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The bloodborne pathogen standard was written in 1991 and published in 1992

Risk Factors of Hep B:

  1. Sharing contaminated needles- IV drug users, piercings, or tattoos
  2. Sexual behaviors with multiple partners
  3. Injuries with sharp objects contaminated with blood or OPIM
  4. Exposures of nonintact skin or mucous membranes to blood or OPIM (parenteral transmission) (no gloves=herpetic whitlow)

Hepatitis B is an enveloped DNA virus.

  1. Synthetic HbsAg (Hep. B surface antigen) is used for the vaccine
  2. Relatively easy to kill, 10 minute direct contact time with disinfectant
  3. 90% recover without becoming a carrier
  4. 1-3% become chronic carriers
  5. >90% of newborns become become chronic carriers - born with it
  6. 40% of cases cannot identify route of transmission
  7. The best method of prevention is vaccination, however we cannot control our patient’s immunizations, so standard precautions must be stringently practiced.
  8. Immunity is demonstrated by blood titer HbsAg > or = 10mlU. 66% of those infected have no symptoms, or too mild to be diagnosed.

Hepatitis A and E are transmitted mainly through contaminated food and water - known as the fecal oral route.

Hepatitis B, D, and E are bloodborne and transmitted through direct or indirect contact with infected bodily fluids.

Hepatitis C - a virus once known as “Non- A and Non-B”

  1. No vaccine
  2. No cure..sort of, medication can be thrown at it
  3. Can be killed with intermediate level disinfectants. Disinfectants must be in direct contact for time listed on the label. This applies to all Hepatitis viruses.
  4. At least 50% become chronic carriers
  5. Blood tests first introduced in 1991
  6. 70-80% show no symptoms
  7. 33% of cases cannot identify route of transmission
  8. Very long incubation period (months/years)
  9. A major emerging disease

Hepatitis D - related to Hepatitis B.

  1. Hepatitis B vaccination can prevent Hepatitis D
  2. Superinfection can cause chronic active Hepatitis. Occurs in HBV carrier.
  3. Co-infections occur at the same time and usually resolve.
  4. Have to have Hepatitis B before Hepatitis D

Hepatitis A and E - are not Bloodborne, but transmit by fecal-oral route

  1. Vaccine for Hepatitis A
  2. Related to poor sanitation. Common in 3rd world countries and should plan on vaccinating before you plan to visit.

HIV

  1. No vaccine
  2. Very easy to kill outside of the body (sunlight/disinfectants)
  3. Impossible to kill inside the body.
  4. Infects T4 Lymphocytes primarily, they regulate immune response
  5. Virus undergoes mutations, which hinders development of effective vaccinations
  6. AIDS is diagnosed when patients begin to experience opportunistic pathogens and cancers
  7. Infections that effect the body may be bacterial, fungal, viral, or cancers.
  8. Oral manifestations may also be bacterial, fungal, viral, or cancers.
  9. Pneumonia is a leading cause of death (pneumocystis jiroveci)
    1. Donated blood has been screened for HIV since 1985
    2. HIV by permucosal route 0.1%

Human Herpes Virus HHV or HSV

  1. Type 1 herpes simplex virus 1 (HSV-1)

  2. Infections of mouth, skin, eyes, and genitals.

  3. 90% of adults have been infected

  4. Causes recurrent infections - fever blisters

  5. Herpetic Whitlow - breaks in skin of hands, common before the use of gloves

2. Type 2 (HSV - 2)

  1. Primarily genital herpes, 90%
  2. Recurrent infections (this is a trait of herpes)
  3. Can be spread whether symptoms are present or absent.

3. Type 3 - Chicken Pox or varicella zoster - comes back as shingles

4. Type 4- Mononucleosis

Oral Candidiasis

  1. Fungal or yeast (candida albicans)

  2. Opportunistic so it affects:

  3. Cancer and Chemo patients

  4. The very old and the very young

  5. Poorly nourished such as - Alcoholics, homeless, and poorly nourished.

  6. HIV and other compromised patients

3. Often one of the first symptoms of HIV

4. Manifests itself as thrush or denture stomatitis

Tuberculosis is a disease that is air-borne. Since all diseases have a particular route of transmission, following protocol for the Blood-borne Pathogen Standard will not help prevent its spread. It is the only disease that has its own set of standars.

Mycobacterium tuberculosis is an emerging disease globally:

  1. Number of cases is stable in the US

  2. Major Risk Groups

  3. Homeless

  4. HIV Infected

  5. Drug abusers

  6. Airborne Transmission (respiratory via Droplet or Aerosol)

  7. Active cases are not to be treated in routine dental offices

  8. No immunization available in the US but used in other countries

  9. The vaccine would make the skin test useless, false positive

  10. New resistant strains occurring. Resistant to Antibiotic TB Drugs (MDRTB - series of medication taken)

  11. TB test is called “mantoux” or purifies, protein derivative (AKA PPD)

Legionnaires and Pseudomonas (two common bacteria found in water) - first identified at an American Legion Convention in 1976.

  1. Primarily Waterborne

  2. CDC recommendations for dental water usage:

  3. To be <500 CFU/ml of tx water

  4. Flush water lines 20-30 seconds between each patient (flush for 2 minutes not between each patient.

  5. Active and aggressive use of HVE (high volume evacuation)

  6. Use sterile water for all surgery

  7. Flush water lines at the beginning of each day

3. Presents greater risk to DHCW than to individual patients because patients are only exposed for an hour.

4. Routine use of the standard dental mask does not effectively prevent spread of airborne diseases. Masks are designed and rated primarily to prevent splash and spatter contact. Ambient room air flows around them.

5. The only mask designed to filter air-borne pathogens is the N-95 respirator which must be leak tested.

Blood Borne Pathogen Standard:

A federal law written in 1991, the BBPS became effective in 1992. It is one of two major standards regulated by OSHA that have a direct bearing on the dental field. However, it is not specific to dentistry. (blood banks, mortuaries, hospitals and doctor offices.

It is the employer’s responsibility to provide everything needed for compliance with the standard. Examples are: PPE and barriers, examinations, immunizations, and blood tests when appropriate, and at least annual training.

  1. Exposure Plan. Every dental office or clinic must have a written exposure plan. An exposure plan includes:

  2. Exposure determination. This is based on employees who perform tasks that involve exposure to blood or OPIM.

  3. A category l employee routinely is exposed (saliva, blood, instruments)

  4. A category ll employee may be exposed on occasion (janitors/custodians)

  5. A category lll employee is never exposed (mailman/work from home)

  6. Schedule of implementation

  7. Offices and clinics must make a written plan to implement the standard including how and when it will be done.

  8. Evaluation of exposure incidents

  9. A report must be completed for each exposure incident.

  10. Document where the incident occured, the route of entry, the source patient information, what task was being done, and the PPE being used at the time.

  11. What should be done to prevent a future injury of the same type

  12. Communication of biohazardz must be done by

  13. Regular training and specific information.

  14. Labels and signs - to tell “biohazard”

  15. Training.

  16. Must be provided at NO COST to all employees, before the employee is placed in a position where exposure may occur, and must be updated at least annually. Sooner if changes are made.

  17. The training session must be conducted by a person knowledgeable about blood borne pathogens, and able to answer questions.

  18. OSHA determines whether a trainer is qualified.

  19. Training must be offered in the employee’s language, education, and literacy levels.

  20. Labeling.

  21. Proper biohazard labels must be placed on anything containing regulated waste, blood, or OPIM. (examples: Laundry, Sharps, any biohazard that is stored (amalgam, lead)

  22. You may use a red bag or container, if employees know its meaning.

  23. Hepatitis B Vaccine:

  24. Must be offered free within 10 days of  a person’s employment

  25. If you decline the series, you must sign a statement

  26. Employers must maintain records on when it was given, and to whom in a Confidential employee file.

  27. Post exposure evaluation and follow up:

  28. Medical evaluation of the employee must occur immediately!! Why? To provide a baseline to monitor from. To see if the person gets infected later from the exposure.

  29. This blood work is no cost to the employee

  30. The employee may decline testing

  31. The employer must request that the source person’s blood be tested.

  32. The source person may decline to be tested.

  33. The employer must pass along test results (confidentially, employees cannot read)

  34. The employer does not have the right to know the results of the testing.

  35. Records:

  36. Training records - dates, subjects, names of trainers and attendees must be kept for 3 years from date of training.

  37. Medical Records - HBV vaccinations, exposure incidents are confidential.

  38. Medical records must be kept for length of employment plus 30 years.

  39. Engineering Controls:

  40. Act on the hazard itself, the employee does not have to take action (examples: safety syringe, sharps container, automated instrument washers)

  41. Work Practice controls:

  42. Alter the way a job is performed. (examples: hand hygiene, disinfecting, opening instruments in front of patients, not wearing over gowns outside of the clinic, disinfecting the front of sterilizers.

  43. PPE:

  44. All items are provided at no cost to the employee by the employer - by law!

  45. The employer is responsible to make sure employees use it.

  46. PPE must be provided in the correct sizes.

  47. Gloves - tx and utility

  48. Masks - they must be changed between each patient minimally

  49. Protective eyewear with shields (side shields)

  50. Protective clothing - may not be laundered at home.

  51. Housekeeping:

  52. A written plan must be made by the office or clinic.

  53. Regulated Waste:

  54. May be more regulated locally, but not less regulated.

  55. Sharps containers, semi-liquid or caked state

  56. OPIM, double bag and label with biohazard symbol or in a red bag.

  57. Laundry:

  58. In order to protect the community at large (break the chain of infection) clothing worn at the chairside must NOT be taken outside of the office.

  59. If sent to a commercial laundry it is labeled as biohazard.

  60. Often washed on - site in the office (washing in the office)