TOSHA for the Dental Office

1. TOSHA for the Dental Office Mitchell Cothran

2. TOSHA believes the information in this presentation to be accurate and delivers this presentation as a community service. As such, it is an academic presentation which cannot apply to every specific fact or situation; nor is it a substitute for any provisions of 29 CFR Part 1910 and/or Part 1926 of the Occupational Safety and Health Standards as adopted by the Tennessee Department of Labor and Workforce Development or of the Occupational Safety and Health Rules of the Tennessee Department of Labor and Workforce Development.

4. Topics To Be Covered 1) Bloodborne/Waterborne/Airborne Disease Transmission 2) Barrier Precautions 3) Needlestick Precautions 4) Disinfection/Sterilization 5) Infection Control 6) Universal Precautions

5. 9 Million Persons Work in Health-Care Professions • 168,000 dentists, • 112,000 registered dental hygienists, • 218,000 dental assistants • 53,000 dental laboratory technicians • Dental health-care personnel (DHCP) refers to all paid and unpaid personnel in the dental health-care setting who might be occupationally exposed to infectious materials, including body substances and contaminated supplies, equipment, environmental surfaces, water, or air.

6. Pathogenic Microorganisms • Dental patients and DHCP can be exposed to pathogenic microorganisms including: • HBV, HCV, • herpes simplex virus types 1 and 2, • HIV, • Mycobacterium tuberculosis, • staphylococci, streptococci, and other viruses and bacteria that colonize or infect the oral cavity and respiratory tract.

7. Organism Transmission 1) Direct contact with blood, oral fluids, or other patient materials; 2) Indirect contact with contaminated objects (e.g., instruments, equipment, or environmental surfaces); 3) Contact of conjunctival, nasal, or oral mucosa with droplets (e.g., spatter) containing microorganisms generated from an infected person and propelled a short distance (e.g., by coughing, sneezing, or talking); and 4) Inhalation of airborne microorganisms that can remain suspended in the air for long periods

8. Conditions Necessary For Infection To Occur • A pathogenic organism of sufficient virulence and in adequate numbers to cause disease; • A reservoir or source that allows the pathogen to survive and multiply (e.g., blood); • A mode of transmission from the source to the host; • A portal of entry through which the pathogen can enter the host; and • A susceptible host (i.e., one who is not immune)

9. Standard Precautions • Standard precautions apply to contact with: 1) blood; 2) all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood; 3) non-intact skin; and 4) mucous membranes. • Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between universal precautions and standard precautions. • Standard precautions include use of PPE (e.g., gloves, masks, protective eyewear or face shield, and gowns) intended to prevent skin and mucous membrane exposures. Other protective equipment (e.g., finger guards while suturing) might also reduce injuries during dental procedures

11. Hierarchy of Controls • Engineering controls that eliminate or isolate the hazard • puncture-resistant sharps containers and • safety sharp devices are the primary strategies for protecting DHCP and patients • Work-practice controls that result in safer behaviors • one-hand needle recapping • not using fingers for cheek retraction while using sharp instruments or suturing and use of • Personal protective equipment (PPE) • protective eyewear, gloves, and mask

13. Preventing Exposures to Blood and OPIM • Use standard precautions (OSHA's bloodborne pathogen standard retains the term universal precautions) for all patient encounters • Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries • Implement a written, comprehensive program designed to minimize and manage DHCP exposures to blood and body fluids

14. Exposure Vrs Exposure Incident • Exposure • Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties • Exposure Incident • Through percutaneous injury (a needlestick or cut with a sharp object), • Through contact between potentially infectious blood, tissues, or other body fluids and mucous membranes of the eye, nose, mouth, • Non-intact skin (exposed skin that is chapped, abraded, or shows signs of dermatitis)

15. Percutaneous Injuries 1) Occur outside the patient's mouth, thereby posing less risk for re-contact with patient tissues; 2) Involve limited amounts of blood; and 3) Are caused by burs, syringe needles, laboratory knives, and other sharp instruments • Injuries among oral surgeons occur more frequently during fracture reductions using wires • Experience does not affect risk of injury among general dentist or oral surgeon

16. Engineering Controls • The primary method to reduce exposures to blood and OPIM from sharp instruments and needles • Are frequently technology-based and often incorporate safer designs of instruments and devices • self-sheathing anesthetic needles • dental units designed to shield burs in handpieces to reduce percutaneous injuries

17. Work Practice Controls • Establish practices to protect DHCP whose responsibilities include handling, using, assembling, or processing sharp devices (e.g., needles, scalers, laboratory utility knives, burs, explorers, and endodontic files) or sharps disposal containers. • can include removing burs before disassembling the handpiece from the dental unit, • restricting use of fingers in tissue retraction or during suturing and administration of anesthesia • minimizing potentially uncontrolled movements of such instruments as scalers or laboratory knives

18. Work Practice Controls for Sharps • Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to where the items were used • Never recap used needles or otherwise manipulate by using both hands, or any other technique that involves directing the point of a needle toward any part of the body • Use a one-handed scoop technique, a mechanical device designed for holding the needle cap to facilitate one-handed recapping, if an engineered sharps injury protection device is not available or appropriate for recapping needles between uses and before disposal • Never bend or break needles before disposal because this practice requires unnecessary manipulation • For procedures involving multiple injections with a single needle, the practitioner should recap the needle between injections by using a one-handed technique or use a device with a needle-resheathing mechanism. • Passing a syringe with an unsheathed needle should be avoided because of the potential for injury.

20. Personal Protective Equipment • Designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of DHCP from exposure to blood or OPIM. .

21. Personal Protective Equipment • Gloves, surgical masks, protective eyewear, face shields, and protective clothing (e.g., gowns and jackets). • All PPE should be removed before DHCP leave patient-care areas • Reusable PPE (e.g., clinician or patient protective eyewear and face shields) should be cleaned with soap and water, and when visibly soiled, disinfected between patients, according to the manufacturer's directions • Wearing gloves, surgical masks, protective eyewear, and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by OSHA • General work clothes (e.g., uniforms, scrubs, pants, and shirts) are neither intended to protect against a hazard nor considered PPE

22. Masks, Protective Eyewear, Face Shields • A surgical mask that covers both the nose and mouth and protective eyewear with solid side shields or a face shield should be worn during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids. • The mask's outer surface can become contaminated with infectious droplets from spray of oral fluids or from touching the mask with contaminated fingers

24. Gloves and Gloving • Wear gloves to prevent contamination of hands when touching mucous membranes, blood, saliva, or OPIM • Reduces the likelihood that microorganisms present on the hands will be transmitted to patients during surgical or other patient-care procedures • Medical gloves, both patient examination and surgeon's gloves, are manufactured as single-use disposable items that should be used for only one patient, then discarded. • Gloves should be changed between patients and when torn or punctured • Wearing gloves does not eliminate the need for handwashing • Gloves can have small, unapparent defects or can be torn during use, and hands can become contaminated during glove removal • In addition, bacteria can multiply rapidly in the moist environments underneath gloves • The hands should be dried thoroughly before donning gloves and washed again immediately after glove removal.

25. OSHA On Sharps • 2001-Revised Bloodborne Pathogens Standard • Clarify the need for employers to consider safer needle devices as they become available and to involve employees directly responsible for patient care (e.g., dentists, hygienists, and dental assistants) in identifying and choosing such devices

27. 800,000 Needlestick Injuries Occur Each Year in the United States

28. Needlestick Injuries Are Underreported by Health Care Workers • Reasons for underreporting: • Lack of time • Employer response • Fear of HIV

29. Viral Hepatitis - Overview Type of Hepatitis A B C D E Source of feces blood/ blood/ blood/ feces virus blood-derived blood-derived blood-derived body fluids body fluids body fluids percutaneous percutaneous Route of fecal-oral percutaneous fecal-oral permucosal transmission permucosal permucosal Chronic no yes yes yes no infection pre/post- Prevention blood donor pre/post- ensure safe pre/post- exposure exposure screening; exposure drinking risk behavior water immunization immunization immunization; modification risk behavior modification

30. HIV • You might have HIV and still feel perfectly healthy • The only way to know for sure if you are infected or not is to be tested

31. Relative Risks of Infection After Exposure • HBV 2-40% • HCV Average 1.8% • HIV Average 0.3%

32. Do Safer Needle Devices Prevent Injury? • Can’t eliminate all, but… • 83% can be prevented Source: Ippolito, et. al., 1997

36. Engineered Sharps Injury Protection • Identify, evaluate, and select devices with engineered safety features at least annually and as they become available on the market (e.g., safer anesthetic syringes, blunt suture needle, retractable scalpel, or needleless IV systems)

37. Sterilization/Disinfection • Single-use disposable instruments are acceptable alternatives if they are used only once and disposed of correctly • Ensure that reusable equipment is decontaminated with a tuberculocidal EPA-registered disinfectant

38. Place biohazard symbol here

40. Sterilization/Disinfection • Designate a central processing area • Train employees to use proper work practices to prevent contamination of clean areas • Minimize handling of loose contaminated instruments during transport to processing area and carry instruments in a covered container • Clean all visible blood and other contamination from instruments and devices before sterilization or disinfection • Minimize contact with sharp instruments if manual cleaning is necessary—NEVER reach by hand into containers of contaminated instruments/devices

42. Sterilization/Disinfection Prepare fresh when needed Develop a written schedule for cleaning of possibly contaminated surfaces

43. How Do You Clean This?

44. Regulated Waste • Discard contaminated items in leak-proof labeled container • Disposed of according to Tennessee Department of Environment and Conservation Rules (615-532-0796)

45. Hepatitis B Vaccination • Take the vaccination that is offered to you • It is safe and effective and free • Follow U.S. Public Health Service Guidelines • HBV Vaccinations • “ Immunization of Health Care Workers: Recommendations of ACIP and HICPAC,” MMWR, Vol. 46, No. RR-18, December 26, 1997 • Declination statement

46. Hepatitis B Vaccination • Antibody testing 1-2 months after completion of 3-dose series • DHCP should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive if no antibody response occurs to the primary vaccine series (IA, IC) Retest for anti-HBs at the completion of the second vaccine series. If no response to the second 3-dose series occurs, non-responders should be tested for HBsAg (IC) Counsel non-responders to vaccination who are HBsAg-negative regarding their susceptibility to HBV infection and precautions to Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline the vaccination should sign a declination form to be kept on file with the employer

47. Post-Exposure Follow-ups • Report all exposure incidents • Health care professional's written opinion • HBV • Follow-up

48. Training--Annually • Five Easy Questions • What is universal precautions? • What do you do when there is a blood spill? • Personal protection • Clean-up and disposal procedures • Disinfection (hazard communication applies) • What do you do with contaminated sharps and laundry? • Have you been offered the HBV vaccination free of charge? • Where is the Exposure Control Plan?

49. Exposure Control Plan • Must be in writing • Must include Exposure Determination • Must be reviewed and updated annually • Plan must be updated to reflect changes in technology that eliminate or reduce employee exposure • Plan must document consideration and implementation of appropriate, commercially available and effective engineering controls

50. Exposure Control Plan • Employer's plan describing how compliance with the standard is achieved • Describes what employees are covered • Describes tasks that are covered • Describes post-exposure follow-up procedures • Must be reviewed and updated annually • Must be accessible to employees • See Journal of the Tennessee Dental Association, Fall 2007