infection control guidelines for dentists

[drsnehamaheshwari]

Creutzfeldt-Jakob Disease and Other Prion Diseases

Creutzfeldt-Jakob disease (CJD) belongs to a group of rapidly progressive, invariably fatal, degenerative neurological disorders, transmissible spongiform encephalopathies (TSEs) that affect both humans and animals and are thought to be caused by infection with an unusual pathogen called a prion. Prions are isoforms of a normal protein, capable of self-propagation although they lack nucleic acid. Prion diseases have an incubation period of years and are usually fatal within 1 year of diagnosis.

Among humans, TSEs include CJD, Gerstmann-Straussler-Scheinker syndrome, fatal familial insomnia, kuru, and variant CJD (vCJD). Occurring in sporadic, familial, and acquired (i.e., iatrogenic) forms, CJD has an annual incidence in the United States and other countries of approximately 1 case/million population. In approximately 85% of affected patients, CJD occurs as a sporadic disease with no recognizable pattern of transmission. A smaller proportion of patients (5%–15%) experience familial CJD because of inherited mutations of the prion protein gene.

vCJD is distinguishable clinically and neuropathologically from classic CJD, and strong epidemiologic and laboratory evidence indicates a causal relationship with bovine spongiform encephalopathy (BSE), a progressive neurological disorder of cattle commonly known as mad cow disease. vCJD, was reported first in the United Kingdom in 1996 and subsequently in other European countries. Only one case of vCJD has been reported in the United States, in an immigrant from the United Kingdom. Compared with CJD patients, those with vCJD are younger (28 years versus 68 years median age at death), and have a longer duration of illness (13 months versus 4.5 months). Also, vCJD patients characteristically exhibit sensory and psychiatric symptoms that are uncommon with CJD. Another difference includes the ease with which the presence of prions is consistently demonstrated in lymphoreticular tissues (e.g., tonsil) in vCJD patients by immunohistochemistry.

CJD and vCJD are transmissible diseases, but not through the air or casual contact. All known cases of iatrogenic CJD have resulted from exposure to infected central nervous tissue (e.g., brain and dura mater), pituitary, or eye tissue. Studies in experimental animals have determined that other tissues have low or no detectable infectivity. Limited experimental studies have demonstrated that scrapie (a TSE in sheep) can be transmitted to healthy hamsters and mice by exposing oral tissues to infectious homogenate. These animal models and experimental designs might not be directly applicable to human transmission and clinical dentistry, but they indicate a theoretical risk of transmitting prion diseases through perioral exposures.

According to published reports, iatrogenic transmission of CJD has occurred in humans under three circumstances: after use of contaminated electroencephalography depth electrodes and neurosurgical equipment; after use of extracted pituitary hormones; and after implant of contaminated corneal and dura mater grafts from humans. The equipment-related cases occurred before the routine implementation of sterilization procedures used in health-care facilities.

Case-control studies have found no evidence that dental procedures increase the risk of iatrogenic transmission of TSEs among humans. In these studies, CJD transmission was not associated with dental procedures (e.g., root canals or extractions), with convincing evidence of prion detection in human blood, saliva, or oral tissues, or with DHCP becoming occupationally infected with CJD. In 2000, prions were not found in the dental pulps of eight patients with neuropathologically confirmed sporadic CJD by using electrophoresis and a Western blot technique.

Prions exhibit unusual resistance to conventional chemical and physical decontamination procedures. Considering this resistance and the invariably fatal outcome of CJD, procedures for disinfecting and sterilizing instruments potentially contaminated with the CJD prion have been controversial for years. Scientific data indicate the risk, if any, of sporadic CJD transmission during dental and oral surgical procedures is low to nil. Until additional information exists regarding the transmissibility of CJD or vCJD, special precautions in addition to standard precautions might be indicated when treating known CJD or vCJD patients; the following list of precautions is provided for consideration without recommendation:

• Use single-use disposable items and equipment whenever possible.
• Consider items difficult to clean (e.g., endodontic files, broaches, and carbide and diamond burs) as single-use disposables and discard after one use.
• To minimize drying of tissues and body fluids on a device, keep the instrument moist until cleaned and decontaminated.
• Clean instruments thoroughly and steam-autoclave at 134^ºC for 18 minutes. This is the least stringent of sterilization methods offered by the World Health Organization. The complete list is available at http://www.who.int/emc-documents/tse/whocdscsraph2003c.html.
• Do not use flash sterilization for processing instruments or devices.

 

        

[drsnehamaheshwari]

Program Evaluation

The goal of a dental infection-control program is to provide a safe working environment that will reduce the risk of health-care–associated infections among patients and occupational exposures among DHCP. Medical errors are caused by faulty systems, processes, and conditions that lead persons to make mistakes or fail to prevent errors being made by others. Effective program evaluation is a systematic way to ensure procedures are useful, feasible, ethical, and accurate. Program evaluation is an essential organizational practice; however, such evaluation is not practiced consistently across program areas, nor is it sufficiently well-integrated into the day-to-day management of the majority of programs.

A successful infection-control program depends on developing standard operating procedures, evaluating practices, routinely documenting adverse outcomes (e.g., occupational exposures to blood) and work-related illnesses in DHCP, and monitoring health-care–associated infections in patients. Strategies and tools to evaluate the infection-control program can include periodic observational assessments, checklists to document procedures, and routine review of occupational exposures to bloodborne pathogens. Evaluation offers an opportunity to improve the effectiveness of both the infection-control program and dental-practice protocols. If deficiencies or problems in the implementation of infection-control procedures are identified, further evaluation is needed to eliminate the problems. 

 

 

        

[drsnehamaheshwari]

Infection-Control Research Considerations

Although the number of published studies concerning dental infection control has increased in recent years, questions regarding infection-control practices and their effectiveness remain unanswered. Multiple concerns were identified by the working group for this report, as well as by others during the public comment period. This list is not exhaustive and does not represent a CDC research agenda, but rather is an effort to identify certain concerns, stimulate discussion, and provide direction for determining future action by clinical, basic science, and epidemiologic investigators, as well as health and professional organizations, clinicians, and policy makers.

Recommendations

Each recommendation is categorized on the basis of existing scientific data, theoretical rationale, and applicability. Rankings are based on the system used by CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) to categorize recommendations:

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementation and supported by experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC. Required for implementation as mandated by federal or state regulation or standard. When IC is used, a second rating can be included to provide the basis of existing scientific data, theoretical rationale, and applicability. Because of state differences, the reader should not assume that the absence of a IC implies the absence of state regulations.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

 

        

[drsnehamaheshwari]

I. Personnel Health Elements of an Infection-Control Program

A. General Recommendations

1. Develop a written health program for DHCP that includes policies, procedures, and guidelines for education and training; immunizations; exposure prevention and postexposure management; medical conditions, work-related illness, and associated work restrictions; contact dermatitis and latex hypersensitivity; and maintenance of records, data management, and confidentiality (IB).
2. Establish referral arrangements with qualified health-care professionals to ensure prompt and appropriate provision of preventive services, occupationally related medical services, and postexposure management with medical follow-up (IB, IC).

B. Education and Training

1. Provide DHCP 1) on initial employment, 2) when new tasks or procedures affect the employee’s occupational exposure, and 3) at a minimum, annually, with education and training regarding occupational exposure to potentially infectious agents and infection-control procedures/protocols appropriate for and specific to their assigned duties (IB, IC).
2. Provide educational information appropriate in content and vocabulary to the educational level, literacy, and language of DHCP (IB, IC).

C. Immunization Programs

1. Develop a written comprehensive policy regarding immunizing DHCP, including a list of all required and recommended immunizations (IB).
2. Refer DHCP to a prearranged qualified health-care professional or to their own health-care professional to receive all appropriate immunizations based on the latest recommendations as well as their medical history and risk for occupational exposure (IB).

D. Exposure Prevention and Postexposure Management

1. Develop a comprehensive postexposure management and medical follow-up program (IB, IC).

a. Include policies and procedures for prompt reporting, evaluation, counseling, treatment, and medical follow-up of occupational exposures.
b. Establish mechanisms for referral to a qualified health-care professional for medical evaluation and follow-up.
c. Conduct a baseline TST, preferably by using a two-step test, for all DHCP who might have contact with persons with suspected or confirmed infectious TB, regardless of the risk classification of the setting (IB).

E. Medical Conditions, Work-Related Illness, and Work Restrictions

1. Develop and have readily available to all DHCP comprehensive written policies regarding work restriction and exclusion that include a statement of authority defining who can implement such policies (IB).
2. Develop policies for work restriction and exclusion that encourage DHCP to seek appropriate preventive and curative care and report their illnesses, medical conditions, or treatments that can render them more susceptible to opportunistic infection or exposures; do not penalize DHCP with loss of wages, benefits, or job status (IB).
3. Develop policies and procedures for evaluation, diagnosis, and management of DHCP with suspected or known occupational contact dermatitis (IB).
4. Seek definitive diagnosis by a qualified health-care professional for any DHCP with suspected latex allergy to carefully determine its specific etiology and appropriate treatment as well as work restrictions and accommodations (IB).

F. Records Maintenance, Data Management, and Confidentiality

1. Establish and maintain confidential medical records (e.g., immunization records and documentation of tests received as a result of occupational exposure) for all DHCP (IB, IC).

 

2. Ensure that the practice complies with all applicable federal, state, and local laws regarding medical recordkeeping and confidentiality (IC).

        

[drsnehamaheshwari]

II. Preventing Transmission of Bloodborne Pathogens

A. HBV Vaccination

1. Offer the HBV vaccination series to all DHCP with potential occupational exposure to blood or other potentially infectious material (IA, IC)
2. Always follow U.S. Public Health Service/CDC recommendations for hepatitis B vaccination, serologic testing, follow-up, and booster dosing (IA, IC)
3. Test DHCP for anti-HBs 1–2 months after completion of the 3-dose vaccination series (IA, IC) .
4. DHCP should complete a second 3-dose vaccine series or be evaluated to determine if they are HBsAg-positive if no antibody response occurs to the primary vaccine series (IA, IC) .
5. Retest for anti-HBs at the completion of the second vaccine series. If no response to the second 3-dose series occurs, nonresponders should be tested for HBsAg (IC) .
6. Counsel nonresponders to vaccination who are HBsAg-negative regarding their susceptibility to HBV infection and precautions to take (IA, IC).
7. Provide employees appropriate education regarding the risks of HBV transmission and the availability of the vaccine. Employees who decline the vaccination should sign a declination form to be kept on file with the employer (IC).

B. Preventing Exposures to Blood and OPIM

1. General recommendations

a. Use standard precautions (OSHA’s bloodborne pathogen standard retains the term universal precautions) for all patient encounters (IA, IC).
b. Consider sharp items (e.g., needles, scalers, burs, lab knives, and wires) that are contaminated with patient blood and saliva as potentially infective and establish engineering controls and work practices to prevent injuries (IB, IC).
c. Implement a written, comprehensive program designed to minimize and manage DHCP exposures to blood and body fluids (IB, IC).

2. Engineering and work-practice controls

a. Identify, evaluate, and select devices with engineered safety features at least annually and as they become available on the market (e.g., safer anesthetic syringes, blunt suture needle, retractable scalpel, or needleless IV systems) (IC).
b. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to the area in which the items are used (IA, IC).
c. Do not 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. Do not bend, break, or remove needles before disposal (IA, IC).
d. Use either a one-handed scoop technique or a mechanical device designed for holding the needle cap when recapping needles (e.g., between multiple injections and before removing from a nondisposable aspirating syringe) (IA, IC).

3. Postexposure management and prophylaxis

a. Follow CDC recommendations after percutaneous, mucous membrane, or nonintact skin exposure to blood or other potentially infectious material (IA, IC).

                              

 

        

[drsnehamaheshwari]

III. Hand Hygiene

A. General Considerations

1. Perform hand hygiene with either a nonantimicrobial or antimicrobial soap and water when hands are visibly dirty or contaminated with blood or other potentially infectious material. If hands are not visibly soiled, an alcohol-based hand rub can also be used. Follow the manufacturer’s instructions (IA).
2. Indications for hand hygiene include
    a. when hands are visibly soiled (IA, IC);
    b. after barehanded touching of inanimate objects likely to be contaminated by blood, saliva, or respiratory secretions
    (IA, IC);
    c. before and after treating each patient (IB);
    d. before donning gloves (IB); and
    e. immediately after removing gloves (IB, IC).
3. For oral surgical procedures, perform surgical hand antisepsis before donning sterile surgeon’s gloves. Follow the manufacturer’s instructions by using either an antimicrobial soap and water, or soap and water followed by drying hands and application of an alcohol-based surgical hand-scrub product with persistent activity (IB).
4. Store liquid hand-care products in either disposable closed containers or closed containers that can be washed and dried before refilling. Do not add soap or lotion to (i.e., top off) a partially empty dispenser (IA).

B. Special Considerations for Hand Hygiene and Glove Use

1. Use hand lotions to prevent skin dryness associated with handwashing (IA).
2. Consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves during product selection and glove use (IB).
3. Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears (II).
4. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) (IA).
5. Use of artificial fingernails is usually not recommended (II).

6. Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integrity of the glove (II).

 

 

        

[drsnehamaheshwari]

IV. PPE

A. Masks, Protective Eyewear, and Face Shields

1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering of blood or other body fluids (IB, IC).
2. Change masks between patients or during patient treatment if the mask becomes wet (IB).
3. Clean with soap and water, or if visibly soiled, clean and disinfect reusable facial protective equipment (e.g., clinician and patient protective eyewear or face shields) between patients (II).

B. Protective Clothing

1. Wear protective clothing (e.g., reusable or disposable gown, laboratory coat, or uniform) that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or OPIM (IB, IC).
2. Change protective clothing if visibly soiled; change immediately or as soon as feasible if penetrated by blood or other potentially infectious fluids (IB, IC).
3. Remove barrier protection, including gloves, mask, eyewear, and gown before departing work area (e.g., dental patient care, instrument processing, or laboratory areas) (IC).

C. Gloves

1. Wear medical gloves when a potential exists for contacting blood, saliva, OPIM, or mucous membranes (IB, IC).
2. Wear a new pair of medical gloves for each patient, remove them promptly after use, and wash hands immediately to avoid transfer of microorganisms to other patients or environments (IB).
3. Remove gloves that are torn, cut, or punctured as soon as feasible and wash hands before regloving (IB, IC).
4. Do not wash surgeon’s or patient examination gloves before use or wash, disinfect, or sterilize gloves for reuse (IB, IC).
5. Ensure that appropriate gloves in the correct size are readily accessible (IC).
6. Use appropriate gloves (e.g., puncture- and chemical-resistant utility gloves) when cleaning instruments and performing housekeeping tasks involving contact with blood or OPIM (IB, IC).
7. Consult with glove manufacturers regarding the chemical compatibility of glove material and dental materials used (II).

D. Sterile Surgeon’s Gloves and Double Gloving During Oral Surgical Procedures

1. Wear sterile surgeon’s gloves when performing oral surgical procedures (IB).

2. No recommendation is offered regarding the effectiveness of wearing two pairs of gloves to prevent disease transmission during oral surgical procedures. The majority of studies among HCP and DHCP have demonstrated a lower frequency of inner glove perforation and visible blood on the surgeon’s hands when double gloves are worn; however, the effectiveness of wearing two pairs of gloves in preventing disease transmission has not been demonstrated (Unresolved issue).

 

        

[drsnehamaheshwari]

VI. Sterilization and Disinfection of Patient-Care Items

A. General Recommendations

1. Use only FDA-cleared medical devices for sterilization and follow the manufacturer’s instructions for correct use (IB).
2. Clean and heat-sterilize critical dental instruments before each use (IA)
3. Clean and heat-sterilize semicritical items before each use (IB).
4. Allow packages to dry in the sterilizer before they are handled to avoid contamination (IB).
5. Use of heat-stable semicritical alternatives is encouraged (IB).
6. Reprocess heat-sensitive critical and semi-critical instruments by using FDA-cleared sterilant/high-level disinfectants or an FDA-cleared low-temperature sterilization method (e.g., ethylene oxide). Follow manufacturer’s instructions for use of chemical sterilants/high-level disinfectants (IB).
7. Single-use disposable instruments are acceptable alternatives if they are used only once and disposed of correctly (IB, IC).
8. Do not use liquid chemical sterilants/high-level disinfectants for environmental surface disinfection or as holding solutions (IB, IC).
9. Ensure that noncritical patient-care items are barrier-protected or cleaned, or if visibly soiled, cleaned and disinfected after each use with an EPA-registered hospital disinfectant. If visibly contaminated with blood, use an EPA-registered hospital disinfectant with a tuberculocidal claim (i.e., intermediate level) (IB).
10. Inform DHCP of all OSHA guidelines for exposure to chemical agents used for disinfection and sterilization. Using this report, identify areas and tasks that have potential for exposure (IC).

B. Instrument Processing Area       

1. Designate a central processing area. Divide the instrument processing area, physically or, at a minimum, spatially, into distinct areas for 1) receiving, cleaning, and decontamination; 2) preparation and packaging; 3) sterilization; and 4) storage. Do not store instruments in an area where contaminated instruments are held or cleaned (II).
2. Train DHCP to employ work practices that prevent contamination of clean areas (II).

C. Receiving, Cleaning, and Decontamination Work Area

1. Minimize handling of loose contaminated instruments during transport to the instrument processing area. Use work-practice controls (e.g., carry instruments in a covered container) to minimize exposure potential (II). Clean all visible blood and other contamination from dental instruments and devices before sterilization or disinfection procedures (IA).
2. Use automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) to remove debris to improve cleaning effectiveness and decrease worker exposure to blood (IB).
3. Use work-practice controls that minimize contact with sharp instruments if manual cleaning is necessary (e.g., long-handled brush) (IC).
4. Wear puncture- and chemical-resistant/heavy-duty utility gloves for instrument cleaning and decontamination procedures (IB).
5. Wear appropriate PPE (e.g., mask, protective eyewear, and gown) when splashing or spraying is anticipated during cleaning (IC).

D. Preparation and Packaging

1. Use an internal chemical indicator in each package. If the internal indicator cannot be seen from outside the package, also use an external indicator (II).

2. Use a container system or wrapping compatible with the type of sterilization process used and that has received FDA clearance (IB).

3. Before sterilization of critical and semicritical instruments, inspect instruments for cleanliness, then wrap or place them in containers designed to maintain sterility during storage (e.g., cassettes and organizing trays) (IA).

E. Sterilization of Unwrapped Instruments

1. Clean and dry instruments before the unwrapped sterilization cycle (IB).
2. Use mechanical and chemical indicators for each unwrapped sterilization cycle (i.e., place an internal chemical indicator among the instruments or items to be sterilized) (IB).
3. Allow unwrapped instruments to dry and cool in the sterilizer before they are handled to avoid contamination and thermal injury (II).
4. Semicritical instruments that will be used immediately or within a short time can be sterilized unwrapped on a tray or in a container system, provided that the instruments are handled aseptically during removal from the sterilizer and transport to the point of use (II).
5. Critical instruments intended for immediate reuse can be sterilized unwrapped if the instruments are maintained sterile during removal from the sterilizer and transport to the point of use (e.g., transported in a sterile covered container) (IB).
6. Do not sterilize implantable devices unwrapped (IB).
7. Do not store critical instruments unwrapped (IB).

F. Sterilization Monitoring

1. Use mechanical, chemical, and biological monitors according to the manufacturer’s instructions to ensure the effectiveness of the sterilization process (IB).
2. Monitor each load with mechanical (e.g., time, temperature, and pressure) and chemical indicators (II).
3. Place a chemical indicator on the inside of each package. If the internal indicator is not visible from the outside, also place an exterior chemical indicator on the package (II).
4. Place items/packages correctly and loosely into the sterilizer so as not to impede penetration of the sterilant (IB).
5. Do not use instrument packs if mechanical or chemical indicators indicate inadequate processing (IB).
6. Monitor sterilizers at least weekly by using a biological indicator with a matching control (i.e., biological indicator and control from same lot number) (IB).
7. Use a biological indicator for every sterilizer load that contains an implantable device. Verify results before using the implantable device, whenever possible (IB).
8. The following are recommended in the case of a positive spore test:

a. Remove the sterilizer from service and review sterilization procedures (e.g., work practices and use of mechanical and chemical indicators) to determine whether operator error could be responsible (II).
b. Retest the sterilizer by using biological, mechanical, and chemical indicators after correcting any identified procedural problems (II).
c. If the repeat spore test is negative, and mechanical and chemical indicators are within normal limits, put the sterilizer back in service (II).

9. The following are recommended if the repeat spore test is positive:

a. Do not use the sterilizer until it has been inspected or repaired or the exact reason for the positive test has been determined (II).
b. Recall, to the extent possible, and reprocess all items processed since the last negative spore test (II).
c. Before placing the sterilizer back in service, rechallenge the sterilizer with biological indicator tests in three consecutive empty chamber sterilization cycles after the cause of the sterilizer failure has been determined and corrected (II).

10. Maintain sterilization records (i.e., mechanical, chemical, and biological) in compliance with state and local regulations (IB).

G. Storage Area for Sterilized Items and Clean Dental Supplies

1. Implement practices on the basis of date- or event-related shelf-life for storage of wrapped, sterilized instruments and devices (IB).
2. Even for event-related packaging, at a minimum, place the date of sterilization, and if multiple sterilizers are used in the facility, the sterilizer used, on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure (IB).
3. Examine wrapped packages of sterilized instruments before opening them to ensure the barrier wrap has not been compromised during storage (II).
4. Reclean, repack, and resterilize any instrument package that has been compromised (II).

5. Store sterile items and dental supplies in covered or closed cabinets, if possible (II).

 

 

        

[drsnehamaheshwari]

VII. Environmental Infection Control

A. General Recommendations

1. Follow the manufacturers’ instructions for correct use of cleaning and EPA-registered hospital disinfecting products (IB, IC).
2. Do not use liquid chemical sterilants/high-level disinfectants for disinfection of environmental surfaces (clinical contact or housekeeping) (IB, IC).
3. Use PPE, as appropriate, when cleaning and disinfecting environmental surfaces. Such equipment might include gloves (e.g., puncture- and chemical-resistant utility), protective clothing (e.g., gown, jacket, or lab coat), and protective eyewear/face shield, and mask (IC).

B. Clinical Contact Surfaces

1. Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean (e.g., switches on dental chairs) and change surface barriers between patients (II)
2. Clean and disinfect clinical contact surfaces that are not barrier-protected, by using an EPA-registered hospital disinfectant with a low- (i.e., HIV and HBV label claims) to intermediate-level (i.e., tuberculocidal claim) activity after each patient. Use an intermediate-level disinfectant if visibly contaminated with blood (IB)

C. Housekeeping Surfaces

1. Clean housekeeping surfaces (e.g., floors, walls, and sinks) with a detergent and water or an EPA-registered hospital disinfectant/detergent on a routine basis, depending on the nature of the surface and type and degree of contamination, and as appropriate, based on the location in the facility, and when visibly soiled (IB)
2. Clean mops and cloths after use and allow to dry before reuse; or use single-use, disposable mop heads or cloths (II)
3. Prepare fresh cleaning or EPA-registered disinfecting solutions daily and as instructed by the manufacturer. (II)
4. Clean walls, blinds, and window curtains in patient-care areas when they are visibly dusty or soiled (II)

D. Spills of Blood and Body Substances

1. Clean spills of blood or OPIM and decontaminate surface with an EPA-registered hospital disinfectant with low- (i.e., HBV and HIV label claims) to intermediate-level (i.e., tuberculocidal claim) activity, depending on size of spill and surface porosity (IB, IC)

E. Carpet and Cloth Furnishings

1. Avoid using carpeting and cloth-upholstered furnishings in dental operatories, laboratories, and instrument processing areas (II)

F. Regulated Medical Waste

1. General Recommendations

a. Develop a medical waste management program. Disposal of regulated medical waste must follow federal, state, and local regulations (IC)
b. Ensure that DHCP who handle and dispose of regulated medical waste are trained in appropriate handling and disposal methods and informed of the possible health and safety hazards (IC) .

2. Management of Regulated Medical Waste in Dental Health-Care Facilities

a. Use a color-coded or labeled container that prevents leakage (e.g., biohazard bag) to contain nonsharp regulated medical waste (IC).
b. Place sharp items (e.g., needles, scalpel blades, orthodontic bands, broken metal instruments, and burs) in an appropriate sharps container (e.g., puncture resistant, color-coded, and leakproof). Close container immediately before removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping (IC).

c. Pour blood, suctioned fluids or other liquid waste carefully into a drain connected to a sanitary sewer system, if local sewage discharge requirements are met and the state has declared this an acceptable method of disposal. Wear appropriate PPE while performing this task (IC).

 

 

        

[drsnehamaheshwari]

VIII. Dental Unit Waterlines, Biofilm, and Water Quality

A. General Recommendations

1. Use water that meets EPA regulatory standards for drinking water (i.e., <500 CFU/mL of heterotrophic water bacteria) for routine dental treatment output water (IB, IC).
2. Consult with the dental unit manufacturer for appropriate methods and equipment to maintain the recommended quality of dental water (II).
3. Follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product (II).
4. Discharge water and air for a minimum of 20–30 seconds after each patient, from any device connected to the dental water system that enters the patient’s mouth (e.g., handpieces, ultrasonic scalers, and air/water syringes) (II).
5. Consult with the dental unit manufacturer on the need for periodic maintenance of antiretraction mechanisms (IB).

B. Boil-Water Advisories

1. The following apply while a boil-water advisory is in effect:

a. Do not deliver water from the public water system to the patient through the dental operative unit, ultrasonic scaler, or other dental equipment that uses the public water system (IB, IC).
b. Do not use water from the public water system for dental treatment, patient rinsing, or handwashing (IB, IC).
c. For handwashing, use antimicrobial-containing products that do not require water for use (e.g., alcohol-based hand rubs). If hands are visibly contaminated, use bottled water, if available, and soap for handwashing or an antiseptic towelette (IB, IC).

2. The following apply when the boil-water advisory is cancelled:

a. Follow guidance given by the local water utility regarding adequate flushing of waterlines. If no guidance is provided, flush dental waterlines and faucets for 1–5 minutes before using for patient care (IC).

b. Disinfect dental waterlines as recommended by the dental unit manufacturer (II).

 

 

        

[drsnehamaheshwari]

IX. Special Considerations

A. Dental Handpieces and Other Devices Attached to Air and Waterlines

1. Clean and heat-sterilize handpieces and other intraoral instruments that can be removed from the air and waterlines of dental units between patients (IB, IC).
2. Follow the manufacturer’s instructions for cleaning, lubrication, and sterilization of handpieces and other intraoral instruments that can be removed from the air and waterlines of dental units (IB).
3. Do not surface-disinfect, use liquid chemical sterilants, or ethylene oxide on handpieces and other intraoral instruments that can be removed from the air and waterlines of dental units (IC).
4. Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids (II).

B. Dental Radiology

1. Wear gloves when exposing radiographs and handling contaminated film packets. Use other PPE (e.g., protective eyewear, mask, and gown) as appropriate if spattering of blood or other body fluids is likely (IA, IC).
2. Use heat-tolerant or disposable intraoral devices whenever possible (e.g., film-holding and positioning devices). Clean and heat-sterilize heat-tolerant devices between patients. At a minimum, high-level disinfect semicritical heat-sensitive devices, according to manufacturer’s instructions (IB).
3. Transport and handle exposed radiographs in an aseptic manner to prevent contamination of developing equipment (II).
4. The following apply for digital radiography sensors:

a. Use FDA-cleared barriers (IB).
b. Clean and heat-sterilize, or high-level disinfect, between patients, barrier-protected semicritical items. If the item cannot tolerate these procedures then, at a minimum, protect with an FDA-cleared barrier and clean and disinfect with an EPA-registered hospital disinfectant with intermediate-level (i.e., tuberculocidal claim) activity, between patients. Consult with the manufacturer for methods of disinfection and sterilization of digital radiology sensors and for protection of associated computer hardware (IB).

C. Aseptic Technique for Parenteral Medications

1. Do not administer medication from a syringe to multiple patients, even if the needle on the syringe is changed (IA). 2. Use single-dose vials for parenteral medications when possible (II).
3. Do not combine the leftover contents of single-use vials for later use (IA).
4. The following apply if multidose vials are used:

a. Cleanse the access diaphragm with 70% alcohol before inserting a device into the vial (IA).
b. Use a sterile device to access a multiple-dose vial and avoid touching the access diaphragm. Both the needle and syringe used to access the multidose vial should be sterile. Do not reuse a syringe even if the needle is changed (IA).
c. Keep multidose vials away from the immediate patient treatment area to prevent inadvertent contamination by spray or spatter (II).
d. Discard the multidose vial if sterility is compromised (IA).

5. Use fluid infusion and administration sets (i.e., IV bags, tubings and connections) for one patient only and dispose of appropriately (IB).

D. Single-Use (Disposable) Devices

1. Use single-use devices for one patient only and dispose of them appropriately (IC).

 

 

        

[Anonymous]

I have a question in regards to aerosols generated in the dental office from hand-pieces and ultrasonic devices. Dental evacuation systems differ in offices. Some suction systems have very low air flow rates while other offices have high air flow rates (cubic ft per minute). My question is are there any studies which have determined what level of flow rate the dental suction system should be in order to remove the aerosols adequately during procedures? I know many hygienists do no use HV at all when using ultrasonic devices. the CDC has come out and said that a saliva ejector (or LV) is NOT effective in aerosol reduction and is not to be used for Ultrasonic therapy. Only HV suction should be used. Well, if the HV flow rate is really low, one may think they compliant because they are using HVE but in reality, it could be as low as a saliva ejector in performance. This is HUGE! and should be looked at and addressed carefully especially for large clinics with many ultrasonic devices or hand pieces being used! When I contacted a major manufacturer of dental Vacuum systems, they only have the Power or strength of the motor listed which measures inches of mercury pulled. This is totally different than measuring airflow rate of the vacuum systems and I think most dentists and sales manufacturers have the two confused. I would love to hear your thoughts or if you can give me any information on this issue.
Thank you very much.
Laura

        

[Anonymous]

Wow that is a lot of information. Thanks

        

[Author]

Posts