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FAQ's Training & Personnel

Frequently Asked Questions (FAQs) on Dental Infection Control


Top|Training & Personnel Part 2

 

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 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?

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 Does OSAP have a list of companies that provide biological monitoring?


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 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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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 Does OSAP have a list of companies that provide biological monitoring?

A OSAP does not maintain a list of companies that provide biological monitoring. However, we can provide you with the following information:

Although in-office spore tests are available, most dental offices choose to use a mail-in service that provides third party verification. These services are available through major dental suppliers and many university dental schools.

You may contact your state's dental school for further information regarding services they may provide to the dental community.

Also, your State Board of Dental Examiners/Licensing Board and/or State/Local Dental Societies may maintain a list of companies/laboratories in your state that offer this service.

OSAP provides links to state agencies that may be viewed at:

http://www.osap.org/resources/links/index.php?name=52

In addition, we have been able to identify two resources for you. These include:

1. Global Autoclave Compliance Services. They are reported as being a widely recognized
industry leader. Further information may be viewed at:

http://www.globaltesting.org/services.html

2. Enviro Tech Laboratories is another reported leader in industry. Further information may be
viewed at:

http://www.sporestriptesting.com/



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