Transcript Guidelines for Infection Control in Dental Health

TOSHA for the Dental Office
Mitchell Cothran
TOSHA believes the information in this presentation to
be accurate and delivers this presentation as a
community service. As such, it is an academic
presentation which cannot apply to every specific fact
or situation; nor is it a substitute for any provisions of
29 CFR Part 1910 and/or Part 1926 of the
Occupational Safety and Health Standards as adopted
by the Tennessee Department of Labor and Workforce
Development or of the Occupational Safety and Health
Rules of the Tennessee Department of Labor and
Workforce Development.
Topics To Be Covered
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Bloodborne/Waterborne/Airborne
Disease Transmission
Barrier Precautions
Needlestick Precautions
Disinfection/Sterilization
Infection Control
Universal Precautions
9 Million Persons Work in
Health-Care Professions
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168,000 dentists,
112,000 registered dental hygienists,
218,000 dental assistants
53,000 dental laboratory technicians
– Dental health-care personnel (DHCP) refers to all paid
and unpaid personnel in the dental health-care
setting who might be occupationally exposed to
infectious materials, including body substances and
contaminated supplies, equipment, environmental
surfaces, water, or air.
Pathogenic Microorganisms
• Dental patients and DHCP can be exposed to
pathogenic microorganisms including:
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HBV, HCV,
herpes simplex virus types 1 and 2,
HIV,
Mycobacterium tuberculosis,
staphylococci, streptococci, and other viruses and
bacteria that colonize or infect the oral cavity and
respiratory tract.
Organism Transmission
1) Direct contact with blood, oral fluids, or other
patient materials;
2) Indirect contact with contaminated objects
(e.g., instruments, equipment, or environmental
surfaces);
3) Contact of conjunctival, nasal, or oral mucosa
with droplets (e.g., spatter) containing
microorganisms generated from an infected
person and propelled a short distance (e.g., by
coughing, sneezing, or talking); and
4) Inhalation of airborne microorganisms that can
remain suspended in the air for long periods
Conditions Necessary For
Infection To Occur
• A pathogenic organism of sufficient virulence
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and in adequate numbers to cause disease;
A reservoir or source that allows the pathogen
to survive and multiply (e.g., blood);
A mode of transmission from the source to the
host;
A portal of entry through which the pathogen
can enter the host; and
A susceptible host (i.e., one who is not immune)
Standard Precautions
• Standard precautions apply to contact with:
1) blood;
2) all body fluids, secretions, and excretions (except sweat),
regardless of whether they contain blood;
3) non-intact skin; and
4) mucous membranes.
• Saliva has always been considered a potentially infectious
material in dental infection control; thus, no operational
difference exists in clinical dental practice between universal
precautions and standard precautions.
• Standard precautions include use of PPE (e.g., gloves,
masks, protective eyewear or face shield, and gowns)
intended to prevent skin and mucous membrane exposures.
Other protective equipment (e.g., finger guards while
suturing) might also reduce injuries during dental procedures
Hierarchy of Controls
• Engineering controls that eliminate or isolate the hazard
– puncture-resistant sharps containers and
– safety sharp devices are the primary strategies for protecting
DHCP and patients
• Work-practice controls that result in safer behaviors
– one-hand needle recapping
– not using fingers for cheek retraction while using sharp
instruments or suturing and use of
• Personal protective equipment (PPE)
– protective eyewear, gloves, and mask
Preventing Exposures to Blood
and OPIM
• Use standard precautions (OSHA's bloodborne
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pathogen standard retains the term universal
precautions) for all patient encounters
Consider sharp items (e.g., needles, scalers, burs,
lab knives, and wires) that are contaminated with
patient blood and saliva as potentially infective
and establish engineering controls and work
practices to prevent injuries
Implement a written, comprehensive program
designed to minimize and manage DHCP
exposures to blood and body fluids
Exposure Vrs Exposure Incident
• Exposure
– Reasonably anticipated skin, eye, mucous membrane, or
parenteral contact with blood or other potentially
infectious materials that may result from the
performance of an employee's duties
• Exposure Incident
– Through percutaneous injury (a needlestick or cut with a
sharp object),
– Through contact between potentially infectious blood,
tissues, or other body fluids and mucous membranes of
the eye, nose, mouth,
– Non-intact skin (exposed skin that is chapped, abraded,
or shows signs of dermatitis)
Percutaneous Injuries
1) Occur outside the patient's mouth, thereby
posing less risk for re-contact with patient
tissues;
2) Involve limited amounts of blood; and
3) Are caused by burs, syringe needles, laboratory
knives, and other sharp instruments
– Injuries among oral surgeons occur more frequently
during fracture reductions using wires
– Experience does not affect risk of injury among
general dentist or oral surgeon
Engineering Controls
• The primary method to reduce exposures to
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blood and OPIM from sharp instruments and
needles
Are frequently technology-based and often
incorporate safer designs of instruments and
devices
– self-sheathing anesthetic needles
– dental units designed to shield burs in handpieces to
reduce percutaneous injuries
Work Practice Controls
• Establish practices to protect DHCP whose
responsibilities include handling, using,
assembling, or processing sharp devices (e.g.,
needles, scalers, laboratory utility knives, burs,
explorers, and endodontic files) or sharps
disposal containers.
– can include removing burs before disassembling the
handpiece from the dental unit,
– restricting use of fingers in tissue retraction or during
suturing and administration of anesthesia
– minimizing potentially uncontrolled movements of
such instruments as scalers or laboratory knives
Work Practice Controls for Sharps
• Place used disposable syringes and needles, scalpel blades, and other
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sharp items in appropriate puncture-resistant containers located as close
as feasible to where the items were used
Never recap used needles or otherwise manipulate by using both hands,
or any other technique that involves directing the point of a needle
toward any part of the body
Use a one-handed scoop technique, a mechanical device designed for
holding the needle cap to facilitate one-handed recapping, if an
engineered sharps injury protection device is not available or
appropriate for recapping needles between uses and before disposal
Never bend or break needles before disposal because this practice
requires unnecessary manipulation
For procedures involving multiple injections with a single needle, the
practitioner should recap the needle between injections by using a onehanded technique or use a device with a needle-resheathing
mechanism.
Passing a syringe with an unsheathed needle should be avoided because
of the potential for injury.
Personal Protective Equipment
• Designed to protect the skin and the mucous
membranes of the eyes, nose, and mouth of
DHCP from exposure to blood or OPIM.
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Personal Protective Equipment
• Gloves, surgical masks, protective eyewear, face shields,
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and protective clothing (e.g., gowns and jackets).
All PPE should be removed before DHCP leave patientcare areas
Reusable PPE (e.g., clinician or patient protective
eyewear and face shields) should be cleaned with soap
and water, and when visibly soiled, disinfected between
patients, according to the manufacturer's directions
Wearing gloves, surgical masks, protective eyewear, and
protective clothing in specified circumstances to reduce
the risk of exposures to bloodborne pathogens is
mandated by OSHA
General work clothes (e.g., uniforms, scrubs, pants, and
shirts) are neither intended to protect against a hazard
nor considered PPE
Masks, Protective Eyewear, Face
Shields
• A surgical mask that covers both the nose and
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mouth and protective eyewear with solid side
shields or a face shield should be worn during
procedures and patient-care activities likely to
generate splashes or sprays of blood or body
fluids.
The mask's outer surface can become
contaminated with infectious droplets from spray
of oral fluids or from touching the mask with
contaminated fingers
Gloves and Gloving
• Wear gloves to prevent contamination of hands when touching
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mucous membranes, blood, saliva, or OPIM
Reduces the likelihood that microorganisms present on the hands will
be transmitted to patients during surgical or other patient-care
procedures
Medical gloves, both patient examination and surgeon's gloves, are
manufactured as single-use disposable items that should be used for
only one patient, then discarded.
Gloves should be changed between patients and when torn or
punctured
Wearing gloves does not eliminate the need for handwashing
Gloves can have small, unapparent defects or can be torn during use,
and hands can become contaminated during glove removal
In addition, bacteria can multiply rapidly in the moist environments
underneath gloves
The hands should be dried thoroughly before donning gloves and
washed again immediately after glove removal.
OSHA On Sharps
• 2001-Revised Bloodborne Pathogens Standard
• Clarify the need for employers to consider safer
needle devices as they become available and to
involve employees directly responsible for
patient care (e.g., dentists, hygienists, and
dental assistants) in identifying and choosing
such devices
800,000 Needlestick
Injuries Occur Each Year in
the United States
Needlestick Injuries Are
Underreported by Health Care
Workers
• Reasons for underreporting:
– Lack of time
– Employer response
– Fear of HIV
Viral Hepatitis - Overview
Type of Hepatitis
A
Source of
virus
feces
Route of
transmission
Chronic
infection
Prevention
B
C
D
E
blood/
blood/
blood/
feces
blood-derived blood-derived blood-derived
body fluids body fluids body fluids
fecal-oral percutaneous percutaneous percutaneous fecal-oral
permucosal permucosal permucosal
no
yes
yes
yes
no
pre/postblood donor
pre/post- ensure safe
pre/postexposure
exposure
screening;
exposure
drinking
immunization immunization risk behavior immunization; water
modification risk behavior
modification
HIV
• You might have HIV and still feel perfectly
healthy
• The only way to know for sure if you
are infected or not is to be tested
Relative Risks of Infection After
Exposure
• HBV
2-40%
• HCV
Average 1.8%
• HIV
Average 0.3%
Do Safer Needle Devices
Prevent Injury?
• Can’t eliminate all, but…
• 83% can be prevented
Source: Ippolito, et. al., 1997
Engineered Sharps Injury
Protection
• Identify, evaluate, and select devices with
engineered safety features at least
annually and as they become available on
the market (e.g., safer anesthetic
syringes, blunt suture needle, retractable
scalpel, or needleless IV systems)
Sterilization/Disinfection
• Single-use disposable instruments are
acceptable alternatives if they are used
only once and disposed of correctly
• Ensure that reusable equipment is
decontaminated with a tuberculocidal EPAregistered disinfectant
Place
biohazard
symbol
here
Sterilization/Disinfection
• Designate a central processing area
• Train employees to use proper work practices to prevent
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contamination of clean areas
Minimize handling of loose contaminated instruments
during transport to processing area and carry
instruments in a covered container
Clean all visible blood and other contamination from
instruments and devices before sterilization or
disinfection
Minimize contact with sharp instruments if manual
cleaning is necessary—NEVER reach by hand into
containers of contaminated instruments/devices
Sterilization/Disinfection
Prepare fresh
when needed
Develop a written schedule for cleaning of possibly contaminated surfaces
How Do You Clean This?
Regulated Waste
• Discard contaminated items in leak-
proof labeled container
• Disposed of according to Tennessee
Department of Environment and
Conservation Rules
(615-532-0796)
Hepatitis B Vaccination
• Take the vaccination that is offered to you
• It is safe and effective and free
• Follow U.S. Public Health Service
Guidelines
– HBV Vaccinations
– “ Immunization of Health Care Workers:
Recommendations of ACIP and HICPAC,”
MMWR, Vol. 46, No. RR-18, December 26,
1997
• Declination statement
Hepatitis B Vaccination
• Antibody testing 1-2 months after completion of 3-dose
series
• DHCP should complete a second 3-dose vaccine series or
be evaluated to determine if they are HBsAg-positive if
no antibody response occurs to the primary vaccine
series (IA, IC)
Retest for anti-HBs at the completion of the second
vaccine series. If no response to the second 3-dose
series occurs, non-responders should be tested for
HBsAg (IC)
Counsel non-responders to vaccination who are
HBsAg-negative regarding their susceptibility to HBV
infection and precautions to Provide employees
appropriate education regarding the risks of HBV
transmission and the availability of the vaccine.
Employees who decline the vaccination should sign a
declination form to be kept on file with the employer
Post-Exposure Follow-ups
• Report all exposure
incidents
• Health care
professional's
written opinion
– HBV
– Follow-up
Training--Annually
• Five Easy Questions
– What is universal precautions?
– What do you do when there is a blood spill?
• Personal protection
• Clean-up and disposal procedures
• Disinfection (hazard communication applies)
– What do you do with contaminated sharps and
laundry?
– Have you been offered the HBV vaccination free of
charge?
– Where is the Exposure Control Plan?
Exposure Control Plan
• Must be in writing
• Must include Exposure Determination
• Must be reviewed and updated annually
– Plan must be updated to reflect changes in
technology that eliminate or reduce employee
exposure
– Plan must document consideration and
implementation of appropriate, commercially
available and effective engineering controls
Exposure Control Plan
• Employer's plan describing how compliance with
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the standard is achieved
Describes what employees are covered
Describes tasks that are covered
Describes post-exposure follow-up procedures
Must be reviewed and updated annually
Must be accessible to employees
See Journal of the Tennessee Dental Association,
Fall 2007
Call TOSHA for Help
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Web Resources
• Federal OSHA-www.osha.gov
• TOSHA-www.tennessee.gov/labor-wfd/tosha
• Centers for Disease Control- www.cdc.gov
• National Institute of Occupational Safety and
Health-www.cdc.gov/niosh