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Patient and Clinician Protection: Immunizations, Testing, PPE and Exposure Controls
- 1. Exposure Control:Exposure Control: Barriers forBarriers for Patient and ClinicianPatient and Clinician
- 2. Immunizations and PeriodicImmunizations and Periodic TestingTesting Basic Immunizations:Basic Immunizations: Hepatitis A, BHepatitis A, B DiphtheriaDiphtheria TetanusTetanus PertussisPertussis Influenza type BInfluenza type B Measles, mumps,Measles, mumps, rubella (MMR)rubella (MMR) VaricellaVaricella MeningococcalMeningococcal Boosters:Boosters: May occur uponMay occur upon exposureexposure Adult Recommendations: Tetanus andTetanus and diphtheriadiphtheria =every 10 years=every 10 years Annual influenzaAnnual influenza Annual TB skinAnnual TB skin testtest
- 3. ReviewReview Which of the following should be done annually?Which of the following should be done annually? A) Tuberculin skin test (Mantoux)A) Tuberculin skin test (Mantoux) B) Influenza vaccineB) Influenza vaccine C) HBV vaccine boosterC) HBV vaccine booster D) Tuberculin skin test and influenza vaccineD) Tuberculin skin test and influenza vaccine E) HBV booster, tuberculin skin test, and influenza vaccineE) HBV booster, tuberculin skin test, and influenza vaccine
- 4. AnswerAnswer D) Tuberculin skin test and influenzaD) Tuberculin skin test and influenza vaccinevaccine The tuberculosis skin test needs to beThe tuberculosis skin test needs to be done annually as well as thedone annually as well as the influenza (flu) vaccine. The HBVinfluenza (flu) vaccine. The HBV vaccine does not have a specifiedvaccine does not have a specified booster schedule.booster schedule.
- 5. Personal ProtectivePersonal Protective Equipment(PPE)Equipment(PPE) 1.Clinical attire: Gown1.Clinical attire: Gown Hair: Pulled back from field of visionHair: Pulled back from field of vision 2.Face mask: pulled over nose and chin2.Face mask: pulled over nose and chin 3.Protective eyewear with side-shields3.Protective eyewear with side-shields 4.Gloves: changed often4.Gloves: changed often OSHA Recommendations: OccupationalOSHA Recommendations: Occupational Safety and Health AdministrationSafety and Health Administration Protects the worker from physical, chemical orProtects the worker from physical, chemical or infectious hazards in the workplace.infectious hazards in the workplace.
- 6. PPE’sPPE’s When is it appropriate to wearWhen is it appropriate to wear personal protective gear?personal protective gear? A. When in contact with aerosols,A. When in contact with aerosols, spatter, or body fluidsspatter, or body fluids B. When taking radiographsB. When taking radiographs C. Handling denturesC. Handling dentures D. All of the aboveD. All of the above
- 7. AnswerAnswer D. All of the aboveD. All of the above
- 8. What is OSHA?What is OSHA? Occupational Safety and HealthOccupational Safety and Health AdministrationAdministration A government agency in theA government agency in the Department of Labor to maintain aDepartment of Labor to maintain a safe and healthy work environmentsafe and healthy work environment
- 9. Material Safety Data SheetMaterial Safety Data Sheet MSDS:MSDS: OSHA requires chemicalOSHA requires chemical products in the clinic and companyproducts in the clinic and company information be made available to allinformation be made available to all individuals in the work placeindividuals in the work place Contains:Contains: hazard chemical inventoryhazard chemical inventory of each product, exact name, productof each product, exact name, product number and supplier’s name andnumber and supplier’s name and addressaddress
- 10. Test your KnowledgeTest your Knowledge What does MSDS mean?What does MSDS mean? Where is it located?Where is it located?
- 11. AnswerAnswer Material Safety Data SheetMaterial Safety Data Sheet Dental clinic/front desk areaDental clinic/front desk area
- 12. Facial andFacial and Respiratory ProtectionRespiratory Protection Use of a face maskUse of a face mask Mask efficiencyMask efficiency Filtration:Filtration: 95% of particles as small as 3 u95% of particles as small as 3 u Fit :Fit : cover entire nose and chin areacover entire nose and chin area Moisture absorption:Moisture absorption: change after eachchange after each patient and wore no longer than 1 hourpatient and wore no longer than 1 hour Comfort: supports complianceComfort: supports compliance Mask removal: graspMask removal: grasp side stringside string
- 13. ReviewReview When should the face mask be changed?When should the face mask be changed? A) Every hourA) Every hour B) When it becomes wetB) When it becomes wet C) For each patientC) For each patient D) For each patient, when it becomes wet, andD) For each patient, when it becomes wet, and at least every hourat least every hour
- 14. AnswerAnswer D) For each patient, when it becomes wet, andD) For each patient, when it becomes wet, and at least every hourat least every hour A new face mask should be used with eachA new face mask should be used with each patient to prevent cross-contamination. Thepatient to prevent cross-contamination. The effectiveness of the face mask iseffectiveness of the face mask is compromised when wet and after use for ancompromised when wet and after use for an hour and should be changed accordingly.hour and should be changed accordingly.
- 16. Protective EyewearProtective Eyewear Clinician protection:Clinician protection: prevent injury andprevent injury and infectioninfection Patient protection:Patient protection: prevent injury,prevent injury, contact lens protectioncontact lens protection Features:Features: wide lens, side shieldswide lens, side shields Types of eyewear:Types of eyewear: goggles or glassesgoggles or glasses (magnification loupes)(magnification loupes) Eyewash station:Eyewash station: located at each sink inlocated at each sink in clinicclinic
- 17. Face ShieldFace Shield Worn over mask and safety glassesWorn over mask and safety glasses Used during polishing and ultrasonicUsed during polishing and ultrasonic scalerscaler
- 19. Hand CareHand Care Hands: means of transmission,Hands: means of transmission, reservoir, port of entryreservoir, port of entry Hand care:Hand care: avoid breaks in cuticlesavoid breaks in cuticles Fingernails:Fingernails: Short, trimmedShort, trimmed Jewelry wear:Jewelry wear: traps bacteriatraps bacteria CDC 2002 guidelinesCDC 2002 guidelines http://www.cdc.gov/handhygiene/http://www.cdc.gov/handhygiene/
- 20. Handwashing PrinciplesHandwashing Principles Rationale:Rationale: prevent organismsprevent organisms acquired from patientacquired from patient Purposes:Purposes: Reduce bacteria floraReduce bacteria flora Facilities:Facilities: foot control to avoid cross-foot control to avoid cross- contaminationcontamination Agents:Agents: antimicrobial soap or alcoholantimicrobial soap or alcohol rubrub
- 21. ““Handwashing is considered the most importantHandwashing is considered the most important single procedure for prevention of cross-single procedure for prevention of cross- contamination.”contamination.” Dr. Esther M. WilkinsDr. Esther M. Wilkins
- 22. Indications for HandwashIndications for Handwash Before gloves placedBefore gloves placed After gloves removedAfter gloves removed Torn, punctured glovesTorn, punctured gloves After bare hands touch inanimate objectAfter bare hands touch inanimate object When visibly soiledWhen visibly soiled Entering and leaving operatoryEntering and leaving operatory
- 23. Gloving TechniqueGloving Technique Mask and eyewear placement:Mask and eyewear placement: prior toprior to handwashing and glovinghandwashing and gloving Preglove handwash:Preglove handwash: Glove placement:Glove placement: Glove removal:Glove removal: wash promptly afterwash promptly after removalremoval
- 25. Factors AffectingFactors Affecting Glove IntegrityGlove Integrity Torn, cut, or punctured gloves:Torn, cut, or punctured gloves: replacereplace Length of time worn:Length of time worn: each new patient, no more than 1 hour,each new patient, no more than 1 hour, when they become stickywhen they become sticky Size of glove:Size of glove: proper fit important for tactile sensitivityproper fit important for tactile sensitivity Agents used in care provision:Agents used in care provision: vaseline, antisepticvaseline, antiseptic handwash, and alcohol breakdown glove integrityhandwash, and alcohol breakdown glove integrity Hazards from hands, jewelry:Hazards from hands, jewelry: long nails and ringslong nails and rings
- 26. Latex SensitivityLatex Sensitivity Clinical manifestations: dermatitis to anaphylaxisClinical manifestations: dermatitis to anaphylaxis Individuals at riskIndividuals at risk: health care workers, multiple: health care workers, multiple surgeries, food allergiessurgeries, food allergies Clinical management: patient may ask about our clinic…Clinical management: patient may ask about our clinic… latex freelatex free
- 27. ReviewReview Which of the following are at high risk of developing aWhich of the following are at high risk of developing a latex allergy?latex allergy? A) A person with spina bifidaA) A person with spina bifida B) Healthcare workersB) Healthcare workers C) A person allergic to bananasC) A person allergic to bananas D) A person allergic to bananas, a person with spinaD) A person allergic to bananas, a person with spina bifida, and healthcare workersbifida, and healthcare workers
- 28. AnswerAnswer D) A person allergic to bananas, a person with spinaD) A person allergic to bananas, a person with spina bifida, and healthcare workersbifida, and healthcare workers Individuals at high risk for latex sensitivity have hadIndividuals at high risk for latex sensitivity have had frequent exposure to latex products; this wouldfrequent exposure to latex products; this would include healthcare workers and persons who haveinclude healthcare workers and persons who have had multiple surgeries. Also, persons with certainhad multiple surgeries. Also, persons with certain food allergies such as avocado, banana, kiwi fruit,food allergies such as avocado, banana, kiwi fruit, chestnuts, and papaya are at higher risk for latexchestnuts, and papaya are at higher risk for latex allergies.allergies.
- 29. Factors to TeachFactors to Teach the Patientthe Patient Importance of medical history forImportance of medical history for patient and clinicianpatient and clinician Necessity for personal protectiveNecessity for personal protective equipmentequipment Importance of eye protection duringImportance of eye protection during clinical proceduresclinical procedures
Editor's Notes
- All DHCPs should be aware of signs/symptoms of diseases that are occupational hazards and be encouraged to seek medical consult for early diagnosis and treatment of conditions that could be communicable disease. At time of employment, dentist/employer should request immunization records, with most recent updates, and results of any testing—such as annual tuberculosis skin tests. These should be documented and updated as part of the setting’s “Exposure Control Plan” for each team member. Basic immunizations include: protection against hepatitis B; diphtheria, tetanus; pertussis; haemophilus influenza type b; poliomyelitis; measles, mumps, rubella (MMR); varicella; meningococcal; pneumococcus; influenza; and hepatitis A. Booster dosages or reimmunization may occur upon intimate contact or exposure. Adult recommendations: tetanus and diphtheria booster every 10 years; annual influenza vaccine; pneumococcal vaccine; hepatitis B series; hepatitis A series; MMR; varicella; and meningococcal vaccine. Periodic testing: annual tuberculin skin test, with chest radiograph as indicated; periodic throat culture for possible hemolytic streptococcus carrier. Written confidential records of immunizations, boosters, reimmunization, and plans for medical follow-up should be kept for each employee. Current immunization status documentation saves time following any accidental exposure.
- PPE is a barrier for the clinician in the dental healthcare setting. It provides protection against contaminants and cross-contamination from splash, spatter, aerosols, and patient contact. Each area will be explored in detail in following slides. The CDC link provides up-to-date information and resources for PPE. Which makes the most sense for placement of PPE’S? Gown, mask, glasses, gloves
- The face mask should be positioned first when preparing for clinical care procedures. The mask provides respiratory protection as well as a barrier to spatter during clinical procedures. Essential characteristics of the appropriate face mask: Filtration (measure in BFE [bacterial filtration efficiency]) where a standard mask blocks 95% of particles as small as 3 µ. Greater filtration is required when higher classification of risk patients present for care. Particles smaller than 3 µ (such as droplet nuclei of TB) range from 0.5 to 1 µ and can penetrate to the alveoli of the lower respiratory tract, where their infectivity is increased. Fit: proper fit of the mask over the face is vital to protect against inhaling droplet nuclei from aerosols. Moisture absorption: soak-through is important factor. The mask lining should be impervious. Mask should be changed for each patient and be worn no longer than 1 hour. Comfort: degree of comfort encourages compliance in wearing the mask. Mask material composition: masks may be made from gauze and other cloth, plastic foam, fiberglass, synthetic fiber mat, and paper. Mask use: adjust the mask before positioning eyewear and protective handwash. Use a fresh mask for each patient. Change mask each hour or when it becomes wet. Keep mask on after completing a procedure while still in the presence of aerosols. If a chin-cover face shield is used, supplement with a fitted face mask. Do not handle contaminated side of mask with gloved or bare hands. Mask removal: grasp side elastic or tie strings to remove (see figure on next slide).
- Removal of mask. Handle only by the elastic or tie strings, carefully avoiding the contaminated mask.
- Eye protection necessary for DHCPs and patients to prevent physical injuries and infections of the eyes from contaminants during care provision. Patient medical history review may reveal previous eye surgery, implants, or other special concerns. Injury possible from dropped instrument or splashing of agents or materials during dental procedures. Contamination from saliva, biofilm, carious tissues, restorative materials during cavity preparation, bacteria-laden calculus during scaling procedures, or microorganisms contained in aerosols or spatter. Features: wide lens coverage around orbit area, with OSHA-mandated side shields to protect sides of eye; shatterproof; frames with rounded smooth edges to prevent discomfort; easily disinfected. Patient lenses could be tinted to prevent glare, especially for cataract or glaucoma patients. Lenses should be light enough in color for clinician to view patient’s eyes to observe patient reactions and responses. Types of eyewear: goggles: shielding on all sides of the glasses may give the best protection, provided close fit around the edges. This form is especially protective during laboratory work. Eyewear with side shields: for the DHCP dependent on a prescription lens correction, separate side shields are available that can be attached to the frame. Eyewear with curved frames: curved back sides may provide protection similar to that offered by side shields. Surgical magnification loupes attached to safety glasses with side shields: magnification aids in visualization of the working area in the oral cavity, while the safety glass frame provides protection to the eyes of the clinician. Postmydriatic spectacles (used by ophthalmologists) are disposable glasses made of flexible plastic. Child-sized glasses: sunglasses and play spectacles have been used for patient protection. Application and care in the clinical setting: patient asked to wear protective lenses during procedures can be provided a simple rationale. DHCPs and patients who wear contact lenses should always wear protective lenses during DH/dental procedures. Care of protective lenses: rinse under running water to remove any abrasive agent on lenses, clean with detergent, and rinse again thoroughly. Let air dry. Some lenses may be damaged by disinfectants. Surgical though-the-lens loupes may not be able to be run under water. Check manufacturer’s directions. Check all lenses periodically for scratches on the lens, and replace appropriately. Eyewash station: should be available in the dental care setting for lavage of agents or materials that get into the eye. Station should not be hooked up to hot water lines, and should be located at a sink not used by clinicians for patient preparation.
- Protective eyewear. Protective cover for both patient and clinician may be goggles style (A) or glasses with side shields (B and C).
- The hands may serve as a means of transmission of blood, saliva, and dental biofilm from the patient. Hands and fingernails may serve as a reservoir for microorganisms. Skin breaks in the hands may serve as a port of entry for potential pathogenic microorganisms. Primary cross-contamination can be controlled by using effective handwash, and following basic rules for gloving and asepsis. Resident bacteria: relatively stable flora inhabiting the surface epithelium, deeper areas in ducts of skin glands, and depths of hair follicles. Bacteria are shed with exfoliated surface cells or with excretion of skin glands. Flora may be altered by newly introduced pathogens or reduced by washing. Resident bacteria tend to be less susceptible to destruction by disinfection procedures. Transient bacteria: reflect continuous contamination by routine contacts; some bacteria are pathogens and may act temporarily as residents. They may be washed away, or in the event of skin breaks, may cause infection. Most transients can be removed with soap and water by washing thoroughly. Fingernails: maintain clean, smoothly trimmed, short fingernails with well-cared-for cuticles to prevent breaks where microorganisms can enter. Short nails make handwashing more effective; prevent cuts from long nails in disposable gloves; permit selection of a closer fit of glove; and allow greater dexterity during instrumentation. NO ACRYLIC ARTIFICIAL NAILS SHOULD BE WORN DURING CLINICAL CARE PROVISION. If nail polish is worn under gloves, it should not have chipped edges, which can harbor bacteria (CDC guidelines 2002). Jewelry: remove hand and wrist jewelry at beginning of clinic day. Microorganisms can become lodged in crevices of rings, watchbands, and watches, where sanitation is not possible. After handwash, don gloves. Never expose open skin lesions to patient’s oral tissues or body fluids. After glove removal, wash hands to remove microorganisms.
- Effective and frequent handwashing can reduce overall bacterial flora of the skin and prevent organisms acquired from a patient from become part of the clinician’s skin resident flora. Purpose: reduce bacteria flora to absolute minimum. It removes surface dirt and transient bacteria; it can dissolve the normal greasy film on the skin; and it can rinse and remove all loosened debris and microorganisms. Facilities: use a sink with foot or electronic controls for water flow to avoid contamination to/from faucet handles; if using faucet-controlled water flow, leave stream of water flowing throughout entire procedure, turning off faucets with towel after drying hands. Clear around rim of sink with disinfectant. Do not use the same sink for handwashing prior to patient care that is used for instrument washing; contaminated instruments should be removed from the treatment room prior to preparation for patient care. Agents: soap: use a liquid surgical scrub containing an antimicrobial agent. Povidone-iodine has a broad spectrum of action. Apply the soap from a foot- or knee-activated or electronically controlled dispenser. This avoids contamination from hand-operated dispenser or cake soap. Scrub brushes may be traumatic to the skin, but disposable sponges are a viable alternative. Towels should be disposable and contained within a dispenser that requires no contact except with the towel itself. Cloth towels are not recommended. Antimicrobial soaps include chlorhexidine, iodine and iodophors, chloroxylenol (PCMX), and triclosan.
- Indications for handwash: before and after treating a patient (before gloves placed, after gloves removed); before regloving after removal of torn, cut, or punctured gloves; after barehanded touching inanimate objects that may be contaminated with blood or saliva; when hands are visibly soiled; and before leaving the treatment room. Routine handwash: water and nonantimicrobial soap to remove soil and transient microorganisms. Wet hands, apply soap, and avoid hot water. Rub hands together for at least 15 seconds; cover all surfaces of fingers, hands, and wrists. Interlace fingers and rub to cover all sides. Rinse under running water; dry thoroughly with disposable towels. Turn off faucet with the towel. Antiseptic handwash: water and antimicrobial soap to remove or destroy transient microorganisms and reduce resident flora. Remove arm and hand jewelry. Fasten hair back securely. Put on protective eyewear and mask before handwashing to prevent contamination of washed hands ready for gloving. Use cool water. Lather hands, wrists, and forearms quickly with liquid antimicrobial soap. Rub all surfaces vigorously, interlacing fingers, and rub back and forth with pressure. Rinse thoroughly, running water from fingertips down the hands. Keep water moving. Repeat two more times. Lathering serves to loosen the debris and bacteria and the rinsings wash them away. Antiseptic handrub: alcohol-based hand rub (60% to 95% ethanol or isopropanol) to remove or destroy transient flora and reduce resident flora. Wash away visible dirt prior to use. Decontaminate hands with alcohol-based rub. Apply the product (following manufacturer’s directions for amount to use) to the palm of one hand; rub hands together. Rub hands vigorously, covering all surfaces of fingers and hands, until hands are dry. Surgical antisepsis: also called surgical scrub. Removes or destroys transient flora and reduces resident flora with a persistent or prolonged effect that inhibits proliferation or survival of microorganisms. Follow rules for specific hospital/clinic; rules usually are posted over scrub sinks. Surgical antisepsis performed as the first one of the day will be 10 minutes, with subsequent ones of 3 to 5 minutes’ duration. Following treatment of a contagious or isolated patient, the procedure will take at least 5 minutes. Specific directions for basic method are listed in Chapter 3 of the text. This method uses orangewood stick to clean around nails and sterile surgical brushes to accomplish the scrub.
- Placement: Place mask and eyewear prior to handwashing and gloving. This prevents the need to manipulate the mask around the face and hair after washing hands. Use an antiseptic handwash prior to gloving. Hands must be dried thoroughly to control moisture inside glove and discourage growth of bacteria. Glove/deglove in front of patients so they are assured of your adherence to infection control protocol—that you are using a clean set of gloves for them. Place gloves over cuff of long-sleeved clinic garment to provide complete protection of arms from exposure to contaminants. Avoid contamination: keep gloved hands away from face, hair, clothing (pockets), telephone, patient records, operator stool, and parts of dental equipment that have not been disinfected or covered with a barrier. If gloves are torn, punctured, or cut, remove gloves, wash hands thoroughly, and put on new gloves. Removal: develop a routine to remove glove without contaminating hands from the outer glove surface. Wash hands promptly after glove removal.
- Removal of gloves. (A) Use left fingers to pinch right glove near edge to fold back. (B) Fold edge back without contact with clean inside surface. (C) Use right fingers to contact outside of left glove at the wrist to invert and remove. (D) Bunch glove into the palm. (E) With ungloved left hand, grasp inner noncontaminated portion of the right glove to peel it off, enclosing other glove as it is inverted.
- Interruption of the glove surface allows contaminants to contact clinician’s hands. Replace gloves when a cut, tear, or puncture affects the glove material. Time worn: a new pair for each patient is the rule. Total time worn should be no more than 1 hour; when gloves develop a sticky surface, remove, wash hands, and reglove with a fresh pair. Certain procedures are more likely to promote perforation, such as the use of sharp instruments, prompting frequent changes of gloves during the appointment. Size: glove fit must be precise; otherwise, tactile sensitivity is affected. Too long of a glove in fingertip area can get caught or torn or impede instrumentation. Storage: keep glove boxes in cool, dark place. Exposure to heat, sun, or fluorescent lights increases potential for deterioration. Agents: certain chemicals react with glove material. Petroleum jelly (Vaseline or Chapstick used by patient for lip lubrication), alcohol, and products made with alcohol tend to break down the glove integrity. Hazards: long fingernails and rings worn inside gloves promote tears in the gloves.
- Patients and clinicians may have or develop sensitivity to natural rubber latex. Symptoms of hypersensitivity range from dermatitis to life-threatening anaphylaxis. These individuals should avoid all contact with latex materials. When gloves are powdered, cornstarch can disperse the latex protein (allergen) into the air of the clinical setting. Methods of exposure: aeroallergen inhalation, donning gloves, mucosal contact. Hypersensitivity type I (immediate reaction): includes urticaria, dermatitis, sneezing, itchy/runny nose, breathing difficulties (wheezing or coughing), watery/itchy eyes, drop in blood pressure (shock), and anaphylaxis. Hypersensitivity type IV (delayed reaction): contact dermatitis develops 6 to 72 hours after contact. Individuals at risk: occupational exposure who have frequent exposure/use of latex products; multiple medical surgeries or treatment requiring placement of rubber tubes or drains; history of other documented allergies (especially food allergies to avocado, banana, kiwi fruit, chestnuts, and papaya); workers in rubber manufacturing plants. Management: questions in medical history should reveal all allergies, follow up with specific questions about latex and other products that prompt allergic response. Advise allergic patients to obtain/wear alert badge (bracelet). Document all information on allergic response for future and continuing reference. Appointment planning: appoint patient early in the day, because there is less powder or latex proteins in the operatory air. Clinic garments become laden with air-borne latex during the day as well. Sanitation should be accomplished wearing nonlatex gloves. Wipe all surfaces to remove latex allergens. For those patients who are at high risk for latex sensitivity, use NO latex products in the treatment room. Prepare a latex-free cart for use with high-risk patients. Emergency treatment equipment and drugs: inform entire dental team of appointment. Have latex-free emergency cart available. Be alert for emergency.
- Discuss the importance of the patient’s complete history for the protection of both the patient and the professional person. Discuss the necessity for use of barriers (face mask, protective eyewear, and gloves) by the clinician for the benefit of the patient. Describe the importance of eye protection for both the patient and clinician during clinical procedures.