New disease-control strategies reduce transmissions from recognized and non-recognized sources.
By Cynthia A. Chillock, CDA, RDH, EF and Charles John Palenik, MS, PhD, MBA
Infectious Diseases! Who wants one? Unfortunately, practicing dentistry today has associated elements of risk, including contracting infectious diseases. Infection-control precautions must be extended to protect practitioners, patients, and the surrounding community. Successful infection control and prevention involves creating policies, procedures, and state-of-the-art equipment, plus education and hands-on training to follow through with these new practice strategies.
Some infection control precautions involve the revised Occupational Safety and Health Administration's Bloodborne Pathogens Standard, which applies only to the workplace. The central concerns are the performances of the employers and safety of employees.
On December 19, 2003, the Centers for Disease Control and Prevention updated its 1993 guidelines and issued new infection-control recommendations. The focus of CDC recommendations is the health of all Americans — not just workers, but the public at large.
Guidelines are available in print [MMWR 2003;52(RR-17):1-68] or electronically at www.cdc.gov/mmwr/preview/ mmwrhtml/rr5217a1.htm.
It's standard precautions now
During the early 1990s, the CDC emphasized "universal precautions." Concern was primarily directed toward people infected with bloodborne pathogens (hepatitis B and C and HIV). Because many were unknowingly infected, patient blood and blood products had to be considered potentially infectious.
In 1996, the CDC combined the concepts of universal precautions and body substance isolation into one set of precautions called standard precautions. Standard precautions represent a system of barrier precautions to be used by all personnel for contact with blood, all body fluids, secretions, excretions, non-intact skin, and mucous membranes of all patients, regardless of diagnosis. Other potentially infectious materials (see Table of Definitions) also are considered problematic. These precautions are now considered the "standard of care."
Standard precautions are designed to reduce disease transmission from both recognized and unrecognized sources of infection. Standard precautions are more procedure-directed, rather than precautions against specific patients. For example, a dental health care practitioner may choose to double glove, not because of the status of a patient, but because of the length or type of procedure to be performed.
Standard precautions should provide protection in most situations. Nevertheless, some cases require additional processes commonly called "transmission-base precautions." Examples include additional ventilation requirements, special respiratory protection for DHCP, or postponement of non-emergency procedures.
OSHA states in its Bloodborne Pathogens Standard, "Uengineering and work-practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used." Engineering controls, work-practice controls, and personal protective barriers can prevent occupational exposures in dentistry.
Personal protective equipment prevents many occupational exposures, but not all. For example, gloves — even heavy-duty utility gloves — are not totally protective against contaminated sharps.
More effective are engineering and work-practice controls that minimize employee exposure.
Engineering controls are the primary means of eliminating or minimizing employee exposure. Some of these controls are sharps-disposal containers, self-sheathing needles, safer medical devices, and needleless systems. These newer devices help isolate or remove bloodborne pathogen hazards from the workplace by placing a barrier between the practitioner and patient body fluids.
Engineering controls must be examined and maintained or replaced on a regular schedule to ensure their effectiveness. No single medical device is considered appropriate or effective for all circumstances. Employers must select devices that will not jeopardize patient or employee safety or be medically inadvisable. Selecting better devices will reduce the chances of having an exposure incident involving a contaminated sharp.
Work-practice controls are controls that reduce the likelihood of exposure by altering the manners in which tasks are performed.
By changing work practices such as prohibiting re-capping of needles by a two-handed technique and never passing an uncapped contaminated syringe to another person, we can greatly reduce the risks of contamination to an infectious agent.
Dental practices are now required to meet annually to review changes in technology with effective, safer devices that eliminate or reduce exposure to bloodborne pathogens. Nevertheless, there are additional mandatory requirements at this meeting. Non-managerial employees, meaning anyone handling sharps (from assistant, to hygienist, to doctor), must attend.
In addition, minutes of this meeting are to be kept and must record participants, which devices or practices were considered, and the rationale regarding their conclusions and decisions. OSHA requires we all share responsibility for improving the safety of our work environments.
Dr. Charles J. Palenik is director of Infection Control Research at Indiana University School of Dentistry in Indianapolis, Ind. He may be reached by e-mailing [email protected]. Cynthia A. Chillock, CDA, RDH, EF, is CEO of The Perio-Data Company in Tucson, Ariz. Reach her at (800) 411-7792 or [email protected].
Terms to know
Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Controls that isolate or remove the bloodborne pathogens hazard from the workplace: sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps-injury protections and needleless systems.
Means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.
Involves reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.
Other potentially infectious materials
Means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.
Personal protective equipment, PPE
PPE is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.
Sharps with engineered sharps-injury protections
Means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.
Is a procedure-specific set of precautions. In 1996, the CDC combined the major components of universal (blood and body fluids) precautions (designed to reduce the risk of transmission of bloodborne pathogens) and body-substance isolation precautions (designed to reduce the risk of transmission of pathogens from most body substances) into one set of precautions known as standard precautions.
Is one approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Process involves patient-specific procedures.
Means controls that isolate or remove the bloodborne pathogens hazard from the workplace: sharps-disposal containers, self-sheathing needles, safer medical devices such as sharps with engineered sharps-injury protections and needleless systems.