Disease Transmission and Infection Prevention Chapter 19 Copyright

Disease Transmission and Infection Prevention Chapter 19 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2

The Chain of Infection n The chain of infection consists of four parts: n n Virulence Number of microorganisms Susceptible host Portal of entry Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

Fig. 19 -1 At least one part must be removed to break the chain of infection. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

Virulence n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5

Number of Microorganisms n In addition to being virulent, pathogenic n 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. n n “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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6

Susceptible Host n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

Portal of Entry n n n 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 are the mouth and nose. Bloodborne pathogens must have access to the blood supply to gain entry into the body. n This occurs through a break in the skin caused by a needlestick, a cut, or even a human bite. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

Types of Infections n n Acute infection: Symptoms are often quite severe and appear soon after the initial infection occurs. Chronic infection: 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. n Oral herpes simplex and genital herpes are latent viral infections Opportunistic infection: Caused by normally nonpathogenic organisms, opportunistic infections occur in individuals whose resistance is decreased or compromised. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

Modes of Disease Transmission n Direct transmission n n Occurs when someone comes into direct contact with the infectious lesion or infected body fluids (e. g. , blood, saliva, semen, vaginal secretions). Indirect transmission n 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. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

Modes of Disease Transmission n Airborne transmission n n Also known as droplet infection, involves the spread of disease through droplets of moisture containing bacteria or viruses. Aerosol, spray, or spatter n n Contain saliva, blood, and microorganisms, are created with the use of the high-speed 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. Happens during a dental procedure when the mucosa (mouth or eyes) or nonintact skin is splashed with blood or bloodcontaminated saliva. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

Modes of Disease Transmission (continued) n n Parenteral transmission n Can take place through needlestick injuries, human bites, cuts, abrasions, or any break in the skin. Bloodborne transmission n Involves direct or indirect contact with blood and other body fluids. Food and water transmission n 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 n Occurs when proper sanitation procedures, such as hand washing 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

Fig. 19 -2 Pathogens can be transferred from staff to patient, patient to staff, and patient to patient through contaminated equipment. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

The Immune System n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

The Immune System n Naturally acquired immunity occurs when a person has contracted and is recovering from a disease. n n n Active immunity Passive immunity Artificially acquired immunity n Antibodies are introduced into the body by means of immunization or vaccination. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

Fig. 19 -4 Acquired immunity. (From Applegate EJ: The anatomy and physiology learning system, ed 4, Philadelphia, 2011, Saunders. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16

Disease Transmission in the Dental Office n Every dental office should have an infectioncontrol program designed to prevent the transmission of disease from: n n n Patient to dental team Dental team to patient Patient to patient Dental office to community (including dental team’s family) Community to dental office to patient Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17

Patient to Dental Team n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18

Patient to Dental Team n Ways to prevent disease transmission from the patient to the dental team member: n n n Gloves Hand washing Masks Rubber dams Patient mouthrinses Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19

Dental Team to Patient n n n Very unlikely to happen. Can result if the dental team member has lesions on the hands, or if the hands are cut while in the patient’s mouth, permitting the transfer of microorganisms. Infection control measures that help to prevent teamto-patient transmission include: n n Masks Gloves Hand washing Immunization Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20

Patient to Patient n n n 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) hand washing, (4) gloves, and (5) use of sterile instruments. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21

Dental Office to Community n Microorganisms can leave the dental office and enter the community in a variety of ways. n n Contaminated impressions sent to the dental laboratory Contaminated equipment sent out for repair In theory, transportation of microorganisms out of the office on the dental team’s clothing or hair The following measures can prevent this type of disease transmission: n n n Hand washing Changing clothes before leaving the office Disinfecting impressions and contaminated equipment before such items leave the office Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22

Community to Dental Office to Patient Transmission n Microorganisms enter the dental office through the municipal water that supplies the dental unit. n n Waterborne organisms colonize the inside of the dental unit waterlines and form biofilm. As water flows through the handpiece, air-water syringe, and ultrasonic scaler, a patient could swallow contaminated water. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23

Roles and Responsibilities of the CDC and OSHA in Infection Control n n n 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 healthrelated 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24

Guidelines for Infection Control in Dental Healthcare Settings (CDC) n In December of 2003, the CDC released the Guidelines for Infection Control in Dental Health Care Settings 2003. n n n The new guidelines have expanded upon the existing OSHA Bloodborne Pathogens Standard, and have included some areas that were not already covered. The guidelines are based on scientific evidence and are categorized on the basis of existing scientific data, theoretical rationale, and applicability. 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. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25

OSHA Bloodborne Pathogens Standard n The bloodborne pathogens standard (BBP) is the most important infection control law in dentistry. n n It is designed to protect employees against occupational exposure to bloodborne pathogens, such as hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26

OSHA Bloodborne Pathogens Standard n The BBP applies to any type of facility in which employees might be exposed to blood and/or other body fluids, which include: n n n Dental and medical offices Hospitals Funeral homes Emergency medical services Nursing homes OSHA requires that a copy of the BBP be present in every dental office and clinic. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27

Exposure Control Plan n n Each office must have one Clearly describes how the office complies with the standard. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28

Standard and Universal Precautions n n 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. The CDC expanded the concept and changed the term to Standard Precautions. n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29

Categories of Employees n The BBP defines an occupational exposure as “any reasonably anticipated skin, eye, mucous membrane contact, or percutaneous injury with blood or any other potentially infectious materials. ” n n Percutaneous means through the skin, such as needlesticks, cuts, and human bites Permucosal means contact with mucous membranes, such as the eyes or mouth Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30

Table 19 -1 Occupational Exposure Determination Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31

Postexposure Management n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32

Follow-up Measures for Exposed Worker Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33

Employee Training n n n The BBP Standard requires the dentist/employer to provide training in infection control procedures and safety issues to all personnel who may come in contact with blood, saliva, or contaminated instruments or surfaces. The employer must keep records of all training sessions. The record must include the date of the session, the name of the presenter, the topic, and the names of all employees who attended. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34

Hepatitis B Immunization n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35

Hepatitis B Immunization n n 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). n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36

Hepatitis B Immunization n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37

Need for a Booster n n n 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38

Employee Medical Records n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39

Managing Contaminated Sharps n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40

Fig. 19 -7 A puncture-resistant sharps disposal container should be located as close as possible to the area where the disposal of sharps takes place. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41

Preventing Needle Sticks n n 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. Always use the single-handed scoop technique or some type of safety device. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42

Hand Hygiene n Hand-washing guidelines n n n 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 hand washing. 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43

Fig. 19 -10 Areas of the hand not thoroughly washed because of poor hand-washing technique. (From Samaranayake LP, Essential microbiology for dentistry, ed 3, New York, 2007, Churchill Livingstone. ) Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44

Hand Hygiene n Hand-washing guidelines n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 45

Alcohol-Based Hand Rubs n n n 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. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 46

Hand Care Recommendations n n n 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 a 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 47

Fig. 19 -13 Water-based hand products will not break down latex gloves. (Courtesy Essential Dental Systems, Hackensack, NJ. ) Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 48

Personal Protective Equipment n n OSHA requires the employer to provide employees with the appropriate personal protective equipment (PPE) without charge to the employee. Examples of PPE n n Protective clothing Surgical masks Face shields Protective eyewear Disposable patient-treatment gloves n. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 49

Protective Clothing n n 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 50

Protective Clothing Requirements n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 51

Fig. 19 -14 Appropriate clinical attire consists of long-sleeved gowns, gloves, and eyewear. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 52

Handling Contaminated Laundry n n The BBP Standard states the protective clothing may not be taken home and washed by employees. It may be laundered in the office if the equipment is available and if Standard Precautions are followed for handling and laundering the contaminated clothing. Contaminated linens that are removed from the office for laundering should be placed in a leakproof bag with a biohazard label or an appropriately colorcoded label. Disposable gowns must be discarded daily and more often if visibly soiled. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 53

Protective Masks n n n 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 mm 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 54

Protective Masks n Guidelines for the Use of Masks n n 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. n. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 55

Protective Eyewear n n n 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 56

Face Shields n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 57

Fig. 19 -21 Face shields provide adequate eye protection, but a face mask is still required during assistance with aerosol-generating procedures. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 58

Patient Eyewear n n Patients should be provided with protective eyewear because they also may be subject to eye damage during the procedure. This may result from: n n n Handpiece spatter Spilled or splashed dental materials, including caustic chemical agents Airborne bits of acrylic or tooth fragments Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 59

Fig. 19 -22, Patients should be provided with protective eyewear. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 60

Gloves n n n Because dental personnel are most likely to come into contact with 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 61

Fig. 19 -23 Nonsterile exam gloves. (Courtesy Crosstex, Dallas, TX. ) Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 62

Gloves n Guidelines for the use of Examination Gloves n n 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 medical-quality gloves may be used for patient examinations and dental procedures. Torn or damaged gloves must be replaced immediately. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 63

Gloves n Guidelines for the use of Examination Gloves n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 64

Gloves Damaged During Treatment n n 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: n n Excuse yourself and leave the chairside. Remove and discard the damaged gloves. Wash hands thoroughly. Reglove before returning to the dental procedure. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 65

Gloves Damaged by Dental Materials n n The chemical you come in contact with on a daily basis may damage your gloves. Because so many dental materials are available on the market, you should consult the glove manufacturer about the compatibility of the glove material with various chemicals. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 66

Overgloves n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 67

Overgloves n Guidelines for the Use of Overgloves n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 68

Sterile Surgical Gloves n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 69

Utility Gloves n n Utility gloves are not used for direct patient care. Utility gloves must be worn: n n n When the treatment room is being cleaned and disinfected between patients. While contaminated instruments are being cleaned or handled. For surface cleaning and disinfection. 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 70

Fig. 19 -25 Utility gloves are used when instruments are prepared for sterilization. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 71

Non–Latex-Containing Gloves n n 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 non–latex-containing materials. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 72

Maintaining Infection Control While Gloved n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 73

Maintaining Infection Control While Gloved n Opening drawers and cabinets n n Opening containers n n Set up instruments, medications, and impression materials ahead of time, and use disposable and unit-dose items whenever possible. When opening a container, use overgloves, a paper towel, or a sterile gauze sponge to remove the lid or cap. Use sterile cotton pliers to remove an item from the container. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 74

High Tech Equipment n n n Every aspect of dentistry is entering the arena of high technology equipment and devices You must carefully consider what infection control procedures are needed to make each piece of equipment safe to use Always follow the manufacturer’s infection control recommendations for every device and piece of equipment Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 75

Latex Allergies n n n 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. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 76

Latex Allergies n n There are three common types of allergic reactions to latex. Two types involve an immune reaction and one type involves only surface irritation. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 77

Irritant Dermatitis n 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. n 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. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 78

Fig. 19 -28 Irritant dermatitis. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 79

Type IV Allergic Reaction n The most common type of latex allergy, type IV sensitivity, is a delayed contact reaction, and it involves the immune system. n n n 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. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 80

Type I Allergic Reaction n This is the most dangerous type of latex allergy, and it can result in death. n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 81

Treatment of Latex Allergies n n 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 life. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 82

Treatment n Remember… n 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 latexcontaining products. These practices include the wearing of powder-free gloves by all dental staff members to minimize the risk of airborne latex particles. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 83

Latex-Sensitive Patients n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 84

Waste Management in the Dental Office n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 85

Classification of Waste n General waste n n n Contaminated waste n n n All nonhazardous, nonregulated waste should be discarded in covered containers. Examples include disposable paper towels, paper mixing pads, and empty food containers. Waste that has had contact with blood or other body fluids. Examples include used barriers and patient napkins. Hazardous waste n Poses a risk to human beings and the environment. Toxic chemicals and materials are hazardous waste. Examples include scrap amalgam, spent fixer solution, n. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 86

Classification of Waste n Infectious or regulated waste (biohazard) n n n Contaminated waste that is capable of transmitting an infectious disease. 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). Most dental offices are exposed to the following types of infectious waste. n Blood and blood-soaked materials Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 87

Handling of Extracted Teeth n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 88

Handling Contaminated Waste n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 89

Handling of Medical Waste n n Medical waste is any solid waste generated in the diagnosis, treatment, or immunization of human beings or animals in research. Infectious waste n n n 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 90

Fig. 19 -29 Waste is separated into clearly marked containers. Left, unregulated waste. Right, regulated waste. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 91

Disposal of Medical Waste n n 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 92

Additional Infection Control Practices n OSHA Bloodborne pathogens standard n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 93

CDC Guidelines: Special Considerations n Saliva Ejectors n Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids. n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 94

n CDC Guidelines: Special Considerations Dental Laboratory n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 95

CDC Guidelines: Special Considerations n Preprocedural Mouthrinses n n Preprocedural mouthrinses 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 96

CDC Guidelines: Special Considerations n Mycobacterium Tuberculosis n n For patients with known or suspected active TB, the CDC recommends that elective dental treatment be delayed until the patient is noninfectious. For patients who require urgent dental care, the CDC recommends referring the patient to a facility with TB engineering controls and a respiratory protection program. Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 97

CDC Guidelines: Special Considerations n Creutzfeldt-Jakob Disease and Other Prion Diseases n n n 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 © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. 98

CDC Guidelines: Special Considerations n Laser/Electrosurgery Plumes or Surgical Smoke In surgical procedures involving the use of a laser or electrosurgical unit, a smoke by-product is created during thermal destruction of the tissue. n Laser plumes and surgical smoke pose a risk to dental healthcare professionals. n 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. n 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 Copyright © 2012, 2009, 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Saunders, an imprint of Elsevier Inc. All rights reserved. evaluated (unresolved issue). n 99