INFECTIOUS DISEASE CONTROL IN DENTISTRY

GDS 211

James H. Howard, D.D.S., M.S.

Course Overview
Why Infection Control ? Practical Infection Control OSHA Requirements Hazard Communication Competency Examination Questions and Answers

Manual $160 CD ROM $149 Manual + CD ROM $260

Bloodborne Pathogens Hazard Communication Waste Management Other Regulatory Issues

!www.cdc.gov/OralHealth/guidelines.html

www.osap.org
Manufacturers Clinicians Academics

$55/ year Monthly Newsletter Annual Meeting

www.osap.org $57.95 plus S&H

Other Sources of Information

OSHA www.osha.gov/SLTC/dentistry/index.html Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008. www.cdc.gov Dental Evaluation and Consultation Services https://decs.nhgl.med.navy.mil/infcontrol.htm

In the beginning...
Man and microbes
Guns, Germs, and Steel Jared Diamond

Man and Microbes

Hunter-Gatherer - from origins to 10,000 yrs taller, healthier, strong bones, caries-free accidents, wounds, parasites, animal diseases Agrarian Society increased food, increased population high carbos, low protein smaller, shorter life nutrient deficiencies, caries

Man and Microbes (Contd)

Urbanization
population density in large cities poor sanitation, contaminated food and water interpersonal interactions physical contact, inhalation stage set for great plagues
cholera, polio, typhoid, smallpox

WARS

Man and Microbes

Modern Man (from mid 19th-20th century) Vaccination Jenner (1790) Germ theory of disease - Pasteur, Koch (1860s) Pure water supplies - Snow Insect vectors - Ross Worldwide higher standards of sanitation Antibiotics, Pesticides (1929) Decline in classic epidemic diseases Smallpox eradicated (1977)

1976!
American Legion Convention Philadelphia, PA Independence Hall

Emerging Diseases
75 - Lyme disease 76 - Ebola hemorrhagic fever - Legionnaires disease 78 - Toxic shock syndrome 81 GRID / 82 - AIDS 82 - E.coli 0157:H7 food poisoning 93 - Hantavirus pulmonary syndrome 02 - West Nile Fever 03 SARS 04 Asian Bird Flu (Avian Flu) 09 - H1N1

Lyme Disease

E. coli O157:H7
1982 - First recognized as a pathogen 1985 - Associated with hemolytic uremic syndrome 1990/91 - Outbreak from drinking water, apple cider 1993 - Multi-state outbreak from fast food hamburgers 1995 - Outbreak from fresh produce 1996 - Multistate outbreak from unpasteurized apple juice 1997 25 million pounds of beef recalled 2002 18 million pounds of beef recalled 2006 Outbreak from spinach 09/2007- 21.7 million pounds of beef recalled

Cryptosporidiosis
1976 - First human case recorded 1984 - First well water outbreak 1987 - First river water outbreak 1992 - Multiple municipal water supply outbreaks 1993 - Largest recorded waterborne outbreak in U.S. history (Milwaukee, WI) 1993 - fresh pressed apple cider outbreak (Maine) 1994 - First outbreak in community with state of the art water treatment (Las Vegas)

Theyre Back
Yellow fever Dengue fever Malaria Staphylococcus Cholera Tuberculosis (MDR TB and XDR TB)

Where Do They Come From? other species From existing diseases of

Newly identified unrecognized diseases Lyme Disease - bacterial disease of deermice vectored by ticks cycling thru whitetail deer 10,000 Americans/year Hantavirus Pulmonary Disease disease of deermice, contracted by humans who inhale virus in airborne particles of mouse urine and feces

Source?
Ebola Virus - Suspected sources: bats, rodents, monkeys HIV - virus from African Chimps? 62 human diseases found in other animals Insect vectored - malaria, dengue fever, yellow fever, Rift Valley fever, encephalitis, West Nile Blood spills or bites

Why Now?
Human assault on the natural world Air / water pollution Soil erosion Reduction in biodiversity Examples: elimination of large predators Lyme disease pampas to corn - Junin virus in new mouse Aswan Dam - new habitat for

Superbugs
Natural Selection Antibiotic -resistant forms: TB and Staph aureus Horizontal gene transfer: picking up new DNA from mating or other bacteria in the environment New strains of E.coli have a deadly toxin gene picked up from Shigella which lives alongside it in the guts of cattle

Human Action
Widespread use of antibiotics in lessthan-critical situations Viral infections Live stock 30 times as many antibiotics are used on farm animals as on humans in USA

October, 1990

Cytomegalovirus Hepatitis B (HBV) Hepatitis C (HCV) Herpes Simplex Virus 1 and 2 Human Immunodeficiency Virus (HIV) M. Tuberculosis Staph, strep, and viruses in the oral cavity

Dental Health Care Personnel are at risk

Dental Health Care Personnel (DHCP)

168, 000 Dentists 112,000 RDH 218,000 Dental Assistants 53,000 Dental Laboratory Technicians

Practical Infection Control

Infectious Disease Process

Essential components:
Pathogen of sufficient virulence and adequate numbers to cause disease Reservoir for pathogen to survive & multiply Mode of transmission Portal of entry Susceptible host

All are necessary for the spread of infection. If one is missing, the chain is broken and the possibility of infection is eliminated.

Causative Agents
Pathogens: any microorganism capable of causing disease may include viruses, bacteria, protozoa, fungi Bloodborne pathogens - present in human blood
Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human Immunodeficiency virus (HIV)

Susceptible Host
Lacking effective resistance to a particular pathogen. Factors that influence susceptibility:
Heredity, nutritional status, medications, therapeutic procedures, underlying disease, and immunization status Immunization status

Vaccination Acquired

Modes of Transmission
The mechanism by which an infectious agent is transferred to a susceptible host. By contact, inhalation, or through a vehicle (food, water, blood)
Contact may be direct or indirect Inhalation of airborne suspension, e.g. TB, measles Vehicle - blood is single most important vehicle for HIV, HBV and HCV

Goals of Infection Control

To eliminate the transfer of microorganisms (cross - contamination). To reduce the number of available pathogenic microbes to a level where normal resistance of the body may prevent infection. To use barrier equipment and proper techniques to disrupt modes of transmission. To reduce susceptibility by immunizations.

Standard Precautions
Combines components of: Universal Precautions

All human blood and all body fluids are to treated as if known to be infectious for HIV, HBV, and other Bloodborne pathogens
with

Moist body substances isolation (mucous membranes, and non-intact skin) Used for the care of all patients, regardless of infection status

Occupational Exposure
Direct contact with infectious lesions or infected blood or saliva Splatter of blood or saliva directly onto broken or intact skin or mucosa Aerosolization, the airborne transfer of microbes Parenteral exposure - piercing the skin barrier

Parenteral Exposure
Risk of acquiring disease after needlestick
HIV : 0.3% HCV : 3.0 % (3-10%) HBV : 30 % (6 -30%)

Factors that influence risk of transmission

Route of exposure Dose of virus transferred during an exposure Differences in host susceptibility The number of exposure incidents

Fundamentals of Infection Control

Patient Assessment Personal Protection Sterilization and Disinfection Environmental Surface and Equipment Disinfection Aseptic Technique Training

Personal Protection
Standard Precautions Vaccinations

Hepatitis B Measles, Mumps &Rubella Influenza Poliomyelitis Diphtheria -Tetanus Varicella

Practical Barrier Techniques

Gloves, masks, protective eyewear, rubber dams, clothing, surface covers,

Engineering / Work Practice Controls

Engineering controls reduce exposure by removing the hazard or isolating the worker from it
rubber dam, high volume evacuation, needle recapping devices, self sheathing needles

Work practice controls reduce chance of exposure by changes in the way a task is performed
Handwashing Sharps Personal habits and eating

Handwashing

Hand Hygiene
Austrian Physician Attributed maternity deaths in hospital to cadaveric particles on hands of physicians who performed autopsies and then delivered babies without washing hands
Ignaz Semmelweiss 1818-65

Handwashing
Skin harbors resident and transient flora Microbes can infect through dermal defects Fingernails can harbor bacteria >5 days Removes transient bacteria & decreases number of microbes Mechanically Chemically Substantivity- residual effects of chemical

Handwashing Protocol
Remove visible debris Avoid abrading skin Use cool/warm water, not hot Use antimicrobial handwash
4% Chlorhexadine gluconate 3% Parachlormetaxylenol (PCMX) .25% - 3% Triclosan

Rub gently: 15 sec. minimum, 2 min. preferred Rinse and repeat

Handwashing Protocol

(Contd.)

Dry thoroughly Turn off faucet with paper towel Wash any other skin contacting OPIM immediately MANDATORY

Before treatment Between patients After glove removal Needle stick or cut

3% Triclosan

Hand Hygiene
!CDC

Guidelines, Oct., 2002

!Recommend:

Alcohol (60-95%) gels, sprays, or foams between patients in lieu of washing with water
!Goal:

Better compliance due to ease of use

Gloves
Purpose: To prevent cross contamination To protect hands Types: (dictated by task) Patient exam Surgical (best fit, most expensive) Non-medical Utility (puncture resistant for cleanup)

Glove Materials
Natural-rubber latex Nitrile Nitrile & chloroprene (neoprene) Polyvinyl chloride (vinyl) Polyurethane Styrene-based coploymers Butyl-rubber fluoroelastomers

Gloves

(Contd.)

Gloving does not replace handwashing ADA recommends routinely wear for all treatment Do not reuse or wash gloves Cover cuffs, avoid long nails, jewelry Avoid contaminating unprotected skin during removal Latex hypersensitivity

Latex Allergies
Natural Rubber Latex (NRL)- natural product from rubber trees Hevea brazilienis ! Tapping trees produces rubber and proteins ! Increased exposure to allergenic proteins accounts for increased incidence of allergies. ! Incidence: 6-17% healthcare workers 6.2% Type I (JADA, Jan. 1998) up to 65% spina bifida patients

LATEX PRODUCTION
1992 2002 28-30 billion 1800 ug 100 mg

Gloves used Protein/glove Powder/glove

3-5 billion 5000 ug 500 mg

Latex Allergies
! Hand

Dermatitis - irritation of the skin Irritant Contact Dermatitis Allergic Contact Dermatitis (Delayed or Type IV hypersensitivity) Immediate or Type I hypersensitivity

Irritant Contact Dermatitis

! Causes

- Heat & perspiration - Metals & jewelry - Improper drying - Detergents & soaps
! Symptoms

- Disinfectants - Excessive scrubbing - Lotions - Solvents

- Redness - Soreness - Drying

- Peeling, cracking - Burning, itching

Allergic Contact Dermatitis

Delayed (Type IV) Allergy
!

Causes
- Accelerators - Antioxidants - Emulsifiers - Disinfectants - Fungicides - Stabilizers - Odorants - Bonding agents - Erythema - Edema - Itching - Swelling

Symptoms
- Dryness - Fissures - Hyperkeratosis - Scabbing

Allergic Contact Dermatitis

Hamann, et al,: JADA, Vol. 134, Feb 2003

Immediate (Type I) Allergy

! Cause:
IgE mediated response to NRL allergens

! Symptoms:

- Burning - Itching - Dermatitis - Hives (urticaria)

- Respiratory - Cardiovascular - Gastrointestinal - Otolaryngal

Recommendation: Be Prepared
! Recognize

high risk groups ! Obtain health histories including allergies

Question patients regarding itching, rash, rhinitis,

wheezing, eyelid edema, previous reactions

! Label

patient chart and records ! Establish latex-safe areas, equipment, and emergency procedures ! Educate staff and patients about latex

Face Masks
! Worn

whenever aerosol or splatter generated ! Reduce inhalation of potentially infectious aerosol particles
Created by handpiece and ultrasonic scalers

! Protect

mouth and mucosa from direct contamination

Face Masks (Contd.)

! Requirements
New mask for each patient Must fit snugly Remove it when treatment is over Handle by elastic or string, do not touch the

mask itself

Face Masks (Contd.)

Efficacy
At least 95% bacterial filtering efficiency

for small particle aerosols (3-5)

! Filtration:

Surgical > Dome ! Splatter Control: Surgical < Dome ! Duration of Effectiveness
Dry Environment: 5 - 6 hours Water Spray: less than 1 hour

Protective Eyewear
Purpose To prevent infection to eyes To prevent physical / chemical damage to eyes ! Types Goggles Side shields Face shields ! Worn by both patients and providers
!

Gowns
! Purpose To avoid contamination of street clothing To prevent cross-contamination of family

members

! Worn

/ removed only in treatment area ! Laundered separately from street clothes ! Changed daily, and when visibly soiled ! Cover arms and fit snugly around neck

Black Death
1347-1352 25 million people died in Europe ! Transmitted by fleas on rats ! Recurred throughout the next 200 years ! Outbreak in San Francisco at turn of this century
!

Sharps
Sterile syringe, new needle, and solution for each patient ! Handle all sharp instruments carefully ! Avoid manual handling of needles ! Never leave needles unsheathed ! Avoid two-handed recapping of needles ! Use scoop, one-handed, or holder to recap ! Never break, cut or bend after use ! Discard in puncture resistant containers
!

Two Handed Technique

Recapping Device

Scoop Technique

DECONTAMINATION

Disinfection / Sterilization

Asepsis
a!sep!sis (noun)
1.The state of being free of pathogenic microorganisms. 2. The process of removing pathogenic microorganisms or protecting against infection by such organisms.

Decontamination Processes
CLEANING DISINFECTING STERILIZING

Cleaning
Physical removal of debris (BIOBURDEN) and reduction in microorganisms Basic FIRST step in decontamination Performed before disinfection or sterilization

Ultrasonic cleaners

Thermal Disinfector/ Instrument Washer

Reduced handling/touching Elimination of aerosols from ultrasonics and hand scrubbing Reduced potential for injuries Increased efficacy of cleaning and disinfection Decreased staff time $7,850 vs $600-$1000 for ultrasonics

Disinfection
The destruction of pathogenic microorganisms on inanimate objects Not ALL microbes killed, particularly the more resistant forms, e.g. spores Three levels of disinfection LOW
Kills HIV, HBV

INTERMEDIATE
Kills HIV, HBV, and TB

HIGH
Kills HIV, HBV, TB, and some, but not all, spores

Low-level Disinfection
Least effective, but will kill HIV and HBV Does not kill bacterial spores or Mycobacterium tuberculosis var. bovis (MTB)
Very resistant microbe used to test killing power of chemical agents Used to classify strength of chem. disinfectants

Kills most vegetative bacteria, some fungi, and some viruses

Intermediate-level Disinfection
Kills M. tuberculosis var. bovis (MTB) Tuberculocidal activity label claim Kills microbes that cause HBV and HIV Hospital Disinfectant EPA classification Kills three species of test bacteria
Staphylococcus aureus Salmonella typhimurium Pseudomonas aeriginosa

High-level Disinfection
Kills some, not all , bacterial spores Kills MTB, other bacteria, fungi, and viruses Sterilant/Disinfectant - EPA registered Must use for recommended contact time ( longer for sterilization )

NOTE: products capable of killing spores will be so designated

IDEAL Disinfectant *
Broad spectrum Fast acting Long use life Non-toxic Economical Simple to use Residual effect Odorless Surface compatible Unaffected by debris

* IDEAL does not exist

Disinfectants vs Antiseptics
Disinfectants are regulated and registered by EPA For use on environmental, inanimate objects Antiseptics are regulated by FDA For use on living tissue DO NOT interchange the use of the two

Environmental Surfaces
Clinical Contact directly contacted by contaminated instruments, devices, gloves light handles, switches, x-ray equipment, drawer handles, countertops, pens, telephone, doorknobs Housekeeping surfaces that require regular cleaning and removal of soil and dust Floors, walls, sinks

Clinical Contact Surfaces

Visible blood and organic material should first be removed Low level disinfectants are effective Cleaned and disinfected after each patient, and at end of day Barriers are also effective

Housekeeping Surfaces
No evidence HBV, HIV, HCV has ever been transmitted from housekeeping surfaces Should be cleaned and decontaminated after any spill of blood or OPIM

Wear PPE Remove organic material Clean and disinfect with intermediate level disinfectant

Factors Influencing Disinfection

Type and number of microorganisms present Concentration of chemical agent Contact time Amount of bioburden present

EPA Registered Surface Disinfectants for Dentistry

Chlorines Complex Phenols Dual/synergized quaternary ammonium compounds Iodophors Phenol-alcohol combinations Other halogens

EPA Registration Numbers

EPA issues registration numbers that appear on product label EPA Reg. No. XXXX-YY
XXXX identifies the company holding the registration YY represents the specific product

If marketed under different brand names, EPA Reg. No. XXXX-YY-ZZZ

where ZZZ identifies distributor

Chlorines
ADVANTAGES Economical Rapid broad spectrum activity Tuberculocidal Effective in dilute solutions DISADVANTAGES Diluted solutions must be prepared fresh daily Corrosive to some metals May destroy fabrics Irritates skin Chlorine dioxide is a poor cleaner

Contact time 2-10 min/ 200C or 250C* * Varies by active ingredient/brand

Complex Phenols
!

ADVANTAGES

DISADVANTAGES

Broad spectrum

Not sporicidal Tuberculocidal Many must be prepared fresh daily Residual biocidal action Degrades certain plastics and etches Useful on metal, glass, glass rubber, and plastic Film accumulation Economical Skin and eye irritation Effective cleaner Contact time 10 min/ 200C or 250C* * Varies by active ingredient/brand

Dual/Synergized Quaternary Ammonium Compounds

ADVANTAGES Broad spectrum Tuberculocidal Low toxicity Contains detergent DISADVANTAGES Inactivated by anionic detergents and organic matter Can damage some materials Contact time 6 or 10 min/ 200C *

* Varies by active ingredient/brand

Iodophors
ADVANTAGES DISADVANTAGES Tuberculocidal Unstable at high temps Broad spectrum Dilution and contact time are critical Effective in dilute Must prepare fresh daily solution Few side reactions Discolors some surfaces Residual biocidal action Rust inhibitor necessary Effective cleaner Inactivated by hard water, alcohol Contact time 10 min/ 200C

Phenol-alcohol combinations
ADVANTAGES Tuberculocidal Fast acting Residual activity Some inhibit growth of mold, fungi DISADVANTAGES May cause porous surfaces to dry and crack Poor cleaning capabilities

Contact time 10 min/ 200C or 250C* * Varies by active ingredient/brand

Other Halogens
(sodium bromide and chlorine)
ADVANTAGES DISADVANTAGES Fast acting Use on hard surfaces only Tuberculocidal Chlorine smell Supplied in tablet form for simple dilution Minimal storage space Contact time 5 min/ 200C or 250C* * Varies by active ingredient/brand

Alcohols
NOT RECOMMENDED FOR SURFACE DISINFECTION ADVANTAGES Rapidly bactericidal DISADVANTAGES Not sporicidal Diminished activity with bioburden Damages rubber and plastics Rapid evaporation

Sterilization
Definition The destruction or removal of all forms of life, with particular reference to microbial organisms Basic Criterion Destruction of bacterial and mycotic spores, which are the most heat resistant microbial forms

Decontamination Decision
How an item is used is the major factor determining whether it must be sterilized, disinfected, or simply cleaned Critical - Tissue or bone -- sterilize Semicritical - Mucosa -- sterilize/high level disinfection Noncritical - Intact skin -intermediate to low level disinfection DO NOT DISINFECT WHEN YOU CAN STERILIZE

Sterilization Methods
Steam under pressure (2500F) Dry Heat (320-3400F) Chemical Vapor (2700F) Ethylene Oxide Liquid Chemicals Glutaraldehydes Hypochlorites Chlorine Dioxide

Steam Sterilization
Temp: 1210 C (2500 F) Pressure: 15 psi Cycle time: 30 min (gravity displacement) 4 min. ( pre-vacuum sterilizer) @ 2700F Use small bundles so steam can freely circulate

Steam Autoclave Items

High quality stainless steel instruments Autoclavable handpieces Metal prophy angles Contra angles Cloth goods Glass slabs, dishes, dry stones Large plastic suction tips

Dry Heat
The time needed to sterilize with dry heat depends on the temperature A typical dry heat cycle is 6o min @ 1700C (3400F ) plus time required to bring load up to sterilization temperature. Important: Follow manufacturer instructions.

Dry Heat
Static air
1 hour @ 1700 C (3400F) 2 hours @ 1600C (3200F) 2 " hours @ 1500C (3000F)

Forced air
12 min. @ 1900C ( 3750C)

Dry Heat Items

Contra angles Mirrors, dry metal instruments except handpieces Low quality stainless steel (ortho) Oils, wax, dry powder Curettes, burs, non-stainless steel

Chemical Vapor
Deodorized alcohol-formaldehyde /H2O solution under pressure at 1320C (2700F) @ 20 psi for 20-40 min (unwrapped or bagged) Vapor should be discharged thru an aircooled coil into container beneath sterilizer (not reused)

Chemical Vapor

Ethylene Oxide
Room temperature for 10-16 hours Limitations Degrades plastics with repeated exposure Not reliable for unwrapped goods or towels Toxic Expensive Requires additional time for gas

FDA Immersion High Level Disinfectants/ Sterilants

Category Glutaraldehyde Contact Times Sterilant 6-10 hrs. Disinfect 20-90 min. Sterilant 6 hrs. Disinfect 30 min.

Hydrogen Peroxide

Category Ortho-pthalaldehyde

FDA Immersion High Level Disinfectants/ Sterilants

Contact Times Disinfect 12 min.

Synergistic solutions Gluteraldehyde/phenol

Sterilant Disinfect Sterilant Disinfect

12 hrs 20 min. 6 hrs. 30 min.

Hydrogen-peroxide/ phosphoric acid

Hydrogen-peroxide/ phosphoric acid

Liquid Chemical Disinfectants/ Sterilants

For most products the only factor determining whether it will sterilize or disinfect something is contact time. To sterilize: prolonged exposure time of up to 10 hours is required therefore its important to follow mfgr directions exactly

Bead Sterilizers
Inconsistent heating Significant temperature variation FDA has deemed them not safe or effective

Cold Sterilization
Immersion in high-level disinfectants for less than the required sterilization time (minimum of 10 hours) One of the most abused aspects of infection control Cannot verify sterilization Often rinsed with tap water NOT an accepted method of sterilization

Cold Sterilization

Advantages and Disadvantages of Sterilization Methods

Steam Autoclave
ADVANTAGES
Quick and easy Allows for sterile packaging Penetrates fabric and paper wrapping Very reliable

DISADVANTAGES
Wet instruments /rust Requires packaging Damages plastics Dulls unprotected cutting edges Corrodes carbon steel

Dry Heat
ADVANTAGES
Dry instruments No rusting Cheap and easy Little maintenance Very reliable

DISADVANTAGES
Slow Longer processing time Careful loading Damages plastics Melts or destroys some metal or solder joints Chars fabric Unsuitable for handpieces

Chemical Vapor
ADVANTAGES
Short cycle time No rusting or corroding Does not dull cutting edges Used with packaged items Very reliable

DISADVANTAGES
Instruments must be dry Requires good ventilation Cannot handle large loads Cannot sterilize liquids Damages certain plastics Costly solution

Chemical Disinfectant/Sterilant
ADVANTAGES
Sterilizes items damaged by heat Cheap initially

DISADVANTAGES
Has a limited life Is expensive in the long run; may rust instruments No effectiveness monitors Special ventilation req.... Protective clothing req.... Not used with pkg.... item Rinse with sterile water

Glutaraldehydes
ADVANTAGES
EPA registered as chem. sterilant Most potent chem. germicide Sporicidal at room temp. after 6-10 hrs. Noncorrosive Penetrates organic debris

DISADVANTAGES
Not an antiseptic Not a surface disinfectant Severe tissue irritation Allergenic Discolors some metals Biologically non verifiable Reuse life varies with biourden Cannot package items

Glutaraldehydes (Cont'd.)
ADVANTAGES
Useful for rubber and plastic items Instrument sterilant or disinfectant Prolonged activated life

DISADVANTAGES
Reuse life varies with bioburden Cannot package items Corrosive activity can increase with dilution

Disinfectant Properties of Hypochlorites

ADVANTAGES
Some products are EPA registered and ADA accepted Rapid antimicrobial action Broad spectrum: Bactericidal, virucidal tuberculocidal Effective in dilute solution Economical

DISADVANTAGES
Sporicidal only at high concentrations Cannot be reused Must be prepared fresh daily Activity diminished by organic matter Unpleasant, persistent odor Corrodes metals

Chlorine Dioxide
ADVANTAGES Immersion or surface disinfectant/sterilant Rapid acting: 3min for disinfection / 6 hrs for sterilization DISADVANTAGES Discard daily 24 hrs sterilant use-life Does not readily penetrate organic debris Protective eyewear / gloves required Closed containers Adequate ventilation for surface disinf Corrodes aluminum

Monitoring Sterilization
Mechanical: observing pressure, temperature gauges, and printouts Chemical: Process Indicators
Exposed to heat, color changes Placed in or on all packs Does NOT verify sterilization

Biological: Spore Testing

Verifies sterilization, validates equipment Specific for sterilization method

Spore Testing
Proper functioning of sterilization cycles should be verified by the periodic use (at least once weekly) of biologic indicators
CDC 2003 recommendations

Weekly sporicidal tests provide biological verification and control of sterilization process

Biological Indicators
Steam/Chemical autoclave: B. stearothermophilis Dry Heat / ETO: B.Subtilis Combination: B. stearothermophilis and B.Subtilis

Process Indicators
Exposure to a heat as indicated by several types of color-change tapes Placed prior to sterilize on a few inst. in unwrapped loads, or on outside of packs & trays Verifies items have undergone processing Does not prove sterilization

Alliance, NE

Somewhere in England

Clinical Applications

Clinical Applications
Pre-treatment Phase Treatment Phase Post-treatment Phase

Pre-treatment Phase
Preplan the materials needed Remove unnecessary items Use pre-set trays for routine procedures Use individualized, sterilized bur blocks If indicated , have rubber dam setup on tray

Pre-treatment Phase

Use disposable items where practical

Pre-treatment (Contd.)
Identify those items that will become contaminated Disinfect Barriers Place radiographs on viewbox Flush water lines on unit to limit microbial contamination Prepare personnel involved in care

Always wear personal protection when using spray disinfectants

SPRAY

WIPE

SPRAY

Surface Barriers
Time-saving alternative to betweenpatient cleaning and disinfection of operatory surfaces. Fluid impervious cover on surfaces prone to contamination. As long as the barrier remains intact , the surface it protects remains free of patient material, and thus does not need to be disinfected after each patient.

Benefits of Barriers
Reduced chemical use Protects equipment & furniture Simple, easy technique Reliable, consistent efficacy Visible to patient

Barrier Placement

Variety Of Designs & Sizes

Flush All Water Lines

Treatment Phase
Seat Patient Place eyewear, mask, wash hands, gloves Mouthwash rinse Use care when handling sharp instruments Take special precaution with needles Use rubber dam whenever possible

Pre-procedural Mouth Rinse

Antimicrobial rinses prior to procedure will reduce the number of microorganisms the patient may release in the form of aerosols or splatter. (up to 98%) May also decrease number of microorganisms introduced into bloodstream during invasive procedures.

Treatment Phase (Contd.)

Use high volume evacuation minimizes splashing, spattering, spraying Avoid touching unprotected switches, handles, and other equip. once gloved Avoid entering drawers, cabinets, or touching dental records Deglove or overglove to replace instruments

Treatment Phase
Sharps/ waste disposal Dismiss patient Keep eyewear, mask on Remove treatment gloves Wash hands

(Contd.)

Post-treatment Phase
Continue to wear PPE during cleanup Remove all disposable barriers Clean and disinfect all items not protected by barriers Wash all instruments that have solids adhering to them Use utility gloves

Post-treatment Phase (Contd.)

Sterilize instruments Autoclave all handpieces Dispose of contaminated waste properly

Post-treatment Phase (Contd.)

Handle sharps carefully Place sharps in receptacle Avoid picking up sharp instruments by the handful Wash, dry, remove, then disinfect utility gloves Wash hands

Cleaning
Heavy duty utility gloves Clean any hard deposits, eg. cements, composite resins, etc. Wash gloves, disinfect work area Scrub brush or ultrasonic cleaner

Wrapping
Paper, muslin, nylon Cover tips of pointed instruments Sterilize hinged instruments in open position If unwrapped, must store in clean area Wrap according to sterilizing method Event related packaging

Handle one instrument at a time, avoid sharp ends

Continue to wear utility gloves

Hinged instruments in the open position

Steam Autoclaves

Storing
Avoid aerosols / dust 12-14 inches from floor Disinfect drawers & shelves Remove only with clean hands Package seldom-used items If pkg. becomes torn or wet, repackage and sterilize again

NO LIQUIDS ON KEYBOARD/ MOUSE

Laboratory Infection Control

The first step in decontamination is cleaning

Followed by Disinfection

Disinfected Prosthesis returned from the Lab

Dont contaminate multi-use materials

Occupational Exposure to Bloodborne Pathogens; Final Rule Federal Register, Dec. 6, 1991 Standard applying to occupational exposure to blood and other potentially infectious material (OPIM) saliva in dentistry is considered OPIM Revisions: Federal Register, Jan 18, 2001 Needlestick Safety and PreventionAct

OSHA Requirements
Exposure Control Plan Training Program Record Keeping

Exposure Determination
Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material (OPIM) that may result from the performance of an employees duties
Determined without regard to the use of personal protective equipment

Exposure Determination
(Contd.)
Job Classifications
ALL - job classifications in which all employees on the list have occupational exposure, e.g. dentist, dental hygienist, dental assistant

Not necessary to list tasks that give rise to exposure

SOME - jobs in which some employees have exposure

List the tasks

Training Program Contents

Exposure Control Plan and OSHA Standard Epidemiology, Transmission, Symptoms, and Prevention of HIV and HBV (HCV) Use of Personal Protective Equipment Proper Work Practices and Standard Precautions Labels and Handling Infectious Waste Procedures for exposure incidents

Manner of Presentation of Training

Initial assignment to exposure prone duties Annually, or as soon as possible when there are changes in procedures or job assignments In an understandable manner and language In an interactive style By a knowledgeable person

Employee Training Record

Document each training session Retained by employer for three years Must include: Dates of training Summary of contents of training Name(s) and qualifications of trainer Names and job titles of all attendees

Exposure Control Plan

Specific for employees workplace Reviewed and updated annually Accessible to employees Made available to OSHA upon request Exposure determination Procedures to evaluate exposure incidents

Exposure Control Plan

(Contd.)

Standard Precautions Engineering and Work Practice Controls* Handwashing Personal Protective Equipment (PPE) Housekeeping Procedures Cleaning and Decontamination Regulated Waste Containment *Needlestick Safety

Exposure Control Plan

(Contd.)

Laundry for PPE HBV Vaccination for all employees at risk Postexposure Evaluation Labeling Procedures Information and Training

Record Keeping
Employee Medical Record Employee Training Record Hepatitis B Vaccine Declination Informed refusal by employee of postexposure medical evaluation and follow-up (not an OSHA requirement) Posters and Regulations Annual evaluation of new devices to prevent needlesticks

Needlestick Safety and Prevention Act

Passed by Congress Nov.6, 2000 Enforcement began July 17, 2001 Employer must: Involve non-managerial workers in evaluation of new devices designed to reduce risk of exposure Document this consideration in the Exposure Control Plan

AIDS IN THE PREVENTION OF NEEDLESTICK INJURIES

Needlestick Safety
Solicit employee input in any manner appropriate to the workplace Documentation includes: Listing employees involved Describing the process by which the input was requested Other documents, such as meeting minutes, copies of requests for input, records of responses received from employees

Steps for Selecting and Evaluating Dental Safety Programs and Devices*
Assign responsibility to someone for coordinating the process
Identify available devices Organize education and training Coordinate product evaluation Monitor safety performance Document in exposure cintrol plan

Identify devices to evaluate Bench Test devices

Review literature Include staff who will use device Compare to traditional devices in use Assess ease of use/practicality

Safety Products
www.Safe-Mate.com

www.milesci.com

 Evaluate the Device

*

Steps for Selecting and Evaluating Dental Safety Programs and Devices*
Set a reasonable time period Provide adequate training Monitor patient safety Involve staff in decisions Solicit ongoing feedback Review safety performance periodically Document annually www.cdc.gov/oralhealth/infectioncontrol/forms.htm

Implement and monitor use if deemed acceptable

Required Documents in the Office

Form 3165 (3167 Spanish)
OSHA Poster

29 CFR 1910.1200
Hazard Communication Standard

29 CFR 1910.1030
OSHA Bloodborne Pathogens Standard

29 CFR 1910.1020
Access to Employee Exposure and Medical Records

Required Documents in the Office

(Contd.)

For offices with 11 or more employees: OSHA Form 101 Log of Individual Injury or Illness OSHA Form 200 Yearly Log of Occupational Illness and Injury As of Jan 2002, private dental offices exempt from the above

Labeling and Color Coding

Biohazard Symbol and legend Biohazard
Orange-red or fluorescent orange, lettering in contrasting color

Must be affixed to container so there is no possibility of loss Red bags or containers can be substituted for labels Placed on containers of regulated waste, contaminated laundry

Employee Medical Record

Required for all employees with occupational exposure Confidential Kept separate from personnel records May be kept on site OR by healthcare professional who provides services to the dental healthcare employees Retained for the duration of employment plus 30 years

Medical Record
Contents

(Contd.)

Name and social security number HBV vaccination status, including dates received If exposure occurs, copies of all examinations, medical testing, followup procedures and written opinion of the health care professional (HCP) Copies of info provided to HCP regarding HBV vaccination and/or

9 Ohio veterans test positive for hepatitis March 3, 2011 8:50 p.m.
STORY HIGHLIGHTS Hepatitis tests for hundreds follow dental treatment VA dentist voluntarily retires Dentist admitted to not washing hands or changing gloves between patients during 18-year period

The ABCs of Hepatitis

Hepatitis A, B, C, D, and E Each has unique particle structure and genetic composition All infect, inflame, and damage liver tissue

Hepatitis A (HAV)
Enterically transmitted Spread by fecal-oral route
Soiled hands/objects Consumption of contaminated food, water

Mild disease, does not lead to chronic infection Infection leads to lifelong immunity Isolated cases and widespread epidemics occur

Hepatitis A (HAV)
Incubation is 30 days 1/3 of Americans have serological evidence of previous infection Disease severity increases with age Symptoms last about 2 months HAV vaccine (1995) has resulted in 85% decrease from 1975 NOT an occupational hazard for dental healthcare workers

Hepatitis D (HDV)
Requires HBV to replicate Takes up residence within the HBV particle Modes of transmission and risk groups same as HBV Can infect simultaneously with HBV or superinfect chronic HBV HBV VACCINATION PREVENTS HDV INFECTION

Hepatitis E (HEV)
Common outside U.S. Domestic cases involve travelers returning from endemic areas Transmission and symptoms similar to HAV No vaccine exists for HEV Avoidance of contaminated food and drinks, including ice

Hepatitis B Virus (HBV)

Epidemiology 400 million worldwide (75% in Asia) 260,000 / yr. in 1982 (prior to HBV vaccine)

10,000 - 12,000 with occupational exposure

60,000 / yr in 2004 (77% decrease from pre-vaccine era) 1.25 million chronic carriers in U.S. 90% undergo complete recovery

5-10% become viral carriers

Attack rate unvaccinated dental personnel three times general population

HBV Modes of Transmission

Percutaneous or permucosal contact with contaminated blood and body fluids
injuries from contaminated sharps contamination of cuts or cracks in the skin or ungloved hands spray, splash, or splatter onto open lesions or mucous membranes Sexual transmission and perinatal spread

Transfer of contaminated blood on inanimate objects or environmental surfaces has been shown to cause infection in health care workers

HBV Symptoms
1/3 have NO symptoms 1/3 have relatively mild flu-like illness 1/3 have severe disease: jaundice, dark urine, extreme fatigue, anorexia, nausea, abdominal pain, joint pain, rash, fever, vomiting incubation ranges from 45 -160 days

Hepatitis B Vaccination
Two types of vaccine Plasma derived, only for those allergic to yeast DNA recombinant Series of three injections (0, 1, and 6 months) Induces protective antibody levels If do not develop antibodies after first series: 15-25% develop antibodies after 1 injection Up to 50% develop after second series

HBV Vaccination

(Contd.)

Highly effective in preventing HBV and its complications 50 million children, 30 million adults vaccinated (OSAP , Feb 2007) Pregnancy not a contraindication noninfectious Hepatitis B surface antigen particles Contraindicated in individuals with previous anaphylactic reaction to common bakers yeast

HBV Vaccination

(Contd.)

Must be offered to all employees with occupational exposure , at employers expense If decline, must sign HBV Vaccine Declination form for Medical Record Employer may not require prescreening prior to vaccination

HBV Vaccination

(Contd.)

Booster not recommended (CDC, 2003) If booster doses recommended in the future, employer must provide these at no cost If employee wishes to be evaluated before vaccination, employer must obtain HCP written opinion, and give to employee within 15 days of its completion
states if vaccine indicated & if received

HEPATITIS C
Identified in 1988 as parenterally acquired non-A, non-B hepatitis
20,000 infections per year (2008) leading reason for liver

transplantation in U.S.

cause of almost half the viral

hepatitis cases per year

85% will develop chronic hepatitis 3.2 million Americans are

chronically infected
170 million infected worldwide

(3.1% of world population)

HCV Transmission
Spreads through direct contact with blood Risk related to type and size of inoculum and route of transmission Social practices using percutaneous procedures and non-sterile instruments
body-piercing, tattooing, ornamental scarring, circumcision

Occupational exposure of HCW to parenteral exposure of blood

any mucous membrane or non-intact skin contact with patient fluids, including saliva, must be considered an exposure

HCV Symptoms
65-75% have no symptoms 25 -35% will have jaundice, fatigue, abdominal pain, loss of appetite, intermittent nausea, and vomiting. Incubation of 6 - 7 weeks 15-20% resolve without lasting sequelae.
70% develop chronic liver disease.

Chronic hepatitis may be unrecognized until symptoms of advanced liver disease appear (20 - 30 years).

HCV Vaccination /Treatment

NO vaccine available Postexposure prophylaxis with immune globulin not effective in preventing HCV infection. CDC discourages use of antivirals as prophylaxis Antivirals effective to treat chronic HCV Postexposure follow-up for evaluation of chronic liver disease

Human Immunodeficiency Virus (HIV) Epidemiology

First reported 30 years ago , June 5, 1981 World Health Organization Statistics
33.3 million infected with HIV/AIDS (2009) 25 million have died from AIDS 2.6 million new cases in 2009 1.8 million deaths in 2009

United States Statistics

1,185,000 infected with HIV (end of 2008)
24-27% undiagnosed or unaware 56,300 new HIV/AIDS cases in 2008 529,113 deaths, (14,000 per year )

HIV Epidemiology
57 healthcare workers have seroconverted after occupational exposure (CDC 12/2004) 22 developed AIDS No documented seroconversions associated with dentistry

HIV Modes of Transmission

Isolated from blood, semen, breast milk, vaginal secretions, saliva, tears, urine, cerebrospinal fluid, amniotic fluid BUT, transmitted in blood, semen, vaginal secretions, and perhaps , breast milk Amount of virus is important 890/1000 transfusions 3/1000 needlesticks

HIV Transmission
Sexual intercourse with an infected person Contaminated needles Parenteral, mucous membrane, or nonintact skin contact with HIV-infected blood, blood components, or blood products Transplants of HIV-infected organs/tissues Transfusions of HIV-infected blood Perinatal ( mother to child at birth)

HIV Symptoms
Within a month after exposure, may develop flu-like illness fever, lymphadenopathies, myalgias, arthralgias, diarrhea, fatigue, and rash self-limiting, and develop antibodies may be symptom-free for up to 10 years AIDS - Acquired Immune Deficiency Syndrome

AIDS
An HIV-infected person is considered to have AIDS when one or more indicator diseases has been diagnosed:
Pneumocystis carninii pneumonia Esophageal candidiasis Neurologic disorders or dementia Cancers such as Kaposis sarcoma and non-Hodgkins lymphoma Less than 200 T-helper lymphocytes / mm3

 Bacterium carried in airborne particles, called droplet nuclei, aerosolized from patients 1-5 particles can be suspended in air for hours Infection in lungs by inhalation Within 2-12 weeks immune system prevents spread, and becomes latent (LTBI)

Mycobacterium tuberculosis (TB)

Positive tuberculin skin test (TST) Not infectious Can become active if not treated 90% of US patients do not progress to active TB

Symptoms of Active TB
Productive cough Night sweats Fatigue Malaise Fever Unexplained weight loss

Risk of TB Transmission
Standard precautions not sufficient to prevent transmission Risk to DHCP is quite low (only one reported case in a dental office, 1982) Community risk assessment Medical History of TB If suspected, referred promptly

TB
Elective dental care should be deferred until confirmed not infectious If emergency dental care required, refer to facility with engineering controls such as isolation rooms, and air filtration Respirators should be used, face masks inadequate

Creutzfeldt-Jakob Disease (CJD) Encephalopathies Transmissible Spongiform

Caused by an unusual pathogen Prions Isoforms of a normal protein Capable of self-propagation Incubation period of years Usually fatal within 1 year of diagnosis

1 case/million population Linked to BSE, mad cow disease Resistant to conventional decontamination procedures
Transmission during dental procedures low to nil

Creutzfeldt-Jakob Disease (CJD)

Special precautions: Single-use disposable items whenever possible Consider difficult to clean items as disposable Keep contaminated mateerial moist unto=il cleaned and deconatminated Steam-autoclave at 1340C for 18 minutes, (Normal sterilization temp. is 1210C)

Workplace Emergency
If an emergency occurs that has potential for exposure to blood don appropriate PPE: Gloves, mask, clinic attire, and protective eyewear for a blood spill and its decontamination If patients life at risk, may deviate from Standard Professional judgment of employee Pocket masks and resuscitation bags

Postexposure Procedures
Following a report of an exposure incident, employer shall make available a confidential medical evaluation and follow-up to include: Exposure information: routes and circumstances of the incident Identify of source individual Test source for HIV and HBV ASAP after consent is obtained
document if consent not obtained

Postexposure Procedures

(Contd.)

Make results available to employee, respect confidentiality of source status Test employees blood, with consent, as soon as feasible Provide postexposure prophylaxis, when medically recommended Provide counseling Evaluate illnesses that are reported in the first 12 weeks after exposure

Postexposure Prophylaxis
HBV
Test source blood for HBsAg Provide HBIG if required

HCV - None available HIV

Test source blood for HIV antibody If source positive, or if refuses testing, exposed employee should be evaluated clinically immediately, at 6 weeks, 12 weeks, and 12 months Evaluate any flu-like illness within 12 weeks ZDV plus 3TC plus IDV

Postexposure Prophylaxis
CDC recommendations for HCW exposed to HIV Exposure : a percutaneous injury, contact of mucous membranes or nonintact skin, or contact with intact skin when duration of contact is prolonged or involves an extensive area, with blood, tissue, or other body fluids In the absence of visible blood in saliva, exposure to saliva from a person infected with HIV is NOT considered a risk for HIV transmission
MMWR, May 15,1998

Postexposure Prophylaxis
(Cont'd.) Postexposure evaluation for HBV and possibly HCV still required after exposure to non-bloody saliva or after contamination of mucous membranes Low incidence of seroconversion to HCV (1.8%, range 0-7%)

Rationale for prophylaxis

Brief window during which antiretroviral intervention may modify viral replication 24 - 48 hrs. infected cells migrate to lymph nodes Within 5 days in peripheral blood Rapid replication: up to 5,000 particles from each replicating cell

Antiretroviral Agents
Three Classes: Nucleoside analogue reverse transcriptase inhibitors Zidovudine (ZDV) - Only agent shown to prevent HIV transmission in humans Lamivudine (3TC) Non-nucleoside reverse transcriptase inhibitors Protease inhibitors Combination regimens : reduce viral load in HIV infected patients active at different stages in viral replication

Risk of occupational acquisition of HIV

0.3% after percutaneous exposure to HIV infected blood 0.1% after mucous membrane exposure 57 HCW have seroconverted associated with an exposure incident 95% seroconverted within 6 months Factors that affect risk amount of blood blood from terminally ill (high titer of HIV)

OSHA Inspections
Oct 2004-Sept 2005 Inspected 21 dental offices Issued 97 citations Total penalties $20,000 Covers those states that do not have their own OSHA program (about half of all states) Bloodborne Pathogens source of most citations (67 of 97)

CDC Guidelines
Consolidates recommendations
for preventing and controlling infectious diseases for managing personnel health and safety concerns related to infection control

Updates and revises previous CDC recommendations Incorporates relevant measures from other CDC guidelines Discusses concerns not addressed previously

Updates and additional topics Standard precautions

Work restrictions for Health Care Personnel Occupational exposures Hand hygiene Engineering controls to prevent sharps injury Dental unit water quality Contact dermatitis, Latex allergies Research considerations Variant Creutzfeldt- Jakob Disease Laser/electrosurgery plumes Aseptic parenteral medications Infection Control Program evaluation

Program Evaluation
Systematic approach to ensure procedures are useful, ethical, feasible and accurate Develop SOPs Evaluate Document Includes checklists, calendars, observations, reviews COACH

Dental Unit Water Lines

WHAT ABOUT WATERLINES? Biofilm and the Dental Office

Dental Unit Waterlines (DUWL)

Biofilm: microbial accumulation on the interior of DUWL acts as reservoir for free-floating microbes in water exiting DUWL Water-borne diseases: Pseudomonas, Legionella, Mycobacteria No definable health effects associated with DUWL, but ...

Characteristics Of Dental Unit Water Systems

Low flow rates - 1 droplet/second Low water volume - <100ml in unit Small tubing cross sections - 1/16 high surface-to-volume ratio Room temperature Atomization Tubing/plumbing materials Heated water by design - 98.6 Older units: retraction or suckback

 Microbial counts of <500 cfu/ml (CDC 2003) A good coolant mist (atomization) Adjustable low flow rates for handpiece coolant - 1 droplet/second Low water volume for restorative work, higher volume for hygiene

Manufacturers Requirements For Dental Unit Water Systems

Lightweight, flexible, easy to clean handpiece lines Warmed water (in some locales) No water retraction Safety for patients and chairside team Easy asepsis procedures Economical

Laminar Flow In Tubing

Tubing Material Main Flow Slow Flow No Flow Biofilm

Tubing Cross Section

Dental Unit Water System With Check Valves

Syringe Water Handpiece Water

Water Water

Control

Air In

Foot Control

Water Lines With Check Valves

In-flow Pressure To Handpiece

No Pressure

Static

Water Quality Improvements

Independent water reservoir Chemical treatment regimens Daily draining and air purging Point- of- use filters Monitoring devices Training and education Research

Self-contained Dental Unit Water System

Syringe Water Flush Water Handpiece Water

Water Water Air Water Bottle

Control

Air In

Foot Control

Microfiltration

Output
Water Water

Control
Foot Control

At each outlet Proven technology Installation requires waterline surgery Daily or weekly change 89-$2.00/day/outlet; $2.67-$6.00/day/oper.

Chairside Technology
Output
Silver ion Iodine Glutaraldehyde Hydrogen Peroxide Proprietary Chemicals U/V Light Reverse Osmosis Micro Filtration Turbulent flow Ozone

Water

Control

Treatment Device In Post Box Water

Foot Control

Chairside Technology
Output
Silver ion Iodine Glutaraldehyde Hydrogen Peroxide Proprietary Chemicals U/V Light Reverse Osmosis Micro Filtration Turbulent flow Ozone

Water

Control

Treatment Device In Junction Box Water

Foot Control

Two Water Purifiers

Sterisil Ag Ion

Dentapure Iodine

Centralized
Chair #1

Chair #3

Central Treatment Device

Chair #4

De-ionization TechnologySuper chlorination Reverse Osmosis Silver Ion Others...

Chair #2

Manual Chemical Treatment

Output
Alkaline Peroxide Chlorhexidine gluconate Mouthwashes Citric Acid Disinfectants Bleach

Water Water Air

Control

Water Bottle

Foot Control

Challenges with Manual Systems

Time, $, labor Requires understanding of the water system Requires procedures, written and recorded Large vs. small clinics Ownership vs. lack of ownership Room for error Health and safety

Challenges With Automatic Systems

Cost Maintenance Reliability Proprietary Chemicals

ADA: Interim Recommendations

Waterlines (without handpieces) run for several minutes at the start of the day Run highspeed handpieces for 20-30 seconds after each patient Follow unit manufacturers instructions for waterlines Consider use of commercial options for improving water quality Sterile saline/water when cutting bone

Infection Control Costs-2007*

Cost /Patient for DDS or DH $11.92

Cost for each assistant Annual cost (3600 visits) Cost for each assistant 28% increase since 1999

$ 0.94 $42,912 $ 3,384

*CRA Foundation Newsletter March 2007

The Cost of Infection Control

Medical Waste Management

Dental Office Waste Management

Two types of Medical wastes
Contaminated or general medical (Nonregulated) Regulated

Regulated Wastes (OSHA)

Liquid or semi-liquid blood or OPIM Contaminated items that would release blood or OPIM if compressed Contaminated sharps Items caked with dried blood Pathological or microbiological wastes Used needles, sharps, used and expired chemicals

Regulated Medical Waste

Limited subset of total waste 9-15% in a hospital 1%-2% in a dental office Requires special handling, storage, and disposal per Federal, state and local regulations

Dental Office Waste Management

The majority of soiled items in dental offices are general medical waste and thus can be disposed of with ordinary waste CDC -2003 Gloves, masks, gowns, lightly soiled gauze or cotton rolls, and environmental barriers

Regulated Wastes In Dentistry

Needles, sharp objects Extracted teeth Scalpel blades, glass ampules Files, broaches, reamers, orthodontic wires Blood soaked non-sharps Pathological waste Blood & blood products Sutures Burs, broken instruments

Steps In Waste Management

Prepare a Waste Management plan Written description in the Exposure Control Plan Designate regulated waste Items considered Laws/regulations http:/www.epa.gov/ epaoswer/other/medical

Package and Label Containers

Puncture resistant Leak-proof Closeable lid Spill-proof Autoclavable (if necessary) Adequate size Avoid overfilling Disposable / nonreusable Biohazard symbol Red-bagfor nonsharps

Sharps Containers

Available from local dealer www.mcinc.net

Storage Of Regulated Waste

Avoid damage to bags Protect from weather Protect from vermin Keep cool, marked, secured Can usually store for up to 90 days after begin filling a container

Effective Methods Of Treatment (EPA)

Steam sterilization Incineration Thermal inactivation Formaldehyde vapor sterilization Chemical disinfection Ionizing radiation

Disposal by USPS
Select a vendor through state dental society Ask to see permits and proof of insurance coverage Collect all manifests of waste transported from the office and maintain for 3 years

Silver, Tin, Copper, Zinc

50% of Hg in the environment comes from human activity 53% from combustion of fuels 34% from combustion of wastes Less than 1% from dentistry

Collects in waterways, methylated by bacteria, enters food chain EPA estimates that 3,426,244 acres are impaired

Best Management Practices for Amalgam Waste

!

Segregate contact and non-contact scrap amalgam into separate containers

Wide mouthed, airtight Label appropriately

! ! !

Recap empty capsules, place in noncontact container Place disposable chairside traps in contact container Empty contents of reusable traps in contact container

Amalgam Waste

DOs

Amalgam Waste

DONTs

Strategies For Proper Amalgam Waste Management Grey bag It.Never dispose in a red bag Recycle It.Select a responsible amalgam
recycler

Install it.Amalgam separator can capture 99%

of mercury leaving through drains

Teach It.Educate staff about proper

management of dental amalgam in the office

Amalgam Accumulation in Plumbing

ADA 2005

Heavy material, accumulates in P traps and longer horizontal runs. Precaution needed:
Plumbing being done in areas where waste likely to adhere In work is such that it is likely to dislodge adhered waste elsewhere Demolition or major operatory renovations Whenever pipes are cleaned out

Plumbing Guidelines
Hire Licensed plumber, provide guidelines Place bucket on non-porous tarp to catch waste Avoid prolonged use of torch (heat) Gloves, impervious gown (apron) Assume sludge is hazardous if significant waste amalgam exists Place waste in recycling container Licensed waste hauler Receipt that waste will be disposed or recycled

New Operatory Design

Adhere to local codes Consider ease of future access to traps or low points Minimize long horizontal runs Install apprpriate traps Follow ADA BMPs for amalgam Use smallest sized filters and traps practicable Isolate operatory plumbing from other plumbing to extent practicable

New Operatory Design

Adhere to local codes Consider ease of future access to traps or low points Minimize long horizontal runs Install apprpriate traps Follow ADA BMPs for amalgam Use smallest sized filters and traps practicable Isolate operatory plumbing from other plumbing to extent practicable

Hazard Communication Employee Right to Know

29 CFR 1910.1200 Requires employers to inform employees about hazardous chemical in their workplace Warning can be through use of: Container labels Material Safety Data Sheets (MSDSs) Hazard communication plans

Container labeling
Identity of hazardous chemical Name of manufacturer Appropriate hazard warning

Inventory of Hazardous Chemicals

List of all hazardous chemicals Chemicals come in many forms, liquids, solids, gases, fumes, and mists Take widest view of what qualifies as hazardous

Overview of MSDSs
Provided by the manufacturer, comes with shipment Provides detailed information on hazards and properties Many can be accessed via Internet Updates mandated when composition changes, or new information obtained

Employee Access to MSDSs

Ready access for employees May be paper or electronic If electronic, must have : reliable device, Training on device Backup Access to hard copies if desired

Excluded Products
Ordinary consumer products if their use is same as that of typical consumer, e.g. household cleaners Cosmetics Tobacco Hazardous wastes Wood products Biohazards Drugs in solid final form (tablets) Office supplies

Sections of MSDSs
I II III IV V VI VII VIII Manufacturers Information Hazardous ingredients, exposure times Physical/Chemical Characteristics, e.g., boiling, melting points Fire and Explosion Hazard Data Reactivity Data Health Hazard Data, First Aid Precautions for safe handling Control measures

Employee Training
When: at time of initial assignment Whenever a new hazard is introduced May be at one setting, or several small sessions Lectures, videos, self-instruction materials Must include question and answer

Training Topics
Copy of the Standard and explanation of contents Location of written Hazard Communication Program Chemicals present in workplace Physical and health effects of chemical on the inventory

Method and observation techniques used to determine presence or release of hazardous chemicals

Training Topics (Contd.)

How to limit exposure through work practice and engineering controls Steps taken in the office to limit exposure Emergency procedures to follow if exposed Explanation of labeling system Explanation of MSDS

 Source reduction Recycling Amalgam, lead foil, silver from x-ray processors, batteries, alcohol containing fluids, fluorescent lights Use a licensed Treatment, Storage and Disposal (TSD) company Cradle-to-grave responsibility The generator is ultimately responsible

Hazardous Waste Management

NCAA College World Series

QUIZ ?

Group Effort

Questions and Answers

Course Content
Emerging Diseases OSHA Inspections Costs of Infection Control Dental Unit Waterlines Waste Management Best Management Practice: Dental Amalgam HAZCOM Question and Answers

Legal Issues
ADA policy bars dentists from denying treatment because of HIV/AIDS status.

HIV patients may be safely treated in private dental offices.

Bragdon vs Abbott

Maine dentist refused to treat HIV positive patient in his private dental office. offered to treat her in hospital dental clinic

Legal Issues (Contd.)

Plaintiff claimed:

unable to bear children for fear of transmitting disease to offspring. inability to reproduce constitutes disability because reproduction qualifies as a major life activity.
Appeal to Supreme Court

Returned to appeals court Follow the policy of acknowledged expert organizations: American Dental