Disease Transmission and Infection Control Chapter 19 Copyright

Disease Transmission and Infection Control Chapter 19 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 19 Lesson 19. 1 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Identify the links in the chain of infection. Describe the differences between a chronic infection and an acute infection. Give an example of a latent infection. Describe the routes of disease transmission in a dental office. Describe the types of immunity and give examples of each. Describe the roles of the CDC and OSHA in infection control. Describe the components of an OSHA exposurecontrol plan. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives (Cont’d) Explain the difference between universal precautions and standard precautions. Explain the rationale for standard precautions. Identify the OSHA categories of risk for occupational exposure. Describe the first aid necessary after an exposure incident. Discuss the rationale for hepatitis B vaccination for dental assistants. Describe the proper handling and disposal methods for each type of waste generated in dentistry. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Introduction As a member of the dental healthcare team, the dental assistant is at risk of exposure to disease agents through contact with blood and other potentially infectious materials. By carefully following infection-control and safety guidelines, you can minimize your risk of disease transmission in the dental office. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Chain of Infection The chain of infection consists of four parts: Virulence Ø Numbers Ø Susceptible host Ø Portal of entry Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -1 At least one part must be removed to break the chain of infection. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Virulence The virulence of an organism refers to the degree of pathogenicity or strength of that organism in its ability to produce disease. Because we cannot change the virulence of microorganisms, we must rely on our body defenses and specific immunizations. Avoid contact with microorganisms by always using infection-control techniques. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Numbers In addition to being virulent, pathogenic microorganisms must be present in large enough numbers to overwhelm the body’s defenses. The number of pathogens may be directly related to the amount of bioburden present. Ø “Bioburden” refers to organic materials such as blood and saliva. The use of the dental dam and high-volume evacuation helps minimize bioburden on surfaces and reduce the number of microorganisms in the aerosol. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Susceptible Host A susceptible host is a person who is unable to resist infection by the pathogen. An individual who is in poor health, chronically fatigued, or under extreme stress or who has a weakened immune system is more likely to become infected. Staying healthy, washing hands frequently, and keeping immunizations up to date will help members of the dental team resist infection and stay healthy. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Portal of Entry To cause infection, a pathogen must have a portal of entry (or means of getting into the body). The portals of entry for airborne pathogens the mouth and nose. Bloodborne pathogens must have access to the blood supply to gain entry into the body. Ø This occurs through a break in the skin caused by a needlestick, a cut, or even a human bite. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Infections Acute infection: Symptoms are often quite severe and appear soon after the initial infection occurs. Chronic infections: In these infections, the microorganism is present for a long period; some may persist for life. Latent infection: A latent infection is a persistent infection in which the symptoms come and go; cold sores fall in this category. Ø Oral herpes simplex and genital herpes are latent viral infections Opportunistic infections: Caused by normally nonpathogenic organisms, opportunistic infections occur in individuals whose resistance is decreased or compromised. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Routes of Disease Transmission Direct transmission occurs when someone comes into direct contact with the infectious lesion or infected body fluids (e. g. , blood, saliva, semen, vaginal secretions). Indirect transmission involves the transfer of organisms to a susceptible person through, for example, the handling of contaminated instruments or touching of contaminated surfaces and then touching the face, eyes, or mouth. Splash or spatter transmission happens during a dental procedure when the mucosa (mouth or eyes) or nonintact skin is splashed with blood or bloodcontaminated saliva. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Routes of Disease Transmission (Cont’d) Airborne transmission, also known as droplet infection, involves the spread of disease through droplets of moisture containing bacteria or viruses. Aerosols, containing saliva, blood, and microorganisms, are created with the use of the highspeed handpiece, air-water syringe, and ultrasonic scaler during dental procedures. Mists are droplet particles larger than those generated in aerosol spray. Spatter is large droplet particles contaminated with blood, saliva, and other debris. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Routes of Disease Transmission (Cont’d) Parenteral transmission can take place through needlestick injuries, human bites, cuts, abrasions, or any break in the skin. Bloodborne transmission involves direct or indirect contact with blood and other body fluids. Food-and-water transmission occurs when contaminated food that has not been cooked or refrigerated properly or water that has been contaminated with human or animal fecal material is consumed. Fecal/oral transmission occurs when proper sanitation procedures, such as handwashing after use of the toilet, are not followed and one of the many pathogens present in fecal matter is transmitted when the infected person touches another person or makes contact with surfaces or food. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -2 Pathogens can be transferred from staff to patient, from patient to staff, and from patient to patient through the use of contaminated equipment. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Immune System The human body receives resistance to communicable diseases from the immune system. A communicable disease is one that can be transmitted from one person to another or by contact with the body fluids from another person. Inherited immunity is present at birth. Acquired immunity is developed over a person’s lifetime. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Acquired Immunity Acquired immunity can occur either naturally or artificially. Naturally acquired immunity occurs when a person has contracted and is recovering from a disease. • Active immunity • Passive immunity Ø In artificially acquired immunity, antibodies are introduced into the body by means of immunization or vaccination. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -3 Acquired immunity. (From Applegate EJ: The anatomy and physiology learning system, ed 2, Philadelphia, 2000, Saunders. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Disease Transmission in the Dental Office Every dental office should have an infectioncontrol program designed to prevent the transmission of disease from: Patient to dental team Ø Dental team to patient Ø Patient to patient Ø Dental office to community (including the dental team’s families) Ø Community to patient Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient–to–Dental Team Transmission The most common route is through direct contact (touching) of the patient’s blood or saliva. Droplet infection occurs through mucosal surfaces of the eyes, nose, and mouth. It can occur when the dental-team member inhales aerosol generated by the dental handpiece or air-water syringe. Indirect contact occurs when the team member touches a contaminated surface or instrument. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Disease Transmission Ways to prevent disease transmission from the patient to the dental team member. Gloves Ø Handwashing Ø Masks Ø Rubber dams Ø Patient mouth rinses Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient-to-Patient Disease Transmission Patient-to-patient disease transmission has occurred in the medical field, but no cases of this type of transmission have been documented in dentistry. Although such transmission is possible, contamination from instruments used on one patient must be transferred to another patient for this to occur. Infection-control measures that can prevent patient-to -patient transmission include (1) instrument sterilization, (2) surface barriers, (3) handwashing, (4) gloves, and (5) use of sterile instruments. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Dental Office–to–Community Transmission Microorganisms can leave the dental office and enter the community in a variety of ways. Contaminated impressions sent to the dental laboratory Ø Contaminated equipment sent out for repair Ø In theory, transportation of microorganisms out of the office on the dental team’s clothing or hair Ø The following measures can prevent this type of disease transmission: Handwashing Ø Changing clothes before leaving the office Ø Disinfecting impressions and contaminated equipment before such items leave the office Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Community–to–Dental Office–to– Patient Transmission Microorganisms enter the dental office through the municipal water that supplies the dental unit. Waterborne organisms colonize the inside of the dental unit waterlines and form biofilm. Ø As water flows through the handpiece, air-water syringe, and ultrasonic scaler, a patient could swallow contaminated water. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Roles and Responsibilities of CDC and OSHA in Infection Control The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) are federal agencies that play very important roles in infection control for dentistry. The CDC is not a regulatory agency. Its role is to issue specific recommendations based on sound scientific evidence on health-related matters. CDC’s recommendations are not law, but they do establish a standard of care for the dental profession. OSHA is a regulatory agency. Its role is to issue specific standards to protect the health of employees in the U. S. In 1991, based on the CDC guidelines, OSHA issued the Bloodborne Pathogens Standard (BBP). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines for Infection Control in Dental Health-Care Settings In December of 2003, the CDC released the Guidelines for Infection Control in Dental Health Care Settings-2003. The new guidelines have expanded upon the existing OSHA Bloodborne Pathogens Standard, and have included some areas that were not already covered. Ø The guidelines are based on scientific evidence and are categorized on the basis of existing scientific data, theoretical rationale, and applicability. Ø The guidelines apply to all paid or unpaid dental health professionals who might be occupationally exposed to blood and body fluids by direct contact or through contact with contaminated environmental surfaces, water, or air. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

OSHA Bloodborne Pathogens Standard The bloodborne pathogens standard (BBP) is the most important infection control law in dentistry. It is designed to protect employees against occupational exposure to bloodborne pathogens, such as hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). Ø Employers are required to protect their employees from exposure to blood and other potentially infectious materials (OPIM) in the workplace and to provide proper care to the employee if an exposure should occur. Ø (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

OSHA Bloodborne Pathogens Standard (Cont’d) The BBP applies to any type of facility in which employees might be exposed to blood and/or other body fluids, which include: Dental and medical offices Ø Hospitals Ø Funeral homes Ø Emergency medical services Ø Nursing homes Ø OSHA requires that a copy of the BBP be present in every dental office and clinic. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Requirements of the Standard Exposure control plan clearly describes how the office complies with the standard. The term Universal Precautions is referred to in the OSHA Bloodborne Pathogens Standard. Universal precautions is based on the concept that all human blood and body fluids (including saliva) are to be treated as if known to be infected with the bloodborne disease, HBV, HCV, or HIV. Ø The CDC expanded the concept and changed the term to Standard Precautions. Ø Standard Precautions integrate and expand the elements of universal precautions into a standard of care designed to protect healthcare providers from pathogens that can be spread by blood or any other body fluid, excretion, or secretion. It is not possible to identify those individuals who are infectious, so infection precautions are used for all healthcare personnel and their patients. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Table 19 -1 Occupational Exposure Determination Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Postexposure Management Accidents happen! Before an accident occurs, the BBP requires the employer to have a written plan. This plan explains exactly what steps the employee must follow after the exposure incident occurs and the type of medical follow -up that will be provided to the employee at no charge. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Follow-up Measures for Exposed Worker* Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hepatitis B Immunization OSHA requires the dentist to offer the hepatitis B virus (HBV) vaccination series to all employees whose jobs include category I and II tasks. Vaccine must be offered within 10 days of employment. The dentist/employer must obtain proof from the physician who administered the vaccination. The employee has the right to refuse the HBV vaccine; however, the employee must sign an informed refusal form that is kept on file in the dental office. The employee always has the right to change his or her mind and receive the vaccine at a later date at no charge. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hepatitis B Vaccine The vaccine is administered in a series of three injections. The most common vaccination schedule is 0, 1, and 6 months. The preferred injection site is in the deltoid muscle (on the arm). Ø The seroconversion rate (development of immunity) is higher than when the vaccine is administered in the buttocks. The Centers for Disease Control and Prevention (CDC) states that pregnancy should not be considered a contraindication to the HBV vaccine; however, the woman’s obstetrician should be consulted. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Post-vaccine Testing as Recommended by the CDC Between 1 to 2 months after the series has been completed, a blood test should be performed to ensure that the individual has developed immunity. Individuals who have not developed immunity should be evaluated by their physician to determine the need for an additional dose of HBV vaccine. Individuals who do not respond to the second 3 -dose series of the vaccine should be counseled regarding their susceptibility to HBV infection and precautions to take. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Need for a Booster Routine booster doses of the HBV vaccine are not recommended by the CDC. The CDC does not recommend routine blood testing (after the initial testing to determine initial immunity) to monitor the HBV antibody level in individuals who have already had the vaccine. The exception to this recommendation is if an immunized individual has a documented exposure incident and the attending physician orders the administration of a booster dose. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Employee Medical Records The dentist/employer must keep a confidential medical record for each employee. These records are confidential and must be stored in a locked file. The employer must keep these records for 30 years. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Managing Contaminated Sharps Contaminated needles and other disposable sharps, such as scalpel blades, orthodontic wires, and broken glass, must be placed into a sharps container. The sharps container must be puncture-resistant, closable, leak-proof, and color-coded or labeled with the biohazard symbol. Sharps containers must be located as close as possible to the place of immediate disposal. Do not cut, bend, or break the needles before disposal. Never attempt to remove a needle from a disposable syringe. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -4 A puncture-resistant sharps disposal container should be located as close as possible to the area where the disposal of sharps takes place. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Preventing Needlesticks as Recommended by the CDC Never recap used needles by using both hands or any other technique that involves directing the point of a needle toward any part of the body. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 19 Lesson 19. 2 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Explain the importance of hand care for dental assistants. Explain proper hand hygiene for dental assistants. Explain the advantages of alcohol-based hand rubs. Discuss the types of personal protective equipment (PPE) needed for dental assistants. Demonstrate the proper sequence for donning and removing PPE. Discuss the various types of gloves used in a dental office. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hand Hygiene Wash your hands each time before you put on gloves and immediately after you remove gloves. Wash your hands when you inadvertently touch contaminated objects or surfaces while barehanded. Always use liquid soap during handwashing. Bar soap should never be used because it may transmit contamination. For most routine dental procedures, such as examinations and nonsurgical procedures, an antimicrobial soap can be used. For surgical procedures, you should use a germicidal surgical scrub product. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -7 Areas of the hand not thoroughly washed because of poor handwashing technique. (From Samaranayake LP, Essential microbiology for dentistry, ed. 2, New York, 2002, Churchill Livingstone. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hand Care Dry hands well before donning gloves. Keep nails short and well manicured; rings (except for wedding rings), fingernail polish, and artificial nails are not to be worn at work. Microorganisms thrive around rough cuticles and can enter the body through any break in the skin. Dental personnel with open sores or weeping dermatitis must avoid activities involving direct patient contact and handling contaminated instruments or equipment until the condition on the hands is healed. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Alcohol-Based Hand Rubs Waterless antiseptic agents are alcohol-based products that are available in gels, foams, or rinses. They do not require the use of water. The product is simply applied to the hands, which are then rubbed together to cover all surfaces. These products are more effective at reducing microbial flora than a plain soap, or even an antimicrobial hand wash. Concentrations of 60% to 95% are the most effective. Higher concentrations are actually less effective. They contain emollients that reduce the incidence of chapping, irritation, and drying of the skin. These products are very “dose sensitive. ” This means that you must use the amount that is recommended. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Recommendations for Hand Care For most routine dental procedures, such as examinations and nonsurgical procedures, wash your hands with either a nonantimicrobial or antimicrobial soap and water. If your hands are not visibly soiled, you may use an waterless alcohol-based hand rub. For surgical procedures, you should perform a surgical scrub using either a nonantimicrobial or antimicrobial soap and water, dry your hands, and apply an alcohol-based surgical hand rub. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -10 Hand lotions must be compatible with glove material. (Courtesy of Crosstex. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Personal Protective Equipment OSHA requires the employer to provide employees with the appropriate personal protective equipment (PPE) without charge to the employee. Examples of PPE Ø Ø Ø Protective clothing Surgical masks Face shields Protective eyewear Disposable patient-treatment gloves Heavy-duty utility gloves Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Protective Clothing Types of protective clothing include smocks, slacks, skirts, laboratory coats, surgical scrubs (hospital operating room clothing), scrub (surgical) hats, pants, and shoe covers. The type of protective clothing you should wear is based on the degree of anticipated exposure to infectious materials. The BBP prohibits the employee from taking protective clothing home to be laundered. Laundering of contaminated protective clothing is the responsibility of the employer. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Protective Clothing Requirements Protective clothing should be made of fluid-resistant material. As a means of minimizing the amount of uncovered skin, clothing should have long sleeves and a high neckline. Note: The type and characteristics of protective clothing depend on the anticipated degree of exposure. The design of the sleeve should allow the cuff to be tucked inside the band of the glove. During high-risk procedures, protective clothing must cover dental personnel at least to the knees when seated. Buttons, trim, zippers, and other ornamentation should be kept to a minimum. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -11 Appropriate clinical attire consists of long-sleeved gowns, gloves, and eyewear. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Protective Masks A mask is worn over the nose and mouth to protect you from inhaling possible infectious organisms spread by the aerosol spray of the handpiece or air-water syringe and accidental splashes. A mask with at least 95% filtration efficiency for particles 3 to 5 mm in diameter should be worn whenever splash or spatter is likely. The two most commonly used types of masks are dome-shaped and flat. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Guidelines for the Use of Masks Masks should be changed for every patient or more often (CDC guideline). To handle a mask, touch the side edges only; avoid contact with the more heavily contaminated body of the mask. The mask should conform well to the face. The mask should not make contact with the mouth while being worn because the moisture that is generated will decrease filtration efficiency. A damp or wet mask is not an effective mask. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Protective Eyewear Eyewear is worn to protect eyes against the danger of damage caused by aerosolized pathogens. Protective eyewear also prevents spattered solutions or caustic chemicals from injuring the eyes. OSHA requires the use of eyewear with both front and side protection (solid side shields) during exposure-prone procedures. If you wear contact lenses, you must wear protective eyewear with side shields or a face shield. After each treatment or patient visit, clean and decontaminate your protective eyewear in accordance with the manufacturer's instructions (CDC guideline). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Face Shields A chin-length plastic face shield may be worn as an alternative to protective eyewear. A shield cannot be substituted for a face mask because it does not protect against inhalation of contaminated aerosols. When splashing or spattering of blood or other body fluids is likely during a procedure (such as surgery), a face shield is often worn in addition to a protective mask. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -18 Face shields provide adequate eye protection, but a face mask is still required during assistance with aerosol-generating procedures. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Protective Eyewear for Patients should be provided with protective eyewear because they also may be subject to eye damage during the procedure. This may result from: Handpiece spatter Ø Spilled or splashed dental materials, including caustic chemical agents Ø Airborne bits of acrylic or tooth fragments Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -19 Patients should be provided with protective eyewear. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Gloves Because dental personnel are most likely to come into contact blood or contaminated items with their hands, gloves may be the most critical PPE. You must wear a new pair of gloves for each patient, remove them promptly after use, and wash your hands immediately to avoid the transfer of microorganisms to other patients or the environment (CDC guideline). Consult with the glove manufacturer regarding the chemical compatibility of the glove material and the dental materials you use (CDC guideline). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -21 Nonsterile exam gloves. (Courtesy of Crosstex. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Guidelines for the Use of Gloves All gloves used in patient care must be discarded after a single use. These gloves may not be washed, disinfected, or sterilized; however, they may be rinsed with water to remove excess powder. Latex, vinyl, or other disposable medicalquality gloves may be used for patient examinations and dental procedures. Torn or damaged gloves must be replaced immediately. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Guidelines for the Use of Gloves (Cont’d) Do not wear jewelry under gloves. (Rings harbor pathogens and may tear gloves. ) Change gloves frequently. (If the procedure is long, change gloves about once each hour. ) Remove contaminated gloves before leaving the chairside during patient care and replace them with new gloves before returning to patient care. Hands must be washed after glove removal and before regloving. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Gloves Damaged During Treatment Gloves are effective only when they are intact (not damaged, torn, ripped, or punctured). If gloves are damaged during treatment, they must be changed immediately. The procedure for regloving is: Excuse yourself and leave the chairside. Ø Remove and discard the damaged gloves. Ø Wash hands thoroughly. Ø Reglove before returning to the dental procedure. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Overgloves Overgloves, which also are known as “food handler” gloves, are made of lightweight, inexpensive clear plastic. These may be worn over contaminated treatment gloves (overgloving) to prevent the contamination of clean objects handled during treatment. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Guidelines for the Use of Overgloves are not acceptable alone as a hand barrier or for intraoral procedures. Overgloves must be worn carefully to avoid contamination during handling with contaminated procedure gloves. Overgloves are donned before the secondary procedure is performed and removed before the patient treatment that was in progress is resumed. Overgloves are discarded after a single use. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Sterile Surgical Gloves Sterile gloves should be worn for invasive procedures involving the cutting of bone or significant amounts of blood or saliva, such as oral surgery or periodontal treatment. Sterile gloves are supplied in prepackaged units to maintain their sterility before use. They are provided in specific sizes and are fitted to the left or right hand. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Utility Gloves Utility gloves are not used for direct patient care. Utility gloves must be worn: When the treatment room is being cleaned and disinfected between patients. Ø While contaminated instruments are being cleaned or handled. Ø For surface cleaning and disinfection. Ø Utility gloves may be washed, disinfected, or sterilized and reused. Used utility gloves must be considered contaminated and handled appropriately until they have been properly disinfected or sterilized. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -22 Utility gloves are used in preparing instruments for sterilization. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Maintaining Infection Control While Gloved During a dental procedure, it may be necessary to touch surfaces or objects such as drawer handles and material containers. If you touch these objects with a gloved hand, both the surface and glove become contaminated. To minimize the possibility of crosscontamination, use an overglove when it is necessary to touch a surface. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Non–Latex-Containing Gloves Healthcare providers or patients may experience serious allergic reactions to latex. For the person who is sensitive to latex, there are gloves made from vinyl, nitrile, and other nonlatex-containing materials. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Glove Caution Chemicals such as glutaraldehyde and acrylates readily permeate (pass through) latex gloves and can irritate the skin. Ø Note that irritation can be mistaken for an allergic reaction to the chemicals in the latex glove. This is why latex gloves should never be worn for the handling of chemicals. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 19 Lesson 19. 3 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Explain the types and symptoms of latex reactions. Describe the proper handling and disposal methods for each type of waste generated in dentistry. Describe the roles of the CDC and OSHA in infection control. Explain the CDC recommendations regarding the use of a saliva ejector. Explain the precautions necessary when treating a patient with active tuberculosis. Describe the rationale of CDC recommendations regarding Creutzfeldt-Jakob disease and other prion-related diseases. Describe the rationale of CDC recommendations regarding laser plumes. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Latex Allergies The use of natural-rubber latex gloves has proved one of the most effective means of protecting the dental worker and the patient from the transmission of disease. The number of healthcare workers and patients who have become hypersensitive to latex has increased dramatically. The CDC Guidelines include recommendations for contact dermatitis and latex hypersensitivity. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Latex Allergies (Cont’d) There are three common types of allergic reactions to latex. Two types involve an immune reaction and one type involves only surface irritation. Ø Irritant dermatitis, a nonimmunologic process (does not involve the body’s immune system), is caused by contact with a substance that produces chemical irritation of the skin. • The skin becomes reddened, dry, irritated, and, in severe cases, cracked. Irritant dermatitis can be reversed by identifying and correcting the cause of the problem. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -24 Irritant dermatitis. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Latex Allergies (Cont’d) Type IV sensitivity Ø The most common type of latex allergy, type IV sensitivity, is a delayed contact reaction, and it involves the immune system. • It may take as long as 48 or 72 hours for the red, itchy rash to appear. • Reactions are limited to the areas of contact and do not involve the entire body. • An immune response is produced by the chemicals that are used to process the latex used in manufacturing the gloves, not by the proteins in the latex. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Latex Allergies (Cont’d) Type I allergic reaction Ø This is the most dangerous type of latex allergy, and it can result in death. • The reaction comes in response to the latex protein in the glove (in contrast to the reaction to chemical additives in type IV reactions). • A severe immunologic (immune system) response usually occurs 2 to 3 minutes after the latex allergens make contact with the skin or mucous membranes. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Treatment of Latex Allergies There is no specific cure for latex allergy. The only options are prevention, avoidance of latexcontaining products, and treatment of the symptoms. Anyone who suspects that he or she has an allergy to latex should see a qualified healthcare provider to have a test to confirm the allergy. Once a latex allergy has been diagnosed, the affected person should practice latex avoidance in all aspects of his or her personal and professional lives. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Remember… When a latex allergy has been diagnosed in one employee in the dental office, all staff members should use practices to minimize the use of latex-containing products. These practices include the wearing of powder-free gloves by all dental staff members to minimize the risk of airborne latex particles. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Latex-Sensitive Patients In the healthcare setting, patients with latex allergies should be treated with the use of alternatives to latex. Vinyl gloves and nonlatex rubber dams should be available in all dental offices. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Waste Management in the Dental Office Dental practices are subject to a wide variety of federal, state, and local regulations concerning waste management issues. The Environmental Protection Agency (EPA) and most state and local regulations do not categorize saliva or saliva-soaked items as infectious waste. Because of the high probability that blood may be carried in saliva during dental procedures, CDC guidelines and OSHA regulations consider saliva in dentistry a potentially infectious body fluid. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Classifications of Waste General waste: All nonhazardous, nonregulated waste should be discarded in covered containers. Ø Contaminated waste is waste that has had contact with blood or other body fluids. Ø Examples include disposable paper towels, paper mixing pads, and empty food containers. Examples include used barriers and patient napkins. Hazardous waste poses a risk to human beings and the environment. Toxic chemicals and materials are hazardous waste. Ø Examples include scrap amalgam, spent fixer solution, and lead foil from x-ray film packets. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Classifications of Waste (Cont’d) Some items, such as extracted teeth with amalgam restorations, may be both hazardous waste (because of the amalgam) and infectious waste (because of the blood). Infectious or regulated waste (biohazard) is contaminated waste that is capable of transmitting an infectious disease. Blood and blood-soaked materials Ø Pathologic waste Ø Sharps Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Handling Dental Office Waste Contaminated waste: Items that may contain the body fluids of patients, such as gloves and patient napkins, should be placed in a lined trash receptacle. Medical waste is any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals in research. Infectious waste is a subset of medical waste. Only a small percentage of medical waste is infectious and needs to be regulated. Ø Must be labeled with the universal biohazard symbol Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines for Handling Extracted Teeth Dispose of extracted teeth as regulated medical waste unless they are being returned to the patient. When teeth are returned to the patient, the provisions of the standard no longer apply. Do not dispose of extracted teeth containing amalgam in regulated medical waste that will be incinerated. Note: Because of the mercury in amalgam fillings, you should check with state and local authorities for regulations regarding disposal of teeth containing amalgam. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Handling Contaminated Waste Contaminated items that may contain the body fluids of patients, such as gloves and patient napkins, should be placed in a lined trash receptacle. A receptacle for contaminated waste should be covered with a properly fitted lid that can be opened with a foot pedal. Keeping the lid closed prevents air movement and the spreading of contaminants. Red bags or containers should not be used for unregulated waste. Check the specific requirements of your local state or county health department. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 19 -25 Waste is separated into clearly marked containers. Left, unregulated waste. Right, regulated waste. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Handling of Medical Waste Medical waste is any solid waste generated in the diagnosis, treatment, or immunization of human beings or animals in research. Infectious waste is a subset of medical waste. Only a small percentage of medical waste is infectious and needs to be regulated. Containers of infectious waste (regulated waste) must be labeled with the universal biohazard symbol, identified in compliance with local regulations, or both. Containers used for holding contaminated items must be labeled. Examples of such containers include contaminated sharps containers, pans or trays used to hold contaminated instruments, bags of contaminated laundry, specimen containers, and storage containers. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Disposal of Medical Waste Once contaminated waste leaves the office, it is regulated by the EPA and by state and local laws. Under most regulations, the manner of disposal is determined by the amount (weight) of infectious materials requiring disposal. The average dental practice is categorized as a “small producer” of infectious waste, and disposal is regulated accordingly. The law requires the dentist to maintain records of the final disposal of this medical waste, including documentation of how, when, and where it was disposed of. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Additional Infection Control Practices Never eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in any area of the dental office where contamination is possible, such as the dental treatment rooms, dental laboratory, sterilization area, or the area for the processing of x-rays. Never store food or drink in a refrigerator that contains any potentially contaminated items. You can minimize the amount of splash and spatter contamination produced during dental procedures with the skillful use of a dental dam and high-volume evacuation. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines Special Considerations: Saliva Ejectors Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids. Ø Rationale: Backflow from low-volume saliva ejectors occurs when the pressure in the patient’s mouth is less than that in the evacuator. This backflow can be a source of cross-contamination between patients. Although no adverse health effects associated with the saliva ejector have been reported, you should be aware that in certain situations backflow could occur with the use of a saliva ejector. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines Special Considerations: Dental Laboratories Use PPE when handling items in the laboratory until they have been decontaminated. Clean, disinfect, and rinse all dental prostheses and prosthodontic materials (e. g. , impressions, bite registrations, occlusal rims, and extracted teeth). Consult with manufacturers regarding the stability of specific materials (e. g. , impression materials) relative to disinfection procedures. Clean and heat-sterilize heat-tolerant items used in the mouth (e. g. , metal impression trays and face-bow forks). Follow manufacturers' instructions for cleaning, sterilizing, or disinfecting items that become contaminated but do not normally come into contact with the patient (e. g. , burs, polishing points, rag wheels, articulators, case pans, and lathes. ) If manufacturer instructions are unavailable, clean and sterilize heat-stable items and disinfect them. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines Special Considerations: Preprocedural Mouth Rinses Preprocedural mouth rinses are intended to reduce the number of microorganisms released in the form of aerosol or spatter. Preprocedural mouth rinsing can decrease the number of microorganisms introduced into the patient’s bloodstream during invasive dental procedures. Scientific evidence that preprocedural mouth rinsing prevents clinical infections among dental health professionals or patients is inconclusive. This is an unresolved issue, and no recommendation has been made. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines Special Considerations: Creutzfeldt-Jakob Disease and Other Prion Diseases Creutzfeldt-Jakob Disease (CJD) belongs to a group of rapidly progressive and invariably fatal degenerative neurologic disorders. They affect both human beings and animals and are thought to be caused by infection with prions. Prion diseases have an incubation period of years but are usually fatal within 1 year of diagnosis. The infectivity of oral tissues in CJD patients is an unresolved issue. Scientific data indicate that the risk, if any, of sporadic CJD transmission during dental and oral surgical procedures is low to nil. No recommendation is offered regarding the use of special precautions in addition to standard precautions in the treatment of patients with known CJD (unresolved issue). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CDC Guidelines Special Considerations: Laser/Electrosurgery Plumes or Surgical Smoke In surgical procedures involving the use of a laser or electrosurgical unit, a smoke byproduct is created during thermal destruction of the tissue. Laser plumes and surgical smoke pose a risk to dental healthcare professionals. One concern is that the aerosolized infectious material in the laser plume may reach the nasal mucosa of the operator or other members of the dental team. However, airborne exposure to an infectious agent in a laser plume might not be enough to cause disease. The effect of the exposure (e. g. , disease transmission or adverse respiratory effects) on dental healthcare professionals resulting from the use of lasers in dentistry has not been adequately evaluated (unresolved issue). Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.