Infection Control Rationale and Regulations

• Patient to dental team

• Dental team to patient

• Patient to patient

• Dental office to community, including the dental team’s families

• Community to patient

PATIENT TO DENTAL TEAM

The opportunities for spread of patient microorganisms to members of the dental team are numerous, and this pathway is more difficult to control than the other fourpathways. Direct contact (touching) with patient’s saliva or blood may lead to entrance of microorganisms through nonintact skin resulting from cuts, abrasions, or dermatitis. Invisible breaks in the skin also exist, especially around the fingernails. Sprays, spatter, or aerosols from the patient’s mouth may lead to droplet infection through nonintact skin; mucosal surfaces of the eyes, nose, and mouth; or inhalation. Indirect contact involves transfer of microorganisms from the source (e.g., the patient’s mouth) to an item or surface and subsequent contact with the contaminated item or surface. Examples include cuts or punctures with contaminated sharp objects (e.g., instruments, needles, burs, files, scalpel blades, and wire) and entrance through nonintact skin as a result of touching contaminated instruments, surfaces, or other items. Another opportunity for disease spread occurs by direct contact with infectious skin lesions or other nonintact skin of the patient with entrance of microorganisms through nonintact skin on the dental member’s hands. This latter route of disease spread in the office is not common.

Infection control procedures to prevent patient-to- dental team spread are listed in Table 8-1 and are described in detail in subsequent chapters.

DENTAL TEAM TO PATIENT

Spread of disease agents from the dental team to patients is a rare event but could happen if members do not follow proper procedures. If the hands of dental team members contain lesions or other nonintact skin, or if their hands are injured while in the patient’s mouth, blood-borne pathogens or other microorganisms could be transferred by direct contact with the patient’s mouth, and they might gain entrance through mucous membranes or open tissue. The patient may have indirect contact with blood-borne pathogens or other agents if a member of the dental team bleeds on instruments or other items that then are used in the patient’s mouth. Chapter 6 describes apparent spread of blood-borne diseases from dentists to patients. Droplet infection of the patient from the dental team could occur, but this can occur in everyday life and is certainly not unique to the dental office.

Infection control procedures that interfere with this pathway of cross-contamination are listed in Table 8-1 and are described later.

PATIENT-TO-PATIENT

Disease agents might be transferred from patient to patient by indirect contact through improperly prepared instruments, handpieces and attachments, operatory surfaces, and hands. Although, at the time of this writing, disease transmission from contaminated instruments or surfaces to dental patients has not been documented, the potential for such transfer does exist and has been documented to occur in the medical field. Conversely, transfer of the herpes simplex virus from a patient to the hands of a hygienist and then to the mouths of several patients has been documented, as described further in Chapter 10 under the discussion on gloves.

PATIENT-TO-PATIENT SPREAD OF HUMANIM MUNODEFICIENCY VIRUS

A report indicates the apparent spread of humanimmunodeficiency virus (HIV) from patient to patient in a medical/surgical practice in New South Wales, Australia. Five of nine patients seen in that medical office on the same day in November 1989 became HIV-positive, but the surgeon was HIV-negative. All five of these patients had minor surgeries that day involving the removal of moles or small cysts. Four of the five patients who became HIV-positive did not have any apparent risk factors for acquiring HIV disease (e.g., intravenous drug abuse, multiple sex partners of unknown HIV status, blood transfusions, or sexually transmitted diseases). These four patients also experienced sore throat, swollen glands under the chin, slight joint pains, and slight fever in December 1989. These are the symptoms of an HIV infection, referred to as acute retroviral syndrome, that usually occur about a month after the initial infection. The fifth patientadmitted to having sex with male partners of unknown HIV status—likely his source of HIV. This patient died of Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia (a leading cause of infectious disease death in patients with acquired immunodeficiency syndrome) in 1990. This strongly suggests that he already was infected in November 1989 when he was in the New South Wales medical office and that this patient served as the source of HIV in this incident.

The surgeon in this practice indicated that he ran the office by himself and that he did not use multiple dose injection vials (an important mode of disease spread), did not reuse scalpel blades but did reuse the handles, and changed gloves for every patient. He stated that he processed his contaminated instruments by soaking them in 1% glutaraldehyde, washing them in water, and placing them in boiling water for 5 to 10 minutes. These procedures have several problems (Chapter 11 describes the correct procedures for processing contaminated instruments). Because glutaraldehyde disinfectant/ sterilant is commercially available only at concentrations between 2.0% and 3.4%, the surgeon apparently diluted his glutaraldehyde before using it, which saves money but also dilutes microbial effectiveness. Apparently, the instruments were not scrubbed or ultrasonically cleaned in a detergent, which suggests that blood could have remained on them after “washing in water.” Although boiling likely can kill most microorganisms on instruments, if the instruments are clean, boiling is not a recognized method of sterilization. Obviously, the instruments were not wrapped before processing, so they may have become recontaminated as a result of improper handling after the boiling step but before they were reused on another patient.

The surgeon also stated that the instrument processing area was about 9 feet away from where the surgeries were performed. Without a physical separation between “clean” areas and “dirty” areas, chances increase for cross-contamination. Thus several breaches in infection control procedures are apparent in this medical practice that may have resulted in the spread of HIV from onepatient to four others that day. Unfortunately, theappointment schedule for that day was not available to confirm that the HIV-positive man was an early patient of the day. The infection control procedures used to prevent patient-to-patient spread of disease agents are listed in Table 8-1 and are described in more detail later.

PATIENT-TO-PATIENT SPREAD OF HEPATITIS B VIRUS

Although dental workers are at occupational risk of acquiring hepatitis B, there has been a decline in such cases over the last 20 years due to the vaccine andenhanced infection control procedures. Also, no cases of hepatitis B spread from dentist-to-patient have been reported since 1987. However, the very first report of patient-to-patient spread of the hepatitis B virus (HBV) in a dental office appeared in 2007. This incidentoccurred in September 2001 in an oral surgery practice in New Mexico. The investigation by the CDC and the state department of health showed that the woman who acquired hepatitis B (index patient) had 11 teeth extracted in the same operatory used earlier that day for the extraction of 3 teeth from a patient later found to be HBV-positive (source patient). The same doctor and assisting staff performed the surgeries on both of these patients, but none of the office workers had serologic evidence of HBV-infection. Genetic analysis and viral typing showed that the viruses from theindex and source patients matched. The source patient was HBeAg-positive, which indicated a high viral load. Further investigation revealed no unusual events on that day in question. Medication vials were managed appropriately. Standard precautions for preventing the spread of blood-borne viruses were followed, including appropriate hand antisepsis. Gloves, gowns, and masks were changed for each patient. Nitrous oxide masks were cleaned and disinfected between use, and surgical instruments were hand scrubbed, rinsed, dried, packaged, and processed through a steam sterilizer between patients. High-touch areas in the operatory were covered with plastic or foil and changed for each patient. Surfaces were also disinfected between patients.

Thus, whereas he evidence indicated that patient-to-patient spread of HBV occurred, there was no evidence of a breakdown in procedures. The investigators could only speculate on the mode of transmission. One possibility was cross-contamination from an environmental surface that was not adequately cleaned and disinfected despite the good standard operating procedures detected. The use of multidose vials in general are highly suspect in transmission events, but the procedures performed in this instance were found to be totally appropriate. One interesting note is that 3 of the 5 patients seen on that day after the source patient had already been vaccinated against hepatitis B. This may have limited the spread and prevented the investigators from identifying the mechanisms of the spread by possibly identifying common factors.

DENTAL OFFICE TO COMMUNITY

The dental office to community pathway may occur if microorganisms from the patient contaminate items that are sent out or are transported away from the office. For example, contaminated impressions or appliances or equipment needing service in turn may contaminate personnel or surfaces in dental laboratories and repair centers indirectly. Dental laboratory technicians have been infected occupationally with hepatitis B virus (HBV).

This pathway may also occur if members of thedental team transport microorganisms out of the office on contaminated clothing. In addition, if a member of the dental team acquires an infectious disease at work, the disease could be spread to personal contacts outside the office.

Regulated waste that contains infectious agents and is transported from the office may contaminate waste haulers if it is not in proper containers. Immunity from hepatitis B vaccination protects the dental team from acquiring the disease and passing it along to family members. Other infection control procedures that interfere with the office to community pathway are listed in Table 8-1 and are described in later chapters.

COMMUNITY TO PATIENT

The community to patient pathway involves the entrance of microorganisms into the dental office in the water that supplies the dental unit. These waterborne microorganisms colonize the inside of the dental unit water lines and form a film of microorganisms (biofilm) on the inside of these lines. As water flows through the lines during use of the air-water syringe, high-speed handpiece, or ultrasonic scaler on some units, it “picks up” microorganisms shed by the biofilm. Although municipal water may have a dozen or so bacteria per milliliter (mL) of water as it enters the dental unit, the water exiting a dental unit through the air-water syringe or through the spray from a high-speed handpiece may contain more than 100,000 bacteria per mL. One mL is equivalent to about one fourth of a teaspoon.

No evidence exists that this contaminated water is making individuals sick on any wide scale, but use of heavily contaminated water during dental care is not good infection control practice. Such water certainly must not be used during surgery. Potential pathogens (e.g., Pseudomonas aeruginosa and Legionella pneumophila) may be present in the incoming water and in the dental unit water line biofilm. One report from England describes how in 1988 two cancer-compromised patients acquired oral infections with P. aeruginosa that was later found to be present in water from a dental unit previously used in the care of those patients. Chapter 13 presents more details about contaminated dental unit water, and Table 8-1 suggests infection control procedures to improve the microbial quality of dental unit water.

CENTERS FOR DISEASE CONTROL AND PREVENTION

The current infection control recommendations for dentistry from the Centers for Disease Control and Prevention (CDC) are summarized in this chapter and are presented in total in Appendix B. Although the CDC began making general infection control recommendations many years ago, their first set of complete recommendations directed specifically toward dentistry was in 1986, with updates in 1993 and in 2003. Most infection control procedures practiced in dentistry today are based on the 2003 recommendations. The CDC is a part of the Public Health Service, which is a division of the U.S. Department of Health and Human Services. The CDC has a Division of Oral Health that studies oral diseases, fluoride applications, and infection control in dentistry. The CDC does not have the authority to make laws, but many of the local, state, and federal agencies use CDC recommendations to formulate the laws. See Appendix B for further information on the CDC and how to access their Web site and infection control recommendations.

The CDC also has published guidelines on preventing the transmission of tuberculosis in health care settings, which include dental offices. Excerpts from these guidelines are presented in Appendixes B and C.

AMERICAN DENTAL ASSOCIATION

The American Dental Association (ADA) has provided detailed infection control recommendations since the 1970s and currently makes such recommendations through its Councils on Scientific Affairs and Dental Practice. The most recent detailed recommendations from the ADA were published in the August 1996 issue of the Journal of the American Dental Association. The ADA supports the 2003 CDC infection control recommendations as described in the ADA’s Statement on Infection Control in Dentistry (see Appendix G). The ADA’s main office is located in Chicago, and Appendix A gives its Web address.

ORGANIZATION FOR SAFETY AND ASEPSIS PROCEDURES

The Organization for Safety and Asepsis Procedures (OSAP) (see Appendix A) is a not-for-profit professional organization composed of dentists, hygienists, assistants, university professors, researchers, manufacturers, distributors, consultants, and others interested in infection control. This broad-based group is the premier infection control education organization in dentistry. The organization provides a monthly publication to keep its members in pace with new information and also provides a newsletter, reports, position papers, announcements, and press releases. This organization also sponsors regional and national educational programs related to infection control for its members. All members of the dental team should join this organization to keep up to date in the area of infection control (see Appendixes A and D).

ASSOCIATION FOR THE ADVANCEMENT OF MEDICAL INSTRUMENTATION

The Association for the Advancement of Medical Instrumentation (AMMI) (see Appendix A) is another voluntary organization that is composed of manufacturers, distributors, researchers, regulators, and users of medical/dental equipment. One component of this organization is devoted to developing sterilization standards, including recommended practices on how properly to use sterilizers and technical documents on the equipment. For example, two documents of particular interest to the dental team describe the proper use and monitoring of small office steam and dry heat sterilizers.

STATE AND LOCAL

Some state and local regulations exist in relation to medical waste management, instrument sterilization, and sterilizer spore testing in dentistry. Examples of states with such special dental infection control regulations include California, Connecticut, Florida, Indiana, Missouri, Ohio, Oregon, and Washington. In some instances these regulations are made by the county health departments and in others by state legislatures, state boards of dental examiners, state dental disciplinary boards, or state departments of health.

Twenty-six states also have their own division of the Occupational Safety and Health Administration (OSHA) in their state departments of labor (see Appendix A). These states must administer regional OSHA standards, including those for occupational exposure to blood-borne pathogens and for management of hazardous materials, which are at least as stringent as the federal OSHA standards (see the section on OSHA, p. 86).

Because infection control regulations can vary from state to state, particularly in the areas of instrument sterilization, waste management, and sterilizer spore testing, it is important for the dental team to keep in contact with the various state agencies for the latest information that may affect infection control in the dental office. Two other sources of information may be the state dental association and the infection control officer in a school of dentistry located in the state.

FOOD AND DRUG ADMINISTRATION

The Food and Drug Administration (FDA) (see Appendix A) is a part of the U.S. Department of Health and Human Services. In relation to infection control, the FDA regulates the manufacturing and labeling of medical devices (such as sterilizers, biologic and chemical indicators, ultrasonic cleaners and cleaning solutions, liquid sterilants [e.g., glutaraldehydes], gloves, masks, surgical gowns, protective eyewear, handpieces, dental instruments, dental chairs, and dental unit lights) and of antimicrobial handwashing agents and mouth rinses.

The purpose of the FDA is to ensure the safety and effectiveness of drugs and medical devices by requiring “good manufacturing practices” and reviewing the devices against associated labeling to ensure that claims can be supported. The FDA may require general controls, certain performance standards, or various items such as notification from a manufacturer that a device is about to be marketed to requiring certain performance standards or approval of the device before marketing. All medical devices to be sold in the United States first must be cleared by the FDA. To do this, the manufacturers submit to the FDA a 510(k) application (premarket notification) that describes the device and the manufacturing facilities and presents the results of studies conducted to support any claims of effectiveness and safety made for the device. The FDA does not control the actual use of a medical device but indicates that misuse (using an item contrary to instructions on the device) transfers any liability for problems that develop from the manufacturer to the user.

ENVIRONMENTAL PROTECTION AGENCY

The U.S. Environmental Protection Agency (EPA) (see Appendix A) is associated with infection control by attempting to ensure the safety and effectiveness of disinfectants. The EPA also is involved in regulating medical waste after it leaves the dental office. Information on the safety and effectiveness of disinfectants must be submitted by manufacturers to the EPA for review to make sure that safety and the antimicrobial claims stated for the products are supported with scientific evidence. If the claims meet the criteria, the disinfectant product receives an EPA registration number that must appear on the product label. Chapter 16 discusses EPA involvement with waste management.

OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

The Occupational Safety and Health Administration (OSHA) (see Appendix A) is a division of the U.S. Department of Labor, and its charge is to protect the workers of America from physical, chemical, or infectious hazards in the workplace. Chapter 22 describes the OSHA standard for protection against hazardous chemicals. OSHA began to develop its standard for protection against occupational exposure to blood-borne pathogens in 1986 and published the final rules in 1991. The standard is known as the blood-borne pathogens standard, and it became effective nationwide in 1992. OSHA requires that a copy of the regulatory text of this standard be present in every dental office and clinic. Appendix H provides the text of the standard.

This standard indicates that the employer has the responsibility to protect employees from exposure to blood and other potentially infectious materials in the workplace and to give proper care if such exposure does occur. The standard applies to employers in any type of facility in which employees have a potential for exposure to body fluids, including dental and medical offices; dental, clinical, and research laboratories; hospitals; funeral homes; emergency medical services; nursing homes; and others.

Compliance with this standard is monitored through investigations of facilities by OSHA compliance officers after a complaint by an employee of the facility to OSHA. Compliance officers also may investigate a facility with 11 or more employees in the absence of an employee complaint. Noncompliance with any rule in the standard can result in a fine.

The standard is effective throughout the United States and in 26 states is administered by the state OSHA programs. In the other states, the standard is administered through regional branches of the federal OSHA (see Appendix A for details).

EXPOSURE DETERMINATION

An occupational exposure is defined as any reasonably anticipated skin, eye, mucous membrane, or parenteral (e.g., needlestick, cut, abrasion, or instrument puncture) contact with blood or other potentially infectious material such as saliva that may result from the performance of an employee’s duties. For the exposure determinations, one must survey all tasks performed by all employees and make a list of all job classifications in the office in which all of the employees in that classification have occupational exposure (e.g., “dentist,” “dental hygienist,” “clinical dental assistant”) and then make a second list of job classifications in which some of the employees in that classification may have occupational exposure (e.g., “receptionist,” “bookkeeper,” “office manager”). The employer must make these determinations as if gloves, masks, eyeglasses, and protective clothing are not being used.

Now the employer must make a list of all tasks and procedures or groups of closely related tasks and procedures in which occupational exposure occurs (without regard to personal protective equipment or clothing) and that are performed by employees in job classifications noted in the second list.

Employees in these job classifications on the first and second lists are covered under the standard.

SCHEDULE OF IMPLEMENTATION

The employer must prepare a schedule of when and how each provision of the standard will be implemented. The provisions to be included are listed in Box 8-2 and described further in this chapter. One approach in a small office is simply to make notes on a copy of the standard of when (a specific date) and how each provision will be implemented. Larger facilities may wish to prepare a more extensive document covering all health and safety provisions that includes the exposure control plan.

EVALUATION OF EXPOSURE INCIDENTS

If an employee is exposed to blood, saliva, or other potentially infectious materials, the employer must evaluate the circumstances surrounding the incident. The route of exposure needs to be documented (e.g., splash in the eyes or needlestick in the left thumb), and the source patient, types of protective barriers worn at the time of exposure, and what the employee was doing at the time of exposure should be documented. Documentation can best be accomplished by using an exposure incident report form (see an example in Appendix E). Evaluation of this information will assist in the postexposure medical evaluation (described later) of the employee and will determine whether the employee may need further training in attempts to prevent future exposures.

EVALUATION AND USE OF SAFETY DEVICES

Each dental office must document annually the consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupationalexposure. An employer who is required to establish an exposure control plan shall solicit input from nonmanagerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in theexposure control plan.

INFORMATION AND TRAINING

The OSHA standard indicates that employers shall ensure that all employees with occupational exposure participate in a training program on the hazards associated with body fluids and the protective measures to be taken to minimize the risk of occupational exposure. Box 8-3 gives the minimum content of the required training program. The training is to be provided at no cost to the employee at the time of initial appointment (before the employee is placed in a position in which occupational exposure may occur) and at least annually thereafter, as well as whenever job tasks change that may reflect the employee’s potential for exposure. The training must be given to full-time, part-time, and temporary employees who have a potential for exposure.

A person must conduct the training or at least be available during the training to answer questions. Training solely by means of a film or videotape or written material without the opportunity for discussion is not acceptable. Likewise, a generic computer program, even an interactive one, is not considered appropriate unless it is supplemented with the site-specificinformation required (e.g., the location of the exposure control plan and the procedures to be followed if an exposure incident occurs) and a person is accessible for interaction.

The OSHA standard requires that the person conducting the training be knowledgeable about blood-borne pathogens and about infection control procedures related to the dental workplace. The dentist-employer, hygienists, assistants, dental school professors, or others may conduct the training, provided they are familiar with blood-borne pathogen control and the subject matter required to be presented. The trainer must be able to answer questions related to the information presented.

The manner of the training must be at a level that is appropriate for the employees being trained (e.g., employee’s education, language, and literacy level). If an employee is proficient only in a foreign language, the trainer or an interpreter must convey the information in that language.

The required record keeping (described subsequently) on the training session includes a description of the qualifications of the person providing the training. Occupational Safety and Health Administration compliance officers will verify the competency of the trainer based on the completion of specialized courses, degree programs, or work experiences if the officer determines during an investigation that deficiencies in training exist.

USE OF SIGNS AND LABELS

Warning labels containing the biohazard symbol and the word “Biohazard” are fluorescent orange or orange-red with the lettering and symbol in a contrasting color (Figure 8-1). Such labels must be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport, or ship blood or other potentially infectious materials. Red bags or red containers may be substituted for labels (if employees are trained as to the meaning of the red bags or containers). Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment, or disposal are exempt from the labeling requirement. Contaminated equipment that is to be shipped for service must be labeled, however, and the label must include a description of the part of the equipment that is contaminated.

Contaminated laundry also must be labeled properly, as described later in this chapter.

DOCUMENTATION OF EXPOSURE

After a report of an exposure incident, the employer must make immediately available to the exposed employee a confidential medical evaluation and follow-up at no cost to the employee at a reasonable time and place and performed or supervised by a licensed physician or other licensed health care professional (Box 8-5). The employer must document the exposure and surrounding circumstances, a task best accomplished by using an exposure incident report form as previously mentioned (see Appendix E). The employer gives this documentation and a job description of the employee as related to the incident, any information documenting the exposed employee’s hepatitis B vaccination status (e.g., past written opinions from the health care professional), any written opinions of a health care professional from past exposure incidents, and a copy of the OSHA standard to the evaluating health care professional.

TESTING OF THE SOURCE INDIVIDUAL

The source individual is any patient whose body fluid is involved in the exposure incident. After an employee exposure, the employer must request promptly that the source individual’s blood be tested (with consent) to determine HBV and HIV infectivity, unless this person already is known to be infected with HBV or HIV. If the source individual does not give consent for testing or if it is not feasible to obtain consent, the employer shall establish that this consent cannot be obtained. If consent is given, the source individual may be sent to the health care professional or an appropriate accredited laboratory or testing site for the testing. The results of the source individual’s tests are confidential and are to be directed only to the health care professional evaluating the exposed employee. The employer must ensure that the exposed employee is informed confidentially of these results by the attending health care professional, but the employer does not have the right to know the source individual’s test results.

TESTING THE EXPOSED EMPLOYEE

The employer must make available collection and testing of blood from the exposed employee for HBV and HIV status with the employee’s consent. The collection can be arranged through the health care professional. If the employee consents to blood collection but does not give consent for testing for HIV, the blood sample is to be preserved for 90 days, in case the employee later consents to testing. The health care professional is to provide medical evaluation and follow-up according to the U.S. Public Health Service recommendations and to provide the employer with a written opinion within 15 days after the evaluation. This written opinion shall include only the following information: (1) that the employee has been informed of the results of the evaluation and (2) that the employee has been told about any medical conditions resulting from exposure that require further evaluation or treatment. All other findings or diagnoses shall remain confidential and shall not be included in the written opinion.

The employer is to keep this written opinion in a confidential employee medical records file with the hepatitis B vaccination written opinion for that employee.

TRAINING RECORDS

Records documenting that employees covered under the standard received the required training must contain (1) dates of the training sessions, (2) contents or summary of the training, (3) names and qualifications of the persons conducting the training, and (4) names and job titles of all persons attending the training sessions. The records are to be kept for 3 years from the date on which the training occurred.

EMPLOYEE MEDICAL RECORDS

Medical records for each employee covered under the standard are to include (1) the name and Social Security number of the employee; (2) the hepatitis B vaccination status, including the dates of vaccination and the written opinion from the health care professional regarding the vaccination or the signed statement that the employee declined the offer to be vaccinated; and (3) reports documenting occupational exposure incidents, as well as the written opinion from the health care professional who made the evaluation.

These medical records are confidential and are not to be disclosed except to the employee, anyone having written consent of the employee, representatives of the secretary of labor (on request), or as required or permitted by state or federal law. The records must be maintained for 30 years past the last date of employment.

HANDWASHING

Readily accessible handwashing facilities are to be provided to employees. In the rare instances when this is not feasible, antiseptic towelettes or an antiseptic hand cleaner and cloth or paper towels are to be provided, with soap and water handwashing to follow as soon as feasible. Employers are to ensure that employees wash their hands as soon as possible after removal of gloves or other personal protective equipment. Hands and other skin are to be washed with soap and water, and mucous membranes are to be flushed with water as soon as feasible after contact of these body sites with blood/saliva.

HANDLING OF DISPOSABLE CONTAMINATED SHARPS

Contaminated needles and other sharps are not to be bent, recapped, or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure. Clearly, disposable needles must be removed from the nondisposable dental anesthetic syringes. Recapping is to be accomplished using a one-handed technique or a mechanical device. Shearing or breaking of contaminated needles also is prohibited.

HANDLING OF REUSABLE CONTAMINATED SHARPS

Contaminated reusable sharps (e.g., special needles and sharp instruments) are to be placed in appropriate containers as soon as possible after use. The containers shall be puncture-resistant and color coded or labeled with a biohazard symbol and be leakproof on the sides and bottom. The sharps shall not be stored or processed (before decontamination) in a manner that requires employees to reach blindly into containers where these sharps have been placed.

RESTRICTED ACTIVITIES IN THE WORK AREA

Eating, drinking, smoking, applying of cosmetics or lip balm, and handling of contact lenses are prohibited in work areas where a chance exists for occupational exposure. Food and drink cannot be stored in refrigerators or freezers or kept on shelves or on countertops or in cabinets where blood or saliva is present.

MINIMIZING SPATTER

All procedures involving blood or saliva are to be performed in such a manner that minimizes splashing, spraying, spattering, and generation of droplets of these substances. Although OSHA does not mention specific procedures that limit spatter and generation of droplets in dentistry, one might consider using a rubber dam, high-volume evacuation, and preprocedure mouth rinsing.

SPECIMEN CONTAINERS

Specimens of blood or saliva or other potentially infectious material are to be placed in a container that prevents leakage during collection, handling, processing, storage, or shipping. The container is to be closed and color coded or labeled with a biohazard symbol for storage, transport, or shipping. A second container with the same characteristics is to be used if the outside of the primary container is contaminated. If the specimen could puncture the primary container, a second container with the same characteristics plus being puncture resistant is to be used.

SERVICING OF CONTAMINATED EQUIPMENT

Equipment that may become contaminated with blood or saliva or other potentially infectious materials is to be examined before servicing or shipping and is to be decontaminated as necessary unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible. If portions remain contaminated, these portions are to be identified and labeled with a biohazard symbol. This identification and labeling information is to be conveyed to all affected employees, the servicing representative, and the manufacturer, as appropriate, before handling, servicing, or shipping so that proper precautions will be taken.

GLOVES

Gloves are to be worn when the employee may have hand contact with blood or saliva, mucous membranes, nonintact skin, or when handling or touching contaminated items or surfaces. Handwashing isrequired after glove removal. Surgical or examination gloves are to be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or otherwise compromised. Disposable gloves are not to be washed or decontaminated for reuse. Utility gloves may be decontaminated for reuse if the integrity of the glove is not compromised. However, they must be discarded if cracked, peeling, torn, or punctured or if they become deteriorated in any way.

MASKS, EYE PROTECTION, AND FACE SHIELDS

Masks in combination with eye protection devices such as goggles or glasses with solid side shields, or chin-length face shields, are to be worn whenever splashes, spray, spatter, or droplets of blood or saliva may be generated and eye, nose, or mouth contamination may occur. If face shields are used, they need to be curved to give protection to the sides of the eyes. If regular prescription glasses are used as protective eyewear, they should have clip-on side shields.

PROTECTIVE CLOTHING

Appropriate protective clothing such as gowns, aprons, lab coats, clinic jackets, or similar outer garments are to be worn in occupational exposure situations. The employer must evaluate the task to determine the appropriate nature of the protective clothing to be used. Examples of different levels of exposure given by OSHA are “soiled” (low level, requiring laboratory coats), “splashed, splattered, or sprayed” (medium level, requiring fluid-resistant garments), “soaked” (high level, requiring fluid-proof garments).

Protective clothing must not permit blood or saliva to pass through or reach the employees’ work clothes, street clothes, undergarments, or skin. If an item of clothing is intended to protect the employees’ person or work clothes or street clothes against contact with blood or saliva, then it would be considered as personal protective clothing. If a uniform is used to protect the employee from exposure, the uniform is considered personal protective clothing. If a lab coat or protective gown is placed over the uniform, the uniform is not protective clothing; the lab coat or gown is. Thus, the outer covering is the protective clothing that the employer must provide.

The employer also is required to maintain, clean, launder, and dispose of all personal protective equipment, including protective clothing, at no cost to the employee. Furthermore, employees cannot launder the protective clothing at home. Thus, employers must provide disposable protective clothing or reusable protective clothing that is laundered in the office or is cleaned by a laundry service. OSHA reasons that, with these options, the employer has control over the protective clothing to ensure proper disposal or cleaning.

CONTAMINATED SHARPS

Contaminated sharps (anything that could puncture the skin and contains blood or other potentially infectious materials) are to be placed in containers that are closable, puncture-resistant, leakproof on the sides and bottom, and color coded red or marked with a biohazard symbol. These are called sharps containers or sharps boxes. The containers are to be easily accessible and located as close as possible to where sharps are used or may be found (e.g., at chairside and in the sterilizing room). The containers are to be maintained in an upright position (so that the contents do not spill out) and are to be replaced routinely and not allowed to overflow. The containers are to be closed during handling, storage, transport, and shipment. If the outside of the container is contaminated or if the container leaks, the container is to be placed in a second leakproof, puncture-resistant, color-coded or labeled container during handling, storage, transport, or shipping.

OTHER REGULATED WASTE

Other regulated waste that is nonsharp (e.g., any item that could release liquid, semiliquid, or caked blood or other potentially infectious materials when compressed, such as a blood- or saliva-saturated gauze square) is to be placed in containers that are leakproof, closable, and color coded or labeled with a biohazard symbol. An example is a biohazard bag. The containers are to be closed before handling, storage, transport, or shipping, and if the outside of the container is contaminated, the container is to be placed in a second closable, leakproof, color-coded or labeled container that is closed before handling, storage, transport, and shipping.

a. Food and Drug Administration

b. Environmental Protection Agency

c. Occupational Safety and Health Administration

d. Centers for Disease Control and Prevention

a. Food and Drug Administration

b. Environmental Protection Agency

c. Occupational Safety and Health Administration

d. Centers for Disease Control and Prevention

a. Food and Drug Administration

b. Environmental Protection Agency

c. Occupational Safety and Health Administration

d. Centers for Disease Control and Prevention

a. patient to dental team

b. dental team to patient

c. patient to patient

d. community to office

a. community to office

b. dental team to patient

c. patient to dental team

a. eliminate all microbes in the office

b. prevent all pathogenic microbes from entering the office

c. sterilize all operatory surfaces between patients

d. reduce the dose of microorganisms that may be shared between individuals

a. Association for Advancement of Medical Instrumentation

b. Organization for Safety and Asepsis Procedures

c. Occupational Safety and Health Administration

d. Environmental Protection Agency

a. wearing a surgical mask at chairside during patient care

b. wearing gloves during instrument processing and operatory cleanup

c. handwashing

d. cleaning and sterilizing reusable hand instruments between patients

a. the employee

b. the employee’s insurance company

c. the employer

a. cover more topics than the blood-borne pathogens standard

b. are identical to the blood-borne pathogens standard

c. have not been updated since 1993

d. say nothing about instrument sterilization