2018 Oregon Dental Conference Course Handout - Sam Barry, DMD Course 9135: "Review of CDC Guidelines for Infection Control in Dental Health Care ...
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2018 Oregon Dental
Conference®
Course Handout
Sam Barry, DMD
Course 9135: “Review of CDC Guidelines for
Infection Control in Dental Health Care Settings”
Friday, April 6
9 am - 12 pm
Review of CDC Guidelines for Disclaimers & Acknowledgements
Infection Control in Dental • The speaker is an employee of Henry Schein Dental
Health-Care Settings • The speaker may mention certain products and
services provided by Henry Schein Dental
• Some slide content & images provided by:
Oregon Dental Conference - HPTC, Inc.
April 6, 2018 - Centers for Disease Control and Prevention
- Washington Dept. of Labor & Industries
Samuel Barry, DMD - OSHA
541-969-6129 - OSAP
- Karen Gregory, RN – Total Medical Compliance
1 2
In the News “CDC Guidelines for Infection Control
March 2018
in Dental Health-Care Settings – 2003”
www.cdc.gov/mmwr/PDF/rr/rr5217.pdf
http://jada.ada.org/article/S0002-8177(17)30938-8/fulltext 4
3
1
Federal Agencies & National Organizations Infection Control/Prevention is Important
• To make sure we protect both healthcare workers
and patients from disease (infection prevention)
• Infectious disease death rate was 46 per 100,000
people in the U.S. in 2014 – 3rd leading cause of death*
• Increasing worldwide antibiotic resistance
• Very little R & D for new antibiotics
• Emerging and reemerging infectious diseases
*Miller, CH. Infection Control and Management of Hazardous Material for the Dental
Team. 6th Ed., St. Louis, 2018, Elsevier, page 26 6
5
CDC & FDA Advisory
CDC Quote
“We need to take a comprehensive
approach to infection control in all dental
settings. Robust infection control practices in
dental clinics are critical for the health of both
patients and staff.”
Arjun Srinivasan, MD, FSHEA
Associate Director for Healthcare Associated Infection
Prevention Programs at the Centers for Disease Control and
Prevention
7 https://emergency.cdc.gov/han/han00382.asp 8
2
Routes of Transmission Modes of Disease Transmission
• Direct contact with blood or body fluids (OPIM)
Patient DHCP • Indirect contact with a contaminated
instrument or surface
DHCP Patient
• Contact of mucosa of the eyes, nose, or mouth
Patient Patient with droplets or spatter (droplet transmission)
• Inhalation of airborne microorganisms
9 10
What is the goal? CDC Guidelines
OSHA can enforce CDC guidelines that apply
to employees, even though they are written by
the CDC, under the “General Duty Clause”
Must comply with OSHA BBP Standard
State Dental Boards and State Health
Departments can/will also enforce them
Legal liability – increased public awareness
Infection prevention is a public trust and
expectation!
12
11
3
Bloodborne Pathogens Idaho Board of Dentistry
OAR 437, Division 2
Subdivision Z
1910.1030
Bloodborne Pathogens Documents Incorporated by Reference:
“CDC Guidelines for Infection Control in Dental
Health-Care Settings - 2003”
https://isbd.idaho.gov/IBODPortal/BoardAddition
http://osha.oregon.gov/OSHARules/div2/div2Z-1030-bloodborne.pdf
al.aspx?Board=BOD&BoardLinkID=70
www.lni.wa.gov/safety/rules/chapter/823/ 14
13
Oregon Board of Dentistry Oregon Board of Dentistry
Division 12 - Standards of Practice
OAR 818-012-0040 OAR 818-042-0030 - Infection Control
Infection Control Guidelines
The supervising dentist shall be responsible for assuring
“In determining what constitutes unacceptable patient care with
respect to infection control, the Board may consider current that dental assistants are trained in infection control,
infection control guidelines such as those of the Centers for bloodborne pathogens and universal precautions,
Disease Control and Prevention and the American Dental exposure control, personal protective equipment,
Association…………” infectious waste disposal, Hepatitis B and C and post
exposure follow-up.
Stat. Auth.: ORS 679.120, 679.250(7), 680.075 & 680.150
Stats. Implemented: ORS 679.140, 679.140(4) & 680.100
Stat. Auth.: ORS 679
https://secure.sos.state.or.us/oard/viewSingleRule.action;JSESSIONID_OARD=rjtdl_2H Stats. Implemented: ORS 679.140
RaTvGNBxJgRviKTGZwkNhRamMjkUMBarOTfffe- Hist.: OBD 9-1999, f. 8-10-99, cert. ef. 1-1-00
o9hPE!2072817505?ruleVrsnRsn=200127
15 16
4
Oregon Board of Dentistry Oregon Board of Dentistry
DIVISION 21 - EXAMINATION AND LICENSING DIVISION 21 - EXAMINATION AND LICENSING
OAR 818-021-0060 OAR 818-021-0070
Continuing Education — Dentists Continuing Education — Dental Hygienists
(6) At least 2 hours of continuing education must (6) At least 2 hours of continuing education must be
be related to infection control. related to infection control.
(Effective January 1, 2015) (Effective January 1, 2015)
Stat. Auth.: ORS 679 Stat. Auth.: ORS 679
Stats. Implemented: ORS 679.250(9) Stats. Implemented: ORS 679.250(9)
17 18
Washington Board of Dentistry CDC Guidelines
Currently under review with numerous changes being proposed
WAC 246-817-601 Infection Control
The purpose of WAC 246-817-601 through 246-817-630 is to establish
requirements for infection control in dental offices to protect the
health and well-being of the people of the state of Washington. For
purposes of infection control, all dental staff members and all patients
shall be considered potential carriers of communicable diseases.
Infection control procedures are required to prevent disease
transmission from patient to doctor and staff, doctor and staff to
patient, and from patient to patient. Every dentist is required to
comply with the applicable standard of care in effect at the time of
treatment. At a minimum, the dentist must comply with the
requirements defined in WAC 246-817-620 and 246-817-630.
[Statutory Authority: RCW 18.32.035. WSR 95-21-041, § 246-817-601, filed 10/10/95,
effective 11/10/95.]
http://apps.leg.wa.gov/WAC/default.aspx?cite=246-817&full=true 19 www.cdc.gov/mmwr/PDF/rr/rr5217.pdf 20
5
CDC - March 28, 2016 CDC Dental Checklist App
Interactive version of the new
“Infection Prevention Checklist
for Dental Settings”
For use on all mobile IOS
devices only
Does not replace 2003 Guidelines – it highlights and clarifies existing CDC Guidelines,
updates source documents and references, provides a dental specific checklist Free download at:
- iTunes App store
www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm
- Android App store
21
22
ADA Statement CDC Standard Precautions
…The ADA urges all practicing dentists, dental
auxiliaries and dental laboratories to employ
appropriate infection control procedures as described • Must use the same infection control
in the 2003 CDC Guidelines, and 2016 CDC Summary procedures for all patients
and to keep up to date as scientific information leads
to improvements in infection control, risk assessment,
• Assume all patients are infectious
and disease management in oral health care.
• Infection control policies are determined by
American Dental Association the procedure, not from your view of the
www.ada.org/en/member-center/oral-health-topics/infection-control- patient
resources
23 24
6
Essentials for Standard Precautions CDC Guidelines
• Proper hand hygiene “Guidelines for Infection Control in Dental
Healthcare Settings - December 2003”
• Proper use of personal protective equipment (PPE)
1. Develop written comprehensive policies and
• Proper cleaning and disinfecting environmental programs for infection control (IC) – appoint an
Infection Control Coordinator
surfaces
2. Follow the CDC Guidelines as close as possible
• Proper cleaning and sterilization of instruments and
3. Follow the manufacturer’s instructions for use (IFU)
devices
4. Provide Training on procedures, products and
• Sharps safety - engineering and work practice devices
controls - on hiring, new tasks or procedures, at least annually
5. Use FDA registered equipment and devices - 510(K)
• Respiratory hygiene and cough etiquette
6. Use EPA registered disinfectant products
• Safe injection practices 25 26
CDC Guidelines CDC Guidelines
7. Cleaning is a very important step in IC
13. Examine wrapped packages of sterilized
8. Allow packages to dry and cool, in the sterilizer, instruments before using to ensure the barrier wrap
before they are handled to avoid contamination has not been compromised & chemical indicators
have changed color
9. Designate a central processing area into distinct
14. Avoid using carpeting and cloth-upholstered
areas; receiving, packaging, sterilization and furnishings in operatories, lab, and sterilization
storage
15. Owner’s Manuals/Directions (IFU) for equipment
10. Transport instruments in a covered container - routine maintenance performed
11. Do not refill soap dispensers without washing and 16. Document – keep Logs
drying them first - Training – Competency
- Testing/Monitoring
12. SINGLE USE (disposable) items - throw them away!
28
27
7
Infectious Diseases Infectious Disease Update
Bacterial Resistance Bacterial & Viral
• 700 + species of bacteria isolated from the oral
cavity • Additional bacteria and viruses to be concerned
• Bacterial antibiotic resistance increasing rapidly – about in the dental setting:
“super bugs” -Treponema pallidum – syphilis
• Very few new antibiotics on the horizon - Herpes Simplex Virus – HSV1 & HSV2
- Varicella Zoster Virus (VZV) - shingles
• Some bacterial pathogens of concern:
- Staphylococcus aureus (MRSA) - Epstein Barr Virus – mono, cancer
- Mycobacterium tuberculosis – XDR in India, Italy, Iran - Human Papilloma Virus – cancer
- Streptococcus pyogenes – flesh eating
- Streptococcus pneumonia
- Neisseria gonorrhoeae
- Pseudomonas aeruginosa
29
30
HBV - Hepatitis B Virus HBV - Hepatitis B Virus
• Hearty - can live for 7+ days on Clinical Features
surfaces
Average 60-90 days
• 100 times more contagious than Incubation period
Range 45-180 days
HIV
30%
• Approximately 21,900* new No sign or symptoms
30%-50% (5 years
infections per year Acute illness (jaundice)
old)
• Estimated up to 2.2 million* Chronic infection 5%-10% (of infected
chronic carriers (carrier) adults)
• 1,750 deaths reported in 2015 Premature death
15-25% (of chronically
from chronic liver
• No cure, but there is a disease infected)
preventative vaccine
* 2015 CDC estimates Protected from future
Immunity
31
infection 32
8
HCV - Hepatitis C Virus New Hepatitis C Medications
• The most common chronic bloodborne
infection in the U.S. • Harvoni - once daily pill that may cure the disease
• 8-12 week treatment for most people
Copyright 1998 Trustees of Dartmouth College
• Can live from up to 6 weeks at room • Clinical trials cure rate was 94%
temperature on environmental surfaces
• Cost is $1,125 per pill (cost can exceed $95,000)
• CDC estimates 3.5 million chronically Healthy human liver
infected in 2015 • Sovaldi - once daily pill combined with ribavirin
• 12 week treatment for most people
• CDC estimated 33,900 new infections
in 2015 • Cure rate of over 85%
• Cost is $1,000 per pill plus the cost of ribavirin (can exceed
• Leading cause of liver transplantation $150,000)
• 19,629 deaths reported in 2015 Hepatitis C liver
• Viekira Pak - multi-pill combination of 3 anti-viral medications
• Three new FDA approved medications A healthy human liver • 12 week treatment for most people
contrasted with a liver
from an individual who • Clinical trials cure rate was 91%-98%
• Various genotypes – at least 6 died from hepatitis C. • Cost is $990 per dose plus the cost of ribavirin (Cost can
• No vaccine available 33 exceed $85,000) 34
Human Immunodeficiency Virus (HIV) Human Immunodeficiency Virus (HIV)
HIV Infection AIDS
• Fragile – survives only a few hours
• Many have no symptoms or
in dry environment
mild flu-like symptoms
• Attacks the human immune
• Most infected with HIV
system
eventually develop AIDS
• Cause of AIDS
• Incubation period 10-12 yrs.
• >1.2 million infected in the U.S.
• Opportunistic infections &
– estimated 13% unaware AIDS-related diseases - TB,
toxoplasmosis, Kaposi’s sarcoma,
• Estimated about 40,000 new oral thrush (candidiasis)
infections annually in U.S. HIV - seen as small
spheres on the • Treatments are limited; do not
• No cure; no vaccine available surface of white cure
blood cells 35 36
9Tuberculosis Tuberculosis
• Bacterial infection primarily of the lungs • Spread by microscopic airborne particles called
droplet nuclei
• Mycobacterium tuberculosis
- airborne – speaking, coughing, sneezing,
• Risk in dental settings is usually low laughing, singing
- can travel at least 1 meter
• Immune system usually prevents spread
- respiratory aerosols can remain airborne for
• Usually needs repeated exposures to infect several hours
• Follow CDC Guidelines for preventing TB transmission • Bacteria can remain alive in the lungs for many
in healthcare settings (OR-OSHA requires) years (latent TB) – if untreated ~10% will develop
active TB
- conduct an annual risk assessment
• TB bacteria can survive on dry surfaces for weeks
- develop a written TB infection control plan 37
Tuberculosis High Risk for Developing TB
• Signs & Symptoms of active tuberculosis disease:
• Close contact with someone with TB
- productive cough (may have streaks of blood) • Immigrated from an area with a high TB rate
- fever - India, Indonesia, China, Nigeria, Pakistan, South Africa
- night sweats
• Children less that 5 y.o. with positive TB test
- weight loss
• Injection drug users
- fatigue
• Homeless
- malaise
- chest pain • Work or reside in correctional facilities, nursing
homes, residential homes for HIV/AIDS
• One fourth of the world’s population infected with TB • HIV infection (35% of HIV deaths was from TB in 2015)
– 10.4 million worldwide became sick in 2016 • Compromised immunity – corticosteroids, silicosis,
• About 1.7 million TB-related deaths worldwide in 2016 diabetes, severe kidney disease, organ transplant
– 470 deaths in U.S. in 2015 39 40
10Tuberculosis Tuberculosis
• 9,272 TB cases confirmed in the U.S. in 2016 • Assess patients for history and risk of TB
• 2.9 cases/100,000 population • Isolate patient, then refer for medical evaluation, if
suspect TB
• Annual Community Risk Assessment
- call County Health Department • Defer all elective dental treatment until medically
- develop a written TB infection control plan cleared
• Tuberculin skin test (TST) – low risk =Immunizations for DHCW Hepatitis B Vaccine
CDC Guidelines for Infection Control in Dental Health Care Settings – 2003 (page 65) • No cost to you (within 10 days of employment)
• Hepatitis B (mandatory by OSHA) • Need written proof of vaccination or antibody
titer
• Influenza (annually) • 3 injections: 0, 1, & 6 months
• Measles, Mumps, Rubella (MMR) • Effective for 85 - 95% of adults
• Post-vaccination testing for high risk HCW
• Tetanus, Diphtheria, Pertussis (Tdap) 1 - 2 months after 3rd dose (60 – 70% no titer after 12 years)
• Varicella (Chickenpox) • Post-exposure treatment (if not vaccinated or
no proof of immunity)
o Hepatitis B immune globulin (< 24 hours)
• Possibly others based on age, medical conditions, o Begin vaccination series
travel plans • If decline, you must sign a “Declination Form”
- consult with personal physician o vaccine available at later date if desired
45 46
Hepatitis B Vaccine Exposure Incident
CDC Updates
If you have an exposure incident to blood or OPIM,
Pre-exposure evaluation immediately do the following:
for health-care personnel
Thoroughly clean the affected area:
previously vaccinated with
complete, ≥3-dose
• Wash needle sticks, cuts, and
Hepatitis B vaccine
skin with soap and water
series who have
not had post vaccination • Flush with water splashes to the
serologic testing. nose and mouth
• Irrigate eyes with clean water,
www.cdc.gov/mmwr/pdf/
saline, or sterile irrigants
rr/rr6210.pdf
Report exposure to (supervisor,
December 20, 2013 person or department responsible
for managing exposures, etc.); fill
47 out an Incident/Accident Report Form48
12Exposure Incident Post Exposure Evaluation
Our company’s responsibility:
Exposure Incident/Accident report form should include
Provide immediate (with in 2 hours) post-
at least the following: exposure medical evaluation and follow-up
to exposed employees from a qualified HCP:
Date and time of exposure • At no cost
Procedure details: where, when, how, with what device • Confidential
Exposure details: route, body substance involved, volume • Testing for HBV, HCV, HIV
and duration of contact • Preventive treatment when indicated
Information about source patient
Test blood of source person if HBV/HCV/HIV
Exposure management details status unknown, if possible (document
refusal); provide results to exposed
Check with your Worker’s Compensation Insurance Company employee, if possible
49 50
Post Exposure Evaluation Post Exposure Evaluation
Items to Consider Our company’s responsibility:
Who will manage the post exposure process???
- Emergency Room Make arrangements in advance as to where to go for
- Urgent Care medical evaluation
- County Health Department Provide to the evaluating health care professional:
- Occupational Health/Medicine
- A copy of BBP regulation
Establish the relationship in advance
- Description of exposed employees duties
- Current with most recent guidance on BBP exposures
- Documentation of the routes of exposure & circumstances
- Business hours & wait times – evaluated within 2 hours
- Rapid HIV test - Results of the source patient’s blood tests, if available
- Availability of post exposure medications - All medical records relevant to the appropriate treatment
- Timely HCP written opinion of the employee, including vaccination status
- Payment of services 51 52
13Post Exposure Evaluation Post Exposure Evaluation
Our company’s responsibility: Our Company’s Responsibility
Provide exposed employee with
Make an incident packet (not required, but good idea – saves copy of the evaluating health care
time, reduces stress): professional’s (HCP) written
- Incident/Accident report form opinion within 15 days of
completion of evaluation
- BBP regulations
- Release forms Provide employee with information
- Any other forms that evaluating HCP recommends about laws on confidentiality for
the source individual
- “PEP Steps” pamphlet
- “CDC Exposure to Blood” pamphlet Provide post-exposure treatment
Put name, address and phone number of facility, on outside of as needed, including counseling
envelope, of where to go for medical evaluation Our HCP is: ???
53 54
Post Exposure Evaluation – CDC Update
Occupational Exposure Flow Chart
Exposure Employer Healthcare Professional
incident Occurs
Direct employee to Healthcare Evaluates exposure incident
Clean/Flush Professional, obtain authorization
for testing. Tests employee and source
patient (rapid HIV)
Send to HCP: Notifies employee of results
Employee’s job description, Provides counseling
incident report, HBV,HCV,HIV
Employee status including B vaccine & titers. Provides post-exposure
prophylaxis
reports to Patient’s identity, HBV/HIV/HCV Evaluates reported illnesses
employer status or send for testing.
ABOVE ITEMS CONFIDENTIAL
immediately Document event.
Employee Sends written opinion to
Receives copy and employer:
receives
copy of forwards to employee Need for follow-up
written within 15 days Employee informed
opinion 56
55
Slide courtesy of Karen Gregory
14Post-exposure Treatment Medical Records
• Required by OSHA BBP standard
• HCV – no prophylaxis treatment
• Confidential – secured location
• HBV - Immune globulin B and vaccination
series if not immune • Name and social security number
• HIV – Anti-HIV medications for high risk • Hepatitis B vaccination and post-exposure
exposures – 2 or 3 drugs evaluations or declination forms
• Test for infection at baseline, then varies
• Incident/Accident forms
from 6 weeks to 12 months depending on
which virus, testing method, status of source • HCP’s written opinions
patient and status of injured employee
• Information provided to HCP
Hot line: 888-448-4911
http://nccc.ucsf.edu/clinical-resources/pep-resources/pep-quick-guide/ • Maintain for length of employment plus 30 years
57 58
Medical Conditions/Work Restrictions Medical Conditions/Work Restrictions
Policies should include restrictions for the following:
(CDC Guidelines for Infection Control in Dental Healthcare Settings – Table 1)
• DHCP are responsible to monitor their own health
• Conjunctivitis • Mumps
• If acute or chronic conditions, consult with physician
• Diarrheal diseases • Pediculosis (lice)
• Decisions on work restrictions are based on
• Enteroviral infection • Pertussis
- mode of transmission • Hepatitis A • Rubella
- period of infectivity • Hepatitis B • Staphylococcus
• Policies should be in writing • Hepatitis C infection
• Herpetic whitlow • Tuberculosis
• www.cdc.gov/mmwr/PDF/rr/rr5217.pd (Table 1) • HIV • Varicella (chicken pox)
• Measles • Zoster (shingles)
• www.shea- • Viral respiratory
• Meningococcal
online.org/images/guidelines/BBPathogen_GL.pdf infection infection
59 60
15Respiratory Hygiene
Why Is Hand Hygiene Important?
Post CDC Poster
• Hands are one of the most important sources of
Provide tissues and disposal microorganisms in disease spread
receptacles
• Hands contaminated with transient pathogenic
Provide resources for hand
microbes pose a high risk for the transmission of
hygiene
disease
Offer masks to coughing
patients • Hand hygiene is considered the single most critical
measure for reducing the risk of transmitting
Encourage patients with microbes to patients and HCP
symptoms to sit away from
others if possible • Good hand hygiene helps prevent healthcare
acquired infections (HAI)
www.cdc.gov/flu/pdf/protect/cdc_cough.pdf 61
62
Hands Need to be Cleaned When:
Hand Hygiene Definitions
• Visibly soiled/dirty • Hand washing
o Washing hands with plain soap and water
• After touching contaminated objects or surfces with
bare hands • Antiseptic hand wash
o Washing hands with water and soap or other
• Before and after patient treatment (before glove detergents containing an antiseptic agent
placement and after glove removal) • Alcohol-based hand rubs (60% - 95%)
o Rubbing hands with an alcohol-containing
• 15 - 20 seconds minimum wash preparation
• Dry with disposable towel • Surgical antisepsis
o Hand washing (2-6 minutes) with an antiseptic
• Turn off faucet with a dry towel soap or plain soap and an alcohol-based hand
rub
- consider no-touch electric or foot controlled faucet
16Efficacy of Hand Hygiene Alcohol-based Preparations
Preparations in Reduction of Bacteria Benefits Limitations
• Rapid and effective • Cannot be used if
Good Better Best antimicrobial action hands are visibly
• Improved skin condition soiled
• More accessible than
sinks • Follow IFU for amount
Plain Soap Antimicrobial Alcohol-based (hand size)
soap handrub • Better compliance
• Store away from high
www.cdc.gov/handhygiene/providers/guideline.html temperatures or
*Rub hands until DRY!
flames
www.cdc.gov/handhygiene/Basics.html (15 – 20 seconds) 66
65
WHO Hand Hygiene Special Hand Hygiene Considerations
• Use hand lotions to prevent skin dryness
• Consider compatibility of hand care products
with gloves (e.g. mineral oils and petroleum bases
may cause early glove failure)
• Keep fingernails short - NO artificial nails
• Avoid watches and bracelets
• Avoid any hand jewelry that may tear gloves
www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf • Place a band aid over any existing lesion before
donning gloves
www.who.int/gpsc/5may/resources/posters/en/ 67 68
17OSHA BBP Standard Gloves
Personal Protective Equipment (PPE) • Gloves should be worn whenever hand contact with
You must wear all required PPE. Employer must provide blood or OPIM is likely to occur
employees with appropriate PPE at no cost to the employee • Gloves should be worn when touching contaminated
such as but not limited to: items or surfaces
Gloves Face shields or
Masks and eye protection • Do not reuse clinical gloves - single use only
Lab coats
Gowns Head covers – optional ? • Replace gloves if they become torn or punctured
Shoe covers - optional? Resuscitation devices
• Use HD utility gloves for clean-up activities (disinfect daily)
PPE used: • Use sterile surgical gloves for surgical procedures
Based on procedures – the degree of • Beware of Dermatitis & Hypersensitivity (latex, nitrile?)
anticipated exposure
• Gloves do NOT replace the need for hand washing
Aerosols can travel up to 15 feet 70
69
Masks, Protective Eyewear, Face Shields Protective Clothing
• Wear a surgical mask and eye protection with solid
side shields or a mask and face shield to protect • Wear gowns, lab coats, or uniforms that
mucous membranes of the eyes, nose, and mouth cover skin and personal clothing likely to
become soiled with blood, saliva, or
infectious material (long sleeves, and knee
length)
• Eyewear (ANSI Z87.1) – also provide patient eyewear
• Change if visibly soiled or at end of day
• Change masks between patients and when they
become wet - cover nose • Remove all barrier PPE before leaving the
work area (before entering break room,
• Clean and disinfect reusable face protection when bathroom, or leaving the building)
visibly soiled 71
18Exposure Controls
Personal Protective Equipment (PPE)
Donning Sequence:
1. Protective Clothing gown/jacket
2. Mask
3. Protective eyewear
4. Wash Hands
5. Gloves
Removal (doffing) Sequence:*
1. Gloves
2. Protective eyewear – from side
3. Protective clothing – gown/jacket
4. Mask – from side *Perform hand hygiene between
steps if hands become contaminated
5. Wash hands and immediately after removing all www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf 74
PPE 73
Sharps Safety Instrument Transport Containers
• Consider contaminated sharp items potentially infective
CDC Guidelines & OSHA Bloodborne Pathogen Standard
• Whenever possible use engineering controls (device
based) to reduce exposures:
- needle re-cappers, safety scalpels, sharps containers,
scalpel blade removers, transport containers
• When engineering controls unavailable or not
appropriate, use work practice controls (behavior based)
- one handed scoop technique
- don’t pass syringe with uncapped needle
- don’t wipe sharp instruments with gauze in hand
- remove bur from handpiece when done
• See “Sharps Safety” handout
75 76
19Spaulding Classification Spaulding Classification
Definitions Examples
• Critical: penetrates soft tissue, contacts bone, • Critical: e.g. surgical instruments, scalpels,
enters into or contacts the bloodstream or other periodontal instruments, burs, etc.
normally sterile tissue
• Semi-critical: e.g. mouth mirrors, amalgam
carriers, condensers, reusable impression trays,
• Semi-critical: contacts mucous membranes or dental high and low speed handpieces
non-intact skin; will not penetrate soft tissue, (includes low speed motors), x-ray sensors, bib
contact bone, enter into or contact the clips
bloodstream or other normally sterile tissue
• Non-critical: e.g. blood pressure cuff,
• Non-critical: contacts intact skin stethoscope, pulse oximeter, facebow
77 78
Spaulding Classification Heat Sterilize
Sterilization Methods
• Critical: heat sterilize
• Semi-critical: heat sterilize if at all possible; if heat-
sensitive then at minimum process with an FDA
cleared, and registered sterilant/high-level
disinfectant
- try to avoid heat sensitive items – use is discouraged
• Non-critical: clean and disinfect with EPA
registered hospital intermediate-level (TB claim)
cleaner/disinfectant
79
135C = 275F 80
20Heat Sterilize Manual Cleaning
• Avoid manual cleaning instruments if possible
use automated methods
• Place in holding solution if not cleaned
right away after patient treatment
• If you must hand scrub - wear
heavy-duty utility gloves, mask,
eyewear, protective clothing
• Scrub only 2 or 3 instruments at a time near
the bottom of a deep sink under running
water. Use a long handled brush – these
minimize injury risk and splatter
81
Automated Cleaning Automated Cleaning
• Ultrasonic cleaner • Automated cleaners increase the efficiency of
the cleaning process
• Instrument washer
• Reduces risk of an exposure incident
• Washer-disinfector
• Know how to properly operate the device
*Use only FDA approved • Follow the manufacturer’s instructions for use (IFU)
devices – no household
dishwashers
84
21Automated Cleaning Automated Cleaning
Ultrasonic Use
• Follow the manufacturer’s directions for time, Ultrasonic Use
solution, and maintenance
• De-gas new solution
• Do not lay instruments on bottom, always place
them in a basket, don’t overload, don’t add o The removal of air bubbles found in fresh solution that
additional items to cycle act as a barrier to efficient cleaning
• Cover the unit with the lid while in use
o Is necessary every time new solution is added
• Rinse instruments thoroughly and allow to dry
o De-gas by activating unit for 15 minutes before
• Change solution at least daily
adding any items to be cleaned
- Maintain on Chemical Inventory List & SDS
• Labels – chemical & biohazard
85 86
Automated Cleaning Foil Test
Ultrasonic Use
• Aluminum Foil Test
- Monthly, quarterly ? – keep Log
- Cut a piece of aluminum foil to fit the chamber
- Prepare fresh solution and de-gas
- Insert foil vertically, the length of the chamber,
1 inch rom bottom
- Hold foil steady or drape over a stiff wire, dowel,
etc.
- Run for 20 seconds
- Remove foil – uniform indentations (pebbling)
- Follow the manufacturer’s instructions for use
87
22Preparation and Packaging Preparation and Packaging
• Wear heavy-duty, puncture-resistant utility gloves
• Place a chemical indicator inside the cassette or
• Critical and semi-critical items, that will be stored, pouch and outside if the inside one cannot be seen
should be in wrapped cassettes or placed in and in the chamber with unwrapped instruments
pouches before heat sterilization (if not used in 15
– 20 minutes) • Do not overfill the pouch – use proper size pouch,
flat in single line, finger width space on each side
• Instruments should be clean and dry and top
• Hinged instruments opened and unlocked • Cassettes (“gold standard”) – in a pouch or
wrapped with indicator strip inside
• Make sure packaging material is compatible with
sterilization process and is FDA approved • Make sure pouch is sealed properly
• Do NOT reuse packaging material – pouches or CSR • Date, load number, and identify sterilizer on the
wrap
pouch or wrapped cassette – non-toxic, water
89 proof ink 90
Seal & Label Pouches Pouches - Incorrect
• Remove excess air, fold end tab/flap straight
across at scribed line, 50% on plastic and 50% on
paper – press firmly
• Do Not write on paper side
• Write on end tab/flap folded over on to plastic
or on the plastic side
• Some approved ink:
- Sharpie Industrial Marker – fine point #13601
- Sharpie Markers labeled - “AP”
- Hu-Friedy ID Marker - #IMS-1235
91
92
23Pouches - Correct Sterilization Monitoring
• Mechanical - sterilizer device
- Measure time, temperature, pressure
- Review after each sterilizer cycle
• Chemical - internal and external indicator strips
- Change in color when physical parameter is reached
- Check each pouch/pack when removed from the
sterilizer to verify color change
- Multi-parameter indicators provide more reliability
• Biological Indicator (BI)- spore tests
- Use biological spores to verify the sterilization process at
least weekly and when implantable devises in the load
93
Sterilization Monitoring Spore Test
ANSI/AAMI Classification of Chemical Indicators • Performed at least WEEKLY – backup person to test
Type 1 Process indicator for use on outside of packages • Follow manufacturer’s instructions
Type 2 For use in specific test procedures, i.e. Bowie Dick • Control should have same Lot #
• Steam & Chemical Vapor Sterilizers
Type 3 Single variable that reacts to one variable, i.e. time
– Geobacillus stearothermophilus
Type 4 Multi-variable that reacts to two or more variables • Dry Heat & Ethylene Oxide Sterilizers
i.e. time, temperature, presence of steam
– Bacillus atrophaeus
Type 5 Integrating indicator that reacts to all critical • Keep Spore Testing Log (check with state board of dentistry)
variables Washington – at least 5 years
Type 6 Emulating indicator that reacts to all critical Oregon – current calendar year and the two preceding calendar
variables for a specified sterilization processes years
Idaho – at least one year
95 96
24Spore Test Failure Spore Test Failure
• Remove the failed sterilizer (positive spore test) from • If mechanical & chemical indicators are normal, a
service and review: single spore test failure may not indicate a steam
- operating procedures sterilizer malfunction
- maintenance records
- mechanical & chemical monitoring records • Items other that implantable devices do not
necessarily need to be recalled from a steam
• Use a BACKUP sterilizer
sterilizer
• Retest sterilizer immediately, using spore test,
mechanical and chemical indictors after correcting • Conservative approach is recommended
any procedural problems - recall all items, if possible, from last cycle with a
• If repeat spore test passes (negative), and passed spore test and reprocess or quarantine them
mechanical and chemical indicators are WNL, put until results of the repeat spore test is known
it back in service - always use for chemical vapor, dry heat and ETO
97 98
Spore Test Failure Spore Test Failure
• If repeat spore test fails (positive) do not use - have
sterilizer repaired or replaced • Spore test sterilizers with 3 consecutive cycles:
- after initial installation
- when relocated
• Recall, to the extent possible, all items processed in
that sterilizer, since the last cycle with a passed - after a major repair
(negative) spore test
• Spore test failure rate is about 2%
• Before placing sterilizer back in service, retest in 3
consecutive cycles after the cause of the failure
has been determined and corrected
99 100
25Spore Test Failure Bowie-Dick Test
• For Class B pre-vacuum sterilizers
Common Causes of spore test failure: - Scican Bravo
- Adec Lisa
- Tuttnauer Elara & Nova
- running sterilizer from a cold start
- over loading the chamber • Daily air removal test – test pack
- improper packaging • Follow manufacturer’s instructions (IFU) – sterilizer & test
- selecting the wrong cycle pack
- first thing in the morning
- inadequate maintenance of sterilizer
- place at lowest level over drain in an empty chamber
- run at 273F/134C for 3.5 minutes
• May not be indicated in newer models with built in tests
101
102
Sterilization – Sterilizer/Autoclave
Sterilization
Sterilizer/Autoclave
• Do not overload sterilizer or stack packages in a
• Do NOT handle packages while they are wet,
manner that prevents circulation and penetration of
should allow to dry and cool in sterilizer
steam – single layers, ¼ inch between, do not overlap
• Verify that chemical indicators have changed color
• Stand pouches & solid cassettes on edge is preferred
• Keep handling of sterile instruments to a minimum
• Perforated cassettes flat
• Follow the manufacturer’s recommended operation
• Pouches – alternate paper to plastic side & maintenance instructions (IFU) for the sterilizers
• Consider using a vertical rack • Access to owner’s manual
• Allow the appropriate drying time • Make sure employees are trained and the training is
documented
• Do not interrupt a sterilization cycle 103 104
26Sterilization Sterilization
Liquid Sterilant/High-level Disinfection Liquid Sterilant/High-level Disinfection
• Chemical Sterilants or “Cold Sterile” Solutions • Disadvantages (continued):
- PPE required during use – utility gloves, mask, eyewear
- glutaraldehyde, OPA, hydrogen peroxides, etc.
- Need good ventilation – at least 10 air exchanges per hour
• Disadvantages: - Items must be rinsed off with sterile water, sterile gloves
- If items stored – not considered sterile
- Toxic – keep container lid closed, good ventilation
- May rust and corrode metal
- Less reliable than heat sterilization - Maintain on Chemical Inventory List and SDS
- Has a limited use life - Disposal issues – Washington requires neutralization
- Time consuming - up to 12 hours
- Cannot be spore tested • Use is discouraged - heat sterilize or single use items
- Cannot be used with packaged items are better options
- PPE required during use – utility gloves, mask,
• www.osha.gov/Publications/glutaraldehyde.pdf
eyewear 105 106
Sterilization Sterilization
Liquid Sterilant/High-level Disinfection Liquid Sterilant/High-level Disinfection
• Use only with heat sensitive semi-critical items “Heat-sensitive critical and semi-critical instruments and
• Use an FDA approved product and use test strip daily devices can be sterilized by immersing them in liquid
chemical germicides registered by FDA as sterilants. When
• Log for changing solution using a liquid chemical germicide for sterilization, certain
• Follow the manufacturer’s directions post sterilization procedures are essential. Items need to
• Keep container closed/covered - label be 1) rinsed with sterile water after removal to remove
• Allow to soak for proper time completely submerged – toxic or irritating residues; 2) handled using sterile gloves
time starts over when new a item is added and dried with sterile towels; and 3) delivered to the point
of use in an aseptic manner. If stored before use, the
• Use heavy duty utility gloves and PPE
• Rinse well - sterile water is best instrument should not be considered sterile and should be
sterilized again just before use.”
• Handle with aseptic technique – sterile gloves or tongs
• Dry and place in clean/sterile packaging for storage
107 Page 23 – CDC Guidelines for Infection Control in Dental Healhtcare Settings - 2003 108
27Storage of Sterile, Clean Items and Supplies General Cleaning Recommendations
• Use date or event-related shelf-life practices • Use PPE barrier precautions – heavy-duty utility
gloves, masks & protective eyewear when
• Use “oldest” sterile packs first - FIFO cleaning and disinfecting environmental surfaces
• Examine wrapped items carefully prior to use
• Physical removal of microorganisms by cleaning is
• Verify chemical indicators have changed color as important as the disinfection process - vigorous
wipe
• When the packaging of sterile items is damaged, wet,
or indicators not changed - re-clean, re-wrap, and re- • Follow manufacturer’s instructions for proper use
sterilize of EPA registered intermediate-level hospital
cleaner/disinfectants
• Storage area should be clean, dry and enclosed or - Maintain on Chemical Inventory List and SDS
covered for sterile items and clean patient care
supplies – dust free and protected from obvious
sources of contamination (below 75F and 30 -70% • Do not use liquid sterilants/high-level disinfectants
humidity)
on environmental surfaces – eg. glutaraledhydes
109 110
Environmental Surfaces Clinical Contact Surfaces
• Clinical Contact Surfaces: • Risk of transmitting infections greater than for
- light handles - x-ray equipment housekeeping surfaces
- switches - reusable containers of materials • Surface barriers can be used and changed between
- drawer handles - counter tops patients – disinfect if barrier tears and at end of day
- HVE & SE valves - pens/pencils
- stool handles - chair side computers and / or
- faucet handles - doorknobs
• Clean then disinfect using an EPA registered
- air/water syringe - radiograph equipment intermediate-level (tuberculocidal claim) hospital
cleaner/disinfectant
• Housekeeping Surfaces:
- floors • “Wipe-Discard-Wipe-Wait” or “Spray-Wipe-Spray-Wait”
- walls
- sinks
• AVOID – presoaked 4x4 gauze (mfg’s., effectiveness,
111 expense)
28Surface Disinfectant Selection Operatory Processing
• EPA registered hospital disinfectant - label claim for
healthcare settings
• Broad antimicrobial spectrum
• Intermediate level versus low level
• Label claim as a cleaner
• Alcohol content
• Contact time – varies with different microbes
• Approved by manufacturer of equipment or devise
• Compatible with dental team members – toxicity
• Ease of use
This resource was reprinted with the permission of OSAP. OSAP is a nonprofit organization
• Cost 113 providing information and education on dental infection control and safety. For more
information, go to www.osap.org 114
Cleaning Housekeeping Surfaces Dental Unit Waterlines and Biofilm
• Routinely clean (written schedule) with floor • Biofilms form in small bore
soap/detergent and water or an EPA-registered tubing of dental units
detergent/hospital floor disinfectant
• Biofilms serve as a
• Clean mops and cloths and allow to dry thoroughly microbial reservoir
before re-using or use disposable mops
• Prepare fresh cleaning and disinfecting solutions • A primary source of
daily per the manufacturer’s instructions for use microorganisms is the
water supply
115
29Sources of Dental Unit Dental Unit Water Quality
Water Line Contamination
• Using water of uncertain quality is
• Source water - this is not universally controlled. Some inconsistent with infection control principles
areas will have higher CFU/ml than other areas
• Separate water reservoirs – not managed correctly • Colony counts in water from untreated
systems can exceed 1,000,000 CFU/mL
• Retracted oral fluids - all new dental units have anti- CFU = colony forming units
retraction valves built in, but they can wear out or
fail. Many older units have no anti-retraction valves
• Untreated dental units cannot reliably
• Biofilms – these will always form in dental unit produce water that meets drinking water
waterlines – it’s the nature of the beast standards
117 118
Dental Water Quality
Amoeba in Water Lines
For routine dental treatment, water must meet EPA
regulatory standards for drinking water*
*Available DUWL Technology
First Documented Patient DEATH
• Independent reservoirs
- when filling water bottle – Don’t touch pickup tube
• “The Lancet” - February 18-24, 2012 • Chemical treatments – continuous, intermittent
• Filtration – DentaPure, Sterisil, Vistaclear, etc.
• 82 year old woman in Rome, Italy
• Combinations
• Legonnaires’ Disease • Sterile water delivery systems
• Anti-retraction valves – studies show some retraction still can
• Genetic sequencing matched the bacteria occur
Legionnaires pneumonphilia to the dental unit
waterlines • Avoid “dead legs” – unused water lines, unit water heaters
121 • Follow the manufacturer’s instructions for use (IFU) 122
Flush Dental Devices Monitoring Options
• Anti-retraction valves or devices – maintain, test • Water testing laboratory – mail-in, local, dental
- follow mfgs. instructions for use (IFU) schools
• Devices connected to dental unit water system • In-office testing with self-contained kits
and enter the mouth should be flushed after
each patient • Follow recommendations provided by the
manufacturer of the dental unit and waterline
• Minimum of 20 – 30 seconds
treatment product for monitoring water quality and
• Includes: maintenance routines
o Handpieces
o Ultrasonic scalers • Test source water and DUWL
o Air/Water syringes • Test at least Quarterly – Document – Keep a Log
123
31Monitoring Options Monitoring Options
• In office testing - advantages
- relative short lag time for results
- can test frequently Common in office test:
- simple, visual reading of results
- can use as screening tool for regular DUWL quality • Aquasafe HPC Water Test Kit
• In office testing – disadvantages • Correction factor of 1.5
- personnel dependent - multiply colony count by 1.5
- limited bacterial range
- cost per test
- less accurate 125
126
Monitoring Options Monitoring Options
• Mail-in lab testing advantages
- third party DUWL validation & documentation
- consistent sample test analysis
- broad spectrum bacterial culturing
- easy, requires little time
• Mail-in lab testing disadvantages
- potential for sampling errors
- lag time for mailing and results
- bacterial viability during mailing
These tests indicate bacterial growth - costly – lab test plus overnight shipping
127 128
32Pass Rate by Product
Monitoring Options Product
BluTab
R2A Pass Rate
80%
Total
3545
BluTab and all shocks 81% 3871
69%
Laboratory Testing:
Patterson Waterline tablets 42
ICX and ICX w/ all shocks 76% 4719
Citrisil and Citrisil Blue Total 71% 2017
BASED ON 22,196 TESTS Z3 76% 274
• ProEdge Laboratory, 888-843-3343 TABLET TOTAL 77% 10923
Dentapure 76% 2280
66%
• OHSU School of Dentistry, 503-494-4641
Sterisil Straw 1366
STRAW TOTAL 72% 3675
• Loma Linda Univ. School of Dentistry, 909-558-0656 The 2017 Data proves: Ozone and Ozone Water
Sterisil (& System)
40%
70%
48
551
Oso Pure or UV 18% 28
• Other labs available Products don’t always Vista Clear (& System)
Centralized System Total
25%
58%
129
756
work as promised Sterilex 66% 412
Lab needs to test sample within 24 hours of Bleach
Citrisil Shock
64%
61%
415
23
collecting the sample Monarch 70% 109
MintaKleen 40% 283
SHOCK TOTAL 60% 1242
Spread plate method with R2 agar incubated to Vista Team and Vista Tabs
MicroCLEAR
45%
70%
202
226
20 - 28 for 7 days (APHA method 9215 C) Daily Liquid Total 58% 428
Product not Specified 61% 5172
129 Slide courtesy of ProEdge Dental Water Labs
Treated Water Totals/Avg 70% 22196
Surgical Water Quality
SOURCE WATER
City tap water:
77% Pass Rate Use only sterile water for Surgery
In office R/O Units, Options:
Distillers, Filters:
• Sterile water source with sterile disposable or
16% Pass Rate
autoclavable tubing
(84% Fail Rate!)
• Turn off handpiece water and use bottled sterile
R/O = reverse osmosis water or saline and a sterile irrigating syringe
slide courtesy of ProEdge Dental Water Labs
132
33Boil Water Advisory
Saliva Ejectors
• Do not use water from Public Water System for:
- use in dental unit, ultrasonic scalers, other devices
- patients to rinse
- hand hygiene • Previously suctioned fluids
- mixing dental materials might be retracted into the
- mix or dilute germicides patient’s mouth when a seal
is created
• Use bottled water
• When advisory is cancelled flush all incoming • Do not advise patients to
waterlines from PWS – optimal time not established, close their lips tightly around
varies with type & length of plumbing – 1 to 5 the tip of the saliva ejector
minutes recommended – local authorities guidance
• Disinfect DUWL per mfgs. IFUs - if used PWS water
133
Basic Aseptic Techniques Pre-procedural Mouth Rinses
• Proper hand hygiene
• Proper PPE • Antimicrobial mouth rinses prior to a dental
• Touch as few surfaces as possible procedure (CHX, essential oils, cetylpyridinium chloride, iodophor)
- remove gloves or use over gloves
- Can reduce the number of microorganisms in
- use cotton pliers or tongs to retrieve items
• Minimize aerosols & spatter aerosols, spatter and direct contact
- HVE - Decreases the number of microorganisms
- Rubber dam
- Pre-procedure mouth rinse introduced into the bloodstream ???
• Store items so they are out of aerosol & spatter area - unresolved issue – no evidence that
• Consider unit dose items
infections are prevented
• Proper disinfection and sterilization procedures
135 136
34Oral Surgical Procedures Precautions for Surgical Procedures
Sterile Surgeon’s
• Presents a risk for microorganisms to enter the body Surgical Gloves
Scrub
• Involves the incision, excision, or reflection of tissue
that exposes normally sterile areas of the oral cavity
Sterile Irrigating
• Examples include: biopsy, periodontal surgery, Solutions
implant surgery, apical surgery, and surgical
extractions of teeth One time use!
137 138
Lasers Parenteral Medications
• ANSI Z136.1 and ANSI Z136.3 (Healthcare)
• Training • Medications that are injected into the body – most
frequently by intravenous or intramuscular routes
• Protective eyewear – specific to wavelength
• Appoint a “Laser Safety Officer” • Cases of disease transmission have been reported
• Use HVE – laser plume has viable microbes – within 2
inches
• Handle safely to prevent transmission of infections
• Mask – filter to 0.1 micron
• Disposable tips are biohazardous waste • Follow safe injection practices
• Warning signs posted
• BEWARE of alcohol products and oxygen use
139 140
35Safe Injection Practices Safe Injection Practices
• Prepare injections using aseptic technique in a clean • Do not use SDV, ampules, bags or bottles of IV solution
area for more than one patient
• Disinfect diaphragm on vial with 70% alcohol • Do not combine leftover contents of SDVs
• Do not use needles and syringes for more than one • Dedicate MDV to a single patient whenever possible
patient
• If MDVs will be used for more that one patient, they
• Do not reuse needles or syringes to enter a medication
should be restricted to a centralized medication area
vial
and not enter the patient treatment area
• Do not use fluid infusion or administration sets for more
• Date MDVs when opened, discard in 28 days – unless
than one patient
the mfg. specifies a shorter or longer date
• Use SDV whenever possible
141 142
Regulated Waste Extracted Teeth
• Liquid or semi-liquid blood or OPIM
• Contaminated items that would release • Considered regulated medical
blood or OPIM in a liquid or semi-liquid state if waste
compressed o Do not incinerate extracted teeth
containing amalgam
• Items caked with dried blood or OPIM that o Clean and disinfect before sending
are capable of releasing these materials to lab for shade comparison
during handling
• Contaminated sharps • Can be given back to patient
- Clean and disinfect before giving to
• Pathological and microbiological patient
wastes containing blood or OPIM
143
36Regulated Waste - Containers Regulated Waste - Containers
• Easily accessible • Close immediately before removing
or replacing
• Labeled or color-coded
• Place in second container if leaking
• Leak-proof, closeable
possible or if outside contamination
• Puncture-resistant for sharps of primary container occurs
• Replaced routinely • If reusable - open, empty, and clean
(do not overfill!) it in a manner that will not expose
you and other employees
• Ensure acceptable with state
and local regulations • Maintain disposal records – manifest
145 - for at least 3 years 146
Regulated Waste Regulated Waste
Washington Department of Ecology – Dental Waste: • Oregon:
https://ecology.wa.gov/Regulations-Permits/Guidance- www.oregondental.org/docs/librariesprovider42/default-
technical-assistance/Dangerous-waste- document-library/best-management-
guidance/Common-dangerous-waste/Dentists practicesc24fc2dcb07d6e0c8f46ff0000eea05b.pdf?sfvrsn=
0
https://ecology.wa.gov/Regulations-Permits/Guidance-
technical-assistance/Dangerous-waste- www.oregondental.org/government-affairs/regulatory-
guidance/Common-dangerous-waste/Pharmaceutical- information/infectious-waste
waste/Guidance-for-specific-wastes
http://www.oregon.gov/deq/Hazards-and-
https://ecology.wa.gov/Regulations-Permits/Guidance- Cleanup/hw/Pages/HW-Management.aspx
technical-assistance/Dangerous-waste-
guidance/Common-dangerous-waste/Pharmaceutical- http://public.health.oregon.gov/diseasesconditions/com
waste/Guidance-for-specific-wastes/Epinephrine municabledisease/pages/infectw.aspx
147 148
37Radiography Radiography
• Barrier protect surfaces – change between • Film based intraoral
patients
- use film packet barriers if possible
- tube head/x-ray cone
- control panel - open in lighted area with gloves on
- exposure button - drop film onto paper towel or in paper cup
- work surfaces/countertops - film can be opened in darkroom without gloves
- keyboards, mouse
• Digital sensors & phosphor plates
• Once gloves on – only touch barrier protected - use FDA approved barriers – 44% failure rate
surfaces - clean & disinfect per manufacturer’s directions
with EPA registered product
149 150
Dental Laboratory Dental Laboratory
• Clean and disinfect prostheses, impressions
and lab equipment • Impressions
• Wear appropriate PPE until disinfection has been - Clean & rinse under running water
completed - disinfect with appropriate intermediate or
• Clean and heat sterilize heat-tolerant items used high level disinfectant
in the mouth - follow the manufacturer’s IFU
• Communicate specific information about - should use longest contact time on the label
cleaning & disinfection procedures with - rinse well to remove any chemical residue
commercial lab - oral bacteria are viable in set gypsum for up
• Disinfect prostheses before delivery to patient to 7 days
152
38Dental Laboratory Dermatitis and Hypersensitivity
• Lathe
- use plexiglass shield and protective eyewear • Irritant contact dermatitis
- use mask - common
- turn on vacuum - dry, itchy, irritated area around area of contact
- cover pumice tray with barrier/liner - increased risk of exposure to body fluids
- mix pumice with clean water or 1:10 bleach
- change pumice and barrier for each case • Allergic contact dermatitis (type IV hypersensitivity)
- Heat sterilize burs, rag wheels, lab knives, - rash beginning hours to days after contact
polishing points, etc. if used on contaminated - confined to area of contact
or potentially contaminated appliances or - similar to irritant contact dermatitis
materials
153 154
Dermatitis and Hypersensitivity Dermatitis and Hypersensitivity
• Latex allergy (type I immediate hypersensitivity)
- whole body reaction that usually begins in minutes
• Get tested – do not self diagnose
- runny nose, sneezing, itchy eyes, scratchy throat;
- Average HCW with skin disease suffers 3
hives, burning skin sensations
years before seeking help
- More severe symptoms include difficulty breathing,
coughing, wheezing
- rare cases can be life threating – anaphylaxis • Can have serious consequences
- Osteomyelitis in fingers
• Predisposing conditions to latex allergy - Increase risk to BBP
- history of spina bifida, urogenital abnormalities - Anaphylaxis
- allergies to kiwis, nuts, bananas
155 156
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