface Texture
Firm
Attached gingiva firmly bound
down
237
Junctions
between the pink, stippled,
attached gingiva and the
darker alveolar mucosa with
smooth shiny surface
(1) Color changes may
extend full height of the
gingiva; mucogingival
line obliterated
(2) Probing reveals that
the bottom of the pocket
extends into the alveolar
mucosa
(3) Frenal pull may
displace the gingival
margin from the tooth
junctional epithelium
Attached gingiva
decreases with pocket
deepening
Inflammation extends
into alveolar mucosa
Bleeding
No spontaneous bleeding or
upon probing
Spontaneous bleeding
Bleeding on probing:
bleeding near margin in
acute condition; bleeding
deep in pocket in chronic
condition
Degeneration of the
sulcular epithelium with
the formation of pocket
epithelium
Blood vessels engorged
Tissue edematous
Exudate
No exudate expressed on
pressure
White fluid, pus, visible
on digital pressure
Amount not related to
pocket depth
Inflammation in the
connective tissue
Excessive accumulation
of white blood cells with
serum and tissue makes
up the exudate (pus)
Periodontal Probing
Periodontal probing is the most reliable way to detect periodontal pockets. Probing will allow the
clinician to determine the depth and shape of pockets, and the clinical attachment loss (CAL). IMPLANTS
should NOT be probed. Radiographs are primarily used to detect problems around implants.
Periodontal charting is a systematic means of recording periodontal pockets. (Pictures taken from
Wilkins 11th ed pg 228-30.)
238
Technique for probing:
 Insert the probe along the tooth surface, angling
it slightly to keep the tip in contact with the
root, to the depth of the pocket. Note: Depths
are measured from the base of the pocket/junctional
epithelium to the margin of the gingiva.

To move to the next area,
gently "walk" the probe
around the sulcus.
Interproximal Probing

Place the probe up against the interdental
contacts when inserting.

The tip of the probe should be in contact
with the root, with the probe slightly
tilted, reaching the area just apical to
the contact area.
Reading the Measurement
Six measurements should be recorded for each tooth and from six specific areas on each tooth.
(Taken from Wilkins 11th ed. Pg 231)
Example from Dentrix Periodontal Charting Form
The method used to obtain the six measurements:
 Record the deepest reading obtained in each of the six areas.
 From the mesiobuccal line angle to the direct mesial
 Buccal surface
 From the distobuccal line angle to the direct distal
 From the mesiolingual line angle to the direct mesial
 Lingual surface
239

From the distolingual line angle to the direct distal

Probe measurements are given in whole numbers, such as 1 millimeter or 5 millimeters.


If the margin of gingiva does not fall exactly on a probe marking, the next highest
marking/measurement is used as the depth of the pocket.
Record the reading in the appropriate box as described.

Probe readings of 4 mm and deeper are charted in red.
Recording the measurements
After marking out all missing teeth, measurements are recorded in the patient's periodontal chart. Be
accurate.
Position of gingival margin
If the position of the free gingival margin is other than at or near the CEJ, the amount of recession (or
gingival enlargement) is noted in millimeters.
Bleeding points
When periodontal disease is present, sulcular tissue will bleed when gently probed.
Record bleeding which results from probing by placing a red dot above the number corresponding to the
location.
Suppuration/Exudate
Place a yellow dot above the probe number corresponding to the location of the exudate.
Mobility
All teeth have a slight normal mobility. Increased tooth mobility occurs when there has been loss of
bone support and should be considered a sign of disease. Mobility is recording as Roman Numerals (I, II,
III). (See Periodontal Charting Example in Appendix C)
Technique:
1. Placing a finger one side and the end of an instrument on the other side of the tooth.
2. Apply alternating pressure in a faciolingual direction.
3. Apply vertical pressure with end of instrument or finger.
Clinical Attachment Level
Attachment level refers to the position of the periodontal attached tissues at the base of a sulcus or
pocket. It is measured from a fixed point to the attachment, whereas the probing depth is measured
240
from a changeable point (the crest of the free gingiva) to the attachment.
(Taken from Wilkins 11h ed.pg 232)
Furcation
Areas where loss of attachment and alveolar bone destruction allows furcation detection on posterior
teeth should be charted. Indicate, using tooth number, what class of furcation is involved.
Beginning furcation involvement: (I)
Explorer or probe can detect
the concavity of a furcation
but cannot enter it.
Definite furcation involvement:
(II)
Explorer or probe can enter
the furcation area, but cannot
extend through to the opposite area.
Through and through furcation involvement: (III)
Explorer or probe can pass all
the way through the furcation
to opposite side.
th
Picture from Wilkins 11 ed. Pg 233
Through and through furcation involvement clinically visible: (IV)
Explorer or probe can pass all the way through the furcation to the opposite side and it is clinically
visible.
241
Classification of Home Care
1.
Very clean - no debris, less than 25% plaque score.
2.
Light plaque and debris with 25%- 50% plaque score.
3.
Moderate plaque and debris throughout the mouth with 50 - 75% plaque score.
4.
Heavy plaque and debris with 75 -100% plaque score
Number of teeth
Total # of surfaces
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
121
124
128
32 31 30 29 28 27 26 25
128 124 120 116 112 108 104 100
1 1 1 1 1 1 1 1
3 3 3 3 4 4 4 4
5 5 6 6 6 6 7 7
8 8 8 9 9 9 10 10
10 10 11 11 12 12 13 13
13 13 13 14 14 15 15 16
15 15 16 16 17 18 18 19
16 18 18 19 20 20 21 22
20 20 21 22 22 23 24 25
22 23 23 24 25 26 27 28
24 25 26 27 28 29 30 31
27 27 28 29 30 31 33 34
29 30 31 32 33 34 36 37
31 32 33 34 36 37 38 40
34 35 36 37 38 40 41 43
39 37 38 40 41 43 44 46
38 40 41 42 44 45 47 49
41 42 43 45 46 48 50 52
43 44 46 47 49 51 53 55
45 47 48 50 52 54 56 58
48 49 51 53 54 56 59 61
50 52 53 55 57 59 62 64
52 54 56 58 60 62 64 67
55 56 58 60 63 65 67 70
57 59 61 63 65 68 70 73
59 61 63 66 68 70 73 76
62 64 66 68 71 73 76 79
64 66 68 71 73 76 79 82
66 69 71 73 76 79 82 85
69 71 73 76 79 81 85 88
71 73 76 78 81 84 88 91
72 76 78 81 84 87 90 94
76 78 81 84 87 90 93 97
78 81 83 86 89 93 96 100
80 83 86 89 92 95 99
83 85 88 91 95 98
85 88 91 94 97
88 90 93 97 100
89 93 96 99
92 95 98
95 98
97 100
100
24
96
1
4
7
10
14
17
20
23
26
29
32
35
39
42
45
48
51
54
57
60
64
67
70
73
76
79
82
85
89
92
95
98
23 22
92 88
1 1
4 5
8 8
11 11
14 15
17 18
21 22
24 25
27 28
30 32
34 35
37 39
40 42
43 45
47 49
50 52
53 56
57 59
60 63
63 66
66 69
70 73
73 76
76 80
79 83
83 86
86 90
89 93
92 97
96 100
99
21
84
1
5
8
12
16
19
23
26
30
34
37
40
44
48
51
55
58
62
65
69
73
76
80
83
87
90
94
98
20
80
1
5
9
13
16
20
24
28
31
35
39
43
46
50
54
58
61
65
69
73
76
80
84
86
91
95
99
19 18
76 72
1 1
5 6
9 10
13 14
17 18
21 21
25 26
29 31
33 35
37 39
41 43
45 47
49 51
53 56
57 60
61 64
64 68
68 72
72 76
76 81
80 85
84 88
88 93
92 97
96
100
17
68
1
6
10
15
19
24
28
32
37
41
46
50
54
59
63
68
72
76
81
85
90
93
99
16
64
2
6
11
16
20
25
30
34
39
44
48
53
58
63
67
72
77
81
86
91
95
99
15
60
2
7
12
17
22
27
32
37
42
47
52
57
62
67
72
77
82
87
92
97
14 13 12
56 52 48
2 2 2
7 8 8
13 13 15
18 19 21
23 25 27
29 31 33
34 37 40
39 42 46
45 48 52
50 54 58
55 60 65
61 65 71
66 71 77
71 77 83
77 83 90
82 88 96
88 94
93 100
98
11
44
2
9
16
23
30
36
43
50
57
64
70
77
84
91
98
10 _ 9
40 36
3 3
10 11
18 19
25 28
33 36
40 44
48 53
55 61
63 69
70 78
78 86
85 94
93
100
Total #
of Surfaces
With
Bleeding or
PLAQUE
242
Classification of Degree of Difficulty
Determination of the Dental Hygiene Diagnosis and Degree of Difficulty is based on:
1. Tissue description: Gradual progression of oral health status from health to stages of disease
with bone loss.
2. Deposit description:
Definition of Amount of Deposits:
Calc 0 No calculus present.
Calc 1 Light localized or generalized supragingival calculus covering less than ¼ of the exposed
tooth surface; limited to the mandibular anteriors and buccal of the maxillary molars.
Roughness felt on tooth but instrument does not catch or jump over deposit
Calc 2 Moderate generalized supragingival calculus covering more than ¼ but not more than
½ of the exposed tooth surface OR the presence of individual flecks of moderate
generalized subgingival calculus around the cervical portion of the tooth or both. Up to
half the teeth in the mouth must have this level of calculus.
Calc 3 Moderate to heavy generalized supragingival calculus covering more than ½ of the
exposed tooth surface OR a continuous heavy band of generalized subgingival calculus
around the cervical portion of the tooth or both. Over half of the teeth in the mouth
must have this level of calculus.
Definition of Location of Deposits:
LOCALIZED
1/4th of the teeth present (6-8) have stain, plaque, or calculus
GENERALIZED 1/2 of the teeth or more have stain, plaque, or calculus
3.
Pocket Description: Gradual progression of oral health status from health (1-3mm) to stages of
disease (7 mm or >)
Charting Guidelines, General Charting Step Definitions
1.
2.
3.
4.
Mark out all missing teeth.
Beginning with tooth #1, dry teeth and examine.
Mark all existing conditions according to the procedure (amalgam, composite, etc).
Mark conditions which need to be restored/corrected separately. Examples: carious lesions,
fractures, leaking margins.
5. Utilize current radiographs to assist charting procedures.
Charting the Deciduous, Permanent or Mixed Dentition
• Deciduous dentition: only first/primary teeth present.
• Permanent dentition: only secondary/permanent teeth present.
• Mixed dentition: combination of both deciduous and permanent teeth: occurs when first
permanent tooth erupts and extends until last primary tooth is exfoliated.
243
Use the following instructions when DECIDUOUS teeth are present:
1. Change dentition within Dentrix to primary if only primary teeth are present by selecting
Prim/Perm (see diagram below)
2. If the deciduous tooth has exfoliated, but the permanent tooth has not erupted yet, mark out
the deciduous tooth, but do not include the permanent tooth. Do this by selecting the tooth,
click Conditions, OK, and EO for existing.
Use the following instructions for MIXED and PERMANENT Dentition:
Charting Missing, Partially Erupted, and Unerupted Teeth. Marking all missing teeth is the first step
when charting the dentition. This step is especially important when charting a mixed dentition.
1. Missing Teeth should be documented first (verify with radiographs). This can be done for the
entire dentition by selecting Prim/Perm from the top toolbar.
a. Then selecting the missing tooth by clicking on the tooth in the chart.
b. Select the Conditions button and locate the procedure code for missing tooth (15101)
2. Partially Erupted Teeth should be noted as partially erupted following the same procedure for
missing tooth except selecting the code for partially erupted (15116)
3. Unerupted Teeth should be noted as unerupted following the same procedure for missing tooth
except selecting the code for partially erupted (15114)
Charting Removable Prostheses
Full Denture 1. Highlight each tooth that is replaced by the denture.
2. Chart them as missing/extracted.
3. With those teeth still selected, click on Prostho Fixed to find the appropriate procedure code for
the type of denture present.
4. Select the procedure code and then EO to add it as existing.
Partial Denture 1. Select the teeth replaced by the partial by clicking on each tooth.
2. Chart them as missing/extracted.
3. With those teeth still selected, click on Prostho Fixed to find the appropriate procedure code for
the type of denture present.
4. Select the procedure code and then EO to add it as existing.
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Charting Prostheses -- Permanent Bridges
1. Select the teeth replaced by the pontic of the bridge and chart it/them as missing.
2. Indicate teeth replaced by the bridge as pontic(s) by ensuring it/they are still selected.
3. Click on Prostho Fixed to find the procedure code that corresponds with the material of the
pontic and on EO to add it as existing.
4. Then select the teeth that are abutments to the bridge.
5. Click on Prostho Fixed to find the appropriate procedure code for the type of bridge abutment
present.
6. Select the procedure code and then EO to add it as existing.
Charting Dental Restorations
1. Select the tooth with the restoration and click Restorative.
2. Find the appropriate procedure code for the type of filling present.
3. Select the surfaces of the filling and click OK.
4. Then select EO to add it as existing.
Charting Dental Caries- (“Watches”)
1. If examination reveals decay, highlight the tooth with decay and, if appropriate, the surfaces
with decay.
2. Select Conditions and find the procedure code that indicates caries (15104-15107).
a. The area is marked in RED, indicating caries. This decay is then termed a suspicious
area.
3. Dark questionable pits and grooves may be marked as incipient cares (15106) or caries
(15105 - if confirmed by dentist).
a. Look for "halo effect" around suspicious pits and grooves.
4. Relate findings to treatment planning and patient instruction on caries control.
Charting Fractures
Fractured Tooth
1. Highlight the tooth with a fracture.
2. Select Conditions and find the procedure code for a fracture.
3. Click EO for existing
Fractured Restoration
1. Fractured restorations are considered defective and thus will appear red on the charting.
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Restorative materials labeling key for paper charting:
A
= Amalgam
CRV = Composite Resin Veneer
ABF = Abfraction
CV = Ceramic Veneer
ABS = Abscess
F
= Fracture
ACC = All Ceramic Crown
FC = Full Coverage Metal Crown
CL
= Clasp
FGC = Full Gold Crown
CO = Composite Onlay
GF = Gold Foil
CR = Composite Resin
GI = Gold Inlay
GIN = Glass Ionomer
GO = Gold Onlay
I
= Implant
P&C = Post and Core
P
= Pontic
PE = Partially Erupted
PFM = Porcelain fused to metal crown
RCT = Root Canal Therapy
SSC = Stainless Steel Crown
S
= Sealant
T
= Temporary Restoration
W = Watch
~All existing restorations were drawn in the shape of the restoration and indicated with blue pencil.
~All suspicious areas, including watches, were indicated in red pencil; exceptions: abfractions and
attrition were indicated with blue pencil (indicating no decay present.)
~Supernumerary Teeth = teeth were outlined where they were located- and the deciduous
corresponding letter was circled.
~Tooth Colored Restorations (CR) were outlined with blue pencil.
~Amalgam Restorations were outlined and filled in with blue pencil.
~Gold Restorations were outlined with blue pencil and marked with diagonal blue lines.
F. Progress Notes
The Progress Notes Sheet is used to document all treatment and contact with a patient.
In addition to treatment notes, telephone conversations, cancellations or failed appointments should
also be recorded. See Appendix C for an example of progress notes.
GUIDELINES FOR COMPLETING PROGRESS NOTES (A detailed example is given in Appendix C)
 All entries are to be dated and digitally signed by the clinician and supervising faculty member.
 Write in narrative, paragraph form, under each prompt.
G.
Patient Counseling and Education
An integral part of a patient's treatment plan is the oral health education plan, which is developed by
the dental hygienist. The plan should reflect the following:
1. Is developed on the basis of the dental hygiene diagnosis.
2. Is related to the patient's motivational needs.
3. Is comprehensive and an integral part of the dental hygiene treatment plan and reflects a total
body wellness philosophy.
4. Reinforces the patient's responsibility for their oral health
5. Involves the patient in establishing goals for self-care, and assessing their attainment.
Dental Hygienist’s Role in Patient Counseling and Education
1. Establish rapport with the patient as soon as they are greeted. Examine health history/dental
history to elicit background information which may influence oral habits.
2. Show and explain to the patient the condition of his oral cavity (i.e. bleeding, inflammation).
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3. Show and explain to the patient how he can evaluate the condition of his own oral cavity,
recognizing what is healthy for his oral condition and what is unhealthy.
4. Discuss the patient's oral hygiene and the effect it can and does have on his oral tissues and the
rest of the body (systemically).
5. Discuss with the patient the consequences of a healthy and unhealthy mouth.
General Procedures for Patient Counseling/Education during the Dental Hygiene Appointment
Prior to seating the patient, check the patient's folder for information on his dental background, history,
knowledge, previous counseling, etc.
1. Call the patient from reception area.
 Begin your appraisal of the patient immediately. Observe their --Response to your call -hesitancy, facial expression, etc. …Stature…Gait
2. Talk with your patient to begin establishing rapport and obtaining information about this
patient, i.e. educational level, socio-economic level and background, attitudes toward oral
health, occupation, etc.
 After seating the patient, ask questions on any items needing verification, clarification, or
completeness.
 Charting: evaluation of the patient's oral condition.
 Simultaneously with your case history preparation, inspections, observations, and charting
procedures, and throughout the appointment, you should be talking with
 your patient to help you assess the patient's
 Dental knowledge in general so you know what instructional level should be used.
 If you use dental terms, be sure to explain them to the patient.
 Follow dental terms with the lay term.
 EX: when speaking of gingival tissue, you might say "the gingival tissue or gum tissue".
 Motivating factors: Through your conversation with the patient, while performing
the plaque control procedures, find a key to interest your patient in his own dental
health.
 With this information in mind, you are ready to start the technical aspects of patient
counseling and education.
Instruction procedure for the teenager and adult.
 Explain to the patient what you are going to do.
 Have the patient show to you and explain his oral condition.
 The dental hygienist acts to guide the patient in his recognition and explanation.
 Discuss what disclosing solution is and why you are using it.
 Discuss with the patient why he should look for after the disclosing solution has
been applied. May have to explain to the patient what biofilm/plaque is, etc.
 Apply the disclosing solution.
 Have the patient evaluate his own oral hygiene, determining those areas where
improvement is needed.
 Record these areas on the Plaque Control Record/worksheet.
 Compute the patient's plaque index.
 Plaque Control Record index is used as a visual tool and given to the patient in their patient
education bag.
 Demonstration by the patient, in his own mouth, of the toothbrushing technique
currently being used.
 Give the patient a toothbrush. New and recare patients receive a new IUSB Dental Hygiene
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Clinic toothbrush. Re-appointment patients may receive an educational toothbrush if
needed or bring their toothbrush with them to the appointment for further
education/discussion.
Discuss the effectiveness of the technique.
Demonstration by the patient (guided by the dental hygienist), in his own mouth any
modification or change in his toothbrushing technique where needed.
Demonstration by the patient, in his own mouth, of the modifications or changes in his
toothbrushing technique suggested by the dental hygienist.
Demonstration by the patient, in his own mouth, of any interdental cleaning aids
currently being used.
If the patient is CURRENTLY USING an interdental cleaning aid (floss) or adjunct (proxibrush,
Stimudent):
Is the patient using it daily?
Have the patient show you, in his own mouth, if feasible, or on a model, how he is using the
product.
Correct or modify the technique as needed.
Demonstration by the dental hygienist, in the patient's mouth, of an modification or
changes in adjunct technique.
Demonstration by the patient, in his own mouth, of the modifications or
changes in his adjunct technique as suggested by the dental hygienist.
Praise improvement and correctness. It can go a long way with patients when it is
deserved.
If a NEW RECOMMENDATION is being made for a new interdental cleaning
product (floss, proxibrush):
 Show the patient the product and demonstrate how to use it on a typodont
 Have the patient demonstrate their understanding on the typodont, and finally in their
mouth
Instruction Procedure for a Child/Pedo Patient
1. Apply disclosing solution to the child's teeth.
 Have the patient point out areas he is missing.
 Discuss with the child what this means.
2. Toothbrushing
 Select a child's size toothbrush.
 Have the child show you, in his own mouth, how he is currently brushing.
 Modify this method, so as to clean those areas currently being missed.
 Select the proper method or modification for this patient's needs.
 Demonstrate and explain the bristle placement.
o Probably start on the anterior teeth, facial surfaces, so the patient and
operator can see, then continue in all areas of the mouth.
o Demonstrate and explain the activation motion.
o Discuss a pattern, amount of time for brushing, etc.
3. Interdental Cleaning/Adjunct Aids
o Instruct the child in the proper use of the adjuncts.
o Remember, coordination will limit the child's ability to use an adjunct
effectively and therefore their practicality.
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If the child cannot coordinate the techniques effectively on his own,
instruct one parent while instructing the child.
Additional suggestions.
Points to emphasize and explain in toothbrushing techniques.
1.
Proper angulation of the bristles.
2.
Proper activation motion.
3.
Proper pressure.
4.
Careful brushing in the cuspid area.
5.
Thorough cleaning of the lingual surfaces of the mandibular posterior teeth.
6.
Scrub brush method on the occlusal surfaces.
7.
Distal surfaces of the last tooth in each quadrant must be thoroughly cleaned.
8.
Interproximal surfaces next to open spaces must be thoroughly cleaned.
9.
Necessity for gingival message.
o
When instructing a child to brush his teeth properly, both the parent and child should be counseled so
that any limiting factor in the learning process may be overcome.
Be sure to review oral physiotherapy with all patients -- including dentists, professors, dental students,
dental assisting students, fellow dental hygiene students, etc.
The following concepts should guide the dental hygienist when counseling a patient in oral
physiotherapy:
1.
Many patients will need at least two sessions of instruction to master even the
simplest new home care technique.
2.
Mastery of a complex home care technique will require many sessions of
instruction.
3.
All patients need review and reinstruction periodically.
Use visual aids and pamphlets such as the "Chairside Instructor" to reinforce instructions and
techniques when the patient leaves the clinic.
HOME CARE INSTRUCTION RECOMMENDATIONS
BASED ON PATIENT PERIO LEVEL
Perio Level 0 and I PATIENTS
1.
Brush at least twice daily with soft nylon brush.
2.
Floss at least once daily.
3.
Use ADA approved fluoride toothpaste
4.
Recare appointment: 6 months
Perio Level II PATIENTS
1.
Brush at least twice daily with soft nylon brush.
2.
Floss at least once daily.
3.
Use water pik (to improve tissue tone and promote healing) daily as follows:
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a.
b.
4.
5.
Add 2 capfuls of mouth rinse to reservoir of warm water.
Turn unit to highest setting. (May start lower and gradually increase pressure over
time.)
c.
Place tip at each interproximal space and hold for 5 seconds in each space.
d.
Tip should be held at right angle to long axis of tooth.
Use ADA approved fluoridated toothpaste.
Recare appointment: 3 months
Perio Level III OR IV PATIENTS
1.
Brush at least twice daily with soft nylon brush.
2.
Use Proxabrush and brush all interproximal spaces from facial to lingual. Floss where
Proxabrush won't go.
3.
Use water pik (to improve tissue tone and promote healing) daily as follows:
a.
Add 2 capfuls of mouth rinse to reservoir of warm water.
b.
Turn unit to highest setting.
c.
Place tip at each interproximal space and hold for 5 seconds in each space.
d.
Tip should be held at right angle to long axis of tooth.
4.
Use ADA approved fluoridated toothpaste.
5.
Recare appointment: 3 months
H. Topical Fluoride Applications
A topical fluoride treatment is offered at the end of patient treatment based on the patient’s Caries Risk
Assessment. If sealants are to be applied at the same appointment, the fluoride treatment should be
given after the sealants have been applied.
Fluoride Available in the IU South Bend Dental Hygiene Clinic
1. 5% Neutral Sodium Fluoride (varnish)
2. Non-Acidulated Phosphate Gluten-Free Fluoride ACP formula (EnamelPro Gel)
Application of Fluoride
For Gel Application Assemble:
2 - suitable trays, convenient for the operator and will be of proper size to be tolerated comfortably by
the patient. All teeth must be covered.
Small Tray: primary dentition
Medium: mixed dentition
Large: adult dentition
Fluoride Gel, Saliva Ejector and HVE tip
Cup of water
Tissue
For Varnish Application Assemble:
One packet of fluoride varnish (5% Neutral Sodium)
Procedure:
1. Slightly dry the teeth removing any excess saliva
2. Using a paint on technique, apply a thin ribbon/layer of varnish to all surfaces of teeth
3. Post op instructions:
a. Do not brush the area for the duration of the day
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b. Eat a soft non-abrasive diet after the application
Procedure:
1. Polishing is not required before treatment, but teeth should be free of stains and calculus before
application.
2. Offer patient a drink of water and a tissue
GEL
1. A thin ribbon of GEL is put in the trough portion of the maxillary and mandibular tray. This is to
be done at one of the counters, not at individual units.
2. Thoroughly dry mandibular teeth with compressed air. Seat mandibular tray over entire arch.
3. Insert a saliva ejector in the floor of the mouth. Thoroughly dry maxillary arch and insert and
seat tray over maxillary arch.
4. Advise patient to close and bite gently to insure the gel covers all of the teeth and flows
interproximally. Saliva ejector is maintained in the floor of the mouth.
5. Begin timing -- the tray is kept in place for 4 minute period. (One minute applications have not
proven to be effective)
6. Remove both trays, allow patient to expectorate. Use saliva ejector to remove excess.
7. Instruct patient not to eat or drink for 30 minutes.
I. Procedures to Follow When an Instrument Tip Breaks
The following procedures are to be followed when an instrument tip is broken off in the patient's mouth
during the dental hygiene appointment.
1. Stop operating, maintain retraction without moving the patient's head unnecessarily, and isolate the
area with gauze or cotton rolls.
2. DO NOT ALARM THE PATIENT by describing the accident.
3. Examine the immediate field of operation, the floor of the mouth, and mucobuccal fold for the
broken tip. Blot the gingival tissue dry with a gauze square and examine around the tooth.
4. The gingival sulcus can be gently examined using a curette in a spooning like stroke, but with care not
to push the tip into the base of the sulcus.
5. Consult with an instructor if the above procedures do not locate the tip.
6. When the tip is not removed by the above means, periapical and/or bitewing radiographs must be
made of the area. This is recorded on the patient's chart.
J. Implant Care
Oral hygiene is of utmost importance to all patients treated with implants. Most hygiene steps can be
carried out with traditional armamentarium such as various kinds of toothbrushes, floss, etc. Minimal,
or no, instrumentation may be necessary for an implant with a healthy gingival attachment.
The ultimate goal in the treatment of implants is the removal of bacterial deposits and calculus without
altering the implant surface. Excessive pressure or trauma to the perimucosal seal during
instrumentation is contraindicated. Current implant instruments on the market are; plastic, graphite,
and titanium. All are safe to use on titanium implants without scratching the surface; however titanium
curettes are recommended for use on titanium implants coated with hydroxyapatite or titanium plasma
spray (TPS) coatings and are effective in removing all residual debris.
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Implant Maintenance
1. Review patient’s medical history
2. Assess implant with a visual soft exam. Record any signs of inflammation or bleeding, including
peri-mucositis (a reversible inflammatory reaction with no bone loss) or peri-implantitis (an
irreversible inflammation with bone loss) , exudate, and / or mobility. * The signs of a failing
implant are presence of infection, pain, mobility, or unacceptable bone loss.
3. Provide proper implant instrumentation by removing microbial deposits without altering the
implant surfaces or adversely affecting biocompatibility.
4. Provide proper coronal polishing around implants include using a soft rubber tip or cup, not
brush, with appropriate nonabrasive paste. Aluminum oxide, tin oxide, APF-free prophy paste,
and low-abrasive dentifrice are all considered acceptable polishing abrasives for implants.
Coarse abrasive polishing pastes are contraindicated, as is air-polishing.
5. Make home-care recommendations.
Cleaning and Sterilization
Implant scalers are cleaned and sterilized according to manufacturer’s directions.
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Section 3
Patient Care Policies and Procedures
A.
Blood Pressure Measurement and Evaluation
• Recommendations for Follow-up
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B. Significant Medical Findings
• Incapacitating diseases
• Anticoagulant therapy
• Pregnancy
• Monitoring compliance with medications
• Tuberculosis: diagnosis and referral
• Endocarditis prophylaxis
• Prosthetic joint prophylaxis
• Chemotherapy
• Radiation
• Bisphosphonate induced osteonecrosis
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C.
Epinephrine in Local Anesthetics for Cardiac Patients
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D.
Medical Emergencies
• Student responsibilities
• Messenger responsibilities
• Faculty responsibilities
• Guidelines for calling 911
• Emergency Drugs
• Supplemental oxygen
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315
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A. Blood Pressure Measurement and Evaluation
• Blood pressure is measured on all patients 18 and over at the first appointment and on recare
appointments before the health history is approved by the faculty dentist.
•
Optimal blood pressure is defined as systolic blood pressure (SBP) less than 120 mm Hg and
diastolic blood pressure (DBP) less than 80 mm Hg.
•
Pre-hypertension: SBP 120 - 139 mm Hg and DPB 80 - 89 mm Hg.
•
Elevated readings on adults with undiagnosed high blood pressure are to be followed up
according to recommendations of the Joint National Committee, Seventh Report
(http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf):
o
For SBP of 121 – 139 mm Hg or DBP of 80 – 89 mm: advise patient that they fall into
the classification of “pre-hypertension” and should consult with their physician. The
blood pressure reading does not need to be confirmed at a subsequent appointment.
o
For SBP of 140 - 159 mm and/or DBP of 90 - 99 mm (Stage I hypertension): confirm at a
subsequent appointment. (Do not confirm at the same appointment, but within two
months). If confirmed at a subsequent appointment, refer the patient to a source of
care.
o
For SBP greater than 159 and /or DBP greater than 100 mm Hg (Stage II hypertension):
refer to source of care within one month.
o
For patients with SBP of 180 mm Hg or higher and/or DBP of 110 mm Hg. or higher,
recheck in five minutes. If still elevated, a medical consultation is required before
starting any dental or dental hygiene treatment.
* Refer patients without a physician to Indiana Health Centers or Sister Maura Brannick
Health Center*
•
Isolated systolic hypertension is defined as SBP equal to or greater than 140 mm and DBP less
than 90 mm.
•
Patients with Diabetes, in accordance with the American Diabetic Association and the Joint
Commission, are recommended to have their blood pressure controlled at 130/80mmHg or
lower.
• When retaking blood pressure because of a technical error, wait two minutes before retaking.
Enter the average of the two readings in the treatment record.
• Avoid the error of measuring blood pressure with the patient's arm resting on the arm of the
dental chair because it can result in falsely elevated DBP.
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B. Significant Medical Findings (preventing medical emergencies)
The following conditions require a physician’s consult to determine the appropriate course of action for
dental hygiene treatment. In some cases, the supervising dentist may elect to defer dental hygiene
treatment.
 History of a heart attack within the past six months
 History of a stroke within the past six months
 Unstable angina
 Uncontrolled epilepsy
 Brittle adult-onset diabetes
 Severe congestive heart failure
 Severe chronic obstructive pulmonary disease
 Systolic blood pressure of 180 mm Hg or higher
 Diastolic blood pressure of 115 mm Hg or higher
 Active tuberculosis (refer to B 5-6 below)
 Patient undergoing cancer chemotherapy treatment and/or radiation treatment
Note: if there is doubt as to any significant medical finding, consult an instructor and the supervising
dentist. In cases of noncompliance with any medical condition, the decision to treat is made by the
faculty dentist on a case-by-case basis, i.e., in the case of antihypertensive medication, the decision
would be based on the duration of noncompliance and evaluation of the patient's blood pressure at the
time of the dental hygiene appointment.
•
Anticoagulant therapy: do not treat patients taking Coumadin (warfarin sodium) without the
physician's approval. Patients on Coumadin (warfarin sodium) therapy should have a
prothrombin time test (PTT/INR) performed monthly and this reading should be recorded in the
patient’s record prior to every appointment. Other anti-platelet agents such as aspirin, Plavix
(clopidogrel bisulfate), Aggrenox (Dipyridamole + aspirin) and Ticlid (ticlopidine) do not require
regular monitoring of bleeding control. The INR value should be less than of 2.0-3.5 for safe
treatment. The INR times are valid for 30 days.
•
Pregnancy: avoid dental hygiene treatment during the first trimester and the last half of the third
trimester of pregnancy. The second trimester is best for elective treatment.
•
Medications: all medications that the patient is taking, both prescription and non-prescription
(OTC- over the counter) should be recorded in the patient's medical history. Monitoring
compliance with physician-prescribed medications: students are expected at each appointment
to note on the medical history (under Comments/Changes) that medication was taken (applies to
high blood pressure, prophylactic antibiotics, and insulin - dependent diabetes and nonprescription medications).
•
Tuberculosis:
o The medical history is unreliable for TB. Exceptions are:
 Positive family history of TB
 Contact with TB
o The signs and symptoms of TB are usually absent until the lesions are extensive.
o TB is ruled in or ruled out by the PPD tuberculin skin test.
o A positive skin test is presumptive evidence of exposure to TB. It does not indicate
active disease, and the patient must be treated with chemotherapy.
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o
o
A positive skin test is usually followed up with a chest x-ray.
Guidelines for providing or deferring dental hygiene services
 A person who is infected with M .tuberculosis [refer to 1) and 2) below] but who
does not have active disease is not infectious to others and may receive hygiene
care in our clinic.
 A person with active disease [refer to 3) below] is infectious; therefore, hygiene
services should be deferred. Refer patients with active disease to a physician or
the St. Joseph County Health Department, 235-9750.
 Guidelines based on TB tests:
1)
+ skin test
Must be treated by M.D. If not being treated, refer to M.D.
2)
3)
•
+ skin test
- chest x-ray
+ skin test
+ chest x-ray
Safe to provide dental hygiene services.
Active TB. Defer dental hygiene services. In all cases, patient
Must be treated by M.D. Do not treat until therapy is adequate
and completed (verify first with M.D.).
Endocarditis Prophylaxis: The American Heart Association’s latest guidelines were published in
its scientific journal, Circulation, in April 2007 and there is good news: the AHA recommends
that most of these patients no longer need short-term antibiotics as a preventive measure
before their dental treatment.
The American Dental Association participated in the development of the new guidelines and has
approved those portions relevant to dentistry. The guidelines were also endorsed by the
Infectious Diseases Society of America and by the Pediatric Infectious Diseases Society.
The guidelines are based on a growing body of scientific evidence that shows the risks of taking
preventive antibiotics outweigh the benefits for most patients. The risks include adverse
reactions to antibiotics that range from mild to potentially severe and, in very rare cases, death.
Inappropriate use of antibiotics can also lead to the development of drug-resistant bacteria.
Scientists also found no compelling evidence that taking antibiotics prior to a dental procedure
prevents IE in patients who are at risk of developing a heart infection. Their hearts are already
often exposed to bacteria from the mouth, which can enter their bloodstream during basic daily
activities such as brushing or flossing. The new guidelines are based on a comprehensive review
of published studies that suggests IE is more likely to occur as a result of these everyday
activities than from a dental procedure.
The guidelines say patients who have taken prophylactic antibiotics routinely in the past but
no longer need them include people with:
•
•
•
•
mitral valve prolapse
rheumatic heart disease
bicuspid valve disease
calcified aortic stenosis
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•
congenital heart conditions such as ventricular septal defect, atrial septal defect and
hypertrophic cardiomyopathy.
The new guidelines are aimed at patients who would have the greatest danger of a bad outcome
if they developed a heart infection.
Preventive antibiotics prior to a dental procedure are advised for patients with:
1. artificial heart valves
2. a history of infective endocarditis
3. certain specific, serious congenital (present from birth) heart conditions, including
o unrepaired or incompletely repaired cyanotic congenital heart disease, including
those with palliative shunts and conduits
o a completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
six months after the procedure
o any repaired congenital heart defect with residual defect at the site or adjacent
to the site of a prosthetic patch or a prosthetic device
4. a cardiac transplant that develops a problem in a heart valve.
The standard prophylactic regimen for adults:
Amoxicillin Tablets 500 mg
Sig: Take four tablets by mouth one hour before dental appointment
Allergy to penicillin: 600 mg. of Clindamycin or
500 mg. of Azithromycin or Clarithromycin
*Antibiotic prophylaxis is not indicated in patients with pins, plates, or screws.
Patients who need more than one appointment to complete dental hygiene
treatment: AHA recommends observing an interval of 7 days between
appointments to reduce the potential for resistant strains of organisms.
Notes: Prescriptions, written or telephoned, are entered by the dentist in the Patient Health Record.
Identify Rx's from other MDs/DDSs.
Monitoring compliance: before beginning dental hygiene treatment, the student records in the
Patient Health Record that the patient has taken the initial dose of antibiotic.
•
Seizures: the most serious complication of seizures is the occurrence of repeated seizures over a
short time referred to as status epilepticus. A patient who reports a history of seizures or
epilepsy should be asked the following follow up questions, and their responses should be
recorded on the medical history:
o Type of seizure
o Cause of seizures or known precipitation factors
o Date of last seizure
o Frequency of seizures
o Medications used to prevent seizures
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•
Patients with prosthetic joint replacements: In 2014, a panel of experts convened by the
American Dental Association Council on Scientific Affairs developed an evidenced-based clinical
practice guideline (CPG) on the use of prophylactic antibiotics in patients with prosthetic joints
who are undergoing dental procedures. The panel based the current CPG on literature search
results and direct evidence contained in the comprehensive systemic review published by a
2012 panel of experts from the American Dental Association Council on Scientific Affairs and
the American Academy of Orthopaedic Surgeons. The results of the 2014 panel, which are
inscribed below, were published in the February, 2014 Journal of the American Dental
Association (JADA).
Clinical Recommendation: In general, for patients with prosthetic joint implants, prophylactic
antibiotics are not recommended prior to dental procedures to prevent prosthetic joint
infection. For patients with a history of complications associated with their joint replacement
surgery who are undergoing dental procedures that include gingival manipulation or mucosal
incision, prophylactic antibiotics should only be considered after consultation with the patient
and orthopaedic surgeon.* To assess a patient’s medical status, a complete health history is
always recommended when making final decisions regarding the need for antibiotic
prophylaxis.
Clinical Reasoning for the Recommendation:
-There is evidence that dental procedures are not associated with prosthetic joint implant
infections.
-There is evidence that antibiotics provided before oral care do not prevent prosthetic joint
infections.
-There are potential harms of antibiotics including risk for anaphylaxis, antibiotic resistance,
and opportunistic infections like Clostridium difficile.
-The individual patient’s circumstances and preferences should be considered when deciding
whether to prescribe prophylactic antibiotics prior to dental procedures.
*In cases where antibiotics are deemed necessary, it is most appropriate that the orthopaedic
surgeon recommend the appropriate antibiotic regimen and when reasonable write the
prescription.
•
Patients undergoing chemotherapy or radiation therapy: Consult with the faculty dentist on
each individual case. The patient’s oncologist MUST be consulted prior to treatment.
The following information, to be used as reference material on these conditions, is taken from
the National Institutes of Health National Cancer Institute (accessed on July 15, 2013
at: http://www.cancer.gov/cancertopics/pdq/supportivecare/oralcomplications/HealthProfessional/Table3)
Oral and Dental Management before Cancer Therapy
Poor oral health has been associated with increased incidence and severity of oral complications in
cancer patients, hence the adoption of an aggressive approach to stabilizing oral care before
treatment.[1,2] Primary preventive measures such as appropriate nutritional intake, effective oral
hygiene practices, and early detection of oral lesions are important pretreatment interventions.
306
There is no universally accepted pre–cancer therapy dental protocol because of the lack of clinical trials
evaluating the efficacy of a specific protocol. A systematic review of the literature revealed two articles
on oral care protocols prior to cancer therapy.[3] One study examined the benefits of a minimal
intervention pre–cancer therapy (mostly chemotherapy) dental protocol, and the other examined the
impact of an intensive preventive protocol on patients undergoing chemotherapy. Both studies had
several flaws, including small sample size or the lack of comparison groups.[3]
The involvement of a dental team experienced with oral oncology may reduce the risk of oral
complications via either direct examination of the patient or in consultation with the community-based
dentist. The evaluation should occur as early as possible before treatment.[4,5] The examination allows
the dentist to determine the status of the oral cavity before cancer treatment begins and to initiate
necessary interventions that may reduce oral complications during and after that therapy. Ideally, this
examination should be performed at least 1 month before the start of cancer treatment to permit
adequate healing from any required invasive oral procedures. A program of oral hygiene should be
initiated, with emphasis on maximizing patient compliance on a continuing basis.
Chemotherapy Patients
Oral evaluation and management of patients scheduled to undergo myeloablative chemotherapy should
occur as early as possible before initiation of therapy (refer to the list on Oral Disease Stabilization
Before Chemotherapy and/or Hematopoietic Stem Cell Transplantation below). To maximize outcomes,
the oncology team should clearly advise the dentist as to the patient’s medical status and oncology
treatment plan. In turn, the dental team should delineate and communicate a plan of care for oral
disease management before, during, and after cancer therapy.[5]
Oral Disease Stabilization Before Chemotherapy and/or Hematopoietic Stem Cell Transplantation
•
Data provided by oncology team to dental providers:
Underlying disease:
 Cancer: type, stage, prognosis.
 Aplastic anemia status, complete blood count (CBC).
 Other.
o Type of transplant:
 Autologous.
 Allogeneic donor types:
 Matched related and unrelated.
 Mismatched related.
 Mismatched unrelated.
 Syngeneic.
o Hematopoietic stem cell source:
 Bone marrow.
 Peripheral stem cells.
 Cord blood stem cells.
o Conditioning regimen:
 Myeloablative.
 Reduced-intensity conditioning (including nonmyeloablative regimens).
o Planned date of transplant.
o Conditioning regimen:
 Chemotherapy.
o
307
Total-body irradiation.
Radioactive antibodies.
o Current hematologic status and immunologic status.
o Present medications.
o Other medical considerations:
 Cardiac disease (including murmurs).
 Pulmonary disease.
 Indwelling venous access line.
 Coagulation status.
 Splenectomy.
• Data provided by dental providers to oncology team:
o Dental caries (number of teeth and severity, including designation of number of teeth that
should be treated before cancer treatment begins).
o Endodontic disease:
 Teeth with pulpal infection.
 Teeth with periapical infection.
o Periodontal disease status.
o Number of teeth requiring extraction.
o Other urgent care required.
o Time necessary to complete stabilization of oral disease.


The overall goal is to complete a comprehensive oral care plan that eliminates or stabilizes oral disease
that could otherwise produce complications during or following chemotherapy. Achieving this goal will
most likely reduce risk of oral toxicities with resultant reduced risk for systemic sequelae, reduced cost
of patient care, and enhanced quality of life. If the patient is unable to receive the medically necessary
oral care in the community, the oncology team should assume responsibility for oral management.
It is important to realize that dental treatment plans need to be realistic relative to type and extent of
dental disease and how long it could be before resumption of routine dental care. For example, teeth
with minor caries may not need restoration before cancer treatment begins, especially if more
conservative disease stabilization strategies can be used (e.g., aggressive topical fluoride protocols,
temporary restorations, or dental sealants).
Specific interventions are directed to:
•
•
•
•
•
•
•
Mucosal lesions.
Dental caries and endodontic disease.
Periodontal disease.
Ill-fitting dentures.
Orthodontic appliances.
Temporomandibular dysfunction.
Salivary abnormalities.
Guidelines for dental extractions, endodontic management, and related interventions (see Table 3) can
be used as appropriate.[6,7] Antibiotic prophylaxis prior to invasive oral procedures may be warranted
in the context of central venous catheters; the current American Heart Association (AHA) protocol for
infective endocarditis and oral procedures is frequently used for these patients.
308
Table 3. Management Guidelines Relative to Invasive Dental Procedures
Medical Status
Guideline
Comments
Patients with
AHA prophylactic antibiotic recommendations (low
chronic indwelling risk).
venous access lines
(e.g., Hickman).
There is no clear scientific proof detailing
infectious risk for these lines following
dental procedures. This recommendation
is empiric.
Neutrophils
Order CBC with differential.
>2,000/mm3
No prophylactic antibiotics.
1,000–2,000/mm3
AHA prophylactic antibiotic recommendations (low
risk).
<1,000/mm3
Amikacin 150 mg/m2 1 h presurgery; ticarcillin 75 mg/kg If organisms are known or suspected,
IV ½ h presurgery. Repeat both 6 h postoperatively.
appropriate adjustments should be
based on sensitivities.
Plateletsa
Clinical judgment is critical. If infection is
present or unclear, more aggressive
antibiotic therapy may be indicated.
Order platelet count and coagulation
tests.
>60,000/mm3
No additional support needed.
30,000–
60,000/mm3
Platelet transfusions are optional for noninvasive
treatment; consider administering preoperatively and
24 h later for surgical treatment (e.g., dental
extractions). Additional transfusions are based on
clinical course.
Utilize techniques to promote
establishing and maintaining control of
bleeding (i.e., sutures, pressure packs,
minimize trauma).
<30,000/mm3
Platelets should be transfused 1 h before procedure;
obtain an immediate postinfusion platelet count;
transfuse regularly to maintain counts >30,000–
40,000/mm3 until initial healing has occurred. In some
instances, platelet counts >60,000/mm3 may be
required.
In addition to above, consider using
hemostatic agents (i.e., microfibrillar
collagen, topical thrombin).
Aminocaproic acid may help stabilize
nondurable clots. Monitor sites carefully.
CBC = complete blood cell count; IV = intravenous.
a
Assumes that all other coagulation parameters are within normal limits and that platelet counts will be
maintained at or above the specified level until initial stabilization/healing has occurred.
Head/Neck Radiation Patients
Head and neck radiation patients are a significant challenge relative to both intratherapy and
posttherapy oral complications resulting from radiation therapy. Unlike the oral complications of
chemotherapy that are of shorter duration and significant for only a short period (a few weeks to 2
months) after the cessation of therapy, the oral complications of head and neck radiation are more
309
predictable, are often more severe, and can lead to permanent tissue changes that put the patient at
risk for serious chronic complications.
Preradiation Dental Evaluation and Oral Disease Stabilization
Elimination of oral disease and implementation of oral care protocols designed to maintain maximum
oral health must be components of patient assessment and care before radiation therapy begins. During
and after radiation therapy, oral management will be dictated by the following:
•
•
•
Specific needs of the patient.
Specifics of the radiation therapy.
Chronic complications caused by radiation therapy.
Ongoing oral assessment and treatment of complications are essential because radiation to oral tissues
typically conveys a lifelong risk of oral complications. In addition, invasive oral procedures can cause
additional sequelae. Dental care typically needs to be altered because of underlying chronic radiationinduced tissue damage.
Patients should receive a comprehensive oral evaluation several weeks before high-dose upper-mantle
radiation begins. This timing provides an appropriate interval for tissue healing in the event that invasive
oral procedures, including dental extractions, dental scaling/polishing, and endodontic therapy, are
necessary. The goal of this evaluation is to identify teeth at significant risk of infection and/or
breakdown that would ultimately require aggressive or invasive dental treatment during or after the
radiation that increases the risk of soft tissue necroses and osteonecroses. The likelihood of these
lesions occurring postradiation increases over the patient’s lifetime as the risk of significant dental
disease (restorative, periodontal, and endodontic) increases. Salivary gland hypofunction and
xerostomia frequently occur postradiation. It is thus especially important that preradiation dental care
strategies are instituted to reduce the impact of the complications of severely decreased saliva secretion
and the associated high risk of dental caries.
In addition, three radiation-specific issues emerge:
1. Radiation injury is oral tissue–specific and dependent on dosage and portals of therapy.
2. Radiation-induced oral mucositis typically lasts 6 to 8 weeks, versus the approximate 5 to 14
days observed in chemotherapy patients. The extended radiation treatment protocols are
chiefly responsible for this difference.
3. The primary cause of oral cancer is tobacco use; alcohol abuse further escalates risk. It is
therefore critical that head/neck cancer patients permanently cease tobacco use. (Refer to the
PDQ summary on Smoking in Cancer Care for more information.)
o Most patients with smoking-related cancer appear motivated to quit smoking at the
time of cancer diagnosis.
o Continued smoking substantially increases the likelihood of recurrence or occurrence of
a second cancer in survivors, particularly in those who previously received radiation
therapy.
o A stepped-care approach to tobacco cessation is recommended, including direct
physician advice to quit and provision of basic information to all patients at each contact
310
during the first month of diagnosis, followed by more intensive pharmacologic
treatment or counseling for those having difficulty quitting or remaining abstinent.
Bisphosphonate-associated Osteonecrosis (BON)
Patients who have risk factors for BON MUST have a medical consult prior to commencing dental
hygiene treatment. The faculty dentist will make a determination on patient treatment. A referral may
be required.
Bisphosphonates are potent inhibitors of osteoclasts. They are used in cancer patients with skeletal
metastasis, including breast, prostate, or lung cancer; and in patients with multiple myeloma.
Bisphosphonates are also used to treat hypercalcemia of malignancy. (Refer to the PDQ summary
on Hypercalcemia for more information.) Bisphosphonates reduce the risk of fracture and skeletal pain,
improving the quality of life of patients with malignant bone disease.[1] (Refer to the PDQ summary
on Pain for more information.)
Bisphosphonate osteonecrosis (BON) is an oral complication of bisphosphonate therapy in cancer
patients.[2] First reported in 2003,[3,4] BON is defined as the unexpected appearance of exposed
necrotic bone anywhere in the oral cavity of an individual who is receiving a bisphosphonate and who
has not received radiation therapy to the head and neck. The exposed bone persists for 6 to 8 weeks
despite the provision of standard dental care. It is also possible that symptoms of dental and/or
periodontal disease may be present, without visible exposed bone.[5] The occurrence of BON is based
on cases reported in the literature, and occurrence ranges between 1% and 10% for patients receiving
the intravenous formulation (pamidronate and zoledronic acid) and less than 1% for patients taking oral
bisphosphonate.[6,7]
Risk factors for BON include the following:
•
•
•
•
•
Dental extractions.[14][Level of evidence: II][15]
Ill-fitting dentures.[14]
Intravenous bisphosphonate (zoledronic acid, denosumab).[14,15][Level of evidence:
I][8];[16][Level of evidence: I]
Time on medication.[8,15]
Multiple myeloma.[8]
The incidence of BON may be reduced by the implementation of dental preventive measures before
bisphosphonate therapy is initiated in solid-tumor patients with bone metastases.[17]
C. Epinephrine in Local Anesthetics for Cardiac Patients
•
Epinephrine is contraindicated in patients with:
o Ventricular dysrhythmias
o Cardiac pacemakers
o Allergy to sulfites
o Severe asthma
311
•
o A request from a physician not to use a vasoconstrictor
o A history of tachycardia after injection with an anesthetic containing a vasoconstrictor
When epinephrine is contraindicated, plain local anesthetic (without vasoconstrictor) should be
used.
IU SOUTH BEND DENTAL HYGIENE CLINIC
D. MEDICAL EMERGENCIES PROTOCOL
Student
w/Emergency
Messenger
Faculty Dentist
Faculty
Hygienist
Clinic
Receptionist
• Appoints a messenger
• Remains with patient
• Positions patient in loss of consciousness
• Assesses airway, breathing, and circulation
• Notifies instructors
• Brings oxygen and drug kit to chairside
• Stands by at chairside
• Makes 911 call
• Takes vital signs
• Administers drugs
• Initiates request for 911
• Performs CPR with Faculty Hygienist
• Administers oxygen
• Records vital signs, drugs given
• Performs CPR with faculty dentist
• Appoints student/s to remove patients from site of emergency
and clinic reception area to the student lounge area (“we
anticipate an emergency and need to clear this area, please
follow me”).
• Goes to Education and Arts building sign on Esther St. to flag and
guide emergency vehicle
312
Messenger's Responsibilities
1.
Notify instructors: give the name of student and the unit number.
2.
Oxygen to chair side (oxygen cart is in the Storage Alcove EA1224 cabinet near Washer).
3.
Drug kit to chair side
4.
Remain at chair side for further instructions.
(located in the Storage Alcove EA1224 cabinet near Washer).
CALLING 911: if asked by dentist to call 911:
Place call at front desk and call 911.
The dispatcher will ask for the following information:
 Location: “Education and Arts Building in the Dental Hygiene Clinic on the IUSB
campus. We are located at 1002 S. Esther St. on the southwest corner of the
building.”
 Telephone number (520-4156).
 The nature of the emergency.
 Condition of the patient.
 What aid is being given to the patient.
Hang up last to be sure the dispatcher has no further questions:
Record the time 911 call is placed.
5.
Notify instructors that 911 call was made.
6.
Post a student at the driveway on Esther St. to direct the rescue squad to the main
entrance.
7.
Wait inside the main entrance to direct the rescue squad to the hygiene clinic.
8.
Record the time the rescue squad arrives.
Faculty responsibilities
1. Diagnosis and treatment (faculty dentist)
2. Monitoring vital signs
3. CPR (performed with patient on floor. Students take their patients to waiting room).
4. Calling 911: request to call is responsibility of faculty dentist
5. Administering drugs: faculty dentist
6. Administering supplemental oxygen: faculty dentist
313
Guidelines for calling 911 (list is not inclusive)
o If the patient requests emergency attention
o If unconsciousness persists for 30 seconds.
o If hypoglycemia leads to unconsciousness.
o If seizures last for more than 5 minutes.
o If anginal pain in a diagnosed cardiovascular patient does not subside after administration of
nitroglycerine by the faculty dentist (maximum is three doses within 15 minutes).
o If chest pain in a "healthy" patient without diagnosed cardiovascular disease does not subside in
2 minutes.
o If an asthmatic attack does not respond to 1 - 2 doses of bronchodilator.
o If an allergic reaction involves body systems.
o If a foreign body leads to airway obstruction.
Medical Emergency Kit Contents with Indications for Use
INDICATION
DRUG
ROUTE
Respiratory Distress
Cardiac disease
OXYGEN
Inhaled through mask or cannula
to tank
Syncope
AMMONIA CAPSULE
Inhaled
Angina Pectoris
NITROGLYCERIN
400 mcg
(no more than 3 doses in 15
minutes)
Acute Allergic Reaction
Acute Asthma Attack
EPINEPHRINE
Inject 1:1000 dose
Needle/syringe
Subcutaneous
Bronchospasm (asthma)
BRONCHODILATOR
(ALBUTEROL)
Inhaled
Dose: 90 mcg
Allergic Reaction
ANTIHISTAMINE
(BENADRYL)
Oral
Hypoglycemia
GLUCOSE TABLET
FROSTING
Oral: 4 g carb/tablet
Place ½ teaspoon under tongue
Anti-inflammatory
Analgesia
Antipyretic
ASPIRIN
Oral: 325mg /tablet
314
Other items in drug kit subsided
o CPR mask with one-way valve
o Alcohol wipes
o Sterile 4 x 4 gauze pads
o Pediatric oxygen mask
o Non-rebreathing mask
o Nasal cannula (21 - 40% oxygen flow at 1 – 3 LPM)
o Flowchart and clipboard to record administration of drugs and vital signs
o Glucose tablets (4 g carb/tablet) or cake icing
o Sterile Res-Q-Vac for quick suction of fluids
o An ampule of aromatic ammonia is taped to the light post on the units in the hygiene and
assisting clinics, in the emergency kit and 1st aid kits
Administering supplemental oxygen
1. An oxygen E cylinder with attached mask is located in EA1224 Storage Alcove area.
2. Oxygen may be administered in a number of conditions, including chest pain, asthmatic attack,
recovery from syncope, recovery from seizures and to resuscitate a patient who is not breathing
spontaneously.
3. Oxygen is contraindicated in hyperventilation.
4. Oxygen is administered to decrease the actual work of breathing, to decrease the work of the
heart and to prevent hypoxia (oxygen deficiency)
Administering oxygen to a patient who is breathing spontaneously
1. Release oxygen from the tank by turning the green handle on top of the regulator
counterclockwise.
2. Adjust the flow meter to the 10 LPM, allow the mask to fill 3/4 and apply mask to patient's face.
3. Monitor the patient. The bag must partially but not completely deflate. Readjust flow rate, if
indicated.
4. When oxygen is no longer needed, turn the green handle clockwise until fully closed, wait for
the pressure to reach zero, then turn the flow meter to zero.
Administering oxygen to a non-breathing patient (positive pressure ventilation)
1. Disconnect the non-rebreathing mask from the tubing and connect the CPR mask located in
the emergency drug kit.
2. Adjust the flow meter to 10 L/M for 50% oxygen.
3. Ventilate the patient appropriately, depending on diagnosis (respiratory arrest or cardiac
arrest).
315
Summary Chart
Oxygen devices
Inspired
O2
LPM
Indication
Mask w/ reservoir
(non-rebreathing)
90%
8-15*
Patient breathing
spontaneously
CPR Mask
w/ one way valve
50%
10
Respiratory / Cardiac arrest
Nasal Cannula
21-40%
1-3
Patient clinically stable regular
breathing pattern
Set flow rate at 10 L/M and allow reservoir bag to fill 2/3 before applying mask
Section 4
Exposure Control
A. Biosafety Policies for the Vera Z. Dwyer College of Health Sciences
Students
• Objectives for the delivery of care
• Guidelines: admission and progression of students who are
HIV or HBV positive
• Guidelines: bloodborne pathogen healthcare worker
• HBV vaccination policy
B. Exposure Control Policies for Programs in Dental Education
C. Bloodborne Pathogens Standard Introduction
D. Standardized Protocols
• Standard #1: Personal Protective Equipment
• Standard #2: Hand Washing and Gloving
• Standard #3: Minimizing Aerosols and Droplets
• Standard #4: Patient Care
• Standard #5: Items to be Sterilized
• Standard #6: Exposure Incident Policies and Procedures
• Standard #7: Sharps and Needle Management
• Standard #8: Waste Disposal/Housekeeping
• Standard #9: Patients’ Charts/Records
• Standard #10: Dental Waterlines
• Standard #11: Engineering and Work Practice Controls
E. Procedures for Exposure Incidents
F. Management Protocol for Exposure Incidents
G. Map for Health Care Facility for Post-Exposure Blood Tests
H. Exposure Incident Report Form
I. Request for Post-Exposure Blood Test Form
J. Standard Precautions and Patient’s Rights
K. Hazards Communication Program
a. Annual Training Requirements
401
401
402
402
404
405
407
409
409
411
413
413
415
416
417
417
419
419
420
420
420
424
425
426
427
428
430
401
A. BIOSAFETY POLICIES
Indiana University South Bend
VERA Z. DWYER COLLEGE OF HEALTH SCIENCES
Guiding Principles
Approved April 21, 2003
Health care workers (HCW) have both a professional and legal obligation to render
treatment utilizing the highest standards of infection control available. Strict adherence
to the principles and practices of infection control will ensure the standard of care and
practice expected by both practitioner and patient.
The Vera Z. Dwyer College of Health Sciences Exposure/Infection Control policies and
procedures are based on the concept of Standard Precautions and are in compliance
with the current recommendations of the United States Public Health Service and
Occupational Safety and Health Administration. Standard Precautions refers to an
approach to infection control that assumes all human blood and other potentially
infectious materials (OPIM's) of all patients are potentially infectious with HIV, HBV, or
other bloodborne pathogens. Standard Precautions are intended to prevent health
care workers from parenteral, mucous membrane and non intact skin exposure to
blood-borne pathogens while carrying out the tasks associated with their occupation.
SECTION I
Objectives for the Delivery of Care
Infectious Diseases: The Vera Z. Dwyer College of Health Sciences has the obligation to
maintain standards of health care and professionalism that are consistent with the
public's expectations of the health professions. The following principles should be
reflected in the education, research, and patient care divisions for all health care
workers, students, faculty and staff:
a. All health care workers are ethically obligated to provide competent patient care
with compassion and respect for human dignity.
b. No health care workers may ethically refuse to treat a patient whose condition is
within their realm of competence solely because the patient is at risk of
contracting, or has, an infectious disease, such as human immunodeficiency virus
(HIV) infection, acquired immunodeficiency syndrome (AIDS), hepatitis B infection,
or other similar diseases. These patients must not be subjected to discrimination.
c. All health care workers are ethically obligated to respect the rights of privacy and
confidentiality of patients with infectious diseases.
d. Health care workers who pose a risk of transmitting an infectious agent should
consult with appropriate health care professionals to determine whether
continuing to provide professional services represents any material risk to the
patient, and if so, should not engage in any professional activity that would create
a risk of transmission of the disease to others.
402
SECTION II
GUIDELINES: ADMISSION AND PROGRESSION OF STUDENTS WHO
ARE HIV OR HBV POSITIVE
Policy:
Qualified individuals will not be denied admission into courses in the Vera Z. Dwyer
College of Health Sciences on the basis of HIV or HBV status.
Guidelines:
1.
Upon voluntary report of HIV or HBV infection by a student to any faculty
member, administrator, or dean, efforts will be made to:
a.
Maintain infection information confidential.
b.
Advise the student to receive appropriate treatment and counseling from
a qualified healthcare professional.
c.
Reinforce the consistent use of Standard Precautions in clinical practice.
d.
Assign responsibilities to the infected student that do not require the
performance of exposure-prone invasive procedures.
2.
Any modifications in clinical activity will be determined by a Blood-Borne
Pathogen (BBP) Expert Review Panel who will take into account the nature of the
clinical activity, the technical expertise of the infected student, the risks imposed
by HIV or HBV carriage, functional disabilities, and the transmissibility of
simultaneously carried infectious agents.
3.
Refusal for admission to a clinical course will occur only after attempts to make
reasonable accommodations result in undue hardship to the Vera Z. Dwyer
College of Health Sciences.
SECTION III
GUIDELINES: BLOODBORNE PATHOGEN-INFECTED HEALTH CARE WORKER
Currently available data provide no basis for recommendations to restrict the practice of
healthcare workers infected with HIV or HBV who perform invasive procedures not
identified as exposure-prone, provided that Standard Precautions are adhered to in
practice.
In order to reduce, to the greatest extent currently possible, the potential for
transmission of bloodborne pathogen from the BBP-infected HCW to a patient, and to
support the HCW's efforts to practice safely, the Vera Z. Dwyer College of Health
Sciences has adopted the following guidelines.
403
1. All activities related to patient care by students of Indiana University South Bend
will be carried out in accordance with the division’s Biosafety Policies. The
policies and procedures in this document are based upon Standard Precautions
currently practiced by the faculty, staff and students in the Indiana University
South Bend Vera Z. Dwyer College of Health Sciences and are consistent with
United States Public Health Service, Indiana State Department of Health and the
Indiana Occupational Health and Safety regulations.
2. All HCW's who provide direct patient care (including faculty, staff and students)
are encouraged to undergo voluntary HIV testing and to know their hepatitis B
virus (HBV) immune status. HIV testing is not mandatory.
3. Any HCW involved in clinical practice that believes that he/she may be at risk of
HIV or HBV infection should be voluntarily tested for confirmation.
4. Upon voluntary report of HIV or HBV infection by students, faculty or staff to
their unit director or Dean of the Vera Z. Dwyer the College of Health Science
efforts will be made to:
a.
Maintain infection information confidential.
b.
Advise the student to receive appropriate treatment and counseling from
a qualified healthcare professional.
c.
Reinforce the consistent use of Standard Precautions in clinical practice.
d.
Assign responsibilities to the infected student that do not require the
performance of exposure-prone invasive procedures
5. When a HCW who provides direct patient care is infected with a BBP and informs
the administration, the Dean of the Vera Z. Dwyer College of Health Science may
refer the case to the BBP Expert Review Panel for review and recommendation.
The BBP Expert Review Panel has the responsibility to:
a)
Review each case of a BBP-infected HCW and determine if he/she may
represent an increased risk for transmission of BBP infection to a patient.
b)
Make a recommendation to the Dean regarding the suitability of any
BBP-infected HCW to continue to fulfill his/her clinical responsibilities or
requirements in a complete or modified fashion or to have his/her clinical
privileges suspended.
c)
Develop guidelines for use in determining the need for both temporary
and permanent administrative acts including guidelines on patient
notification.
The review panel should include experts who represent a balanced perspective.
Such experts might include all of the following: a) the HCW’s personal
physician(s), b) an infectious disease specialist with expertise in the
404
epidemiology of HIV and HBV transmission, c) a health professional with
expertise in the procedures performed by the HCW, and d) state or local public
health officials(s). If the HCW’s practice is institutionally based, the expert
review panel might also include a member of the infection-control committee,
preferably a hospital epidemiologist.
6.
The Dean of Vera Z. Dwyer the College of Health Sciences will, within a
reasonable period of time, considering the above-mentioned recommendation
and take appropriate action. This may include continuation of clinical
responsibilities at the current level, modification of those responsibilities or
suspension of clinical privileges.
7.
Prior to receiving the Panel's individual recommendations, the Dean may
temporarily suspend or modify privileges based on guidelines developed by the
Panel.
8.
This protocol is subject to annual review and modification as new knowledge and
recommendations from appropriate agencies become available.
SECTION IV
HBV Vaccination Policy
Policy: Prior to registration in any clinical course and at the student’s expense, every
full-time or part-time, graduate or undergraduate student of the Vera Z. Dwyer
College of Health Sciences must undergo HBV vaccination and vaccine response
evaluation unless the student is shown to be immune, the vaccine is
contraindicated for medical reasons, or a declination is signed.
Procedures: Evidence of receipt of the HBV vaccination and vaccine response, immunity
to HBV, or declination will be filed with the student’s program director/dean
prior to registration in a clinical course. When the vaccine is contraindicated for
medical reasons, a declination form must be signed.
Evidence of the receipt of the HBV vaccination series including vaccine response should
be in the form of a signed statement from the student’s health care professional (HCP)
and evidence of declination can be submitted on the Vera Z. Dwyer College of Health
Sciences form or on the program’s form. Evidence of immunity to HBV, medical risk
from the vaccine, or receipt of a booster(s) should be in the form of a signed statement
from the health care provider.
Students who have completed the HBV series prior to entry into any clinical course are
governed by the CDC guidelines on vaccine response evaluation.
405
CDC Guidelines for Non Responders:
HCW should be tested for antibody to HBsAg (anti-HB’s) 1 to 2 months after completion
of the 3-dose vaccination series (CDC Immunization 1997). Persons, who do not respond
to the primary vaccine series, should complete a second 3- dose vaccine series or be
evaluated to determine if they are HBsAg-positive. Revaccinated persons should be
retested at the completion of the second vaccine series. Persons who prove to be
HBsAg-positive should be counseled regarding how to prevent HBV transmission to
other and regarding the need for medical evaluation. Non-responders to vaccination
who are HBsAg-negative should be considered susceptible to HBV infection and should
be counseled regarding precautions to prevent HBV infection and the need to obtain
HBIG prophylaxis for any know or probable perenteral exposure to HBsAg-positive
blood.
Declination Form should be stated as follows (source: FR Doc. 91-28886, December 6,
1991):
I understand that, due to my occupational exposure to blood or other potentially infectious
materials as a student in a health care program, I may be at risk of acquiring hepatitis B virus
(HBV) infection. I have been given the opportunity to be vaccinated with the hepatitis B vaccine
at my own expense. However, I decline hepatitis B vaccination at this time. I understand that by
declining this vaccine I continue to be at risk of acquiring hepatitis B, a serious disease. If in the
future I continue to have occupation exposures to blood or other potentially infectious materials
and I want to be vaccinated with the hepatitis B vaccine, I can receive the vaccination series at
my own expense.
B. EXPOSURE CONTROL POLICIES
The objectives of the program are to:
• Protect students, patients, staff, herein known as “Clinicians”, and the
environment from biological and chemical hazards
• Follow OSHA and CDC guidelines that promote health and safety of health care
workers
• Provide knowledge of how to safely practice dental hygiene
• Augment the student's textbooks with practical "hands on" knowledge of
procedures
The program includes:
1. Student/Faculty Information and Training
In addition to this manual, all Clinicians will receive annual health and safety
instruction on infection control procedures, proper use of all materials and
equipment, and exposure control protocols. This lecture content is presented
during the beginning weeks of each academic year.
Education in this program involves
• Bloodborne pathogens and hazardous chemicals
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MSDS sheets available in the clinic and laboratory
Clinicians knowledge requirements on hazardous chemicals in our workplace
Clinicians methods of controlling exposure and personal precautions for
preventing the transmission of bloodborne pathogens and handling products
that contain hazardous chemicals
2. Updating
Revisions to the manual and course materials will be made at least annually. Minor
revisions will be made during the year, as needed. Changes, after the initial annual
publication of the Exposure Control Program, will be presented verbally during
classes and in writing, if new or modified tasks and procedures that affect
occupational exposure are implemented.
3. Container Labeling
The Programs in Dental Education faculty will verify that all containers received for
use will:
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be clearly labeled as to contents
list the manufacturer's name and address
if a secondary bottle is replenished, its contents will be emptied and the
expiration date of the refill contents will be written on the bottle.
4. Material Safety Data Sheets (MSDS)
For all hazardous chemicals in our clinic and laboratories there are Copies of MSDS
sheets stored in notebooks marked "MSDS". The MSDS notebooks are located in
the clinical area or sterilization room. If MSDS are not available or new chemicals
in use do not have an MSDS, contact the Clinic Manager. MSDS forms are also
available through Internet Resources.
5. Clinic Coordinators are the designated employees responsible for maintaining
and overseeing this plan during their clinics and labs.
6. Clinic Coordinators are responsible for maintaining records and assuring
security in confidential situations.
Immunization Program
Dental personnel are considered to be at substantial risk for acquiring or transmitting
Hepatitis B, influenza, measles, mumps and varicella. Clinicians are advised to receive
vaccinations for these diseases prior to the entry in the program.
Risk of exposure to HBV is high and immunization protocol must begin prior to
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September 30 of the 1st year in the professional program. If necessary, a declination
statement for the Clinician will be available. The Clinician’s personal physician serves as
the primary source of counseling and advisement regarding the titer level after
completion of the vaccine series.
C. BLOODBORNE PATHOGEN STANDARD INTRODUCTION
The Federal Occupational Safety and Health Administration (OSHA) states that dental
health care workers (DHCW’s) are at risk of exposure through skin, mucous membrane,
or parenteral contact to disease producing micro-organisms, which may be transmitted
in human blood and other body fluids during routine patient care.
Hepatitis B virus (HBV), Hepatitis C, Herpes Simplex Virus, and Human Immunodeficiency Virus (HIV) are major concerns. However, other diseases may be transmitted
in a similar fashion.
The Bloodborne pathogens standard is OSHA's regulation, which describes how to
determine who is covered and the ways to reduce workplace exposure to Bloodborne
pathogens in the health care industry. It consists of an Exposure Control Program which
includes identification of job classifications, tasks where there is exposure to blood and
other potentially infectious materials (OPIM), a description of how the standard will be
implemented, how it will be communicated to health care workers, hepatitis B
vaccination, post-exposure evaluation, follow-up, record keeping and implementation of
the methods of compliance such as:
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Personal protective equipment (PPE)
Housekeeping and waste disposal
Engineering and work practice controls
Procedures for evaluating exposure incidents
A copy of the PowerPoint/DVD presentation on these subjects that is presented each
semester is available.
Standard Precautions
"Standard Precautions" is the term given to describe the primary approach to infection
control. Standard Precautions combines the major features of standard precautions and
body substance isolation; integrates, and expands those elements into a standard of
care designed to protect Health Care Workers and patients from pathogens that may be
spread by blood or secretion. All treatment materials are considered contaminated
because it is impossible to determine which patients are infectious for bloodborne
pathogens from data recorded by the patient on the medical history or from the
patient's verbal comments. To prevent contact with potentially infectious secretions
(saliva, blood, mucous, etc.), personal protective equipment (PPE) will be worn during all
patient contact.
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Standard Precautions include:
• Washing hands before and after every patient contact
• Wearing gloves when touching blood, body fluids, secretions, and contaminated
items
• Wearing a mask and eye protection, or a face shield during procedures likely to
generate splashes, sprays, or aerosols of blood, body fluids, secretions, or
excretions
• Handling used patient-care equipment and barriers in a manner that prevents
the transfer of microorganisms to people or equipment
• Using care when handling sharps
Exposure Categories
During the course of training in clinical and laboratory courses, Clinicians will contact
blood/and or body fluids. To protect themselves from exposure they will use PPE and
adhere to procedures of personal protection taught in their classes.
STUDENTS AND CLINICAL STAFF - During patient care: personal protective gear as
described herein is required.
CLERICAL STAFF - (including students who may have occasional unplanned contact with
blood products, during clean up, handling instruments, materials, etc.) will be aware of
potential contamination during tasks they perform and will use protective equipment
when indicated.
STAFF - who have no exposure to blood or body fluids, who never give emergency
medical care, who only "touch" surfaces are pens, pencils, phones, etc. are not affected.
Personal Habits and Eating
Eating, drinking, applying cosmetics or lip balm, handling contact lenses, etc. in work
areas, where there is a reasonable likelihood of exposure to hazardous or infectious
materials, is prohibited. Contamination of hands and containers may occur, which could
transmit infection to the Clinicians. Dental health programs facilities and instrument
“contaminated” centers are examples of hazardous areas. Clinicians shall not store
consumables in any area where bloodborne pathogens may contaminate the area.
Clinicians may be excused from clinic, if they have open lesions on their hands or a
communicable disease, which could be passed to patients or fellow students.
Fingernails shall be kept short and even with the pad of the finger so that when viewed
from the palm side of the hand the fingernails cannot be seen. Only sheer or pastel nail
color will be allowed and should not be chipped or worn.
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D. STANDARDIZED PROTOCOLS
Indiana University South Bend Programs in Dental Education uses the following
standards for guidance and completion of tasks within the dental facilities.
STANDARD #1
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Personal Protective Equipment (PPE) includes clothing and equipment worn specifically
as protection during potential contact with bloodborne pathogens (blood, saliva,
mucous membranes, or OPIM), or while handling hazardous materials. The Clinicians
will use the appropriate PPE designated for each task.
The proper use of PPE will prevent potentially infectious or hazardous materials from
contacting the Clinician’s street clothes, clinical scrubs, undergarments, skin, eyes,
mouth, or other mucous membranes under normal conditions of use and for the
duration of time, which the protective equipment is used. Dedicated professional PPE is
to be worn only while working in the clinic and learning labs. Lab coats and disposable
overgowns are not to be worn outside of clinic.
The program will provide non-latex gloves and utility gloves for clinic and laboratory
classroom tasks; however, students are responsible for purchasing and maintaining
protective eyewear (including side shields), gloves, and masks for individual patient
treatment. Students will also purchase their own scrubs and lab jackets. The program
will launder the lab jackets and house them on-site.
Gloves are worn only in the clinic, and are worn for all situations when exposure to
blood or body fluids may be anticipated. Gloves are single use items and must not be
reused. Hands are washed with an antimicrobial soap or an alcohol-based hand rub
before/after glove removal. Nitrile/synthetic gloves may be worn to reduce problems
with sensitivity and allergy to latex. Boxes of latex and synthetic/vinyl are separated in
dispensing areas.
For routine clinical procedures, examination gloves are used. A new pair is used for each
patient and changed during the appointment when torn, punctured, or when a great
deal of hemorrhage/contamination occurs over an hour's duration. Gloves are removed
when leaving the treatment area and hands are washed with an antimicrobial soap or
an alcohol-based hand rub immediately upon glove removal.
Utility gloves are worn for cleaning and sterilizing instruments. These heavy-duty gloves
are autoclaved following use. Utility gloves are located in the sterilization room and in
each student’s bin located in the sterilization room.
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Glove Integrity: Gloves have limitations and may develop defects. They provide
protection against transfer of body fluids, but are inadequate protection against
penetration by needle stick or "sharps." If the integrity of the glove is compromised
(torn, punctured) it should be changed immediately.
Some HCWs and patients are allergic to latex. Non-latex gloves are available. In the
event of an adverse reaction to latex gloves, emergency protocols are followed.
Emergency protocols can be found in the Emergency Procedures Section 5 of this
manual.
Gloves are discarded in the unit waste containers or other trash receptacles. Blood
tinged gloves; gauze and other disposables are contained and disposed of in paper bag
receptacles at each unit.
Masks are required for the majority of procedures within the dental clinic. They provide
protection from inhalation of aerosols, while they are dry. If they become wet, the mask
is changed. Masks used in the dental clinic have a 95 percent filtration efficiency. Masks
are changed for each patient and handled only by the ear loop or periphery, after glove
removal and handwashing. Masks are molded/pinched over the nose, pulled snugly
under the chin and secured to prevent inhalation of aerosols.
The mask and protective eyewear are placed on the face before hand washing and
donning gloves. Masks are not touched during treatment.
Protective eyewear is required at all times when there is a probability of exposure from
airborne debris to the mucous membranes of the eye.
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Eyewear consists of glasses with solid side shields, goggles, or face shields. It
must fit comfortably and remain securely in position at all times
Do not touch eyewear with contaminated gloves
Eyewear shall be worn during dental treatment, mixing chemicals, working in the
dental materials laboratory, contaminated instrument procedures, assisting a
fellow Clinician, and performing routine housekeeping tasks
Eyewear can be satisfactorily cleaned with soap and water and disinfected
between patients
Patient eyewear must be disinfected between patients
Scrubs/lab jackets: The goal is to protect the Clinician’s skin from contact with
hazardous chemicals and bloodborne pathogens. Laundered lab jackets are worn over
scrubs and will be changed immediately when soiled. To provide maximum protection
to all exposed skin, lab jackets should have cuffed sleeves and provide coverage of the
operators’ lap, secured by button closure on the front; they should also cover the
operator’s neck.
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The instructors wear laundered lab jackets. Lab jackets exposed during patient care
must never be worn outside the treatment area.
*No gowns, gloves, or masks may be worn outside the clinical treatment area.
STANDARD #2
HAND WASHING and GLOVING
Sinks, germicidal soaps, and disposable towels are located at the ends of the center
islands and in the laboratory facility. Alcohol-based hand rub for hands that have no
visible debris, is available throughout the clinic/radiology areas.
Prior to hand washing:
• Fingernails will be inspected to ascertain that they are short and even with the
finger pad. Nails that are long are trimmed at this time. Pastel or sheer nail
colors are acceptable but should not be chipped or worn.
• No jewelry is allowed. Rings and wrist jewelry (including watches) shall be
removed.
When to wash with soap and water:
• In the morning, prior to beginning the day's treatment
• Before and after eating
• At the end of the day
• After using bathroom
When to use an alcohol-based hand rub
• If gloves become punctured or torn and need to be removed
• After removing gloves or other PPE
• Between patients, before changing into fresh gloves
• Anytime contact is made with potentially contaminated surface by a bare hand:
touching a fomite contaminated with blood, saliva, or respiratory secretions
Handwashing Protocol
• Remove visible debris from hand and arms with appropriate cleaner. Do not
abrade skin by using a brush or sharp instrument
• Wet hands and wrists under cool running water
• Dispense sufficient soap to cover hands and wrist
• Rub the hand washing agent gently onto all areas -- with particular emphasis on
areas around nails and between fingers -- for 15 seconds minimum before
rinsing under cool water
• Dry hands thoroughly with a separate paper towel for each hand
• Apply an alcohol-based hand rub
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GLOVES
Patient Treatment Gloves are worn:
During patient treatment only, including x-ray procedures:
• Patient should observe operator putting on new gloves prior to
treatment
• Gloves are changed between patients or if punctured, ripped or torn. It is
also advisable to change gloves after prolonged treatment
• No jewelry is worn under gloves
Utility Gloves are worn:
When cleaning and sterilizing instruments:
• Whenever handling contaminated sharps, until those items are wrapped
for sterilization or disposed of
• When cleaning HVE System (glasses and mask also)
• During unit preparation and clean up
• Rinse after use, dry, and sterilize. Gloves are sterilized after each use.
• Gloves will be placed in an autoclave tray, indicator tape will be placed on
the tray with each load of gloves
• Student’s sterilized utility gloves are stored in the DH Sterilization Room
in student bins. Clinic supply sterilized utility gloves are stored in the DH
Sterilization Room
Technique for treatment gloving:
• All other protective PPE gear is applied first
• Gloves are the last PPE applied prior to patient care
• Hold glove by folded portion of cuff to avoid contact with external surface, and
insert the opposite hand
• Place the fingers of the gloved hand into the folded area of the second glove and
pull on
• Pull the folded portion of the first glove up using the now gloved opposite hand
• After use, remove gloves by grasping the external surface of the glove near the
cuff and folding inside out. Do not “snap” the gloves off
• Discard gloves appropriately, and then wash hands
• If gloves are penetrated or become damaged during use, they should be
removed, hands washed, and fresh gloves donned
After washing and gloving:
• Minimize "touch" surfaces. Touch only the inside of the patient’s mouth, sterile
or disinfected items, or surfaces adequately covered with barriers
• Petroleum products break down latex. Water soluble lubricants are the only lip
lubricants available in our clinic. Special hand creams that do not break down
latex are also available in our clinic.
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STANDARD #3
MINIMIZING AEROSOLS AND DROPLETS
Aerosols will be controlled or reduced by using procedures to contain aerosol
contamination.
Equipment that creates aerosols includes:
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Ultrasonic scaler
Ultrasonic instrument cleaner
Air/water syringe
Air polisher
Oral irrigation devices
High velocity evacuation is recommended to prevent the dissemination of droplets and
aerosols during the use of the ultrasonic scaler or air polisher.
A pre-procedural rinse with an antimicrobial mouthwash is always used to further
reduce potential pathogens.
STANDARD #4
PATIENT CARE
Assess the dental unit area, clinic counters and remove or relocate any materials not
necessary for patient care.
SETUP
• Wash hands using the protocols
• Don appropriate PPE (utility gloves, mask, eye protection)
• Apply disinfectants to items/surfaces that can be disinfected, per manufacturer’s
instructions
• Pre-clean and disinfect surfaces
• Remove gloves and disinfect
• Apply an alcohol-based hand rub
*PRECLEANING - A basic principle of infection control is to start with clean surfaces.
Disinfection will only be effective on clean surfaces. Precleaning means to remove
debris, blood or body fluids and soil from environmental surfaces and instruments
(counter tops, cabinets, etc.) with an appropriate disinfectant/cleaner or ultrasonic
cleaning (for instruments).
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Surface/Item Decontamination/Disinfection
Many surfaces could become contaminated during dental procedures. If a surface is
contaminated, it should be cleaned and disinfected. If it cannot be cleaned and disinfected, it
should be covered with a barrier that is impervious to liquid. Barriers must be single use and
replaced between patients.
Disinfection is a two-step/wipe process involving pre-cleaning and removal of surface debris
prior to application of disinfectant. After the cleaning step, the area is sprayed or wiped with an
EPA registered tuberculocidal disinfectant. The surface is allowed to remain wet for the length of
time specified by manufacturer.
During patient care:
• Patient performs a pre-procedural rinse with Listerine
• Barriers are used when making chart entries in the computer
At the completion of patient care:
• Remove treatment gloves
• Wash hands with an alcohol-based hand rub
• Remove any items that were not contaminated from the treatment area. This includes all
patient records
• Don clean utility gloves
• Any local anesthetic needles should be recapped using the “scoop” techniques
• All items to be sterilized should be placed on the patient tray or instrument cassette
• Using a double wipe method, saturate A/W syringes holders and hoses, HVE/saliva
ejector holders, handpiece connectors and hoses, etc. These items will be disinfected
according to the instructions provided by the disinfectant’s manufacturer
• After the first wipe/disinfection take the contaminated tray/instruments to the
sterilization room
• In the sterilization room, contaminated items that cannot be placed in the ultrasonic
bath shall be rinsed under running water and placed on paper towel to dry
• If there are sharps on the tray, remove them and place them in the sharp’s container
• Return to the dental unit and begin second wipe disinfection
• After the recommended disinfectant exposure time, and having removed the gloves used
for disinfection, the unit can be set up for the next appointment.
PROSTHETIC APPLIANCE MANAGEMENT
These items cannot be sterilized in the clinic.
Prior to cleaning any removable prosthetic appliance, have the patient seat the appliance in
their mouth. Check to see that the appliance is secure and properly fitted. Check clasps, plastic,
etc. Inform the patient of findings and document.
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While wearing treatment gloves and other PPE, ask the patient place it in a labeled resealable
bag. Take the appliance to the ultrasonic cleaning area. Fill bag with stain and calculus removal
solution enough to cover the prosthesis. Place the bag in a beaker with water, and then place
the beaker into an ultrasonic unit for 10 minutes. Remove the beaker from the ultrasonic but do
not set down in a contaminated place, like the sink. Then drain and rinse out the bag while
holding firmly onto the prosthesis through the bag and fill bag with water. Place bag back into
the uncontaminated beaker and deliver chair side of patient.
Prior to returning the prosthesis to the patient (donning treatment gloves) evaluate the
prosthesis for deposit removal. If additional deposit removal is necessary, careful scale outer
surfaces of the appliance at chairside. Have patient inspect the appliance before placing it in
their mouth. Record in the clinic notes that appliance was returned to the patient undamaged.
Rinse, wipe and disinfect beaker.
ULTRASONIC UNIT CLEANING/TESTING
At the end of the day, Clinicians wearing PPE will drain all solutions from the tanks. If debris is
visible, flush the tank with water. Finally, wipe the tank with the appropriate disinfectant wipes.
To test the unit for efficiency, use a piece of aluminum foil that is 4 x 6 inches and submerge in
the unit for a 20 second cycle. Remove and hold up to the light. Examine the aluminum for
holes. The hole should be uniform is size and spacing. If holes are not uniform or absent the unit
should be repaired or replaced.
STANDARD #5
ITEMS TO BE STERILIZED
During instrument cleaning in preparation for sterilization, heavy duty utility gloves are required
along with protective eyewear, face mask and appropriate barrier attire.
(No type of glove provides complete protection against injury from sharps. All disposable sharps
should be removed and immediately placed in the sharp’s container.)
INSTRUMENT TRANSPORT - Instruments are transported carefully on the tray used for treatment
to the sterilization room.
WASTE DISPOSAL - Dispose of waste in general disposal waste.
ULTRASONIC CLEANING - This is the safest and most thorough method of cleaning. Appropriate
PPE must be worn at all stages. Utility gloves are required during all instrument handling.
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Prepare 2 gallons of fresh solution for each ultrasonic unit
Place instrument set ups in the bath in closed containers/cassettes
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Do not overload the container, be sure all instruments are covered, keep the lid on while
operating, and operate the ultrasonic units for 5-10 minutes
When the unit is “Off”, remove instruments
Items are not added during the cycle
Instruments are removed, rinsed under running water, and air dried on paper towels.
(Eliminate handling of sharp instruments as much as possible.)
The ultrasonic solution is changed daily. The solution is always considered infectious
Clean and disinfect the unit at the end of the day. Contaminated solution is washed down
the sink by opening the automatic drain. Thoroughly wipe the inside of the tank with
disinfectant wipes
PACKAGING FOR STERILIZATION
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Instrument baskets/cassettes, that have been processed in the ultrasonic cleaner are
rinsed, then placed on reusable/washable towels at the packaging area for limited drying
Individual or multiple instruments may be packaged in autoclave bags
Cassettes are bagged in the largest reusable sterilization bag, taped and labeled with
student’s last name and ranking (1st or 2nd year) for storing in student designated bins
STANDARD #6
STERILIZATION
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All items that can be steam sterilized shall be processed between patients
Read and follow the manufacturers’ manuals that apply to each autoclave
Recommended temperature, pressure, and time shall be followed
All cassettes and packages are stacked loosely within the chambers
After the drying cycle and prior to removal, all packages/cassettes are inspected for
integrity, dryness and chemical indicator changes
After sterilization, items are returned to student storage bins or their storage areas in the
clinic areas
STERILIZATION MONITORING
The facility uses chemical and biological monitoring
Chemical
• Autoclave tape is used on all wrapped cassettes
• All pouches have indicators
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Biological
• Biological monitoring Is the most accurate determination of sterilization
• Biological monitoring is conducted according to the autoclave’s use
• Biological indicators are incubated and sent to STERILIZATION MONITORING SERVICE,
INFECTION CONTROL RESEARCH & SERVICES, Indiana University School of Dentistry
• Results are effectively monitored and documented
• Sterilization tape is used on wrapped cassettes
• Sterilization pouches with chemical indicators shall be used for loose instruments
• Pouches are sealed completely, folding seals and labeling
HANDPIECES – All hand pieces are cleaned and disinfected following patient care using a twowipe, high level disinfectant. Disposable prophy angles/brushes are used with all handpieces.
Utility gloves are sterilized following use. Wash your hands after removal!
STANDARD #7
SHARPS AND NEEDLE MANAGEMENT
Potential bloodborne pathogens can perforate intact skin by improper handling of the following
item in the DH clinic:
• Local anesthetic injection needles
• Scalers
• Curets
• Explorers
• Irrigating syringes
The most common reasons that lead to an exposure include:
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Distraction or hurrying while removing/discarding sharps
Packaging instruments improperly
Sharpening instruments during patient treatment
Wiping debris from instruments using hand held gauze square
Not scooping or using a recapping device to recap a needle
STANDARD # 8
WASTE DISPOSAL / HOUSEKEEPING
PATIENT TREATMENT ITEMS
General use gauze squares are contained inside a trash receptacle located chairside. Heavily
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blood-soaked (dripping with blood) gauze should be contained in a brown bag chairside and
then autoclaved in an autoclave bag or bag securely fastened with autoclave tape; then disposed
of in general clinic disposal.
SHARPS - Contaminated "one time use" sharps are considered "infectious waste" and are placed
in red sharps containers. Sharps (needles, scalpels, etc.) are regulated waste. Sharps
containers are disposed of using the University’s Hazardous Materials Plan found at
https://www.iusb.edu/safety/ and copied below:
Waste Disposal
Waste Minimization
The Resource Conservation and Recovery Act (RCRA) outlines proper hazardous waste
management, placing special emphasis on waste reduction and recycling. Through waste
minimization, you can help reduce unnecessary expenditure of university funds on waste
disposal and material procurement by following the guidelines below.
Inventory your chemicals: The most important step you can take toward waste minimization is
to maintain a running inventory of chemicals present in your lab. An inventory will prevent you
from ordering more of what you already have. It also helps you to store chemicals properly and
can be an invaluable tool in emergency situations.
Order only what you need: Please consider that the economy of larger sizes may be offset by
the cost of disposing your excess. Before ordering chemicals, check your current stock; and it
may be possible to borrow small amounts of chemicals from other labs. It pays to take the time
to check.
Substitute non-hazardous or less hazardous materials: There are many non-hazardous
substitutes for commonly used chemicals, such as chromic acid. Other alternatives may be much
less toxic. These substitutions can be done with satisfactory results in most cases.
Do not mix hazardous and non-hazardous waste: Non-hazardous waste, when mixed with
hazardous waste, will become hazardous itself. Do not mix small quantities of hazardous waste
with non-hazardous waste because it will increase the volume of hazardous waste produced.
Likewise, high concentration waste should not be mixed with low concentration waste.
Biohazardous Waste Disposal
The Office of Environmental Health and Safety is responsible for ensuring the proper
management and disposal of all biohazardous waste generated on the IU South Bend campus.
Biohazardous waste is broadly defined as all biological waste (or biologically contaminated
waste) that could have the potential to cause harm to humans, domestic or wild animals, or
plants. Specific examples of biohazardous waste include cell cultures or animal tissues
containing infectious agents or recombinant DNA; or human tissue, blood, or fluids.
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Hazardous Waste Management
IU South Bend generates a wide variety of hazardous wastes. An institution this size has a
diverse set of operations ranging from academics to the maintenance of buildings. Nearly all
facets of the university community generate some form of hazardous waste.
Household Hazardous Wastes
Many common household products have hazardous properties. Look for the words Danger,
Warning or Caution on the product label. They are used in cleaning, home improvement
projects, automobile maintenance, lawn and garden care, and a variety of other tasks. In order
to protect our health and the environment, we must know how to properly use, store and
dispose of these products.
Recycling
Recycling is a series of activities that includes collecting recyclable materials that would
otherwise be considered waste, sorting and processing recyclables into raw materials such as
fibers, and manufacturing raw materials into new products.
STANDARD #9
PATIENTS’ PAPER and ELECTRONIC CHARTS/RECORDS
Charts and computer equipment are maintained as clean surfaces. A patient paper chart is
obtained from the dental reception office with clean, glove free hands.
PRIOR TO PATIENT CARE – Review all records and ensure patient electronic record is ready for
viewing/entry on the monitor.
DURING PATIENT CARE - Treatment gloved hands are never to touch the patient records or
computer equipment unless a plastic barrier impervious to liquid is in place.
COMPLETION OF PATIENT CARE – All paper charts and x-rays are removed from the dental unit
area, prior to cleaning/disinfecting.
STANDARD #10
DENTAL WATERLINES – Every time the water bottle is filled, an enzymatic tablet, found in the
sterilization room, must be used. Further procedures are in the Clinic Procedures Manual in the
sterilization room.
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STANDARD #11
ENGINEERING AND WORK PRACTICE CONTROLS
• Engineering and work practice controls shall be used to eliminate or minimize employee
exposure
• Personal protective equipment shall be used when occupational exposure may occur
even though the engineering and work practice controls are in place
• Hand washing facilities shall be provided and maintained with adequate supplies
• Hand washing shall be performed after removal of gloves and after contact with blood or
OPIM
• Alcohol –based hand rub are available for use if the hands have not become visibly soiled
• Contaminated sharps and needles shall be disposed of in puncture resistant, color-coded,
or labeled, leak-proof containers
• Eating, drinking, handling contact lenses, and applying cosmetics are prohibited in work
areas where there is a potential for blood or OPIM exposure
• Food and drink are prohibited in work areas where there is a potential for blood or OPIM
exposure
• All procedures involving blood and OPIM shall be performed in such a manner to
minimize splashing, spraying, spattering, generation of droplets, or aerosols of these
substances
• Using mouth mirrors instead of fingers for retraction
• Resuscitation devices, including mouthpieces or resuscitation bags, shall be available in
the clinic
E. PROCEDURES FOR EXPOSURE INCIDENTS
Exposure incident: The Bloodborne Pathogens Standard defines an exposure incident as:
• Any percutaneous inoculation with contaminated instruments or needles, (cuts,
abrasions, needlestick, punctures)
• Entry of blood or OPIMs through wounds or unprotected breaks in the skin
• Splattering or splashing of blood or OPIMs onto mucous membranes
Exposure to the patient’s blood or saliva on the UNBROKEN SKIN IS NOT CONSIDERED
SIGNIFICANT (not an exposure incident).
Responsibility at chairside
• Awareness of patient’s medical history
• Care in the manipulation of contaminated instruments
• Reporting to supervising faculty any incident of exposure, regardless of the patient’s
history
F. MANAGEMENT PROTOCOL FOR EXPOSURE INCIDENTS
(The information included here is ALSO posted on the OSHA Bulletin Board in the Dental Hygiene Sterilization Room)
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Preventive measures for students, faculty at chairside
• Wear barrier devices with all patients
• Update and review patient's medical history for hepatitis B, Non A Non B, HIV or other
infectious or high risk categories for such infections
Responsibility of Supervising Faculty:
Before completing the EXPOSURE INCIDENT REPORT:
The faculty member should ensure that the exposed clinician has washed the site thoroughly
with soap and water and applied a protective covering. In case of eye injury, eye/s should be
washed for 15 minutes at the eye wash unit located in the DH clinic and Lab Classroom 1233.
Wall-mounted first-aid kits are located in the hygiene clinic, in Classroom 1231 and 1233.
1. If exposure occurs (with any patient), talk with student, and assess and determine
procedures for student to follow
2. Complete the IU South Bend Dental Education EXPOSURE INCIDIENT REPORT (copy is
posted on the OSHA Bulletin Board located in the sterilization room)
3. Before source patient is dismissed, describe what has happened
a. Ask patient to consider voluntary blood testing for HIV, HBV, and HCV unless their
status is known. The clinician will be informed of the results of this test as
permitted by the source individual.
b. If the source patient declines testing, the exposed clinician shall still be referred
to physician/hospital for evaluation. The exposed person has the right to receive
hepatitis or HIV serological testing under any circumstance.
4. Sign the REQUEST FOR POST-EXPOSURE BLOOD TESTS.
5. The exposed person and the source patient (if consent is given) may make appointments
at the designated facility below. Give directions (see following document) to the
exposed clinician and source patient. Exposed clinician may choose to be evaluated by
their personal health care provider to minimize additional costs for testing.
6. Make photocopies of the EXPOSURE INCIDENT REPORT and REQUEST FOR BLOOD TESTS
and give copies of both forms to the exposed clinician and to the source patient.
7. Give originals to Director of Programs in Dental Education.
8. Inform department secretary of incident so she may begin a purchase order for the
source patient’s blood work.
*Note: if the exposed is an IU South Bend Employee, an IUSB Occupational Injury
Illness Report must also be completed within 24 hours and sent to Human
Resources.
** Expenses for post-exposure evaluation and follow-up for the exposed student
will be the responsibility of the student.
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423
424
G. Map of HEALTH CARE FACILITY for Post-Exposure Blood Tests
South Bend Medical Foundation
530 North Lafayette Blvd.
South Bend, Indiana 46601
(574)234-1157
Contact: http://www.sbmf.org/index.php/webpages/contact for more locations
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H.
Indiana University South Bend
PROGRAMS IN DENTAL EDUCATION
EXPOSURE INCIDENT REPORT
EXPOSED PERSON/CLINICIAN ____________________________________________________
Date of exposure _________Exposure Setting: Clinic_______ Sterilization Room ____________
Hepatitis B vaccination status: ______________________________
Puncture/Laceration _______ mucous membrane/other non-intact skin contact _____________
Facility name if off-site: ___________________________________________________________
Barriers used: gloves (type) ________________ mask _______ eyewear _______ gown _______
SOURCE PATIENT (if identifiable)
________________________________________________________________
Has been informed: yes _______ no ______Consent for blood tests:
yes _____ no _______
Have appointments been arranged:
Exposed Person
yes _______ no _______
Source Patient
yes _______ no _______
Source Patient Address: ____________________________________________________
___________________________________________________
Telephone:
Home (
)
_
Work (
) __________ Cell (
_)___________
-------------------------------------------------------------------------------------------------------------------------------Information below to be obtained by a Faculty Member and the Exposed Person:
Circumstances surrounding exposure (specify injury site):
______________________________________________________________________________
______________________________________________________________________________
Recommendations to prevent/minimize recurrence:
______________________________________________________________________________
Faculty Signature _________________________________Date _________________________
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I.
SUBJECT:
Request for POST-EXPOSURE BLOOD TESTS
From:
Indiana University South Bend
Programs in Dental Education
P. O. Box 7111
South Bend, IN 46634
To:
South Bend Medical Foundation
530 North Lafayette Blvd.
South Bend, Indiana 46601
(574)234-1157
EXPOSED PERSON: (named in the attached Exposure Incident Report)
1. Anti-HIV
2. Anti-HBs
SOURCE PATIENT: (if one is identified in the Exposure Incident Report)
1. Please provide Post-Exposure Source Patient Testing for the following patient:
__________________________________________________________________
Name
__________________________________________________________________
Address
City
State
Zip
__________________________________________________________________
Telephone (home)
Alternate (work)
(cell)
2. Determine infectious status of this source patient:
______Presence of HBsAG
______Presence of HCV antibody
______Presence of HIV antibody
3. Please obtain patient release for the results of the Post-Exposure Tests to be sent to:
Director, Programs in Dental Education
1002 S. Esther St.
South Bend, IN 46615
IU South Bend Dental Education will pay for the blood tests ordered above for the source patient (if one is
identified). It is the responsibility of the exposed student to pay for all of his /her tests, vaccinations,
boosters, etc. that may be recommended in the PEP (Post Exposure Prophylaxis).
In accordance with the OSHA requirements, notify the Director of Dental Education at the above address
that you have informed the exposed person and the source patient of the evaluation results and the need
for further follow-up.
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J. STANDARD PRECAUTIONS AND PATIENT’S RIGHTS
Health care facilities providing services in which there is a risk of skin, eye, mucous membrane, or
parenteral (broken skin) contact to human blood or other potentially infectious materials must practice
standard precautions.
STANDARD PRECAUTIONS means the prevention of disease transmission through the use of infection
control practices with all patients.
This clinic complies with the exposure control practices required by the Indiana State Department of
Health (ISDH), which were adopted by Indiana law, Indiana Occupational Safety and Health
Administration (IOSHA) standards and Centers for Disease Control and prevention (CDC)
recommendations.
The following infection control practices include, but are not limited to; those required by the Standard
Precautions Rule and are used to prevent transmission of bloodborne pathogens to patients and treating
staff:
o Appropriate use of protective barriers, including gloves for hand contact, masks, gowns,
laboratory coats, and protective eyewear or face shields are used for procedures having the
potential of creating a spray or splatter of blood or other potentially infectious materials.
o Gloves, when required, are changed and hands are washed after each patient with an alcoholbase hand rub or with soap and water if visibly dirty.
o Heat stable, non-disposable instruments requiring sterilization that are contaminated with blood
or other potentially infectious materials are heat sterilized after treatment of each patient.
o Precautions are taken to prevent injuries caused by needles, scalpels, and other contaminated
sharp instruments during procedures.
o Disposable contaminated sharps, needles, syringes, and other contaminated sharp objects are
discarded in puncture-resistant containers.
o Surfaces and equipment contaminated with blood or other potentially infectious materials that
need not be sterilized are cleaned and disinfected after treatment of each patient. Disposable
coverings may be used on some surfaces to prevent expulsion.
o Infectious waste is placed in containers labeled with the biohazard symbol, impervious to
moisture and of sufficient strength to prevent expulsion.
o Containers of infectious waste are stored in a secure area prior to treatment and final disposal.
o Patient care staff receives training on infection control.
The exposure control procedures listed and others that are not readily observable protect you from
disease transmission. Indiana law requires that health care facilities be committed to appropriate use of
standard precautions. Any deviation from this commitment should be brought to the attention of
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Interim Director, Kim DeOrto. If you are not satisfied with the explanation of standard precautions
provided by this facility, you may file an official complaint with the Indiana State Department of Health by
writing to the following address:
Indiana State Department of Health
c/o Standard Precautions Coordinator
1330 West Michigan Street
P. O. Box 1
Indianapolis, IN 46206-1964
(317) 633-0825
Revised 1999
K. HAZARDS COMMUNICATION PROGRAM
A hazardous substance could cause physical damage to an individual from inhalation, absorption, or
ingestion.
CRITICAL FACTS
•
•
•
•
•
•
•
•
Consult the MSDS sheets for detailed information on any chemical
Read labels and use products as directed by the manufacturer
Store chemicals in their original containers
Use PPE as indicated (gloves, masks and eye protection)
Wash hands immediately after removing gloves
Never mix chemicals, unless directed by the manufacturer
If a chemical exposure occurs, immediate action is required
Know the guidelines for treatment, after an exposure – flushing eyes, rinsing skin, removing
exposed articles of clothing, etc.
WORK PRACTICE CONTROLS
These reduce the risk of injury by changing the manner in which the procedure is performed.
•
•
•
•
•
•
•
•
Wear PPE when performing a potentially hazardous task
Recap anesthetic needles with one handed scoop method or recapping device
Use instruments, instead of fingers, to retract tissues
Pass instruments with sharp end pointed away
Maintain appropriate care during the passing of instruments
Minimize handling during clean up...cassettes, ultrasonic cleaning
Use utility gloves during clean up
Grasp the sterilization pouch in the middle, when loading the autoclaves
HANDPIECES
•
Use standard precautions during operation
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ORAL IRRIGATING DEVICES
•
•
Use standard precautions during operation
Recap needle using scoop protocol and dispose of sharps properly
ULTRASONIC SCALER
•
•
Use gloves, fluid resistant mask, protective eyewear
Use HVE if possible
CURING LIGHTS
• Use light protective glasses for operator and patient
• If protective glasses for the operator are not available, place a shield over the light surfaces
during application of sealant material
• Do not look directly at curing light source
STUDY MODELS
• Contaminated models are disinfected prior to handling.
INSTRUMENT PREPARATION AREA
• Utility gloves and PPE when loading autoclaves or disinfecting trays
ULTRASONIC CLEANER
• Utility gloves and PPE when mixing the solution, loading and unloading items, and draining/cleaning at
the end of the clinic session
• Cover lids must be in place before activating
AUTOCLAVE
• Use PPE for loading contaminated items
• Remove contaminated gloves and wash hands before operating the autoclaves
• Do not touch the metal doors during operation
• Keep your face and hands away from the door, when opening the door after the chamber has been
vented
• Use heavy duty mitts, if an item must be retrieved while still hot
EVACUATION SYSTEM CLEANER
• Wear appropriate PPE when mixing or dispensing
• HVE/saliva ejector holders will be disinfected, prior to handling
• Follow the manufacturer’s instructions for use
X-RAY PROCESSOR
• Wear appropriate PPE when adding, changing chemicals, or cleaning processor
• Lead liners from x-ray packets shall be recycled
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LABELING
• Biohazard labels are placed on containers or counter tops, which may contain or become contaminated
by potentially infectious materials
• All chemicals should be stored in their original containers or others with the appropriate manufacturers’
labels intact and readable
• Solutions dispensed to another container for immediate use, do not require labels
• When the 1:10 bleach solution is prepared, check the containers for intact labels
MSDS SHEETS
• MSDS manuals are available in the dental clinic and laboratory
• MSDS sheets are provided by the manufacturer for products containing hazardous substances
• Consult the MSDS for cleanup of any spills
• Consult the MSDS for proper handling and disposal
RECORD KEEPING
IMMUNIZATION RECORDS - All Clinicians should have: vaccines on record against rubella, influenza, measles, polio,
tetanus, and diphtheria. Hepatitis B vaccine, if not completed or declined, it must be recorded.
AUTOCLAVE TESTING - Records of biological testing are maintained in the department administrative sterilization
monitoring records and available for review.
EXPOSURES INCIDENTS – These confidential records shall be maintained in a secure area in the Programs in Dental
Education administrative offices.
ANNUAL STUDENT/FACULTY/EMPLOYEE OSHA TRAINING
All students/faculty/employees must read this manual, attend the annual training session, and sign a form indicating
such. Records of annual education of students and department employees are maintained in administrative offices of
the Department of Dental Education.
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Section 5
RADIOLOGY POLICIES AND PROCEDURES
A. Harmful Effects of Radiation
501
B. Location of Equipment and Supplies
501
C. Minimizing Radiation Exposure
502
D. Monitoring Exposure To Radiation
503
E. Radiation ALARA Policy
503
F. Radiation Overexposure Policy
503
G. Department Rules for Radiation Safety and Protection
504
H. Safe Operating Procedures
505
I. Exposure Guidelines
505
J. IU South Bend Radiographic Policies and Procedures
507
K. Infection Control and Radiographic Exposure Procedures
508
L. Radiographic Techniques
508
M. Film Processing and Duplicating
510
N. Mailing Films and Images
511
O. Assessing Films and Images
511
P. Interpretation of Radiographs
512
Q. Progress in Radiology Clinic
512
R. Compliance Form
514
Appendix A – Guidelines for the Selection of Patients for Dental Radiographic
Examinations
A-1
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RADIATION SAFETY AND INSTRUCTION MANUAL
The purpose of this manual is to ensure the proper and safe utilization of all radiographic
equipment in the Dental Education Program. It will promote safety awareness of the faculty,
staff, and students and benefit the patients, by instructing all associated dental personnel in the
applicable rules for protection from unnecessary exposure and overexposure to ionizing
radiation.
Why is radiation harmful?
Dental X-rays are a high frequency electromagnetic energy that will ionize molecules in the
body, possibly causing cellular injury or death. Since X-rays are invisible, colorless and odorless,
it could be easy for one to mistakenly assume that they are harmless. However, with a large
dosage, or an accumulation of many small dosages, injury will occur. Scientists cannot predict
the minimum dosage that would cause injury. Therefore, we must assume any amount of
radiation could be harmful.
When considering X-ray exposure, it is important to assess the need for radiographs. Dental
professionals must weigh the “risk vs. the benefit”. The operator should take measures to
ensure that the least amount of exposure is used to achieve the desired result. This radiation
safety manual is a guide to ensure that safety measures are used in the Dental Education
Program.
Location of Equipment and Supplies
The locations of the radiographic supplies, equipment, and documents for the Dental Education
Program are listed below:
1.
Intraoral radiograph equipment is located in Education and Arts rooms 1227 A-E
2.
Automatic and manual processors are located in the Darkroom of the Lab Classroom
(EA1233).
3.
Practice manikins (DXTTR; 3 adults, 1 pedo) are located and stored in EA1233A.
502
4.
All radiographic exposures must be made with the operator outside the room or behind
protective walls to eliminate any measurable exposure to the operator. The rooms meet
requirements for a safe work environment.
5.
No one other than the patient will be in the x-ray room during a radiographic exposure.
6.
A lead apron with a thyroid collar is located in each radiography room.
7.
A panoramic style apron is located in the Pan room (EA1227D), on the wall.
10.
Completed exposure records are kept in the patient’s Dentrix chart.
9.
The master copy of the Radiation Safety and Instruction Manual (Manual) is located in
the Clinic Manual. A copy of the Manual is provided to each student, faculty and staff.
10.
The current equipment registration certificate is posted on the wall of each radiology
room.
11.
The Quality Assurance Plan for equipment is located in the Radiation Safety and
Instruction Manual; current schedules of processing equipment maintenance are posted
in the darkroom and on the automatic processors.
MINIMIZING RADIATION EXPOSURE
Exposure to the patient and operator can be kept to a minimum by keeping the exposures as
low as reasonably achievable (ALARA) using the following patient and operator techniques:
1. Clinical faculty must read the Radiation Safety and Instruction Manual and hold an
appropriate license relative to the exposure of radiographs.
2. Only dental hygiene and dental assisting students that are enrolled in, or completed,
DHYG-H303 Dental Radiology, and H305 Dental Radiology Lab are permitted to operate
the radiography equipment. Dental hygiene faculty may also operate the equipment.
3. Students enrolled in H305 Dental Radiology Lab, are required to read, and sign the
Radiation Safety and Instruction Manual, prior to exposing patients to ionizing radiation.
MONITORING EXPOSURE TO RADIATION
1.
2.
Dosimeter badges are used to monitor exposure to radiation.
Area monitoring badges are affixed to maximum exposure areas outside each room
where radiographs are exposed.
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3.
Badges are exchanged as scheduled and reports are available to all students and faculty.
Reports are maintained in the Program’s office file.
4.
The H305 Radiology Instructor and Coordinator is responsible for exchanging the badges
and maintaining the reports.
RADIATION ALARA POLICY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Use the fastest film speed available (F Speed or digital)
Use proper filtration (2.5 mm when over 70 kVp).
Use proper collimation for small beam size (maximum of 2 ¾” diameter -intraoral).
Use only open-ended, lead lined position indicating device (cone).
Use the 8 inch recessed long cones.
Use a film or digital holder of some type (other than the human finger).
Use proper exposure and processing techniques.
Limit retakes to four per full mouth series under direct supervision of a licensed
practitioner.
Avoid exposing radiographs on a patient who is, or may be pregnant.
In every case, final determination for prescribing radiographs is made by a licensed
dentist who determines what type and number of radiographs are appropriate to
properly diagnose an individual patient’s treatment needs.
Use a leaded apron and leaded thyroid collar for patients having intraoral exposure.
RADIATION OVEREXPOSURE POLICY
In the event of notification of a positive reading through the dosimetry service, the following
steps will be taken immediately for the safety and well-being of faculty, staff, students, and
patients:
1. Determine how many area badges were identified as being “overexposed” by doing
one or both of the following:
a. inquire when notification phone call is received
b. analyze the written report
c. investigate the exposure and badge maintenance with the area involved.
2. Immediately call for service. Cease taking radiographs with the unit in the specific
problem area until safe operation is validated. Continue taking radiographs using
any unaffected units.
In the event that use of one of more units must be ceased while awaiting service and/or
repair, a sign reading “DO NOT USE THIS X-RAY UNIT” will be clearly posted on the
affected unit(s).
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3. Document, in writing, the nature and date of any positive findings, and actions
taken, and place in the Radiation Safety Notebook. Insert a copy of the service
report with findings and repair notes. Service report with positive findings should
include a statement that the unit is now safe to operate.
In the event of notification through a professional inspection of radiation generating
equipment that a unit does not meet safety standards, the following steps will be taken:
1. Cease exposing radiographs with the problem unit(s) until safe operation is validated.
Continue exposing radiographs with units that are not problematic, if available.
2. Schedule an immediate service call and authorize repair or replacement, as
necessary.
3. Insert a copy of the service report with findings and repair notes and/or evidence of
the purchase of new equipment.
DEPARTMENT RULES FOR RADIATION SAFETY AND PROTECTION
The radiation protection policies have been developed specifically for the Dental Hygiene
Program and are detailed in the previous sections of this document.
1. Location of the radiographic equipment and supplies.
2. Use of the lead apron with the thyroid collar for intraoral exposures; use of the
panoramic lead apron for panoramic exposures.
3. Minimizing exposure to radiation.
4. Monitoring of radiation exposure.
5. Managing reported radiation overexposure / failed inspections
ALL FACULTY, STAFF, AND STUDENTS WHO EXPOSE AND PROCESS RADIOGRAPHS IN THE
DENTAL HYGIENE FACILTY MUST:
1. Read and practice the Safe Operating Procedures.
2. Read and follow the Radiation Safety and Instruction Manual.
3. Tour and be instructed (self or group) in using the “Indiana University South Bend” X-ray
facilities.
4. Verify compliance with all of the above by placing signature on file.
5. Verifying knowledge of alterations to the current information by reading and validating
by signature document revisions
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SAFE OPERATING PROCEDURES (S.O.P.)
Indiana University South Bend
Programs in Dental Education
1. Study the standards and the program’s safe operating procedures prior to initially
operating the x-ray machine.
2. Neither the instructor nor student will hold patient films or sensors during exposure, nor
will any other individual be regularly in the room during an x-ray examination
(procedure).
3. Neither the tube housing nor the cone will be hand-held during exposure.
4. During each exposure, the individual operating the x-ray machine will stand at least six
(6) feet from the patient. Only the patient will be in the useful beam. When exposing
radiographs, the operator must exit the radiography operatory and stand behind an
adequately shielded wall. When exposing panoramic radiographs, the operator must
exit the unit area and stand behind the protective wall. The exposure switch location
for all x-ray equipment prohibits activation inside the room.
5. Lead apron shielding is required for all intraoral exposures on all patients regardless of
age or number of exposures.
6. No radiographs will be exposed on a pregnant patient or one who is suspected of being
pregnant unless those radiographs are deemed absolutely necessary for emergency
treatment.
7. X-ray examinations will be performed only as ordered by a licensed dentist.
8. Exposure of a student’s first two patients will be performed only under direct
supervision by a licensed dental health professional. Exposures on a manikin may be
performed under direct or indirect supervision by a licensed dental health professional.
9. With few exceptions, retakes on patients are limited to a maximum of four. Each retake
is taken only under the direct supervision of a licensed dental health professional.
The following guidelines will be followed regarding exposure of radiographs on patients
following the review of the current medical and dental history.
1. All radiographs, including retakes, must be authorized by a licensed dentist.
2. Four bitewings may be taken once every twelve months.
3. A complete series (14 periapicals/4 bitewings) may be taken if one has not been taken if
deemed appropriate by a dental faculty member. A complete series should be exposed
on a patient not more than once every three years unless the faculty dentist determines
that a complete series is necessary to diagnose a patient’s treatment needs.
506
4. Bitewings may be taken either as a separate entity or as part of a complete series, but
not both if a set of bitewings has been exposed on a patient in the previous twelve
months.
5. Radiographs will be mounted, labeled and placed on file with the patient records.
a. Upon request, duplicate radiographs may be made and sent to a patient’s
dentist or
b. Hand carried by the patient if printed.
6. Those authorized to use x-ray equipment are:
1. Dental Health Faculty licensed to operate x-ray equipment according to
Indiana Law
2. Dental Hygiene Program Students enrolled in or having completed DHYG
H303 and H305.
7. An exposure technique chart and additional notices are posted in each radiography
room.
8. Types of radiographs taken in this facility include periapical, bitewing, occlusal and
panoramic radiographs
9. Dosimeter monitoring is placed at each radiation generating units. Reports are located
in the Dental Education Program office files.
10. Radiographs may be exposed on a patient digitally or with the use of processed film.
a. Technique instructions are posted in each area.
11. In the case of an unusual event, the Program Director, Radiology Supervisor, and
Supervising Dentist should be notified immediately. The same individuals should also be
contacted if an employee or student has questions concerning these policies or
radiation protection.
12. Panoramic radiographic service is provided for patients of record for the IUSB dental
clinic and for patients that are not of record at IUSB whose dentist of record has made a
request for a panoramic radiograph. Images are evaluated for quality by clinic faculty
and forwarded to the requesting dentist. A panoramic image will not be exposed on a
patient who is, or is suspected of being pregnant, unless it is needed for emergency
treatment.
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IU South Bend Radiographic Policies and Procedures
I. Radiographic Exposure Policies
A. Selection criteria for patient radiographs
1. Radiographs are exposed on patients who have a documented diagnostic need.
2. Patient selection is in accordance with the patient selection guidelines as established by
the American Dental Association.
3. IUSB exposure policies:
 Dentists in the local community refer their patients to IUSB for diagnostic
radiographs. These practitioners provide a written or telephone request to our
clinic.
 Following a clinical screening in the IUSB clinic, a faculty dentist may determine a
diagnostic need for a radiographic survey or an individual radiograph.
 IUSB Dental Clinic does not assume responsibility for comprehensive dental
examinations. Radiographs taken in the IUSB clinic can be sent to the patient’s
dentist of record. Instructions are given to the patient to visit their dentist of record
for a complete clinical exam.
B. Consent for radiographic procedures
1. All patients 18 years of age and older must give verbal consent to expose radiographs on
them BEFORE the procedure. Patients under 18, consent must be obtained by parent or
guardian.
2. All radiographic patients must have a current medical history, updated and signed by
the patient or guardian on the day of the procedure prior to any exposures.
3. The supervising dentist must approve the patient’s medical history prior to any
radiographic exposures on the day of the procedures.
C.
IUSB Dental Clinic radiographic procedure policies
1. All exposures must be taken in the IUSB clinic during clinic hours unless prior
arrangements have been made with a faculty dentist.
2. All radiographs must be evaluated by a clinical instructor so that the student’s progress
may be monitored before leaving clinic.
3. All radiographs are to be submitted within 7 business days of exposure for grading.
4. Bitewing and Full Mouth series should be evaluated by the clinic instructor
5. All radiographs are to be submitted to the radiology grader for a grade
a. All radiographs must remain available in the IUSB Dental Clinic. Students will
not receive credit for images that are not submitted for grading.
Professionalism points may be deducted from the course grade if students
misplace or delete radiographs exposed on a patient.
6. Students exposing radiographs are responsible for the exposure settings on all of the xray heads.
7. X-ray rooms 1-5 are to be utilized for patients
8. Priority in room utilization will be given to those students who have signed up in the
radiology appointment book (Dentrix Clinic DHADMIN) to reserve a room. Students
should check the radiology appointment book, DHADMIN, for availability prior to
scheduling the patient.
9. Students should allot ONE HOUR for each FMX, ½ hour for BWX or retakes.
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10. There is a fee associated with all radiographic procedures. Check at the reception desk
for the current fee schedule. The paid receipt is necessary for credit and should be
placed in the patients file prior to submitting the images for grading.
11. A $ 5.00 fee is assessed for duplicate copies of images exposed in the clinic. Images will
not be sent out to a private dental office unless the fee has been paid.
II.
Infection Control and Radiographic Exposure Procedures
A. Operator
1. Students exposing radiographs on patients must wear OSHA approved attire.
2. Hair must be secured while exposing radiographs.
3. Chewing of gum is unacceptable.
4. It is recommended that a face mask and protective eyewear be worn at all times.
5. Immediately prior to exposing radiographs on a patient the operator is to follow the
recommended hand washing procedure and don fresh treatment gloves.
6. Immediately following exposing radiographs, the operator is to remove gloves to
remove the lead apron from the patient.
7. Gloves are to be worn when cleaning the room following treatment and when removing
protective barriers from the sensors.
B. Operatory
1. Using a hospital level disinfectant (the disinfectant currently used in the clinic) all
surfaces that were touched by the operator’s hands during the exposure of radiographs
are to be disinfected using the two wipe method of disinfecting. These surfaces include
but are not limited to: the head rest adjustment, head rest, the chair, (all parts) the xray head and PID and arm, and the counter tops.
2. The exposure button requires a clean sticky cover over it for each patient.
C. Tray set-up
1. A sterile tray should be set-up prior to the seating of the patient that may contain the
following items: an autoclaved XCP and Snap-a-ray in an unopened autoclave bag, 1
rubber band, 1 cotton roll, bitewing tabs, and a patient bib.
2. Following hand washing and gloving, open the XCP and assemble.
D.
Patient
1. Complete the required medical history and consent forms.
2. Request the patient remove any removable dental appliance prior to exposing images.
Place the appliance into a cup or bag and place it in an area where it will not be
misplaced or damaged.
3. Request that the patient remove their eye glasses.
4. Request the patient remove any jewelry that may interfere with the beam of the x-ray
such as: large earnings, nose rings, lip rings....
5. It may be necessary for the patient to remove their cap, hair clip, or hooded sweatshirt
so that they are able to stabilize their head against the back of the headrest.
III.
Radiographic Techniques
Consulting with the clinic zone instructor, the student is to determine the appropriate radiographic
series to be taken on the patient. Points will be deducted for inappropriate decision making
according to the course syllabus.
509
A. Full mouth surveys-18 exposures using size 2 sensors with 4 horizontal BW’s
1. On the FMX grade sheet there is a diagram that demonstrates which teeth should be
exposed on each individual image in the series.
2. For patients that have difficulty tolerating the XCP device there are Snap-A-Ray
radiograph holders that can be used to expose images using the bisecting –the-angle
technique.
B. Full mouth perio series- 18 exposures using size 2 sensors with the 4 vertical BW’s
C. Bitewings
1. Adult dentition
 Patients’ occlusal plane is parallel to the floor.
 Size 2 horizontal sensors-this series of bitewing exposures should be used on
patients who have their second molars and have two premolars in one or more
quadrants of their dentition.
 Premolar exposure-the sensor is placed on the mandibular arch, mesial edge
touches the lingual of the lower incisors.
 The PID is at 0 to +10 degrees, the central ray is directed between the contacts
of maxillary premolars at a point approximately down from the pupil of the
patients’ eye, on the same plane as the film or sensor. The horizontal center of
the PID should be slightly above the patients’ occlusal plane.
 Molar exposure- the sensor is placed on the mandibular arch, the mesial edge
should cover half of the mandibular 2nd premolar; the distal edge should be
tucked behind the ascending ramus of the mandible.
 The PID is at 0 to +10 degrees, the central ray is directed between the distal
contacts of the maxillary first molar at a point down from the outer canthus of
the patients’ eye. The horizontal center of the PID should be slightly above the
patients occlusal plane
D. Vertical bitewings
1. These exposures are useful for patients who exhibit clinical signs of periodontal disease,
have extensive restorations or have very large clinical crowns.
2. Size 2 sensors are used. The films or sensors are placed vertically in the patient's mouth
in the same manner as horizontal bitewings.
3. It is recommended that a bitewing XCP be employed when exposing vertical bitewings
E. Mixed dentition- all four first molars are fully erupted into the oral cavity.
1. One exposure per side of the oral cavity with a size 2 sensor.
2. The exposure is taken like a premolar view.
F. Primary dentition - radiographs are only exposed when the contacts in the primary dentition
are closed.
1. On a dentition of 20 teeth two exposures one on each side using size 0 sensors are
utilized.
2. The PID is directed like a premolar view.
3. On a dentition of 20 teeth with erupting first molars a size 1 sensor may be utilized.
G. Panoramic technique- Panoramic images are indicated for patients who cannot tolerate
periapical radiographs, edentulous patients, views of patient’s third molars, or patients who
require an orthodontic evaluation, or where a periapical radiographs do not provide an
adequate view of the mandible and/or maxilla.
510
IV.
Film processing in H305
A. Infection control
1. Disinfection
 Using a hospital level disinfectant, wipe exposed films on both sides.
 Let films dry prior to processing the films.
 Use clean treatment gloves to unwrap and process the films.
 While films are being processed, place a labeled mount including the patient’s name
on the top of the running processor. This allows the CA to assist you in mounting
the films and signals others that films are running in the machine.
 Remove gloves, wash hands and mount processed films.
B. Film Drop Technique
1. While working in safe light conditions and wearing gloves, prepare a clean paper towel
to your right and the contaminated films to your left.
2. Carefully open each film by pulling the poly wrap back far enough so that the film drops
onto the clean paper towel.
3. Discard the film wraps immediately to avoid contaminating the films.
4. When all of the films have been opened, remove your gloves and place films in the
processor.
V.
Film Duplicating
Films can be duplicated, however, most patient films are digital and should be printed or emailed.
A. Preparation
1. The duplication of films must be done in the safe light
2. Lock the door to the dark room while working under the safe light
3. Identify the box of duplicating film before turning off the white lights, ( the box
resembles the panoramic film box-they are different films)
4. Check the automatic film processor for chemicals and turn on the processor.
5. Check to see if the glass on the duplicator is free of streaks.
6. Set the duplicator time to 20 seconds.
B. Duplicating procedures
1. With the safe light and or the view light on, place the original films dot side down on the
duplicating glass.
2. Films may be in a plastic mount
3. Open the box of duplicating film and select a piece of film and replace the lid
4. Use an entire sheet for a full mouth set of films
5. Cut an entire sheet for bitewings or single films
6. Examine the film under the safe light, there will be a dark side and a light side to the
film.
7. The LIGHT side of the film has emulsion
8. The DARK side of the film has no emulsion.
9. Place the film light side down on the “back” of the original films; The indentation on the
duplicating film should be placed on the glass with the indented portion of the film on
the upper right.
10. Close the lid
11. Change the toggle switch from view to “duplicate”
12. Depress the white center button in the timer
511
13. When the 20 seconds has lapsed, remove the duplicate film under the safe light and
process in the automatic processor.
i. Date and label the duplicate film
ii. Trouble shooting
14. No image: film was dark side down, film was not exposed, panoramic film was used.
15. Light image: film was exposed to duplicating light too long, film was exposed to white
light
16. Dark image: film was not exposed to duplicating light long enough.
C. Two film packets
1. These packets are to be used if the patient requests their radiographs to be sent to their
dentist of record.
2. When processing these films, be careful to separate the films when inserting them into
the processor.
3. When the films are processed, mount them into two mounts. One mount will remain in
the patient’s chart and the other will be sent to the patient’s dentist of record.
D. Duplicate Films (single film packets)
1. When patients request duplicates of existing films that do not have a duplicate, a
duplicate copy should be made.
2. The original copy of the films should be kept in the patient’s file.
VI.
Mailing/Emailing images
A. Mailing (traditional films)
1. Complete address and zip code of the dentist to whom the films are being sent.
2. IUSB return address stamp (available from the reception desk)
3. A stamp that says “X-rays do not bend”
4. The patients films, correctly labeled with the patients name and date of exposure.
5. The envelope is given to clinic manager.
6. When you mail a set of films, record in the patient’s chart the date the films were
mailed.
B. Mailing digital images
1. If a patient needs their digital images sent to their dentist of record, let the clinic
manager know and document in the progress notes.
C. Emailing images
1. If a patient needs their digital images sent to their dentist of record, let the clinic
manager know and document in the progress notes.
VII.
Assessing images
A. Ideally, while your patient is still in the clinic, critically examine your technique.
1. Determine if all of the teeth, root tips, crowns and contacts are represented in the
radiographs
2. Determine if all of the images are of diagnostic quality.
3. If you feel that there is a image you should retake, place an “R” under the
image
on your grade sheet.
4. Present your clinic instructor with your images and your grade sheet and discuss your
retakes.
512
5. Your clinic instructor will verify the images to be retaken.
6. Retakes are only taken to improve diagnostic quality of images.
7. Unless the instructor gives the student other instructions, all retakes should be directly
supervised by a clinic instructor.
8. All images must be reviewed for retakes by clinic instructor before leaving clinic, (they
do not need to be graded in clinic, just reviewed for retakes).
B. When you have completed your images and dismissed your patient evaluate your images for
technique and caries if you are in H306 or H307.
1. Using the radiographic evaluation form self evaluate your radiographic technique.
2. Submit your FMX to your grader.
VIII.
Interpretation of Radiographs
A. Current radiographs should be in the view box at the time of the assessment.
B. The student is to refer to the radiographs to evaluate the patient’s periodontal condition,
dental charting and any radiographic findings.
C. Radiographic findings are to be recorded in the patient's assessment.
IX.
Progress in Radiology Clinic
A. Due dates: all requirements must be completed and handed in each semester five school
days prior to the last clinic for that semester or otherwise noted in the course syllabus
a. If a student has one missing requirement for H305 or H306 the student will not
pass the course and must repeat the course the next time it is offered.
b. If a student has any requirements missing for H307, they will not pass the
course. Failure to pass this course will restrict the student from graduating.
B. Professionalism- The Components of Professional behavior of the Dental Hygiene Program
and Essential Abilities of the Dental Assisting Program apply to all aspects of Radiology
Clinic.
a. Any form of academic misconduct constitutes grounds for dismissal for the
program.
b. Failure to progress, as demonstrated by the following, may constitute a failing
grade or additional requirements.
i.
repeated radiographs of poor quality
ii.
failure to consistently follow prescribed Radiology policies and
procedures
iii.
repeated errors in paperwork
c. Requirements, check the syllabi for H305, 306 and 307
C. Grading Scale
a. Bitewing Radiographs (BWX)
i. The total point reduction for errors on each radiograph is multiplied by two
(X2) and is subtracted from 100 to determine the grade. See course syllabi
for specific grading guidelines.
513
ii. H 305 - 75% is passing, anything less than 75% is not acceptable and the
student will not be credited toward their patient requirements for the
course. H306 is 80%, H307 is 90%.
iii. The following are examples of errors that result in point reduction on BWX
films or digital images:
a. Cone cut: slight = 1 point reduction; moderate (<10% of image) =
2 point reduction; large (>10% of image) = 3 point reduction
b. Image position: image does not demonstrate information
intended (e.g., tooth not centered, midline not centered or occlusal
plane not straight) = 1-3 point reduction
c. Vertical angulation: elongation or foreshortening = 1-3point
reduction
d. Horizontal angulation (Providing image is diagnostic, horizontal
overlap may occur in molar views when 3rd molars are
demonstrated): Proximal contacts must be open (unless teeth
overlap in the arch) slight = 1 point reduction; moderate = 2 point
reduction; generalized = 3 point reduction
e. Bending: 1-2 point reduction per bend
f. Film or digital exposure retakes: maximum of two retakes per
patient
b.
Full Mouth Series (FMX) Radiographs
i. The total point reduction for errors on each radiograph is totaled and is
subtracted from 100 to determine the periapical grade. There is a
maximum reduction of seven (7) points for errors per periapical and 12
points per bitewing (X2 = 24 points). Correct mounting of radiographs or
proper positioning of digital exposures and properly completing all
paperwork is worth two (2) points per set.
ii. A separate grade is given for FMX (periapical) and BWX (bite-wing x-ray);
BWX can be 2 or 4 images, horizontal or vertical, processed film or digital. A
FMX is 14 periapical plus 4 bitewing images.
iii. H 305 - 75% is passing, anything less than 75% is not acceptable and the
student will not be credited toward their patient requirements for the
course. H306 is 80%, H307 is 90%.
iv. The following are examples of errors that result in point reduction on
periapicals:
a. Cone cut: slight = 1 point reduction; moderate (<10% of image) = 2 point
reduction; large (>10% of image) = 3 point reduction
b. Position: image does not demonstrate information intended (e.g., tooth
not centered, midline not centered or occlusal plane not straight) = 1-3
point reduction
c. Vertical angulation: elongation or foreshortening = 1-3 point reduction
d. Horizontal angulation (Providing image is diagnostic, horizontal overlap
may occur in molar views when 3rd molars are demonstrated): Proximal
contacts must be open (unless teeth overlap in the arch) slight = 1 point
reduction; moderate = 2 point reduction; generalized = 3 point reduction
e. Bending: 1-2 point reduction per bend
f. Film or digital exposure retakes: maximum of two retakes per patient
514
c. Paperwork Errors
When a mounting error or paperwork error is noted the chart will be returned to the
student and each error will be tabulated. Paper work includes: having the radiographic
history form properly filled out and signed by the instructors; having the grade sheet
completely filled out with the student and patient’s name, date, type of radiographs
taken and self-evaluation completed; radiographs taken noted in the chart progress
notes; and all consent forms properly filled out and signed by the patient. Each
paperwork error and mounting error is deducted from the student’s grade. Paperwork
errors do not have a limit. If a paperwork error is made, the student will not get credit
until the errors are corrected and resubmitted to the grader. Students are advised to
check their charts and radiographs for errors prior to submitting them for grading. The
student’s zone instructor in clinic should evaluate the radiographs and sign and date the
student’s grade sheet prior to the student submitting the images for grading. The only
exception to this policy is if an instructor evaluates and grades the images while the
student is treating the patient in clinic. Point reduction for paperwork errors remain part
of the grade for the images even after corrections are made by the student.
VERA Z. DWYER COLLEGE OF HEALTH SCIENCES
Programs in Dental Education
I ____________________________, have read, understand, and will comply with
the policies of the Radiation Safety and Instruction Manual.
Printed Name: ______________________________________________________
Signature_____________________________________, Date ________________
Vera Z. Dwyer College of Health Sciences
Programs in Dental Education
Education and Arts 1250
1002 S. Esther St.
South Bend, IN 46615
(574) 520- 4158
fax (574) 520-4854
http://www.iusb.edu/dental/
Bloodborne pathogens. - 1910.1030
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What's New | Offices  Regulations (Standards - 29 CFR) - Table of Contents
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Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:
Appendix:
GPO Source:
1910
Occupational Safety and Health Standards
Z
Toxic and Hazardous Substances
1910.1030
Bloodborne pathogens.
A
e-CFR
1910.1030(a)
Scope and Application . This section applies to all occupational exposure to blood or other potentially infectious
materials as defined by paragraph (b) of this section.
1910.1030(b)
Definitions . For purposes of this section, the following shall apply:
Assistant Secretary means the Assistant Secretary of Labor for Occupational Safety and Health, or designated
representative.
Blood means human blood, human blood components, and products made from human blood.
Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in
humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus
(HIV).
Clinical Laboratory means a workplace where diagnostic or other screening procedures are performed on blood or
other potentially infectious materials.
Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious
materials on an item or surface.
Contaminated Laundry means laundry which has been soiled with blood or other potentially infectious materials or
may contain sharps.
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Contaminated Sharps means any contaminated object that can penetrate the skin including, but not limited to,
needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne
pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and
the surface or item is rendered safe for handling, use, or disposal.
Director means the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health
and Human Services, or designated representative.
Engineering Controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices,
such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the
bloodborne pathogens hazard from the workplace.
Exposure Incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with
blood or other potentially infectious materials that results from the performance of an employee's duties.
Handwashing Facilities means a facility providing an adequate supply of running potable water, soap, and single-use
towels or air-drying machines.
Licensed Healthcare Professional is a person whose legally permitted scope of practice allows him or her to
independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-exposure Evaluation
and Follow-up.
HBV means hepatitis B virus.
HIV means human immunodeficiency virus.
Needleless systems means a device that does not use needles for:
(1) The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; (2)
The administration of medication or fluids; or (3) Any other procedure involving the potential for occupational
exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.
Occupational Exposure means 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.
Other Potentially Infectious Materials means (1) The following human body fluids: semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental
procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult
or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a
human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing
culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV
or HBV.
Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites,
cuts, and abrasions.
Personal Protective Equipment is specialized clothing or equipment worn by an employee for protection against a
hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a
hazard are not considered to be personal protective equipment.
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Production Facility means a facility engaged in industrial-scale, large-volume or high concentration production of HIV
or HBV.
Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that
would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that
are caked with dried blood or other potentially infectious materials and are capable of releasing these materials
during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other
potentially infectious materials.
Research Laboratory means a laboratory producing or using research-laboratory-scale amounts of HIV or HBV.
Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production
facilities.
Sharps with engineered sharps injury protections means a nonneedle sharp or a needle device used for withdrawing
body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or
mechanism that effectively reduces the risk of an exposure incident.
Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a
source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic
patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment
facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood
components.
Sterilize means the use of a physical or chemical procedure to destroy all microbial life including highly resistant
bacterial endospores.
Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all
human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other
bloodborne pathogens.
Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task
is performed (e.g., prohibiting recapping of needles by a two-handed technique).
1910.1030(c)
Exposure Control -1910.1030(c)(1)
Exposure Control Plan .
1910.1030(c)(1)(i)
Each employer having an employee(s) with occupational exposure as defined by paragraph (b) of this section shall
establish a written Exposure Control Plan designed to eliminate or minimize employee exposure.
1910.1030(c)(1)(ii)
The Exposure Control Plan shall contain at least the following elements:
1910.1030(c)(1)(ii)(A)
The exposure determination required by paragraph (c)(2),
1910.1030(c)(1)(ii)(B)
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Bloodborne pathogens. - 1910.1030
The schedule and method of implementation for paragraphs (d) Methods of Compliance, (e) HIV and HBV Research
Laboratories and Production Facilities, (f) Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up, (g)
Communication of Hazards to Employees, and (h) Recordkeeping, of this standard, and
1910.1030(c)(1)(ii)(C)
The procedure for the evaluation of circumstances surrounding exposure incidents as required by paragraph (f)(3)(i)
of this standard.
1910.1030(c)(1)(iii)
Each employer shall ensure that a copy of the Exposure Control Plan is accessible to employees in accordance with 29
CFR 1910.1020(e).
1910.1030(c)(1)(iv)
The Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary to reflect new or
modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions
with occupational exposure. The review and update of such plans shall also:
1910.1030(c)(1)(iv)(A)
Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; and
1910.1030(c)(1)(iv)(B)
Document annually consideration and implementation of appropriate commercially available and effective safer
medical devices designed to eliminate or minimize occupational exposure.
1910.1030(c)(1)(v)
An employer, who is required to establish an Exposure Control Plan shall solicit input from non-managerial employees
responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the
identification, evaluation, and selection of effective engineering and work practice controls and shall document the
solicitation in the Exposure Control Plan.
1910.1030(c)(1)(vi)
The Exposure Control Plan shall be made available to the Assistant Secretary and the Director upon request for
examination and copying.
1910.1030(c)(2)
Exposure Determination .
1910.1030(c)(2)(i)
Each employer who has an employee(s) with occupational exposure as defined by paragraph (b) of this section shall
prepare an exposure determination. This exposure determination shall contain the following:
1910.1030(c)(2)(i)(A)
A list of all job classifications in which all employees in those job classifications have occupational exposure;
1910.1030(c)(2)(i)(B)
A list of job classifications in which some employees have occupational exposure, and
1910.1030(c)(2)(i)(C)
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Bloodborne pathogens. - 1910.1030
A list of all tasks and procedures or groups of closely related task and procedures in which occupational exposure
occurs and that are performed by employees in job classifications listed in accordance with the provisions of
paragraph (c)(2)(i)(B) of this standard.
1910.1030(c)(2)(ii)
This exposure determination shall be made without regard to the use of personal protective equipment.
1910.1030(d)
Methods of Compliance -1910.1030(d)(1)
General . Universal precautions shall be observed to prevent contact with blood or other potentially infectious
materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body
fluids shall be considered potentially infectious materials.
1910.1030(d)(2)
Engineering and Work Practice Controls.
1910.1030(d)(2)(i)
Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Where
occupational exposure remains after institution of these controls, personal protective equipment shall also be used.
1910.1030(d)(2)(ii)
Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their
effectiveness.
1910.1030(d)(2)(iii)
Employers shall provide handwashing facilities which are readily accessible to employees.
1910.1030(d)(2)(iv)
When provision of handwashing facilities is not feasible, the employer shall provide either an appropriate antiseptic
hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers
or towelettes are used, hands shall be washed with soap and running water as soon as feasible.
1910.1030(d)(2)(v)
Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves
or other personal protective equipment.
1910.1030(d)(2)(vi)
Employers shall ensure that employees wash hands and any other skin with soap and water, or flush mucous
membranes with water immediately or as soon as feasible following contact of such body areas with blood or other
potentially infectious materials.
1910.1030(d)(2)(vii)
Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted in
paragraphs (d)(2)(vii)(A) and (d)(2)(vii)(B) below. Shearing or breaking of contaminated needles is prohibited.
1910.1030(d)(2)(vii)(A)
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Bloodborne pathogens. - 1910.1030
Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless the employer
can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental
procedure.
1910.1030(d)(2)(vii)(B)
Such bending, recapping or needle removal must be accomplished through the use of a mechanical device or a onehanded technique.
1910.1030(d)(2)(viii)
Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers
until properly reprocessed. These containers shall be:
1910.1030(d)(2)(viii)(A)
Puncture resistant;
1910.1030(d)(2)(viii)(B)
Labeled or color-coded in accordance with this standard;
1910.1030(d)(2)(viii)(C)
Leakproof on the sides and bottom; and
1910.1030(d)(2)(viii)(D)
In accordance with the requirements set forth in paragraph (d)(4)(ii)(E) for reusable sharps.
1910.1030(d)(2)(ix)
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas
where there is a reasonable likelihood of occupational exposure.
1910.1030(d)(2)(x)
Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where
blood or other potentially infectious materials are present.
1910.1030(d)(2)(xi)
All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to
minimize splashing, spraying, spattering, and generation of droplets of these substances.
1910.1030(d)(2)(xii)
Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
1910.1030(d)(2)(xiii)
Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage
during collection, handling, processing, storage, transport, or shipping.
1910.1030(d)(2)(xiii)(A)
The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and
closed prior to being stored, transported, or shipped. When a facility utilizes Universal Precautions in the handling of
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Bloodborne pathogens. - 1910.1030
all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as
containing specimens. This exemption only applies while such specimens/containers remain within the facility.
Labeling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the
facility.
1910.1030(d)(2)(xiii)(B)
If outside contamination of the primary container occurs, the primary container shall be placed within a second
container which prevents leakage during handling, processing, storage, transport, or shipping and is labeled or colorcoded according to the requirements of this standard.
1910.1030(d)(2)(xiii)(C)
If the specimen could puncture the primary container, the primary container shall be placed within a secondary
container which is puncture-resistant in addition to the above characteristics.
1910.1030(d)(2)(xiv)
Equipment which may become contaminated with blood or other potentially infectious materials shall be examined
prior to servicing or shipping and shall be decontaminated as necessary, unless the employer can demonstrate that
decontamination of such equipment or portions of such equipment is not feasible.
1910.1030(d)(2)(xiv)(A)
A readily observable label in accordance with paragraph (g)(1)(i)(H) shall be attached to the equipment stating which
portions remain contaminated.
1910.1030(d)(2)(xiv)(B)
The employer shall ensure that this information is conveyed to all affected employees, the servicing representative,
and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will
be taken.
1910.1030(d)(3)
Personal Protective Equipment -1910.1030(d)(3)(i)
Provision . When there is occupational exposure, the employer shall provide, at no cost to the employee, appropriate
personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and
eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective
equipment will be considered "appropriate" only if it does not permit blood or other potentially infectious materials to
pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other
mucous membranes under normal conditions of use and for the duration of time which the protective equipment will
be used.
1910.1030(d)(3)(ii)
Use . The employer shall ensure that the employee uses appropriate personal protective equipment unless the
employer shows that the employee temporarily and briefly declined to use personal protective equipment when, under
rare and extraordinary circumstances, it was the employee's professional judgment that in the specific instance its
use would have prevented the delivery of health care or public safety services or would have posed an increased
hazard to the safety of the worker or co-worker. When the employee makes this judgement, the circumstances shall
be investigated and documented in order to determine whether changes can be instituted to prevent such
occurrences in the future.
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1910.1030(d)(3)(iii)
Accessibility . The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is
readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or
other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally
provided.
1910.1030(d)(3)(iv)
Cleaning, Laundering, and Disposal . The employer shall clean, launder, and dispose of personal protective equipment
required by paragraphs (d) and (e) of this standard, at no cost to the employee.
1910.1030(d)(3)(v)
Repair and Replacement . The employer shall repair or replace personal protective equipment as needed to maintain
its effectiveness, at no cost to the employee.
1910.1030(d)(3)(vi)
If a garment(s) is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed
immediately or as soon as feasible.
1910.1030(d)(3)(vii)
All personal protective equipment shall be removed prior to leaving the work area.
1910.1030(d)(3)(viii)
When personal protective equipment is removed it shall be placed in an appropriately designated area or container
for storage, washing, decontamination or disposal.
1910.1030(d)(3)(ix)
Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with
blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular
access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items
or surfaces.
1910.1030(d)(3)(ix)(A)
Disposable (single use) gloves such as surgical or examination gloves, shall be replaced as soon as practical when
contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is
compromised.
1910.1030(d)(3)(ix)(B)
Disposable (single use) gloves shall not be washed or decontaminated for re-use.
1910.1030(d)(3)(ix)(C)
Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised. However, they must
be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability
to function as a barrier is compromised.
1910.1030(d)(3)(ix)(D)
If an employer in a volunteer blood donation center judges that routine gloving for all phlebotomies is not necessary
then the employer shall:
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1910.1030(d)(3)(ix)(D)(1)
Periodically reevaluate this policy;
1910.1030(d)(3)(ix)(D)(2)
Make gloves available to all employees who wish to use them for phlebotomy;
1910.1030(d)(3)(ix)(D)(3)
Not discourage the use of gloves for phlebotomy; and
1910.1030(d)(3)(ix)(D)(4)
Require that gloves be used for phlebotomy in the following circumstances:
1910.1030(d)(3)(ix)(D)(4)(i)
When the employee has cuts, scratches, or other breaks in his or her skin;
1910.1030(d)(3)(ix)(D)(4)(ii)
When the employee judges that hand contamination with blood may occur, for example, when performing
phlebotomy on an uncooperative source individual; and
1910.1030(d)(3)(ix)(D)(4)(iii)
When the employee is receiving training in phlebotomy.
1910.1030(d)(3)(x)
Masks, Eye Protection, and Face Shields . Masks in combination with eye protection devices, such as goggles or
glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or
droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination
can be reasonably anticipated.
1910.1030(d)(3)(xi)
Gowns, Aprons, and Other Protective Body Clothing. Appropriate protective clothing such as, but not limited to,
gowns, aprons, lab coats, clinic jackets, or similar outer garments shall be worn in occupational exposure situations.
The type and characteristics will depend upon the task and degree of exposure anticipated.
1910.1030(d)(3)(xii)
Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can
reasonably be anticipated (e.g., autopsies, orthopaedic surgery).
1910.1030(d)(4)
Housekeeping -1910.1030(d)(4)(i)
General . Employers shall ensure that the worksite is maintained in a clean and sanitary condition. The employer shall
determine and implement an appropriate written schedule for cleaning and method of decontamination based upon
the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being
performed in the area.
1910.1030(d)(4)(ii)
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All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood
or other potentially infectious materials.
1910.1030(d)(4)(ii)(A)
Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedures;
immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other
potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since
the last cleaning.
1910.1030(d)(4)(ii)(B)
Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover
equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly
contaminated or at the end of the workshift if they may have become contaminated during the shift.
1910.1030(d)(4)(ii)(C)
All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming
contaminated with blood or other potentially infectious materials shall be inspected and decontaminated on a
regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible
contamination.
1910.1030(d)(4)(ii)(D)
Broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up
using mechanical means, such as a brush and dust pan, tongs, or forceps.
1910.1030(d)(4)(ii)(E)
Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or
processed in a manner that requires employees to reach by hand into the containers where these sharps have been
placed.
1910.1030(d)(4)(iii)
Regulated Waste -1910.1030(d)(4)(iii)(A)
Contaminated Sharps Discarding and Containment.
1910.1030(d)(4)(iii)(A)(1)
Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:
1910.1030(d)(4)(iii)(A)(1)(i)
Closable;
1910.1030(d)(4)(iii)(A)(1)(ii)
Puncture resistant;
1910.1030(d)(4)(iii)(A)(1)(iii)
Leakproof on sides and bottom; and
1910.1030(d)(4)(iii)(A)(1)(iv)
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Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard.
1910.1030(d)(4)(iii)(A)(2)
During use, containers for contaminated sharps shall be:
1910.1030(d)(4)(iii)(A)(2)(i)
Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can
be reasonably anticipated to be found (e.g., laundries);
1910.1030(d)(4)(iii)(A)(2)(ii)
Maintained upright throughout use; and
1910.1030(d)(4)(iii)(A)(2)(iii)
Replaced routinely and not be allowed to overfill.
1910.1030(d)(4)(iii)(A)(3)
When moving containers of contaminated sharps from the area of use, the containers shall be:
1910.1030(d)(4)(iii)(A)(3)(i)
Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling,
storage, transport, or shipping;
1910.1030(d)(4)(iii)(A)(3)(ii)
Placed in a secondary container if leakage is possible. The second container shall be:
1910.1030(d)(4)(iii)(A)(3)(ii)(A)
Closable;
1910.1030(d)(4)(iii)(A)(3)(ii)(B)
Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping; and
1910.1030(d)(4)(iii)(A)(3)(ii)(C)
Labeled or color-coded according to paragraph (g)(1)(i) of this standard.
1910.1030(d)(4)(iii)(A)(4)
Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose
employees to the risk of percutaneous injury.
1910.1030(d)(4)(iii)(B)
Other Regulated Waste Containment -1910.1030(d)(4)(iii)(B)(1)
Regulated waste shall be placed in containers which are:
1910.1030(d)(4)(iii)(B)(1)(i)
Closable;
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1910.1030(d)(4)(iii)(B)(1)(ii)
Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;
1910.1030(d)(4)(iii)(B)(1)(iii)
Labeled or color-coded in accordance with paragraph (g)(1)(i) this standard; and
1910.1030(d)(4)(iii)(B)(1)(iv)
Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
1910.1030(d)(4)(iii)(B)(2)
If outside contamination of the regulated waste container occurs, it shall be placed in a second container. The
second container shall be:
1910.1030(d)(4)(iii)(B)(2)(i)
Closable;
1910.1030(d)(4)(iii)(B)(2)(ii)
Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping;
1910.1030(d)(4)(iii)(B)(2)(iii)
Labeled or color-coded in accordance with paragraph (g)(1)(i) of this standard; and
1910.1030(d)(4)(iii)(B)(2)(iv)
Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
1910.1030(d)(4)(iii)(C)
Disposal of all regulated waste shall be in accordance with applicable regulations of the United States, States and
Territories, and political subdivisions of States and Territories.
1910.1030(d)(4)(iv)
Laundry .
1910.1030(d)(4)(iv)(A)
Contaminated laundry shall be handled as little as possible with a minimum of agitation.
1910.1030(d)(4)(iv)(A)(1)
Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or
rinsed in the location of use.
1910.1030(d)(4)(iv)(A)(2)
Contaminated laundry shall be placed and transported in bags or containers labeled or color-coded in accordance
with paragraph (g)(1)(i) of this standard. When a facility utilizes Universal Precautions in the handling of all soiled
laundry, alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as
requiring compliance with Universal Precautions.
1910.1030(d)(4)(iv)(A)(3)
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Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through of or leakage from the
bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through
and/or leakage of fluids to the exterior.
1910.1030(d)(4)(iv)(B)
The employer shall ensure that employees who have contact with contaminated laundry wear protective gloves and
other appropriate personal protective equipment.
1910.1030(d)(4)(iv)(C)
When a facility ships contaminated laundry off-site to a second facility which does not utilize Universal Precautions in
the handling of all laundry, the facility generating the contaminated laundry must place such laundry in bags or
containers which are labeled or color-coded in accordance with paragraph (g)(1)(i).
1910.1030(e)
HIV and HBV Research Laboratories and Production Facilities .
1910.1030(e)(1)
This paragraph applies to research laboratories and production facilities engaged in the culture, production,
concentration, experimentation, and manipulation of HIV and HBV. It does not apply to clinical or diagnostic
laboratories engaged solely in the analysis of blood, tissues, or organs. These requirements apply in addition to the
other requirements of the standard.
1910.1030(e)(2)
Research laboratories and production facilities shall meet the following criteria:
1910.1030(e)(2)(i)
Standard Microbiological Practices . All regulated waste shall either be incinerated or decontaminated by a method
such as autoclaving known to effectively destroy bloodborne pathogens.
1910.1030(e)(2)(ii)
Special Practices .
1910.1030(e)(2)(ii)(A)
Laboratory doors shall be kept closed when work involving HIV or HBV is in progress.
1910.1030(e)(2)(ii)(B)
Contaminated materials that are to be decontaminated at a site away from the work area shall be placed in a
durable, leakproof, labeled or color-coded container that is closed before being removed from the work area.
1910.1030(e)(2)(ii)(C)
Access to the work area shall be limited to authorized persons. Written policies and procedures shall be established
whereby only persons who have been advised of the potential biohazard, who meet any specific entry requirements,
and who comply with all entry and exit procedures shall be allowed to enter the work areas and animal rooms.
1910.1030(e)(2)(ii)(D)
When other potentially infectious materials or infected animals are present in the work area or containment module,
a hazard warning sign incorporating the universal biohazard symbol shall be posted on all access doors. The hazard
warning sign shall comply with paragraph (g)(1)(ii) of this standard.
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1910.1030(e)(2)(ii)(E)
All activities involving other potentially infectious materials shall be conducted in biological safety cabinets or other
physical-containment devices within the containment module. No work with these other potentially infectious
materials shall be conducted on the open bench.
1910.1030(e)(2)(ii)(F)
Laboratory coats, gowns, smocks, uniforms, or other appropriate protective clothing shall be used in the work area
and animal rooms. Protective clothing shall not be worn outside of the work area and shall be decontaminated before
being laundered.
1910.1030(e)(2)(ii)(G)
Special care shall be taken to avoid skin contact with other potentially infectious materials. Gloves shall be worn when
handling infected animals and when making hand contact with other potentially infectious materials is unavoidable.
1910.1030(e)(2)(ii)(H)
Before disposal all waste from work areas and from animal rooms shall either be incinerated or decontaminated by a
method such as autoclaving known to effectively destroy bloodborne pathogens.
1910.1030(e)(2)(ii)(I)
Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters or filters
of equivalent or superior efficiency and which are checked routinely and maintained or replaced as necessary.
1910.1030(e)(2)(ii)(J)
Hypodermic needles and syringes shall be used only for parenteral injection and aspiration of fluids from laboratory
animals and diaphragm bottles. Only needle-locking syringes or disposable syringe-needle units (i.e., the needle is
integral to the syringe) shall be used for the injection or aspiration of other potentially infectious materials. Extreme
caution shall be used when handling needles and syringes. A needle shall not be bent, sheared, replaced in the
sheath or guard, or removed from the syringe following use. The needle and syringe shall be promptly placed in a
puncture-resistant container and autoclaved or decontaminated before reuse or disposal.
1910.1030(e)(2)(ii)(K)
All spills shall be immediately contained and cleaned up by appropriate professional staff or others properly trained
and equipped to work with potentially concentrated infectious materials.
1910.1030(e)(2)(ii)(L)
A spill or accident that results in an exposure incident shall be immediately reported to the laboratory director or
other responsible person.
1910.1030(e)(2)(ii)(M)
A biosafety manual shall be prepared or adopted and periodically reviewed and updated at least annually or more
often if necessary. Personnel shall be advised of potential hazards, shall be required to read instructions on practices
and procedures, and shall be required to follow them.
1910.1030(e)(2)(iii)
Containment Equipment .
1910.1030(e)(2)(iii)(A)
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Certified biological safety cabinets (Class I, II, or III) or other appropriate combinations of personal protection or
physical containment devices, such as special protective clothing, respirators, centrifuge safety cups, sealed centrifuge
rotors, and containment caging for animals, shall be used for all activities with other potentially infectious materials
that pose a threat of exposure to droplets, splashes, spills, or aerosols.
1910.1030(e)(2)(iii)(B)
Biological safety cabinets shall be certified when installed, whenever they are moved and at least annually.
1910.1030(e)(3)
HIV and HBV research laboratories shall meet the following criteria:
1910.1030(e)(3)(i)
Each laboratory shall contain a facility for hand washing and an eye wash facility which is readily available within the
work area.
1910.1030(e)(3)(ii)
An autoclave for decontamination of regulated waste shall be available.
1910.1030(e)(4)
HIV and HBV production facilities shall meet the following criteria:
1910.1030(e)(4)(i)
The work areas shall be separated from areas that are open to unrestricted traffic flow within the building. Passage
through two sets of doors shall be the basic requirement for entry into the work area from access corridors or other
contiguous areas. Physical separation of the high-containment work area from access corridors or other areas or
activities may also be provided by a double-doored clothes-change room (showers may be included), airlock, or other
access facility that requires passing through two sets of doors before entering the work area.
1910.1030(e)(4)(ii)
The surfaces of doors, walls, floors and ceilings in the work area shall be water resistant so that they can be easily
cleaned. Penetrations in these surfaces shall be sealed or capable of being sealed to facilitate decontamination.
1910.1030(e)(4)(iii)
Each work area shall contain a sink for washing hands and a readily available eye wash facility. The sink shall be foot,
elbow, or automatically operated and shall be located near the exit door of the work area.
1910.1030(e)(4)(iv)
Access doors to the work area or containment module shall be self-closing.
1910.1030(e)(4)(v)
An autoclave for decontamination of regulated waste shall be available within or as near as possible to the work area.
1910.1030(e)(4)(vi)
A ducted exhaust-air ventilation system shall be provided. This system shall create directional airflow that draws air
into the work area through the entry area. The exhaust air shall not be recirculated to any other area of the building,
shall be discharged to the outside, and shall be dispersed away from occupied areas and air intakes. The proper
direction of the airflow shall be verified (i.e., into the work area).
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1910.1030(e)(5)
Training Requirements . Additional training requirements for employees in HIV and HBV research laboratories and HIV
and HBV production facilities are specified in paragraph (g)(2)(ix).
1910.1030(f)
Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up -1910.1030(f)(1)
General .
1910.1030(f)(1)(i)
The employer shall make available the hepatitis B vaccine and vaccination series to all employees who have
occupational exposure, and post-exposure evaluation and follow-up to all employees who have had an exposure
incident.
1910.1030(f)(1)(ii)
The employer shall ensure that all medical evaluations and procedures including the hepatitis B vaccine and
vaccination series and post-exposure evaluation and follow-up, including prophylaxis, are:
1910.1030(f)(1)(ii)(A)
Made available at no cost to the employee;
1910.1030(f)(1)(ii)(B)
Made available to the employee at a reasonable time and place;
1910.1030(f)(1)(ii)(C)
Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed
healthcare professional; and
1910.1030(f)(1)(ii)(D)
Provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and
procedures take place, except as specified by this paragraph (f).
1910.1030(f)(1)(iii)
The employer shall ensure that all laboratory tests are conducted by an accredited laboratory at no cost to the
employee.
1910.1030(f)(2)
Hepatitis B Vaccination .
1910.1030(f)(2)(i)
Hepatitis B vaccination shall be made available after the employee has received the training required in paragraph
(g)(2)(vii)(I) and within 10 working days of initial assignment to all employees who have occupational exposure
unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed
that the employee is immune, or the vaccine is contraindicated for medical reasons.
1910.1030(f)(2)(ii)
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The employer shall not make participation in a prescreening program a prerequisite for receiving hepatitis B
vaccination.
1910.1030(f)(2)(iii)
If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard
decides to accept the vaccination, the employer shall make available hepatitis B vaccination at that time.
1910.1030(f)(2)(iv)
The employer shall assure that employees who decline to accept hepatitis B vaccination offered by the employer sign
the statement in Appendix A.
1910.1030(f)(2)(v)
If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date,
such booster dose(s) shall be made available in accordance with section (f)(1)(ii).
1910.1030(f)(3)
Post-exposure Evaluation and Follow-up . Following a report of an exposure incident, the employer shall make
immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the
following elements:
1910.1030(f)(3)(i)
Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred;
1910.1030(f)(3)(ii)
Identification and documentation of the source individual, unless the employer can establish that identification is
infeasible or prohibited by state or local law;
1910.1030(f)(3)(ii)(A)
The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine
HBV and HIV infectivity. If consent is not obtained, the employer shall establish that legally required consent cannot
be obtained. When the source individual's consent is not required by law, the source individual's blood, if available,
shall be tested and the results documented.
1910.1030(f)(3)(ii)(B)
When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known
HBV or HIV status need not be repeated.
1910.1030(f)(3)(ii)(C)
Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be
informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source
individual.
1910.1030(f)(3)(iii)
Collection and testing of blood for HBV and HIV serological status;
1910.1030(f)(3)(iii)(A)
The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.
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1910.1030(f)(3)(iii)(B)
If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic
testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee
elects to have the baseline sample tested, such testing shall be done as soon as feasible.
1910.1030(f)(3)(iv)
Post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service;
1910.1030(f)(3)(v)
Counseling; and
1910.1030(f)(3)(vi)
Evaluation of reported illnesses.
1910.1030(f)(4)
Information Provided to the Healthcare Professional .
1910.1030(f)(4)(i)
The employer shall ensure that the healthcare professional responsible for the employee's Hepatitis B vaccination is
provided a copy of this regulation.
1910.1030(f)(4)(ii)
The employer shall ensure that the healthcare professional evaluating an employee after an exposure incident is
provided the following information:
1910.1030(f)(4)(ii)(A)
A copy of this regulation;
1910.1030(f)(4)(ii)(B)
A description of the exposed employee's duties as they relate to the exposure incident;
1910.1030(f)(4)(ii)(C)
Documentation of the route(s) of exposure and circumstances under which exposure occurred;
1910.1030(f)(4)(ii)(D)
Results of the source individual's blood testing, if available; and
1910.1030(f)(4)(ii)(E)
All medical records relevant to the appropriate treatment of the employee including vaccination status which are the
employer's responsibility to maintain.
1910.1030(f)(5)
Healthcare Professional's Written Opinion. The employer shall obtain and provide the employee with a copy of the
evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.
1910.1030(f)(5)(i)
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The healthcare professional's written opinion for Hepatitis B vaccination shall be limited to whether Hepatitis B
vaccination is indicated for an employee, and if the employee has received such vaccination.
1910.1030(f)(5)(ii)
The healthcare professional's written opinion for post-exposure evaluation and follow-up shall be limited to the
following information:
1910.1030(f)(5)(ii)(A)
That the employee has been informed of the results of the evaluation; and
1910.1030(f)(5)(ii)(B)
That the employee has been told about any medical conditions resulting from exposure to blood or other potentially
infectious materials which require further evaluation or treatment.
1910.1030(f)(5)(iii)
All other findings or diagnoses shall remain confidential and shall not be included in the written report.
1910.1030(g)
Medical Recordkeeping . Medical records required by this standard shall be maintained in accordance with paragraph
(h)(1) of this section.
1910.1030(g)
Communication of Hazards to Employees -1910.1030(g)(1)
Labels and Signs -1910.1030(g)(1)(i)
Labels .
1910.1030(g)(1)(i)(A)
Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other
potentially infectious material; and other containers used to store, transport or ship blood or other potentially
infectious materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G).
1910.1030(g)(1)(i)(B)
Labels required by this section shall include the following legend:
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1910.1030(g)(1)(i)(C)
These labels shall be fluorescent orange or orange-red or predominantly so, with lettering and symbols in a
contrasting color.
1910.1030(g)(1)(i)(D)
Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents
their loss or unintentional removal.
1910.1030(g)(1)(i)(E)
Red bags or red containers may be substituted for labels.
1910.1030(g)(1)(i)(F)
Containers of blood, blood components, or blood products that are labeled as to their contents and have been
released for transfusion or other clinical use are exempted from the labeling requirements of paragraph (g).
1910.1030(g)(1)(i)(G)
Individual containers of blood or other potentially infectious materials that are placed in a labeled container during
storage, transport, shipment or disposal are exempted from the labeling requirement.
1910.1030(g)(1)(i)(H)
Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which
portions of the equipment remain contaminated.
1910.1030(g)(1)(i)(I)
Regulated waste that has been decontaminated need not be labeled or color-coded.
1910.1030(g)(1)(ii)
Signs .
1910.1030(g)(1)(ii)(A)
The employer shall post signs at the entrance to work areas specified in paragraph (e), HIV and HBV Research
Laboratory and Production Facilities, which shall bear the following legend:
(Name of the Infectious Agent)
(Special requirements for entering the area)
(Name, telephone number of the laboratory director or other responsible person.)
1910.1030(g)(1)(ii)(B)
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These signs shall be fluorescent orange-red or predominantly so, with lettering and symbols in a contrasting color.
1910.1030(g)(2)
Information and Training.
1910.1030(g)(2)(i)
The employer shall train each employee with occupational exposure in accordance with the requirements of this
section. Such training must be provided at no cost to the employee and during working hours. The employer shall
institute a training program and ensure employee participation in the program.
1910.1030(g)(2)(ii)
Training shall be provided as follows:
1910.1030(g)(2)(ii)(A)
At the time of initial assignment to tasks where occupational exposure may take place;
1910.1030(g)(2)(ii)(B)
At least annually thereafter.
1910.1030(g)(2)(iii)
[Reserved]
1910.1030(g)(2)(iv)
Annual training for all employees shall be provided within one year of their previous training.
1910.1030(g)(2)(v)
Employers shall provide additional training when changes such as modification of tasks or procedures or institution of
new tasks or procedures affect the employee's occupational exposure. The additional training may be limited to
addressing the new exposures created.
1910.1030(g)(2)(vi)
Material appropriate in content and vocabulary to educational level, literacy, and language of employees shall be
used.
1910.1030(g)(2)(vii)
The training program shall contain at a minimum the following elements:
1910.1030(g)(2)(vii)(A)
An accessible copy of the regulatory text of this standard and an explanation of its contents;
1910.1030(g)(2)(vii)(B)
A general explanation of the epidemiology and symptoms of bloodborne diseases;
1910.1030(g)(2)(vii)(C)
An explanation of the modes of transmission of bloodborne pathogens;
1910.1030(g)(2)(vii)(D)
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An explanation of the employer's exposure control plan and the means by which the employee can obtain a copy of
the written plan;
1910.1030(g)(2)(vii)(E)
An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to
blood and other potentially infectious materials;
1910.1030(g)(2)(vii)(F)
An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate
engineering controls, work practices, and personal protective equipment;
1910.1030(g)(2)(vii)(G)
Information on the types, proper use, location, removal, handling, decontamination and disposal of personal
protective equipment;
1910.1030(g)(2)(vii)(H)
An explanation of the basis for selection of personal protective equipment;
1910.1030(g)(2)(vii)(I)
Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the
benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;
1910.1030(g)(2)(vii)(J)
Information on the appropriate actions to take and persons to contact in an emergency involving blood or other
potentially infectious materials;
1910.1030(g)(2)(vii)(K)
An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the
incident and the medical follow-up that will be made available;
1910.1030(g)(2)(vii)(L)
Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee
following an exposure incident;
1910.1030(g)(2)(vii)(M)
An explanation of the signs and labels and/or color coding required by paragraph (g)(1); and
1910.1030(g)(2)(vii)(N)
An opportunity for interactive questions and answers with the person conducting the training session.
1910.1030(g)(2)(viii)
The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained
in the training program as it relates to the workplace that the training will address.
1910.1030(g)(2)(ix)
Additional Initial Training for Employees in HIV and HBV Laboratories and Production Facilities. Employees in HIV or
HBV research laboratories and HIV or HBV production facilities shall receive the following initial training in addition to
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Bloodborne pathogens. - 1910.1030
the above training requirements.
1910.1030(g)(2)(ix)(A)
The employer shall assure that employees demonstrate proficiency in standard microbiological practices and
techniques and in the practices and operations specific to the facility before being allowed to work with HIV or HBV.
1910.1030(g)(2)(ix)(B)
The employer shall assure that employees have prior experience in the handling of human pathogens or tissue
cultures before working with HIV or HBV.
1910.1030(g)(2)(ix)(C)
The employer shall provide a training program to employees who have no prior experience in handling human
pathogens. Initial work activities shall not include the handling of infectious agents. A progression of work activities
shall be assigned as techniques are learned and proficiency is developed. The employer shall assure that employees
participate in work activities involving infectious agents only after proficiency has been demonstrated.
1910.1030(h)
Recordkeeping -1910.1030(h)(1)
Medical Records.
1910.1030(h)(1)(i)
The employer shall establish and maintain an accurate record for each employee with occupational exposure, in
accordance with 29 CFR 1910.1020.
1910.1030(h)(1)(ii)
This record shall include:
1910.1030(h)(1)(ii)(A)
The name and social security number of the employee;
1910.1030(h)(1)(ii)(B)
A copy of the employee's hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and any
medical records relative to the employee's ability to receive vaccination as required by paragraph (f)(2);
1910.1030(h)(1)(ii)(C)
A copy of all results of examinations, medical testing, and follow-up procedures as required by paragraph (f)(3);
1910.1030(h)(1)(ii)(D)
The employer's copy of the healthcare professional's written opinion as required by paragraph (f)(5); and
1910.1030(h)(1)(ii)(E)
A copy of the information provided to the healthcare professional as required by paragraphs (f)(4)(ii)(B)(C) and (D).
1910.1030(h)(1)(iii)
Confidentiality. The employer shall ensure that employee medical records required by paragraph (h)(1) are:
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1910.1030(h)(1)(iii)(A)
Kept confidential; and
1910.1030(h)(1)(iii)(B)
Not disclosed or reported without the employee's express written consent to any person within or outside the
workplace except as required by this section or as may be required by law.
1910.1030(h)(1)(iv)
The employer shall maintain the records required by paragraph (h) for at least the duration of employment plus 30
years in accordance with 29 CFR 1910.1020.
1910.1030(h)(2)
Training Records.
1910.1030(h)(2)(i)
Training records shall include the following information:
1910.1030(h)(2)(i)(A)
The dates of the training sessions;
1910.1030(h)(2)(i)(B)
The contents or a summary of the training sessions;
1910.1030(h)(2)(i)(C)
The names and qualifications of persons conducting the training; and
1910.1030(h)(2)(i)(D)
The names and job titles of all persons attending the training sessions.
1910.1030(h)(2)(ii)
Training records shall be maintained for 3 years from the date on which the training occurred.
1910.1030(h)(3)
Availability.
1910.1030(h)(3)(i)
The employer shall ensure that all records required to be maintained by this section shall be made available upon
request to the Assistant Secretary and the Director for examination and copying.
1910.1030(h)(3)(ii)
Employee training records required by this paragraph shall be provided upon request for examination and copying to
employees, to employee representatives, to the Director, and to the Assistant Secretary.
1910.1030(h)(3)(iii)
Employee medical records required by this paragraph shall be provided upon request for examination and copying to
the subject employee, to anyone having written consent of the subject employee, to the Director, and to the
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Assistant Secretary in accordance with 29 CFR 1910.1020.
1910.1030(h)(4)
Transfer of Records. The employer shall comply with the requirements involving transfer of records set forth in 29
CFR 1910.1020(h).
1910.1030(h)(5)
Sharps injury log .
1910.1030(h)(5)(i)
The employer shall establish and maintain a sharps injury log for the recording of percutaneous injuries from
contaminated sharps. The information in the sharps injury log shall be recorded and maintained in such manner as to
protect the confidentiality of the injured employee. The sharps injury log shall contain, at a minimum:
1910.1030(h)(5)(i)(A)
The type and brand of device involved in the incident,
1910.1030(h)(5)(i)(B)
The department or work area where the exposure incident occurred, and
1910.1030(h)(5)(i)(C)
An explanation of how the incident occurred.
1910.1030(h)(5)(ii)
The requirement to establish and maintain a sharps injury log shall apply to any employer who is required to maintain
a log of occupational injuries and illnesses under 29 CFR part 1904.
1910.1030(h)(5)(iii)
The sharps injury log shall be maintained for the period required by 29 CFR 1904.33.
1910.1030(i)
Dates —
1910.1030(i)(1)
Effective Date. The standard shall become effective on March 6, 1992.
1910.1030(i)(2)
The Exposure Control Plan required by paragraph (c) of this section shall be completed on or before May 5, 1992.
1910.1030(i)(3)
Paragraphs (g)(2) Information and Training and (h) Recordkeeping of this section shall take effect on or before June
4, 1992.
1910.1030(i)(4)
Paragraphs (d)(2) Engineering and Work Practice Controls, (d)(3) Personal Protective Equipment, (d)(4)
Housekeeping, (e) HIV and HBV Research Laboratories and Production Facilities, (f) Hepatitis B Vaccination and PostExposure Evaluation and Follow-up, and (g)(1) Labels and Signs of this section, shall take effect July 6, 1992.
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Bloodborne pathogens. - 1910.1030
[56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996;
66 FR 5325 Jan., 18, 2001; 71 FR 16672 and 16673, April 3, 2006; 73 FR 75586, Dec. 12, 2008; 76 FR 33608, June 8, 2011; 76 FR
80740, Dec. 27, 2011; 77 FR 19934, April 3, 2012]
 Next Standard (1910.1030 App A)
 Regulations (Standards - 29 CFR) - Table of Contents
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