Dental Infection Control Update. Jennifer A. Harte DDS, MS Lt Col, USAF, DC USAF Dental Investigation Service

Transcription

1 Dental Infection Control Update Jennifer A. Harte DDS, MS Lt Col, USAF, DC USAF Dental Investigation Service

2 Official Disclaimer The opinions expressed in this presentation are those of the speaker and do not necessarily reflect the official position of the US Air Force or the Department of Defense. Devices or materials appearing in this presentation are used as examples of currently available products/technologies and do not imply an endorsement by the speaker.

3 Guidelines for Infection Control in Dental Health- Care Settings, 2003 Update Consolidate New format Scientific support and rankings for recommendations

4 Guidelines for Infection Control in Dental Health-Care Settings, MMWR R&R 66 pages including appendices and over 500 references Evidence-based but also expert committee, strong theoretical rationale, medical standards

5 Dissemination of Guidelines Mass mailing to all dentists Web site interactive linked to other CDC guidelines CEU section in the MMWR, & on ADA Web site, DIS Article in JADA

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7 Principle 1 Take Action to Stay Healthy Protect with immunizations Report occupational exposures to blood Perform hand hygiene Keep hands healthy

8 Principle 2 Avoid Contact with Blood Handle sharp instruments with care Use safety devices when appropriate Manage occupational exposures to blood Wear gloves, protective clothing, and face and eye protection

9 Principle 3 Limit the Spread of Contamination Cover surfaces that may become contaminated Clean and disinfect surfaces Minimize sprays and splashes Properly dispose of medical waste

10 Principle 4 Make Objects Safe for Use Clean and heat sterilize patient care items Monitor processes Follow manufacturer s instructions

11 Personnel Health Elements of an Infection Control Program Objectives Educate dental personnel on infection control principles Identify work-related related infection risks Institute appropriate preventive measures Provide preventive services for exposure management and follow-up

12 Personnel Health Elements of an Infection Control Program Written infection control program Education programs Immunization programs Exposure prevention and postexposure management Medical condition management and work-related related illnesses and restrictions Health record maintenance

13 Immunizations Substantially reduce the potential for disease transmission to DHCP & patients Essential part of prevention & IC programs Varicella Measles Mumps Rubella Influenza Hepatitis B

14 Work Restrictions Policies should encourage personnel to seek care &report their illnesses Selected diseases & work restrictions: Conjunctivitis Diarrheal disease Herpes simplex Measles/rubella Pertussis Strep Group A Varicella Viral respiratory illness Shingles/zoster Until no discharge Until symptoms stop Until lesions heal About 1 week 5 days after antibiotics 24 hours after antibiotics Until lesions crust Until symptoms resolve Cover lesions/crusted

15 Standard Precautions THE SAME IC PROCEDURES ARE USED FOR ALL PATIENTS Assume all patients are potentially infectious Infection control policies are determined by the procedure, not the patient 1996

16 Why Is Infection Control Important in Dentistry? Contact with blood, oral and respiratory secretions, and contaminated equipment occurs Both patients and dental healthcare personnel can be exposed to pathogens Proper procedures can prevent transmission of infections among patients and dental healthcare personnel

17 Hepatitis B, Hepatitis C, & HIV Bloodborne viruses Can produce chronic infection Transmissible in health-care settings To assess risk of occupational transmission, CDC uses information from multiple sources

18 Factors Influencing Occupational Risk of Bloodborne Virus Infection Prevalence of infection in patients Risk of infection after single blood contact Nature and frequency of blood contact Susceptibility of the exposed person

19 Average Risk of Transmission after Percutaneous Exposure to Blood Source Risk (%) HIV Hepatitis C Hepatitis B (only HBeAg+)

20 Transmission of HBV from Infected Dentists to Patients 1965-Isolation of Hepatitis B Virus Nine clusters of HBV transmission from infected dentists and oral surgeons to patients were documented between Lack of documented transmissions since 1987 may reflect increased use of gloves and hepatitis B vaccination

21 Hepatitis B Vaccination Among U.S. Dentists % Source: Cleveland, et.al. JADA 1996;

22 Vaccine Safe Effective Long - lasting

23 Occupational Risk of HCV Transmission among Health- Care Personnel Inefficiently transmitted by occupational exposures Three reports of transmission from blood splash to the eye Report of simultaneous transmission of HIV and HCV after non-intact skin exposure

24 HCV Infection in Dentistry Frequency of HCV infection among dentists similar to that of general population (~ 1-2%) 1 No reports of an HCV transmission from infected dental personnel to patients No reports of patient-to to-patient transmission of HCV Risk of HCV transmission is very low

25 Dentist to Patient Transmission of HIV/AIDS Only one documented case of HIV transmission from an infected dentist to patients No transmissions documented in the investigation of 57 HIV-infected health-care personnel (including 33 dentists or dental students)

26 Occupational Exposure Incident Specific eye, mouth, other mucous membrane, non- intact skin or parenteral contact with blood/opim (including saliva in dental settings) resulting from performance duties

27 Annual Number of Percutaneous Injuries* Number *ADA Health Screening, per dentist

28 Characteristics of Percutaneous Injuries Among Dental Personnel Among general dentists, caused by burs, syringe needles, and other sharps Occur outside the patient s mouth Involve small amounts of blood

29 Preventing Transmission of Bloodborne Pathogens Standard Precautions Engineering Controls Work Practice Controls Postexposure Management and Prophylaxis

30 Engineering & Work Practice Controls Using a one-handed scoop technique, a mechanical device designed for holding the needle cap to facilitate one-handed recapping, or an engineered sharps injury protection device (e.g., needles with resheathing mechanisms) for recapping needles between uses and before disposal; Not bending or breaking needles before disposal; Avoiding passing a syringe with an unsheathed needle;

31 Engineering & Work Practice Controls Removing burs before disassembling the handpiece from the dental unit; Using instruments, rather than fingers, to grasp needles, retract tissue, and load/unload needles and scalpels; Placing used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to where the items were used; and Giving verbal announcements when passing sharps.

32 Engineering and Work Practice Controls 2001: Identify, evaluate, and select devices with engineered safety features as they become available & at least annually 2001

33 Postexposure Management Follow current CDC recommendations for postexposure management and prophylaxis after percutaneous,, mucous membrane, or non-intact skin exposure to blood or blood-contaminated saliva. MMWR, June 29, 2001;50 (No. RR-11)

34 Elements of an Effective Postexposure Management Program Clear policies/procedures Education of HCP Rapid access to clinical care postexposure prophylaxis (PEP) testing of source patients/hcp

35 Elements of an Effective Postexposure Management Program The Qualified HCP Qualified to manage, counsel, provide medical follow-up Selected before exposure incident Familiar with dental aspects of risk assessment and management

36 Elements of Postexposure Management Wound management Exposure reporting Assessment of infection risk type and severity of exposure bloodborne infection status of source person

37 Postexposure Management Wound Care Clean wounds with soap and water Flush mucous membranes with water No evidence of benefit for: application of antiseptics or disinfectants squeezing ( milking( milking ) puncture sites Avoid use of bleach and other agents caustic to skin

38 Postexposure Management: The Exposure Report Date and time of exposure Procedure details what, where, how, with what device Exposure details...route, body substance involved, volume/duration of contact Information about source person Information about the exposed person Exposure management details

39 Postexposure Management Immediate evaluation & follow- up completed by a qualified health-care professional After each incident review circumstances surrounding the injury & the postexposure plan Provide training to implement changes as needed

40 Promote Hepatitis B vaccination Treat all blood as potentially infectious Use barriers to prevent blood contact Prevent percutaneous injuries Safely dispose of sharps and blood- contaminated materials

41 Hand Hygiene Technique HANDWASHING Wet with water, apply product, rub hands together for at least 15 seconds Rinse & dry with disposable towel Use towel to turn off the faucet HAND RUB Apply to palm of one hand, rub hands together covering all surfaces until dry Volume based on manufacturer Cannot use if hands are visibly soiled or contaminated!

42 Surgical Hand Hygiene/Antisepsis Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturer (2-6 min)

43 Which Hand Hygiene Method is Best at Killing Bacteria? Plain soap & water Antimicrobial soap & water Alcohol-based hand rub

44 Which Hand Hygiene Method is Best at Killing Bacteria? Plain soap & water Antimicrobial soap & water Alcohol-based hand rub

45 Ability to Kill Bacteria on Hands % log Time after disinfection minutes Bacterial Reduction Alcohol handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Baseline Adapted from: Hospital Epidemiology and Infection Control, 2nd Edition, 1999.

46 Which of the following hand hygiene agents is LEAST drying to your skin? 1. Plain soap and water 2. Antimicrobial soap and water 3. Alcohol-based hand rub

47 Which of the following hand hygiene agents is LEAST drying to your skin? 1. Plain soap and water 2. Antimicrobial soap and water Alcohol-based hand rub

48 Effect of Alcohol Handrub on Self-reported skin score Dry Healthy 0 Baseline 2 weeks Alcohol rub Soap and water Skin Condition Epidermal water content Baseline 2 weeks Alcohol rub Soap and water Healthy Dry ~ Alcohol-based handrub is less damaging to the skin ~ Boyce, Infection Control and Hospital Epidemiology 2000;21(7):

49 Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcoholbased Preparations

50 Alcohol-based Preparations Benefits Rapid and effective antimicrobial action Improved skin condition More accessible than sinks- potential to increase compliance Limitations Cannot be used if hands are visibly soiled Follow instructions for amount to rub Flammable- implement safety precautions Build-up

51 Skin Care Use hand lotions or creams Check compatibility with the manufacturer Some lotions may make medicated soaps less effective Some lotions cause breakdown of latex gloves (e.g., petroleum based) Lotions can become contaminated with bacteria if dispensers are refilled

52 PERSONAL PROTECTIVE EQUIPMENT

53 Recommendations for Gloving Wear gloves when contact with blood, saliva, mucous membranes is possible Remove gloves after patient care Wear a new pair of gloves for each patient

54 Gloves Do not wash gloves before use or for reuse Remove gloves that are cut, torn, or punctured

55 Wearing gloves does not replace the need for hand hygiene Small, inapparent defects Frequently torn during use Hands frequently become Hands frequently become contaminated during removal DeGroot-Kosolcharoen 1989, Korniewicz 1989, Kotilainen 1989, Olsen 1993, Larson 1995, Murray 2001, Burke 1996, Burke 1990, Nikawa 1994, Nikawa 1996, Otis 1989

56 Leakage rates Vary by glove material Duration of use Type of procedure performed Outpatient oral surgery/surgical gloves 6-16% Morgan 1989, Otis 1989, Burke 1990, Albin 1992, Merchant 1992, Nikawa 1996, Avery 1998, Burke 1996, Schwimmer 1994, Patton 1995

57 Glove Failure: Dentistry & Medicine 44-83% leaks not recognized (Avery 1998, Burke 1990, Nikawa 1994) 92% continue to wear with known leaks (Otis & Cottone 1989)

58 Contact Dermatitis & Latex Hypersensitivity Screen all patients for latex allergy Obtain a definitive diagnosis by a qualified health-care professional (allergist, dermatologist) for any DHCP with suspected latex allergy Provide a latex-safe environment for patients & DHCP with latex allergy Have emergency treatment kits with latex-free products available

59 Instrument Cleaning Manual Vs. Automated Effective Dangerous Use engineering & work practice controls Effective Efficiency Exposure to blood & body fluids Exposure to sharps

60 Instrument Processing Sterilization Monitoring

61 Sterility Assurance All aspects of sterilization process Initial & ongoing training & supervision Mechanical, chemical, biological monitoring Maintenance & calibration of equipment Recordkeeping

62 Environmental Infection Control Cleaning & Disinfection

63 DENTAL UNIT WATERLINES, BIOFILM, & WATER QUALITY

64 BIOFILM Microbial communities that adhere to solid surfaces whenever there is sufficient moisture Colonize and replicate on the interior surfaces of the waterline tubing

65 Dental Unit Water Quality Use water that meets standards set by the EPA for drinking water (fewer( than 500 CFU/mL of heterotrophic water bacteria) for non-surgical dental treatment output water Use sterile solutions for surgical procedures

66 Dental Unit Water Quality Untreated or unfiltered dental unit waterlines are unlikely to meet drinking water standards

67 Measures to Improve Dental Unit Water Quality Independent water reservoir system Allows daily draining and air purging if indicated Allows application of periodic &/or continuous chemical germicides Water purification cartridges/systems Sterile water delivery systems Filtration COMBINATION OF METHODS

68 Dental Unit Water Quality In-office testing with self-contained test kits Water laboratory testing using Method 9215 Test each unit according to manufacturer instructions

69 CONCLUSIONS CDC/ADA goal of 500 CFU/mL is achievable DUWL cleanliness is not a public health crisis however WATER THAT IS UNFIT TO DRINK IS UNSUITABLE FOR THERAPEUTIC USE IN DENTISTRY

70 Principle 1 Take Action to Stay Healthy Principle 3 Limit the Spread of Contamination Principle 2 Avoid Contact with Blood Principle 4 Make Objects Safe for Use