Infection Control in Dental Health-Care Settings Terri L. Deal.

Infection Control in Dental Infection Control in Dental Health-Care SettingsHealth-Care Settings

Terri L. DealTerri L. Deal

Infection ControlInfection Control

Center for Disease Control updated in 2003Center for Disease Control updated in 2003– Previously released in 1986, 1993Previously released in 1986, 1993– Consolidates recommendations for :Consolidates recommendations for :

Preventing infectious diseasesPreventing infectious diseases Managing personnel health and safetyManaging personnel health and safety

– Updates previous CDC recommendationsUpdates previous CDC recommendations– Incorporates relevant infection control measuresIncorporates relevant infection control measures– Discusses concerns not previously mentionedDiscusses concerns not previously mentioned


General recommendationsGeneral recommendations– Develop a written program Develop a written program

PoliciesPolicies ProceduresProcedures Education and training guidelinesEducation and training guidelines ImmunizationsImmunizations


Exposure preventionExposure prevention Post-exposure managementPost-exposure management Medical conditionsMedical conditions Work restrictionsWork restrictions Contact dermatitis, latex sensitivityContact dermatitis, latex sensitivity Maintenance of records, data management and Maintenance of records, data management and

confidentialityconfidentiality

– Establish referral arrangements Establish referral arrangements


Education and trainingEducation and training– Provide to new employeesProvide to new employees– When new tasks or procedures affect When new tasks or procedures affect

employees exposureemployees exposure– Provided annually re: exposure to potentially Provided annually re: exposure to potentially

infectious agents and infection control infectious agents and infection control proceduresprocedures

– Provide educational information appropriate in Provide educational information appropriate in content, vocabulary for the health care providercontent, vocabulary for the health care provider


ImmunizationImmunization– List of all required and recommended List of all required and recommended

immunizationsimmunizations– Refer employee to prearranged health care Refer employee to prearranged health care

provider or their own health care providerprovider or their own health care provider

Exposure Prevention and Post-exposure Exposure Prevention and Post-exposure ManagementManagement– Develop post-exposure management and Develop post-exposure management and

medical follow up programmedical follow up program


Medical conditions, work-related illness, and Medical conditions, work-related illness, and work restrictionswork restrictions– Develop written policies re: work restriction and Develop written policies re: work restriction and

exclusion and who can implementexclusion and who can implement– Policies for preventive and curative care and Policies for preventive and curative care and

reporting illnesses. Don’t penalize with loss of reporting illnesses. Don’t penalize with loss of wages, benefits or job statuswages, benefits or job status

– Policies for evaluation, diagnosis and Policies for evaluation, diagnosis and management of occupational contact dermatitismanagement of occupational contact dermatitis

– Definitive diagnosis of suspected latex allergy, Definitive diagnosis of suspected latex allergy, work restrictions and accommodationswork restrictions and accommodations


Records Maintenance, data management Records Maintenance, data management and confidentialityand confidentiality– Establish and maintain confidential medical Establish and maintain confidential medical

records for all dental health care providersrecords for all dental health care providers– Ensure compliance of federal, state and local Ensure compliance of federal, state and local

laws re: medical recordkeeping and laws re: medical recordkeeping and confidentialityconfidentiality


Occupational exposure: Occupational exposure: – ““reasonably anticipated skin, eye, mucous reasonably anticipated skin, eye, mucous

membrane, or parenteral contact with blood or membrane, or parenteral contact with blood or other potentially infectious materials that may other potentially infectious materials that may result from the performance of an employee’s result from the performance of an employee’s duties”duties”


Occupational exposure occurs when your ..Occupational exposure occurs when your ..– Skin Skin – EyesEyes

Mucous membraneMucous membrane– BloodBlood


Come into contact with…Come into contact with…– Blood or saliva from a patientBlood or saliva from a patient– Contaminated instrumentsContaminated instruments– Equipment of laundry contaminated by blood or Equipment of laundry contaminated by blood or

saliva from a patientsaliva from a patient


Who is potentially infectious?Who is potentially infectious?

Universal Precautions:Universal Precautions:

“…“…all human blood and certain human body all human blood and certain human body fluids are treated as if known to be fluids are treated as if known to be infectious…”infectious…”

Universal PrecautionsUniversal Precautions

Transmission of infectious diseases from Transmission of infectious diseases from patient to health care workers usually patient to health care workers usually involves patients who do not know they involves patients who do not know they have an infectious disease.have an infectious disease.

Occupational Exposure Occupational Exposure DeterminationDetermination

Category I – Routinely exposed to blood, Category I – Routinely exposed to blood, saliva or both saliva or both

Examples: Dentist, Hygienist, Assistant, Examples: Dentist, Hygienist, Assistant, Infection Control/Sterilization Assistant, Lab Infection Control/Sterilization Assistant, Lab TechnicianTechnician

Category II – May on occasion be exposed Category II – May on occasion be exposed to blood, saliva or bothto blood, saliva or both

Disease Transmission in the Disease Transmission in the Dental OfficeDental Office

Every dental office should have an infection Every dental office should have an infection control program designed to prevent the control program designed to prevent the transmission of disease from: transmission of disease from: • Patient to dental teamPatient to dental team• Dental team to patientDental team to patient• Patient to patientPatient to patient• Dental office to community (includes Dental office to community (includes

dental team’s family)dental team’s family)• Community to patientCommunity to patient

Therefore…Therefore…

Health care workers must…Health care workers must…

– Consider blood and saliva from all patients as Consider blood and saliva from all patients as potentially infectiouspotentially infectious

– Take precautions to protect themselves from Take precautions to protect themselves from exposureexposure

Hepatitis B VaccineHepatitis B Vaccine

Employer must educate employees.Employer must educate employees. Employer must offer the vaccine within 10 Employer must offer the vaccine within 10

working days and pay for the vaccine.working days and pay for the vaccine. Employee can decline, but must sign Employee can decline, but must sign

declination statement.declination statement.

Post-Exposure Evaluation and Post-Exposure Evaluation and Follow-upFollow-up

Employer must:Employer must:– Document exposure and circumstancesDocument exposure and circumstances– Document source individualDocument source individual– Source individual’s blood testedSource individual’s blood tested– If source is known to be infected, blood test is If source is known to be infected, blood test is

not necessary.not necessary.

Post-Exposure Evaluation and Post-Exposure Evaluation and Follow-upFollow-up

Employee’s blood is tested.Employee’s blood is tested. If employee refuses HIV testing, then If employee refuses HIV testing, then

blood is stored at least 90 days.blood is stored at least 90 days. Confidential medical evaluationConfidential medical evaluation When indicated use post-exposure When indicated use post-exposure

prophylaxis which will prevent HIV prophylaxis which will prevent HIV infectioninfection

Medical WasteMedical Waste

Blood or saliva mixed with bloodBlood or saliva mixed with blood

Medical Waste:Medical Waste:

Items that release blood or saliva-blood if Items that release blood or saliva-blood if compressed or during handlingcompressed or during handling

Medical Waste:Medical Waste:

Pathological wastePathological waste– Teeth Teeth – TissueTissue

Contaminated sharpsContaminated sharps

Disposal of regulated Waste:Disposal of regulated Waste:

LandfillsLandfills Private pick-up servicesPrivate pick-up services HospitalsHospitals On-siteOn-site

Remember:Remember:

Items that do not release blood and/or saliva Items that do not release blood and/or saliva when compressed or handled do NOT need when compressed or handled do NOT need special disposal.special disposal.

Requirements for Transmission of Requirements for Transmission of InfectionInfection

A reservoir of pathogenA reservoir of pathogen A pathogen of sufficient infectivity and A pathogen of sufficient infectivity and

numbernumber A mode of escape from the hostA mode of escape from the host A mode of spread to the new hostA mode of spread to the new host A portal of entryA portal of entry A susceptible hostA susceptible host


Preventing Transmission of Blood Preventing Transmission of Blood borne Pathogensborne Pathogens– HBV vaccinationHBV vaccination– Preventing exposure to Blood and Preventing exposure to Blood and

OPIM (other potentially infectious OPIM (other potentially infectious material)material) Use standard precautions for all Use standard precautions for all

patientspatients


Consider sharp items contaminated with Consider sharp items contaminated with blood and saliva as potentially infectiveblood and saliva as potentially infective

Implement written program to minimize Implement written program to minimize exposuresexposures

SterilizationSterilization

Destruction of all microorganisms including Destruction of all microorganisms including bacterial sporesbacterial spores

Should be used for all instruments which Should be used for all instruments which come in contact with blood or salivacome in contact with blood or saliva

DisinfectionDisinfection

Destroys most microorganisms but not Destroys most microorganisms but not bacterial sporesbacterial spores

Used for surfaces and impressionsUsed for surfaces and impressions

Disinfectants Versus Disinfectants Versus AntisepticsAntiseptics

DisinfectantsDisinfectants are chemicals that are applied are chemicals that are applied to inanimate surfaces (such as countertops to inanimate surfaces (such as countertops and dental equipment).and dental equipment).

AntisepticsAntiseptics are antimicrobial agents that are antimicrobial agents that are applied to living tissue. are applied to living tissue.

Disinfectants and antiseptics should never Disinfectants and antiseptics should never be used interchangeably because tissue be used interchangeably because tissue toxicity and damage to equipment can result.toxicity and damage to equipment can result.

Disinfectants Versus Disinfectants Versus AntisepticsAntiseptics

If there were an ideal surface If there were an ideal surface disinfectant, it would have a rapid kill of a disinfectant, it would have a rapid kill of a broad spectrum of bacteria, have broad spectrum of bacteria, have residual activity, minimal toxicity, and residual activity, minimal toxicity, and would not damage surfaces to be would not damage surfaces to be treated. In addition, it would be odorless, treated. In addition, it would be odorless, inexpensive, work on surfaces with inexpensive, work on surfaces with remaining bio-burden, and be simple to remaining bio-burden, and be simple to use.use.

The “Perfect Disinfectant?”The “Perfect Disinfectant?” Unfortunately, no single disinfectantUnfortunately, no single disinfectant

product on the market today meets all product on the market today meets all these criteria. these criteria.

The “Perfect Disinfectant?”The “Perfect Disinfectant?” When selecting a surface disinfectant, you When selecting a surface disinfectant, you

must carefully consider the advantages and must carefully consider the advantages and disadvantages of various products.disadvantages of various products.

Often the manufacturers of dental Often the manufacturers of dental equipment will recommend the type of equipment will recommend the type of surface disinfectant that is most appropriate surface disinfectant that is most appropriate for their dental chairs and units.for their dental chairs and units.

Types of Chemical Types of Chemical DisinfectantsDisinfectants

IodophorsIodophors are EPA-registered are EPA-registered intermediate-intermediate-levellevel hospital disinfectants with hospital disinfectants with tuberculocidal actiontuberculocidal action.. Because iodophors Because iodophors contain iodine, they may corrode or discolor contain iodine, they may corrode or discolor certain metals and may temporarily cause certain metals and may temporarily cause reddish or yellow stains on clothing and other reddish or yellow stains on clothing and other surfaces.surfaces.

Types of Chemical Types of Chemical DisinfectantsDisinfectants

Synthetic phenolSynthetic phenol compounds are EPA- compounds are EPA-registered intermediate-level hospital registered intermediate-level hospital disinfectants with broad-spectrum disinfecting disinfectants with broad-spectrum disinfecting action. Phenols can be used on metal, glass, action. Phenols can be used on metal, glass, rubber, or plastic. They also may be used as a rubber, or plastic. They also may be used as a holding solution for instruments; however, holding solution for instruments; however, phenols leave a residual film on treated phenols leave a residual film on treated surfaces. Synthetic phenol compound is surfaces. Synthetic phenol compound is prepared daily.prepared daily.

Types of Chemical Types of Chemical DisinfectantsDisinfectants cont cont’’dd

Sodium hypochloriteSodium hypochlorite ( (household bleachhousehold bleach) is a fast-acting, ) is a fast-acting, economic, and broad-spectrum intermediate-level economic, and broad-spectrum intermediate-level disinfectant (1:100 dilution for surface decontamination).disinfectant (1:100 dilution for surface decontamination).

• Disadvantages:Disadvantages: It is unstable and must be It is unstable and must be prepared daily, has a strong odor and is prepared daily, has a strong odor and is corrosive to some metals. It is also destructive corrosive to some metals. It is also destructive to fabrics and irritating to the eyes and skin; it to fabrics and irritating to the eyes and skin; it may eventually cause plastic chair covers to may eventually cause plastic chair covers to crack.crack.

Types of Chemical DisinfectantsTypes of Chemical Disinfectants contcont’’dd

AlcoholsAlcohols are are notnot effective in the presence of blood and effective in the presence of blood and saliva. They evaporate quickly and are damaging to certain saliva. They evaporate quickly and are damaging to certain materials such as plastics and vinyl. materials such as plastics and vinyl.

• The American Dental Association (ADA), CDC, The American Dental Association (ADA), CDC, and the Office of Safety and Asepsis Procedures and the Office of Safety and Asepsis Procedures Research Foundation (OSAP) Research Foundation (OSAP) do not do not recommendrecommend alcohol as an environmental alcohol as an environmental surface disinfectant.surface disinfectant.

Classification of Instruments and Classification of Instruments and EquipmentEquipment

Instruments and equipment are divided into Instruments and equipment are divided into three classifications: three classifications: • CriticalCritical• Semi-criticalSemi-critical• Non-critical Non-critical

The classifications are used to determine the The classifications are used to determine the minimalminimal type of post-treatment processing. type of post-treatment processing.

PPEsPPEs

Utility glovesUtility gloves

Protective eyewear and mask or face shieldProtective eyewear and mask or face shield

Protective gownProtective gown

Surface DisinfectionSurface Disinfection

Use PPE for preparation and use of Use PPE for preparation and use of disinfectantsdisinfectants

Use an EPA-registered, ADA-accepted Use an EPA-registered, ADA-accepted disinfectant for cleaning and disinfectingdisinfectant for cleaning and disinfecting

Follow manufacturer’s directions on the Follow manufacturer’s directions on the disinfectant labeldisinfectant label

Use water if dilution is requiredUse water if dilution is required

Surface DisinfectionSurface Disinfection

Spray, Wipe, Spray……………WipeSpray, Wipe, Spray……………Wipe– Spray and wipe to clean surfaceSpray and wipe to clean surface– Spray again and leave disinfectant on surface Spray again and leave disinfectant on surface

long enough to be tuberculocidal (usually 10 long enough to be tuberculocidal (usually 10 min.)min.)

Do not pre-saturate gauze squares with Do not pre-saturate gauze squares with disinfectantdisinfectant

Surface BarriersSurface Barriers

Surfaces that are difficult to disinfect may be Surfaces that are difficult to disinfect may be wrapped with water-impervious material that wrapped with water-impervious material that is changed between patients.is changed between patients.

Types of Surface BarriersTypes of Surface Barriers There is a wide variety of surface barriers There is a wide variety of surface barriers

available on the market today. available on the market today. All should be resistant to fluids to keep All should be resistant to fluids to keep

microorganisms in saliva, blood or other microorganisms in saliva, blood or other liquids from soaking through to contact the liquids from soaking through to contact the surface underneath. surface underneath.

Types of Surface BarriersTypes of Surface Barriers Some plastic bags are designed especially Some plastic bags are designed especially

to the shape of items such as the dental to the shape of items such as the dental chair, air-water syringe, hoses, pens, light chair, air-water syringe, hoses, pens, light handles, etc.handles, etc.

Plastic-barrier sticky tape is frequently used Plastic-barrier sticky tape is frequently used to protect smooth surfaces such as touch to protect smooth surfaces such as touch pads on equipment, electrical switches on pads on equipment, electrical switches on chairs, or x-ray equipment. Aluminum foil chairs, or x-ray equipment. Aluminum foil can also be used because it is easily formed can also be used because it is easily formed around any shape.around any shape.

Cross-ContaminationCross-Contamination

Something is contaminated if:Something is contaminated if:– You touch it with your bare skinYou touch it with your bare skin

– You touch it after you touch the patientYou touch it after you touch the patient

– You touch it after you touch a contaminated itemYou touch it after you touch a contaminated item

To avoid cross-contaminationTo avoid cross-contamination

Use over-glovesUse over-gloves

Use clean towel or paper towelUse clean towel or paper towel

Infection ControlInfection Control Hand hygieneHand hygiene Wash hands:Wash hands:

– When visibly soiledWhen visibly soiled– After barehanded touching likely contaminated objects After barehanded touching likely contaminated objects

(by blood, saliva or respiratory secretions)(by blood, saliva or respiratory secretions)

BEFORE BEFORE and and AFTER AFTER treating each patienttreating each patient– Before putting on glovesBefore putting on gloves– Immediately after removing glovesImmediately after removing gloves– Liquid hand care products stored in containers that Liquid hand care products stored in containers that

can be washed and dried. Don’t top offcan be washed and dried. Don’t top off


Special hand considerationsSpecial hand considerations– Use hand lotions to prevent skin drynessUse hand lotions to prevent skin dryness– Avoid lotions with petroleum or other oil Avoid lotions with petroleum or other oil

emollientsemollients– Fingernails shortFingernails short

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– No artificial nails or extenders or polishNo artificial nails or extenders or polish– No jewelry -it compromises the fit and No jewelry -it compromises the fit and

integrity of the gloveintegrity of the glove

– Microorganisms thrive around rough Microorganisms thrive around rough cuticles and enter through break in the skincuticles and enter through break in the skin

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PPE (personal protective equipment)PPE (personal protective equipment)– OSHA requires employer to provide employees OSHA requires employer to provide employees

with appropriate PPE at no chargewith appropriate PPE at no charge– Masks, Eyewear and Face shieldsMasks, Eyewear and Face shields

Solid side shields on eyewear protects mucous Solid side shields on eyewear protects mucous membranes of eyes, nose and mouthmembranes of eyes, nose and mouth

Infection ControlInfection Control eyewear and face-shield should be eyewear and face-shield should be

disinfecteddisinfected Change masks between patients or if mask Change masks between patients or if mask

gets wet or is visibly soiledgets wet or is visibly soiled Touch masks only on sideTouch masks only on side Mask should not contact the mouthMask should not contact the mouth Mask with 95% filtration for particles 3-5mm Mask with 95% filtration for particles 3-5mm

in diameterin diameter


Face shieldsFace shields– Chin-length shield replaces eyewear but not Chin-length shield replaces eyewear but not

mask. mask. – Doesn’t protect against inhaling aerosolsDoesn’t protect against inhaling aerosols– Patient eyewearPatient eyewear

Protect from Protect from –Handpeice splatterHandpeice splatter–Spilled or splashed materialsSpilled or splashed materials–Airborne bits of acrylic or tooth fragmentsAirborne bits of acrylic or tooth fragments


Protective clothing-covers area likely to be Protective clothing-covers area likely to be soiled with blood, saliva or OPIMsoiled with blood, saliva or OPIM

–Change if soiledChange if soiled–Remove PPE when leaving work areaRemove PPE when leaving work area

GlovesGloves– New pair each pt.New pair each pt.– Remove if torn, cut or puncturedRemove if torn, cut or punctured– Do not wash gloves before use-may be rinsed Do not wash gloves before use-may be rinsed

to remove excess powderto remove excess powder– Wash hands before re-glovingWash hands before re-gloving– Proper fitProper fit

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– Double gloving-effectiveness in Double gloving-effectiveness in preventing disease transmission has NOT preventing disease transmission has NOT been demonstrated. been demonstrated.

– Over-gloves-not acceptable alone as Over-gloves-not acceptable alone as hand barrierhand barrier

– Sterile gloves-invasive proceduresSterile gloves-invasive procedures


Latex HypersensitivityLatex Hypersensitivity

– Educate staff to signs, symptoms and Educate staff to signs, symptoms and diagnosis of skin reactiondiagnosis of skin reaction


Three types of allergic reactions to latexThree types of allergic reactions to latex– 1. 1. Irritant dermatitisIrritant dermatitis, non-immunologic , non-immunologic

process involves only surface irritation. process involves only surface irritation. Chemical substance causes irritation. Red, Chemical substance causes irritation. Red, dry, irritated and sometimes cracked.dry, irritated and sometimes cracked.

– 2.Type IV2.Type IV –most common, involves immune –most common, involves immune system. Delayed contact reaction. 48-72 hrs. system. Delayed contact reaction. 48-72 hrs. Limited to areas of contact. Caused by Limited to areas of contact. Caused by chemicals used to process latexchemicals used to process latex


– 3. 3. Type IType I –MOST dangerous. Can cause death. –MOST dangerous. Can cause death. Reaction to latex protein. Occurs 2-3 minutes Reaction to latex protein. Occurs 2-3 minutes after contact. after contact.


Remember:Remember:– When one employee in the dental office has When one employee in the dental office has

been diagnosed as having a latex allergy, all been diagnosed as having a latex allergy, all staff members should use practices to minimize staff members should use practices to minimize the use of latex-containing products. These the use of latex-containing products. These practices include the wearing of powder-free practices include the wearing of powder-free gloves by all dental staff members to minimize gloves by all dental staff members to minimize the risk of airborne latex particles.the risk of airborne latex particles.

BackgroundBackground Dental health care workers are exposed to Dental health care workers are exposed to

LegionellaLegionella bacteria at a much higher rate than bacteria at a much higher rate than the general public. the general public.

Dental personnel are exposed to contaminated Dental personnel are exposed to contaminated dental unit waterlines by inhaling the aerosol dental unit waterlines by inhaling the aerosol generated by the hand piece and the air-water generated by the hand piece and the air-water syringe. syringe.

BackgroundBackground There is at least one suspected fatality of a There is at least one suspected fatality of a

dentist from legionellosis. dentist from legionellosis. Case reports have been published of immuno-Case reports have been published of immuno-

compromised patients who developed compromised patients who developed postoperative infections caused by postoperative infections caused by contaminated dental water.contaminated dental water.

Microorganisms in Microorganisms in WaterlinesWaterlines

The The primary sourceprimary source of microorganisms in of microorganisms in dental waterlines is the public water supply.dental waterlines is the public water supply.

It is possible that saliva may be retracted back It is possible that saliva may be retracted back into the waterlines during treatment. This into the waterlines during treatment. This process is also called process is also called ““suck back.suck back.””

Microorganisms in WaterlinesMicroorganisms in Waterlines Anti-retraction valves on dental units and Anti-retraction valves on dental units and

thorough flushing of the dental lines between thorough flushing of the dental lines between patients minimize the chance of this occurring. patients minimize the chance of this occurring.

Entering public water source has a colony Entering public water source has a colony forming units (CFU) count of less than 500; forming units (CFU) count of less than 500; once that water enters the dental waterlines once that water enters the dental waterlines and colonizes within the bio-film, the CFU and colonizes within the bio-film, the CFU count skyrockets. count skyrockets.

Communities of BacteriaCommunities of Bacteria There are two There are two ““communitiescommunities”” of bacteria in of bacteria in

dental unit waterlines: dental unit waterlines:

• One bacterial community exists in the One bacterial community exists in the water itself and is referred to as water itself and is referred to as planktonicplanktonic (free floating). (free floating).

• The other exists in the bio-film attached The other exists in the bio-film attached to the walls of the waterlines. to the walls of the waterlines.

Bio-filmBio-film Bio-filmBio-film exists in all places where moisture exists in all places where moisture

and a suitable solid surface exist.and a suitable solid surface exist. Bio-film consists of bacterial cells and other Bio-film consists of bacterial cells and other

microbes that adhere to surfaces and form a microbes that adhere to surfaces and form a protective slime layer.protective slime layer.

Bio-film can contain many types of bacteria, Bio-film can contain many types of bacteria, as well as fungi, algae, and protozoa. as well as fungi, algae, and protozoa.

Viruses, such as the human Viruses, such as the human immunodeficiency virus (HIV), immunodeficiency virus (HIV), cannot cannot multiply in the dental unit waterline.multiply in the dental unit waterline.

Methods to Reduce Methods to Reduce ContaminationContamination

It is not yet possible to totally eliminate bio-It is not yet possible to totally eliminate bio-film, but it can be minimized by:film, but it can be minimized by:

• Self-contained water reservoirs Self-contained water reservoirs

• Chemical treatment regimens Chemical treatment regimens

• Micro-filtration Micro-filtration

• Daily draining and drying of lines Daily draining and drying of lines

Self-Contained Water Self-Contained Water Reservoirs Reservoirs

These systems supply air pressure to the These systems supply air pressure to the water bottle (water bottle (reservoirreservoir). ).

The air pressure in the bottle forces the The air pressure in the bottle forces the water from the bottle up into the dental unit water from the bottle up into the dental unit water lines (DUWL) and out to the hand water lines (DUWL) and out to the hand piece and air-water syringe. piece and air-water syringe.

Self-Contained Water Self-Contained Water Reservoirs Reservoirs

Self-contained water systems have two Self-contained water systems have two advantages:advantages:• The dental personnel can select the quality of The dental personnel can select the quality of

water to be used, such as distilled, tap, or water to be used, such as distilled, tap, or sterile.sterile.

• Maintenance of the water system (between the Maintenance of the water system (between the reservoir bottle and the hand pieces and reservoir bottle and the hand pieces and syringes) is under the control of the dentist and syringes) is under the control of the dentist and staff. staff.

Micro-filtration CartridgeMicro-filtration Cartridge A disposable inline micro-filtration cartridge A disposable inline micro-filtration cartridge

also can dramatically reduce the bacterial also can dramatically reduce the bacterial contamination in the dental unit water.contamination in the dental unit water.

Micro-filtration CartridgeMicro-filtration Cartridge This device must be inserted as close to This device must be inserted as close to

the hand piece or air-water syringe as the hand piece or air-water syringe as possible. possible.

It should be replaced at least daily on each It should be replaced at least daily on each line. The use of filtration cartridges line. The use of filtration cartridges combined with water reservoirs can ensure combined with water reservoirs can ensure improved water quality. improved water quality.

Chemical AgentsChemical Agents Chemicals can be used to help control bio-Chemicals can be used to help control bio-

film in two ways: film in two ways: • Periodic or Periodic or ““shockshock”” treatment with bio- treatment with bio-

cidal levels (levels that will kill cidal levels (levels that will kill microorganisms) of chemicals. microorganisms) of chemicals.

• Continuous application of chemicals to the Continuous application of chemicals to the system (at the level to kill the system (at the level to kill the microorganisms but not harm humans). microorganisms but not harm humans).

Chemical AgentsChemical Agents

AlwaysAlways check with the manufacturer of the check with the manufacturer of the dental equipment to determine which dental equipment to determine which chemical product and maintenance protocol chemical product and maintenance protocol they recommend. they recommend.

Water for Surgical ProceduresWater for Surgical Procedures Dental unit water should Dental unit water should notnot be used as an be used as an

irrigant for surgery involving the exposure of irrigant for surgery involving the exposure of bone.bone.

Only use sterile water from special sterile Only use sterile water from special sterile water delivery systems or hand irrigation water delivery systems or hand irrigation using sterile water in a sterile disposable using sterile water in a sterile disposable syringe. syringe.

Flushing WaterlinesFlushing Waterlines All dental waterlines and hand pieces All dental waterlines and hand pieces

should be flushed in the mornings and should be flushed in the mornings and between patients. between patients.

Although this will Although this will not removenot remove bio-films from bio-films from the lines, it may temporarily reduce the the lines, it may temporarily reduce the microbial count in the water.microbial count in the water.

Flushing WaterlinesFlushing Waterlines It will help clean the hand piece waterlines It will help clean the hand piece waterlines

of materials that may have entered from of materials that may have entered from the patientthe patient’’s mouth.s mouth.

Flushing also brings a fresh supply of Flushing also brings a fresh supply of chlorinated water from the main waterlines chlorinated water from the main waterlines into the dental unit. into the dental unit.

Minimize AerosolMinimize Aerosol Always use the high-volume evacuator Always use the high-volume evacuator

when using the high-speed hand piece, when using the high-speed hand piece, ultrasonic scaler, and air-water syringe. ultrasonic scaler, and air-water syringe.

The high-volume evacuation may also The high-volume evacuation may also reduce exposure of the patient to these reduce exposure of the patient to these waterborne microorganisms. waterborne microorganisms.

Use Protective BarriersUse Protective Barriers The dental dam greatly reduces direct The dental dam greatly reduces direct

contact.contact. The dam also greatly reduces the The dam also greatly reduces the

aerosolizing and spattering of the patientaerosolizing and spattering of the patient’’s s oral microorganisms onto the dental team.oral microorganisms onto the dental team.

Protective barriers, including masks, Protective barriers, including masks, eyewear, and face shields, also serve as eyewear, and face shields, also serve as barriers for the dental team. barriers for the dental team.

Several government agencies and professional Several government agencies and professional organizations have a direct influence on dentistry, organizations have a direct influence on dentistry, infection control, and other health care safety infection control, and other health care safety issues. issues.

In addition to issuing In addition to issuing recommendationsrecommendations and and regulationsregulations some have regulatory roles and some have regulatory roles and others are advisory. others are advisory.

These agencies can serve as an excellent These agencies can serve as an excellent resource for information and educational materials.resource for information and educational materials.

Recommendations and Recommendations and RegulationsRegulations

RecommendationsRecommendations are made by are made by individuals, groups, or agencies that are individuals, groups, or agencies that are advisory and have advisory and have nono authority for authority for enforcement. enforcement.

Recommendations and Recommendations and RegulationsRegulations

RegulationsRegulations are made by groups or are made by groups or agencies that agencies that do havedo have the authority to the authority to enforce compliance with the regulations. enforce compliance with the regulations. Enforcement penalties may include fines, Enforcement penalties may include fines, imprisonment, or suspension or imprisonment, or suspension or revocation of licenses. revocation of licenses.

Recommendations may be made by Recommendations may be made by anyone, but regulations are made by anyone, but regulations are made by governmental groups or licensing boards governmental groups or licensing boards in towns, cities, counties, and states. in towns, cities, counties, and states.

Associations and Associations and OrganizationsOrganizations

The The American Dental Association (ADA)American Dental Association (ADA) is is the professional organization for dentists. The the professional organization for dentists. The ADA periodically updates its infection control ADA periodically updates its infection control recommendations as new scientific information recommendations as new scientific information becomes available. becomes available.

Associations and Associations and OrganizationsOrganizations

The The Organization for Safety and Asepsis Organization for Safety and Asepsis Procedures (OSAP)Procedures (OSAP) is a not-for-profit is a not-for-profit organization composed of dentists, organization composed of dentists, hygienists, dental assistants, government hygienists, dental assistants, government representatives, dental manufacturers, representatives, dental manufacturers, university professors, researchers, and dental university professors, researchers, and dental consultants. This organization is an excellent consultants. This organization is an excellent resource for information on infection control, resource for information on infection control, injury prevention, and occupational health injury prevention, and occupational health issues.issues.

State and local dental societies can be State and local dental societies can be

helpful to you in complying with regulatory helpful to you in complying with regulatory issues in your specific area. issues in your specific area.

National, state, and local dental assisting National, state, and local dental assisting societies can often answer questions and societies can often answer questions and provide opportunities for continuing dental provide opportunities for continuing dental education.education.

Associations and Organizations cont’dAssociations and Organizations cont’d

Governmental AgenciesGovernmental Agencies Centers for Disease Control and Prevention Centers for Disease Control and Prevention

(CDC) (CDC) Food and Drug Administration (FDA) Food and Drug Administration (FDA) Occupational Safety and Health Occupational Safety and Health

Administration (OSHA) Administration (OSHA) National Institute for Occupational Safety National Institute for Occupational Safety

and Health (NIOSH) and Health (NIOSH)

Centers for Disease Control Centers for Disease Control and Prevention (CDC)and Prevention (CDC)

The CDC is recognized as the lead federal The CDC is recognized as the lead federal agency for protecting the health and safety of agency for protecting the health and safety of people at home and abroad. people at home and abroad.

The CDC bases its public health The CDC bases its public health recommendations on the highest quality recommendations on the highest quality scientific data. scientific data.

Food and Drug Food and Drug Administration (FDA) Administration (FDA)

The FDA is a The FDA is a regulatory agencyregulatory agency and is and is part of the United States Department of part of the United States Department of Health and Human Services.Health and Human Services.

Food and Drug Administration Food and Drug Administration (FDA) (FDA)

The FDA regulates the manufacturing and The FDA regulates the manufacturing and labeling of medical devices (such as labeling of medical devices (such as sterilizers, biologic and chemical sterilizers, biologic and chemical indicators, ultrasonic cleaners and indicators, ultrasonic cleaners and cleaning solutions, liquid sterilants, cleaning solutions, liquid sterilants, gloves, masks, protective eyewear, dental gloves, masks, protective eyewear, dental handpieces and instruments, dental handpieces and instruments, dental chairs, and dental unit lights). chairs, and dental unit lights).

It also regulates antimicrobial It also regulates antimicrobial handwashing products and mouth rinses.handwashing products and mouth rinses.

Environmental Protection Environmental Protection AgencyAgency

The EPA is a The EPA is a regulatory agencyregulatory agency. . It ensures the safety and effectiveness of It ensures the safety and effectiveness of

disinfectants.disinfectants.

Environmental Protection Environmental Protection AgencyAgency

Manufacturers of disinfectants must submit Manufacturers of disinfectants must submit information about the safety and information about the safety and effectiveness of the product. effectiveness of the product.

If the claims meet the EPA criteria, the If the claims meet the EPA criteria, the product receives an EPA registration number product receives an EPA registration number that must appear on the product label. that must appear on the product label.

The EPA regulates discharge and final The EPA regulates discharge and final treatment of waste materials (i.e., chemicals), treatment of waste materials (i.e., chemicals), as well as medical waste, after it leaves the as well as medical waste, after it leaves the dental office.dental office.

Occupational Safety and Health Occupational Safety and Health Administration (OSHA) Administration (OSHA)

OSHA is a regulatory agency.OSHA is a regulatory agency. It protects workersIt protects workers’’ against physical, against physical,

chemical, or infectious hazards in the chemical, or infectious hazards in the workplace.workplace.

Occupational Safety and Health Occupational Safety and Health Administration (OSHA) Administration (OSHA)

It establishes protective standards, enforces It establishes protective standards, enforces those standards, and offers technical those standards, and offers technical assistance and consultation programs.assistance and consultation programs.

OSHA is a federal agency, but 22 states OSHA is a federal agency, but 22 states administer their own state-operated OSHA administer their own state-operated OSHA programs. programs.

In states that administer their own OSHA In states that administer their own OSHA programs, the state standards must be programs, the state standards must be equivalent to, or more stringent, than those equivalent to, or more stringent, than those of the federal agency. of the federal agency.

National Institute for Occupational National Institute for Occupational Safety and Health (NIOSH) Safety and Health (NIOSH)

NIOSH does not have regulatory authority.NIOSH does not have regulatory authority. It is responsible for conducting research and It is responsible for conducting research and

making recommendations for the prevention making recommendations for the prevention of work-related disease and injury. of work-related disease and injury.

National Institute for Occupational National Institute for Occupational Safety and Health (NIOSH) Safety and Health (NIOSH)

NIOSH makes recommendations and NIOSH makes recommendations and disseminates information on preventing disseminates information on preventing workplace disease, injury, and disability.workplace disease, injury, and disability.

It provides training to occupational safety It provides training to occupational safety and health professionals. and health professionals.

Outbreaks of waterborne disease have Outbreaks of waterborne disease have occurred in a broad range of facilities. occurred in a broad range of facilities. Although there is no evidence of a Although there is no evidence of a widespread public health problem, published widespread public health problem, published reports have associated illness with exposure reports have associated illness with exposure to water from dental units. The fact that there to water from dental units. The fact that there are bacteria capable of causing disease in are bacteria capable of causing disease in humans found in dental unit waterlines is humans found in dental unit waterlines is reason for concern. reason for concern.

In community water, the number of waterborne In community water, the number of waterborne bacteria is kept below 500 colony-forming units bacteria is kept below 500 colony-forming units (CFU) per milliliter. (CFU) per milliliter.

The water from air-water syringes and dental The water from air-water syringes and dental hand pieces frequently has bacteria levels that hand pieces frequently has bacteria levels that are hundreds or thousands of times are hundreds or thousands of times greatergreater than than is permissible in drinking water. is permissible in drinking water.

The types of bacteria that are found in dental The types of bacteria that are found in dental unit water are frequently the same types as unit water are frequently the same types as those found in community water, but the levels of those found in community water, but the levels of bacteria found in the dental units are almost bacteria found in the dental units are almost always always higherhigher. .

WebsitesWebsites

www.engenderhealth.org/ ip/sharps/nsm3.html

www.ada.org

www.fda.gov

www.osha.gov

www.cdc.govwww.cdc.gov

http://www.engenderhealth.org/ip/sharps/nsm3.html

http://www.engenderhealth.org/ip/sharps/nsm3.html

http://www.ada.org/

http://www.fda.gov/

http://www.osha.gov/

Infection Control in Dental Health-Care Settings Terri L. Deal.

Documents

infectious slide

infection control procedures

infection control education

infection control center

confidentiality slide

patient slide

program slide

disease control