Transcript File - Whitney Hoff RDH

ADVANCED POWER DRIVEN SCALERS
ULTRASONIC INSTRUMENTATION
Presented by
Tammy Maahs, RDH, BSDH
DH 220 Fall Term 2014
Types of Power Driven Scaling Devices
 Magnetostrictive Ultrasonic Scaler: converts high
frequency electrical current into rapid mechanical
vibrations; operates at 18-42 thousand cycles per
second (cps).
 Piezoelectric Ultrasonic Scaler: activated by
dimensional changes in quartz or crystal
transducers (25-50K).
 Sonic Scaler: air-driven; only 2000-6300 cps.
Magnetostrictive Ultrasonic
Scaler
 Tip movement is elliptical; all sides of the
working end are active.
 Frequency (cycles per second = cps) is
described in kilohertz (1 kHz = 1000 cps).
 Manual-tuned or auto-tuned units.
 Most common.
Magnetostrictive Cavitron
Handpiece
Electrical energy is applied to coils of copper wire in the
handpiece and magnetically changes the dimension of the
stack to produce vibrations in the tip.
Magnetostrictive Technology
ELLIPTICAL TIP MOVEMENT
Piezoelectric Ultrasonic
Scaler
 Used widely in Europe and Asia
 Growing popularity in the U.S.
 Tip movement is linear; only 2 sides (lateral
borders) are active
Piezoelectric Ultrasonic Scalers
Sonic Scaler
 Uses compressed air to produce vibrations
 Tip movement elliptical or orbital
 Technique is pressure sensitive
 Frequency much less powerful than with
ultrasonic scalers (2,000-6,300 cps)
Sonic Scalers
*
*This example has a protective sheath for
use around implants
MAGNETOSTRICTIVE
ULTRASONIC SCALERS
Manual Tuned Units
Automatic Tuned Units
Manual Tuning Units: 3 controls
 Power control (amplitude)
 Tuning control (frequency)
 Water control (amount)
USI Manual-Tuned Unit
Holbrook Technique “favorite” for low power and
frequency; less sensitivity for the patient.
“Old” Dentsply Cavitron
Manual Tuned Unit
Power Control (Amplitude)
 Stroke: maximum distance the tip moves during
ONE (back and forth) cycle.
 Amplitude: Tip displacement; the length of the
stroke (½ the stroke).
 The higher the power the longer the stroke.
 More energy created by a longer stroke.
 Longer stroke = increased ability to remove
dense/tenacious calculus deposits
More Efficient “Chipping” Action
Tuning Control (Frequency)
 The number of times per second the tip completes
one back and forth cycle.
 1 kHz (kilohertz) = 1000 cycles per second (cps).
 The higher the frequency, the faster the tip
movement—increasing the ability to remove
deposits.
 OPTIMUM frequency is 18-32 cps.
 Affects the speed of the movement of the tip.
Water Control (amount)
 Used to cool the stack and tip.
 Cavitation: the resulting water spray on the
vibrating tip (bubbles collapse and lyse bacterial
cell walls).
 Acoustic Turbulence or Microstreaming:
hydrodynamic wave around oscillating tip disrupts
bacteria.
 Functions as a lavage (flushes debris from the area,
removes LPS, removes attached plaque and loosely
adherent plaque).
Water Coolant
Automatic Tuning Units
 Frequency is pre-set (controlled
automatically by the system): automatically
changes as load conditions change
 25K or 30K
 Two controls:


Power Control (amplitude)
Water Control (amount)
Dentsply Automatic Units
Cavitron Bobcat, Bobcat Pro, SPS, Plus, and Select
Parkell Turbo Sensor
 Can use 25K and 30K tips
 Burnett thin power tip can be used on high power
LOAD
 Definition: the resistance on an insert when it
is place against a deposit or the tooth/root
surface.
 With an auto-tuned unit, the insert maintains
the [pre-set] frequency even though pressure
is being applied to the tip, therefore scaling
efficiency is not compromised.
Parts of an Insert System
 Stacks
 Connecting Body
 O-ring
 Insert Tip: the working end of the
insert
Parts of an Insert System
Stacks
 Energy source for insert
 Move by elongation and contraction in a
horizontal plane
 Should be straight for peak performance
Connecting Body
(Grip/Handle/Finger Grasp)
 Can be metal or plastic
 ‘Experts’ (Anna Pattison, S.N. Bhaskar)
prefer the all metal inserts (i.e., metal grip)
for more power and efficiency
O-Ring
 Stops water from flowing outside the
handpiece
 Should be wet prior to inserting the insert
into the handpiece
Insert Tip
 The WORKING END of the insert
Dentsply Inserts 25K & 30K
Active Tip Area
 The portion of the tip that is capable of doing work.
 Affected by the frequency.
 The higher the frequency, the shorter the active tip
area.
 The power to remove calculus is concentrated in the
last 2-4 mm of the length of the tip.
 The higher the frequency, the shorter the active tip
area.
Ultrasonic Tip Power
Power concentrated
in the TIP
Care & Maintenance of Inserts
 Do not submerge in glutaraldehyde or use surface
disinfectants (e.g., Birex); VOIDS THE
WARRANTY.
 Do not put in ultrasonic bath (solutions are not able
to be rinsed well from the stacks).
 Rinse ,or scrub tip and grip gently with a
brush/soap/water and rinse well, and place in
individual packaging (sterilization pouches or
cassettes especially made for ultrasonic tips).
Care & Maintenance of Inserts
 Check periodically for wear: replace if too
short.
 Replace O-ring if water leaking or insert is
loose in handpiece.
 Place on the top of the load if using pouches,
take care not to bend the tip or water conduit.
Care & Maintenance of Inserts
 When using pouches, must be all paper or
combination paper/plastic pouches; paper side
down in a steam autoclave or Statim.
 “In a steam sterilizer, if paper/poly packages must
be placed flat in a single layer, place them paper
side down. Placing paper/poly packaging plastic
side down may cause condensate to pool inside the
pouch resulting in a wet pack, which must then be
considered contaminated.” ~Confirm Monitoring Systems
Sterilization Pouches
 It is important to place inserts in pouches TIP(s) to
the bottom of the package and fold the top (seal)
properly (arrows lined up). TIP(s) down allows
view of which tips are in the package; sealing the
package often covers the tip if it is placed tip to top.
 Package STRAIGHT tips separately, and be sure to
package the CURVED PAIR of right/left inserts
together correctly (a right and left, not 2 rights or
2 lefts!).
Sterilization Pouches: prepared
for sterilization
Sterilization Pouches: Curved
Tips Sterile
Hu-Friedy IMS Cassette for
Ultrasonic Tips
 Are in your student issue for sterilization and
storage of the set of inserts purchased
Variables for Replacement
 Efficiency indicator template: use to check
for wear in tip length. Literature suggests
that inserts with 2 mm of wear lose about
50% scaling efficiency.
 Condition of stacks: replace if stack is so
bent or splayed that energy is no longer being
delivered to the tip.
Efficiency Indicator Template
Asepsis & Infection Control
 Operator: PPE including face shield
 Client: protective lenses, cloth towel
 Ultrasonic unit: drape unit with plastic wrap to
cover the controls that may be touched when
adjusting during treatment!
 Handpiece: small barrier with sticky to hold in
place. Bleed the handpiece for 1 minute to remove
contaminants.
Asepsis & Infection Control
 Pre-procedural rinse to reduce
microorganisms the patient might release in
the form of aerosol
 Water spray: external water source tends to
have less aerosol
Infection Control (continued)
Water Evacuation: High-volume if working with
an assistant; saliva ejector or hygoformic saliva
ejector if working without an assistant.
Advantages of Ultrasonic Scalers







Water lavage: clears area of debris & bacteria
Lyses bacterial cell walls
Removes attached and loosely adherent plaque
Gram– bacteria most susceptible to lavage
Less trauma to soft tissue than curettes
Increased client comfort (usually)
Decreased operator fatigue
Advantages (continued)
 MAY require less treatment time.
 BETTER (excellent!) access to deep, narrow
pockets and furcation areas (with slimline inserts).
 No sharpening of inserts and less sharpening of
curettes
 Reduces lateral pressure
 Less tissue distention
Disadvantages of Ultrasonic Scalers
 Decreased tactile sensitivity (improves with
experience!).
 Requires water evacuation.
 Produces contaminated aerosol.
 Possible effects of noise/vibrations
 Potential for damaging certain restorative materials.
 Handpiece sterilization.
Contraindications: Pacemakers
Pacemaker or implanted defibrillator (with
magnetostrictive)
 "Although all modern pacemakers are shielded, care must be
taken if magnetostrictive ultrasonics or ultrasonic cleaning
devices are used that generate a magnetic field that might
interfere with certain types of cardiac pacemakers."
(Bennett, Contemporary Oral Hygiene, June 2007).
 Dentsply Cavitron (directions for use): recommend that the
handpiece and cables be kept at least 6-9 inches away from
any device and their leads.
Pacemakers
 In Touch, January 2006: Clients with Cardiac Pacemakers:
“Most dental hygiene/dental procedures do not involve
strong electromagnetic signals and are unlikely to interfere
with a shielded pacemaker or ICD. Those considered safe
are [dental] radiographs, handpieces, composite curing
lights, sonic scalers and piezoelectric scalers. There is some
evidence that…magnetostrictive (Cavitron) scalers,
ultrasonic cleaning baths, and electrosurgical units can cause
marked interference with cardiac implant devices when
tested in-vitro setting and placed at close proximity.”
~http://www.crdha.ca/portals/0/newletters/InTouch_Jan06.pdf
Contraindications: Other
Implanted Medical Devices
 Implanted Cardiac Defibrillators
 Spinal Cord Stimulators
 Vagus Nerve Stimulators
 Insulin Pumps
 It has been recommended not to use
magnetostrictive ultrasonics for patients with
these devices or use a lead apron.
Pacemakers: LCC Policy
 Our policy for patients with a cardiac pacemaker,
implanted defibrillator , or other implanted devices:
the piezo electric unit should be used.
 NOTE: when calling physicians for other implanted
devices as listed in previous slide, recommendation
is to NOT use the magnetostrictive ultrasonic
scaler.
Contraindications
 Active communicable or infectious diseases
transmissible by aerosols
 Pulmonary or respiratory disease
 Gagging or problems swallowing
 Metal inserts on dental implants
 Lack of consent of therapy
Ultrasonic Tip Design
 Water source external or internal
 Gross Debridement (standard diameter) Tip
 Assorted Specialty Tips
 Slimline inserts


Straight
Paired (curved left and right)
External Water Source
Gross Debridement Tip
 Higher power setting can be used
 “Chips” away at heavy deposits
 Once accomplished, power should be
reduced to medium or low
Gross Debridement
Heavy Calculus
Loose tissue will accommodate larger tips
Assorted Specialty Tips
Dentsply DiamondCoat Tip
For perio surgery only (must have
visibility!)
Implant Tips
Hu-Friedy Inserts
Furcation Insert
After-Five (Slim) Inserts
(curved & straight)
Triple Bend Insert
Hu-Friedy Swivel Inserts
 Allows for single-handed adjustment
Protégé Ultrasonics by
Discus Dental
Protégé™ LED Ultrasonic insert:
has a unique grip has a built-in light emitting diode
(LED) that illuminates the working surface.
Sonic and Ultrasonic Scalers
with Specialized Tips
 Remove plaque and calculus from titanium surface
without damaging titanium.
 It was noted previously that the sonic or ultrasonic
vibrations might have the potential to adversely
affect the connective tissue adherence. However,
the consensus is with the specialized tips used on
LOW POWER; this is an effective method for
debriding implants. (Samuel B. Low, DDS, MS, MEd)
Dentsply Ultrasonic
SofTipTM Insert
Disposable prophy tip is for single-use only
Piezo Electric Scaler with Peek®
[Composite] Tip
Piezo Electric Scaler with
Peek® Tip
 This tip is fabulous and I use it regularly for
debriding implants and other porcelain and
gold types of restorations!
 Autoclavable and durable tip; however once
the tip wears down, it must be disposed of
and replaced.
 Use only on a lower power!
Thin Design Ultrasonic Tips
Dentsply FSI Slimline Inserts
Curved Inserts
Paired: Left and Right
Curved Inserts
Angles [curves] are important for access with
ultrasonics. Curved inserts not only access
deeper pockets and furcations better, but
these also provide better access when
posterior teeth have bulbous crowns.
Curved Inserts
 Adapt to concave root anatomy
Instrumentation Technique
 Grasp: feather-light, writing pen grasp.
Drape cord over arm to decrease pull on
handpiece.
Cord Management
Fulcrum
 Calculus removal: intraoral or extraoral
fulcrum.
 Biofilm disruption and removal (deplaquing):
extraoral fulcrum will help the clinician to
use lighter pressure.
Strokes
 Multiple, rapid, multi-directional, erasing, or
sweeping strokes.
 Keep tip moving at all times.
 The lighter the pressure, the more effective
the vibrations.
Strokes
Insertion
 Insert tip parallel to the long axis of the
tooth/root
 For CEJ areas, insertion is approximately 90°
Insertion
Parallel
Oblique
Oblique/Proximal
Adaptation
 Use lateral side or rounded back of tip
 Adapt side of tip to tooth surface; tip/face to
tooth angulation near zero degrees.
 Keep tip moving continuously and
submarginally on root surface.
 Clean several surfaces at a time; do not
continuously start and stop.
Adaptation
Pocket Negotiation
 Enter pocket using the lateral side or back surface;
keeping the [side of] tip in contact [and parallel] with the
tooth/root surface.
 Negotiate to the apical extent using short, overlapping
strokes.
Adaptation for Piezo Scalers
Adaptation for Piezo Scalers
 Adapt the lateral surface of the tip for optimal
performance
 Maintain tip angulation near ZERO degrees
(parallel to the tooth surface)
 NEVER adapt tip at a 90◦ angle to avoid tooth/root
damage
 Use minimal or no lateral pressure; let the tip do the
work for you
Tip Design for Piezo Scalers
 The variety of tip designs offers more
options
 They offer thin designs and contra-bend
bladed curettes
 HuFriedy: “Clinicians love this tip because
looks and functions like their bladed hand
instruments”
STAIN
Piezo Scaler for Stain Removal
 View the You-Tube Video on Moodle
Techniques to Avoid Sensitivity
 Decrease power.
 Decrease frequency (if manual tuned unit—known
as “detuning” or tuning “out of phase”).
 Increase water flow.
 Always keep the tip moving at all times, maintain
constant water flow.
 Determine the source of sensitivity; either avoid
instrumenting sensitive tooth surface(s) [debride
with alternate methods] or consider using
desensitizing agents or topical (Oraqix).
NUPRO® Sensodyne®
Prophylaxis Paste with Novamin
Colgate® Sensitive Pro-Relief™
Desensitizing Polishing Paste
 With Pro-Argin™
 Used to be marketed by Ortek as Proclude; Colgate
then distributed Proclude, then repackaged (same
ingredient)
Oraqix® lidocaine/prilocaine
gel intra-pocket anesthetic
Calculus Deposit Removal
The type, amount, and tenacity of calculus
must be considered for proper tip
selection.
Calculus Deposit Removal
 Adapt appropriate insert using the anterior 1/3 of
the working end (active tip area).
 Engage the most coronal portion of the deposit with
the insert tip.
 Use light, intermittent “tapping”strokes against the
deposit.
 Continue the strokes in a lateral and apical
direction until the deposit is removed.
Tapping Strokes
Summary
 Can remove deposits from any direction.
 Can instrument coronally to apically on the
root surface (unlike hand/manual
instrumentation). It is not necessary to place
the instrument beneath the deposit in order to
remove it.
Gross Debridement
Slimline Inserts/Tips
 A low (narrow stroke width) power setting
recommended.
 A maximum of medium power should be
used for moderate calculus removal during
root scaling.
 Use of high power setting has been
associated with breaking the slimline tips.
BASIC PRINCIPLE
The thinner the ultrasonic tip, the
lower the power setting.
Combination/Blended
Approach to Debridement
 Dense/hard/tenacious deposits generally require
ultrasonics and the manual use of curettes to ensure
complete debridement.
 Scaling with curettes for final finishing should
always follow the use of ultrasonics (when
removing calculus OR biofilm).
 Following hand scaling with ultrasonics is also
efficient in additional irrigation/lavage and
cleanliness.
Biofilm Removal and
Disruption (i.e. deplaquing)
 Use short, overlapping brush-like strokes
 Keep the side of the tip (active tip area) in
contact with the tooth/root surface while
moving with a series of gentle erasing
motions
 The instrument must touch every square mm
of the tooth surface to remove biofilm
Complementary Methods for
Debridement
Anna Pattison, RDH, MS
Words of Wisdom
“Experienced clinicians appreciate the
synergy that occurs when powerdriven instrumentation and manual
[curettes] are used in conjunction
with one another.”
~Technology & Ultrasonic Debridement, Low, S.B.
“The best results are probably obtained by
combining sonic/ultrasonic instruments
with manual scaling.”
~ Charles M. Cobb, DDS, MS, PhD
Clinical Application of Root
Morphology
 DH 220 A
 Prepared by Leslie Clark, RDH, M.Ed
Objectives
Understand relationship of tooth
support and root morphology
Identify relationship of root anatomy
and anomalies on periodontal disease
Identify periodontal therapy options
Terminology Review
Periodontium: gingiva, cementum,
PDL, alveolar and supporting bone,
alveolar mucosa
Gingivitis: inflammation (disease) of
the gingiva
Periodontitis: inflammation (disease) of
the supporting tissues of the teeth,
usually resulting in progressive
destruction of those tissues
Terminology Review
Periodontal disease: pathologic
processes affecting the periodontium,
most often gingivitis and periodontitis
Dental biofilm: layer containing
microorganisms that adhere to teeth;
contributes to the development of
gingival and periodontal disease and
caries
Terminology Review
Calculus: hard concretion that forms on the
teeth (or dental protheses) through
calcification of bacterial biofilm
Furcation Involvement
As periodontal disease progresses
attachment loss increases
Bone loss may reach a furcation area
These areas are difficult for the patient to
clean
Furcation areas readily accumulate biofilm
and calculus mineralization
Furcation Location
Maxillary Molars:
Mid-buccal
Mesial (accessed from lingual)
Distal (accessed from lingual)
Furcation Location
Mandibular Molars:
Mid-buccal
Mid-lingual
Furcation Location
Maxillary Premolars: (with buccal and
lingual roots)
middle of mesial
middle of distal
Furcation Location
Key points
Where
Type (type I, II or III)
Accessibility
Radiographs ARE an important tool
Gingival Recession
Loss of gingival tissue resulting in the
exposure of more root surface
The gingival margin is apical to the
cementoenamel margin
The papillae may be blunted or rounded,
and no longer fill the interproximal
embrasure
Gingival Recession
Contributing Factors:
plaque biofilm
poorly aligned teeth
lack of attached gingiva
aggressive tooth brushing
abnormal tooth and root prominence
Gingival Recession
Key Points:
Deviations of general characteristics
CEJ configuration
Root sensitivity
Oral Hygiene Instruction
Other Factors
Other factors that affect periodontal health:
Mobility
CAL
Bleeding
Tooth Support and Root
Morphology
Root attachment is primary importance
to stability of tooth
Root attachment depends on length of
root, number of roots, presence or
absence of concavities and curvatures
In Health
Connective tissue fibers insert into
cementum on entire root surface
gingival fibers (supracrestal)
PDL
In Health
Long roots and wide roots increase support
Concavities and root curvatures increase
support in two ways:
augment (increase) total surface area
concave configuration provides multidirectional fiber orientation
In Health:
Generally: (based on root surface area)
Maxillary canines most stable single rooted
teeth
Mandibular incisors least stable single rooted
teeth
In Health
Generally:
Maxillary 1st molar (3 divergent roots) more
stable than 3rd molars (frequent fused roots)
Additional Factors
Presence or absence of periodontal disease
Excessive occlusal forces
Density and structure of supporting bone
Root Anomalies and
Periodontal Disease
Enamel extension on mandibular molar
and enamel pearls on maxillary molars
prevent normal connective tissue
attachment
may channel disease into furcation area
Root Anomalies and
Periodontal Disease
Palatal gingival grooves occur on
maxillary incisors; readily collect and
retain plaque biofilm, which can lead to
periodontal destruction
Root fractures predispose periodontal
destruction along fracture line
Other Root Anomalies
Concrescence: fusion of two teeth at the
root
Fusion: formation of a single tooth from
the union of two adjacent tooth buds
Hypercementosis: excessive formation
of cementum around the root after the
tooth has erupted
Accessory roots: extra roots that form
on teeth after birth
Dwarfed roots: abnormally short roots
with normal-sized crowns
Dilaceration: distortion of the root and
crown from their normal vertical
position
Flexion: sharp bend or curvature of a
root that only affects the root portion of
the tooth
Importance of Root Anomalies
Identify what is different or unique
about the tooth and root structure
Provide instrumentation with a purpose
Provide Oral Hygiene Instruction based
on anomalies
Periodontal Therapy Options
Non-surgical Periodontal Therapy may
include:
Effective debridement and root planing
Oral Hygiene Instructions
Antimicrobial agents
Periodontal Therapy Options
Surgical Therapy:
Correct results of periodontal disease
Removal of soft and hard tissue
components of pocket wall
Periodontal Therapy Options
Gingivectomy
Root resection
Periodontal flaps
Osseous surgery
Regenerative periodontal surgery
Bone grafting
Root Morphology/
Instrumentation
Identify unique characteristics of
individual root anatomy
explorer
periodontal probe
radiographic evaluation
Root Morphology/
Instrumentation
CEJ
Anterior teeth: arc interproximally making
it difficult to instrument due to limited
accessibility and close proximity or
adjacent teeth
Improper instrument adaptation results in
incomplete scaling
Root Morphology/
Instrumentation
CEJ:
Molars are generally easy to follow with
explorer
CEJ: generally feels smooth, may have
slight groove based on anatomy
Root Morphology/
Instrumentation
Furcations:
Identify number and location of roots
Furcations are generally narrow and difficult to
reach
Clinician must picture roots from facial, lingual,
distal and mesial perspectives and identify
specific characteristics
Root Morphology/
Instrumentation
Instrument Selection:
Visualize root surface to be treated using
assessment tools including radiographs

Consider root surfaces of multi-rooted
teeth as independent areas to be
instrumented
EXAMPLES:
The Gracey 11/12 can access the mesial
surface of the mandibular molar’s distal root
The Gracey 13/14 can access the distal of the
maxillary first molar’s mesiobuccal root
Instrumentation
After-Five Curettes: terminal shank
elongated to allow access to deep
pockets and adaptation to root surfaces
Mini-Five Curettes: modification of
after-five design. Length of blade is
reduced to allow ease of
instrumentation and improved
adaptation for difficult to instrument
areas
Clinical Application
Clinician must use a variety of tools to
identify effective instrumentation
techniques
Instrument selection is based on the
anatomy of the area being treated
Knowing what is ‘usual’ root
morphology aids the clinician in
modifying traditional instrumentation
techniques to provide quality
periodontal therapy
Dentinal Hypersensitivity
Presented by Tammy Maahs, RDH,
EP, BSDH
DH 220A Fall 2014
Dentinal Hypersensitivity
defined:
 Pain arising from exposed dentin in response
to a stimulus or stimuli, which cannot be
explained as arising from any other form,
dental defect, or pathology.
 A variety of treatment interventions have
been developed to treat hypersensitivity, but
no single therapy has been found to solve the
problem.
Dentinal Hypersensitivity
 A “unique entity” apart from other sources of
dental pain.
 Represents a transient type of pain.
 NOT all exposed dentin is hypersensitive.
 No consensus on what causes it and how to
best manage it.
Dentinal Hypersensitivity
 Can occur at any site on any tooth.
 More commonly buccal or lingual surfaces at the
gingival margin.
 Pain is sporadic and can range over time from being
localized, sharp or intense, to generalized with
varying degrees of pain.
 Symptoms are individual and episodic.
 Usually described as a short, sharp pain as a
response to stimuli such as cold, hot, sweet, or air.
First Step
 Behavioral Modification
 Eliminating or reducing personal habits that
encourage tooth sensitivity is the first step in
controlling hypersensitivity
 Even though hypersensitivity is associated
with exposed dentin, not ALL exposed
dentin is hypersensitive
Stimuli That Elicit Pain
Response:
 Mechanical (touch): 29% of clients
 Thermal (temperature): 75% of clients
(primarily cold)
 Chemical (usually acids): can elicit pain
response or may be the cause
 Osmotic (sugar or salt solution)
 Evaporative (drying)
Causes and Locations for
Dentin Exposure
 Most frequently found at CEJ.
 Usually facial/buccal surfaces of most teeth.
 Canines and first premolars show the highest
incidence.
Enamel Loss:
Cementum/Dentin Exposure
 Exposed cementum and/or dentin are readily
abraded when compared with enamel.
 Dentin abrades 25 times faster than enamel.
 Cementum abrades 35 times faster than
enamel.
Causes and Locations:
 Recession: observed with normal aging.
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Tooth apposition also may predispose a tooth to
gingival tissue loss since the buccal alveolar plate may
be thin.
Abrasion: mechanical wear.
Erosion (chemical): acidic foods and drinks.
Attrition: occlusal or incisal wear.
Scaling and Root Planing (periodontal treatment).
Abfraction
Abfraction defined:
Biomechanical wearing of tooth structure
through occlusal loading; causing stress,
fatique, deformation and fracture of dentin
and enamel. Causes wedge-shaped notches
at the CEJ. This is caused by tensile and
compressive forces during tooth flexure.
Abfraction
Differential Diagnosis
 A differential diagnosis to rule out other
conditions must be established before
treating for hypersensitivity.
 Need a radiographic examination and clinical
examination (e.g., percussion test, occlusal
evaluation) to rule out other possible causes.
Dental Conditions That Mimic
Dentinal Hypersensitivity
 Caries or demineralization
 Fractured restorations
 Cracked tooth syndrome
 Post-restorative sensitivity
 Teeth in “hyperfunction”
Tooth Slooth
(for detecting cusp fractures)
Brännström’s Hydrodynamic Theory
 Dentin is permeable
 Lymphatic fluid present in the dentinal tubules
transmit stimuli
 Odontoblasts and their processes act as receptors
and transmitters of sensory stimuli
 Stimuli create movement of fluids, causing nerve
endings at the pulpal wall to be stimulated
 Fluid movement can be caused by pressure,
desiccation, heat, cold, and hypertonic solutions
Hydrodynamic Theory
 The number of tubules varies
 There can be as many as 30,000 tubules in a
square millimeter of dentin
 Tome’s fibers extend from the odontoblasts
into the tubules
 These fibers are what communicate to the
pulp
Hydrodynamic Theory
Fluid movement within tubules transmits a
signal to the nerves in the pulp chamber.
Hydrodynamic Theory
 The fluid movement stimulates the small,
myelinated A-delta fibers
 These nerve fibers transmit to the brain
 Results in the sensation of a localized, sharp
pain [that is associated with dentinal
hypersensitivity].
Hydrodynamic Theory
Odontoblastic processes are stimulated
(excited) due to ion exchange.
Smear Layer:
 An organic matrix of hard tissue composed of
cementum, dentin, and calculus particles.
 Remains over the dentin surface after
instrumentation or restorative procedures.
 Acts as a natural desensitizer (barrier) for a short
period until removed by toothbrushing, plaque
acids, or acid-etching.
How Plaque Affects Dentinal
Hypersensitivity:
 Invades open tubules; implicated as a pain
provoking stimulus.
 PLAQUE EXACERBATES SENSITIVITY!
 More sensitivity occurs with poor plaque control.
 Brushing technique (Bass Technique) important!
Stress no “scrubbing”, which abrades the gingiva
and possibly(?) susceptible tooth surface(s).
Sulcular Brushing
Some Newer Research on Plaque/Biofilm
 Information from Terri Tilliss, RDH, MS,
MA, PhD: “There is not a correlation
between teeth with plaque biofilm and teeth
with hypersensitivity. In fact, teeth with less
biofilm have more sensitivity.”
 NOTE: it is still this author’s (me!) opinion and
experience that acidic bacterial plaque can
exacerbate sensitivity; and plaque removal is
important!
Etiology of the Reduction of Dentin
Sensitivity Over Time
 Natural desensitization:


Natural formation of secondary, reparative, tertiary, or
sclerotic dentin. (Explains why hypersensitivity
generally diminishes over time and with aging).
The creation of a smear layer and calculus formation on
the dentin surface.
 Deposition of minerals in the tubule openings
(usually from fluoride) or from other salivary
minerals.
TREATMENT STRATEGIES:
 The ideal desensitizing agent does not exist!
 Clinicians must use a systematic trial and
error approach based on available evidence
and professional experience.
 One decision-making component as to which
product to use is if the sensitivity is
LOCALIZED or GENERALIZED.
Treatment Strategies








Oxalates
Cavity Varnish
Bonding Agents
Fluorides
Laser Treatment
Connective Tissue Grafts
Corticosteroids
Others
Oxalates
 Protect (Butler): potassium oxalate
 Sensodyne Sealant Dentin Desensitizing Kit:
ferric oxalate
 D/Sense Crystal (Centrix): potassium
binoxalate
 BisBlock: oxalate
 Super Seal: potassium oxalate
ADVANTAGE of oxalates: Tissue friendly!!!!
Cavity Varnish (Solution Liners)
 Copalite
 Varnal
 Barrier Dentin Sealant
 Cavi-Line
 Handi-Liner
90% solvent mixture and 10% copal resin
A chemical barrier that reduces permeability of the
dentinal tubules
Bonding Agents
 Glass Ionomers: have been used for class V
restorations. Releases fluoride and chemically
bonds to the tooth surface.
 Composite Restorations: work well (and can be
placed with a glass ionomer base) if greater than 1
mm depth of abrasion or erosion.
Primers (used prior to placing restorations or as
chemical desensitizing agents alone)
 Gluma Primer/Desensitizer



Does not leave a film layer on the tooth.
Acts within the tubules.
Gluteraldehyde reacts with the organics in the tubules
and seals the “ends” [openings] by “clotting” the organic
liquid.
 Acqua Seal

A gluteraldehyde formula combined with fluoride.
More Primers
 HurriSeal: same ingredients as the new
formulation of Acquaseal (benefit is no
gluteraldehyde)
 Isodan: combination product—potassium
nitrate, sodium fluoride, HEMA and
excipients, also used prior to placement of
restorations
 Pain Free: self-cure primer
Fluorides
 Varnish: 5% Neutral Sodium Fluoride


DURAPHAT (Colgate), DURAFLOR
(Medicom), CAVITY SHIELD (Omnii),
FLUORIDEX LONG-LASTING DEFENSE
(Discus Dental).
FDA approved for sensitivity; ADA approved
for caries prevention.
Fluorides
 Gel-Kam Dentin Bloc: an aqueous solution of
sodium fluoride, stannous fluoride, and hydrogen fluoride
available in unit doses with a foam applicator; applied for 1
minute.
 Other in-office methods: a four-minute NSF or APF
fluoride tray placed prior to scaling (for generalized
sensitivity) or localized placement with cotton-tipped
applicator.
Iontophoresis
 Desensitron (Parkell): Uses an electric current to
create a positively charged tooth surface, which attracts
negatively charged fluoride ions and imbeds them into
dentin tubules.
Laser Treatment
 Coalesces the tooth structure (tubules).
 Can be used in conjunction with sodium
fluoride varnish or a stannous fluoride gel.
Connective Tissue Grafts
 For root coverage; a physical barrier.
 Outcomes unpredictable.
Before
After
Colgate® Sensitive ProRelief™
 Pro-Argin technology
 Contains calcium carbonate and arginine
(same ingredient in Proclude)
 Dispensed in a 3 oz. tube or 60 unit dose
cups
 Recommended for pre-polishing/
desensitizing prior to scaling
Colgate® Sensitive ProRelief™
NUPRO® Sensodyne® Prophylaxis Paste
with Novamin
 Made by Dentsply (makers of NuPro prophy
paste)
 Desensitizing ingredient is NovaMin
(calcium sodium phophosilicate—induces
the formation of new hydroxyapatite)
 Low in abrasion
 Available in “stain removal” and “polishing”
grits
NUPRO® Sensodyne® Prophylaxis Paste
with Novamin
(Formerly NUSolutions)
NUPRO® Sensodyne® Prophylaxis Paste
with Novamin
 Remember that this product also enhances
remineralization!
 Also available as a 5000ppm fluoride
prescription toothpaste with NovaMin for
sensitivity relief, caries prevention and
superior remineralization. Can be used as a
daily treatment in place of regular toothpaste.
OTC Products for Client Application
 Desensitizing Dentifrices: containing strontium
chloride, potassium nitrate* (*most contain), sodium citrate.
 Sensitivity Protection Crest
 Crest Pro-Health (contains stannous fluoride)
 Colgate Sensitive
 Sensodyne
 Mouthrinses (Avoid mouthrinses with an acidic pH)
 ACT fluoride rinse (.05% sodium fluoride), or other
fluoride rinses
Sensodyne Pronamel
“Protects your teeth from sensitivity and the effects of acid
wear. Everyday foods such as fruit, sodas, orange juice and
wine contain acids that soften the enamel surface which is
then more easily worn away by brushing. As the enamel
layer becomes thinner, teeth can become visibly less white
and older looking.”
Dentifrices Continued:
 Sodium Bicarbonate dentifrices play an important
role; they neutralize acids and are low in abrasion.
 New “combination” dentifrices (of calcium &
phosphate) that may help remineralize the teeth
offer protection by continually abating the erosion
process. (Arm & Hammer EnamelCare and
Mentadent Replenishing White toothpastes), both
with “liquid calcium”.
Liquid Calcium
Prescription Products for Client
Application
 Fluoride Products (pastes and gels are OTC)


Stannous Fluoride Gel .4% (Gel Kam, Gel Tin, Stop,
Omnii Gel, Fluoridex Daily Renewal)
1.1% Sodium Fluoride (Prevident, Fluoridex)
 Mouthrinses


.12% CHX followed by .2% sodium fluoride rinse
(Hodges)
Stannous Fluoride Rinse .63%: Gel Kam (Colgate),
PerioMed (Omnii) [rinses require Rx]
More “Others”:
“At Home” (prescription/patient applied) Therapies
 SootheRx (Omnii): also utilizes Novamin (calcium
sodium phophosilicate—induces the formation of
new hydroxyapatite).
 Recaldent: PROSPEC MI Paste (GC America,
Inc.): calcium phosphate combination (marketed as
a remineralizing agent but also cited as reducing
dentinal hypersensitivity by occluding dentinal
tubules).
Whitening Considerations
 Recommend (ALWAYS provide!) desensitizing
toothpaste during whitening procedures.
 Ultradent (Opalescence) adds fluoride and
potassium nitrate to some of their bleaching
products and have a separate product (UltraEZ—
3% sodium nitrate and .11% fluoride ion in a gel
form) for use in the custom tray for desensitizing.
Behavioral Modification
 Dietary Counseling
 Patients may need to consider some lifestyle
changes, such as altering their diet/habits
 Caution patients NOT to brush directly after
eating acidic foods
Treatment Tips from Practicing
Clinician
That would be me…
For Generalized Root Exposure/
Dentin Sensitivity
 PRE-POLISH with NovaMin based prophy paste:
don’t bother with “polish” vs. “stain removal”
formulas; I only use the ‘polish’ formula for general
full mouth polishing for root sensitivity.
For Generalized Root Exposure/
Dentin Sensitivity (continued)
 If a patient “feels” (reports sensitivity) it on
the first application (touch/tactile), re-polish
that surface a second time with NUPRO
Sensodyne polish.
 Be sure to leave on the teeth for several
minutes (do not rinse immediately).
 Proceed with debridement procedures
(ultrasonic and/or hand instrumentation).
For Localized Root Exposure/
Dentin Sensitivity
 Purchase the Colgate Sensitive Pro Relief in
TUBE form
For Localized Root Exposure/
Dentin Sensitivity (continued)
 Put a “dab” (pea-size) on top of your
regular prophy paste;
I prefer Enamel Pro with ACP
coarse for heavier plaque and/or
stain removal.
For Localized Root Exposure/
Dentin Sensitivity (continued)
 Again PRE-POLISH the sensitive areas and
do not rinse immediately
 Continue with generalized polishing with
“regular” prophy paste to remove plaque
biofilm and stain
A little “dab” will do ya!
INFECTION CONTROL/
BLOODBORNE PATHOGENS REVIEW
DH 220A
presented by Tammy
Maahs, RDH, BSDH
OSHA
 Occupational Safety & Health
Administration
 Created in 1970 by the U.S. Department of
Labor
 Purpose is to protect the health and safety of
ALL workers
EXPOSURE CONTROL
 To identify and manage the prevention of
exposure to workplace hazards in order to
reduce or eliminate harm to the employee or
patient
 NOT the same as INFECTION CONTROL
Components of Exposure
Control
 Infection Control Policy and Practice
 Physical Precautions
 Chemical Safety
 Warning Signs and Labels
 Waste Management
 Record Keeping
Exposure Control Manual
 Contain written health and safety plans
 Contain post-exposure management plan
 Centrally located in the office with access to
all employees
 Maintain record keeping for employee
Employee Records:
Must be kept private and contain:
 Job description with Exposure Risk
Determination
 Accident/Incident reports (injuries,
exposures)
 Training Records
 Basic medical information
 Hepatitis B record
OCCUPATIONAL
EXPOSURE
Physical, chemical, or infectious hazards
Physical Exposure (Hazards)
 Exposure to equipment
 Exposure to sharps
 Exposure to dental waste
Chemical Exposure
Hazardous Communication Standard:
Regulates and establishes a standard for
hazards associated with the production,
transportation, usage, storage and disposal of
chemicals
MSDS
 Material Safety Data Sheets
 Used to communicate the hazard of a product
Infectious Exposure
 Exposure to bloodborne pathogens
 BLOODBORNE PATHOGENS
STANDARD: deals with infectious disease
exposure control to prevent transmission of
bloodborne diseases
HAZARD ABATEMENT
 Exposure control
 The use of certain controls to reduce the
probability of occupational exposure
Standard Precautions
 Method of exposure control that treats all
patients and materials as potentially
infectious
 New term is Body Substance Isolation
(BSI)
 Used to be called ‘Universal Precautions’
Principles of BSI
 Provide a barrier between yourself and the
blood/body fluid of another person
 Treat all blood/body fluid as if it is infectious
Work Practice Controls
 Methods that reduce the chance of exposure
incident (e.g., handwashing, one handed
needle recapping)
Engineering Controls
 Use of devices that isolate and promote
safety (e.g., instrument cassettes, recapping
devices)
 Sharps or biomedical waste containers within
easy reach to dispose of infectious materials
Personal Protective Equipment
(PPE)
 Gloves: first line of defense


ALWAYS wash hands as soon as possible after
removing gloves!
CHANGE if torn or soiled
 Masks
 Protective eyewear with side shields
 Face shields
 Lab coats
Housekeeping (Regulated
Waste Disposal)
 Safe handling of waste and laundry
 Cleanliness of environment and clothing
 Sharps containers do not go into regular trash
INFECTIOUS DISEASE
PROCESS
 Causative agent: microorganism capable of
causing disease
 Susceptible host: lacks effective resistance to
a particular agent
 Mode of Transmission:



Direct contact
Indirect contact
Airborne inhaled droplets
Occupational Exposure to
Pathogens
As defined by OSHA:
“A specific eye, mouth, mucous membrane,
non-intact skin or parenteral contact with
blood or other potentially infectious
materials as a result of performing
employee’s duties.”
Exposure Access
 Parenteral exposure: piercing of the skin with
a needle or sharp instrument
 Contact with mucous membrane
 Contact with a wound or abrasions in the
skin (non-intact skin)
NOT all exposures result in
infection
Infection depends upon:
 Route of transmission
 Dosage of the virus
 Host susceptibility
 Volume of the infectious fluid
Infection = increased virulence of agent +
decreased host resistance + the amount of
the agent
Exposure Risk Determination
Categories
 Category I: employees who perform tasks
that involve exposure to blood or potentially
infectious materials
 Category II: employees who do not perform
tasks involving exposure during work, but
may be called upon to do so
 Uncategorized: administrative employees
who have no risk
Exposure Protocol
 Treat injury
 Notify exposure control manager


Evaluate situation
Document incident
 Testing if indicated (informed consent)
 Baseline testing for HIV, HBV, and HCV as
close to time of exposure as possible
 Follow up--CONFIDENTIAL
Post-exposure Prophylaxis
 Evidence for post-exposure prophylaxis is
great enough to support the use of highly
active anti-retroviral therapy [HAART]
agents to prevent HIV infection.
 Post-exposure prophylaxis is not 100%
effective but can alter the course of the
disease if given early enough.
Post-exposure Prophylaxis to
HIV Considerations
 Type of exposure (needle stick or puncture
wound highest risk)
 Source person’s medical history
 Toxicity of the prophylactic drugs (AZT, and
3TC, possibly IDV)—risk vs. benefit!
Other Infectious Diseases
 Hepatitis A
 Hepatitis B
 Hepatitis C (highly virulent)
 Tuberculosis
 Meningitis
 Staphylococcus Aureus
 MRSA (Healthcare associated and
community associated)
BARRIERS
 Provide protection from workplace hazards;
either chemical or infectious and
encompasses standard precautions.
 Two types:


Biological (immunizations)
Physical: second line of defense—must be
between the person and the agent
Personal Hygiene:
Handwashing
Two types of microflora on hands:
 Resident: survive and multiply on the skin.
Many are not highly infectious but may
cause infection
 Transient: recent contaminants that can
survive on the skin only a limited period of
time (e.g., HBV)
Thorough Handwashing
 Requires time
 Use liquid antimicrobial soap with residual
effect



3% PCMX (parachlorometaxylenol)
4% CHX (chlorhexidine)
NO bar soap
Proper Handwashing
Technique (SOP)
 Remove jewelry (rings, watches, bracelets)
 Wet hands, wrists, forearms with cool water
 Dispense soap and work gently into all areas
(minimum 15 seconds)
 Rinse thoroughly and pat dry with disposable
paper towel
 If no foot control or hands-free control, turn
off with paper towel and then throw away
More Hand Hygiene
 Soap used for hand washing
 Antimicrobial/alcohol hand sanitizers are the
main method on unsoiled hands
 Use EPA approved healthcare products
 DO BOTH THROUGHOUT THE DAY


Wash hands with soap and water to remove
contaminants
Use alcohol hand rub to kill most organisms
GLOVES: protect the clinician and the
patient!
Types:
 Latex
 Nitrile or vinyl
 Over-gloves
 Utility gloves
 Heat resistant oven mitts
More on Gloves
 GLOVES FAIL
 Organisms grow under gloves, doubling
every 12 minutes
Protective Eyewear
 Belong over the clinician’s EYES, not worn
on top of his/her head!
 Put on before donning treatment gloves
Protective Eyewear (continued)
 Shatter resistant goggle with side shields or
prescription personal eyewear with
removable side shields
 Must be worn (over the eyes!) to protect from
spatter of blood and saliva or injury from
foreign particles
 Clean eyewear between patients with soap
and water
 Recommended that patients also wear
protective eyewear
Masks
 Protect face and mucous membranes of nose
and mouth from spatter
 Should cover nose, mouth, and most of cheek
and skin
 Fit snugly against the face
 Change when wet or contaminated between
patients
 Never leave dangling from one ear or around
neck
Face Shields
 Should be worn when aerosols are generated
 Can be worn instead of goggles with a mask
Clinical Attire
 Launderable lab coats or disposable
 Not worn outside the office
 Employer is responsible for laundering lab
coats
INFECTION CONTROL
KEY TERMS (in
alphabetical order)
AEROSOLIZATION
Spray generated by dental devices that can
transfer microorganisms through the air.
Infection may result in direct transmission
from air or indirect transmission via fomites.
AIDS
Acquired Immune Deficiency Syndrome
caused by the Human Immunodeficiency
Virus (HIV); a bloodborne virus that affects
the immune system.
ANTIMICROBIAL
An agent that prevents microbial growth
ANTISEPTIC
A chemical agent applied to living tissue to
reduce the amount of microorganisms
ASEPSIS
The absence of disease producing
microorganisms
ASEPTIC TECHNIQUE
A procedure that reduces or eliminates
pathogens through disinfecting or sterilizing
of instruments and surfaces to avoid
contamination of the patient.
BACTERICIDAL
Capable of killing bacteria
BARRIER
A means of protection from a workplace
hazard either chemical or infectious
BIO-BURDEN
Biologically contaminated debris found on
instruments; MUST be removed before
sterilization
BLOOD-BORNE
Microorganisms within the bloodstream that
are able to be transmitted to other via blood
CAUSATIVE AGENT
Microorganism capable of causing a disease
CENTERS FOR DISEASE
CONTROL (CDC)
A governmental agency responsible for the
epidemiological study of a disease. It is not a
regulatory agency, but provides information
and advises.
CROSS-CONTAMINATION
Contamination as a result of transfer of a
microorganism from one source to another,
(i.e., person to person, OR person to object to
another person).
CROSS-INFECTION
Infection as a result of transfer of
microorganisms between people
DIRECT CONTACT
Transmission via blood to an individual
DISINFECTANT
A chemical agent applied to inanimate objects
or surfaces to reduce the risk of infection by
reducing the number of microorganisms
present
ENGINEERING CONTROL
An abatement or device that removes or
isolates a workplace hazard
ENVIRONMENTAL
PROTECTION AGENCY
(EPA)
A governmental agency responsible for
regulating items than impact the
environment, such as chemicals and waste
ETIOLOGY
The cause of a disease, finding an etiological
agent which is responsible microbe for a
specific infectious disease
FOOD & DRUG
ADMINISTRATION (FDA)
A governmental agency responsible for
regulating that which impacts living tissue
(e.g., food, drugs, and medical services).
FOMITES
Inanimate, potentially contaminated objects
that serve as agents of disease transmission
FUNGICIDAL
Capable of killing fungi
GERMICIDE
A chemical agent capable of destroying
bacteria
HAZARD ABATEMENT
Those procedures which reduce your risk of
occupational exposure to bloodborne
diseases and hazardous chemical usage in the
workplace
HAZARDOUS WASTE
Waste that poses a threat to people
 HBIG: Hepatitis B Immune Globulin
 HBV: Hepatitis B Virus (bloodborne virus
that affects the liver)
 HCV: Hepatitis C Virus
 HIV: Human Immunodeficiency virus
(bloodborne virus that affects the immune
system and can ultimately lead to AIDS)
INDIRECT CONTACT
Transmission via a contaminated object
INFECTIOUS DISEASE
A disease induced by microorganisms that can
be transmitted from one host to another via
an infectious process
INFECTIOUS WASTE
Waste capable of causing infection
MSDS
Material Data Safety Sheets
MICROBIAL DOSE LOAD
The dose level of microbes present in a specific
area
MICROORGANISM
A microscopic form of life
MODE OF TRANSMISSION
A method by which a disease is transmitted
OCCUPATIONAL
EXPOSURE
Contact with infectious material at an
individual’s workplace that puts him or her at
risk of harm or contacting a disease
OSHA
Occupational Safety & Health Administration:
a federal regulatory agency responsible for
ensuring workplace safety and health
PATHOGENIC
The inherent ability of a microorganism to
cause disease
PERSONAL PROTECTIVE
EQUIPMENT (PPE)
Personal attire worn by the health care worker
to protect them from an infectious or
chemical hazard
SANITIZATION
The process by which the number of organisms
on inanimate objects is reduced to a “safe”
level. Helps to reduce the cleaning process.
SEPSIS
The presence of disease producing organisms
SPORICIDAL
Capable of killing spores
STANDARD
PRECAUTIONS
 The method of infection control that treats all
patients and all materials as potentially
infectious
 Current terminology is Body Substance
Isolation (BSI)
 OLD term was Universal Precautions
STATIC AGENTS
Chemicals that inhibit the growth of
microorganisms, but do NOT kill them
STERILIZATION
The process by which all life forms are
destroyed by physical or chemical means
SURFACE DISINFECTION
The process of killing some types of
microorganisms on environmental surfaces
SUSCEPTIBLE HOST
A host (person) who lacks effective resistance
to a particular agent
VIRUCIDAL
Capable of killing viruses
VIRULENCE
The ability of pathogens to cause infectious
disease due to its strength, and ability to
reproduce and organize
WORK PRACTICE
CONTROLS
Method of performing one’s duties in a manner
that reduces or eliminates risk of an exposure
incident
Guidelines for Infection Control
in Dental Health-Care Settings—
2003
CDC. MMWR 2003;52(No. RR-17)
http://www.cdc.gov/oralhealth/
infectioncontrol/guidelines/index.htm
This slide set “Guidelines for Infection
Control in Dental Health-Care SettingsCore” 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
Health-Care Settings: An Overview

Background

Personnel Health Elements

Bloodborne Pathogens

Hand Hygiene

Personal Protective Equipment

Latex Hypersensitivity/Contact Dermatitis

Sterilization and Disinfection
Environmental Infection Control


Dental Unit Waterlines
Guidelines for Infection Control in Dental Health Special
Considerations
Care
Settings—2003.
MMWR 2003; Vol. 52, No.
RR-17.
 Program Evaluation
CDC Recommendations

Improve effectiveness and impact of public health
interventions

Inform clinicians, public health practitioners, and the
public

Developed by advisory committees, ad hoc groups, and
CDC staff

Based on a range of rationale, from systematic reviews
to expert opinions
Background
Why Is Infection Control Important
in Dentistry?



Both patients and dental health care personnel
(DHCP) can be exposed to pathogens
Contact with blood, oral and respiratory
secretions, and contaminated equipment occurs
Proper procedures can prevent transmission of
infections among patients and DHCP
Modes of Transmission




Direct contact with blood or body fluids
Indirect contact with a contaminated
instrument or surface
Contact of mucosa of the eyes, nose, or
mouth with droplets or spatter
Inhalation of airborne microorganisms
Chain of Infection
Pathogen
Susceptible Host
Entry
Source
Mode
Standard Precautions


Apply to all patients
Integrate and expand Universal Precautions
to include organisms spread by blood and
also
Body fluids, secretions, and excretions except
sweat, whether or not they contain blood
Non-intact (broken) skin
Mucous membranes
Elements of Standard Precautions





Handwashing
Use of gloves, masks, eye protection,
and gowns
Patient care equipment
Environmental surfaces
Injury prevention
Personnel Health
Elements
Personnel Health Elements of an
Infection Control Program





Education and training
Immunizations
Exposure prevention and postexposure
management
Medical condition management and workrelated illnesses and restrictions
Health record maintenance
Bloodborne Pathogens
Preventing Transmission of
Bloodborne Pathogens
Bloodborne viruses such as hepatitis B virus
(HBV), hepatitis C virus (HCV), and human
immunodeficiency virus (HIV)



Are transmissible in health care settings
Can produce chronic infection
Are often carried by persons unaware of
their infection
Potential Routes of Transmission
of Bloodborne Pathogens
Patient
DHCP
DHCP
Patient
Patient
Patient
Factors Influencing Occupational
Risk of Bloodborne Virus Infection



Frequency of infection among patients
Risk of transmission after a blood exposure
(i.e., type of virus)
Type and frequency of blood contact
Average Risk of Bloodborne Virus
Transmission after Needlestick
Source
HBV
Risk
HBsAg+ and HBeAg+ 22.0%-31.0% clinical hepatitis;
37%-62% serological evidence of
HBV infection
HBsAg+ and HBeAg-
HCV
HIV
1.0%-6.0% clinical hepatitis; 23%37% serological evidence of HBV
infection
1.8% (0%-7% range)
0.3% (0.2%-0.5% range)
Concentration of HBV in Body
Fluids
High
Detectable
Blood
Serum
Wound exudates
Moderate
Semen
Vaginal Fluid
Saliva
Low/Not
Urine
Feces
Sweat
Tears
Breast Milk
Estimated Incidence of HBV Infections Among
HCP and General Population,
United States, 1985-1999
Health Care Personnel
General U.S. Population
Percent
HBV Infection Among U.S.
Dentists
Yea
Source: Cleveland et al., JADA 1996;127:1385-90.
r
Personal communication ADA, Chakwan Siew, PhD, 2005.
Hepatitis B Vaccine

Vaccinate all DHCP who are at risk of
exposure to blood

Provide access to qualified health care
professionals for administration and
follow-up testing

Test for anti-HBs 1 to 2 months after
3rd dose
Transmission of HBV from Infected
DHCP to Patients




Nine clusters of transmission from dentists and
oral surgeons to patients, 1970–1987
Eight dentists tested for HBeAg were positive
Lack of documented transmissions since 1987
may reflect increased use of gloves and vaccine
One case of patient-to-patient transmission,
2003
Occupational Risk of HCV
Transmission among HCP



Inefficiently transmitted by occupational
exposures
Three reports of transmission from blood
splash to the eye
Report of simultaneous transmission of
HIV and HCV after non-intact skin
exposure
HCV Infection in
Dental Health Care Settings



Prevalence of HCV infection among
dentists similar to that of general population
(~ 1%-2%)
No reports of HCV transmission from
infected DHCP to patients or from patient
to patient
Risk of HCV transmission appears very low
Transmission of HIV from
Infected Dentists to Patients


Only one documented case of HIV
transmission from an infected dentist to
patients
No transmissions documented in the
investigation of 63 HIV-infected HCP
(including 33 dentists or dental students)
Health Care Workers with Documented and
Possible Occupationally Acquired HIV/AIDS
CDC Database as of December 2002
Dental Worker
Nurse
Documented
0
24
Possible
6*
35
Lab Tech, clinical
Physician, nonsurgical
Lab Tech, nonclinical
16
6
3
17
12
–
Other
Total
8
57
69
139
* 3 dentists, 1 oral surgeon, 2 dental assistants
Risk Factors for HIV Transmission after
Percutaneous Exposure to HIV-Infected Blood
CDC Case-Control Study




Deep injury
Visible blood on device
Needle placed in artery or vein
Terminal illness in source patient
Source: Cardo, et al., N England J Medicine 1997;337:1485-90.
Characteristics of Percutaneous
Injuries Among DHCP





Reported frequency among general dentists
has declined
Caused by burs, syringe needles, other
sharps
Occur outside the patient’s mouth
Involve small amounts of blood
Among oral surgeons, occur more
frequently during fracture reductions and
procedures involving wire
Exposure Prevention Strategies



Engineering controls
Work practice controls
Administrative controls
Engineering Controls


Isolate or remove the hazard
Examples:
Sharps container
Medical devices with injury protection
features (e.g., self-sheathing needles)
Work Practice Controls
Change the manner of performing tasks
 Examples include:
• Using instruments instead of fingers to

•
retract or palpate tissue
One-handed needle recapping
Administrative Controls


Policies, procedures, and enforcement
measures
Placement in the hierarchy varies by the
problem being addressed
Placed before engineering controls for
airborne precautions (e.g., TB)
Post-exposure Management
Program



Clear policies and procedures
Education of dental health care personnel
(DHCP)
Rapid access to
 Clinical care
 Post-exposure prophylaxis (PEP)
 Testing of source patients/HCP
Post-exposure Management



Wound management
Exposure reporting
Assessment of infection risk
Type and severity of exposure
Bloodborne status of source person
Susceptibility of exposed person
Hand Hygiene
Why Is Hand Hygiene Important?

Hands are the most common mode of
pathogen transmission

Reduce spread of antimicrobial resistance

Prevent health care-associated infections
Hands Need to be Cleaned When



Visibly dirty
After touching
contaminated objects with
bare hands
Before and after patient
treatment (before glove
placement and after glove
removal)
Hand Hygiene Definitions

Handwashing
 Washing hands with plain soap and water

Antiseptic handwash
 Washing hands with water and soap or other detergents
containing an antiseptic agent

Alcohol-based handrub
 Rubbing hands with an alcohol-containing preparation

Surgical antisepsis
 Handwashing with an antiseptic soap or an alcohol-based
handrub before operations by surgical personnel
Efficacy of Hand Hygiene
Preparations in Reduction of
Bacteria
Good
Better
Plain Soap
Antimicrobial
soap
Best
Alcohol-based
handrub
Source: http://www.cdc.gov/handhygiene/materials.htm
Alcohol-based Preparations
Benefits



Rapid and effective
antimicrobial action
Improved skin
condition
More accessible than
sinks
Limitations



Cannot be used if hands
are visibly soiled
Store away from high
temperatures or flames
Hand softeners and
glove powders may
“build-up”
Special Hand Hygiene
Considerations





Use hand lotions to prevent skin dryness
Consider compatibility of hand care products with
gloves (e.g., mineral oils and petroleum bases may
cause early glove failure)
Keep fingernails short
Avoid artificial nails
Avoid hand jewelry that may tear gloves
Personal Protective
Equipment
Personal Protective
Equipment

A major component of Standard
Precautions

Protects the skin and mucous
membranes from exposure to infectious
materials in spray or spatter

Should be removed when leaving
treatment areas
Masks, Protective Eyewear, Face Shields



Wear a surgical mask and either eye protection
with solid side shields or a face shield to
protect mucous membranes of the eyes, nose,
and mouth
Change masks between patients
Clean reusable face protection between
patients; if visibly soiled, clean and disinfect
Protective Clothing

Wear gowns, lab coats, or
uniforms that cover skin and
personal clothing likely to
become soiled with blood,
saliva, or infectious material

Change if visibly soiled

Remove all barriers before
leaving the work area
Gloves




Minimize the risk of health care personnel
acquiring infections from patients
Prevent microbial flora from being
transmitted from health care personnel to
patients
Reduce contamination of the hands of
health care personnel by microbial flora
that can be transmitted from one patient to
another
Are not a substitute for handwashing!
Recommendations for Gloving



Wear gloves when contact
with blood, saliva, and
mucous membranes is
possible
Remove gloves after patient
care
Wear a new pair of gloves for
each patient
Recommendations for Gloving
Remove gloves that
are torn, cut or punctured
Do not wash, disinfect
or sterilize gloves for reuse
Latex Hypersensitivity and
Contact Dermatitis
Latex Allergy



Type I hypersensitivity to
natural rubber latex proteins
Reactions may include nose,
eye, and skin reactions
More serious reactions may
include respiratory distress–
rarely shock or death
Contact Dermatitis


Irritant contact dermatitis
Not an allergy
Dry, itchy, irritated areas
Allergic contact dermatitis
Type IV delayed hypersensitivity
May result from allergy to chemicals used
in glove manufacturing
General Recommendations
Contact Dermatitis and Latex Allergy





Educate DHCP about reactions associated
with frequent hand hygiene and glove use
Get a medical diagnosis
Screen patients for latex allergy
Ensure a latex-safe environment
Have latex-free kits available (dental and
emergency)
Sterilization and Disinfection
of Patient Care Items
Critical Instruments



Penetrate mucous membranes or contact
bone, the bloodstream, or other normally
sterile tissues (of the mouth)
Heat sterilize between uses or use sterile
single-use, disposable devices
Examples include surgical instruments,
scalpel blades, periodontal scalers, and
surgical dental burs
Semi-critical Instruments



Contact mucous membranes but do not
penetrate soft tissue
Heat sterilize or high-level disinfect
Examples: Dental mouth mirrors,
amalgam condensers, and dental
handpieces
Noncritical Instruments
and Devices



Contact intact skin
Clean and disinfect using a low to intermediate
level disinfectant
Examples: X-ray heads, facebows, pulse
oximeter, blood pressure cuff
Instrument Processing Area


Use a designated processing area to control
quality and ensure safety
Divide processing area into work areas
 Receiving, cleaning, and decontamination
 Preparation and packaging
 Sterilization
 Storage
Automated Cleaning



Ultrasonic cleaner
Instrument washer
Washer-disinfector
Manual Cleaning


Soak until ready to clean
Wear heavy-duty utility
gloves, mask, eyewear,
and protective clothing
Preparation and Packaging




Critical and semi-critical items that will
be stored should be wrapped or placed in
containers before heat sterilization
Hinged instruments opened and unlocked
Place a chemical indicator inside the pack
Wear heavy-duty, puncture-resistant
utility gloves
Heat-Based Sterilization



Steam under pressure (autoclaving)
Gravity displacement
Pre-vacuum
Dry heat
Unsaturated chemical vapor
Liquid Chemical
Sterilant/Disinfectants



Only for heat-sensitive
critical and semi-critical
devices
Powerful, toxic chemicals
raise safety concerns
Heat tolerant or disposable
alternatives are available
Sterilization Monitoring
Types of Indicators

Mechanical
 Measure time, temperature, pressure

Chemical
 Change in color when physical parameter is reached

Biological (spore tests)
 Use biological spores to assess the sterilization
process directly
Storage of Sterile and
Clean Items and Supplies




Use date- or event-related shelf-life
practices
Examine wrapped items carefully prior
to use
When packaging of sterile items is
damaged, re-clean, re-wrap, and resterilize
Store clean items in dry, closed, or
covered containment
Environmental Infection Control
Environmental Surfaces



May become contaminated
Not directly involved in infectious disease
transmission
Do not require as stringent decontamination
procedures
Categories of Environmental Surfaces

Clinical contact surfaces
High potential for direct contamination from
spray or spatter or by contact with DHCP’s
gloved hand

Housekeeping surfaces
Do not come into contact with patients or
devices
Limited risk of disease transmission
Clinical Contact Surfaces
Housekeeping Surfaces
General Cleaning Recommendations

Use barrier precautions (e.g., heavy-duty utility
gloves, masks, protective eyewear) when
cleaning and disinfecting environmental surfaces

Physical removal of microorganisms by cleaning
is as important as the disinfection process

Follow manufacturer’s instructions for proper
use of EPA-registered hospital disinfectants

Do not use sterilant/high-level disinfectants on
environmental surfaces
Cleaning Clinical Contact Surfaces

Risk of transmitting infections
greater than for housekeeping
surfaces

Surface barriers can be used and
changed between patients
OR

Clean then disinfect using an
EPA-registered low- (HIV/HBV
claim) to intermediate-level
(tuberculocidal claim) hospital
Cleaning Housekeeping Surfaces



Routinely clean with soap and water or an
EPA-registered detergent/hospital
disinfectant routinely
Clean mops and cloths and allow to dry
thoroughly before re-using
Prepare fresh cleaning and disinfecting
solutions daily and per manufacturer
recommendations
Medical Waste

Medical Waste: Not considered infectious,
thus can be discarded in regular trash

Regulated Medical Waste: Poses a
potential risk of infection during handling
and disposal
Regulated Medical Waste Management



Properly labeled containment to
prevent injuries and leakage
Medical wastes are “treated” in
accordance with state and local
EPA regulations
Processes for regulated waste
include autoclaving and
incineration
Dental Unit Waterlines, Biofilm,
and Water Quality
Dental Unit Waterlines
and Biofilm



Microbial biofilms form
in small bore tubing of
dental units
Biofilms serve as a
microbial reservoir
Primary source of
microorganisms is
municipal water supply
Dental Unit Water Quality


Using water of uncertain quality is
inconsistent with infection control
principles
Colony counts in water from untreated
systems can exceed 1,000,000 CFU/mL
CFU=colony forming unit

Untreated dental units cannot reliably
produce water that meets drinking water
standards
Dental Water Quality
For routine dental treatment,
meet regulatory standards for
drinking water.*
* <500 CFU/mL of heterotrophic water
bacteria
Available DUWL Technology





Independent reservoirs
Chemical treatment
Filtration
Combinations
Sterile water delivery systems
Monitoring Options



Water testing laboratory
In-office testing with self-contained kits
Follow recommendations provided by the
manufacturer of the dental unit or waterline
treatment product for monitoring water
quality
Sterile Irrigating Solutions

Use sterile saline or sterile
water as a coolant/irrigator
when performing surgical
procedures

Use devices designed for the
delivery of sterile irrigating
fluids
Special Considerations






Dental handpieces and other
devices attached to air and
waterlines
Dental radiology
Aseptic technique for
parenteral medications
Single-use (disposable)
Devices
Preprocedural mouth rinses
Oral surgical procedures






Handling biopsy specimens
Handling extracted teeth
Laser/electrosurgery
plumes or surgical smoke
Dental laboratory
Mycobacterium
tuberculosis
Creutzfeldt-Jacob Disease
(CJD) and other prionrelated diseases
Dental Handpieces and Other Devices
Attached to Air and Waterlines



Clean and heat sterilize intraoral devices
that can be removed from air and waterlines
Follow manufacturer’s instructions for
cleaning, lubrication, and sterilization
Do not use liquid germicides or ethylene
oxide
Components of Devices Permanently
Attached to Air and Waterlines



Do not enter patient’s mouth but may
become contaminated
Use barriers and change between uses
Clean and intermediate-level disinfect the
surface of devices if visibly contaminated
Saliva Ejectors


Previously suctioned fluids
might be retracted into the
patient’s mouth when a seal
is created
Do not advise patients to
close their lips tightly
around the tip of the saliva
ejector
Dental Radiology




Wear gloves and other appropriate personal
protective equipment as necessary
Heat sterilize heat-tolerant radiographic
accessories
Transport and handle exposed radiographs
so that they will not become contaminated
Avoid contamination of developing
equipment
Parenteral Medications



Definition: Medications that are injected into the
body
Cases of disease transmission have been reported
Handle safely to prevent transmission of
infections
Precautions for Parenteral Medications


IV tubings, bags,
connections, needles, and
syringes are single-use,
disposable
Single dose vials
Do not administer to multiple
patients even if the needle on
the syringe is changed
Do not combine leftover
contents for later use
Single-Use (Disposable) Devices




Intended for use on one patient during a
single procedure
Usually not heat-tolerant
Cannot be reliably cleaned
Examples: Syringe needles, prophylaxis
cups, and plastic orthodontic brackets
Preprocedural Mouth Rinses

Antimicrobial mouth rinses prior to a dental
procedure
Reduce number of microorganisms in
aerosols/spatter
Decrease the number of microorganisms introduced
into the bloodstream

Unresolved issue–no evidence that infections
are prevented
Oral Surgical Procedures

Present a risk for microorganisms to enter the
body

Involve the incision, excision, or reflection of
tissue that exposes normally sterile areas of
the oral cavity

Examples include biopsy, periodontal
surgery,
implant surgery, apical surgery, and surgical
extractions of teeth
Precautions for Surgical Procedures
Surgical
Scrub
Sterile Irrigating
Solutions
Sterile Surgeon’s
Gloves
Handling Biopsy Specimens

Place biopsy in sturdy,
leakproof container

Avoid contaminating the
outside of the container

Label with a biohazard
symbol
Extracted Teeth

Considered regulated medical
waste
Do not incinerate extracted teeth
containing amalgam
Clean and disinfect before sending to
lab for shade comparison

Can be given back to patient
Handling Extracted Teeth
in Educational Settings




Remove visible blood and debris
Maintain hydration
Autoclave (teeth with no amalgam)
Use Standard Precautions
Laser/Electrosurgery Plumes and Surgical
Smoke




Destruction of tissue creates smoke that may
contain harmful by-products
Infectious materials (HSV, HPV) may
contact mucous membranes of nose
No evidence of HIV/HBV transmission
Need further studies
Dental Laboratory

Dental prostheses, appliances, and items
used in their making are potential sources
of contamination

Handle in a manner that protects patients
and DHCP from exposure to
microorganisms
Dental Laboratory

Clean and disinfect prostheses and
impressions

Wear appropriate PPE until disinfection has
been completed

Clean and heat sterilize heat-tolerant items
used in the mouth

Communicate specific information about
disinfection procedures
Transmission of
Mycobacterium tuberculosis



Spread by droplet nuclei
Immune system usually prevents spread
Bacteria can remain alive in the lungs for many years
(latent TB infection)
Risk of TB Transmission in
Dentistry

Risk in dental settings is low

Only one documented case of transmission

Tuberculin skin test conversions among
DHP are rare
Preventing Transmission of TB in Dental
Settings



Assess patients for history of TB
Defer elective dental treatment
If patient must be treated:
DHCP should wear face mask
Separate patient from others/mask/tissue
Refer to facility with proper TB infection
control precautions
Creutzfeldt-Jakob Disease
(CJD)

and other Prion Diseases
A type of a fatal degenerative disease of
central nervous system

Caused by abnormal “prion” protein

Human and animal forms

Long incubation period

One case per million population worldwide
New Variant CJD (vCJD)



Variant CJD (vCJD) is the human version
of Bovine Spongiform Encephalopathy
(BSE)
Case reports in the UK, Italy, France,
Ireland, Hong Kong, Canada
One case report in the United States –
former UK resident
Infection Control for Known CJD or
vCJD Dental Patients





Use single-use disposable items and
equipment
Consider items difficult to clean (e.g.,
endodontic files, broaches) as single-use
disposable
Keep instruments moist until cleaned
Clean and autoclave at 134°C for 18 minutes
Do not use flash sterilization
Program Evaluation
“Systematic way
to improve (infection
control) procedures so they are useful,
feasible, ethical, and accurate”
Develop standard operating procedures
Evaluate infection control practices
Document adverse outcomes
Document work-related illnesses
Monitor health care-associated infections
Infection Control Program Goals

Provide a safe working
environment
Reduce health care-associated
infections
Reduce occupational
exposures
Program Evaluation

Strategies and Tools
 Periodic observational
assessments
 Checklists to document
procedures
 Routine review of
occupational exposures to
bloodborne pathogens
“Program evaluation provides an
opportunity to identify and change
inappropriate practices, thereby
improving the effectiveness of your
infection control program.”