California Dental Board Approved: Infection Control (2 Units)

Strategies and Controls that Limit Exposure to Infection

More than 8 million US health care workers may be exposed to blood or other body fluids through the following types of contact (NIOSH, 2004):

  • Percutaneous injuries (injuries through the skin) with contaminated sharp instruments such as needles, explorers, scalers and scalpels (82%).
  • Contact with mucous membranes of the eyes, nose, or mouth (14%).
  • Exposure of broken or abraded skin (3%).
  • Human bites (1%) Up to 800,000 percutaneous injuries may occur annually among all U.S. healthcare workers (both hospital-based workers and those in other health care settings).

After percutaneous injury with a contaminated sharp instrument, the average risk of infection is 0.3% for HIV and ranges from 6% to 30% for hepatitis B (NIOSH, 2004).

Avoiding exposure is the best method for the prevention of occupational exposure to bloodborne pathogens. There are a number of different preventive practices that dental professionals can utilize to protect themselves and their patients from the threat of exposure.

Dental professionals need to become familiar with the hierarchy of controls that categorize and prioritize prevention strategies. The hierarchy of safety and health controls include (CDC, 2004a):

  • Legal and regulatory controls.
  • Administrative and Training controls.
  • Engineering controls.
  • Work practice controls.

Legal and Regulatory controls are those instituted by federal, state and local laws. Federal laws include those of the Occupational Safety and Health Administration (OSHA) Occupational Safety and Health Act of 1970, General Duty Clause requires that each employer:

  1. Shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to employees;
  2. Shall comply with occupational safety and health standards promulgated under this Act. And each employee shall comply with occupational safety and health standards and all rules, regulations, and orders issued pursuant to this Act which are applicable to his own actions and conduct.

In 1991 OSHA promulgated the Occupational Exposure to Bloodborne Pathogens Standard. This standard was designed to protect millions of healthcare workers and related occupations from the risk of exposure to bloodborne pathogens, such as the Human Immunodeficiency Virus (HIV) and the Hepatitis B Virus (HBV).

Legal and Regulatory controls also include the component of the Dental Practice Act in California that requires dental professionals to utilize proper infection control procedures. The failure to do so can include charges of professional misconduct.

Administrative and training controls include policies, procedures, and enforcement measures to prevent exposure to disease-causing organisms. Each healthcare facility must provide such administrative control to their employees, outlining the policies and procedures related to any issue in the occupational setting in which the employee is to utilize proper infection control practices. The training of employees regarding infection control issues are also a component of administrative controls, as each facility determines the need for training.

Each dental office should have a written plan for an Infection Control Program that includes elements to protect personnel.

The objectives are to educate dental professionals regarding the principles of infection control, identify work-related infection risks, institute preventive measures, and ensure prompt exposure management and medical follow-up. Elements of the plan should include:

  • Education programs for staff members - Personnel are more likely to comply with an Infection Control Program and Exposure Control Plan if they understand its rationale. Clearly written policies, procedures, and guidelines can help ensure consistency, efficiency, and effective coordination of activities. Personnel subject to occupational exposure are mandated receive infection control training on initial assignment, when new tasks or procedures affect their occupational exposure, and at a minimum, annually.

    Education and training should be appropriate to the assigned duties of specific dental professional (e.g., techniques to prevent cross-contamination or instrument sterilization). For dental professionals who perform tasks or procedures likely to result in occupational exposure to infectious agents, training should include:

    1. A description of their exposure risks;
    2. Review of prevention strategies and infection-control policies and procedures;
    3. Discussion regarding how to manage work-related illness and injuries, including PEP (Post Exposure Prophylaxis); and
    4. Review of work restrictions for the exposure or infection. Inclusion of dental staff with minimal exposure risks (e.g., administrative employees) in education and training programs will enhance facility wide understanding of infection control principles and the importance of the program (CDC, 2003).

  • Immunization plan of vaccines for preventable diseases - Immunizations are an essential part of prevention and infection control programs for dental professionals, and a comprehensive immunization policy should be implemented for all dental health care facilities. Immunizations substantially reduce both the number of dental professionals susceptible to vaccine preventable diseases and the potential for disease transmission to other healthcare professionals and patients. Thus, The Advisory Committee on Immunization Practices (ACIP) provides national guidelines for immunization of healthcare providers, which includes dental providers (See Appendix A).

    On the basis of documented healthcare associated transmission, healthcare providers are considered to be at substantial risk for acquiring or transmitting hepatitis B, influenza, measles, mumps, rubella, and varicella. All of these diseases are vaccine-preventable. ACIP recommends that all HCP be vaccinated or have documented immunity to these diseases. ACIP does not recommend routine immunization of healthcare providers against TB (i.e., inoculation with bacille Calmette-Guérin vaccine) or hepatitis A. No vaccine exists for HCV. ACIP guidelines also provide recommendations regarding immunization of healthcare providers with special conditions (e.g., pregnancy, HIV infection, or diabetes) (CDC, 1997).

    OSHA requires that employers make hepatitis B vaccination available to all employees who have potential contact with blood or other potentially infectious material (OPIM). Employers are also required to follow CDC recommendations for vaccinations, evaluation, and follow-up procedures. Non-patient care staff (e.g., administrative or housekeeping) might be included, depending on their potential risk of coming into contact with blood or OPIM. Employers are also required to ensure that employees who decline to accept hepatitis B vaccination sign an appropriate declination statement (CDC, 2003) to be kept on file.

  • Medical condition management and work-related illnesses and restrictions

    Dental programs in institutional settings, (e.g., hospitals, health centers, and educational institutions) can coordinate with departments that provide personnel health services. The majority of dental practices are in ambulatory, private settings that do not have licensed medical staff and facilities to provide complete on-site health service programs. In such settings, the infection-control coordinator should establish programs that arrange for site-specific infection control services from external health care facilities and providers before dental health care personnel are placed at risk for exposure. Referral arrangements can be made with qualified healthcare professionals in an occupational health program of a hospital, with educational institutions, or with healthcare facilities that offer personnel health services.

    This is particularly needed in the case of occupational exposure to bloodborne pathogens (post-exposure prophylaxis will be discussed later in this course).

  • Maintenance of health records in accordance with all applicable state and federal laws.

  • Exposure prevention and post exposure management, with follow-up of staff exposed to infectious organisms or potentially harmful materials - Despite the hierarchy of controls in the avoiding exposure to blood and OPIM, occupational exposures can still occur. Written policies and procedures to facilitate prompt reporting, evaluation, counseling, treatment, and medical follow-up of all occupational exposures should be available to all dental professionals. Written policies and procedures should be consistent with federal, state, and local requirements addressing education and training, post exposure management, and exposure reporting.

    The CDC has guidelines for the post-exposure management of occupational exposure to blood and OPIM (CDC, 2005). These guidelines can be found at

The infection control program should identify an infection control coordinator (a dentist or other dental health care professional) knowledgeable or willing to be trained who is assigned responsibility for coordinating the program. The effectiveness of the infection control program should be evaluated on a regular basis.

It is important to remember that some training controls are also a legal control, for example, this course is a legislated requirement for dental professionals in the state of California.

Engineering controls eliminate, isolate or reduce exposure to a threat such as a pathogenic organism or physical hazard through the use or substitution of engineered machinery or equipment. Such controls are often technology based, incorporating a safer design to necessary equipment.

Examples include needleless syringes, needle recapping devices, N2O2 scavenging devices, sharps disposal containers, positive pressure ventilation patient rooms, dilution ventilation, high-efficiency particulate air (HEPA) filtration, ultraviolet lights, ventilation systems, sound-dampening materials to reduce noise levels, safety interlocks, and radiation shielding. Well designed engineering controls eliminate human error. The dental professional has greater protection from the hazard because it is either eliminated or reduced through no additional effort on the part of the healthcare worker.

Where engineering controls are not available or appropriate, work practice controls must be used. Work practice controls result in safer behavior that is aimed at reducing the risk of exposure by changing the way a task is performed. Examples include using instruments rather than fingers to retract or palpate tissue during suturing and administration of anesthesia, not passing an unsheathed needle to another healthcare provider. The utilization of barriers such as personal protective equipment (PPE) when coming in contact with potentially infectious materials is also a work practice control (this will be explained in detail later in this course).

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