Infectious Control Practices for a Dental Office

1. Infectious Control Practicesfor a Dental Office Presented by: Thomas J. Weber, Esquire Goldberg Katzman, P.C. P.O. Box 6991 | Harrisburg, PA 17112 (717) 234-4161 | (717) 234-6808 - fax tjw@goldbergkatzman.com Hosted by:

2. 49 Pa. Code § 33.211 (a)(7) Failing to follow current infection control recommendations issued by the Federal Centers for Disease Control or to ensure that auxiliary personnel and other supervisees follow these Federal guidelines. In effect since prior to 2000.

3. Centers for Disease Control and Prevention (CDC) • Guidelines for Infection Control in Dental Health Care Settings - - - 2003 • 11 years old So why address now…?

4. April 18, 2013 • “At least 60 people have tested positive for hepatitis or HIV after visiting an Oklahoma dentist slammed by the state dental board for poor sterilization practices, the Tulsa Health Department said today.” • A surprise inspection of [the dentist’s] practice on March 18 was prompted by a patient’s positive test…revealed the use of old needles and rusty instruments. Since then…

5. At least three Pennsylvania dentists have been disciplined. • At least one family practice doctor and a group practice have been disciplined. • At the State Dental Board meeting September 5, 2014, two consent agreements were presented to the Board for consideration. • Incidents usually produce a great deal of publicity and an emergency suspension of the practitioner’s license.

6. CDC Covers a Broad Range of Practices and Procedures • Personnel health elements • Blood borne pathogens • Hand hygiene • Personal protective equipment • Sterilization and disinfection • Latex hypersensitivity/Contact Dermatitis • Environmental infection control • Dental unit waterlines • Training and procedures

7. In an hour, we hope to: • Highlight the most important aspects of each element • Help identify potential problem spots in your office • Provide a tool for training • Establish a protocol for inspection and recordkeeping

8. Overriding General Theme Use Standard (universal) Precautions • Hand washing • Use of gloves, masks, eye protection and gowns • Patient care equipment (instruments) • Environmental surfaces (counters) • Injury prevention

9. Intended to Prevent the Spread of OrganismsSpread by Blood and also: • Body fluids, secretions and excretions, except sweat (whether or not they contain blood) • Non-intact (broken) skin • Mucus membranes

10. Personnel Health Elements • Education and training • Immunizations (strongly recommended) • Hepatitis B • Influenza • Measles • Mumps • Rubella • Varicella-zoster • Exposure prevention and post-exposure management • Medical condition management and work-related restrictions • Health record maintenance

11. Bloodborne Pathogens Risk Factors • Frequency of infection among patients • Risk of transmission after a blood exposure (type of virus) HBV, HCV, HIV • Type and frequency of blood contact

12. Characteristics of Percutaneous Injuries in Dental Setting • Reported frequency among general dentists declining • Caused by burs, syringe needles, other sharps • Occur outside the patient’s mouth • Small amounts of blood • OMS – fracture reductions and procedures involving wire

13. Precautions • Use sharps containers • Self-sheathing needles • Use instruments instead of fingers to retract or palpate tissue • One-handed needle recapping

14. Post-Exposure Protocol • Education available for health care personnel • Access to: • Clinical care • Post-exposure prophylaxis • Testing of source

15. Hand Hygiene • Hands are the most common mode of pathogen transmission • Clean: • Visibly dirty • After touching contaminated objects • Before and after each patient treatment

16. Degrees of Hand Hygiene • Routine hand wash • Plain soap and water: 15 seconds • Antiseptic hand wash • Antimicrobial soap and water: 15 seconds • Antiseptic hand rub • Alcohol based hand rubs: until hands are dry • Surgical antisepsis • Antimicrobial soap and water: 2-6 minutes (forearms) • Plain soap and water followed by alcohol-based surgical scrub: manufacturer’s instructions

17. Hand Hygiene Other Considerations • Storage • Alcohol based away from flames • Do not “top off” • Keep fingernails short • Avoid artificial nails or jewelry that may tear gloves • Consider compatibility between hand lotions and gloves

18. Personal Protective Equipment • Trying to protect skin and mucus membranes from splashes or sprays • Remove protective gear when leaving the treatment area

19. Types of Protective Materials • Surgical mask or eye protection OR • Face shield • Clean reusable face protection between patients • If soiled, clean and disinfect • Change masks in between patients (do not wear as a necklace)

20. Clothing • Gowns/lab coats • Should cover personal clothing • Change if visibly soiled • Remove before leaving work area

21. Gloves • Not a replacement for hand washing • New pair for each patient • Change if tear noticed • Do not wash or disinfect for reuse • Be aware of sensitivity/allergy concerns of both wearer and patient (health history)

22. Sterilization and Disinfection • Critical Instruments • Penetrate mucus membranes or contact bone, the bloodstream or other normally sterile tissues of the mouth • Heat sterilize between uses or use single-use, disposable devices • Scalpel blades, periodontal scalers, surgical burs

23. Semi-Critical Instruments • Contact mucus membranes but do not penetrate • Heat sterilize or high-level disinfectants • Dental mirrors, amalgam condensers, dental handpieces

24. Non-Critical Instruments and Devices • Contact intact skin • Use low to intermediate level disinfectant • X-ray heads, pulse oximeter, blood pressure cuff

25. Instrument Processing Area • Have a designated area – it helps maintain integrity of protocol and assists with training and performance • Receiving, cleaning and decontamination • Preparation and packaging • Sterilization • Storage

26. Automated Cleaning • Ultrasonic cleaner • Instrument washer • Washer-disinfector Follow manufacturer’s specifications

27. Manual Cleaning • Soak until ready • Wear protective materials: • Mask • Eyewear • Utility gloves

28. Preparation and Packaging • Wrap or place critical and semi-critical items in containers prior to heat sterilization • Hinged instruments should be opened and unlocked • Place chemical indicator in package or container • Use utility gloves

29. Heat-Based • Autoclaving – steam under pressure • Dry heat • Unsaturated chemical vapor (DEP concerns) • Use FDA approved equipment • Follow manufacturer’s recommendations for equipment, packaging, loading… • Dry/cool inside the machine

30. Unwrapped Instruments • Sterilize unwrapped instruments only if: • They have been thoroughly cleaned and dried • Mechanical monitors are checked and chemical indicatorsused for each cycle • Care is given to avoid heat injury • Items transported aseptically to point of use • Never store critical instruments unwrapped • Storage of unwrapped semi-critical instruments is discouraged. If done, should have clear protocol in place and follow it

31. Liquid Chemical Sterilant/Disinfectant • Only for heat-sensitive critical and semi-critical devices • Use only FDA approved material and post-sterilization steps • Rinse with sterile water • Handle with sterile gloves and dry with sterile towels • Deliver to point of use in aseptic manner If stored before use, needs to be re-sterilized.

32. Liquid Chemical Sterilant/Disinfectant Cont’d. • Follow manufacturer specifications as to: • Dilution • Immersion time • Temperature • Safety precautions must be followed • Not typically used for critical instruments • Use discouraged

33. Other Forms of Sterilization • Low temperature • Not practical for private office setting • Bead sterilizers – use at your own risk

34. Sterilization Monitoring • Mechanical • Cycle time • Temperature • Pressure • Chemical indicators • Internal indicator should be placed in every package • External – if internal cannot be seen from outside package • Manufacturer specifications

35. Sterilization Monitoring Cont’d. • Biological indicators • At least weekly • Every load containing implantable material • Use a control BI from same lot • Use BI’s whenever: • A new type of packaging material or tray is used • After training new sterilization personnel • After repair • After change in loading procedures

36. What to do if Positive BI • If mechanical and chemical indicators were ok: • If implantable – recall • If not, repeat spore test using same cycle • If negative and operating procedures were correct, return sterilizer to service. • If positive, do not use until inspected and repaired – and three consecutive empty chamber negative results • Document results of biological and monitoring sterilization

37. Storage • Use date or event-related shelf-life practices: event – torn – wet (still record date) • Record machine • Clean, dry, closed environment • Examine wrapping carefully – if damaged, re-clean, wrap, sterilize

38. Environmental Infection Control • Clinical contact surfaces • High potential for direct contamination from spray, splatter or hand • Housekeeping surfaces • Walls, floors, ceilings, sinks Everything else Clinical

39. Cleaning • Use appropriate barrier precautions • Elbow grease is as important as the disinfection process • EPA- registered hospital disinfectants – manufacturer • Do not use chemicals used in sterilization process

40. Clinical Contact • Surface barriers changed in between patients OR • Clean then disinfect using EPA-registered low to intermediate-level hospital disinfectant

41. Housekeeping Surfaces • Routinely use soapy water or EPA detergent • Clean mops and cloths – allow them to dry • Prepare cleaning and disinfecting solutions daily – manufacturer • Avoid carpet – upholstery in treatment areas

42. Medical Waste • Medical waste – not considered infectious, discard with regular trash (98-99%) • Regulated medical waste – potential risk of infection during handling and disposal (1-2%) • Solid waste soaked with blood or saliva • Extracted teeth • Surgically removed hard or soft tissues • Contaminated sharps • Biohazard bag – sharps container

43. Dental Unit Waterlines • For routine dental treatment – water has to meet standards for drinking water • <500 CFU/mL • How to maintain • Independent reservoirs • Chemical treatment • Filtration • Sterile water delivery system • Monitor – test • Use sterile saline or water as irrigator

44. Special Considerations • Dental Hand pieces • Clean and heat sterilize intraoral removable devices • Do not use liquid germicides • Follow manufacturer’s instructions

45. Components Permanently Attached • Use barriers and change between uses • Clean and use intermediate-level disinfect for the surface of devices if visibly contaminated • Saliva ejectors • Advise patients to not close their lips around the top

46. Parenteral Medications • IV tubing, bags, connections, needles and syringes are single-use, disposable • Single dose vials • Do not administer to multiple patients even if the needle is changed • Do not combine leftovers

47. Oral Surgical Procedures • Biopsy, periodontal surgery, implants, surgical extractions • Surgical scrub • Sterile surgeon’s gloves • Sterile irrigating solutions (and delivery system)

48. Infectious Disease Protocol • Develop standard operating procedures • Evaluate • Document/checklists • Monitor health care-associated infections

49. Miscellaneous • Radiology • Pre-procedural mouth rinses • Handling biopsy specimens • Place in sturdy, leak-proof container • Label with biohazard • Extracted teeth - Regulated Medical Waste • Do not incinerate if they contain amalgam • Clean/disinfect before sending to lab • Can give to patient • Dental laboratories

50. Miscellaneous Cont’d. • TB • Health history • Defer elective treatment • Wear mask/separation • Creutzfeldt-Jakob Disease (CJD) and varient CJD • Single use items • Consider difficult items to clean (endo files) single use • Keep instruments moist until cleaned • Autoclave at 134° for 18 minutes