INFECTION CONTROL MANUAL*

DENTAL HYGIENE PROGRAM

LEXINGTON COMMUNITY COLLEGE

2002-2003

By

Debbie Kelly, RDH, M Ed.

Janella Spencer, RDH, MS Ed.

*Adapted with permission from ECAETC, The East Central AIDS Education and Training Center Infection Control A Guide for Protection. Dr. Robert Calmes and Paula Parise, R.D.H., UKCD.

INFECTION CONTROL

The premise of infection control is that precautions minimize the risk of exposure to pathogens, thereby protecting health care professionals from occupationally acquired infections. Do you need to practice infection control? If you are exposed to blood, saliva, gingival fluid, or mucous membranes, either directly or indirectly during your workday activities, then you need to protect yourself by following infection control guidelines. Fluids and tissues are vectors that transmit infectious agents. Nearly all patient care procedures expose dental professionals to body fluids and tissues.

The most efficient way to prevent transmission of disease during patient care is to integrate infection control methods with treatment procedures. Infection control should be the environment in which patient care occurs.

GOALS OF INFECTION CONTROL

The purpose of infection control for dentistry is to prevent transmission of disease during dental treatment by using a concept called standard/universal precautions. Using standard/universal precautions for all patients prevents cross‑infection among dental professionals and patients.

OBJECTIVES

· FIRST PROTECT YOURSELF from occupational acquired infections; REDUCE the numbers of cross‑infecting pathogens.

· BREAK the chain of cross‑infection.

· APPLY standard/universal precautions; TREAT every case as if the patient had a positive diagnosis for hepatitis B, HIV infection or AIDS, tuberculosis, or other serious infectious disease.

· PROTECT patients from cross‑infection. PROTECT incomes of dental professionals.

· PROTECT dental professionals from liability for negligence and/or noncompliance with federal, state, and local regulations.

GOAL OF THIS DOCUMENT

The objectives of the Infection Control Program are achieved by strictly applying common sense principles related to seven components. These will be described thoroughly, as they are applied in the Dental Hygiene Program of the Lexington Community College.

COMPONENTS OF INFECTION CONTROL

1. Medical screening

2. Personal protection (management of exposures)

3. Instrument sterilization

4. Surface and equipment disinfection

5. X‑ray asepsis

6. Dental laboratory asepsis

7. Liability

1. MEDICAL SCREENING

Medical screening provides information about many aspects of a patient; some of these may alert you to premedicate or refer the patient for specialty medical or dental care. Medical screening may also warn you of the infectious disease status, but not always. Remember that about 95% of HIV‑infected individuals are asymptomatic carriers of a virus. The medical history cannot reliably detect carriers of HIV or other pathogens (e.g., HIV and asymptomatic herpes simplex virus (HSV) shedders or patients with high risk lifestyle behaviors.

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Specific questions designed to help reveal HIV‑infection should be asked at the first visit and at each subsequent appointment. These questions should address current and chronic illnesses, lymphadenopathy, unintentional weight loss and oral lesions. Questions should also address a history of hepatitis or other sexually transmitted diseases.

Specific questions should also be asked about medications (current and past), and history of hemophilia or blood transfusion (between 1979 and 1985).

Patients with oral and perioral conditions indicative of AIDS such as esophageal candidiasis, Kaposi's sarcoma or hairy leukoplakia should be referred to a physician for evaluation. Patients with histories such as chronic lymphadenopathy, recurrent major aphthous ulcers or oral candidiasis should also be evaluated.

For those patients who have contact with persons with infectious diseases, ask follow‑up questions about the nature of the contact and refer them for diagnostic procedures, counseling and medical follow‑up as indicated.

Remember, the medical history cannot reliably identify all infectious patients without further testing.

The CDC and ADA recommend that you treat all patients as potentially infectious and routinely use standard/universal precautions to protect yourself from exposure to HIV and other blood‑ and body fluid‑borne pathogens.

The goal of infection control for dentistry is to block cross‑infection through use of standard/universal precautions.

What are Standard/Universal Precautions?

The CDC^[1] and the ADA^[2] recommend using a concept called "universal blood and body fluids precautions" or "universal precautions" (standard) with all patients to reduce the potential for exposure to blood‑ and body fluid‑borne pathogens. This means that the blood and body fluids of all patients is considered infectious and treated so. Universal precautions are embodied in standards of care for infection control recommended by the CDC and ADA. Universal precautions are intended to supplement rather than replace recommendations for infection control, such as hand washing.

2. PERSONAL PROTECTION

One of the most important aspects of infection control is the use of personal protective equipment and methods. They will protect you from infectious agents such as HIV, herpes simplex virus and Mycobacterium tuberculosis that are transmitted by blood and saliva of dental patients. Use the following personal protection methods with all patients.

Specific Items of Personal Protection

· General Vaccinations

Measles, Mumps, Diphtheria, Tetanus, Pertussis, Polio, Influenza

· Specific Vaccinations

Hepatitis B, Rubella

· Tuberculosis testing

· Hand washing

· Barriers

· Hidden dangers

· Handling sharps

A. Vaccination

Many infectious diseases can be transmitted from dental patients to attending dental professionals by droplets and aerosols of oral secretions. These include AIDS, hepatitis viruses, herpes simplex, tuberculosis, measles, mumps, rubella, influenza and a number of respiratory diseases.

Vaccinations are available for many of these diseases. However, currently no vaccine exists for HIV infection and AIDS. Infection control is the only protection for dental professionals from blood- and oral secretion-borne infections in the dental setting. Although no vaccine exists for HIV disease, infection control would not be complete without a brief note on vaccinations.

The Public Health Service considers vaccines to be the ideal method for preventing infectious diseases. Vaccines have been developed for several infectious diseases; measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, and influenza. Because these infectious diseases can be transmitted by droplets, they pose occupational hazards for dental professionals whose immunity to many diseases may have declined. Vaccination records should be checked and dental professionals should be re-vaccinated for those diseases for which they have inadequate protection.

B. Specific Vaccinations

1. Hepatitis B

There are several vaccines available for immunization against hepatitis B. They offer dental and other health care professionals protection against HBV and its sequela, including protection against possible transmission to family members.

All attending dentists, dental hygiene students, patient care staff, dispensary clerks, and others who have patient contact or contact with materials that are contaminated with blood or saliva of dental patients must take the vaccine. All personnel in these groups in the College are required to attend an educational session on the benefits and risks of vaccinations for hepatitis B.

2. Rubella

This viral disease (often called German measles) is usually a mild disease in children who suffer no sequelae. Rubella is a more serious illness in adults, with 25 to 40% complaining of short-lived joint pain. The most serious effect of rubella is Congenital Rubella Syndrome. CRS occurs in the fetus whose susceptible mother becomes infected during the first trimester of pregnancy. Severely affected infants may have cataracts, sensorineural deafness, myocarditis, and mental retardation.

Infection with rubella virus is acquired via the respiratory route. The virus is present in the oral secretions of infected dental patients and others. It is easily transmitted to a susceptible person.

A live, attenuated rubella vaccine has been available since 1969; it is protective in about 95% of vaccines. Vaccination for rubella is via rubella vaccine or through a combined measles-mumps-rubella (MMR) vaccine that provide lifelong immunity.

Students must be vaccinated if they have not had rubella.

C. Tuberculosis Testing

Tuberculosis was, until the advent of modern medicine during this century, a leading cause of death. Unfortunately, TB has shown a recent, dramatic increase in occurrence in the United States. While initially brought here primarily by third world immigrants, it has re-established itself in the population. The convenience and frequency of world wide travel have also contributed to its’ spread. TB is now also impacting the HIV epidemic, hastening the death of the advanced AIDS patient.

For these reasons, the U.S. Department of Health and Human Services has recently initiated a strategic plan for elimination of tuberculosis from this country within the next 20 years. Drug resistant strains, which are being found in increasing numbers, will sorely test our ability to meet this ambitious goal.

Tuberculosis is a communicable disease that is transmitted from an infected person to an uninfected person by respiratory secretions containing the Mycobacterium Tuberculosis bacterium, the causative agent of the disease. Person to person spread of tuberculosis is therefore usually through air. When people with tuberculosis of the respiratory tract cough, airborne infectious particles are produced. If these bacteria are inhaled by other people, an infection will almost always occur. This infection then may spread throughout the body. Fortunately, most individuals who become infected do not develop a clinical illness. This is because the body's immune system may bring the infection under control; however, infected people do develop a positive reaction to a tuberculin skin test. This infection can persist for years, perhaps even for life. The infected person remains at risk of developing the disease at any time, especially if the immune system becomes impaired. Although the disease usually affects the lung, it can occur at virtually any site in the body.

Infection control techniques are designed to minimize cross-infections by such pathogen as TB, but they cannot eliminate the risk entirely. It is therefore very important for dental professional and student dental hygienist to employ standard/universal precautions to reduce the likelihood of acquiring a tubercular infection.

Because TB is such a highly infectious disease and it is increasing in prevalence, all dental personnel are required to show proof of a negative TB test. Lexington Community College Dental Hygiene Students can be tested free of charge at UK student health center.

D. Hand Washing

Hand washing is one of the most important infection control methods to reduce cross-infection. The CDC and ADA have recommended that strict attention be given to hand washing and the care of hands to reduce the risk of cross-infection of HBV, HIV and other blood- or oral secretion-borne infectious agents.

The importance of hand washing is in no way reduced by the use of gloves. Hands may be contaminated by potentially infectious secretions of the patient through small, inherent defects in gloves or by puncture or tear during treatment. These holes and micro-sized pores reduce the barrier protection provided by intact gloves resulting in contaminated hands. Because of this, it is especially important to wash hands after degloving and after touching inanimate objects likely to be contaminated by blood or saliva.

WHEN SHOULD HANDS BE WASHED?

· At the beginning of the workday, before gloving

· Between patient contacts, before gloving and after degloving

· If gloves become torn or defective

· After gloves are removed

· If hands become contaminated with blood or saliva

· After touching inanimate objects contaminated by blood or saliva

· Before leaving the operatory or laboratory

· Prior to leaving the office for the day

HOW SHOULD YOU WASH YOUR HANDS?

The way in which you wash your hands and the type of detergent used are important. Multiple cycles of washing are more effective in removing transient pathogens and debris than a singe cycle for the equivalent amount of time. A two-cycle hand wash is recommended, with each cycle being approximately 10 seconds long, increasing the time if hands are visibly soiled or contaminated. Do not use bar soap; it becomes contaminated and serves as a vehicle of infection. Liquid detergent dispenses are convenient.

ROUTINE HAND WASHING

* Wet hands and wrists with warm water.

* Apply an antimicrobial hand washing

solution generously.

* Lather and rub vigorously all surfaces of

hands and wrists for at least 10

seconds. Rinse completely.

* Lather and rub hands and wrists for 10

seconds, a second time.

* Rinse completely and dry hands using a disposable,

single-use paper towel.

CARE OF HANDS:

Avoid hand injuries during dental procedures. If an accidental skin penetration occurs, or gloves become torn or punctured, remove gloves as soon as is compatible with patient's safety. Wash hands thoroughly as specified above and re-glove prior to returning to patient care activities.

CDC and ADA recommended that attending dentists, dental hygienists, dental hygiene students, and clinical staff with exudative lesions or weeping dermatitis refrain from all direct patient contact and from handling patient care equipment until the condition resolves.

E. Barriers

Barrier techniques reduce the risk of exposure to blood- and body fluid-borne pathogens for dental health care workers as well as protect patients from possible transmission from the worker. Barrier techniques include gloves, masks, protective eye wear and protective clinical attire. Chin-length plastic shields may be worn over masks and eye wear when using the prophy angle, cavitron and/or air-abrasive instruments.

Gloves:

The physical barrier of disposable gloves furnishes protection from potentially infectious agents. As long as the gloves are not defective and do not tear during use, they reduce the risk of exposure to blood, saliva and mucous membranes. Gloves must be worn for all patients; for all procedures; anytime there is the potential for contact with blood, saliva, or mucous membranes; or when touching contaminated objects or surfaces.

Use examination gloves for all diagnostic and therapeutic dental procedures other than surgery. Use sterile surgical gloves for all procedures where a portal of entry may be established.

Gloves should cover cuffs of long-sleeved clinic wear and wrist watches to protect bare skin from a potential exposure. Gloves should not be washed or disinfected for reuse. Detergents, disinfectants and alcohols damage glove material, causing micro pores and a tacky surface. The resulting defective gloves offer diminished barrier effectiveness. Reusing gloves presents a danger of cross-infection between patients^[3].

Change gloves between patient contacts. One pair of gloves is usually adequate for each patient. However, gloves may need to be replaced during lengthy procedures such as treatment in the dental hygiene clinic. To maintain barrier integrity, change gloves at intervals less than two hours^[4]. Additionally, replace gloves if a perforation is noted, after prolonged use or following complex procedures and those procedures involving materials that can degrade the glove.

GLOVING PROTOCOL

* Wear gloves for all treatment procedures.

* Remove jewelry and wash hands.

* Put on gloves. Do not wear jewelry with

gloves.

* Do not reuse gloves.

* Washing gloves is prohibited.

* Change gloves after each patient contact;

during lengthy or complex procedures; if

gloves become defective; or if glove surface

becomes tacky.

* Remove gloves and wash hands as

prescribed after treatment.

Never wear gloves outside cubicle or operatory for any reason. Either don over gloves (see following section), or remove latex gloves and wash hands before going to the dispensary, x-ray room, patient education room, another clinic, to the restroom, or elsewhere.

Allergies to Gloves:

If an allergy (redness, rash, scaliness, blisters, etc.) develops to latex or glove powder, contact the Director of Infection Control for advice.

Over-Gloving

If it is necessary to leave the patient briefly, to go to the dispensary, or to handle objects such as charts, telephones, and x-rays, over gloves may be used. Over gloves are made of polyethylene and resemble food handler's gloves. This technique reduces the number of gloves used, yet maintains effective infection control for safety.

Masks

Splashing or spattering of blood and saliva commonly occurs in the practice of dental hygiene. Because of this, wearing a mask is essential to protect mucous membranes of the nose and mouth. At least one health care worker has been infected with HIV as a result of a splash to the face and mouth.^[5]

To reduce potential exposures wear a mask for all patient contacts, even those procedures perceived to have minimal potential for spatter. Change masks between patients.

Because of the close proximity between you and the patient during treatment procedures, a mask is easily contaminated with potentially infectious spatter. Replace a mask that has become wet. Microbes can penetrate a wet mask. A chin-length plastic face shield may be worn over masks.

Important considerations regarding masks

* Choose a dome, ear-loop or a tie-on mask

* Use a new mask for each patient.

* Do not reuse masks.

* Change mask if it becomes wet.

* Do not touch mask nor drape around the neck.

Face Shields

A chin-length plastic face shield may be worn using the prophy angle, ultrasonic scaler and airbrasive polisher to reduce potential spatter from these aerosols. Wash and disinfect the face shield between patients. Refer to manufacturer's recommendations for appropriate disinfectant. Students may check out a face shield for use in the clinic.

Important considerations regarding face shields

· Choose a chin-length plastic shield.

· Wear always when using a prophy angle, ultrasonic scaler or air abrasive polisher.

· Wash and disinfect face shield between patients.

Protective Eye Wear

Protective eye wear protects the conjunctivae and periorbital membranes from infectious spatter. Wear protective eye wear with all patients for all clinical procedures. Also use protective eye wear in the dental laboratory when using equipment that creates droplets, spatter, chips or dust.

Protective eye wear should fit closely at the bridge, brow, cheeks, and corners of the eyes. Use large-diameter, durable and scratch-resistant glasses with side shields. If corrective glasses are worn, they must be of large diameter. For those who wear contact lenses or "half glasses", over glasses with large-diameter lenses and side shields must also be worn.

Wash and disinfect all protective and corrective eye wear between patients using a germicide that is EPA-registered as a tuberculocidal. Because mycobacteria represent one of the most resistant groups of microorganisms, a mycobactericidal germicide is also effective against other bacteria and viral pathogens. Some disinfectants cause damage to the plastic, so refer to the manufacturer's recommendations before using. Rinse and dry eye wear well after disinfection.

Important considerations regarding protective eye wear

* Wear protective eye wear for all patient contacts.

* Use large-diameter, durable, scratch-resistant eye wear with side shields.

* Wash and disinfect eye wear between patients.

* All patients must wear protective wear.

Protective Clothing

All personnel must wear garments that protect them from droplets, spatters and aerosols of blood or saliva of patients. These protective garments must cover street clothes and must not be worn outside the treatment environment.

Protective clothing may be a reusable lab coat, uniform, or gown. These garments must have long sleeves and a high buttoned collar. Change protective clothing at least daily, and more often if visibly soiled.

Contaminated protective attire may be a potential source of infection. After use, place in a disposal bag before leaving the treatment environment. Launder garments in a standard washing machine on a normal cycle using hot water, laundry detergent, and chlorine bleach. Dry cleaning methods also kill HIV and HBV.

Important considerations regarding protective clothing

* Wear protective clothing for all patients.

* Change and wash garments at least daily or more often if visibly soiled.

* Do not wear protective attire outside of the clinical environment.

* Place lab coat in plastic bag at end of clinic session.

F. Hidden Dangers

Many seldom considered reservoirs of infection exist in and around the patient care areas. For example, infectious bacteria and viruses remain alive on dental charts for lengthy periods of time and are potentially transmissible to dental personnel and clerical staff.

Studies at the CDC indicate that the numbers of viable HIV in blood on surfaces decreases with time^[6], but the viability of HIV on surfaces is generally just a few hours. On the other hand, other viruses such as HBV, can remain alive for up to six months on surfaces. Although HIV and HBV remain viable for varying amounts of time, no viral transmission for a contaminated surface has been documented^[7].

However, avoid eating, drinking and smoking around materials or supplies that may be suspect to hidden contaminants. This includes morning coffee, lunch and afternoon snacks at the reception desk or in the dental laboratory.

Hidden sources of contamination include dental charts, and pens and pencils.

Dental charts

Prevent contamination of dental charts before the fact, rather than attempting to decontaminate charts afterward. Place the patient evaluation form (buff-colored) in a plastic protective cover before inserting in the chart. The form is to stay in the plastic protective cover for a minimum of six months from the time the last recording was entered on the form.

Important considerations regarding the handling of dental charts

* Avoid handling dental charts with contaminated hands, either gloved or bare.

* Before handling the chart during treatment, over glove or remove gloves and wash bare hands. Alternatively, ask non-treatment personnel to handle charts.

Pens and pencils.

Writing instruments are easily contaminated with oral secretions that are potentially infectious.

Important considerations regarding the handling of writing instruments

* Use and label pens and pencils with colored tape for operatory use only.

* Clean and disinfect writing instruments used in patient care areas after each patient.

* Avoid hand to mouth pathways. Never place a writing instrument in your mouth.

* Do not offer your pens and pencils to clinical instructors. 

G. Handling Sharps

Any item that could puncture the skin such as, needles, scalpel blades, explorers, curets, burs or orthodontic wires are considered sharps. Sharps are contaminated and potentially infectious. Handle all sharps carefully and place disposable sharps, for example, needles, scalpel blades and orthodontic wires in a sharps container after use. While the emphasis of a sharps discussion is needles safety, other items with sharp tips or cutting edges also pose a threat.

Needle sticks constitute the most common type of occupationally-acquired exposure in the health care field^[8]. Dental Hygiene however, holds additional dangers because of other sharps such as instruments, burs and orthodontic wires. Take precautions to prevent injuries caused by handling sharps during procedures, especially while cleaning and during disposal.

Assess when sharps are handled and modify unsafe practices. Include such seemingly unlikely exposures such as scratches on the forearm of an operator inflicted while reaching past the handpiece holder apparatus. To eliminate this risk, seat the handpiece in the holder with the head of the handpiece or ultrasonic tip directed downward.

Disposable needle shield

Attach the needle shield to an assembled syringe before injection. The cap slides into the hole in the shield.

After handing the dentist the syringe, place the needle shield and cap on the tray in a location where the dentist can easily "spear" it with the needle. After the dentist is finished, do not remove the cap after the re-sheathing has occurred.

Important considerations regarding needle and “sharps” safety

* Never move your hand in the direction of an uncapped needle.

* Do not bend, break or cut used needles.

* Do not recap needles directly by hand. Either use the "spear" method or use a disposable needle shield.

* Never lay an uncovered needle on the tray.

* Dispose of needles and carpules in an approved sharps container in the operatory for transport. Do not carry sharps by hand.

* Never dispose of needles in operatory waste container.

Dispose of contaminated needles and used needle shields properly. To reduce the possibility of an accidental needle stick to clinical staff and housekeeping staff, used needles must be discarded into an OSHA-approved, puncture-resistant, breakage-resistant container, located in the sterilization room, which are sealed when full and incinerated by the U.K. Hospital.

WARNING - Fayette County Ordinance: Never discard used needles in any waste receptacle other than an OSHA-approved Sharps Container, marked with a "biohazard symbol" or labeled "infectious waste".

3. INSTRUMENT STERILIZATION

Sterilization is the process that kills all life forms--viruses, bacteria, fungi/mold and spores. It is the property of complete killing that distinguishes sterilization from disinfection. There is no such condition as "nearly sterile". A dental instrument is either sterile or it is not sterile. Sterilization is unique.

To eliminate the risk of disease transmission, sterilize all reusable instruments, equipment and additional items after each use. That includes handpieces, ultrasonic scalers and prophy jets. Common methods of sterilization in dentistry are steam under pressure (autoclave), chemical vapor under pressure, dry heat oven and liquid chemical sterilants.

Sterilization of dental instruments protects from cross-infection. The most efficient way to manage sterilizing instruments is using procedure-specific instrument tray set-ups. This system offers protection from cross-infection caused by contaminated dental instruments. Other items commonly used in dentistry which must be sterilized after each patient contact include burs, endodontic files and reamers, rubber dam frames and clasps, impression trays, sharpening stones, bite blocks, mouth mirrors and cotton pliers. The sterilization process has six steps.

STERILIZATION PROCESS

* consolidation and transport of instruments

* cleaning

* packaging instruments

* sterilization

* storage

* sterilizer monitoring

Consolidation and transport

Upon completion of patient care activities, instruments and equipment must be cleaned and packaged to be transported to the sterilization area and the operatory must be disinfected. Use the following guide for consolidation and transport of instruments and equipment.

Important considerations regarding consolidation and transport

* Remove gloves and wash hands as prescribed.

* Put on heavy-duty, puncture-resistance gloves.

* Place non-sharps disposables in a waste container in the operatory. Follow specific rules decreed by your county or municipality, (if any) for special handling and disposal of infectious waste.

* Place sharps (needles, scalpel blades, anesthetic carpules, orthodontic wires, endodontic files, reamers or broaches, and other sharps) in a puncture-resistant sharps container located on the mobile cart.

* Do not discard sharps in operatory waste container.  

Cleaning

All instruments and equipment must be cleaned before sterilization. Cleaning can be accomplished by ultrasonic cleaning or hand scrubbing. Sonication in a detergent solution achieves a high level of disinfection. This works even better if the ultrasonic cleaner is heated. Ultrasonic cleaning is the preferred method; it minimizes manual manipulation of instruments which reduces the risk of cross-contamination.

Important considerations regarding instruments: Hand Scrubbing

* Glove with heavy-duty gloves.

* Hand scrub each instrument using a long-handled scrub brush, hot water and a detergent.

* Rinse instruments under running, hot water to remove detergent.

* Drain instruments before packaging.

Important considerations regarding instruments: Ultrasonic Cleaning

* Glove with heavy-duty gloves.

* Place instrument cassette in ultrasonic unit containing a detergent dissolved in tap water.

* Sonicate for 12 minutes.

* Do not rinse instruments this will remove the rust preventative coating in the solution.

* Drain instruments on paper towel.

Important considerations regarding Handpieces

* Scrub handpieces and accessories with water and detergent to remove blood, saliva and debris.

* Sterilize according to the manufacturer's instruction.

NOTE: If a handpiece cannot be sterilized, then it must be disinfected between patients. Refer to the Section: Surface and Equipment Disinfection, for details.

Important considerations regarding Safety Glasses for patients

* Spray 4x4 gauze with surface disinfectant and wipe glasses to preclean.

* Spray again with surface disinfectant and allow to remain wet

for 10 minutes.

* Place in autoclave bag.

Important considerations regarding oxygen tank masks and tubing

* Clean masks and tubing for oxygen tank as for instruments.

* Immerse in disinfectant according to the Manufacturer's instructions, rinse with water, air-dry and package.

Instruments: Ultrasonic Cleaning (Preferred Method)

1. Glove with heavy-duty gloves

2. Load basket with instruments approximately 1 layer deep - DO NOT OVERLOAD! (if cassettes are used, do not use basket) Dirty instruments should be submerged at least ½ inch under solution. Never place instruments directly in tank - always use the basket.

3. Use HIGH setting for faster or heavier cleaning tasks. Use LOW setting for milder cleaning tasks.

4. Run 1 layer load of instruments for approximately 12 minutes. Check visually if any debris noted then run another 10-12 minutes.

5. Do not rinse instruments. This will remove the rust preventative coating in the solution.

6. Drain instruments on paper towel.

Operating the Ultrasonic Cleaner

1. Plug in close to sink.

2. Make sure stainless steel drain screen is installed in tank drain hole. When metal tab on backside of ultrasonic cleaner is up - the drain is closed. When metal tab is pushed down - water will drain out of tank. Never drain tank unless plastic drain hose is inserted in metal tab on back of ultrasonic cleaner tank.

3. For regular instrument clean-up use: 1.75 oz. of all purpose ultrasonic solution and fill tank to within 1½ inch of tank top with tap water.

4. Every time you change the solution, let the tank run for 15 minutes without basket of instruments (called degassing). In-between solution changes let ultrasonic run 3 minutes to degas before inserting instruments/basket.

5. Change solution weekly. Every Monday morning.

6. Cover should be placed over tank whenever possible to reduce evaporation, noise levels and surface contamination.

7. Foil test should be performed every 4-6 months. (See the operating manual for further details.)

WRAPPING INSTRUMENT CASSETTE

1. Place cassette diagonally on wrap

2. Fold wrap around cassette like a diaper

3. Seal edges with two pieces of indicator tape

4. Place in sterilizing box or basket

PACKAGING INSTRUMENTS NOT INCLUDED IN CASSETTE

1. Instruments cleaned ultrasonically and thoroughly dried

2. Place instruments diagonally on paper towel

3. Roll corner to completely cover instruments

4. Protect mirror by wrapping with 2x2 gauge (disassemble mirror head)

5. Roll instruments to center of towel

6. Fold ends of towel to center

7. Finish roll

8. Obtain sterilizing bag and mark name, date and contents of bag on front of bag in pencil

9. Place rolled instruments in sterilization bag

10. Fold bag ends twice

11. Tape completely around folded edge of sterilizing bag with indicator tape

12. Place in sterilizing box

STERILIZATION

The primary methods of sterilization of dental instruments and equipment are steam autoclave, chemical vapor and dry heat. The instruments and equipment used in the LCC Dental Hygiene Clinic are sterilized in a steam autoclave.

STEAM AUTOCLAVE

Primary method of sterilization for stainless steel instruments and some expendables.

Process at 132^oC (270^oF) for fifteen minutes; drying cycle requires an additional 20 minutes.

Because a variety of steam autoclaves are available, it is essential that you follow the manufacturer’s instructions for the correct temperature and time to process instruments for sterilization.

Sterilizer Monitoring

Sterilizers are monitored to ensure that they are actually sterilizing instruments and other items. Sterilizer monitoring systems consist of a set of indicators and a record keeping system.

Three types of indicators are used: process indicators, activity indicators and biological monitors. Only a biological monitor provides proof that the contents of the sterilizer have been sterilized.

Process Indicators

The primary purpose of a process indicator is to reveal that a package has been exposed to the sterilant.- It does not mean that the instruments in the package are sterile. Commonly called "autoclave" tape, process indicators have heat-sensitive strips that change color when sterilant is applied, regardless of whether or not the temperature and/or time are insufficient for sterilization.

There are process indicators for steam, chemical vapor and dry heat sterilization. Process indicator tape is usually applied to each pack.

Activity Indicator

Activity indicators signal (by color change) that required conditions for sterilization have been attained inside the sterilizer. Activity indicators also do not signify that the instruments in the pack are sterile.

Activity indicators are used for steam only.

Biologic Monitors

Biologic monitors test sterilizers for their ability to kill bacterial endospores, the most resistant forms of life known. The ADA (Council on Dental Materials, Instruments, and Equipment, 1988) recommends that biologic monitors be used routinely to determine the adequacy of sterilizer function. There are biologic monitors specified for each sterilizer. For most dental practices, biologic monitoring should be done weekly. Larger dental practices and clinics should monitor sterilizing cycles twice a week or as often as daily depending on the volume of instruments sterilized.

At the end of the sterilization cycle, check the activity indicator and record the results in a Sterilization Log Book. Then, handle the biologic monitor as prescribed by the manufacturer. After processing the biologic monitor, record the results in the Sterilization Log Book.

Failure of a Sterilizer

If an indicator system shows that a sterilizer has failed to cycle properly, that is the contents are not sterilized, retrieve all the items processed since the last sterilization date and reprocess. Retest the sterilizer and have it repaired as necessary.

Record keeping

All items sterilized are documented in the Sterilization Log Book, as per previously attached label. Activity indicators for each load are taped in the Sterilization Log Book with the corresponding load. Also logged are the time and temperature chart for each cycle. Record the results of the biologic monitor in the Sterilization Log Book at the end of the incubation period. Maintain all documentation for future reference.

4. SURFACE AND EQUIPMENT DISINFECTION

Disinfection is a process using chemicals to kill most, but not all life forms. Disinfection does not kill spores and some viruses which differentiates it from sterilization.

Surfaces contaminated with blood and saliva must be cleaned and disinfected before the next patient is seated. Although HIV transmission from a contaminated surface has not been documented^[9], surfaces must be disinfected. Studies at the CDC indicate that the number of HIV in blood on surfaces decreases with time, but it is not known how long the virus remains virulent^[10].

Materials

The technique of surface disinfection is quite simple and requires a minimum of experience to become proficient. The items required for disinfection are few.

· EPA approved hospital disinfectant

· Several 4 x 4 gauze sponges

· Heavy-duty, puncture-resistant gloves

· Face mask

· Examination gloves

1. A HOSPITAL DISINFECTANT ^[11]

“Hospital Disinfectants” are generally accepted for disinfecting environmental surfaces. Use a “Hospital Disinfectant” on all operatory surfaces and units; for example, counters and cabinet tops, bracket trays, light handles and lenses, x-ray heads and yokes, and other "touch surfaces" such as unit switches and controls.

Because a variety of disinfectants are available, it is essential that you follow the manufacture's dilution, contact time and temperature recommendations.

A fresh solution (prepared daily) of sodium hypochlorite (household bleach) is an inexpensive and effective alternative germicide. However, because bleach is corrosive to metals, particularly aluminum, exercise caution in its use. The ADA Council on Dental Therapeutics suggest 1:5 to 1:100 dilution for 10 to 30 minutes^[12]. The dilution chosen should also depend on the amount of organic material present on the surface to be disinfected.

2. GAUZE SPONGES (use 4 x 4's only)

Use multiple 4 x 4 sponges on contaminated surfaces. Large 4 x 4's clean more efficiently than smaller 2 x 2's. Discard sponges often so that effective cleaning occurs. Never store gauze in the disinfectant-it will become inactive.

3. HEAVY-DUTY RUBBER GLOVES

Use heavy-duty rubber gloves at all times when disinfecting surfaces and equipment or handling contaminated items. Do not use latex gloves for disinfection and housekeeping tasks in dental operatories. Latex gloves are easily penetrated by sharp objects and edges, especially when haste is important.

4. FACE MASK

Use a dome, ear-loop or a tie-on mask at all times when disinfecting surfaces and equipment. This prevents excessive inhalation of disinfectant when sprayed.

5. PROTECTIVE EYE WEAR

Use protective eye wear as described for all clinical procedures. These will protect eyes from disinfectant spray.

Surface Disinfection

Surface disinfection is a two-step process. Step 1 is the precleaning step. Step 2 is the disinfection step. Both steps are done wearing heavy-duty gloves.

Step 1: Precleaning

Precleaning is essential for effective disinfection. Organic material such as blood, saliva and debris must be removed from surfaces before disinfecting. Organic matter reduces the ability of disinfectant to kill microorganisms. Be very meticulous with precleaning.

PRECLEANING PROCEDURE

1. Spray disinfectant cleaner on several 4 x 4 gauze sponges until saturated. Use several sponges to preclean contaminated surfaces.

2. Preclean surfaces from the top down, starting at the top of lights, cabinets, counters, units, chairs, x-ray and other equipment, and work downward.

Step 2: Disinfecting

Most microorganisms are killed during this process. Be very meticulous with disinfecting.

DISINFECTING PROCEDURE

1. Spray disinfection solution on 4 x 4 gauze sponges until saturated.

2. Wipe with saturated 4 x 4 gauze sponges to ensure complete coverage.

3. Allow surfaces to remain wet and glistening for 10 minutes.

4. Dry surfaces with 4 x 4 sponges if necessary. Leave disinfectant in corners, cracks and crevices for residual effect in difficult to clean and disinfect areas.

5. Spray disinfectant in sinks and leave wet.

6. Remove gloves and wash hands using the two cycle method.

7. Use protective covering on items highly touched during treatment.

Dental Hygiene Clinic Disinfection Protocol

Dental Hygiene Students will thoroughly disinfect the cubicle.

Prior to Each Patient

General

· Preclean and disinfect the surfaces and equipment in each cubicle.

· WORK FROM THE TOP DOWN! Start at the tops of lights, cabinets, counters, units, chairs, and other equipment. Work downward, paying strict attention to detail-be scrupulous, impeccable.

Chair

· Arms and slings

· Headrest and switches must be covered with a disposable barrier

Light

· Handles, switch, lens

· Handles and switch must be covered with a disposable barrier.

Unit

· Handpiece holders and tubing

· Unit controls, switches, and arms

· Tray surface

· HVE, holders and tubing

· Saliva ejector(must be covered with disposable barrier), holder, and tubing

· Air/water syringe(must be covered with disposable barrier), holder, and tubing

· Furniture

· Counter tops

· Soap dispenser pump

· View box switches

· Faucet handles (cover with disposable barrier)

· Stool arms and touch surfaces

· Door handles

· Sinks

After the Appointment

· Dismiss the patient.

· Remove latex gloves and discard.

· Lather and rinse hands two times, 10 seconds each, to remove accumulated transient or extraneous microorganisms and dry with a paper towel.

· Don heavy-duty rubber gloves.

· Consolidate instruments and other items to be sterilized on the tray to be cleaned and wrapped for sterilization.

· Discard sharps: place needles, syringes, anaesthetic carpules, etc., in an OSHA-approved, red sharps container that is located in the sterilization room. NO SHARPS WILL BE DISPOSED IN TRASH RECEPTACLES; IT IS ILLEGAL TO DO SO IN FAYETTE COUNTY.

· Discard all disposable items: tray covers, headrest covers, suction tips, gauze sponges, cotton rolls, etc., in the red bag taped to mobile cart. Discard the red bag into large red infectious waste receptacle located by sterilization room.

· Preclean and disinfect the surfaces and equipment in the cubicle.

NOTE: If for some unexpected reason, a student must move to another cubicle, this disinfection protocol must also be followed in the subsequent operatory.

Evacuator Sanitation

· The high-volume evacuator and saliva ejector must be sanitized at the beginning and end of the day using a hospital-level disinfectant.

· Immerse the ends of the HVE and saliva ejector in the disinfectant.

· Turn on suction and aspirate cleaning solution before the first patient of each day and after the last patient each day.

Water-line Asepsis

Microorganisms accumulate in the water lines of dental units and equipment (such as handpieces, ultrasonic scalers and three-way syringes), between patients and overnight. These microorganisms are then sprayed into the mouth of the patient upon next use. To minimize cross-infection by aspirated infectious matter, cleaning, flushing and disinfecting is required at the beginning of the work day and after each patient.

At the Beginning of Each Workday:

* Flush all water lines (ultrasonic scalers and air/water syringe) for 2 ½ minutes prior to the first use each day.

After each patient:

· Flush contaminated water lines for 30 seconds, and thoroughly scrub equipment with a disinfectant to remove adherent material.

· Wipe equipment with 4 x 4 gauze sponge saturated with a hospital disinfectant for the contact time specified by the manufacturer.

· Use a sterile tip on three-way syringe, ultrasonic scalers, and handpieces for each patient.

5. DENTAL RADIOGRAPHY ASEPSIS

Radiographs should be taken on dental patients using the same infection control standards as for other procedures. This includes personal protection (such as gloves, mask, eye protection, and protective clinic attire), sterilization of equipment and disinfection of surfaces and equipment. (Refer to appropriate sections for these methods as necessary).

Aseptic operating procedures to be used before, during, and after film exposures are as follows:

Technique Asepsis

Prepare radiography room

· Wearing heavy-duty rubber gloves, disinfect chair, x-ray tube head and cone, activator button and power switch on the control panel.

(Note: Spray disinfectant solution once, wipe with 4 x 4 gauze squares.)

· Place protective plastic coverings on chair (headrest and control switches), x-ray tube head and cone, and activator button.

· Remove gloves. Wash hands.

· Gather all necessary items before seating the patient:

· Blue Autoclaving Paper, film mount guide, sterile XCP instruments, film, cotton rolls, bite-wing tabs, elastics, and plastic cup. Everything should be placed on the blue autoclaving paper - not on the counter top.

· Seat patient and place lead apron on patient.

· Wash hands. Put on gloves, mask and glasses.

Þ When not using Barrier Film Packets:

a. Place exposed film in plastic cup

Þ When using Barrier Film Packets:

a. Place exposed film on disposable towel and wipe dry any excess fluids.

b. Open each envelope at the "V" cut in the center of the barrier packet

c. Hold over the transfer container (plastic cup) and allow the film packet to drop out.

d. Do not touch the transfer container of the film packet with contaminated gloves.

e. Dispose of barrier packet envelope as clinical waste.

· Remove mask, gloves, glasses.

· Wash hands.

· Remove lead apron from the patient.

· Re-glove.

· Transport plastic cup containing films into darkroom.

Processing Asepsis

Darkroom Processing

Þ When not using Barrier Packet Films:

a. Open film packets, taking care not to touch films and let films fall onto clean disposable surface.

b. Remove gloves and wash hands.

c. Send clean films through processor.

Þ When Using Barrier Film Packets:

a. Open film packets with clean hands/gloves

b. Send clean films through processor

Þ Retakes should be taken using the same guidelines.

· Dismiss patient.

· Remove protective coverings and disinfect.

· Disassemble XCP instruments and place in ultrasonic cleaner. (Refer to appropriate section.)

· Package XCP instruments in sterilizing bags and identify. Place in designated autoclaving container.

6. LABORATORY ASEPSIS

Due to the potential for injury in the lab, students are strongly urged to consider the following general safety precautions when working in the lab:

· Remove all rings and/or jewelry.

· Wear safety glasses.

· Wear a lab coat over street clothes and/or uniform.

· Pull long hair back or pin‑up out of the working zone.

Lab Procedures

Disinfecting Alginate Impressions

· Use protective clothing, masks, glasses, and gloves when handling contaminated impressions.

· Perform the initial cleaning of the impression in the operatory immediately after the impression is removed from the mouth.

· Remove saliva, blood, and debris from the impression with running tap water. Gently shake the impression to remove excess water.

· Immerse the impression and the wax bite registration in hypochlorite solution (1.0%) or spray with a glutaraldehyde solution (0.13%) and leave for at least 10- 30 minutes. This can be accomplished in a sealed plastic bag which is then discarded.

· Rinse the impression under running water.

· Carefully discard disposable items (gloves, masks, wipes, plastic bags) in proper OSHA approved impervious plastic bags.

· Thoroughly clean and rinse metal impression trays with soap and water before autoclaving.

Procedure: Disinfecting Stone Casts

· Immerse cast in sodium hypochlorite (5.25%) solution saturated with dental stone for one hour, or

· Immerse cast in solution of glutaraldehyde (0.13%) saturated with dental stone for 30 minutes, or

· Although we do not have this option available, one could place the cast in a Chemiclave for one complete cycle (according to manufacturer's directions).

7. LEGAL IMPLICATIONS

The legal implications of the Aids epidemic are critical to dentistry. Legal statutes vary from state to state compounded by exclusionary statements and conflicting state dental practice acts. While several AIDS-related legal cases are pending, as of 1989 relatively few legal decisions have been made and many areas remain gray.

Because the legal issues concerning AIDS are being decided for the first time in the courts, dental professionals are advised to seek expert legal counsel when a questionable circumstance arises involving an AIDS-related situation.

The legal issues pertaining to infection control in dentistry include the following:

· Liability for transmission

· Infected dental workers

· Refusal to treat

Liability for transmission

Dental professionals who do not use proper infection control gamble on the transmission issue. They argue that their chances of treating an HIV -infected patient are very low. Actually, it is likely that any given dental professional will at some time treat an HIV -infected patient.

CDC guidelines on HIV transmission advise all dental professionals to use universal precautions with all patients^[13]. It is the duty of all dental professionals to use infection control guidelines^[14]. Dental professionals who do not use infection control are playing AIDS roulette, possibly threatening themselves, their staff, their patients and their families.

Liability to staff

If an employee contracts an infectious disease and can trace its cause to the work environment, the dentist employer is responsible under the worker's compensation laws. The employee would not be required to prove negligence or fault of the dentist employer^[15].

Liability to patients

Cases of liability to patients rely on the malpractice standards--was there a breach of duty (negligence), and if so, did the breach of duty result in injury to the patient? The primary issue is whether an HIV -infected dental professional is negligent for treating patients in an infected state. The pivotal issue may be infection control.

It is likely that a court or jury would find that a reasonably prudent dental worker under the circumstances would or should have followed CDC guidelines for infection control. A case of an infected dental professional who does not follow CDC guidelines for infection control would most likely result in liability to the worker^[16].

APPENDIX A

LEXINGTON COMMUNITY COLLEGE

DENTAL HYGIENE PROGRAM POLICY

MANAGEMENT OF EXPOSURES TO

BLOOD BORNE PATHOGENS^[17]

GENERAL INFORMATION

The Lexington Community College will pay for serologic testing and medical follow-up for all patients and university employees who may have a possible blood borne exposure to HBV or HIV. The University does not however, pay for expenses incurred by students in this regard. Full time students pay for university health insurance as part of their semester fees and are therefore protected. Part-time students may not take advantage of this option. It is therefore strongly recommended that these students acquire some medical insurance coverage as the college is not responsible for any student cost related to a potential exposure.

If a student or clinical faculty member has a parenteral (e.g., needle stick or cut) or mucous membrane (e.g., splash or splatter to the eye or mouth) exposure to blood and oral secretions, or has a cutaneous exposure involving large amounts of blood or prolonged contact with blood -- especially when the exposed skin is chapped, abraded, or afflicted with dermatitis -- the source patient should be informed of the incident. Consent for serological testing for HIV infection should be requested.

If the source patient consents to be tested and is found to have AIDS, is positive for the HIV antibody, or refuses to be tested, the exposed person should be counseled by the Coordinator of the Dental Hygiene Program regarding the risk of infection. The protocol is as follows:

· The exposed individual will be advised to be evaluated for exposure by a physician. A serological evaluation should be included to establish a baseline for future reference.

· The exposed person should seek further medical evaluation for any acute febrile illness that occurs within 12 weeks after exposure. Such an illness, particularly one characterized by fever, rash, or lymphadenopathy, may be indicative of recent HIV infection.

· Seronegative results should be retested at 6 weeks, 12 weeks and 6 months post-exposure to determine whether transmission has occurred.

· During this follow-up period, especially the first 6 to 12 weeks post-exposure, when most infected persons are expected to seroconvert, exposed personnel or students should follow U.S. Public Health Service recommendations for preventing transmission of HIV.

No further follow-up of the exposed persons is necessary if the source patient is seronegative and does not engage in HIV high risk behaviors. If the source person is a high risk for HIV infection, a subsequent specimen (e.g., 12 weeks following exposure) may be requested from the source for retesting.

If the source patient cannot be identified or refuses to be tested, decisions regarding appropriate follow-up should be individualized. Continued serologic testing should be considered for any exposed individual who is concerned that he/she may have been infected.

If, on the other hand, a patient has a parenteral or mucous membrane exposure to blood (or other body fluid) from a student or member of the teaching staff, the patient should be informed of the incident. The same procedure outlined above for management of exposures should be followed for both the source and the exposed patient.

APPENDIX B

LEXINGTON COMMUNITY COLLEGE

DENTAL HYGIENE PROGRAM POLICY

INSTRUCTIONS FOR THE EXPOSED PERSON

GENERAL INSTRUCTIONS:

1. If a Lexington Community College clinician is exposed to the blood or other body fluid of another, such that cross infection may have occurred, the exposed individual must notify the Dental Hygiene Program Coordinator of the occurrence.

2. A “Post-Exposure Management Record” will be completed.

3. The source must be informed of the exposure incident and consent requested for serological testing. The Program Coordinator will, with consent, facilitate referral to the source’s primary care provider or other health care facility. The source will be advised of the college’s policy to pay for related expenses of testing and follow-up.

4. If the patient's tests are negative (no BLOOD BORNE infection), generally no further treatment will be required.

5. If the source's test is positive (inferring possible BLOOD BORNE infection), the exposed individual will be notified and appropriate follow-up testing or immunization, or both, will be initiated. The college will pay for all expenses of testing and follow-up for university employees. Students, however, are responsible for their own incurred expenses.

APPENDIX C

LEXINGTON COMMUNITY COLLEGE

DENTAL HYGIENE PROGRAM

MANAGEMENT RECORD FOR

STUDENT EXPOSURE

(Confidential)

1. EXPOSURE INFORMATION

(Name)______________________ SS# ___________________________ was exposed to potentially infectious bodily fluid on (date)_________________.

Circumstances and route of exposure (describe) _____________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

2. SOURCE PATIENT INFORMATION:

Name _______________________ Chart# ________ Telephone #______________

The following apply:

___ Source patient could not be identified (not available or legally precluded).

___ Source patient was identified but refused to contribute blood.

___ Source patient is known HBV and/or HIV infected. (Circle appropriate)

___ Source patient was identified and consented to blood testing. (Results of testing, if legally allowed, are attached hereto).

___ Referred to Employee Health, Department of Medicine Clinic, UK Medical Plaza (257-5365)

___ Referred to private physician

Name:

Address:

Phone #:

3. EXPOSED STUDENT INFORMATION:

Immediately following the exposure incident described above, the Healthcare professional was advised to review the infection control plan “Post Exposure and Follow-up” Section.

The following apply:

___ Student refuses to contribute baseline blood or allow testing.

___ Student agrees to contribute baseline blood (to be stored at least 90 days), but refuses testing.

___ Student agrees to contribute blood and grants permission for testing for HIV-1 and/or hepatitis B antibodies; for prophylaxis; and for follow-up evaluation/treatment.

The incident was evaluated and the following changes are recommended to prevent a recurrence:__________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

4. EXPOSED STUDENT SIGNATURE

___________________________

Date _______________________

5. FOLLOW-UP

Initial treatment information:

Healthcare professional or facility providing care: ___________________________

Student seen on (Date) ________________

Treatment included:

___ Prophylactic treatment

___ Blood drawn

___ Test for human immunodeficiency virus (HIV-1) antibodies

___ Test for hepatitis B virus antibodies

___ Vaccination for hepatitis B

___ Follow-up evaluation and treatment

Did the student choose to share the results with the college?

___ No

___ Yes, if so, see below

Follow-up of Results:

Date of arrival of source patients records: _________

Date of arrival of exposed Students records: _______

Discussion of Results with Exposed Student included:

___ Route(s) and circumstances of exposure.

___ Results of source individual's blood testing (where available).

___ All medical records relevant to treatment, including vaccination status.

___ Healthcare professional's written opinion concerning the incident, and assuring that the Healthcare professional has informed the student of medical conditions resulting from the exposure and of any further evaluations and treatment that are required.

___ Informing the student that all other findings and/or diagnoses are confidential and are not included in the Healthcare professional's written opinion and are not included in any record in the college.

FACULTY signature _________________________ Date _____________

STUDENT signature _________________________ Date _____________

Note: This record shall be indefinitely retained in a confidential file by the program coordinator.

APPENDIX D

LEXINGTON COMMUNITY COLLEGE

DENTAL HYGIENE PROGRAM POLICY

MANAGEMENT OF INFECTED

DENTAL PERSONNEL

GENERAL DISCUSSION

The issue of an infected health care worker or student raises innumerable concerns. Should an infected worker or student be allowed to continue to practice? Can an infected worker perform patient care duties safely without exposing patients or other workers? What are the obligations of an educational program to a student, or employer to a staff member, who is a carrier of serious infectious disease such as AIDS or HBV? Is the employer or school, or the infected worker or student liable if the person is allowed to continue clinical activities and patient contact?

There are currently no clear cut answers to these questions. However, informed consent is a critical issue. Informed consent is the basis of the responsibility of an infected dental worker to inform patients of HIV status. The premise of informed consent requires dental professionals to disclose significant risks of dental procedures to patients. While the risk of contracting HIV may be interpreted by a judge or jury as the type of risk about which a patient should be informed, infection control experts agree that an infected dental worker and patients can be protected as long as strict infection control methods are used.

RISK TO PATIENT

The legal question, and underlying principle of informed consent, is whether an infected worker who complies with infection control poses any material risk of harm to patients and staff. Material risk of harm would require that the worker inform patients of an infectious disease state. Infection control experts^{[18] [19] [20]} agree, however, that an infected dental worker who uses infection control poses no material risk of harm. Therefore, it should be safe legally for an infected dental worker adhering to precautions to continue working without disclosure to other--"Without material risk of harm, there is no need to inform"^[21].

Furthermore, if there is no material risk of harm to patients, the dental employer or program may be obligated to allow an infected worker or student to continue clinical activities as long as the person performs adequately according to institutional policy. The dental employer or educational program may actually be prohibited from restricting the infected person's duties and activities.

RISK TO PATIENT

Dental personnel with impaired immune systems resulting from HIV infection or other causes are at increased risk of acquiring or experiencing serious complications of infectious diseases. Of particular concern is the risk of severe infection following exposure to dental patients with infectious diseases that are easily transmitted if appropriate precautions are not taken (e.g., measles, chickenpox). Any dental personnel with an impaired immune system should be counseled about the potential risk of exposure to other infectious agents. Recommendations of the Centers for Disease Control's Immunization Practices Advisory Committee policies concerning requirement for vaccinating dental personnel with live-virus vaccines (e.g., measles, rubella) should also be considered.

OTHER CONSIDERATIONS

The question of whether dental personnel infected with HIV, who routinely perform invasive procedures, can adequately and safely be allowed to perform patient care duties or whether their work assignments should be changed, or should be allowed to continue working must be determined on an individual basis. These decisions should be made by the dental personnel's physician(s) in conjunction with the college.

A definitive legal precedent is likely to be established in the near future ruling that the standard of care requires dental professionals to use barrier techniques at all times^[22]. The CDC and ADA have recommended the use of barrier techniques for some time. In addition, OSHA recently decided to make barrier techniques mandatory, making them the standard of care.

Employers are encouraged to follow the guidelines below to legally protect themselves and their staff from liability.

Educate staff about disease transmission and its prevention.

Require all employees to use universal precautions with all patients and laboratory cases.

Monitor and document staff training sessions and compliance with infection control policies and exposure protocols.

Dental Practice Acts

Professional activities of an infected dental worker may be limited depending on the state dental practice act. Dental practice acts in several states expressly limit or prohibit the practice of dentistry by those who have or are carriers of infectious diseases, or whose physical illness threatens the patient or the public health and safety^[23]. The applicability of these restrictions may be challenged by an infected dental worker who is physically capable of handling the work and who poses no material risk of harm to others^[24].

Refusal to treat

Historically, dentists have been able to choose whether or not to accept a new patient for treatment. They did not have to worry about a charge of abandonment provided no emergency existed and the individual was not already a patient of record. However, refusal to treat patients solely on the basis of HIV infection violates handicap discrimination laws^[25]. Human rights commissions are filing discrimination charges against dentists who refuse to treat patients with HIV infection.

Discrimination

Discrimination arguments are based on the contention that there is no health risk to dental workers treating HIV -infected patients provided that CDC and ADA infection control guidelines are followed. Without any health risk, there is no legitimate reason for refusal to treat or referral^[26]. Dental professionals who refuse to treat patients solely on the basis of HIV infection may find themselves entangled in a discrimination claim.

Much of the flurry behind the legal implications of the AIDS epidemic for dentistry surrounds the practice of infection control. The preoccupation with transmission through an occupational exposure can be deflected by infection control. Adherence to the CDC and ADA guidelines remains the best means of protection from liability and transmission.

Dental professionals have the unique opportunity to improve their profession and their practices before legal precedents are set. Considering the cost-effectiveness of infection control precautions, it behooves every dental professional to strictly adhere to CDC and ADA guidelines to protect themselves from occupational transmission of infectious diseases and legal entanglements.

CONCLUSION

Standards of care must be universally applied concepts and practices in health care settings. Infection control can help promote and maintain these standards. Because infection control provides protection from disease transmission, discriminatory choices about treating infected patients are no longer valid.

Infection control for dental professionals is the most effective way to minimize occupational transmission of HIV and other blood-and body fluid-borne pathogens. Infection control is a relatively simple and inexpensive process by which to protect yourself, staff and patients from potential infection and liability.

The CDC, ADA and OSHA published infection guidelines recommended for dentistry. These guidelines are consistent among the recommending agencies and studies consistently demonstrate the routine use of infection control methods by all dental professionals with all patients markedly reduces the risk of occupational transmission. The fear of contagion can be directly addressed and put to rest as health care workers more clearly understand the modes of HIV transmission and use infection control methods to reduce the risk of contagion.

APPENDIX E

INFECTION CONTROL CHECKLIST^[27]

GENERAL CONSIDERATIONS FOR ALL CLINICIANS

Immunizations

· All dental health care workers should have appropriate immunizations such as that for hepatitis B virus.

Prior to Patient Treatment

· Obtain a complete and thorough medical history.

· Disinfect prostheses and appliances received from the dental laboratory.

· Place disposable coverings on equipment and surfaces difficult to disinfect.

· Disinfect equipment and surfaces (before the first patient contact and after each contact thereafter).

During Patient Treatment

· Treat all patients as potentially infective.

· Use protective attire and barrier techniques when indicated.

wear gloves

wear a mask

wear protective eyewear

wear uniforms, laboratory coats, or gowns

· Open contaminated x-ray film packets in the dark room wearing disposable gloves without touching the film itself.

Þ Ideally, film with the Barrier Packets is used to prevent contaminated films from entering the darkroom.

· Minimize the formation of aerosols, spatter and splashes.

use a rubber dam when possible

use high volume evacuation

· Protect your hands.

wash hands before gloving and after removing gloves

change gloves between each patient

discard gloves that are torn, punctured or cut

avoid hand injuries

· Avoid injury with sharp instruments and needles.

handle sharp items carefully

do not bend or break disposable needles

if needles are not recapped, place in a safe area in a sterile field

if needles are recapped, use a safe method to protect your hands from accidental injury

place sharp items in appropriate containers

After Patient Treatment

· Wear heavy duty/utility rubber gloves for cleaning and decontamination.

· Clean instruments thoroughly.

· Sterilize instruments.

sterilize all instruments if possible. Use appropriate disinfection when sterilization is not possible.

monitor the sterilizer using biological monitors (weekly biological monitoring of sterilizers is adequate for most dental practices.)

· Clean handpieces, dental units, and ultrasonic scalers.

flush handpieces, dental units, ultrasonic scalers, and air/water syringes between patients

clean and sterilize handpieces, air/water syringes tips and ultrasonic scalers between patients if possible, otherwise disinfect them

· Handle sharp instruments and items carefully.

place disposable needles, scalpels, and other sharps into puncture-resistant sharps containers before disposal

· Decontaminate environmental surfaces.

remove debris with an absorbent toweling and dispose of the toweling appropriately

disinfect with a suitable chemical germicide

change protective coverings on light handles, x-ray units heads and other surfaces covered

· Decontaminate supplies and materials.

rinse and disinfect impressions, bite registrations and appliances to be sent to the dental laboratory

· Communicate your infection control program to the dental laboratory.

· Remove contaminated waste appropriately.

pour blood, suctioned fluids, and other liquid waste into a drain connected to a sanitary sewer

place solid waste contaminated with blood or saliva in sealed, sturdy impervious bags and dispose of according to local government regulations

· Remove utility gloves and wash hands.

APPENDIX F

LEXINGTON COMMUNITY COLLEGE

NATURAL SCIENCES AND HEALTH

TECHNOLOGIES DIVISION

HEALTH RISK INFORMATION STATEMENT

Please note the following health risks (and the respective protective actions) associated with health care delivery. In addition, there may be other health risks associated with your chosen health field. Therefore, it is imperative that you take responsibility to protect yourself.

Health Risk Suggested Action

TB PPD Skin Test + or -

Hepatitis Vaccine (Recombivax)

Rubella Rubella Titer/Vaccine (if needed)

HIV Universal Precautions

STUDENT VERIFICATION OF RISK NOTIFICATION

I hereby verify that I have been advised by Dental Hygiene faculty of the Lexington Community College regarding health risks and the suggested protective actions associated with my chosen health career. I realize that it is my personal responsibility to decide if I will follow these suggested actions and to remain informed of future risks and/or protective therapeutic advances.

_________________________________ _______________

Student's Signature Date

APPENDIX G

LEXINGTON COMMUNITY COLLEGE

DENTAL HYGIENE PROGRAM

NEEDLE STICK POLICY FOR

UNIVERSITY EMPLOYEES

Post exposure evaluation and follow-up: Following a report of an exposure incident, the college shall make available to exposed individuals a confidential medical evaluation and follow-up and provide appropriate prophylaxis to prevent HBV infection (e.g., administration of HBV vaccine and/or hepatitis B immune globulin).

GUIDELINES:

1. Documentation of the route(s) of exposure, HBV and HIV antibody status of the source patient(s) (if known), and the circumstances under which the exposure occurred.

2. The college shall assure that all medical evaluations and procedures are performed by or under the supervision of a licensed physician and that all laboratory tests are conducted by an accredited laboratory.

3. The college shall assure that all evaluations, procedures, vaccinations, and post-exposure management are provided according to standard recommendations for medical practice.

HBV VACCINATION:

1. HBV vaccination shall be offered unless the exposed individual has a previous HBV vaccination or unless antibody testing has revealed immunity. If the individual initially declines HBV vaccination but at a later date (while still covered under the CDC standard) decides to accept the HBV vaccine, the college shall provide the vaccine at that time. Should a booster dose(s) be recommended at a future date, such booster dose(s) shall be provided according to standard recommendations for medical practice.

2. HBV antibody testing shall be made available to an exposed individual who desires such testing prior to deciding whether or not to receive HBV vaccination. If immunity to HBV is found, then the college is not required to offer the HBV vaccine.

3. If the source patient grants permission for testing, the source patient's blood will be evaluated to determine the presence of HIV or HBV infection.

4. Collection of blood from the exposed individual will occur as soon as possible after the exposure incident to determine HIV and/or HBV status. (Actual antibody or antigen testing of the blood or serum sample may be done at that time or at a later date if the employee so requests.)

5. Follow-up, including antibody or antigen testing, counseling, illness reporting, and safe and effective post-exposure prophylaxis, according to standard recommendations for medical practice will occur.

INFORMATION PROVIDED TO THE PHYSICIAN

The college will provide the following information to the evaluating physician.

1. A copy of this regulation and,

2. A description of the affected individual's duties as they related to the exposure.

PHYSICIAN'S WRITTEN OPINION

The college shall obtain and provide the individual with a copy of the evaluating physician's written opinion upon completion of the evaluation. The written opinion shall be limited to the following information:

1. The physician's recommendation regarding hepatitis B vaccination.

2. A statement that the individual has been informed of the results of the medical evaluation and that he/she has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

3. Specific findings or diagnoses, which are related to the desirability to receive HBV vaccination. Any other findings and diagnoses shall remain confidential.

---

^[1] 1987, MMWR, 36(2S); 1988, MMWR, 37(24)

^[2] 1988, JADA, 116

^[3] CDC, 1988, MMWR, 37(24)

^[4] Otis & Cottone, 1989

^[5] CDC, 1987, MMWR, 36(19)

^[6] CDC, 1988, MMWR, 37(4S)

^[7] CDC, 1987, MMWR, 36(2S)

^[8] Jagger, et al. 1988

^[9] CDC, 1987, MMWR, 36(2S)

^[10] CDC, 1988, MMWR, 27(4S)

^[11] Disinfectant is defined as a germicidal chemical that is registered with the E.P.A. as a "hospital disinfectant."

^[12] ADA, 1988, "Facts..."

^[13] CDC, 1988, MMWR, 37(24)

^[14] DOL, DHHS, 1987

^[15] (Logan, 1987)

^[16] Logan, 1987

^[17] Modified from Centers for Disease Control and Prevention “Recommendations for Prevention of HIV Transmission in Healthcare Settings”,MMWR 1987; 36(2S).

^[18] ADA, 1987, "Infection Control: Fact and Reality"

^[19] CDC, 1987, MMWR, 37(2S)

^[20] American Hospital Association, 1987

^[21] Logan, 1987

^[22] Logan, 1987

^[23] ADA News, 1987

^[24] Logan, 1987

^[25] Personnel Manager's Legal Reporter, 1988

^[26] Logan, 1987

^[27] ADA, 1988, Infection Control: Fact and Reality