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歯科医療における感染管理のための CDCガイドライン

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Contents

1.
2.
3.
4.
5. II A HBV Ae eT MAP T OO BEN ERE BIC L CLR
6. 1
7. 1 2
8. PPE IA B c i 4 1 243 254
9. 3 a AGAR BREE CDC 110 112 59
10. HEPA N95
11. D kis TI t k URTE E E 1 IA BIC I IA IB IC I IAITBEIIC II Poan A B ic i 4 a
12. 32 4 242
13. 254 We 2 247 255 257
14. 48 a S Recommendations 49 CDC 2003 a Recommendations CDC Healthcare Infection Control Practices Advisory Committee HICPAC
15. 7 HO EE 7 IB IC I a 243 248
16. 66 44 24 60 7 30 755 BABE AB ORF
17. vegetative bacteria HBV HCV HIV EPA
18. AIBEIIC II Poa 6 HIV HBV EPA
19. 26 27 32 249 clinical contact surfaces
20. CMV HBV HCV 1 2 HIV 1 2 3
21. 275 276 2 7 137 73Z FDA
22. 37 241
23. EPA Mycobacterium bovis EPA EPA
24. egjo7e a Pseugo 7o7as 244
25. ADA 1995 200 CFU mL 339 340 EPA American Public Health Association APHA American Water Works Association AWWA
26. Occupational Safety and Health Administration OSHA 13 CD OSHA other potentially infectious materials OPIM 8 amp 1 HBV 79 OSHA
27. CUD CJD X pears
28. EPA PPE 242
29. 3 21 22 23 FDA 788 79 penetrability
30. 2 174 National Institute for Occupational Safety and Health NIOSH N95 N99 N100 20 N95 50L gt 95 1 m 5 1 5 m
31. steam sterilization 260 28
32. 248 1 2 3 4 248
33. OF CARICHIET S 127 128 10 15 146 142 143 FROG F
34. 243 243 ETO 243 1
35. 122 123 756 123 1575160 157 160 123 142 ies 61 62
36. HBV HCV HIV OPIM OSHA 13 291 113 244 244 292 PPE
37. 1980 98 102 103 104 1 2 3 burs 99 102 105 706 104 107
38. IC IA De ge OB Woon IC IC 50
39. C HCV F GABE 3B REDECOPS
40. FDA EPA 245 3 2 242 26
41. X AY 260 288 1
42. Kis HK 426 427 HIV Corynebacterium NeisseriaBmt E 428 434 HIV HBV 435
43. 5 73 76 BREF ORE 1 73
44. 1992 HIV HBV 1987 ee a 1 2 CHEE 3
45. 3 FERD Bit RH MR BRR BR CUD CJD TSE TSE
46. Eat E 311 344 20 30 2
47. 36 HIV 95 AIDS HIV RELER Mig OFS L ORE TEHETSZ ZEF BARA HBV HCV HIV 19 96 97 BR
48. 7Z PPE PPE 79 PPE 2 73
49. 42Z7
50. 289 PPE housekeeping surfaces PR BE 244 290
51. IA B ic i Poan 2 a b
52. 1 3 Reet 5 eee 5 5 RER MOORES 7 ABDSOREORES 1 3 R
53. FDA FDA 1 56 IA BIC I EPA
54. 400 407 American Heart Association 4202
55. 34 13
56. 109 22 FDA FDA ON E
57. 1 2 288 1 HIV HBV EPA OPIM 2 244 13
58. 303 309 glycocalyx 303 310 311 IRE 303 305 312 373 eg o7e a 303 306 373 303 304 dental water systems 2 305 314 375
59. 109 blunt suture needles 110 112 2 7 13 113 115
60. HEE saliva ejectors p V EPA HES ER SOURED o NDH BOORAH Wo HEE BAIE BAD EE Fy TEC DALES OE TRIERER tot 364 366 30
61. flushing 3 4 7 TB CJD CDC
62. p VI 101 103 108 scaler 3 laboratory utility knives 4 explorers endodontic files p VI 11 12
63. 13 74 K 403 404 40 405 45 1 2
64. dental treatment water JN disinfectant Environmental Protection Agency EPA j disinfection
65. 20 30 KA 345 500 CFU mL
66. 3 5 6 9 9 9 9 10 10 11 7 B 14 D 75 C 15 15 REDLER 16 REeOSEC PM 17 78 20 20 20 20 20 27 21 23 23 23 23
67. 60 53 CDC 2003 I A IAItBIIC II 4 a
68. 2 3 11 CDC 2003 1
69. YR
70. BI 9 243 24 BI 260 BI
71. 266 268 200 269 270 1 10 266 2Z7 29 CDC 2003 ethylene oxide ETO
72. 306 312 376 Pseudomonas 317 320 321 323 324 eg o7e g 325 327 328 329 330
73. bulb syringes 2 2 727 29 36 316 1
74. 244 OSHA 13 9 159 1 2 CHS 298 299 6 297 300 307 79
75. 723 124 126 1938 72Z
76. gop e7 nuclei 5 m FRA droplets endotoxin germicide germicide
77. X 260 367 368 KIEL HIV HBV EPA X X radiographic tubehead 7 control pannel V
78. 18 CDC 2003 OPIM OSHA PHS 13 19 MAAT SH LORE EBS DECI BIO TT le SAB CBA LEW BIB EBL THEE H
79. nm Tc Tr 5 ee D AIBEIIC I nm Tc Tr 5 ee OPIM EPA HBV HIV eas ae a A z gt H E A B ic 1 RER at F 293 295 AIBIIC II SZih a b
80. 182 184 186 189 191 192 194 HEOO 6 16 181 185 195 796 186 190 191 197 30 3 bonding agents 2
81. 243 247 unsaturated chemical vapor sterilization 0 23 1 dry heat sterilization BAM lt
82. 79 gt Eee ARF ERSEREO ERAN RO aH c LC REED HELE
83. EPA HIV HBV AIBEIIC II 4 EPA EPA
84. 267 oven type rapid heat transfer sterilization of unwrapped instruments flash sterilization
85. 24 30 5 31 33 IS DEHER 1
86. 165 166 KOTORA ditat LTOS OA CRORE 767 170 170 LOL 2 169 7Z7
87. HBV HIV EPA EPA EPA 100 5 25 4 1 1 113 33 CDC 2003
88. FDA ARMED AH 1 346 349 351 13 722
89. X X PPE X X a FDA b
90. infection control doctor ICD infection control nurse ICN CDC
91. 192 FDA FDA FDA 214 dimethyacrylates 2 1 2 3
92. 411 412 KER RER KAR EPA 2 244 249 407 260 413 416 o
93. FDA EPA X 62 C am A B IC I RR SZan 1 a 6 709
94. 31 32 38 364 366 X X p V
95. NIOSH OSHA 19 20 air water syringes 21 CDC 2003 RS FDA NRL 1 patient
96. HS Em gt a ACIP Bolyard EA Hospital Infection Control Practices Advisory Committee Guidelines for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 Advisory Committee on Immunization Practices ACIP 8 CDC 2003
97. CDC EPA FDA CDC DHCP EPA FDA DHCP variola major Yersinia pestis 1
98. CJD CJD CJD CJD CJD 46 243 249 277 469 1 1 134 18 WHO HAR
99. 20 21 9 22 5 1 p 12 13
100. FDA 243 247 37 CDC 2003 E Aaa A DIS Tal Al IC II Zan
101. 1 CDC 7 2 2 CDC 3 universal precautions standard precautions HCP B HBV C HCV HIV CRX BRS L RORA ER FB post exposure prophylaxis PEP SHARRI k D Ea ETSI kI GRD
102. 2 EIS Cryptosporidium Giardia Shigella 3 tota coliform rule EPA surface water treatment rule EPA 4 5 346 4 JR Cryptosporidium parvum 403 000 347 348
103. H HAKOR V Pk A B ic i Sci fiz AIBE IC II 4 PPE MRA KEREM KER TRAM EC EPA
104. 260 417 419 Z 420 7 427 48 49 50 42
105. i LIE Mycobacterium 0SHA bovis EMME LIAS HIV HBV EPA FDA FDA EPA FDA 1 http www_ epa gob oppsfO01 chemregindex htm http www fda ov cdrh indexhtm 3 http www fda gov cdrh ode gemfab htm 8 HBV HCV
106. EPA X vials 39 933 X X 34 X 35 X 36 X
107. CDC 003 aB Background 900 16 8 000 11 2 000 21 8 000A 3 5 3 000 4 dental health care personnel DHCP environmental surfaces FE WEE BHF
108. i BA BRA ARR HIV 447 20 27 1 442 443 444
109. 2 7 13 9Z 113 114 one hand scoop technique 8 2 7 13 113 114 1 1
110. List B List C HIV List D HIV HBV List E HIV 1 HBV A FDA Geobacillus stearothermophilus CDC Bacillus atrophaeus oe EPA E o POOE ER Aspergillus Candida EPA Staphylococcus species CDC Pseudomonus species fe Salmonella species HIV
111. 24 60 7 30 755 HBC RE ORCC 40 397 399 173
112. 1 2 3 LO HERS dk URSE 253
113. 1 2 3 N95 7 N95 particle respirator 12
114. 1 1
115. 72 HBV HCV HIV B HBV 36 3 HBV HBV HBV HBsAg HBV HBeAg HBV HBsAg HBeAg 22 319 HBV 37 629 79 HBsAg HBeAg
116. DHCP DHCP EPA FDA OSHA CDC 1 GH
117. CJD CJD CJD CJD CJD MU ay 7 IA B ICi SZ 1 Pee 66 A A Regulatory Framework for Disinfectants and Sterilants DHCP
118. BI 280 BI 1 2 9 134 243 278 279 248 BI 25 30 BI BI
119. Sg 7o7e g A BESES7TARKTC B B B e e USENET DIELS
120. 422 EPA HE 423 425
121. Sl v 7 25 CDC 2003 24 critical semicritical X noncritical
122. 1 246 2 EPA OPIM EPA 2 243 244
123. BI BI 8 BI 281 282 243 247 1
124. EAR OB 13 2 13 5 13 7
125. b c 58 IA B ic i Poan 9 a b c
126. p 21 p 2 32 34 SHA CDC 2003 Guidelines for Infection Control in Dental Health Care Settings 2003 MMWR Recommendations and Reports December 19 2003 52 RR17 1 61 http www cdc gov mmwr PDF rr rr5217 pdf p 2 32 34
127. 248 1 ART 244 249 252 13
128. 15 FREE 15 ERRORI PCMX ERROR 2 67
129. PPE EPA 500 CFU mL 3 20 30
130. 5 A CDC BMS X p 39 X X X HES p 38 p 40 AUZITE WIE ail Sekt 2 QB SE V CDC FRET p 16 p 2 16 21 p 40 46 p 16 40 PIL ase p 4 21 ERARO
131. 500 ppm 800 ppm 5 5 259 1 4 1 FDA critical FDA C RAKE
132. EPA PA EPA OPIM OSHA 78
133. 254 134 biological indicators Blis Geobacillus Bacillus 243 278 279 BI
134. 378 single use device disposable device 383 high volume evacuator tips V E irrig
135. EPA EPA EPA FIFRA EPA DHCP
136. gt at 129 131 121 132 135 122 19 CDC 2003
137. 276 sterilization monitoring RA 247 248 2ZZ 243 248 F chiemical indicators
138. 10 48 2Z2 2Z ETO 250 2Z5 hydrogen peroxide gas plasma bead sterilizer FDA FDA
139. 4 5 5 fl 6 1 CDC
140. anaes 174 176 http 7 Www cdc dov niosh 99 143 html 2 7 10 11 13 137 OSHA PPE OPIM 13 7
141. 3 21 3 1999 2003 71 C DC 003 References 1 2 3 10 11 12 13 14 15 16 I7 72 CDC Recommended infection control practices for dentistry MMWR 1986 35 237 42 CDC Recommended infection control practices for dentistry 1993 MMWR 1993 42 No RR 8 US Census Bureau Statistical Abstract of the United States 2001 Washington DC US Census Bureau 2001 Available at http www census gov prod www statistical abstract 02 html Health Resources and Services Administr
142. OSHA 93 tite ARYL Yr YTE PPE p IV gt 95 7Z3
143. 1 CJD 8 468 CJD CJD
144. HBV 1 CDC 2003 HBV 2 13 17 19 69 HBV
145. OPIM 53 CDC 2003 D 2 V
146. bead sterilizer 1 2 1 5 mm 217 232 45 RTS Ce CMEMER Food and Drug Administration FDA bioburden bioload microbial load colony forming unit CFU CFU CFU mL AERE decontamination
147. 14 manufacturer s Material Safety Data Sheets MSDS 75 CDC 8 airborne precaution N95 CDC 2003 CDC Guideline for disinfection and sterilization in health care facilities recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR in press CDC Guidelines for environmental infection control in health care facilities recommendations of CDC and the Healthcare Infection Control Practices Advisory Commit tee HICPAC MMWR 2003 52 No RR 10 CDC Guidelines for the prevention of intravascular catheter related infections MMWR 2002 51 No RR 10 CDC Guideline for hand hygiene in health care settin
148. 469 http www who int emcdocuments tse whocdsc sraph2003c html CJD CJD CDC CJD http www cdc gov ncidod diseases cjd cjd htm 470
149. A G4 PPD 7S REE HIOORES OHBD SRROREE 1 CkPRECREIOD VZIG SORESCOBHAKC BRER MOORES OR BD OmieO ERR 1 VZIG 8
150. 224 IV methacrylates 2
151. ALAR DASE ETE Centers for Disease Control and Prevention CDC CDC CDC 2003 12 19 MMWR http www cdc govV mmwr PDF rrrr5217 pdf http Wwww cdc gov mmwr PDF rr rr4208 pdf 1993 10
152. 5 11 20 44 ARARE tS CERF Es THES ND 20 21
153. BI 3 BI 9 243 BI 9 283 247 Zh
154. 2 2 356 357 246 275 356 357 360 250 2Z5 361 363
155. Bo http www cdc gov OralHealth infectioncontrol forms htm http www cdc gov niosh topics bbp 7 114 OSHA 13 19 OPIM 79
156. 1 2 3 4 5 6 7 8 dental unit 9 handpieces X CDC 1 2 F xt X Introduction
157. 149 471 CDC CDC
158. E 122
159. 260 PPE 1 27 10 13 polishing points 5 rag wheels 260 407 metal impression tray 53 D VI face bow fork E 2 240Z articulators case pans lathes 7
160. AIB IIC II 4 K 1 a b amp 20 c d 1 2 3 4 ael CDC 6 20 21 20 21 65 CDC 2003
161. ow eve disinfectant EPA HIV HBV OSHA A microfilter 0 03 10 um 3 20 90 m nosocomial RRE occupational exposure OPIM
162. B 3 HBV IFA HCP HBV 1 1 3 2 4 HBs HCP HBs 1 HBs gt 10 mlU mL 2 1
163. 142 143 PPE p IV OPIM ultrasonic scaler p VI 2 p V F 10 um
164. 1993 CDC 2 315 338 343 500 CFU mL 303 309 376 500 CFU mL KEK RAK RAKA E
165. 1 HCP 50 HCP 3 1 2 1957 4 HCP 1 1 HIV 2 MMR 1 2 3 3 1963 1967 1957
166. EPA 3 Association of Official Analytical Chemists AOAC Salmonella choleraesuis HIV HBV C HCV AOAC
167. OSHA 73 OSHA EPA OSHA OSHA 14
168. HDV HBV HBV 10 pb 8 HDV 70 C C HCV 1 8 0 7 71 Z74 72 HCV 2 75 Z6 HCV HIV 1
169. 249 254 er 243 243 247 1 2 9 243 247 278 ee 279 8 a
170. 52 B Wikis KOZ DUO VETER HERE OPIM oto Obese PPG 1 a OSHA c 2 a retractable scalpel IV needle less IV systems 1 b
171. b c 51 CDC 003 E Pape a ARLOT 55 LEER OU THET 50 ERT E95 LOE
172. VI CDC 2003 Guidelines for Infection Control in Dental Health Care Settings 2003 G S ae L A gt d s M KERERE FR ORB t gt amp ORFF CDC 2 KA EK TUSINAFLT KL 72 974 44 ARAM HFa tey YNZ bY Prepared by William G Kohn D D S Amy S Collins M P H Jennifer L Cleveland D D S Jennifer A Harte D D S Kathy J Eklund M H P Dolores M Malvitz Dr P H Division of Oral Health National Center for Chronic Disease Prevention and Health Promotion CDC United States Air Force Dental Investigation Service Great Lakes Illinois The Forsyth Institute Boston Massachusetts CDC 2003 CDC 003 Guidelines for Infection Control in Dental Health Care Settings 2003 2a
173. a 341 342 ae 341 342 b 346 349 350 c FENERE 63 100 CFU mL 64 65 61 CDC 2003 AFAV
174. 245 C 73 24Z
175. VII A eli IA IB IC I 1 EPA 2 clinical contact surfaces housekeeping surfaces 3 PPE 59 CDC 003 60 B AIBIIC II SZih
176. 237 232 236 237 239 NIOSH 32 31 240
177. 40 41 HBV 1 44 LEP oT XLOR PRR HEE HBV lS BRO5 o DSB Baas KE TENER 14 HBV 45 47 HBV HBV 48 50 1980 57 909 HBV 1972 149 1992 9 52 1993 2001 Chakwan Siew Ph D American Dental
178. 1 1994 1995 2 000 6 29 1 226 5 8 59 4 39 22Z 228 230
179. 2 181 185 195 196 198 217 219 gt 45 10 796 220 221 223
180. 77 1 2 6 7 3 4 THAS ND Blt Cnet COMPRASHICS 77
181. CDC 003 Prepared by William G Kohn D D S Amy S Collins M P H Jennifer L Cleveland D D S Jennifer A Harte D D S Kathy J Eklund M H P Dolores M Malvitz Dr P H Division of Oral Health National Center for Chronic Disease Prevention and Health Promotion CDC United States Air Force Dental Investigation Service Great Lakes Illinois The Forsyth Institute Boston Massachusetts Guidelines for Infection Control in Dental Health Care Settings 2008 CONTENTS Intreduction eae RR CS 84 Aseptic Technique for Parenteral Medications 105 Backeround oa ete ei eR 85 Single Use or Disposable Devices 105 Previous Recommendations i 86 Preprocedural Mouth Rinses kk 105 Selected DetinitiOns SR Li 86 Oral Surgical Procedures 105 Review of Science Related to Dental Infection Handling of Biopsy Specimens 105 ml MHR 87 Handling of Extracted Teeth kk 106 Personnel Health Elements of an Infection Control Dental Laboratory iccecccsecssesessessessecssessesarssesscsessesssesaseass 106 Prodtam EEE 87 Laser Electrosurgery Plumes or Surgical Smoke 106 Preventing Transmission of Bloodborne Pathogens 89 M tuberculosis kk 107 FANG AY GIGI RR 93 Creutzfeldt Jakob Disease and Other Prion Diseases 107 Personal Protective Equipment cccccsesscessessecseesteseesseeneeseenes 95 P
182. MAVEK 6 PPE F 13 302 6
183. virucide HB fungicide bactericide tupeycu oc ge sporicide GL hand hygiene health care associated infection B hepatitis B immune globulin HBIG HBV HBIG B HBsAb 3 6 B
184. 247 31 CDC 2003 285 light handles p IV switches p IV
185. 7 BE PD DEREE 8 7 et ae 4 BEAR ERIE G4 9 BE MOORE CAB DORRORE WQCARBKC Kclt A hRROM 8 ACIP Bolyard EA Hospital Infection Control Practices Advisory Committee Guidelines for infection control in health care personnel 998 Am J Infect Control 1998 26 289 354 Advisory Committee on Immunization Practices ACIP Rl
186. Z HCP 1 HOCP MMR 19857 1 1 4 HCP HCP
187. other potentially infectious materials OPIM OPIM OSHA 1 b K 2 3 HIV HIV HBV HIV HBV parenteral RIL e hRS WE B persistent activity residual activity
188. 378 379 709 380 381 380 381 382 IV
189. 57 91 AIDS 1 6 HIV 2 92 93 CDC 1993 9 30 33 63 HIV 22 000 CDC 2003 55 93 HIV 1 HIV 0 39 0 2 0 5 92 HIV 0 19 76 KY HIV
190. 37 X 38 X 39 CDC 2003 prefilled syringes 1 376 377 376 3ZZ
191. BRE 5 p 48 CDC 47 CDC 003
192. 389 390 9 39 40 41 42 43 44
193. 5 7 17 18 Advisory Committee on Immunization Practices ACIP 17 Public Health Service PHS 7 B CDC 2003 B
194. 449 451 CJD 1996 449 452 CJD 1 453 CJD CJD 28 vs 68 13 vs 4 5 CJD CJD CJD 454 CJD CJD CJD
195. OSHA 1 2 OSHA 3 30 IN RI a OSHA employee Access to Medical and Exposure Records standard 13 35 HBV HCV HIV RRMA
196. BiB ROR Re HIV HIV B KRALLARI HOT HBV HVS kU HIV 18 BROR RB ORE BE EERO RAK ERA ORE 19 PEP PHS 1990 1998
197. EPA FDA critical semicritical noncritical antimicrobial potency high level intermediate level low level 4 6 FDA CDC EPA antimicrobial activity EPA CDC CDC EPA EPA 68 EPA
198. 286 287 clinical contact surfaces housekeeping surfaces 249 244 1 2 3
199. 3 41 CDC 2003 405 406 406 403 405
200. 24 24 25 26 26 27 27 28 31 32 I U N H 33 33 34 34 34 34 35 35 36 36 36
201. NIOSH 425 Association of periOperative Registered Nurses AORN 436 1 437 2 3 438 CDC
202. 1 2 3 FDA RA 243 247 HRA RARE 248 260 247
203. FDA 1976 Medical Devices Amendment to the Food Drug and Cosmetic Act FDA OSHA OSHA OSHA 1991
204. 1 2 3 RR ONRET PEP 4 RREZ NEW 5 13
205. Federal Register evidence
206. CDC 79 OPIM B 13 tie Rds KU eee te ie FRB KS FMC ESIC MAR POPIMADE 19
207. L A 1 2 3 REF 4 5 6 Ego Os he SS BEERS StL BEARRAC T ORR LOMB bE 1 2 il ais Leila 3 1 1
208. PCMX 7 9 11 13 113 120 123 125 126 136 138 3 a A 139 15
209. CJD E CJD 465 467 2000 45 CDC 2003 5 EPA 500 CFU mL
210. J IA B Ic 0 4 1 RET SU AT CERT SLICER a b c
211. AS 7Z3 MENA AR 243 284
212. prion CJD BSE retraction seroconversion sterile 100 1 WE sterilization surfactants BE MB RHEE ultrasonic cleaner
213. vaccination vaccine washer disinfector wicking Review of Science Related to Dental Infection Control
214. IAITBIIC II RRA Pa VI A IAITBIIC II SZ 1 FDA L
215. 1 243 1 2
216. BEE 1 5 244 346 351 352 346 37 CDC 003 Special Considerations prophylaxis angles p VI air abras
217. 1 69 HBV 23 379 38 HBV HBsAg HBsAg HBV 19 HBsAg HBV 100 1 000 39 HBV HBV B 3 1 HBsAg 42 43
218. 260 260 other sterilization method FDA 1 2 3 263
219. 63 64 CDC 2003 F IA B ic i o 1 a a b oS c CORRELA 47 3 RORARII APA LAO RH HL G AIBEIIC I 4 1 2
220. Occupational Exposure to Blood borne pathogens final rule 29CER Part1910 1030 A 5 OSHA EPA AIDS HIV B HBV 67 CDC 2003 EPA HIV HBV CDC
221. 2 3 2 3 3 4 6 3 4 6 t1 NRL 3 4 5 6 mi 174 7Z5 N95 NIOSH
222. 12 249 12 90 glutaraldehyde peracetic acid hydrogen peroxyide 244 264 265 15 245
223. 440 RH 2 12 ERWI YR 59 1 2 5 90
224. engineering controls work practice controls tuberculin skin test TST 2 0
225. 198 206 vinyl polysiloxane 3 207 209 EEL E 20Z 208 E 13 210 277 FRC 177 212 273 738 23 CDC 2003
226. AIHBIIC II Pa 2 a b c L CID AIBE IC II 4 CJD CJD CJD CJD
227. b c d e a 144 145 izi IAIBIIC II Rie Pa
228. 2004 7 1 2 17 60 T 107 0052 Tel 03 5573 9205 Fax 03 5573 0810 E mail IMP imp kokusaiigaku com 2 2 8 Tel 06 6706 6122 Fax 06 6797 0033 URL http www saraya com E mail gakujutsu saraya com SARAYA 546 0013 2 2 8 TEL 06 6706 6122 FAX 06 6797 0033 http www saraya com E gakujutsu saraya com 46 0543 00 4
229. 244 14 6 13 1
230. MMR 1957 KEBSRBED 13 0 05 71 mL 2 4 8 93 HCP 6 Bolyard EA Hospital Infection Control Practices Advisory Committee Guidelines for infection control in health care personnel 1998 Am J Infect Control 1 998 26 289 354 CDC Immunization of health care workers recommendations of the Advisory Committee on Immunization Practices ACIP and the Hospital Infection Control Practices Advisory Committee HICPAC MMWR 1997 46 No RR 18 CDC Prevention and control of influenza recommendations of the Advisory Committee on Immunization Practices ACIP MMWR 2003 52 1 34 CDC Using live
231. 149 750 20 151 752 153 154
232. EPA OSHA BH en Wye IA B ic i Sik 1 2 3 4 BR UBM POMBE a SZ
233. Goodman RA Ahtone JL Finton RJ Hepatitis B transmission from dental personnel to patients unfinished business Ann Intern Med 1982 96 119 Shaw FE Jr Barrett CL Hamm R et al Lethal outbreak of hepatitis B in a dental practice JAMA 1986 255 3260 4 CDC Epidemiologic notes and reports outbreak of hepatitis B associated with an oral surgeon New Hampshire MMWR 1987 36 132 3 US Department of Labor Occupational Safety and Health Administration 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogens final rule Federal Register 1991 56 64004 182 CDC Hepatitis B virus a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination recommendations of the Immunization Practices Advisory Committee ACIP MMWR 1991 40 No RR 13 Polish LB Gallagher M Fields HA Hadler SC Delta hepatitis molecular biology and clinical and epidemiological features Clin Microbiol Rev 1993 6 211 29 Alter MJ The epidemiology of acute and chronic hepatitis C Clin Liver Dis 1997 1 559 68 Puro V Petrosillo N Ippolito G Risk of hepatitis C seroconversion after occupational exposures in health care workers Italian Study Group on Occupational Risk of HIV and Other Bloodborne Infections Am J Infect Control 1995 23 273 7 Lanphear BP Linnemann CC Jr Cannon CG DeRonde MM Pendy L Kerley LM Hepatitis C virus infection in healthcare workers risk of e
234. B 1 OPIM 2 3 PHS PEP OPIM OPIM PEP 17
235. 243 455 456 TSE 457 458 CJD 3 459 460 467 462 463 464 TSE
236. 69 Salmonella choleraesuis 2 C 3 3 SIF p 82 http Www wakutin or jp htp Www pmda go jp 68 2003 6 17 FDA 3 LAIV Flu Mist 3 2003 2004 A A B 3 3 15
237. 2 13 14 137 13 OPIM 1 2 7 10 1 122 177 187 CDE
238. HBV HCV HIV PEP 69 776 779 2001 PHS 79 HIV PEP HIV PEP 2001 HIV PEP PEP 19 120 123
239. 3 10 ye ay O gt SEED te HEE m zs G ee
240. HBV 3 1 1 2 HBsAb 17 1 HBsAb lt 10 mlU mL 2 3 HBsAg 7 2 HBsAb 1 2 3 2 HBsAg 7 HBsAg HBV
241. HBV HCV Bond WW Ott BU Franke K McCracken JE Effective use of liquid chemical germicides on medical devices instrument design problems In Block SS ed Disinfection sterilization and preservation 4th ed Philadelphia PA Lea amp Gebiger 1991 1 100 e List F HCV EPA CDC p 82 69 CDC 003 B HCP Immunizations Strongly Recommended for Health Care Personnel HCP
242. isoform 58 1 TSE CJD CJD CJD 100 1 445 448 MER LEBEO 9 685 Ln EE LEHR 5 15 CJD 448 CJD 58 CJD BSE
243. ACIP 5 17 BCG bacille Calmette Guerin A ACIP 7 HCV ACIP HIV 5 120 OSHA OPIM B
244. 2 3 4 32 Mir 1996 Privacy Rule of the Health Insurance Portability and Accountability Act 45 CFR 160 and 164 HIPAA OSHA Occupational Exposure to Bloodborne Pathogens Final Rule 29 CFR 1910 1030 h 1 i iv 34 73 HIPAA
245. C DC 003 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 80 Microbiol 1992 30 401 6 Checchi L Montebugnoli L Samaritani S Contamination of the turbine air chamber a risk of cross infection J Clin Periodontol 1998 25 607 11 Epstein JB Rea G Sibau L Sherlock CH Le ND Assessing viral retention and elimination in rotary dental instruments J Am Dent Assoc 1995 126 87 92 Kolstad RA How well does the chemiclave sterilize handpieces J Am Dent Assoc 1998 129 985 91 Kuehne JS Cohen ME Monroe SB Performance and durability of autoclavable high speed dental handpieces NDRI PR 92 03 Bethesda MD Naval Dental Research Institute 1992 Andersen HK Fiehn NE Larsen T Effect of steam sterilization inside the turbine chambers of dental turbines Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999 87 184 8 Leonard DL Charlton DG Performance of high speed dental handpieces subjected to simulated clinical use and sterilization J Am Dent Assoc 1999 130 1301 11 Barbeau J ten Bokum L Gauthier C Prevost AP Cross contamination potential of saliva ejectors used in dentistry J Hosp Infect 1998 40 303 11 Mann GL Campbell TL Crawford JJ Backflow in low volume suction lines the impact of pressure changes J Am Dent Assoc
246. 19 41 29 5 43 5 10 X 39 42 27 28 BER 18 40 34 37 V 27 19 27 20 30 24 25 5 39 120 Index BSRAT F VI 21 27 78 10 40 23 43 477 33 41 34 25 39 HEE V 38 EREE RO REPRE PEP 9 RAER 16 7Z VI 21 38 B 14 30 15 REPR 4 39 4 28 11 29 40 2
247. 730 CDC 2002 123 122 123 147 148
248. V EPA EPA 259 6 100 C EA MES PORE 67
249. universal precautions 1 2 hit WA 9 10 1 2 rubber dams p VI 3 4 FR VAI HEAD protective eyewear 7 p IV CDC 1996 standard precautions
250. HBsAg HBV HBV HBsAqg HBIG 609 12 7Z 7 D HBV 49 hepatitis Delta virus HDV HDV 1977 HBV HBV HDV HBV
251. hepatitis B virus surface antibody B hepatitis B virus health care personnel C hepatitis C virus D hepatitis D virus the Healthcare Infection Control Practices Advisory Committee human immunodeficiency virus live attenulated influenza vaccine manufacturer s Material Safety Data Sheets National Institute for Occupational Safety and Health other potentially infectious materials Occupational Safety and Health Administration RRF post exposure prophylaxis Public Health Service personal protective equipment tuberculosis transmissible spongiofrom encephalopathies Il CDC IV VI
252. 51 52 53 54 55 56 57 43 CDC 2003 439 1 5gm
253. UD 1000 lt Aii 7546 0013 2 2 8 TEL 06 6797 2525 TEL 06 6706 6122 UD 1000 UD 1000 SARAYA Centers for Disease Control and Prevention CDC MMWR 2003 12 19 Vol 52 No RR 17 Guidelines for Infection Control in Dental Health Care Settings 2003 Copyright U S DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control and Prevention CDC Atlanta Georgia 30333 Guidelines for Infection Control in Dental Health Care Settings 2003 CDC
254. X film packets 3 PPE 11 13 367 X film holding devices D V positloning devices X Ay THE FDA FDA cleared film barrier pouches
255. mm yarm n _ 500mL 500mL 2 5 O 76 9 81 4 Vv9 MRSA ORY CER UD 1000 EGO 500mL EGO EGO 500mL 500mL
256. 293 295 296 297 298
257. 3 examination gloves 2 3 NRL 1 2 3 2 3 PVC 4 4 4 5 FDA NRL 1 2 surgeon s 2 3 gloves 2 3 NRL 2 3 4 5 4 FDA NRL nonmedical 3 gloves 3
258. 2 AGETKO ARDY ARS ERIC ISL RIC BIB SAT 3 a pre 1 5 b IX A Sie 361 363
259. X FDA 369 374 X 44 6 375
260. b c d IV DR af AIB IIC II SZih
261. 100 104 107 98 100 703 PPE p IV finger guards 104 OPIM
262. ijndependent water reservoir PSM HANS intermediate level disinfection intermediate level disinfectant EPA A latex cis 1 4 ow eve disinfection
263. 19 669 2004 4 54 g OF IV PPE As N Symes 3 5l A E 5 es IA IB IC I OPIM
264. BIL AIBIIC II Bi OPIM 5
265. I 32 225 American Dental Association ADA 1994 ADA 24 24
266. 109 2 403 OSHA MSDS 15 dental prostheses appliances impressions 4 occlusal rims 4 bite registrations 2
267. 13 10 14 15 16 16 707 105 2000 Needlestick Safety and Prevention Act 2001 OSHA
268. 28 p 35 dental water dental treatment water EPA 500 CFU mL CDC CDC 100 CFUMLUFE SH CHEWY MLV http www waterworks metro tokyo jp w_info s_kijun1 htm 39 CDC 2003 500 CFU mL 341 342 EPA APHA AWWA 500 CFU mL
269. 3 4 134 258 262 implantable device 134 260
270. 122 755 FR 756 722 157 160 161 164
271. 404 405 CDC Recommendations for preventing transmission of infections among chronic hemodialysis patients MMWR 2001 50 No RR 5 Food and Drug Administration Labeling recommendations for single use devices reprocessed by third parties and hospitals final guidance for industry and FDA Rockville MD US Department of Health and Human Services Food and Drug Administration 2001 Villasenor A Hill SD Seale NS Comparison of two ultrasonic cleaning units for deterioration of cutting edges and debris removal on dental burs Pediatr Dent 1992 14 326 30 Rapisarda E Bonaccorso A Tripi TR Condorelli GG Effect of sterilization on the cutting efficiency of rotary nickel titanium endodontic files Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999 88 343 7 Filho IB Esberard RM Leonardo R del Rio CE Microscopic evaluation of three endodontic files pre and postinstrumentation J Endodontics 1998 24 461 4 Silvaggio J Hicks ML Effect of heat sterilization on the torsional properties of rotary nickel titanium endodontic files J Endodontics 1997 23 731 4 Kazemi RB Stenman E Spangberg LS The endodontic file is a disposable instrument J Endodontics 1995 21 451 5 Dajani AS Bisno AL Chung KJ et al Prevention of bacterial endocarditis recommendations by the American Heart Association JAMA 1990 264 2919 22 Pallasch TJ Slots J Antibiotic prophylaxis and the medically compromised patient Periodontology 2000 19
272. 37 ss 38 HEE 38 X 39 39 40 40 41 41 41 41 41 42 43 43 CUD 45 47 47 A B oe 67 HCP 70 C 71 72 m SES iv Rm X 83 120 ACIP ADA AOAC AORN APHA API AWWA CDC CFU CJD CMV DHCP EPA ETO FDA FIFRA HBeAg HBIG HBsAg HBsAb HBV HCP HCV HDV HICPAC HI
273. Mills SE Lauderdale PW Mayhew RB Reduction of microbial contamination in dental units with povidone iodine 10 J Am Dent Assoc 1986 113 280 4 Williams JF Johnston AM Johnson B Huntington MK Mackenzie CD Microbial contamination of dental unit waterlines prevalence intensity and microbiological characteristics J Am Dent Assoc 1993 124 59 65 Mills SE The dental unit waterline controversy defusing the myths defining the solutions J Am Dent Assoc 2000 131 1427 41 Jones F Bartlett CL Infections associated with whirlpools and spas Soc Appl Bacteriol Symp Ser 1985 14 61S 6S Hollyoak V Allison D Summers J Pseudomonas aeruginosa wound infection associated with a nursing home s whirlpool bath Commun Dis Rep CDR Rev 1995 5 R100 2 Begg N O Mahony M Penny P Richardson EA Basavaraj DS Mycobacterium chelonei associated with a hospital hydrotherapy pool Community Med 1986 8 348 30 Laussucq S Baltch AL Smith RP et al Nosocomial Mycobacterium fortuitum colonization from a contaminated ice machine Am Rev Respir Dis 1988 138 891 4 Struelens MJ Rost F Deplano A et al Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy an outbreak investigation using DNA macrorestriction analysis Am J Med 1993 95 489 98 Kuritsky JN Bullen MG Broome CV Silcox VA Good RC Wallace RJ Jr Sternal wound infections and endocarditis due to organisms of the Mycobacterium fortuitum complex Ann Int
274. Monitor each load with mechanical e g time temperature and pressure and chemical indicators II 243 248 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 243 254 257 Place items packages correctly and loosely into the sterilizer so as not to impede penetration of the sterilant IB 243 Do not use instrument packs if mechanical or chemical indicators indicate inadequate processing IB 243 247 248 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 2 9 243 247 278 279 Use a biological indicator for every sterilizer load that contains an implantable device Verify results before using the implantable device whenever possible IB 243 248 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 8 b Retest the sterilizer by using biological mechanical and chemical indicators after correcting any identified procedural problems ID c If the repeat spore test is negative and mechanical and chemical indicators are within normal limi
275. Sawchuk WS Weber PJ Lowry DR Dzubow LM Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation detection and protection J Am Acad Dermatol 1989 21 41 9 Baggish MS Poiesz BJ Joret D Williamson P Rafai A Presence of human immunodeficiency virus DNA in laser smoke Lasers Surg Med 1991 11 197 203 Capizzi PJ Clay RP Battey MJ Microbiologic activity in laser resurfacing plume and debris Lasers Surg Med 1998 23 172 4 McKinley IB Jr Ludlow MO Hazards of laser smoke during endodontic therapy J Endodontics 1994 20 558 9 Favero MS Bolyard EA Microbiologic considerations Disinfection and sterilization strategies and the potential for airborne transmission of bloodborne pathogens Surg Clin North Am 1995 75 1071 89 Association of Operating Room Nurses Recommended practices for laser safety in the practice setting In Fogg D ed Standards recommended practices and guidelines Denver CO AORN 2003 Streifel AJ Recognizing IAQ risk and implementing an IAQ program In Hansen W ed A guide to managing indoor air quality in health care organizations Oakbrook Terrace IL Joint Commission on Accreditation of Healthcare Organizations Publishers 1997 US Department of Labor Occupational Safety and Health Administration Safety and health topics laser electrosurgery plume Washington DC US Department of Labor Occupational Safety and Health Administration 2003 Available at
276. 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 2 7 8 13 97 113 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 2 7 8 13 14 113 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 13 14 19 IMI 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 723 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 before and after treating each patient IB before donning gloves IB and e immediately after removing gloves IB IC 7 9 11 13 113 120 123 125 126 138 ao For oral su
277. hepatitis B surface antigen HBsAg HBV B e hepatitis B e antigen HBeAg HBV HBV B hepatitis B surface antibody HBsAb HBsAg HBV HBV B heterotrophic bacteria high level disinfection
278. 243 284 Reclean repack and resterilize any instrument package that has been compromised II Store sterile items and dental supplies in covered or closed cabinets if possible II 285 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 243 245 Do not use liquid chemical sterilants high level disinfectants for disinfection of environmental surfaces clinical contact or housekeeping IB IC 243 245 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 13 15 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 7 2 260 288 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 2 243 244 C
279. Determine the most effective methods to disinfect dental impression materials Investigate the viability of pathogenic organisms on dental materials e g impression materials acrylic resin or gypsum materials and dental laboratory equipment Determine the most effective methods for sterilization or disinfection of digital radiology equipment Evaluate the effects of repetitive reprocessing cycles on burs and endodontic files Investigate the potential infectivity of vapors generated from the various lasers used for oral procedures Clinical and population based epidemiologic research and development Continue to characterize the epidemiology of blood contacts particularly percutaneous injuries and the effectiveness of prevention measures Further assess the effectiveness of double gloving in preventing blood contact during routine and surgical dental procedures e Continue to assess the stress placed on gloves during dental procedures and the potential for developing defects during different procedures Develop methods for evaluating the effectiveness and cost effectiveness of infection control interventions Determine how infection control guidelines affect the knowledge attitudes and practices of DHCP 109 Guidelines for Infection Control in Dental Health Care Settings 2008 Recommendations Each recommendation is categorized on the basis of existing scientific data theoretical rati
280. No restriction prophylaxis recommended Exclude from duty Exclude from duty Exclude from duty Restrict from contact with patients and patient s environment or food handling No restriction unless personnel are epidemiolo gically linked to transmission of the organism Restrict from patient care contact with patient s environment and food handling Exclude from duty No restriction Exclude from duty Exclude from duty Cover lesions restrict from care of patients at high risk Restrict from patient contact Restrict from patient contact Consider excluding from the care of patients at high risk or contact with such patients environments during community outbreak of respiratory syncytial virus and influenza Duration Until treated and observed to be free of adult and immature lice From beginning of catarrhal stage through third week after onset of paroxysms or until 5 days after start of effective antibiotic therapy Until 5 days after start of effective antibiotic therapy Until 5 days after rash appears From seventh day after first exposure through twenty first day after last exposure Until lesions have resolved Until 24 hours after adequate treatment started Until proved noninfectious Until all lesions dry and crust From tenth day after first exposure through twenty first day twenty eighth day if varicella zoster immune globulin VZIG administered after last exposure Until all lesio
281. Source Adapted from Bolyard EA Hospital Infection Control Practices Advisory Committee Guidelines for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 Modified from recommendations of the Advisory Committee on Immunization Practices ACIP t Unless epidemiologically linked to transmission of infection Those susceptible to varicella and who are at increased risk of complications of varicella e 9 neonates and immunocompromised persons of any age Patients at high risk as defined by ACIP for complications of influenza 90 TABLE 1 Continued Suggested work restrictions for health care personnel infected with or exposed to major infectious diseases in health care settings in the absence of state and local regulations Disease problem Pediculosis Pertussis Active Postexposure asymptomatic personnel Postexposure symptomatic personnel Rubella Active Postexposure susceptible personnel Staphylococcus aureus infection Active draining skin lesions Carrier state Streptococcal infection group A Tuberculosis Active disease PPD converter Varicella chicken pox Active Postexposure susceptible personnel Zoster shingles Localized in healthy person Generalized or localized in immunosup pressed Postexposure susceptible personnel Viral respiratory infection acute febrile Work restriction Restrict from patient contact Exclude from duty
282. lh W 256 259 27 CDC 2003 A 260 sterization procedures
283. 1 2 3 9 Z 23
284. 407 408 GABOR BRC 2 407 409 OSHA 46 47 73 410 EPA
285. Effectiveness of ethylene oxide for sterilization of dental handpieces J Dent 1995 23 113 3 Alfa MJ Olson N Degagne P Hizon R New low temperature sterilization technologies microbicidal activity and clinical efficacy Chapter 9 In Rutala WA ed Disinfection sterilization and antisepsis in health care Champlain NY Polyscience Publications 1998 67 78 Rutala WA Weber DJ Clinical effectiveness of low temperature sterilization technologies Infect Control Hosp Epidemiol 1998 19 798 804 Miller CH Tan CM Beiswanger MA Gaines DJ Setcos JC Palenik CJ Cleaning dental instruments measuring the effectiveness of an instrument washer disinfector Am J Dent 2000 13 39 43 Association for the Advancement of Medical Instrumentation Chemical indicators guidance for the selection use and interpretation of results AAMI Technical Information Report No 25 Arlington VA Association for the Advancement of Medical Instrumentation 1999 Ninemeier J Central service technical manual 5 ed Chicago IL International Association of Healthcare Central Service Materiel Management 1998 Rutala WA Weber DJ Choosing a sterilization wrap for surgical packs Infection Control Today 2000 4 64 70 Association for the Advancement of Medical Instrumentation American National Standards Institute Good hospital practice steam sterilization and sterility assurance ANSI AAMI ST46 1993 Arlington VA Association for the Advancement o
286. Housekeeping Surfaces i 4 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 243 244 Clean mops and cloths after use and allow to dry before reuse or use single use disposable mop heads or cloths II 243 244 Prepare fresh cleaning or EPA registered disinfecting solutions daily and as instructed by the manufacturer II 243 244 Clean walls blinds and window curtains in patient care areas when they are visibly dusty or soiled II 9 244 D Spills of Blood and Body Substances k 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 13 113 E Carpet and Cloth Furnishings 1 Avoid using carpeting and cloth upholstered furnishings in dental operatories laboratories and instrument processing areas II 9 293 295 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 13 301
287. Percutaneous injuries among DHCP usually 1 occur outside the patient s mouth thereby posing less risk for recontact with patient tissues 2 involve limited amounts of blood and 3 are caused by burs syringe needles laboratory knives and other sharp instruments 99 102 105 106 Injuries among oral surgeons might occur more frequently during fracture reductions using wires 104 107 Experience as measured by years in practice does not appear to affect the risk of injury among general dentists or oral surgeons 100 104 107 The majority of exposures in dentistry are preventable and methods to reduce the risk of blood contacts have included use of standard precautions use of devices with features engineered to prevent sharp injuries and modifications of work practices These approaches might have contributed to the decrease in percutaneous injuries among dentists during recent years 98 00 03 However needlesticks and other blood contacts continue to occur which is a concern because percutaneous injuries pose the greatest risk of transmission Standard precautions include use of PPE e g gloves masks protective eyewear or face shield and gowns intended to prevent skin and mucous membrane exposures Other protective equipment e g finger guards while suturing might also reduce injuries during dental procedures 104 Engineering controls are the primary method to reduce exposures to blood and OPIM from sharp instruments
288. Report Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1990 HETA 88 101 2008 CDC National Institute for Occupational Safety and Health Control of smoke from laser electric surgical procedures Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1996 DHHS publication no NIOSH 96 128 Taravella MJ Weinberg A Blackburn P May M Do intact viral particles survive excimer laser ablation Arch Ophthalmol 1997 115 1028 30 Hagen KB Kettering JD Aprecio RM Beltran F Maloney RK 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 Lack of virus transmission by the excimer laser plume Am J Ophthalmol 1997 124 206 11 Kunachak S Sithisarn P Kulapaditharom B Are laryngeal papilloma virus infected cells viable in the plume derived from a continuous mode carbon dioxide laser and are they infectious A preliminary report on one laser mode J Laryng Otol 1996 110 1031 3 Hughes PS Hughes AP Absence of human papillomavirus DNA in the plume of erbium YAG laser treated warts J Am Acad Dermatol 1998 38 426 8 Garden JM O Banion MK Shelnitz LS et al Papillomavirus in the vapor of carbon dioxide laser treated verrucae JAMA 1988 259 1199 1202
289. Tuberculocide products effective against Mycobacterium species List C Products effective against human HIV 1 virus List D Products effective against human HIV 1 virus and HBV List E Products effective against Mycobacterium species human HIV 1 virus and HBV List F Products effective against HCV Microorganisms vary in their resistance to disinfection and sterilization enabling CDC s designation of disinfectants as high intermediate and low level when compared with EPA s designated organism spectrum Figure However exceptions to this general guide exist and manufacturer s label claims and instructions should always be followed 117 Guidelines for Infection Control in Dental Health Care Settings 2008 vaccine Hepatitis B recombinant vaccine Influenza vaccine inactivated Measles live virus vaccine Mumps live virus vaccine Rubella live virus vaccine Varicella zoster live virus vaccine Dose schedule Three dose schedule administered intramuscularly IM in the deltoid 0 1 6 second dose administered 1 month after first dose third dose administered 4 months after second Booster doses are not necessary for persons who have developed adequate antibodies to hepatitis B surface antigen anti HBs Annual single dose vaccination IM with current vaccine One dose administered subcutaneously SC second dose gt 4 weeks later One dose SC no booste
290. ZZ HCV HCV 1 2 78 86 HCV 80 HCV HCV 0 17 87 90 HIV 2001 12 HIV HIV
291. e g suctioned fluids can be inactivated in accordance with state approved treatment technologies or the contents can be carefully poured down a utility sink drain or toilet 6 Appropriate PPE e g gloves gown mask and protective eyewear should be worn when performing this task 73 No evidence exists that bloodborne diseases have been transmitted from contact with raw or treated sewage Multiple bloodborne pathogens particularly viruses are not stable in the environment for long periods 302 and the discharge of limited quantities of blood and other body fluids into the sanitary sewer is considered a safe method for disposing of these waste materials 6 State and local regulations vary and dictate whether blood or other body fluids require pretreatment or if they can be discharged into the sanitary sewer and in what volume Dental Unit Waterlines Biofilm and Water Quality Studies have demonstrated that dental unit waterlines i e narrow bore plastic tubing that carries water to the high speed handpiece air water syringe and ultrasonic scaler can become colonized with microorganisms including bacteria fungi and protozoa 303 309 Protected by a polysaccharide slime layer known as a glycocalyx these microorganisms colonize and replicate on the interior surfaces of the waterline tubing and form a biofilm which serves as a reservoir that can amplify the number of free floating i e planktonic micro organisms in wat
292. http www osha slc gov SLTC laserelectrosurgeryplume American Thoracic Society CDC Diagnostic standards and classification of tuberculosis in adults and children Am J Resp Crit Care 2000 161 1376 95 Wells WF Aerodynamics of droplet nuclei Chapter 3 In Wells WF ed Airborne contagion and air hygiene an ecological study of droplet infections Cambridge MA Harvard University Press 1955 CDC Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus principles of therapy and revised recommendations MMWR 1998 47 No RR 20 Smith WH Davies D Mason KD Onions JP Intraoral and pulmonary tuberculosis following dental treatment Lancet 1982 1 842 4 CDC Self reported tuberculin skin testing among Indian Health Service and Bureau of Prisons dentists 1993 MMWR 1994 43 209 11 Mikitka D Mills SE Dazey SE Gabriel ME Tuberculosis infection in US Air Force dentists Am J Dent 1995 8 33 6 CDC World Health Organization consultation on public health issues related to bovine spongiform encephalopathy and the emergence of a new variant of Creutzfeldt Jakob Disease MMWR 1996 45 295 6 CDC Surveillance for Creutzfeldt Jakob disease United States MMWR 1996 45 665 8 Johnson RT Gibbs CJ Jr Creutzfeldt Jakob disease and related transmissible spongiform encephalopathies N Engl J Med 1998 339 1994 2004 CDC New variant CJD fact sheet Atlanta GA US Department of Health and Hum
293. of the glove II 123 142 143 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 7 8 11 13 137 2 Change masks between patients or during patient treatment if the mask becomes wet IB 2 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 2 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 7 8 11 13 137 2 Change protective clothing if visibly soiled 134 change immediately or as soon as feasible if penetrated by blood or other potentially infectious fluids IB IC 3 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 13 C Gloves 1 Wear medical gloves when a potential exists for contacting blood saliva OPIM or mucous membranes IB IC 2 7 8 13 2 Wear a new pair of medical gloves for each patient remove them promptl
294. surfaces also protects against health care associated infections Environmental surfaces can be divided into clinical contact surfaces and housekeeping surfaces 249 Because housekeeping surfaces e g floors walls and sinks have limited risk of disease transmission they can be decontaminated with less rigorous methods than those used on dental patient care items and clinical contact surfaces 244 Strategies for cleaning and disinfecting surfaces in patient care areas should consider the 1 potential for direct patient contact 2 degree and frequency of hand contact and 3 potential contamination of the surface with body substances or environmental sources of microorganisms e g soil dust or water Cleaning is the necessary first step of any disinfection process Cleaning is a form of decontamination that renders the environmental surface safe by removing organic matter salts and visible soils all of which interfere with microbial inactivation The physical action of scrubbing with detergents and surfactants and rinsing with water removes substantial numbers of microorganisms If a surface is not cleaned first the success of the disinfection process can be compromised Removal of all visible blood and inorganic and organic matter can be as critical as the germicidal activity of the disinfecting agent 249 When a surface cannot be cleaned adequately it should be protected with barriers 2 Clinical Contact Surfaces Clin
295. 1991 1100 also test specifically against organisms of known concern in health care practices e g HIV HBV hepatitis C virus HCV and herpes although it is considered likely that any product satisfying AOAC tests for hospital disinfectant designation will also be effective against these relatively fragile organisms when the product is used as directed by the manufacturer Potency against Mycobacterium tuberculosis has been recognized as a substantial benchmark However the tuberculocidal claim is used only as a benchmark to measure germicidal potency Tuberculosis is not transmitted via environmental surfaces but rather by the airborne route Accordingly use of such products on environmental surfaces plays no role in preventing the spread of tuberculosis However because mycobacteria have among the highest intrinsic levels of resistance among the vegetative bacteria viruses and fungi any germicide with a tuberculocidal claim on the label is considered capable of inactivating a broad spectrum of pathogens including such less resistant organisms as bloodborne pathogens e g HBV HCV and HIV It is this broad spectrum capability rather than the product s specific potency against mycobacteria that is the basis for protocols and regulations dictating use of tuberculocidal chemicals for surface disinfection EPA also lists disinfectant products according to their labeled use against these organisms of interest as follows List B
296. 1996 127 611 5 Watson CM Whitehouse RL Possibility of cross contamination between dental patients by means of the saliva ejector J Am Dent Assoc 1993 124 77 80 Glass BJ Terezhalmy GT Infection control in dental radiology Chapter 15 In Cottone JA Terezhalamy GT Molinari JA eds Practical infection control in dentisty 2nd ed Baltimore MD Williams amp Wilkins 1996 229 38 Haring JI Jansen L Infection control and the dental radiographer In Haring JI Jansen L eds Dental radiography principles and techniques Philadelphia PA WB Saunders Co 2000 194 204 Hignett M Claman P High rates of perforation are found in endovaginal ultrasound probe covers before and after oocyte retrieval for in vitro fertilization embryo transfer J Assist Reprod Genet 1995 12 606 9 Fritz S Hust MH Ochs C Gratwohl I Staiger M Braun B Use of a latex cover sheath for transesophageal echocardiography TEE instead of regular disinfection of the echoscope Clin Cardiol 1993 16 737 40 Milki AA Fisch JD Vaginal ultrasound probe cover leakage implications for patient care Fertil Steril 1998 69 409 11 Storment JM Monga M Blanco JD Ineffectiveness of latex condoms in preventing contamination of the transvaginal ultrasound transducer head South Med J 1997 90 206 8 Amis S Ruddy M Kibbler CC Economides DL MacLean AB Assessment of condoms as probe covers for transvaginal sonography J Clin Ultrasound 2000 28 295 8 Rooks VJ Yan
297. 2 training and educating DHCP 3 monitoring symptoms and 4 substituting nonlatex products where appropriate 32 see Contact Dermatitis and Latex Hypersensitivity Maintenance of Records Data Management and Confidentiality The health status of DHCP can be monitored by maintaining records of work related medical evaluations screening tests immunizations exposures and postexposure management Such records must be kept in accordance with all applicable state and federal laws Examples of laws that might apply include the Privacy Rule of the Health Insurance Portability and Accountability Act HIPAA of 1996 45 CFR 160 and 164 and the OSHA Occupational Exposure to Bloodborne Pathogens Final Rule 29 CFR 1910 1030 h 1 G_iv 34 13 The HIPAA Privacy Rule applies to covered entities including certain defined health providers health care clearinghouses and health plans OSHA requires employers to ensure that certain information contained in employee medical records is 1 kept confidential 2 not disclosed or reported without the employee s express written consent to any person within or outside the workplace except as required by the OSHA standard and 3 maintained by the employer for at least the duration of employment plus 30 years Dental practices that coordinate their infection control program with off site providers might consult OSHA s Bloodborne Pathogen standard and employee Access to Medical and Exposure Records standar
298. 33 34 35 36 HICPAC MMWR 1997 46 No RR 18 Association for Professionals in Infection Control and Epidemiology APIC position paper immunization Am J Infect Control 1999 27 52 3 CDC Updated U S Public Health Service guidelines for the management of occupational exposures to HBV HCV and HIV and recommendations for postexposure prophylaxis MMWR 2001 50 No RR 11 CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities 1994 MMWR 1994 43 No RR 13 Cleveland JL Gooch BF Bolyard EA Simone PM Mullan RJ Marianos DW TB infection control recommendations from the CDC 1994 considerations for dentistry J Am Dent Assoc 1995 126 593 9 Herwaldt LA Pottinger JM Carter CD Barr BA Miller ED Exposure workups Infect Control Hosp Epidemiol 1997 18 850 71 Nash KD How infection control procedures are affecting dental practice today J Am Dent Assoc 1992 123 67 73 Berky ZT Luciano WJ James WD Latex glove allergy a survey of the US Army Dental Corps JAMA 1992 268 2695 7 Bubak ME Reed CE Fransway AF et al Allergic reactions to latex among health care workers Mayo Clin Proc 1992 67 1075 9 Fisher AA Allergic contact reactions in health personnel J Allergy Clin Immunol 1992 90 729 38 Smart ER Macleod RI Lawrence CM Allergic reactions to rubber gloves in dental patients report of three cases Br Dent J 1992 172 445 7 Yassin MS Lierl MB Fischer T
299. FDA hospital disinfectant EPA Salmonella choleraesuis iatrogenic immunization CDC 2003 implantable device 30
300. J Dental In Association for Professionals in Infection Control and Epidemiology Inc APIC APIC text of infection control and epidemiology Washington DC Association for Professionals in Infection Control and Epidemiology Inc 2002 Sofou A Larsen T Fiehn NE Owall B Contamination level of alginate impressions arriving at a dental laboratory Clin Oral Invest 2002 6 161 5 McNeill MR Coulter WA Hussey DL Disinfection of irreversible hydrocolloid impressions a comparative study Int J Prosthodont 1992 5 563 7 Gerhardt DE Sydiskis RJ Impression materials and virus J Am Dent Assoc 1991 122 51 4 Leung RL Schonfeld SE Gypsum casts as a potential source of microbial cross contamination J Prosthet Dent 1983 49 210 1 Huizing KL Palenik CJ Setcos JC Sheldrake MA Miller CH Method of evaluating the antimicrobial abilities of disinfectant containing gypsum products QDT Yearbook 1994 17 172 6 Verran J Kossar S McCord JF Microbiological study of selected risk areas in dental technology laboratories J Dent 1996 24 77 80 CDC National Institute for Occupational Safety and Health NIOSH Health Hazard Evaluation and Technical Assistance Report Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1988 HETA 85 136 1932 CDC National Institute for Occupational Safety and Health NIOSH Health Hazard Evaluation and Technical Assistance
301. T b TREED HS HBV B Public Health Service CDC 1 3 1 2 HBsAb 1 2 3 HBsAg 2 HBsAb 2 HBsAg HBsAg HBV HBV
302. after removal from the patient s mouth before drying of blood or other bioburden can occur Specific guidance regarding cleaning and disinfecting techniques for various materials is available 260 413 416 DHCP are advised to consult with manufacturers regarding the stability of specific materials during disinfection In the laboratory a separate receiving and disinfecting area should be established to reduce contamination in the production area Bringing untreated items into the laboratory increases chances for cross infection 260 If no communication has been received regarding prior cleaning and disinfection of a material the dental laboratory staff should perform cleaning and disinfection procedures before handling If during manipulation of a material or appliance a previously undetected area of blood or bioburden becomes apparent cleaning and disinfection procedures should be repeated Transfer of oral microorganisms into and onto impressions has been documented 4 7 419 Movement of these organisms onto dental casts has also been demonstrated 420 Certain microbes have been demonstrated to remain viable within gypsum cast materials for lt 7 days 421 Incorrect handling of contaminated impressions prostheses or appliances therefore offers an opportunity for transmission of microorganisms 260 Whether in the office or laboratory PPE should be worn until disinfection is completed 2 7 0 13 If laboratory items e g bur
303. allows the pathogen to survive and multiply e g blood e amode of transmission from the source to the host e a portal of entry through which the pathogen can enter the host and e a susceptible host i e one who is not immune Occurrence of these events provides the chain of infection 6 Effective infection control strategies prevent disease transmission by interrupting one or more links in the chain Previous CDC recommendations regarding infection control for dentistry focused primarily on the risk of transmission of bloodborne pathogens among DHCP and patients and use of universal precautions to reduce that risk 2 7 8 Universal precautions were based on the concept that all blood and body fluids that might be contaminated with blood should be treated as infectious because patients with bloodborne infections can be asymptomatic or unaware they are infected 9 0 Preventive practices used to reduce blood exposures particularly percutaneous exposures include 1 careful handling of sharp instruments 2 use of rubber dams to minimize blood spattering 3 handwashing and 4 use of protective barriers e g gloves masks protective eyewear and gowns The relevance of universal precautions to other aspects of disease transmission was recognized and in 1996 CDC expanded the concept and changed the term to standard precautions Standard precautions integrate and expand the elements of universal precautions into a standar
304. 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 107 Guidelines for Infection Control in Dental Health Care Settings 2008 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 445 448 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 448 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 449 451 vCJD was reported first in the United Kingdom in 1996 449 and subsequently in other European countries 452 Only one case of vCJD has been reported in the United States in an immigrant from the United Kingdom 453 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
305. an infected DHCP might be viremic unless the second and third conditions are also met transmission cannot occur The risk of occupational exposure to bloodborne viruses is largely determined by their prevalence in the patient population and the nature and frequency of contact with blood and body fluids through percutaneous or permucosal routes of exposure The risk of infection after exposure to a bloodborne virus is influenced by inoculum size route of exposure and susceptibility of the exposed HCP 2 The majority of attention has been placed on the bloodborne pathogens HBV HCV and HIV and these pathogens present different levels of risk to DHCP Hepatitis B Virus HBV is a well recognized occupational risk for HCP 36 37 HBV is transmitted by percutaneous or mucosal exposure to blood or body fluids of a person with either acute or chronic HBV infection Persons infected with HBV can transmit the virus for as long as they are HBsAg positive The risk of HBV transmission is highly related to the HBeAg status of the source person In studies of HCP who sustained injuries from needles contaminated with blood containing HBV the risk of developing clinical hepatitis if the blood was positive for both HBsAg and HBeAg was 22 31 the risk of developing serologic evidence of HBV infection was 37 62 19 By comparison the risk of developing clinical hepatitis from a needle contaminated with HBsAg positive HBeAg negative blood was 1 6 a
306. and needles These controls are frequently technology based and often incorporate safer designs of instruments and devices e g self sheathing anesthetic needles and dental units designed to shield burs in handpieces to reduce percutaneous injuries 101 103 108 Work practice controls establish practices to protect DHCP whose responsibilities include handling using assembling or processing sharp devices e g needles scalers laboratory utility knives burs explorers and endodontic files or sharps disposal containers Work practice controls can include removing burs before disassembling the handpiece from the dental unit restricting use of fingers in tissue retraction or palpation during suturing and administration of anesthesia and minimizing potentially uncontrolled movements of such instruments as scalers or laboratory knives 707 705 As indicated needles are a substantial source of percutaneous injury in dental practice and engineering and work practice controls for needle handling are of particular importance In 2001 revisions to OSHA s bloodborne pathogens standard as mandated by the Needlestick Safety and Prevention Act of 2000 became effective These revisions clarify the need for employers to consider safer needle devices as they become available and to involve employees directly responsible for patient care e g dentists hygienists and dental assistants in identifying and choosing such devices 709 Safer versions
307. and use of particulate respirators certified under 42 CFR 84 Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1996 DHHS publication no NIOSH 96 101 DeGroot Kosolcharoen J Jones JM Permeability of latex and vinyl gloves to water and blood Am J Infect Control 1989 17 196 201 Korniewicz DM Laughon BE Butz A Larson E Integrity of vinyl and latex procedure gloves Nurs Res 1989 38 144 6 Olsen RJ Lynch P Coyle MB Cummings J Bokete T Stamm WE Examination gloves as barriers to hand contamination in clinical practice JAMA 1993 270 350 3 Murray CA Burke FJ McHugh S An assessment of the incidence of punctures in latex and non latex dental examination gloves in routine clinical practice Br Dent J 2001 190 377 80 Burke FJ Baggett FJ Lomax AM Assessment of the risk of glove puncture during oral surgery procedures Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996 82 18 21 Burke FJ Wilson NH The incidence of undiagnosed punctures in non sterile gloves Br Dent J 1990 168 67 71 Nikawa H Hamada T Tamamoto M Abekura H Perforation and proteinaceous contamination of dental gloves during prosthodontic treatments Int J Prosthodont 1994 7 559 66 Nikawa H Hamada T Tamamoto M Abekura H Murata H Perforation of dental gloves during prosthodontic treatments as assessed by the conductivity and water inflation tests Int J Prostho
308. are associated with an increased risk of influenza Measles mumps rubella MMR is the recommended vaccine if recipients are also likely to be susceptible to rubella or mumps persons vaccinated during 1963 1967 with 1 measles killed virus vaccine alone 2 killed virus vaccine followed by live virus vaccine or 3 a vaccine of unknown type should be revaccinated with two doses oflive virus measles vaccine MMR is the recommended vaccine Women pregnant when vaccinated or who become pregnant within 4 weeks of vaccination should be counseled regarding theoretic risks to the fetus however the risk of rubella vaccine associated malformations among these women is negligible MMR is the recommended vaccine Because 71 93 of U S born persons without a history of varicella are immune serologic testing before vaccination might be cost effective Sources Adapted from Bolyard EA Hospital Infection Control Practices Advisory Committee Guidelines for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 CDC Immunization of health care workers recommendations of the Advisory Committee on Immunization Practices ACIP and the Hospital Infection Control Practices Advisory Committee HICPAC MMWR 1997 46 No RR 18 CDC Prevention and control of influenza recomm endations of the Advisory Committee on Immunization Practices ACIP MMWR 2003 52 1 34 CDC Using live attenuated influenza vac
309. associated with the saliva ejector have been reported practitioners should be aware that in certain situations backflow could occur when using a saliva ejector Dental Radiology When taking radiographs the potential to cross contaminate equipment and environmental surfaces with blood or saliva is high if aseptic technique is not practiced Gloves should be worn when taking radiographs and handling contaminated film packets Other PPE e g mask protective eyewear and gowns should be used if spattering of blood or other body fluids is likely 3 367 Heat tolerant versions of intraoral radiograph accessories are available and these semicritical items e g film holding and positioning devices should be heat sterilized before patient use After exposure of the radiograph and before glove removal the film should be dried with disposable gauze or a paper towel to remove blood or excess saliva and placed in a container e g disposable cup for transport to the developing area Alternatively if FDA cleared film barrier pouches are used the film packets should be carefully removed from the pouch to avoid contamination of the outside film packet and placed in the clean container for transport to the developing area Various methods have been recommended for aseptic transport of exposed films to the developing area and for removing the outer film packet before exposing and developing the film Other information regarding dental radiogra
310. attenuated influenza vaccine for prevention and control of influenza supplemental recommendations of the Advisory Committee on Immunization Practices ACIP MMWR 2003 52 No RR 13 1991 12 0ccupational Safety and Health Act CD B follow up HIV X 8 L h 70 ive attenulated HC
311. 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 3 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 3 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 2 8 73 113 115 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 7 9 13 VIII Unit Waterlines Biofilm and Water Quality A General Recommendations 1 Use water that meets EPA regulatory standards for drinking water i e lt 500 CFU mL of heterotrophic water bacteria for routine dental treatment output water IB IC 341 342 Consult with the dental unit manufacturer for appropriate methods and equipment to maintain the recommended quality
312. bacteria and Pseudomonas aeruginosa for effectiveness against a primarily nosocomial pathogen Substantiated label claims of effectiveness of a disinfectant against specific microorganisms other than the test microorganisms are permitted but not required provided that the test microorganisms are likely to be present in or on the recommended use areas and surfaces Therefore manufacturers might FIGURE Decreasing order of resistance of microorganisms to germicidal chemicals Organism Bacterial spores Geobacillus stearothermophilus Bacillus atrophaeus Mycobacteria Mycobacterium tuberculosis Nonlipid or small viruses Polio virus Coxsackle virus Rhinovirus Fungi Aspergillus Candida Vegetative bacteria Staphylococcus species Pseudomonus species Salmonella species Lipid or medium sized viruses Human immunodeficiency virus Herpes simplex virus Hepatitis B and hepatitis C Coronavirus EPA hospital disinfectant with CDC intermediate level disinfectant EPA hospital disinfectant CDC low level disinfectant Processing Level Required Sterilization FDA sterilant high level disinfectant CDC sterilant high level disinfectant tuberculocidal claim Source Adapted from Bond WW Ott BJ Franke K McCracken JE Effective use of liquid chemical germicides on medical devices instrument design problems In Block SS ed Disinfection sterilization and preservation 4th ed Philadelphia PA Lea amp Gebiger
313. body fluid exposures that inoculated HBV into cutaneous scratches abrasions burns other lesions or on mucosal surfaces 45 47 The potential for HBV transmission through contact with environmental surfaces has been demonstrated in investigations of HBV outbreaks among patients and HCP in hemodialysis units 48 50 Since the early 1980s occupational infections among HCP have declined because of vaccine use and adherence to universal precautions 51 Among U S dentists gt 90 have been vaccinated and serologic evidence of past HBV infection decreased from prevaccine levels of 14 in 1972 to approximately 9 in 1992 52 During 1993 2001 levels remained relatively unchanged Chakwan Siew Ph D American Dental Association Chicago Illinois personal communication June 2003 Infection rates can be expected to decline further as vaccination rates remain high among young dentists and as older dentists with lower vaccination rates and higher rates of infection retire Although the potential for transmission of bloodborne infections from DHCP to patients is considered limited 53 55 precise risks have not been quantified by carefully designed epidemiologic studies 53 56 57 Reports published during 1970 1987 describe nine clusters in which patients were thought to be infected with HBV through treatment by an infected DHCP 58 67 However transmission of HBV from dentist to patient has not been reported since 1987 possibly reflecting
314. control from CDC and other public agencies academia and private and professional organizations l e hand hygiene products and surgical hand antisepsis ntroduction e contact dermatitis and latex hypersensitivity This report consolidates recommendations for preventing and e sterilization of unwrapped instruments controlling infectious diseases and managing personnel health and e dental water quality concerns e g dental unit waterline biofilms safety concerns related to infection control in dental settings This delivery of water of acceptable biological quality for patient care report 1 updates and revises previous CDC recommendations usefulness of flushing waterlines use of sterile irrigating solutions regarding infection control in dental settings 2 2 incorporates for oral surgical procedures handling of community boil water relevant infection control measures from other CDC guidelines and 3 advisories discusses concerns not addressed in previous recommendations for e dental radiology dentistry These updates and additional topics include the following e aseptic technique for parenteral medications e application of standard precautions rather than universal e preprocedural mouth rinsing for patients precautions e oral surgical procedures e work restrictions for health care personnel HCP infected with or e laser electrosurgery plumes occupationally exposed to infectious diseases e tuberculosis TB e management of occupati
315. control recommendations for the dental office and the dental laboratory J Am Dent Assoc 1996 127 672 80 Dental Laboratory Relationship Working Group Organization for Safety and Asepsis Procedures OSAP Laboratory asepsis position paper Annapolis MD OSAP Foundation 1998 Available at http www osap org issues pages position LAB pdf Kugel G Perry RD Ferrari M Lalicata P Disinfection and communication practices a survey of U S dental laboratories J Am Dent Assoc 2000 131 786 92 US Department of Transportation 49 CFR 173 196 infectious substances etiologic agents 173 197 regulated medical waste Available at http www access gpo gov nara cfr waisidx_02 49cfr173_02 html Chau VB Saunders TR Pimsler M Elfring DR In depth disinfection of acrylic resins J Prosthet Dent 1995 74 309 13 Powell GL Runnells RD Saxon BA Whisenant BK The presence and identification of organisms transmitted to dental laboratories J Prosthet Dent 1990 64 235 7 Giblin J Podesta R White J Dimensional stability of impression materials immersed in an iodophor disinfectant Int J Prosthodont 1990 3 72 7 Plummer KD Wakefield CW Practical infection control in dental laboratories Gen Dent 1994 42 545 8 Merchant VA Infection control in the dental laboratory equipment Chapter 16 In Cottone JA Terezhalamy GT Molinari JA eds Practical infection control in dentisty 2nd ed Baltimore MD Williams amp Wilkins 1996 239 54 Molinari
316. describe procedures for promptly reporting and evaluating such exposures and 3 identify a health care professional who is qualified to provide counseling and perform all medical evaluations and procedures in accordance with current recommendations of the U S Public Health Service PHS including PEP with chemotherapeutic drugs when indicated DHCP including students who might reasonably be considered at risk for occupational exposure to blood or OPIM should be taught strategies to prevent contact with blood or OPIM and the principles of postexposure management including PEP options as part of their job orientation and training Educational programs for DHCP and students should emphasize reporting all exposures to blood or OPIM as soon as possible because certain interventions have to be initiated promptly to be effective Policies should be consistent with the practices and procedures for worker protection required by OSHA and with current PHS recommendations for managing occupational exposures to blood 13 19 After an occupational blood exposure first aid should be administered as necessary Puncture wounds and other injuries to the skin should be washed with soap and water mucous membranes should be flushed with water No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission however use of antiseptics is not contraindicated The appl
317. eg o7e g Pseudomonas 329 D E C amp 4 Cladosporium E K 331 dental water 2 332 eg o7e a 333 334 2 372 dental treatment water Cia 78
318. engineering controls work practice controls personal protective equipment PPE 13
319. environment should be adequately covered or isolated Persons might also be allergic to chemicals used in the manufacture of natural rubber latex and synthetic rubber gloves as well as metals plastics or other materials used in dental care Taking thorough health histories for both patients and DHCP followed by avoidance of contact with potential allergens can minimize the possibility of adverse reactions Certain common predisposing conditions for latex allergy include previous history of allergies a history of spina bifida urogenital anomalies or allergies to avocados kiwis nuts or bananas The following precautions should be considered to ensure safe treatment for patients who have possible or documented latex allergy e Be aware that latent allergens in the ambient air can cause respiratory or anaphylactic symptoms among persons with latex hypersensitivity Patients with latex allergy can be scheduled for the first appointment of the day to minimize their inadvertent exposure to airborne latex particles e Communicate with other DHCP regarding patients with latex allergy e g by oral instructions written protocols and posted signage to prevent them from bringing latex containing materials into the treatment area e Frequently clean all working areas contaminated with latex powder or dust e Have emergency treatment kits with latex free products available at all times e If latex related complications occur during or after a pro
320. fluid synovial fluid pleural fluid pericardial fluid peritoneal fluid amniotic fluid saliva in dental procedures any body fluid visibly contaminated with blood and all body fluids in situations where differentiating between body fluids is difficult or impossible 2 any unfixed tissue or organ other than intact skin from a human living or dead and 3 HIV containing cell or tissue cultures organ cultures HIV or HBV containing culture medium or other solutions and blood organs or other tissues from experimental animals infected with HIV or HBV Parenteral Means of piercing mucous membranes or skin barrier through such events as needlesticks human bites cuts and abrasions Persistent activity Prolonged or extended activity that prevents or inhibits proliferation or survival of microorganisms after application of a product This activity can be demonstrated by sampling a site minutes or hours after application and demonstrating bacterial antimicrobial effectiveness when compared with a baseline level Previously this property was sometimes termed residual activity Prion Protein particle lacking nucleic acid that has been implicated as the cause of certain neurodegenerative diseases e g scrapie CJD and bovine spongiform encephalopathy BSE Retraction Entry of oral fluids and microorganisms into waterlines through negative water pressure Seroconversion The change of a serological test from negative to positive ind
321. have been published describing transmission from HCV infected surgeons which apparently occurred during performance of invasive procedures the overall risk for infection averaged 0 17 87 90 Human Immunodeficiency Virus In the United States the risk of HIV transmission in dental settings is extremely low As of December 2001 a total of 57 cases of HIV seroconversion had been documented among HCP but none among DHCP after occupational exposure to a known HIV infected source 91 Transmission of HIV to six patients of a single dentist with AIDS has been reported but the mode of transmission could not be determined 2 92 93 As of September 30 1993 CDC had information regarding test results of gt 22 000 patients of 63 HIV infected HCP including 33 dentists or dental students 55 93 No additional cases of transmission were documented Prospective studies worldwide indicate the average risk of HIV infection after a single percutaneous exposure to HIV infected blood is 0 3 range 0 2 0 5 94 After an exposure of mucous membranes in the eye nose or mouth the risk is approximately 0 1 76 The precise risk of transmission after skin exposure remains unknown but is believed to be even smaller than that for mucous membrane exposure Certain factors affect the risk of HIV transmission after an occupational exposure Laboratory studies have determined if needles that pass through latex gloves are solid rather than hollow bore o
322. in Dental Health Care Settings 2008 is provided flush dental waterlines and faucets for 1 5 minutes before using for patient care IC 244 346 351 352 b Disinfect dental waterlines as recommended by the dental unit manufacturer ID IX Special Considerations A Dental Handpieces and Other Devices Attached to Air and Waterlines 114 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 2 246 275 356 357 360 407 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 361 363 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 2 246 250 275 Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids II 364 366 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 11 13 Use heat tolerant or disposable intraoral devices whenever possible e g film holding and po
323. likely to be contaminated by blood or saliva Before leaving the dental operatory or the dental laboratory When visibly soiled Before regloving after removing gloves that are torn cut or punctured 15 seconds Rub hands until the 2 6 minutes Before donning sterile surgeon s gloves for surgical procedures instructions for surgical hand scrub product with persistent activity q t Pathogenic organisms have been found on or around bar soap during and after use 739 Use of liquid soap with hands free dispensing controls is preferable Time reported as effective in removing most transient flora from the skin For most procedures a vigorous rubbing together of all surfaces of premoistened lathered hands and fingers for gt 15 seconds followed by rinsing under a stream of cool or tepid water is recommended 9 120 123 140 141 Hands should always be dried thoroughly before donning gloves Alcohol based hand rubs should contain 60 95 ethanol or isopropanol and should not be used in the presence of visible soil or organic material If using an alcohol based hand rub apply adequate amount to palm of one hand and rub hands together covering all surfaces of the hands and fingers until hands are dry Follow manufacturer s recommendations regarding the volume of product to use If hands feel dry after rubbing them together for 10 15 seconds an insufficient volume of product likely was applied The drying effect of alc
324. liquid chemical sterilant high level disinfectant e g glutaraldehyde as a holding solution is not recommended 244 Using work practice controls e g long handled brush to keep the scrubbing hand away from sharp instruments is recommended 4 To avoid injury from sharp instruments DHCP should wear puncture resistant heavy duty utility gloves when handling or manually cleaning contaminated instruments and devices 6 Employees should not reach into trays or containers holding sharp instruments that cannot be seen e g sinks filled with soapy water in which sharp instruments have been placed Work practice controls should include use of a strainer type basket to hold instruments and forceps to remove the items Because splashing is likely to occur a mask protective eyewear or face shield and gown or jacket should be worn 3 Preparation and Packaging In another section of the processing area cleaned instruments and other dental supplies should be inspected assembled into sets or trays and wrapped packaged or placed into container systems for sterilization Hinged instruments should be processed open and unlocked An internal chemical indicator should be placed in every package In addition an external chemical indicator e g chemical indicator tape should be used when the internal indicator cannot be seen from outside the package For unwrapped loads at a minimum an internal chemical indicator should be placed in the t
325. minimum number i e tens of millions of separable cells on the surface of or in semisolid agar medium that give rise to a visible colony of progeny CFUs can consist of pairs chains clusters or as single cells and are often expressed as colony forming units per milliliter CFUs mL Decontamination Use of physical or chemical means to remove inactivate or destroy pathogens on a surface or item so that they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling use or disposal Dental treatment water Nonsterile water used during dental treatment including irrigation of nonsurgical operative sites and cooling of high speed rotary and ultrasonic instruments Disinfectant A chemical agent used on inanimate objects e g floors walls or sinks to destroy virtually all recognized pathogenic microorganisms but not necessarily all microbial forms e g bacterial endospores The U S Environmental Protection Agency EPA groups disinfectants on the basis of whether the product label claims limited general or hospital disinfectant capabilities Disinfection Destruction of pathogenic and other kinds of microorganisms by physical or chemical means Disinfection is less lethal than sterilization because it destroys the majority of recognized pathogenic microorganisms but not necessarily all microbial forms e g bacterial spores Disinfection does not ensure the degree of safet
326. occupational human immunodeficiency virus infection Seminars in Infection Control 2001 1 2 18 CDC National Institute for Occupational Safety and Health NIOSH alert Preventing needlestick injuries in health care settings Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1999 Klein RS Phelan JA Freeman K et al Low occupational risk of human immunodeficiency virus infection among dental professionals N Engl J Med 1988 318 86 90 Gruninger SE Siew C Chang SB et al Human immuno deficiency virus type I infection among dentists J Am Dent Assoc 1992 123 39 64 Siew C Gruninger SE Miaw CL Neidle EA Percutaneous injuries in practicing dentists a propective study using a 20 day diary J Am Dent Assoc 199S 126 1227 34 Cleveland JL Lockwood SA Gooch BF et al Percutaneous injuries in dentistry an observational study J Am Dent Assoc 1995 126 745 S1 Ramos Gomez F Ellison J Greenspan D Bird W Lowe S Gerberding JL Accidental exposures to blood and body fluids among health care workers in dental teaching clinics a prospective study J Am Dent Assoc 1997 128 1253 61 Cleveland JL Gooch BF Lockwood SA Occupational blood exposure in dentistry a decade in review Infect Control Hosp Epidemiol 1997 18 717 21 Gooch BF Siew C Cleveland JL Gruninger SE Lockwood SA Joy ED Occupational blood exposure and HIV infection among or
327. of dental water II 339 Follow recommendations for monitoring water quality provided by the manufacturer of the unit or waterline treatment product II 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 2 311 344 Consult with the dental unit manufacturer on the need for periodic maintenance of antiretraction mechanisms IB 2 311 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 341 342 346 349 350 b Do not use water from the public water system for dental treatment patient rinsing or handwashing IB IC 341 342 346 349 350 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 73 122 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 113 Guidelines for Infection Control
328. of sharp devices used in hospital settings have become available e g blunt suture needles phlebotomy devices and butterfly needles and their impact on reducing injuries has been documented 110 112 Aspirating anesthetic syringes that incorporate safety features have been developed for dental procedures but the low injury rates in dentistry limit assessment of their effect on reducing injuries among DHCP Work practice controls for needles and other sharps include placing used disposable syringes and needles scalpel blades and other sharp items in appropriate puncture resistant containers located as close as feasible to where the items were used 2 7 3 113 115 In addition used needles should never be recapped or otherwise manipulated by using both hands or any other technique that involves directing the point of a needle toward any part of the body 2 7 3 97 113 114 A one handed scoop technique a mechanical device designed for holding the needle cap to facilitate one handed recapping or an engineered sharps injury protection device e g needles with resheathing mechanisms should be employed for recapping needles between uses and before disposal 2 7 3 13 114 DHCP should never bend or break needles before disposal because this practice requires unnecessary manipulation Before attempting to remove needles from nondisposable aspirating syringes DHCP should recap them to prevent injuries For procedures involving multip
329. one study evaluating double gloves during oral surgical and dental hygiene procedures the perforation of outer latex gloves was greater during longer procedures i e gt 45 minutes with the highest rate 10 of perforation occurring during oral surgery procedures 196 Based on these studies double gloving might provide additional protection from occupational blood contact 220 Double gloving does not appear to substantially reduce either manual dexterity or tactile sensitivity 227 223 Additional protection might also be provided by specialty products e g orthopedic surgical gloves and glove liners 224 Contact Dermatitis and Latex Hypersensitivity Occupationally related contact dermatitis can develop from frequent and repeated use of hand hygiene products exposure to chemicals and glove use Contact dermatitis is classified as either irritant or allergic Irritant contact dermatitis is common nonallergic and develops as dry itchy irritated areas on the skin around the area of contact By comparison allergic contact dermatitis type IV hypersensitivity can result from exposure to accelerators and other chemicals used in the manufacture of rubber gloves e g natural rubber latex nitrile and neoprene as well as from other chemicals found in the dental practice setting e g methacrylates and glutaraldehyde Allergic contact dermatitis often manifests as a rash beginning hours after contact and similar to irritant der
330. precautions e g closed containers to limit vapor release chemically resistant gloves and aprons goggles and face shields glutaraldehyde based products can be used without tissue irritation or adverse health effects However dermatologic eye irritation respiratory effects and skin sensitization have been reported 266 268 Because of their lack of chemical resistance to glutaraldehydes medical gloves are not an effective barrier 200 269 270 Other factors might apply e g room exhaust ventilation or 10 air exchanges hour to ensure DHCP safety 266 271 For all of these reasons using heat sensitive semicritical items that must be processed with liquid chemical germicides is discouraged heat tolerant or disposable alternatives are available for the majority of such items Low temperature sterilization with ethylene oxide gas ETO has been used extensively in larger health care facilities Its primary advantage is the ability to sterilize heat and moisture sensitive patient care items with reduced deleterious effects However extended sterilization times of 10 48 hours and potential hazards to patients and DHCP requiring stringent health and safety requirements 272 274 make this method impractical for private practice settings Handpieces cannot be effectively sterilized with this method because of decreased penetration of ETO gas flow through a small lumen 250 275 Other types of low temperature sterilization e g hydroge
331. prophylaxis MMWR 2001 50 No RR 11 e Mangram AJ Horan TC Pearson ML Silver LC Jarvis WR Hospital Infection Control Practices Advisory Committee Guideline for prevention of surgical site infection 1999 Infect Control Hosp Epidemiol 1999 20 250 78 e Bolyard EA Tablan OC Williams WW Pearson ML Shapiro CN Deitchman SD Hospital Infection Control Practices Advisory Committee Guideline for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 e CDC Immunization of health care workers recommendations of the Advisory Committee on Immunization Practices ACIP and the Hospital Infection Control Practices Advisory Committee HICPAC MMWR 1997 46 No RR 18 e Rutala WA Association for Professionals in Infection Control and Epidemiology Inc APIC guideline for selection and use of disinfectants Am J Infect Control 1996 24 313 42 e Garner JS Hospital Infection Control Practices Advisory Committee Guideline for isolation precautions in hospitals Infect Control Hosp Epidemiol 1996 17 53 80 e Larson EL 1992 1993 and 1994 Guidelines Committee APIC guideline for handwashing and hand antisepsis in health care settings Am J Infect Control 1995 23 25 1 69 e CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities 1994 MMWR 1994 43 No RR 13 e CDC Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus
332. spas 328 swimming pools 329 and a grocery store mist machine 330 Although the majority of these outbreaks are associated with species of Legionella and Pseudomonas 329 the fungus Cladosporium 331 has also been implicated Researchers have not demonstrated a measurable risk of adverse health effects among DHCP or patients from exposure to dental water Certain studies determined DHCP had altered nasal flora 332 or substantially greater titers of Legionella antibodies in comparisons with control populations however no cases of legionellosis were identified among exposed DHCP 333 334 Contaminated dental water might have been the source for localized Pseudomonas aeruginosa infections in two immunocompromised patients 3 2 Although transient carriage of P aeruginosa was observed in 78 healthy patients treated with contaminated dental treatment water no illness was reported among the group In this same study a retrospective review of dental records also failed to identify infections 3 2 Concentrations of bacterial endotoxin lt 1 000 endotoxin units mL from gram negative water bacteria have been detected in water from colonized dental units 335 No standards exist for an acceptable level of endotoxin in drinking water but the maximum level permissible in United States Pharmacopeia USP sterile water for irrigation is only 0 25 endotoxin units mL 336 Although the consequences of acute and chronic exposure to aerosolized
333. sterile water in a self contained water system will not eliminate bacterial contamination in treatment water if biofilms in the water system are not controlled Removal or inactivation of dental waterline biofilms requires use of chemical germicides Patient material e g oral microorganisms blood and saliva can enter the dental water system during patient treatment 311 344 Dental devices that are connected to the dental water system and that enter the patient s mouth e g handpieces ultrasonic scalers or air water syringes should be operated to discharge water and air for a minimum of 20 30 seconds after each patient 2 This procedure is intended to physically flush out patient material that might have entered the turbine air or waterlines The majority of recently manufactured dental units are engineered to prevent retraction of oral fluids but some older dental units are equipped with antiretraction valves that require periodic maintenance Users should consult the owner s manual or contact the manufacturer to determine whether testing or maintenance of antiretraction valves or other devices is required Even with antiretraction valves flushing devices for a minimum of 20 30 seconds after each patient is recommended Maintenance and Monitoring of Dental Unit Water DHCP should be trained regarding water quality biofilm formation water treatment methods and appropriate maintenance protocols for water delivery systems Water
334. 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 465 467 In 2000 prions were not found in the dental pulps of eight patients with neuropatho logically confirmed sporadic CJD by using electrophoresis and a Western blot technique 468 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 243 249 277 469 e Use single use disposable items and equipment whenever possible
335. to date immunizations Report occupational exposures to infectious agents Document the steps that occurred around the exposure and plan how such exposure can be prevented in the future Ensure the postexposure management plan is clear complete and available at all times to all DHCP All staff should understand the plan which should include toll free phone numbers for access to additional information Observe and document circumstances of appropriate or inappropriate handwashing Review findings in a staff meeting Observe and document the use of barrier precautions and careful handling of sharps Review findings in a staff meeting Monitor paper log of steam cycle and temperature strip with each sterilization load and examine results of weekly biologic monitoring Take appropriate action when failure of sterilization process is noted Conduct an annual review of the exposure control plan and consider new developments in safer medical devices Monitor dental water quality as recommended by the equipment manufacturer using commercial self contained test kits or commercial water testing laboratories Observe the safe disposal of regulated and nonregulated medical waste and take preventive measures if hazardous situations occur Assess the unscheduled return of patients after procedures and evaluate them for an infectious process A trend might require formal evaluation 469 is available at http www who int emc documents t
336. to patients during exposure prone invasive procedures MMWR 1991 40 No RR 8 e Garner JS CDC guideline for prevention of surgical wound infections 1985 Supersedes guideline for prevention of surgical wound infections published in 1982 Originally published in November 1985 Revised Infect Control 1986 7 193 200 e Garner JS Favero MS CDC guideline for handwashing and hospital environmental control 1985 Infect Control 1986 7 23 1 43 Selected Definitions Alcohol based hand rub An alcohol containing preparation designed for reducing the number of viable microorganisms on the hands Antimicrobial soap A detergent containing an antiseptic agent 86 Antiseptic A germicide used on skin or living tissue for the purpose of inhibiting or destroying microorganisms e g alcohols chlorhexidine chlorine hexachlorophene iodine chloroxylenol PCMX quaternary ammonium compounds and triclosan Bead sterilizer A device using glass beads 1 2 1 5 mm diameter and temperatures 217 C 232 C for brief exposures e g 45 seconds to inactivate microorganisms This term is actually a misnomer because it has not been cleared by the Food and Drug Administration FDA as a sterilizer Bioburden Microbiological load i e number of viable organisms in or on an object or surface or organic material on a surface or object before decontamination or sterilization Also known as bioload or microbial load Colony forming unit CFU The
337. treatment and monitoring products require strict adherence to maintenance protocols and noncompliance with treatment regimens has been associated with persistence of microbial contamination in treated systems 345 Clinical monitoring of water quality can ensure that procedures are correctly performed and that devices are working in accordance with the manufacturer s previously validated protocol Dentists should consult with the manufacturer of their dental unit or water delivery system to determine the best method for maintaining acceptable water quality i e lt 500 CFU mL and the recommended frequency of monitoring Monitoring of dental water quality can be performed by using commercial self contained test kits or commercial water testing laboratories Because methods used to treat dental water systems target the entire biofilm no rationale exists for routine testing for such specific organisms as Legionella or Pseudomonas except when investigating a suspected waterborne disease outbreak 244 Delivery of Sterile Surgical Irrigation Sterile solutions e g sterile saline or sterile water should be used as a coolant irrigation in the performance of oral surgical procedures where a greater opportunity exists for entry of microorganisms exogenous and endogenous into the vascular system and other normally sterile areas that support the oral cavity e g bone or subcutaneous tissue and increased potential exists for localized or systemi
338. which liquid chemical germicides are evaluated and regulated is included Appendix A Three levels of disinfection high intermediate and low are used for patient care devices that do not require sterility and two levels intermediate and low for environmental surfaces 242 The intended use of the patient care item should determine the recommended level of disinfection Dental practices should follow the product manufacturer s directions regarding concentrations and exposure time for disinfectant activity relative to the surface to be disinfected 245 A summary of sterilization and disinfection methods is included Appendix C Transporting and Processing Contaminated Critical and Semicritical Patient Care Items DHCP can be exposed to microorganisms on contaminated instruments and devices through percutaneous injury contact with nonintact skin on the hands or contact with mucous membranes of the eyes nose or mouth Contaminated instruments should be handled carefully to prevent exposure to sharp instruments that can cause a percutaneous injury Instruments should be placed in an appropriate container at the point of use to prevent percutaneous injuries during transport to the instrument processing area 13 Instrument processing requires multiple steps to achieve sterilization or high level disinfection Sterilization is a complex process requiring specialized equipment adequate space qualified DHCP who are provided with ongoing tr
339. 0 Chiarello LA Bartley J Prevention of blood exposure in healthcare personnel Seminars in Infection Control 2001 1 30 43 US Department of Labor Occupational Safety and Health Administration 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogens needlesticks and other sharps injuries final rule Federal Register 2001 66 5317 25 As amended from and includes 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogens final rule Federal Register 1991 356 64174 82 Available at http www osha gov SLTC dentistry index html US Department of Labor Occupational Safety and Health Administration OSHA instruction enforcement procedures for the occupational exposure to bloodborne pathogens Washington DC US Department of Labor Occupational Safety and Health Administration 2001 directive no CPL 2 2 69 US Department of Labor Occupational Safety and Health Administration 29 CFR 1910 1200 Hazard communication Federal Register 1994 59 17479 Gershon RR Karkashian CD Grosch JW et al Hospital safety climate and its relationship with safe work practices and workplace exposure incidents Am J Infect Control 2000 28 211 21 CDC Immunization of health care workers recommendations of the Advisory Committee on Immunization Practices ACIP and the Hospital Infection Control Practices Advisory Committee 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
340. 0 Mast EE Alter MJ Prevention of hepatitis B virus infection among health care workers In Ellis RW ed Hepatitis B vaccines in clinical practice New York NY Marcel Dekker 1993 295 307 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 6l 62 63 64 Beltrami EM Williams IT Shapiro CN Chamberland ME Risk and management of blood borne infections in health care workers Clin Microbiol Rev 2000 13 385 407 Werner BG Grady GF Accidental hepatitis B surface antigen positive inoculations use of e antigen to estimate infectivity Ann Intern Med 1982 97 367 9 Bond WW Petersen NJ Favero MS Viral hepatitis B aspects of environmental control Health Lab Sci 1977 14 235 52 Garibaldi RA Hatch FE Bisno AL Hatch MH Gregg MB Nonparenteral serum hepatitis report of an outbreak JAMA 1972 220 963 6 Rosenberg JL Jones DP Lipitz LR Kirsner JB Viral hepatitis an occupational hazard to surgeons JAMA 1973 223 395 400 Callender ME White YS Williams R Hepatitis B virus infection in medical and health care personnel Br Med J 1982 284 324 6 Chaudhuri AK Follett EA Hepatitis B virus infection in medical and health care personnel Letter Br Med J 1982 284 1408 Bond WW Favero MS Petersen NJ Gravelle CR Ebert JW Maynard JE Survival of hepatitis B virus after drying and storage for one week Lette
341. 0 1 chemregindex htm FDA http www fda gov Immunization Action Coalition http www immunize org acip Infectious Diseases Society of America http www idsociety org PG toc htm OSHA Dentistry Bloodborne Pathogens http www osha gov SLTC dentistry index html http www osha gov SLTC bloodbornepathogens index html Organization for Safety and Asepsis Procedures http www osap org Society for Healthcare Epidemiology of America Inc Position Papers http www shea online org PositionPapers html Acknowledgement The Division of Oral Health thanks the working group as well as CDC and other federal and external reviewers for their efforts in developing and reviewing drafts of this report and acknowledges that all opinions of the reviewers might not be reflected in all of the recommendations 115 Guidelines for Infection Control in Dental Health Care Settings 2008 Appendix A Regulatory Framework for Disinfectants and Sterilants When using the guidance provided in this report regarding use of liquid chemical disinfectants and sterilants dental health care personnel DHCP should be aware of federal laws and regulations that govern the sale distribution and use of these products In particular DHCPs should know what requirements pertain to them when such products are used Finally DHCP should understand the relative roles of the U S Environmental Protection Agency EPA the U S Food and Drug Administration FDA the
342. 0 381 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 380 381 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 380 381 Use fluid infusion and administration sets i e IV bags tubings and connections for one patient only and dispose of appropriately IB 378 D Single Use Disposable Devices if Use single use devices for one patient only and dispose of them appropriately IC 383 E Preprocedural Mouth Rinses 1 No recommendation is offered regarding use of preproce dural antimicrobial mouth rinses to prevent clinical infections among DHCP or patients Although studies have demonstrated that a preprocedural antimicrobial rinse e g chlorhexidine gluconate essential oils or povidone iodine can reduce the level of oral microorganisms in aerosols and spatter generated during routine dental procedures and can decrease the number of microorganisms introduced in the patient s bloodstream during invasive dental procedures 391 399 the scientific evidence is inconclusive that using these rinses prevents clinical infections among DHCP or patients see discussion Preprocedural Mo
343. 04 6 Clark A Bacterial colonization of dental units and the nasal flora of dental personnel Proc Roy Soc Med 1974 67 1269 70 Fotos PG Westfall HN Snyder IS Miller RW Mutchler BM Prevalence of Legionella specific IgG and IgM antibody in a dental clinic population J Dent Res 198S 64 1382 5 Reinthaler FF Mascher F Stunzner D Serological examinations 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 for antibodies against Legionella species in dental personnel J Dent Res 1988 67 942 3 Putnins EE Di Giovanni D Bhullar AS Dental unit waterline contamination and its possible implications during periodontal surgery J Periodontol 2001 72 393 400 United States Pharmacopeial Convention Sterile water for irrigation In United States Pharmacopeial Convention United States pharmacopeia and national formulary USP 24 NF 19 Rockville MD United States Pharmacopeial Convention 1997 1753 Milton DK Wypij D Kriebel D Walters MD Hammond SK Evans JS Endotoxin exposure response in a fiberglass manufacturing facility Am J Ind Med 1996 29 3 13 Santiago JI Microbial contamination of dental unit waterlines short and long term effects of flushing Gen Dent 1994 42 528 35 Shearer BG Biofilm and the dental office J Am Dent Assoc 1996 127 181 9 Association for the Advancement of Medical Instrum
344. 1993 6 Dewar NE Gravens DL Effectiveness of septisol antiseptic foam as a surgical scrub agent Appl Microbiol 1973 26 344 9 Lowbury EJ Lilly HA Disinfection of the hands of surgeons and nurses Br Med J 1960 1445 50 Rotter M Hand washing and hand disinfection In Mayhall CG ed Hospital epidemiology and infection control 2nd ed Philadelphia PA Lippincott Williams amp Wilkins 1999 1339 55 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 Widmer AF Replace hand washing with use of a waterless alcohol hand rub Clin Infect Dis 2000 31 136 43 Larson EL Butz AM Gullette DL Laughon BA Alcohol for surgical scrubbing Infect Control Hosp Epidemiol 1990 11 139 43 Faoagali J Fong J George N Mahoney P O Rouke V Comparison of the immediate residual and cumulative antibacterial effects of Novaderm R Novascrub R Betadine Surgical Scrub Hibiclens and liquid soap Am J Infect Control 1995 23 337 43 Association of Perioperative Registered Nurses Recommended practices for sterilization in the practice setting In Fogg D Parker N Shevlin D eds 2002 standards recommended practices and guidelines Denver CO AORN 2002 333 42 US Department Of Health and Human Services Food and Drug Administration Tentative final monograph for healthcare antiseptic drug p
345. 3 BANS 9 120 123 140 141 60 95 19 396 123 144 745 122 123 137 2
346. 3 dose vaccine series or be evaluated to determine if they are HBsAg positive 17 Revaccinated persons should be retested for anti HBs at the completion of the second vaccine series Approximately half of nonresponders to the primary series will respond to a second 3 dose series If no antibody response occurs after the second series testing for HBsAg should be performed 7 Persons who prove to be HBsAg positive should be counseled regarding how to prevent HBV transmission to others and regarding the need for medical evaluation Nonresponders to vaccination who are HBsAg negative should be considered susceptible to HBV infection and should be counseled regarding precautions to prevent HBV infection and the need to obtain HBIG prophylaxis for any known or probable parenteral exposure to HBsAg positive blood Vaccine induced antibodies decline gradually over time and 60 of persons who initially respond to vaccination will lose detectable antibodies over 12 years Even so immunity continues to prevent clinical disease or detectable viral infection 17 Booster doses of 89 Guidelines for Infection Control in Dental Health Care Settings 2008 TABLE 1 Suggested work restrictions for health care personnel infected with or exposed to major infectious diseases in health care settings in the absence of state and local regulations Disease problem Conjunctivitis Cytomegalovirus infection Diarrheal disease Acute stage diarrhea w
347. 312 51 000 EU mL 335 United States Pharmacopeia USP 0 25 EU mL 336 329 337 5 200 000 CFU mL 305 106CFU mL 309 338
348. 8 9 547 24 11 24 32 43 B 14 C 15 D 15 TAA a B09 RE RI VI gt Gow Gie EGO 76 9 81 4Wv9 FloM se TEIA FIGTEDL TI FAS SRO Wy OT ama EGO BESFCRO MASTLIGCMORBAT ERR EGO 500mL 42070 ANEFCRO LOGE tananan 5 5 EGO 9 9 5 EGO 1 on uN On Ma F 420 OPED MRE GOGA TCE EMEL TRE COS ee ma ese Orie BIM WW BAA 1 3 sanaa 889 782 614 AER an EGO 500mL MF 2000 ew eu 9 IOOmL 0m pner i n 1 0707 2520 ore e000 manar
349. 93 75 29 1 2 Watts D Tassler PL Dellon AL The effect of double gloving on cutaneous sensibility skin compliance and suture identification Contemp Surg 1994 44 289 92 Wilson SJ Sellu D Uy A Jaffer MA Subjective effects of double gloves on surgical performance Ann R Coll Surg Engl 1996 78 20 2 Food and Drug Administration Guidance for industry and FDA medical glove guidance manual Draft guidance Rockville MD US Department of Health and Human Services Food and Drug 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 Administration 1999 Available at http www fda gov cdrh dsma 135 html _Toc458914315 Dillard SF Hefflin B Kaczmarek RG Petsonk EL Gross TP Health effects associated with medical glove use AORN J 2002 76 88 96 Hamann CP Turjanmaa K Rietschel R et al Natural rubber latex hypersensitivity incidence and prevalence of type I allergy in the dental professional J Am Dent Assoc 1998 129 43 54 Siew C Hamann C Gruninger SE Rodgers P Sullivan KM 2003 Type I Latex Allergic Reactions among Dental Professionals 1996 2001 Journal of Dental Research 82 Special Issue 1718 Saary MJ Kanani A Alghadeer H Holness DL Tarlo SM Changes in rates of natural rubber latex sensitivity among dental school students and staff members after changes in latex gloves J Al
350. 96 10 107 38 Litsky BY Mascis JD Litsky W Use of an antimicrobial mouthwash to minimize the bacterial aerosol contamination generated by the high speed drill Oral Surg Oral Med Oral Pathol 1970 29 25 30 Mohammed CI Monserrate V Preoperative oral rinsing as a means of reducing air contamination during use of air turbine handpieces Oral Surg Oral Med Oral Pathol 1970 29 29 1 4 Wyler D Miller RL Micik RE Efficacy of self administered preoperative oral hygiene procedures in reducing the concentration of bacteria in aerosols generated during dental procedures J Dent Res 1971 50 509 Muir KF Ross PW MacPhee IT Holbrook WP Kowolik MJ Reduction of microbial contamination from ultrasonic scalers Br Dent J 1978 145 76 8 Fine DH Mendieta C Barnett ML et al Efficacy of preprocedural rinsing with an antiseptic in reducing viable bacteria in dental aerosols J Periodontol 1992 63 821 4 Fine DH Furgang D Korik I Olshan A Barnett ML Vincent JW Reduction of viable bacteria in dental aerosols by preprocedural rinsing with an antiseptic mouthrinse Am J Dent 1993 6 219 21 Fine DH Yip J Furgang D Barnett ML Olshan AM Vincent J Reducing bacteria in dental aerosols pre procedural use of an antiseptic mouth rinse J Am Dent Assoc 1993 124 56 8 Logothetis DD Martinez Welles JM Reducing bacterial aerosol contamination with a chlorhexidine gluconate pre rinse J Am Dent Assoc 1995 126 1634 9 Klyn SL Cummings DE Richardso
351. Association Chicago Illinois 2003 6 HBV 53 55 53 56 57 1970 1987 HBV HBV 9 58 67 HBV 1987 1 2 3 B 4 1991 OSHA 68 5
352. B EPA FDA 4A 7 A 3 EPA FDA X Antimicrobials Division Office of Pesticide Programs EPA HAX KAANAA FIFRA 1947 1996 E A 4 FIFRA
353. DG Hassemer CA Flash sterilization carefully measured haste Infect Control 1987 8 307 10 Andres MT Tejerina JM Fierro JF Reliability of biologic indicators in a mail return sterilization monitoring service a review of 3 years Quintessence Int 1995 26 865 70 Miller CH Sheldrake MA The ability of biological indicators to detect sterilization failures Am J Dent 1994 7 95 7 Association of Operating Room Nurses AORN standards and recommended practices for perioperative nursing Denver CO AORN 1987 Mayworm D Sterile shelf life and expiration dating J Hosp Supply Process Distrib 1984 2 32 5 Cardo DM Sehulster LM Central sterile supply Chapter 65 In Mayhall CG ed Hospital Epidemiology and Infection Control 2nd ed Philadelphia PA Lippincott Williams amp Wilkins 1999 1023 30 Maki DG Alvarado CJ Hassemer CA Zilz MA Relation of the inanimate hospital environment to endemic nosocomial infection N Engl J Med 1982 307 1562 6 Danforth D Nicolle LE Hume K Alfieri N Sims H Nosocomial infections on nursing units with floors cleaned with a disinfectant compared with detergent J Hosp Infect 1987 10 229 35 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 Crawford JJ Clinical asepsis in dentistry Mesquite TX Oral Medicine Press 1987 Food and Drug Administration Design
354. J O Brien K Cross J Steinmetz C Latex allergy in hospital employees Ann Allergy 1994 72 245 9 Zaza S Reeder JM Charles LE Jarvis WR Latex sensitivity among perioperative nurses AORN J 1994 60 806 12 Hunt LW Fransway AF Reed CE et al An epidemic of occupational allergy to latex involving health care workers J Occup Environ Med 1995 37 1204 9 American Dental Association Council on Scientific Affairs The dental team and latex hypersensitivity J Am Dent Assoc 1999 130 257 64 CDC National Institute for Occupational Safety and Health NIOSH Alert preventing allergic reactions to natural rubber latex in the workplace Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1997 Terezhalmy GT Molinari JA Personal protective equipment and barrier techniques In Cottone JA Terezhalmy GT Molinari JA eds Practical infection control in dentisty 2nd ed Baltimore MD Williams amp Wilkins 1996 136 145 US Department of Health and Human Services Office of the Secretary Office for Civil Rights 45 CFR Parts 160 and 164 Standards for privacy of individually identifiable health information final rule Federal Register 2000 65 82462 829 Occupational Safety and Health Administration Access to medical and exposure records Washington DC US Department of Labor Occupational Safety and Health Administration 2001 OSHA publication no 311
355. N might be practical 436 These practices include using 1 standard precautions e g high filtration surgical masks and possibly full face shields 437 2 central room suction units with in line filters to collect particulate matter from minimal plumes and 3 dedicated mechanical smoke exhaust systems with a high efficiency filter to remove substantial amounts of laser plume particles Local smoke evacuation systems have been recommended by consensus organizations and these systems can improve the quality of the operating field Employers should be aware of this emerging problem and advise employees of the potential hazards of laser smoke 438 However this concern remains unresolved in dental practice and no recommendation is provided here M tuberculosis Patients infected with M tuberculosis occasionally seek urgent dental treatment at outpatient dental settings Understanding the pathogenesis of the development of TB will help DHCP determine how to manage such patients M tuberculosis is a bacterium carried in airborne infective droplet nuclei that can be generated when persons with pulmonary or laryngeal TB sneeze cough speak or sing 439 These small particles 1 5 um can stay suspended in the air for hours 440 Infection occurs when a susceptible person inhales droplet nuclei containing M tuberculosis which then travel to the alveoli of the lungs Usually within 2 12 weeks after initial infection with M tuberculosis
356. Occupational Safety and Health Administration OSHA and CDC The choice of specific cleaning or disinfecting agents is largely a matter of judgment guided by product label claims and instructions and government regulations A single liquid chemical germicide might not satisfy all disinfection requirements in a given dental practice or facility Realistic use of liquid chemical germicides depends on consideration of multiple factors including the degree of microbial killing required the nature and composition of the surface item or device to be treated and the cost safety and ease of use of the available agents Selecting one appropriate product with a higher degree of potency to cover all situations might be more convenient In the United States liquid chemical germicides disinfectants are regulated by EPA and FDA 4 7 4 3 In healthcare settings EPA regulates disinfectants that are used on environmental surfaces housekeeping and clinical contact surfaces and FDA regulates liquid chemical sterilants high level disinfectants e g glutaraldehyde hydrogen peroxide and peracetic acid used on critical and semicritical patientcare devices Disinfectants intended for use on clinical contact surfaces e g light handles radiographic ray heads or drawer knobs or housekeeping surfaces e g floors walls or sinks are regulated in interstate commerce by the Antimicrobials Division Office of Pesticide Programs EPA under the authority
357. P influenza vaccine LAIV 88 5 49 FDA LAIV mg C C Immunizations Strongly Recommended for Health Care Personnel HCP ABM
358. PIM and requiring implementation of a written exposure control plan annual employee training HBV vaccinations and postexposure follow up 3 Interpretations and enforcement procedures are available to help DHCP apply this OSHA standard in practice 14 Also manufacturer s Material Safety Data Sheets MSDS should be consulted regarding correct procedures for handling or working with hazardous chemicals 5 Previous Recommendations This report includes relevant infection control measures from the following previously published CDC guidelines and recommendations e CDC Guideline for disinfection and sterilization in health care facilities recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR in press e CDC Guidelines for environmental infection control in health care facilities recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR 2003 52 No RR 10 e CDC Guidelines for the prevention of intravascular catheter related infections MMWR 2002 51 No RR 10 e CDC Guideline for hand hygiene in health care settings recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC SHEA APIC IDSA Hand Hygiene Task Force MMWR 2002 51 No RR 16 e CDC Updated U S Public Health Service guidelines for the management of occupational exposures to HBV HCV and HIV and recommendations for postexposure
359. Passaro DJ Waring L Armstrong R et al Postoperative Serratia marcescens wound infections traced to an out of hospital source J Infect Dis 1997 175 992 S Foca M Jakob K Whittier S et al Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit N Engl J Med 2000 343 693 700 Parry MF Grant B Yukna M et al Candida osteomyelitis and diskitis after spinal surgery an outbreak that implicates artificial nail use Clin Infect Dis 2001 32 352 7 Moolenaar RL Crutcher M San Joaquin VH et al A prolonged outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit did staff fingernails play a role in disease transmission Infect Control Hosp Epidemiol 2000 21 80 S Baumgardner CA Maragos CS Walz J Larson E Effects of nail polish on microbial growth of fingernails dispelling sacred cows AORN J 1993 58 84 8 Wynd CA Samstag DE Lapp AM Bacterial carriage on the fingernails of OR nurses AORN J 1994 60 796 799 805 Lowbury EJ Aseptic methods in the operating suite Lancet 1968 1 705 9 Hoffman PN Cooke EM McCarville MR Emmerson AM Micro organisms isolated from skin under wedding rings worn by hospital staff Br Med J 1985 290 206 7 Jacobson G Thiele JE McCune JH Farrell LD Handwashing ring wearing and number of microorganisms Nurs Res 1985 34 186 8 Trick WE Vernon MO Hayes RA et al Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital Cli
360. V LAIV MSDS NIOSH OPIM OSHA PEP PHS PPE TB TSE Advisory Committee on Immunization Practice American Dental Association Association of Official Analytical Chemists Association of periOperative Registered Nurses American Public Health Association Association for Professional in Infection Control and Epidemiology INC American Water Works Association Centers for Disease Control and Prevention colony forming unit Creutzfeld Jakob disease cytomegalovirus dental health care personnel Environmental Protection Agency ethylene oxide Food and Drug Administration Federal Insecticide Fungicide and Rodenticide Act B e hepatitis B virus e antigen B hepatitis B immune globulin B hepatitis B virus surface antigen B
361. a gov cdrh ode germlab html t Contact time is the single critical variable distinguishing the sterilization process from high level disinfection with FDA cleared liquid chemical sterilants FDA defines a high level disinfectant as a sterilant used under the same contact conditions as sterilization except for a shorter immersion time C 1 The tuberculocidal claim is used as a benchmark to measure germicidal potency Tuberculosis TB is transmitted via the airborne route rather than by environmental surfaces and accordingly use of such products on environmental surfaces plays no role in preventing the spread of TB Because mycobacteria have among the highest intrinsic levels of resistance among vegetative bacteria viruses and fungi any germicide with a tuberculocidal claim on the label i e an intermediate level disinfectant is considered capable of inactivating a broad spectrum of pathogens including much less resistant organisms including bloodborne pathogens e g HBV hepatitis C virus HCV and HIV It is this broad spectrum capability rather than the product s specific potency against mycobacteria that is the basis for protocols and regulations dictating use of tuberculocidal chemicals for surface disinfection T Chlorine based products that are EPA registered as intermediate level disinfectants are available commercially In the absence of an EPA registered chlorine based product a fresh solution of sodium hypochlorite e g househo
362. actice infection control program The objectives are to educate DHCP regarding the principles of infection control identify work related infection risks institute preventive measures and ensure prompt exposure management and medical follow up Coordination between the dental practice s infection control coordinator and other qualified health care professionals is necessary to provide DHCP with appropriate services Dental programs in institutional settings e g hospitals health centers and educational institutions can coordinate with departments that provide personnel health services However the majority of dental practices are in ambulatory private settings that do not have licensed medical staff and facilities to provide complete on site health service programs In such settings the infection control coordinator should establish programs that arrange for site specific infection control services from external health care facilities and providers before DHCP are placed at risk for exposure Referral arrangements can be made with qualified health care professionals in an occupational health program of a hospital with educational institutions or with health care facilities that offer personnel health services 87 Guidelines for Infection Control in Dental Health Care Settings 2008 Education and Training Personnel are more likely to comply with an infection control program and exposure control plan if they understand its rationa
363. actices routinely used by health care practitioners cannot be rigorously examined for ethical or logistical reasons In the absence of scientific evidence for such practices certain recommendations are based on strong theoretical rationale suggestive evidence or opinions of respected authorities based on clinical experience descriptive studies or committee reports In addition some recommendations are derived from federal regulations No recommendations are offered for practices for which insufficient scientific evidence or lack of consensus supporting their effectiveness exists Background In the United States an estimated 9 million persons work in health care professions including approximately 168 000 dentists 112 000 registered dental hygienists 218 000 dental assistants 3 and 53 000 dental laboratory technicians 4 In this report dental health care personnel DHCP refers to all paid and unpaid personnel in the dental health care setting who might be occupationally exposed to infectious materials including body substances and contaminated supplies equipment environmental surfaces water or air DHCP include dentists dental hygienists dental assistants dental laboratory technicians in office and commercial students and trainees contractual personnel and other persons not directly involved in patient care but potentially exposed to infectious agents e g administrative clerical housekeeping maintenance or volunt
364. ainer If the outside of the container becomes visibly contaminated it should be cleaned and disinfected or placed in an impervious bag 2 3 The container must be labeled with the biohazard symbol during storage transport shipment and disposal 13 14 105 Guidelines for Infection Control in Dental Health Care Settings 2008 Handling of Extracted Teeth Disposal Extracted teeth that are being discarded are subject to the containerization and labeling provisions outlined by OSHA s bloodborne pathogens standard 3 OSHA considers extracted teeth to be potentially infectious material that should be disposed in medical waste containers Extracted teeth sent to a dental laboratory for shade or size comparisons should be cleaned surface disinfected with an EPA registered hospital disinfectant with intermediate level activity i e tuberculocidal claim and transported in a manner consistent with OSHA regulations However extracted teeth can be returned to patients on request at which time provisions of the standard no longer apply 14 Extracted teeth containing dental amalgam should not be placed in a medical waste container that uses incineration for final disposal Commercial metal recycling companies also might accept extracted teeth with metal restorations including amalgam State and local regulations should be consulted regarding disposal of the amalgam Educational Settings Extracted teeth are occasionally collected f
365. aining and regular monitoring for quality assurance 247 Correct cleaning packaging sterilizer loading procedures sterilization methods or high level disinfection methods should be followed to ensure that an instrument is adequately processed and safe for reuse on patients Instrument Processing Area DHCP should process all instruments in a designated central processing area to more easily control quality and ensure safety 248 The central processing area should be divided into sections for 1 receiving cleaning and decontamination 2 preparation and packaging 3 sterilization and 4 storage Ideally walls or partitions should separate the sections to control traffic flow and contain contaminants generated during processing When physical separation of these sections cannot be achieved adequate spatial separation might be satisfactory if the DHCP who process instruments are trained in work practices to prevent contamination of clean areas 248 Space should be adequate for the volume of work anticipated and the items to be stored 248 Receiving Cleaning and Decontamination Reusable instruments supplies and equipment should be received sorted cleaned and decontaminated in one section of the processing area Cleaning should precede all disinfection and sterilization processes it should involve removal of debris as well as organic and inorganic contamination Removal of debris and contamination is achieved either by scrubb
366. al Investigation of patients of health care workers infected with HIV the Centers for Disease Control and Prevention database Ann Intern Med 1995 122 653 7 CDC Investigations of persons treated by HIV infected health care workers United States MMWR 1993 42 329 331 337 Siew C Chang SB Gruninger SE Verrusio AC Neidle EA Self reported percutaneous injuries in dentists implications for HBV HIV transmission risk J Am Dent Assoc 1992 123 36 44 Ahtone J Goodman RA Hepatitis B and dental personnel transmission to patients and prevention issues J Am Dent Assoc 1983 106 219 22 Hadler SC Sorley DL Acree KH et al An outbreak of hepatitis B ina dental practice Ann Intern Med 1981 95 133 8 CDC Epidemiologic notes and reports hepatitis B among dental patients Indiana MMWR 1985 34 73 S Levin ML Maddrey WC Wands JR Mendeloff AL Hepatitis B transmission by dentists JAMA 1974 228 1139 40 Rimland D Parkin WE Miller GB Jr Schrack WD Hepatitis B outbreak traced to an oral surgeon N Engl J Med 1977 296 953 8 Goodwin D Fannin SL McCracken BB An oral surgeon related hepatitis B outbreak California Morbidity 1976 14 1 Reingold AL Kane MA Murphy BL Checko P Francis DP Maynard JE Transmission of hepatitis B by an oral surgeon J Infect Dis 1982 145 262 8 65 66 67 68 69 70 TA 72 73 74 75 76 TI 78 79 80 81 82 83 84 85 86
367. al and maxillofacial surgeons Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998 8S 128 34 Gooch BF Cardo DM Marcus R et al Percutaneous exposures to HIV infected blood among dental workers enrolled in the CDC needlestick study J Am Dent Assoc 1995 126 1237 42 Younai FS Murphy DC Kotelchuck D Occupational exposures to blood in a dental teaching environment results of a ten year surveillance study J Dent Educ 2001 65 436 8 Carlton JE Dodson TB Cleveland JL Lockwood SA Percutaneous injuries during oral and maxillofacial surgery procedures J Oral Maxillofac Surg 1997 55 553 6 Harte J Davis R Plamondon T Richardson B The influence of dental unit design on percutaneous injury J Am Dent Assoc 1998 129 1725 31 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 US Department of Labor Occupational Health and Safety Administration 29 CFR Part 1910 Occupational exposure to bloodborne pathogens needlesticks and other sharps injuries final rule Federal Register 2001 66 5325 CDC Evaluation of safety devices for preventing percutaneous injuries among health care workers during phlebotomy procedures Minneapolis St Paul New York City and San Francisco 1993 1995 MMWR 1997 46 21 5 CDC Evaluation of blunt suture needles in preventing percutaneous injuries among health care workers during gynec
368. al disinfectant Germicide registered by EPA for use on inanimate objects in hospitals clinics dental offices and other medical related facilities Efficacy is demonstrated against Salmonella choleraesuis Staphylococcus aureus and Pseudomonas aeruginosa Iatrogenic Induced inadvertently by HCP medical including dental treatment or diagnostic procedures Used particularly in reference to an infectious disease or other complication of treatment Immunization Process by which a person becomes immune or protected against a disease Vaccination is defined as the process of administering a killed or weakened infectious organism or a toxoid however vaccination does not always result in immunity Implantable device Device placed into a surgically or naturally formed cavity of the human body and intended to remain there for gt 30 days Independent water reservoir Container used to hold water or other solutions and supply it to handpieces and air and water syringes attached to a dental unit The independent reservoir which isolates the unit from the public water system can be provided as original equipment or as a retrofitted device Intermediate level disinfection Disinfection process that inactivates vegetative bacteria the majority of fungi mycobacteria and the majority of viruses particularly enveloped viruses but not bacterial spores Intermediate level disinfectant Liquid chemical germicide registered with EPA as a hospital
369. am should embody principles of infection control and occupational health reflect current science and adhere to relevant federal state and local regulations and statutes An infection control coordinator e g dentist or other DHCP knowledgeable or willing to be trained should be assigned responsibility for coordinating the program The effectiveness of the infection control program should be evaluated on a day to day basis and over time to help ensure that policies procedures and practices are useful efficient and successful see Program Evaluation Although the infection control coordinator remains responsible for overall management of the program creating and maintaining a safe work environment ultimately requires the commitment and accountability of all DHCP This report is designed to provide guidance to DHCP for preventing disease transmission in dental health care settings for promoting a safe working environment and for assisting dental practices in developing and implementing infection control programs These programs should be followed in addition to practices and procedures for worker protection required by the Occupational Safety and Health Administration s OSHA standards for occupational 85 Guidelines for Infection Control in Dental Health Care Settings 2008 exposure to bloodborne pathogens 3 including instituting controls to protect employees from exposure to blood or other potentially infectious materials O
370. an Services Public Health Service CDC 2003 Available at http www cdc gov ncidod diseases cjd 81 C DC 003 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 82 cjd_fact_sheet htm Will RG Ironside JW Zeidler M et al A new variant of Creutzfeldt Jakob disease in the UK Lancet 1996 347 921 5 Bruce ME Will RG Ironside JW et al Transmission to mice indicate that new variant CJD is caused by the BSE agent Nature 1997 389 498 501 Collinge J Sidle KC Meads J Ironside J Hill AF Molecular analysis of prion strain variation and the aetiology of new variant CJD Nature 1996 383 685 90 World Health Organization Bovine spongiform encephalopathy BSE Fact Sheet No 113 Geneva Switzerland World Health Organization 2002 Available at http www who int mediacentre factsheets fs 1 13 en CDC Probable variant Creutzfeldt Jakob disease in a U S resident Florida 2002 MMWR 2002 51 927 9 Hill AF Butterworth RJ Joiner S et al Investigation of variant Creutzfeldt Jakob disease and other human prion diseases with tonsil biopsy specimens Lancet 1999 353 183 9 Brown P Gibbs CJ Jr Rodgers Johnson P et al Human spongiform encephalopathy the National Institutes of Health series of 300 c
371. ant or a tuberculocidal claim i e intermediate level disinfectant Intermediate level disinfectant should be used when the surface is visibly contaminated with blood or OPIM 2 244 Also general cleaning and disinfection are recommended for clinical contact surfaces dental unit surfaces and countertops at the end of daily work activities and are required if surfaces have become contaminated since their last cleaning 13 To facilitate daily cleaning treatment areas should be kept free of unnecessary equipment and supplies Manufacturers of dental devices and equipment should provide information regarding material compatibility with liquid chemical germicides whether equipment can be safely immersed for cleaning and how it should be decontaminated if servicing is required 289 Because of the risks associated with exposure to chemical disinfectants and contaminated surfaces DHCP who perform environmental cleaning and disinfection should wear gloves and other PPE to prevent occupational exposure to infectious agents and hazardous chemicals Chemical and puncture resistant utility gloves offer more protection than patient examination gloves when using hazardous chemicals Housekeeping Surfaces Evidence does not support that housekeeping surfaces e g floors walls and sinks pose a risk for disease transmission in dental health care settings Actual physical removal of microorganisms and soil by wiping or scrubbing is probably as c
372. are less likely than patient examination gloves to harbor pathogens that could contaminate an operative wound 88 Appropriate gloves in the correct size should be readily accessible 3 Glove Integrity Limited studies of the penetrability of different glove materials under conditions of use have been conducted in the dental environment Consistent with observations in clinical medicine leakage rates vary by glove material e g latex vinyl and nitrile duration of use and type of procedure performed 82 184 186 189 191 as well as by manufacturer 192 194 The frequency of perforations in surgeon s gloves used during outpatient oral surgical procedures has been determined to range from 6 to 16 181 185 195 196 Studies have demonstrated that HCP and DHCP are frequently unaware of minute tears in gloves that occur during use 186 190 191 197 These studies determined that gloves developed defects in 30 minutes 3 hours depending on type of glove and procedure Investigators did not determine an optimal time for changing gloves during procedures During dental procedures patient examination and surgeon s gloves commonly contact multiple types of chemicals and materials e g 96 disinfectants and antiseptics composite resins and bonding agents that can compromise the integrity of latex as well as vinyl nitrile and other synthetic glove materials 198 206 In addition latex gloves can interfere with the setting of
373. ases of experimentally transmitted disease Ann Neurol 1994 35 513 29 Brown P Environmental causes of human spongiform encephalopathy Chapter 8 In Baker HF Baker HF eds Prion diseases Totowa NJ Humana Press Inc 1996 139 54 Carp RI Transmission of scrapie by oral route effect of gingival scarification Lancet 1982 1 170 1 Ingrosso L Pisani F Pocchiari M Transmission of the 263K scrapie strain by the dental route J Gen Virol 1999 80 3043 7 Bernoulli C Siegfried J Baumgartner G et al Danger of accidental person to person transmission of Creutzfeldt Jakob disease by surgery Lancet 1977 1 478 9 Brown P Gajdusek DC Gibbs CJ Jr Asher DM Potential epidemic of Creutzfeldt Jakob disease from human growth hormone therapy N Engl J Med 1985 313 728 31 CDC Fatal degenerative neurologic disease in patients who received pituitary derived human growth hormone MMWR 1985 34 359 60 365 6 Duffy P Wolf J Collins G DeVoe AG Streeten B Cowen D Possible person to person transmission of Creutzfeldt Jakob disease N Engl J Med 1974 290 692 3 CDC Epidemiologic notes and reports rapidly progressive dementia in a patient who received a cadaveric dura mater graft MMWR 1987 36 49 50 55 Thadani V Penar PL Partington J et al Creutzfeldt Jakob disease probably acquired from a cadaveric dura mater graft Case report J Neurosurg 1988 69 766 9 Kondo K Kuroiwa Y A case control study of Creutzfeldt Jakob disease associat
374. ashing and hand antisepsis is achieved by using either a plain or antimicrobial soap and water If the hands are not visibly soiled an alcohol based hand rub is adequate The purpose of surgical hand antisepsis is to eliminate transient flora 93 Guidelines for Infection Control in Dental Health Care Settings 2008 TABLE 2 Hand hygiene methods and indications Method Agent Purpose Routine handwash Water and nonantimicrobial soap e g plain soap Antiseptic handwash Water and antimicrobial soap e g chloroxylenol PCMX triclosan Antiseptic hand rub Alcohol based hand rub Surgical antisepsis Water and antimicrobial soap e g chloroxylenol PCMX triclosan Water and non antimicrobial soap e g plain soap followed by an alcohol based surgical hand scrub product with persistent activity 7 9 11 13 113 120 123 125 126 136 138 Remove soil and transient 15 seconds microorganisms Remove or destroy chlorhexidine iodine and iodophors transient microorganisms and reduce resident flora Remove or destroy transient microorganisms agent is dry and reduce resident flora Remove or destroy chlorhexidine iodine and iodophors transient microorganisms and reduce resident flora Follow manufacturer persistent effect Duration minimum Indication Before and after treating each patient e g before glove placement and after glove removal After barehanded touching of inanimate objects
375. atient care items can be difficult or damage the surfaces therefore use of disposable barrier protection of these surfaces might be a preferred alternative FDA cleared sterilant high level disinfectants and EPA registered 97 Guidelines for Infection Control in Dental Health Care Settings 2008 TABLE 4 Infection control categories of patient care instruments Category Definition Critical Penetrates soft tissue contacts bone enters into or contacts the blood stream or other normally sterile tissue Semicritical Contacts mucous membranes or nonintact skin will not penetrate soft tissue contact bone enter into or contact the bloodstream or other normally sterile tissue Noncritical Contacts intact skin Dental instrument or item Surgical instruments periodontal scalers scalpel blades surgical dental burs Dental mouth mirror amalgam condenser reusable dental impression trays dental handpieces Radiograph head cone blood pressure cuff facebow pulse oximeter Although dental handpieces are considered a semicritical item they should always be heat sterilized between uses and not high level disinfected 246 See Dental Handpieces and Other Devices Attached to Air or Waterlines for detailed information disinfectants must have clear label claims for intended use and manufacturer instructions for use must be followed 245 A more complete description of the regulatory framework in the United States by
376. atients with active TB who require urgent dental care and DHCP education counseling and TST screening e DHCP who have contact with patients should have a baseline TST preferably by using a two step test at the beginning of employment The facility s level of TB risk will determine the need for routine follow up TST e While taking patients initial medical histories and at periodic updates dental DHCP should routinely ask all patients whether they have a history of TB disease or symptoms indicative of TB e Patients with a medical history or symptoms indicative of undiagnosed active TB should be referred promptly for medical evaluation to determine possible infectiousness Such patients should not remain in the dental care facility any longer than required to evaluate their dental condition and arrange a referral While in the dental health care facility the patient should be isolated from other patients and DHCP wear a surgical mask when not being evaluated or be instructed to cover their mouth and nose when coughing or sneezing e Elective dental treatment should be deferred until a physician confirms that a patient does not have infectious TB or if the patient is diagnosed with active TB disease until confirmed the patient is no longer infectious e If urgent dental care is provided for a patient who has or is suspected of having active TB disease the care should be provided in a facility e g hospital that provides airborne in
377. ating syringes broaches VI 384 385 388
378. ation Bureau of Health Professions United States health workforce personnel factbook Rockville MD US Department of Health and Human Services Health Resources and Services Administration 2000 Bolyard EA Tablan OC Williams WW Pearson ML Shapiro CN Deitchman SD Hospital Infection Control Practices Advisory Committee Guideline for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 Greene VW Microbiological contamination control in hospitals 1 Perspectives Hospitals 1969 43 78 88 CDC Perspectives in disease prevention and health promotion update universal precautions for prevention of transmission of human immunodeficiency virus hepatitis B virus and other bloodborne pathogens in health care settings MMWR 1988 38 377 382 387 8 CDC Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health care and public safety workers a response to P L 100 607 The Health Omnibus Programs Extension Act of 1988 MMWR 1989 38 suppl No 6S Garner JS Favero MS CDC guideline for handwashing and hospital environmental control 1985 Infect Control 1986 7 231 43 CDC Recommendations for prevention of HIV transmission in health care settings MMWR 1987 36 suppl No 2S Garner JS Hospital Infection Control Practices Advisory Committee Guideline for isolation precautions in hospitals Infect Control Hosp Epidemiol 1996 17 53 8
379. atter that subsequently can contaminate DHCP and equipment operatory surfaces In addition preprocedural rinsing can decrease the number of microorganisms introduced in the patient s bloodstream during invasive dental procedures 389 390 No scientific evidence indicates that preprocedural mouth rinsing prevents clinical infections among DHCP or patients but studies have demonstrated that a preprocedural rinse with an antimicrobial product e g chlorhexidine gluconate essential oils or povidone iodine can reduce the level of oral microorganisms in aerosols and spatter generated during routine dental procedures with rotary instruments e g dental handpieces or ultrasonic scalers 397 399 Preprocedural mouth rinses can be most beneficial before a procedure that requires using a prophylaxis cup or ultrasonic scaler because rubber dams cannot be used to minimize aerosol and spatter generation and unless the provider has an assistant high volume evacuation is not commonly used 173 The science is unclear concerning the incidence and nature of bacteremias from oral procedures the relationship of these bacteremias to disease and the preventive benefit of antimicrobial rinses In limited studies no substantial benefit has been demonstrated for mouth rinsing in terms of reducing oral microorganisms in dental induced bacteremias 400 401 However the American Heart Association s recommendations regarding preventing bacterial endocarditis d
380. aumann MA Rath B Fischer JH Iffland R The permeability of dental procedure and examination gloves by an alcohol based disinfectant Dent Mater 2000 16 139 44 Ready MA Schuster GS Wilson JT Hanes CM Effects of dental medicaments on examination glove permeability J Prosthet Dent 1989 61 499 503 Richards JM Sydiskis RJ Davidson WM Josell SD Lavine DS Permeability of latex gloves after contact with dental materials Am J Orthod Dentofacial Orthop 1993 104 224 9 Andersson T Bruze M Bjorkner B In vivo testing of the protection of gloves against acrylates in dentin bonding systems on patients with known contact allergy to acrylates Contact Dermatitis 1999 41 254 9 Reitz CD Clark NP The setting of vinyl polysiloxane and condensation silicone putties when mixed with gloved hands J Am Dent Assoc 1988 116 371 5 Kahn RL Donovan TE Chee WW Interaction of gloves and rubber dam with a poly vinyl siloxane impression material a screening test Int J Prosthodont 1989 2 342 6 Matis BA Valadez D Valadez E The effect of the use of dental gloves on mixing vinyl polysiloxane putties J Prosthodont 1997 6 189 92 Wright JG McGeer AJ Chyatte D Ransohoff DF Mechanisms of glove tears and sharp injuries among surgical personnel JAMA 1991 266 1668 71 Dodds RD Guy PJ Peacock AM Duffy SR Barker SG Thomas MH Surgical glove perforation Br J Surg 1988 75 966 8 Adams D Bagg J Limaye M Parsons K Absi EG A clinical evalua
381. avily colonized than comparable areas of skin on fingers without rings 167 170 In a study of intensive care nurses multivariable analysis determined rings were the only substantial risk factor for carriage of gram negative bacilli and Staphylococcus aureus and the concentration of organisms correlated with the number of rings worn 70 However two other studies demonstrated that mean bacterial colony counts on hands after handwashing were similar among persons wearing rings and those not wearing rings 169 171 Whether wearing rings increases the likelihood of transmitting a pathogen is unknown further studies are needed to establish whether rings result in higher transmission of pathogens in health care settings However rings and decorative nail jewelry can make donning gloves more difficult and cause gloves to tear more readily 42 43 Thus jewelry should not interfere with glove use e g impair ability to wear the correct sized glove or alter glove integrity Personal Protective Equipment PPE is designed to protect the skin and the mucous membranes of the eyes nose and mouth of DHCP from exposure to blood or OPIM Use of rotary dental and surgical instruments e g handpieces or ultrasonic scalers and air water syringes creates a visible spray that contains primarily large particle droplets of water saliva blood microorganisms and other debris This spatter travels only a short distance and settles out quickly landing o
382. be 1 rinsed with sterile water after removal to remove toxic or irritating residues 2 handled using sterile gloves and dried with sterile towels and 3 delivered to the point of use in an aseptic manner If stored before use the instrument should not be considered sterile and should be sterilized again just before use In addition the sterilization process with liquid chemical sterilants cannot be verified with biological indicators 263 Because of these limitations and because liquid chemical sterilants can require approximately 12 hours of complete immersion they are almost never used to sterilize instruments Rather these chemicals are more often used for high level disinfection 249 Shorter immersion times 12 90 minutes are used to achieve high level disinfection of semicritical instruments or items These powerful sporicidal chemicals 99 Guidelines for Infection Control in Dental Health Care Settings 2008 e g glutaraldehyde peracetic acid and hydrogen peroxide are highly toxic 244 264 265 Manufacturer instructions e g regarding dilution immersion time and temperature and safety precautions for using chemical sterilants high level disinfectants must be followed precisely 15 245 These chemicals should not be used for applications other than those indicated in their label instructions Misapplications include use as an environmental surface disinfectant or instrument holding solution When using appropriate
383. be worn to prevent contamination of street clothing and to protect the skin of DHCP from exposures to blood and body substances 2 7 10 11 13 137 OSHA bloodborne pathogens standard requires sleeves to be long enough to protect the forearms when the gown is worn as PPE i e when spatter and spray of blood saliva or OPIM to the forearms is anticipated 13 14 DHCP should change protective clothing when it becomes visibly soiled and as soon as feasible if penetrated by blood or other potentially infectious fluids 2 3 14 137 All protective clothing should be removed before leaving the work area 3 Gloves and Gloving DHCP wear gloves to prevent contamination of their hands when touching mucous membranes blood saliva or OPIM and also to reduce the likelihood that microorganisms present on the hands of DHCP will be transmitted to patients during surgical or other patient care procedures 2 7 10 Medical gloves both patient examination and surgeon s gloves are manufactured as single use disposable items that should be used for only one patient then discarded Gloves should be changed between patients and when torn or punctured Wearing gloves does not eliminate the need for handwashing Hand hygiene should be performed immediately before donning gloves Gloves can have small unapparent defects or can be torn during use and hands can become contaminated during glove removal 122 177 187 These circumstances increase the risk of
384. biol 1996 62 3954 9 Atlas RM Williams JF Huntington MK Legionella contamination of dental unit waters Appl Environ Microbiol 1995 61 1208 13 Kelstrup J Funder Nielsen T Theilade J Microbial aggregate contamination of water lines in dental equipment and its control Acta Pathol Microbiol Scand B 1977 85 177 83 Challacombe SJ Fernandes LL Detecting Legionella pneumophila in water systems a comparison of various dental units J Am Dent Assoc 1995 126 603 8 Mayo JA Oertling KM Andrieu SC Bacterial biofilm a source of contamination in dental air water syringes Clin Prev Dent 1990 12 13 20 Scheid RC Kim CK Bright JS Whitely MS Rosen S Reduction 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 of microbes in handpieces by flushing before use J Am Dent Assoc 1982 105 658 60 Bagga BS Murphy RA Anderson AW Punwani I Contamination of dental unit cooling water with oral microorganisms and its prevention J Am Dent Assoc 1984 109 712 6 Martin MV The significance of the bacterial contamination of dental unit water systems Br Dent J 1987 163 152 4 Pankhurst CL Philpott Howard JN Hewitt JH Casewell MW The efficacy of chlorination and filtration in the control and eradication of Legionella from dental chair water systems J Hosp Infect 1990 16 9 18
385. blic water supply N Engl J Med 1994 331 161 7 Kaminski JC Cryptosporidium and the public water supply N Engl J Med 1994 331 1529 30 CDC Assessing the public health threat associated with waterborne cryptosporidiosis report of a workshop MMWR 1995 44 No RR 6 CDC Surveillance for waterborne disease outbreaks United States 1993 1994 MMWR 1996 45 No SS 1 Office of Water US Environmental Protection Agency Lead and copper rule summary of revisions EPA 81S R 99 020 Washington DC US Environmental Protection Agency 2000 US Environmental Protection Agency 65 CFR Parts 141 and 142 National primary drinking water regulations for lead and copper final rule Federal Register 2000 1949 2015 Gooch B Marianos D Ciesielski C et al Lack of evidence for patient to patient transmission of HIV in a dental practice J Am Dent Assoc 1993 124 38 44 Crawford JJ Broderius C Control of cross infection risks in the dental operatory prevention of water retraction by bur cooling spray systems J Am Dent Assoc 1988 116 685 7 Mills SE Kuehne JC Bradley DV Jr Bacteriological analysis of high speed handpiece turbines J Am Dent Assoc 1993 124 59 62 Lewis DL Arens M Appleton SS et al Cross contamination potential with dental equipment Lancet 1992 340 1252 4 Lewis DL Boe RK Cross infection risks associated with current procedures for using high speed dental handpieces J Clin 79
386. c infection see Oral Surgical Procedures Conventional dental units cannot reliably deliver sterile water even when equipped with independent water reservoirs because the water bearing pathway cannot be reliably sterilized Delivery devices e g bulb syringe or sterile single use disposable products should be used to deliver sterile water 2 121 Oral surgery and implant handpieces as well as ultrasonic scalers are commercially available that bypass the dental unit to deliver sterile water or other solutions by using single use disposable or 103 Guidelines for Infection Control in Dental Health Care Settings 2008 sterilizable tubing 3 6 Boil Water Advisories A boil water advisory is a public health announcement that the public should boil tap water before drinking it When issued the public should assume the water is unsafe to drink Advisories can be issued after 1 failure of or substantial interruption in water treatment processes that result in increased turbidity levels or particle counts and mechanical or equipment failure 2 positive test results for pathogens e g Cryptosporidium Giardia or Shigella in water 3 violations of the total coliform rule or the turbidity standard of the surface water treatment rule 4 circumstances that compromise the distribution system e g watermain break coupled with an indication of a health hazard or 5 a natural disaster e g flood hurricane or earthquake 346 In
387. ce for flushing of waterlines to reduce residual microbial contamination All incoming waterlines from the public water system inside the dental office e g faucets waterlines and dental equipment should be flushed No consensus exists regarding the optimal duration for flushing procedures after cancellation of the advisory recommendations range from 1 to 5 minutes 244 346 351 352 The length of time needed can vary with the type and length of the plumbing system leading to the office After the incoming public water system lines are flushed dental unit waterlines should be disinfected according to the manufacturer s instructions 346 Special Considerations Dental Handpieces and Other Devices Attached to Air and Waterlines Multiple semicritical dental devices that touch mucous membranes are attached to the air or waterlines of the dental unit Among these devices are high and low speed handpieces prophylaxis angles ultrasonic and sonic scaling tips air abrasion devices and air and water syringe tips Although no epidemiologic evidence implicates these instruments in disease transmission 353 studies of high speed handpieces using dye expulsion have confirmed the potential for retracting oral fluids into internal compartments of the device 354 358 This determination indicates that retained patient material can be expelled intraorally during subsequent uses Studies using laboratory models also indicate the possibility for reten
388. cedure manage the reaction and seek emergency assistance as indicated Follow current medical emergency response recommendations for management of anaphylaxis 32 Sterilization and Disinfection of Patient Care Items Patient care items dental instruments devices and equipment are categorized as critical semicritical or noncritical depending on the potential risk for infection associated with their intended use Table 4 242 Critical items used to penetrate soft tissue or bone have the greatest risk of transmitting infection and should be sterilized by heat Semicritical items touch mucous membranes or nonintact skin and have a lower risk of transmission because the majority of semicritical items in dentistry are heat tolerant they also should be sterilized by using heat If a semicritical item is heat sensitive it should at a minimum be processed with high level disinfection 2 Noncritical patient care items pose the least risk of transmission of infection contacting only intact skin which can serve as an effective barrier to microorganisms In the majority of cases cleaning or if visibly soiled cleaning followed by disinfection with an EPA registered hospital disinfectant is adequate When the item is visibly contaminated with blood or OPIM an EPA registered hospital disinfectant with a tuberculocidal claim i e intermediate level disinfectant should be used 2 243 244 Cleaning or disinfection of certain noncritical p
389. cey MK Elg SA Brueske L Comparison of probe sheaths for endovaginal sonography Obstet Gynecol 1996 87 27 9 Hokett SD Honey JR Ruiz F Baisden MK Hoen MM Assessing the effectiveness of direct digital radiography barrier sheaths and finger cots J Am Dent Assoc 2000 131 463 7 ASHP Council on Professional Affairs ASHP guidelines on quality assurance for pharmacy prepared sterile products Am J Health Syst Pharm 2000 57 1150 69 Green KA Mustachi B Schoer K Moro D Blend R McGeer A Gadolinium based MR contrast media potential for growth of microbial contaminants when single vials are used for multiple patients Am J Roentgenol 1995 165 669 71 American Society of Anesthesiologists Recommendations for infection control for the practice of anesthesiology 2nd ed Park Ridge IL American Society of Anesthesiologists 1999 Henry B Plante Jenkins C Ostrowska K An outbreak of Serratia marcescens associated with the anesthetic agent propofol Am J Infect Control 2001 29 312 5 Plott RT Wagner RF Jr Tyring SK Iatrogenic contamination of multidose vials in simulated use A reassessment of current patient injection technique Arch Dermatol 1990 126 1441 4 Arrington ME Gabbert KC Mazgaj PW Wolf MT Multidose vial contamination in anesthesia AANA J 1990 58 462 6 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403
390. cine for prevention and control of influenza supplemental recommendations of the Advisory Committee on Immunization Practices ACIP MMWR 2003 52 No RR 13 A federal standard issued in December 1991 under the Occupational Safety and Health Act mandates that hepatitis B vaccine be made available at the employer s expense to all HCP occupationally exposed to blood or other potentially infectious materials The Occupational Safety and Health Administration requires that employers make available hepatitis B vaccinations evaluations and follow up procedures in accordance with current CDC recommendations t Persons immunocompromised because of immune deficiencies HIV infection leukemia lymphoma generalized malignancy or persons receiving immunosuppressive therapy with corticosteroids alkylating drugs antimetabolites or persons receiving radiation Vaccination of pregnant women after the first trimester might be preferred to avoid coincidental association with spontaneous abortions which are most common during the first trimester However no adverse fetal effects have been associated with influenza vaccination 1A live attenuated influenza vaccine LAIV is FDA approved for healthy persons aged 5 49 years Because of the possibility of transmission of vaccine viruses from recipients of LAIV to other persons and in the absence of data on the risk of illness and among immunocompromised persons infected with LAIV viruses the inactivated influenza vacc
391. community served by the dental facility might be at relatively high risk for exposure to TB Surgical masks do not prevent inhalation of M tuberculosis droplet nuclei and therefore standard precautions are not sufficient to prevent transmission of this organism Recommendations for expanded precautions to prevent transmission of M tuberculosis and other organisms that can be spread by airborne droplet or contact routes have been detailed in other guidelines 5 7 7 20 TB transmission is controlled through a hierarchy of measures including administrative controls environmental controls and personal respiratory protection The main administrative goals of a TB infection control program are early detection of a person with active TB disease and prompt isolation from susceptible persons to reduce the risk of transmission Although DHCP are not responsible for diagnosis and treatment of TB they should be trained to recognize signs and symptoms to help with prompt detection Because potential for transmission of M tuberculosis exists in outpatient settings dental practices should develop a TB control program appropriate for their level of risk 20 21 e A community risk assessment should be conducted periodically and TB infection control policies for each dental setting should be based on the risk assessment The policies should include provisions for detection and referral of patients who might have undiagnosed active TB management of p
392. control guidance for medical device manufacturers Rockville MD US Department of Health and Human Services Food and Drug Administration 1997 Fauerbach LL Janelle JW Practical applications in infection control Chapter 45 In Block SS ed 5th ed Disinfection sterilization and preservation Philadelphia PA Lippincott Williams amp Wilkins 2001 935 44 Martin LS McDougal JS Loskoski SL Disinfection and inactivation of the human T lymphotrophic virus type III 1ymphadenopathy associated virus J Infect Dis 1985 152 400 3 Bloomfield SF Smith Burchnell CA Dalgleish AG Evaluation of hypochlorite releasing disinfectants against the human immunodeficiency virus HIV J Hosp Infect 1990 15 273 8 Gerson SL Parker P Jacobs MR Creger R Lazarus HM Aspergillosis due to carpet contamination Infect Control Hosp Epidemiol 1994 15 221 3 Suzuki A Namba Y Matsuura M Horisawa A Bacterial contamination of floors and other surfaces in operating rooms a five year survey J Hyg Lond 1984 93 559 66 Skoutelis AT Westenfelder GO Beckerdite M Phair JP Hospital carpeting and epidemiology of Clostridium difficile Am J Infect Control 1994 22 212 7 Rutala WA Odette RL Samsa GP Management of infectious waste by US hospitals JAMA 1989 262 1635 40 CDC Perspectives in disease prevention and health promotion Summary of the Agency for Toxic Substances and Disease Registry report to Congress the public health implications of
393. ctions for use of chemical sterilants high level disinfectants IB 243 Single use disposable instruments are acceptable alternatives if they are used only once and disposed of correctly IB IC 243 383 Do not use liquid chemical sterilants high level disinfectants for environmental surface disinfection or as holding solutions IB IC 243 245 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 2 243 244 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 5 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 decontamina tion 2 preparation and packaging 3 sterilization and 4 storage Do not store instruments in an area where contaminated instruments are held or cleaned II 173 247 248 Train DHCP to employ work practices that prevent contamination of clean areas II C Receiving Cleaning and Decontamination Work Area l Mi
394. d as well as other applicable local state and federal laws to determine a location for storing health records 13 35 Preventing Transmission of Bloodborne Pathogens Although transmission of bloodborne pathogens e g HBV HCV and HIV in dental health care settings can have serious consequences such transmission is rare Exposure to infected blood can result in transmission from patient to DHCP from DHCP to patient and from one patient to another The opportunity for transmission is greatest from patient to DHCP who frequently encounter patient blood and blood contaminated saliva during dental procedures Since 1992 no HIV transmission from DHCP to patients has been reported and the last HBV transmission from DHCP to patients was reported in 1987 HCV transmission from DHCP to patients has not been reported The majority of DHCP infected with a bloodborne virus do not pose a risk to patients because they do not perform activities meeting the necessary conditions for transmission For DHCP to pose a risk for bloodborne virus transmission to patients DHCP must 1 be viremic i e have infectious virus circulating in the bloodstream 2 be injured or have a condition e g weeping dermatitis that allows direct exposure to their blood or other infectious body fluids and 3 enable their blood or infectious body fluid to gain direct access to a patient s wound traumatized tissue mucous membranes or similar portal of entry Although
395. d of care designed to protect HCP and patients from pathogens that can be spread by blood or any other body fluid excretion or secretion 77 Standard precautions apply to contact with 1 blood 2 all body fluids secretions and excretions except sweat regardless of whether they contain blood 3 nonintact skin and 4 mucous membranes Saliva has always been considered a potentially infectious material in dental infection control thus no operational difference exists in clinical dental practice between universal precautions and standard precautions In addition to standard precautions other measures e g expanded or transmission based precautions might be necessary to prevent potential spread of certain diseases e g TB influenza and varicella that are transmitted through airborne droplet or contact transmission e g sneezing coughing and contact with skin 11 When acutely ill with these diseases patients do not usually seek routine dental outpatient care Nonetheless a general understanding of precautions for diseases transmitted by all routes is critical because 1 some DHCP are hospital based or work part time in hospital settings 2 patients infected with these diseases might seek urgent treatment at outpatient dental offices and 3 DHCP might become infected with these diseases Necessary transmission based precautions might include patient placement e g isolation adequate room ventilation respiratory protecti
396. designed to be used on one patient and then discarded not reprocessed for use on another patient e g cleaned disinfected or sterilized 383 Single use devices in dentistry are usually not heat tolerant and cannot be reliably cleaned Examples include syringe needles prophylaxis cups and brushes and plastic orthodontic brackets Certain items e g prophylaxis angles saliva ejectors high volume evacuator tips and air water syringe tips are commonly available in a disposable form and should be disposed of appropriately after each use Single use devices and items e g cotton rolls gauze and irrigating syringes for use during oral surgical procedures should be sterile at the time of use Because of the physical construction of certain devices e g burs endodontic files and broaches cleaning can be difficult In addition deterioration can occur on the cutting surfaces of some carbide diamond burs and endodontic files during processing 384 and after repeated processing cycles leading to potential breakage during patient treatment 385 388 These factors coupled with the knowledge that burs and endodontic instruments exhibit signs of wear during normal use might make it practical to consider them as single use devices Preprocedural Mouth Rinses Antimicrobial mouth rinses used by patients before a dental procedure are intended to reduce the number of microorganisms the patient might release in the form of aerosols or sp
397. dical or surgical intervention The term health care associated replaces nosocomial which is limited to adverse infectious outcomes occurring in hospitals Hepatitis B immune globulin HBIG Product used for prophylaxis against HBV infection HBIG is prepared from plasma containing high titers of hepatitis B surface antibody anti HBs and provides protection for 3 6 mos Hepatitis B surface antigen HBsAg Serologic marker on the surface of HBV detected in high levels during acute or chronic hepatitis The body normally produces antibodies to surface antigen as a normal immune response to infection Hepatitis B e antigen HBeAg Secreted product of the nucleocapsid gene of HBV found in serum during acute and chronic HBV infection Its presence indicates that the virus is replicating and serves as a marker of increased infectivity Hepatitis B surface antibody anti HBs Protective antibody against HBsAg Presence in the blood can indicate past infection with and immunity to HBV or immune response from hepatitis B vaccine Heterotrophic bacteria Those bacteria requiring an organic carbon source for growth i e deriving energy and carbon from organic compounds High level disinfection Disinfection process that inactivates vegetative bacteria mycobacteria fungi and viruses but not necessarily high numbers of bacterial spores FDA further defines a high level disinfectant as a sterilant used for a shorter contact time Hospit
398. disinfectant and with a label claim of potency as tuberculocidal Appendix A Latex Milky white fluid extracted from the rubber tree Hevea brasiliensis that contains the rubber material cis 1 4 polyisoprene Low level disinfection Process that inactivates the majority of vegetative bacteria certain fungi and certain viruses but cannot be relied on to inactivate resistant microorganisms e g mycobacteria or bacterial spores Low level disinfectant Liquid chemical germicide registered with EPA as a hospital disinfectant OSHA requires low level hospital disinfectants also to have a label claim for potency against HIV and HBV if used for disinfecting clinical contact surfaces Appendix A Microfilter Membrane filter used to trap microorganisms suspended in water Filters are usually installed on dental unit waterlines as a retrofit device Microfiltration commonly occurs at a filter pore size of 0 03 10 um Sediment filters commonly found in dental unit water regulators have pore sizes of 20 90 um and do not function as microbiological filters Nosocomial Infection acquired in a hospital as a result of medical care Occupational exposure Reasonably anticipated skin eye mucous membrane or parenteral contact with blood or OPIM that can result from the performance of an employee s duties OPIM Other potentially infectious materials OPIM is an OSHA term that refers to 1 body fluids including semen vaginal secretions cerebrospinal
399. disruption while waiting for the repeat BI If the repeat test is negative and chemical and mechanical monitoring indicate adequate processing the sterilizer can be put back into service If the repeat BI test is positive and packaging loading and operating procedures have been confirmed as performing correctly the sterilizer should remain out of service until it has been inspected repaired and rechallenged with BI tests in three consecutive empty chamber sterilization cycles 9 243 When possible items from suspect loads dating back to the last negative BI should be recalled rewrapped and resterilized 9 283 A more conservative approach has been recommended 247 in which any positive spore test is assumed to represent sterilizer malfunction and requires that all materials processed in that sterilizer dating from the sterilization cycle having the last negative biologic indicator to the next cycle indicating satisfactory biologic indicator results should be considered nonsterile and retrieved if possible and reprocessed or held in quarantine until the results of the repeat BI are known This approach is considered conservative because the margin of safety in steam sterilization is sufficient enough that infection risk associated with items in a load indicating spore growth is minimal particularly if the item was properly cleaned and the temperature was achieved e g as demonstrated by acceptable chemical indicator or tempera
400. dont 1996 9 362 6 Avery CM Hjort A Walsh S Johnson PA Glove perforation during surgical extraction of wisdom teeth Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998 86 23 5 Otis LL Cottone JA Prevalence of perforations in disposable latex gloves during routine dental treatment J Am Dent Assoc 1989 118 321 4 Kotilainen HR Brinker JP Avato JL Gantz NM Latex and vinyl examination gloves Quality control procedures and implications for health care workers Arch Intern Med 1989 149 2749 53 Food and Drug Administration Glove powder report Rockville MD US Department of Health and Human Services Food and Drug Administration 1997 Available at http www fda gov cdrh glvpwd html Morgan DJ Adams D Permeability studies on protective gloves used in dental practice Br Dent J 1989 166 11 3 Albin MS Bunegin L Duke ES Ritter RR Page CP Anatomy of a defective barrier sequential glove leak detection in a surgical and dental environment Crit Care Med 1992 20 170 84 Merchant VA Molinari JA Pickett T Microbial penetration of gloves following usage in routine dental procedures Am J Dent 1992 3 95 6 Pitten FA Herdemann G Kramer A The integrity of latex gloves in clinical dental practice Infection 2000 28 388 92 Jamal A Wilkinson S The mechanical and microbiological integrity of surgical gloves ANZ J Surg 2003 73 140 3 Korniewicz DM El Masri MM Broyles JM Martin CD O Connell KP A laboratory based study to a
401. dwashing and hand antisepsis in health care settings Am J Infect Control 1995 23 251 69 CDC Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities 1994 MMWR 1994 43 No RR 13 CDC Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure prone invasive procedures MMWR 1991 40 No RR 8 Garner JS CDC guideline for prevention of surgical wound infections 1985 Supersedes guideline for prevention of surgical wound infections published in 1982 Originally published in November 1985 Revised Infect Control 1986 7 193 200 Garner JS Favero MS CDC guideline for handwashing and hospital environmental control 1985 Infect Control 1986 7 231 43 alcohol based hand rub antimicrobial soap AA antiseptic agent PCMX 4
402. e Consider items difficult to clean e g endodontic files broaches and carbide and diamond burs as single use disposables and discard after one use e To minimize drying of tissues and body fluids on a device keep the instrument moist until cleaned and decontaminated e Clean instruments thoroughly and steam autoclave at 134 C for 18 minutes This is the least stringent of sterilization methods offered by the World Health Organization The complete list TABLE 5 Examples of methods for evaluating infection control programs Program element Appropriate immunization of dental health care personnel DHCP Assessment of occupational exposures to infectious agents Comprehensive postexposure management plan and medical follow up program after occupational exposures to infectious agents Adherence to hand hygiene before and after patient care Proper use of personal protective equipment to prevent occupational exposures to infectious agents Routine and appropriate sterilization of instruments using a biologic monitoring system Evaluation and implementation of safer medical devices Compliance of water in routine dental procedures with current drinking U S Environmental Protection Agency water standards fewer than 500 CFU of heterotrophic water bacteria Proper handling and disposal of medical waste Health care associated infections 108 Evaluation activity Conduct annual review of personnel records to ensure up
403. e mode of transmission and the period of infectivity of the disease 5 Table 1 Exclusion policies should 1 be written 2 include a statement of authority that defines who can exclude DHCP e g personal physicians and 3 be clearly communicated through education and training Policies should also encourage DHCP to report illnesses or exposures without jeopardizing wages benefits or job status With increasing concerns regarding bloodborne pathogens and introduction of universal precautions use of latex gloves among HCP has increased markedly 7 23 Increased use of these gloves has been accompanied by increased reports of allergic reactions to natural rubber latex among HCP DHCP and patients 24 30 as well as increased reports of irritant and allergic contact dermatitis from frequent and repeated use of hand hygiene products exposure to chemicals and glove use DHCP should be familiar with the signs and symptoms of latex sensitivity 5 3 33 A physician should evaluate DHCP exhibiting symptoms of latex allergy because further exposure could result in a serious allergic reaction A diagnosis is made through medical history physical examination and diagnostic tests Procedures should be in place for minimizing latex related health problems among DHCP and patients while protecting them from infectious materials These procedures should include 1 reducing exposures to latex containing materials by using appropriate work practices
404. ecial storage handling neutralization and disposal and is covered by federal state and local tules and regulations 6 297 300 301 Examples of regulated waste found in dental practice settings are solid waste soaked or saturated with blood or saliva e g gauze saturated with blood after surgery extracted teeth surgically removed hard and soft tissues and contaminated sharp items e g needles scalpel blades and wires 13 Regulated medical waste requires careful containment for treatment or disposal A single leak resistant biohazard bag is usually adequate for containment of nonsharp regulated medical waste provided the bag is sturdy and the waste can be discarded without contaminating the bag s exterior Exterior contamination or puncturing of the bag requires placement in a second biohazard bag All bags should be securely closed for disposal Puncture resistant containers with a biohazard label located at the point of use i e sharps containers are used as containment for scalpel blades needles syringes and unused sterile sharps 13 Dental health care facilities should dispose of medical waste regularly to avoid accumulation Any facility generating regulated medical waste should have a plan for its management that complies with federal state and local regulations to ensure health and environmental safety Discharging Blood or Other Body Fluids to Sanitary Sewers or Septic Tanks All containers with blood or saliva
405. econtaminated are subject to OSHA and U S Department of Transportation regulations regarding transportation and shipping of infectious materials 73 410 Appliances and prostheses delivered to the patient should be free of contamination Communication between the laboratory and the dental 106 practice is also key at this stage to determine which one is responsible for the final disinfection process If the dental laboratory staff provides the disinfection an EPA registered hospital disinfectant low to intermediate should be used written documentation of the disinfection method provided and the item placed in a tamper evident container before returning it to the dental office If such documentation is not provided the dental office is responsible for final disinfection procedures Dental prostheses or impressions brought into the laboratory can be contaminated with bacteria viruses and fungi 411 412 Dental prostheses impressions orthodontic appliances and other prosthodontic materials e g occlusal rims temporary prostheses bite registrations or extracted teeth should be thoroughly cleaned i e blood and bioburden removed disinfected with an EPA registered hospital disinfectant with a tuberculocidal claim and thoroughly rinsed before being handled in the in office laboratory or sent to an off site laboratory 2 244 249 407 The best time to clean and disinfect impressions prostheses or appliances is as soon as possible
406. eer personnel Recommendations in this report are designed to prevent or reduce potential for disease transmission from patient to DHCP from DHCP to patient and from patient to patient Although these guidelines focus mainly on outpatient ambulatory dental health care settings the recommended infection control practices are applicable to all settings in which dental treatment is provided Dental patients and DHCP can be exposed to pathogenic microorganisms including cytomegalovirus CMV HBV HCV herpes simplex virus types 1 and 2 HIV Mycobacterium tuberculosis staphylococci streptococci and other viruses and bacteria that colonize or infect the oral cavity and respiratory tract These organisms can be transmitted in dental settings through 1 direct contact with blood oral fluids or other patient materials 2 indirect contact with contaminated objects e g instruments equipment or environmental surfaces 3 contact of conjunctival nasal or oral mucosa with droplets e g spatter containing microorganisms generated from an infected person and propelled a short distance e g by coughing sneezing or talking and 4 inhalation of airborne microorganisms that can remain suspended in the air for long periods 5 Infection through any of these routes requires that all of the following conditions be present e a pathogenic organism of sufficient virulence and in adequate numbers to cause disease e a reservoir or source that
407. egarding the transmissibility of CJD or vCJD during dental procedures special precautions in addition to standard precautions might be indicated when treating known CJD or vCJD patients a list of such precautions is provided for consideration without recommendation see Creutzfeldt Jakob Disease and Other Prion Diseases Unresolved issue M Program Evaluation 1 Establish routine evaluation of the infection control program including evaluation of performance indicators at an established frequency II 470 471 Infection Control Internet Resources Advisory Committee on Immunization Practices http www cdce gov nip ACIP default htm American Dental Association http www ada org American Institute of Architects Academy of Architecture for Health http www aahaia org American Society of Heating Refrigeration Air conditioning Engineers http www ashrae org Association for Professionals in Infection Control and Epidemiology Inc http www apic org resc guidlist cfm CDC Division of Healthcare Quality Promotion http www cdc gov ncidod hip CDC Division of Oral Health Infection Control http www cdce gov OralHealth infectioncontrol index htm CDC Morbidity and Mortality Weekly Report http www cde gov mmwr CDC NIOSH http www cdc gov niosh homepage htm CDC Recommends Prevention Guidelines System http www phppo cdc gov cdcRecommends AdvSearchV asp EPA Antimicrobial Chemicals http www epa gov oppad0
408. egulations or recommendations No restrictions on professional activity HCV positive health care personnel should follow aseptic technique and standard precautions No restriction Restrict from patient contact and contact with patient s environment Evaluate need to restrict from care of patients at high risk Do not perform exposure prone invasive procedures until counsel from an expert review panel has been sought panel should review and recommend procedures that personnel can perform taking into account specific procedures as well as skill and technique Standard precautions should always be observed Refer to state and local regulations or recommendations Exclude from duty Exclude from duty Exclude from duty Exclude from duty Exclude from duty Duration Until discharge ceases Until symptoms resolve Until symptoms resolve consult with local and state health authorities regarding need for negative stool cultures Until symptoms resolve Until 7 days after onset of jaundice Until hepatitis B e antigen is negative Until lesions heal Until 7 days after the rash appears From fifth day after first exposure through twenty first day after last exposure or 4 days after rash appears Until 24 hours after start of effective therapy Until 9 days after onset of parotitis From twelfth day after first exposure through twenty sixth day after last exposure or until 9 days after onset of parotitis
409. endotoxin in dental health care settings have not been investigated endotoxin has been associated with exacerbation of asthma and onset of hypersensitivity pneumonitis in other occupational settings 329 337 Dental Unit Water Quality Research has demonstrated that microbial counts can reach lt 200 000 colony forming units CFU mL within 5 days after installation of new dental unit waterlines 305 and levels of microbial contamination lt 10 CFU mL of dental unit water have been documented 309 338 These counts can occur because dental unit waterline factors e g system design flow rates and materials promote both bacterial growth and development of biofilm Although no epidemiologic evidence indicates a public health problem the presence of substantial numbers of pathogens in dental unit waterlines generates concern Exposing patients or DHCP to water of uncertain microbiological quality despite the lack of documented adverse health effects is inconsistent with accepted infection control principles Thus in 1995 ADA addressed the dental water concern by asking manufacturers to provide equipment with the ability to deliver treatment water with lt 200 CFU mL of unfiltered output from waterlines 339 This threshold was based on the quality assurance standard established for dialysate fluid to ensure that fluid delivery systems in hemodialysis units have not been colonized by indigenous waterborne organisms 340 Standards als
410. ent and effective use of vaccines in health care settings Some educational institutions and infection control programs provide immunization schedules for students and DHCP OSHA requires that employers make hepatitis B vaccination available to all employees who have potential contact with blood or OPIM Employers are also required to follow CDC recommendations for vaccinations evaluation and follow up procedures 3 Nonpatient care staff e g administrative or housekeeping might be included depending on their potential risk of coming into contact with blood or OPIM Employers are also required to ensure that employees who decline to accept hepatitis B vaccination sign an appropriate declination statement 3 DHCP unable or unwilling to be vaccinated as required or recommended should be educated regarding their exposure risks infection control policies and procedures for the facility and the management of work related illness and work restrictions if appropriate for exposed or infected DHCP Exposure Prevention and Postexposure Management Avoiding exposure to blood and OPIM as well as protection by immunization remain primary strategies for reducing occupationally acquired infections but occupational exposures can still occur 19 A 88 combination of standard precautions engineering work practice and administrative controls is the best means to minimize occupational exposures Written policies and procedures to facilitate pr
411. entation American National Standards Institute Hemodialysis systems ANSI AAMI RD5 1992 Arlington VA Association for the Advancement of Medical Instrumentation 1993 US Environmental Protection Agency National primary drinking water regulations 1999 list of contaminants Washington DC US Environmental Protection Agency 1999 Available at http www epa gov safewater mcl html American Public Health Association American Water Works Association Water Environment Foundation In Eaton AD Clesceri LS Greenberg AE eds Standard methods for the examination of water and wastewater Washington DC American Public Health Association 1999 Williams HN Johnson A Kelley JI et al Bacterial contamination of the water supply in newly installed dental units Quintessence Int 1995 26 331 7 Scheid RC Rosen S Beck FM Reduction of CFUs in high speed handpiece water lines over time Clin Prev Dent 1990 12 9 12 Williams HN Kelley J Folineo D Williams GC Hawley CL Sibiski J Assessing microbial contamination in clean water dental units and compliance with disinfection protocol J Am Dent Assoc 1994 125 1205 11 CDC Working Group on Waterborne Cryptosporidiosis Cryptosporidium and water a public health handbook Atlanta GA US Department of Health and Human Services Public Health Service CDC 1997 MacKenzie WR Hoxie NJ Proctor ME et al A massive outbreak in Milwaukee of cryptosporidium infection transmitted through the pu
412. eptonstall J Aitken C Transmission of hepatitis C virus from a surgeon to a patient the Incident Control Team Commun Dis Public Health 1999 2 188 92 Ross RS Viazov S Gross T Hofmann F Seipp HM Roggendorf M Brief report transmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients N Engl J Med 2000 343 185 1 4 Cody SH Nainan OV Garfein RS et al Hepatitis C virus transmission from an anesthesiologist to a patient Arch Intern Med 2002 162 345 50 Do AN Ciesielski CA Metler RP Hammett TA Li J Fleming PL Occupationally acquired human immunodeficiency virus HIV infection national case surveillance data during 20 years of the HIV epidemic in the United States Infect Control Hosp Epidemiol 2003 24 86 96 Ciesielski C Marianos D Ou CY et al Transmission of human immunodeficiency virus in a dental practice Ann Intern Med 1992 116 798 805 CDC Investigations of patients who have been treated by HIV infected health care workers United States MMWR 1993 42 329 31 337 Bell DM Occupational risk of human immunodeficiency virus infection in healthcare workers an overview Am J Med 1997 102 5B 9 15 Cardo DM Culver DH Ciesielski CA et al Centers for Disease Control and Prevention Needlestick Surveillance Group A case control study of HIV seroconversion in health care workers after percutaneous exposure N Engl J Med 1997 337 1485 90 Beltrami EM The risk and prevention of
413. er particles become aerosolized and can be inhaled contacting mucous membranes 237 As a result allergic patients and DHCP can experience cutaneous respiratory and conjunctival symptoms related to latex protein exposure DHCP can become sensitized to latex protein with repeated exposure 232 236 Work areas where only powder free low allergen latex gloves are used demonstrate low or undetectable amounts of latex allergy causing proteins 237 239 and fewer symptoms among HCP related to natural rubber latex allergy Because of the role of glove powder in exposure to latex protein NIOSH recommends that if latex gloves are chosen HCP should be provided with reduced protein powder free gloves 32 Nonlatex e g nitrile or vinyl powder free and low protein gloves are also available 37 240 Although rare potentially life threatening anaphylactic reactions to latex can occur dental practices should be appropriately equipped and have procedures in place to respond to such emergencies DHCP and dental patients with latex allergy should not have direct contact with latex containing materials and should be in a latex safe environment with all latex containing products removed from their vicinity 3 7 Dental patients with histories of latex allergy can be at risk from dental products e g prophylaxis cups rubber dams orthodontic elastics and medication vials 247 Any latex containing devices that cannot be removed from the treatment
414. er used for dental treatment Although oral flora 303 310 311 and human pathogens e g Pseudomonas aeruginosa 303 305 312 313 Legionella species 303 306 313 and nontuberculous Mycobacterium species 303 304 have been isolated from dental water systems the majority of organisms recovered from dental waterlines are common heterotrophic water bacteria 305 314 315 These exhibit limited pathogenic potential for immunocompetent persons Clinical Implications Certain reports associate waterborne infections with dental water systems and scientific evidence verifies the potential for transmission of waterborne infections and disease in hospital settings and in the community 306 312 316 Infection or colonization caused by Pseudomonas species or nontuberculous mycobacteria can occur among susceptible patients through direct contact with water 317 320 or after exposure to residual waterborne contamination of inadequately reprocessed medical instruments 327 323 Nontuberculous mycobacteria can also be transmitted to patients from tap water aerosols 324 Health care associated transmission of pathogenic agents e g Legionella species occurs primarily through inhalation of infectious aerosols generated from potable water sources or through use of tap water in respiratory therapy equipment 325 327 Disease outbreaks in the community have also been reported from diverse environmental aerosol producing sources including whirlpool
415. ern Med 1983 98 938 9 Bolan G Reingold AL Carson LA et al Infections with Mycobacterium chelonei in patients receiving dialysis and using processed hemodialyzers J Infect Dis 1985 152 1013 9 Lessing MP Walker MM Fatal pulmonary infection due to Mycobacterium fortuitum J Clin Pathol 1993 46 27 1 2 Arnow PM Chou T Weil D Shapiro EN Kretzschmar C Nosocomial Legionnaires disease caused by aerosolized tap water from respiratory devices J Infect Dis 1982 146 460 7 Breiman RF Fields BS Sanden GN Volmer L Meier A Spika JS Association of shower use with Legionnaires disease possible role of amoebae JAMA 1990 263 2924 6 Garbe PL Davis BJ Weisfeld JS et al Nosocomial Legionnaires disease epidemiologic demonstration of cooling towers as a source JAMA 1985 254 521 4 Fallon RJ Rowbotham TJ Microbiological investigations into an outbreak of Pontiac fever due to Legionella micdadei associated with use of a whirlpool J Clin Pathol 1990 43 479 83 Rose CS Martyny JW Newman LS et al Lifeguard lung endemic granulomatous pneumonitis in an indoor swimming pool Am J Public Health 1998 88 1795 1800 CDC Epidemiologic notes and reports Legionnaires disease outbreak associated with a grocery store mist machine Louisiana 1989 MMWR 1990 39 108 10 Jacobs RL Thorner RE Holcomb JR Schwietz LA Jacobs FO Hypersensitivity pneumonitis caused by Cladosporium in an enclosed hot tub area Ann Intern Med 1986 105 2
416. ernary ammonium compounds with alcohol phenolics iodophors EPA registered chlorine based product EPA registered hospital disinfectant with no label claim regarding tuberculocidal activity The Occupational Safety and Health Administration also requires label Health care application Type of patient care item Heat tolerant critical and semicritical Heat sensitive critical and semicritical Heat sensitive critical and semicritical Heat sensitive semicritical Noncritical with visible blood Noncritical without visible blood Environmental surfaces Not applicable Not applicable Clinical contact surfaces blood spills on housekeeping surfaces Clinical contact surfaces housekeeping surfaces inactivate Mycobacterium bovis claims of human immunodeficiency virus HIV and hepatitis B virus HBV potency for clinical contact surfaces e g quaternary ammonium compounds some phenolics some iodophors EPA and the Food and Drug Administration FDA regulate chemical germicides used in health care settings FDA regulates chemical sterilants used on critical and semicritical medical devices and the EPA regulates gaseous sterilants and liquid chemical disinfectants used on noncritical surfaces FDA also regulates medical devices including sterilizers More information is available at 1 http www epa gov oppad001 chemregindex htm 2 http www fda gov cdrh index html and 3 http www fd
417. es Advisory Committee HICPAC MMWR 2003 52 No RR 10 US Environmental Protection Agency 40 CFR Parts 152 156 246 247 248 249 250 251 252 253 254 235 256 257 258 259 260 261 262 263 and 158 Exemption of certain pesticide substances from federal insecticide fungicide and rodenticide act requirements Amended 1996 Federal Register 1996 61 8876 9 Food and Drug Administration Dental handpiece sterilization Letter Rockville MD US Department of Health and Human Services Food and Drug Administration 1992 Association for the Advancement of Medical Instrumentation American National Standards Institute Steam sterilization and sterility assurance in health care facilities ANSI AAMI ST46 2002 Arlington VA Association for the Advancement of Medical Instrumentation 2002 Association for the Advancement of Medical Instrumentation American National Standards Institute Steam sterilization and sterility assurance using table top sterilizers in office based ambulatory care medical surgical and dental facilities ANSI AAMI ST40 1998 Arlington VA Association for the Advancement of Medical Instrumentation 1998 Favero MS Bond WW Chemical disinfection of medical and surgical material Chapter 43 In Block SS ed Disinfection sterilization and preservation 5th ed Philadelphia PA Lippincott Williams amp Wilkins 2001 881 917 Parker HH 4 Johnson RB
418. f Medical Instrumentation 1993 Association for the Advancement of Medical Instrumentation American National Standards Institute Flash sterilization steam sterilization of patient care items for immediate use ANSI AAMI ST37 1996 Arlington VA Association for the Advancement of Medical Instrumentation 1996 Association for the Advancement of Medical Instrumentation American National Standards Institute Ethylene oxide sterilization in health care facilities safety and effectiveness ANSI AAMI ST41 1999 Arlington VA Association for the Advancement of Medical Instrumentation 1999 Miller CH Palenik CJ Sterilization disinfection and asepsis in dentistry Chapter 53 In Block SS ed 5th ed Disinfection sterilization and preservation Philadelphia PA Lippincott Williams amp Wilkins 2001 1049 68 Joslyn LJ Sterilization by heat Chapter 36 In Block SS ed 5 ed Disinfection sterilization and preservation Philadelphia PA Lippincott Williams amp Wilkins 2001 695 728 Rutala WA Weber DJ Chappell KJ Patient injury from flash sterilized instruments Infect Control Hosp Epidemiol 1999 20 458 Bond WW Biological indicators for a liquid chemical sterilizer a solution to the instrument reprocessing problem Infect Control Hosp Epidemiol 1993 14 309 12 77 C DC 003 264 265 266 267 Stin
419. fection isolation i e using such engineering controls as TB isolation rooms negatively pressured relative to the corridors with air either exhausted to the outside or HEPA filtered if recirculation is necessary Standard surgical face masks do not protect against TB transmission DHCP should use respiratory protection e g fit tested disposable N 95 respirators e Settings that do not require use of respiratory protection because they do not treat active TB patients and do not perform cough inducing procedures on potential active TB patients do not need to develop a written respiratory protection program e Any DHCP with a persistent cough i e lasting gt 3 weeks especially in the presence of other signs or symptoms compatible with active TB e g weight loss night sweats fatigue bloody sputum anorexia or fever should be evaluated promptly The DHCP should not return to the workplace until a diagnosis of TB has been excluded or the DHCP is on therapy and a physician has determined that the DHCP is noninfectious 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
420. geni L Lapomarda V Lisi P Occupational hand dermatitis in hospital environments Contact Dermatitis 1995 33 172 6 Ashdown BC Stricof DD May ML Sherman SJ Carmody RF Hydrogen peroxide poisoning causing brain infarction neuroimaging findings Am J Roentgenol 1998 170 1653 5 Ballantyne B Toxicology of glutaraldehyde review of studies and human health effects Danbury CT Union Carbide 1995 CDC National Institute for Occupational Safety and Health Glutaraldehyde occupational hazards in hospitals Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 2001 DHHS publication no NIOSH 2001 115 268 CDC Epidemiologic notes and reports symptoms of irritation 269 270 271 272 273 274 215 276 277 278 279 280 281 282 283 284 285 286 287 78 associated with exposure to glutaraldehyde Colorado MMWR 1987 36 190 1 Lehman PA Franz TJ Guin JD Penetration of glutaraldehyde through glove material tactylon versus natural rubber latex Contact Dermatitis 1994 30 176 7 Hamann CP Rodgers PA Sullivan K Allergic contact dermatitis in dental professionals effective diagnosis and treatment J Am Dent Assoc 2003 134 185 94 Association for the Advancement of Medical Instrumentation American National Standards Institute Safe use and handling of glutaraldehyde based products
421. gh some DHCP have expressed concern that delays caused by mailing specimens might cause false negatives studies have determined that mail delays have no substantial effect on final test results 287 282 Procedures to follow in the event of a positive spore test have been developed 243 247 If the mechanical e g time temperature and pressure and chemical i e internal or external indicators demonstrate that the sterilizer is functioning correctly a single positive spore test probably does not indicate sterilizer malfunction Items other than implantable devices do not necessarily need to be recalled however the spore test should be repeated immediately after correctly loading the sterilizer and using the same cycle that produced the failure The sterilizer should be removed from service and all records reviewed of chemical and mechanical monitoring since the last negative BI test Also sterilizer operating procedures should be reviewed including packaging loading and spore testing with all persons who work with the sterilizer to determine whether operator error could be responsible 9 243 247 Overloading failure to provide adequate package separation and incorrect or excessive packaging material are all common reasons for a positive BI in the absence of mechanical failure of the sterilizer unit 260 A second monitored sterilizer in the office can be used or a loaner from a sales or repair company obtained to minimize office
422. gies 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 Examples of infection control program evaluation activities are provided Table 5 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 Box 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 Design strategies to communicate to the public and providers the risk of disease transmission in dentistry Promote use of protocols for recommended postexposure managemen
423. gle use disposable mop heads and cloths should be used to avoid spreading contamination Cost safety product surface compatibility and acceptability by housekeepers can be key criteria for selecting a cleaning agent or an EPA registered hospital disinfectant detergent PPE used during cleaning and housekeeping procedures followed should be appropriate to the task In the cleaning process another reservoir for microorganisms can be dilute solutions of detergents or disinfectants especially if prepared in dirty containers stored for long periods of time or prepared incorrectly 244 Manufacturers instructions for preparation and use should be followed Making fresh cleaning solution each day discarding any remaining solution and allowing the container to dry will minimize bacterial contamination Preferred cleaning methods produce minimal mists and aerosols or dispersion of dust in patient care areas Cleaning and Disinfection Strategies for Blood Spills The majority of blood contamination events in dentistry result from spatter during dental procedures using rotary or ultrasonic instrumentation Although no evidence supports that HBV HCV or HIV have been transmitted from a housekeeping surface prompt removal and surface disinfection of an area contaminated by either blood or OPIM are appropriate infection control practices and required by OSHA 13 291 Strategies for decontaminating spills of blood and other body fluids differ by
424. gloves in a hospital Allergy Clin Immunol 1998 102 841 6 Tarlo SM Sussman G Contala A Swanson MC Control of airborne latex by use of powder free latex gloves J Allergy Clin Immunol 1994 93 985 9 Swanson MC Bubak ME Hunt LW Yunginger JW Warner MA Reed CE Quantification of occupational latex aeroallergens in a medical center J Allergy Clin Immunol 1994 94 445 551 Hermesch CB Spackman GK Dodge WW Salazar A Effect of powder free latex examination glove use on airborne powder levels in a dental school clinic J Dent Educ 1999 63 814 20 Miller CH Infection control strategies for the dental office Chapter 29 In Ciancio SG ed ADA guide to dental therapeutics 2 ed Chicago IL ADA Publishing 2000 543 58 Primeau MN Adkinson NF Jr Hamilton RG Natural rubber pharmaceutical vial closures release latex allergens that produce skin reactions J Allergy Clin Immunol 2001 107 958 62 Spaulding EH Chemical disinfection of medical and surgical materials Chapter 32 In Lawrence CA Block SS eds Disinfection sterilization and preservation Philadelphia PA Lea amp Febiger 1968 517 31 CDC Guideline for disinfection and sterilization in healthcare facilities recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR in press CDC Guidelines for environmental infection control in health care facilities recommendations of CDC and the Healthcare Infection Control Practic
425. gs recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC SHEA APIC IDSA Hand Hygiene Task Force MMWR 2002 51 No RR 16 CDC Updated U S Public Health Service guidelines for the management of occupational exposures to HBV HCV and HIV and recommendations for postexposure prophylaxis MMWR 2001 50 No RR 11 Mangram AJ Horan TC Pearson ML Silver LC Jarvis WR Hospital Infection Control Practices Advisory Committee Guideline for prevention of surgical site infection 1999 Infect Control Hosp Epidemiol 1999 20 250 78 Bolyard EA Tablan OC Williams WW Pearson ML Shapiro CN Deitchman SD Hospital Infection Control Practices Advisory Committee Guideline for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 CDC Immunization of health care workers recommen dations of the Advisory Committee on Immunization Practices ACIP and the Hospital Infection Control Practices Advisory Committee HICPAC MMWR 1997 46 No RR 18 Rutala WA Association for Professionals in Infection Control and Epidemiology Inc APIC guideline for selection and use of disinfectants Am J Infect Control 1996 24 313 42 Garner JS Hospital Infection Control Practices Advisory Committee Guideline for isolation precautions in hospitals Infect Control Hosp Epidemiol 1996 17 53 80 Larson EL 1992 1993 and 1994 Guidelines Committee APIC guideline for han
426. hem in containers designed to maintain sterility during storage e g cassettes and organizing trays IA 2 247 255 256 E Sterilization of Unwrapped Instruments 1 T Clean and dry instruments before the unwrapped sterilization cycle IB 248 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 243 258 Allow unwrapped instruments to dry and cool in the sterilizer before they are handled to avoid contamination and thermal injury ID 260 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 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 258 Do not sterilize implantable devices unwrapped IB 243 247 Do not store critical instruments unwrapped IB 248 F Sterilization Monitoring i Use mechanical chemical and biological monitors according to the manufacturer s instructions to ensure the effectiveness of the sterilization process IB 248 278 279
427. ical contact surfaces can be directly contaminated from patient materials either by direct spray or spatter generated during dental procedures or by contact with DHCP s gloved hands These surfaces can subsequently contaminate other instruments devices hands or gloves Examples of such surfaces include e light handles switches dental radiograph equipment dental chairside computers reusable containers of dental materials drawer handles faucet handles countertops pens telephones and e doorknobs Barrier protection of surfaces and equipment can prevent contamination of clinical contact surfaces but is particularly effective for those that are difficult to clean Barriers include clear plastic wrap bags sheets tubing and plastic backed paper or other materials impervious to moisture 260 288 Because such coverings can become contaminated they should be removed and discarded between patients while DHCP are still gloved After removing the barrier examine the surface to make sure it did not become soiled inadvertently The surface needs to be cleaned and disinfected only if contamination is evident Otherwise after removing gloves and performing hand hygiene DHCP should place clean barriers on these surfaces before the next patient 1 2 288 If barriers are not used surfaces should be cleaned and disinfected between patients by using an EPA registered hospital disinfectant with an HIV HBV claim i e low level disinfect
428. icating the development of antibodies in response to infection or immunization Sterile Free from all living microorganisms usually described as a probability e g the probability of a surviving microorganism being 1 in 1 million Sterilization Use of a physical or chemical procedure to destroy all microorganisms including substantial numbers of resistant bacterial spores Surfactants Surface active agents that reduce surface tension and help cleaning by loosening emulsifying and holding soil in suspension to be more readily rinsed away Ultrasonic cleaner Device that removes debris by a process called cavitation in which waves of acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to surfaces Vaccination See immunization Vaccine Product that induces immunity therefore protecting the body from the disease Vaccines are administered through needle injections by mouth and by aerosol Washer disinfector Automatic unit that cleans and thermally disinfects instruments by using a high temperature cycle rather than a chemical bath Wicking Absorption of a liquid by capillary action along a thread or through the material e g penetration of liquids through undetected holes in a glove Review of Science Related to Dental Infection Control Personnel Health Elements of an Infection Control Program A protective health component for DHCP is an integral part of a dental pr
429. ication of caustic agents e g bleach or the injection of antiseptics or disinfectants into the wound is not recommended 19 Exposed DHCP should immediately report the exposure to the infection control coordinator or other designated person who should initiate referral to the qualified health care professional and complete necessary reports Because multiple factors contribute to the risk of infection after an occupational exposure to blood the following information should be included in the exposure report recorded in the exposed person s confidential medical record and provided to the qualified health care professional e Date and time of exposure e Details of the procedure being performed including where and how the exposure occurred and whether the exposure involved a sharp device the type and brand of device and how and when during its handling the exposure occurred e Details of the exposure including its severity and the type and amount of fluid or material For a percutaneous injury severity might be measured by the depth of the wound gauge of the needle and whether fluid was injected for a skin or mucous membrane exposure the estimated volume of material duration of contact and the condition of the skin e g chapped abraded or intact should be noted e Details regarding whether the source material was known to contain HIV or other bloodborne pathogens and if the source was infected with HIV the stage of disea
430. immune response prevents further spread of the TB bacteria although they can remain alive in the lungs for years a condition termed latent TB infection Persons with latent TB infection usually exhibit a reactive tuberculin skin test TST have no symptoms of active disease and are not infectious However they can develop active disease later in life if they do not receive treatment for their latent infection Approximately 5 of persons who have been recently infected and not treated for latent TB infection will progress from infection to active disease during the first 1 2 years after infection another 5 will develop active disease later in life Thus approximately 90 of U S persons with latent TB infection do not progress to active TB disease Although both latent TB infection and active TB disease are described as TB only the person with active disease is contagious and presents a risk of transmission Symptoms of active TB disease include a productive cough night sweats fatigue malaise fever and unexplained weight loss Certain immunocompromising medical conditions e g HIV increase the risk that TB infection will progress to active disease at a faster rate 44 Overall the risk borne by DHCP for exposure to a patient with active TB disease is probably low 20 2 Only one report exists of TB transmission in a dental office 442 and TST conversions among DHCP are also low 443 444 However in certain cases DHCP or the
431. in health care facilities ANSI AAMI ST58 1996 Arlington VA Association for the Advancement of Medical Instrumentation 1996 Fisher AA Ethylene oxide dermatitis Cutis 1984 34 20 22 24 Jay WM Swift TR Hull DS Possible relationship of ethylene oxide exposure to cataract formation Am J Ophthalmol 1982 93 727 32 US Department of Labor Occupational Safety and Health Administration Review of the ethylene oxide standard Federal Register 2000 65 35 127 8 Pratt LH Smith DG Thornton RH Simmons JB Depta BB Johnson RB The effectiveness of two sterilization methods when different precleaning techniques are employed J Dent 1999 27 247 8 US Department of Health and Human Services Food and Drug Administration 21 CFR Part 872 6730 Dental devices endodontic dry heat sterilizer final rule Federal Register 1997 62 2903 Favero MS Current issues in hospital hygiene and sterilization technology J Infect Control Asia Pacific Edition 1998 1 8 10 Greene WW Control of sterilization process Chapter 22 In Russell AD Hugo WB Ayliffe GA eds Principles and practice of disinfection preservation and sterilization Oxford England Blackwell Scientific Publications 1992 605 24 Favero MS Developing indicators for sterilization Chapter 13 In Rutala W ed Disinfection sterilization and antisepsis in health care Washington DC Association for Professionals in Infection Control and Epidemiology Inc 1998 119 32 Maki
432. ine is preferred for HCP who have close contact with immunocompromised persons 118 Appendix C Methods for Sterilizing and Disinfecting Patient Care Items and Environmental Surfaces Process Result Sterilization Destroys all microorgan isms including bacterial spores High level Destroys all microorgan disinfection isms but not necessarily high numbers of bacterial spores Intermediate Destroys vegetative level bacteria and the majority disinfection of fungi and viruses Inactivates Mycobacterium bovis Not necessarily capable of killing bacterial spores Low level Destroys the majority of disinfection vegetative bacteria certain fungi and viruses Does not Method Heat automated High temperature Low temperature Liquid immersion Heat automated Liquid immersion Liquid contact Liquid contact Examples Steam dry heat unsaturated chemical vapor Ethylene oxide gas plasma sterilization Chemical sterilants Glutaraldehyde glutaraldehydes with phenol hydrogen peroxide hydrogen peroxide with peracetic acid peracetic acid Washer disinfector Chemical sterilants high level disinfectants Glutaraldehyde glutaraldehyde with phenol hydrogen peroxide hydrogen peroxide with peracetic acid ortho phthalaldehyde U S Environmental Protection Agency EPA registered hospital disinfectant with label claim of tuberculocidal activity e g chlorine containing products quat
433. ing with a surfactant detergent and water or by an automated process e g ultrasonic cleaner or washer disinfector 98 using chemical agents If visible debris whether inorganic or organic matter is not removed it will interfere with microbial inactivation and can compromise the disinfection or sterilization process 244 249 252 After cleaning instruments should be rinsed with water to remove chemical or detergent residue Splashing should be minimized during cleaning and rinsing 3 Before final disinfection or sterilization instruments should be handled as though contaminated Considerations in selecting cleaning methods and equipment include 1 efficacy of the method process and equipment 2 compatibility with items to be cleaned and 3 occupational health and exposure risks Use of automated cleaning equipment e g ultrasonic cleaner or washer disinfector does not require presoaking or scrubbing of instruments and can increase productivity improve cleaning effectiveness and decrease worker exposure to blood and body fluids Thus using automated equipment can be safer and more efficient than manually cleaning contaminated instruments 253 If manual cleaning is not performed immediately placing instruments in a puncture resistant container and soaking them with detergent a disinfectant detergent or an enzymatic cleaner will prevent drying of patient material and make cleaning easier and less time consuming Use of a
434. inst certain emerging pathogens e g Norwalk virus potential terrorism agents e g variola major or Yersinia pestis or Creutzfeldt Jakob disease agents One point of clarification is the difference in how EPA and FDA classify disinfectants FDA adopted the same basic terminology and classification scheme as CDC to categorize medical devices i e critical semicritical and noncritical and to define antimicrobial potency for processing surfaces i e sterilization and high intermediate and low level disinfection A 6 EPA registers environmental surface disinfectants based on the manufacturer s microbiological activity claims when registering its disinfectant This difference has led to confusion on the part of users because the EPA does not use the terms intermediate and low level disinfectants as used in CDC guidelines CDC designates any EPA registered hospital disinfectant without a tuberculocidal claim as a low level disinfectant and any EPA registered hospital disinfectant with a tuberculocidal claim as an intermediate level disinfectant To understand this comparison one needs to know how EPA registers disinfectants First to be labeled as an EPA hospital disinfectant the product must pass Association of Official Analytical Chemists AOAC effectiveness tests against three target organisms Salmonella choleraesuis for effectiveness against gram negative bacteria Staphylococcus aureus for effectiveness against grampositive
435. ion pb V 353 354 358 Z NKE DNA 356 357 359 20 30
436. ion with physical injuries Ann Neurol 1982 11 377 81 Van Duijn CM Delasnerie Laupretre N Masullo C et al and European Union EU Collaborative Study Group of Creutzfeldt Jacob disease CJD Case control study of risk factors of Creutzfeldt Jakob disease in Europe during 1993 95 Lancet 1998 351 1081 S Collins S Law MG Fletcher A Boyd A Kaldor J Masters CL Surgical treatment and risk of sporadic Creutzfeldt Jakob disease a case control study Lancet 1999 353 693 7 Blanquet Grossard F Sazdovitch V Jean A et al Prion protein is not detectable in dental pulp from patients with Creutzfeldt Jakob disease J Dent Res 2000 79 700 World Health Organization Infection control guidelines for transmissible spongiform encephalopathies report of a WHO consultation Geneva Switzerland 23 26 March 1999 Geneva Switzerland World Health Organization 2000 Available at http www who int emc documents tse whocdscsraph2003c html 470 471 Institute of Medicine Committee on Quality of Health Care in America Kohn LT Corrigan JM Donaldson MS eds To err is human building a safe health system Washington DC National Academy Press 1999 CDC Framework for program evaluation in public health MMWR 1999 48 No RR 11 A A 1 A 3 A 4 A 5 A 6 Food and Drug Administration FDA and US Environmental Protection Agency EPA Memorandum of understanding between the FDA and EPA notice regarding matte
437. ith other symptoms Convalescent stage Salmonella species Enteroviral infection Hepatitis A Hepatitis B Personnel with acute or chronic hepatitis B surface antigenemia who do not perform exposure prone procedures Personnel with acute or chronic hepatitis B e antigenemia who perform exposure prone procedures Hepatitis C Herpes simplex Genital Hands herpetic whitlow Orofacial Human immunodeficiency virus personnel who perform exposure prone procedures Measles Active Postexposure susceptible personnel Meningococcal infection Mumps Active Postexposure susceptible personnel Work restriction Restrict from patient conact and contact with patient s environment No restriction Restrict from patient contact contact with patient s environment and food handling Restrict from care of patients at high risk Restrict from care of infants neonates and immunocompromised patients and their environments Restrict from patient contact contact with patient s environment and food handing No restrictiont refer to state regulations Standard precautions should always be followed Do not perform exposure prone invasive procedures until counsel from a review panel has been sought panel should review and recommend procedures that personnel can perform taking into account specific procedures as well as skill and technique Standard precautions should always be observed Refer to state and local r
438. ivity and maintenance of records data management and confidentiality IB 5 16 18 22 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 5 13 19 22 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 5 11 13 14 16 19 22 2 Provide educational information appropriate in content and vocabulary to the educational level literacy and language of DHCP IB IC 5 13 C Immunization Programs 1 Develop a written comprehensive policy regarding immunizing DHCP including a list of all required and recommended immunizations IB 5 7 8 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 5 17 D Exposure Prevention and Postexposure Management 1 Develop a comprehensive postexposure management and medical follow up pr
439. izer fails the air removal test it should not be used until inspected by sterilizer maintenance personnel and it passes the test 243 247 Manufacturer s instructions with specific details regarding operation and user maintenance information should be followed Unsaturated Chemical Vapor Sterilization Unsaturated chemical vapor sterilization involves heating a chemical solution of primarily alcohol with 0 23 formaldehyde in a closed pressurized chamber Unsaturated chemical vapor sterilization of carbon steel instruments e g dental burs causes less corrosion than steam sterilization because of the low level of water present during the cycle Instruments should be dry before sterilizing State and local authorities should be consulted for hazardous waste disposal requirements for the sterilizing solution Dry Heat Sterilization Dry heat is used to sterilize materials that might be damaged by moist heat e g burs and certain orthodontic instruments Although dry heat has the advantages of low operating cost and being noncorrosive it is a prolonged process and the high temperatures required are not suitable for certain patient care items and devices 261 Dry heat sterilizers used in dentistry include static air and forced air types e The static air type is commonly called an oven type sterilizer Heating coils in the bottom or sides of the unit cause hot air to rise inside the chamber through natural convection e The forced air
440. ld bleach is an inexpensive and effective intermediate level germicide Concentrations ranging from 500 ppm to 800 ppm of chlorine 1 100 dilution of 5 25 bleach and tap water or approximately 1 4 cup of 5 25 bleach to 1 gallon of water are effective on environmental surfaces that have been cleaned of visible contamination Appropriate personal protective equipment e g gloves and goggles should be worn when preparing hypochlorite solutions C 2 C 3 Caution should be exercised because chlorine solutions are corrosive to metals especially aluminum Germicides labeled as hospital disinfectant without a tuberculocidal claim pass potency tests for activity against three representative microorganisms Pseudomonas aeruginosa Staphylococcus aureus and Salmonella choleraesuis 119 24 7 27 27 29 34 30 5 29 29 30 28 5 34 25 29 45 36 43 5 10
441. le 5 13 16 Clearly written policies procedures and guidelines can help ensure consistency efficiency and effective coordination of activities Personnel subject to occupational exposure should receive infection control training on initial assignment when new tasks or procedures affect their occupational exposure and at a minimum annually 3 Education and training should be appropriate to the assigned duties of specific DHCP e g techniques to prevent cross contamination or instrument sterilization For DHCP who perform tasks or procedures likely to result in occupational exposure to infectious agents training should include 1 a description of their exposure risks 2 review of prevention strategies and infection control policies and procedures 3 discussion regarding how to manage work related illness and injuries including PEP and 4 review of work restrictions for the exposure or infection Inclusion of DHCP with minimal exposure risks e g administrative employees in education and training programs might enhance facilitywide understanding of infection control principles and the importance of the program Educational materials should be appropriate in content and vocabulary for each person s educational level literacy and language as well as be consistent with existing federal state and local regulations 5 13 Immunization Programs DHCP are at risk for exposure to and possible infection with infectious organisms I
442. le injections with a single needle the practitioner should recap the needle between injections by using a one handed technique or use a device with a needle resheathing mechanism Passing a syringe with an unsheathed needle should be avoided because of the potential for injury Additional information for developing a safety program and for identifying and evaluating safer dental devices is available at e http www cdc gov OralHealth infectioncontrol forms htm forms for screening and evaluating safer dental devices and e http www cdc gov niosh topics bbp state legislation on needlestick safety Postexposure Management and Prophylaxis Postexposure management is an integral component of a complete program to prevent infection after an occupational exposure to blood During dental procedures saliva is predictably contaminated with blood 7 114 Even when blood is not visible it can still be present in limited quantities and therefore is considered a potentially infectious material by OSHA 3 9 A qualified health care professional should evaluate any occupational exposure incident to blood or OPIM including saliva regardless of whether blood is visible in dental settings 3 Dental practices and laboratories should establish written comprehensive programs that include hepatitis B vaccination and postexposure management protocols that 1 describe the types of contact with blood or OPIM that can place DHCP at risk for infection 2
443. lerant items or clean and disinfect with an EPA registered hospital disinfectant with low HIV HBV effectiveness claim to intermediate level tuberculocidal claim activity depending on the degree of contamination In J Laser Electrosurgery Plumes Surgical Smoke 1 No recommendation is offered regarding practices to reduce DHCP exposure to laser plumes surgical smoke when using lasers in dental practice Practices to reduce HCP exposure to laser plumes surgical smoke have been suggested including use of a standard precautions e g high filtration surgical masks and possibly full face shields 437 b central room suction units with in line filters to collect particulate matter from minimal plumes and c dedicated mechanical smoke exhaust systems with a high efficiency filter to remove substantial amounts of laser plume particles The effect of the exposure e g disease transmission or adverse respiratory effects on DHCP from dental applications of lasers has not been adequately evaluated see previous discussion Laser Electrosurgery Plumes or Surgical Smoke Unresolved issue K Mycobacterium tuberculosis 1 General Recommendations a Educate all DHCP regarding the recognition of signs symptoms and transmission of TB IB 20 27 b Conduct a baseline TST preferably by using a two step test for all DHCP who might have contact with persons with suspected or confirmed active TB regardless of the risk classifica
444. lergy Clin Immunol 2002 109 131 5 Hunt LW Kelkar P Reed CE Yunginger JW Management of occupational allergy to natural rubber latex in a medical center the importance of quantitative latex allergen measurement and objective follow up J Allergy Clin Immunol 2002 110 suppl 2 S96 106 Turjanmaa K Kanto M Kautiainen H Reunala T Palosuo T Long term outcome of 160 adult patients with natural rubber latex allergy J Allergy Clin Immunol 2002 110 suppl 2 S70 4 Heilman DK Jones RT Swanson MC Yunginger JW A prospective controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room J Allergy Clin Immunol 1996 98 325 30 Baur X Jager D Airborne antigens from latex gloves Lancet 1990 335 912 Turjanmaa K Reunala T Alenius H Brummer Korvenkontio H Palosuo T Allergens in latex surgical gloves and glove powder Lancet 1990 336 1588 Baur X Chen Z Allmers H Can a threshold limit value for natural rubber latex airborne allergens be defined J Allergy Clin Immunol 1998 101 24 7 Trape M Schenck P Warren A Latex gloves use and symptoms in health care workers 1 year after implementaion of a policy restricting the use of powdered gloves Am J Infec Control 2000 28 352 8 Allmers H Brehler R Chen Z Raulf Heimsoth M Fels H Baur X Reduction of latex aeroallergens and latex specific IgE antibodies in sensitized workers after removal of powdered natural rubber latex
445. ly attached to dental unit waterlines and although they do not enter the patient s oral cavity they are likely to become contaminated with oral fluids during treatment procedures Such components e g handles or dental unit attachments of saliva ejectors high speed air evacuators and air water syringes should be covered with impervious barriers that are changed after each use If the item becomes visibly contaminated during use DHCP should clean and disinfect with an EPA registered hospital disinfectant intermediate level before use on the next patient Saliva Ejectors Backflow from low volume saliva ejectors occurs when the pressure in the patient s mouth is less than that in the evacuator Studies have reported that backflow in low volume suction lines can occur and microorganisms be present in the lines retracted into the patient s mouth when a seal around the saliva ejector is created e g by a patient closing lips around the tip of the ejector creating a partial vacuum 364 366 This backflow can be a potential source of cross contamination occurrence is variable because the quality of the seal formed varies between patients Furthermore studies have demonstrated that gravity pulls fluid back toward the patient s mouth whenever a length of the suction tubing holding the tip is positioned above the patient s mouth or during simultaneous use of other evacuation high volume equipment 364 366 Although no adverse health effects
446. matitis is usually confined to the area of contact Latex allergy type I hypersensitivity to latex proteins can be a more serious systemic allergic reaction usually beginning within minutes of exposure but sometimes occurring hours later and producing varied symptoms More common reactions include runny nose sneezing itchy eyes scratchy throat hives and itchy burning skin sensations More severe symptoms include asthma marked by difficult breathing coughing spells and wheezing cardiovascular and gastrointestinal ailments and in rare cases anaphylaxis and death 32 225 The American Dental Association ADA began investigating the prevalence of type I latex hypersensitivity among DHCP at the ADA annual meeting in 1994 In 1994 and 1995 approximately 2 000 dentists hygienists and assistants volunteered for skin prick testing Data demonstrated that 6 2 of those tested were positive for type I latex hypersensitivity 226 Data from the subsequent 5 years of this ongoing cross sectional study indicated a decline in prevalence from 8 5 to 4 3 227 This downward trend is similar to that reported by other studies and might be related to use of latex gloves with lower allergen content 228 230 Natural rubber latex proteins responsible for latex allergy are attached to glove powder When powdered latex gloves are worn more latex protein reaches the skin In addition when powdered latex gloves are donned or removed latex protein powd
447. medical waste MMWR 1990 39 822 4 Palenik CJ Managing regulated waste in dental environments J Contemp Dent Pract 2003 4 76 Rutala WA Mayhall CG Medical waste Infect Control Hosp Edidemiol 1992 13 38 48 Greene R State and Territorial Association on Alternate Treatment Technologies Technical assistance manual state regulatory oversight of medical waste treatment technologies 2nd ed Washington DC US Environmental Protection Agency 1994 Available at http www epa gov epaoswer other medical mwpdfs ta 1 pdf US Environmental Protection Agency 40 CFR Part 60 Standards of performance for new stationary sources and emission guidelines for existing sources hospital medical infectious waste incinerators final rule Federal Register 1997 62 48347 91 Slade JS Pike EB Eglin RP Colbourne JS Kurtz JB The survival of human immunodeficiency virus in water sewage and sea water Water Sci Tech 1989 21 55 9 Walker JT Bradshaw DJ Bennett AM Fulford MR Martin MV Marsh PD Microbial biofilm formation and contamination of dental unit water systems in general dental practice Appl Environ Microbiol 2000 66 3363 7 Schulze Robbecke R Feldmann C Fischeder R Janning B Exner M Wahl G Dental units an environmental study of sources of potentially pathogenic mycobacteria Tuber Lung Dis 1995 76 318 23 Barbeau J Tanguay R Faucher E et al Multiparametric analysis of waterline contamination in dental units Appl Environ Micro
448. minated sharps or chemicals Commonly referred to as utility industrial or general purpose gloves Should be puncture or chemical resistant depending on the task Latex gloves do not provide adequate Nitrile Butyl rubber CO IO IO IO IO chemical protection Not for use during patient care Santitize after use Fluoroelastomer 4 6 Polyethylene and ethylene vinyl alcohol copolymer 3 4 6 Physical properties can vary by material manufacturer and protein and chemical composition 1 contains allergenic NRL proteins 2 vulcanized rubber contains allergenic rubber processing chemicals 3 likely to have enhanced chemical or puncture resistance 4 nonvulcanized and does not contain rubber processing chemicals 5 inappropriate for use with methacrylates 6 resistant to most methacrylates Medical or dental gloves include patient examination gloves and surgeon s i e surgical gloves and are medical devices regulated by the FDA Only FDA cleared medical or dental patient examination gloves and surgical gloves can be used for patient care hands should be dried thoroughly before donning gloves and washed again immediately after glove removal Types of Gloves Because gloves are task specific their selection should be based on the type of procedure to be performed e g surgery or patient examination Table 3 Sterile surgeon s gloves must meet standards for sterility assurance established by FDA and
449. mmunizations substantially reduce both the number of DHCP susceptible to these diseases and the potential for disease transmission to other DHCP and patients 5 7 Thus immunizations are an essential part of prevention and infection control programs for DHCP and a comprehensive immunization policy should be implemented for all dental health care facilities 17 18 The Advisory Committee on Immunization Practices ACIP provides national guidelines for immunization of HCP which includes DHCP 17 Dental practice immunization policies should incorporate current state and federal regulations as well as recommendations from the U S Public Health Service and professional organizations 7 Appendix B On the basis of documented health care associated transmission HCP are considered to be at substantial risk for acquiring or transmitting hepatitis B influenza measles mumps rubella and varicella All of these diseases are vaccine preventable ACIP recommends that all HCP be vaccinated or have documented immunity to these diseases 5 77 ACIP does not recommend routine immunization of HCP against TB i e inoculation with bacille Calmette Gu rin vaccine or hepatitis A 17 No vaccine exists for HCV ACIP guidelines also provide recommendations regarding immunization of HCP with special conditions e g pregnancy HIV infection or diabetes 5 17 Immunization of DHCP before they are placed at risk for exposure remains the most effici
450. 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 454 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 243 455 456 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 457 458 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 459 after use of extracted pituitary hormones 460 46 and after implant of contaminated corneal 462 and dura mater grafts 463 464 from humans The equipment related cases occurred before
451. n BW Davis RD Reduction of bacteria containing spray produced during ultrasonic scaling Gen Dent 2001 49 648 52 Brown AR Papasian CJ Shultz P Theisen FC Shultz RE Bacteremia and intraoral suture removal can an antimicrobial rinse help J Am Dent Assoc 1998 129 1455 61 Lockhart PB An analysis of bacteremias during dental extractions A double blind placebo controlled study of chlorhexidine Arch Intern Med 1996 156 513 20 Dajani AS Bisno AL Chung KJ et al Prevention of bacterial endocarditis recommendations by the American Heart Association JAMA 1997 277 1794 1801 Tate WH White RR Disinfection of human teeth for educational purposes J Dent Educ 1991 55 583 S Pantera EA Jr Zambon JJ Shih Levine M Indirect immunofluorescence for the detection of Bacteroides species in human dental pulp J Endodontics 1988 14 218 23 Pantera EA Jr Schuster GS Sterilization of extracted human 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 teeth J Dent Educ 1990 54 283 5 Parsell DE Stewart BM Barker JR Nick TG Karns L Johnson RB The effect of steam sterilization on the physical properties and perceived cutting characteristics of extracted teeth J Dent Educ 1998 62 260 3 American Dental Association s Council on Scientific Affairs and Council on Dental Practice Infection
452. n Infect Dis 2003 36 1383 90 Salisbury DM Hutfilz P Treen LM Bollin GE Gautam S The effect of rings on microbial load of health care workers hands Am J Infec Control 1997 25 24 7 Cochran MA Miller CH Sheldrake MS The efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment J Am Dent Assoc 1989 119 141 4 Miller CH Palenik DJ Aseptic techniques Chapter 10 In Miller CH Palenik DJ eds Infection control and management of hazardous materials for the dental team 2 ed St Louis MO Mosby 1998 CDC National Institute for Occupational Safety and Health TB respiratory protection program in health care facilities administrator s guide Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1999 DHHS publication no NIOSH 99 143 US Department of Labor Occupational Safety and Health Administration OSHA 29 CFR 1910 139 Respiratory protection for M tuberculosis Federal Register 1998 49 442 9 CDC National Institute for Occupational Safety and Health 75 C DC 003 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 76 NIOSH guide to the selection
453. n peroxide gas plasma exist but are not yet practical for dental offices Bead sterilizers have been used in dentistry to sterilize small metallic instruments e g endodontic files FDA has determined that a risk of infection exists with these devices because of their potential failure to sterilize dental instruments and has required their commercial distribution cease unless the manufacturer files a premarket approval application If a bead sterilizer is employed DHCP assume the risk of employing a dental device FDA has deemed neither safe nor effective 276 Sterilization Monitoring Monitoring of sterilization procedures should include a combination of process parameters including mechanical chemical and biological 247 248 277 These parameters evaluate both the sterilizing conditions and the procedure s effectiveness Mechanical techniques for monitoring sterilization include assessing cycle time temperature and pressure by observing the gauges or displays on the sterilizer and noting these parameters for each load 243 248 Some tabletop sterilizers have recording devices that print out these parameters Correct readings do not ensure sterilization but incorrect readings can be the first indication of a problem with the sterilization cycle Chemical indicators internal and external use sensitive chemicals to assess physical conditions e g time and temperature during the sterilization process Although chemical indicators d
454. n the floor nearby operatory surfaces DHCP or the patient The spray also might contain certain aerosols i e particles of respirable size lt 10 um Aerosols can remain airborne for extended periods and can be inhaled However they should not be confused with the large particle spatter that makes up the bulk of the spray from handpieces and ultrasonic scalers Appropriate work practices including use of dental dams 72 and high velocity air evacuation should minimize dissemination of droplets spatter and aerosols 2 Primary PPE used in oral health care settings includes gloves surgical masks protective eyewear face shields and protective clothing e g gowns and jackets All PPE should be removed before DHCP leave patient care areas 3 Reusable PPE e g clinician or patient protective eyewear and face shields should be cleaned with soap and water and when visibly soiled disinfected between patients according to the manufacturer s directions 2 3 Wearing gloves surgical masks protective eyewear and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by OSHA 3 General work clothes e g uniforms scrubs pants and shirts are neither intended to protect against a hazard nor considered PPE Masks Protective Eyewear Face Shields A surgical mask that covers both the nose and mouth and protective eyewear with solid side shields or a face shield sho
455. nd Hygiene Hand hygiene e g handwashing hand antisepsis or surgical hand antisepsis substantially reduces potential pathogens on the hands and is considered the single most critical measure for reducing the risk of transmitting organisms to patients and HCP 120 123 Hospital based studies have demonstrated that noncompliance with hand hygiene practices is associated with health care associated infections and the spread of multiresistant organisms Noncompliance also has been a major contributor to outbreaks 723 The prevalence of health care associated infections decreases as adherence of HCP to recommended hand hygiene measures improves 124 126 The microbial flora of the skin first described in 1938 consist of transient and resident microorganisms 27 Transient flora which colonize the superficial layers of the skin are easier to remove by routine handwashing They are often acquired by HCP during direct contact with patients or contaminated environmental surfaces these organisms are most frequently associated with health care associated infections Resident flora attached to deeper layers of the skin are more resistant to removal and less likely to be associated with such infections The preferred method for hand hygiene depends on the type of procedure the degree of contamination and the desired persistence of antimicrobial action on the skin Table 2 For routine dental examinations and nonsurgical procedures handw
456. nd the risk of developing serologic evidence of HBV infection 23 37 38 Blood contains the greatest proportion of HBV infectious particle titers of all body fluids and is the most critical vehicle of transmission in the health care setting HBsAg is also found in multiple other body fluids including breast milk bile cerebrospinal fluid feces nasopharyngeal washings saliva semen sweat and synovial fluid However the majority of body fluids are not efficient vehicles for transmission because they contain low quantities of infectious HBV despite the presence of HBsAg 9 The concentration of HBsAg in body fluids can be 100 1 000 fold greater than the concentration of infectious HBV particles 39 Although percutaneous injuries are among the most efficient modes of HBV transmission these exposures probably account for only a minority of HBV infections among HCP In multiple investigations of nosocomial hepatitis B outbreaks the majority of infected HCP could not recall an overt percutaneous injury 40 4 although in certain studies approximately one third of infected HCP recalled caring for a patient who was HBsAg positive 42 43 In addition HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for lt 1 week 44 Thus HBV infections that occur in HCP with no history of nonoccupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or
457. ner P Efficacy of a barrier cream and its vehicle as protective measures against 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 occupational irritant contact dermatitis Contact Dermatitis 2000 42 77 80 McCormick RD Buchman TL Maki DG Double blind randomized trial of scheduled use of a novel barrier cream and an oil containing lotion for protecting the hands of health care workers Am J Infect Control 2000 28 302 10 Larson E Anderson JK Baxendale L Bobo L Effects of a protective foam on scrubbing and gloving Am J Infect Control 1993 21 297 301 McGinley KJ Larson EL Leyden JJ Composition and density of microflora in the subungual space of the hand J Clin Microbiol 1988 26 930 3 Pottinger J Burns S Manske C Bacterial carriage by artificial versus natural nails Am J Infect Control 1989 17 340 4 McNeil SA Foster CL Hedderwick SA Kauffman CA Effect of hand cleansing with antimicrobial soap or alcohol based gel on microbial colonization of artificial fingernails worn by health care workers Clin Infect Dis 2001 32 367 72 Rubin DM Prosthetic fingernails in the OR a research study AORN J 1988 47 944 5 Hedderwick SA McNeil SA Lyons MJ Kauffman CA Pathogenic organisms associated with artificial fingernails worn by healthcare workers Infect Control Hosp Epidemiol 2000 21 505 9
458. nimize 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 243 249 252 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 2 253 Use work practice controls that minimize contact with sharp instruments if manual cleaning is necessary e g long handled brush IC 7 Wear puncture and chemical resistant heavy duty utility gloves for instrument cleaning and decontamination procedures IB 7 Wear appropriate PPE e g mask protective eyewear and gown when splashing or spraying is anticipated during cleaning IC 13 D Preparation and Packaging ile 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 243 254 257 Use a container system or wrapping compatible with the type of sterilization process used and that has received FDA clearance IB 243 247 256 Before sterilization of critical and semicritical instruments inspect instruments for cleanliness then wrap or place t
459. ns dry and crust Until all lesions dry and crust From tenth day after first exposure through twenty first day twenty eighth day if VZIG administered after last exposure or if varicella occurs when lesions crust and dry Until acute symptoms resolve Source Adapted from Bolyard EA Hospital Infection Control Practices Advisory Committee Guidelines for infection control in health care personnel 1998 Am J Infect Control 1998 26 289 354 Modified from recommendations of the Advisory Committee on Immunization Practices ACIP Unless epidemiologically linked to transmission of infection Those susceptible to varicella and who are at increased risk of complications of varicella e g neonates and immunocompromised persons of any age Patients at high risk as defined by ACIP for complications of influenza 91 Guidelines for Infection Control in Dental Health Care Settings 2008 vaccine and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series are not necessary for vaccine responders 17 Hepatitis D Virus An estimated 4 of persons with acute HBV infection are also infected with hepatitis Delta virus HDV Discovered in 1977 HDV is a defective bloodborne virus requiring the presence of HBV to replicate Patients coinfected with HBV and HDV have substantially higher mortality rates than those infected with HBV alone Because HDV infection is dependent on HBV for
460. ntact Dermatitis and Latex Hypersensitivity A General Recommendations 1 Educate DHCP regarding the signs symptoms and diagnoses of skin reactions associated with frequent hand hygiene and glove use IB 5 3 32 2 Screen all patients for latex allergy e g take health history and refer for medical consultation when latex allergy is suspected IB 32 3 Ensure a latex safe environment for patients and DHCP with latex allergy IB 32 4 Have emergency treatment kits with latex free products available at all times II 32 111 Guidelines for Infection Control in Dental Health Care Settings 2008 VI Sterilization and Disinfection of Patient Care Items A General Recommendations 112 1 Use only FDA cleared medical devices for sterilization and follow the manufacturer s instructions for correct use IB 248 Clean and heat sterilize critical dental instruments before each use IA 2 137 243 244 246 249 407 Clean and heat sterilize semicritical items before each use IB 2 249 260 407 Allow packages to dry in the sterilizer before they are handled to avoid contamination IB 247 Use of heat stable semicritical alternatives is encouraged IB 2 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 instru
461. o exist for safe drinking water quality as established by EPA the American Public Health Association APHA and the American Water Works Association AWWA they have set limits for heterotrophic bacteria of lt 500 CFU mL of drinking water 341 342 Thus the number of bacteria in water used as a coolant irrigant for nonsurgical dental procedures should be as low as reasonably achievable and at a minimum lt 500 CFU mL the regulatory standard for safe drinking water established by EPA and APHA AWWA Strategies To Improve Dental Unit Water Quality In 1993 CDC recommended that dental waterlines be flushed at the beginning of the clinic day to reduce the microbial load 2 However studies have demonstrated this practice does not affect biofilm in the waterlines or reliably improve the quality of water used during dental treatment 315 338 343 Because the recommended value of 500 CFU mL cannot be achieved by using this method other strategies should be employed Dental unit water that remains untreated or unfiltered is unlikely to meet drinking water standards 303 309 Commercial devices and procedures designed to improve the quality of water used in dental treatment are available 3 6 methods demonstrated to be effective include self contained water systems combined with chemical treatment in line microfilters and combinations of these treatments Simply using source water containing lt 500 CFU mL of bacteria e g tap distilled or
462. o not prove sterilization has been achieved they allow detection of certain equipment malfunctions and they can help identify procedural errors External indicators applied to the outside of a package e g chemical indicator tape or special markings change color rapidly when a specific parameter is reached and they verify that the package has been exposed to the sterilization process Internal chemical indicators should be used inside each package to ensure the sterilizing agent has penetrated the packaging material and actually reached the instruments inside A single parameter internal chemical indicator provides information regarding only one sterilization parameter e g time or temperature Multiparameter internal chemical indicators are designed to react to gt 2 parameters e g time and temperature or time temperature and the presence of steam and can provide a more reliable indication that sterilization conditions have been met 254 Multiparameter internal indicators are available only for steam sterilizers i e autoclaves Because chemical indicator test results are received when the 100 sterilization cycle is complete they can provide an early indication of a problem and where in the process the problem might exist If either mechanical indicators or internal or external chemical indicators indicate inadequate processing items in the load should not be used until reprocessed 134 Biological indicators BIs i e
463. of the Federal Insecticide Fungicide and Rodenticide Act FIFRA of 1947 as amended in 1996 A 4 Under FIFRA any substance or mixture of substances intended to prevent destroy repel or mitigate any pest including microorganisms but excluding those in or on living man or animals must be registered before sale or distribution To obtain a registration a manufacturer must submit specific data regarding the safety and the effectiveness of each product EPA requires manufacturers to test formulations by using accepted methods for microbicidal activity stability and toxicity to animals and humans Manufacturers submit these data to EPA with proposed labeling If EPA concludes a product may be used without causing unreasonable adverse effects the product and its labeling are given an EPA registration number and the manufacturer may then sell and distribute the product in the United States FIFRA requires users of products to follow the labeling directions on each product explicitly The following statement appears on all EPA registered product labels under the Directions for Use heading It is a violation of federal law to use this product inconsistent with its labeling This means that DHCP must follow the safety precautions and use directions on the labeling of each registered product Not following the specified dilution contact time method of application or any other condition of use is considered misuse of the product FDA under
464. ogram IB IC 5 13 14 19 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 110 the risk classification of the setting IB 20 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 5 22 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 5 22 Develop policies and procedures for evaluation diagnosis and management of DHCP with suspected or known occupational contact dermatitis IB 32 Seek definitive diagnosis by a qualified health care professional for any DHCP with suspected latex allergy to carefully determine its specific etiology and app
465. ohol can be reduced or eliminated by adding 1 3 glycerol or other skin conditioning agents 123 After application of alcohol based surgical hand scrub product with persistent activity as recommended allow hands and forearms to dry thoroughly and immediately don sterile surgeon s gloves 144 145 Follow manufacturer instructions 122 123 137 146 Before beginning surgical hand scrub remove all arm jewelry and any hand jewelry that may make donning gloves more difficult cause gloves to tear more readily 142 143 or interfere with glove usage e g ability to wear the correct sized glove or altered glove integrity and reduce resident flora for the duration of a procedure to prevent introduction of organisms in the operative wound if gloves become punctured or torn Skin bacteria can rapidly multiply under surgical gloves if hands are washed with soap that is not antimicrobial 127 128 Thus an antimicrobial soap or alcohol hand rub with persistent activity should be used before surgical procedures 729 131 Agents used for surgical hand antisepsis should substantially reduce microorganisms on intact skin contain a nonirritating antimicrobial preparation have a broad spectrum of activity be fast acting and have a persistent effect 727 732 735 Persistence i e extended antimicrobial activity that prevents or inhibits survival of microorganisms after the product is applied is critical because microorganisms can colonize on hand
466. ologic surgical procedures New York City March 1993 June 1994 MMWR 1997 46 25 9 Mendelson MH Lin Chen BY Solomon R Bailey E Kogan G Goldbold J Evaluation of a safety resheathable winged steel needle for prevention of percutaneous injuries associated with intravascular access procedures among healthcare workers Infect Control Hosp Epidemiol 2003 24 105 12 CDC Recommendations for prevention of HIV transmission in health care settings MMWR 1987 36 No S2 CDC Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health care and public safety workers a response to P L 100 607 The Health Omnibus Programs Extension Act of 1988 MMWR 1989 38 No S6 CDC National Institute for Occupational Safety and Health Selecting evaluating and using sharps disposal containers Cincinnati OH US Department of Health and Human Services Public Health Service CDC National Institute for Occupational Safety and Health 1998 DHHS publication no NIOSH 97 111 CDC Public Health Service statement on management of occupational exposure to human immunodeficiency virus including considerations regarding zidovudine postexposure use MMWR 1990 39 No RR 1 CDC Notice to readers update provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV MMWR 1996 45 468 72 CDC Public Health Service guidelines for the management of health care worker expo
467. ompt reporting evaluation counseling treatment and medical follow up of all occupational exposures should be available to all DHCP Written policies and procedures should be consistent with federal state and local requirements addressing education and training postexposure management and exposure reporting see Preventing Transmission of Bloodborne Pathogens DHCP who have contact with patients can also be exposed to persons with infectious TB and should have a baseline tuberculin skin test TST preferably by using a two step test at the beginning of employment 20 Thus if an unprotected occupational exposure occurs TST conversions can be distinguished from positive TST results caused by previous exposures 20 21 The facility s level of TB risk will determine the need for routine follow up TSTs see Special Considerations Medical Conditions Work Related Illness and Work Restrictions DHCP are responsible for monitoring their own health status DHCP who have acute or chronic medical conditions that render them susceptible to opportunistic infection should discuss with their personal physicians or other qualified authority whether the condition might affect their ability to safely perform their duties However under certain circumstances health care facility managers might need to exclude DHCP from work or patient contact to prevent further transmission of infection 22 Decisions concerning work restrictions are based on th
468. on e g N 95 masks for DHCP or postponement of nonemergency dental procedures DHCP should be familiar also with the hierarchy of controls that categorizes and prioritizes prevention strategies 72 For bloodborne pathogens engineering controls that eliminate or isolate the hazard e g puncture resistant sharps containers or needle retraction devices are the primary strategies for protecting DHCP and patients Where engineering controls are not available or appropriate work practice controls that result in safer behaviors e g one hand needle recapping or not using fingers for cheek retraction while using sharp instruments or suturing and use of personal protective equipment PPE e g protective eyewear gloves and mask can prevent exposure 3 In addition administrative controls e g policies procedures and enforcement measures targeted at reducing the risk of exposure to infectious persons are a priority for certain pathogens e g M tuberculosis particularly those spread by airborne or droplet routes Dental practices should develop a written infection control program to prevent or reduce the risk of disease transmission Such a program should include establishment and implementation of policies procedures and practices in conjunction with selection and use of technologies and products to prevent work related injuries and illnesses among DHCP as well as health care associated infections among patients The progr
469. onal exposures to bloodborne pathogens e Creutzfeldt Jakob disease CJD and other prion related diseases including postexposure prophylaxis PEP for work exposures to e infection control program evaluation and hepatitis B virus HBV hepatitis C virus HCV and human e research considerations immunodeficiency virus HIV These guidelines were developed by CDC staff members in e selection and use of devices with features designed to prevent collaboration with other authorities on infection control Draft sharps injury documents were reviewed by other federal agencies and professional organizations from the fields of dental health care public health and The material in this report originated in the National Center for Chronic hospital epidemiology and infection control A Federal Register notice Disease Prevention and Health Promotion James S Marks M D elicited public comments that were considered in the decision making M P H Director and the Division of Oral Health William R Maas process Existing guidelines and published research pertinent to dental D D S M P H Director infection control principles and practices were reviewed Wherever 84 possible recommendations are based on data from well designed scientific studies However only a limited number of studies have characterized risk factors and the effectiveness of prevention measures for infections associated with dental health care practices Some infection control pr
470. onale 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 Unresolved issue No recommendation Insufficient evidence or no consensus regarding efficacy exists 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 hypersensit
471. operative wound contamination and exposure of the DHCP s hands to microorganisms from patients In addition bacteria can multiply rapidly in the moist environments underneath gloves and thus the 95 Guidelines for Infection Control in Dental Health Care Settings 2008 TABLE 3 Glove types and indications Commercially available glove materials Glove Indication Comment Material Attributes Patient Patient care examinations Medical device regulated by the Food and Natural rubber latex NRL 1 2 examination other nonsurgical proce Drug Administration FDA Nitrile 2 3 gloves dures involving contact with Nitrile and chloroprene neoprene blends 2 3 mucous membranes and Nonsterile and sterile single use Nitrile amp NRL blends 1 2 3 laboratory procedures disposable Use for one patient and Butadiene methyl methacrylate 2 3 discard appropriately Polyvinyl chloride PVC vinyl 4 Polyurethane 4 Styrene based copolymer 4 5 Surgeon s Surgical procedures Medical device regulated by the FDA NRL 1 2 gloves Sterile and single use disposable Use for Nitrile 2 3 one patient and discard appropriately Chloroprene neoprene 2 3 NRL and nitrile or chloroprene blends 2 3 Synthetic polyisoprene 2 Styrene based copolymer 4 5 Polyurethane 4 Nonmedical Housekeeping procedures Not a medical device regulated by the FDA NRL and nitrile or chloroprene blends gloves e g cleaning and Chloroprene neoprene disinfection Handling conta
472. or use in preclinical educational training These teeth should be cleaned of visible blood and gross debris and maintained in a hydrated state in a well constructed closed container during transport The container should be labeled with the biohazard symbol 3 4 Because these teeth will be autoclaved before clinical exercises or study use of the most economical storage solution e g water or saline might be practical Liquid chemical germicides can also be used but do not reliably disinfect both external surface and interior pulp tissue 403 404 Before being used in an educational setting the teeth should be heat sterilized to allow safe handling Microbial growth can be eliminated by using an autoclave cycle for 40 minutes 405 but because preclinical educational exercises simulate clinical experiences students enrolled in dental programs should still follow standard precautions Autoclaving teeth for preclinical laboratory exercises does not appear to alter their physical properties sufficiently to compromise the learning experience 405 406 However whether autoclave sterilization of extracted teeth affects dentinal structure to the point that the chemical and microchemical relationship between dental materials and the dentin would be affected for research purposes on dental materials is unknown 406 Use of teeth that do not contain amalgam is preferred in educational settings because they can be safely autoclaved 403 405 Extrac
473. phy infection control is available 260 367 368 However care should be taken to avoid contamination of the developing equipment Protective barriers should be used or any surfaces that become contaminated should be cleaned and disinfected with an EPA registered hospital disinfectant of low i e HIV and HBV claim to intermediate level i e tuberculocidal claim activity Radiography equipment e g radiograph tubehead and control panel should be protected with surface barriers that are changed after each patient If barriers are not used equipment that has come into contact with DHCP s gloved hands or contaminated film packets should be cleaned and then disinfected after each patient use Digital radiography sensors and other high technology instruments e g intraoral camera electronic periodontal probe occlusal analyzers and lasers come into contact with mucous membranes and are considered semicritical devices They should be cleaned and ideally heat sterilized or high level disinfected between patients However these items vary by manufacturer or type of device in their ability to be sterilized or high level disinfected Semicritical items that cannot be reprocessed by heat sterilization or high level disinfection should at a minimum be barrier protected by using an FDA cleared barrier to reduce gross contamination during use Use of a barrier does not always protect from contamination 369 374 One study determined that a b
474. posure to mechanical e g sharps fingernails or jewelry and chemical e g dimethyacrylates hazards and over time These variables can be controlled ultimately optimizing glove performance by 1 maintaining short fingernails 2 minimizing or eliminating hand jewelry and 3 using engineering and work practice controls to avoid injuries with sharps Sterile Surgeon s Gloves and Double Gloving During Oral Surgical Procedures Certain limited studies have determined no difference in postoperative infection rates after routine tooth extractions when surgeons wore either sterile or nonsterile gloves 215 216 However wearing sterile surgeon s gloves during surgical procedures is supported by a strong theoretical rationale 2 7 137 Sterile gloves minimize transmission of microorganisms from the hands of surgical DHCP to patients and prevent contamination of the hands of surgical DHCP with the patient s blood and body fluids 737 In addition sterile surgeon s gloves are more rigorously regulated by FDA and therefore might provide an increased level of protection for the provider if exposure to blood is likely Although the effectiveness of wearing two pairs of gloves in preventing disease transmission has not been demonstrated 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 8 185 195 196 198 217 219 In
475. pped and unwrapped critical and semicritical items that are not sensitive to heat and moisture 260 Steam sterilization requires exposure of each item to direct steam contact at a required temperature and pressure for a specified time needed to kill microorganisms Two basic types of steam sterilizers are the gravity displacement and the high speed prevacuum sterilizer The majority of tabletop sterilizers used in a dental practice are gravity displacement sterilizers although prevacuum sterilizers are becoming more widely available In gravity displacement sterilizers steam is admitted through steam lines a steam generator or self generation of steam within the chamber Unsaturated air is forced out of the chamber through a vent in the chamber wall Trapping of air is a concern when using saturated steam under gravity displacement errors in packaging items or overloading the sterilizer chamber can result in cool air pockets and items not being sterilized Prevacuum sterilizers are fitted with a pump to create a vacuum in the chamber and ensure air removal from the sterilizing chamber before the chamber is pressurized with steam Relative to gravity displacement this procedure allows faster and more positive steam penetration throughout the entire load Prevacuum sterilizers should be tested periodically for adequate air removal as recommended by the manufacturer Air not removed from the chamber will interfere with steam contact If a steril
476. r One dose SC no booster Two 0 5 mL doses SC 4 8 weeks apart if aged gt 13 years Appendix B Immunizations Strongly Recommended for Health Care Personnel HCP Indications Health care personnel HCP at risk for exposure to blood and body fluids HCP who have contact with patients at high risk or who work in chronic care facilities HCP aged gt 50 years or who have high risk medical conditions HCP who were born during or after 1957 without documenta tion of 1 receipt of 2 doses of live vaccine on or after their first birthday 2 physician diagnosed measles or 3 laboratory evidence of immunity Vaccine should also be considered for all HCP who have no proof of immunity including those born before 1957 HCP believed susceptible can be vaccinated adults born before 1957 can be considered immune HCP both male and female who lack documentation of receipt of live vaccine on or after their first birthday or lack of laboratory evidence of immunity can be vaccinated Adults born before 1957 can be considered immune except women of childbearing age HCP without reliable history of varicella or laboratory evidence of varicella immunity Major precautions and contraindications History of anaphylactic reaction to common baker s yeast Pregnancy is not a contraindication History of anaphylactic hypersensi tivity to eggs or to other components of the vaccine Pregnancy immunocompromised s
477. r Lancet 1981 1 550 1 Francis DP Favero MS Maynard JE Transmission of hepatitis B virus Review Semin Liver Dis 1981 1 27 32 Favero MS Maynard JE Petersen NJ et al Hepatitis B antigen on environmental surfaces Letter Lancet 1973 2 1455 Lauer JL VanDrunen NA Washburn JW Balfour HH Jr Transmission of hepatitis B virus in clinical laboratory areas J Infect Dis 1979 140 5 13 6 Hennekens CH Hemodialysis associated hepatitis an outbreak among hospital personnel JAMA 1973 225 407 8 Garibaldi RA Forrest JN Bryan JA Hanson BF Dismukes WE Hemodialysis associated hepatitis JAMA 1973 225 384 9 Snydman DR Bryan JA Macon EJ Gregg MB Hemodialysis associated hepatitis a report of an epidemic with further evidence on mechanisms of transmission Am J Epidemiol 1976 104 363 70 Shapiro CN Occupational risk of infection with hepatitis B and hepatitis C virus Surg Clin North Am 1995 75 1047 56 Cleveland JL Siew C Lockwood SA Gruninger SE Gooch BF Shapiro CN Hepatitis B vaccination and infection among U S dentists 1983 1992 J Am Dent Assoc 1996 127 1383 90 CDC Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure prone invasive procedures MMWR 1991 40 No RR 8 Chamberland ME HIV transmission from health care worker to patient what is the risk Letter Ann Intern Med 1992 116 871 3 Robert LM Chamberland ME Cleveland JL et
478. r are of small gauge e g anesthetic needles commonly used in dentistry they transfer less blood 36 In a retrospective case control study of HCP an increased risk for HIV infection was associated with exposure to a relatively large volume of blood as indicated by a deep injury with a device that was visibly contaminated with the patient s blood or a procedure that involved a needle placed in a vein or artery 95 The risk was also increased if the exposure was to blood from patients with terminal illnesses possibly reflecting the higher titer of HIV in late 92 stage AIDS Exposure Prevention Methods Avoiding occupational exposures to blood is the primary way to prevent transmission of HBV HCV and HIV to HCP in health care settings 19 96 97 Exposures occur through percutaneous injury e g a needlestick or cut with a sharp object as well as through contact between potentially infectious blood tissues or other body fluids and mucous membranes of the eye nose mouth or nonintact skin e g exposed skin that is chapped abraded or shows signs of dermatitis Observational studies and surveys indicate that percutaneous injuries among general dentists and oral surgeons occur less frequently than among general and orthopedic surgeons and have decreased in frequency since the mid 1980s 98 102 This decline has been attributed to safer work practices safer instrumentation or design and continued DHCP education 703 104
479. rand of commercially available plastic barriers used to protect dental digital radiography sensors failed at a substantial rate 44 This rate dropped to 6 when latex finger cots were used in conjunction with the plastic barrier 375 To minimize the potential for device associated infections after removing the barrier the device should be cleaned and disinfected with an EPA registered hospital disinfectant intermediate level after each patient Manufacturers should be consulted regarding appropriate barrier and disinfection sterilization procedures for digital radiography sensors other high technology intraoral devices and computer components Aseptic Technique for Parenteral Medications Safe handling of parenteral medications and fluid infusion systems is required to prevent health care associated infections among patients undergoing conscious sedation Parenteral medications can be packaged in single dose ampules vials or prefilled syringes usually without bacteriostatic preservative agents and intended for use on a single patient Multidose vials used for more than one patient can have a preservative but both types of containers of medication should be handled with aseptic techniques to prevent contamination Single dose vials should be used for parenteral medications whenever possible 376 377 Single dose vials might pose a risk for contamination if they are punctured repeatedly The leftover contents of a single dose vial
480. ray or cassette with items to be sterilized 254 see Sterilization of Unwrapped Instruments Dental practices should refer to the manufacturer s instructions regarding use and correct placement of chemical indicators see Sterilization Monitoring Critical and semicritical instruments that will be stored should be wrapped or placed in containers e g cassettes or organizing trays designed to maintain sterility during storage 2 247 255 257 Packaging materials e g wraps or container systems allow penetration of the sterilization agent and maintain sterility of the processed item after sterilization Materials for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes peel pouches of plastic or paper and sterilization wraps i e woven and nonwoven Packaging materials should be designed for the type of sterilization process being used 256 259 Sterilization The sterilization section of the processing area should include the sterilizers and related supplies with adequate space for loading unloading and cool down The area can also include incubators for analyzing spore tests and enclosed storage for sterile items and disposable single use items 260 Manufacturer and local building code specifications will determine placement and room ventilation requirements Sterilization Procedures Heat tolerant dental instruments usually are sterilized by 1 steam under pre
481. recent years increased numbers of boil water advisories have resulted from contamination of public drinking water systems with waterborne pathogens Most notable was the outbreak of cryptosporidiosis in Milwaukee Wisconsin where the municipal water system was contaminated with the protozoan parasite Cryptosporidium parvum An estimated 403 000 persons became ill 347 348 During a boil water advisory water should not be delivered to patients through the dental unit ultrasonic scaler or other dental equipment that uses the public water system This restriction does not apply if the water source is isolated from the municipal water system e g a Separate water reservoir or other water treatment device cleared for marketing by FDA Patients should rinse with bottled or distilled water until the boil water advisory has been cancelled During these advisory periods tap water should not be used to dilute germicides or for hand hygiene unless the water has been brought to a rolling boil for gt 1 minute and cooled before use 346 349 351 For hand hygiene antimicrobial products that do not require water e g alcohol based hand rubs can be used until the boil water notice is cancelled If hands are visibly contaminated bottled water and soap should be used for handwashing if bottled water is not immediately available an antiseptic towelette should be used 73 122 When the advisory is cancelled the local water utility should provide guidan
482. replication immunization to prevent HBV infection through either pre or postexposure prophylaxis can also prevent HDV infection 70 Hepatitis C Virus Hepatitis C virus appears not to be transmitted efficiently through occupational exposures to blood Follow up studies of HCP exposed to HCV infected blood through percutaneous or other sharps injuries have determined a low incidence of seroconversion mean 1 8 range 0 7 71 74 One study determined transmission occurred from hollow bore needles but not other sharps 72 Although these studies have not documented seroconversion associated with mucous membrane or nonintact skin exposure at least two cases of HCV transmission from a blood splash to the conjunctiva 75 76 and one case of simultaneous transmission of HCV and HIV after nonintact skin exposure have been reported 77 Data are insufficient to estimate the occupational risk of HCV infection among HCP but the majority of studies indicate the prevalence of HCV infection among dentists surgeons and hospital based HCP is similar to that among the general population approximately 1 2 78 86 In a study that evaluated risk factors for infection a history of unintentional needlesticks was the only occupational risk factor independently associated with HCV infection 80 No studies of transmission from HCV infected DHCP to patients have been reported and the risk for such transmission appears limited Multiple reports
483. rgery Plumes or Surgical Smoke During surgical procedures that use a laser or electrosurgical unit the thermal destruction of tissue creates a smoke byproduct Laser plumes or surgical smoke represent another potential risk for DHCP 423 425 Lasers transfer electromagnetic energy into tissues resulting in the release of a heated plume that includes particles gases e g hydrogen cyanide benzene and formaldehyde tissue debris viruses and offensive odors One concern is that aerosolized infectious material in the laser plume might reach the nasal mucosa of the laser operator and adjacent DHCP Although certain viruses e g varicella zoster virus and herpes simplex virus appear not to aerosolize efficiently 426 427 other viruses and various bacteria e g human papilloma virus HIV coagulase negative Staphylococcus Corynebacterium species and Neisseria species have been detected in laser plumes 428 434 However the presence of an infectious agent in a laser plume might not be sufficient to cause disease from airborne exposure especially if the agent s normal mode of transmission is not airborne No evidence indicates that HIV or HBV have been transmitted through aerosolization and inhalation 435 Although continuing studies are needed to evaluate the risk for DHCP of laser plumes and electrosurgery smoke following NIOSH recommendations 425 and practices developed by the Association of periOperative Registered Nurses AOR
484. rgical 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 121 123 127 133 144 145 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 9 20 122 149 150 B Special Considerations for Hand Hygiene and Glove Use i IV PPE Use hand lotions to prevent skin dryness associated with handwashing IA 153 154 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 2 14 122 155 Keep fingernails short with smooth filed edges to allow thorough cleaning and prevent glove tears II 122 123 156 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 123 157 160 Use of artificial fingernails is usually not recommended II 157 160 Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises the fit and integrity
485. ritical if not more so than any antimicrobial effect provided by the agent used 244 290 The majority of housekeeping surfaces need to be cleaned only with a detergent and water or an EPA registered hospital disinfectant detergent depending on the nature of the surface and the type and degree of contamination Schedules and methods vary according to the area e g dental operatory laboratory bathrooms or reception rooms surface and amount and type of contamination Floors should be cleaned regularly and spills should be cleaned up promptly An EPA registered hospital disinfectant detergent designed for general housekeeping purposes should be used in patient care areas if uncertainty exists regarding the nature of the soil on the surface e g 101 Guidelines for Infection Control in Dental Health Care Settings 2008 blood or body fluid contamination versus routine dust or dirt Unless contamination is reasonably anticipated or apparent cleaning or disinfecting walls window drapes and other vertical surfaces is unnecessary However when housekeeping surfaces are visibly contaminated by blood or OPIM prompt removal and surface disinfection is appropriate infection control practice and required by OSHA 13 Part of the cleaning strategy is to minimize contamination of cleaning solutions and cleaning tools e g mop heads or cleaning cloths Mops and cloths should be cleaned after use and allowed to dry before reuse or sin
486. roducts proposed rule Federal Register 1994 59 31441 52 Larson E A causal link between handwashing and risk of infection Examination of the evidence Infection Control 1988 9 28 36 Mangram AJ Horan TC Pearson ML Silver LC Jarvis WR Hospital Infection Control Practices Advisory Committee Guideline for prevention of surgical site infection 1999 Infect Control Hosp Epidemiol 1999 20 250 78 Doebbeling BN Pfaller MA Houston AK Wenzel RP Removal of nosocomial pathogens from the contaminated glove Ann Intern Med 1988 109 394 8 Kabara JJ Brady MB Contamination of bar soaps under in use conditions J Environ Pathol Toxicol Oncol 1984 5 1 14 Ojajarvi J The importance of soap selection for routine hand hygiene in hospital J Hyg Lond 1981 86 275 83 Larson E Leyden JJ McGinley KJ Grove GL Talbot GH Physiologic and microbiologic changes in skin related to frequent handwashing Infect Control 1986 7 59 63 Larson E Handwashing it s essential even when you use gloves Am J Nurs 1989 89 934 9 Field EA McGowan P Pearce PK Martin MV Rings and watches should they be removed prior to operative dental procedures J Dent 1996 24 65 9 Hobson DW Woller W Anderson L Guthery E Development and evaluation of a new alcohol based surgical hand scrub formulation with persistent antimicrobial characteristics and brushless application Am J Infect Control 1998 26 507 12 Mulberry G Snyder AT Heilman J Pyrek J Stahl J E
487. rogram Evaluation saena 109 Contact Dermatitis and Latex Hypersensitivity 97 Infection Control Research Considerations 109 Sterilization and Disinfection of Patient Care Items 97 Recommendations kk 110 Environmental Infection Control uci Infection Control Internet Resources oe 115 Dental Unit Waterlines Biofilm and Water Quality Acknowledgement ee 115 Special Considerations kk Appendix A Dental Handpieces and Other Devices Attached Appendix B to Air and Waterline i 104 Appendix C Saliva EjJeCtOrS nare rer EE RE 104 References sesssseersssssreressssestrressserenesessoereressoeeerossnsreresssen 72 Dental Radiology gn 104 Summary This report consolidates previous recommendations and adds new ones for infection control in dental settings Recommendations are provided regarding 1 educating and protecting dental health care personnel 2 preventing transmission of bloodborne pathogens 3 hand hygiene 4 personal protective equipment 5 contact dermatitis and latex hypersensitivity 6 sterilization and disinfection of patient care items 7 environmental infection control 8 dental unit waterlines biofilm and water quality and 9 special considerations e g dental handpieces and other devices radiology parenteral medications oral surgical procedures and dental laboratories These recommendations were developed in collaboration with and after review by authorities on infection
488. ropriate treatment as well as work restrictions and accommodations IB 32 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 5 13 2 Ensure that the practice complies with all applicable federal state and local laws regarding medical recordkeeping and confidentiality IC 13 34 II Preventing Transmission of Bloodborne Pathogens A HBV Vaccination Offer the HBV vaccination series to all DHCP with potential occupational exposure to blood or other potentially infectious material IA IC 2 13 14 19 Always follow U S Public Health Service CDC recommendations for hepatitis B vaccination serologic testing follow up and booster dosing IA IC 13 14 19 Test DHCP for anti HBs 1 2 months after completion of the 3 dose vaccination series IA IC 74 19 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 14 19 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 14 19 Counsel nonresponders to vaccination who are HBsAg negative regarding their susceptibilit
489. rs of mutual responsibility tegulation of liquid chemical germicides intended for use on medical devices Rockville MD US Department of Health and Human Services Public Health Service Food and Drug Administration US Environmental Protection Agency 1993 Food and Drug Administration FDA Interim measures for registration of antimicrobial products liquid chemical germicides with medical device use claims under the memorandum of understanding between EPA and FDA Rockville MD US Department of Health and Human Services Food and Drug Administration 1994 Food and Drug Administration Guidance for industry and FDA reviewers content and format of premarket notification 510 k submissions for liquid chemical sterilants high level disinfectants Rockville MD US Department of Health and Human Services Food and Drug Administration 2000 Available at http www fda gov cdrh ode 397 pdf US Environmental Protection Agency 40 CFR Parts 152 156 and 158 Exemption of certain pesticide substances from federal insecticide fungicide and rodenticide act requirements Amended 1996 Federal Register 1996 61 8876 9 US Department of Labor Occupational Safety and Health Administration 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogens needlesticks and other sharps injuries final rule Federal Register 2001 66 5317 25 As amended from and includes 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogen
490. rt DHCP should choose from commercially available HCP handwashes when selecting agents for hand antisepsis or surgical hand antisepsis Storage and Dispensing of Hand Care Products Handwashing products including plain i e nonantimicrobial soap and antiseptic products can become contaminated or support the growth of microorganisms 22 Liquid products should be stored in closed containers and dispensed from either disposable containers or containers that are washed and dried thoroughly before refilling Soap should not be added to a partially empty dispenser because this practice of topping off might lead to bacterial contamination 149 150 Store and dispense products according to manufacturers directions Lotions The primary defense against infection and transmission of pathogens is healthy unbroken skin Frequent handwashing with soaps and antiseptic agents can cause chronic irritant contact dermatitis among DHCP Damage to the skin changes skin flora resulting in more frequent colonization by staphylococci and gram negative bacteria 151 152 The potential of detergents to cause skin irritation varies considerably but can be reduced by adding emollients Lotions are often recommended to ease the dryness resulting from frequent handwashing and to prevent dermatitis from glove use 153 154 However petroleum based lotion formulations can weaken latex gloves and increase permeability For that reason lotions that contain petrole
491. rus HIV and hepatitis B virus HBV is appropriate Hospital disinfectants with such HIV and HBV claims can be used provided surfaces are not contaminated with agents or concentration of agents for which higher level i e intermediate level disinfection is recommended In addition as with all disinfectants effectiveness is governed by strict adherence to the label instructions for intended use of the product CDC is not a regulatory agency and does not test evaluate or otherwise recommend specific brand name products of chemical germicides This report is intended to provide overall guidance for providers to select general classifications of products based on certain infection control principles In this report CDC provides guidance to practitioners regarding appropriate application of EPA and FDA registered liquid chemical disinfectants and sterilants in dental health care settings CDC recommends disinfecting environmental surfaces or sterilizing or disinfecting medical equipment and DHCP should use products approved by EPA and FDA unless no such products are available for use against certain microorganisms or sites However if no registered or approved products are available for a specific pathogen or use situation DHCP are advised to follow the specific guidance regarding unregistered or unapproved e g off label uses for various chemical germicides For example no antimicrobial products are registered for use specifically aga
492. s final rule Federal Register 1991 56 64174 82 Available at http www osha gov SLTC dentistry index html Spaulding EH Role of chemical disinfection in preventing nosocomial infections In Proceedings of the International Conference on Nosocomial Infections 1970 Brachman PS Eickhoff TC eds Chicago IL American Hospital Association 1971 247 54 C C 1 C 2 C 3 Food and Drug Administration Guidance for industry and FDA reviewers content and format of premarket notification 510 k submissions for liquid chemical sterilants high level disinfectants Rockville MD US Department of Health and Human Services Food and Drug Administration 2000 Available at http www fda gov cdrh ode 397 pdf US Department of Labor Occupational Safety and Health Administration 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogens needlesticks and other sharps injuries final rule Federal Register 2001 66 5317 25 As amended from and includes 29 CFR Part 1910 1030 Occupational exposure to bloodborne pathogens final rule Federal Register 1991 56 64174 82 Available at http www osha gov SLTC dentistry index html CDC Guidelines for environmental infection control in health care facilities recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee HICPAC MMWR 2003 52 No RR 10 Guidelines for Infection Control in Dental Health Care Settings 2003
493. s polishing points rag wheels or laboratory knives are used on contaminated or potentially contaminated appliances prostheses or other material they should be heat sterilized disinfected between patients or discarded i e disposable items should be used 260 407 Heat tolerant items used in the mouth e g metal impression tray or face bow fork should be heat sterilized before being used on another patient 2 407 Items that do not normally contact the patient prosthetic device or appliance but frequently become contaminated and cannot withstand heat sterilization e g articulators case pans or lathes should be cleaned and disinfected between patients and according to the manufacturer s instructions Pressure pots and water baths are particularly susceptible to contamination with microorganisms and should be cleaned and disinfected between patients 422 In the majority of instances these items can be cleaned and disinfected with an EPA registered hospital disinfectant Environmental surfaces should be barrier protected or cleaned and disinfected in the same manner as in the dental treatment area Unless waste generated in the dental laboratory e g disposable trays or impression materials falls under the category of regulated medical waste it can be discarded with general waste Personnel should dispose of sharp items e g burs disposable blades and orthodontic wires in puncture resistant containers Laser Electrosu
494. s in the moist environment underneath gloves 722 Alcohol hand rubs are rapidly germicidal when applied to the skin but should include such antiseptics as chlorhexidine quaternary ammonium compounds octenidine or triclosan to achieve persistent activity 130 Factors that can influence the effectiveness of the surgical hand antisepsis in addition to the choice of antiseptic agent include duration and technique of scrubbing as well as condition of the hands and techniques used for drying and gloving CDC s 2002 guideline on hand hygiene in health care settings provides more complete information 23 Selection of Antiseptic Agents Selecting the most appropriate antiseptic agent for hand hygiene requires consideration of multiple factors Essential performance characteristics of a product e g the spectrum and persistence of activity and whether or not the agent is fast acting should be determined before selecting a product Delivery system cost per use reliable vendor support and supply are also considerations Because HCP acceptance is a major factor regarding compliance with recommended hand hygiene protocols 22 23 147 148 considering DHCP needs is critical and should include possible chemical allergies skin integrity after repeated use compatibility with lotions used and 94 offensive agent ingredients e g scent Discussing specific preparations or ingredients used for hand antisepsis is beyond the scope of this repo
495. s used for each cycle 3 care is taken to avoid thermal injury to DHCP or patients and 4 items are transported aseptically to the point of use to maintain sterility 134 258 262 Because all implantable devices should be quarantined after sterilization until the results of biological monitoring are known unwrapped or flash sterilization of implantable items is not recommended 34 Critical instruments sterilized unwrapped should be transferred immediately by using aseptic technique from the sterilizer to the actual point of use Critical instruments should not be stored unwrapped 260 Semicritical instruments that are sterilized unwrapped on a tray or in a container system should be used immediately or within a short time When sterile items are open to the air they will eventually become contaminated Storage even temporary of unwrapped semicritical instruments is discouraged because it permits exposure to dust airborne organisms and other unnecessary contamination before use on a patient 260 A carefully written protocol for minimizing the risk of contaminating unwrapped instruments should be prepared and followed 260 Other Sterilization Methods Heat sensitive critical and semicritical instruments and devices can be sterilized by immersing them in liquid chemical germicides registered by FDA as sterilants When using a liquid chemical germicide for sterilization certain poststerilization procedures are essential Items need to
496. se whocdscsraph2003c html e Do not use flash sterilization for processing instruments or devices Potential infectivity of oral tissues in CJD or vCJD patients is an unresolved concern CDC maintains an active surveillance program on CJD Additional information and resources are available at http www cdc gov ncidod diseases cjd cjd htm 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 470 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 47 A successful infection control program depends on developing standard operating procedures evaluating practices routinely BOX Dental infection control research considerations Education and promotion documenting adverse outcomes e g occupational exposures to blood and work related illnesses in DHCP and monitoring health care associated infections in patients Strate
497. se history of antiretroviral therapy and viral load if known e Details regarding the exposed person e g hepatitis B vaccination and vaccine response status e Details regarding counseling postexposure management and follow up Each occupational exposure should be evaluated individually for its potential to transmit HBV HCV and HIV based on the following e The type and amount of body substance involved e The type of exposure e g percutaneous injury mucous membrane or nonintact skin exposure or bites resulting in blood exposure to either person involved e The infection status of the source e The susceptibility of the exposed person 19 All of these factors should be considered in assessing the risk for infection and the need for further follow up e g PEP During 1990 1998 PHS published guidelines for PEP and other management of health care worker exposures to HBV HCV or HIV 69 116 119 In 2001 these recommendations were updated and consolidated into one set of PHS guidelines 79 The new guidelines reflect the availability of new antiretroviral agents new information regarding the use and safety of HIV PEP and considerations regarding employing HIV PEP when resistance of the source patient s virus to antiretroviral agents is known or suspected In addition the 2001 guidelines provide guidance to clinicians and exposed HCP regarding when to consider HIV PEP and recommendations for PEP regimens 19 Ha
498. setting and volume of the spill 713 244 Blood spills on either clinical contact or housekeeping surfaces should be contained and managed as quickly as possible to reduce the risk of contact by patients and DHCP 244 292 The person assigned to clean the spill should wear gloves and other PPE as needed Visible organic material should be removed with absorbent material e g disposable paper towels discarded in a leak proof appropriately labeled container Nonporous surfaces should be cleaned and then decontaminated with either an EPA registered hospital disinfectant effective against HBV and HIV or an EPA registered hospital disinfectant with a tubercu locidal claim i e intermediate level disinfectant If sodium hypo chlorite is chosen an EPA registered sodium hypochlorite product is preferred However if such products are unavailable a 1 100 dilution of sodium hypochlorite e g approximately 1 4 cup of 5 25 household chlorine bleach to 1 gallon of water is an inexpensive and effective disinfecting agent 113 Carpeting and Cloth Furnishings Carpeting is more difficult to clean than nonporous hard surface flooring and it cannot be reliably disinfected especially after spills of blood and body substances Studies have documented the presence of diverse microbial populations primarily bacteria and fungi in carpeting 293 295 Cloth furnishings pose similar contamination risks in areas of direct patient care and places where con
499. should be discarded and never combined with medications for use on another patient 376 377 Medication from a single dose syringe should not be administered to multiple patients even if the needle on the syringe is changed 378 The overall risk for extrinsic contamination of multidose vials is probably minimal although the consequences of contamination might result in life threatening infection 379 If necessary to use a multidose vial its access diaphragm should be cleansed with 70 alcohol before inserting a sterile device into the vial 380 381 A multidose vial should be discarded if sterility is compromised 380 381 Medication vials syringes or supplies should not be carried in uniform or clothing pockets If trays are used to deliver medications to individual patients they should be cleaned between patients To further reduce the chance of contamination all medication vials should be restricted to a centralized medication preparation area separate from the treatment area 382 All fluid infusion and administration sets e g IV bags tubing and connections are single patient use because sterility cannot be guaranteed when an infusion or administration set is used on multiple patients Aseptic technique should be used when preparing IV infusion and administration sets and entry into or breaks in the tubing should be minimized 378 Single Use or Disposable Devices A single use device also called a disposable device is
500. sitioning 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 243 Transport and handle exposed radiographs in an aseptic manner to prevent contamination of developing equipment II The following apply for digital radiography sensors a Use FDA cleared barriers IB 243 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 243 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 378 Use single dose vials for parenteral medications when possible II 376 377 Do not combine the leftover contents of single use vials for later use IA 376 377 The following apply if multidose vials are used a Cleanse the access diaphragm with 70 alcohol before inserting a device into the vial IA 38
501. spore tests are the most accepted method for monitoring the sterilization process 278 279 because they assess it directly by killing known highly resistant microorganisms e g Geobacillus or Bacillus species rather than merely testing the physical and chemical conditions necessary for sterilization 243 Because spores used in BIs are more resistant and present in greater numbers than the common microbial contaminants found on patient care equipment an inactivated BI indicates other potential pathogens in the load have been killed 280 Correct functioning of sterilization cycles should be verified for each sterilizer by the periodic use at least weekly of BIs 2 9 134 243 278 279 Every load containing implantable devices should be monitored with such indicators 248 and the items quarantined until BI results are known However in an emergency placing implantable items in quarantine until spore tests are known to be negative might be impossible Manufacturer s directions should determine the placement and location of BI in the sterilizer A control BI from the same lot as the test indicator and not processed through the sterilizer should be incubated with the test BI the control BI should yield positive results for bacterial growth In office biological monitoring is available mail in sterilization monitoring services e g from private companies or dental schools can also be used to test both the BI and the control Althou
502. ssess the performance of surgical gloves AORN J 2003 77 772 9 Schwimmer A Massoumi M Barr CE Efficacy of double gloving to prevent inner glove perforation during outpatient oral surgical procedures J Am Dent Assoc 1994 125 196 8 Patton LL Campbell TL Evers SP Prevalence of glove perforations during double gloving for dental procedures Gen Dent 1995 43 22 6 Gerberding JL Littell C Tarkington A Brown A Schecter WP Risk of exposure of surgical personnel to patients blood during surgery at San Francisco General Hospital N Engl J Med 1990 322 1788 93 Klein RC Party E Gershey EL Virus penetration of examination gloves Biotechniques 1990 9 196 9 Mellstrom GA Lindberg M Boman A Permeation and destructive effects of disinfectants on protective gloves Contact Dermatitis 1992 26 163 70 Jordan SL Stowers MF Trawick EG Theis AB Glutaraldehyde permeation choosing the proper glove Am J Infect Control 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 1996 24 67 9 Cappuccio WR Lees PS Breysse PN Margolick JB Evaluation of integrity of gloves used in a flow cytometry laboratory Infect Control Hosp Epidemiol 1997 18 423 5 Monticello MV Gaber DJ Glove resistance to permeation by a 7 5 hydrogen peroxide sterilizing and disinfecting solution Am J Infec Control 1999 27 364 6 B
503. ssure autoclaving 2 dry heat or 3 unsaturated chemical vapor All sterilization should be performed by using medical sterilization equipment cleared by FDA The sterilization times temperatures and other operating parameters recommended by the manufacturer of the equipment used as well as instructions for correct use of containers wraps and chemical or biological indicators should always be followed 243 247 Items to be sterilized should be arranged to permit free circulation of the sterilizing agent e g steam chemical vapor or dry heat manufacturer s instructions for loading the sterilizer should be followed 248 260 Instrument packs should be allowed to dry inside the sterilizer chamber before removing and handling Packs should not be touched until they are cool and dry because hot packs act as wicks absorbing moisture and hence bacteria from hands 247 The ability of equipment to attain physical parameters required to achieve sterilization should be monitored by mechanical chemical and biological indicators Sterilizers vary in their types of indicators and their ability to provide readings on the mechanical or physical parameters of the sterilization process e g time temperature and pressure Consult with the sterilizer manufacturer regarding selection and use of indicators Steam Sterilization Among sterilization methods steam sterilization which is dependable and economical is the most widely used for wra
504. such factors as 1 adoption of universal precautions 2 routine glove use 3 increased levels of immunity as a result of hepatitis B vaccination of DHCP 4 implementation of the 1991 OSHA bloodborne pathogen standard 68 and 5 incomplete ascertainment and reporting Only one case of patient to patient transmission of HBV in the dental setting has been documented CDC unpublished data 2003 In this case appropriate office infection control procedures were being followed and the exact mechanism of transmission was undetermined Because of the high risk of HBV infection among HCP DHCP who perform tasks that might involve contact with blood blood contaminated body substances other body fluids or sharps should be vaccinated 2 13 17 19 69 Vaccination can protect both DHCP and patients from HBV infection and whenever possible should be completed when dentists or other DHCP are in training and before they have contact with blood Prevaccination serological testing for previous infection is not indicated although it can be cost effective where prevalence of infection is expected to be high in a group of potential vacinees e g persons who have emigrated from areas with high rates of HBV infection DHCP should be tested for anti HBs 1 2 months after completion of the 3 dose vaccination series 17 DHCP who do not develop an adequate antibody response i e anti HBs lt 10 mIU mL to the primary vaccine series should complete a second
505. sures to HIV and recommendations for postexposure prophylaxis MMWR 1998 47 No RR 7 CDC Recommendations for prevention and control of hepatitis C virus HCV infection and HCV related chronic disease MMWR 1998 47 No RR 19 Steere AC Mallison GF Handwashing practices for the prevention of nosocomial infections Ann Intern Med 1975 83 683 90 Garner JS CDC guideline for prevention of surgical wound infections 1985 Supersedes guideline for prevention of surgical wound infections published in 1982 Originally published in November 1985 Revised Infect Control 1986 7 193 200 Larson EL APIC guideline for hand washing and hand antisepsis in health care settings Am J Infect Control 1995 23 25 1 69 CDC Guideline for hand hygiene in health care settings recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC SHEA APIC IDSA Hand Hygiene Task Force MMWR 2002 51 No RR 16 Casewell M Phillips I Hands as route of transmission for Klebsiella species Br Med J 1977 2 1315 7 Larson EL Early E Cloonan P Sugrue S Parides M An organizational climate intervention associated with increased handwashing and decreased nosocomial infections Behav Med 2000 26 14 22 Pittet D Hugonnet S Harbarth S et al Effectiveness of a hospital wide programme to improve compliance with hand hygiene Lancet 2000 356 1307 12 Price PB New studies in surgical bacteriology and surgical technique JAMA 1938 111
506. t and follow up Educate and train dental health care personnel DHCP to screen and evaluate safer dental devices by using tested design and performance criteria Laboratory based research Develop animal models to determine the risk of transmitting organisms through inhalation of contaminated aerosols e g influenza produced from rotary dental instruments Conduct studies to determine the effectiveness of gloves i e material compatibility and duration of use Develop devices with passive safety features to prevent percutaneous injuries Study the effect of alcohol based hand hygiene products on retention of latex proteins and other dental allergens e g methylmethacrylate glutaraldehyde thiurams on the hands of DHCP after latex glove use Investigate the applicability of other types of sterilization procedures e g hydrogen peroxide gas plasma in dentistry Encourage manufacturers to determine optimal methods and frequency for testing dental unit waterlines and maintaining dental unit water quality standards Determine the potential for internal contamination of low speed handpieces including the motor and other devices connected to dental air and water supplies as well as more efficient ways to clean lubricate and sterilize handpieces and other devices attached to air or waterlines Investigate the infectivity of oral tissues in Creutzfeldt Jakob disease CJD or variant CJD patients
507. taminated materials are managed e g dental operatory laboratory or instrument processing areas For these reasons use of carpeted flooring and fabric upholstered furnishings in these areas should be avoided Nonregulated and Regulated Medical Waste Studies have compared microbial load and diversity of micro organisms in residential waste with waste from multiple health care settings General waste from hospitals or other health care facilities e g dental practices or clinical research laboratories is no more infective than residential waste 296 297 The majority of soiled items in dental offices are general medical waste and thus can be disposed of with ordinary waste Examples include used gloves masks gowns 102 lightly soiled gauze or cotton rolls and environmental barriers e g plastic sheets or bags used to cover equipment during treatment 298 Although any item that has had contact with blood exudates or secretions might be infective treating all such waste as infective is neither necessary nor practical 244 Infectious waste that carries a substantial risk of causing infection during handling and disposal is regulated medical waste A complete definition of regulated waste is included in OSHA s bloodborne pathogens standard 3 Regulated medical waste is only a limited subset of waste 9 15 of total waste in hospitals and 1 2 of total waste in dental offices 298 299 Regulated medical waste requires sp
508. tate including human immunode ficiency virus HIV infected persons with severe immunosup pression history of anaphylactic reactions after gelatin ingestion or receipt of neomycin or recent receipt of antibody containing blood products Pregnancy immunocompromised state history of anaphylactic reaction after gelatin ingestion or receipt of neomycin Pregnancy immunocompromised state history of anaphylactic reaction after receipt of neomycin Pregnancy immunocompromised state history of anaphylactic reaction after receipt of neomycin or gelatin recent receipt of antibody containing blood products salicylate use should be avoided for 6 weeks after vaccination Special considerations No therapeutic or adverse effects on hepatitis B virus HBV infected persons cost effectiveness of prevaccination screening for susceptibility to HBV depends on costs of vaccination and antibody testing and prevalence of immunity in the group of potential vaccinees health care personnel who have ongoing contact with patients or blood should be tested 1 2 months after completing the vaccination series to determine serologic response If vaccination does not induce adequate anti HBs gt 10 mlU mL a second vaccine series should be administered Recommended for women who will be in the second or third trimesters of pregnancy during the influenza season and women in any stage of pregnancy who have chronic medical conditions that
509. ted teeth containing amalgam restorations should not be heat sterilized because of the potential health hazard from mercury vaporization and exposure If extracted teeth containing amalgam restorations are to be used immersion in 10 formalin solution for 2 weeks should be effective in disinfecting both the internal and external structures of the teeth 403 If using formalin manufacturer MSDS should be reviewed for occupational safety and health concerns and to ensure compliance with OSHA regulations 5 Dental Laboratory Dental prostheses appliances and items used in their fabrication e g impressions occlusal rims and bite registrations are potential sources for cross contamination and should be handled in a manner that prevents exposure of DHCP patients or the office environment to infectious agents Effective communication and coordination between the laboratory and dental practice will ensure that appropriate cleaning and disinfection procedures are performed in the dental office or laboratory materials are not damaged or distorted because of disinfectant overexposure and effective disinfection procedures are not unnecessarily duplicated 407 408 When a laboratory case is sent off site DHCP should provide written information regarding the methods e g type of disinfectant and exposure time used to clean and disinfect the material e g impression stone model or appliance 2 407 409 Clinical materials that are not d
510. the authority of the 1976 Medical Devices Amendment to the Food Drug and Cosmetic Act regulates chemical germicides if they are advertised and marketed for use on specific medical devices e g dental unit waterline or flexible endoscope A liquid chemical germicide marketed for use on a specific device is considered for regulatory purposes a medical device itself when used to disinfect that specific medical device Also this FDA regulatory authority over a particular instrument or device dictates that the manufacturer is obligated to provide the user with adequate instructions for the safe and effective use of that device These instructions must include methods to clean and disinfect or sterilize the item if it is to be marketed as a 116 reusable medical device OSHA develops workplace standards to help ensure safe and healthful working conditions in places of employment OSHA is authorized under Pub L 95 251 and as amended to enforce these workplace standards In 1991 OSHA published Occupational Exposure to Bloodborne Pathogens final rule 29 CFR Part 1910 1030 A 5 This standard is designed to help prevent occupational exposures to blood or other potentially infectious substances Under this standard OSHA has interpreted that to decontaminate contaminated work surfaces either an EPA registered hospital tuberculocidal disinfectant or an EPA registered hospital disinfectant labeled as effective against human immunodeficiency vi
511. tion of glove washing and re use in dental practice J Hosp Infect 1992 20 153 62 Martin MV Dunn HM Field EA et al A physical and microbiological evaluation of the re use of non sterile gloves Br Dent J 1988 165 32 1 4 US Department of Health and Human Services Food and Drug Administration 21 CFR Part 800 Medical devices patient examination and surgeon s gloves Adulteration final rule Federal Register 1990 55 51254 8 Giglio JA Roland RW Laskin DM Grenevicki L The use of sterile versus nonsterile gloves during out patient exodontia Quintessence Int 1993 24 543 5 Cheung LK Chow LK Tsang MH Tung LK An evaluation of complications following dental extractions using either sterile or clean gloves Int J Oral Maxillofac Surg 2001 30 550 4 Gani JS Anseline PF Bissett RL Efficacy of double versus single gloving in protecting the operating team Aust N Z J Surg 1990 60 171 5 Short LJ Bell DM Risk of occupational infection with blood borne pathogens in operating and delivery room settings Am J Infect Control 1993 21 343 30 Tokars JI Culver DH Mendelson MH et al Skin and mucous membrane contacts with blood during surgical procedures risk and prevention Infect Control Hosp Epidemiol 1995 16 703 11 Tanner J Parkinson H Double gloving to reduce surgical cross infection Cochrane Review The Cochrane Library 2003 Issue 2 1 32 Webb JM Pentlow BD Double gloving and surgical technique Ann R Coll Surg Engl 19
512. tion of the setting IB 20 c Assess each patient for a history of TB as well as symptoms indicative of TB and document on the medical history form IB 20 21 d Follow CDC recommendations for 1 developing maintaining and implementing a written TB infection control plan 2 managing a patient with suspected or active TB 3 completing a community risk assessment to guide employee TSTs and follow up and 4 managing DHCP with TB disease IB 2 21 The following apply for patients known or suspected to have active TB a Evaluate the patient away from other patients and DHCP When not being evaluated the patient should wear a surgical mask or be instructed to cover mouth and nose when coughing or sneezing IB 20 2 b Defer elective dental treatment until the patient is noninfectious IB 20 21 c Refer patients requiring urgent dental treatment to a previously identified facility with TB engineering controls and a respiratory protection program IB 20 21 L Creutzfeldt Jakob Disease CJD and Other Prion Diseases 1 No recommendation is offered regarding use of special precautions in addition to standard precautions when treating known CJD or vCJD patients Potential infectivity of oral tissues in CJD or vCJD patients is an unresolved issue 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 r
513. tion of viral DNA and viable virus inside both high speed handpieces and prophylaxis angles 356 357 359 The potential for contamination of the internal surfaces of other devices e g low speed handpieces and ultrasonic scalers has not been studied but restricted physical access limits their cleaning Accordingly any dental device connected to the dental air water system that enters the patient s mouth should be run to discharge water air or a combination for a minimum of 20 30 seconds 104 after each patient 2 This procedure is intended to help physically flush out patient material that might have entered the turbine and air and waterlines 2 356 357 Heat methods can sterilize dental handpieces and other intraoral devices attached to air or waterlines 246 275 356 357 360 For processing any dental device that can be removed from the dental unit air or waterlines neither surface disinfection nor immersion in chemical germicides is an acceptable method Ethylene oxide gas cannot adequately sterilize internal components of handpieces 250 275 In clinical evaluations of high speed handpieces cleaning and lubrication were the most critical factors in determining performance and durability 361 363 Manufacturer s instructions for cleaning lubrication and sterilization should be followed closely to ensure both the effectiveness of the process and the longevity of handpieces Some components of dental instruments are permanent
514. to educational institutions or a dental laboratory IC 13 14 Heat sterilize teeth that do not contain amalgam before they are used for educational purposes IB 403 405 406 I Dental Laboratory 1 Use PPE when handling items received in the laboratory until they have been decontaminated IA IC 2 7 11 13 113 2 Before they are handled in the laboratory clean disinfect and rinse all dental prostheses and prosthodontic materials e g impressions bite registrations occlusal rims and extracted teeth by using an EPA registered hospital disinfectant having at least an intermediate level i e tuberculocidal claim activity IB 2 249 252 407 Consult with manufacturers regarding the stability of specific materials e g impression materials relative to disinfection procedures II Include specific information regarding disinfection techniques used e g solution used and duration when laboratory cases are sent off site and on their return II 2 407 409 Clean and heat sterilize heat tolerant items used in the mouth e g metal impression trays and face bow forks IB 2 407 6 Follow manufacturers instructions for cleaning and sterilizing or disinfecting items that become contaminated but do not normally contact the patient e g burs polishing points rag wheels articulators case pans and lathes If manufacturer instructions are unavailable clean and heat sterilize heat to
515. ts put the sterilizer back in service ID 9 243 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 9 243 b Recall to the extent possible and reprocess all items processed since the last negative spore test II 9 243 283 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 9 243 283 10 Maintain sterilization records i e mechanical chemical and biological in compliance with state and local regulations IB 243 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 243 284 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 243 247 Examine wrapped packages of sterilized instruments before opening them to ensure the barrier wrap has not been compromised during storage II
516. tudy Committee Use of the hepatitis B vaccine and infection with hepatitis B and C among orthopaedic surgeons J Bone Joint Surg Am 1996 78 179 1 800 Gerberding JL Incidence and prevalence of human immunodeficiency virus hepatitis B virus hepatitis C virus and cytomegalovirus among health care personnel at risk for blood exposure final report from a longitudinal study J Infect Dis 1994 170 1410 7 Klein RS Freeman K Taylor PE Stevens CE Occupational risk for hepatitis C virus infection among New York City dentists Lancet 1991 338 1539 42 Thomas DL Gruninger SE Siew C Joy ED Quinn TC Occupational risk of hepatitis C infections among general dentists and oral surgeons in North America Am J Med 1996 100 41 5 Cleveland JL Gooch BF Shearer BG Lyerla RL Risk and prevention of hepatitis C virus infection implications for dentistry J Am Dent Assoc 1999 130 641 7 Gruninger SE Siew C Azzolin KL Meyer DM Update of hepatitis C infection among dental professionals Abstract 1825 J Dent Res 2001 80 264 73 C DC 003 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 74 Esteban JI Gomez J Martell M et al Transmission of hepatitis C virus by a cardiac surgeon N Engl J Med 1996 334 555 60 Duckworth GJ H
517. ture chart 243 Published studies are not available that document disease transmission through a nonretrieved surgical instrument after a steam sterilization cycle with a positive biological indicator 243 This more conservative approach should always be used for sterilization methods other than steam e g dry heat unsaturated chemical vapor ETO or hydrogen peroxide gas plasma 243 Results of biological monitoring should be recorded and sterilization monitoring records i e mechanical chemical and biological retained long enough to comply with state and local regulations Such records are a component of an overall dental infection control program see Program Evaluation Storage of Sterilized Items and Clean Dental Supplies The storage area should contain enclosed storage for sterile items and disposable single use items 173 Storage practices for wrapped sterilized instruments can be either date or event related Packages containing sterile supplies should be inspected before use to verify barrier integrity and dryness Although some health care facilities continue to date every sterilized package and use shelf life practices other facilities have switched to event related practices 243 This approach recognizes that the product should remain sterile indefinitely unless an event causes it to become contaminated e g torn or wet packaging 284 Even for event related packaging minimally the date of sterilization sho
518. type is also known as a rapid heat transfer sterilizer Heated air is circulated throughout the chamber at a high velocity permitting more rapid transfer of energy from the air to the instruments thereby reducing the time needed for sterilization Sterilization of Unwrapped Instruments An unwrapped cycle sometimes called flash sterilization is a method for sterilizing unwrapped patient care items for immediate use The time required for unwrapped sterilization cycles depends on the type of sterilizer and the type of item i e porous or nonporous to be sterilized 243 The unwrapped cycle in tabletop sterilizers is preprogrammed by the manufacturer to a specific time and temperature setting and can include a drying phase at the end to produce a dry instrument with much of the heat dissipated If the drying phase requirements are unclear the operation manual or manufacturer of the sterilizer should be consulted If the unwrapped sterilization cycle in a steam sterilizer does not include a drying phase or has only a minimal drying phase items retrieved from the sterilizer will be hot and wet making aseptic transport to the point of use more difficult For dry heat and chemical vapor sterilizers a drying phase is not required Unwrapped sterilization should be used only under certain conditions 1 thorough cleaning and drying of instruments precedes the unwrapped sterilization cycle 2 mechanical monitors are checked and chemical indicator
519. uld be placed on the package and if multiple sterilizers are used in the facility the sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure 247 If packaging is compromised the instruments should be recleaned packaged in new wrap and sterilized again Clean supplies and instruments should be stored in closed or covered cabinets if possible 285 Dental supplies and instruments should not be stored under sinks or in other locations where they might become wet Environmental Infection Control In the dental operatory environmental surfaces i e a surface or equipment that does not contact patients directly can become contaminated during patient care Certain surfaces especially ones touched frequently e g light handles unit switches and drawer knobs can serve as reservoirs of microbial contamination although they have not been associated directly with transmission of infection to either DHCP or patients Transfer of microorganisms from contaminated environmental surfaces to patients occurs primarily through DHCP hand contact 286 287 When these surfaces are touched microbial agents can be transferred to instruments other environmental surfaces or to the nose mouth or eyes of workers or patients Although hand hygiene is key to minimizing this transferal barrier protection or cleaning and disinfecting of environmental
520. uld be worn by DHCP during procedures and patient care activities likely to generate splashes or sprays of blood or body fluids Protective eyewear for patients shields their eyes from spatter or debris generated during dental procedures A surgical mask protects against microorganisms generated by the wearer with gt 95 bacterial filtration efficiency and also protects DHCP from large particle droplet spatter that might contain bloodborne pathogens or other infectious microorganisms 173 The masK s outer surface can become contaminated with infectious droplets from spray of oral fluids or from touching the mask with contaminated fingers Also when a mask becomes wet from exhaled moist air the resistance to airflow through the mask increases causing more airflow to pass around edges of the mask If the mask becomes wet it should be changed between patients or even during patient treatment when possible 2 174 When airborne infection isolation precautions expanded or transmission based are necessary e g for TB patients a National Institute for Occupational Safety and Health NIOSH certified particulate filter respirator e g N95 N99 or N100 should be used 20 N95 refers to the ability to filter 1 um particles in the unloaded state with a filter efficiency of gt 95 i e filter leakage lt 5 given flow rates of lt 50 L min i e approximate maximum airflow rate of HCP during breathing Available data indicate infectio
521. um or other oil emollients should only be used at the end of the work day 22 55 Dental practitioners should obtain information from lotion manufacturers regarding interaction between lotions gloves dental materials and antimicrobial products Fingernails and Artificial Nails Although the relationship between fingernail length and wound infection is unknown keeping nails short is considered key because the majority of flora on the hands are found under and around the fingernails 156 Fingernails should be short enough to allow DHCP to thoroughly clean underneath them and prevent glove tears 122 Sharp nail edges or broken nails are also likely to increase glove failure Long artificial or natural nails can make donning gloves more difficult and can cause gloves to tear more readily Hand carriage of gram negative organisms has been determined to be greater among wearers of artificial nails than among nonwearers both before and after handwashing 757 160 In addition artificial fingernails or extenders have been epidemiologically implicated in multiple outbreaks involving fungal and bacterial infections in hospital intensive care units and operating rooms 161 164 Freshly applied nail polish on natural nails does not increase the microbial load from periungual skin if fingernails are short however chipped nail polish can harbor added bacteria 165 166 Jewelry Studies have demonstrated that skin underneath rings is more he
522. uring dental procedures 402 provide limited support concerning preprocedural mouth rinsing with an antimicrobial as an adjunct for patients at risk for bacterial endocarditis Insufficient data exist to recommend preprocedural mouth rinses to prevent clinical infections among patients or DHCP Oral Surgical Procedures The oral cavity is colonized with numerous microorganisms Oral surgical procedures present an opportunity for entry of microorganisms i e exogenous and endogenous into the vascular system and other normally sterile areas of the oral cavity e g bone or subcutaneous tissue therefore an increased potential exists for localized or systemic infection Oral surgical procedures involve the incision excision or reflection of tissue that exposes the normally sterile areas of the oral cavity Examples include biopsy periodontal surgery apical surgery implant surgery and surgical extractions of teeth e g removal of erupted or nonerupted tooth requiring elevation of mucoperiosteal flap removal of bone or section of tooth and suturing if needed see Hand Hygiene PPE Single Use or Disposable Devices and Dental Unit Water Quality Handling of Biopsy Specimens To protect persons handling and transporting biopsy specimens each specimen must be placed in a sturdy leakproof container with a secure lid for transportation 73 Care should be taken when collecting the specimen to avoid contaminating the outside of the cont
523. us droplet nuclei measure 1 5 um therefore respirators used in health care settings should be able to efficiently filter the smallest particles in this range The majority of surgical masks are not NIOSH certified as respirators do not protect the user adequately from exposure to TB and do not satisfy OSHA requirements for respiratory protection 174 175 However certain surgical masks i e surgical N95 respirator do meet the requirements and are certified by NIOSH as respirators The level of protection a respirator provides is determined by the efficiency of the filter material for incoming air and how well the face piece fits or seals to the face e g qualitatively or quantitatively tested in a reliable way to obtain a face seal leakage of lt 10 and to fit the different facial sizes and characteristics of HCP When respirators are used while treating patients with diseases requiring airborne transmission precautions e g TB they should be used in the context of a complete respiratory protection program 175 This program should include training and fit testing to ensure an adequate seal between the edges of the respirator and the wearer s face Detailed information regarding respirator programs including fit test procedures are available at http www cdc gov niosh 99 143 html 174 176 Protective Clothing Protective clothing and equipment e g gowns lab coats gloves masks and protective eyewear or face shield should
524. uth Rinses Unresolved issue F Oral Surgical Procedures I The following apply when performing oral surgical procedures a Perform surgical hand antisepsis by using an antimicrobial product e g antimicrobial soap and water or soap and water followed by alcohol based hand scrub with persistent activity before donning sterile surgeon s gloves IB 27 132 137 b Use sterile surgeon s gloves IB 2 7 121 123 137 c Use sterile saline or sterile water as a coolant irrigatant when performing oral surgical procedures Use devices specifically designed for delivering sterile irrigating fluids e g bulb syringe single use disposable products and sterilizable tubing IB 2 121 G Handling of Biopsy Specimens J 2 During transport place biopsy specimens in a sturdy leakproof container labeled with the biohazard symbol IC 2 13 14 If a biopsy specimen container is visibly contaminated clean and disinfect the outside of a container or place it in an impervious bag labeled with the biohazard symbol IC 2 13 H Handling of Extracted Teeth 1 2 4 Dispose of extracted teeth as regulated medical waste unless returned to the patient IC 13 14 Do not dispose of extracted teeth containing amalgam in regulated medical waste intended for incineration II Clean and place extracted teeth in a leakproof container labeled with a biohazard symbol and maintain hydration for transport
525. valuation of a waterless scrubless chlorhexidine gluconate ethanol surgical scrub for antimicrobial efficacy Am J Infect Control 2001 29 377 82 Association of Perioperative Registered Nurses Recommended practices for surgical hand scrubs In Fogg D Parker N eds 2003 standards recommended practices and guidelines Denver CO AORN Inc 2003 277 80 Larson E Killien M Factors influencing handwashing behavior of patient care personnel Am J Infect Control 1982 10 93 9 Zimakoff J Kjelsberg AB Larson SO Holstein B A multicenter questionnaire investigation of attitudes toward hand hygiene assessed by the staff in fifteen hospitals in Denmark and Norway Am J Infec Control 1992 20 58 64 Grohskopf LA Roth VR Feikin DR et al Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center N Engl J Med 2001 344 1491 7 Archibald LK Corl A Shah B et al Serratia marcescens outbreak associated with extrinsic contamination of 1 chlorxylenol soap Infect Control Hosp Epidemiol 1997 18 704 9 Larson EL Norton Hughes CA Pyrak JD Sparks SM Cagatay EU Bartkus JM Changes in bacterial flora associated with skin damage on hands of health care personnel Am J Infect Control 1998 26 513 21 Ojaj rvi J M kel P Rantasalo I Failure of hand disinfection with frequent hand washing a need for prolonged field studies J Hyg Lond 1977 79 107 19 Berndt U Wigger Alberti W Gabard B Els
526. vinyl polysiloxane impression materials 207 209 although the setting is apparently not adversely affected by synthetic vinyl gloves 207 208 Given the diverse selection of dental materials on the market dental practitioners should consult glove manufacturers regarding the chemical compatibility of glove materials If the integrity of a glove is compromised e g punctured it should be changed as soon as possible 13 210 211 Washing latex gloves with plain soap chlorhexidine or alcohol can lead to the formation of glove micropunctures 177 212 213 and subsequent hand contamination 738 Because this condition known as wicking can allow penetration of liquids through undetected holes washing gloves is not recommended After a hand rub with alcohol the hands should be thoroughly dried before gloving because hands still wet with an alcohol based hand hygiene product can increase the risk of glove perforation 192 FDA regulates the medical glove industry which includes gloves marketed as sterile surgeon s and sterile or nonsterile patient examination gloves General purpose utility gloves are also used in dental health care settings but are not regulated by FDA because they are not promoted for medical use More rigorous standards are applied to surgeon s than to examination gloves FDA has identified acceptable quality levels e g maximum defects allowed for glove manufacturers 214 but even intact gloves eventually fail with ex
527. xposure and infection Infect Control Hosp Epidemiol 1994 15 745 50 Mitsui T Iwano K Masuko K et al Hepatitis C virus infection in medical personnel after needlestick accident Hepatology 1992 16 1109 14 Sartori M La Terra G Aglietta M Manzin A Navino C Verzetti G Transmission of hepatitis C via blood splash into conjunctiva Scand J Infect Dis 1993 25 270 1 Ippolito G Puro V De Carli G The risk of occupational human immunodeficiency virus in health care workers Italian Multicenter Study The Italian Study Group on Occupational Risk of HIV Infection Arch Intern Med 1993 153 1451 8 Beltrami EM Kozak A Williams IT et al Transmission of HIV and hepatitis C virus from a nursing home patient to a health care worker Am J Infec Control 2003 31 168 75 Cooper BW Krusell A Tilton RC Goodwin R Levitz RE Seroprevalence of antibodies to hepatitis C virus in high risk hospital personnel Infect Control Hosp Epidemiol 1992 13 82 5 Panlilio AL Shapiro CN Schable CA et al Serosurvey of human immunodeficiency virus hepatitis B virus and hepatitis C virus infection among hospital based surgeons Serosurvey Study Group J Am Coll Surg 1995 180 16 24 Polish LB Tong MJ Co RL Coleman PJ Alter MJ Risk factors for hepatitis C virus infection among health care personnel in a community hospital Am J Infect Control 1993 21 196 200 Shapiro CN Tokars JI Chamberland ME American Academy of Orthopaedic Surgeons Serosurvey S
528. y after use and wash hands immediately to avoid transfer of microorganisms to other patients or environments IB 7 8 123 3 Remove gloves that are torn cut or punctured as soon as feasible and wash hands before regloving IB IC 13 210 211 4 Do not wash surgeon s or patient examination gloves before use or wash disinfect or sterilize gloves for reuse IB IC 13 138 177 212 213 5 Ensure that appropriate gloves in the correct size are readily accessible IC 3 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 13 15 7 Consult with glove manufacturers regarding the chemical compatibility of glove material and dental materials used ID 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 8 137 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 demon strated Unresolved issue V Co
529. y associated with sterilization processes Droplet nuclei Particles lt 5 um in diameter formed by dehydration of airborne droplets containing microorganisms that can remain suspended in the air for long periods of time Droplets Small particles of moisture e g spatter generated when a person coughs or sneezes or when water is converted to a fine mist by an aerator or shower head These particles intermediate in size between drops and droplet nuclei can contain infectious microorganisms and tend to quickly settle from the air such that risk of disease transmission is usually limited to persons in close proximity to the droplet source Endotoxin The lipopolysaccharide of gram negative bacteria the toxic character of which resides in the lipid protein Endotoxins can produce pyrogenic reactions in persons exposed to their bacterial component Germicide An agent that destroys microorganisms especially pathogenic organisms Terms with the same suffix e g virucide fungicide bactericide tuberculocide and sporicide indicate agents that destroy the specific microorganism identified by the prefix Germicides can be used to inactivate microorganisms in or on living tissue 1 e antiseptics or on environmental surfaces i e disinfectants Hand hygiene General term that applies to handwashing antiseptic handwash antiseptic hand rub or surgical hand antisepsis Health care associated infection Any infection associated with a me
530. y to HBV infection and precautions to take IA IC 14 19 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 13 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 13 19 53 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 6 3 1 3 c Implement a written comprehensive program designed to minimize and manage DHCP exposures to blood and body fluids IB IC 13 14 19 97 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 13 97 110 112 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 2 7 13 19 113 115

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