managing infectious diseases in the dental office draft 2 · 5/6/2020 · title: microsoft...

2020-05-06

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Managing Infectious Diseases in the Dental Office

Doug Risk, DDS

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Objectives

• How 4 elements of infection control practices prevent the transmission of unique types of pathogens

• Environmental Disinfection and Operatory Preparation• Reprocessing and Sterilization of Instruments and Devices• Procedure Protocols to prevent infections• Dental Unit Waterlines

• What practices in routine dentistry can enhance the safety of patients and staff?

• Are there elements of infection control which may need attention in my practice?

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Background

• Infection Control practices are the key elements in managing infectious diseases in the dental office. The prevention of the spread of diseases from staff to patients, from patients to staff and from patient to patient or staff member to staff member is why each and every infection prevention protocol, procedure and intervention is important and must be carried out in detail without short cutting the steps that break the chain of infection.

• New normal in Post COVID-19 Dental Practice:• Meticulous concern over patient safety and infection control• Knowledge of how to control infections based on probability of transmission

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Environmental Cleaning

• Environmental Cleaning• Non-contact surfaces• Contact surfaces

• Appropriate cleaning, removal of debris and microorganisms• Appropriate disinfection

• Disinfection Agent• Contact time• Staff protection during useo https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2o https://www.epa.gov/pesticide-registration/list-b-epas-registered-tuberculocide-products-effective-

against-mycobacterium

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Have a seat! Look around!

• Sitting in a dental chair as a provider and getting the patient’s perspective is critical to understanding the risks to patients

• Look at all the equipment with fresh eyes• Look at all the surfaces that might be touched• Imagine what you look like with your mask, loupes, headlamp and face shield

• Do you look scary?• Do you project safety and confidence?

• Next look at the sterile and disposable equipment , think of how that instrument was sterilized or how clean that disposable device is.

• Doyle JE, Ernst RR. Resistance of Bacillus subtilis var. niger spores occluded in water-insoluble crystals to three sterilization agents. Appl. Environ. Microbiol.. 1967 Jul 1;15(4):726-30.

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Aerosol Mitigation, Air Flow Disinfection

• CDC, ADA, OSHA, and WHO guidance recommend that aerosols not be generated during the performance of dental treatment.

• If aerosols are generated, the dental team must be protected with N95 respirators, face shields, gloves and gowns; some sources recommend hair and shoe covers.

• What about protection of the environment or subsequent patients, even patients and staff in adjacent spaces such as hallways?

• Will technology provide an answer?

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Instrument Reprocessing

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Instrument Processing

• 10 easy steps!• Many instruments are complex• Some clinics have highly specialized equipment with unique

sterilization requirements such as a dry heat sterilizer

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Pre-cleaning: Step 1• As instruments are used, they must be wiped clean between uses chairside

• Debris being wiped will be blood, saliva, dental materials, calculus, etc• Instruments should not be cleaned in the operatory

• Wiping between uses is not “cleaning,” it is pre-cleaning• Wiping between uses is removing non-adherent material before it dries and is adherent• Dental materials removed will not be set and will be easily removed• This step must be done safely and carefully

• If Dental cement or debris is allowed to harden on an instrument, that instrument will need special cleaning in the dental instrument processing area (DIPSA), this type of cleaning is beyond the scope of pre-cleaning

1. Pre-cleaning 6. Maintenance2. Transport 7. Packaging3. Receiving 8. Sterilization4. Decontamination 9. Equipment monitoring5. Inspection 10. Sterile Storage

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Transporting instruments: Step 2• Transport should be done in a rigid container with a biohazard symbol or red lid;

instruments may be treated with an enzymatic spray or foam to prevent bioburden from drying; the enzymatic spray will have no effect on dried-on dental cements.

• Lid should “snap closed” so contents cannot spill out if dropped• If container is dropped or if another person is encountered, contaminated instruments should not spill • Lid should “click shut” as opposed to being hinged and closed by gravity, no special tools required to open• Passive latches are best (e.g. Sterlite and Rubbermaid lids latch when pressed closed)

• Inside of container is contaminated, should not be entered without utility gloves and preferably not at all (instruments should be dumped out)

• Outside of container is clean and should be wiped clean frequently (before and after transporting instruments) should not need PPE to touch outside (no gloves in hallways)

• Sharps are discarded into sharps container at point of use, prior to instrument transport


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Instrument Receiving: Step 3 Receive instruments in the Dental Instrument Processing area in rigid

container Don PPE: heavy duty utility gloves, mask, eye protection, gown Dump instruments out of container and inspect for debris

Instruments with dried-on inorganic debris (cement) will need special cleaning Dried-on organic material may need an enzymatic soak 15-30 min IAW DFU


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Decontamination: Step 4

Don PPE: heavy duty utility gloves, mask, eye protection, gown Instruments are placed in ultrasonic cleaner for 10-30 minutes IAW DFU (normal: 15

min at 110°F) Use of automatic instrument washers is preferable to all other methods of decon Instruments are inspected after ultrasonic cleaning for residual debris

If debris present, repeat ultrasonic cleaning or repeat automatic instrument wash cycle If debris is still present after second cycle, manual cleaning (hand scrubbing) is necessary or

instruments may be ruined and need to be discarded

After thorough cleaning, instruments must be dried

IAW: In Accordance With, DFU: Instructions for Use, PPE: Personal Protective Equipment


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Hand Scrubbing Instruments

Don PPE: heavy duty utility gloves, mask, eye protection, gown SAFETY IS PARAMOUNT during hand scrubbing instruments Hand scrub using dedicated brushes and running water with down-and-away action

clean and disinfect brush when finished Toothbrushes are not designed to scrub instruments

Use wire brush as needed (clean and disinfect wire brush when finished) Discard instruments that do not get clean Burs should be single use (difficult to clean, susceptible to damage), replace with new burs in

block and sterilize new burs if not already sterile Brushes and sink then should be cleaned and disinfected prior to reuse


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Inspection: Step 5

• Only accept instruments if absolutely clean• If instruments are not clean, return to step 4 or replace• Instruments which are clean may be forwarded to the next step

• Instruments must be inspected for breakage, contamination, organic and inorganic debris, as well as rust and corrosion

• Clean instruments must be handled with gloves unless disinfected in an automatic washer-disinfector (195°F rinse for 5-10 min)

• When clean, instruments must be dried prior to packaging


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Maintenance: Step 6

• Handpieces should be run in a dedicated handpiece maintainer• Instruments should be replaced periodically

• Over-sharpened instruments, thin blades are susceptible to breakage during use• Stiff operating hinged instruments should be lubricated or discarded• Broken instruments should be replaced

• Perio probes that are missing the last segments are corroded, non-sterile and inaccurate• Scissors with broken tips are not sterile and do not cut as intended

• Pitted instruments or rust which cannot be wiped off easily cannot adequately be cleaned• Cement on the handles or blades of instruments inhibit sterilization of the instrument


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Packaging: Step 7• Instruments must be dry• Package instruments only single level in pouch• If more than 1 pack for procedure (e.g. surgery packs), number packs # of

##• Fold seal along perforation,

• Adhesive must contact/seal paper and plastic• Seal must be absolute in order to maintain sterility

• Every load must contain Type 5 indicator in pouch


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Pouch labeling

• Pouches must be labeled IAW current clinic protocol • Enables instrument recall• Helps quality assurance and accountability

• Pouch contents would be helpful not required unless contents are obscured• Pouch labeling information is recorded on the load release document• Use non-toxic pen • Label on paper side of seal not next to instruments for pouches


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Sterilization: Step 8• Sterilization by approved method, cycle validated IAW manufacturers directions for use

(DFU)• Sterilizer loading must be according to sterilizer manual, has to do with the way steam

enters and leaves the pouch according to sterilizer design, assists drying cycle• Pouches must be single layer• Instruments in pouches should be single layer, allows better drying• Cycle must match validated instrument sterilization parameters per instrument, see DFU

of instruments• Fill out Load Release Document at end of cycle

• Parameters Met? Y or N; Error messages: None?• Staple type 5 integrator to load release document in box


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Equipment Monitoring: Step 9• Sterilizer load monitoring: According to protocol, documented on load release form• Spore tests are run in all sterilizers according to protocol• Ultrasonic foil test or Hu-Friedy WashCheck® should be run at least weekly• Automatic Washer verification test is run according to protocol• Loads are not released unless parameters were verified, no error codes are shown• Load Release Chart must be filled out for every load to facilitate recall of

instruments


Sterile Storage: Step 10

• Storage of instruments must maintain sterility• Heavy pouches will promote poke-through of sharp instruments,

handle gently• Storage vessels, drawers, shelves must be kept clean, periodic

removal of all pouches to facilitate deep cleaning is necessary


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Exposure Control

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Procedure Protocols Controlling Exposure

https://www.cdc.gov/niosh/topics/hierarchy/default.html

• Controlling exposure to occupational risks is fundamental to keeping health care providers safe

• This table provides a hierarchy of control from most effective (top) to least effective

• Emphasis can be placed on the most effective opportunities to control exposure

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Elimination of exposure

• Elimination is where testing can make the biggest difference• Testing for viral presence and viral load at the time of an office visit

would be most helpful to dental practitioners in screening for exposure to staff from patients

• The same tests could be helpful in screening for staff infection• Tests should provide immediate results, be cost effective, and be widely

available• These tests do not yet exist

• Tailoring treatment to exposure prone procedures in the presence of this information would be helpful in providing a safe environment for dental providers

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Substitution

• Changing a treatment plan due to a patient's symptoms, or viral presence if asymptomatic, would be a benefit to staff safety

• Patients who present and are found to be infectious could be rescheduled or referred to a practice geared to proper precautions

• Treatment plans could be adjusted so that elective aerosol producing procedures may be postponed

• Routine treatment would be reserved for patients who exhibit no detectable virus and are asymptomatic for other illnesses

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Engineering Controls

• Isolation of operative sites have been advocated with rubber dam in order to reduce the contamination of aerosols along with high volume evacuation

• A combination approach of pre-rinse, isolation and post-rinse of the operative field after isolation, may be a way to reduce contamination and reduce the virus in aerosols during procedures

• Rinses remain controversial for lack of clinical evidence of effectiveness; most data on rinses comes from laboratory studies

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Administrative Controls

• Changing the way Providers approach patient care is the new normal• Just as HIV changed the practice of Dentistry concerning bloodborne pathogens• Dental providers will have an increased appreciation for transmission-based

precautions which are already very prevalent in Medical practice• Droplet precautions – initially discussed with SARS-CoV-2• Airborne precautions – more of a concern with SARS-CoV-2• Contact precautions – less of a concern with current conditions• Standard precautions – most concerned with bloodborne pathogens

• Airborne Infection Isolation Rooms (AIIRs) may not be practical for dentistry• Systematic approaches to patient care is practical

• Pre-screening• Enhanced disinfection of common areas• Other controls to reduce exposure risk and enhance safety

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Personal Protective Equipment

• Seems to get the most attention with N95 shortages• Least effective protection method• May be the most difficult to test effectiveness in vivo

• Randomized clinical trials and control groups are unethical• Proper vs common wear of various PPE elements confounds variables

• Respiratory protection program recommended• Program administration• Medical evaluation• Fit testing• Training

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Dental Unit Waterlines

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Dental Unit Waterlines

• Well known risk of disease transmission• Legionella death, Italy 2011• Mycobacterium abscessus outbreak, California, Georgia 2016

• Proper maintenance and treatment reduces risk of transmission• Periodic monitoring enhances compliance

• Problems caught early• Shock treatments prevent blooms

• Maintain water quality equal to potable water• Clean water act 1972, 33 USC Sections 1251-1387• <500 CFU heterotrophic bacteria: indicator of well maintained system

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Sterile Irrigation for Surgery

• Critical (Spaulding): Penetrates soft tissue, contacts bone, enters into or contacts the bloodstream or other normally sterile tissues

• Oral surgical procedures (CDC, 2003) involve the incision, excision, or reflection of tissue that exposes the normally sterile areas of the oral cavity. Examples include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth (e.g., removal of erupted or nonerupted tooth requiring elevation of mucoperiosteal flap, removal of bone or section of tooth, and suturing)

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Sterile Irrigation for Surgery

• “Oral surgical procedures present an opportunity for entry of microorganisms (i.e., exogenous and endogenous) into the vascular system and other normally sterile areas of the oral cavity (e.g., bone or subcutaneous tissue); therefore, an increased potential exists for localized or systemic infection.” CDC 2003

• California Legislation 2017: “require(s) water or other methods used for irrigation to be sterile or contain recognized disinfecting or antibacterial properties when performing dental procedures that expose dental pulp.“

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Microorganisms of Concern

• Oral bacteria• Cross contamination• Patient to patient inoculation

• Anti-retraction failure• Opportunistic infections• Staph aureus

• Water bacteria• Immunocompromised host

• Legionella• Pseudomonas• Mycobacteria

• Opportunistic infections• Low pathogenicity

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For more information: OSAP White Paper on Dental unit waterlines (Mills S, Porteous N, Zawada J. Dental unit water quality: organization for safety, asepsis and prevention white paper and recommendations–2018. Journal of Dental Infection Control and Safety. 2018 Oct 31;1(1):5075.)

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Flushing

• 20-30 sec between patients• 2003 CDC guidelines• 2016 CDC update• No effect on biofilm• May reduce bacteria prone to

retraction• Handpiece attachments have

been known to contain bacteria and must be sterilized

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Independent Reservoir

• Affects the entire dental unit• Controls water source• Allows waterline treatment• Allows continuous and intermittent treatment• Advantage in “Boil Water” scenarios• Sterile or distilled water alone will not control biofilm• Alternative is to treat entire building or portion of

building before the water contacts the dental units• Requires human interaction for compliance

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Waterline Treatments• Chlorhexidine• Chlorhexidine/Ethanol• Sodium hypochlorite• Iodine impregnated resin• Chlorine dioxide• Hydrogen Peroxide based• Sodium Percarbonate, silver

nitrate, surfactant

• Silver ions• In-line filters• Sterile water delivery• Ozone• UV light• Enzole• Citric acid based• Beware off-label products, not

recommended

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Continuous Use Products

• Tablets or cartridges designed to treat water• May be attached to separate bottle system or installed in-line with

municipal water system• Variety of active ingredients

• Iodinated resin• Silver compounds• Magnesium chloride with other compounds• Hydrogen peroxide with other compounds

• Designed to protect against biofilm formation, may also have a shock component or recommendation based on monitoring

• Must be safe for human consumption

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Intermittent Use Products

• Usually liquids added to separate water systems• Variety of active ingredients

• Iodine compounds• Bleach (sodium hypochlorite)• Quaternary ammonium chloride• Chlorhexidine gluconate, ethanol

• May be detrimental to dental unit if left unattended for longer than recommended

• Usually must be cleared/flushed prior to patient care

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Combination Use Products

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Water Purifiers

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Choosing a System

• Manufacturer’s recommendations• FDA Clearance, EPA Registration• Scientific Literature

• Efficacy, Sound basic science• Proven technology• New technology

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Waterline Testing and Monitoring

• In-house or send it out, both ways work• Frequency: about every 3 months once you have established a baseline• Value of an independent lab report verification and documentation• Convenience and easy to use• Interpretation of results

• Time• Temperature• Culture medium

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Summary

• Meticulous cleaning of the environment• Check to see if there are any gaps or improvement opportunities in

instrument processing departments• Remove opportunities for failure• Document sterility assurance

• Assess the exposure risk• Use 5 criteria for exposure risk management• PPE is least effective at reducing risk of exposure

• Treat and monitor dental unit waterlines

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References used for this presentation

• Doyle JE, Ernst RR. Resistance of Bacillus subtilis var. niger spores occluded in water-insoluble crystals to three sterilization agents. Appl. Environ. Microbiol.. 1967 Jul 1;15(4):726-30.

• Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings—2003. MMWR 2003;52(No. RR-17): https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf

• Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; October 2016. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf

• Rutala WA, Weber DJ. Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008. Center for disease control. Latest update May 2019

• CDC.gov, who.int, OSHA.gov

• Mills S, Porteous N, Zawada J. Dental unit water quality: organization for safety, asepsis and prevention white paper and recommendations–2018. Journal of Dental Infection Control and Safety. 2018 Oct 31;1(1):5075.

• Association for the Advancement of Medical Instrumentation. ANSI/AAMI: ST 79 2017 Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation. 2017.

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managing infectious diseases in the dental office draft 2 · 5/6/2020 · title: microsoft...

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