chapter 10 pt1 darby

Professional Opportunities

  • Infection prevention and control (IPC) is crucial in all clinical practices.
  • Both patients and dental hygiene professionals can be exposed to infectious agents during dental treatments.
  • Following evidence-based infection prevention practices can significantly reduce or eliminate the risk of infectious disease transmission.
  • Dental hygienists with expertise in infection control can lead and educate dental teams.

Competencies

  • Discuss basic IPC concepts.
  • Explain the similarities and differences between the IPC model and the dental hygiene care model.
  • Identify government agencies involved in regulating IPC standards.
  • Discuss the standard of care, including risk assessment for disease transmission and appropriate control measures.
  • Explain the four principles of IPC:
    • Select appropriate protective attire.
    • Prepare the dental environment before and after patient care.
  • Discuss strategies for preventing disease transmission and actions for healthcare personnel to stay healthy.

Basic Infection Prevention and Control Concepts

  • IPC is essential for safe dental care.
  • The main goals in healthcare settings are:
    • Preventing healthcare-associated infections (HAIs) in patients.
    • Preventing occupational injuries and illnesses in personnel.
  • Transmission of infectious agents in dental settings is rare but has been documented.
  • Noncompliance with infection prevention procedures increases the risk of transmission.
  • IPC is a comprehensive program that reduces the risk of transmission of infectious agents.
  • The goal of IPC is to maintain a safe clinical environment to reduce disease transmission from clinician to patient, patient to clinician, or patient to patient.
  • Risk of transmission occurs when an infectious agent has a viable portal of entry to a susceptible host.
    • Examples: accidental puncture with a contaminated instrument or use of inadequately reprocessed instruments.
  • IPC practices prevent unintended harm to dental hygienists, patients, and staff.
  • Hygienists use patient assessment findings to decide on appropriate interventions and consider procedures to reduce disease transmission risk.
  • Infection prevention starts with assessing the healthcare delivery environment to determine site-specific IPC measures.
  • Steps to prevent exposure to potential infectious hazards:
    1. What procedures will be performed?
    2. What exposure risks are associated with those procedures?
    3. What IPC measures are indicated?

Infection Prevention and Control Model

  • The IPC model is similar to the dental hygiene care model.
  • Patients must understand the selection and use of IPC procedures and their protective outcomes.
  • The IPC model focuses on protecting both patient and provider.
  • Standard precautions are used because scrutinizing each health history does not determine the degree of risk for disease transmission.
  • Patients may be unknowingly infected and asymptomatic.
  • Many infections are contagious before symptoms appear (e.g., common cold, influenza, COVID-19).
  • Individuals with HBV or HCV may be asymptomatic but still contagious.
  • Dental procedures generate varying amounts of body fluids, and instruments vary in their tendency to release fluids.
  • IPC is procedurally based, not patient based.
  • Cognitive goals in the IPC model include explaining IPC, its protective intent, and its standard of care status.
  • Effective goals in the IPC model aim to positively change a patient's attitude and reduce fear or anxiety.
  • IPC should be viewed as protective, not punitive.

Government Agencies and Infection Prevention and Control

  • Four US government agencies play key roles in IPC.
  • Guidelines and regulations from these agencies establish national standards for patient care, equipment, materials, and the environment.
  • State, county, and city government agencies also have regulations for IPC, including state boards of licensure and health departments.
  • The Centers for Disease Control and Prevention (CDC) is one of eight federal public health agencies within the US Department of Health and Human Services (HHS).
  • The CDC's mission is to promote health and quality of life by preventing and controlling disease, injury, and disability.
  • The CDC develops guidelines and recommendations for infection control in healthcare settings but is not a regulatory agency and does not enforce them.
  • The Occupational Safety and Health Administration (OSHA), within the US Department of Labor, protects persons by ensuring a safe and healthy workplace.
  • OSHA enforces workplace safety regulations, including IPC in healthcare settings.
  • Some states have state-administered OSHA agencies, which must be followed if more stringent than the federal plan.
  • The US Food and Drug Administration (FDA) and the US Environmental Protection Agency (EPA) regulate products used in IPC.
  • The FDA's regulatory mission is to:
    • Promote and protect public health by helping safe and effective products reach the market quickly.
    • Monitor products for continued safety after use.
    • Help the public obtain accurate, science-based information to improve health.
  • The FDA regulates all medical devices, from simple items to complex technologies, with different approval levels based on complexity and risk.
  • Some products (e.g., new drugs, complex medical devices) must be proven safe and effective before being sold.
  • Other products (e.g., x-ray machines, medical sterilizers) must meet performance standards.
  • Since 1970, the EPA's regulatory mission has been to protect human health and the environment.
  • The EPA regulates chemical germicides used in healthcare and biohazardous and chemical waste.

Standard of Care

  • The standard of care is the level of care a reasonably prudent practitioner would exercise; it is the minimum acceptable level.
  • Infection-control regulations, evidence-based guidelines, government agencies, licensing boards, other practitioners, and expert opinion determine the standard of care for IPC in dentistry.
  • The standard of care provides a basis for promoting excellence and performance improvement.
  • The goal of IPC is to prevent HAIs among patients and injuries/illnesses in DHCP.
  • Dental patients and DHCP can be exposed to pathogenic microorganisms, including:
    • Cytomegalovirus (CMV)
    • Hepatitis B virus (HBV)
    • Hepatitis C virus (HCV)
    • Herpes simplex virus types 1 and 2
    • Human immunodeficiency virus (HIV)
    • Mycobacterium tuberculosis (TB)
    • Staphylococci
    • Streptococci
    • Influenza
    • Coronavirus
    • Other viruses and bacteria in the oral cavity and respiratory tract
  • Transmission can occur through:
    • Direct contact with blood, oral fluids, or other patient materials.
    • Indirect contact with contaminated objects (instruments, equipment, surfaces).
    • Contact of conjunctiva, nasal membranes, or oral mucosa with droplets (spatter) from coughing, sneezing, or talking.
    • Inhalation of airborne microorganisms that remain suspended in the air.
  • Infection requires:
    • A pathogenic organism of sufficient virulence and in adequate numbers.
    • A reservoir or source for pathogen survival and multiplication.
    • A mode of transmission from the source to the host.
    • A portal of entry for the pathogen.
    • A susceptible (non-immune) host.
  • These conditions constitute a chain of infection.
  • Effective infection-control strategies interrupt one or more links in the chain.

Four Principles of Infection Control and Prevention

  • The CDC identifies four IPC principles to protect health in the dental environment.

Principle 1: Take Action to Stay Healthy

  • All persons, especially healthcare personnel (HCP), must maintain their own health.
  • Develop a personnel health program based on CDC guidelines, including:
    • Hand hygiene
    • Medical evaluation
    • Health and safety education and training
    • Management of work-related illness
    • Postexposure management
    • Counseling
    • Work restrictions
    • Immunization
Immunizations for Vaccine-Preventable Diseases
  • Immunization is highly effective in preventing disease transmission.
  • Vaccination provides immunity.
  • Hygienists should obtain immunizations recommended for HCP, per the CDC's Advisory Council on Immunization Practices (ACIP).
  • Consult physicians for appropriate immunizations based on disease risk in specific locations.
  • All children typically receive DPT (diphtheria, pertussis, and tetanus) vaccine.
  • Adults need a tetanus-diphtheria (Td) booster every 10 years or more often if indicated.
  • A one-time tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended for all adolescents and adults, replacing a Td booster.
  • After Tdap, resume the Td booster schedule.
  • Additional vaccines for HCP include HBV, annual influenza, measles, mumps, rubella, and varicella (if no natural immunity).
  • Pneumococcal vaccine is recommended for adults age 65 or older.
  • Additional vaccines may be indicated during public health emergencies (e.g., SARS-CoV-2 pandemic, monkeypox outbreak).
  • OSHA requires employers to offer HBV vaccination to all personnel at risk of exposure to blood and OPIM unless they have proof of prior immunization or immunity.
  • Employees can decline immunization by signing an OSHA-designated waiver after receiving information on the vaccine's safety, efficacy, and benefits, as well as the risks of not vaccinating.
  • If an employee initially declines but later accepts the vaccination, the employer must provide it.
  • Vaccination is administered according to US Public Health Service recommendations, currently a three-part series with postvaccine testing for hepatitis B surface antibodies (anti-HBs) 1 to 2 months after the third dose.
  • Nonresponders should consult their healthcare professional and may receive an additional single dose or a second three-dose series.
  • After additional doses, an anti-HBs titer should be completed.
  • Those who do not develop detectable anti-HBs are considered nonresponders and tested for hepatitis B surface antigen (HBsAg) to check for active infection or carrier status.
  • If the HBsAg test is negative, the individual is susceptible to HBV infection and counseled on precautions and postexposure management.
Work Restrictions
  • DHCP should be aware of their health and take action to remain healthy.
  • A written infection-control plan discussing conditions requiring restriction or exclusion from direct patient care is necessary.
  • The US Public Health Service recommends work restrictions for HCP with specific infections or after exposure to some diseases.
  • Precautions to protect HCP and patients:
    • HCP with diphtheria should not work until the illness resolves.
    • HCP with mumps or measles should not work during the acute illness as well as after exposure and during the incubation phase if not immunized.
    • HCP with hepatitis A should not have direct patient contact or handle food for others.
    • HCP with an upper-respiratory infection should avoid contact with medically compromised persons.
    • HCP with active herpes zoster (shingles) may work unrestricted if lesions are covered to protect against exposure of nonintact skin to blood and body fluids.
    • In 2012, the CDC updated recommendations for managing HBV-infected HCP, advising no restrictions for practitioners performing dental procedures (except major oral or maxillofacial surgery) due to the lack of documented DHCP-to-patient transmission after adopting universal and standard precautions.
    • HCP with HIV are not specifically restricted, but some modifications may be needed for certain procedures; an expert review panel and physician should be consulted.
  • Consult current CDC recommendations and state laws for more information on applicable workplace restrictions.

Principle 2: Avoid Contact With Blood and Other Infectious Body Substances

  • Avoid contact with blood and other potentially infectious body fluids by using safe-work practices and behaviors.