INFECTION CONTROL MANUAL*
DENTAL HYGIENE PROGRAM
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
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.
|
? |
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
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
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
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
D. Hand Washing
Hand
washing is one of the most important infection control methods to reduce
cross-infection. The CDC and
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
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.
*
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.
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.
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.
* 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.
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 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.
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.
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.
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 -
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.
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.
Primary
method of sterilization for stainless steel instruments and some expendables.
Process
at 132oC (270oF) 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.
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
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 test sterilizers for their ability to kill bacterial endospores, the most resistant forms of life known. The
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.
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.
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
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
·
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.
Ž
When
not using Barrier Film Packets:
a. Place
exposed film in plastic cup
Ž
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.
Darkroom Processing
Ž
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.
Ž
When
Using Barrier Film Packets:
a. Open film packets with clean
hands/gloves
b. Send clean films through
processor
Ž
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
DENTAL HYGIENE PROGRAM POLICY
MANAGEMENT OF
EXPOSURES TO
BLOOD BORNE PATHOGENS[17]
GENERAL INFORMATION
The
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
DENTAL HYGIENE PROGRAM POLICY
INSTRUCTIONS FOR THE EXPOSED PERSON
GENERAL INSTRUCTIONS:
1. If
a
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
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
___
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
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
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
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
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
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,
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.
Ž
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
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
_________________________________ _______________
Student's
Signature Date
APPENDIX G
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]
[13] CDC, 1988, MMWR, 37(24)
[14] DOL, DHHS, 1987
[15] (
[16]
[17] Modified
from Centers for Disease Control and Prevention “Recommendations for Prevention
of HIV Transmission in Healthcare Settings”,MMWR
1987; 36(2S).
[19] CDC,
1987, MMWR, 37(2S)
[20]
[21]
[22]
[23]
[24]
[25] Personnel Manager's Legal Reporter,
1988
[26]
[27]