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Case 7: Infection Control

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John Tankersley

on 29 September 2014

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Transcript of Case 7: Infection Control

Role of the Dentist
Expected to follow standard infection control preventive procedures - careful handling of sharp instruments, rubber dams, handwashing and protective barriers. (6)
Dentist should assist in the development of written infection control program for their office so everyone is aware. (6)
The infection control coordinator is responsible for overall management of the program, but all DHCP must be committed to following the guidelines to ensure a safe work place. (6)
What information should you provide the patient to allay their fears about their safety in your office?
Written infection control plan
Damaged and old instruments
Ultrasonic cleaning devices
Heat sterilization (1, 2)
What is needlestick injury?

A needlestick injury happens when a needle punctures the skin. These injuries can happen whenever people use, disassemble or dispose of needles. When used needles are not disposed of properly, these can be hidden in linen or garbage and cause injuries to those who encounter them unexpectedly.
What diseases have the potential to be
transmitted by needle stick?
What is the risk for disease transmission?
Through the accidental puncturing of the skin with a used needle, harmful fluids can be injected into the body leading to the transmission of infectious diseases (10).

-Hepatitis B
-Hepatitis C

Other pathogens that have been transmitted:
Cutaneous gonorrhea
Mycoplasma caviae
Rocky Mountain spotted fever
Staphylococcus aureus
Streptococcus pyogenes
Tuberculosis (10)
New clinic personnel must be shadowed by someone that is already trained in proper procedures (7)
The dentist must be sure that this person is competent in proper infection control (7)
The dentist must be a good example to his staff of what is expected in the clinic
A clear outline may be needed to define what is and is not acceptable (7)
Methods of Action for Sterilization and Disinfection
§108.21: Requirements
"A person practicing dentistry in the State of Texas must maintain the entire dental office... in compliance with all health requirements of the city, county or both." Offices must be in compliance with the health laws of Texas. Dentist must provide clean restroom facilities for staff and patients. All instruments and supplies must be properly sterilized(13).
§108.22: Access to Dental Office
" A person practicing dentistry in Texas must grant immediate access to the entire dental practice to any employee of
the State Board of Dental Examiners when
responding to a santitation complaint.
Failure may result in license suspension.
Patient Resources
Our Office Procedures
According to the UTSD Clinical Manual, a needle stick injury exposure is defined as:

Percutaneous inoculation with a needle contaminated with patient blood or saliva.
Percutaneous inoculation with any item (bur, scaler, broken glass, etc.) contaminated with patient blood or saliva.
Patient blood or saliva contact with an open wound, non-intact skin or mucous membrane.

*Blood or saliva contact with unbroken skin is not considered to be a "needlestick" type exposure. (12)
What is the correct protocol for avoiding a needlestick injury?
1. http://www.hu-friedy.com/content/infection-control-news-–-how-address-patient-safety-concerns
2. http://www.rdhmag.com/articles/print/volume-27/issue-4/feature/instrument-sterilization-in-dentistry.html
3: UTSD-Clinic-Manual2013-Section-2.39
4: http://www.uthouston.edu/dotAsset/72ecab8a-686c-4c12-9b55-cd1fe29a59e1.pdf
5. http://books.google.com/books?id=k5t2SnoRgjEC&pg=PA313&lpg=PA313&dq=personal+hygiene+for+dental+office+staff+to+prevent+infection&source=bl&ots=rddhvKsqCC&sig=qs88NSozAjxlzfZGH4s6LfExiGY&hl=en&sa=X&ei=wkFMUqu0GYKQrgHL6oCwDA&ved=0CFYQ6AEwAw#v=onepage&q=personal%20hygiene%20for%20dental%20office%20staff%20to%20prevent%20infection&f=false
6. "Guidelines for Infection Control in Dental Health-Care Settings --- 2003." Centers for Disease Control and Prevention. N.p., n.d. Web. 30 Sept. 2013. <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm>.
7. "infection control policy - Hygeia Dental Care." Hygeia Dental Care. N.p., n.d. Web. 30 Sept. 2013. <http://www.hygeia.co.uk/index.php?option=com_content&task=view&id=47&Itemid=30>.
8. " Guidelines for Infection Control in Dental Health Care Settings | Continuing Education Course | dentalcare.com Course Pages | DentalCare.com." DentalCare. N.p., n.d. Web. 29 Sept. 2013. <http://www.dentalcare.com/en-US/dental-education/continuing-education/ce90/ce90.aspx?ModuleName=coursecontent&PartID=3&SectionID=-1>.
9. http://books.google.com/books?id=b1L2kNnZKzMC&pg=PA194&dq=hep+b+vaccine+for+dental+office+staff&hl=en&sa=X&ei=4khMUpb3GsLnrAGXmIHQDg&ved=0CEYQ6AEwAA#v=onepage&q=hep%20b%20vaccine%20for%20dental%20office%20staff&f=false
10.Canadian Centre for Occupational Health and Safety (2005, January 25). Needlestick Injuries : OSH Answers. Retrieved October 2, 2013, from http://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html
11.Centers for Disease Control and Prevention (2003, December 19). American Dental Association. Retrieved 2, 2013, from http://ada.org/sections/professionalResources/pdfs/guidelines_cdc_infection.pdf
12.The University of Texas School of Dentistry at Houston (2013). Clinical manual:Clinic policy and procedures. UT Health The University of Texas School of Dentistry.
13. Texas State Board of Dental Examiners Rules and Regulations. 108.20-108.25. 2010
14. "ADA.org: Sterilization and Disinfection of Dental Instruments." Google. N.p., 1 July 2009. Web. 3 Oct. 2013. <http://webcache.googleusercontent.com/search?q=cache:G6qLCRK7xjkJ:www.ada.org/sections/professionalResources/pdfs/cdc_sterilization.pdf+&cd=2&hl=en&ct=clnk&gl=us&client=firefox-a>.
15. http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/index.htm
Beyond improperly cleaned instruments, what other issues related to infection control may occur in the dental office?
Dentist must ensure that OSHA guidelines are followed (8)
Failure to follow proper infection control procedures could result in monetary fines or jail time (8)
Although all personnel in the dental office are personally obligated to ensure the safety and protection of themselves and the patients, the dentist ultimately bares the majority of the responsibility.
-Care in handling sharp instruments
-Use of needle cappers
-"Scoop" technique
-Remove needles and dispose in sharps container
Personal Protective Equipment
Personal Hygiene
Protective eyewear
Hand hygiene (1)
Dental instruments are classified under 3 categories based on risk of transmission
- instruments used to penetrate soft tissue, bone or blood [14]
Must be sterilized after each use
Sterilized by autoclaving or dry heat
Forceps, scalers, scalpel , surgical burs
- do not penetrate soft tissue or bone but contact mucous membranes and non-intact skin [14]
Should be sterilized after each use.
If sterilization not feasible then use high-level disinfectant
Mirrors and reusable impression trays
- only come into contact with intact skin [14]
Can be reprocessed between patients with low-level disinfection
Blood pressure cuffs and pulse oximeters
-Safe-Point Device

-$304 on their website

In the case of a needlestick injury, what is the UTSD protocol for response?
Michael Chilton Rubi Perez
Jose Gonzales Courtney Kiel
Megan Bender Jonathan Tankersley

Group 12
Case Overview
Your Monday morning patient arrives at your office with a copy of the above article on the dentist in Oklahoma expressing concern about their dental appointment that morning and their safety.
60 Oklahoma Dental Patients Test Positive for Hepatitis, HIV
Tulsa Dentist W. Scott Harrington Faces Hearing Friday

1: Apply 1st aid
-clean exposed area with soap and water for >15 minutes
-flush mucous membranes with water or saline for >15 minutes
2: If source patient is known and present, keep them on site for bloodwork
3: Notify instructor / clinic supervisor / hospital supervisor to report injury
4: Obtain medical evaluation and treatment at:
Student Health Services Clinic
UTPB Suite 130
Hours: M-F 8:30am – 5:00pm
5: If after hours, call the Needlestick Hotline: 713-951-8013 (24-hr pager --
enter your contact number & exposure coordinator will call you back shortly)
6: Complete the ‘Supervisor’s First Report of Injury Form’ to document the injury and
submit to Risk Management & Insurance Program at OCB 1.330 or fax 713-500-8111 (4)
Refrain from touching anything not required in the procedure
Cover cuts
Pull back long hair
No jewelry or long fingernails
Wash hands before and after each procedure (5)
***In the State of Texas, you have the right to the identification,
documentation, testing, and results of the source individual
infectious disease status. Arrangements should be made
immediately with UT Student Health Services or the hospital
where the incident takes place for testing the source individual.
Source individual testing should include HIV antibody, Hepatitis C
antibody, and Hepatitis B surface antigen.
Processing Instruments
Hepatitis B
Flu (7, 9)
*HBsAg- surface antigen of HBV that indicates the person has the infection
*HBeAg-antigen that circulates in infected blood when the virus is actively replicating.

Persons infected with HBV can transmit the disease as long as they are HBsAg Positive

Risk for developing clinical hepatitis if blood if positive for HBsAg and HBeAg --> 22-31%

Risk of developing serologic evidence of HBV infection--> 37-62%

Risk for developing clinical hepatitis if HBsAg-positive and HBeAg negative--->1-6%

Risk of developing serologic evidence of HBV infection----> 23-37%

An estimated 4% of people infected with acute HBV infection, also have hepatitis Delta virus
requires HBV to replicate
persons coinfected have higher mortality rates (11)

Prior to sterilization instrumentation should be cleaned and debris removed
Enzymatic and non-enzymatic solution may be used to facilitate cleaning [14]
Gloves should be used when handling contaminated instruments
Reduce direct handling of contaminated instruments when possible (cassettes)
Use rust inhibitors to prevent corrosion
Most importantly follow the manufacturers' instruction in order to preserve the instruments most effectively
Hepatitis B Virus
Hepatitis C Virus
Not transmitted effectively through occupational exposure to blood
Low levels of seroconversion
mean 1.8% (range 0-7%)
Prevalence among health care providers 1-2% (11)
Human Immunodeficiency Virus (HIV)
Risk after a single percutaneus exposure to HIV-infected blood is 0.2-0.5% (11)
Modes of transmission:

From DHCP to patient
Patient to DHCP
Patient to patient (11)

Risk of disease transmission varies. The following factors affect it:
- Inoculum size
- Route of exposure
- Susceptibility of the exposed health care personnel (11)

Texas State Board of Dental Examiners
Chapter 108
Subchapter B: Sanitation and infection control
§108.23: Definitions
1. Barrier Techniques: use of protective items against infection-transmission during any intraoral or invasive procedure. This includes protective eye wear and nasal/oral masks.

2. Disinfection - partial elimination of active growth stage bacteria and the inactivation of some viruses. Risk of infection still remains for M. tuberculosis, hepatitis A virus (HAV) and hepatitis B virus (HBV). virus (HIV) following disinfection.

3. Sterilization - process by which all forms of life within a defined environment are completely destroyed.
s §108.24 Require sterilization and disinfection
(a-b) Sterilization is required for all surgical and other instruments that may be used intraorally or extraorally. must be disinfected with an American Dental Association-registered solution that is tuberculocidal. Must undergo at least one of the following procedures.
(1) Steam autoclave
(2) Chemical Vapor
(3) Dry-heat oven
(4) Ethylene oxide
(5) Chemical sterilant
(c-e). instruments, operatory equipment
and oral prosthetic appliances must
be sterilized by a CDC or ADA-approved
method before being used or being
placed in patients mouth.
(f). Disposable items must be used only once. Includes gloves,
needles, IV fluids and administering tubing, and catheters should
be disposed by OSHA guidelines.
s §108.25 Dental Health Care Workers.
(a) Dental health care workers shall comply with the universal precautions, as
recommended for dentistry by the CDC and required by THSC, §85.202, in the
care, handling, and treatment of patients.
(b.) Dental health care workers with exudative lesions shall refrain from contact
with equipment that may be used for or during patient care unless proper
barrier techniques will prevent contact with the wound.
(c-d.) Dental health care workers with HIV or HBV shall report his/her health
status to an expert review panel. You must also notify a prospective patient of the
seropositivity. You must obtain consent from the patient before evasive procedures.
(e). Dental care workers should receive TB tests annually. The Board encourages
compliance with the guidelines for tuberculosis testing and control recommended
by the CDC and Prevention and the Texas Department of Health (13).
(g-i) Items such as extracted teeth are considered biohazardous and must be
considered non-biohazardous before sending or returning items to the patient.
Teeth or tissue fragments, used for microscopic testing or educational purposes must
be sterilized. Items that must be sent or received from a dental laboratory must be
considered non-biohazardous by the OSHA guidelines.

Cold Sterilization
Liquid chemical germicide
Used on heat sensitive dental instruments
Procedure can take up to 10 hours of exposure to chemical agent in order to fully disinfect or sterilize instrumentation [14]
Ultimately, instruments rinsed with sterile water then dried and placed into a sterile container
To allay fears about safety in the office we would display a written infection control plan. The infection control plan would include how we handle damaged and old instruments as well as how we sterilize equipment.

A person practicing dentistry in the State of Texas must maintain the entire dental office... in compliance with all health requirements of the city, county or both

Dentists are expected to follow standard infection control preventive procedures. The dentist should assist in the development of written infection control program for their office.

Instruments are sterilized and disinfected based on which category of risk transmission it falls under. Instruments that are heat sensitive undergo cold sterilization. Cold sterilization utilizes liquid chemical germicide.

Other than instrument sterilization, dental offices may control infection by increasing personal hygiene and obtaining vaccinations.

A needle stick injury happens when a needle punctures the skin. These injuries can happen whenever people use, disassemble or dispose of needles. Blood or saliva contact with unbroken skin is not considered to be a "needlestick" type exposure.

HIV/AIDS, Hepatitis B, and Hepatitis C have the potential to be transmitted by needle stick.

Individuals may use needle cappers, “scoop technique”, and improve their sharp instrument handling to avoid a needle stick injury.

UTSD protocol for needle stick injury includes: applying first aid, performing bloodwork on source patient, notifying instructor and/or supervisors, and obtaining medical evaluation. If needlestick occurs after hours, individuals can call the Needlestick Hotline.

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