Infectious Control Practices

for a Dental Office

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P R ES E N T E D BY: Hosted by:

THOMAS J. WEBER, ESQUIRE
G O L D B E R G K AT Z M A N , P. C .
P. O . B O X 6 9 9 1 | H A R R I S B U R G ,
PA 1 7 1 1 2
(717) 234-4161 | (717) 234-
6 8 0 8 - FA X
T J W @ G O L D B E R G K AT Z M A N . C O
M
 49 Pa. Code § 33.211
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(a)(7) Failing to follow current infection control

recommendations issued by the Federal Centers
for Disease Control or to ensure that auxiliary
personnel and other supervisees follow these
Federal guidelines.

In effect since prior to 2000.

Centers for Disease Control and Prevention (CDC)
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Guidelines for Infection Control in Dental Health

Care Settings - - - 2003

11 years old

So why address now…?

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 April 18, 2013

 “At least 60 people have tested positive for hepatitis or HIV

after visiting an Oklahoma dentist slammed by the state dental
board for poor sterilization practices, the Tulsa Health
Department said today.”

 A surprise inspection of [the dentist’s] practice on March 18

was prompted by a patient’s positive test…revealed the use of
old needles and rusty instruments.

Since then…
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 At least three Pennsylvania dentists have been disciplined.

 At least one family practice doctor and a group practice have

been disciplined.

 At the State Dental Board meeting September 5, 2014, two

consent agreements were presented to the Board for
consideration.

 Incidents usually produce a great deal of publicity and an

emergency suspension of the practitioner’s license.
CDC Covers a Broad Range of Practices and Procedures
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 Personnel health elements  Latex hypersensitivity/Contact

 Blood borne pathogens Dermatitis

 Hand hygiene  Environmental infection control

 Personal protective equipment  Dental unit waterlines

 Sterilization and disinfection  Training and procedures

 In an hour, we hope to:
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 Highlight the most important aspects of each element

 Help identify potential problem spots in your office

 Provide a tool for training

 Establish a protocol for inspection and recordkeeping

Overriding General Theme Use Standard (universal) Precautions
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 Hand washing

 Use of gloves, masks, eye protection and gowns

 Patient care equipment (instruments)

 Environmental surfaces (counters)

 Injury prevention
 Intended to Prevent the Spread of Organisms
Spread by Blood and also:
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Body fluids, secretions and excretions, except sweat

(whether or not they contain blood)

Non-intact (broken) skin

Mucus membranes
 Personnel Health Elements
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 Education and training

 Immunizations (strongly recommended)
 Hepatitis B
 Influenza
 Measles
 Mumps
 Rubella
 Varicella-zoster
 Exposure prevention and post-exposure management
 Medical condition management and work-related restrictions
 Health record maintenance
 Bloodborne Pathogens Risk Factors
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Frequency of infection among patients

Risk of transmission after a blood exposure (type of

virus) HBV, HCV, HIV

Type and frequency of blood contact
Characteristics of Percutaneous Injuries in Dental Setting
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Reported frequency among general dentists

declining
Caused by burs, syringe needles, other sharps
Occur outside the patient’s mouth
Small amounts of blood
OMS – fracture reductions and procedures
involving wire
 Precautions
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Use sharps containers

Self-sheathing needles

Use instruments instead of fingers to retract or

palpate tissue
One-handed needle recapping
 Post-Exposure Protocol
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Education available for health care personnel

Access to:
 Clinical care
 Post-exposure prophylaxis
 Testing of source
 Hand Hygiene
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Hands are the most common mode of pathogen

transmission
Clean:
 Visibly dirty
 After touching contaminated objects
 Before and after each patient treatment
 Degrees of Hand Hygiene
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 Routine hand wash

 Plain soap and water: 15 seconds
 Antiseptic hand wash
 Antimicrobial soap and water: 15 seconds
 Antiseptic hand rub
 Alcohol based hand rubs: until hands are dry
 Surgical antisepsis
 Antimicrobial soap and water: 2-6 minutes (forearms)
 Plain soap and water followed by alcohol-based surgical scrub:
manufacturer’s instructions
 Hand Hygiene Other Considerations
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 Storage
 Alcohol based away from flames
 Do not “top off”
 Keep fingernails short
 Avoid artificial nails or jewelry that may tear gloves
 Consider compatibility between hand lotions and gloves
 Personal Protective Equipment
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Trying to protect skin and mucus

membranes from splashes or sprays
 Remove protective gear when leaving the
treatment area
 Types of Protective Materials
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Surgical mask or eye protection

OR
Face shield
 Clean reusable face protection between patients
 If soiled, clean and disinfect
 Change masks in between patients (do not wear as
a necklace)
 Clothing
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Gowns/lab coats
 Should cover personal clothing
 Change if visibly soiled

 Remove before leaving work area

 Gloves
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 Not a replacement for hand washing

 New pair for each patient
 Change if tear noticed
 Do not wash or disinfect for reuse

 Be aware of sensitivity/allergy concerns of both wearer

and patient (health history)
 Sterilization and Disinfection
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Critical Instruments
 Penetrate mucus membranes or contact bone, the
bloodstream or other normally sterile tissues of the mouth
 Heat sterilize between uses or use single-use,
disposable devices
 Scalpel blades, periodontal scalers, surgical burs
 Semi-Critical Instruments
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Contact mucus membranes but do not penetrate

Heat sterilize or high-level disinfectants

Dental mirrors, amalgam condensers, dental

handpieces
 Non-Critical Instruments and Devices
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Contact intact skin

Use low to intermediate level disinfectant

X-ray heads, pulse oximeter, blood pressure cuff

 Instrument Processing Area
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Have a designated area – it helps maintain

integrity of protocol and assists with training
and performance
 Receiving, cleaning and decontamination
 Preparation and packaging
 Sterilization

 Storage
 Automated Cleaning
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Ultrasonic cleaner

Instrument washer

Washer-disinfector

Follow manufacturer’s specifications

 Manual Cleaning
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Soak until ready

Wear protective materials:
 Mask
 Eyewear

 Utility gloves
 Preparation and Packaging
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 Wrap or place critical and semi-critical items in

containers prior to heat sterilization

 Hinged instruments should be opened and unlocked

 Place chemical indicator in package or container

 Use utility gloves

 Heat-Based
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 Autoclaving – steam under pressure

 Dry heat
 Unsaturated chemical vapor (DEP concerns)
 Use FDA approved equipment
 Follow manufacturer’s recommendations for equipment,
packaging, loading…

 Dry/cool inside the machine

 Unwrapped Instruments
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 Sterilize unwrapped instruments only if:

1. They have been thoroughly cleaned and dried
2. Mechanical monitors are checked and chemical indicators
used for each cycle
3. Care is given to avoid heat injury
4. Items transported aseptically to point of use

 Never store critical instruments unwrapped

 Storage of unwrapped semi-critical instruments is

discouraged. If done, should have clear protocol in place
and follow it
Liquid Chemical Sterilant/Disinfectant
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 Only for heat-sensitive critical and semi-critical devices

 Use only FDA approved material and post-sterilization
steps
 Rinse with sterile water
 Handle with sterile gloves and dry with sterile towels
 Deliver to point of use in aseptic manner

If stored before use, needs to be re-sterilized.

Liquid Chemical Sterilant/Disinfectant Cont’d.
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 Follow manufacturer specifications as to:

 Dilution
 Immersion time
 Temperature
 Safety precautions must be followed

 Not typically used for critical instruments

 Use discouraged
 Other Forms of Sterilization
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Low temperature
 Not practical for private office setting

Bead sterilizers – use at your own risk

 Sterilization Monitoring
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Mechanical
 Cycle time
 Temperature
 Pressure

Chemical indicators
 Internal indicator should be placed in every package
 External – if internal cannot be seen from outside package
 Manufacturer specifications
 Sterilization Monitoring Cont’d.
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 Biological indicators
 At least weekly
 Every load containing implantable material
 Use a control BI from same lot

 Use BI’s whenever:

 A new type of packaging material or tray is used
 After training new sterilization personnel
 After repair
 After change in loading procedures
 What to do if Positive BI
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 If mechanical and chemical indicators were ok:

 If implantable – recall
 If not, repeat spore test using same cycle

 If negative and operating procedures were correct, return

sterilizer to service.

 If positive, do not use until inspected and repaired – and three

consecutive empty chamber negative results

 Document results of biological and monitoring sterilization

 Storage
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 Use date or event-related shelf-life practices:

event – torn – wet (still record date)

 Record machine

 Clean, dry, closed environment

 Examine wrapping carefully – if damaged, re-clean,

wrap, sterilize
 Environmental Infection Control
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 Clinical contact surfaces

 High potential for direct contamination from spray,
splatter or hand

 Housekeeping surfaces
 Walls, floors, ceilings, sinks

Everything else Clinical

 Cleaning
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 Use appropriate barrier precautions

 Elbow grease is as important as the disinfection process

 EPA- registered hospital disinfectants – manufacturer

 Do not use chemicals used in sterilization process

 Clinical Contact
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 Surface barriers changed in between patients

OR

 Clean then disinfect using EPA-registered low to

intermediate-level hospital disinfectant
 Housekeeping Surfaces
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 Routinely use soapy water or EPA detergent

 Clean mops and cloths – allow them to dry

 Prepare cleaning and disinfecting solutions daily –

manufacturer
 Avoid carpet – upholstery in treatment areas
 Medical Waste
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 Medical waste – not considered infectious, discard with

regular trash (98-99%)

 Regulated medical waste – potential risk of infection

during handling and disposal (1-2%)
 Solid waste soaked with blood or saliva
 Extracted teeth
 Surgically removed hard or soft tissues
 Contaminated sharps

 Biohazard bag – sharps container

 Dental Unit Waterlines
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 For routine dental treatment – water has to meet

standards for drinking water
 <500 CFU/mL

 How to maintain
 Independent reservoirs
 Chemical treatment
 Filtration
 Sterile water delivery system

 Monitor – test
 Use sterile saline or water as irrigator
 Special Considerations
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Dental Hand pieces

 Clean and heat sterilize intraoral removable devices

 Do not use liquid germicides
 Follow manufacturer’s instructions
Components Permanently Attached
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 Use barriers and change between uses

 Clean and use intermediate-level disinfect for the

surface of devices if visibly contaminated

 Saliva ejectors

 Advise patients to not close their lips around the top

 Parenteral Medications
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IV tubing, bags, connections, needles and syringes

are single-use, disposable

Single dose vials

 Do not administer to multiple patients even if the
needle is changed
 Do not combine leftovers
 Oral Surgical Procedures
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Biopsy, periodontal surgery, implants, surgical

extractions
 Surgical scrub
 Sterile surgeon’s gloves
 Sterile irrigating solutions (and delivery system)
 Infectious Disease Protocol
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Develop standard operating procedures

Evaluate

Document/checklists

Monitor health care-associated infections

 Miscellaneous
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 Radiology
 Pre-procedural mouth rinses
 Handling biopsy specimens
 Place in sturdy, leak-proof container
 Label with biohazard

 Extracted teeth - Regulated Medical Waste

 Do not incinerate if they contain amalgam
 Clean/disinfect before sending to lab
 Can give to patient

 Dental laboratories
 Miscellaneous Cont’d.
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 TB
 Health history
 Defer elective treatment
 Wear mask/separation

 Creutzfeldt-Jakob Disease (CJD) and varient CJD

 Single use items
 Consider difficult items to clean (endo files) single use
 Keep instruments moist until cleaned
 Autoclave at 134° for 18 minutes
 Helpful Resources
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 Centers for Disease Control and Prevention

 Google Infection Control in Dental Health Settings

 Guideline
 PowerPoint presentation (can download)
 Frequently asked questions
 In-person CE opportunity
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What’s New with OSHA and Infection Prevention

 Mechanicsburg, PA
 Thursday, October 23
 Presented by Mary Govoni, CDA, RDH, MBA
 Offered from 8:30 a.m. to 11:30 a.m.
 Course will be repeated from 1 p.m. to 4 p.m.

Visit www.padental.org/calendar for more information. You must be logged in to the

website to register. Please contact Rebecca at rvn@padental.org or (717) 234-5941,
ext. 117 with any questions or for more information.
 Thank you for your attention
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Thomas J. Weber, Esquire

Goldberg Katzman, P.C.
4250 Crums Mill Road, Suite 301
P.O. Box 6991 A full service law firm with offices in
Harrisburg, Lancaster and Carlisle
Harrisburg, PA 17112
(717) 234-4161 | (717) 234-6808 – fax Check us out on the web:
tjw@goldbergkatzman.com www.goldbergkatzman.com
 Claim Your CE Credit!
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Email the following code to mss@padental.org

9183341
Please email the code within 72 hours of the webinar and
PDA will email your verification of participation form and
provide a form so the doctor can request CE credit for any
staff members who also participated in the webinar.