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Pathogen

Learningtothinkinside Learningtothinkinside thebox.

Reservoir

Non immunity

PeterO.Sildve
Director/DentronixUltronics DivisionofColteneWhaledent,Inc.
Portal Mode

TheWorldhaschanged.

CommonAbbreviations
BBPStandard BloodbornePathogensStandard CDC CentersforDiseaseControl CFR CodeofFederalRegulations DHCP DentalHealthCarePersonnel(CDC) DHCW DentalHealthCareWorkers(OSHA) ECP ExposureControlPlan ISO InternationalStandardsOrganization OPIM OtherPotentiallyInfectiousMaterial OSDB OhioStateDentalBoard PPE PersonalProtectiveEquipment
OrinScrivello,DDS

OSHA

YourBox
OSDB

CDC

InsuranceCompanies

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TheOccupationalHealth&Safety Administration(OSHA)
EstablishedbytheUSCongressin1970,to insuresafeandhealthfulworking conditionsforworkingmenandwomenby di i f ki d b settingandenforcingstandardsandby providingtraining,outreach,education,and assistance.
OSHAispartoftheUSDepartmentofLabor.

BloodbornePathogensStandard
CFR29.1910.1030
Establishedin1991 Protectsallworkers

OtherOSHAStandardsThatAffect theDentalOffice
HazardCommunicationStandard(29CFR.1910.1200) g ( 9 9 9 ) IonizingRadiationStandard(29CFR.1910.1096) ExitRoutesStandards(CFR29.1910.3539) ElectricalStandards(CFR29.1910.301399) PostingyourOSHAPoster

thatareoccupationally exposedtobloodorOPIM. d bl d OPIM CornerstoneofOSHAsInfectionControl guidelines.

TheCentersforDiseaseControl(CDC)
AgencyoftheUSPublicHealth

TheCentersforDiseaseControl(CDC)
Primarydocument

TheCentersforDiseaseControl(CDC)

Service Responsibleforguidelinesand recommendationsregarding infectiousagents. FocusedonDHCPand Patient Exposure. Isnotaregulatorybody. HasabroadreachthroughOSHA andStateDentalBoards.

isInfectionControlin theDentalHealthCareSetting(2003) [www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm]

Isitsafe? Dr.ChristianSzell

61of180specificCDCguidelinesare

mandatedbystateorfederallaw.
Balance ofrecommendationscanbe

arguedtoprovideastrongbasisfor StandardofCare.

ActualCDCdocumentmandatedbyFederalLawis RecommendationsforPreventingTransmissionof HIVandHBVtoPatientsduringExposureprone HIVandHBVtoPatientsduringExposure InvasiveProcedures. [www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm]

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Itallstartedwith Itallstartedwith
KimberlyBergalis
19681991

TheBox TheBox takesshape.

5otherpatientswereallegedlyinfectedbyDr.DavidAcer inFlorida. TheKimberlyBergalisBillwasintroducedintheUS TheKimberlyBergalisBill HouseofRepresentativesin1991torequireHIVtestingof allHCWintheUS.Itdidntpass. Section633oftheTreasury,PostalService,and S i 6 f h T P lS i d GeneralAppropriationsActof1991 waspassedtomake legallybindingcertainCDCrecommendationstobe enforcedbystates. OSHABloodbornePathogensStandards OSHABloodbornePathogensStandards 1991 TaskForceontheTransmissionofBloodborne PathogensbyHealthcareProfessionals PathogensbyHealthcareProfessionalswasestablished bytheOhioGeneralAssembly 1992.

TheBox TheBox takesshape.

TheCalifornia Model
CAStateBoardofDentalExaminershastakentheCDC guidelinesandsystematicallystrippedthemofany flexibilitymakingthemeasiertoenforce. Baggingguidelineforsterilizationextendedtodisinfection B i id li f t ili ti t d dt di i f ti procedures.Recentlyrepealed. Guidelinesadministeredbyindividualswithlittle knowledgeofdentistry. Duetostatesfinancialcrisis,complianceenforcementis seenasarevenuebuildingtool. WhathappensinCAusuallyhappenslaterinotherpartsof thecountry.

December1987 Molar extractions/Dr D Acer extractions/Dr. D.Acer. March1989 symptoms ofAIDS. 1990 Diagnosedwith AIDS. 1991 Deceased.

TheBox TheBox takesshape.

InsuranceCompanies

Differentboxes.
Challenges
Tremendousvarietyofproducts. Allrequiremeasurableconsistency. Mustincorporatecustomerfeedback. Meetglobalregulatoryandcompliancerequirements. Effectivecommunicationofexpectationsinalargefacility. Weneedtomakemoneytostayinbusiness.

Thelastwallofthebox. Activeinspecificregions. UseCDCguidelinesasprimarytool. Administeredbyindividualsusuallylackingindental knowledge. Targetspecificareasofnoncomplianceofinterestto insuranceliabilityandrisksuchassterilizationprocedures.

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OurBox
ISO ISO InternationalStandardsOrganization
Minimumoperatingsystemforanyonewithglobaloperations.

BenefitsofaProcessControlSystem.

1. 2. 2 3. 4.

DocumentedProcedures OngoingTraining CorrectiveandPreventiveAction ManagementReview Saywhatyoudoanddowhatyousay.

Defininganoptimum protocol. Creatingabaselinefromwhichtomeasure successorfailure. Createanenvironmentforcommunication andemployeeinputthatcenterson continualimprovement. Compliancecanbeaburdenoratoolfor makingyourbusinessunitbetter.

Bringingoutsideexperiences insidethebox.

Curleys Tattoo.

Singleor multiple needles inject indelibleink intothe dermallayer.

Anotherkindofdrillingandfilling.Notmuchsplashandsplatter.

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Dentistryandtattoosarebothdone inanonsterileenvironment. inanon

Nonsterilegloves Unsterile(andpossibly

Pathogenin sufficient numbers

TheChainof Infection. Infection.

Reservoir (resideand multiply)

OrganizationforSafety andAsepsisProcedures
Non Nonprofitgroupofdentalprofessionals,teachers, scientists,andproductmanufacturersfoundedin 1984,committedtoprovideinfectioncontroland safetyinformationtodentalhealthcareworkers throughouttheworld.

soiled)garments Breatheunsterileair h l Treatnonsterile (potentiallyinfectious) patients

Beingadentistdemandsahigherlevelof StandardofCare.

Non immunityof newhost

Portalof Entry

Transmission Mode

Ifanyofthese conditionsarenot met,transmissionof diseasecannot occur.

www.osap.org

ItallstartedwithHIV/AIDS,but.. ItallstartedwithHIV/AIDS,but..
HBV Virus Concentration 1tspbloodcan contain1billion particles HIV 1 tspblood contains15 particles Usuallydiesin secondsatroom d temp. <100(19821992)

HAVvs..HBVvs.HCV HAVvs..HBVvs.HCV
HAV Mostcommonofthe sevenknowntypesofviral hepatitis. HBVover350millionpeople HBV infectedworldwide.50100 infectedworldwide 50 100 timesmoreinfectivethan HIV. HCV morepersistentthan HAVorHBV
Result:Inflammationoftheliver,but complicationsarerarelyserious. Spreadby:Feces.Prevalentinpartsofthe worldwithsanitationandsewage infrastructureissues.ClassedasSTD. Vaccine:Yes Result:similartoHAVinsymptomsbutis morelikelytocausechroniclongterm illnessandpermanentdamagetotheliver. ill d td t th li Spreadby:exchangeofbodilyfluids; primarilyblood Vaccine:Yes Result:Inflammationoftheliver;chronic liverdamage,livercancer Spreadby:primarilyblood Vaccine:No

WhataboutHERPES?
Herpesisoneofthemostdifficultvirusestocontrolandhasplagued mankindforthousandsofyears.

SurvivalOutside 10daysevenin theBody driedblood h B d d i dbl d Occupational Exposure Victims Vaccine Fatality Rate Cure 10,000peryear

HerpesSimplexVirus1 oralherpes Result:coldsoresandfeverblisters. HSV1canalsocausegenitalherpes. Spreadby:saliva;skincontact Vaccine:No HerpesSimplesVirus2 genitalherpes Result:blistersandopensoresonthegenitals Spreadby:skintoskincontactduringsex Vaccine:No

Yes Verylow No

No High No

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CommonlyOccurring Infectious DiseasesinDentistry

Bloodborne HepatitisB p HepatitisC HIV Contact Chickenpox HepatitisA HerpesSimplex Droplet Mumps Rubella(GermanMeasles) Rubella Influenza Airborne Chickenpox Measles Tuberculosis

Asusceptiblehost mustbepresent foraninfectionto occur.

Treateverypatient asinfectious.

GetImmunized.USPublicHealthService recommendsthefollowingimmunizations: HBV Rubella Influenza Tetanus(boosterevery10years) Measles Chickenpox Mumps Reportoccupationalinjuriesandexposuresimmediately. Followtheadviceofyourmedicaladviserevaluatingyour occupationalexposure.

Weargloves,protectiveclothing,andface&eye protection. Handlesharpswithcare. Usesafetydevicesasappropriate. Usemechanicaldevicestocleaninstruments wheneverpossible.

Anyitemthatyou contaminatecan becomeasource ofpotential infection

Clean. Disinfect. Sterilize.

IfSalivawereRed OSAPVideo 1990something. 8minutes

Setuptheoperatorybeforestartingtreatment.Use unitdosesupplies. Coversurfacesthatmaybecomecontaminated. Minimizesplashandspatter. Properlydisposeofallwaste.

Knowthedifferentdecontamination processes. Readgermicidelabels. Monitorprocessestomakesuretheyare efficacious. Followmanufacturersuseguidelinesfor sterilizationanddisinfection.

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Everyonelovesjewelry.

UseofPPEshavechangedovertheyears,butaerosolsarestillaerosols.

Thechartconnectsthefrontofficewiththeoperatoryinthispractice.

OSHAcanbeadministeredatthefederal levelorthestatelevel.
Currentlythereare25stateswiththeirownOSHAplan. C l h i h h i OSHA l Ohioisnotoneofthem.

In20092010,the5mostcitedviolations ofOSHAstandardsindentaloffices were:

OSHArequiresthatyoumaintainacopyand complywiththeBloodbornePathogens Standard.

BreakingtheChain canbeaboutchangingbehaviorandbreakingbadhabits.

1910.1030,BloodbornePathogensStandard 1910.1200,HazardCommunication 1910.132o, Personalprotectiveequipment,general requirements 1910.120, Hazardouswasteoperationsandemergency response 1910.37, Maintenance,safeguards,andoperationalfeatures forexitroutes

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Step1instayingcompliantiskeeping yourOSHABinderuptodate.
1. TheBloodbornePathogensStandard (CFR29.1910.1030) 2. TheHazardCommunicationStandard (CFR29.1910.1200) 3. Writtenproceduresonhowyoucomplywiththese standardsincludinganExposureControlPlan 4. Vaccinationrecords 5. AnnualOSHAtrainingdocumentation

Inaddition,OSAPrecommendsthatthepractice shouldhaveacomprehensivepersonnelhealth serviceprogram(employeehealthhandbook)that addresses:

Educationandtraining Educationandtraining Immunizationprograms Exposurepreventionandpostexposuremanagement Medicalconditions,workrelatedillnesses,andwork restrictions Latexhypersensitivityandotherworkrelatedallergic reactions Maintenanceofrecords,datamanagement,and confidentiality

OtherOSAPrecommendationsinclude:
Areferralarrangementwithaqualifiedmedical professionalsothatjobrelatedinjuriesorillnesscanbe evaluatedandtreatedappropriatelyandquickly. Aneducationandtrainingscheduletailoredtoeach employeesdutiesandresponsibilities. Awrittenimmunizationprogramthatoutlinesall recommendedvaccinationsforstaffbyjobtitleplusa referraltogetthosevaccinations. Aconfidential,uptodatemedicalrecordforallworkers.
Theserecordsshouldonlyincludeimmunizationsandanytestsrelatedto occupationalexposure.

OSHAComplianceHierarchy
ExposureControlPlan UniversalPrecautions EngineeringControls WorkPracticeControls PersonalProtectiveEquipment(PPEs)

ExposureControlPlan(ECP)
Thisisawrittenplantoeliminateorminimize occupationalexposurestobloodandOPIM. Itmustincludealistofalljobclassificationsthat havepotentialoccupationalexposureandthe tasksandprocedureswhichresultinthat exposure.Thisevaluationshouldthentarget methodsandtechnologiestominimizeexposures.

ExposureControlPlan(ECP)
AkeyelementoftheECPisanannualreviewthat reflectsanychangesintasks,proceduresand positionsthateffectoccupationalexposures,as wellasdocumentedevidenceofevaluation andreviewofnewtechnologiesand commerciallyavailableproductsthataresafer andminimizeoreliminateexposures.

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UniversalPrecautions/ StandardPrecautions
TreatallbloodandOPIMasifitwasinfected / withHIV/HBVandotherbloodborne pathogens. Thereisvirtuallynodifferenceotherthan Universal wasfocusedprimarilyonbloodwhile Standard addressesbloodandallotherpotentially infectiousbodilyfluids(OPIM).

EngineeringControls
Thesearedevicesthat isolateorremovethe bloodbornepathogens hazardfromthe workplace.Theseinclude sharpsdisposalcontainers, selfsheathingneedles,and safermedicaldevicessuch asneedlelesssystems.

WorkPracticeControls
Thesearebehavior Thesearebehavior basedpracticesand proceduresthatreduce thepotentialfor exposurebychanging thewaythatataskis performed.

PPEs
PersonalProtective Equipmentisan importantpartof protectingyourselfduring patienttreatment.Gloves, ti tt t t Gl masks,gogglesand shields,gowns,shoe coversallareessentialto breakingthechainof crosscontaminationand crossinfection.

Andtheresmore..
TheavailabilityofHBVvaccinations within10 y g j daysofinitialassignmenttoajobwith occupationalexposureand Theavailabilityofpostexposureevaluation and followuptoanyoccupationallyexposedstaff member.
Anexposureincidentisaspecificeye,mouth,mucousmembrane,non intactskinorparenteralcontactwithbloodorOPIM.

Andtheresmore..
NeedlestickSafetyandPreventionPlan(2000) 1.UpdatesExposureControlPlan Takeintoaccountinnovationsinproceduresand technologicaldevelopmentsthatreducetheriskof exposure Documentconsiderationanduseofappropriate commerciallyavailableandeffectivesafer devices.

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Andtheresmore..
NeedlestickSafetyandPreventionPlan(2000) 2.Employeeinput Employersmustsolicitinputfromnonmanagerial employeesresponsiblefordirectpatientcare regardingtheidentification,evaluation,and selectionofeffectiveengineeringcontrols. 3.Documentationofemployeeinput

Andtheresmore..
NeedlestickSafetyandPreventionPlan(2000) p g 4.Recordkeeping SharpsInjuryLog
29CFR1904.1 Ifyourcompanyhadten(10)orfeweremployeesatalltimesduringthe lastcalendaryear,youdonotneedtokeepOSHAinjuryandillness recordsunlessOSHAortheBLSinformsyouinwritingthatyoumust keeprecordsunder 1904.41or 1904.42.However,asrequiredby 1904.39,allemployerscoveredbytheOSHActmustreporttoOSHA anyworkplaceincidentthatresultsinafatalityorthehospitalizationof threeormoreemployees.

TheOSAPGuide BasicCompliance
ToStart: OSHABinder yourECP yourHAZCOMdata yourvaccinations yourtrainingdocumentation
Connectswhatyoudowiththeguidelines.

TheOSAPGuide
InfectionControl/CDCGuidelines:From PolicytoPractice.AppendixAsummaryofthe requirementslistedintheCDCguidelinesfor InfectionControlintheDentalHealthcare setting. Thereare180specificrecommendations.61are mandatedbyfederalorstatelaws.Thisappendix identifieswhichiswhich.Furthermore,each recommendationiscategorized:

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TheOSAPGuide
IA Stronglyrecommendedforimplementationandstrongly supportedbywelldesignedexperimental,clinical,orepidemiologic studies. IB Stronglyrecommendedforimplementationandsupportedby gy p pp y welldesignedexperimental,clinical,orepidemiologicstudiesanda strongtheoreticalrationale. IC Requiredforimplementationasmandatedbyfederalorstate regulationorstandard. II Suggestedforimplementationandsupportedbysuggestive experimentalclinicalstudiesoratheoreticalrationale. UnresolvedIssue Norecommendation.Insufficientevidenceorno consensus.

TheOSAPGuide
Here are some CDC recommendations that are law:
Develop a comprehensive post-exposure management and medical follow-up program. (I.D.1) Remove barrier protection (gloves mask, eyewear, and gown) mask eyewear before leaving work area. (IV.B.3) Do not use liquid chemical sterilants/ high-level disinfectants for environmental surface disinfection or as a holding solution. (VI.A.8) Use work-practice controls that minimize contact with sharp instruments if manual cleaning is necessary. (VI.C.3) Use water that meets EPA regulatory standards for drinking water (<500 CFU/mL of heterotrophic water bacteria) for routine dental treatment water. (VIII.A.1)

TheOSAPGuide
HerearesomeCDCrecommendationsthatareNOT law:
DevelopandhavereadilyavailabletoallDHCPcomprehensive writtenpoliciesregardingworkrestrictionandexclusion.(I.E.1) i li i di k i i d l i (I E ) TrainDHCPtoemployworkpracticesthatpreventcontaminationof cleanareas.(VI.B.2) Wearpuncture andchemicalresistant/heavydutyutilityglovesfor instrumentcleaninganddecontaminationprocedures.(VI.C.4) Useautomatedcleaningequipmenttoimprovecleaningeffectiveness anddecreaseworkerexposuretoblood. Dischargewaterandairforaminimumof2030secondsaftereach patientfromanydeviceconnectedtothedentalwatersystemthat entersthepatientsmouth.(VIII.A.4)

TheOSAPGuide
MostoftherecommendationsintheCDCguidelines makeforsoundInfectionControlpolicy. p y NoncompliancewithCDCGuidelinescouldcreate potentiallegalriskinnotmeetingrecognized StandardofCare.

InfectionControlManual
ComparedtoOSHA(thatexistsfortheprotectionof dentalemployees),TheOhioStateDentalBoardis p y ), is responsibleforprotectionofthepublic byenforcing responsibleforprotectionofthepublic theprovisionoftheDentalPracticeAct,specifically, OhioRevisedCodeandOhioAdministrativeCode Chapters4715.

InfectionControlManual
LastRevision2004 Section1 PatientandPersonnel Protection
HBVImmunization(dentistscannot administerandpregnancyisnotanautomatic waiver) BarrierTechniques Gloves HandHygiene FaceProtection FaceShields MasksandEyeProtection
Noregsonprotectiveclothing/deferstoOSHABBP.

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InfectionControlManual
Section2 SterilizationandDisinfection
A)HeatSterilization a) HeatSterilizers SterilizationmustbeaccomplishedbyanFDA HeatSterilizers approveddeviceormethod. b) Handpieces,etc. allhandpiecesand componentsmustbe heatsterilizedbyanFDAapproveddeviceormethod. c) Instruments allheatresistantinstrumentsaretobeheat sterilized.Packaging/nonpackagedstandardsdefertoCDC. Alsoguidanceforcleaning. d) BiologicalSporeTesting weeklytestingwithacontrol. e) Documentation sporetestdocumentationmustbe maintainedfor2years.

InfectionControlManual
Section2 SterilizationandDisinfection B)ChemicalSterilization ) h l l provisionforprocessingheatresistantitemsinchemical sterilants primarilygluteraldehydes.Sincethesemethods arenotbiologicallyverifiabletheiruseshouldbe minimized.

InfectionControlManual
Section2 SterilizationandDisinfection C)SurfaceDisinfection a) cleaninganddisinfectionprocessespluscategories ofEPAproducts b) surfacecovers/barriers c) Singleuseitems shouldnotbereusedevenifthey areabletobeheatorchemicalprocessed D)DentalLabItems itemsthathavebeenplacedinthe mouthmustbeproperlypackagedandhavelabeling indicatingbiohazard.

InfectionControlManual
Section3 DisposalofWastesandSharps
A)Sharps deferstolocalandstateenvironmentalagencies.Needles, deferstolocalandstateenvironmentalagencies Needles scalpelblades,endofiles,orthowiresandothersharpitemsshouldbe placedinasharpscontainer.Descriptionofappropriatecontaineris provided. B)Wastes Bloodandsalivatingeditemsarenotconsidered regulatedwaste.Glovesandpatientbibsmaybeplacedinaregular trashreceptacleastheyarenotsubjecttoinfectiouswasteregulations. a)Regulatedwasteitemsaresharps,extractedteeth,tissue, saturatedpatientcareitems,oranyitemsthatthedentist determinesshouldbehandledasinfectiouswaste.

InfectionControlManual
Section46 Resources,Acknowledgementsand Appendix

ReadtheBBPStandard
[http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standa rds&p_id=10051]

ReadtheguidetoComplianceforDentalOffices
[http://www.osha.gov/Publications/OSHA3187/osha3187.html] [h // h /P bli i /OSHA 8 / h 8 h l]

ReadtheCDCGuidelines
[www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm]

ReadtheOhioStateDentalBoardInfectionControl Manual [http://www.dental.ohio.gov/icmanual.pdf] GettheOSAPCDCGuidelines:fromPolicytoPractice

[https://osap.siteym.com/store/?]

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Getstarted!
Ifyoudonthaveone,createanExposureControlPlan.
ManyStandardsallowflexibility.Justfigureoutwhatyouwanttodo y f y J fg y basedonyourprofessionalassessmentofriskandtheguidelines.

Getuptodateonvaccinations,medicalhistories,training, andannualreviewdocumentation.

peter@dentronix.com

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