May elp You? nfection ontrol Training for Unregistered ...carolynmortensen.com/PDF/Outline.pdf · A. Chain of Infection: A chain is an interconnected series of links. A chain of infection,

©Copyright 2014 May I Help You 1

May I Help You? Infection Control Training for Unregistered Dental Assistants

Course Description This 8 hour course focuses on all aspects of infection control in a dental healthcare setting including

disinfection and sterilization, universal & standard precautions, and operatory set-up and clean-up. In

this course, students will learn and practically apply the dental assistant’s responsibilities in the office

according to the updated Center for Disease Control (CDC) guidelines and regulations from the Dental

Board of California. Upon the successful completion of this course, students will meet the requirements

of sections 1750 or 1752:1 from the Dental Board of California.

This is a two-part course. The lecture material is provided online for self-paced study. Part II is an in-

person session that begins with a test covering the online material, followed by four-hours of clinical

application and assessment.

Learning Objectives (LO) Upon completion of this course, students will be able to:

1. Explain the importance of implementing minimum standards for infection control in the

Dental Healthcare Setting (DHS);

2. Describe the role of CDC & OSHA in infection control;

3. Understand Dental healthcare personnel’s (DHCP) responsibility to comply with and

incorporate the minimum standards in their daily work practices;

4. Describe potential effects of not incorporating minimum standards for infection control to

the DHS;

5. Define the causes of infection and the different types of microorganisms that contribute to

infection in the dental healthcare environment;

6. Explain the chain of infection and modes of transmission;

7. Summarize strategies and practices for prevention and control of pathogens;

8. Describe the post-management procedure and follow-up of an exposure injuries;

9. Explain the different types of waste generated in a dental office, and the correct way to

handle, store, and dispose of the various types of waste using infection control guidelines;

10. Describe and demonstrate proper hand hygiene procedures for DHCP;

11. Demonstrate correct techniques for wearing and removing personal protective equipment

(PPE) in order to effectively protect against splatter, splash and contamination;

12. Demonstrate proper disinfecting techniques for clinical contact surfaces;

13. Perform disinfection and sterilization of patient care items according to infection control

guidelines;

14. Perform specific Dental Boards requirement to maintain safe dental unit water lines.

15. Demonstrate correct infection control disinfection and protection strategies when

performing lab procedures.


DETAILED COURSE OUTLINE

Section 1: Introduction/Overview (Online) A. Potential Effects of Infection to the Dental Healthcare Setting (DHS)

1. Due to the nature of their work, Dental Healthcare Personnel (DHCP) come in contact

with a variety of potentially infectious diseases on a daily basis and risk both contracting

and transmitting these diseases.

2. In order to prevent and reduce healthcare associated infections, it is critical that DHCP

comply with mandated regulations, recommended guidelines, practices, and

precautions, thereby reducing the risk of transmission of infectious disease from patient

to patient.

B. Recommending and Regulatory Agencies

1. The CDC is part of the Public Health Service, which is a division of the US Department of

Health. It is not a regulatory agency; however, it issues health and safety

recommendations based on scientific research.

a. The CDC is concerned with minimizing the transmission and spread of infectious

diseases in the DHS.

b. The CDC issued the first recommendations for DHS to prevent the transmission

of blood-borne disease in 1986. In 2003, the CDC issued its Guidelines for

Infection Control in Dental Healthcare Settings, which expands on its earlier

guidelines and added new information.

c. In 2003, the CDC created “Guidelines for Infection Control in DHS in order to

educate DHCP of strategies and precautions to minimize spread of infection.

2. OSHA is a regulatory agency, meaning that it is mandatory for DHCP to implement,

practice, and adhere to all OSHA guidelines and policies. Concerned with safety and

health of DHCP (employees)

a. OSHA is concerned with the safety and health of an organization’s employees

(DHCP).

b. OSHA created the Bloodborne Pathogen Standard (BBP), which mandates

that specific regulations including Universal Precautions be followed in the

DHS, based on CDC’s recommended guidelines first published in 1986.

c. On December 1, 2013, OSHA adopted a new Hazard Communication Standard

known as the Global Harmonized System for Hazard Communication.

Employers are required to provide training to their employees regarding new

labeling, warnings, pictograms and the new format for Safety Data Sheets.

1. California Occupational Safety & Health Administration (CAL/OSHA) is a regulating

agency

a. In 2009, CAL/OSHA adopted the Aerosol Transmissible Disease (ATD) Standard

b. Any DHS in which patients with suspected or confirmed ATD (e.g. TB) must

comply with the ATD Standard

2. Dental Board of California (DBC) is a regulatory agency

c. The DBC created the “Minimum Standards for Infection Control” that must be

posted in every DHS

d. Every DHCP whether licensed or not must follow the DBC’s minimum

standards. And it is a requirement to renew a dental license.


C. Consequences of Non-compliance

a. Non-compliance with the DBC’s Minimum Standards for Infection Control, OSHA’s

Bloodborne Pathogen Standard, and Global Harmonized System for Hazard

Communication, or CAL/OSHA’s Aerosol Transmissible Disease Standard could lead to

cross-contamination, infections, and illness to the dental patient and/or the DHCP.

b. Employees could contaminate their vehicles, or even their homes, if Universal

Precautions are not followed. Employee’s families could potentially suffer illnesses and

infections if OSHA regulations are not followed in the DHS.

c. Dentists could be subject to fines and/or have their offices closed by the Regulating

Agencies.

After completing Section 1, students will be able to explain the importance of implementing minimum

standards for infection control in the DHS (LO1); describe the roles of the CDC and OSHA in infection

control (LO2); understand their personal responsibility to comply with the standards and guidelines for

infection control (LO3); and describe potential effects of not incorporating the minimum standards for

infection control to the DHS (LO4).

Section 2: The Five Types of Microorganisms (Online) A. Bacteria: One-celled organisms that vary in size, shape, and arrangement

1. Human beings host a variety of beneficial bacteria that combat pathogens

2. Infection occurs when a specific type of bacteria invades an area of the body in which it

does not naturally occur

3. Bacterial diseases include: TB, Legionnaires’ disease, Tetanus, Syphillis, Methicillin-

Resistant Staphylococcus aureus (MRSA)

B. Algae: Can be microscopic, single-celled organisms, as well as large, multi-celled organisms

that contain chlorophyll. Found in freshwater and marine habitats and generally do not

produce disease

C. Protozoa: A large groups of single- or multi-celled organisms without a rigid cell wall.

1. Larger than bacteria, protozoa are found in freshwater, marine habitats, and soil.

2. Though in general protozoa do not cause disease, some are pathogenic and can lead to

intestinal infection in humans including: Malaria, diarrhea, and amebic dysentery

D. Fungi: Common single- or multi-celled organisms such as mushrooms, yeasts, and molds.

1. Certain types of mold and yeast can cause disease in humans affecting the lungs and

other organs, tissues, or the skin, nails, scalp, and hair.

2. Common fungal diseases includes pulmonary infections, candidiasis, and athlete’s foot

E. Viruses: Much smaller than bacteria, viruses have many different shapes, but all have a

nucleic acid core (DNA or RNA) surrounded by a capsid, or protein coating.

1. A virus lives and multiplies itself in a host cell.

2. First it invades a host cell, multiplies and replicates itself, and then enters the body by

destroying the host cell.

3. Types of Viral Diseases include Hepatitis A, B, and C; HIV, Herpes; Measles, the common

cold, influenza and mononucleosis

After completing Section 2, students will be able to define the causes of infection and the different types

of microorganisms that contribute to infection in the dental healthcare environment (LO5).


Section 3: Disease Transmission (Online) A. Chain of Infection: A chain is an interconnected series of links. A chain of infection, then, is

the group of links that must be present in order for infection to occur. The following are the

links required for an infection to exist:

1. Pathogen (Virulence & Numbers): A pathogen is an infectious agent; an organism

capable of producing disease.

a. Virulence: The strength of an organism’s ability to produce disease.

b. Numbers: A high enough number of pathogenic microorganisms must be

present to produce disease.

2. Source or Reservoir: Reservoirs are where germs live and grow, and are the source of

pathogens. The primary source of pathogens in the Dental Healthcare environment is

the mouth of the patient: saliva, blood, and respiratory secretions.

3. Mode of Transmission: An infectious disease is capable of being transmitted and spread

to others. This is the link that we have control over since there are precautions that can

be taken against transmission (these precautions will be covered in section III). There

are several ways disease is transmitted:

a. Direct: Person-to-person contact; examples include droplets spread through

sneezing & coughing, contact with infected body fluids or lesions. Hepatitis,

HIV, and TB are examples of diseases spread through direct contact.

b. Indirect: Infected agents are first transmitted to an object, surface, or another

person, and then transferred to an individual. Examples include unwashed

hands, infected countertops, a dental chart handled by a gloveless DHCP.

c. Airborne (Droplet infection): Disease is spread through droplets of moisture in

the air that contain bacteria or viruses. Most contagious respiratory diseases

are transmitted through droplets in the air (generally caused by coughing

&/or sneezing).

d. Aerosol, Spray, or Spatter (Airborne): Terms used to describe droplets of

potentially infectious microorganisms.

i. Aerosols are the finest form of droplets and disease is generally spread

through inhaling infectious droplets. Aerosols are created by using high-

speed-handpieces and ultrasonic scalers.

ii. Sprays & Spatter are larger than aerosols and generally spread infection

through contact with non-intact skin (skin in which a cut, scrape, or

needle prick has occurred). They are created in the same ways as

aerosol, as well as when using the air-water syringe.

4. Portal of Entry: The means through which an infectious microorganism enters the body.

These are typically the mouth and nose for airborne pathogens, and non-intact skin for

bloodborne pathogens.

5. ‘Susceptible Host: Someone who is unable to resist infection by a specific infectious

agent. A compromised immune system can make one a susceptible host. Factors such as

fatigue, stress, poor eating habit, and cuts and scrapes in the skin can contribute to a

compromised immune system. It is important to note that at times even healthy

individuals are susceptible hosts for pathogens.


B. Transmission in the Dental Office: As discussed in the previous section, there are many ways

in which patient microorganisms can be transmitted in a dental health care setting.

1. Patient to Dental Health Care Practitioner (DHCP): There are many ways microorganisms

can spread from the patient to the DHCP, which is why this pathway is the most difficult

to control. The modes of transmission (which were discussed in detail in the previous

section) are: Direct contact, droplet infection, and indirect contact.

2. DHCP to Patient: This pathway is rare; however, disease may be transmitted from DHCP

to patient if proper infection control procedures are not followed (these will be

discussed in detail in section IV). If a DHCP has lesions or other non-intact skin, of if a cut

or other injury occurs while the hands are in the patient’s mouth, it is possible to

transmit microorganisms.

3. Patient to Patient: Though extremely rare, patient-to-patient infection may occur when

contamination from instruments used from one patient is passed to another patient via

non-sterilized instruments, handpieces, surfaces, and hands.

4. Dental Office to Community: Spread of disease from the dental office to the community

can occur when contaminated items used on the patient are sent out, such as

impressions sent to a lab. DHCPs can transport microorganisms out of the office via their

hair or contaminated clothing.

5. Community to Patient: Patients can become infected via waterborne microorganisms

that colonize inside the dental unit after coming through the municipal water supply.

After completing Section 3, students will be able to explain the chain of infection and modes of

transmission (LO6).

Section 4: Prevention Strategies & Practices (Online) A. Overview of CDC Guidelines for Infection Control in the Dental Office

1. Use of Standard Precautions rather than Universal Precautions

2. Work restrictions for healthcare personnel infected with infectious disease

3. Post exposure management of occupational exposures to blood-borne pathogens

4. Selection of devices with sharps injury-prevention features

5. Hand hygiene products and surgical hand asepsis

6. Contact dermatitis and latex hypersensitivity

7. Sterilization of instruments

8. Laboratory infection control

9. Dental unit waterline concerns

10. Dental radiology infection control

11. Preprocedural mouth rinses for patients

12. Oral surgical procedures

13. Tuberculosis

14. Infection control program evaluation

B. Overview OSHA Bloodborne Pathogen Standard

1. Exposure Control Plan

a. Each dental office shall have a written exposure control plan that clearly

describes how the office complies with the BBP Standard.


b. The Exposure Control Plan must be accessible to employees and updated at

least annually, or when there are significant changes to procedures or

processes.

2. Universal Precautions

a. OSHA’s created the term Universal Precautions. Universal Precautions is the

concept that all human blood and certain bodily fluids are treated as if they are

infected with blood-borne pathogens. The reason to practice Universal

Precautions is that it is impossible to know which patients may carry blood-

borne pathogens, so all dental healthcare personnel should treat every patient

as if they were infected. OSHA’s Universal Precautions primary concern is for

the Health and Safety of employees in the dental office.

b. Standard Precautions is term created by CDC and adopted by the DBC. It is

similar to Universal Precautions that extend the rationale to include all body

fluids, secretions, and excretions. CDC and DBC primary concern is the health

and safety of dental patients.

3. Exposure Determination

a. OSHA categorizes employees by the risks associated with their job functions.

i. Category I: Routinely exposed to blood, saliva, or both (Dentist,

assistant, hygienist, lab technician)

ii. Category II: May occasionally be exposed to blood, saliva, or both (front

office employee that may occasionally disinfect an operatory after

patient treatment, process contaminated instrument or x-rays and/or is

trained in CPR).

iii. Category III: Never exposed to blood, saliva, or both (Front office)

4. Post-exposure Management: Even with precautionary measures in place, exposure

Incidents do happen; therefore, the BBPS requires employers to have a written plan that

explains the steps and procedure to follow if an employee has an Exposure Incident (see

Section 5).

5. Hepatitis B Immunization: Employers must offer the HBV vaccination series to all

category I & II employees within the first ten day hire.

a. Right of Refusal

i. The employee, however, has the right to refuse the vaccination for any

reason. If the employee refuses the vaccine, s/he must sign a

Declination form.

ii. If the employee changes his/her mind at a later time, the employer

must provide the Hep. B vaccination series at no cost to the employee

b. The employer shall not make participation in a prescreening program a

prerequisite for receiving the Hep. B vaccination or for hiring the employee.

c. The vaccination process

i. Hepatitis B vaccine comes in a series of three separate injections. These

must be taken in the specified order.

ii. If the second or third injection of the series is missed, the employee

must start over.


iii. In order to know if the employee is protected, a blood test for Hepatitis

B antibodies should be done one – two months after final vaccine

injection of the series.

iv. For the few who do not form antibodies, a second series of injections

can be taken to improve the response.

v. People who do not respond after the second series should be warned

that they may be susceptible to Hepatitis B virus.

vi.

6. Record Keeping

a. Employers are required to keep confidential employee medical records for all

employees for the length of employment, and for 30 years following end of

employment if an Exposure Incident happened during employment.

i. Medical records must include:

a) A file folder with the employees first and last name.

b) The employee’s social security number.

c) The signed Hep. B Declination form.

d) Current proof of immunity to Hep. B.

e) Dates of the vaccines

f) Records of exposure and post-exposure follow up

ii. The only person/s having access to this file is the employer and the

designated Safety Manager.

b. Employee Training Records: Employers must keep records documenting that

they have provided employees with OSHA required training.

i. Employers are required to provide employees with initial Bloodborne

Pathogen and Office Safety training, and then annual Bloodborne

Pathogen training.

ii. OSHA requires the required training be done during regular office hours

at no cost to the employee.

iii. Employers must keep documentation of all training sessions in the

office Injury and Illness Prevention Plan for at least three years.

After completing Section 4, students will be able to summarize strategies and practices for

prevention and control of pathogens (LO7).

Section 5: Exposure Injury Management & Procedures (Online) OSHA mandates that all dental offices must prepare a written exposer control plan that documents

the procedures that must be followed as a result of an exposure incident. An exposure incident is

when an employee comes in contact with a specific splash of blood, saliva or OPIM into the eyes,

nose, mouth, or non-intact, or is poked with a contaminated sharp.

A. Determination of employees covered under the standard: Any employee that has occupational

exposure (Categories I & II)

1. Any category I or category II employee is susceptible to exposure to blood, saliva, OPIM,

and pokes from contaminated sharps.


2. Should an exposure incident occur, employer and employee must follow post-exposure

and follow-up procedures.

B. Exposure Control Plan

1. Hepatitis B Vaccination

2. Post-exposure procedures:

a) Following a report of an exposure incident, the employer shall make

immediately available to the exposed employee a confidential medical

evaluation and follow-up, including at least the following elements:

1) Send employee to Health Care Professional (HCP) with:

2) A copy of the BBP Standard.

3) The completed Incident report.

4) Employee's Hepatitis B vaccination status.

5) Employers Workers compensation Insurance information.

3. Post-exposure follow-up from health care professional (urgent care)

a) Evaluates Exposure Incident.

b) Arranges for testing of employee and source individual (if agreeable)

c) Notifies employee of results of all testing.

d) Provides post-exposure prophylaxis.

4. Record keeping

A. Within seven days of the exposure incident the HCP sends Written Opinion

(only) to employer:

B. Documentation that employee was informed of evaluation results and the need

for further follow-up.

C. Whether Hepatitis B vaccine is indicated and if vaccine was received.

D. Provides copy of HCP's Written Opinion to employee and a copy is kept in the

employees CONFIDENTIAL medical record.

E. Within 14 days of the exposure incident the employer must investigate the

exposure incident and complete a “SHARPS INJURY LOG” form.

After completing Section 5, students will be able to describe the post-management procedure and

follow-up of an exposure injury (LO8).

Section 6: Waste Generated in Dental Offices (Online) Federal, state, and local agencies regulate the various types of waste found in dental office. Often these

agencies require Dental Offices to have permits because they create waste that is biohazardous or

hazardous in nature. Specific guidelines and regulations address the manner in which the types of waste

are handled, stored and properly disposed. Waste found in dental offices is classification as follows:

A. General Waste: Waste that is created in the regular course of a day such as paper towels,

paper mixing pads, empty food containers and is nonhazardous and non-regulated.

1. Does not pose any hazard to humans.

2. Dispose of waste in a sturdy, covered trash receptacle.

B. Contaminated Waste: Waste that has been in contact with blood, saliva, and/or other bodily

fluid and includes patient napkins and used barriers.


1. Generally does not pose a risk to humans and may be disposed of in the same manner

as general waste.

2. In cases in which the contaminated waste could potentially release blood, or other

potentially infected material (OPIM) such as in blood-saturate gauze pads, must be

disposed of and handled according to regulatory agency guidelines.

C. Hazardous Waste: Waste that contains toxicity, including photo processing chemicals,

extracted teeth with amalgam & cold sterile solutions.

1. Poses risk to humans and the environment.

2. Must be handled and disposed of according to regulatory agency guidelines.

D. Infectious/Regulated Waste (Biohazardous): Contaminated waste that has contains

pathogens strong and numerous enough to cause infectious disease.

1. Poses risk to humans

2. Must be handled and disposed of according to regulatory agency guidelines.

a. Medical Waste

1) Extracted Teeth, blood-soaked gauze & cotton rolls, human tissue from

surgical procedure must be treated according to the Medical Waste

Management Plan of California.

2) Contaminated Sharps (needles, scalpel blades, orthodontic wires)

i. Dispose of in a puncture-resistant, sealable, leak proof sharps

container that is properly labeled as Biohazard.

ii. Sharps containers have to be located where it is likely Sharps

will be generated (each operatory, sterilization area, and lab).

iii. Sharps safety is a serious matter; in order to reduce the risk of

exposure, safe handling must be practiced. Recapping needles

using the single-handed scoop technique, or an appropriate

recapping device must be used. Placing sharps in the Sharps

container as soon as possible reduces the risk of injury.

After completing Section 6, students will be able to explain the different types of waste generated in

a dental office, and the correct way to handle, store, and dispose of the various types of waste using

infection control guidelines (LO9).

Section 7: Hand Hygiene (Online & Clinical Application) In order to reduce the number of microbes present on the hands of DHCP, and lessen the number of

microbes transferred to surfaces they touch, all DHCP must follow the minimum standards for infection

control's guidelines for hand hygiene that include required times to wash hands, and specific methods

and materials to use.

A. Required Times to Wash Hands: DHCP must clean their hands according to the stated

methods and with the appropriate materials at the following times:

1. At the beginning if their work shift each day

2. Routine hand washing throughout the day

a. Before eating

b. After using the restroom

c. When hands are visibly soiled


3. Before & after routine dental procedures

4. Before glove placement & after glove removal (including when re-gloving due to tear or

puncture)

5. After touching items potentially contaminated with blood or saliva

6. Before surgery

7. After contact with patient’s intact skin

8. After contact with non-intact skin, mucous membranes, body fluids

9. At the end of their work shift each day

B. Materials & Methods for Hand Washing: Depending on the type of patient treatment, DHCP

may use soap & water, antimicrobial hand wash, or alcohol-based hand rubs incorporating

the following methods:

1. Routine hand washing:

a. Remove jewelry, rings, etc.

b. Use paper towel, or other barrier, to turn faucet on and to apply the hand

cleaner (pump or hands free dispenser)

c. Scrub hands vigorously for 15-20 seconds

d. Wash from the finger tips to the wrist

e. Thoroughly rinse under a stream of water

f. Pat dry; never friction rub with disposable towels

g. Use disposable towel or other barrier to turn off faucet (Do Not touch faucet)

2. Antiseptic hand washing: If hands are not visibly soiled or contaminated DHCP may use

Antiseptic hand rub or hand sanitizer.

a. The Hand Sanitizer must contain 65% or more Ethanol Alcohol

b. Use a sufficient amount of alcohol- based antiseptic, hands should remain wet

for 30 seconds or until hands are dry. This method will not remove dirt.

c. Hand Sanitizer may be used 3 consecutive times before hands must be washed

with soap/water.

3. For surgical procedures:

a. Prior to a surgical procedure, a surgical scrub needs to be done with an

antimicrobial soap.

b. Wash with antimicrobial soap & water for 2 – 6 minutes. Scrub from the finger

tips and the forearm up to the elbow.

C. When to Refrain from Patient Care: According to the DBC’s Minimum Standards for

Infection Control, DHCP must refrain from providing direct patient care when:

1. The conditions of the hands may render DHCP or patients more susceptible to

opportunistic infection or exposure

2. Hands have any kind of oozing from a wound, cut, or dermatitis. In this case, DHCP shall

also refrain from handling patient care equipment.

3. When the above conditions are present, employee must be reassigned to a non-clinical

task until conditions improves.

D. Clinical Application & Competency


After completing Section 7, students will be able to describe and demonstrate proper hand hygiene

procedures for DHCP (LO10).

Section 8: Personal Protective Equipment (PPE): (Clinical Application) As part of their daily responsibilities, Dental Assistants come in contact with potentially infectious

material. As discussed in previous sections, this can occur through patient blood, saliva, and aerosol s. In

order to protect from infection, all DHCP are required to wear items designed to protect them, and their

patients, from disease. These items must be provided at no cost to the employee by their employer and

laundered (as applicable) according to OSHA guidelines. . If PPE is damaged in anyway and rendered

ineffective, the employer is responsible to repair or replace as necessary.

The selection of PPE is determined by the procedures being performed by the DHCP. PPE includes but is

not limited to:

A. Gloves (latex or non-latex & heavy-duty utility): There are several different types of gloves

DHCP must use in the DHS. The specific type of glove used depends on the procedure being

performed. Gloves are considered medical devises and regulated by the U.S. Food and Drug

Administration (FDA).

1. Examination gloves are the most commonly used in the DHS and are made of latex or

vinyl

2. Sterile Surgical gloves are to be used during all oral surgeries and periodontal

treatments that involve cutting bone, significant amounts of blood, or saliva

3. Non-latex gloves – these gloves are made from nitrile, vinyl, and other non-latex

materials for use by DHCPs with latex sensitivity and/or allergies.

4. Overgloves are clear plastic gloves that may be used over treatment gloves to prevent

contamination of items handled during treatment

5. Utility gloves should be made of puncture resistant heavy latex or nitrile rubber and

worn when cleaning and disinfecting instruments and surfaces, and when handling

contaminated laundry.

B. Face Masks: DHCP must wear face masks in order to protect themselves from exposure to

infectious organisms spread through inhaling aerosol spray from handpieces, air-water

syringes, and/or splashes.

1. DHCP are required to wear masks when performing the following:

a. Patient treatment procedures

b. Disinfecting

c. Cleaning and sterilizing contaminated instruments.

2. Masks should:

a. Fit the face well

b. Be changed between patients or during treatment if they become visibly soiled

or moist

c. Never be worn below the nose or chin

d. Be disposed of after each patient

C. Eye Protection (Face Shields & Eyewear): In order to protect the eyes from exposure to

potentially infectious material, all DHCP must wear one of the approved forms of eye

protection.


1. OSHA and the DBC’s Minimum Standards for Infection Control, eye protection

requirements:

a. Eye protection must have solid front and side protection

b. A chin length face shield must be worn during procedures when blood or other

bodily material may splash or splatter(masks must still be worn when wearing a

face shield)

c. Goggles and/or glasses with shields must be worn to protect DHCP from spatter

from handpieces and splashed chemical agents that could damage the eyes

d. Patients are required to wear special filtered-lens glasses during certain types of

laser treatments.

2. Please Note: Prescription Glasses DO NOT meet OSHA & DBC’s Minimum Standards for

Infection Control

D. Gowns: In order to protect the skin and underclothing from exposure to potentially

infectious material, all DHCP must wear protective gowns in the DHS. These gowns may be

disposable or reusable. Gowns must comply with, and be laundered according to, OSHA and

the DBC’s Minimum Standards for Infection Control.

1. Gowns worn in the DHS must be:

a. Made of fluid resistant material (no liquid can get through)

b. Have long sleeves and high necklines

c. Worn for disinfection, sterilization, and housekeeping procedures involving

germicides, or handling contaminated items

d. Worn when there is potential for aerosol spray, splashing, or spattering of

blood, OPIM, or chemicals

e. Changed daily or between patients when they become moist or visibly soiled

f. Removed when leaving treatment and lab areas

2. Handling & Laundering Reusable Gowns (& towels): Laundry (reusable gowns and

towels) that has been soiled with blood or other potentially infectious materials, or may

contain sharps must be handled according to Cal/OSHA BBP standards:

a. The employer shall ensure that employees who have contact with contaminated

laundry wear heavy duty nitrile gloves and other appropriate personal

protective equipment

b. Contaminated laundry may never be taken home either by an employee or the

employer

c. Contaminated laundry shall be bagged or containerized at the location where it

was used and shall not be sorted or rinsed in the location of use (e.g. the dental

office)

d. When contaminated laundry is wet, the laundry shall be placed in a container

that prevents soak-through and/or leakage of fluids to the exterior

E. Clinical Application & Competency

After completing Section 8, students will be able to demonstrate correct techniques for wearing and

removing personal protective equipment PPE in order to effectively protect against splatter, splash

and contamination (LO11).


Section 9: Clinical Contact Surfaces (Clinical Application) Clinical Contact Surfaces are surfaces that can be contaminated via direct spray or spatter from dental

procedures, or via gloves on a DHCP.

A. The main sources of contamination are touch, transfer, and splash, spatter, and aerosol.

1. Touch: Surfaces that DHCP directly touch during procedures, and therefore potentially

contaminated. These surfaces include: dental unit controls, x-ray switches, chair

switches, chair side computers, computer mouse, light handles, cabinet handles, pens,

etc. Surfaces should be barrier protected or disinfected and cleaned between each

patient.

2. Transfer: Instrument trays and handpieces that are touched by contaminated

instruments or supplies. Surfaces should be barrier protected or disinfected and cleaned

between each patient

3. Splash, splatter, droplets: Oral fluids generated using the high and slow speed

handpieces, ultrasonic cleaners, and air/water syringe. At the minimum, surfaces that

may be contaminated via splash, spatter, or droplets must be disinfected after patient

treatment.

4. Aerosol: Fine, dust like particles generated while using high and slow speed handpieces,

ultrasonic cleaners, and air/water syringe. At the minimum, surfaces that may be

contaminated via s aerosol must be disinfected after patient treatment.

B. Methods for dealing with Surface Contamination: There are two methods that may be used

to deal with surface contamination, the barrier method, and precleaning & disinfecting

between patients.

1. Barrier Method: The barrier method entails using fluid resistant materials to prevent a

surface from becoming contaminated. Regulation states that a surface barrier must be

placed onto a surface that is difficult to clean and disinfect.

a. Surfaces that may be protected with barriers include:

1. Dental Chair Headrest & control buttons

2. Light handles & switches

3. Evacuator hoses & controls

4. X-ray controls & switches

5. Air-water syringe handles

6. Patient mirror handles

7. Drawer handles

8. Adjustment handles on operator and assistant chairs and tools

9. Bracket table

b. Requirements when using barriers:

1. After dental procedures surface barriers must be carefully removed so

the surface under the barrier does not become contaminated.

2. If the barrier moved or was torn during dental procedure and the

surface became contaminated the surface must be properly disinfected.

2. Precleaning & Disinfection: OSHA BBP Standard requires that contaminated work

surfaces be disinfected between each patient.


a. Precleaning: Removal of blood, saliva, and other body fluids to prepare for

disinfection. Contaminated surfaces must be precleaned in order to be

effectively disinfected.

b. Disinfection: Kills disease-causing bacteria that remain on surfaces following

precleaning when correct procedures and guidelines are followed. Procudures

and guidelines for disinfection include (please note disinfecting does not kill

spores):

1. Clean and disinfect all clinical contact surfaces that are not protected by

impervious barriers using a California Environmental Protection Agency

(Cal/EPA) registered, hospital grade low- to intermediate-level

germicide after each patient.

2. The low-level disinfectants used shall be labeled effective against HBV

and HIV. Use disinfectants in accordance with the manufacturer's

instructions.

3. Clean all housekeeping surfaces (e.g. floors, walls, sinks) with a

detergent and water or a Cal/EPA registered, hospital grade

disinfectant.

4. Products used to clean items or surfaces prior to disinfection

procedures shall be clearly labeled and DHCP shall follow all safety data

sheet (SDS) handling and storage instructions.

5. Appropriate PPE during disinfecting procedures:

a) Gloves (heavy-duty utility) Exam gloves may not be used for

disinfecting.

b) Gowns

c) Masks

d) Protective Eyewear

6. Use proper category of disinfectant

a) Low-level.

1) This is the least effective disinfection process.

2) It kills some bacteria, some viruses and fungi

3) Does not kill bacterial spores or mycobacterium

tuberculosis var bovis.

b) Intermediate-level

1) Kills many human pathogens, including mycobacterium

tuberculosis var bovis

2) This process does not necessarily kill all spores

3) Used mainly for contaminated clinical surfaces and

items

c) High-level

1) Kills some, but not necessarily all bacterial spores.

2) This process kills mycobacterium tuberculosis var bovis,

bacteria, fungi, and viruses.

3) This is the process that the DBC requires if critical or

semi-critical instruments are heat sensitive


A. Clinical Application & Competency

After completing Section 9, students will be able to Demonstrate proper disinfecting techniques for

clinical contact surfaces (LO12).

Section 10: Instrument Processing & Sterilization Proper processing of contaminated instruments and patient health care items is crucial in preventing

contamination and the spread of infection in the DHS. Therefore, it is important that dental assistants

understand and practice the correct processing methods.

A. Patient Care Item Classifications: The following are the Center for Disease Control and

Prevention (CDC) and the Dental Board of California (DBC) categories for patient care items

based on the risk of infection during their use:

1. Critical Instruments:

a. This class of instruments poses highest risk for infection if they are

contaminated with any microorganism.

b. Examples include surgical instruments, scalers, endo-instruments, bands,

brackets, wire and burs, and other items used to penetrate soft tissue or bone.

c. Most critical instruments are heat-tolerant and can be heat sterilized after each

patient.

2. Semi-critical Instruments:

a. While these instruments do not penetrate soft tissue or bone, they are used in

the patient’s mouth and therefore pose a risk of infection because they come in

contact with blood, saliva, and mucous membranes.

b. Examples include dental mouth mirrors, amalgam carriers, x-ray film holders,

dental hand pieces, and rubber dam forceps.

c. Most semi-critical instruments are heat-tolerant and may therefore be

sterilized. Those that are not heat-tolerant should receive high-level

disinfecting.

3. Non-Critical Instruments:

a. Non-critical items” are instruments, devices, equipment, and surfaces that come

in contact with soil, debris, saliva, blood, OPIM and intact skin, but not oral

mucous membranes.

b. Examples: Dental Chair, Dental Unit, X-ray Heads, Clinical Surfaces & Equipment,

and Curing light etc.

4. Disposable Items:

a. Single use items usually come in large packages and are labeled disposable or

single use.

b. Should be used on just one patient and then properly disposed of in order to

help reduce the chance of patient-to-patient contamination.

c. Examples of disposable items (prophy cups & brushes, Sterilization pouches,

Irrigating syringes, saliva ejectors, evacuation tips, surface barriers, face masks,

exam & surgical gloves, syringe needles, suture needles, plastic orthodontic

brackets.


B. Transporting & Processing: The instrument processing area (sterilization area) should be in

an area easily accessible from all patient care areas in order to reduce the need to carry

contaminated instruments through clean areas of the office. Ideally, the processing areas

should be dedicated only to instrument processing, be separate from the operatories and

examination areas, and should absolutely not be in the path of common walkways. It should

contain separate areas for: (1) receiving, (2) preparation & packaging, (3) sterilization, and

(4) storage.

1. Receiving: The first step in instrument processing is the receiving area, contaminated trays

and disposable items are sorted; disposables are thrown into the regular trash.

Contaminated instruments are placed into the ultrasonic cleaner or holding solution.

a. Cleaning: Cleaning is removing visible debris (organic and inorganic) from

surfaces, dental instruments, and other objects through the use of water with

soap or enzymatic products.

b. Cleaning is required before sterilization and high-level disinfection to ensure

that there are no organic or inorganic materials on the surfaces of instruments

that may interfere with the effectiveness of the sterilization and/or disinfection

processes.

c. Ultrasonic cleaning: Soaking instruments in ultrasonic solutions loosen and

remove debris from instruments.

d. Instrument washing machines: Only FDA approved machines may be used to

disinfect patient care instruments. These machines subject contaminated

instruments to a level of heat that destroys some not all microorganisms.

2. Preparation & Packaging: Instruments should be wrapped or placed into pouches

designed for instrument sterilization prior to sterilizing to prevent re-contamination

once they have been sterilized. The following guidelines must be followed throughout

the preparation and packaging process:

a. Appropriate PPE must be worn when preparing and packaging contaminated

instrument for sterilization or high-level disinfections. The assistant must have

on all appropriate PPE:

1) Heavy duty nitrile utility gloves

2) Face mask

3) Eye protection

4) Fluid resistant gown

b. Heat-resistant critical or semi-critical instruments

1) Must be packaged in new (never reuse sterile pouches) or wrapped

before sterilization

2) Each package or wrapped instruments shall be labeled with the date of

sterilization and the specific sterilizer used if more than one sterilizer is

utilized in the facility

3) Each package must have a heat indicator or indicator tape on it

4) This heat indicator changes color when three things happen to the

pouch.

5) The pouch has come into contact with steam or chemical vapor

6) For a certain length of time


7) Under a certain amount of pressure

8) The color change does not prove the instrument inside the package are

sterile

c. Heat-sensitive Critical or semi-critical instruments

1) Process with high-level disinfection and packaged or wrapped upon

completion of the disinfection process.

2) These instruments, items, and devices, shall remain sealed and stored in

a manner so as to prevent contamination, and shall be labeled with the

date of sterilization and the specific sterilizer used if more than one

sterilizer is utilized in the facility.

3) Each package must have a heat indicator or heat indicator tape on it.

3. Sterilization is the process that destroys all microorganisms including viruses, bacteria,

fungi and spores. Items are either sterile or they are not. All reusable items that come in

contact with patient blood, mucous membranes, or saliva must be heat-sterilized either

through steam, chemical vapor, or dry heat. Items that are heat-sensitive may be

cleaned using a high-level disinfectant. Any of the following methods will meet the

requirements for sterilization.

a. Steam: The processing of sterilizing instruments using steam under pressure.

The equipment used in steam sterilization is the autoclave or Statim.

b. Chemical Vapor: In chemical vapor sterilization, instruments are exposed to

chemical vapors including alcohol, formaldehyde, ketone, and acetone.

Formaldehyde is considered a carcinogen = can possibly cause cancer.

c. Dry Heat: Dry heat is the process of heating air high temperatures

approximately 375 degrees and transferring that air to the contaminated

instruments.

d. Spore test is the method to check correct functioning of sterilization cycle.

Spore testing should be verified for each sterilizer by the periodic use (at least

weekly).

1) Biological indicators (BIs) (i.e., spore tests) are the most accepted

method for monitoring the sterilization process because they assess it

directly by killing known highly resistant microorganisms

2) Spore test failure

3) The spore test should be repeated immediately after correctly loading

the sterilizer and using the same cycle that produced the failure.

4) sterilizer operating procedures should be reviewed, including packaging,

loading, and spore testing, with all persons who work with the sterilizer

to determine whether operator error

5) if there was no human error the sterilizer should remain out of service

until it has been inspected, repaired, or replaced

4. Storage: The final step in the process is the proper storage of sterilized instruments.

Upon completion of the heat sterilization process, instruments shall remain sealed and

stored in a manner so as to prevent contamination as follows:

a. Pouches of sterile instruments, when properly stored, may be stored for 6

months.


b. After 6 months, the packages will be opened, instruments re-cleaned,

repackaged, and re-sterilized.

c. The package will be labeled with the date of sterilization and the specific

sterilizer used if more than one sterilizer is utilized in the facility.

d. Wrapped packages of sterile instruments, when properly stored, may be stored

for 30 days

e. After 30 days, the wrapped packages will be opened, instrument re-cleaned,

repackaged and re-sterilized.

f. The wrapped package will be labeled with the date of sterilization and the

specific sterilizer used if more than one sterilizer is utilized in the facility

g. Any package that is wet, torn, dropped on the floor, or damaged in any way

should not be used and must be re-cleaned, repackaged in new wrap, re-

sterilized, and re-labeled with the date of sterilization and the specific sterilizer

used if more than one sterilizer is utilized in the facility

C. Clinical Application & Competency

After completing Section 10, students will be able to perform disinfection and sterilization of patient

care items according to infection control guidelines (LO13).

Section 11: Dental Unit Waterlines (DUWLs) (Clinical Application) It is important to follow the DBC’s guidelines in order to prevent disease and cross-contamination in the

DHS.

A. Background: DUWLs can become colonized with microorganisms including bacteria, fungi,

and protozoa. These microorganisms can form a biofilm in the waterline tubing. Patients

with weakened immune systems who are exposed to these microorganisms are at risk of

infection.

B. Biofilm in Dental Waterlines: Biofilm is the “slime layer” that develops on surfaces due to

the bacterial cells in the water. Moisture and a suitable surface are all that is required for

biofilm to develop. The inside of dental tubing is an especially favorable location of biofilm.

C. Reducing Bacterial Contamination: There are several methods to use to reduce bacterial

contamination of water lines.

1. Flush waterlines for two full minutes at the start of each day, and 20 seconds between

patients.

2. Use a self-contained water reservoir system.

3. Use a self-contained water reservoir system combined with the application of chemical

germicides, as recommended by the waterline manufacturer.

4. Use a separate, sterile water system for surgical procedures

D. Clinical Application & Competency

After completing Section 11, students will be able to perform specific Dental Boards requirement to

maintain safe dental unit water lines (LO14).


Section 12: Laboratory Infection Control Guidelines (Clinical Application) Items processed in the dental laboratory are sources of potential cross-contamination; therefore, it is

important to practice the following CDC’s guidelines when working in the lab:

A. Splash shields and equipment guards shall be used on dental laboratory lathes.

B. Fresh pumice and a sterilized or new rag-wheel shall be used for each patient.

C. Devices used to polish, trim, or adjust contaminated intraoral devices shall be disinfected or

sterilized, properly packaged or wrapped and labeled with the date and the specific sterilizer

used if more than one sterilizer is utilized in the facility.

D. If packaging is compromised, the instruments shall be recleaned, packaged in new wrap, and

sterilized again.

E. Sterilized items will be stored in a manner so as to prevent contamination.

F. All intraoral items such as impressions, bite registrations, prosthetic and orthodontic

appliances shall be cleaned and disinfected with an intermediate-level disinfectant before

manipulation in the laboratory and before placement in the patient's mouth. Such items

shall be thoroughly rinsed prior to placement in the patient's mouth.

G. Clinical Application & Competency

After completing Section 12, students will be able to demonstrate correct infection control

disinfection and protection strategies when performing lab procedures (LO15).


GLOSSARY Barrier

A material object that separates a person from a hazard

Biohazard

Anything harmful or potentially harmful to humans, other species, or the environment

Biological indicators (BIs) (e.g., spore tests)

The most accepted method for monitoring the sterilization process because they assess it directly by

killing known highly resistant microorganisms

Bloodborne

Carried by the blood or found in the blood

Contamination

The presence of microorganisms on inanimate objects (clothing, surgical instruments) or in substances

(water, food, milk)

Cleaning

The removal of all foreign material (soil, organic debris) from objects

Common Vehicle

Contaminated material, product, or substance that serves as an intermediate means by which an

infectious agent is transported to two or more susceptible hosts

Communicable Disease

An illness due to a specific infectious agent that arises through transmission of that agent from an

infected person, animal, or inanimate reservoir to a susceptible host

Decontamination

The process (physical, chemical, or other means) of removing disease-producing microorganisms from

persons, spaces, surfaces, or objects

Dental Healthcare Personnel (DHCP)

Paid and non-paid personnel in the dental healthcare setting who might be occupationally exposed to

infectious materials, including body substances and contaminated supplies, equipment, environmental

surfaces, water, or air. DHCP includes dentists, dental hygienists, dental assistants, dental laboratory

technicians (in-office and commercial), students and trainees, contractual personnel, and other persons

not directly involved in patient care but potentially exposed to infectious agents (e.g., administrative,

clerical, housekeeping, maintenance, or volunteer personnel).

Dental Unit Water Lines (DUWL)

Small bore tubing usually made of plastic, used to deliver dental treatment water through a dental unit.

Disinfection

A process that results in the elimination of many or all pathogenic microorganisms on inanimate objects

with the exception of bacterial endospores


Engineering Controls

Equipment, devices, or instruments that remove or reduce the risk of exposure to potentially infectious

material/s

Exposure Incident

When an employee has a specific splash of blood, saliva or other potentially infection material into the

eyes, nose, lips or mouth or a poke from a contaminated sharps to any part of the body

Exposure Control Plan

A written plan required by OSHA that describes how expposures to to bloodborne disease agents will be

controlled in a given work site.

High-level Disinfection

Kills bacteria, mycobacteria (TB), fungi, viruses, and some bacterial spores

Infectious Disease

A clinically manifest disease of man or animal resulting from an infection

Intermediate-level Disinfection

Kills bacteria, mycobacteria (TB), most fungi, and most viruses—does not kill resistant bacterial spores

Low-level Disinfection

Kills most bacteria, some fungi and some viruses. Will not kill bacterial spores and is less active against

some gram-negative rods (pseudomonas) and mycobacteria

Microorganism

Very small living organism unseen by eye (e.g. yeast, molds, viruses); may or may not cause disease

Pathogens or Infectious Agent

A microorganism capable of producing disease

Occupational Health Strategies

As applied to infection control, a set of activities intended to assess, prevent, and control infections and

communicable diseases in healthcare workers

Personal Protective Equipment (PPE)

Specialized clothing or equipment worn by a healthcare worker (HCW) for protection

Reservoir

Any person, animal, arthropod, plant, soil or substance (or combination or these) in which an infectious

agent normally lives and multiples, on which it depends primarily for survival, and where it reproduces

itself in such manner that it can be transmitted to a susceptible host

Sharps

Any object used or encountered in the clinical area of a dental office that may cause punctures or cuts

to any part of the body, including but not limited to; all contaminated broken glassware, syringes,

needles, scalpel blades, suture needles, disposable razors and other sharp instruments and items.


Sterilization

A process that completely eliminates or destroys all forms of microbial life

Susceptible Host

A person or animal lacking effective resistance to a particular infectious agent

Tuberculosis (TB)

An infectious disease that is increasing in occurrence. It most commonly affects the lungs, but may

affect the GI and genitourinary tracts, bones, joints, nervous system, lymph nodes and skin as well.

Three types exist: human, bovine (cow) and avian (bird). Humans may become infected by all three

types, but in the U.S., the human type is most common

Transmission

Any mechanism by which a pathogen is spread by a source or reservoir to a person

Virus

The smallest organism that can be seen by an electron microscope a virus can only live inside a cell

where it reproduces itself. Viruses can cause disease immediately or can live in the cell for many years

before becoming active

Work Practice Controls

Controls that reduce or eliminate the likelihood of exposure by altering the manner in which a task is

performed.

Documents

May elp You? nfection ontrol Training for Unregistered ...carolynmortensen.com/PDF/Outline.pdf · A. Chain of Infection: A chain is an interconnected series of links. A chain of infection,