ADVANCED POWER DRIVEN SCALERS ULTRASONIC INSTRUMENTATION
Presented by Tammy Maahs, RDH, BSDH DH 220 Fall Term 2014
Slide 3
Types of Power Driven Scaling Devices Magnetostrictive
Ultrasonic Scaler: converts high frequency electrical current into
rapid mechanical vibrations; operates at 18-42 thousand cycles per
second (cps). Piezoelectric Ultrasonic Scaler: activated by
dimensional changes in quartz or crystal transducers (25-50K).
Sonic Scaler: air-driven; only 2000-6300 cps.
Slide 4
Magnetostrictive Ultrasonic Scaler Tip movement is elliptical;
all sides of the working end are active. Frequency (cycles per
second = cps) is described in kilohertz (1 kHz = 1000 cps).
Manual-tuned or auto-tuned units. Most common.
Slide 5
Magnetostrictive Cavitron Handpiece Electrical energy is
applied to coils of copper wire in the handpiece and magnetically
changes the dimension of the stack to produce vibrations in the
tip.
Slide 6
Magnetostrictive Technology ELLIPTICAL TIP MOVEMENT
Slide 7
Piezoelectric Ultrasonic Scaler Used widely in Europe and Asia
Growing popularity in the U.S. Tip movement is linear; only 2 sides
(lateral borders) are active
Slide 8
Piezoelectric Ultrasonic Scalers
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Sonic Scaler Uses compressed air to produce vibrations Tip
movement elliptical or orbital Technique is pressure sensitive
Frequency much less powerful than with ultrasonic scalers
(2,000-6,300 cps)
Slide 10
Sonic Scalers * * This example has a protective sheath for use
around implants
Slide 11
MAGNETOSTRICTIVE ULTRASONIC SCALERS Manual Tuned Units
Automatic Tuned Units
Slide 12
Manual Tuning Units: 3 controls Power control (amplitude)
Tuning control (frequency) Water control (amount)
Slide 13
USI Manual-Tuned Unit Holbrook Technique favorite for low power
and frequency; less sensitivity for the patient.
Slide 14
Old Dentsply Cavitron Manual Tuned Unit
Slide 15
Power Control (Amplitude) Stroke: maximum distance the tip
moves during ONE (back and forth) cycle. Amplitude: Tip
displacement; the length of the stroke ( the stroke). The higher
the power the longer the stroke. More energy created by a longer
stroke. Longer stroke = increased ability to remove dense/tenacious
calculus deposits
Slide 16
More Efficient Chipping Action
Slide 17
Tuning Control (Frequency) The number of times per second the
tip completes one back and forth cycle. 1 kHz (kilohertz) = 1000
cycles per second (cps). The higher the frequency, the faster the
tip movementincreasing the ability to remove deposits. OPTIMUM
frequency is 18-32 cps. Affects the speed of the movement of the
tip.
Slide 18
Water Control (amount) Used to cool the stack and tip.
Cavitation: the resulting water spray on the vibrating tip (bubbles
collapse and lyse bacterial cell walls). Acoustic Turbulence or
Microstreaming: hydrodynamic wave around oscillating tip disrupts
bacteria. Functions as a lavage (flushes debris from the area,
removes LPS, removes attached plaque and loosely adherent
plaque).
Slide 19
Water Coolant
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Automatic Tuning Units Frequency is pre-set (controlled
automatically by the system): automatically changes as load
conditions change 25K or 30K Two controls: Power Control
(amplitude) Water Control (amount)
Slide 21
Dentsply Automatic Units Cavitron Bobcat, Bobcat Pro, SPS,
Plus, and Select
Slide 22
Parkell Turbo Sensor Can use 25K and 30K tips Burnett thin
power tip can be used on high power
Slide 23
LOAD Definition: the resistance on an insert when it is place
against a deposit or the tooth/root surface. With an auto-tuned
unit, the insert maintains the [pre-set] frequency even though
pressure is being applied to the tip, therefore scaling efficiency
is not compromised.
Slide 24
Parts of an Insert System Stacks Connecting Body O-ring Insert
Tip: the working end of the insert
Slide 25
Parts of an Insert System
Slide 26
Stacks Energy source for insert Move by elongation and
contraction in a horizontal plane Should be straight for peak
performance
Slide 27
Connecting Body (Grip/Handle/Finger Grasp) Can be metal or
plastic Experts (Anna Pattison, S.N. Bhaskar) prefer the all metal
inserts (i.e., metal grip) for more power and efficiency
Slide 28
O-Ring Stops water from flowing outside the handpiece Should be
wet prior to inserting the insert into the handpiece
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Insert Tip The WORKING END of the insert
Slide 30
Dentsply Inserts 25K & 30K
Slide 31
Active Tip Area The portion of the tip that is capable of doing
work. Affected by the frequency. The higher the frequency, the
shorter the active tip area. The power to remove calculus is
concentrated in the last 2-4 mm of the length of the tip. The
higher the frequency, the shorter the active tip area.
Slide 32
Ultrasonic Tip Power Power concentrated in the TIP
Slide 33
Care & Maintenance of Inserts Do not submerge in
glutaraldehyde or use surface disinfectants (e.g., Birex); VOIDS
THE WARRANTY. Do not put in ultrasonic bath (solutions are not able
to be rinsed well from the stacks). Rinse,or scrub tip and grip
gently with a brush/soap/water and rinse well, and place in
individual packaging (sterilization pouches or cassettes especially
made for ultrasonic tips).
Slide 34
Care & Maintenance of Inserts Check periodically for wear:
replace if too short. Replace O-ring if water leaking or insert is
loose in handpiece. Place on the top of the load if using pouches,
take care not to bend the tip or water conduit.
Slide 35
Care & Maintenance of Inserts When using pouches, must be
all paper or combination paper/plastic pouches; paper side down in
a steam autoclave or Statim. In a steam sterilizer, if paper/poly
packages must be placed flat in a single layer, place them paper
side down. Placing paper/poly packaging plastic side down may cause
condensate to pool inside the pouch resulting in a wet pack, which
must then be considered contaminated. ~Confirm Monitoring
Systems
Slide 36
Sterilization Pouches It is important to place inserts in
pouches TIP(s) to the bottom of the package and fold the top (seal)
properly (arrows lined up). TIP(s) down allows view of which tips
are in the package; sealing the package often covers the tip if it
is placed tip to top. Package STRAIGHT tips separately, and be sure
to package the CURVED PAIR of right/left inserts together correctly
(a right and left, not 2 rights or 2 lefts!).
Slide 37
Sterilization Pouches: prepared for sterilization
Slide 38
Sterilization Pouches: Curved Tips Sterile
Slide 39
Hu-Friedy IMS Cassette for Ultrasonic Tips Are in your student
issue for sterilization and storage of the set of inserts
purchased
Slide 40
Variables for Replacement Efficiency indicator template: use to
check for wear in tip length. Literature suggests that inserts with
2 mm of wear lose about 50% scaling efficiency. Condition of
stacks: replace if stack is so bent or splayed that energy is no
longer being delivered to the tip.
Slide 41
Efficiency Indicator Template
Slide 42
Asepsis & Infection Control Operator: PPE including face
shield Client: protective lenses, cloth towel Ultrasonic unit:
drape unit with plastic wrap to cover the controls that may be
touched when adjusting during treatment! Handpiece: small barrier
with sticky to hold in place. Bleed the handpiece for 1 minute to
remove contaminants.
Slide 43
Asepsis & Infection Control Pre-procedural rinse to reduce
microorganisms the patient might release in the form of aerosol
Water spray: external water source tends to have less aerosol
Slide 44
Infection Control (continued) Water Evacuation: High-volume if
working with an assistant; saliva ejector or hygoformic saliva
ejector if working without an assistant.
Slide 45
Advantages of Ultrasonic Scalers Water lavage: clears area of
debris & bacteria Lyses bacterial cell walls Removes attached
and loosely adherent plaque Gram bacteria most susceptible to
lavage Less trauma to soft tissue than curettes Increased client
comfort (usually) Decreased operator fatigue
Slide 46
Advantages (continued) MAY require less treatment time. BETTER
(excellent!) access to deep, narrow pockets and furcation areas
(with slimline inserts). No sharpening of inserts and less
sharpening of curettes Reduces lateral pressure Less tissue
distention
Slide 47
Disadvantages of Ultrasonic Scalers Decreased tactile
sensitivity (improves with experience!). Requires water evacuation.
Produces contaminated aerosol. Possible effects of noise/vibrations
Potential for damaging certain restorative materials. Handpiece
sterilization.
Slide 48
Contraindications: Pacemakers Pacemaker or implanted
defibrillator (with magnetostrictive) "Although all modern
pacemakers are shielded, care must be taken if magnetostrictive
ultrasonics or ultrasonic cleaning devices are used that generate a
magnetic field that might interfere with certain types of cardiac
pacemakers." (Bennett, Contemporary Oral Hygiene, June 2007).
Dentsply Cavitron (directions for use): recommend that the
handpiece and cables be kept at least 6-9 inches away from any
device and their leads.
Slide 49
Pacemakers In Touch, January 2006: Clients with Cardiac
Pacemakers: Most dental hygiene/dental procedures do not involve
strong electromagnetic signals and are unlikely to interfere with a
shielded pacemaker or ICD. Those considered safe are [dental]
radiographs, handpieces, composite curing lights, sonic scalers and
piezoelectric scalers. There is some evidence thatmagnetostrictive
(Cavitron) scalers, ultrasonic cleaning baths, and electrosurgical
units can cause marked interference with cardiac implant devices
when tested in-vitro setting and placed at close proximity.
~http://www.crdha.ca/portals/0/newletters/InTouch_Jan06.pdf
Slide 50
Contraindications: Other Implanted Medical Devices Implanted
Cardiac Defibrillators Spinal Cord Stimulators Vagus Nerve
Stimulators Insulin Pumps It has been recommended not to use
magnetostrictive ultrasonics for patients with these devices or use
a lead apron.
Slide 51
Pacemakers: LCC Policy Our policy for patients with a cardiac
pacemaker, implanted defibrillator, or other implanted devices: the
piezo electric unit should be used. NOTE: when calling physicians
for other implanted devices as listed in previous slide,
recommendation is to NOT use the magnetostrictive ultrasonic
scaler.
Slide 52
Contraindications Active communicable or infectious diseases
transmissible by aerosols Pulmonary or respiratory disease Gagging
or problems swallowing Metal inserts on dental implants Lack of
consent of therapy
Slide 53
Ultrasonic Tip Design Water source external or internal Gross
Debridement (standard diameter) Tip Assorted Specialty Tips
Slimline inserts Straight Paired (curved left and right)
Slide 54
External Water Source
Slide 55
Gross Debridement Tip Higher power setting can be used Chips
away at heavy deposits Once accomplished, power should be reduced
to medium or low
Slide 56
Slide 57
Gross Debridement Heavy Calculus
Slide 58
Loose tissue will accommodate larger tips
Slide 59
Assorted Specialty Tips Dentsply DiamondCoat Tip Implant Tips
For perio surgery only (must have visibility!)
Hu-Friedy Swivel Inserts Allows for single-handed
adjustment
Slide 62
Protg Ultrasonics by Discus Dental Protg LED Ultrasonic insert:
has a unique grip has a built-in light emitting diode (LED) that
illuminates the working surface.
Slide 63
Sonic and Ultrasonic Scalers with Specialized Tips Remove
plaque and calculus from titanium surface without damaging
titanium. It was noted previously that the sonic or ultrasonic
vibrations might have the potential to adversely affect the
connective tissue adherence. However, the consensus is with the
specialized tips used on LOW POWER; this is an effective method for
debriding implants. (Samuel B. Low, DDS, MS, MEd)
Slide 64
Dentsply Ultrasonic SofTip TM Insert Disposable prophy tip is
for single-use only
Slide 65
Piezo Electric Scaler with Peek [Composite] Tip
Slide 66
Piezo Electric Scaler with Peek Tip This tip is fabulous and I
use it regularly for debriding implants and other porcelain and
gold types of restorations! Autoclavable and durable tip; however
once the tip wears down, it must be disposed of and replaced. Use
only on a lower power!
Slide 67
Thin Design Ultrasonic Tips
Slide 68
Dentsply FSI Slimline Inserts
Slide 69
Curved Inserts Paired: Left and Right
Slide 70
Curved Inserts Angles [curves] are important for access with
ultrasonics. Curved inserts not only access deeper pockets and
furcations better, but these also provide better access when
posterior teeth have bulbous crowns.
Slide 71
Curved Inserts Adapt to concave root anatomy
Slide 72
Instrumentation Technique Grasp: feather-light, writing pen
grasp. Drape cord over arm to decrease pull on handpiece.
Slide 73
Cord Management
Slide 74
Fulcrum Calculus removal: intraoral or extraoral fulcrum.
Biofilm disruption and removal (deplaquing): extraoral fulcrum will
help the clinician to use lighter pressure.
Slide 75
Strokes Multiple, rapid, multi-directional, erasing, or
sweeping strokes. Keep tip moving at all times. The lighter the
pressure, the more effective the vibrations.
Slide 76
Strokes
Slide 77
Insertion Insert tip parallel to the long axis of the
tooth/root For CEJ areas, insertion is approximately 90
Slide 78
Insertion Parallel ObliqueOblique/Proximal
Slide 79
Adaptation Use lateral side or rounded back of tip Adapt side
of tip to tooth surface; tip/face to tooth angulation near zero
degrees. Keep tip moving continuously and submarginally on root
surface. Clean several surfaces at a time; do not continuously
start and stop.
Slide 80
Adaptation
Slide 81
Pocket Negotiation Enter pocket using the lateral side or back
surface; keeping the [side of] tip in contact [and parallel] with
the tooth/root surface. Negotiate to the apical extent using short,
overlapping strokes.
Slide 82
Adaptation for Piezo Scalers
Slide 83
Adapt the lateral surface of the tip for optimal performance
Maintain tip angulation near ZERO degrees (parallel to the tooth
surface) NEVER adapt tip at a 90 angle to avoid tooth/root damage
Use minimal or no lateral pressure; let the tip do the work for
you
Slide 84
Tip Design for Piezo Scalers The variety of tip designs offers
more options They offer thin designs and contra-bend bladed
curettes HuFriedy: Clinicians love this tip because looks and
functions like their bladed hand instruments
Slide 85
STAIN
Slide 86
Piezo Scaler for Stain Removal View the You-Tube Video on
Moodle
Slide 87
Techniques to Avoid Sensitivity Decrease power. Decrease
frequency (if manual tuned unitknown as detuning or tuning out of
phase). Increase water flow. Always keep the tip moving at all
times, maintain constant water flow. Determine the source of
sensitivity; either avoid instrumenting sensitive tooth surface(s)
[debride with alternate methods] or consider using desensitizing
agents or topical (Oraqix).
Slide 88
NUPRO Sensodyne Prophylaxis Paste with Novamin
Slide 89
Colgate Sensitive Pro-Relief Desensitizing Polishing Paste With
Pro-Argin Used to be marketed by Ortek as Proclude; Colgate then
distributed Proclude, then repackaged (same ingredient)
Slide 90
Oraqix lidocaine/prilocaine gel intra-pocket anesthetic
Slide 91
Calculus Deposit Removal The type, amount, and tenacity of
calculus must be considered for proper tip selection.
Slide 92
Calculus Deposit Removal Adapt appropriate insert using the
anterior 1/3 of the working end (active tip area). Engage the most
coronal portion of the deposit with the insert tip. Use light,
intermittent tappingstrokes against the deposit. Continue the
strokes in a lateral and apical direction until the deposit is
removed.
Slide 93
Tapping Strokes
Slide 94
Summary Can remove deposits from any direction. Can instrument
coronally to apically on the root surface (unlike hand/manual
instrumentation). It is not necessary to place the instrument
beneath the deposit in order to remove it.
Slide 95
Slide 96
Gross Debridement
Slide 97
Slimline Inserts/Tips A low (narrow stroke width) power setting
recommended. A maximum of medium power should be used for moderate
calculus removal during root scaling. Use of high power setting has
been associated with breaking the slimline tips.
Slide 98
BASIC PRINCIPLE The thinner the ultrasonic tip, the lower the
power setting.
Slide 99
Combination/Blended Approach to Debridement
Dense/hard/tenacious deposits generally require ultrasonics and the
manual use of curettes to ensure complete debridement. Scaling with
curettes for final finishing should always follow the use of
ultrasonics (when removing calculus OR biofilm). Following hand
scaling with ultrasonics is also efficient in additional
irrigation/lavage and cleanliness.
Slide 100
Biofilm Removal and Disruption (i.e. deplaquing) Use short,
overlapping brush-like strokes Keep the side of the tip (active tip
area) in contact with the tooth/root surface while moving with a
series of gentle erasing motions The instrument must touch every
square mm of the tooth surface to remove biofilm
Slide 101
Complementary Methods for Debridement Anna Pattison, RDH,
MS
Slide 102
Words of Wisdom Experienced clinicians appreciate the synergy
that occurs when power- driven instrumentation and manual
[curettes] are used in conjunction with one another. ~Technology
& Ultrasonic Debridement, Low, S.B.
Slide 103
The best results are probably obtained by combining
sonic/ultrasonic instruments with manual scaling. ~ Charles M.
Cobb, DDS, MS, PhD
Slide 104
Clinical Application of Root Morphology DH 220 A Prepared by
Leslie Clark, RDH, M.Ed
Slide 105
Objectives Understand relationship of tooth support and root
morphology Identify relationship of root anatomy and anomalies on
periodontal disease Identify periodontal therapy options
Slide 106
Terminology Review Periodontium: gingiva, cementum, PDL,
alveolar and supporting bone, alveolar mucosa Gingivitis:
inflammation (disease) of the gingiva Periodontitis: inflammation
(disease) of the supporting tissues of the teeth, usually resulting
in progressive destruction of those tissues
Slide 107
Terminology Review Periodontal disease: pathologic processes
affecting the periodontium, most often gingivitis and periodontitis
Dental biofilm: layer containing microorganisms that adhere to
teeth; contributes to the development of gingival and periodontal
disease and caries
Slide 108
Terminology Review Calculus: hard concretion that forms on the
teeth (or dental protheses) through calcification of bacterial
biofilm
Slide 109
Furcation Involvement As periodontal disease progresses
attachment loss increases Bone loss may reach a furcation area
These areas are difficult for the patient to clean Furcation areas
readily accumulate biofilm and calculus mineralization
Slide 110
Furcation Location Maxillary Molars: Mid-buccal Mesial
(accessed from lingual) Distal (accessed from lingual)
Furcation Location Maxillary Premolars: (with buccal and
lingual roots) middle of mesial middle of distal
Slide 113
Furcation Location Key points Where Type (type I, II or III)
Accessibility Radiographs ARE an important tool
Slide 114
Gingival Recession Loss of gingival tissue resulting in the
exposure of more root surface The gingival margin is apical to the
cementoenamel margin The papillae may be blunted or rounded, and no
longer fill the interproximal embrasure
Gingival Recession Key Points: Deviations of general
characteristics CEJ configuration Root sensitivity Oral Hygiene
Instruction
Slide 117
Other Factors Other factors that affect periodontal health:
Mobility CAL Bleeding
Slide 118
Tooth Support and Root Morphology Root attachment is primary
importance to stability of tooth Root attachment depends on length
of root, number of roots, presence or absence of concavities and
curvatures
Slide 119
In Health Connective tissue fibers insert into cementum on
entire root surface gingival fibers (supracrestal) PDL
Slide 120
In Health Long roots and wide roots increase support
Concavities and root curvatures increase support in two ways:
augment (increase) total surface area concave configuration
provides multi- directional fiber orientation
Slide 121
In Health: Generally: (based on root surface area) Maxillary
canines most stable single rooted teeth Mandibular incisors least
stable single rooted teeth
Slide 122
In Health Generally: Maxillary 1st molar (3 divergent roots)
more stable than 3rd molars (frequent fused roots)
Slide 123
Additional Factors Presence or absence of periodontal disease
Excessive occlusal forces Density and structure of supporting
bone
Slide 124
Root Anomalies and Periodontal Disease Enamel extension on
mandibular molar and enamel pearls on maxillary molars prevent
normal connective tissue attachment may channel disease into
furcation area
Slide 125
Root Anomalies and Periodontal Disease Palatal gingival grooves
occur on maxillary incisors; readily collect and retain plaque
biofilm, which can lead to periodontal destruction Root fractures
predispose periodontal destruction along fracture line
Slide 126
Other Root Anomalies Concrescence: fusion of two teeth at the
root Fusion: formation of a single tooth from the union of two
adjacent tooth buds Hypercementosis: excessive formation of
cementum around the root after the tooth has erupted
Slide 127
Accessory roots: extra roots that form on teeth after birth
Dwarfed roots: abnormally short roots with normal-sized crowns
Dilaceration: distortion of the root and crown from their normal
vertical position Flexion: sharp bend or curvature of a root that
only affects the root portion of the tooth
Slide 128
Importance of Root Anomalies Identify what is different or
unique about the tooth and root structure Provide instrumentation
with a purpose Provide Oral Hygiene Instruction based on
anomalies
Slide 129
Periodontal Therapy Options Non-surgical Periodontal Therapy
may include: Effective debridement and root planing Oral Hygiene
Instructions Antimicrobial agents
Slide 130
Periodontal Therapy Options Surgical Therapy: Correct results
of periodontal disease Removal of soft and hard tissue components
of pocket wall
Slide 131
Periodontal Therapy Options Gingivectomy Root resection
Periodontal flaps Osseous surgery Regenerative periodontal surgery
Bone grafting
Slide 132
Root Morphology/ Instrumentation Identify unique
characteristics of individual root anatomy explorer periodontal
probe radiographic evaluation
Slide 133
Root Morphology/ Instrumentation CEJ Anterior teeth: arc
interproximally making it difficult to instrument due to limited
accessibility and close proximity or adjacent teeth Improper
instrument adaptation results in incomplete scaling
Slide 134
Root Morphology/ Instrumentation CEJ: Molars are generally easy
to follow with explorer CEJ: generally feels smooth, may have
slight groove based on anatomy
Slide 135
Root Morphology/ Instrumentation Furcations: Identify number
and location of roots Furcations are generally narrow and difficult
to reach Clinician must picture roots from facial, lingual, distal
and mesial perspectives and identify specific characteristics
Slide 136
Root Morphology/ Instrumentation Instrument Selection:
Visualize root surface to be treated using assessment tools
including radiographs
Slide 137
Consider root surfaces of multi-rooted teeth as independent
areas to be instrumented EXAMPLES: The Gracey 11/12 can access the
mesial surface of the mandibular molars distal root The Gracey
13/14 can access the distal of the maxillary first molars
mesiobuccal root
Slide 138
Instrumentation After-Five Curettes: terminal shank elongated
to allow access to deep pockets and adaptation to root surfaces
Mini-Five Curettes: modification of after-five design. Length of
blade is reduced to allow ease of instrumentation and improved
adaptation for difficult to instrument areas
Slide 139
Clinical Application Clinician must use a variety of tools to
identify effective instrumentation techniques Instrument selection
is based on the anatomy of the area being treated Knowing what is
usual root morphology aids the clinician in modifying traditional
instrumentation techniques to provide quality periodontal
therapy
Slide 140
Dentinal Hypersensitivity Presented by Tammy Maahs, RDH, EP,
BSDH DH 220A Fall 2014
Slide 141
Dentinal Hypersensitivity defined: Pain arising from exposed
dentin in response to a stimulus or stimuli, which cannot be
explained as arising from any other form, dental defect, or
pathology. A variety of treatment interventions have been developed
to treat hypersensitivity, but no single therapy has been found to
solve the problem.
Slide 142
Dentinal Hypersensitivity A unique entity apart from other
sources of dental pain. Represents a transient type of pain. NOT
all exposed dentin is hypersensitive. No consensus on what causes
it and how to best manage it.
Slide 143
Dentinal Hypersensitivity Can occur at any site on any tooth.
More commonly buccal or lingual surfaces at the gingival margin.
Pain is sporadic and can range over time from being localized,
sharp or intense, to generalized with varying degrees of pain.
Symptoms are individual and episodic. Usually described as a short,
sharp pain as a response to stimuli such as cold, hot, sweet, or
air.
Slide 144
Slide 145
First Step Behavioral Modification Eliminating or reducing
personal habits that encourage tooth sensitivity is the first step
in controlling hypersensitivity Even though hypersensitivity is
associated with exposed dentin, not ALL exposed dentin is
hypersensitive
Slide 146
Stimuli That Elicit Pain Response: Mechanical (touch): 29% of
clients Thermal (temperature): 75% of clients (primarily cold)
Chemical (usually acids): can elicit pain response or may be the
cause Osmotic (sugar or salt solution) Evaporative (drying)
Slide 147
Causes and Locations for Dentin Exposure Most frequently found
at CEJ. Usually facial/buccal surfaces of most teeth. Canines and
first premolars show the highest incidence.
Slide 148
Enamel Loss: Cementum/Dentin Exposure Exposed cementum and/or
dentin are readily abraded when compared with enamel. Dentin
abrades 25 times faster than enamel. Cementum abrades 35 times
faster than enamel.
Slide 149
Slide 150
Causes and Locations: Recession: observed with normal aging.
Tooth apposition also may predispose a tooth to gingival tissue
loss since the buccal alveolar plate may be thin. Abrasion:
mechanical wear. Erosion (chemical): acidic foods and drinks.
Attrition: occlusal or incisal wear. Scaling and Root Planing
(periodontal treatment). Abfraction
Slide 151
Abfraction defined: Biomechanical wearing of tooth structure
through occlusal loading; causing stress, fatique, deformation and
fracture of dentin and enamel. Causes wedge-shaped notches at the
CEJ. This is caused by tensile and compressive forces during tooth
flexure.
Slide 152
Abfraction
Slide 153
Differential Diagnosis A differential diagnosis to rule out
other conditions must be established before treating for
hypersensitivity. Need a radiographic examination and clinical
examination (e.g., percussion test, occlusal evaluation) to rule
out other possible causes.
Slide 154
Dental Conditions That Mimic Dentinal Hypersensitivity Caries
or demineralization Fractured restorations Cracked tooth syndrome
Post-restorative sensitivity Teeth in hyperfunction Tooth Slooth
(for detecting cusp fractures)
Slide 155
Brnnstrms Hydrodynamic Theory Dentin is permeable Lymphatic
fluid present in the dentinal tubules transmit stimuli Odontoblasts
and their processes act as receptors and transmitters of sensory
stimuli Stimuli create movement of fluids, causing nerve endings at
the pulpal wall to be stimulated Fluid movement can be caused by
pressure, desiccation, heat, cold, and hypertonic solutions
Slide 156
Hydrodynamic Theory The number of tubules varies There can be
as many as 30,000 tubules in a square millimeter of dentin Tomes
fibers extend from the odontoblasts into the tubules These fibers
are what communicate to the pulp
Slide 157
Hydrodynamic Theory Fluid movement within tubules transmits a
signal to the nerves in the pulp chamber.
Slide 158
Hydrodynamic Theory The fluid movement stimulates the small,
myelinated A-delta fibers These nerve fibers transmit to the brain
Results in the sensation of a localized, sharp pain [that is
associated with dentinal hypersensitivity].
Slide 159
Hydrodynamic Theory Odontoblastic processes are stimulated
(excited) due to ion exchange.
Slide 160
Slide 161
Smear Layer: An organic matrix of hard tissue composed of
cementum, dentin, and calculus particles. Remains over the dentin
surface after instrumentation or restorative procedures. Acts as a
natural desensitizer (barrier) for a short period until removed by
toothbrushing, plaque acids, or acid-etching.
Slide 162
How Plaque Affects Dentinal Hypersensitivity: Invades open
tubules; implicated as a pain provoking stimulus. PLAQUE
EXACERBATES SENSITIVITY! More sensitivity occurs with poor plaque
control. Brushing technique (Bass Technique) important! Stress no
scrubbing, which abrades the gingiva and possibly(?) susceptible
tooth surface(s).
Slide 163
Sulcular Brushing
Slide 164
Some Newer Research on Plaque/Biofilm Information from Terri
Tilliss, RDH, MS, MA, PhD: There is not a correlation between teeth
with plaque biofilm and teeth with hypersensitivity. In fact, teeth
with less biofilm have more sensitivity. NOTE: it is still this
authors (me!) opinion and experience that acidic bacterial plaque
can exacerbate sensitivity; and plaque removal is important!
Slide 165
Etiology of the Reduction of Dentin Sensitivity Over Time
Natural desensitization: Natural formation of secondary,
reparative, tertiary, or sclerotic dentin. (Explains why
hypersensitivity generally diminishes over time and with aging).
The creation of a smear layer and calculus formation on the dentin
surface. Deposition of minerals in the tubule openings (usually
from fluoride) or from other salivary minerals.
Slide 166
TREATMENT STRATEGIES: The ideal desensitizing agent does not
exist! Clinicians must use a systematic trial and error approach
based on available evidence and professional experience. One
decision-making component as to which product to use is if the
sensitivity is LOCALIZED or GENERALIZED.
Cavity Varnish (Solution Liners) Copalite Varnal Barrier Dentin
Sealant Cavi-Line Handi-Liner 90% solvent mixture and 10% copal
resin A chemical barrier that reduces permeability of the dentinal
tubules
Slide 172
Bonding Agents Glass Ionomers: have been used for class V
restorations. Releases fluoride and chemically bonds to the tooth
surface. Composite Restorations: work well (and can be placed with
a glass ionomer base) if greater than 1 mm depth of abrasion or
erosion.
Slide 173
Primers (used prior to placing restorations or as chemical
desensitizing agents alone) Gluma Primer/Desensitizer Does not
leave a film layer on the tooth. Acts within the tubules.
Gluteraldehyde reacts with the organics in the tubules and seals
the ends [openings] by clotting the organic liquid. Acqua Seal A
gluteraldehyde formula combined with fluoride.
Slide 174
More Primers HurriSeal: same ingredients as the new formulation
of Acquaseal (benefit is no gluteraldehyde) Isodan: combination
productpotassium nitrate, sodium fluoride, HEMA and excipients,
also used prior to placement of restorations Pain Free: self-cure
primer
Slide 175
Fluorides Varnish: 5% Neutral Sodium Fluoride DURAPHAT
(Colgate), DURAFLOR (Medicom), CAVITY SHIELD (Omnii), FLUORIDEX
LONG-LASTING DEFENSE (Discus Dental). FDA approved for sensitivity;
ADA approved for caries prevention.
Slide 176
Fluorides Gel-Kam Dentin Bloc: an aqueous solution of sodium
fluoride, stannous fluoride, and hydrogen fluoride available in
unit doses with a foam applicator; applied for 1 minute. Other
in-office methods: a four-minute NSF or APF fluoride tray placed
prior to scaling (for generalized sensitivity) or localized
placement with cotton-tipped applicator.
Slide 177
Iontophoresis Desensitron (Parkell): Uses an electric current
to create a positively charged tooth surface, which attracts
negatively charged fluoride ions and imbeds them into dentin
tubules.
Slide 178
Laser Treatment Coalesces the tooth structure (tubules). Can be
used in conjunction with sodium fluoride varnish or a stannous
fluoride gel.
Slide 179
Connective Tissue Grafts For root coverage; a physical barrier.
Outcomes unpredictable. Before After
Slide 180
Colgate Sensitive Pro- Relief Pro-Argin technology Contains
calcium carbonate and arginine (same ingredient in Proclude)
Dispensed in a 3 oz. tube or 60 unit dose cups Recommended for
pre-polishing/ desensitizing prior to scaling
Slide 181
Colgate Sensitive Pro- Relief
Slide 182
NUPRO Sensodyne Prophylaxis Paste with Novamin Made by Dentsply
(makers of NuPro prophy paste) Desensitizing ingredient is NovaMin
(calcium sodium phophosilicateinduces the formation of new
hydroxyapatite) Low in abrasion Available in stain removal and
polishing grits
Slide 183
NUPRO Sensodyne Prophylaxis Paste with Novamin (Formerly
NUSolutions)
Slide 184
NUPRO Sensodyne Prophylaxis Paste with Novamin Remember that
this product also enhances remineralization! Also available as a
5000ppm fluoride prescription toothpaste with NovaMin for
sensitivity relief, caries prevention and superior
remineralization. Can be used as a daily treatment in place of
regular toothpaste.
Slide 185
OTC Products for Client Application Desensitizing Dentifrices:
containing strontium chloride, potassium nitrate* (*most contain),
sodium citrate. Sensitivity Protection Crest Crest Pro-Health
(contains stannous fluoride) Colgate Sensitive Sensodyne
Mouthrinses (Avoid mouthrinses with an acidic pH) ACT fluoride
rinse (.05% sodium fluoride), or other fluoride rinses
Slide 186
Slide 187
Slide 188
Sensodyne Pronamel Protects your teeth from sensitivity and the
effects of acid wear. Everyday foods such as fruit, sodas, orange
juice and wine contain acids that soften the enamel surface which
is then more easily worn away by brushing. As the enamel layer
becomes thinner, teeth can become visibly less white and older
looking.
Slide 189
Dentifrices Continued: Sodium Bicarbonate dentifrices play an
important role; they neutralize acids and are low in abrasion. New
combination dentifrices (of calcium & phosphate) that may help
remineralize the teeth offer protection by continually abating the
erosion process. (Arm & Hammer EnamelCare and Mentadent
Replenishing White toothpastes), both with liquid calcium.
Slide 190
Liquid Calcium
Slide 191
Prescription Products for Client Application Fluoride Products
(pastes and gels are OTC) Stannous Fluoride Gel.4% (Gel Kam, Gel
Tin, Stop, Omnii Gel, Fluoridex Daily Renewal) 1.1% Sodium Fluoride
(Prevident, Fluoridex) Mouthrinses.12% CHX followed by.2% sodium
fluoride rinse (Hodges) Stannous Fluoride Rinse.63%: Gel Kam
(Colgate), PerioMed (Omnii) [rinses require Rx]
Slide 192
More Others: At Home (prescription/patient applied) Therapies
SootheRx (Omnii): also utilizes Novamin (calcium sodium
phophosilicateinduces the formation of new hydroxyapatite).
Recaldent: PROSPEC MI Paste (GC America, Inc.): calcium phosphate
combination (marketed as a remineralizing agent but also cited as
reducing dentinal hypersensitivity by occluding dentinal
tubules).
Slide 193
Slide 194
Whitening Considerations Recommend (ALWAYS provide!)
desensitizing toothpaste during whitening procedures. Ultradent
(Opalescence) adds fluoride and potassium nitrate to some of their
bleaching products and have a separate product (UltraEZ 3% sodium
nitrate and.11% fluoride ion in a gel form) for use in the custom
tray for desensitizing.
Slide 195
Behavioral Modification Dietary Counseling Patients may need to
consider some lifestyle changes, such as altering their diet/habits
Caution patients NOT to brush directly after eating acidic
foods
Slide 196
Treatment Tips from Practicing Clinician That would be me
Slide 197
For Generalized Root Exposure/ Dentin Sensitivity PRE-POLISH
with NovaMin based prophy paste: dont bother with polish vs. stain
removal formulas; I only use the polish formula for general full
mouth polishing for root sensitivity.
Slide 198
For Generalized Root Exposure/ Dentin Sensitivity (continued)
If a patient feels (reports sensitivity) it on the first
application (touch/tactile), re-polish that surface a second time
with NUPRO Sensodyne polish. Be sure to leave on the teeth for
several minutes (do not rinse immediately). Proceed with
debridement procedures (ultrasonic and/or hand
instrumentation).
Slide 199
For Localized Root Exposure/ Dentin Sensitivity Purchase the
Colgate Sensitive Pro Relief in TUBE form
Slide 200
For Localized Root Exposure/ Dentin Sensitivity (continued) Put
a dab (pea-size) on top of your regular prophy paste; I prefer
Enamel Pro with ACP coarse for heavier plaque and/or stain
removal.
Slide 201
For Localized Root Exposure/ Dentin Sensitivity (continued)
Again PRE-POLISH the sensitive areas and do not rinse immediately
Continue with generalized polishing with regular prophy paste to
remove plaque biofilm and stain
OSHA Occupational Safety & Health Administration Created in
1970 by the U.S. Department of Labor Purpose is to protect the
health and safety of ALL workers
Slide 205
EXPOSURE CONTROL To identify and manage the prevention of
exposure to workplace hazards in order to reduce or eliminate harm
to the employee or patient NOT the same as INFECTION CONTROL
Slide 206
Components of Exposure Control Infection Control Policy and
Practice Physical Precautions Chemical Safety Warning Signs and
Labels Waste Management Record Keeping
Slide 207
Exposure Control Manual Contain written health and safety plans
Contain post-exposure management plan Centrally located in the
office with access to all employees Maintain record keeping for
employee
Slide 208
Employee Records: Must be kept private and contain: Job
description with Exposure Risk Determination Accident/Incident
reports (injuries, exposures) Training Records Basic medical
information Hepatitis B record
Slide 209
OCCUPATIONAL EXPOSURE Physical, chemical, or infectious
hazards
Slide 210
Physical Exposure (Hazards) Exposure to equipment Exposure to
sharps Exposure to dental waste
Slide 211
Chemical Exposure Hazardous Communication Standard: Regulates
and establishes a standard for hazards associated with the
production, transportation, usage, storage and disposal of
chemicals
Slide 212
MSDS Material Safety Data Sheets Used to communicate the hazard
of a product
Slide 213
Infectious Exposure Exposure to bloodborne pathogens BLOODBORNE
PATHOGENS STANDARD: deals with infectious disease exposure control
to prevent transmission of bloodborne diseases
Slide 214
HAZARD ABATEMENT Exposure control The use of certain controls
to reduce the probability of occupational exposure
Slide 215
Standard Precautions Method of exposure control that treats all
patients and materials as potentially infectious New term is Body
Substance Isolation (BSI) Used to be called Universal
Precautions
Slide 216
Principles of BSI Provide a barrier between yourself and the
blood/body fluid of another person Treat all blood/body fluid as if
it is infectious
Slide 217
Work Practice Controls Methods that reduce the chance of
exposure incident (e.g., handwashing, one handed needle
recapping)
Slide 218
Engineering Controls Use of devices that isolate and promote
safety (e.g., instrument cassettes, recapping devices) Sharps or
biomedical waste containers within easy reach to dispose of
infectious materials
Slide 219
Personal Protective Equipment (PPE) Gloves: first line of
defense ALWAYS wash hands as soon as possible after removing
gloves! CHANGE if torn or soiled Masks Protective eyewear with side
shields Face shields Lab coats
Slide 220
Housekeeping (Regulated Waste Disposal) Safe handling of waste
and laundry Cleanliness of environment and clothing Sharps
containers do not go into regular trash
Slide 221
INFECTIOUS DISEASE PROCESS Causative agent: microorganism
capable of causing disease Susceptible host: lacks effective
resistance to a particular agent Mode of Transmission: Direct
contact Indirect contact Airborne inhaled droplets
Slide 222
Occupational Exposure to Pathogens As defined by OSHA: A
specific eye, mouth, mucous membrane, non-intact skin or parenteral
contact with blood or other potentially infectious materials as a
result of performing employees duties.
Slide 223
Exposure Access Parenteral exposure: piercing of the skin with
a needle or sharp instrument Contact with mucous membrane Contact
with a wound or abrasions in the skin (non-intact skin)
Slide 224
NOT all exposures result in infection Infection depends upon:
Route of transmission Dosage of the virus Host susceptibility
Volume of the infectious fluid Infection = increased virulence of
agent + decreased host resistance + the amount of the agent
Slide 225
Exposure Risk Determination Categories Category I: employees
who perform tasks that involve exposure to blood or potentially
infectious materials Category II: employees who do not perform
tasks involving exposure during work, but may be called upon to do
so Uncategorized: administrative employees who have no risk
Slide 226
Exposure Protocol Treat injury Notify exposure control manager
Evaluate situation Document incident Testing if indicated (informed
consent) Baseline testing for HIV, HBV, and HCV as close to time of
exposure as possible Follow up--CONFIDENTIAL
Slide 227
Post-exposure Prophylaxis Evidence for post-exposure
prophylaxis is great enough to support the use of highly active
anti-retroviral therapy [HAART] agents to prevent HIV infection.
Post-exposure prophylaxis is not 100% effective but can alter the
course of the disease if given early enough.
Slide 228
Post-exposure Prophylaxis to HIV Considerations Type of
exposure (needle stick or puncture wound highest risk) Source
persons medical history Toxicity of the prophylactic drugs (AZT,
and 3TC, possibly IDV)risk vs. benefit!
Slide 229
Other Infectious Diseases Hepatitis A Hepatitis B Hepatitis C
(highly virulent) Tuberculosis Meningitis Staphylococcus Aureus
MRSA (Healthcare associated and community associated)
Slide 230
BARRIERS Provide protection from workplace hazards; either
chemical or infectious and encompasses standard precautions. Two
types: Biological (immunizations) Physical: second line of
defensemust be between the person and the agent
Slide 231
Personal Hygiene: Handwashing Two types of microflora on hands:
Resident: survive and multiply on the skin. Many are not highly
infectious but may cause infection Transient: recent contaminants
that can survive on the skin only a limited period of time (e.g.,
HBV)
Slide 232
Thorough Handwashing Requires time Use liquid antimicrobial
soap with residual effect 3% PCMX (parachlorometaxylenol) 4% CHX
(chlorhexidine) NO bar soap
Slide 233
Proper Handwashing Technique (SOP) Remove jewelry (rings,
watches, bracelets) Wet hands, wrists, forearms with cool water
Dispense soap and work gently into all areas (minimum 15 seconds)
Rinse thoroughly and pat dry with disposable paper towel If no foot
control or hands-free control, turn off with paper towel and then
throw away towel
Slide 234
More Hand Hygiene Soap used for hand washing
Antimicrobial/alcohol hand sanitizers are the main method on
unsoiled hands Use EPA approved healthcare products DO BOTH
THROUGHOUT THE DAY Wash hands with soap and water to remove
contaminants Use alcohol hand rub to kill most organisms
Slide 235
GLOVES: protect the clinician and the patient! Types: Latex
Nitrile or vinyl Over-gloves Utility gloves Heat resistant oven
mitts
Slide 236
More on Gloves GLOVES FAIL Organisms grow under gloves,
doubling every 12 minutes
Slide 237
Protective Eyewear Belong over the clinicians EYES, not worn on
top of his/her head! Put on before donning treatment gloves
Slide 238
Protective Eyewear (continued) Shatter resistant goggle with
side shields or prescription personal eyewear with removable side
shields Must be worn (over the eyes!) to protect from spatter of
blood and saliva or injury from foreign particles Clean eyewear
between patients with soap and water Recommended that patients also
wear protective eyewear
Slide 239
Masks Protect face and mucous membranes of nose and mouth from
spatter Should cover nose, mouth, and most of cheek and skin Fit
snugly against the face Change when wet or contaminated between
patients Never leave dangling from one ear or around neck Never
touch with gloved hands
Slide 240
Face Shields Should be worn when aerosols are generated Can be
worn instead of goggles with a mask
Slide 241
Clinical Attire Launderable lab coats or disposable Not worn
outside the office Employer is responsible for laundering lab
coats
Slide 242
INFECTION CONTROL KEY TERMS (in alphabetical order)
Slide 243
AEROSOLIZATION Spray generated by dental devices that can
transfer microorganisms through the air. Infection may result in
direct transmission from air or indirect transmission via
fomites.
Slide 244
AIDS Acquired Immune Deficiency Syndrome caused by the Human
Immunodeficiency Virus (HIV); a bloodborne virus that affects the
immune system.
Slide 245
ANTIMICROBIAL An agent that prevents microbial growth
Slide 246
ANTISEPTIC A chemical agent applied to living tissue to reduce
the amount of microorganisms
Slide 247
ASEPSIS The absence of disease producing microorganisms
Slide 248
ASEPTIC TECHNIQUE A procedure that reduces or eliminates
pathogens through disinfecting or sterilizing of instruments and
surfaces to avoid contamination of the patient.
Slide 249
BACTERICIDAL Capable of killing bacteria
Slide 250
BARRIER A means of protection from a workplace hazard either
chemical or infectious
Slide 251
BIO-BURDEN Biologically contaminated debris found on
instruments; MUST be removed before sterilization
Slide 252
BLOOD-BORNE Microorganisms within the bloodstream that are able
to be transmitted to other via blood
Slide 253
CAUSATIVE AGENT Microorganism capable of causing a disease
Slide 254
CENTERS FOR DISEASE CONTROL (CDC) A governmental agency
responsible for the epidemiological study of a disease. It is not a
regulatory agency, but provides information and advises.
Slide 255
CROSS-CONTAMINATION Contamination as a result of transfer of a
microorganism from one source to another, (i.e., person to person,
OR person to object to another person).
Slide 256
CROSS-INFECTION Infection as a result of transfer of
microorganisms between people
Slide 257
DIRECT CONTACT Transmission via blood to an individual
Slide 258
DISINFECTANT A chemical agent applied to inanimate objects or
surfaces to reduce the risk of infection by reducing the number of
microorganisms present
Slide 259
ENGINEERING CONTROL An abatement or device that removes or
isolates a workplace hazard
Slide 260
ENVIRONMENTAL PROTECTION AGENCY (EPA) A governmental agency
responsible for regulating items than impact the environment, such
as chemicals and waste
Slide 261
ETIOLOGY The cause of a disease, finding an etiological agent
which is responsible microbe for a specific infectious disease
Slide 262
FOOD & DRUG ADMINISTRATION (FDA) A governmental agency
responsible for regulating that which impacts living tissue (e.g.,
food, drugs, and medical services).
Slide 263
FOMITES Inanimate, potentially contaminated objects that serve
as agents of disease transmission
Slide 264
FUNGICIDAL Capable of killing fungi
Slide 265
GERMICIDE A chemical agent capable of destroying bacteria
Slide 266
HAZARD ABATEMENT Those procedures which reduce your risk of
occupational exposure to bloodborne diseases and hazardous chemical
usage in the workplace
Slide 267
HAZARDOUS WASTE Waste that poses a threat to people
Slide 268
HBIG: Hepatitis B Immune Globulin HBV: Hepatitis B Virus
(bloodborne virus that affects the liver) HCV: Hepatitis C Virus
HIV: Human Immunodeficiency virus (bloodborne virus that affects
the immune system and can ultimately lead to AIDS)
Slide 269
INDIRECT CONTACT Transmission via a contaminated object
Slide 270
INFECTIOUS DISEASE A disease induced by microorganisms that can
be transmitted from one host to another via an infectious
process
Slide 271
INFECTIOUS WASTE Waste capable of causing infection
Slide 272
MSDS Material Data Safety Sheets
Slide 273
MICROBIAL DOSE LOAD The dose level of microbes present in a
specific area
Slide 274
MICROORGANISM A microscopic form of life
Slide 275
MODE OF TRANSMISSION A method by which a disease is
transmitted
Slide 276
OCCUPATIONAL EXPOSURE Contact with infectious material at an
individuals workplace that puts him or her at risk of harm or
contacting a disease
Slide 277
OSHA Occupational Safety & Health Administration: a federal
regulatory agency responsible for ensuring workplace safety and
health
Slide 278
PATHOGENIC The inherent ability of a microorganism to cause
disease
Slide 279
PERSONAL PROTECTIVE EQUIPMENT (PPE) Personal attire worn by the
health care worker to protect them from an infectious or chemical
hazard
Slide 280
SANITIZATION The process by which the number of organisms on
inanimate objects is reduced to a safe level. Helps to reduce the
cleaning process.
Slide 281
SEPSIS The presence of disease producing organisms
Slide 282
SPORICIDAL Capable of killing spores
Slide 283
STANDARD PRECAUTIONS The method of infection control that
treats all patients and all materials as potentially infectious
Current terminology is Body Substance Isolation (BSI) OLD term was
Universal Precautions
Slide 284
STATIC AGENTS Chemicals that inhibit the growth of
microorganisms, but do NOT kill them
Slide 285
STERILIZATION The process by which all life forms are destroyed
by physical or chemical means
Slide 286
SURFACE DISINFECTION The process of killing some types of
microorganisms on environmental surfaces
Slide 287
SUSCEPTIBLE HOST A host (person) who lacks effective resistance
to a particular agent
Slide 288
VIRUCIDAL Capable of killing viruses
Slide 289
VIRULENCE The ability of pathogens to cause infectious disease
due to its strength, and ability to reproduce and organize
Slide 290
WORK PRACTICE CONTROLS Method of performing ones duties in a
manner that reduces or eliminates risk of an exposure incident
Slide 291
Guidelines for Infection Control in Dental Health-Care Settings
2003 CDC. MMWR 2003;52(No. RR-17) http://www.cdc.gov/oralhealth/
infectioncontrol/guidelines/index.htm
Slide 292
This slide set Guidelines for Infection Control in Dental
Health-Care Settings- Core and accompanying speaker notes provide
an overview of many of the basic principles of infection control
that form the basis for the CDC Guidelines for Infection Control in
Dental Health-Care Settings 2003. This slide set can be used for
education and training of infection control coordinators,
educators, consultants, and dental staff (initial and periodic
training) at all levels of education.
Slide 293
Infection Control in Dental Health-Care Settings: An Overview
Guidelines for Infection Control in Dental Health- Care
Settings2003. MMWR 2003; Vol. 52, No. RR-17. Background Personnel
Health Elements Bloodborne Pathogens Hand Hygiene Personal
Protective Equipment Latex Hypersensitivity/Contact Dermatitis
Sterilization and Disinfection Environmental Infection Control
Dental Unit Waterlines Special Considerations Program
Evaluation
Slide 294
CDC Recommendations Improve effectiveness and impact of public
health interventions Inform clinicians, public health
practitioners, and the public Developed by advisory committees, ad
hoc groups, and CDC staff Based on a range of rationale, from
systematic reviews to expert opinions
Slide 295
Background
Slide 296
Why Is Infection Control Important in Dentistry? Both patients
and dental health care personnel (DHCP) can be exposed to pathogens
Contact with blood, oral and respiratory secretions, and
contaminated equipment occurs Proper procedures can prevent
transmission of infections among patients and DHCP
Slide 297
Modes of Transmission Direct contact with blood or body fluids
Indirect contact with a contaminated instrument or surface Contact
of mucosa of the eyes, nose, or mouth with droplets or spatter
Inhalation of airborne microorganisms
Slide 298
Chain of Infection Pathogen Source ModeEntry Susceptible
Host
Slide 299
Standard Precautions Apply to all patients Integrate and expand
Universal Precautions to include organisms spread by blood and also
Body fluids, secretions, and excretions except sweat, whether or
not they contain blood Non-intact (broken) skin Mucous
membranes
Slide 300
Elements of Standard Precautions Handwashing Use of gloves,
masks, eye protection, and gowns Patient care equipment
Environmental surfaces Injury prevention
Slide 301
Personnel Health Elements
Slide 302
Personnel Health Elements of an Infection Control Program
Education and training Immunizations Exposure prevention and
postexposure management Medical condition management and work-
related illnesses and restrictions Health record maintenance
Slide 303
Bloodborne Pathogens
Slide 304
Preventing Transmission of Bloodborne Pathogens Are
transmissible in health care settings Can produce chronic infection
Are often carried by persons unaware of their infection Bloodborne
viruses such as hepatitis B virus (HBV), hepatitis C virus (HCV),
and human immunodeficiency virus (HIV)
Slide 305
Potential Routes of Transmission of Bloodborne Pathogens
Patient DHCP Patient
Slide 306
Factors Influencing Occupational Risk of Bloodborne Virus
Infection Frequency of infection among patients Risk of
transmission after a blood exposure (i.e., type of virus) Type and
frequency of blood contact
Slide 307
Average Risk of Bloodborne Virus Transmission after Needlestick
SourceRisk HBV HBsAg + and HBeAg + 22.0%-31.0% clinical hepatitis;
37%-62% serological evidence of HBV infection HBsAg + and HBeAg -
1.0%-6.0% clinical hepatitis; 23%- 37% serological evidence of HBV
infection HCV 1.8% (0%-7% range) HIV 0.3% (0.2%-0.5% range)
Slide 308
Concentration of HBV in Body Fluids High Moderate Low/Not
Detectable Blood Semen Urine Serum Vaginal Fluid Feces Wound
exudates Saliva Sweat Tears Breast Milk
Slide 309
Estimated Incidence of HBV Infections Among HCP and General
Population, United States, 1985-1999 Health Care Personnel General
U.S. Population
Slide 310
Source: Cleveland et al., JADA 1996;127:1385-90. Personal
communication ADA, Chakwan Siew, PhD, 2005. Percent HBV Infection
Among U.S. Dentists Yea r
Slide 311
Hepatitis B Vaccine Vaccinate all DHCP who are at risk of
exposure to blood Provide access to qualified health care
professionals for administration and follow-up testing Test for
anti-HBs 1 to 2 months after 3rd dose
Slide 312
Transmission of HBV from Infected DHCP to Patients Nine
clusters of transmission from dentists and oral surgeons to
patients, 19701987 Eight dentists tested for HBeAg were positive
Lack of documented transmissions since 1987 may reflect increased
use of gloves and vaccine One case of patient-to-patient
transmission, 2003
Slide 313
Occupational Risk of HCV Transmission among HCP 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
Slide 314
HCV Infection in Dental Health Care Settings Prevalence of HCV
infection among dentists similar to that of general population (~
1%-2%) No reports of HCV transmission from infected DHCP to
patients or from patient to patient Risk of HCV transmission
appears very low
Slide 315
Transmission of HIV from Infected Dentists to Patients Only one
documented case of HIV transmission from an infected dentist to
patients No transmissions documented in the investigation of 63
HIV-infected HCP (including 33 dentists or dental students)
Slide 316
Health Care Workers with Documented and Possible Occupationally
Acquired HIV/AIDS CDC Database as of December 2002 * 3 dentists, 1
oral surgeon, 2 dental assistants DocumentedPossible Dental Worker
0 6 * Nurse24 35 Lab Tech, clinical16 17 Physician, nonsurgical 6
12 Lab Tech, nonclinical 3 Other 8 69 Total57139
Slide 317
Risk Factors for HIV Transmission after Percutaneous Exposure
to HIV-Infected Blood CDC Case-Control Study Deep injury Visible
blood on device Needle placed in artery or vein Terminal illness in
source patient Source: Cardo, et al., N England J Medicine
1997;337:1485-90.
Slide 318
Characteristics of Percutaneous Injuries Among DHCP Reported
frequency among general dentists has declined Caused by burs,
syringe needles, other sharps Occur outside the patients mouth
Involve small amounts of blood Among oral surgeons, occur more
frequently during fracture reductions and procedures involving
wire
Slide 319
Exposure Prevention Strategies Engineering controls Work
practice controls Administrative controls
Slide 320
Engineering Controls Isolate or remove the hazard Examples:
Sharps container Medical devices with injury protection features
(e.g., self-sheathing needles)
Slide 321
Work Practice Controls Change the manner of performing tasks
Examples include: Using instruments instead of fingers to retract
or palpate tissue One-handed needle recapping
Slide 322
Administrative Controls Policies, procedures, and enforcement
measures Placement in the hierarchy varies by the problem being
addressed Placed before engineering controls for airborne
precautions (e.g., TB)
Slide 323
Post-exposure Management Program Clear policies and procedures
Education of dental health care personnel (DHCP) Rapid access to
Clinical care Post-exposure prophylaxis (PEP) Testing of source
patients/HCP
Slide 324
Wound management Exposure reporting Assessment of infection
risk Type and severity of exposure Bloodborne status of source
person Susceptibility of exposed person Post-exposure
Management
Slide 325
Hand Hygiene
Slide 326
Why Is Hand Hygiene Important? Hands are the most common mode
of pathogen transmission Reduce spread of antimicrobial resistance
Prevent health care-associated infections
Slide 327
Hands Need to be Cleaned When Visibly dirty After touching
contaminated objects with bare hands Before and after patient
treatment (before glove placement and after glove removal)
Slide 328
Hand Hygiene Definitions Handwashing Washing hands with plain
soap and water Antiseptic handwash Washing hands with water and
soap or other detergents containing an antiseptic agent
Alcohol-based handrub Rubbing hands with an alcohol-containing
preparation Surgical antisepsis Handwashing with an antiseptic soap
or an alcohol-based handrub before operations by surgical
personnel
Slide 329
Efficacy of Hand Hygiene Preparations in Reduction of Bacteria
Good Better Best Plain Soap Antimicrobial soap Alcohol-based
handrub Source: http://www.cdc.gov/handhygiene/materials.htm
Slide 330
Alcohol-based Preparations Rapid and effective antimicrobial
action Improved skin condition More accessible than sinks Cannot be
used if hands are visibly soiled Store away from high temperatures
or flames Hand softeners and glove powders may build-up
BenefitsLimitations
Slide 331
Special Hand Hygiene Considerations Use hand lotions to prevent
skin dryness Consider compatibility of hand care products with
gloves (e.g., mineral oils and petroleum bases may cause early
glove failure) Keep fingernails short Avoid artificial nails Avoid
hand jewelry that may tear gloves
Slide 332
Personal Protective Equipment
Slide 333
A major component of Standard Precautions Protects the skin and
mucous membranes from exposure to infectious materials in spray or
spatter Should be removed when leaving treatment areas
Slide 334
Masks, Protective Eyewear, Face Shields Wear a surgical mask
and either eye protection with solid side shields or a face shield
to protect mucous membranes of the eyes, nose, and mouth Change
masks between patients Clean reusable face protection between
patients; if visibly soiled, clean and disinfect
Slide 335
Protective Clothing Wear gowns, lab coats, or uniforms that
cover skin and personal clothing likely to become soiled with
blood, saliva, or infectious material Change if visibly soiled
Remove all barriers before leaving the work area
Slide 336
Gloves Minimize the risk of health care personnel acquiring
infections from patients Prevent microbial flora from being
transmitted from health care personnel to patients Reduce
contamination of the hands of health care personnel by microbial
flora that can be transmitted from one patient to another Are not a
substitute for handwashing!
Slide 337
Recommendations for Gloving Wear gloves when contact with
blood, saliva, and mucous membranes is possible Remove gloves after
patient care Wear a new pair of gloves for each patient
Slide 338
Recommendations for Gloving Remove gloves that are torn, cut or
punctured Do not wash, disinfect or sterilize gloves for reuse
Slide 339
Latex Hypersensitivity and Contact Dermatitis
Slide 340
Latex Allergy Type I hypersensitivity to natural rubber latex
proteins Reactions may include nose, eye, and skin reactions More
serious reactions may include respiratory distress rarely shock or
death
Slide 341
Contact Dermatitis Irritant contact dermatitis Not an allergy
Dry, itchy, irritated areas Allergic contact dermatitis Type IV
delayed hypersensitivity May result from allergy to chemicals used
in glove manufacturing
Slide 342
General Recommendations Contact Dermatitis and Latex Allergy
Educate DHCP about reactions associated with frequent hand hygiene
and glove use Get a medical diagnosis Screen patients for latex
allergy Ensure a latex-safe environment Have latex-free kits
available (dental and emergency)
Slide 343
Sterilization and Disinfection of Patient Care Items
Slide 344
Critical Instruments Penetrate mucous membranes or contact
bone, the bloodstream, or other normally sterile tissues (of the
mouth) Heat sterilize between uses or use sterile single-use,
disposable devices Examples include surgical instruments, scalpel
blades, periodontal scalers, and surgical dental burs
Slide 345
Semi-critical Instruments Contact mucous membranes but do not
penetrate soft tissue Heat sterilize or high-level disinfect
Examples: Dental mouth mirrors, amalgam condensers, and dental
handpieces
Slide 346
Noncritical Instruments and Devices Contact intact skin Clean
and disinfect using a low to intermediate level disinfectant
Examples: X-ray heads, facebows, pulse oximeter, blood pressure
cuff
Slide 347
Instrument Processing Area Use a designated processing area to
control quality and ensure safety Divide processing area into work
areas Receiving, cleaning, and decontamination Preparation and
packaging Sterilization Storage
Manual Cleaning Soak until ready to clean Wear heavy-duty
utility gloves, mask, eyewear, and protective clothing
Slide 350
Preparation and Packaging Critical and semi-critical items that
will be stored should be wrapped or placed in containers before
heat sterilization Hinged instruments opened and unlocked Place a
chemical indicator inside the pack Wear heavy-duty,
puncture-resistant utility gloves
Slide 351
Heat-Based Sterilization Steam under pressure (autoclaving)
Gravity displacement Pre-vacuum Dry heat Unsaturated chemical
vapor
Slide 352
Liquid Chemical Sterilant/Disinfectants Only for heat-sensitive
critical and semi-critical devices Powerful, toxic chemicals raise
safety concerns Heat tolerant or disposable alternatives are
available
Slide 353
Sterilization Monitoring Types of Indicators Mechanical Measure
time, temperature, pressure Chemical Change in color when physical
parameter is reached Biological (spore tests) Use biological spores
to assess the sterilization process directly
Slide 354
Storage of Sterile and Clean Items and Supplies Use date- or
event-related shelf-life practices Examine wrapped items carefully
prior to use When packaging of sterile items is damaged, re-clean,
re-wrap, and re- sterilize Store clean items in dry, closed, or
covered containment
Slide 355
Environmental Infection Control
Slide 356
Environmental Surfaces May become contaminated Not directly
involved in infectious disease transmission Do not require as
stringent decontamination procedures
Slide 357
Categories of Environmental Surfaces Clinical contact surfaces
High potential for direct contamination from spray or spatter or by
contact with DHCPs gloved hand Housekeeping surfaces Do not come
into contact with patients or devices Limited risk of disease
transmission
Slide 358
Clinical Contact Surfaces
Slide 359
Housekeeping Surfaces
Slide 360
General Cleaning Recommendations Use barrier precautions (e.g.,
heavy-duty utility gloves, masks, protective eyewear) when cleaning
and disinfecting environmental surfaces Physical removal of
microorganisms by cleaning is as important as the disinfection
process Follow manufacturers instructions for proper use of
EPA-registered hospital disinfectants Do not use
sterilant/high-level disinfectants on environmental surfaces
Slide 361
Cleaning Clinical Contact Surfaces Risk of transmitting
infections greater than for housekeeping surfaces Surface barriers
can be used and changed between patients OR Clean then disinfect
using an EPA-registered low- (HIV/HBV claim) to intermediate-level
(tuberculocidal claim) hospital disinfectant
Slide 362
Cleaning Housekeeping Surfaces Routinely clean with soap and
water or an EPA-registered detergent/hospital disinfectant
routinely Clean mops and cloths and allow to dry thoroughly before
re-using Prepare fresh cleaning and disinfecting solutions daily
and per manufacturer recommendations
Slide 363
Medical Waste Medical Waste: Not considered infectious, thus
can be discarded in regular trash Regulated Medical Waste: Poses a
potential risk of infection during handling and disposal
Slide 364
Regulated Medical Waste Management Properly labeled containment
to prevent injuries and leakage Medical wastes are treated in
accordance with state and local EPA regulations Processes for
regulated waste include autoclaving and incineration
Slide 365
Dental Unit Waterlines, Biofilm, and Water Quality
Slide 366
Dental Unit Waterlines and Biofilm Microbial biofilms form in
small bore tubing of dental units Biofilms serve as a microbial
reservoir Primary source of microorganisms is municipal water
supply
Slide 367
Dental Unit Water Quality Using water of uncertain quality is
inconsistent with infection control principles Colony counts in
water from untreated systems can exceed 1,000,000 CFU/mL CFU=colony
forming unit Untreated dental units cannot reliably produce water
that meets drinking water standards
Slide 368
Dental Water Quality For routine dental treatment, meet
regulatory standards for drinking water.* *
Slide 369
Available DUWL Technology Independent reservoirs Chemical
treatment Filtration Combinations Sterile water delivery
systems
Slide 370
Monitoring Options Water testing laboratory In-office testing
with self-contained kits Follow recommendations provided by the
manufacturer of the dental unit or waterline treatment product for
monitoring water quality
Slide 371
Sterile Irrigating Solutions Use sterile saline or sterile
water as a coolant/irrigator when performing surgical procedures
Use devices designed for the delivery of sterile irrigating
fluids
Slide 372
Special Considerations Dental handpieces and other devices
attached to air and waterlines Dental radiology Aseptic technique
for parenteral medications Single-use (disposable) Devices
Preprocedural mouth rinses Oral surgical procedures Handling biopsy
specimens Handling extracted teeth Laser/electrosurgery plumes or
surgical smoke Dental laboratory Mycobacterium tuberculosis
Creutzfeldt-Jacob Disease (CJD) and other prion- related
diseases
Slide 373
Dental Handpieces and Other Devices Attached to Air and
Waterlines Clean and heat sterilize intraoral devices that can be
removed from air and waterlines Follow manufacturers instructions
for cleaning, lubrication, and sterilization Do not use liquid
germicides or ethylene oxide
Slide 374
Components of Devices Permanently Attached to Air and
Waterlines Do not enter patients mouth but may become contaminated
Use barriers and change between uses Clean and intermediate-level
disinfect the surface of devices if visibly contaminated
Slide 375
Saliva Ejectors Previously suctioned fluids might be retracted
into the patients mouth when a seal is created Do not advise
patients to close their lips tightly around the tip of the saliva
ejector
Slide 376
Dental Radiology Wear gloves and other appropriate personal
protective equipment as necessary Heat sterilize heat-tolerant
radiographic accessories Transport and handle exposed radiographs
so that they will not become contaminated Avoid contamination of
developing equipment
Slide 377
Parenteral Medications Definition: Medications that are
injected into the body Cases of disease transmission have been
reported Handle safely to prevent transmission of infections
Slide 378
Precautions for Parenteral Medications IV tubings, bags,
connections, needles, and syringes are single-use, disposable
Single dose vials Do not administer to multiple patients even if
the needle on the syringe is changed Do not combine leftover
contents for later use
Slide 379
Single-Use (Disposable) Devices Intended for use on one patient
during a single procedure Usually not heat-tolerant Cannot be
reliably cleaned Examples: Syringe needles, prophylaxis cups, and
plastic orthodontic brackets
Slide 380
Preprocedural Mouth Rinses Antimicrobial mouth rinses prior to
a dental procedure Reduce number of microorganisms in
aerosols/spatter Decrease the number of microorganisms introduced
into the bloodstream Unresolved issueno evidence that infections
are prevented
Slide 381
Oral Surgical Procedures Present a risk for microorganisms to
enter the body Involve the incision, excision, or reflection of
tissue that exposes normally sterile areas of the oral cavity
Examples include biopsy, periodontal surgery, implant surgery,
apical surgery, and surgical extractions of teeth
Handling Biopsy Specimens Place biopsy in sturdy, leakproof
container Avoid contaminating the outside of the container Label
with a biohazard symbol
Slide 384
Considered regulated medical waste Do not incinerate extracted
teeth containing amalgam Clean and disinfect before sending to lab
for shade comparison Can be given back to patient Extracted
Teeth
Slide 385
Handling Extracted Teeth in Educational Settings Remove visible
blood and debris Maintain hydration Autoclave (teeth with no
amalgam) Use Standard Precautions
Slide 386
Laser/Electrosurgery Plumes and Surgical Smoke Destruction of
tissue creates smoke that may contain harmful by-products
Infectious materials (HSV, HPV) may contact mucous membranes of
nose No evidence of HIV/HBV transmission Need further studies
Slide 387
Dental Laboratory Dental prostheses, appliances, and items used
in their making are potential sources of contamination Handle in a
manner that protects patients and DHCP from exposure to
microorganisms
Slide 388
Dental Laboratory Clean and disinfect prostheses and
impressions Wear appropriate PPE until disinfection has been
completed Clean and heat sterilize heat-tolerant items used in the
mouth Communicate specific information about disinfection
procedures
Slide 389
Transmission of Mycobacterium tuberculosis Spread by droplet
nuclei Immune system usually prevents spread Bacteria can remain
alive in the lungs for many years (latent TB infection)
Slide 390
Risk of TB Transmission in Dentistry Risk in dental settings is
low Only one documented case of transmission Tuberculin skin test
conversions among DHP are rare
Slide 391
Preventing Transmission of TB in Dental Settings Assess
patients for history of TB Defer elective dental treatment If
patient must be treated: DHCP should wear face mask Separate
patient from others/mask/tissue Refer to facility with proper TB
infection control precautions
Slide 392
Creutzfeldt-Jakob Disease (CJD) and other Prion Diseases A type
of a fatal degenerative disease of central nervous system Caused by
abnormal prion protein Human and animal forms Long incubation
period One case per million population worldwide
Slide 393
New Variant CJD (vCJD) Variant CJD (vCJD) is the human version
of Bovine Spongiform Encephalopathy (BSE) Case reports in the UK,
Italy, France, Ireland, Hong Kong, Canada One case report in the
United States former UK resident
Slide 394
Infection Control for Known CJD or vCJD Dental Patients Use
single-use disposable items and equipment Consider items difficult
to clean (e.g., endodontic files, broaches) as single-use
disposable Keep instruments moist until cleaned Clean and autoclave
at 134C for 18 minutes Do not use flash sterilization
Slide 395
Program Evaluation Systematic way to improve (infection
control) procedures so they are useful, feasible, ethical, and
accurate Develop standard operating procedures Evaluate infection
control practices Document adverse outcomes Document work-related
illnesses Monitor health care-associated infections
Slide 396
Infection Control Program Goals Provide a safe working
environment Reduce health care-associated infections Reduce
occupational exposures
Slide 397
Program Evaluation Strategies and Tools Periodic observational
assessments Checklists to document procedures Routine review of
occupational exposures to bloodborne pathogens
Slide 398
Program evaluation provides an opportunity to identify and
change inappropriate practices, thereby improving the effectiveness
of your infection control program.