Infection Control Update: How To Provide A Safe Dental Visit and What the Public Expects

May 7, 2016

Sherry R. Timmons, D.D.S., Ph.D.

Department of Oral Pathology, Radiology and Medicine
College of Dentistry
University of Iowa
sherry-timmons@uiowa.edu

COURSE OUTLINE

I. CDC Guidelines
II. CDC Recommendations for Infection Control- Protocols and Procedures
a. Preventing Transmission of Bloodborne Pathogens
b. Hand Hygiene and Personal Protective Equipment
c. Disinfection and Sterilization of Patient-Care Items
d. Environmental Infection Control
e. Dental Unit Waterlines, Biofilm, and Water Quality
f. Special Considerations
III. OSHA Hazard Communication Standard (HCS)

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Who Regulates the Practice of Dentistry?
Occupational Safety and Health Administration (OSHA)
Requirements = law
Only applies to and protects the employee
Iowa State Board of Dental Examiners
Professional Regulations = law
Protects DHCP and patients
Centers for Disease Control (CDC)
Recommendations = guidelines
Apply to all DHCP

CDC Recommendation Categories

Category IA
Strongly recommended for implementation and strongly supported by well-designed
experimental, clinical, or epidemiologic studies
Category IB
Strongly recommended for implementation and supported by experimental, clinical, or
epidemiologic studies and a strong theoretical rationale
Category IC
Required for implementation as mandated by federal or state regulation or standard (e.g.
OSHA)
Category II
Suggested for implementation and supported by suggestive clinical or epidemiologic
studies or a theoretical rationale
Unresolved issue
No recommendation. Insufficient evidence or no consensus regarding efficacy exists

Which Categories Effect Our Practices?

IA, IB and IC recommendations are required by law in Iowa

Iowa State Board of Dental Examiners

Failure to comply with standard precautions for preventing transmission of infectious
diseases and managing personnel health and safety concerns related to infection control
as required or recommended for dentistry by the Centers for Disease Control and
Prevention of the United States Department of Health and Human Services

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 and skin to skin contact
Indirect contact with a contaminated instrument or surface (fomite)
Contact of mucosa of the eyes, nose, or mouth with droplets or spatter
Inhalation of airborne microorganisms

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

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Potential Routes of Transmission of Bloodborne Pathogens
Patient to DHCP
DHCP to patient
Patient to patient

Standard Precautions* (OSHAs Bloodborne Pathogen Standard uses the term Universal Precautions)
Every patient is potentially infectious
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

Personnel Health Elements of an Infection-Control Program

Healthcare personnel are workers within the healthcare setting (paid or unpaid) who can have an
anticipated risk by direct exposure to blood or other potentially infectious material (OPIM) or
through contact with a contaminated surface or instrument.
Develop a written health program for dental healthcare personnel (DHCP)
Education and training
Immunizations
Exposure prevention and post-exposure management
Medical conditions, work-related illness and associated work restrictions
Contact dermatitis and latex hypersensitivity
Establish and maintain confidential medical records on all DHCP
Establish Referral Arrangements that ensure prompt and appropriate medical services-
Preventive
Occupationally related
Postexposure management and follow-up
DHCP Immunization Considerations
Written policy regarding required and recommended immunizations
Latest immunization recommendations per CDC Guidelines (Advisory Committee on
Immunization Practices, ACIP)
Hepatitis B, Influenza, MMR, Varicella, Tetanus/diphtheria/pertussis
individual medical history
risk for occupational exposure
DHCP may use prearranged medical services or their own health-care professional
Hepatitis B Vaccination
o Follow U.S. Public Health Service/CDC recommendations for
o vaccination
o serologic testing
o follow-up
o booster dosing

Preventing Exposures to Blood and Other Potentially Infectious Material:

Develop a comprehensive post-exposure management and medical follow-up program
Policies and procedures for reporting, evaluation and counseling as well as treatment and
medical follow-up
Establish mechanisms for medical referrals
Establish engineering controls and work practice controls to prevent injuries
o Engineering controls
Are devices or equipment that can remove or eliminate a bloodborne pathogen from
the workplace
Can protect the worker from occupational exposure
E.g. sharp containers, safety scalpels, safety syringes
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 o Work practice controls
Practices based on personnel behaviors as opposed to the equipment
May consist of changing the was a procedure is done to increase worker safety
E.g needle recapping using one-handed scoop method, announcing when sharps are
being passed
o Evaluate Devices with Safety Features
Required at least annually and as available on the market
Identify
Evaluate
Select as appropriate
Cost cannot be a factor in the decision about using a safety device

Needle Recapping and Disposal

o Do not direct the point of a needle toward the body
o Do not bend, break, or remove needles before disposal
o Needle recapping and/or removal- using mechanical device or one-handed technique

General Safety Measures

Eyewash station
First-aid kit
Emergency action plan
Fire prevention plan
Job Safety and Health Protection poster
Written inventory of hazard chemicals, along with current Material Safety Data Sheets
Hazardous chemical containers labeled
Spill kit
Containers of compressed gases

Post-Exposure Report
o Date and time of exposure
o What, where, when, how, what device
o Route of injury, biologic material involved, volume and duration of contact
o Source patient
o Health status about the exposed person
o Management details
Medical Office Evaluation
o Evaluate Exposure source
Assess risk of infection using available information
Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid
testing)
For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection
Do not test discarded needles or syringes for virus contamination
o Evaluate Exposed Person
Assess immune status for HBV infection (i.e., by history of hepatitis B vaccination
and vaccine response)
o Give post exposure prophylaxis (PEP) for exposures posing risk of infection transmission
o PEPline: The National Clinicians' Post-Exposure Prophylaxis Hotline
o Phone: 1-888-448-4911
o Hours: 9 am- 2 am (EST) / 7 days a week
o If PEP is indicated or being considered, efficacy is time sensitive: first dose should be
given as soon as possible. Optimal time to start PEP is within hours of exposure, rather
than days. The Guidelines consider 72 hours post-exposure as the outer limit of
opportunity to initiate PEP

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 o Perform follow-up testing and provide counseling
o Advise exposed persons to seek medical evaluation for any acute illness occurring during
follow-up

Indications for hand hygiene

Hands are visibly soiled
After barehanded touching of objects likely to be contaminated
Before and after treating each patient
Before donning gloves
Immediately after removing gloves

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 (60-95 % alcohol)
Should not be placed adjacent to sinks or flames
National Fire Protection Association amended guidelines
Dispensers spaced at least four feet apart
Maximum capacity of dispensers is 1.2 liters
Surgical antisepsis performed before operations by surgical personnel
Handwashing with an antiseptic soap, usually for 2-6 minutes
Alcohol-based handrub
Clean hands with antiseptic handwash agent
Perform surgical hand-scrub per manufacturers instructions
Storing liquid hand-car products
Use disposable containers or re-usable closed containers
If using re-usable, wash and dry container prior to refilling. Do NOT top off
Hand lotion and glove compatibility
Fingernails
Do not wear artificial nails or extenders if providing direct patient care to patients
with high risk of infections
Short, smooth, filed edges (II)
Artificial nails at any time are not recommended (II)
Hand jewelry or nail jewelry that compromises glove wear or integrity should be
avoided (II)

Personal Protective Equipment (PPE) eye protection, surgical masks, gown, gloves
Are a major component of Standard Precautions
Protects the skin, clothing and mucous membranes from exposure to infectious materials in spray,
splatter and aerosols or when contacting contaminated instruments or surfaces
Should be removed when leaving treatment areas
Provided by employer at no cost to the employee, this includes cleaning, laundering and/or
disposal
Eye Protection
Used if there is a potential for splash, splatter or projectile injury
Needs to be impact resistant and approved for healthcare safety (non-healthcare approved
eye wear may protect against splash or splatter but not be certified to protect against flying
objects)
If solely wearing prescription eyewear, solid side shields must be installed

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 Can use googles
Can use a face shield, Iowa law still requires a facemask with the face shield
If using re-usable equipment, clean with soap and water or if visibly soiled then clean and
disinfect between patients (II)

Masks
Worn if there is the potential for splash, splatter or aerosols to contact the DHCPs mucous
membranes
Change between patients
May need to be changed during a single patient encounter if the mask becomes wet or
soiled
Wear protective clothing (gown) that covers personal clothing and skin likely to be soiled with
blood or OPIM
Gown needs to close at the collar, be long sleeved and cover the lap during the seated
position
Change protective clothing at least daily or more frequently if visibly soiled
Change immediately or as soon as feasible if penetrated by blood or OPIM
Consider storing gowns inside-out
Employers must launder workers reusable personal protective garments or uniforms that
are contaminated with blood or other potentially infectious materials per OSHA 29 CFR
1910.1030
Remove when leaving the patient care area
Contaminated garments may not be taken home by employees for laundering
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!
Wear medical gloves when a potential exposure exists (direct contact with blood, saliva,
OPIM, or mucous membranes or when contacting contaminated surfaces or instruments)
Ensure that appropriate gloves in the correct size are readily accessible
New gloves for each patient
Remove promptly after use
Remove when torn, cut or punctured
Do not wash, disinfect, or sterilize surgeon's or medical gloves before use or for reuse
Use puncture- and chemical-resistant utility gloves for cleaning instruments and
housekeeping tasks involving contact with blood or OPIM
Can be washed and disinfected; some brands can be sterilized
Wear sterile surgeon's gloves when performing oral surgical procedures
Double gloving is an unresolved issue because the effectiveness of preventing
disease transmission has not been demonstrated
There is however, studies demonstrating a lower frequency of inner glove
perforation and visible blood on surgeons hands with double gloving
Remove all personal protective equipment (PPE) before leaving work area

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Instrument and Operatory Surface Management
Wear appropriate PPE when splashing or spraying is anticipated
Cleaning: removes soil and bioburden. Products contain surfactants that facilitate the physical
removal of soil
Disinfection: inactivates microorganisms but does not physically remove the bioburden
Products will probably have different contact times for different actions (cleaning vs. disinfection)
DHCP have to be educated on the OHSA guidelines for exposure to chemical agents

Classification of Patient Care Items

Critical
Semicritical
Noncritical

Cleaning and Decontaminating

Wear appropriate PPE when splashing or spraying is anticipated
Clean off all visible blood and other contamination before sterilization or disinfection
Manual Cleaning
Wear heavy-duty utility gloves
Wear appropriate PPE when splashing or spraying is anticipated
Soaking using detergent, detergent/disinfectant, or enzymatic cleaner
Prevents drying of patient material
Makes cleaning easier
Decreases time
Can decrease corrosion of instruments due to presence of rust
inhibitors
Automated cleaning equipment
Improves cleaning effectiveness
Decreases exposure to blood
Decreases handling of sharps

Consider work practice controls:

Transport contaminated instruments in a covered container (II)
Long-handled brush
Utility gloves
Clean instruments under water to decrease splatter
Rinse with water afterwards

Preparation and Packaging

Place internal chemical indicator in each package
If internal indicator cannot be seen from outside the package, also use external indicator
(indicator tape) (II)
Place date of sterilization and ID of sterilizer used on outside of packaging material to facilitate
retrieval of processed items in event of a sterilization failure

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Sterilizers- must use FDA-cleared devices, must follow manufacturers instruction for use and preventive
maintenance
Heat Based Sterilizers
Steam under pressure (autoclave) * gold standard
Gravity under pressure
Pre-vacuum
Dry Heat
Static air
Forced air
Unsaturated Chemical Vapor
Alcohol/formaldehyde
Chemical Immersion Sterilization- low temperature
Use full strength on pre-cleaned instruments
Most agents require 6-12 hours of uninterrupted contact time
Re-use life varies with bioburden
Unwrapped instruments subject to recontamination
Sterilization cannot be monitored

Sterilization Monitoring
Monitor each load with mechanical and chemical indicators (II)
Use mechanical, chemical, and biological monitors according to manufacturer's instructions

Biologic Sterilization Monitoring

Killing of the most heat resistant spores assures that sterilization has been achieved
Most valid method- assesses the process directly
Perform at least weekly using a biological indicator (BI) with a matching control
Use a BI for every sterilizer load that contains an implantable device (IB)
Verify results before placing the device, whenever possible

Biologic Sterilization Monitoring Laboratory Testing

BI strip is transferred aseptically into nutrient broth
Broth is incubated for up to 7 days
G.stereothermophilus at 55 to 60 C (131 to 140 F)
B. atrophaeus at 30 to 37C (86 to 98.6 F)

Causes of Biologic Monitoring Failure

Most failures due to operator error
Improper
Precleaning
Loading
Overloading
Packaging
Wrong packaging material for sterilization method
Too many instruments per package
Excessive packaging material
Timing
Temperature
Pressure
Inadequate maintenance of sterilization equipment
Use of inappropriate equipment (e.g., household ovens, toaster ovens)

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General Polices for sterilized equipment
Allow packages to dry in the sterilizer before they are handled to avoid contamination
Do not store instruments in area where contaminated instruments are cleaned or held (II)
Store sterile items and dental supplies in covered or closed cabinets (II)
Train DHCP to use work practice controls to prevent contamination of clean areas

Surface Disinfection
Wear appropriate PPE (utility gloves, protective clothing, protective eyewear/face shield, and mask)
Use EPA-registered hospital disinfecting products
Routine: low- or intermediate-level disinfectant
Visibly contaminated with blood: intermediate-level
Spray-Wipe-Spray versus Wipe-Discard-Wipe

Categories of Environmental Surfaces

Clinical contact surfaces
High potential for direct contamination from spray or spatter or by contact with DHCPs
gloved hand
Eg. Countertops, light handles, light switches, dental chair switches, door knob, computer
keyboard and mouse, radiography equipment, faucets, cabinets and drawers
These surfaces can become contaminated via splash or splatter, aerosol generation, contact
with contaminated gloved or ungloved hands, contact with contaminated instruments
Surfaces can be barrier protected or cleaned AND disinfected after use
Housekeeping surfaces (e.g. floors, sinks)
Do not come into contact with patients or devices
Limited risk of disease transmission
Carpeting and cloth furnishings are not recommended in patient care, laboratories and
instrument processing areas (II)
If the surfaces are visibly free of blood and OPIM, then water and detergent with a clean,
dried mop/cloth or disposable mop/cloth
If surfaces are visibly soiled with blood/OPIM, then clean and use an EPA-registered
disinfectant

Dental Unit Waterlines, Biofilm, and Water Quality

For routine dental treatment use water that meets EPA regulatory standards for drinking water
<500 CFU/mL of heterotrophic water bacteria
1995 ADA challenged manufacturers and researchers to deliver patient treatment water of
200 CFU/ml by the year 2000
In the 2003 guidelines the CDC did not recommend flushing waterlines at the beginning of the day
because this practice will not modify biofilm formation or alter water quality delivered from the
unit
However, discharging air and water from the system (handpieces, ultrasonic scalers, air/water
syringes) for 20-30 seconds after each patient is recommended to physically flush out patient
material that may have entered the tubing, turbine, air, or waterlines. (II)
Consult with the dental unit manufacturer regarding periodic maintenance of anti-retraction
mechanisms
Use of self-contained (independent) water systems without using chemical water treatment will
have no effect on waterline biofilms.

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 Water Sources
Municipal (tap water)
Distilled water
Ensures consistent delivery of water with known microbiological quality
Water treated with reverse osmosis
Independent Reservoirs
Sterile Water Systems
Filtration
Water purifiers
Dental Water Treatment Systems
Commercial systems developed because it is unlikely that the water source in untreated,
unfiltered dental unit waterlines meet minimal drinking water standards
Self contained water systems combined with water treatments (periodic or
continuous chemical treatment)
Single chair or entire practice waterline systems that purify or treat incoming water
to remove or inactivate microorganisms (nano-filtration, reverse osmosis, or UV
irradiation, may include chemical agent)
Combinations
Cleaning agents can easily be introduced into the system.
Avoids interruptions in care during boil water advisory.
Chemical Products
o Chemical Products
o Continuous use vs. intermittent use (a.k.a. shock tx)
o Hydrogen Peroxide
o Chlorine dioxide
o Sodium hypochlorite
o Chlorhexidine
o Silver ions
o Iodine
o Ozone
o Peracetic Acid
o Acidic electrolyzed water
Monitoring Water Quality- should be performed weekly
Water samples submitted and cultured at a microbiology lab or bioenvironmental
engineering
Bacterial counts affected by:
Sampling method
Time (must be sent to lab ASAP)
Temp
Transportation
Culture medium
In-office self contained system
HPC Total Count Sampler by Millipore
Convenient
Easy to use
Certain phenotypes do not grow
Underestimates counts
Correct by factor of 1.5
Boil Water Advisory
Do not deliver public water through the dental operative unit
Do not use public water for dental treatment, patient rinsing or handwashing
Handwashing should be done with alcohol based hand rub and if hands are visibly soiled
use bottled water and hand soap or an antiseptic towelette

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 When advisory is cancelled, follow guidelines provided by local water utility. If no
guidelines are provided, flush dental waterlines and faucets for 1-5 minutes before using for patient
care.
Disinfect DUWL per dental unit manufacturer (II)

Special Consideration:

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

Digital Radiography
o Radiography sensors are considered semi-critical devices because they contact mucous
membranes
Use FDA-cleared barriers
Should be cleaned and heat-sterilized or EPA-approved high level disinfectant
Minimally you can barrier protect these items and clean and disinfect with EPA-
registered intermediate level disinfectant between patients
Check with the manufacturers instruction for cleaning and disinfecting

Handling of Extracted Teeth

Dispose of teeth as regulated medical waste unless returned to the patient
Teeth restored with amalgam cannot be disposed in regulated medical waste intended for
incineration

Handling of Extracted Teeth for Educational Purposes or Sent to Laboratory

Clean and place teeth in leakproof container, labeled with a biohazard symbol, and maintain
hydration for transport
Heat-sterilize teeth that do not contain amalgam

Regulated Medical Waste Management

Develop a medical waste management program; educate DHCP on the health and safety hazards
Place sharp items in sharps container
Puncture resistant
Color-coded or labeled
Leakproof on sides and bottom
Closable
Close container for handling, storage, transport, or shipping
Pour blood, suctioned fluids or other liquid waste carefully into a drain connected to a sanitary
sewer system, if local sewage discharge requirements are met and the state has declared this an
acceptable method of disposal

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OSHA Hazard Communication Standard (HCS)
A system for standardizing and harmonizing the classification and labeling of chemicals
Defines health, physical and environmental hazards of chemicals
Communicating hazard information, as well as protective measures, on labels and Safety Data
Sheets (SDS)- formerly known as Material Safety Data Sheets (MSDS)
HCS Labels for a hazardous chemical must contain:
Product Identifier (chemical name, code number, batch number, etc.)
Signal Word to indicate the relative level of severity hazard only two options: Danger or
Warning
Pictogram must be square shape set at a point and include a black hazard symbol on a white
background with a red frame. There are 9 GHS pictograms BUT OSHA will only enforce 8 of
them (the environmental pictogram is not mandatory)
Hazard Statement to describe the nature of the hazard and if appropriate the degree of hazard
should always see the same statement for the same hazards regardless of the chemical or
manufacturer
Precautionary Statement describes the recommended measures used to minimize or prevent
adverse effects resulting from exposure or improper handling or storage
o Prevention
o Response
o Storage
o Disposal
Name, address and telephone number of the chemical manufacturer, distributor, importer or
other responsible party
Supplemental Information: may provide additional information or instructions that are
deemed helpful

Safety Data Sheet Sections

o Section 1: Identification
o Section 2: Hazard(s) Identification
o Section 3: Composition/Information on Ingredients
o Section 4: First-Aid Measures
o Section 5: Fire-Fighting Measures
o Section 6: Accidental Release Measures
o Section 7: Handling and Storage
o Some municipalities and state EPA agency may have regulations regarding disposal of
product containers
o Section 8: Exposure Controls/Personal Protection
o Section 9: Physical and Chemical Properties
o Section 10: Stability and Reactivity
o Section 11: Toxicological Information

o Sections not enforced by OSHA (non-mandatory)

Section 12: Ecological Information
Section 13: Disposal Considerations
Section 14: Transport Information
Section 15: Regulatory Information
Section 16: Other Information
Secondary (In House) Container Labels
o Must contain
o Name of hazardous chemical(s)
o Description of hazards
o Secondary labels are not required if the product is transferred for immediate use

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Written Hazard Communication Program
Hazardous chemical inventory
Office labeling system
Procedures for maintaining SDS and making them available
Precautions used to protect employees from hazardous chemicals
How employees receive information and training

Globally Harmonized System (GHS) of Classification and Labeling of Chemicals

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 INFECTION-CONTROL INTERNET RESOURCES

CDC

Guidelines for Infection Control in Dental Health-Care Settings 2003

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

Issues in Healthcare Settings

http://www.cdc.gov/ncidod/dhqp/index.html

Guideline for Hand Hygiene in Health-Care Settings

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

http://www.cdc.gov/hicpac/Disinfection_Sterilization/13_0Sterilization.html

Hepatitis B
http://www.cdc.gov/ncidod/diseases/hepatitis/b/index.htm

HIV/AIDS
http://www.cdc.gov/hiv/dhap.htm

Tuberculosis
http://www.cdc.gov/tb

Management of Occupational Blood Exposures

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a3.htm

National Institute for Occupational Safety and Health

http://www.cdc.gov/niosh/topics/dentistry/

OSHA

Dentistry
http://www.osha.gov/SLTC/dentistry/index.html

Bloodborne Pathogens and Needlestick Prevention

http://www.osha.gov/SLTC/bloodbornepathogens/index.html

FDA

Center for Devices and Radiological Health

http://www.fda.gov/aboutfda/centersoffices/organizationcharts/ucm347835.htm

EPA

https://www3.epa.gov/

OSAP
Organization for Safety and Asepsis Procedures
http://www.osap.org/

DECS (Dental Evaluation and Consultation Service / US Air Force)

http://www.airforcemedicine.af.mil/DECS

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