Ask students how many of them experience anxiety or have concerns about their exposure to disease or infectious materials. Ask them who controls their safety and how they can minimize their own risks in the dental office.
Imagine a chain with four links. Break any link in the chain, and you stop the process of infection. Each link of the chain will be discussed at greater depth shortly. Ask students whether they can guess what each of these four links represents.
Look at these four links in the chain of infection. Imagine them to be linked together until some strain is placed on them and then one of the links breaks or fails. What is a pathogen? (A disease-causing organism.)
Imagine an organism as a small round cell with an outer shell. The virulence of different organisms can be thought of as a difference in thickness of the outer shell. To reduce or eliminate an organism, you must break down its outer shell.
Imagine that I am telling you a war story and there are three soldiers against 100. Who do you think won the battle: the group of three or the group of 100? By reducing the number of pathogens, the dental assistant can create a safer environment for the patient and the dental team.
An example of a susceptible host: A person has been exposed to jerpes simplex but has never had an outbreak. This person experiences stress during a major life change, such as going away to college. The stress is compounded by the fact that the person is staying up late cramming for exams and socializing and not getting enough sleep. While the person is in this stressful state, a herpetic lesion develops on the person’s upper lip.
To contract an infection, you must be exposed to pathogens, and those pathogens must have an entry point into your body. How can we protect the portals of entry to our bodies when working with patients?
A patient contracts a common cold. which one of the four types of infection does he have? If a patient is undergoing chemotherapy for breast cancer, which one of the four types of infection would she be concerned about? Shingles is an example of which of the four types of infections? Hepatitis C virus is an example of what type of infection?
Direct transmission is the most common route of transmission in the dental office environment. Why? Consider the following case scenario: While assisting the dentist, using the high-speed-evacuation system for a tooth extraction, you realize thath you have left your protective eyewear on the counter. Just then the tooth cracks in half and blood splashes onto your face, including the eye area. How you would manage this situation, and how you would avoid this scenario in the future?
Infections can be transmitted while a dental assistant helps the dentist and inhales aerosols produced by the air-water syringe, ultrasonic scaler, or handpiece. How can a dental assistant reduce the risk of infection? Every patient should be treated as though he or she is a carrier of disease, and personal protective equipment should always be worn.
Food-and-water transmission is an example of transmission from community to dental office to patient. Hepatitis is transmitted through fecal matter and can be easily controlled simply by washing the hands thoroughly after use of the restroom.
Notice the plastic barriers on the cords of the suction apparatus and on the bracket tray. Barriers like these are used to protect surfaces that can be easily contaminated and should be wiped down frequently with disinfectant wipes or spray. All surfaces touched with contaminated gloves and objects that cannot be sterilized with an autoclave should be protected with the use of plastic barriers.
The human body does a wonderful job of taking care of itself most of the time.
The serum used to immunize a person can be created using the organisms from another person who has had the disease, or it can be developed artificially. The hepatitis B vaccine is an example of an artificially acquired immunization. The serum can be harvested from antigens from a person with hepatitis B or developed synthetically.
Can students can think of any other examples of natural passive immunity? (Through breast milk.) Chicken pox used to be an active natural disease; now there are immunizations to prevent it.
It is critical to understand how disease transmission can occur in the dental office. The next five slides will discuss the various types of disease transmission and ways to prevent them.
A dental assistant will be in contact with many patients throughout the day. Some patients may be “carriers” or have a disease that the dental team members and the patient may not be aware of. It is important to use preventive measures on each patient.
Most patients believe that mouth rinses are used solely to reduce halitosis, or bad breath. Explain the benefits of mouth rinses to every patient. Rubber dams are used routinely for endodontic treatment (root canals) to isolate the individual tooth and prevent contamination of the canals. They can protect the dental-team members by preventing a large number of pathogens from becoming airborne.
Many patients are concerned that they will contract a disease from an earlier patient. As a healthcare professional, it is important for the dental assistant to communicate to patients that they are in a safe environment that practices standard infection-control measures.
The community includes members of the dental team’s family. How would you feel about bringing home bacteria that could transmit diseases to your family and friends?
One way to reduce the number of bacteria that colonize in waterlines is to flush the handpiece, air-water syringe, and ultrasonic scaler for 60 seconds at the start of every day. This will reduce the number of bacteria present. There are also commercial products that use chemicals to help reduce bacteria and flush waterlines.
For guidance on recommendations for infection control concerns, contact the Center for Disease Control (CDC). If you are ever concerned that a dental office is consistently noncompliant with regards to OSHA regulations, contact OSHA directly.
The best way to stay abreast of the most recent updates and guidelines from the CDC and OSHA is to check their respective Web sites, www.cdc.gov and www.osha.gov. Which government agency is regulatory, and which only provides recommended guidelines?
OSHA requires that a copy of the BBP be present in every dental office and clinic. For a dental assistant’s own protection and the health and safety of others, they should review the BBP regularly. Students can obtain a copy by visiting www.osha.gov.SLTC/bloodbornepathogens/.
Discuss office concerns and questions, then seek out answers within the BBP manual.
Why do you think a dental office may not have a exposure plan? As a knowledgeable dental assistant, how can you encourage an dental office to develop a exposure plan, and comply with the requirements?
Each category of the dental team should have specific training focusing on their occupational exposure. Why would a category III need training?
How often should a dental office evaluate and update its exposure-control plan? What is another term for the BBP? Discuss the differences between Universal Precautions and Standard Precautions.
It is an employee’s right to have a medical follow-up after an occupational exposure. An employee’s medical information is kept confidential from the employer.
Would you decline or accept the offer of the HBV vaccine? Why or why not?
What would the blood test show if your immunity to hepatitis B was properly developed?
Contact your physician if you have been exposed to a confirmed Hepatitis B patient, and you are concerned about your initial immunization.
The dental assistant should always keep the original and make copies as needed for changes in employment.
Never overload a sharps container by forcing sharps into it.
Sharps containers come in a variety of sizes. Once container is full, close, seal, and dispose of properly according to your state’s laws.
What is the single-handed scoop technique? There are disposable, one-time use needle guards available for dental professionals.
When washing hands, strive to use hands-free faucets, which are activated either with foot pedals or electronically.
Notice the areas most frequently missed. When washing hands, start with the frequently missed areas to ensure thorough washing.
Jewelry and long nails can puncture gloves, creating the potential for disease transmission. Powder in gloves can accumulate in jewelry clasps and crevices, causing damage. For healthcare providers using gloves, what is the maximum length for fingernail tips?
Just as when you are using soap and water, remember to thoroughly apply the alcohol hand rub on areas that are frequently missed. What are the three advantages of using alcohol-based hand rubs over washing hands with soap and water? Ask students whether they can think of any other advantages.
The practice of general dentistry most likely uses a combination of routine hand washing with soap and water and alcohol-based, waterless hand rubs. Evidence suggests that alcohol-based antiseptic hand rubs are more effective at decontaminating the hands than washing with soap and water alone. Remember, if your hands are visibly soiled you must wash with soap and water before applying an alcohol-based hand rub.
Why is it important for a healthcare professional to use hand lotion? Having intact skin is the best defense against infection. What is meant by the caption above, “Hand lotions must be compatible with glove material”?
PPE should be comfortable and functional. For example, if eyewear is too tight or too loose and fogs up, a dental assistant should try different models and brands until he or she finds one that fits properly. What is the purpose of PPE?
Why should a healthcare professional not wear scrubs, lab coats, or any other types of PPE to and from work? Contaminated PPE should be laundered at the dental office only if appropriate equipment is available and proper procedures are followed.
If clothing becomes visibly soiled with blood or saliva, it must be changed immediately. The employer should have on hand an ample supply of clean scrubs and lab coats that fit properly.
There are many examples of proper infection control in this photo. (Ask students to name them.)
The dental assistant should look at the masks’ box to ensure that the masks offer at least 95% filtration efficiency; not all do. During what types of procedures should a protective mask be worn?
Why wouldn’t a face shield worn alone be adequate protection?
If you wear prescription glasses, you must wear side and bottom shields or wear a full face shield over them.
Disposable combination shield–and–ear loop masks are available from dental-supply companies.
This face shield is worn like a visor. Face shields must be able to withstand being properly washed with soap and water before and after every patient.
Some patients may not feel comfortable using eyewear, which may be a new protocol for them. Advise patients that the eyewear is for their protection. What is another procedure for which a patient must wear protective eyewear?
Some putty impression materials may not be compatible with the powder found in gloves. Review manufacturer’s guidelines for handling material while maintaining good infection control.
Notice that the clinician is properly placing the glove over the sleeve to eliminate exposed skin, therefore eliminating a possible portal for contaminants. Nonsterile examination gloves are used most frequently for patient care.
Properly fitting gloves are essential for good patient care. Ambidextrous glove sizes range from XS to XL. Right- and left-handed gloves have a much better fit; however, they are more expensive.
Gloves can be torn or ripped during the manufacturing process. Always inspect both gloves before starting a procedure.
Overgloves can greatly reduce cross-contamination and should be easily accessible in each treatment area. The following situations necessitate the use of overgloves: During a procedure you must open a cabinet door to retrieve an instrument you forgot to lay out on the table. You must open a drawer during a procedure. You must take a phone call (and use the receiver) during a procedure.
Sterile surgical gloves are of a higher quality than treatment gloves and therefore more costly. CDC guidelines, and some state dental boards, require surgical gloves for surgical procedures. Some healthcare professionals choose to wear two pairs of sterile surgical gloves, but this is not necessarily a CDC recommendation.
Appropriately sized utility gloves should be used to ensure good dexterity. After utility gloves are washed and disinfected, they should be hung on a hook until thoroughly dry before further use.
Notice the assistant is properly wearing the utility gloves over the lab coat’s sleeves. Why is she doing this? Utility gloves should be thick enough to withstand instrument punctures.
A dental assistant should have all materials needed for each procedure out and ready for use to avoid cross-contamination.
Many dental clinics/offices are going latex-free to create a safer environment for those who are sensitive to latex.
Healthcare providers who experience any skin irritation in response to latex gloves may want to try products from different manufacturers.
Be certain to review the patient’s medical history to determine whether he or she is allergic to latex before starting a procedure. Some patients may not be aware that they are allergic to latex; watch for symptoms.
Latex is present in many materials used in the dental office, such as the elastic ear loops of masks and prophylaxis angle cups. What are the symptoms of an immune reaction to latex? Is your office prepared if a patient has such an immune reaction?
This photo depicts the red, cracked, irritated skin caused by direct contact with latex or another irritant, such as chemicals.
Many healthcare workers mistake this type of reaction for a latex allergy. The patient should get an allergy test from a physician to rule out any confusion.
Because this type of latex reaction is so severe, every dental office must have a first-aid kit and and an established emergency protocol. What causes death in this type of allergic reaction?
Gloves made of nonlatex materials such as vinyl and nitrile should be used with a latex-sensitive patient.
When treatment gloves are removed or snapped off, they release airborne latex particles that can trigger an allergic reaction. Therefore patients can experience a type I allergic reaction with or without direct latex contact.
Ask students the following question: If you have a patient with a latex allergy, when should you schedule his or her appointment?
It is the dental office’s responsibility to stay current with specific federal, state, and local waste-management regulations to avoid fines or penalties. Even though EPA does not categorize saliva or saliva-soaked items as infectious waste, dental offices should always treat it as such.
A dental assistant must learn the different types of waste and how each is discarded during cleanup, or processing, of a dental treatment room. Waste containers must be labeled with the universal biohazard symbol when applicable.
What are the four areas of waste management a dental assistant needs to be concerned with? Dental assistants need to wear appropriate PPE during waste management.
When giving a patient extracted teeth, be certain to place them in a sealed bag or sealed envelope. You may heat-sterilize the tooth if no amalgams are present.
When removing trash bags from receptacles, one must wear utility gloves.
Notice the foot pedals, which make it possible to avoid touching contaminated lids. Never compact waste with the foot. Biohazard stickers can be purchased through dental-supply companies.
The medical waste generated by most general dentistry practices is minimal and tends to consist mainly of sharps.
A dental practice should direct any questions about waste management to the city where the dental practice is located.
When eating in the workplace, be sure to remove contaminated PPE.
Many patients have become accustomed to closing their lips around the suction.
Disinfection of all lab materials that leave your office and clinic is easy to achieve and takes very little time. Laboratory materials, such as impressions, can be damaged or distorted if they are not disinfected properly.
The CDC has not made a recommendation about the use of preprocedural mouth rinses in the dental office.
Staying abreast of current research through the use of professional journals and continuing-education courses will create a safer environment for both you and your patients. “ Prion” is a term for a protein particle that lacks nucleic acid and is the cause of neurologic disorders such as CJD.
Laser use is becoming more routine in general dentistry. Time, experience, and more research will aid in the creation of more guidelines for this technology.
Direct transmission occurs when someone comes into direct contact with the infectious lesion or infected body fluids (e.g., blood, saliva, semen, vaginal secretions).
Indirect transmission involves the transfer of organisms to a susceptible person through, for example, the handling of contaminated instruments or touching of contaminated surfaces and then touching the face, eyes, or mouth.
Splash or spatter transmission happens during a dental procedure when the mucosa (mouth or eyes) or nonintact skin is splashed with blood or blood-contaminated saliva.
Parenteral transmission can take place through needlestick injuries, human bites, cuts, abrasions, or any break in the skin.
Bloodborne transmission involves direct or indirect contact with blood and other body fluids.
Food-and-water transmission occurs when contaminated food that has not been cooked or refrigerated properly or water that has been contaminated with human or animal fecal material is consumed.
Fecal/oral transmission occurs when proper sanitation procedures, such as handwashing after use of the toilet, are not followed and one of the many pathogens present in fecal matter is transmitted when the infected person touches another person or makes contact with surfaces or food.
Roles and Responsibilities of CDC and OSHA in Infection Control
The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) are federal agencies that play very important roles in infection control for dentistry.
The CDC is not a regulatory agency. Its role is to issue specific recommendations based on sound scientific evidence on health-related matters.
CDC’s recommendations are not law, but they do establish a standard of care for the dental profession.
OSHA is a regulatory agency. Its role is to issue specific standards to protect the health of employees in the U.S.
In 1991, based on the CDC guidelines, OSHA issued the Bloodborne Pathogens Standard (BBP).
CDC Guidelines for Infection Control in Dental Health-Care Settings
In December of 2003, the CDC released the Guidelines for Infection Control in Dental Health Care Settings-2003.
The new guidelines have expanded upon the existing OSHA Bloodborne Pathogens Standard, and have included some areas that were not already covered.
The guidelines are based on scientific evidence and are categorized on the basis of existing scientific data, theoretical rationale, and applicability.
The guidelines apply to all paid or unpaid dental health professionals who might be occupationally exposed to blood and body fluids by direct contact or through contact with contaminated environmental surfaces, water, or air.
The bloodborne pathogens standard (BBP) is the most important infection control law in dentistry.
It is designed to protect employees against occupational exposure to bloodborne pathogens, such as hepatitis B, hepatitis C, and human immunodeficiency virus (HIV).
Employers are required to protect their employees from exposure to blood and other potentially infectious materials (OPIM) in the workplace and to provide proper care to the employee if an exposure should occur.
Exposure control plan clearly describes how the office complies with the standard.
The term Universal Precautions is referred to in the OSHA Bloodborne Pathogens Standard.
Universal precautions is based on the concept that all human blood and body fluids (including saliva) are to be treated as if known to be infected with the bloodborne disease, HBV, HCV, or HIV.
The CDC expanded the concept and changed the term to Standard Precautions.
Standard Precautions integrate and expand the elements of universal precautions into a standard of care designed to protect healthcare providers from pathogens that can be spread by blood or any other body fluid, excretion, or secretion.
It is not possible to identify those individuals who are infectious, so infection precautions are used for all healthcare personnel and their patients.
Keep nails short and well manicured; rings (except for wedding rings), fingernail polish, and artificial nails are not to be worn at work.
Microorganisms thrive around rough cuticles and can enter the body through any break in the skin.
Dental personnel with open sores or weeping dermatitis must avoid activities involving direct patient contact and handling contaminated instruments or equipment until the condition on the hands is healed.
Protective clothing should be made of fluid-resistant material.
As a means of minimizing the amount of uncovered skin, clothing should have long sleeves and a high neckline. Note: The type and characteristics of protective clothing depend on the anticipated degree of exposure.
The design of the sleeve should allow the cuff to be tucked inside the band of the glove.
During high-risk procedures, protective clothing must cover dental personnel at least to the knees when seated.
Buttons, trim, zippers, and other ornamentation should be kept to a minimum.
Because dental personnel are most likely to come into contact blood or contaminated items with their hands, gloves may be the most critical PPE.
You must wear a new pair of gloves for each patient, remove them promptly after use, and wash your hands immediately to avoid the transfer of microorganisms to other patients or the environment (CDC guideline).
Consult with the glove manufacturer regarding the chemical compatibility of the glove material and the dental materials you use (CDC guideline).
When a latex allergy has been diagnosed in one employee in the dental office, all staff members should use practices to minimize the use of latex-containing products. These practices include the wearing of powder-free gloves by all dental staff members to minimize the risk of airborne latex particles.
Medical waste is any solid waste generated in the diagnosis, treatment, or immunization of human beings or animals in research.
Infectious waste is a subset of medical waste. Only a small percentage of medical waste is infectious and needs to be regulated.
Containers of infectious waste (regulated waste) must be labeled with the universal biohazard symbol, identified in compliance with local regulations, or both.
Containers used for holding contaminated items must be labeled. Examples of such containers include contaminated sharps containers, pans or trays used to hold contaminated instruments, bags of contaminated laundry, specimen containers, and storage containers.
Never eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in any area of the dental office where contamination is possible, such as the dental treatment rooms, dental laboratory, sterilization area, or the area for the processing of x-rays.
Never store food or drink in a refrigerator that contains any potentially contaminated items.
You can minimize the amount of splash and spatter contamination produced during dental procedures with the skillful use of a dental dam and high-volume evacuation.
CDC Guidelines Special Considerations: Saliva Ejectors
Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids.
Rationale: Backflow from low-volume saliva ejectors occurs when the pressure in the patient’s mouth is less than that in the evacuator. This backflow can be a source of cross-contamination between patients. Although no adverse health effects associated with the saliva ejector have been reported, you should be aware that in certain situations backflow could occur with the use of a saliva ejector.
CDC Guidelines Special Considerations: Dental Laboratories
Use PPE when handling items in the laboratory until they have been decontaminated.
Clean, disinfect, and rinse all dental prostheses and prosthodontic materials (e.g., impressions, bite registrations, occlusal rims, and extracted teeth).
Consult with manufacturers regarding the stability of specific materials (e.g., impression materials) relative to disinfection procedures.
Clean and heat-sterilize heat-tolerant items used in the mouth (e.g., metal impression trays and face-bow forks).
Follow manufacturers' instructions for cleaning, sterilizing, or disinfecting items that become contaminated but do not normally come into contact with the patient (e.g., burs, polishing points, rag wheels, articulators, case pans, and lathes.) If manufacturer instructions are unavailable, clean and sterilize heat-stable items and disinfect them.
CDC Guidelines Special Considerations: Creutzfeldt-Jakob Disease and Other Prion Diseases
Creutzfeldt-Jakob Disease (CJD) belongs to a group of rapidly progressive and invariably fatal degenerative neurologic disorders.
They affect both human beings and animals and are thought to be caused by infection with prions.
Prion diseases have an incubation period of years but are usually fatal within 1 year of diagnosis.
The infectivity of oral tissues in CJD patients is an unresolved issue. Scientific data indicate that the risk, if any, of sporadic CJD transmission during dental and oral surgical procedures is low to nil.
No recommendation is offered regarding the use of special precautions in addition to standard precautions in the treatment of patients with known CJD (unresolved issue).
CDC Guidelines Special Considerations: Laser/Electrosurgery Plumes or Surgical Smoke
In surgical procedures involving the use of a laser or electrosurgical unit, a smoke byproduct is created during the thermal destruction of the tissue.
Laser plumes and surgical smoke pose a risk to dental healthcare professionals.
One concern is that the aerosolized infectious material in the laser plume may reach the nasal mucosa of the operator or other members of the dental team. However, airborne exposure to an infectious agent in a laser plume might not be enough to cause disease.
The effect of the exposure (e.g., disease transmission or adverse respiratory effects) on dental healthcare professionals resulting from the use of lasers in dentistry has not been adequately evaluated (unresolved issue).