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Q Should face masks be changed between each patient whether there is visible contamination or not?

Q If a biological test strip comes back positive indicating that the instruments should be re-sterilized/processed, are patients required to be notified that the instruments used on them didn't meet sterilization standards?

Q What exposure management protocols should be used in the darkroom?

Q What are the guidelines concerning patient protective eyewear?

Q What items do you suggest be found in the dental office first aid kit?

Q What precautions should I take to be safe in a dental setting when pregnant?


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Q Should face masks be changed between each patient whether there is visible contamination or not?

A Yes, face masks should not only be changed between patients but they should also be changed anytime they become wet.

The Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings states the following:

A surgical mask protects against microorganisms generated by the wearer, with >95% bacterial filtration efficiency, and also protects DHCP from large-particle droplet spatter that might contain bloodborne pathogens or other infectious microorganisms. The mask's outer surface can become contaminated with infectious droplets from spray of oral fluids or from touching the mask with contaminated fingers. Also, when a mask becomes wet from exhaled moist air, the resistance to airflow through the mask increases, causing more airflow to pass around edges of the mask. If the mask becomes wet, it should be changed between patients or even during patient treatment, when possible. (1)

1. Wear a surgical mask and eye protection with solid side shields or a face shield to protect
mucous membranes of the eyes, nose, and mouth during procedures likely to generate
splashing or spattering of blood or other body fluids (IB, IC). (1)


2. Change masks between patients or during patient treatment if the mask becomes wet (IB). (1)


In addition, the authors of Infection Control & Management of Hazardous Materials for the Dental Team state that the mask should be changed with every patient because its outer surface becomes contaminated with droplets from sprays of oral fluids from the previous patient or from touching the mask with saliva coated fingers. Also, when a mask becomes wet from moist exhaled air, the resistance to airflow through the mask increases, causing more unfiltered air to pass by the edges of the mask. Thus one should replace wet masks to maintain high filterability. (2)

Resources:

1) Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

2) Infection Control & Management of Hazardous Materials for the Dental Team. Third Edition.
By Miller and Palenik. Elsevier/Mosby Publishers. Copyright 2005

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Q If a biological test strip comes back positive indicating that the instruments should be re-sterilized/processed, are patients required to be notified that the instruments used on them didn't meet sterilization standards?

A According to the Center's for Disease Control and Prevention's Infection Control Guidelines for Dental Healthcare Settings published studies are not available that document disease transmission through a non-retrieved surgical instrument after a steam sterilization cycle with a positive biological indicator. (1)

A sterilization monitoring log/record should be maintained (some states require documentation), including all test results, and appropriate actions taken when a failure has been noted. The log should also include the date of the test, type of sterilizer, temperature and time of the sterilization cycle, nature of the package containing the biological indicator, and the name of the sterilizer operator. This information documents the test so that one can identify the load and conditions if a sterilization failure occurs. These records may be needed should questions about the sterility of instruments ever arise. (2)

OSAP is not currently aware of any mandate requiring dental patients to be notified if a biological test strip is positive. However, there may be state laws/regulations/statutes that we are not aware of. You should contact the appropriate agencies for all applicable laws in your state (e.g. State Board of Dental Examiners/Licensing Board, State Public Health Agency).

Resource:

1) Center's for Disease Control and Prevention's Infection Control Guidelines for Dental
Healthcare Settings.

http://cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

2) Infection Control & Management of Hazardous Materials for the Dental Team, 3rd. Edition. By
Miller and Palenik. Elsevier/Mosby Publishers. Copyright 2005.

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Q What exposure management protocols should be used in the darkroom?

A OSAP would like to refer you directly to the Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Healthcare Settings. In part, the guidelines state the following:

When taking radiographs, the potential to cross-contaminate equipment and environmental surfaces with blood or saliva is high if aseptic technique is not practiced. Gloves should be worn when taking radiographs and handling contaminated film packets. Other PPE (e.g., mask, protective eyewear, and gowns) should be used if spattering of blood or other body fluids is likely. Heat-tolerant versions of intraoral radiograph accessories are available and these semi-critical items (e.g., film-holding and positioning devices) should be heat-sterilized before patient use. (1)

After exposure of the radiograph and before glove removal, the film should be dried with disposable gauze or a paper towel to remove blood or excess saliva and placed in a container (e.g., disposable cup) for transport to the developing area. Alternatively, if FDA-cleared film barrier pouches are used, the film packets should be carefully removed from the pouch to avoid contamination of the outside film packet and placed in the clean container for transport to the developing area. (1)

Various methods have been recommended for aseptic transport of exposed films to the developing area, and for removing the outer film packet before exposing and developing the film. Other information regarding dental radiography infection control is available. However, care should be taken to avoid contamination of the developing equipment. Protective barriers should be used, or any surfaces that become contaminated should be cleaned and disinfected with an EPA-registered hospital disinfectant of low- (i.e., HIV and HBV claim) to intermediate-level (i.e., tuberculocidal claim) activity. Radiography equipment (e.g., radiograph tubehead and control panel) should be protected with surface barriers that are changed after each patient. If barriers are not used, equipment that has come into contact with DHCP's gloved hands or contaminated film packets should be cleaned and then disinfected after each patient use. (1)

Additionally, OSAP's November 2003 issue of Infection Control In Practice is devoted to infection control and dental radiography. In part, this issue provides the following protocols:

Wear gloves while exposing films in the patient's mouth. Place exposed films in a paper cup. When all films are exposed, remove and discard gloves. Transport to the darkroom, re-glove and carefully open the packs and drop the films on a clean surface. Discard the contaminated wrappers, remove and discard the gloves, and process the films. When using an x-ray processor with a daylight loader, extra precautions are required to avoid contamination of the sleeves, and external and internal components of the processor. X-ray films packaged in fluid impervious barriers are available. A slight modification of the recommended x-ray and darkroom protocol is indicated. After exposing the film, pull on the edges of the barrier pack, allowing the film to drop into a clean paper cup without contaminating the inner film packet. When all films have been exposed and collected in the cup, remove procedure gloves and take films to the darkroom or daylight loader for processing. (2)

Place reusable film-holding devices in the designated area. If film barrier pouches have been used:

Carefully peel back the barrier and allow each film packet to fall from its pouch into a clean disposable container (such as a plastic cup) for transport to the developing area. Use care to avoid contaminating the outside of the film packet and the cup. (2)

If barrier pouches have not been used (to protect the film):

Follow instructions below for Handling Film Without Barriers. (2)

Discard all contaminated disposable items.
Carefully remove contaminated barriers.
Remove gloves and wash hands.
Remove the lead apron and dismiss the patient.
Disinfect all uncovered surfaces that were contaminated.
If barriers are not used, x-ray equipment that has come into contact with gloved hands or contaminated film packets must be cleaned and then disinfected after each patient use. Use protective barriers or clean and disinfect any surfaces that become contaminated by using an EPA-registered low-(with HIV and HBV claim) to intermediate-level (with a tuberculocidal claim) hospital disinfectant. (2)

For developing film:

With clean, ungloved hands, transport the disposable container of exposed film to the processing area. (2)

Unit dose:

gloves
paper cup(s)
paper towel(s)
film mount or paper envelope
Take care to avoid contaminating the developing equipment.
Use barriers or clean and disinfect any surfaces that become contaminated.
Handling Film Without Barrier Pouches:

Barrier sleeves for x-ray film packets are commercially available. These barriers are placed over the x-ray film packet before the film is positioned in the patient mouth and removed immediately after the x-ray is taken, providing dental workers with a clean, uncontaminated film packet for processing. The barriers protect film from contamination, reduce preparation time, and simplify processing. Removed in a lighted area with gloved hands, the barrier is simply peeled back and the film packet dropped onto a clean paper towel or into a clean disposable cup. Barrier-protected film packs are especially useful when using a daylight loader. If your practice setting uses film that is not barrier-protected, add these steps to the infection control protocol for dental x-rays. (2)

a. Place paper towel on your work surface

b. Place container with films next to paper towel

c. Secure door and turn out light (if applicable)

d. Put on gloves

e. Remove film from container

f. Open film packet

g. Allow film to drop onto paper towel

h. Dispose of empty packet

i. After all film packets have been opened, discard container

j. Remove gloves and wash hands

k. Process film by edges only

l. Label film mount or envelope

OSAP members and subscribers have access to Infection Control In Practice. Further information may be viewed at: http://www.osap.org

Resources:

1) Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

2) OSAP's Infection Control In Practice. Vol. 2, No. 8 November 2003.

http://www.osap.org


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Q What are the guidelines concerning patient protective eyewear?

A Dental infection control experts recommend patient protective eyewear during dental treatment for safety reasons.

The Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Healthcare Settings state the following:

Reusable PPE (e.g., clinician or patient protective eyewear and face shields) should be cleaned with soap and water, and when visibly soiled, disinfected between patients, according to the manufacturer's directions. (1)

A surgical mask that covers both the nose and mouth and protective eyewear with solid side shields or a face shield should be worn by DHCP during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids. Protective eyewear for patients shields their eyes from spatter or debris generated during dental procedures. (1)

Resource:

1) Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

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Q What items do you suggest be found in the dental office first aid kit?

A States may have laws that OSAP is not aware of and each dental office will have different needs with regards to first aid kits and the medical emergency kit (sometimes referred to as the doctor's emergency drug kit). However, OSAP can provide you with information that will direct you to the resources that will help answer your question.

Dental medical emergency experts indicate that one of the most commonly seen medical emergency in the dental office is fainting. "Smelling salts” is ammonia inhalants and are used in the management of simple fainting. Therefore, it should be included in the medical emergency kit. Most dental offices keep extra ammonia inhalants in each operatory.

The OSHA regulation concerning standard first aid kits is Standard 29 CFR 1910.151. OSHA only addresses the need to have a first aid kit to treat injured employees and does not address the medical emergency kit that would be utilized for patient medical emergencies. Therefore, the office may have two types of first aid kits, a basic first aid kit (e.g. bandages, non-adhering dressing/gauze pads, eye products; tape, roller bandage, ointments/burn treatment, analgesics, antiseptics, cold pack, scissors/tweezers, etc.) and a medical emergency kit (e.g. sterile syringes, tourniquets, airway devices, oxygen equipment, antihistamines, anticonvulsants, epinephrine, ammonia inhalants, antihypoglycemics, bronchodilator, etc.).

First, with regard to the basic first aid kit, the OSHA Standard states the following:

1910.151(b): In the absence of an infirmary, clinic, or hospital in near proximity to the workplace which is used for the treatment of all injured employees, a person or persons shall be adequately trained to render first aid. Adequate first aid supplies shall be readily available.

OSHA does not require any specific contents, however the kit should contain supplies to treat minor injuries. The selection of first aid supplies should be made by consulting a healthcare professional or by a person who is competent and knowledgeable of the workplace environment hazards. OSHA, however, does recommend the ANSI requirements for the basic first aid kit. All First Aid Kit Company industrial first aid kits meet or exceed Federal OSHA standards.

The size of the kit and the contents should be based on the number of employees and the types of injuries that would occur in the dental office. An example of the minimal contents of a generic first aid kit is described in the American National Standard (ANSI) Z308.1-1998. The contents of the kit would be adequate for small worksites (A basic fill has eight basic minimum required items: absorbent compress; adhesive bandages; adhesive tape; antiseptic; burn treatment; medical exam gloves; sterile pad; and triangular bandage). Any first aid kit that is labeled ANSI Z308 must contain these minimum required items and meet all other applicable requirements.

OSHA does not make the ANSI first aid kit requirement mandatory, however, many States have adopted ANSI standards as their State requirements.

If employees are trained, and would be called upon to perform CPR, the employer must provide a means to safely do so (e.g. one-way valve pocket mask/ventilation devices). In addition, if it is reasonably anticipated that employees will be exposed to blood or other potentially infectious materials while using first aid supplies, employers are required to provide appropriate personal protective equipment (e.g. medical exam gloves, eye protection, etc.).

To view OSHA's Standard and Interpretations for 29 CFR 1910.151 to go:

http://www.osha.gov/pls/oshaweb/owasrch.search_form?p_doc_type=INTERPRETATIONS&p_toc_level=3&p_keyvalue=1910.151&p_text_version=FALSE&p_status=CURRENT

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=24118&p_text_version=FALSE

Regulations (Standards - 29 CFR) Appendix A to § 1910.151 -- First aid kits (Non-Mandatory) - 1910.151 App A

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=9807&p_text_version=FALSE

Further information concerning ANSI requirements and first aid products/information may be found at:

http://www.first-aid-product.com/pgOSHA&ANSI.htm

http://www.safetysourceinc.com/html/updates.html

Second, with regard to medical emergency kits, many State Boards of Dental Examiners/Licensing Boards have lists of emergency drugs and equipment that are required for dentists to obtain. Therefore, OSAP is referring you to your State Board of Dental Examiners and the American Dental Association Council on Scientific Affairs. The JADA Association Report, March 2002, addresses Office Emergencies and Emergency Kits. It is an excellent report that will answer all of your questions concerning medical emergency kit requirements. This report may be found at:

http://www.ada.org/prof/resources/pubs/jada/reports/report_emergency.pdf

To make sure you are compliant with State Laws, contact your State Board of Dental Examiners for further assistance. Your State and local dental society may also have additional information that would be helpful to you.

Listing of all State Boards: http://www.ms-flossy.com/boards.html

The American Dental Association has posted a directory for local and state organization on their website at:

http://www.ada.org/ada/organizations/index.asp

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Q What precautions should I take to be safe in a dental setting when pregnant?

A Although OSAP cannot provide specific medical advice concerning potential risk factors and pregnancy, we can provide you with general information. First and foremost, however, pregnant dental health care workers should consult with their primary care physician and/or an obstetrician for medical advice and recommendations. In addition, OSAP is not aware of individual state/local laws/regulations, therefore, the appropriate state/local agencies should be contacted for specific laws (e.g. State Board of Dental Examiners/Licensing agency, State Health Dept., State/local EPA, etc.).

Pregnant workers generally are not considered to be at an increased risk for acquiring infections occupationally. There are, however, some infections, which if acquired by the mother, can cause problems for the developing fetus. Adherence to appropriate infection control precautions, including standard precautions is indicated. Female workers of childbearing age should ensure that they have received all recommended immunizations and consult with their personal physician regarding which immunizations may require booster doses. (1), (2), (3)

The "Guidelines for Infection Control in Health Care Personnel, 1998" provide specific information for precautions for pregnant healthcare workers. (See table 6 located within the document). (1)

First and foremost, all dental health care workers, whether they are pregnant or not, must adhere to and practice Universal/Standard Precautions with all patients, practice sharps safety protocols, follow all directions for safe handling, use, disposal of chemicals, obtain vaccinations recommended by the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/ ). These vaccinations include, but are not limited to: Hepatitis B; MMR (measles, mumps, rubella); Varicella (chickenpox vaccine); Td booster (at least every 10 years); and the flu vaccine during flu season (except when contraindicated for medical reasons/pregnancy, generally, a pregnant women should avoid receiving any live vaccine and must always consult with their OBGYN/Healthcare Provider concerning vaccinations and contraindications). (3)

Second, one of the most important and effective procedures to perform to prevent and/or reduce the spread of infection is proper hand hygiene as hands serve as conduits for the transfer of microorganisms, including pathogenic microorganisms. The use of appropriate personnel protective equipment PPE's, especially gloves, mask, protective eyewear, and gown must be worn during procedures where there is the potential for spray, splash, splatter of blood and other potentially infectious materials/fluids, including saliva during dental procedures. (3) (5)

The Centers for Disease Control and Prevention published the revised Infection Control for Dental Health Care Facilities in December 2003. These guidelines may be viewed at:

http://www.cdc.gov/OralHealth/infectioncontrol/index.htm.

Other issues include; exposure to chemicals (e.g. surface disinfectants, sterilants, numerous dental materials, etc.); radiation; and the use of compressed gases (specifically, nitrous oxide). Practice radiology safety protocols, and when indicated or required by State law, wear radiation monitoring film badges and monitor nitrous oxide levels.

Prior to using or working with any chemical be sure to read and follow all manufacturer's instructions and refer to the material safety data sheets (MSDA) for further important information. In addition, be sure to wear the appropriate PPE and work in well ventilated areas.

Radiology safety protocols should be strictly adhered to. All workers must follow precautions to prevent occupational exposure to radiation emitted from dental x-ray machines. Dental health care workers (especially pregnant workers) should consider wearing a monitoring dosimeter film bade on uniforms (waste level) for monthly assessment. In some States this is mandate by Law so always check with your State Board of Dental Examiners/licensing agency and other State agencies responsible for radiation safety. X-ray machines should be monitored/inspected according to all local and/or State laws (usually required on an annual basis). Never stand in the direct path of the x-ray beam (stand at least 6-8 feet away or behind a lead-lined wall) and never attempt to hold film in a patient's mouth during x-ray exposure.

Other precautions include: ensuring the machines are properly collimated, the worker is never present in the room during exposure of the film, the worker is not in the path of the active beam, the proper kVP and MA are utilized, and the highest speed film is used to further reduce the amount of radiation needed to expose the film. Additionally, monitoring exposure through the use of radiation monitoring badges may be considered. (2)

Additionally, if you use nitrous oxide, special precautions are warranted. Adverse effects associated with chronic nitrous oxide exposure in dental healthcare workers have been well documented over the years. Chronic exposure to N20 may include defects such as: nausea, spontaneous abortion/miscarriage, neurological defects, liver/kidney problems anemia, and cancer. NIOSH (National Institute for Occupational Safety and Health) recommends that N20 equipment be inspected, maintained, and a scavenger system be utilized. (4)

In addition, nitrous oxide hoses, connections, patient face mask, and fittings should be routinely checked for leaks, and the room air in the treatment areas should be periodically monitored for excessive levels of nitrous oxide. The supplier of the tanks/gases should be able to provide air monitoring service.

The maximal amount of nitrous oxide allowable in a healthcare setting is 50ppm. For further information on Nitrous Oxide, NIOSH's website is: http://www.cdc.gov/niosh/noxidalr.html

For further information on the effects of workplace hazards go to NIOSH's website at: http://www.cdc.gov/niosh and CDC's occupational health guide at:

http://www.cdc.gov/ncidod/hip/occhealt/ocguide.htm

The National Institute For Occupational Safety & Health also has posted on it's website a great deal of information on: "The Effects Of Workplace Hazards On Female Reproductive Health". This information is located at:

http://www.cdc.gov/niosh/99-104.html

Other information concerning OSHA's Bloodborne Pathogens Standard

and Hazardous Communication Standard (hazardous chemicals) may be obtained at OSHA's website at: http://www.osha.gov

OSAP has further information regarding Universal/Standard Precautions, sharp's and safety, and hazardous chemicals on its website at: http://www.osap/org/resources

Resources:

(1) Bolyard EA, Tablan OC, Williams WW, et al. "Guidelines for Infection Control In Health Care Personnel, 1998" AJIC 1998 Jun; 25(3):291-354. Available at:

http://www.cdc.gov/ncidod/hip/guide/infectcont98.htm

(2) OSAP's frequently asked questions: http://www.osap.org/resources/FAQ/index.php?name=9#4

(3) The Centers for Disease Control and Prevention: http://www.cdc.gov and Infection Control Guidelines for Dental Health Care Facilities:

http://www.cdc.gov/OralHealth/infectioncontrol/index.htm.

(4) The National Institute For Occupational Safety & Health: http://www.cdc.gov/niosh

(5) The Occupational Safety & Health Administration: http://www.osha.gov

(6) The Occupational Safety & Health Administration has posted resources for dentistry at:

http://www.osha.gov/SLTC/dentistry/index.html

(7) The American Dental Association has posted a directory for local and state organizations on their website at: http://www.ada.org/ada/resources/societies/searchorg.asp

(8) The Centers for Disease Control and Prevention's Oral Health Resources are available at: http://www.cdc.gov/oralhealth/index.htm

Additional Resources:

(1) CDC's Guidelines for Environmental Infection Control In Health Care Facilities 2003:


http://www.cdc.gov/ncidod/hip/enviro/Enviro_guide_03.pdf

http://www.cdc.gov/ncidod/hlp/enviro/guide.htm

(2) American Dental Association: http://www.ada.org/index.asp

(3) CDC's Hand Hygiene Guidelines: http://www.cdc.gov/handhygiene/default.htm

(4) CDC's Occupational Health: http://www.cdc.gov/ncidod/hip/Occhealt/ochealth.htm

(5) CDC's Workplace Safety and Health: http://www.cdc.gov/node.do?id=0900f3ec8000ec09

(6) CDC's Environmental Health: http://www.cdc.gov/node.do?id=0900f3ec8000e044


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