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Q What is the recommended frequency for water line testing, weekly, monthly, or quarterly?

Q Does OSAP or the CDC have requirements for cleaning and reusing sponges used during endo procedures? This office also insists on reusing irrigation needle tips used to clean the canals by soaking in cold sterile. Can these irrigation needle tips be safely reused? I am also concerned about the number of times they reuse endo files. How safe is it to reuse endo files and how many times can they be reused before breaking down the file? What is the best system to clean, disinfect, and sterilize endo files. And how do I approach a doctor when I am a new employee to change their sterilization techniques?

Q It is time again for me to review and update MSDS information in the office. I am a dental assistant in Mississippi. Is there is a new CD-ROM available with all the MSDS for the products used only in dentistry? Even if there is a service that one could subscribe to include updates and current changes to new or existing products.

Q How long must an office keep the MSDS materials (in years), even if these products are no longer used?

Q We are having our employees take the two step TB test. Do we need to do yearly TB testing or just retest if we suspect contact with a TB case?

 

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Q What is the recommended frequency for water line testing, weekly, monthly, or quarterly?

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. The guidelines state that the dental unit or water delivery system manufacturer should be consulted regarding the frequency of testing/monitoring. You should contact the manufacturer of your dental unit/water delivery system for assistance in determining the correct maintenance protocols and monitoring/testing frequency.

In part, the guidelines state the following:

Maintenance and Monitoring of Dental Unit Water

DHCP should be trained regarding water quality, biofilm formation, water treatment methods, and appropriate maintenance protocols for water delivery systems. Water treatment and monitoring products require strict adherence to maintenance protocols, and noncompliance with treatment regimens has been associated with persistence of microbial contamination in treated system. Clinical monitoring of water quality can ensure that procedures are correctly performed and that devices are working in accordance with the manufacturer's previously validated protocol. (1)

Dentists should consult with the manufacturer of their dental unit or water delivery system to determine the best method for maintaining acceptable water quality (i.e., <500 CFU/mL) and the recommended frequency of monitoring. Monitoring of dental water quality can be performed by using commercial self-contained test kits or commercial water-testing laboratories. Because methods used to treat dental water systems target the entire biofilm, no rationale exists for routine testing for such specific organisms as Legionella or Pseudomonas, except when investigating a suspected waterborne disease outbreak. (1)

The American Dental Association provides a great deal of information on dental unit water that may be viewed at: http://www.ada.org/prof/resources/topics/waterlines/index.asp

In addition, the United States Air Force Dental Evaluation and Consultation Service's

Provides information on dental unit waterlines that may be viewed at:

http://www.airforcemedicine.af.mil/decs/

An article in the Canadian Dental Association Journal, 2000: 66:539-41: Waterborne Biofilms and Dentistry:The Changing Face of Infection Control, byJean Barbeau, PhD, and may be viewed at:

http://www.medent.umontreal.ca/medent/recherche/laboratoires/CDAJ.pdf

OSAP provides a great deal of information concerning dental unit waterlines that may be viewed at:

http://www.osap.org/displaycommon.cfm?an=1&subarticlenbr=24

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 Does OSAP or the CDC have requirements for cleaning and reusing sponges used during endo procedures? This office also insists on reusing irrigation needle tips used to clean the canals by soaking in cold sterile. Can these irrigation needle tips be safely reused? I am also concerned about the number of times they reuse endo files. How safe is it to reuse endo files and how many times can they be reused before breaking down the file? What is the best system to clean, disinfect, and sterilize endo files. And how do I approach a doctor when I am a new employee to change their sterilization techniques?

A First and foremost, if the endodontic sponge manufacturer labels them as single use disposable devices/items, they must be discarded after each patient use. If the label does not provide re-use instructions from the manufacturer you should also consider them as single use disposable items. Even though the CDC Guidelines do not specifically address endodontic sponges, dental infection control experts state that it is difficult to effectively, adequately, or reliably clean the inside of the sponge and they should be discarded after each patient use unless the manufacturer indicates otherwise.

 

The same holds true for irrigating needles. The diameter of the needle lumen can make it difficult to clean and effectively sterilize.

The authors of From Policy to Practice: OSAP's Guide to the Guidelines list irrigating syringes as a single-use item and states that these items are always single-use/disposable. (1)

The authors of Infection Control & Management of Hazardous Materials for the Dental Team state that a disposable item is manufactured for a single use or for use on only one patient. Such items are manufactured from plastics or less expensive metals that are usually not heat tolerant or are not designed to be cleaned adequately. Thus an item that is labeled as disposable must be disposed of properly after use, and one should not attempt to pre-clean and sterilize or disinfect it for reuse on another patient. (2)

The Center's For Disease Control and Prevention's (CDC) Infection Control Guidelines for Dental
Healthcare Settings state that a single-use device, also called a disposable device, is designed to be used on one patient and then discarded, not reprocessed for use on another patient (e.g., cleaned, disinfected, or sterilized). Single-use devices in dentistry are usually not heat-tolerant and cannot be reliably cleaned. Examples include syringe needles, prophylaxis cups and brushes, and plastic orthodontic brackets. Certain items (e.g., prophylaxis angles, saliva ejectors, high-volume evacuator tips, and air/water syringe tips) are commonly available in a disposable form and should be disposed of appropriately after each use. Single-use devices and items (e.g., cotton rolls, gauze, and irrigating syringes) for use during oral surgical procedures should be sterile at the time of use. (3)

Because of the physical construction of certain devices (e.g., burs, endodontic files, and broaches) cleaning can be difficult. In addition, deterioration can occur on the cutting surfaces of some carbide/diamond burs and endodontic files during processing and after repeated processing cycles, leading to potential breakage during patient treatment. These factors, coupled with the knowledge that burs and endodontic instruments exhibit signs of wear during normal use, might make it practical to consider them as single-use devices. (3

You may want to consider asking the person responsible for the office infection control training if the CDC Infection Control Guidelines for Dental Healthcare Settings have been reviewed by the staff. If not, you could consider suggesting it as a topic for staff meetings. Doing so may invite open discussions by the staff.

Resources:

1) From Policy to Practice: OSAP's Guide to the Guidelines. Copyright 2004 by OSAP.

2) Infection Control & Management of Hazardous Materials for the Dental Team, 3rd. edition. by

Miller & Palenik. Elsevier/Mosby Publishers. Copyright 2005.

3) Center's 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 It is time again for me to review and update MSDS information in the office. I am a dental assistant in Mississippi. Is there is a new CD-ROM available with all the MSDS for the products used only in dentistry? Even if there is a service that one could subscribe to include updates and current changes to new or existing products.

A MSDS sheets should be obtained directly from the manufacturer or product distributor. To obtain the MSDS sheets you may contact the manufacturer or distributor directly or on-line. A good resource for obtaining the required MSDS sheets are your sales representatives.

Where to find MSDS sheets on the internet may be viewed at: http://www.ilpi.com/msds

The American Dental Association also offers information, resources, and materials (However, some materials are only available to ADA members), including manuals.

The ADA's information may be viewed at:

http://www.ada.org/prof/resources/topics/index.asp

The ADA also provides a listing for their members, therefore, if your dentists is a member of the ADA they may access the information at: http://www.ada.org/members/library/webresourc.asp

To obtain MSDS sheets on-line go directly to the manufacturer or distributor's website. If you do not have the manufacturer/distributor's website address you should be able to locate it through a google search engine at: http://www.google.com Type in the name of the manufacturer/distributor and the links will be provided. You may also type in the name of the product, be sure to include MSDS (e.g. Birex surface disinfectant for dentistry MSDS).

OSAP does not maintain a listing of manufacturers or distributors, however, we can provide you with several resources that offer free services to search the MSDS data banks.

Resources:

OSHA's Hazardous Communication Standard (Hazardous Chemicals):

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

Examples of listings for manufacturer's with links to their MSDS:

http://www.msdssearch.com/ManuflinksA.htm

http://www.msdssearch.com/backgroundN.htm

http://www.ehso.com/msdsad.php

http://www.oninformation.com/OnInfo2/msds.htm

Alden products:

http://www.metrex.com/TechInfo/msds/MSDS_US_Alden.htm

Biotrol International:

http://www.biotrol.com/msds.htm

Caulk products:

http://www.caulk.com

3M products:

http://www3.3m.com/search/us/en001/msdssearchform.do

Kerr products:

http://www.kerrdental.com/learning/publications/msds/indexUS.cfm

Metrex products:

http://www.metrex.com/TechInfo/msds/MSDS_US.htm

Sultan dental products:

http://www.sultandental.com

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Q How long must an office keep the MSDS materials (in years), even if these products are no longer used?

A OSAP is not in a position to provide legal advice and can only offer general information. You should consult with the college's legal counsel for all applicable laws/regulations in your state.
In addition, should your state operate a State OSHA Plan, you should contact the State OSHA office for technical assistance and interpretations of the Hazard Communication Standard.

A list of State OSHA Plans may be viewed at: http://www.osha.gov/index.html

As far as we can determine, the Hazard Communication Standard 29 CFR 1910.1200 does not specifically address the length of time one should maintain MSDSs for products no longer in use. (1)

Because potential harmful effects of exposure to hazardous chemicals (e.g. respiratory disorders, cancer, etc.) may not be apparent for years, the authors of Practical Infection Control In Dentistry state that MSDSs should never be discarded, even if the product or chemical is no longer used. When a product or chemical is no longer used in the workplace, the MSDS should be moved to an inactive section of the file but maintained as long as the office is in business. (2)

Resources:

1) Hazard Communication Standard 29 CFR 1910.1200

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10099

2) Practical Infection Control In Dentistry, 2nd. Edition. By Cottone, Terezhalmy, and Molinari.
Williams & Wilkins Publishers. Copyright 1996

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Q We are having our employees take the two step TB test. Do we need to do yearly TB testing or just retest if we suspect contact with a TB case?

A The two step TST (TB skin test) should be administered at the time of employment. The need for annual TST is then based on your community risk assessment.

OSAP would like to refer you directly to the CDC's Infection Control Guidelines for Dental Healthcare Facilities. The Guidelines do address TB and the need for screening.

Healthcare workers with a positive PPD/TST history and a negative chest x-ray on file may be asked to complete an annual TB assessment. The TB assessment will determine whether or not additional testing and chest x-ray are necessary.

In part, the Guidelines state:

Patients infected with M. tuberculosis occasionally seek urgent dental treatment at outpatient dental settings. Understanding the pathogenesis of the development of TB will help DHCP determine how to manage such patients. (1)

M. tuberculosis is a bacterium carried in airborne infective droplet nuclei that can be generated when persons with pulmonary or laryngeal TB sneeze, cough, speak, or sing. These small particles (1--5 µm) can stay suspended in the air for hours. Infection occurs when a susceptible person inhales droplet nuclei containing M. tuberculosis, which then travel to the alveoli of the lungs. Usually within 2--12 weeks after initial infection with M. tuberculosis, immune response prevents further spread of the TB bacteria, although they can remain alive in the lungs for years, a condition termed latent TB infection. Persons with latent TB infection usually exhibit a reactive tuberculin skin test (TST), have no symptoms of active disease, and are not infectious. However, they can develop active disease later in life if they do not receive treatment for their latent infection. (1)

Approximately 5% of persons who have been recently infected and not treated for latent TB infection will progress from infection to active disease during the first 1--2 years after infection; another 5% will develop active disease later in life. Thus, approximately 90% of U.S. persons with latent TB infection do not progress to active TB disease. Although both latent TB infection and active TB disease are described as TB, only the person with active disease is contagious and presents a risk of transmission. Symptoms of active TB disease include a productive cough, night sweats, fatigue, malaise, fever, and unexplained weight loss. Certain immunocompromising medical conditions (e.g., HIV) increase the risk that TB infection will progress to active disease at a faster rate. (1)

Overall, the risk borne by DHCP for exposure to a patient with active TB disease is probably low. Only one report exists of TB transmission in a dental office, and TST conversions among DHCP are also low. However, in certain cases, DHCP or the community served by the dental facility might be at relatively high risk for exposure to TB. (1)

Surgical masks do not prevent inhalation of M. tuberculosis droplet nuclei, and therefore, standard precautions are not sufficient to prevent transmission of this organism. Recommendations for expanded precautions to prevent transmission of M. tuberculosis and other organisms that can be spread by airborne, droplet, or contact routes have been detailed in other guidelines. (1)

TB transmission is controlled through a hierarchy of measures, including administrative controls, environmental controls, and personal respiratory protection. The main administrative goals of a TB infection-control program are early detection of a person with active TB disease and prompt isolation from susceptible persons to reduce the risk of transmission. Although DHCP are not responsible for diagnosis and treatment of TB, they should be trained to recognize signs and symptoms to help with prompt detection. Because potential for transmission of M. tuberculosis exists in outpatient settings, dental practices should develop a TB control program appropriate for their level of risk. (1)

A community risk assessment should be conducted periodically, and TB infection-control policies for each dental setting should be based on the risk assessment. The policies should include provisions for detection and referral of patients who might have undiagnosed active TB; management of patients with active TB who require urgent dental care; and DHCP education, counseling, and TST screening.
DHCP who have contact with patients should have a baseline TST, preferably by using a two-step test at the beginning of employment. The facility's level of TB risk will determine the need for routine follow-up TST.
While taking patients' initial medical histories and at periodic updates, dental DHCP should routinely ask all patients whether they have a history of TB disease or symptoms indicative of TB.
Patients with a medical history or symptoms indicative of undiagnosed active TB should be referred promptly for medical evaluation to determine possible infectiousness. Such patients should not remain in the dental-care facility any longer than required to evaluate their dental condition and arrange a referral. While in the dental health-care facility, the patient should be isolated from other patients and DHCP, wear a surgical mask when not being evaluated, or be instructed to cover their mouth and nose when coughing or sneezing.
Elective dental treatment should be deferred until a physician confirms that a patient does not have infectious TB, or if the patient is diagnosed with active TB disease, until confirmed the patient is no longer infectious.
If urgent dental care is provided for a patient who has, or is suspected of having active TB disease, the care should be provided in a facility (e.g., hospital) that provides airborne infection isolation (i.e., using such engineering controls as TB isolation rooms, negatively pressured relative to the corridors, with air either exhausted to the outside or HEPA-filtered if recirculation is necessary). Standard surgical face masks do not protect against TB transmission; DHCP should use respiratory protection (e.g., fit-tested, disposable N-95 respirators).
Settings that do not require use of respiratory protection because they do not treat active TB patients and do not perform cough-inducing procedures on potential active TB patients do not need to develop a written respiratory protection program.
Any DHCP with a persistent cough (i.e., lasting >3 weeks), especially in the presence of other signs or symptoms compatible with active TB (e.g., weight loss, night sweats, fatigue, bloody sputum, anorexia, or fever), should be evaluated promptly.
The DHCP should not return to the workplace until a diagnosis of TB has been excluded or the DHCP is on therapy and a physician has determined that the DHCP is noninfectious.
Resource:

1) CDC's Infection Control Guidelines for Dental Healthcare Facilities:

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

There may be additional State requirements that OSAP would not be aware of, therefore, you should also contact your State Board of Dental Examiners/Licensing Board or other State Public Health Agencies for additional information.

For information concerning all medical and dental healthcare providers, OSAP would like to refer you to the following additional resources:

1) The CDC's Infection Control Guidelines for Dental Health Care Facilities (December 2003)

provides information on exposure incidents and may be viewed at:

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

2) CDC's Division of Tuberculosis: TB Guidelines

http://www.cdc.gov/nchstp/tb/pubs/mmwrhtml/Maj_guide/List_categories.htm

3) CDC's FAQ concerning TB:

http://www.cdc.gov/nchstp/tb/faqs/qa.htm

4) CDC's links to additional TB information including State TB programs and NIOSH:

http://www.cdc.gov/nchstp/tb/links.htm

5) CDC's Issues in Healthcare Settings: TB http://www.cdc.gov/ncidod/hip/guide/tuber.htm

5) OSHA: http://www.osha.gov/SLTC/tuberculosis/index.html

6) OSHA Respiratory Protection: http://www.osha.gov/SLTC/respiratoryprotection/index.html

7) Listing for State Health Departments/Agencies: http://www.statelocalgov.net

8) Listing of State Board of Dental Examiners/Licensing Boards:

http://www.agd.org/cde/state_board_directory.html

 

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