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Géza T. Terézhalmy, D.D.S.,M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland, Ohio [email protected] Preprocedural antimicrobial rinses Procedures shall be performed in such a manner as to minimize splash, spattering, and aerosols Patients MAY rinse with chlorhexidine gluconate-, or an essential oil-, or povidone iodine-containing mouthwash 01/01/2010 Terezhalmy 2 0.12% Chlorhexidine gluconate 01/01/2010 Terezhalmy 3 01/01/2010 Terezhalmy 4 01/01/2010 Terezhalmy 5 Disposition of reusable patient-care items Critical Penetrate soft tissue and bone during their intended use Semi-critical Touch mucous membranes or non-intact skin during their intended use Non-critical Contact only intact skin during their intended use 01/01/2010 Terezhalmy 6 Critical and semi-critical items MUST be cleaned and MUST be heat sterilized Heat-sensitive items MUST be cleaned and MUST be sterilized using Ethylene oxide OR FDA-registered sterilants e.g., glutaraldehyde, glutaraldehyde with phenol, hydrogen peroxide, or hydrogen peroxide with peracetic acid http://www.epa.gov/oppad001/chemregindex.htm 01/01/2010 Terezhalmy 7 Central instrument processing area Receiving and cleaning Clean instruments using an ultrasonic system with a strainer type basket Visually inspect instruments are for residual debris and damage 01/01/2010 Terezhalmy 8 Preparation and packaging Assemble cassettes, tray sets, or packs with hinged instruments unlocked and open Place an internal or an external chemical indicator in or on each cassette, tray set, or pack Date all cassettes, tray sets, or wrapped packs 01/01/2010 Terezhalmy 9 Sterilization MUST use an FDA cleared sterilizer Load cassettes, tray sets, or packs according to manufacturer’s recommendations Set cycle time, temperature, and pressure according to manufacturer’s recommendation Allow packages to cool and dry before removing from the sterilizer 01/01/2010 Terezhalmy 10 Storage MUST be a clean, enclosed, and dry area Cassettes, tray sets, or packs remain sterile indefinitely Instruments in compromised cassettes, tray sets, or packs MUST be re-cleaned, re-wrapped, and re-sterilized Cassettes, tray sets, or packs MUST be delivered to the operatories in a manner that maintains sterility until instruments are used 01/01/2010 Terezhalmy 11 Monitoring the sterilization process Mechanical: each load Assess the cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer Chemical: each load Use time- and temperature-sensitive internal or external indicators to assess physical conditions during the sterilization process 01/01/2010 Terezhalmy 12 Biological: weekly Place a spore strip or vial inside one of the cassettes, tray sets, or packs Place the cassette, tray set, or pack in the center of the load A strip or vial, which is not heat processed, is used as a control Maintain a record of the weekly results 01/01/2010 Terezhalmy 13 Quality assurance procedures following mechanical, chemical, or biological failure Secure sterilizer Make log entry Take corrective action Retest sterilizer using a biological monitor Suspect loads dating back to the last negative biological test MUST be re-called, re-wrapped, and re-sterilized 01/01/2010 Terezhalmy 14 Non-critical items MUST be cleaned MUST be disinfected EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim e.g., chlorine-containing products, quaternary ammonium compounds with alcohol, phenolics, or iodophors http://www.epa.gov/oppad001/chemregindex.htm 01/01/2010 Terezhalmy 15 Disposition of single-use patient-care items Disposable sharps MUST be removed from cassettes, tray sets, or packs in the patient treatment area MUST be placed in a puncture-resistant, leak-proof, labeled/color-coded container in the patient treatment area 01/01/2010 Terezhalmy 16 Other contaminated single-use items Blood- or saliva-soaked cotton rolls, gauze, pellets, tissue coverings (packs) MUST be placed in small biohazard bag Disposed of into a centralized Regulated Waste Receptacle after each appointment 01/01/2010 Terezhalmy 17 Handpieces MUST be sterilized between patients Clean, sterilize, and maintain each handpiece according to manufacturer’s recommendations 01/01/2010 Terezhalmy 18 Saliva ejectors Backflow with low-volume suction Do not place any portion of the suction tubing holding the tip above the patient’s mouth Do not use simultaneously with high-volume evacuation Do not have patient create a seal around the saliva ejector 01/01/2010 Terezhalmy 19 Dental radiography Cover clinical contact areas with protective barrier Hand hygiene and PPE before initiating the 01/01/2010 radiographic process Use disposable or heat-sterilized film-holding and positioning devices Use FDA-cleared film barrier pouches Remove film packet from pouch and place in a clean container Remove gloves, wash hands, and transport the exposed films to the dark room Terezhalmy 20 Panoramic radiography Place disposable plastic cover over bite guide before the patient is positioned in the machine If no barrier is used, use a sterile bite guard Digital radiography sensors and other hightechnology instruments Should be cleaned and sterilized according to manufacturer’s recommendations 01/01/2010 Terezhalmy 21 Oral surgical procedures Perform surgical hand antisepsis Don sterile surgeon’s gloves Use only sterile saline or sterile water as a coolant or irrigant Laser plumes or surgical smoke may contain aerosolized infectious material Follow standard precautions 01/01/2010 Terezhalmy 22 Biopsy Place specimen in leak-proof, puncture-resistant, closed container with a secure lid for storage and transportation If container becomes visibly contaminated, clean it, disinfect it, or placed in an impervious bag Label with the biohazard symbol 01/01/2010 Terezhalmy 23 Extracted teeth If sent to the laboratory for shade and size comparison Clean and disinfect with an EPA-registered, intermediatelevel hospital disinfectant claiming tuberculocidal activity, e.g., chlorine-containing products, quaternary ammonium compounds with alcohol, phenolics, or iodophors With dental amalgams Consult state and local regulations regarding disposal of amalgam 01/01/2010 Terezhalmy 24 Extracted teeth returned to the patient Clean and disinfect Extracted teeth in educational settings Cleaned of visible blood and gross debris and maintained in a hydrated state (e.g., water or saline) in a well constructed closed container The teeth are heat-sterilized (autoclave cycle for 40 minutes) before clinical exercises or study Teeth with amalgam restorations are disinfected by immersion in 10% formalin solution for 2 weeks 01/01/2010 Terezhalmy 25 Laboratory asepsis Environmental surfaces Barrier-protected or cleaned and disinfected Use PPE when handling items in the laboratory until they have been disinfected Impressions, prostheses, and other devices Rinsed under running tap water an disinfected with EPAregistered intermediate level disinfectant with tuberculocidal claim 01/01/2010 Terezhalmy 26 Burs, polishing points, rag wheels, and laboratory knives Cleaned and then heat-sterilized or disinfected following manufacturer’s recommendations or discarded Metal impression trays and face bow forks Cleaned and heat sterilized Articulators, case pans, and water pans Cleaned and disinfected according to manufacturer’s recommendations 01/01/2010 Terezhalmy 27 Dental unit waterlines Must meet the regulatory standard for safe drinking water <500 CFU/mL Self-contained water systems in combination with a chemical germicide Follow the recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product Dental devices connected to the water system Operated for 20-30 seconds after each patient to discharge water and air 01/01/2010 Terezhalmy 28 Boil-water advisory Do not deliver water from the public water system For hand hygiene use an alcohol-based hand rub or bottled water When the boil-water advisory is lifted disinfect dental waterlines according to manufacturer’s recommendations 01/01/2010 Terezhalmy 29 Dental records Charts are notated and radiographs viewed Before gloving After the gloves are removed and the hands are washed While wearing cover gloves 01/01/2010 Terezhalmy 30 01/01/2010 Terezhalmy 31 01/01/2010 Terezhalmy 32 Environmental infection control Provides for a safer work environment Environmental surfaces Clinical contact surfaces May serve as reservoirs for microbial contamination Housekeeping surfaces Do not contribute to significant cross-contamination 01/01/2010 Terezhalmy 33 Clinical contact surfaces Cover with materials impervious to moisture Coverings are removed and discarded between patients Surfaces are examined for visible soil Soiled surfaces are cleaned and disinfected with an EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim General cleaning and disinfection is performed at the end of daily work activities regardless of barrier protection 01/01/2010 Terezhalmy 34 Housekeeping surfaces Walls, window drapes, and other vertical surfaces Unless visibly clean, cleaning is unnecessary Floors and sinks Clean regularly with a detergent and water OR An EPA-registered hospital disinfectant/detergent designed for general housekeeping Carpeting and cloth furnishing Cannot be reliably disinfected 01/01/2010 Terezhalmy 35 Spills and spatter of blood or OPIM Visible organic material is removed using disposable paper towels Discard in a leak-proof, biohazard-labeled container Contaminated surface is cleaned with a detergent and water AND Disinfected with an EPA-registered intermediatelevel hospital disinfectant with tuberculocidal claim 01/01/2010 Terezhalmy 36 Biohazard communication Labels Fluorescent orange or orange red, with lettering or symbols or a contrasting color Affixed to containers or regulated waste by string, wire, adhesive, or other methods Red bags or red containers may be substituted for labels Decontaminated regulated waste is not labeled or color-coded 01/01/2010 Terezhalmy 37 Post-exposure management and followup 01/01/2010 Establishes policies and practices to reduce the risk of post-exposure infection Terezhalmy 38 Post-exposure protocol Immediately after an exposure incident Wash area of injury with soap and water Report the exposure incident immediately Complete the Uniform Needlestick and Sharp Object Injury Report Form 01/01/2010 Terezhalmy 39 Within 2 hours of an exposure incident Arrange for a post-exposure evaluation by a physician A copy of the employee’s medical record A copy of the Uniform Needlestick and Sharp Object Injury Report Any information available about the source individual 01/01/2010 Terezhalmy 40 As soon as feasible after an exposure incident If the source person can be identified and with his/her consent The source person’s blood is tested for HBV, HCV, and HIV Results are made available to the employee Applicable privacy laws and regulations apply 01/01/2010 Terezhalmy 41 Post-exposure management and prophylaxis According to latest CDC recommendations A written report from the consultant physician is obtained within 15 days of the post-exposure evaluation Written report becomes part of the OHCW’s medical record 01/01/2010 Terezhalmy 42 Medical record Maintained on all personnel Name and SSN Documentation of vaccination status A copy of the Mandatory Hepatitis B Vaccination Declination Form (if applicable) A copy of all results of examinations, medical tests, and other post-exposure follow-up data 01/01/2010 Terezhalmy 43 The medical record is confidential Its content is not disclosed except as required by law The medical record is made available to the OHCW for examination A copy is provided upon request The medical record is maintained for at least the duration of employment plus 30 years 01/01/2010 Terezhalmy 44 Administrative controls 01/01/2010 Establish exclusion policies from work and patient care Terezhalmy 45 Minimize latex-related health problems among OHCWs and patients Reduce exposure to latex-containing materials Train and educate OHCWs to recognize signs and symptoms of latex-related adverse effects Monitor signs and symptoms of latex-related adverse effects among OHCWs and patient 01/01/2010 Terezhalmy 46 Minimize the exposure of OHCWs with acute or chronic diseases to patients i.e., to patients who have been diagnosed with a transmissible infectious disease OHCWs shall consult with their personal physician Determine if their condition(s) might affect their ability to safely perform their duties 01/01/2010 Terezhalmy 47 Minimize the exposure of patients to OHCWs i.e., to OHCWs who have been exposed to or have been diagnosed with an infectious disease Restrictions based on the mode of transmission and the period of infectivity of the pathogen 01/01/2010 Terezhalmy 48 Infectious state HBV 01/01/2010 Restrictions OHCWs with acute or chronic HBsAg who do not perform exposure-prone procedures OHCWs with acute or chronic HBeAg who perform exposure-prone procedures No restrictions Do not perform exposure-prone procedures until counsel from a review panel has been sought (State Dental Board) Terezhalmy 49 Infectious state HCV 01/01/2010 Acute or chronic infection Restrictions No restrictions Terezhalmy 50 Infectious state HIV 01/01/2010 HIV infection AIDS Restrictions Do not perform exposureprone procedures until counsel from a review panel has been sought (State Dental Board) Terezhalmy 51 Agent Measles Infectious state Post exposure Exclude from duty from 5th day after first exposure THROUGH 21st day after last exposure OR 4 days after rash appears Acute infection Exclude from duty for 7 days after rash appears Susceptible OHCW (Rubella) 01/01/2010 Restrictions Terezhalmy 52 Agent Mumps Infectious state Post exposure Exclude from duty from 12th day after first exposure THROUGH 26st day after last exposure OR 9 days after onset of parotitis Acute infection Exclude from duty for 9 days after onset of parotitis Susceptible OHCW (Infectious parotitis) 01/01/2010 Restrictions Terezhalmy 53 Agent Infectious state Post exposure Exclude from duty from 7th day after first exposure THROUGH 21st day after last exposure Acute infection Exclude from duty for 5 days after rash appears Exclude from duty for 5 days after rash appears Susceptible OHCW Rubella (German measles) 01/01/2010 Restrictions Terezhalmy 54 Agent HSV-1 and HSV-2 01/01/2010 Infectious state Restrictions Acute orolabial herpes Restrict from care of patients at high risk until lesions heal Acute herpetic whitlow Exclude from duty until lesions heal Acute genital herpes No restrictions Terezhalmy 55 Agent VZV (Chicken pox) 01/01/2010 Infectious state Restrictions Post-exposure Exclude from duty from the 10th day after first exposure THROUGH 21st day after last exposure Acute infection Exclude from duty until all lesions dry and crust Susceptible OHCW Terezhalmy 56 Agent Infectious state Post-exposure Exclude from patient care from the 5th day after first exposure THROUGH 21st day after last exposure Acute infection Restrict from the care of patients at high-risk until lesions dry and crust Susceptible OHCW VZV (Shingles) Healthy OHCW Acute infection Immunocompromised OHCW 01/01/2010 Restrictions Restrict from patient care until lesions dry and crust Terezhalmy 57 Agent Influenza and syncytial viruses Infectious state Acute infection with fever Exclude from the care of patients at high-risk until cute symptoms resolve PPD positive No restrictions Infectious TB disease Exclude from duty until proven non-infectious TB 01/01/2010 Restrictions Terezhalmy 58 SUMMARY Good structure Increases the likelihood of a good process Good process Increases the likelihood of a good outcome 01/01/2010 Terezhalmy 59 References 1. 2. 3. 4. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64004-64182. CDC. Guidelines for infection control in dental health-care settings-2003. MMWR 2003;52(No. RR-17):1-68. Terezhalmy GT. Clinical practice guidelines for an infection control/exposure control program in the oral healthcare setting. Access PDF file at dentalcare.com Huber MA, Terezhalmy GT. Hepatotropic viruses: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com 01/01/2010 Terezhalmy 60 5. 6. 7. 8. Huber MA, Terezhalmy GT. HIV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com Huber MA, Terezhalmy GT. Measles, mumps, rubella: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com Huber MA, Terezhalmy GT: HSV and VZV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com Porteous NB, Terezhalmy GT: Tuberculosis: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com 01/01/2010 Terezhalmy 61 9. 10. 11. 12. Huber MA, Terezhalmy GT: Mandated and highly recommended and highly recommended vaccines for oral health care. Access PDF file at dentalcare.com Huber MA, Terezhalmy GT. Adverse reactions to latex products: preventive and therapeutic strategies. Access PDF file at dentalcare.com Terezhalmy GT, Huber MA. Hand hygiene: infection control/exposure control issues for oral healthcare setting. Access PDF file at dentalcare.com Terezhalmy GT, Huber MA. Environmental infection control in oral healthcare settings. Access PDF file at dentalcare.com 01/01/2010 Terezhalmy 62
