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Guidelines for Infection Control in

Dental Health-Care Settings


Sharon K. Dickinson, CDA, CDPMA, RDA;
Richard D. Bebermeyer, DDS; Karen Ortolano
Continuing Education Units: 4 hours

This continuing education course is intended for general dentists, hygienists, and dental assistants. In
2003, the U.S. Centers for Disease Control and Prevention (CDC) published updated recommendations
for dental infection control. Developed in collaboration with authorities on infection control from CDC and
other public agencies, academia, and private and professional organizations, this course consolidates
and expands previous CDC recommendations and incorporates the infection-control provisions of the
Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. This course
provides an overview of current CDC recommendations for minimizing the potential for disease transmission
during the delivery of dental care.

Conflict of Interest Disclosure Statement


The authors report no conflicts of interest associated with this work.

ADA CERP
The Procter & Gamble Company is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the


provider or to ADA CERP at: http://www.ada.org/goto/cerp

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
Overview
In 2003, the U.S. Centers for Disease Control and Prevention (CDC) published updated recommendations
for dental infection control. Developed in collaboration with authorities on infection control from CDC and
other public agencies, academia, and private and professional organizations, “Guidelines for Infection
Control in Dental Health-Care Settings - 2003” consolidates and expands previous CDC recommendations
and incorporates the infection-control provisions of the Occupational Safety and Health Administration
(OSHA) Bloodborne Pathogens Standard.

Each recommendation in the 2003 document is categorized on the basis of existing scientific data,
theoretical rationale, and applicability. The CDC category designations, as described below, accompany
each recommendation cited in this course.

Category IA recommendations are strongly recommended for implementation and strongly supported by
well-designed experimental, clinical, or epidemiologic studies.

Category IB recommendations are strongly recommended for implementation and supported by


experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC recommendations are required for implementation as mandated by federal or state regulation
or standard.* When the “IC” designation is used, a second rating may be included to provide the basis of
existing scientific data, theoretical rationale, and applicability.

Category II recommendations are suggested for implementation and supported by suggestive clinical or
epidemiologic studies or a theoretical rationale.

* The omission of a Category IC designation in the CDC document should not be construed as a definitive
absence of regulations. Always check with state and local authorities to ensure compliance with all laws
that apply in your area.

The 2003 CDC guidelines address educating and protecting dental healthcare personnel; preventing
transmission of bloodborne pathogens (including postexposure management); hand hygiene; personal
protective equipment; contact dermatitis and latex hypersensitivity; sterilization and disinfection of
patient-care items; environmental infection control (encompassing operatory surface management and
medical waste); dental unit waterlines, biofilm, and water quality; dental handpieces and other devices
that attach to dental unit airlines and waterlines; radiology; aseptic technique for parenteral medications;
disposable devices; oral surgical procedures; handling biopsy specimens; infection control for the dental
laboratory; tuberculosis in dentistry; and program evaluation. The document also discusses preprocedural
mouthrinses, laser/electrosurgery plumes and surgical smoke, and prion diseases such as Creutzfeldt-
Jakob disease. However, because of insufficient scientific evidence or lack of consensus regarding the
efficacy of potential interventions, CDC currently designates these topics as “unresolved issues” and
provides no recommendations. As such, these areas of the 2003 guidelines are not covered in this course.

Although this course provides an overview of current CDC recommendations for minimizing the potential
for disease transmission during the delivery of dental care, all dental healthcare personnel are encouraged
to review the complete guidelines. It includes a wealth of valuable background information and references
that promote understanding the need for a comprehensive dental infection control program. “Guidelines
for Infection Control in Dental Health-Care Settings - 2003”” is available free of charge and in its entirety
through the CDC website: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm

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Learning Objectives
Upon the completion of this course, the dental professional will be able to:
• Differentiate between OSHA standards and CDC guidelines as they relate to dental infection control.
• Outline the objectives and goals in establishing an infection control program in the dental healthcare
setting.
• Differentiate between universal precautions and standard precautions.
• List infectious diseases relevant to dentistry.
• Identify and describe methods of disease transmission.
• Discuss occupational exposures to bloodborne pathogens, including prevention, post-exposure
management, and prophylaxis.
• Summarize how to establish and manage an infection control program.
• Identify infectious hazards in the dental setting.
• Evaluate the practice setting’s infection control program.

Course Contents Glossary


• Glossary Administrative controls – The policies,
• Overview of Agency Roles in Dental Infection procedures, and enforcement measures targeted
Control at reducing the risk of occupational exposure to
• Principles of Disease Transmission infectious persons: examples include postponing
• Standard Precautions non-emergency treatment of patients suspected of
• CDC Guidelines for Infection Control in Dental having active tuberculosis.
Healthcare Settings
Personnel Health Elements of an Infection Aerosols – Particles of respirable size (<10μm)
Control Program generated by both humans and environmental
Preventing Occupational Transmission of sources that can remain viable and airborne for
Bloodborne Pathogens extended periods in the indoor environment;
Hand Hygiene commonly generated in dentistry during use of
Personal Protective Equipment handpieces, ultrasonic scalers, and air/water
Contact Dermatitis and Latex syringes.
Hypersensitivity
Sterilization and Disinfection of Patient- Aseptic – Describing the absence of
Care Items contamination, infectious materials, or agents.
Environmental Infection Control
Dental Unit Waterlines, Biofilm, and Bacteria – A group of one-celled vegetative
Water Quality microorganisms found in nature or in the bodies of
Dental Handpieces and Other Devices plants and animals.
Attached to Airlines and Waterlines
Dental Radiology Biofilm – A complex colony of microorganisms,
Aseptic Technique for Parenteral most notably bacteria, that forms on surfaces that
Medications are bathed in water.
Single-Use (Disposable) Devices
Oral Surgical Procedures Biological indicator – Device that monitors the
Handling of Biopsy Specimens sterilization process by using a standardized
The Dental Laboratory population of resistant bacterial spores; verifies
Tuberculosis and Dentistry that all the parameters necessary for sterilization
Program Evaluation were present. Also called “spore test.”
• Summary
• Course Test Bloodborne disease – An illness transmitted by
• References exposure to pathogens in the blood.
• About the Authors

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Bloodborne pathogens – Disease-producing Engineering controls – Devices that isolate
microorganisms spread by contact with blood or or remove the risk of exposure to bloodborne
other body fluids contaminated with blood from pathogens in a workplace; examples include
an infected person; examples include hepatitis B sharps containers, needle recapping devices, and
virus, hepatitis C virus, and HIV. self-sheathing needles.

Carrier – An individual, immune or recovered Environmental surface – Surfaces within


from a disease, who harbors and can transmit the a dental or medical treatment area that are
infectious agent. not directly involved in patient care, such as
countertops, drawer handles, floors and walls,
Chemical indicator – Device that monitors and instrument control panels, which may or may
the sterilization process by changes in color or not become contaminated during the course of
form with exposure to one or more sterilizing treatment. Also see Clinical contact surfaces and
conditions (e.g., temperature, steam); intended Housekeeping surfaces.
to detect potential sterilization failures due to
incorrect packaging, incorrect sterilizer loading, or Event-related instrument storage – A storage
equipment malfunction. practice that recognizes that a package and its
contents should remain sterile until some event
Clinical contact surface – Environmental causes the item(s) to become contaminated.
surfaces that come into direct contact with hands
or instruments during patient care; examples Fluid infusion system – System for delivering
include light handles, countertops, and device intravenous fluids to patients; includes IV bags,
control switches. flowmeter, tubing, and an intravenous catheter.

Contamination – The presence of microorganisms Flushing – The act of running water through
(usually those capable of causing disease or waterlines and/or the devices attached to them.
infection) on living or nonliving surfaces.
Fungi – Group of microorganisms that includes
Critical – The category of medical devices or yeasts, molds, and mildews and is a source of
instruments that cut or otherwise penetrate opportunistic infections for immunocompromised
bone or soft tissues, providing access to the individuals.
bloodstream or normally sterile tissue; examples
include anesthetic needles, surgical burs, and Hand hygiene – General term that describes the
scalpel blades. removal of debris and organic matter from the
hands by washing and/or the use of an antiseptic
Date-related instrument storage – A storage agent.
practice that distributes sterile instrument packs to
chairside on a “first in, first out” basis. HBV – See Hepatitis B virus.

Direct contact – Physical transfer of Heat sterilization – Temperature-driven process


microorganisms between an infected or colonized that destroys all microbial life, including bacterial
person and a susceptible host. endospores.

Disinfection – Destruction of most pathogenic and Hepatitis – An inflammation of the liver caused by
other kinds of microorganisms (but not spores) by viruses, bacteria, parasites, or toxic reactions to
physical or chemical means. drugs, alcohol, or chemicals; primary symptoms
include jaundice and liver enlargement.
Droplet nuclei – Microscopic particles (5 microns
or less in diameter) formed by the dehydration Hepatitis B virus – A highly transmissible
of airborne droplets containing microorganisms. bloodborne viral agent that may cause
These particles can remain suspended in the air inflammation of and damage to the liver.
for long periods of time. Abbreviated “HBV.”

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Hepatitis C virus – Virus that can cause very resistant microorganisms such as mycobacterium
serious liver disease (acute and chronic); or bacterial spores.
formerly known as “non-A, non-B hepatitis.
Abbreviated “HCV.” Mode of transmission – The means by which
pathogens are transferred from a source to a new
High-level disinfection – The process that host.
inactivates vegetative bacteria, mycobacterium,
fungi, and viruses but not necessarily high OPIM – See Other potentially infectious materials.
numbers of bacterial spores.
Other potentially infectious materials – An
HIV – The human immunodeficiency virus, the Occupational Safety and Health Administration
virus that can cause AIDS. term that refers to body fluids or tissues that
(a) may contain bloodborne pathogens (in
Hospital disinfectant – A germicide registered dentistry, this includes saliva) or (b) are visibly
by the U.S. Environmental Protection Agency contaminated with blood. Abbreviated “OPIM.”
that inactivates the test microbes Salmonella
cholerae-suis, Staphylococcus aureus, and Parenteral – Taken into the body or administered
Pseudomonas aeruginosa a for use on inanimate in a manner other than through the digestive tract,
objects in dental and medical facilities. as by intravenous or intramuscular injection.

Housekeeping surface – Environmental surface Pathogenic – Capable of causing disease in a


that is not involved in the direct delivery of dental host.
care but requires regular cleaning to remove soil
and dust; examples include floors, sinks, and Patient-care item(s) – Instruments and supplies
walls. used to provide dental examinations, prophylaxis,
or treatment; examples include handpieces,
Immunization – The process (for example, cotton rolls, sutures, and air-water syringes.
through vaccination or natural exposure) by
which a person becomes protected against a Percutaneous injury – An injury that penetrates
disease. the skin, such as a needlestick or a cut with a
sharp object.
Indirect contact – Contact between a
susceptible host and a contaminated object that Personal protective equipment – Required
is not the original source of the contamination; clothing or devices worn by workers for protection
examples of contaminated objects that can against hazards; in dentistry: masks, gloves,
contribute to indirect contact include instruments, protective apparel, and protective eyewear.
equipment, surfaces, or a healthcare worker’s Abbreviated “PPE.”
hands when contaminated with patient materials.
PPE – See Personal protective equipment.
t
Intermediate-level disinfection – Process
that inactivates vegetative bacteria, most Qualified healthcare professional – A physician
fungi, mycobacterium, and most viruses but is or other healthcare professional who has the
ineffective against bacterial spores. necessary and current training, expertise, and
credentials to provide occupational health and
Intermediate-level disinfectant – A liquid post-exposure management care to dental team
chemical agent registered by the Environmental members.
Protection Agency as a hospital disinfectant that
also has tuberculocidal activity. Standard precautions - Practices and
procedures that integrate and expand the
Low-level disinfection – Process that elements of universal precautions into a standard
inactivates most vegetative bacteria, some fungi, of care intended to protect healthcare workers
and some viruses but does not reliably inactivate and patients from pathogens that can be spread

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by blood or any other body fluids (except sweat), control guidelines seek to protect both healthcare
regardless of whether they contain blood; applies providers and the patients they treat. Although
to contact with blood, all body fluids, all body CDC has no regulatory authority, its infection
secretions and excretions, non-intact skin, and control recommendations are considered a
mucous membranes. standard of care and have been adopted by some
state dental boards.
Sterilant – A liquid chemical germicide capable
of destroying all forms of microbiological life, While CDC is concerned with public health (that
including high numbers of resistant bacterial is, the health of patients, healthcare providers,
spores. and the population at large), OSHA’s purview is
limited to worker safety.
Sterilization – A physical or chemical process
that destroys all microorganisms, including Under the Occupational Safety and Health Act
spores. of 1970, OSHA’s role is to protect the safety
and health of America’s workers by establishing
Universal precautions – Series of practices and and enforcing legal standards that encourage
procedures designed to reduce the risk of disease occupational safety and health. All employers
transmission by assuming that all blood and other and their employees within the 50 states, the
potentially infectious materials, regardless of their District of Columbia, Puerto Rico, and other U.S.
source, are indeed contaminated with bloodborne territories must comply with OSHA regulations
pathogens. (under federal OSHA or under their OSHA-
approved state job safety and health plan).
Vaccination – Inoculation with a vaccine with the Failure to comply can result in monetary penalties
intent of producing immunity. or even jail time.

Vaccine – A product administered through needle Published in 1991 and updated in 2001, the
injections, by mouth, or by aerosol that produces OSHA Bloodborne Pathogens Standard requires
immunity, therefore protecting the body against employers to adopt practices and procedures that
the disease. it deems reasonably necessary and appropriate
to protect workers against occupational exposure
Viruses – Submicroscopic organisms that infect to blood or other potentially infectious materials.
cells, possibly causing disease. The agency’s enforcement procedures for this
standard are outlined in a directive published in
Work practice controls – Procedures that November 2001.1
reduce the likelihood of exposure to infectious
materials by altering the manner in which a task Although the U.S. Food and Drug Administration
is performed; for examples, recapping a needle (FDA) and the U.S. Environmental Protection
using the one-handed scoop technique is safer (EPA) agency do not establish guidelines for
than using two hands. dental workers per se, these agencies regulate
many of the products and procedures used to
Overview of Agency Roles in Dental promote health and safety.
Infection Control
A number of federal agencies play important The FDA’s Center for Devices and Radiological
roles in dental infection control, either directly or Health (CDRH) is charged with regulating
indirectly. medical devices — that is, those products used
by healthcare professionals in the delivery of
One of 13 branches of the U.S. Department of medical or dental care. Infection control products
Health and Human Services, the CDC is the such as gloves, face masks, safety syringes,
premier nation’s public health agency. As part of sharps containers, sterilizers, waterline cleaners
its mission to prevent and control infectious and and other contamination-control devices, and
chronic diseases, injuries, workplace hazards, automated instrument cleaners are all classified
and environmental health threats, CDC’s infection as medical devices. FDA’s CDRH also must

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approve for market any chemical sterilant/high- streptococci,i or Legionellaa species.
level disinfectant made commercially available • The pathogen must have a reservoir where
in the United States. FDA’s Center for Drug it can reside and multiply. The bloodstream,
Evaluation and Research assesses and approves mucous membranes, a laboratory culture, and
vaccines as well as the drugs used in post a dental unit waterline are all examples of
exposure prophylaxis. potential reservoirs for microorganisms.
• The pathogen must have a mode of
The EPA registers commercially available transmission from a source host. A
intermediate- and low-level disinfectants used on needlestick, a splash to the mucous
environmental surfaces as well as the chemical membranes of the eyes, nose, or mouth,
disinfectants for managing contamination in or inhalation of contaminated aerosols are
dental unit waterlines. Furthermore, EPA examples of various modes of transmission.
issues guidelines and regulations for proper • The pathogen must have a proper portal
management of solid and hazardous wastes of entry into a new host. For example, for
under the Resource Conservation and Recovery a bloodborne pathogen to cause infection in
Act (RCRA). It assigns “cradle to grave” a new host, it must have a way to enter the
responsibility to generators of hazardous waste, bloodstream, such as through a break in the
including dental offices. skin.
• The new host must be susceptible to the
Principles of Disease Transmission pathogen. If the individual is vaccinated
The nature of many dental procedures can place against or has had prior exposure to the
dental team members and patients in close pathogen that resulted in immunity, exposure
contact with potential pathogens, especially those will not result in disease.
found in blood. Diseases can be transmitted from
the patient to the dental worker, from the dental Infection control involves breaking one or more
worker to the patient, or from one patient to links in the chain.
another. In the dental setting, possible modes of
transmission include: Standard Precautions
The concept of universal precautions has been
• direct contact with blood, oral fluids, or other a cornerstone of dental infection control since
patient materials; the mid-1980s. Encompassing a set of infection
• indirect contact with contaminated control and safety procedures intended to
objects (such as instruments, equipment, protect against bloodborne disease transmission,
environmental surfaces, or a team member’s universal precautions included handwashing, the
contaminated hands); use of Personal Protective Equipment (gloves,
• droplet contact, in which spray or spatter eyewear, face protection, protective apparel),
containing microorganisms travels a short controls to prevent injuries, and proper handling
distance before settling on the mucous of patient-care items and contaminated surfaces.
membranes of the eyes, nose, or mouth; and As the word “universal” suggests, the precautions
• inhalation of evaporated microorganisms were applied when treating all patients, regardless
(“droplet nuclei”) that can remain airborne for of their health history or presumed risk of
extended periods of time as aerosols. bloodborne disease.

For a disease to be transmitted, a number of In the 1996, CDC changed its focus from
conditions must be met, referred to as the “chain universal precautions to “standard precautions.”
of infection”. Intended to further reduce the risk of healthcare-
associated infections, standard precautions
• A pathogen must be present in sufficient expands the idea of which fluids are considered
numbers to cause infection. The disease- infectious. While universal precautions mainly
causing agent may be a virus (such as the prevent exposure to blood, standard precautions
ones that cause hepatitis B, hepatitis C, guard against exposure to all body fluids,
or herpes) or bacteria like staphylococci,
i secretions, and excretions, regardless of whether

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
they contain blood. (The exception is sweat, Where engineering controls are not available or
which is not infectious.) appropriate, work-practice controls and use of
personal protective equipment (PPE) become
As explained in From Policy to Practice: OSAP’s even more important in preventing exposure to
Guide to the Guidelines,2 “For in-patient settings blood and body fluids. Always perform tasks in
like hospitals, standard precautions expanded the the safest way possible. Passing instruments
set of infection control procedures required for with sharp ends pointed away from all bodies and
safe patient care. In routine dentistry, however, using a one-handed “scoop” technique to recap
there is little practical difference between needles between injections are examples of
universal precautions and standard precautions. work practice controls. Furthermore, dental team
All the precautions traditionally used to protect members should always use task-appropriate
against blood and blood-contaminated saliva gloves, face protection, eye protection, and
also protect against exposure to any other fluids protective apparel to provide a physical barrier
that would typically be encountered in the dental between themselves and the patient.
setting.”
Dental practices should develop a written
For patients who present diseases that are infection-control program to prevent or reduce
transmitted through airborne, droplet, or contact the risk of disease transmission. The program
transmission, standard precautions should be should outline the policies, procedures, practices,
coupled with expanded or transmission-based technologies, and products used to prevent
precautions. To protect against diseases such as occupational injuries and illnesses among dental
tuberculosis, influenza, or chickenpox, necessary team members as well as healthcare-associated
transmission-based precautions might include infections among patients.
patient placement (isolation), adequate room
ventilation, enhanced respiratory protection (N-95 Personnel Health Elements of an
respirators) for team members, or postponement Infection Control Program
of non-emergency dental procedures. Although As part of a dental facility’s comprehensive
patients who are acutely ill with these diseases infection control program, CDC encourages all
typically do not seek routine outpatient dental practice settings to incorporate a plan for team-
care, dental team members should have a member health in the work setting. Such a plan
general understanding of precautions for diseases should educate staff on the principles of infection
transmitted by all routes. Hospital-based dental control, identify work-related infection risks,
team members may be called upon to treat such institute preventive measures, and ensure prompt
patients; patients infected with these diseases exposure management and medical follow-up.
also may show up at outpatient dental facilities for
emergency dental care. The practice setting should establish a
working relationship with a qualified healthcare
CDC Guidelines for Infection Control in professional/facility to provide dental team
Dental Healthcare Settings members with appropriate occupational health
In addition to vaccination, CDC considers services like vaccinations (hepatitis B, influenza,
engineering controls to be the healthcare measles, mumps, rubella, tetanus, and varicella-
professional’s primary means of preventing or zoster) and postexposure evaluation and
reducing exposure to blood and body fluids. management. To ensure timely management
Engineering controls rely on the device’s of injuries and exposures, such an arrangement
technology (rather than the user’s technique) to should be set up before team members are
reduce the potential for injuries that could result placed at risk for exposure. “Qualified healthcare
in disease transmission. Instrument cassettes, professionals” can be found in an occupational
which minimize handling of contaminated health program of a hospital, in educational
instruments during processing, are an example institutions, or with healthcare facilities that
of an engineering control. Automated instrument offer personnel health services. Check with the
cleaners are another. State Department of Health for required and
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CDC’s administrative recommendations for Exposure Prevention
personnel health elements of an infection control CDC recommends the following general
program are listed in Table 1. precautions for preventing exposures to
bloodborne pathogens:
Preventing Occupational Transmission
of Bloodborne Pathogens • Use standard/universal precautions for all
Dental team members work in close contact with patient encounters (IA, IC).
blood and blood-contaminated saliva, putting • Consider any sharp item (such as needles,
them at risk of exposure to bloodborne pathogens scalers, burs, lab knives, and wires) that is
such as hepatitis B virus (HBV), hepatitis C virus contaminated with patient blood and saliva
(HCV), and the human immunodeficiency virus to be potentially infective, and establish
(HIV). engineering controls and work practices to
prevent injuries (IB, IC).
Vaccination
Vaccination can protect against the hepatitis In addition, CDC strongly supports the use of
B virus, but only if it results in seroconversion several specific engineering and work-practice
(development of antibodies). As such, CDC controls. Practice settings should:
recommendations encourage dental settings to:
• Identify, evaluate, and select devices with
• Offer the HBV vaccination series to all engineered safety features at least annually
dental healthcare personnel with potential and as they become available on the market.
occupational exposure to blood or other Such devices include safer anesthetic
potentially infectious material (IA, IC). syringes, blunt suture needles, retractable
• Always follow U.S. Public Health Service/CDC scalpels, and needleless IV systems) (IC).
recommendations for hepatitis B vaccination, • Place used disposable syringes and needles,
serologic testing, follow-up, and booster scalpel blades, and other sharp items in
dosing (IA, IC). appropriate puncture-resistant containers.
• Test dental healthcare personnel for antibodies Sharps containers should be located as close
one to two months after completion of the to the sharps- point of use as possible (IA, IC).
three-dose HBV vaccination series (IA, IC). If • Avoid using both hands to recap used
antibodies are present, the team member is needles. Likewise, steer clear of any other
immune. If no antibody response occurs to technique that involves directing the sharp end
the primary vaccine series: of a needle toward any part of the body. Do
The team member should complete a not bend, break, or remove needles before
second three-dose vaccine series, or be disposal (IA, IC).
evaluated to determine if he/she is a carrier • Use either a one-handed scoop technique or
(IA, IC). a mechanical device designed for holding the
At the completion of the second vaccine needle cap when recapping needles between
series, retest for antibodies. If no response multiple injections or before removing from a
to the second three-dose series occurs, nondisposable aspirating syringe (IA, IC).
the non-responder should be tested to
determine if he/she is a carrier (IC). Postexposure management and prophylaxis
Counsel non-responders who are not Although infection control precautions are highly
carriers about their susceptibility to HBV effective when used routinely, accidents can
infection and precautions they need to take happen. When sharps injuries or unexpected
(IA, IC). spills or splashes to nonintact skin or mucosa
• Provide employees appropriate education occur, tend to them immediately. Exposure
regarding the risks of HBV transmission and incidents are medical emergencies. Ensuring
the availability of the vaccine. Employees prompt evaluation and treatment gives the
who decline the vaccination should sign a occupationally exposed team member the best
declination form to be kept on file with the chance of avoiding infection.
employer (IC).

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When an exposure occurs: contaminated with blood or other potentially
infectious material. If hands are not visibly
• Follow CDC recommendations after soiled, an alcohol-based hand rub can also be
percutaneous, mucous membrane, or used. Follow the manufacturer’s instructions
nonintact skin exposure to blood or other (IA).
potentially infectious material (IA, IC).
First perform basic first aid to cleanse the Indications for hand hygiene include:
wound or affected area. • when hands are visibly soiled (IA, IC);
Then report the injury to the employer or • after barehanded touching of inanimate objects
infection control coordinator for the practice likely to be contaminated by blood, saliva, or
setting. Providing as much information respiratory secretions (IA, IC);
as possible about the incident will help • before and after treating each patient (IB);
the physician or other qualified healthcare • before donning gloves (IB); and
professional evaluate and manage the • immediately after removing gloves (IB, IC).
exposure.
Follow instructions for obtaining IMMEDIATE To reduce the risk of postoperative infections, oral
and APPROPRIATE medical care from the surgical procedures require more stringent hand-
healthcare professional who handles the hygiene measures that incorporate the use of an
facility’s occupational health program. antimicrobial agent.

Hand Hygiene • For oral surgical procedures, perform surgical


Proper handwashing, hand antisepsis, or hand antisepsis before donning sterile
surgical hand antisepsis are simple acts that surgeon’s gloves. Follow the manufacturer’s
help reduce the risk of disease transmission. instructions by using either a) an antimicrobial
Transient microorganisms can come to rest on soap and water handwash, or b) a soap and
the hands following direct contact with patients water handwash followed by drying of the hands
or contaminated environmental surfaces. These and application of an alcohol-based surgical
microorganisms, which colonize the top layers hand-scrub product with persistent activity (IB).
of the skin, are most frequently associated with
healthcare-acquired infections. Fortunately To prevent contamination of hand-hygiene
they generally can be removed with routine products:
handwashing.
• Store liquid hand-care products in either
Lapses in hand hygiene among hospital workers disposable closed containers or closed
have resulted in major disease outbreaks, containers that can be washed and dried before
numerous healthcare-associated infections, and refilling. Do not add soap or lotion to (i.e., top
the spread of antibiotic-resistant infections. off) a partially empty dispenser (IA).

Recently, alcohol-based hand rubs have been Frequent handwashing can compromise the skin’s
gaining popularity in hospital settings. These integrity. Because breaks in the skin can provide a
agents provide persistent antimicrobial activity portal of entry for bloodborne pathogens:
on the skin and can be very useful in certain
circumstances (for example, during boil-water • Use hand lotions to prevent skin dryness
advisories, when providing humanitarian aid associated with handwashing (IA).
in remote areas without a clean water supply).
These agents are not recommended for routine Some emollients and antiseptics can degrade
hand hygiene as these agents are not effective glove material. As such, CDC encourages dental
cleaners. As such, CDC recommends: team members to consider the compatibility of
lotion and antiseptic products as well as the effect
• Perform hand hygiene with either a of petroleum or other oil emollients on the integrity
nonantimicrobial or antimicrobial soap of gloves during product selection and glove use
and water when hands are visibly dirty or (IB).

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Other recommendations for hand hygiene generate spatter, ensure that forearms are
include: covered.
• Change protective clothing if visibly soiled.
• Keep fingernails short with smooth, filed edges Change the garment immediately (or as soon
to allow thorough cleaning and prevent glove as feasible) if is penetrated by blood or other
tears (II). potentially infectious fluids (IB, IC).
• Do not wear artificial fingernails or extenders
when having direct contact with patients Gloves
at high risk (e.g., those in intensive care Patient-care and utility gloves are offered in a
units or operating rooms) (IA). In fact, the variety of sizes, colors, and materials.
use of artificial fingernails is usually not
recommended (II). • Wear medical gloves when a potential exists
• Avoid wearing hand or nail jewelry if it for contacting blood, saliva, other potentially
makes donning gloves more difficult or if it infectious materials, or mucous membranes (IB,
compromises the fit and integrity of the glove IC).
(II). • Wear a new pair of medical gloves for each
patient, remove them promptly after use, and
Personal Protective Equipment wash hands immediately to avoid transfer
As part of standard precautions, dental team of microorganisms to other patients or
members who are at risk of exposure to environments (IB).
potentially infectious materials must wear task- • Wear sterile surgeon’s gloves when performing
appropriate personal protective equipment. oral surgical procedures (IB).
Choose PPE that fits well and is as comfortable • Remove gloves that are torn, cut, or punctured
as possible. as soon as feasible. Wash hands before
regloving (IB, IC).
Masks, Protective Eyewear, and Face Shields • Never wash surgeon’s or patient examination
To protect the mucous membranes of the eyes, gloves before use. Never wash, disinfect, or
nose, and mouth: sterilize gloves for reuse (IB, IC).
• Ensure that appropriate gloves in the correct
• Wear a surgical mask and eye protection with sizes are readily accessible (IC).
solid side shields or a face shield to protect • Use appropriate puncture, and chemical,
mucous membranes of the eyes, nose, and resistant utility gloves when cleaning
mouth during procedures likely to generate instruments and performing housekeeping
splashing or spattering of blood or other body tasks that involve contact with blood or other
fluids (IB, IC). potentially infectious materials (IB, IC).
• Change masks between patients or during • Consult with glove manufacturers regarding the
patient treatment if the mask becomes wet chemical compatibility of glove material and
(IB). dental materials used (II).
• Clean reusable facial protective equipment
(protective eyewear or face shields) with soap CDC examined the issue of double-gloving for
and water between patients. If visibly soiled, oral surgical procedures. Although the majority
clean and disinfect (II). of studies show a lower frequency of inner glove
perforation and visible blood on a surgeon’s hands
Protective Clothing when double gloves are worn, the effectiveness of
Protective garments are worn over street clothes wearing two pairs of gloves in preventing disease
to protect them from contamination. transmission has not been demonstrated. As
such, the agency makes no recommendation for or
• Wear protective clothing that covers personal against the practice of double-gloving.
clothing and skin likely to be soiled with blood,
saliva, or other potentially infectious materials To limit the spread of contamination from PPE:
(IB, IC). Protective clothing can include a
reusable or disposable gown, laboratory • Remove barrier protection, including gloves,
coat, or uniform. For dental procedures that mask, eyewear, and gown before leaving

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
the work area (IC). Work areas include • Educate dental healthcare personnel
operatories, instrument processing areas, and regarding the signs, symptoms, and diagnoses
laboratories. of skin reactions associated with frequent
hand hygiene and glove use (IB).
Contact Dermatitis and Latex • Screen all patients for latex allergy. Take a
Hypersensitivity thorough health history, and when latex allergy
The benefits of gloving and handwashing are is suspected, refer the patient for medical
undeniable, but some adverse skin conditions can consultation (IB).
result from frequent and repeated handwashing, • Ensure a latex-safe environment for patients
exposure to chemicals, and glove use. and dental team members with latex allergy
(IB).
A very common condition among dental workers, • Have emergency treatment kits with latex-free
irritant contact dermatitis is caused by the products available at all times (II).
physical irritation of the skin. It presents as dry,
itchy, irritated skin around the area of contact with Sterilization and Disinfection of Patient-
the offending agent. Irritant contact dermatitis is Care Items
not an allergic reaction. The CDC categorizes patient-care items based
on the degree of contact they have with patients.
Allergic contact dermatitis (also called type Their degree of contact with the patient suggests
IV hypersensitivity) results from exposure to their risk of disease transmission. In turn, their
methacrylates, glutaraldehyde, and chemicals risk of disease transmission indicates how they
used in rubber manufacturing. It often appears should be processed for reuse.
as a rash beginning several hours after contact.
It usually is confined to the area of contact but Critical items cut bone or penetrate soft tissue.
can extend slightly beyond. These instruments carry the highest risk of
disease transmission.
True latex hypersensitivity is a potentially life-
threatening allergy to the proteins contained in • Clean and heat-sterilize critical dental
natural rubber latex, a common glove material. instruments before each use (IA).
Also referred to as a type I immediate allergy, this
more serious, systemic allergy typically presents Semi-critical items touch only mucous
within minutes of exposure but also can occur membranes. They have a lower risk of
hours later. More common reactions include transmission than critical items.
runny nose, sneezing, itchy eyes, scratchy
throat, hives, and itchy, burning skin sensations. • Clean and heat-sterilize semi-critical items
More severe symptoms include asthma (marked before each use (IB).
by difficult breathing, coughing spells, and • Use heat-stable semi-critical items instead
wheezing), cardiovascular and gastrointestinal of those that are heat-sensitive whenever
symptoms, and in rare cases, anaphylaxis. In possible (IB).
especially severe reactions that are not medically • For heat-sensitive critical and semi-critical
managed, a type I allergy can result in death. instruments, reprocess using FDA-cleared
sterilant/high-level disinfectants or an
Any condition that causes cracks or breaks in the FDA-cleared low-temperature sterilization
skin increases a dental worker’s risk of exposure method (such as ethylene oxide). Follow the
to blood and other body fluids. Furthermore, an manufacturer’s instructions for use of chemical
unrecognized, untreated type I allergic reaction sterilants/high-level disinfectants (IB).
to latex in a patient or dental team member • Single-use disposable instruments are
can result in serious morbidity or mortality. For acceptable alternatives if they are used only
these reasons, CDC includes the following once and disposed of correctly (IB, IC).
recommendations in its 2003 guidelines.

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
Noncritical items only contact intact skin. As Receiving, Cleaning, and Decontamination
such, they have the lowest risk of disease Work Area (The Dirty Side)
transmission.
When collecting, transporting, and cleaning
• Ensure that noncritical patient-care items contaminated instruments:
are barrier-protected or cleaned (or if visibly
soiled, cleaned and disinfected) after each use • Minimize handling of loose contaminated
with an EPA-registered hospital disinfectant. instruments during transport to the instrument
If visibly contaminated with blood, use an processing area. Use work-practice controls
EPA-registered hospital disinfectant with a to minimize exposure potential (for example,
tuberculocidal claim (i.e., an intermediate-level carry instruments in a covered container) (II).
disinfectant) (IB). Clean all visible blood and other contamination
from dental instruments and devices before
With regard to heat sterilization: sterilizing or disinfecting them (IA).
• Use automated cleaning equipment such as
• Use only FDA-cleared medical devices for an ultrasonic cleaner or instrument washer-
sterilization and follow the manufacturer’s disinfector to remove debris, improve cleaning
instructions for correct use (IB). effectiveness, and decrease the potential for
• Allow packages to dry in the sterilizer before team member exposure to blood (IB).
they are handled to avoid contamination (IB). • If manual cleaning is necessary, use work-
practice controls that minimize contact with
Caution also is required when using chemical sharp instruments (for example, use a long-
sterilants. handled brush held away from the bristles)
(IC).
• Do not use liquid chemical sterilants/high- • Wear puncture, and chemical, resistant/heavy-
level disinfectants for environmental surface duty utility gloves for instrument cleaning and
disinfection or as holding solutions (IB, IC). decontamination procedures (IB).
• Inform dental healthcare personnel of all • Wear appropriate personal protective
OSHA guidelines for exposure to chemical equipment when splashing or spraying is
agents used for disinfection and sterilization.4 anticipated during cleaning. Appropriate
• Identify areas and tasks that have potential for equipment would include a mask, protective
exposure (IC). eyewear, and gown. (IC).

The Instrument Processing Area Preparation and Packaging


To limit the spread of contamination, CDC Although the instruments have been cleaned
recommends using a separate instrument to remove debris, they are not sterile. Wear
processing area and further dividing the space puncture-resistant utility gloves when inspecting
into designated “dirty” and “clean” areas. and packaging instruments.

• Designate a central instrument processing • Use an internal chemical indicator in each


area. Divide the instrument processing area, package. If the internal indicator cannot be
physically or, at a minimum, spatially, into seen from outside the package, also use an
distinct areas for: external indicator (II).
receiving, cleaning, and decontamination; • Use a container system or wrapping material
preparation and packaging; that is compatible with the specific type of
sterilization; and sterilization process (that is, steam autoclave,
storage. chemical vapor, dry heat, or ethylene oxide).
• Train dental healthcare personnel to employ Be sure that the packaging has received FDA
work practices that prevent contamination of clearance (IB).
clean areas (II). • Before sterilization of critical and semicritical
• Do not store sterilize instruments in an area items, inspect the instruments for cleanliness,
where contaminated instruments are held or then wrap or place them in containers that will
cleaned (II).

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
allow them to remain sterile during storage. involves the use of mechanical techniques,
Cassettes and organizing trays are appropriate chemical indicators, and biological indicators
for this purpose (IA). (spore tests). While biological monitoring
provides the best assurance that sterilization
Sterilization of Unwrapped Instruments equipment and procedures are working as they
Because they cannot sterilize wrapped should, mechanical or chemical monitoring
instruments, CDC discourages the use of may provide the first indications of a sterilizer
“flash” cycles for routine instrument processing. malfunction.
(Unless instruments are packaged prior to heat
sterilization, they cannot maintain their sterility • Use mechanical, chemical, and biological
after the cycle.) monitors according to the manufacturer’s
instructions to ensure the effectiveness of the
• Do not sterilize implantable devices sterilization process (IB).
unwrapped (IB). • Monitor each load with mechanical (time,
• Do not store critical instruments unwrapped temperature, pressure) and chemical
(IB). indicators (II).
• Place a chemical indicator on the inside of
However, flash cycles may be warranted when each package. If the internal indicator is not
there is an urgent need for an instrument that will visible from the outside, also place an exterior
be used immediately after the cycle (for example, chemical indicator on the package (II).
the instrument is dropped during treatment and • Place items/packages correctly and loosely
no replacement is available). As such, CDC into the sterilizer so as not to impede
suggests the following steps to assuring sterility. penetration of the sterilant (IB).
• Do not use instrument packs if mechanical
• Clean and dry instruments before using a or chemical indicators indicate inadequate
sterilization cycle designated for “unwrapped” processing (IB).
instruments (IB). • Monitor sterilizers at least weekly by using a
• Use mechanical and chemical indicators for biological indicator with a matching control
each unwrapped sterilization cycle. Place (i.e., biological indicator and control from same
an internal chemical indicator among the lot number) (IB).
instruments or items to be sterilized (IB), and • Use a biological indicator for every sterilizer
monitor cycle time and temperature during the load that contains an implantable device.
sterilization sequence. Verify results before using the implantable
• Allow unwrapped instruments to dry and cool device, whenever possible (IB).
in the sterilizer before they are handled to • Maintain sterilization records (mechanical,
avoid contamination and thermal injury (II). chemical, and biological) in compliance with
• Semi-critical instruments that will be used state and local regulations (IB).
immediately or within a short time can
be sterilized unwrapped on a tray or in In the case of a positive spore test, CDC
a container system, provided that the recommends:
instruments are handled aseptically during
removal from the sterilizer and transport to the 1. Remove the sterilizer from service and review
point of use (II). sterilization procedures (for example, work
• Critical instruments intended for immediate practices and use of mechanical and chemical
reuse can be sterilized unwrapped if the indicators) to determine whether operator error
instruments are maintained sterile during could be responsible (II).
removal from the sterilizer and transport to 2. Retest the sterilizer by using biological,
the point of use (for example, transported in a mechanical, and chemical indicators after
sterile covered container) (IB). correcting any identified procedural problems
(II).
Sterilization Monitoring If the repeat spore test is negative and
Proper monitoring of sterilization processes mechanical and chemical indicators are

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
within normal limits, put the sterilizer back in they can be managed using methods that are
service (II). less rigorous than those used for patient-care
If the repeat spore test is positive, do not items.
use the sterilizer until it has been inspected
or repaired, or until the exact reason for the Environmental surfaces are further categorized as
positive test has been determined. Recall, either clinical contact surfaces or housekeeping
to the extent possible, and reprocess surfaces. Clinical contact surfaces are
all items that had been run through the those surfaces that are directly contacted by
sterilizer since the last negative spore test. contaminated instruments, devices, hands, or
Before placing the sterilizer back in service, gloves. Housekeeping surfaces are not directly
rechallenge the sterilizer with biological touched during the delivery of dental care.
indicator tests in three consecutive empty
chamber sterilization cycles after the cause To manage operatory surfaces, barrier-protection
of the sterilizer failure has been determined or intermediate - or low-level disinfection is used.
and corrected (II).
Low-level disinfectants (designated by
Storage Area for Sterilized Items and Clean EPA as “hospital disinfectants”) kill the test
Dental Supplies (The Clean Side) microorganisms Salmonella cholerae-suis,
Store sterile instrument packs to maintain sterility Staphylococcus aureus, and Pseudomonas
until they are needed. aeruginosa. For clinical contact surfaces, efficacy
against hepatitis B virus (HBV) and HIV also
• Use either date- or event-related shelf-life for is desirable. These disinfectants are used for
storage of wrapped, sterilized instruments, and cleaning and disinfecting clinical contact surfaces
devices (IB). that are not visibly soiled with body fluids.
• At a minimum, place the date of sterilization
and identify the sterilizer used (if multiple Intermediate-level disinfectants kill the same
sterilizers are used in the facility) on the test microorganisms as low-level (hospital)
outside of the packaging material. This disinfectants but they also are tuberculocidal (that
facilitates the retrieval of processed items in is, they inactivate Mycobacterium tuberculosis).
the event of a sterilization failure (IB). These agents are used for cleaning and
• Store sterile items and dental supplies in disinfecting clinical contact surfaces with or
covered or closed cabinets, if possible (II). without visible blood or body fluids.
• Examine wrapped packages of sterilized
instruments before opening them at chairside CDC offers these general guidelines for managing
to ensure the barrier wrap has not been environmental surfaces:
compromised during storage (II).
• If packaging material has been compromised • Follow the manufacturers- instructions for
(that is, if it is torn, punctured, wet, or correct use of cleaning and EPA-registered
open), reclean, repack, and resterilize any hospital disinfecting products (IB, IC).
instruments that were inside (II). • Never use liquid chemical sterilants/high-level
disinfectants for disinfection of environmental
Environmental Infection Control surfaces (IB, IC). (Some of these agents
Environmental infection control encompasses two present a respiratory hazard and should not
main themes: managing contaminated surfaces be used outside of a closed container.)
and proper handling and disposal of medical • Wear appropriate personal protective
waste. equipment when cleaning and disinfecting
environmental surfaces. Such equipment
Surface Management may include puncture - and chemical-resistant
Environmental surfaces in the dental operatory - utility gloves; a protective gown, jacket, or lab
surfaces of equipment, furniture, walls, and coat; and protective eyewear or face shield
flooring - are all considered noncritical. Because worn with a mask (IC).
they carry the lowest risk of disease transmission,

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
For maintaining clinical contact surfaces: surfaces also are more difficult to clean than
nonporous surfaces. As such, CDC recommends
• Use surface barriers to protect clinical contact that dental facilities:
surfaces and change surface barriers between
patients (II). Barrier protection is preferred for • Avoid using carpeting and cloth-upholstered
surfaces that are difficult to clean (for example, furnishings in dental operatories, laboratories,
switches on dental chairs). and instrument processing areas (II).
• After each patient, clean and disinfect clinical
contact surfaces that are not barrier-protected. Regulated Medical Waste
Use an EPA-registered hospital disinfectant Although any item that has been in contact with
with low - to intermediate-level activity. Use blood or body fluids may be infective, not all such
an intermediate-level disinfectant if visibly waste requires special disposal. Federal, state,
contaminated with blood (IB). and local guidelines and regulations identify the
specific categories of medical waste that are
Click here
e to view the OSAP Surface Disinfectant subject to regulation - that is, which categories
Reference Chart - 2009 of waste require special disposal by law. They
also outline any requirements associated with
For periodic maintenance of housekeeping treatment and disposal.
surfaces:
Examples of regulated waste found in a dental
• Clean floors, walls, sinks, and other office include solid waste that is soaked or
housekeeping surfaces with a detergent saturated with blood or body fluids (for example,
and water (or an EPA-registered hospital gauze saturated with blood following surgery),
disinfectant/detergent) on a routine basis. extracted teeth as well as surgically removed
Consider the nature of the surface, the type hard and soft tissues, and contaminated sharp
and degree of contamination it receives, and items such as needles, scalpel blades, and
its location in the facility. Decontaminate when orthodontic wires.
visibly soiled (IB).
• Clean mops and cloths after use and allow Consult waste management regulations, and:
them to dry before reuse. Alternatively, use
single-use, disposable mop heads or cloths • Develop a medical waste management
(II). program (IC).
• Prepare fresh cleaning or EPA-registered • Ensure that dental team members who handle
disinfecting solutions daily and as instructed and dispose of regulated medical waste are
by the manufacturer (II). trained in appropriate handling and disposal
• Clean walls, blinds, and window curtains in methods. Make sure they understand the
patient-care areas when they are visibly dusty possible health and safety hazards (IC).
or soiled (II).
From Policy to Practice: OSAP’s Guide to the
For managing spills of blood and body Guideliness2 describes management of regulated
substances: medical waste in the dental facility as a matter of
“divide and conquer.”
• Clean spills of blood or other potentially
infectious materials and decontaminate the • Use a color-coded or labeled container that
surface with an EPA-registered hospital prevents leakage (e.g., a biohazard bag)
disinfectant with low - (i.e., HBV and HIV to collect and contain nonsharp regulated
label claims) to intermediate-level (i.e., medical waste (IC).
tuberculocidal claim) activity, depending on the • Place sharp items such as needles, scalpel
size of spill and surface porosity (IB, IC). blades, orthodontic bands, broken metal
instruments, and burs in a puncture resistant,
Carpet and cloth furnishings provide an ideal color-coded, leak proof sharps container.
breeding ground for microorganisms. These Close the container immediately before

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
removal or replacement to prevent spills Dental unit water that remains untreated or
and to keep contents from protruding during unfiltered is likely to contain high numbers of
handling, storage, transport, or shipping (IC). microorganisms. As such, CDC recommends
• In areas served by a sanitary sewer system, that dental practice settings take steps to improve
pour blood, suctioned fluids, and other liquid dental unit water quality. Used and maintained
waste carefully into the drain (provided local according to the manufacturer’s instructions,
sewage discharge requirements are met and available technologies (such as self-contained
the state considers this an acceptable disposal water systems, chemical treatments, and filters)
method). Be sure to wear appropriate PPE to can greatly improve the quality of treatment water.
protect against exposures (IC).
• Use water that meets EPA regulatory standards
Dental Unit Waterlines, Biofilm, and for drinking water (i.e., <500 CFU/mL of
Water Quality heterotrophic water bacteria) for routine dental
It is well established the inside surface of treatment output water (IB, IC).
dental waterlines served by municipal water
supplies becomes colonized with a variety of Dental units can vary greatly in material
microorganisms. Bacteria, fungi, and protozoa composition, and some biofilm interventions may
reside inside a polysaccharide slime layer that not be compatible with all materials in every
protects and feeds them. commercially available dental unit. As such, CDC
stresses the importance of obtaining input from the
Although biofilm can form in all environments that dental unit manufacturer for compatible waterline
are bathed in water, the narrow-bore of dental treatment methods.
tubing and the typical way dental unit water is
used in the practice setting further encourages • Consult with the dental unit manufacturer for
bacterial growth and the development of biofilm. appropriate methods and equipment to maintain
In the output water of untreated dental units, the recommended quality of dental water (II).
microbial counts can reach as high as 200,000
colony-forming units per milliliter (CFU/ml) within To ensure that efforts to improve dental unit water
five days of installing new dental unit waterlines, quality are working as expected:
and counts greater than 1,000,000 CFU/ml have
been reported. • Follow recommendations for monitoring water
quality provided by the manufacturer of the unit
Dental waterlines hold only a small volume of or waterline treatment product (II).
water, almost all of which is in contact with the • Consult with the dental unit manufacturer
interior surfaces of the tubing. This allows any on the need for periodic maintenance of
microorganisms present in the water to latch on antiretraction mechanisms (IB).
to the internal surface of the tubing, where they
multiply to create a biofilm. Once formed, the Because its effects are only transient, flushing is
biofilm serves as a reservoir that can increase not a recommended dental water-quality control
the number of microorganisms in water used for method. However, briefly flushing lines between
dental treatment. patients can help remove contaminants that may
have been retracted during treatment.
Although oral flora and human pathogens such
as Pseudomonas aeruginosa, Legionella species, • After each patient, discharge water and air for
and nontuberculous mycobacterium species at least 20 to 30 seconds from any device that
have been found in dental water systems, most is connected to the dental water system and
of the microorganisms in dental unit biofilms that enters the patient’s mouth. (Such devices
are common water bacteria that pose limited include handpieces, ultrasonic scalers, and air/
threat to persons with healthy immune systems. water syringes.) (II).
Regardless, CDC contends that exposing
patients or dental members to water “of uncertain For additional information refer to the ADA’s
microbiological quality- is inconsistent with Positions & Statements: ADA Statement on Dental
5
accepted infection-control principles.” Unit Waterlines.

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
Boil water-advisories from the airlines and waterlines of dental units
A boil-water advisory is a public health between patients (IB, IC).
announcement directing residents to boil tap • Follow the manufacturer’s instructions for
water before drinking it because the water cleaning, lubrication, and sterilization of
supply has become unsafe to drink. Advisories handpieces and other intraoral instruments
are issued when water treatment equipment or that can be removed from the airlines and
processes fails; the public supply tests positive waterlines of dental units (IB).
for pathogens or violates the Total Coliform Rule • Do not surface-disinfect, use liquid chemical
or other standards; the distribution system has sterilants, or use ethylene oxide on
been compromised (such as in the case of a water handpieces and other intraoral instruments
main break) and a health hazard is indicated; or that can be removed from the air and
a natural disaster such as a flood, hurricane, or waterlines of dental units (IC).
earthquake compromises the public supply.
Because suctioned fluids can be pulled into the
For dental offices undergoing a boil-water patient’s mouth when a seal is created around the
advisory, CDC offers the following counsel: saliva ejector:

• Do not deliver water from the public water • Do not advise patients to close their lips tightly
system to the patient through the dental unit, around the tip of the saliva ejector when
ultrasonic scaler, or any other dental equipment evacuating oral fluids (II).
that receives its water from the public water
system (IB, IC). Dental Radiology
• Do not use water from the public water The activities involved in taking and developing
system for dental treatment, patient rinsing, or x-ray films provide many opportunities for
handwashing (IB, IC). cross-contamination. All surfaces that
• For handwashing, use antimicrobial-containing contact contaminated x-ray film also become
products that do not require water (for example, contaminated. Even with digital (filmless) x-rays,
alcohol-based hand rubs). If hands are visibly clinical contact surfaces such as the keyboard,
contaminated, use bottled water, if available, mouse, sensor cords, and portable x-ray cart can
and soap for handwashing. Alternatively, use become contaminated.
an antiseptic towelette (IB, IC).
To limit the spread of contamination during dental
When the boil-water advisory is cancelled, dental radiography procedures:
practice settings should:
• Wear gloves when exposing radiographs and
• Follow guidance given by the local water utility handling contaminated film packets. Use
regarding adequate flushing of waterlines. If other PPE (e.g., protective eyewear, mask,
no guidance is provided, flush dental waterlines and gown) as appropriate if spattering of blood
and faucets for one to five minutes before or other body fluids is likely (IA, IC).
using the unit for patient care (IC). • Use heat-tolerant or disposable intraoral
• Disinfect dental waterlines as recommended by film-holding and positioning devices
the dental unit manufacturer (II). whenever possible. Clean and heat-sterilize
heat-tolerant devices between patients. t
Dental Handpieces and Other Devices a minimum, high-level disinfect semi-
Attached to Airlines and Waterlines critical heat-sensitive devices according to
Dental handpieces and other devices that manufacturer’s instructions (IB).
are used in the patient’s mouth and attach to • Transport and handle exposed radiographs in
dental airlines and waterlines are semi-critical an aseptic manner to prevent contamination of
instruments and should be processed accordingly. developing equipment (II).

• Clean and heat-sterilize handpieces and other CDC recommends the following when using
intraoral instruments that can be removed digital radiography sensors:

20
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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
• Use FDA-cleared barriers (IB) to protect the inadvertent contamination by spray or spatter
sensor against contamination. (II).
• Clean and heat-sterilize (or high-level • Discard the multi-dose vial if sterility is
disinfect) semi-critical items between patients, compromised (IA).
even if they were barrier-protected during use.
If the item cannot tolerate heat or chemical When using fluid infusion and administration sets:
immersion, at a minimum, use an FDA-cleared
barrier during intraoral use, and clean and • Use IV bags, tubing, and connections for one
disinfect with an intermediate-level disinfectant patient only and dispose of appropriately (IB).
(that is, an EPA-registered hospital disinfectant
with tuberculocidal activity) between patients. Single-Use (Disposable) Devices
Consult with the manufacturer for methods of A single-use (“disposable”) device should be
disinfection and sterilization of digital radiology used on only one patient and then discarded,
sensors and for protection of associated not cleaned, disinfected, or sterilized for use on
computer hardware (IB). another patient. Single-use devices (for example,
needles, prophylaxis cups and brushes, and
Aseptic Technique for Parenteral plastic orthodontic brackets) are usually not heat-
Medications tolerant and cannot be reliably cleaned.
Parenteral medications (supplied as single-dose
ampoules, vials, or prefilled syringes, or in multi- Some items such as prophylaxis angles, saliva
dose vials for use on more than one patient) and ejectors, high-volume evacuator tips, and air/
fluid infusion systems (such as IV bags, tubing, water syringe tips are now commonly available
and connections) must be safely handled to in disposable form; they should be appropriately
prevent healthcare-associated infections among discarded after each use. Single-use devices
patients undergoing conscious sedation. and items for use during oral surgical procedures
(for example, cotton rolls, gauze, and irrigating
To limit the potential for contamination and syringes) should be sterile at the time of use.
patient-to-patient disease transmission,
CDC recommends the following precautions • Use single-use devices for one patient only
for handling and administering parenteral and dispose of them appropriately (IC).
medications supplied in single-use packaging:
The physical construction of devices like burs,
• Never administer medication from a syringe endodontic files, and broaches can make cleaning
to multiple patients, even if the needle on the difficult. In addition, deterioration can occur on
syringe is changed (IA). the cutting surfaces of some of these instruments
• Use single-dose vials for parenteral during processing, raising the potential for
medications whenever possible (II). instrument breaks during patient treatment.
• Do not combine the leftover contents of single- Because burs and endodontic instruments also
use vials for later use (IA). exhibit signs of wear during normal use, CDC
suggests that these items might practically be
If multi-dose vials are used: considered single-use devices.

• Cleanse the access diaphragm with 70% Oral Surgical Procedures


alcohol before inserting a device into the vial For the purpose of its guideline, CDC defines
(IA). oral surgical procedures as those that involve
• Use a sterile device to access a multiple-dose “the incision, excision, or reflection of tissue
vial and avoid touching the access diaphragm. that exposes normally sterile areas of the oral
Both the needle and syringe used to access cavity.” Such procedures include periodontal
the multi-dose vial should be sterile. Never surgery, apical surgery, implant surgery, and
reuse a syringe even if the needle is changed surgical extractions of teeth in which erupted
(IA). or nonerupted teeth require elevation of the
• Keep multi-dose vials away from the mucoperiosteal flap, removal of bone or a section
immediate patient treatment area to prevent of tooth, and sometimes suturing.

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
Because the level of exposure during oral surgical apply. Because high temperatures release
procedures is so great, these procedures pose mercury vapor from dental amalgam, extracted
an increased potential for localized or systemic teeth containing this restorative material should
infection. As such, CDC recommends the use not be placed in a medical waste container that
of the following more stringent infection control uses incineration for final disposal (as sharps
precautions: containers routinely are). Consult and comply
with state and local regulations for proper disposal
• Before donning sterile surgeon’s gloves, of the amalgam.
perform surgical hand antisepsis by using an
antimicrobial product (antimicrobial soap and • Dispose of extracted teeth as regulated
water, or a soap and water wash followed by medical waste. Alternatively, they may be
an application of an alcohol-based hand scrub returned to the patient (IC).
with persistent activity) (IB). • Do not dispose of extracted teeth containing
• Wear sterile surgeon’s gloves during oral amalgam in regulated medical waste intended
surgical procedures (IB). for incineration (II).
• Use sterile saline or sterile water as a
coolant/irrigant when performing oral surgical For extracted teeth sent to an educational
procedures. Because dental unit waterlines setting or to a dental laboratory for shade or size
cannot deliver sterile water (see above section comparisons:
on “Dental Unit Waterlines, Biofilm, and
Water Quality”), use a bulb syringe, single- • Clean surface using an intermediate-level
use disposable products, sterilizable tubing disinfectant (that is, an EPA-registered hospital
devices, and/or other devices specifically disinfectant with a tuberculocidal claim),
designed for delivering sterile irrigating fluids. and place extracted teeth in a leak proof
(IB) container labeled with a biohazard symbol.
Maintain hydration for transport to educational
Handling of Biopsy Specimens institutions or the dental laboratory (IC).
To protect persons handling and transporting • Heat-sterilize teeth that do not contain
biopsy specimens, CDC recommends that dental amalgam before they are used for educational
team members: purposes (IB).

• Place biopsy specimens in a sturdy, leak proof The Dental Laboratory


container labeled with the biohazard symbol for Dental prostheses, appliances, and items used
transport (IC). in their fabrication (for example, impressions,
occlusal rims, and bite registrations) can be
If a biopsy specimen container becomes visibly sources of cross-contamination, so they should
contaminated: be handled in a manner that prevents exposure
of dental team members, patients, or the office
• Clean and disinfect the outside of a container environment to infectious agents. Effective
to remove external contamination, or place the communication and coordination between the
container in an impervious bag labeled with the laboratory and dental practice can ensure that
biohazard symbol (IC). appropriate cleaning and disinfection procedures
are performed in the dental office or laboratory,
Extracted Teeth materials are not damaged or distorted because
Extracted teeth that are being disposed of are of disinfectant overexposure, and effective
regulated waste, and they are subject to the disinfection procedures are not unnecessarily
containerization and labeling provisions outlined duplicated.
by OSHA’s Bloodborne Pathogens Standard.1
OSHA considers extracted teeth to be a potentially In the dental lab:
infectious material that should be disposed of in
medical waste containers. However, extracted • Use personal protective equipment when
teeth can be returned to patients on request, at handling items until they have been
which time provisions of the standard no longer decontaminated (IA, IC).

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
• Before they are handled in the laboratory, Recommendations for expanded precautions
clean, disinfect with an EPA-registered hospital to prevent transmission of M. tuberculosis
disinfectant with tuberculocidal activity, and and other organisms that can be spread by
rinse all impressions, bite registrations, airborne, droplet, or contact routes have been
occlusal rims, extracted teeth, and other dental detailed in other CDC and Hospital Infection
prostheses and prosthodontic materials (IB). Control Practices Advisory Committee (HICPAC)
• Follow manufacturers’ instructions for cleaning guidelines17 (“Guideline for infection control in
and sterilizing or disinfecting items that health care personnel, 1998”18; “Guidelines for
become contaminated but do not normally Preventing the Transmission of Mycobacterium
contact the patient (e.g., burs, polishing tuberculosis in Health-Care Settings, 2005”19; and
points, rag wheels, articulators, case pans, “Guideline for Isolation Precautions: Preventing
and lathes). If manufacturer instructions are Transmission of Infectious Agents in Healthcare
unavailable, clean and heat-sterilize heat- Setting 2007”20).
tolerant items or clean and disinfect them
with an EPA-registered hospital disinfectant • Follow CDC recommendations for:
with low - (HIV, HBV effectiveness claim) to 1. developing, maintaining, and implementing
intermediate-level (tuberculocidal) activity, a written TB infection-control plan;
depending on the degree of contamination (II). 2. managing a patient with suspected or
active TB;
To ensure that impressions are not compromised 3. completing a community risk-assessment
from exposure to disinfectant chemicals: to guide employee tuberculin skin tests and
follow-up; and
• Consult with manufacturers regarding the 4. managing dental team members with TB
stability of specific materials (e.g., impression disease (IB).
materials) relative to disinfection procedures
(II). To ensure appropriate patient screening and if
necessary, referral:
In the dental practice setting:
• Educate all dental team members on
• Clean and heat-sterilize heat-tolerant items recognizing of signs and symptoms of TB as
used in the mouth (e.g., metal impression well as on how TB is transmitted (IB).
trays and face-bow forks) (IB). • Assess each patient for a history of TB as well
as symptoms indicative of TB and document
To ensure good communication between the findings on the medical history form (IB).
dental practice and the laboratory:
For all dental team members who might have
• Include specific information on the disinfection contact with persons with suspected or confirmed
techniques used (e.g., solution used and active TB:
duration), when laboratory cases are sent off-
site and on their return (II). • Conduct a baseline tuberculin skin test,
preferably by using a two-step test (IB).
Tuberculosis and Dentistry
Patients infected with Mycobacterium tuberculosis The following CDC recommendations apply for
occasionally seek urgent dental treatment at patients who are known or suspected to have
outpatient dental settings. Symptoms of active active TB:
tuberculosis (TB) disease include a productive
cough, night sweats, fatigue, malaise, fever, and • Evaluate the patient away from other patients
unexplained weight loss. Although the overall risk and dental team members. When he or she is
of TB transmission in dentistry is likely very low, not being evaluated, the patient should wear a
policies should be in place to help dental team surgical mask or be instructed to cover his/her
members detect and refer patients with active mouth and nose when coughing or sneezing
tuberculosis for immediate medical care. (IB).

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
• Defer elective dental treatment until the are not susceptible to these transmissible
patient is noninfectious (IB) as confirmed by a illnesses and therefore cannot acquire (or
physician. transmit) the diseases.
• Refer patients requiring urgent dental treatment
to a previously identified facility (such as a • Get vaccinated against hepatitis B and other
hospital) with TB engineering controls and a vaccine preventable diseases.
respiratory protection program (IB). • Report occupational injuries and exposures
immediately.
Program Evaluation • Follow the advice of the medical care provider
The goal of the dental infection-control program evaluating your occupational exposure.
is to provide a safe working environment that
reduces the risk of both healthcare-associated Avoid contacting blood / body fluids
infections among patients and occupational A number of potentially serious diseases are
exposures among dental team members. spread by blood; other diseases are spread
Program evaluation offers an opportunity to through contact with other body fluids. Because
improve the effectiveness of both the infection- it is impossible to know for certain which patients
control program and dental-practice protocols. If are infected, avoid direct contact with blood, body
deficiencies or problems are identified, further fluids, non-intact skin, and mucous membranes.
steps can be taken to eliminate the problems. Always use standard precautions – handwashing,
Furthermore, routinely evaluating practices and personal protective equipment, controls to prevent
protocols provides a specific time for review and injuries, and proper management of patient care
consideration of any newly available technologies items and environmental surfaces – and treat
that could enhance patient and dental team every patient as if infectious.
member safety.
• Wear gloves, protective clothing, and face and
Strategies and tools that dental team members eye protection.
can use to evaluate the facility’s infection- • Handle sharps with care.
control program include periodic observational • Use safety devices as appropriate.
assessments, checklists to document procedures, • Use mechanical devices to clean instruments
and routine review of occupational exposures to whenever possible.
bloodborne pathogens.
Limit the spread of contamination
To ensure that the practice setting’s infection Blood and other patient fluids can be spread
control procedures are useful, feasible, ethical, by spatter, by touching contaminated supplies
and accurate: and surfaces, or by laying contaminated items
down on operatory surfaces. Any contaminated
• Establish routine evaluation of the infection- item is a potential exposure source, so by taking
control program, including evaluation of care to limit contamination to the greatest extent
performance indicators, at an established possible, dental team members limit the risk of
frequency (II) exposure to infectious materials and in turn, the
potential for disease transmission.
Summary
Although the 2003 CDC guidelines provide more • Set up the operatory before beginning
detail on dental infection control policies, practice, treatment.
and procedures than previous documents, the • Cover surfaces that will be contaminated.
ideas behind them break down to four basic • Minimize splashes and spatter.
principles for practical infection control. • Properly dispose of all waste.

Take action to stay healthy Make objects safe for use


An individual must be susceptible for exposure The nature of oral health procedures makes it
to result in disease transmission. Dental workers impossible to completely eliminate contamination.
who are up to date on recommended vaccinations Dental team members must use instruments,

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
activate equipment, and contact the mucous • Monitor processes to make sure they are
membranes of the patient’s oral cavity. As such, working as they should.
properly processing contaminated instruments
and surfaces remains an important part of a Dental team members who use these guiding
comprehensive infective control program. principles to direct their workday activities are
likely to find that infection control efforts may not
• Know the different decontamination processes. be as complex as they seem.
• Read chemical germicide labels.

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
To receive Continuing Education credit for this course, you must complete the online test. Please
go to www.dentalcare.com and find this course in the Continuing Education section.

Course Test Preview


1. An example of an engineering control is __________.
a. the one-handed scoop technique for recapping needles
b. postponement of routine dental treatment for patients suspected of having active TB
c. instrument cassettes used to process instruments for reuse
d. replacing sharps containers when they are full

2. An example of a work practice control is __________.


a. the one-handed scoop technique for recapping needles
b. postponement of routine dental treatment for patients suspected of having active TB
c. instrument cassettes used to process instruments for reuse
d. a color-coded, puncture-resistant sharps container

3. An example of an administrative control is __________.


a. the one-handed scoop technique for recapping needles
b. postponement of routine dental treatment for patients suspected of having active TB
c. instrument cassettes used to process instruments for reuse
d. a color-coded, puncture-resistant sharps container

4. According to the CDC __________ carry the highest risk of disease transmission.
a. non-critical items
b. critical items
c. semi-critical items
d. None of the above.

5. Universal precautions minimizes the risk of exposure to __________.


a. blood and bloody fluids
b. all body fluids except sweat
c. all body secretions and excretions
d. All of the above.

6. Standard precautions minimizes the risk of exposure to __________.


a. blood and bloody fluids
b. all body fluids except sweat
c. all body secretions and excretions
d. All of the above.

7. Vaccines are recommended for healthcare workers to protect against __________.


a. HBV
b. influenza
c. MMR (measles, mumps, and rubella)
d. All of the above.

8. Tetanus vaccination is recommended for healthcare workers.


a. True
b. False

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
9. According to OSHA regulations and CDC guidelines, employees who decline vaccination
against __________ must sign a declination form that the employer keeps on file.
a. HBV
b. HCV
c. influenza
d. MMR (measles, mumps, and rubella)

10. Sharps containers should be located __________.


a. at the front desk
b. near all exits from the facility
c. as close to the point of use as possible
d. All of the above.

11. CDC guidelines specifically recommend against __________.


a. two-handed needle recapping
b. handling needles with the sharp end pointed toward a team member’s body
c. bending, breaking, or removing needles before disposal
d. All of the above.

12. Occupational injuries should be reported, evaluated, and otherwise managed __________.
a. as soon as it happens
b. after all the patients of the day have been treated and sent home
c. on the first day the practice is closed for business so the employee won’t miss work
d. immediately before office hours the next morning

13. If hands are not visibly dirty or contaminated with blood or other potentially infectious
materials, __________.
a. wash hands with an antimicrobial soap and water
b. wash hands with a non-antimicrobial soap and water
c. use an alcohol-based hand rub according to the manufacturer’s instructions
d. Any of the above.

14. When assisting during a cavity preparation using a high-speed handpiece, __________
constitute appropriate personal protective equipment.
a. utility gloves, face mask, protective eyewear, and gown
b. sterile surgeon’s gloves, face mask, protective eyewear, gown, and shoe covers
c. exam gloves, face mask, protective eyewear, and gown
d. exam gloves, face mask, and gown

15. __________ is a common skin condition among dental healthcare personnel that is often
mistaken for an allergic reaction.
a. Type I hypersensitivity
b. Type IV hypersensitivity
c. Irritant contact dermatitis
d. Anaphylaxis

16. __________ is reaction to allergens such as methacrylates, glutaraldehydes, and chemicals


used in the manufacturing of gloves.
a. Type I hypersensitivity
b. Type IV hypersensitivity
c. Irritant contact dermatitis
d. Anaphylaxis

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
17. The “dirty” side of the instrument processing area is used for __________.
a. receiving, cleaning, and decontamination
b. sterilizing
c. recording entries in the sterilizer monitoring log
d. storing instruments before distribution to chairside

18. “Flash” sterilization cycles are considered acceptable for __________.


a. routine instrument sterilization
b. processing implantable devices
c. faster sterilization of a device that will be used immediately
d. critical instruments that will be stored indefinitely before use

19. Use a biological indicator __________.


a. weekly
b. to monitor every load that contains an implantable device
c. to retest a sterilizer that failed its previous spore test
d. All of the above.

20. For clinical contact surfaces that are visibly contaminated with blood, clean the surfaces
and disinfect using a __________.
a. a low-level disinfectant
b. a hospital disinfectant
c. an intermediate-level hospital disinfectant with tuberculocidal activity
d. a high-level disinfectant/sterilant

21. With regard to parenteral medications, CDC recommends __________.


a. using single-dose vials whenever possible
b. using multi-dose vials whenever possible
c. combining leftover contents of vials to save money
d. changing needles so an anesthetic syringe can be reused on another patient

22. Surgical hand antisepsis involves __________.


a. handwashing using an antimicrobial soap and water
b. handwashing with plain (non-antimicrobial) soap and water, followed by application of an
alcohol-based hand rub
c. handwashing with antimicrobial soap and water, followed by application of an alcohol-based
hand rub
d. Either A or B.

23. Extracted teeth containing amalgam should be disposed of in a sharps container.


a. True
b. False

24. Routinely evaluating the practice setting’s infection control program ensures __________.
a. compliance with OSHA’s Hazard Communication Standard
b. that it remains effective and up to date with current technology
c. that new regulations need not be incorporated
d. that disinfectant inventories do not contain expired products

25. Within the dental setting, reducing risk of disease transmission entails __________.
a. avoiding contact with blood and body fluids
b. limiting the number of “high-risk” patients treated in the practice
c. double gloving
d. ensuring that most patients are vaccinated against infectious diseases

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
References
1. OSHA. Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. (CPL
02-02-069). Accessed July 7, 2009.
2. Ortolano K. Organization for Safety and Asepsis Procedures. From Policy to Practice: OSAP’s Guide
to the Guidelines. Annapolis:OSAP, 2004. Accessed July 7, 2009.
3. CDC. Travelers’ Health - Vaccinations. What You Need to Know About Vaccinations and Travel: A
Checklist. Accessed July 7, 2009.
4. OSHA. Hazard Communication. Toxic and Hazardous Substances. Regulations (Standards - 29 CFR.
1910.1200). Accessed July 7, 2009.
5. American Dental Association (ADA). ADA Positions & Statements. ADA Statement on Dental Unit
Waterlines. Accessed July 7, 2009.
6. Kohn WG, Collins AS, Cleveland JL, Harte JA, Eklund KJ, Malvitz DM; Centers for Disease Control
and Prevention (CDC). Guidelines for infection control in dental health-care settings--2003. MMWR
Recomm Rep. 2003 Dec 19;52(RR-17):1-61.
7. Bebermeyer RD, Dickinson SK, Thomas LP. Guidelines for Infection Control in Dental Health Care
Settings--a review. Tex Dent J. 2005 Oct;122(10):1022-6.
8. Bebermeyer RD, Dickinson SK, Thomas LP. Personnel health elements of infection control in the
dental health care setting--a review. Tex Dent J. 2005 Oct;122(10):1028-35.
9. CDC. Recommended infection-control practices for dentistry, 1993. MMWR Recomm Rep. 1993 May
28;42(RR-8):1-12.
10. CDC. Guidelines and Recommendations. Recommended Infection Control Practices for Dentistry.
Accessed July 7, 2009.
11. OSHA. Safety and Health Topics - Dentistry. Accessed July 7, 2009.
12. U.S. Department of Labor, Office of Compliance Assistance Policy. The Occupational Safety
and Health Act of 1970 (OSH Act) (29 USC -651 et seq.; 29 CFR Parts 1900 to 2400). Accessed
July 7, 2009.
13. U.S. Department of Energy. Office of Health, Safety and Security. Resource Conservation and
Recovery Act. Accessed July 7, 2009.
14. OSHA. Bloodborne pathogens. Regulations (Standards - 29 CFR. 1910.1030). Accessed July 7, 2009.
15. CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures
to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep.
2001 Jun 29;50(RR-11):1-52.
16. Cleveland JL, Barker L, Gooch BF, et al. Use of HIV postexposure prophylaxis by dental health care
personnel: an overview and updated recommendations. J Am Dent Assoc. 2002 Dec;133(12):1619-26.
17. Pirwitz S. HICPAC guidelines for isolation precautions: Hospital Infection Control Practices Advisory
Committee. Am J Infect Control. 1997 Jun;25(3):287-8.
18. CDC. Infection Control Guidelines. Guidelines for Infection Control in Health Care Personnel, 1998.
Accessed July 7, 2009.
19. Jensen PA, Lambert LA, Iademarco MF, Ridzon R; CDC. Guidelines for preventing the transmission of
Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-
17):1-141.
20. CDC. Infection Control Guidelines. Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings 2007. Accessed July 7, 2009.

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009
About the Authors

Sharon K. Dickinson, CDA, CDPMA, RDA


Professor Dickinson has been actively involved in the dental profession as a chairside assistant, office
manager, consultant and educator. Since 1981, Professor Dickinson has held the position of director
of the Dental Assisting Program at the El Paso Community College. She is considered a curriculum
expert for the Texas Coordinating Board, infection control expert serving on the infection control test
development committee for the Texas State Board of Dental Examiners. Professor Dickinson is a
federally authorized OSHA Outreach trainer in Occupational Safety and Health for General Industry.
With more than 35 years of clinical and practical experience in dentistry, Professor Dickinson speaks
and consults extensively on OSHA and infection control. In addition Professor Dickinson has published
numerous articles.

Email: sdickins@epcc.edu

Richard D. Bebermeyer, DDS, MBA


Dr. Bebermeyer serves as Chair and Professor in the Department of Restorative Dentistry &
Biomaterials at The University of Texas Health Science Center Houston Dental Branch. He is a general
dentist with interest in infection control and prevention in dentistry. Dr. Bebermeyer received his Doctor
of Dental Surgery from Washington University in St. Louis, and his Masters in Business Administration
from Southern Illinois University at Edwardsville.

Email: Richard.D.Bebermeyer@uth.tmc.edu

Karen Ortolano
Ms. Ortolano has been working with and writing for the dental profession and industry since 1989. She
has authored more than 350 published articles on a variety of topics, including dental infection control
and safety, occupational disease agents, restorative dentistry, periodontal care, regulatory issues,
and new technologies. She has written more than 50 continuing-education (CE)-accredited articles
for dentists and auxiliaries, and she wrote, edited, and designed the 170-page CE workbook, From
Policy to Practice: OSAP’s Guide to the Guidelines. She has served as Scientific Writer/Editor for the
American Dental Association’s Council on Scientific Affairs; Publications Director for the Organization
for Safety and Asepsis Procedures (OSAP); Editor/Managing Editor of the OSAP newsletters Infection
Control In Practice, OSAP Monthly Focus, and The OSAP Report; Managing Editor of Dental Products
Report Europe; Associate Editor and author of the monthly “Infection Control Report”” in Dental Products
Report; and Contributing Editor to Dental Products Reportt and the Chicago Dental Society’s CDS
Review.
w

She owns and operates Karen Gomolka Editorial Services, a sole proprietorship providing freelance
writing, editing, and design services, from her home in Chicago. She can be reached through her
website, http://eyegarden.com.

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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised December 30, 2009