Recommended Infection Control Practices

1. Recommended Infection Control Practices The OSU College of Dentistry August 2003

2. Infection Control Practices • Exposure to variety of microorganisms via blood or oral or respiratory secretions + peri-oral skin • May include CMV, HBV, HIV, HCV, Herpes 1 and 2, TB, Staph, Strep, and other viruses or bacteria

3. Recommended Infection Control Practices • Routes of Transmission • Direct Contact with blood, oral fluid, secretions • Indirect Contact with contaminated instruments, operatory equipment, or surfaces • Contact with airborne contaminants in droplet spatter or aerosols of oral or respiratory fluids.

4. Infection Control Practices Susceptible host CHAIN OF INFECTION Portal Pathogen IC strategies break one or more of these "links" - infection prevented

5. Infection Control Practices • Confirmed transmission of HBV and HIV • Reports published from 1970-1987 • Nine cluster where patients were infected with HBV associated with dental treatment • Six patients contracted HIV from dentist • HBV transmission from dentist to patient has not been reported since 1987

6. Infection Control Practices • Vaccines for DHCW • Hepatitis B - series of 3 shots, antibody verification needed • Measles, Mumps, Rubella • Tetanus • Influenza • TB

7. Infection Control Practices Protective Attire and Barrier Techniques & Dental Techniques & PPE’s

8. Infection Control Practices Personal Protective Equipment (PPE) • Gloves • Mask/Facial Shield • Eye protection/Glasses • Gown/Hat

9. MRSA RESEARCH SETUP

10. MRSA & Infection Control for Restorative Dental Treatment in Nursing Homes David L. Hall, DDS Section of Primary Care - Dr. Mead Van Putten - Chairperson The Ohio State University Geriatrics Program - Dr. Abdel Mohammad - Director Introduction Conclusions Results The combined prevalence of occasional Methicillin-Resistant Staphylococcus Aureus (MRSA) infections and numerous asymptomatic mostly unidentified MRSA carriers in nursing homes now averages 20-35% of residents or more. One of the most common sites for positive MRSA colonization is the nares and mouth (saliva). Routine restorative dental care is performed onsite in local nursing homes by all Ohio State University (OSU) dental students using portable equipment including handpieces that can generate aerosols. This study was initiated after the author encountered three MRSA+ patients in three different nursing homes during consecutive visits involving approximately 30 patients seen by the OSU College of Dentistry Geriatrics Program. Using a series of cultured test swabs and plates, this cross-over study confirmed that the universal barrier precautions (gloves, gowns, masks, hats, facial shields, glasses), and surface disinfectants combined with infection control oriented techniques (rubber dam, hand excavation & bonding, and electric "high" speed handpiece), plus pre op 0.12% chlorhexidene mouth rinses, high volume evacuation, and perioral skin scrubs provide protection for both dental health care personnel and patients in long-term care facilities. This investigation did not reveal any evidence of large oral concentrations of MRSA in the carriers studied nor any special tendency or ability of MRSA to aerosolize. The value of two 60-second Peridex® oral pre-rinses with 15-25 minute waiting periods (p<0.05), perioral facial skin scrubs with both 4% chlorhexidine and 62% ethyl alcohol gel, Birex® counter top surface disinfection (p<0.001), and rubber dams was statistically verified. Lacrosse® alcohol gel showed superior CFU reductions vs. 4% chlorhexidine (p<0.02). The use of hand excavation and bonding; electric, high torque handpiece with water spray; and full high-speed air turbine handpiece with water spray dental restorative techniques were compared. Hand excavation and bonding generated the least aerosol CFUs, high-speed air turbine handpieces by far the most CFUs, and BienAir® electric handpieces (p<0.04) produced intermediate CFU values as measured on facial shields. Methods Locations Served Services Provided Figure 1: MRSA Research Study Set Up CFUs = Colony Forming Units Sponsors OMNII PHARMACEUTICALS (Peridex®) BIOTROL (Birex®) APLICARE (Lacrosse®) BIEN AIR (Bien Air®) STERILIZATION MONITORING SERVICE, DR. JOEN HARING, DIRECTOR DR. JOHN SHERIDAN ORAL BIOLOGY SECTION Bien Air CE-0120 electric handpiece Star 430-SWL air turbine Full Manuscript will appear in July/August Issue of Special Care in Dentistry

11. Infection Control Practices Gloves • Purpose - protect patient & HCW • Wear for contact with blood, saliva, sputum, mucous membranes, non-intact skin • Non latex gloves • Non sterile/sterile

12. Infection Control Practices Soiled Gloves • Remove when treatment is completed • If torn, cut, or punctured remove as soon as patient safety permits • Before leaving dental operatory area • Do not touch environment • Do not touch face, mask

13. Infection Control Practices Face Protection • Prevent mucous membrane contact with spatter & debris • Chin-length plastic face shield, surgical mask and protective eyewear • Change mask between patient or during patient treatment if it becomes wet or moist • Remove when leaving treatment area

14. Infection Control Practices Gowns • To prevent clothing contamination • Clean gown daily • Change if obviously soiled • Wear only in clinic area.

15. Infection Control Practices • Handwashing • Handling of sharps • Environment Dental Techniques: • CHX Pre-rinses (2) • High Vac Suction • Rubber Dam • Elect”HS”<AirHS<USonic

16. Infection Control Practices Handwashing • Before and after treating each patient • Before and after glove placement or removal • After barehanded touching of inanimate objects likely to be contaminated Handwashing with plain soap is okay

17. Infection Control Practices Handwashing • Wet hands • Apply soap • Wash thoroughly (palms, webs, knuckles, thumbs, fingertips) • Sing Happy Birthday • Rinse • Dry well • Turn faucet off with paper towel

18. Infection Control Practices Sharp Instruments and Needles • Handle carefully • Do not recap with 2 hands • Unsheathed multiple injections needles should be placed to prevent contamination and injury • Discard or disinfect\sterilize properly • Report injuries

19. Infection Control Practices Blood and Body Fluid Exposures • Percutaneous injury from contaminated sharps • needle stick • contaminated sharp • bite • Contact of mucous membranes or nonintact skin • Prolonged skin exposure

20. Wash wounds with soap & water Flush mucous membranes with water Apply antiseptic Sterile bandage Complete dental care Take pt & chart to OMS Report ASAP to clinical instructor or manager Complete necessary incident report form Infection Control Practices Exposure Management

21. Infection Control Practices Source Patient Management • Request consent for blood draw • HBsAg • HCAB • HIV • Take to UHC lab

23. Infection Control Practices Risk of Infection After Exposure to HIV* • 0.3% - percutaneous exposure • 0.09% - mucous membrane exposure • < 0.1% - skin contact • Higher risk if • exposure to larger quantity of blood, e.g., • device visibly contaminated • needle placed directly in vein/artery • deep injury *Vs: HBV 10-100X Higher Risks

24. Infection Control Practices Exposed Individual • Report to clinical instructor or manager • Followed by SHC • Baseline blood tests • Prophylactic Rx may be recommended • Advised of patient test results

25. Infection Control Practices Tuberculosis (TB) Information

28. Infection Control Practices Site of Disease • Lungs (85% of all cases) • Pleura • Central Nervous System • Lymphatic System • Genitourinary System • Bones and Joints • Disseminated (miliary)

29. Infection Control Practices Signs and Symptoms Pulmonary • Productive, prolonged cough • Chest pain • Hemoptysis Systemic • Fever • Chills • Night sweats • Easy fatigability • Loss of appetite • Weight Loss

30. Conditions That Increase Risk • HIV infection • Substance abuse (esp. drug injection) • Recent infection with M. tuberculosis • CXR suggestive of previous TB (in a person inadequately treated) • Diabetes mellitus • Silicosis • Low body weight (>10% below ideal) • Cancer of the head and neck • Hematological & reticuloendothelial diseases • End-stage renal disease • Intestinal bypass or gastrectomy • Chronic malabsorption syndromes • Prolonged corticosteroid therapy • Other immunosuppressive therapy

31. Infection Control Practices High Risk Factors • Close contacts of active TB • Foreign-born from endemic areas • Medically underserved, low-income • Elderly • Residents of long-term care facilities • Injecting drug users • Local high-prevalence groups • Occupational exposure

32. Infection Control Practices Evaluation for TB Medical history • History of TB exposure, infection or disease • Symptoms of TB disease • Risk factors for TB Physical examination Mantoux tuberculin skin test (PPD) Chest radiograph Bacteriologic exam (smear and culture)

33. Infection Control Practices TB Skin Test • Intradermal Mantoux test with 0.1 ml of TU PPD tuberculin • Read reaction 48-72 hours after injection • Measure only induration • Record results in millimeters • Annual requirement

34. Infection Control Practices • > 15 mm in all persons • > 10 mm • certain medical conditions • injecting drug users (HIV neg.) • Foreign born from endemic areas • medically underserved, low income groups • residents of long-term care facilities • children < 4 yr. of age • locally identified high-prevalence groups • > 5 mm • known or suspected HIV infection • close contacts with infectious TB • CXR suggestive of previous TB • injecting drug users (HIV status unknown) Positive Skin Test

35. Infection Control Practices Management of Infected Patient • Segregate • Mask • Refer for medical evaluation • No elective treatments until not infectious • Urgent dental care done in neg. air flow facility

36. Preventive Therapy Recommended for PPD + Known or suspected of having HIV Close contacts of a person with active TB CXR suggestive of previous TB and received inadequate treatment Injecting drug users Certain medical conditions Recent tuberculin skin test converters Rx of Active Disease Four drugs in initial regimen: INH, RIF, PZA + EMB or SM x 2 mo. 3 drugs may be adequate if drug resistance very unlikely Adjusted when susceptibilities are known If susceptibility to INH and RIF, continue INH and RIF x 4 mo. Adults - 6 mo. total Longer therapy for children (9 mo.) and HIV-infected persons (12 mo.) Infection Control Practices Therapy

37. Infection Control Practices Latex Safe Powder Free

38. American College of Allergy, Asthma and Immunology: 8% - 17% of HCWs exposed to latex are at risk for a latex reaction.

39. Exposure To Latex Can Result in Three Distinct Reactions Irritant Contact Dermatitis Allergic Contact Dermatitis Immediate Allergic Reaction

40. Non Allergic Reactions to Latex • Irritant Contact Dermatitis - reaction caused by sweating or rubbing under the gloves • Allergic Contact Dermatitis - reaction to chemical additives to latex.

41. What Is Latex Allergy • Allergy to the proteins originating from the rubber tree and still present in products made from natural rubber • S/S of allergy: rash, hay fever type reactions such as itchy swollen eyes, runny nose, and sneezing • Asthma type symptoms chest tightness, wheezing, coughing and SOB.

42. Why Powder Free • Latex proteins adhere to the inside of the gloves. When the gloves are removed, the powder becomes airborne and pulls the latex powder with it, exposing the allergen to the skin, eyes and airways of workers and patients. .