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Infection Control in Dental Health-Care Settings


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Title: Infection Control in Dental Health-Care Settings

Infection Control in Dental Health-Care Settings
  • Terri L. Deal

Infection Control
  • Center for Disease Control updated in 2003
  • Previously released in 1986, 1993
  • Consolidates recommendations for
  • Preventing infectious diseases
  • Managing personnel health and safety
  • Updates previous CDC recommendations
  • Incorporates relevant infection control measures
  • Discusses concerns not previously mentioned

Infection Control
  • General recommendations
  • Develop a written program
  • Policies
  • Procedures
  • Education and training guidelines
  • Immunizations

Infection Control
  • Exposure prevention
  • Post-exposure management
  • Medical conditions
  • Work restrictions
  • Contact dermatitis, latex sensitivity
  • Maintenance of records, data management and
  • Establish referral arrangements

Infection Control
  • Education and training
  • Provide to new employees
  • When new tasks or procedures affect employees
  • Provided annually re exposure to potentially
    infectious agents and infection control
  • Provide educational information appropriate in
    content, vocabulary for the health care provider

Infection Control
  • Immunization
  • List of all required and recommended
  • Refer employee to prearranged health care
    provider or their own health care provider
  • Exposure Prevention and Post-exposure Management
  • Develop post-exposure management and medical
    follow up program

Infection Control
  • Medical conditions, work-related illness, and
    work restrictions
  • Develop written policies re work restriction and
    exclusion and who can implement
  • Policies for preventive and curative care and
    reporting illnesses. Dont penalize with loss of
    wages, benefits or job status
  • Policies for evaluation, diagnosis and management
    of occupational contact dermatitis
  • Definitive diagnosis of suspected latex allergy,
    work restrictions and accommodations

Infection Control
  • Records Maintenance, data management and
  • Establish and maintain confidential medical
    records for all dental health care providers
  • Ensure compliance of federal, state and local
    laws re medical recordkeeping and confidentiality

Infection Control
  • Occupational exposure
  • reasonably anticipated skin, eye, mucous
    membrane, or parenteral contact with blood or
    other potentially infectious materials that may
    result from the performance of an employees

Infection Control
  • Occupational exposure occurs when your ..
  • Skin
  • Eyes
  • Mucous membrane
  • Blood

Infection Control
  • Come into contact with
  • Blood or saliva from a patient
  • Contaminated instruments
  • Equipment of laundry contaminated by blood or
    saliva from a patient

Infection Control
  • Who is potentially infectious?

Universal Precautions
  • all human blood and certain human body fluids
    are treated as if known to be infectious

Universal Precautions
  • Transmission of infectious diseases from patient
    to health care workers usually involves patients
    who do not know they have an infectious disease.

Occupational Exposure Determination
  • Category I Routinely exposed to blood, saliva
    or both
  • Examples Dentist, Hygienist, Assistant,
    Infection Control/Sterilization Assistant, Lab
  • Category II May on occasion be exposed to
    blood, saliva or both

Disease Transmission in the Dental Office
  • Every dental office should have an infection
    control program designed to prevent the
    transmission of disease from
  • Patient to dental team
  • Dental team to patient
  • Patient to patient
  • Dental office to community (includes dental
    teams family)
  • Community to patient

  • Health care workers must
  • Consider blood and saliva from all patients as
    potentially infectious
  • Take precautions to protect themselves from

Hepatitis B Vaccine
  • Employer must educate employees.
  • Employer must offer the vaccine within 10 working
    days and pay for the vaccine.
  • Employee can decline, but must sign declination

Post-Exposure Evaluation and Follow-up
  • Employer must
  • Document exposure and circumstances
  • Document source individual
  • Source individuals blood tested
  • If source is known to be infected, blood test is
    not necessary.

Post-Exposure Evaluation and Follow-up
  • Employees blood is tested.
  • If employee refuses HIV testing, then blood is
    stored at least 90 days.
  • Confidential medical evaluation
  • When indicated use post-exposure prophylaxis
    which will prevent HIV infection

Medical Waste
  • Blood or saliva mixed with blood

Medical Waste
  • Items that release blood or saliva-blood if
    compressed or during handling

Medical Waste
  • Pathological waste
  • Teeth
  • Tissue
  • Contaminated sharps

Disposal of regulated Waste
  • Landfills
  • Private pick-up services
  • Hospitals
  • On-site

  • Items that do not release blood and/or saliva
    when compressed or handled do NOT need special

Requirements for Transmission of Infection
  • A reservoir of pathogen
  • A pathogen of sufficient infectivity and number
  • A mode of escape from the host
  • A mode of spread to the new host
  • A portal of entry
  • A susceptible host

Infection Control
  • Preventing Transmission of Blood borne Pathogens
  • HBV vaccination
  • Preventing exposure to Blood and OPIM (other
    potentially infectious material)
  • Use standard precautions for all patients

Infection Control
  • Consider sharp items contaminated with blood and
    saliva as potentially infective
  • Implement written program to minimize exposures

  • Destruction of all microorganisms including
    bacterial spores
  • Should be used for all instruments which come in
    contact with blood or saliva

  • Destroys most microorganisms but not bacterial
  • Used for surfaces and impressions

Disinfectants Versus Antiseptics
  • Disinfectants are chemicals that are applied to
    inanimate surfaces (such as countertops and
    dental equipment).
  • Antiseptics are antimicrobial agents that are
    applied to living tissue.
  • Disinfectants and antiseptics should never be
    used interchangeably because tissue toxicity and
    damage to equipment can result.

Disinfectants Versus Antiseptics
  • If there were an ideal surface disinfectant, it
    would have a rapid kill of a broad spectrum of
    bacteria, have residual activity, minimal
    toxicity, and would not damage surfaces to be
    treated. In addition, it would be odorless,
    inexpensive, work on surfaces with remaining
    bio-burden, and be simple to use.

The Perfect Disinfectant?
  • Unfortunately, no single disinfectant product on
    the market today meets all these criteria.

The Perfect Disinfectant?
  • When selecting a surface disinfectant, you must
    carefully consider the advantages and
    disadvantages of various products.
  • Often the manufacturers of dental equipment will
    recommend the type of surface disinfectant that
    is most appropriate for their dental chairs and

Types of Chemical Disinfectants
  • Iodophors are EPA-registered intermediate-level
    hospital disinfectants with tuberculocidal
    action. Because iodophors contain iodine, they
    may corrode or discolor certain metals and may
    temporarily cause reddish or yellow stains on
    clothing and other surfaces.

Types of Chemical Disinfectants
  • Synthetic phenol compounds are EPA-registered
    intermediate-level hospital disinfectants with
    broad-spectrum disinfecting action. Phenols can
    be used on metal, glass, rubber, or plastic. They
    also may be used as a holding solution for
    instruments however, phenols leave a residual
    film on treated surfaces. Synthetic phenol
    compound is prepared daily.

Types of Chemical Disinfectants- contd
  • Sodium hypochlorite (household bleach) is a
    fast-acting, economic, and broad-spectrum
    intermediate-level disinfectant (1100 dilution
    for surface decontamination).
  • Disadvantages It is unstable and must be
    prepared daily, has a strong odor and is
    corrosive to some metals. It is also destructive
    to fabrics and irritating to the eyes and skin
    it may eventually cause plastic chair covers to

Types of Chemical Disinfectants- contd
  • Alcohols are not effective in the presence of
    blood and saliva. They evaporate quickly and are
    damaging to certain materials such as plastics
    and vinyl.
  • The American Dental Association (ADA), CDC, and
    the Office of Safety and Asepsis Procedures
    Research Foundation (OSAP) do not recommend
    alcohol as an environmental surface disinfectant.

Classification of Instruments and Equipment
  • Instruments and equipment are divided into three
  • Critical
  • Semi-critical
  • Non-critical
  • The classifications are used to determine the
    minimal type of post-treatment processing.

  • Utility gloves
  • Protective eyewear and mask or face shield
  • Protective gown

Surface Disinfection
  • Use PPE for preparation and use of disinfectants
  • Use an EPA-registered, ADA-accepted disinfectant
    for cleaning and disinfecting
  • Follow manufacturers directions on the
    disinfectant label
  • Use water if dilution is required

Surface Disinfection
  • Spray, Wipe, SprayWipe
  • Spray and wipe to clean surface
  • Spray again and leave disinfectant on surface
    long enough to be tuberculocidal (usually 10
  • Do not pre-saturate gauze squares with

Surface Barriers
  • Surfaces that are difficult to disinfect may be
    wrapped with water-impervious material that is
    changed between patients.

Types of Surface Barriers
  • There is a wide variety of surface barriers
    available on the market today.
  • All should be resistant to fluids to keep
    microorganisms in saliva, blood or other liquids
    from soaking through to contact the surface

Types of Surface Barriers
  • Some plastic bags are designed especially to the
    shape of items such as the dental chair,
    air-water syringe, hoses, pens, light handles,

  • Plastic-barrier sticky tape is frequently used to
    protect smooth surfaces such as touch pads on
    equipment, electrical switches on chairs, or
    x-ray equipment. Aluminum foil can also be used
    because it is easily formed around any shape.

  • Something is contaminated if
  • You touch it with your bare skin
  • You touch it after you touch the patient
  • You touch it after you touch a contaminated item

To avoid cross-contamination
  • Use over-gloves
  • Use clean towel or paper towel

Infection Control
  • Hand hygiene
  • Wash hands
  • When visibly soiled
  • After barehanded touching likely contaminated
    objects (by blood, saliva or respiratory
  • BEFORE and AFTER treating each patient
  • Before putting on gloves
  • Immediately after removing gloves
  • Liquid hand care products stored in containers
    that can be washed and dried. Dont top off

Infection Control
  • Special hand considerations
  • Use hand lotions to prevent skin dryness
  • Avoid lotions with petroleum or other oil
  • Fingernails short

Infection Control
  • No artificial nails or extenders or polish
  • No jewelry -it compromises the fit and integrity
    of the glove
  • Microorganisms thrive around rough cuticles and
    enter through break in the skin

Infection Control
  • PPE (personal protective equipment)
  • OSHA requires employer to provide employees with
    appropriate PPE at no charge
  • Masks, Eyewear and Face shields
  • Solid side shields on eyewear protects mucous
    membranes of eyes, nose and mouth

Infection Control
  • eyewear and face-shield should be disinfected
  • Change masks between patients or if mask gets wet
    or is visibly soiled
  • Touch masks only on side
  • Mask should not contact the mouth
  • Mask with 95 filtration for particles 3-5mm in

Infection Control
  • Face shields
  • Chin-length shield replaces eyewear but not mask.
  • Doesnt protect against inhaling aerosols
  • Patient eyewear
  • Protect from
  • Handpeice splatter
  • Spilled or splashed materials
  • Airborne bits of acrylic or tooth fragments

Infection Control
  • Protective clothing-covers area likely to be
    soiled with blood, saliva or OPIM
  • Change if soiled
  • Remove PPE when leaving work area

  • Gloves
  • New pair each pt.
  • Remove if torn, cut or punctured
  • Do not wash gloves before use-may be rinsed to
    remove excess powder
  • Wash hands before re-gloving
  • Proper fit

Infection Control
  • Double gloving-effectiveness in preventing
    disease transmission has NOT been demonstrated.
  • Over-gloves-not acceptable alone as hand barrier
  • Sterile gloves-invasive procedures

Infection Control
  • Latex Hypersensitivity
  • Educate staff to signs, symptoms and diagnosis of
    skin reaction

Infection Control
  • Three types of allergic reactions to latex
  • 1. Irritant dermatitis, non-immunologic process
    involves only surface irritation. Chemical
    substance causes irritation. Red, dry, irritated
    and sometimes cracked.
  • 2.Type IV most common, involves immune system.
    Delayed contact reaction. 48-72 hrs. Limited to
    areas of contact. Caused by chemicals used to
    process latex

Infection Control
  • 3. Type I MOST dangerous. Can cause death.
    Reaction to latex protein. Occurs 2-3 minutes
    after contact.

Infection Control
  • Remember
  • When one employee in the dental office has been
    diagnosed as having a latex allergy, all staff
    members should use practices to minimize the use
    of latex-containing products. These practices
    include the wearing of powder-free gloves by all
    dental staff members to minimize the risk of
    airborne latex particles.

  • Dental health care workers are exposed to
    Legionella bacteria at a much higher rate than
    the general public.
  • Dental personnel are exposed to contaminated
    dental unit waterlines by inhaling the aerosol
    generated by the hand piece and the air-water

  • There is at least one suspected fatality of a
    dentist from legionellosis.
  • Case reports have been published of
    immuno-compromised patients who developed
    postoperative infections caused by contaminated
    dental water.

Microorganisms in Waterlines
  • The primary source of microorganisms in dental
    waterlines is the public water supply.
  • It is possible that saliva may be retracted back
    into the waterlines during treatment. This
    process is also called suck back.

Microorganisms in Waterlines
  • Anti-retraction valves on dental units and
    thorough flushing of the dental lines between
    patients minimize the chance of this occurring.
  • Entering public water source has a colony forming
    units (CFU) count of less than 500 once that
    water enters the dental waterlines and colonizes
    within the bio-film, the CFU count skyrockets.

Communities of Bacteria
  • There are two communities of bacteria in dental
    unit waterlines
  • One bacterial community exists in the water
    itself and is referred to as planktonic (free
  • The other exists in the bio-film attached to the
    walls of the waterlines.

  • Bio-film exists in all places where moisture and
    a suitable solid surface exist.
  • Bio-film consists of bacterial cells and other
    microbes that adhere to surfaces and form a
    protective slime layer.
  • Bio-film can contain many types of bacteria, as
    well as fungi, algae, and protozoa.
  • Viruses, such as the human immunodeficiency virus
    (HIV), cannot multiply in the dental unit

Methods to Reduce Contamination
  • It is not yet possible to totally eliminate
    bio-film, but it can be minimized by
  • Self-contained water reservoirs
  • Chemical treatment regimens
  • Micro-filtration
  • Daily draining and drying of lines

Self-Contained Water Reservoirs
  • These systems supply air pressure to the water
    bottle (reservoir).
  • The air pressure in the bottle forces the water
    from the bottle up into the dental unit water
    lines (DUWL) and out to the hand piece and
    air-water syringe.

Self-Contained Water Reservoirs
  • Self-contained water systems have two advantages
  • The dental personnel can select the quality of
    water to be used, such as distilled, tap, or
  • Maintenance of the water system (between the
    reservoir bottle and the hand pieces and
    syringes) is under the control of the dentist and

Micro-filtration Cartridge
  • A disposable inline micro-filtration cartridge
    also can dramatically reduce the bacterial
    contamination in the dental unit water.

Micro-filtration Cartridge
  • This device must be inserted as close to the hand
    piece or air-water syringe as possible.
  • It should be replaced at least daily on each
    line. The use of filtration cartridges combined
    with water reservoirs can ensure improved water

Chemical Agents
  • Chemicals can be used to help control bio-film in
    two ways
  • Periodic or shock treatment with bio-cidal
    levels (levels that will kill microorganisms) of
  • Continuous application of chemicals to the system
    (at the level to kill the microorganisms but not
    harm humans).

Chemical Agents
  • Always check with the manufacturer of the dental
    equipment to determine which chemical product and
    maintenance protocol they recommend.

Water for Surgical Procedures
  • Dental unit water should not be used as an
    irrigant for surgery involving the exposure of
  • Only use sterile water from special sterile water
    delivery systems or hand irrigation using sterile
    water in a sterile disposable syringe.

Flushing Waterlines
  • All dental waterlines and hand pieces should be
    flushed in the mornings and between patients.
  • Although this will not remove bio-films from the
    lines, it may temporarily reduce the microbial
    count in the water.

Flushing Waterlines
  • It will help clean the hand piece waterlines of
    materials that may have entered from the
    patients mouth.
  • Flushing also brings a fresh supply of
    chlorinated water from the main waterlines into
    the dental unit.

Minimize Aerosol
  • Always use the high-volume evacuator when using
    the high-speed hand piece, ultrasonic scaler, and
    air-water syringe.
  • The high-volume evacuation may also reduce
    exposure of the patient to these waterborne

Use Protective Barriers
  • The dental dam greatly reduces direct contact.
  • The dam also greatly reduces the aerosolizing and
    spattering of the patients oral microorganisms
    onto the dental team.
  • Protective barriers, including masks, eyewear,
    and face shields, also serve as barriers for the
    dental team.

  • Several government agencies and professional
    organizations have a direct influence on
    dentistry, infection control, and other health
    care safety issues.
  • In addition to issuing recommendations and
    regulations some have regulatory roles and others
    are advisory.
  • These agencies can serve as an excellent
    resource for information and educational

Recommendations and Regulations
  • Recommendations are made by individuals, groups,
    or agencies that are advisory and have no
    authority for enforcement.

Recommendations and Regulations
  • Regulations are made by groups or agencies that
    do have the authority to enforce compliance with
    the regulations. Enforcement penalties may
    include fines, imprisonment, or suspension or
    revocation of licenses.
  • Recommendations may be made by anyone, but
    regulations are made by governmental groups or
    licensing boards in towns, cities, counties, and

Associations and Organizations
  • The American Dental Association (ADA) is the
    professional organization for dentists. The ADA
    periodically updates its infection control
    recommendations as new scientific information
    becomes available.

Associations and Organizations
  • The Organization for Safety and Asepsis
    Procedures (OSAP) is a not-for-profit
    organization composed of dentists, hygienists,
    dental assistants, government representatives,
    dental manufacturers, university professors,
    researchers, and dental consultants. This
    organization is an excellent resource for
    information on infection control, injury
    prevention, and occupational health issues.


Associations and Organizations- contd
  • State and local dental societies can be helpful
    to you in complying with regulatory issues in
    your specific area.
  • National, state, and local dental assisting
    societies can often answer questions and provide
    opportunities for continuing dental education.

Governmental Agencies
  • Centers for Disease Control and Prevention (CDC)
  • Food and Drug Administration (FDA)
  • Occupational Safety and Health Administration
  • National Institute for Occupational Safety and
    Health (NIOSH)

Centers for Disease Control and Prevention (CDC)
  • The CDC is recognized as the lead federal agency
    for protecting the health and safety of people at
    home and abroad.
  • The CDC bases its public health recommendations
    on the highest quality scientific data.

Food and Drug Administration (FDA)
  • The FDA is a regulatory agency and is part of the
    United States Department of Health and Human

Food and Drug Administration (FDA)
  • The FDA regulates the manufacturing and labeling
    of medical devices (such as sterilizers, biologic
    and chemical indicators, ultrasonic cleaners and
    cleaning solutions, liquid sterilants, gloves,
    masks, protective eyewear, dental handpieces and
    instruments, dental chairs, and dental unit
  • It also regulates antimicrobial handwashing
    products and mouth rinses.

Environmental Protection Agency
  • The EPA is a regulatory agency.
  • It ensures the safety and effectiveness of

Environmental Protection Agency
  • Manufacturers of disinfectants must submit
    information about the safety and effectiveness of
    the product.
  • If the claims meet the EPA criteria, the product
    receives an EPA registration number that must
    appear on the product label.
  • The EPA regulates discharge and final treatment
    of waste materials (i.e., chemicals), as well as
    medical waste, after it leaves the dental office.

Occupational Safety and Health Administration
  • OSHA is a regulatory agency.
  • It protects workers against physical, chemical,
    or infectious hazards in the workplace.

Occupational Safety and Health Administration
  • It establishes protective standards, enforces
    those standards, and offers technical assistance
    and consultation programs.
  • OSHA is a federal agency, but 22 states
    administer their own state-operated OSHA
  • In states that administer their own OSHA
    programs, the state standards must be equivalent
    to, or more stringent, than those of the federal

National Institute for Occupational Safety and
Health (NIOSH)
  • NIOSH does not have regulatory authority.
  • It is responsible for conducting research and
    making recommendations for the prevention of
    work-related disease and injury.

National Institute for Occupational Safety and
Health (NIOSH)
  • NIOSH makes recommendations and disseminates
    information on preventing workplace disease,
    injury, and disability.
  • It provides training to occupational safety and
    health professionals.

  • Outbreaks of waterborne disease have occurred
    in a broad range of facilities. Although there is
    no evidence of a widespread public health
    problem, published reports have associated
    illness with exposure to water from dental units.
    The fact that there are bacteria capable of
    causing disease in humans found in dental unit
    waterlines is reason for concern.

  • In community water, the number of waterborne
    bacteria is kept below 500 colony-forming units
    (CFU) per milliliter.
  • The water from air-water syringes and dental hand
    pieces frequently has bacteria levels that are
    hundreds or thousands of times greater than is
    permissible in drinking water.
  • The types of bacteria that are found in dental
    unit water are frequently the same types as those
    found in community water, but the levels of
    bacteria found in the dental units are almost
    always higher.

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