By Mary Govoni, CDA, RDA, RDH, MBA
By now you may have heard about the new CDC Guidelines for Infection Control in Dental Health-Care Settings. You may have even received a copy of the guidelines from the Centers for Disease Control and Prevention (CDC). If you're not sure, the booklet is pictured below. This is a very important document for dental practices, and should be reviewed thoroughly, especially by the office safety/ OSHA manager. If you didn't receive a copy, you can download one from the CDC Web site — www.cdc.gov.
Some dental professionals have questioned me about the relevance of these new guidelines and whether they are legally required to follow them. After all, as they say, they are not OSHA rules. While this is true, the CDC does not have the legal authority of OSHA, the CDC does set standards of care, and this is exactly the case with these and other CDC guidelines. In many states, the dental boards have adopted CDC Guidelines as their standards for patient safety. In these cases, the guidelines do have the force of law in an indirect way. If you are not sure about your state, you should check with your state dental board.
As an infection-control and OSHA consultant, I am very excited about these guidelines because they are easy to understand and finally give dental professionals all the resources they need for managing their own infection-control programs in one comprehensive package. How many times have you been asked a question about an infection-control recommendation, and given an answer, only to hear, "Where does it say that?" Now you can go to the CDC guidelines and show it!
The CDC has documented all of the infectious disease issues (as they have identified them) that affect dental practices and made recommendations for prevention; as well as documented the research that supports their recommendations. This approach is one that we all should applaud, since we have been asking, "Where's the science?" for many years regarding dental infection control. In addition, the CDC also links their recommended practices to federal and state OSHA and other safety regulations. Given the amount of confusion that has reigned over the issues surrounding infection control in dentistry, these guidelines go a long way to resolve much of the confusion. Enough already! Let's get to the practical stuff.
Using the guidelines
The Introduction to the guidelines gives an overview of infection control in dentistry, infectious disease risks to dental health-care personnel (DHCP) and patients, and a summary of previous CDC guidelines that have been incorporated into these new guidelines. A comprehensive list of definitions is included, which will be very helpful for review or for training of DHCP who are new to the profession.
The next section, "Review of Science Related to Dental Infection Control" (pages 6-38), should be reviewed by all members of the dental team. It presents the scientific rationale for all of the recommendations in the document. This section should be the basis of all infection procedures and protocols that are followed in any dental setting, and it should answer many of those lingering questions.
The "Recommendations" (pages 39-48) summarize the science-related information into specific actions that should be followed in everyday practice. The recommendations are categorized, according to the CDC, on the basis of existing scientific data, theoretical rationale, and applicability (see table 1, above). The list of recommendations includes the appropriate category, as well as the applicable studies that support the recommendation. A comprehensive list of the studies and/or references is listed in the guidelines as well (pages 49-60).
While I can't emphasize enough the importance of a thorough review of these guidelines, I know that many of you want to know what's new and different. There are several changes that should be noted. First is a change in terminology from "universal" precautions to "standard" precautions. The practice of universal precautions was applied to all patients regardless of their infection status and focused primarily on the prevention of transmission of bloodborne pathogens. The premise of universal precautions was that all blood and body fluids might be contaminated and appropriate protective measures must be taken to prevent exposures. The CDC concluded that universal precautions were relevant to other aspects of infection control, including pathogens that can be spread by blood or other body fluids. Therefore the term "standard" precautions has been adopted, to be used in place of universal precautions, and it applies to contact with blood, all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood, nonintact skin, and mucous membranes. For practical purposes, this does not change our procedures in dentistry; it merely changes what we call them. This change in terminology should be reflected in your written infection-control plan for your practice.
Another change in the guidelines is the recommendation for a written policy on work restrictions for DHCP who may have been exposed to and/or infected with infectious diseases. Pages 8 and 9 (Table 1 in the guidelines) list the CDC's recommendations for work restrictions related to a number of infectious diseases or conditions. These conditions include latex sensitivity, DHCP infected with conjunctivitis, herpes simplex, measles, mumps or rubella (MMR), tuberculosis, and others. Every dental practice should review this information and formulate a policy that conforms with the recommendations.
Management of an exposure incident in a dental practice has always been a source of some level of confusion over what should be done for the employee, whether the employee and patient should be tested, and what tests should be administered. The protocol for postexposure management is detailed on pages 13 and 14 of the guidelines, and should be adapted in the form of a written policy into your infection-control plan for your practice.
Hepatitis B (HBV) vaccinations and the recommendations for titer testing and boosters have long been a source of confusion. In the new guidelines, the CDC does not recommend routine antibody titer testing and boosters for those who initially responded to the vaccine. It is recommended that DHCP who are completing their initial HBV vaccine series be tested for antibodies one to two months after the last injection to determine if they did respond. In certain cases, DHCP may require another series of injections. Additional information regarding HBV and vaccinations is detailed on page 17 of the guidelines. Be sure to read this section carefully for a more detailed explanation regarding HBV vaccinations.
Updated recommendations regarding sterilization procedures include "at least weekly" monitoring of sterilizers with biological monitors. As a reminder, the color change indicator on sterilization packages or tape is a process indicator only, and does not indicate the sterilizer is necessarily working properly, just that it is reaching the proper temperature. A biological monitor is one that is obtained from a third-party source, such as a dental school sterilizer monitoring program, or from a commercial entity. A list of commercially available sterilizer monitoring services is provided in table 2 (below). In addition, in-office monitoring systems are available for on-site testing, such as the 3M™ Attest™ Biological Monitoring System (pictured at right).
Sterilization methods recommended by the CDC and cleared for use by the Food and Drug Administration (FDA) are steam under pressure (autoclave), dry heat, and unsaturated chemical vapor. Bead sterilizers are not cleared by the FDA, and therefore not included in the CDC recommendations. If your practice is shopping for a new sterilizer, you may want to investigate the new pre- and postvacuum sterilizers that are becoming more widely available. They offer some distinct advantages in instrument processing, especially for drying instruments during the sterilization cycle. (We may want to show the Barnstead/Harvey products.)
The new CDC guidelines are very explicit about wrapping or packaging items for sterilization to protect the sterility of the instrument or items prior to use or while the items are stored. According to the guidelines, when sterile items are open to the air, they will eventually become contaminated. Packaging or wrapping of instruments can be accomplished by using sterilization pouches, nylon tubing, or wraps made of cloth or special paper. (photos from Crosstex) Disposable pouches, tubing or wraps should never be reused.
According to the new guidelines, environmental infection control (pgs. 25-26), commonly referred to as disinfection and cleaning procedures, should be predicated on the following criteria — potential for direct patient contact, degree and frequency of hand contact, and potential contamination of the surface with body substances or environmental sources of microorganisms (soil, dust, or water). Remember that cleaning a surface prior to disinfection is a critical step in infection control since disinfectants are not effective in the presence of blood or other organic matter. To simplify procedures, we typically use a disinfectant that is a cleaner/disinfectant. This means that we can use the same product to clean a surface and then reapply it to the surface for disinfection.
In the past, CDC guidelines recommended the use of intermediate-level, tuberculocidal disinfectants. The new guidelines state that low-level disinfectants that are EPA-registered and have a label claim to kill HIV and HBV are appropriate for use in dentistry, but an intermediate-level disinfectant should be used where blood is present. Since we cannot always be sure whether blood is present or not, I would recommend always using an intermediate-level disinfectant. These products will have label claims against HIV and HBV, and will also be tuberculocidal. Be sure to check the label on the disinfectant products you use for appropriate label claims.
It is interesting to note that the "spray-wipe-spray" technique that we were encouraged to use for environmental infection control in the past is not mentioned in the new guidelines. Cleaning, which was accomplished by the first "spray-wipe," can be done by wiping with a gauze or paper towel saturated with disinfectant, or a pre-moistened wipe. The second "spray" can be accomplished by applying the disinfectant again, after cleaning, with another gauze, towel, or wipe saturated with the same product. There is some research that suggests that continuous exposure to cleaners and disinfectants, especially in sprays, can cause respiratory problems. For information about this research, consult www.chm.msu.edu/oem and click on the resources link. You will see a link for occupational asthma, which will explain the possible problems associated with spraying disinfectants.
The recommendations in the new guidelines which will most likely have the greatest impact on dental practices are those related to dental unit water quality (pages 28-30). The issue of dental unit water contamination is not new, and has been the subject of several national news programs as an exposé that alarmed the public to some degree several years ago. In the late 1990s, the American Dental Association (ADA) and the CDC issued statements on dental unit water quality that included a desired quality level of ≤200 CFU (colony forming units of bacteria)/ml, which was based on standards used for hemodialysis units. Public drinking water standards are ≤500 CFU/ml. The CDC has recommended in the new guidelines that dental treatment water (water from dental units) is acceptable at or below the 500 CFU/ml standard. This means that some dental practices may need to make changes to their dental units in order to achieve this level of water quality. If your practice is not treating or filtering the water in the dental units at the present time, it may be a good idea to test the water as a baseline, with an in-office water test kit. The test kit that is most readily available through dental dealers is the Clearline© Water Test Kit. It is cost-effective and easy to use. The water test kit will detect numbers of CFUs, but will not be specific as to the types of bacteria present, which is not as critical as the numbers of CFUs.
It is not likely that the dental units will test at 500 CFUs or below without some type of filtering or treatment for the water lines. Therefore, your practice needs to research the various options available for your units, which are the most cost-effective and easiest to maintain. These include point of use filters, which are installed on each water line; self-contained water systems, which have a water reservoir separate from the municipal water supply; or point of entry filters, which filter all of the water to the unit and are typically installed at the junction box. The equipment representative for your local dental supplier is an excellent resource for information on the type of systems that are available and appropriate for your office and your equipment.
In addition to treating the dental unit water, the CDC also recommends that a 20- to 30-second flush be performed on each waterline after each procedure to remove any contamination that may have entered the waterlines. For surgical procedures, the guidelines recommend that only sterile water be used for irrigation of surgical sites.
Please remember that this column is intended as an overview of the new CDC guidelines, not as an all-inclusive discussion of issues or available products. Do your homework and review the guidelines. If you do, you can even receive continuing-education credit through the CDC by completing the test enclosed in the document. For additional information on compliance with the guidelines, the Organization for Safety and Asepsis Procedures (OSAP) has developed a new workbook, From Policy to Practice: OSAP's Guide to the Guidelines, which is available from their website, www.osap.org, or by calling (800) 298-6727.
Mary Govoni is a Certified and Registered Dental Assistant and a Registered Dental Hygienist, with over 28 years of experience in the dental profession as a chairside assistant, office administrator, clinical hygienist, educator, consultant, and speaker. She is the owner of Clinical Dynamics, a consulting company dedicated to the enhancement of the clinical and communication skills of dental teams. She can be reached at [email protected].
Table 1 — Categories for CDC recommendations
Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB Strongly recommended for implementation, and supported by experimental, clinical, or epidemiologic studies.
Category IC Required for implementation as mandated by federal or state regulation or standard. When IC is used, a second rating can be included to provide the basis of existing scientific data, theoretical rationale, and applicability. Because of state differences, the reader should not assume that the absence of a IC implies the absence of state regulations.
Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
Unresolved Issue No recommendation. Insufficient evidence or no consensus regarding efficacy exists.
Table 2 — Third-party commercially available sterilizer monitoring services
Certol — www.gocertol.com
Confirm — www.confirmmonitoring.com
North Bay Bioscience — www.nbbs.com
SPS Medical — www.spsmedical.com
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