Current Issues in Dental Safety and Infection Control

Infection Control

Current Issues in Dental Safety and Infection Control

Patricia Podolak, DDS, MPH, and Shannon Mills, DDS

Much is happening in 21st century dentistry. Dental technology continues to grow and expand, and with it the safety and infection control issues including waterlines, lasers, challenging new organisms such as prions, growing resistance to antibiotics, sharps safety and disinfectants and barriers.

Dental Unit Waterlines Biofilm in dental waterlines continues to be a concern for the

profession. As research reveals more about the nature of these complex microbial communities, investigators are also probing the links between chronic exposure to contaminated aerosols and respiratory health.

On the technological front, a wide range of new products are now available to help improve the quality of water produced by dental units and other dental devices. Virtually all new dental units come equipped with independent water reservoirs that allow the user to use various chemical treatments to control biofilm formation. The reservoir also allows the user to introduce water of known microbiolgical quality. Additionally, devices are available to treat incoming municipal water to remove bacteria and to treat water to prevent biofilm formation.

Compliance with treatment protocols has shown to be very important to the success of dental water treatment in clinical settings. In many cases, more complex and time consuming proce-

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dures result in greater likelihood of user error. Processes that are automated or passive can reduce compliance as a variable. As with all dental products, the best results will be attained by conscientiously following manufacturer recommendations for use.

Dentists need to become informed consumers when selecting dental equipment and products to treat dental water systems. When buying new dental units or devices that use water, ask the manufacturer to describe how to maintain good water quality. Include questions such as: How much time and effort does the process require? Have you tested any specific products for safety and effectiveness on your unit or device? Do any scientific studies support the approach that you have taken?

The same approach will be helpful when deciding on devices or chemical agents to remove or prevent biofilms. Find out how the product is to be used. How frequent and complex are the instructions for use? How much will it cost to use the product over a year? Ask the company to provide you with copies of studies and user evaluations that have been performed on its product.

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Laser Dentistry

Prion Diseases

The field of laser dentistry continues to grow. As more dental In recent years, there has been an increase in both the scientific

practitioners use lasers in their offices, it is important to remember and public awareness regarding prion diseases. Prion diseases, or

that there are related safety and infection control requirements.

transmissible spongiform encephalopathies (TSEs) are a family of

Let's review some of these issues.

diseases that affect both humans and animals. The causative agent

When lasers are used during surgical procedures, the thermal is believed to be a prion. These diseases are rare, and characterized

destruction of tissue produces what is termed "surgical smoke," or by long incubation periods, progressive neurodegeneration, and a

a "laser plume." Laser smoke can be com-

failure to induce inflammatory response.

posed of particles, gases, tissue debris, viruses

Human prion diseases include:

and odor-causing substances. Employers

? Creutzfeldt-Jakob Disease (CJD)

should advise employees of the potential

? Variant Creutzfeldt-Jakob Disease (vCJD)

hazards of laser smoke. The latest CDC

? Gerstmann-Straussler-Scheinker Syndrome

guidelines for infection control in dentistry

? Fatal Familial Insomnia

recommend the use of:

? Kuru

1. Standard precautions (high filtration sur-

CJD and vCJD are fatal diseases. There is

gical mask and possibly full-face shield)

strong scientific evidence to link vCJD with

2. For minimal laser plumes, central room

bovine spongiform encephalopathy (BSE),

suction units with in-line filters

also known as mad cow disease.

3. For substantial laser plumes, dedicated

The prevalence of prion disease in North

smoke exhaust systems with high efficiency

America is low. However, there is the possibil-

filters

ity that CJD or vCJD cases from other

Always utilize laser safety eyewear appro-

nations may seek dental treatment, and pose a

priate for the wavelength in use. Failure to

risk of iatrogenic transmission. Prions have

use such eyewear by those exposed to the

been found to exhibit unusual resistance to

laser (including patients) can result in seri-

conventional chemical and physical deconta-

ous eye injury. One should never look

mination procedures. The risk of CJD trans-

directly into the laser beam, even when

mission through dental procedures remains

wearing safety eyewear.

unclear, and an area of continued controversy

Class IV lasers can cause fires.

and research. The current CDC guidelines for

Appropriate procedures should be followed. For example, use only non-combustible

The field of laser

infection control in dentistry provide precautions for consideration without recommenda-

anesthetic agents, and wet or fire retardant materials in the operative field. Staff should know the location of, and be trained in the

dentistry continues to grow. As more dental

tion. When treating known CJD or vCJD patients, in addition to standard precautions other precautions include:

use of, fire extinguishers. Regarding sterilization, steam steriliza-

practitioners use lasers

? Use of single-use disposable items and equipment whenever possible

tion is appropriate. All the components used (optic fibers, handpieces, and tips) should be

in their offices, it is

? Consider items difficult to clean (such as endodontic files, broaches and burs) as sin-

sterilized in separate sterilization pouches after each use, and according to the manufacturer's instructions. It should also be

important to remember that there are related

gle-use disposables and discard after each use ? Clean instruments thoroughly and

steam-autoclave at 134 degrees Celsius for

noted that the port (connecting) end of the fiber must remain clean and oil free. The

safety and infection

18 minutes. ? Do not use flash sterilization methods

fiber should never be sterilized together with a lubricated high-speed turbine.

control requirements

Future research should shed more light upon the relationship between prions and

Certain types of lasers use water sprays

dentistry.

for hard tissue procedures. As with all dental

water delivery systems, measures should be

Antibiotic Resistance

taken to control biofilm formation in dental

Antibiotics (or antimicrobial drugs) are

waterlines connected to the laser.

drugs used to combat infections caused by bac-

Each dental office should have a Laser Safety Officer (LSO) teria. Due to widespread use over time, the bacteria that antibi-

who is trained through an accredited safety program. The position otics control have developed resistance to these drugs. This is rec-

of LSO is a good match for the job duties of the dental assistant. ognized as a worldwide public health threat, and the need to

In assuming this role, the LSO directs laser safety practices, and develop new classes of antibiotics has become a serious concern.

ensures a safe environment while the laser is in use.

Many pathogenic bacteria are developing resistance. For exam-

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June 2006

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Infection Control

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ple, we have seen the media attention Methicillin Resistant

Disinfectants and Barriers

Staphylococcus aureus (MRSA) has gained as it has spread from

Equipment and environmental surfaces in the dental office

hospital environments into the community. One recent study has become contaminated during patient procedures as a result of

found that the pathogens associated with bacterial endocarditis

direct or indirect contact. The extent to which surfaces become

exhibited elevated resistance rates against the antibiotics used for contaminated and the relative risks of cross infection posed by this

prophylaxis in dentistry.

contamination is highly variable.

Antibiotic resistance is recognized as a

By discriminating between "touch" surfaces

concern for dentistry. It has been estimated

that require attention between patients and

that dentists prescribe between 7-11% of all common antibiotics. The ADA Council on

By discriminating between

environmental surfaces that are part of daily housekeeping, the dental team can reduce

Scientific Affairs has issued a report on antibiotic resistance and the overuse of

"touch" surfaces that

unnecessary effort and expense. Equipment or environmental surfaces such as light handles,

antibiotics. The guidelines that the Council

require attention between

handpiece couplers and hoses, air water

offers include: ? Make an accurate diagnosis

patients and environmental

syringes and x-ray equipment that are touched with contaminated gloves during treatment

? Use appropriate antibiotics and dosing schedules

surfaces that are part of

pose the greatest risk of transmitting microorganisms from patient to patient. These sur-

? Consider using narrow-spectrum antibiotics in simple infections to minimize the

daily housekeeping, the

faces must at a minimum either be barrier protected or cleaned with a hospital disinfectant

disturbance of the normal flora. And, use

dental team can reduce

between patients. Other surfaces such as coun-

broad-spectrum antibiotics for more complex infections

unnecessary effort and

tertops, floors and walls that are not contacted during treatment should be cleaned at least

? Avoid the unnecessary use of antibiotics in treating viral infections

expense.

daily or whenever they are visibly soiled with blood or other patient material.

? If treating empirically, revise the treatment

When choosing disinfectants, be sure that

regimen based on patient progress or test

the product is a good cleaner as well as a disin-

results

fectant and will not harm the surfaces that will

? Obtain thorough knowledge of the side

be disinfected. Some dental unit and equip-

effects of the antibiotic, and drug interac-

ment manufacturers can supply a list of prod-

tions before prescribing it

ucts that they have evaluated and have been

? Patient education??Educate the patient

found to be safe. When making purchasing

regarding the proper use of the antibiotic

decisions, consider all of the costs of using a

and the need to complete the full course

disinfectant. A low-cost product with a short

of antibiotic as prescribed.

shelf life (unopened product) or use life

Antibiotic resistance is a problem that

(opened or mixed product) may actually be

dentistry will continue to face, and the need

more expensive to use than another product

for new classes of antibiotics is recognized.

with longer use or shelf life.

Safety of staff and patients is paramount

Sharps Safety

when using disinfectants or other chemicals.

Sharps safety is another important area

Always read the label instructions and be

that should not be overlooked. In general,

aware of the hazards listed. If disinfectants are

needles, burs, syringes, laboratory knives,

mixed or stored in containers that are not sup-

and other sharp instruments can cause per-

plied by the manufacturer, the user must affix

cutaneous injuries. Additionally, needles

a label that includes hazard warnings.

have been recognized as a significant source

of percutaneous injury in dental practice.

Conclusion

The revised OSHA Bloodborne Pathogens Standard requires The topics discussed above are just a few of the many issues in dental

employers to consider safer needles and other sharps devices when safety and infection control that dental practitioners are faced with

they conduct their annual review of the Exposure Control Plan. today. OSAP has been dentistry's safety and infection control resource

Employees who are directly responsible for patient care should

since 1984. To learn more about current issues regarding disinfectants,

always be involved in identifying and choosing these safer devices.

please refer to the May 2006 issue of

Engineering controls remove or isolate a hazard in the workplace.

Infection Control in Practice, OSAP's

Safety engineered sharps are considered to be appropriate engi-

newsletter or to learn more about

neering controls. Employers should on an ongoing basis stay

these and other safety and infection

informed of the latest developments in safety engineered sharps

control topics, please visit the OSAP

technology.

Web site at .

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Bios Dr. Podolak, who is both a dentist and a safety engineer, is a 9-year member of OSAP. She possesses four degrees, and her training and background includes Public Health, Risk Management, and Occupational Safety and Health. She is President of Springhurst Associates, LLC, a safety consultancy. Additionally, Dr. Podolak is co-editor of OSAP's monthly newsletter, The OSAP Report Online, the author of OSAP's Executive News Summaries, and a regular contributor to the OSAP Web site. She can be reached at patricia.podolak@. Shannon E. Mills, DDS, FAGD, FICD is Associate Professor and Assistant Director of the Dental General Practice Residency Program, University of Nevada School of Medicine (UNSOM). In July of 2005, Dr. Mills retired from the U.S. Air Force in the rank of Colonel after 28 years of service. While on active duty, Dr. Mills served in military healthcare facilities in the US and overseas, gaining diverse experience in clinical general dentistry, education, research and healthcare policy. Dr. Mills has authored or coauthored numerous papers on dental infection control in peerreviewed journals and was a member of the American Dental Association (ADA) panel that drafted the 1995 statement on dental unit water lines. He is a consultant to the ADA and the Centers for Disease Control and Prevention, Division of Oral Health as well as an active member of numerous professional organizations including OSAP, Dentistry's Infection Control and Safety Resource.

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