géza t. terézhalmy, d.d.s.,m.a. professor and dean emeritus school of dental medicine case western...

Géza T. Terézhalmy, D.D.S.,M.A.Géza T. Terézhalmy, D.D.S.,M.A.

Professor and Dean EmeritusProfessor and Dean Emeritus

School of Dental MedicineSchool of Dental Medicine

Case Western Reserve UniversityCase Western Reserve University

Cleveland, OhioCleveland, Ohio

[email protected]@case.edu

Preprocedural antimicrobial rinses Procedures shall be performed in such a

manner as to minimize splash, spattering, and aerosols Patients MAY rinse with chlorhexidine gluconate-, or

an essential oil-, or povidone iodine-containing mouthwash

01/01/2010 Terezhalmy 2


0.12% Chlorhexidine gluconate


Disposition of reusable patient-care items Critical

Penetrate soft tissue and bone during their intended use

Semi-critical Touch mucous membranes or non-intact skin during

their intended use

Non-critical Contact only intact skin during their intended use


Critical and semi-critical items MUST be cleaned and MUST be heat sterilized Heat-sensitive items MUST be cleaned and

MUST be sterilized using Ethylene oxide OR FDA-registered sterilants

e.g., glutaraldehyde, glutaraldehyde with phenol, hydrogen peroxide, or hydrogen peroxide with peracetic acid

http://www.epa.gov/oppad001/chemregindex.htmhttp://www.epa.gov/oppad001/chemregindex.htm


Central instrument processing area Receiving and cleaning

Clean instruments using an ultrasonic system with a strainer type basket

Visually inspect instruments are for residual debris and damage


Preparation and packaging Assemble cassettes, tray sets, or packs with hinged

instruments unlocked and open Place an internal or an external chemical indicator

in or on each cassette, tray set, or pack Date all cassettes, tray sets, or wrapped packs


Sterilization MUST use an FDA cleared sterilizer

Load cassettes, tray sets, or packs according to manufacturer’s recommendations

Set cycle time, temperature, and pressure according to manufacturer’s recommendation

Allow packages to cool and dry before removing from the sterilizer


Storage MUST be a clean, enclosed, and dry area

Cassettes, tray sets, or packs remain sterile indefinitely

Instruments in compromised cassettes, tray sets, or packs MUST be re-cleaned, re-wrapped, and re-sterilized

Cassettes, tray sets, or packs MUST be delivered to the operatories in a manner that maintains sterility until instruments are used


Monitoring the sterilization process Mechanical: each load

Assess the cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer

Chemical: each load Use time- and temperature-sensitive internal or

external indicators to assess physical conditions during the sterilization process


Biological: weekly Place a spore strip or vial inside one of the

cassettes, tray sets, or packs Place the cassette, tray set, or pack in the center of

the load A strip or vial, which is not heat processed, is used

as a control Maintain a record of the weekly results


Quality assurance procedures following mechanical, chemical, or biological failure Secure sterilizer Make log entry Take corrective action Retest sterilizer using a biological monitor Suspect loads dating back to the last

negative biological test MUST be re-called, re-wrapped, and re-sterilized


Non-critical items MUST be cleaned MUST be disinfected

EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim e.g., chlorine-containing products, quaternary

ammonium compounds with alcohol, phenolics, or iodophors

http://www.epa.gov/oppad001/chemregindex.htmhttp://www.epa.gov/oppad001/chemregindex.htm


Disposition of single-use patient-care items Disposable sharps

MUST be removed from cassettes, tray sets, or packs in the patient treatment area

MUST be placed in a puncture-resistant, leak-proof, labeled/color-coded container in the patient treatment area


Other contaminated single-use items Blood- or saliva-soaked cotton rolls, gauze, pellets,

tissue coverings (packs) MUST be placed in small biohazard bag

Disposed of into a centralized Regulated Waste Receptacle after each appointment

Handpieces MUST be

sterilized between patients

Clean, sterilize, and maintain each handpiece according to manufacturer’s recommendations


Saliva ejectors Backflow with low-volume suction

Do not place any portion of the suction tubing holding the tip above the patient’s mouth

Do not use simultaneously with high-volume evacuation

Do not have patient create a seal around the saliva ejector


Dental radiography Cover clinical contact areas with protective

barrier Hand hygiene and PPE before initiating the

radiographic process Use disposable or heat-sterilized film-holding

and positioning devices Use FDA-cleared film barrier pouches Remove film packet from pouch and place in a

clean container Remove gloves, wash hands, and transport

the exposed films to the dark room01/01/2010 Terezhalmy 20

Panoramic radiography Place disposable plastic cover over bite

guide before the patient is positioned in the machine

If no barrier is used, use a sterile bite guard Digital radiography sensors and other

high-technology instruments Should be cleaned and sterilized according

to manufacturer’s recommendations


Oral surgical procedures Perform surgical hand antisepsis Don sterile surgeon’s gloves Use only sterile saline or sterile water as a

coolant or irrigant Laser plumes or surgical smoke may contain

aerosolized infectious material Follow standard precautions


Biopsy Place specimen in leak-proof, puncture-

resistant, closed container with a secure lid for storage and transportation If container becomes visibly contaminated, clean it,

disinfect it, or placed in an impervious bag Label with the biohazard symbol


Extracted teeth If sent to the laboratory for shade and size

comparison Clean and disinfect with an EPA-registered,

intermediate-level hospital disinfectant claiming tuberculocidal activity, e.g., chlorine-containing products, quaternary

ammonium compounds with alcohol, phenolics, or iodophors

With dental amalgams Consult state and local regulations regarding

disposal of amalgam


Extracted teeth returned to the patient Clean and disinfect

Extracted teeth in educational settings Cleaned of visible blood and gross debris and

maintained in a hydrated state (e.g., water or saline) in a well constructed closed container

The teeth are heat-sterilized (autoclave cycle for 40 minutes) before clinical exercises or study

Teeth with amalgam restorations are disinfected by immersion in 10% formalin solution for 2 weeks


Laboratory asepsis Environmental surfaces

Barrier-protected or cleaned and disinfected

Use PPE when handling items in the laboratory until they have been disinfected

Impressions, prostheses, and other devices Rinsed under running tap water an disinfected with

EPA-registered intermediate level disinfectant with tuberculocidal claim


Burs, polishing points, rag wheels, and laboratory knives Cleaned and then heat-sterilized or disinfected

following manufacturer’s recommendations or discarded

Metal impression trays and face bow forks Cleaned and heat sterilized

Articulators, case pans, and water pans Cleaned and disinfected according to

manufacturer’s recommendations


Dental unit waterlines Must meet the regulatory standard for safe

drinking water <500 CFU/mL

Self-contained water systems in combination with a chemical germicide Follow the recommendations for monitoring water

quality provided by the manufacturer of the unit or waterline treatment product

Dental devices connected to the water system Operated for 20-30 seconds after each patient to

discharge water and air


Boil-water advisory Do not deliver water from the public water system For hand hygiene use an alcohol-based hand rub or

bottled water When the boil-water advisory is lifted disinfect

dental waterlines according to manufacturer’s recommendations


Dental records Charts are notated and radiographs viewed

Before gloving After the gloves are removed and the hands are

washed While wearing cover gloves



Environmental infection control Provides for a safer work environment

Environmental surfaces Clinical contact surfaces

May serve as reservoirs for microbial contamination

Housekeeping surfaces Do not contribute to significant cross-

contamination


Clinical contact surfaces Cover with materials impervious to moisture Coverings are removed and discarded

between patients Surfaces are examined for visible soil Soiled surfaces are cleaned and disinfected

with an EPA-registered intermediate-level hospital disinfectant with tuberculocidal claim

General cleaning and disinfection is performed at the end of daily work activities regardless of barrier protection


Housekeeping surfaces Walls, window drapes, and other vertical

surfaces Unless visibly clean, cleaning is unnecessary

Floors and sinks Clean regularly with a detergent and water OR An EPA-registered hospital disinfectant/detergent

designed for general housekeeping

Carpeting and cloth furnishing Cannot be reliably disinfected


Spills and spatter of blood or OPIM Visible organic material is removed using

disposable paper towels Discard in a leak-proof, biohazard-labeled

container Contaminated surface is cleaned with a

detergent and water AND Disinfected with an EPA-registered

intermediate-level hospital disinfectant with tuberculocidal claim


Biohazard communication Labels

Fluorescent orange or orange red, with lettering or symbols or a contrasting color

Affixed to containers or regulated waste by string, wire, adhesive, or other methods

Red bags or red containers may be substituted for labels

Decontaminated regulated waste is not labeled or color-coded


Post-exposure management and follow-up Establishes policies and practices to

reduce the risk of post-exposure infection


Post-exposure protocol Immediately after an exposure incident

Wash area of injury with soap and water Report the exposure incident immediately Complete the Uniform Needlestick and Sharp Object

Injury Report Form


Within 2 hours of an exposure incident Arrange for a post-exposure evaluation by a

physician A copy of the employee’s medical record A copy of the Uniform Needlestick and Sharp

Object Injury Report Any information available about the source

individual


As soon as feasible after an exposure incident If the source person can be identified and with

his/her consent The source person’s blood is tested for HBV, HCV,

and HIV Results are made available to the employee Applicable privacy laws and regulations apply


Post-exposure management and prophylaxis According to latest CDC recommendations

A written report from the consultant physician is obtained within 15 days of the post-exposure evaluation

Written report becomes part of the OHCW’s medical record


Medical record Maintained on all personnel

Name and SSN Documentation of vaccination status

A copy of the Mandatory Hepatitis B Vaccination Declination Form (if applicable)

A copy of all results of examinations, medical tests, and other post-exposure follow-up data


The medical record is confidential Its content is not disclosed except as required by

law

The medical record is made available to the OHCW for examination A copy is provided upon request

The medical record is maintained for at least the duration of employment plus 30 years


Administrative controls Establish exclusion policies from work

and patient care


Minimize latex-related health problems among OHCWs and patients Reduce exposure to latex-containing

materials Train and educate OHCWs to recognize signs

and symptoms of latex-related adverse effects Monitor signs and symptoms of latex-related

adverse effects among OHCWs and patient


Minimize the exposure of OHCWs with acute or chronic diseases to patients i.e., to patients who have been diagnosed

with a transmissible infectious disease OHCWs shall consult with their personal physician

Determine if their condition(s) might affect their ability to safely perform their duties


Minimize the exposure of patients to OHCWs i.e., to OHCWs who have been exposed to or

have been diagnosed with an infectious disease Restrictions based on the mode of transmission and

the period of infectivity of the pathogen

Infectious state Restrictions

HBV

OHCWs with acute or chronic HBsAg who do

not perform exposure-prone

procedures

No restrictions

OHCWs with acute or chronic

HBeAg who perform

exposure-prone procedures

Do not perform exposure-prone procedures until counsel from a review panel has been sought

(State Dental Board)



HCVAcute or chronic infection

No restrictions



HIV HIV infection AIDS

Do not perform exposure-prone procedures until

counsel from a review panel has been sought

(State Dental Board)



SUMMARYSUMMARYGood structureGood structure

Increases the likelihood of a good process

Good process Good process Increases the likelihood of a good outcome


References1.Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1910.1030. Occupational exposure to bloodborne pathogens; final rule. Federal Register 1991;56:64004-64182.2.CDC. Guidelines for infection control in dental health-care settings-2003. MMWR 2003;52(No. RR-17):1-68.3.Terezhalmy GT. Clinical practice guidelines for an infection control/exposure control program in the oral healthcare setting. Access PDF file at dentalcare.com 4.Huber MA, Terezhalmy GT. Hepatotropic viruses: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com


5. Huber MA, Terezhalmy GT. HIV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com

6. Huber MA, Terezhalmy GT. Measles, mumps, rubella: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com

7. Huber MA, Terezhalmy GT: HSV and VZV: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com

8. Porteous NB, Terezhalmy GT: Tuberculosis: Infection control/exposure control issues for oral healthcare workers. Access PDF file at dentalcare.com


9. Huber MA, Terezhalmy GT: Mandated and highly recommended and highly recommended vaccines for oral health care. Access PDF file at dentalcare.com

10. Huber MA, Terezhalmy GT. Adverse reactions to latex products: preventive and therapeutic strategies. Access PDF file at dentalcare.com

11. Terezhalmy GT, Huber MA. Hand hygiene: infection control/exposure control issues for oral healthcare setting. Access PDF file at dentalcare.com

12. Terezhalmy GT, Huber MA. Environmental infection control in oral healthcare settings. Access PDF file at dentalcare.com

géza t. terézhalmy, d.d.s.,m.a. professor and dean emeritus school of dental medicine case western...

Documents

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intended use slide

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damage slide

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appointment slide

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sterilization process