guidelines for infection control in dental health-care settings2003 cdc. mmwr 2003;52(no. rr-17)
TRANSCRIPT
Guidelines for Infection Guidelines for Infection Control in Dental Health-Care Control in Dental Health-Care
Settings—2003Settings—2003
CDC. CDC. MMWRMMWR 2003;52(No. RR-17) 2003;52(No. RR-17)
http://www.cdc.gov/oralhealth/http://www.cdc.gov/oralhealth/
infectioncontrol/guidelines/index.htminfectioncontrol/guidelines/index.htm
This slide set “Guidelines for Infection
Control in Dental Health-Care Settings-Core”
and accompanying speaker notes provide an
overview of many of the basic principles of
infection control that form the basis for the
CDC Guidelines for Infection Control in
Dental Health-Care Settings — 2003.
This slide set can be used for education and training of infection control coordinators, educators, consultants, and dental staff (initial and periodic training) at all levels of education.
Infection Control in Dental Infection Control in Dental Health-Care Settings: An OverviewHealth-Care Settings: An Overview
Guidelines for Infection Control in Dental Health-Care Settings—2003. MMWR 2003; Vol. 52, No. RR-17.
Background
Personnel Health Elements
Bloodborne Pathogens
Hand Hygiene
Personal Protective Equipment
Latex Hypersensitivity/Contact Dermatitis
Sterilization and Disinfection Environmental Infection Control
Dental Unit Waterlines
Special Considerations
Program Evaluation
CDC RecommendationsCDC Recommendations
Improve effectiveness and impact of public health Improve effectiveness and impact of public health interventionsinterventions
Inform clinicians, public health practitioners, and the Inform clinicians, public health practitioners, and the publicpublic
Developed by advisory committees, ad hoc groups, Developed by advisory committees, ad hoc groups, and CDC staffand CDC staff
Based on a range of rationale, from systematic reviews Based on a range of rationale, from systematic reviews to expert opinionsto expert opinions
BackgroundBackground
Why Is Infection Control Important Why Is Infection Control Important in Dentistry?in Dentistry?
Both patients and dental health care personnel Both patients and dental health care personnel (DHCP) can be exposed to pathogens(DHCP) can be exposed to pathogens
Contact with blood, oral and respiratory secretions, Contact with blood, oral and respiratory secretions, and contaminated equipment occursand contaminated equipment occurs
Proper procedures can prevent transmission of Proper procedures can prevent transmission of infections among patients and DHCPinfections among patients and DHCP
Modes of TransmissionModes of Transmission
Direct contact with blood or body fluidsDirect contact with blood or body fluids
Indirect contact with a contaminated Indirect contact with a contaminated instrument or surfaceinstrument or surface
Contact of mucosa of the eyes, nose, or mouth Contact of mucosa of the eyes, nose, or mouth with droplets or spatterwith droplets or spatter
Inhalation of airborne microorganismsInhalation of airborne microorganisms
Chain of InfectionChain of Infection
Pathogen
Source
ModeEntry
Susceptible Host
Standard PrecautionsStandard Precautions
Apply to Apply to allall patients patients
Integrate and expand Universal Precautions Integrate and expand Universal Precautions to include organisms spread by blood and to include organisms spread by blood and also also
• Body fluids, secretions, and excretions except Body fluids, secretions, and excretions except sweat, whether or not they contain bloodsweat, whether or not they contain blood
• Non-intact (broken) skinNon-intact (broken) skin
• Mucous membranesMucous membranes
Elements of Standard PrecautionsElements of Standard Precautions
HandwashingHandwashing
Use of gloves, masks, eye protection, and Use of gloves, masks, eye protection, and gownsgowns
Patient care equipmentPatient care equipment
Environmental surfacesEnvironmental surfaces
Injury preventionInjury prevention
Personnel Health Personnel Health ElementsElements
Personnel Health Elements of an Personnel Health Elements of an Infection Control ProgramInfection Control Program
Education and trainingEducation and training
ImmunizationsImmunizations
Exposure prevention and postexposure managementExposure prevention and postexposure management
Medical condition management and work-related Medical condition management and work-related illnesses and restrictionsillnesses and restrictions
Health record maintenanceHealth record maintenance
Bloodborne PathogensBloodborne Pathogens
Preventing Transmission of Preventing Transmission of Bloodborne PathogensBloodborne Pathogens
Are transmissible in health care settingsAre transmissible in health care settings
Can produce chronic infectionCan produce chronic infection
Are often carried by persons unaware of their Are often carried by persons unaware of their infectioninfection
Bloodborne viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)
Potential Routes of Transmission Potential Routes of Transmission of Bloodborne Pathogensof Bloodborne Pathogens
Patient DHCP
DHCP Patient
Patient Patient
Factors Influencing Occupational Factors Influencing Occupational Risk of Bloodborne Virus InfectionRisk of Bloodborne Virus Infection
Frequency of infection among patientsFrequency of infection among patients
Risk of transmission after a blood Risk of transmission after a blood exposure (i.e., type of virus)exposure (i.e., type of virus)
Type and frequency of blood contactType and frequency of blood contact
Average Risk of Bloodborne Virus Average Risk of Bloodborne Virus Transmission after NeedlestickTransmission after Needlestick
SourceSource RiskRisk
HBVHBVHBsAgHBsAg++ and HBeAg and HBeAg++ 22.0%-31.0% clinical hepatitis; 37%-62% 22.0%-31.0% clinical hepatitis; 37%-62%
serological evidence of HBV infectionserological evidence of HBV infection
HBsAgHBsAg++ and HBeAg and HBeAg-- 1.0%-6.0% clinical hepatitis; 23%-37% 1.0%-6.0% clinical hepatitis; 23%-37% serological evidence of HBV infectionserological evidence of HBV infection
HCVHCV 1.8% (0%-7% range)1.8% (0%-7% range)
HIVHIV 0.3% (0.2%-0.5% range)0.3% (0.2%-0.5% range)
Concentration of HBV in Body FluidsConcentration of HBV in Body Fluids
HighHigh ModerateModerate Low/Not DetectableLow/Not Detectable
BloodBlood SemenSemen UrineUrine
SerumSerum Vaginal FluidVaginal Fluid FecesFeces
Wound exudatesWound exudates SalivaSaliva SweatSweat
TearsTears
Breast MilkBreast Milk
Estimated Incidence of HBV Infections Among Estimated Incidence of HBV Infections Among HCP and General Population, HCP and General Population,
United States, 1985-1999United States, 1985-1999
0
50
100
150
200
250
300
350
1985 1987 1989 1991 1993 1995 1997 1999
Year
Inci
den
ce p
er 1
00,0
00
Health Care Personnel
General U.S. Population
Source: Cleveland et al., JADA 1996;127:1385-90. Personal communication ADA, Chakwan Siew, PhD, 2005.
Per
cen
tHBV Infection Among U.S. DentistsHBV Infection Among U.S. Dentists
Year
0
2
4
6
8
10
12
14
16
1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003
Hepatitis B VaccineHepatitis B Vaccine
Vaccinate all DHCP who are at risk of Vaccinate all DHCP who are at risk of exposure to bloodexposure to blood
Provide access to qualified health care Provide access to qualified health care professionals for administration and professionals for administration and follow-up testingfollow-up testing
Test for anti-HBs 1 to 2 months after Test for anti-HBs 1 to 2 months after 3rd dose3rd dose
Transmission of HBV from Infected Transmission of HBV from Infected DHCP to PatientsDHCP to Patients
Nine clusters of transmission from dentists and oral Nine clusters of transmission from dentists and oral surgeons to patients, 1970–1987surgeons to patients, 1970–1987
Eight dentists tested for HBeAg were positiveEight dentists tested for HBeAg were positive
Lack of documented transmissions since 1987 may Lack of documented transmissions since 1987 may reflect increased use of gloves and vaccinereflect increased use of gloves and vaccine
One case of patient-to-patient transmission, 2003One case of patient-to-patient transmission, 2003
Occupational Risk of HCV Occupational Risk of HCV Transmission among HCPTransmission among HCP
Inefficiently transmitted by occupational Inefficiently transmitted by occupational exposuresexposures
Three reports of transmission from blood Three reports of transmission from blood splash to the eye splash to the eye
Report of simultaneous transmission of HIV Report of simultaneous transmission of HIV and HCV after non-intact skin exposureand HCV after non-intact skin exposure
HCV Infection in HCV Infection in Dental Health Care SettingsDental Health Care Settings
Prevalence of HCV infection among Prevalence of HCV infection among dentists similar to that of general population dentists similar to that of general population (~ 1%-2%) (~ 1%-2%)
No reports of HCV transmission from No reports of HCV transmission from infected DHCP to patients or from patient infected DHCP to patients or from patient to patient to patient
Risk of HCV transmission appears very lowRisk of HCV transmission appears very low
Transmission of HIV from Infected Transmission of HIV from Infected Dentists to PatientsDentists to Patients
Only one documented case of HIV Only one documented case of HIV transmission from an infected dentist to transmission from an infected dentist to patientspatients
No transmissions documented in the No transmissions documented in the investigation of 63 HIV-infected HCP investigation of 63 HIV-infected HCP (including 33 dentists or dental students)(including 33 dentists or dental students)
Health Care Workers with Documented and Possible Occupationally Acquired HIV/AIDS
CDC Database as of December 2002
* 3 dentists, 1 oral surgeon, 2 dental assistants
Documented Possible
Dental Worker 0 6 *
Nurse 24 35
Lab Tech, clinical 16 17
Physician, nonsurgical 6 12
Lab Tech, nonclinical 3 –
Other 8 69
Total 57 139
Risk Factors for HIV Transmission after Risk Factors for HIV Transmission after Percutaneous Exposure to HIV-Infected Blood Percutaneous Exposure to HIV-Infected Blood
CDC Case-Control StudyCDC Case-Control Study
Deep injuryDeep injury
Visible blood on deviceVisible blood on device
Needle placed in artery or veinNeedle placed in artery or vein
Terminal illness in source patientTerminal illness in source patient
Source: Cardo, et al., Source: Cardo, et al., N England J Medicine N England J Medicine 1997;337:1485-90.1997;337:1485-90.
Characteristics of Percutaneous Characteristics of Percutaneous Injuries Among DHCPInjuries Among DHCP
Reported frequency among general dentists has Reported frequency among general dentists has declineddeclined
Caused by burs, syringe needles, other sharps Caused by burs, syringe needles, other sharps
Occur outside the patient’s mouthOccur outside the patient’s mouth
Involve small amounts of bloodInvolve small amounts of blood
Among oral surgeons, occur more frequently Among oral surgeons, occur more frequently during fracture reductions and procedures during fracture reductions and procedures involving wireinvolving wire
Exposure Prevention StrategiesExposure Prevention Strategies
Engineering controlsEngineering controls Work practice controlsWork practice controls Administrative controlsAdministrative controls
Engineering ControlsEngineering Controls
Isolate or remove the hazard Isolate or remove the hazard
Examples:Examples:
• Sharps containerSharps container
• Medical devices with injury protection Medical devices with injury protection features (e.g., self-sheathing needles)features (e.g., self-sheathing needles)
Work Practice ControlsWork Practice Controls
Change the manner of performing tasksChange the manner of performing tasks
Examples include:Examples include:
• Using instruments instead of fingers to Using instruments instead of fingers to retract or palpate tissueretract or palpate tissue
• One-handed needle recappingOne-handed needle recapping
Administrative ControlsAdministrative Controls
Policies, procedures, and enforcement Policies, procedures, and enforcement measuresmeasures
Placement in the hierarchy varies by the Placement in the hierarchy varies by the problem being addressedproblem being addressed
• Placed before engineering controls for Placed before engineering controls for airborne precautions (e.g., TB) airborne precautions (e.g., TB)
Post-exposure Management Post-exposure Management ProgramProgram
Clear policies and proceduresClear policies and procedures
Education of dental health care personnel Education of dental health care personnel (DHCP) (DHCP)
Rapid access toRapid access to
• Clinical careClinical care
• Post-exposure prophylaxis (PEP)Post-exposure prophylaxis (PEP)
• Testing of source patients/HCPTesting of source patients/HCP
Wound managementWound management Exposure reportingExposure reporting Assessment of infection riskAssessment of infection risk
• Type and severity of exposureType and severity of exposure
• Bloodborne status of source personBloodborne status of source person
• Susceptibility of exposed personSusceptibility of exposed person
Post-exposure ManagementPost-exposure Management
Hand HygieneHand Hygiene
Why Is Hand Hygiene Important?Why Is Hand Hygiene Important?
Hands are the most common mode of Hands are the most common mode of
pathogen transmissionpathogen transmission
Reduce spread of antimicrobial resistanceReduce spread of antimicrobial resistance
Prevent health care-associated infectionsPrevent health care-associated infections
Hands Need to be Cleaned WhenHands Need to be Cleaned When
Visibly dirtyVisibly dirty
After touching contaminated After touching contaminated objects with bare handsobjects with bare hands
Before and after patient Before and after patient treatment (before glove treatment (before glove placement and after glove placement and after glove removal)removal)
Hand Hygiene DefinitionsHand Hygiene Definitions
HandwashingHandwashing• Washing hands with plain soap and waterWashing hands with plain soap and water
Antiseptic handwashAntiseptic handwash• Washing hands with water and soap or other detergents Washing hands with water and soap or other detergents
containing an antiseptic agentcontaining an antiseptic agent
Alcohol-based handrubAlcohol-based handrub• Rubbing hands with an alcohol-containing preparationRubbing hands with an alcohol-containing preparation
Surgical antisepsisSurgical antisepsis• Handwashing with an antiseptic soap or an alcohol-based Handwashing with an antiseptic soap or an alcohol-based
handrub before operations by surgical personnelhandrub before operations by surgical personnel
Efficacy of Hand Hygiene Efficacy of Hand Hygiene Preparations in Reduction of BacteriaPreparations in Reduction of Bacteria
Good Better Best
Plain Soap Antimicrobial soap
Alcohol-based handrub
Source: http://www.cdc.gov/handhygiene/materials.htm
Alcohol-based PreparationsAlcohol-based Preparations
Rapid and effective Rapid and effective antimicrobial actionantimicrobial action
Improved skin conditionImproved skin condition
More accessible than More accessible than sinkssinks
Cannot be used if hands Cannot be used if hands are visibly soiledare visibly soiled
Store away from high Store away from high temperatures or flamestemperatures or flames
Hand softeners and Hand softeners and glove powders may glove powders may “build-up”“build-up”
Benefits Limitations
Special Hand Hygiene ConsiderationsSpecial Hand Hygiene Considerations
Use hand lotions to prevent skin dryness Use hand lotions to prevent skin dryness
Consider compatibility of hand care products with Consider compatibility of hand care products with gloves (e.g., mineral oils and petroleum bases may gloves (e.g., mineral oils and petroleum bases may cause early glove failure)cause early glove failure)
Keep fingernails shortKeep fingernails short
Avoid artificial nails Avoid artificial nails
Avoid hand jewelry that may tear glovesAvoid hand jewelry that may tear gloves
Personal Protective Personal Protective EquipmentEquipment
Personal Personal Protective Protective EquipmentEquipment
A major component of Standard PrecautionsA major component of Standard Precautions
Protects the skin and mucous membranes Protects the skin and mucous membranes from exposure to infectious materials in spray from exposure to infectious materials in spray or spatter or spatter
Should be removed when leaving treatment Should be removed when leaving treatment areasareas
Masks, Protective Eyewear, Face ShieldsMasks, Protective Eyewear, Face Shields
Wear a surgical mask and either eye protection with Wear a surgical mask and either eye protection with solid side shields or a face shield to protect mucous solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouthmembranes of the eyes, nose, and mouth
Change masks between patientsChange masks between patients
Clean reusable face protection between patients; if Clean reusable face protection between patients; if visibly soiled, clean and disinfectvisibly soiled, clean and disinfect
Protective ClothingProtective Clothing
Wear gowns, lab coats, or Wear gowns, lab coats, or uniforms that cover skin and uniforms that cover skin and personal clothing likely to become personal clothing likely to become soiled with blood, saliva, or soiled with blood, saliva, or infectious materialinfectious material
Change if visibly soiledChange if visibly soiled
Remove all barriers before leaving Remove all barriers before leaving the work areathe work area
GlovesGloves
Minimize the risk of health care personnel Minimize the risk of health care personnel acquiring infections from patientsacquiring infections from patients
Prevent microbial flora from being transmitted Prevent microbial flora from being transmitted from health care personnel to patientsfrom health care personnel to patients
Reduce contamination of the hands of health Reduce contamination of the hands of health care personnel by microbial flora that can be care personnel by microbial flora that can be transmitted from one patient to anothertransmitted from one patient to another
Are not a substitute for handwashing!Are not a substitute for handwashing!
Recommendations for GlovingRecommendations for Gloving
Wear gloves when contact with Wear gloves when contact with blood, saliva, and mucous blood, saliva, and mucous membranes is possiblemembranes is possible
Remove gloves after patient care Remove gloves after patient care
Wear a new pair of gloves for Wear a new pair of gloves for each patienteach patient
Recommendations for GlovingRecommendations for Gloving
Remove gloves that are torn, cut or punctured
Do not wash, disinfect or sterilize gloves for reuse
Latex Hypersensitivity Latex Hypersensitivity and Contact Dermatitisand Contact Dermatitis
Latex AllergyLatex Allergy
Type I hypersensitivity to natural Type I hypersensitivity to natural rubber latex proteinsrubber latex proteins
Reactions may include nose, eye, Reactions may include nose, eye, and skin reactionsand skin reactions
More serious reactions may More serious reactions may include respiratory distress–rarely include respiratory distress–rarely shock or deathshock or death
Contact DermatitisContact Dermatitis
Irritant contact dermatitisIrritant contact dermatitis
• Not an allergyNot an allergy
• Dry, itchy, irritated areasDry, itchy, irritated areas
Allergic contact dermatitis Allergic contact dermatitis
• Type IV delayed hypersensitivityType IV delayed hypersensitivity
• May result from allergy to chemicals used in glove May result from allergy to chemicals used in glove manufacturingmanufacturing
General RecommendationsGeneral RecommendationsContact Dermatitis and Latex AllergyContact Dermatitis and Latex Allergy
Educate DHCP about reactions associated with Educate DHCP about reactions associated with frequent hand hygiene and glove use frequent hand hygiene and glove use
Get a medical diagnosisGet a medical diagnosis
Screen patients for latex allergyScreen patients for latex allergy
Ensure a latex-safe environmentEnsure a latex-safe environment
Have latex-free kits available (dental and Have latex-free kits available (dental and emergency)emergency)
Sterilization and Disinfection Sterilization and Disinfection of Patient Care Itemsof Patient Care Items
Critical InstrumentsCritical Instruments
Penetrate mucous membranes or contact bone, Penetrate mucous membranes or contact bone, the bloodstream, or other normally sterile the bloodstream, or other normally sterile tissues (of the mouth)tissues (of the mouth)
Heat sterilize between uses or use sterile single-Heat sterilize between uses or use sterile single-use, disposable devicesuse, disposable devices
Examples include surgical instruments, scalpel Examples include surgical instruments, scalpel blades, periodontal scalers, and surgical dental blades, periodontal scalers, and surgical dental bursburs
Semi-critical InstrumentsSemi-critical Instruments
Contact mucous membranes but do not Contact mucous membranes but do not penetrate soft tissue penetrate soft tissue
Heat sterilize or high-level disinfect Heat sterilize or high-level disinfect
Examples: Dental mouth mirrors, Examples: Dental mouth mirrors, amalgam condensers, and dental amalgam condensers, and dental handpieceshandpieces
Noncritical Instruments Noncritical Instruments and Devicesand Devices
Contact intact skinContact intact skin
Clean and disinfect using a low to intermediate Clean and disinfect using a low to intermediate level disinfectantlevel disinfectant
Examples: X-ray heads, facebows, pulse Examples: X-ray heads, facebows, pulse oximeter, blood pressure cuffoximeter, blood pressure cuff
Instrument Processing AreaInstrument Processing Area
Use a designated processing area to control quality Use a designated processing area to control quality and ensure safetyand ensure safety
Divide processing area into work areasDivide processing area into work areas
• Receiving, cleaning, and decontaminationReceiving, cleaning, and decontamination
• Preparation and packaging Preparation and packaging
• Sterilization Sterilization
• StorageStorage
Automated Cleaning Automated Cleaning
Ultrasonic cleanerUltrasonic cleaner
Instrument washerInstrument washer
Washer-disinfectorWasher-disinfector
Manual CleaningManual Cleaning
Soak until ready to cleanSoak until ready to clean
Wear heavy-duty utility Wear heavy-duty utility gloves, mask, eyewear, gloves, mask, eyewear, and protective clothingand protective clothing
Preparation and PackagingPreparation and Packaging
Critical and semi-critical items that will be Critical and semi-critical items that will be stored should be wrapped or placed in stored should be wrapped or placed in containers before heat sterilizationcontainers before heat sterilization
Hinged instruments opened and unlockedHinged instruments opened and unlocked
Place a chemical indicator inside the packPlace a chemical indicator inside the pack
Wear heavy-duty, puncture-resistant utility Wear heavy-duty, puncture-resistant utility glovesgloves
Heat-Based SterilizationHeat-Based Sterilization
Steam under pressure (autoclaving)Steam under pressure (autoclaving)
• Gravity displacementGravity displacement
• Pre-vacuum Pre-vacuum
Dry heatDry heat
Unsaturated chemical vaporUnsaturated chemical vapor
Liquid Chemical Liquid Chemical Sterilant/DisinfectantsSterilant/Disinfectants
Only for heat-sensitive critical Only for heat-sensitive critical and semi-critical devicesand semi-critical devices
Powerful, toxic chemicals Powerful, toxic chemicals raise safety concernsraise safety concerns
Heat tolerant or disposable Heat tolerant or disposable alternatives are availablealternatives are available
Sterilization Monitoring Sterilization Monitoring Types of IndicatorsTypes of Indicators
Mechanical Mechanical
• Measure time, temperature, pressureMeasure time, temperature, pressure
Chemical Chemical
• Change in color when physical parameter is Change in color when physical parameter is reachedreached
Biological (spore tests)Biological (spore tests)
• Use biological spores to assess the sterilization Use biological spores to assess the sterilization process directlyprocess directly
Storage of Sterile and Storage of Sterile and Clean Items and SuppliesClean Items and Supplies
Use date- or event-related shelf-life practicesUse date- or event-related shelf-life practices
Examine wrapped items carefully prior to useExamine wrapped items carefully prior to use
When packaging of sterile items is damaged, When packaging of sterile items is damaged, re-clean, re-wrap, and re-sterilizere-clean, re-wrap, and re-sterilize
Store clean items in dry, closed, or covered Store clean items in dry, closed, or covered containmentcontainment
Environmental Infection Environmental Infection ControlControl
Environmental SurfacesEnvironmental Surfaces
May become contaminated May become contaminated
Not directly involved in infectious disease Not directly involved in infectious disease transmissiontransmission
Do not require as stringent decontamination Do not require as stringent decontamination proceduresprocedures
Categories of Environmental SurfacesCategories of Environmental Surfaces
Clinical contact surfacesClinical contact surfaces
• High potential for direct contamination from High potential for direct contamination from spray or spatter or by contact with DHCP’s spray or spatter or by contact with DHCP’s gloved handgloved hand
Housekeeping surfacesHousekeeping surfaces
• Do not come into contact with patients or Do not come into contact with patients or devicesdevices
• Limited risk of disease transmissionLimited risk of disease transmission
Clinical Contact SurfacesClinical Contact Surfaces
Housekeeping SurfacesHousekeeping Surfaces
General Cleaning RecommendationsGeneral Cleaning Recommendations
Use barrier precautions (e.g., heavy-duty utility gloves, Use barrier precautions (e.g., heavy-duty utility gloves, masks, protective eyewear) when cleaning and masks, protective eyewear) when cleaning and disinfecting environmental surfacesdisinfecting environmental surfaces
Physical removal of microorganisms by cleaning is as Physical removal of microorganisms by cleaning is as important as the disinfection processimportant as the disinfection process
Follow manufacturer’s instructions for proper use of Follow manufacturer’s instructions for proper use of EPA-registered hospital disinfectantsEPA-registered hospital disinfectants
Do not use sterilant/high-level disinfectants on Do not use sterilant/high-level disinfectants on environmental surfacesenvironmental surfaces
Cleaning Clinical Contact SurfacesCleaning Clinical Contact Surfaces
Risk of transmitting infections greater Risk of transmitting infections greater than for housekeeping surfacesthan for housekeeping surfaces
Surface barriers can be used and Surface barriers can be used and changed between patientschanged between patients
OROR
Clean then disinfect using an EPA-Clean then disinfect using an EPA-registered low- (HIV/HBV claim) to registered low- (HIV/HBV claim) to intermediate-level (tuberculocidal intermediate-level (tuberculocidal claim) hospital disinfectantclaim) hospital disinfectant
Cleaning Housekeeping SurfacesCleaning Housekeeping Surfaces
Routinely clean with soap and water or an EPA-Routinely clean with soap and water or an EPA-registered detergent/hospital disinfectant routinelyregistered detergent/hospital disinfectant routinely
Clean mops and cloths and allow to dry thoroughly Clean mops and cloths and allow to dry thoroughly before re-usingbefore re-using
Prepare fresh cleaning and disinfecting solutions Prepare fresh cleaning and disinfecting solutions daily and per manufacturer recommendationsdaily and per manufacturer recommendations
Medical WasteMedical Waste
Medical Waste: Medical Waste: Not considered infectious, Not considered infectious, thus can be discarded in regular trashthus can be discarded in regular trash
Regulated Medical Waste: Regulated Medical Waste: Poses a Poses a potential risk of infection during handling potential risk of infection during handling and disposaland disposal
Regulated Medical Waste ManagementRegulated Medical Waste Management
Properly labeled containment to Properly labeled containment to prevent injuries and leakage prevent injuries and leakage
Medical wastes are “treated” in Medical wastes are “treated” in accordance with state and local EPA accordance with state and local EPA regulations regulations
Processes for regulated waste include Processes for regulated waste include autoclaving and incinerationautoclaving and incineration
Dental Unit Waterlines, Dental Unit Waterlines, Biofilm, Biofilm,
and Water Qualityand Water Quality
Dental Unit Waterlines Dental Unit Waterlines and Biofilmand Biofilm
Microbial biofilms form in Microbial biofilms form in small bore tubing of dental small bore tubing of dental units units
Biofilms serve as a microbial Biofilms serve as a microbial reservoirreservoir
Primary source of Primary source of microorganisms is municipal microorganisms is municipal water supplywater supply
Dental Unit Water QualityDental Unit Water Quality
Using water of uncertain quality is inconsistent Using water of uncertain quality is inconsistent with infection control principleswith infection control principles
Colony counts in water from untreated systems Colony counts in water from untreated systems can exceed 1,000,000can exceed 1,000,000 CFU/mL CFU/mL
CFU=colony forming unitCFU=colony forming unit
Untreated dental units cannot reliably produce Untreated dental units cannot reliably produce water that meets drinking water standards water that meets drinking water standards
Dental Water QualityDental Water Quality
For routine dental treatment, For routine dental treatment, meet regulatory standards for meet regulatory standards for drinking water.*drinking water.*
** <500 CFU/mL of heterotrophic water <500 CFU/mL of heterotrophic water bacteriabacteria
Available DUWL TechnologyAvailable DUWL Technology
Independent reservoirsIndependent reservoirs
Chemical treatmentChemical treatment
FiltrationFiltration
CombinationsCombinations
Sterile water delivery systemsSterile water delivery systems
Monitoring OptionsMonitoring Options
Water testing laboratoryWater testing laboratory
In-office testing with self-contained kitsIn-office testing with self-contained kits
Follow recommendations provided by the Follow recommendations provided by the manufacturer of the dental unit or waterline manufacturer of the dental unit or waterline treatment product for monitoring water qualitytreatment product for monitoring water quality
Sterile Irrigating SolutionsSterile Irrigating Solutions
Use sterile saline or sterile water Use sterile saline or sterile water as a coolant/irrigator when as a coolant/irrigator when performing surgical proceduresperforming surgical procedures
Use devices designed for the Use devices designed for the delivery of sterile irrigating fluidsdelivery of sterile irrigating fluids
Special ConsiderationsSpecial Considerations Dental handpieces and other Dental handpieces and other
devices attached to air and devices attached to air and waterlineswaterlines
Dental radiologyDental radiology
Aseptic technique for Aseptic technique for parenteral medicationsparenteral medications
Single-use (disposable) Single-use (disposable) DevicesDevices
Preprocedural mouth rinsesPreprocedural mouth rinses
Oral surgical proceduresOral surgical procedures
Handling biopsy specimensHandling biopsy specimens
Handling extracted teethHandling extracted teeth
Laser/electrosurgery Laser/electrosurgery plumes or surgical smokeplumes or surgical smoke
Dental laboratoryDental laboratory
Mycobacterium Mycobacterium tuberculosistuberculosis
Creutzfeldt-Jacob Disease Creutzfeldt-Jacob Disease (CJD) and other prion-(CJD) and other prion-related diseasesrelated diseases
Dental Handpieces and Other Devices Dental Handpieces and Other Devices Attached to Air and WaterlinesAttached to Air and Waterlines
Clean and heat sterilize intraoral devices Clean and heat sterilize intraoral devices that can be removed from air and that can be removed from air and waterlineswaterlines
Follow manufacturer’s instructions for Follow manufacturer’s instructions for cleaning, lubrication, and sterilizationcleaning, lubrication, and sterilization
Do not use liquid germicides or ethylene Do not use liquid germicides or ethylene oxideoxide
Components of Devices Permanently Components of Devices Permanently Attached to Air and WaterlinesAttached to Air and Waterlines
Do not enter patient’s mouth but may Do not enter patient’s mouth but may become contaminatedbecome contaminated
Use barriers and change between usesUse barriers and change between uses Clean and intermediate-level disinfect the Clean and intermediate-level disinfect the
surface of devices if visibly contaminatedsurface of devices if visibly contaminated
Saliva EjectorsSaliva Ejectors
Previously suctioned fluids Previously suctioned fluids might be retracted into the might be retracted into the patient’s mouth when a seal is patient’s mouth when a seal is createdcreated
Do not advise patients to close Do not advise patients to close their lips tightly around the tip their lips tightly around the tip of the saliva ejectorof the saliva ejector
DentalDental RadiologyRadiology
Wear gloves and other appropriate personal Wear gloves and other appropriate personal protective equipment as necessaryprotective equipment as necessary
Heat sterilize heat-tolerant radiographic Heat sterilize heat-tolerant radiographic accessories accessories
Transport and handle exposed radiographs so Transport and handle exposed radiographs so that they will not become contaminatedthat they will not become contaminated
Avoid contamination of developing equipmentAvoid contamination of developing equipment
ParenteralParenteral MedicationsMedications
Definition: Medications that are injected into the Definition: Medications that are injected into the bodybody
Cases of disease transmission have been Cases of disease transmission have been reportedreported
Handle safely to prevent transmission of Handle safely to prevent transmission of infectionsinfections
Precautions for ParenteralPrecautions for Parenteral MedicationsMedications
IV tubings, bags, connections, IV tubings, bags, connections, needles, and syringes are single-needles, and syringes are single-use, disposableuse, disposable
Single dose vialsSingle dose vials
• Do not administer to multiple Do not administer to multiple patients even if the needle on the patients even if the needle on the syringe is changedsyringe is changed
• Do not combine leftover contents Do not combine leftover contents for later usefor later use
Single-Use (Disposable) DevicesSingle-Use (Disposable) Devices
Intended for use on one patient during a single Intended for use on one patient during a single procedureprocedure
Usually not heat-tolerantUsually not heat-tolerant
Cannot be reliably cleanedCannot be reliably cleaned
Examples: Syringe needles, prophylaxis cups, and Examples: Syringe needles, prophylaxis cups, and plastic orthodontic brackets plastic orthodontic brackets
Preprocedural Mouth RinsesPreprocedural Mouth Rinses
Antimicrobial mouth rinses prior to a dental Antimicrobial mouth rinses prior to a dental procedure procedure
• Reduce number of microorganisms in aerosols/spatterReduce number of microorganisms in aerosols/spatter
• Decrease the number of microorganisms introduced Decrease the number of microorganisms introduced into the bloodstreaminto the bloodstream
Unresolved issueUnresolved issue–no evidence that infections –no evidence that infections are preventedare prevented
Oral Surgical ProceduresOral Surgical Procedures
Present a risk for microorganisms to enter the bodyPresent a risk for microorganisms to enter the body
Involve the incision, excision, or reflection of tissue Involve the incision, excision, or reflection of tissue that exposes normally sterile areas of the oral that exposes normally sterile areas of the oral cavitycavity
Examples include biopsy, periodontal surgery, Examples include biopsy, periodontal surgery, implant surgery, apical surgery, and surgical implant surgery, apical surgery, and surgical extractions of teethextractions of teeth
Precautions for Surgical ProceduresPrecautions for Surgical Procedures
Sterile Irrigating Solutions
Sterile Surgeon’s Gloves
Surgical Scrub
Handling Biopsy SpecimensHandling Biopsy Specimens
Place biopsy in sturdy, Place biopsy in sturdy, leakproof containerleakproof container
Avoid contaminating the Avoid contaminating the outside of the containeroutside of the container
Label with a biohazard Label with a biohazard symbolsymbol
Considered regulated medical Considered regulated medical wastewaste• Do not incinerate extracted teeth Do not incinerate extracted teeth
containing amalgamcontaining amalgam
• Clean and disinfect before sending to Clean and disinfect before sending to lab for shade comparisonlab for shade comparison
Can be given back to patientCan be given back to patient
Extracted TeethExtracted Teeth
Handling Extracted TeethHandling Extracted Teethin Educational Settingsin Educational Settings
Remove visible blood and debris Remove visible blood and debris
Maintain hydrationMaintain hydration
Autoclave (teeth with no amalgam)Autoclave (teeth with no amalgam)
Use Standard PrecautionsUse Standard Precautions
Laser/Electrosurgery Plumes and Laser/Electrosurgery Plumes and Surgical SmokeSurgical Smoke
Destruction of tissue creates smoke that may Destruction of tissue creates smoke that may contain harmful by-productscontain harmful by-products
Infectious materials (HSV, HPV) may contact Infectious materials (HSV, HPV) may contact mucous membranes of nosemucous membranes of nose
No evidence of HIV/HBV transmissionNo evidence of HIV/HBV transmission
Need further studiesNeed further studies
Dental LaboratoryDental Laboratory
Dental prostheses, appliances, and items Dental prostheses, appliances, and items used in their making are potential sources used in their making are potential sources of contaminationof contamination
Handle in a manner that protects patients Handle in a manner that protects patients and DHCP from exposure to and DHCP from exposure to microorganismsmicroorganisms
Dental LaboratoryDental Laboratory
Clean and disinfect prostheses and impressions Clean and disinfect prostheses and impressions
Wear appropriate PPE until disinfection has been Wear appropriate PPE until disinfection has been completed completed
Clean and heat sterilize heat-tolerant items used Clean and heat sterilize heat-tolerant items used in the mouthin the mouth
Communicate specific information about Communicate specific information about disinfection proceduresdisinfection procedures
Transmission ofTransmission of Mycobacterium tuberculosisMycobacterium tuberculosis
Spread by droplet nucleiSpread by droplet nuclei
Immune system usually prevents spreadImmune system usually prevents spread
Bacteria can remain alive in the lungs for many years Bacteria can remain alive in the lungs for many years (latent TB infection)(latent TB infection)
Risk of TB Transmission in DentistryRisk of TB Transmission in Dentistry
Risk in dental settings is lowRisk in dental settings is low
Only one documented case of transmission Only one documented case of transmission
Tuberculin skin test conversions among Tuberculin skin test conversions among
DHP are rareDHP are rare
Preventing Transmission of TB in Preventing Transmission of TB in Dental SettingsDental Settings
Assess patients for history of TBAssess patients for history of TB
Defer elective dental treatmentDefer elective dental treatment
If patient must be treated:If patient must be treated:
• DHCP should wear face maskDHCP should wear face mask
• Separate patient from others/mask/tissueSeparate patient from others/mask/tissue
• Refer to facility with proper TB infection control Refer to facility with proper TB infection control precautionsprecautions
Creutzfeldt-Jakob Disease (CJD)Creutzfeldt-Jakob Disease (CJD)and other Prion Diseasesand other Prion Diseases
A type of a fatal degenerative disease of central A type of a fatal degenerative disease of central nervous system nervous system
Caused by abnormal “prion” protein Caused by abnormal “prion” protein
Human and animal formsHuman and animal forms
Long incubation periodLong incubation period
One case per million population worldwideOne case per million population worldwide
New Variant CJD (vCJD)New Variant CJD (vCJD)
Variant CJD (vCJD) is the human version of Variant CJD (vCJD) is the human version of Bovine Spongiform Encephalopathy (BSE) Bovine Spongiform Encephalopathy (BSE)
Case reports in the UK, Italy, France, Case reports in the UK, Italy, France, Ireland, Hong Kong, CanadaIreland, Hong Kong, Canada
One case report in the United States – One case report in the United States – former UK residentformer UK resident
Infection Control for Known CJD or Infection Control for Known CJD or vCJD Dental PatientsvCJD Dental Patients
Use single-use disposable items and equipment Use single-use disposable items and equipment
Consider items difficult to clean (e.g., endodontic Consider items difficult to clean (e.g., endodontic files, broaches) as single-use disposable files, broaches) as single-use disposable
Keep instruments moist until cleaned Keep instruments moist until cleaned
Clean and autoclave at 134°C for 18 minutes Clean and autoclave at 134°C for 18 minutes
Do not use flash sterilization Do not use flash sterilization
Program EvaluationProgram Evaluation
““Systematic way to improve (infection control) Systematic way to improve (infection control) procedures so they are useful, feasible, ethical, procedures so they are useful, feasible, ethical, and accurate”and accurate”
• Develop standard operating proceduresDevelop standard operating procedures
• Evaluate infection control practicesEvaluate infection control practices
• Document adverse outcomesDocument adverse outcomes
• Document work-related illnessesDocument work-related illnesses
• Monitor health care-associated infectionsMonitor health care-associated infections
Infection Control Program GoalsInfection Control Program Goals
Provide a safe working Provide a safe working environmentenvironment
• Reduce health care-associated Reduce health care-associated infections infections
• Reduce occupational Reduce occupational exposuresexposures
Program EvaluationProgram Evaluation
Strategies and ToolsStrategies and Tools
• Periodic observational Periodic observational assessmentsassessments
• Checklists to document Checklists to document proceduresprocedures
• Routine review of Routine review of occupational exposures to occupational exposures to bloodborne pathogensbloodborne pathogens
“ “Program evaluation provides an Program evaluation provides an
opportunity to identify and change opportunity to identify and change
inappropriate practices, thereby inappropriate practices, thereby
improving the effectiveness of your improving the effectiveness of your
infection control program.”infection control program.”