# Presentation: 023034

## CDC’s Guidelines for Infection Control in the Dental Operatory 

- Pamela Alston, DDS, MPP

## CDC Guidelines

- CDC staff collaborated with infection control experts
- Evidence-based
- Strong theoretical rationale, respected opinions
- In-depth review process

## Job Corps’ Policy and Requirement

- “The center shall use protective measures as recommended by the CDC.”—PRH-6.12 (R13)(b)

## Applicable DHCP

- “All paid or unpaid dental healthcare personnel who might be occupationally exposed to blood and body fluids by direct contact or through contact with contaminated supplies, equipment, environmental surfaces, water, or air”

## Microbes in the Mouth

- Mouth is most important infectious disease agent source
- microbes must escape from the source

## Chain of Infection

- Pathogenic organism
- a suitable source that allows microorganism to survive and multiply
- mode of escape from source
- mechanism of transmission
- portal of entry
- a susceptible host

## Infectious Disease Transmission

- Exposure to all blood and other potentially infected materials
- From patient to dental worker
- Dental worker to patient
- Patient to patient

## Transmission in Dental Setting

- Direct contact with body fluids
- Indirect contact with contaminated objects
- Contact of conjuctival, nasal, or oral mucosa with droplets
- Inhalation of airborne microorganisms suspended in air

## Goal of Infection Control 

- To reduce the dose of microbes shared among people

## In the Dental Setting

- Treat all patients as potentially infectious
- Use personal protective equipment
- proper sharps handling techniques
- Receive immunizations
- Limit contamination
- Wash hands
- Sterilize if you can
- implement safe work practices

## Ways to Prevent Transmission 

- Standard precautions
- Engineering Controls
- Work Practice Controls

## Standard Precautions

- Blood
- All body fluids, secretions/excretions
- Non-intact skin
- Mucous membranes
- Doesn’t include sweat

## Personal Protective Equipment

- Use whenever potentially infectious materials could contact skin or mucous membranes
- Includes:
-  Gloves
-  Masks
-  Eye and face protectors
-  Gowns

## Patient Barrier Preferences

- “Dental clinical attire and infection-control procedures:  Patient Attitudes,”  Shulman ER, Brehm WT, JADA 2001
- Masks for DDS  77% (tx)/74% (exams)
- Eyewear for DDS 54% (tx)/43% (exams)
- Eyewear for Patient 19%
- Surface barriers 63%

## Gloves

- When contact with body fluids is expected
- New pair for each patient, sooner if damaged
- Removed  and hand hygiene performed promptly after use
- Available in correct size and readily accessible
- Puncture resistant gloves for housekeeping, handling contaminated instruments

## Dermatitis

- Weeping dermatitis
- Irritant contact dermatitis
- allergic contact dermatitis

## Latex Allergy

- “Type I hypersensitivity to latex proteins”
- serious whole-body allergic reaction
- skin, nose, and eye symptoms
- more severe symptoms:  asthma, cardiovascular, and gastrointestinal symptoms

## Latex Allergy

- Screen all patients for latex allergy
- consider sources of latex other than gloves
- schedule latex allergic patients for the first appointment of the day
- have latex-free kits available
- manage latex-related complications during or after a procedure

## Hand Hygiene

- Prior to glove placement and removal
- After accidental barehanded contact with objects likely to be contaminated
- Before leaving the treatment area

## CDC’s Handwashing Guidelines

- To improve hand hygiene practices and reduce health care-acquired infections:
-  Wash hands with a non-antimicrobial 	soap and water when hands are visibly dirty or contaminated
-  Use an alcohol-based waterless antiseptic agent routinely

## CDC’s Handwashing Guidelines 

-  Don’t add soap to partially empty soap dispenser
-  Provide health care workers with hand lotions
-  Do not wear artificial fingernails or 	extenders

## Employer Obligations

- provide handwashing facilities for employees
- ensure that employees wash their hands ASAP following contact with blood or saliva
- ensure that employees wash their hands after removing PPE

## Handwashing Technique

- Lather hands with soap and water
- Rub vigorously for >9 seconds
- Rinse hands 2-3 times
- Rinse under a stream of water
- Dry with a disposable towel

## Hand Hygiene

- Liquid hand-care products stored in  closed containers
- Hand lotions used to prevent skin dryness associated with handwashing
- Hand lotions free of petroleum and compatible with antiseptics

## Gowns

- Required whenever risky materials are likely to splash or spill; during any procedure where fluids could soak through clothing
- barrier to contaminants
- comfortable

## Linens

- Handle linens soiled with blood or OPIM as little as possible
- Bag soiled linen
- Use standard laundry cycles; neither HIV nor HBV can survive standard laundry cycles

## Masks

- Required for whenever blood and other risky materials could splash, splatter, or spray into face
- sizing
- filtration efficiency of 95% for particles 3 to 5 microns in diameter
- comfort

## Eye Protectors

- Required for whenever risky materials could splash, splatter, or spray into your face
- impact resistance
- side protection
- suited for specific applications in practice

## Make sure all items needed for treatment are present
remove unnecessary supplies and equipment from the operatory
use barriers

- remove unnecessary supplies and equipment from the operatory
- use barriers

- Safe Work Practices Before Tx

## Mouthrinses

- Scientific evidence is inconclusive about pre-treatment use
- Reduce microbial levels
- CDC offers no recommendation

## Safe Work Practices During Tx

- Wear PPE
- Use rubber dams
- Use high volume saliva evacuation
- Touch as few operatory surfaces as possible
- one-handed scoop technique                for recapping

## Safe Work Practices After Tx

- disposable needles in a puncture-resistant container
- Spray uncovered operatory surfaces with a disinfectant
- flush the waterlines
- cover tray of instruments when they are transported

## Sharps Management

- Place all disposable sharps in sharps disposal containers that must be:
- Readily available in all patient care areas
- Clearly marked
- Closable
- Puncture-resistant
- Maintained in upright position
- Remove disposal containers before they become three quarters full

## Sharps Safety

- Place contaminated reusable sharp instruments in appropriate containers until processed

## Clean-up & Decontamination

- Wear protective gloves to clean up spills of blood, body fluids, or tissue
- Wear mask to minimize                 inhalation
- Wear eyewear
- Use standard cleaning and decontamination procedures for reusable equipment, floors, and walls

## Levels of Disinfection

- high-level disinfection
- intermediate-level disinfection
- low-level disinfection

## The Perfect Disinfectant

- broad-spectrum antimicrobial activity
- Acts quickly
- unaffected by bioburden
- nontoxic and hypoallergenic
- non-staining and compatible
- economical lengthy shelf life
- no harsh smell

## No Single Best Choice

- Make a list of the characteristics of your practice
- Rank the performance characteristics you want in the disinfectants you use
- Compare your list with the advantages and disadvantages of today’s disinfectants

## Choosing a Disinfectant

- Choose an EPA-registered, tuberculocidal disinfectant
- cleans and disinfects
- For agents requiring dilution prior to use, use water rather than alcohol

## EPA Surface Disinfectants

- Chlorines
- Complex phenols
- Dual/synergized quaternary ammonium compounds
- Iodophors
- Phenol-alcohol combinations
- Other halogens (sodium bromide and chlorine)

## Read the Label

- Know:
-  What you are using
-  Why you are using it
-  How it should be used
-  What precautions you need to use it 	safely

## “What do I want from my solutions?”

- Can one solution do the work of two?
- Are workers in the office using each product as directed?
- Are the solutions we’re using appropriate for their application in the practice?

## Hazard Communication Standard

- Container labeling
- Material safety data sheets
- Employee information and training
- Hazardous chemicals lists in each work area

## Compliance Organizations

- ADA—appropriate disinfectants for oral health practices
- CDC—disinfectant criteria and choices for dental applications
- EPA—list of registered antimicrobial pesticides including low and intermediate level antimicrobials
- FDA—high-level disinfectants & sterilants

## Surface Disinfection Process

- Clean the surface by spraying with cleaner/disinfectant and vigorously wiping with paper towels
- Spray the pre-cleaned surface with disinfectant
- Allow surface to remain moist for the contact time recommended by the manufacturer
- Wipe dry before seating patient

## Modified CDC/Spaulding

- Critical items—penetrate tissues; high risk of disease
- Semicritical items—contact mucosa; intermediate risk
- Noncritical items with intraoral contact—may contact skin and/or mucous membranes of dental personnel or patients; low risk

## Modified CDC/Spaulding (continued)

- Noncritical items with no intraoral contact—contact with unbroken skin; low risk
- Environmental surfaces: patient care—usually contact DHCP but not patients; very low risk
- Environmental surfaces:  housekeeping — minimal risk

## Surface Barriers

- Eliminates the need for between-patient cleaning and disinfection
- Time-saving option for clinical contact surfaces that are difficult to clean

## Infection Control Assurance

- All infection control practices are _always_ consistent with written procedures
- all infection control equipment is used according to directions
- all infection control products are used properly
- all infection control products are disposed of properly

## Dental Unit Waterline Quality

- Biofilm forms and acts as a reservoir
- Dental unit water has been found to be grossly contaminated with waterborne microorganisms
- for nonsurgical procedures CFU should be < or = 500 (CDC)

## Improving Waterline 	Quality

- Anti-retraction devices in dental unit water lines shall be installed and maintained
- flush water lines at beginning of day
- run any dental device connected to a dental water system to discharge water and air for 20-30 seconds after each patient (CDC)

## Housekeeping Schedules

- Create monthly dental office calendar listing chores
- Include periodic maintenance, recordkeeping, and infection control activities
- Consider kinds of products, the practice type, and patient volume
- Always follow equipment         manufacturer’s instructions

## Project a Safe Practice Image

- Wash hands and wear gloves.
- Wear proper clothing in the reception area.
- Open packaged sterilized instruments in front of the patient.
- Offer patient eyewear.
- Offer a pre-treatment                                        mouthrinse.

## Cost-Effectiveness

- Compare outright and backend costs
- Cost and user satisfaction
- go with reuse items instead of disposables

## Risk of Occupational Exposure

- Prevalence in the patient population
- nature of contact with blood and bloody fluids
- frequency of contact with blood and bloody fluids

## High Risk Tasks/Situations

- Using, handling, cleaning, and disposing of used needles or contaminated sharps
- Invasive procedures
- Any task where infectious materials could spill, splatter, or splash
- Any situation where large amounts of blood are present

## Risk Factors

- Route of exposure
- Dose of the virus transferred during an exposure incident
- Differences in host susceptibility
- Possible variations in the infectiveness of the infected patient
- Number of exposure incidents

## Characteristics to Determine Exposure Type

- Exposure type
- type of device
- visible blood depth of injury

## Risk of Transmission

- 10-30 out of every 100 needlestick injuries involving known HBV contamination transmit infection
- 4 out of 1,000 needlestick injuries involving needles contaminated with HIV will transmit infection

## Dental Setting Transmission

- As of 6/2001, no DHCP with documented HIV seroconversion following a specific occupational exposure to a known HIV-infected source
- HIV transmission from provider to patient—almost undetectable
- HIV Transmission from patient to patient—no documented evidence in oral health settings

## Decreasing Percutaneous Injuries

- Safer work practices
- safer instrumentation or design
- continued worker education
- percutaneous injuries generally occur outside the patient’s mouth, involve very small amounts of blood, and are caused by sharps

## In Conclusion

- Take actions to stay healthy
- Avoid contact with blood
- Limit the spread of blood
- Make objects safe for use

## Use appropriate engineering controls to limit the risk of accidental exposure
Apply work practice controls
Wear personal protective equipment (PPE) that is suitable for the procedure
Receive regular immunizations

- Apply work practice controls
- Wear personal protective equipment (PPE) that is suitable for the procedure
- Receive regular immunizations

- In summary---