Infection Control in Dental Hygiene: OSHA, PPE, Sterilization, and Waterline Management

OSHA

Occupational Safety and Health Administration; a division of the U.S. Department of Labor.

OSHA Purpose

To ensure the protection of employee safety through the enforcement of standards or regulations.

OSHA Standards (Infection Control)

Protect the employee's right to a safe workplace by enforcing standards that reduce exposure to bloodborne pathogens, provide and maintain personal protection, guide the handling of items containing body fluids, and guide the use and storage of drugs and chemicals (MSDS sheets).

MSDS Sheets

Material Safety Data Sheets; provide information on all chemical products used in the office or clinic.

MSDS Hazard Rating Scale

Numerical scale from 0 (minimal hazard) to 4 (severe hazard). • 0 = minimal hazard • 1 = slight hazard • 2 = moderate hazard • 3 = serious hazard • 4 = severe hazard

MSDS Hazard Color Codes

Colors used to identify types of hazards. • Blue = Health hazard • Red = Fire hazard • Yellow = Reactivity hazard • White = Special hazard

Standard Precautions

The principle that you cannot be certain of the health status of each patient, therefore, you must treat all patients as if they are infected with a contagious disease.

Five Steps to Reduce Infection Exposure Risks

1. Host Immunity and Immunization 2. Restriction of duties during illness 3. Patient health history 4. Extraoral / intraoral examination 5. Personal Hygiene and appearance

Natural Immunity

Immunity developed when an individual is exposed to a pathogen, stimulating the immune system to produce specific antibodies that destroy the pathogen (e.g., chicken pox).

Artificial or Active Immunity

Immunity developed through vaccinations or immunizations that stimulate the immune system to produce specific antibodies without the individual experiencing the disease (e.g., Measles, mumps, rubella).

Passive Immunity

Temporary immunity that develops in infants from antibodies received from the mother.

Restriction of Duties During Illness

Healthcare workers should withdraw from direct patient contact and indirect-contact activities when exhibiting symptoms of infectious diseases.

Patient Health History (Purpose)

A tool to provide information that may indicate if modification to dental care procedures is necessary.

Patient Health History (Misuse)

NOT to be used to screen patients or to justify the use of additional barriers.

Extraoral / Intraoral Examination

A comprehensive patient examination that often identifies lesions associated with systemic diseases, providing important information for appropriate treatment and management of the patient's overall health.

Personal Hygiene and Appearance

Important practices include tying hair up and pulling it back, avoiding personal jewelry (which may harbor high levels of bacteria), and maintaining proper hand care (nails, broken skin, hand lotions, soap, and hand washing).

Personal Protection Equipment (PPE) Purpose

To protect the clinician's skin, eyes, nose, mucous membranes, and clothing from exposure to biohazardous materials in the workplace, as well as to reduce direct and minimize indirect transmission of infectious agents.

When to Change PPE

PPE must be changed if it is compromised (visibly soiled, wicked from moisture produced by the operator, or torn/has visible holes).

Examples of PPE

1. Gloves 2. Protective Eyewear 3. Face masks and Shields 4. Protective Garments

Types of Gloves in Dentistry

• Examination or procedure gloves • Surgical gloves • Utility gloves (used when handling sharp instruments).

Glove Use Guidelines

Gloves are always worn, a new pair for each patient, removed before leaving the operatory, and changed often.

Factors Compromising Glove Integrity

• Length of time worn • Complexity of procedure • Packaging of the gloves • Pressure of time • Storage of gloves • Agents used • Hazard from hands (long nails, rings, etc.)

Protective Eyewear Use

ALWAYS wear protective eyewear during treatment and clean-up of the dental unit and instruments.

Types of Protective Eyewear

Safety glasses, face shields, loupes, and patient protective eyewear.

Face Mask Use Guidelines

Worn for all procedures and clean-up; must cover the nose, mouth, and facial hair; should fit snugly with no gaps.

Face Mask Changing Guidelines

The mask MUST be changed for each patient OR if it becomes contaminated by touch, visibly soiled, or wet (wicked). Surgical masks should be changed every hour or more often if used in a moist/wet environment (e.g., with an ultrasonic scaler).

Face Mask Filtration Standard

Should have a 95% BFE (Bacterial Filtration Efficiency) with a 1 to 3 micron particle filtration level.

Protective Garments Guidelines

Clinic attire that protects the clinician's clothes and skin from contamination. Garments should cover the lap area when sitting, cover arms, have cuffs on sleeves to seal the arms, pants cover ankles, and have a velcro or secured collar on the coat.

PPE Placement (Donning) Order

1. Hand hygiene 2. Gown 3. Mask 4. Protective eyewear (safety glasses or loupes and face shield) 5. Hand hygiene 6. Don gloves

PPE Removal (Doffing) Order

1. Remove gloves 2. Remove Gown - turn inside out 3. Leave operatory and perform hand hygiene 4. Place new gloves and remove eyewear and disinfect 5. Remove mask 6. Remove gloves 7. Perform hand hygiene

Implementation of Work Practice (Infection Control)

Includes barrier protection, high-velocity evacuation, reduction of microbial load, use of disposable items, and chairside safety.

Biofilm (Dental Waterlines)

Colonies of cell growth that attach to the wet inner surfaces of small tubing. These microbes develop into a matrix ('slime') which can be up to 400 micrometers thick and may serve as a reservoir for transmission of pathogens.

ADA Standard for Dental Waterlines

Water used during patient treatment should contain no more than 500 CFU/ml (colony-forming units), similar to normal, safe drinking water.

Dental Waterline Flushing Procedure

• Flush waterlines for 1-2 minutes prior to patient treatment. • Flush for 20-30 seconds between patients.

Sharps Container

A designated container for disposing of sharp regulated waste, such as needles and scalpels.

Regulated Waste / Biohazard Waste

Includes sharps and waste saturated with blood and/or saliva or hard or soft tissue removed from the patient.

Non-regulated Waste

Waste that is not saturated with blood or saliva, such as patient bibs, barriers, PPEs, and other disposable items.

Principles of Handwashing

To reduce the overall bacterial flora of the skin to a minimum by removing surface dirt and bacteria, dissolving normal greasy film on the skin, and rinsing away loosened debris and microorganisms.

Importance of Handwashing

Considered the most important single procedure for the prevention of cross-contamination.

Indications for Handwashing

Before placement and after glove removal; when hands appear visibly soiled; or after contaminated surfaces were touched with a bare hand.

Handwashing Equipment/Supplies (Sink)

Should have a foot pedal or electronic start for water-flow. If hand controls are present, they should be turned on, left on during the procedure, and turned off with a paper towel.

Handwashing Equipment/Supplies (Soap)

Liquid surgical soap containing an antimicrobial agent (e.g., Povidone-iodine, iodophore, Chlorhexidine).

Handwashing Equipment/Supplies (Other)

Paper towels; scrub brushes (used with caution to avoid skin irritation); disposable sponges (less irritating); disposable paper towels.

Four Types of Handwashing Procedures

1. Antiseptic handwash 2. Routine handwash 3. Antiseptic hand rub 4. Surgical antisepsis (Surgical scrub)

Antiseptic Handwash (Procedure Summary)

Preliminary steps include removing jewelry and donning PPE. Involves lathering hands, wrists, and forearms with liquid antimicrobial soap, vigorous rubbing with interlaced fingers, and thorough rinsing. Repeated multiple times, then dried with a disposable towel.

Routine Handwash (Procedure Summary)

Wet hands, apply soap (avoid hot water), rub hands together for at least 15 seconds covering all surfaces, interlace fingers, rinse under running water, and dry thoroughly with a disposable towel. Turn off faucet with a towel.

Antiseptic Hand Rub (Procedure Summary)

Decontaminate hands with a hand rub product according to manufacturer's recommendations, covering all surfaces and rubbing until dry. If hands dry in less than 10-15 seconds, another application is needed.

Surgical Antisepsis (Surgical Scrub Procedure Summary)

Preliminary steps include removing jewelry, pulling hair back, donning PPE, and opening a surgical brush. Involves washing hands and arms with a strong brushing motion, thorough rinsing while holding hands higher than elbows, and cleaning nails with an orangewood stick.

General Environmental and Equipment Procedures

Include defining work zones, daily preparation, surface protection, operatory preparation, operatory clean-up, and end-of-day procedures.

Work Zones

Defined work areas with a floor plan that flows to minimize cross-contamination.

Daily Preparation (Staff)

Involves aseptic handwashing, putting on a gown, and beginning to place barriers with clean hands.

Environmental Surface Protection (Examples)

Potential areas of contamination include counter tops & cabinets, dental unit & light, clinician chair, sink, computer monitor/keyboard, internal supplies in cabinets, and X-ray equipment.

End of Day (Treatment Room Clean-up)

Remove all contaminated barriers, disinfect the unit with Advantaclear (all surfaces), and pull out the trash can from under the sink.

Sanitization

The process by which the number of microorganisms is reduced to a relatively safe level.

Disinfection

Kills most microorganisms; hospital-level disinfection agents should be used in dentistry.

EPA Standard for Disinfection Solutions

Disinfection solutions MUST destroy Pseudomonas species, lipophilic microbes, S. aureus, hydrophilic microbes, salmonella, and TB.

Qualities of an Ideal Disinfectant

Broad spectrum, fast acting, non-toxic, compatible with different types of surfaces, easy to use, residual effect, and odorless.

High-Level Disinfection

Used in surgical areas (hospital, perio or oral surgery); Example: 3% glutaraldehyde.

Intermediate-Level Disinfection

Most common in dental offices or clinics; kills Mycobacterium tuberculosis; Examples: complex phenols and Iodophors.

Low-Level Disinfection

Unacceptable in the dental office; Example: Simple phenol.

Sterilization

Designed to kill ALL microorganisms including spores; heat sterilization is considered most effective.

Methods of Sterilization in Dentistry

1. Steam Autoclave 2. Chemical vapor 3. Dry Heat

Steam Autoclave (Method 1)

Heats water in the chamber to create steam under pressure, causing coagulation and inactivation of microbes through steam penetration into instrument packages/cassettes.

Steam Autoclave (Temperature/Time)

250 degrees F for 20-30 minutes (time can vary depending on wrapped or unwrapped items).

Steam Autoclave (Disadvantage)

Corrosion of non-stainless steel instruments.

Steam Autoclave (Spore Test)

Geobacillus stearothermophilus.

Chemical Vapor (Method 2)

Destroys microbes with heat, pressure, and chemistry using a chemical vapor.

Chemical Vapor (Requirements & Temperature/Time)

Requires adequate ventilation due to vapors; 270 degrees F for 20 minutes.

Chemical Vapor (Disadvantage)

May damage plastic and rubber items.

Chemical Vapor (Spore Test)

Geobacillus stearothermophilus.

Dry Heat (Method 3)

Relies on heat alone to oxidize cellular material or microbes.

Dry Heat (Temperature/Time)

320 degrees F for 60-120 minutes.

Dry Heat (Spore Test)

Bacillus subtilis.

Dry Heat (Recommendations & Disadvantage)

Recommended for metal instruments (no corrosion); do not use paper products. Disadvantage: May damage handpieces, plastic, or rubber materials.

Occupational Safety and Health Administration (OSHA)

A division of the U.S. Department of Labor, OSHA's primary goal is to ensure employee safety through the enforcement of standards and regulations, particularly concerning workplace hazards.

Standards in Dentistry

Reducing exposure to bloodborne pathogens. Providing and maintaining personal protection equipment (PPE). Guiding the handling of items containing body fluids. Guiding the use and storage of drugs and chemicals (MSDS sheets).

Hazard Rating System

0 = minimal hazard, 1 = slight hazard, 2 = moderate hazard, 3 = serious hazard, 4 = severe hazard.

Color-Coded Hazards

Blue = Health hazard, Red = Fire hazard, Yellow = Reactivity hazard, White = Special hazard.

Core Principle of Standard Precautions

Due to the inability to ascertain the health status of every patient, all patients must be treated as if they are infected with a contagious disease.

Artificial/Active Immunity

Achieved via vaccinations or immunizations, stimulating antibody production without experiencing the disease (e.g., Measles, Mumps, Rubella).

Patient Health History

A crucial tool to identify necessary modifications to dental care procedures.

Purpose of PPE

To protect the clinician's skin, eyes, nose, mucous membranes, and clothing from exposure to biohazardous materials.

PPE Integrity and Changing Protocols

Must be changed if compromised: visibly soiled, wicked (moisture produced by operator), torn, or has visible holes.

Types of PPE

Gloves: Types: Examination/procedure, surgical, and utility gloves (for handling sharp instruments). Usage: Always worn; a new pair for each patient; removed before leaving the operatory; changed often.

Compromise of PPE

Length of time worn, complexity of procedure, packaging, time pressure, storage, agents used, and hand hazards (long nails, rings).

Protective Eyewear

ALWAYS worn during treatment and clean-up of the dental unit and instruments. Types: Safety glasses, face shields, loupes, and patient protective eyewear.

Face Masks and Shields

Worn for all procedures and clean-up. Must cover nose, mouth, and facial hair, fitting snugly without gaps.

Changing Protocol for Masks

Changed for each patient OR if contaminated by touch, visibly soiled, or wet (wicked). Surgical masks changed every hour or more often in moist environments (e.g., ultrasonic scaler).

Filtration Requirement

Must have 95% Bacterial Filtration Efficiency (BFE) with 1 to 3 micron particle filtration.

Protective Garments Purpose

Protect clinician's clothes and skin from contamination.

Protective Garments Features

Should cover lap area when sitting, cover arms, have cuffs on sleeves to seal arms, pants cover ankles, and velcro/secured collar on coat.

PPE Placement (Donning)

Hand hygiene, Gown, Mask, Protective eyewear (safety glasses or loupes and face shield), Hand hygiene, Gloves.

PPE Removal (Doffing)

Remove gloves, Remove gown (turn inside out), Leave operatory and perform hand hygiene, Place new gloves and remove eyewear and disinfect. Remove mask, Remove gloves, Perform hand hygiene.

Work Practice Enhancements

Barrier protection, High-velocity evacuation, Reduction of microbial load, Disposable items, Chairside safety.

Dental Waterline Management - Biofilm

Colonies of cell growth that attach to the wet inner surfaces of small tubing. A 'slime' matrix (up to 400 micrometers thick) that serves as a reservoir for pathogens.

ADA Standard for Water

Water used during patient treatment should contain no more than 500 CFU/ml (colony-forming units), mirroring safe drinking water standards.

Flushing Procedures

1-2 minutes prior to patient treatment. 20-30 seconds between patients.

Most Important Single Procedure

Prevention of cross-contamination.

Handwashing Equipment/Supplies - Sink

Foot pedal or electronic start for water-flow; if hand controls, turn on, leave on, turn off with paper towel.

Handwashing Equipment/Supplies - Soap

Liquid surgical soap with an antimicrobial agent (e.g., Povidone-iodine, iodophore, Chlorhexidine).