Leslie D. Canham, CDA, RDA
Speaker, Consultant, and Trainer
Leslie Seminars
Copperopolis, California
Phone: 888.853.7543
Email:
Web site:www.LeslieCanham.com

Abstract

Infection control in dentistry not only means safe care for patients, but also safe work conditions for dental health care providers. Every dental office should have at least one person in charge of the infection control program. This article will define the role of the infection control coordinator, help the reader locate reliable resources for infection control and safety information, and provide helpful checklists.

Learning Objectives

After reading this article, the reader should be able to:

• define the role of the infection control coordinator.
• locate reliable resources for infection control in dentistry.
• list the necessary personal protective equipment.
• develop a written protocol for instrument processing.

The results of a 2006 Dental Assisting National Board survey show that the responsibility for infection con-trol and US Occupational Safety and Health Admini-stration (OSHA) compliance often rests on the shoulders of at least one dental assistant in the dental office.1 The term infection control means controlling the spread of disease agents by performing specific procedures. As the infection control coordinator, the dental assistant needs to be compe-tent in infection control practices and understand the basic elements of an infection control program. The position's basic responsibilities include:

• ensuring that employee training has been conducted and that necessary immunizations have been made available.
• evaluating the office infection control protocols for patient and employee safety.
• ensuring that appropriate disinfectants and sterilants are used.
• monitoring office infection control systems for effectiveness and compliance with state and federal regulations.

To simplify this seemingly overwhelming task, the infection control coordinator should seek out reliable resources, such as the US Centers for Disease Control and Prevention's (CDC) Guidelines for Infection Control in Dental Health-Care Settings—2003 (available at www.cdc.gov) and the Organization for Safety and Asepsis Procedures (OSAP) manual CDC Guidelines: From Policy to Practice. This manual makes the infection control guidelines easier to understand and implement. Also, check with your state dental board to determine if your state's minimum standards for infection control differ from the CDC guidelines.

Training

The first step in an effective infection control program is proper training for dental health care providers (DHCP). The infection control coordinator can conduct the infection control and safety training as it relates to the workplace. A good resource for information to include is the OSHA Web site (www.osha.gov), which provides 6 printable fact sheets on blood-borne pathogens. Another helpful resource is OSAP's Interact Employee Infection Control and Safety Training System, which includes videos, workbooks, a manager's guide, exposure control checklists, and postexposure management materials. The office's OSHA manual is also a good training resource. If your office does not have a current OSHA manual, it is important to obtain one that is designed specifically for dental offices. Be sure to review and personalize the manual by filling in the information that describes your office.

OSHA requires that initial training be provided to all employees before they perform tasks that could expose them to infectious agents. This training should include techniques to prevent contact with infectious agents, instrument processing protocols, and personal protective equipment (PPE) that is available for use. The training must be site-specific and include information on the office's exposure control plan.

The exposure control plan is a written plan that requires the employer to identify which individuals have occupational exposure and who will receive training, PPE, vaccinations, and other protections as stated in the Bloodborne Pathogen Standard (29 CFR—1910.1.302).

An effective exposure control plan is designed to eliminate or minimize employee exposure to bloodborne pathogen hazards in the workplace. The exposure control plan must include a section on your office's plan for exposure incidents. An exposure incident is a specific incident involving contact with blood or other potentially infectious material (OPIM) to the eye, mouth, other mucous membrane, nonintact skin, or percutaneous contact (under the skin, eg, needlestick) that occurs during the performance of DHCP duties.

When an exposure incident occurs, immediate action must be taken to assure compliance with the OSHA Bloodborne Pathogen Standard and to expedite medical treatment for the exposed individual. A sample exposure incident protocol that can be personalized for your office is available as a downloadable pdf (0.5 MB). The infection control coordinator should review the written office exposure control plan step by step with employees. Employees should be advised of whom to contact in the event of an exposure incident (whether it is the employer, office manager, or infection control coordinator) and given instructions on where to go for medical treatment. Each office should have a step-by-step checklist for exposure incidents, including immediate first aid protocols. The infection control coordinator also should provide information on where the eye wash station and first aid kit are located.

OSHA requires that bloodborne pathogen training be provided at least annually, at no charge to employees, and include a review of the office exposure control plan. Employees must have an opportunity to ask questions of the person conducting the training and the training must be documented and records maintained for a period of 3 years. The infection control coordinator should review the training records and update training as needed.

Immunizations

The infection control coordinator must ensure that employees have information about recommended immunizations. DHCP are at risk for exposure to, and possible infection with, infectious organisms. Immunizations substantially reduce both the number of DHCP susceptible to these diseases and the potential for disease transmission to other DHCP and patients. Thus, immunizations are an essential part of prevention and infection control programs for DHCP, and a comprehensive immunization policy should be implemented.³

The infection control coordinator should have access to all employees' medical recordkeeping forms to verify that these immunizations have been offered:

• Hepatitis B as required by OSHA. (Employees may decline the vaccine and, if declined, the infection control coordinator must verify that the employee's refusal is documented in writing.)
• Influenza vaccine, if offered by the employer.

While not required by OSHA, the infection control coordinator also should gather information from employees to check that they have been vaccinated against measles, mumps, rubella, and varicella. DHCP are at substantial risk of contracting these diseases, which are all vaccine-preventable. If employees have questions or concerns about vaccinations, the infection control coordinator should refer them to Appendix B of the CDC's Guidelines for Infection Control in Dental Health-Care Settings—2003 (available as a downloadable pdf (0.8 MB) or at the CDC Web site, www.cdc.gov).

Hand Hygiene

The infection control coordinator must evaluate whether hand hygiene procedures are followed. Employees must wash hands before donning gloves and every time gloves are removed. Effective handwashing includes vigorously rubbing together all surfaces of lathered hands for at least 20 seconds, followed by rinsing under a stream of water. Hands must be washed before donning gloves. If the hands are not visibly soiled, an alcohol based hand rub is adequate. The CDC's Guideline on Hand Hygiene in Health-Care Settings⁴ provides complete handwashing information.

Personal Protective Equipment

The infection control coordinator can help employees locate and order PPE. He or she gives instructions on disposal of paper gowns and gloves and single-use face shields and surgical masks. For reusable items, the infection control coordinator should train employees on proper decontamination techniques. If employees decline to wear PPE in situations where the employee is likely to come in contact with blood, OPIM, or chemicals, the infection control coordinator is responsible for confronting the employee and explaining the office policy for safety as it relates to the OSHA requirements. Often, employees will conform to procedure if well-fitting, nonirritating items can be found.

• Clinical attire, such as lab coats, gowns, or clinical jackets, are worn to prevent contamination of street clothing and to protect the skin from exposures to blood and body substances. OSHA requires sleeves to be long enough to protect the forearms. DHCP should change protective clothing when it becomes visibly soiled and as soon as feasible if penetrated by blood or other potentially infectious fluids. All protective clothing should be removed before leaving the work area.
• Eye protection should include safety glasses that are rated by the American National Standards Institute. Prescription glasses alone do not protect the wearer from splashes and flying debris that often are generated during dental procedures. A full-face shield offers better protection by covering more of the face and is a handy alternative for those who prefer not to wear protective eyewear. The use of a face shield does not eliminate the need to wear a surgical face mask.
• A surgical face mask should be worn whenever there is the potential for splashes of blood or OPIM. It should be changed after every patient and more often if it becomes moist or contaminated. The surgical face mask's outer surface can become contaminated from splashes and sprays generated during patient treatment and from touching the mask with contaminated, gloved hands.
• Gloves come in many different styles, sizes, and materials. It is easy to find gloves that meet the needs of most DHCP. Be sure to provide the appropriate gloves for the task, including puncture resistant/chemical resistant utility gloves for decontaminating instruments and working with chemicals. A common complaint with regard to wearing utility gloves when required by OSHA is that gloves are bulky and difficult to use. The infection control coordinator should explain that instrument pokes and sticks can be less injurious when utility gloves are worn. After acceptable gloves are found, the infection control coordinator can use permanent ink to mark each employee's name on his or her utility gloves. Employees should be instructed to inform the infection control coordinator when gloves become cracked or worn out so new gloves may be purchased.

Environmental Surface Disinfection

Environmental surfaces are surfaces that become contaminated during patient treatment. These surfaces include the dental cart, countertops, the dental chair, and x-ray equipment. The infection control coordinator should make sure that environmental surfaces are disinfected correctly. After each patient, environmental surfaces must be cleaned and then disinfected with an Environmental Protection Agency (EPA)–registered, low- to intermediate-level disinfectant. The level of the disinfectant can be found on the product label kill claims.

EPA-registered low-level disinfectants are effective against hepatitis B virus (HBV) and HIV. EPA-registered intermediate-level disinfectants are effective against HBV and HIV, as well as having a tuberculocidal kill claim. When surfaces are visibly contaminated with blood or OPIM, an intermediate-level disinfectant should be used.

It is necessary to clean surfaces first and then begin the disinfection process. When using a spray disinfectant, the protocol should be spray, wipe, spray again. To reduce the possibility of respiratory problems, DHCP should follow OSHA's guidelines for spray disinfectants, including the use of a face mask, protective eyewear, and utility gloves. When using premoistened wipes, one unfolded wipe should be used to clean the surface and remove the debris. Then another wipe should be used to disinfect the surface. If a surface is not cleaned first, disinfection can be compromised. Removal of all visible blood, inorganic, and organic matter can be as critical as the germicidal activity of the disinfecting agent.³ HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week.⁵

Barriers

Items or surfaces that are likely to become contaminated and are difficult to clean and disinfect should be protected with barriers. Barriers include clear plastic wrap, bags, tubing, plastic-backed paper, or other moisture-impervious materials. Digital radiography sensors and other high-technology instruments, such as intraoral cameras and lasers, should be barrier protected by using an FDA-cleared barrier to reduce gross contamination during use.³

Because barriers can become contaminated, they should be removed and discarded between patients, before DHCP remove their gloves. After removing the barrier, if the surface becomes soiled inadvertently, it must be cleaned and disinfected. After removing gloves and washing hands, DHCP should place clean barriers on these surfaces before the next patient.

The Sterilization Area

The infection control coordinator must make certain that the sterilization area has a clear distinction between dirty and clean. The flow pattern of incoming contaminated instruments should be clearly identified, thereby eliminating crosscontamination. It is helpful to place signs or labels identifying "dirty" vs "clean" areas in the sterilization room. The 4 main areas of the sterilization room should be:

• Receiving, cleaning, and
• Preparation and packaging
• Sterilization
• Storage

The receiving, cleaning, and decontamination area is best located by the sink. This area should have a sharps container, a biohazard waste container, and a trash container. The ultrasonic tank or instrument washer should be located in this area. The preparation and packaging area should have adequate lighting so DHCP can inspect instruments for remaining debris. After instruments have been dried and packaged or wrapped, they are ready for sterilization. After instruments have been sterilized, they should never be placed on the contaminated countertops of the sterilization room. If instrument packs cannot be stored immediately, they should be placed only on a clean countertop. Instruments should be stored in covered areas or closed cabinets, never under sinks or next to trash receptacles. Instrument packs should be inspected for tears, and for chemical indicator color change, which indicates a processed vs an unprocessed item.

The infection control coordinator can observe the activity in the sterilization area to make sure that employees move instruments in the flow pattern of contaminated to clean to sterile, and verify that instruments remain sterile by periodically inspecting instrument bags and checking to ensure instruments are stored appropriately.

Disinfection and Sterilization of Patient Care Items

The infection control coordinator is responsible for overseeing disinfection and sterilization of patient care items. The CDC categorizes patient care items as critical, semicritical, or noncritical, based on the potential risk of infection during use. Critical items penetrate soft tissue or bone, have the greatest risk of transmitting infection, and should be sterilized by heat. Semicritical items touch mucous membranes or nonintact skin and have a lower risk of transmission. Because the majority of semicritical items in dentistry are heat-tolerant, they also should be sterilized by using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection. Noncritical patient care items pose the least risk of transmission of infection, contacting only intact skin.³ Noncritical items may be cleaned with detergent and water. If visibly soiled, cleaning should be followed by disinfection with an EPA-registered hospital disinfectant. When the item is visibly contaminated with blood or OPIM, an EPA-registered hospital disinfectant with a tuberculocidal claim (ie, intermediate-level disinfectant) should be used.³

It is helpful to have a written checklist for the office instrument processing protocol to ensure that instruments are properly cleaned and sterilized. A sample instrument processing protocol that can be personalized for your office is available as a downloadable pdf (261 KB).

When using sterilizers, ultrasonic tanks, instrument washers, or other cleaning devices, it is important to follow the manufacturers' instructions. Sterilizers should be properly maintained, serviced, and operated. The infection control coordinator should create and post lists of the standard operating procedures for the proper use and maintenance of each device.

The sterilizer chamber should not be overloaded with instruments or cassettes because steam and/or the sterilizing agent need to circulate around the instruments. Ultrasonic tank solutions should be changed frequently per the manufacturers' instructions. Instruments placed in the ultrasonic tank should be suspended in a basket or container so they do not touch the floor of the tank. Also, instruments should never be bound together because the cavitation (cleaning) action will be hindered. Instrument washers should be FDA-approved devices and used only with recommended types of detergent. Improper use of instrument washers may corrode or damage instruments and void the manufacturers' warranty. Instruments to be stored for use at a later date should be packaged or wrapped before placement in the sterilizer and remain in the package until time of use. Packaging materials should be designed for the type of sterilization process being used. An unwrapped cycle (sometimes called flash sterilization) is a method for sterilizing unwrapped patient care items for immediate use only.³

The infection control coordinator should verify that sterilization monitoring is performed. Correct functioning of sterilization cycles should be verified for each sterilizer by the periodic use, at least weekly, of biological indicators. Biological indicators, also known as spore tests, are the most accepted method for monitoring the sterilization process.³ Spore test results must be maintained in a log. The infection control coordinator is responsible for documenting the results of these tests and reviewing any failed tests. To investigate why the sterilizer is not functioning, the infection control coordinator must first rule out operator error. If it is determined that directions for use were followed and subsequent spore testing shows a failed sterilization cycle, the sterilizer should be considered malfunctioning and the infection control coordinator should remove it from use immediately and arrange to have it repaired. All instruments sterilized after the date of the last successful sterilization test should be resterilized.

Conclusion

The role of the infection control coordinator includes making sure patients and DHCP are safe from disease transmission, patient-to-patient, patient-to-DHCP, and DHCP-to-patient. Following the CDC guidelines for infection control and OSHA bloodborne pathogen standards will help accomplish these goals. If you wish to run the infection control program in your office, start by contacting OSHA or OSAP. Also consult your office's OSHA manual for tools, training, and resource materials. If your office already has an infection control coordinator, do your part by being attentive during training and following the established protocols. Although the infection control coordinator is responsible for the infection control program, the entire team must be committed to having a safe work environment.

References

1. Dental Assisting National Board. Contributing to the critical mission of infection control. Contemporary Dental Assisting. Jul/Aug 2007;4:35.
2. Occupational Safety and Health Administration. Regulations (Standards - 29 CFR). Bloodborne pathogens. 1910.1030. Available at: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051. Accessed Sep 6, 2007.
3. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care settings—2003. MMWR Recomm Rep. 2003;52(RR-17):1-61. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Accessed Aug 22, 2007.
4. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1-45. Available at: www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Accessed Sep 6, 2007.
5. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2001;50(RR-11):1-42. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm. Accessed Sep 4, 2007.