Dental Branch

1
Bloodborne Pathogens Infection Control

• Dental Branch
• 2008 Annual Clinic Update
• Presented by Environmental Health Safety

2
Objectives

• Bloodborne Pathogens
• Preventive Measures
• Spill, Injury/Potential Exposure
• TB, MRSA, Flu
• Water Lines Quality
• General Safety (drills, physical, x-ray, laser)

3
Regulations Guidelines

• Occupational Safety Health Administration
  (OSHA)
• Centers for Disease Control Prevention (CDC)
• American Dental Association (ADA)
• Texas Department of State Health Services (DHSH)
• Texas Commission on Environmental Quality (TCEQ)

4
Training Requirements

• All health care workers with potential for
  exposure to blood or other body fluids must
  receive training
• At time of initial assignment
• Annually

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Bloodborne PathogensOSHA 1910.1030
Definition Any pathogenic microorganism that
is present in human blood or other potentially
infectious materials (OPIM), and can infect and
cause disease in humans.
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Bloodborne Pathogens (BBP)

• Examples
• HIV
• HBV
• HCV
• T. pallidum
• Herpes Virus
• M. tuberculosis (typically an aerosol hazard)
• Human T-Lymphotropic Virus Type I (HTLV-I)

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Bloodborne Pathogens (BBP)

• Body fluids that can harbor BBP
• Blood
• Semen and vaginal secretions
• Saliva involved in dental procedures
• Synovial fluid
• Cerebrospinal fluid
• Human tissue and cell cultures
• All body fluids containing blood

8
Occupational Exposure

• Mucous membrane contact
• Splash to the eyes, nose or mouth
• Percutaneous inoculation
• Misuse of sharps (broken glass, needles,
  scalpels, dental bur, knife)
• Exposure to broken/damaged skin
• Risk increases if contact involves a large area
  of broken/damaged skin or if contact is prolonged
• Risk increases with high titer levels in the
  source

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Why Is Infection Control Important in Dentistry?

• Both patients dental health care personnel
  (DHCP) can be exposed to pathogens
• Contact with blood, oral respiratory
  secretions, contaminated equipment occurs
• Proper procedures can prevent transmission of
  infections among patients and DHCP

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Potential Routes of Transmission
Patient
DHCP
Patient
DHCP
Patient
Patient
11
Break the Chain of Infection
Pathogen
Source
Susceptible Host
Mode
Entry
12
Preventive Measures

• Risk of exposure can be minimized or eliminated
  by using the following controls
• Engineering controls
• Personal protective equipment (PPE)
• Administrative controls
• Work place practices

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Engineering Controls

• Leakproof containers
• Use for storage transportation of ALL
  bloodborne pathogen material
• Sharps containers
• Fill no greater than ¾ full
• Needleless devices
• Use retractable syringes, self-sheathing needles
  (if possible)

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Personal Protective Equipment (PPE)

• Consider that all patients are infectious
• Wear personal protective equipment
• Gowns
• Gloves
• Masks
• Protective Eyewear

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Clinic Gown

• The official protective gown for use in all
  Dental Branch clinics is the Clinic Gown
• White for faculty
• Blue for students

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Laboratory Gown

• Working in a clinical dental laboratory
• Yellow gown should be used

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Nonsurgical Gloves
Vinyl, nitrile, or latex examination gloves
must be worn when treating nonsurgical patients
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Surgical Gloves
Sterile disposable gloves must be worn during
all surgical procedures
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Utility Gloves

• Each student must have a pair of heavy-duty
  utility gloves for break down after patient
  treatment
• Must be washed with antimicrobial soap, rinsed
  dried
• Stored in plastic bag in locker

20
Masks

• Masks must be worn to protect
• Face
• Oral nasal mucosa

21
Masks

• Masks must be changed if they become damp
• The mask must be changed for each new patient,
  except for short exams!
• If a face shield is worn it must be worn at the
  same time as a surgical mask

22
Special Masks
A laser plume face mask must be worn during a
laser or electrosurgery procedure!
23
Protective Eyewear

• Must be worn to protect from aerosol spatter
• Regular eyewear must have side shields
• Side shields must be securely attached to the
  eyewear frame, abutting the lenses free of
  vents or openings
• Special protective eyewear for laser procedures

24
Administrative Controls

• Medical surveillance
• TB skin (PPD) or Quantiferon test, baseline serum
• Immunizations
• Hepatitis B series
• Training
• BBP, infection control, hazard communication
• Management of staff
• SOP compliance
• Background checks

25
Hepatitis B Vaccination

• Available at no cost to employees
• All health care workers must have vaccination
• Employees can decline vaccination, but must sign
  a declination statement

26
Good Work Place Practices

• Universal/Standard precautions
• A standard of care designed to protect health
  care providers patients from pathogens that can
  spread by blood other body fluids
• Treat all human blood body fluids as if known
  to be infectious for HIV, HBV or other BBP
• ALL BLOOD AND BODY FLUIDS ARE CONSIDERED
  TO BE INFECTIOUS !

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Good Work Place Practices (cont.)

• Follow SOPs
• NEVER recap needles with two hands!
• Establish maintain clean dirty zones
• Decontaminate work surfaces
• At start end of procedures
• Immediately after spill
• Before removal of equipment
• Survey work area
• Note locations of all necessary equipment, waste
  containers, disinfectants, soaps

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Good Work Place Practices (cont.)

• Wash hands frequently, always between patients
  always before leaving work area!
• DO NOT eat, drink, or apply cosmetics in the work
  area
• Practice proper personal hygiene for the dental
  clinic setting
• Label containers - hazard communication
• Chemical biological working stocks
• Dispose of waste properly

29
Exposure Control Plan

• Written plan to eliminate exposure to blood
  body fluids
• Exposure determination
• Plan must be accessible
• Compliance
• UTHSC-H Dental School Clinic Manual
• www.db.uth.tmc.edu/clinicpat/Documents/Clinic_Manu
  al.pdf
• UTHSC-H Biological Safety Manual
• www.uth.tmc.edu/safety

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Injury Prevention

• Remove burs from handpiece immediately after
  completion of dental procedure
• Recap anesthetic needles using proper technique
• Restrict use of fingers in tissue retraction or
  palpation during suturing or administration of
  anesthesia
• Avoid uncontrolled movements of dental
  instruments. THINK BEFORE MOVING AN INSTRUMENT!

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Injury Prevention (cont.)

• Burs
• Must be removed from handpiece immediately upon
  completion of patient treatment

32
Recapping Anesthetic Needles

• Use the needle recapper to recap anesthetic
  needles
• NEVER use two hands!

33
Recapping Anesthetic Needles

• Use the one-handed scoop technique to recap if
  a recapper is not available
• NEVER use two hands!

34
Sharps

• Handle carefully
• Do not recap with two hands
• Discard in sharps container
• Do not bend or break needles
• Report all injuries

35
Sharps

• Discard in sharps containers
• Used needles
• Blades, scalpels
• Burs
• Anesthetic cartridges
• Broken glass

36
Sharps Red Handled Lab Knife

• USE OF SHARP INSTRUMENTS
• To prevent accidental exposure injuries related
  to trimming wax with a red handled lab knife at
  chair-side, DISINFECT when possible and
• BE EXTREMELY CAREFUL WHEN USING THE RED HANDLED
  LAB KNIFE!
• Policy 2.39

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Maintain the Clinical Worksite

• Worksite must be maintained in a clean sanitary
  condition
• Equipment work surfaces must be cleaned
  disinfected before after procedures, after
  any contact with blood or OPIM
• Protective covering must be used to cover
  equipment and work surfaces
• Biological waste contaminated materials must be
  disposed of in appropriate biological waste
  containers

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Contact Surfaces
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Clinical Contact Surfaces

• Risk of transmitting infections greater for
  clinical contact surfaces than for general
  housekeeping surfaces
• Clean disinfect surfaces
• Apply barriers

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Routine Surface Decontamination

• Sani-Cloth Plus Disinfectant
• EPA registered
• Meets OSHA CDC guidelines
• Double ammonium chloride alcohol
• Tuberculocidal, bactericidal virucidal
• Use on surfaces in dental operatories

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Sani-Cloth Plus Disinfectant

• Effective against
• Methicillin Resistant Staphylococcus aureus
  (MRSA)
• Vancomycin Resistant Enterococci (VRE)
• Mycobacterium tuberculosis
• Flu Viruses
• RSV (Respiratory Syncytial Virus)
• Pseudomonas sp.
• Hepatitis B C Viruses (HBV, HCV)
• Herpes Simplex Virus (HSV)
• Human Immunodeficiency Virus (HIV)
• Others

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Routine Surface Decontamination

• Sani-Cloth Plus Disinfectant
• The disinfecting process is a two-step process
• Wipe to clean the surface remove bioburden
• Wipe a second time to disinfect
• All disinfectants must be used correctly to be
  effective!

43
Surface Covers
Handles, handpieces similar surfaces that may
be contaminated by blood, saliva or OPIM must be
wrapped with clear plastic wrap
44
Rubber Dam

• Provides protection from aerosols and spatters

45
Clinical Computer Equipment

• Procedures should be followed to avoid
  contamination of electronic equipment when
  possible
• If it will be necessary to enter data while a
  patient is in the operatory, barrier protection
  for equipment must be utilized high touch areas
  must be disinfected
• Follow established guidelines

46
Electronic Equipment Barriers

• Apply two lengths of plastic wrap to cover entire
  keyboard tuck in on all sides
• Use Sani-Cloth Plus Disinfectant
• Disinfect daily, or if contaminated or visibly
  soiled
• Touch monitor screen with cotton tipped
  applicator only (no Sani-Cloth Plus on the
  monitor screen)

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Hand Hygiene

• On average only 40 of health care workers
  regularly wash their hands
• Hospital acquired infections result in
  transmission of
• MRSA Methicillin resistant S. aureus
• VRE Vancomycin resistant Enterococci
• Methods for contamination
• Moving patients
• Taking blood pressure
• Touching bedrails

Source Hand Hygiene Resource Center
http//www.handhygiene.org/
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Hand Hygiene (cont.)

• Proper hand washing is VITAL to infection
  prevention!
• You may not realize you have germs on your hands!
• Wash your hands, even if gloves have been worn
• Before patient contact, including between
  different patients
• After contact with anything contaminated
• During patient care
• Before after invasive procedure
• Before after contact with wound
• Between procedures on different parts of same
  patient
• Between glove changes
• Immediately if skin is contaminated or an injury
  occurs

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Proper Hand Washing

• Wet hands with warm (not hot) water
• Apply soap on hands
• Liquid soap is better (germs can live on wet soap
  bars)
• Rub hands together for at least 15 seconds
• Wash longer if there is visible dirt on hands
• Cover all surfaces of hands fingers - including
  between fingers, backs of hands, thumbs, under
  fingernails
• Rinse hands thoroughly with warm water
• Dry hands thoroughly
• If using air dryer, push button with elbow
• If available, use towel to turn off water
• What song is about 15 seconds long.
• Source Hand Hygiene Resource Center
  http//www.handhygiene.org/

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Where do we miss?
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Hand Hygiene (cont.)

• Alcohol sanitizers
• 62 ethyl alcohol
• Accepted as effective under certain conditions
• Should not be used when there is visible dirt or
  grime!

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Good Work Place Practices (cont.)

• Eating drinking prohibited in all clinical
  areas
• Do not wear jewelry in clinic areas

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Hair

• Hair should be short well-managed
• Long hair should be pulled back or completely
  covered with a surgical cap to minimize the
  possibility of contamination
• Beards, mustaches, or other facial hair must be
  neatly trimmed to fit under the mask

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Fingernails

• Fingernails must be short to help prevent
  collections of microbes tears in gloves
• Colored nail polish is prohibited
• May obscure soil under the nails
• False fingernails are prohibited

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Blood (or OPIM) Spill Clean up

• Wear appropriate PPE clean up all blood (or
  OPIM) spills with a 10 bleach solution or
  another EPA-approved disinfectant
• Apply disinfectant to perimeter of spill
• Slowly proceed inwards
• Allow at least 15 minutes of disinfectant contact
  time
• Be careful of sharps! Remove any sharps from the
  spill (after disinfectant contact time) using
  forceps discard in sharps container
• Slowly wipe up spill, working from the perimeter
  of the spill inwards clean area with
  disinfectant again
• Materials used to clean up the spill (e.g.,
  towels) should be disposed in biohazard container

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Biological Waste Disposal

• Blood, saliva or OPIM saturated items must be
  discarded in biohazard bags at chairside
• Biohazard bags must be maintained in hard-walled,
  leakproof, secondary containment
• Small biohazard bags must be discarded in larger
  biohazard bags (at the dispensary)

57
Biological Waste Disposal

• Place sharps in appropriate hard-walled,
  leakproof sharps container
• Do not overfill (no more than ¾ full), see fill
  line
• Call for pickup UTHSC-H Waste Line 713-500-5837

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Regulated Medical Waste

• Contaminated waste disposal
• Sharps disposal
• In compliance with OSHA, DSHS TCEQ

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Injury/Potential Exposure

• Stop procedure
• Apply routine first aid immediately
• Clean site of injury with soap or antiseptic
  flush with warm water for at least 15 minutes
• Flush mucous membranes with water or saline for
  at least 15 minutes
• DO NOT dismiss patient
• Report incident to nearest dispensary
• Notify supervisor
• Complete Supervisors First Report of Injury
  form
• Seek medical attention

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Injury/Potential Exposure

• REMEMBER!
• If you have received a puncture or laceration
  injury from a contaminated needle or instrument
• REMOVE THE ANESTHETIC SYRINGE OR INSTRUMENT
  FROM CASSETTE DO NOT REUSE INSTRUMENT !

61
Injury/Potential Exposure
Please wait here for a few minutes
DO NOT DISMISS THE PATIENT!
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Medical Surveillance

• Baseline Labs
• HIV antibody (with consent)
• RPR (Syphilis)
• Hepatitis B surface antibody
• HCV antibody
• If source is known to be Hepatitis C, also
  obtain a liver function HCV RNA tests
• CBC with differential platelets, chemistry
  profile, urine pregnancy test if source is known
  HIV and if exposed personnel chooses to utilize
  post-exposure prophylaxis
• Hepatitis B Vaccination
• Tuberculin skin test, Quantiferon test

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Rights

• In the event of a potential exposure to BBP, the
  person is entitled to
• Confidential medical evaluation follow-up
• UT Student or Employee Health Services Clinic
• Documentation of routes of exposure
• Identification, documentation, testing results
  of the source individual
• Source blood draw for testing
• Counseling
• Evaluation of reported illness

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Record Keeping

• Medical records related to exposure incidents
  must be retained for duration of employment plus
  30 years
• Training records must be maintained for three
  years

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Tuberculosis

• Caused by Mycobacterium tuberculosis
• Spread by airborne droplets coughing, sneezing,
  speaking
• Also considered to be bloodborne

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Patient Assessment for Risk of Tuberculosis

• Routinely ask all patients
• Do you have a history of TB disease?
• Do you have symptoms suggestive of TB?

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TB Presentation Isolation

• Cough
• Chest Pain
• Coughing up blood
• Weakness
• Fever or night sweats
• Weight loss

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Patients with History or Symptoms of Undiagnosed
TB

• Should be referred promptly for medical
  evaluation of possible infection
• Should not remain in the dental facility any
  longer than required to arrange a referral
• Should wear surgical mask while in the dental
  facility
• Should have urgent dental care provided in areas
  that can provide TB isolation

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Patients with History or Symptoms of Undiagnosed
TB (cont.)

• Should have elective dental treatment deferred
  until a physician confirms that the patient does
  not have infectious TB
• If diagnosed as having active TB, elective dental
  treatment should be deferred until no longer
  infectious

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Methicillin Resistant Staphylococcus aureus (MRSA)

• Responsible for difficult-to-treat infections
• Multiple- or multidrug-resistant (MRSA), or
  oxacillin-resistant (ORSA) bacteria
• Resistant to beta-lactam antibiotics
• Methicillin
• Dicloxacilliln
• Nafcillin
• Oxacillin

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Methicillin Resistant Staphylococcus aureus (MRSA)

• According to CDC, each year
• Over 94,000 people develop a serious MRSA
  infection
• Nearly 19,000 die from serious MRSA infections

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Staphylococcus (Staph.) Bacteria

• Most common cause of skin infections
• Most are minor (pimples, boils)
• Some can be serious (surgical wound infections,
  blood stream infections, pneumonia)
• Nose colonization in 25 - 30 of population
• MRSA colonization in 1 of population

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Staph. Skin Infection Wounds
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What Does Colonized with MRSA Mean?

• MRSA is present in or on the body, but is not
  causing infection
• Colonized individuals are the main source of
  infection for susceptible individuals

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Transmission

• Most common source
• Individuals who have MRSA but do not have
  symptoms (i.e., colonized with MRSA)
• Main mode of transmission
• Through human hands (especially health care
  workers hands)

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Who Gets Serious MRSA Infections?

• Individuals with compromised immune systems are
  susceptible to serious MRSA infections
• Colonized individuals can be the source of MRSA
  for immunocompromised patients in the dental
  office

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MRSA in Dentistry - What is Our Responsibility?

• Prevent transmission of MRSA in dental settings
• Frequent handwashing
• Sterilization of instrumentation
• Appropriate use of disinfectants barriers
• Prescribe responsibly

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Seasonal or Pandemic Flu

• Person to person transmission by
• Coughing, sneezing, spitting
• Droplets from infected person on
• Hands
• Environmental surfaces
• Table tops, door knobs, handrails, phones
• Droplets reach uninfected person
• Directly from coughing, sneezing, spitting
• Hand shakes
• Touching contaminated environmental surfaces

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Help Prevent Flu Transmission

• Cover your mouth nose with a tissue when you
  cough or sneeze
• Cover your mouth nose with your upper sleeve
  (not your hands), if you do not have a tissue
  need to cough or sneeze
• Wash your hands as soon as possible after
  coughing, sneezing, or blowing your nose
• Practice social distancing during flu season or a
  flu pandemic

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Help Prevent Flu Transmission (cont.)

• Keep surfaces touched by more than one person
  clean disinfected (door knobs, handrails)
• Remember to clean first then disinfect
• Wash your hands frequently always before eating
  
• Carry alcohol-based (60 95), sanitizing hand
  wipes or gel with you to disinfect your hands
• Teach your children to practice good hand hygiene
• Flu is often transmitted at school

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Pandemic Preparedness

• UTHSC-H has an appointed Task Force that includes
  input from
• Harris County Health Dept.
• City of Houston Health Dept.
• TMC
• Memorial Hermann Hospital

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Pandemic Preparedness How to protect yourself

• Get vaccinated for seasonal flu
• Wash hands frequently
• Practice teach cough etiquette
• Practice social distancing
• Avoid close contact with sick people
• Avoid close contact if sick
• Stay home if sick!

83
Dental Unit Waterlines Biofilm

• Microbial biofilms form in small bore tubing of
  dental units
• Biofilms serve as a microbial reservoir
• Primary source of microorganisms is municipal
  water supply

84
Dental Unit Water Quality

• Using water of uncertain quality is inconsistent
  with infection control principles
• Microbial counts in water from untreated systems
  can exceed 1,000,000 CFU/mL (CFU colony
  forming unit)
• Untreated dental units cannot reliably produce
  water that meets drinking water standards

85
Dental Unit Water Quality (cont.)

• For routine dental treatment, meet regulatory
  standards for drinking water
• ADA standards

86
Dental Unit Water Quality (cont.)

• ICX Tablets
• Available on gray cabinets at the back of the
  bays
• Instructions posted in each cubicle

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Dental Unit Water Quality (cont.)

• ICX Tablets
• Rinse empty water bottle with tap water
• Prior to rinsing, make sure the water from tap
  has run for at least 30 seconds or until clear
• Add one tablet of ICX to empty water bottle
  avoid touching the tablet
• Fill bottle with tap water
• Wait 60 seconds for tablet to fully dissolve

88
Fire Alarm Design

• Stop patient procedure
• Send one person to emergency exit to listen to
  announcement, ask that person to tell you if
  there is a need to evacuate
• Alarm sounds on involved floor, floor
  immediately above below
• If fire discovered, alarm will sound in entire
  building
• If you see smoke or fire, evacuate immediately
  using the nearest stairwell exit

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89
Safe Handling Ergonomics

• Squat down, bending at the hips knees only.
• Press your chest straight forward. This helps
  keep your upper back straight while maintaining a
  slight arch in your lower back.
• Slowly lift by straightening your hip knee
  joints (not your back).
• Hold the load as close to your body as possible,
  at naval level of your navel.
• Set down your load carefully, squatting with the
  knees hips only.
• Do not attempt to lift or set down by bending
  forward at the waist.
• Avoid turning or twisting your body while holding
  a heavy object.
• Work with objects at a surface near waist high,
  rather than bending to the items on the floor.

90
X-Ray Laser Safety

• Special training is available for personnel that
  will use X-Rays Lasers
• Programs are available for individuals who are
  pregnant

91
Contact Information

• General safety concerns, emergency response
  (including after hours)
• Ext. 5832
• Hazardous waste
• Ext. 5837
• Environmental Health Safety
• Ext. 8100 (Main number)

92
Resources

• UTHSC-H Dental School Clinic Manual
• www.db.uth.tmc.edu/clinicpat/Documents/Clinic_Manu
  al.pdf
• UTHSC-H Biological Safety Manual
• www.uth.tmc.edu/safety
• OSHA
• www.osha.gov
• CDC
• www.cdc.gov

93
Resources (cont.)

• ADA
• www.ada.org
• DSHS
• www.dshs.state.tx.us
• TCEQ
• www.tceq.state.tx.us

94
Questions??