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FAQ's Practice Safety

Frequently Asked Questions (FAQs) on Dental Infection Control


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Frequently Asked Questions for Practice Safety

Q Our dental office is planning to conduct evaluations of dental safety devices. Can you tell me which safety dental needles or syringes are currently available?

Q I have found that when debriding an instrument, taping a cotton roll to the bracket tray does not work. First of all, if the cotton roll is wet the tape does not stick. Secondly, ergonomically the operator must keep turning since we do not put the tray over the patient for safety issues. What can OSAP recommend?

Q Does OSHA prohibit the passing of sharp instruments between assistant and operator?

Q I need some information on handwashing agents in dentistry.

Q What specific infection control recommendations apply to oral surgery procedures?

Q We were all trained in the 1990s to avoid using Cavitrons and Prophy jets on patients with active diseases (i.e., HIV, HBV, HCV) because of the likelihood of blood aerosolization. Most of the recent research I've checked has been unclear as to whether anything other than typical standard precautions are needed (plus pre-procedure mouthrinse, high speed evacuation, etc.). As far as you know, is this still the case? I can't find anything really definitive.

Q I am looking for some photos and articles on artificial nails, nail polish and infection control.

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

Q Are nose piercings of the HCW a health and safety issue or is a nose piercing acceptable in the HCW? Clearly rings and hand jewelry are a health & safety issue and must be removed. What about earrings?

Q I am looking for information concerning the management of latex allergic patients. Can OSAP send me information or point me in the right direction on how to find it?

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Q Our dental office is planning to conduct evaluations of dental safety devices. Can you tell me which safety dental needles or syringes are currently available?

A The International Health Care Worker Safety Center at the University of Virginia maintains a list of available sharps safety products at http://www.healthsystem.virginia.edu/internet/epinet. OSAP's Issue Focus on Sharps Safety also has some valuable information on safer sharps devices.

The Centers for Disease Control and Prevention (CDC) has developed some tools to assist dental practices in evaluating and, if appropriate, incorporating safer sharps devices in practice. First, the CDC has developed Sample Screening and Device Evaluation Forms to assist dental clinicians in determining which safety devices may be suitable for their practices. Also, CDC has posted information on a program called "Safer Device Implementation in Healthcare Facilities," which shares the experiences of medical and dental professionals who have already considered and evaluated safety devices for their work settings.

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Q I have found that when debriding an instrument, taping a cotton roll to the bracket tray does not work. First of all, if the cotton roll is wet the tape does not stick. Secondly, ergonomically the operator must keep turning since we do not put the tray over the patient for safety issues. What can OSAP recommend?

A Try taping four cotton rolls to the bracket tray first. Next, only moisten the two inner cotton rolls. This may solve the problem of the tape not adhering to the bracket tray cover. Although this will not totally eliminate the need to stop during the procedure to remove residual debris, it may be helpful to remind students to remove residual debris before picking up the instruments and/or when they are placing it back on the tray. Also, try using autoclave tape to hold the cotton rolls in place.

A recent Infection Control In Practice Practice Tip from OSAP member Dr. Joe Olk suggests securing a 1” strip of self-adhering elastic orthopedic wrap around the mirror handle, just under the curved neck. With a simple turn of the wrist, the sharp end can be gently wiped over the wrap until the debris is left behind. The tape is about 2-mm thick, so it's thin enough not to affect instrument handling yet thick enough to cushion the sharp end and grab any dental materials or bioburden sticking to it. Because it's attached to the mirror, the clinician need not turn away from the working field.

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Q Does OSHA prohibit the passing of sharp instruments between assistant and operator?

A OSHA does not specifically prohibit the passing of sharps, although it does require that engineering controls and safe work practices be in place.

The use of sharps with engineered safety features that reduce the risk of injury is an example of an engineering control. Announcing instrument passes and completing them with the sharp ends pointing away from both the passer and the receiver is an example of a work practice control.(1,2,3)

References:
(1) OSAP Issue Focus: Needle and sharps safety.
(2) OSHA. Safety and Health Page for Needle Sticks.
(3) NIOSH. What every worker should know; how to protect yourself from needlestick injuries.

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Q I need some information on handwashing agents in dentistry.

A The Centers for Disease Control and Prevention (CDC) issued a new Guideline for Hand Hygiene in Health-Care Settings in October 2002. This document provides guidelines for selecting and using hand cleaning agents such as plain soap, alcohols, chlorhexidine (CHG), chloroxylenol (PCMX), hexachlorophene, iodine and iodophors, quaternary ammonium compounds, and triclosan. Becoming familiar with each of these product classifications will help you make informed choices for your practice setting.

Some of the issues to consider in selecting a handwashing agent:

the type of procedure performed (i.e. surgical v. nonsurgical),
how to make the agent readily available to all users,
persistent antimicrobial activity (particularly for surgical hand asepsis),
inhibition of the active ingredient in the presence of organic material such as blood, and
user preferences.
For most routine procedures, washing with plain soap/detergent appears adequate. Use antimicrobial soap/agents/products for more invasive procedures, such as surgery. Conveniently placed sinks, towels, and soaps encourage their use. When possible, use alternative sink controls such as foot- or sensor-activated faucets. When you have to use your hands to turn off the water, use a paper towel to contact the faucet.

Vigorously rubbing lathered hands together under a stream of water for a minimum of ten seconds is adequate for routine handwashing. Always follow the handwashing agent's label instructions for contact time. Follow with thorough rinsing under a stream of water, then dry hands well.

OSAP's Infection Control Guidelines note the following:
Adequate handwashing will remove or inhibit both transient and resident organisms. [Dental healthcare workers] should wash hands before donning gloves, upon removal of gloves, and after inadvertent barehanded touching of contaminated surfaces or objects."

For more handwashing info, check out CDC's Hand Hygiene FAQs.

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Q What specific infection control recommendations apply to oral surgery procedures?

A The Centers for Disease Control and Prevention (CDC) addressed this issue in Guidelines for Infection Control in Dental Health-Care Settings, 2003.(1) They state the following:

"Perform surgical hand antisepsis by using an antimicrobial product (e.g., antimicrobial soap and water, or soap and water followed by alcohol-based hand scrub with persistent activity) before donning sterile surgeon's gloves (IB). b. Use sterile surgeon's gloves (IB).c. Use sterile saline or sterile water as a coolant/irrigant (sic) when performing oral surgical procedures. Use devices specifically designed for delivering sterile irrigating fluids (e.g., bulb syringe, single-use disposable products, and sterilizable tubing) (IB)."

1) CDC. Guidelines for Infection Control in Dental Health-Care Settings --- 2003. December 19, 2003 MMWR 52(RR17);1-61

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Q We were all trained in the 1990s to avoid using Cavitrons and Prophy jets on patients with active diseases (i.e., HIV, HBV, HCV) because of the likelihood of blood aerosolization. Most of the recent research I've checked has been unclear as to whether anything other than typical standard precautions are needed (plus pre-procedure mouthrinse, high speed evacuation, etc.). As far as you know, is this still the case? I can't find anything really definitive.

A First and foremost, if a patient presents with any active, infectious disease, dentists should consult with the patient's treating physician prior to dental care. Modifications to the treatment plan may be necessary.

OSAP can provide general information regarding infection control guidelines. However, it is often a personal choice as to whether or not a dental healthcare worker chooses hand scalers or ultrasonic scaling. According to dental infection control experts, there shouldn't be a need to refrain from use of ultrasonic scalers with HIV/Hep. B & C positive patients. As with the use of ultrasonic scalers on any patient, proper PPE, HVE, engineering controls, work practice controls, etc. should be followed. Following Standard Precautions means all patients should be treated the same regardless of their status (e.g. HIV, Hep. B & C). In other words, all patients should be treated as if they are carrying an infectious disease. Therefore, if a clinician would not ultrasonic an HIV/HBV/HCV positive patient, then following Standard Precautions means you should not use it for any patient.

The Centers for Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental Health Care Settings (December 2003), in part, states the following:

Preprocedural Mouth Rinses:

Antimicrobial mouth rinses used by patients before a dental procedure are intended to reduce the number of microorganisms the patient might release in the form of aerosols or spatter that subsequently can contaminate DHCP and equipment operatory surfaces. In addition, preprocedural rinsing can decrease the number of microorganisms introduced in the patient's bloodstream during invasive dental procedures. (1)

No scientific evidence indicates that preprocedural mouth rinsing prevents clinical infections among DHCP or patients, but studies have demonstrated that a preprocedural rinse with an antimicrobial product (e.g., chlorhexidine gluconate, essential oils, or povidone-iodine) can reduce the level of oral microorganisms in aerosols and spatter generated during routine dental procedures with rotary instruments (e.g., dental handpieces or ultrasonic scalers). Preprocedural mouth rinses can be most beneficial before a procedure that requires using a prophylaxis cup or ultrasonic scaler because rubber dams cannot be used to minimize aerosol and spatter generation and, unless the provider has an assistant, high-volume evacuation is not commonly used. (1)

The science is unclear concerning the incidence and nature of bacteremias from oral procedures, the relationship of these bacteremias to disease, and the preventive benefit of antimicrobial rinses. In limited studies, no substantial benefit has been demonstrated for mouth rinsing in terms of reducing oral microorganisms in dental-induced bacteremias (400,401). However, the American Heart Association's recommendations regarding preventing bacterial endocarditis during dental procedures provide limited support concerning preprocedural mouth rinsing with an antimicrobial as an adjunct for patients at risk for bacterial endocarditis. Insufficient data exist to recommend preprocedural mouth rinses to prevent clinical infections among patients or DHCP. (1)

Although transmission of bloodborne pathogens (e.g., HBV, HCV, and HIV) in dental health-care settings can have serious consequences, such transmission is rare. Exposure to infected blood can result in transmission from patient to DHCP, from DHCP to patient, and from one patient to another. The opportunity for transmission is greatest from patient to DHCP, who frequently encounter patient blood and blood-contaminated saliva during dental procedures. (1)

Since 1992, no HIV transmission from DHCP to patients has been reported, and the last HBV transmission from DHCP to patients was reported in 1987. HCV transmission from DHCP to patients has not been reported. The majority of DHCP infected with a bloodborne virus do not pose a risk to patients because they do not perform activities meeting the necessary conditions for transmission. For DHCP to pose a risk for bloodborne virus transmission to patients, DHCP must 1) be viremic (i.e., have infectious virus circulating in the bloodstream); 2) be injured or have a condition (e.g., weeping dermatitis) that allows direct exposure to their blood or other infectious body fluids; and 3) enable their blood or infectious body fluid to gain direct access to a patient's wound, traumatized tissue, mucous membranes, or similar portal of entry. Although an infected DHCP might be viremic, unless the second and third conditions are also met, transmission cannot occur. (1)

The risk of occupational exposure to bloodborne viruses is largely determined by their prevalence in the patient population and the nature and frequency of contact with blood and body fluids through percutaneous or permucosal routes of exposure. The risk of infection after exposure to a bloodborne virus is influenced by inoculum size, route of exposure, and susceptibility of the exposed HCP. The majority of attention has been placed on the bloodborne pathogens HBV, HCV, and HIV, and these pathogens present different levels of risk to DHCP. (1)

DHCP should be familiar also with the hierarchy of controls that categorizes and prioritizes prevention strategies. For bloodborne pathogens, engineering controls that eliminate or isolate the hazard (e.g., puncture-resistant sharps containers or needle-retraction devices) are the primary strategies for protecting DHCP and patients. Where engineering controls are not available or appropriate, work-practice controls that result in safer behaviors (e.g., one-hand needle recapping or not using fingers for cheek retraction while using sharp instruments or suturing), and use of personal protective equipment (PPE) (e.g., protective eyewear, gloves, and mask) can prevent exposure. In addition, administrative controls (e.g., policies, procedures, and enforcement measures targeted at reducing the risk of exposure to infectious persons) are a priority for certain pathogens (e.g., M. tuberculosis), particularly those spread by airborne or droplet routes. (1)

Dental practices should develop a written infection-control program to prevent or reduce the risk of disease transmission. Such a program should include establishment and implementation of policies, procedures, and practices (in conjunction with selection and use of technologies and products) to prevent work-related injuries and illnesses among DHCP as well as health-care--associated infections among patients. The program should embody principles of infection control and occupational health, reflect current science, and adhere to relevant federal, state, and local regulations and statutes. An infection-control coordinator (e.g., dentist or other DHCP) knowledgeable or willing to be trained should be assigned responsibility for coordinating the program. (1)

The effectiveness of the infection-control program should be evaluated on a day-to-day basis and over time to help ensure that policies, procedures, and practices are useful, efficient, and successful (see Program Evaluation). (1)

Standard precautions include use of PPE (e.g., gloves, masks, protective eyewear or face shield, and gowns) intended to prevent skin and mucous membrane exposures. Other protective equipment (e.g., finger guards while suturing) might also reduce injuries during dental procedures. (1)

Engineering controls are the primary method to reduce exposures to blood and OPIM from sharp instruments and needles. These controls are frequently technology-based and often incorporate safer designs of instruments and devices (e.g., self-sheathing anesthetic needles and dental units designed to shield burs in handpieces) to reduce percutaneous injuries. (1)

Work-practice controls establish practices to protect DHCP whose responsibilities include handling, using, assembling, or processing sharp devices (e.g., needles, scalers, laboratory utility knives, burs, explorers, and endodontic files) or sharps disposal containers. Work-practice controls can include removing burs before disassembling the handpiece from the dental unit, restricting use of fingers in tissue retraction or palpation during suturing and administration of anesthesia, and minimizing potentially uncontrolled movements of such instruments as scalers or laboratory knives. (1)

Again, it is often a personal choice as to whether or not a dental healthcare worker chooses hand scalers or ultrasonic scaling.

You may also contact CDC's Oral Health Resource Division for further guidance regarding ultrasonic scaling. They may have additional research data regarding the use of ultrasonic scalers that OSAP would not be aware of. Contact information is available at: http://www.cdc.gov/oralhealth/contact.htm

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 I am looking for some photos and articles on artificial nails, nail polish and infection control.

A OSAP does not maintain photos or images, however, we can provide you with information concerning artificial nails and nail polish and links to additional information.

OSAP would like to refer you to the Centers for Disease Control and Prevention's Guidelines for Dental Healthcare Settings and the CDC's Hand Hygiene Guidelines for Healthcare Settings. Both of these guidelines should provide you with helpful information. The Hand Hygiene Guidelines also provide powerpoint slides.

The CDC Guidelines for Dental Healthcare Settings state:

Fingernails and Artificial Nails

Although the relationship between fingernail length and wound infection is unknown, keeping nails short is considered key because the majority of flora on the hands are found under and around the fingernails. Fingernails should be short enough to allow DHCP to thoroughly clean underneath them and prevent glove tears. Sharp nail edges or broken nails are also likely to increase glove failure. Long artificial or natural nails can make donning gloves more difficult and can cause gloves to tear more readily. Hand carriage of gram-negative organisms has been determined to be greater among wearers of artificial nails than among nonwearers, both before and after handwashing. In addition, artificial fingernails or extenders have been epidemiologically implicated in multiple outbreaks involving fungal and bacterial infections in hospital intensive-care units and operating rooms. Freshly applied nail polish on natural nails does not increase the microbial load from periungual skin if fingernails are short; however, chipped nail polish can harbor added bacteria. (1)

Detailed hand hygiene information including bacteria and artificial nails may be viewed in the CDC's hand hygiene guidelines. A Powerpoint slide presentation is also provide. This information may be viewed at: http://www.cdc.gov/handhygiene

CDC hand hygiene guidelines state:


Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing. Personnel wearing artificial nails also have been epidemiologically implicated in several other outbreaks of infection. While these studies provide evidence that wearing artificial nails poses an infection hazard, additional studies are warranted. (2)

Resource:

1) CDC Infection Control Guidelines for Dental Healthcare Settings:

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

2) CDC Hand Hygiene Guidelines: http://www.cdc.gov/handhygiene

Additional resources include:

1) CDC's Materials to promote hand hygiene: http://www.cdc.gov/handhygiene/materials.htm

2) CDC provides a link to the hand hygiene center. The link is: http://www.handhygiene.org

3) CDC photos of fingernail infections: http://phil.cdc.gov/Phil/advancedsearchresults.asp

4) Article in Medscape: http://www.medscape.com/viewarticle/547793_print

5) Abstract From Infection Control and Hospital Epidemiology: http://xnet.kp.org/nursingpathways/ncal/quality/infection/generaltopics/artificialnails/pathorganisms_abstract.html

6) Google search provides links to numerous articles: http://search.yahoo.com/search?ei=utf-8&fr=slv1-adbe&p=healthcare+workers+wearing+artificial+nails

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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.#arenose


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Q Are nose piercings of the HCW a health and safety issue or is a nose piercing acceptable in the HCW? Clearly rings and hand jewelry are a health & safety issue and must be removed. What about earrings?

A OSAP is not in a position to provide body piercing, earrings, or general jewelry policies for schools and/or dental facilities. Each school program and/or employer must establish their own policies.

We are not currently aware of any specific regulations concerning healthcare workers and/or students with body/oral/facial piercing. OSAP will refer you to the Centers for Disease Control and Prevention (CDC) and the American Dental Association (ADA) for information on this topic.

The Centers for Disease Control and Prevention (CDC) provides information that may be viewed at:

http://www.cdc.gov/ncidod/EID/vol8no8/01-0458.htm

The American Dental Association's position statement may be viewed at;

http://www.ada.org/prof/resources/positions/statements/piercing.asp

The following report may be viewed at: Oral Piercing Jewelry Can Increase Risk for Tooth Loss, Researchers Report:

http://www.ada.org/public/media/releases/0307_release01.asp

With regard to earrings, the CDC Infection Control Guidelines for Dental Healthcare Settings does discuss hand jewelry but not earrings. In part, the guidelines state:

Jewelry

Studies have demonstrated that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings. In a study of intensive-care nurses, multivariable analysis determined rings were the only substantial risk factor for carriage of gram-negative bacilli and Staphylococcus aureus, and the concentration of organisms correlated with the number of rings worn. However, two other studies demonstrated that mean bacterial colony counts on hands after handwashing were similar among persons wearing rings and those not wearing rings. Whether wearing rings increases the likelihood of transmitting a pathogen is unknown; further studies are needed to establish whether rings result in higher transmission of pathogens in health-care settings. However, rings and decorative nail jewelry can make donning gloves more difficult and cause gloves to tear more readily. Thus, jewelry should not interfere with glove use (e.g., impair ability to wear the correct-sized glove or alter glove integrity). (1)

Resource:

1) CDC Infection Control Guidelines for Dental Healthcare Settings:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

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Q I am looking for information concerning the management of latex allergic patients. Can OSAP send me information or point me in the right direction on how to find it?

A OSAP can provide you with links to several latex allergy resources.

The Centers for Disease Control and Prevention's (CDC) Oral Health Division provides latex allergy information for dentistry, including patients. The information may be viewed at:

http://www.cdc.gov/oralhealth/infectioncontrol/faq/latex.htm

The CDC provides additional information at:

http://www.cdc.gov/search.do?action=search&queryText=Managing+dental+patients+with+latex+allergies

The Institute for Occupational Safety and Health (NIOSH) provides information that may be viewed at: http://www.cdc.gov/niosh/topics/latex

The American Dental Association (ADA) has information that may be viewed at:

http://www.ada.org/public/topics/latex_allergy_faq.asp

http://www.ada.org/public/topics/latex_allergy.asp

OSAP provides links to other latex information at: OSAP links: http://www.osap.org/displaycommon.cfm?an=1&subarticlenbr=314

Additional resources include:

Latex Allergy Resources: Links For Dentistry: http://www.latexallergylinks.org/dental.html
American Latex Allergy Association (List Of Latex Free Dental Products): http://my.execpc.com/~alert/dentalprod.html
Pub Med Abstract: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12572185&dopt=Abstract

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