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Infection Control In The Dental Office: A Review For A National Infection Control Exam – Part 4

Eve Cuny, MS; and Charles J. Palenik, PHD, MS, MBA

June 2022 Course - Expires Sunday, December 31st, 2023

American Dental Assistants Association

Abstract

Human health and safety including infection control is essential to every dental practice. The well being of dental practitioners, patients and the surrounding community is very important. These areas are in constant flux. New products, equipment and processes seemingly appear on a daily basis. In addition, governmental agencies and professional associations regularly release new rules, regulations and recommendations. 
Dental practices must comply with certain requirements, but the methods involved often seem complex, time consuming and relatively expensive. However, there really is no alternative to an effective workplace health and safety program. Each dental practice must make the commitment to establish and maintain a safe work and treatment environment. 
In December of 2003, the Center for Disease Control and Prevention (CDC) released an extensive review and set of recommendations regarding infection control in dental environments. This document as well as others will serve as “guiding lights” for this course. The guidelines update previous CDC recommendations, incorporating relevant infection control measures, and discuss a number of concerns not previously addressed in dentistry. 
Every dental practice should have a copy of the 2003 CDC infection control guidelines for dentistry. Every person having a dental license received a copy. Electronic copies also are available at www.cdc.gov/mmwr/PDF/RR/RR5217.pdf. 
One effective way dental practices can improve and maintain compliant health and safety programs is through the appointment of a safety coordinator (compliance officer). The CDC indicates that a knowledgeable infection control coordinator (a member of the practice team) or a person willing to be trained should be given the responsibility for coordinating the program. The educated dental assistant should be readily capable of performing the tasks required.

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PART IV: OFFICE HEALTH AND SAFETY

Chapter 16: Hazard Communication

The intent of the Hazard Communication Standard is to protect workers from hazardous chemicals in the workplace. Sometimes referred to as the "employee right to know" law, it ensures that employees are aware of hazardous materials present in the workplace and appropriate protective measures to prevent accidental hazardous exposure.

The U.S. officially adopted the Globally Harmonized System (GHS) on March 26, 2012. The GHS was developed by the United Nations as a way to bring into agreement the chemical regulations and standards of different countries. It is an international attempt to get everyone on the same page. The GHS is meant to be a logical and comprehensive approach to: (1) defining health, physical and environmental hazards of chemicals; (2) creating classification processes that use available data on chemicals for comparison with the defined hazard criteria; and (3) communicating hazard information in a prescribed and uniform way on labels and safety data sheets.

The GHS uses two sets of pictograms, one for the labeling of containers and for workplace hazard warnings, and a second for use during the transport of dangerous goods. The GHS chemical hazard pictograms are intended to provide the basis for or to replace national systems of hazard pictograms.

To be compliant with the standard, the dentist must develop, implement, and maintain a written Hazard Communication Program. The dentist is ultimately responsible for compliance with the standard, but will often designate one employee to be the

safety/compliance officer. The written Hazard Communication Program must include the following:

1. A List of Hazardous Chemicals in the Workplace.

The employer or compliance officer must inventory the chemicals used in the office and then compile a list of the products that contain hazardous chemicals. It is best to organize the list alphabetically for quick reference, if needed. To determine if it is appropriate to include a product on the list, look for a hazard warning statement on the original label. Any product that presents any potential health hazard (e.g.: avoid contact with eyes, harmful if swallowed, etc.) should be included in your inventory list. For every item on the list, there must be a SDS (see next paragraph) on file. The list must also include the location where each chemical-containing product is stored. Add new products to the list as they are introduced to the workplace. All employees must know the location of the chemicals list and understand how it is organized.

2. Safety Data Sheets

Reference found at: MSDSonline, 10 GHS Factsin 6 Seconds, Retrieved from World Wide Web www.msdsonline.com on April 2016. For each hazardous chemical on the list, a Safety Data Sheet (SDS) must be on file. A SDS contains information about the product such as health hazards, fire and explosion risks, safe handling instructions, and emergency and first aid information. Collecting and sorting the SDS alphabetically makes it easy to find one specific form when needed. A SDS must include at least the following information:

• Product information, including trade and generic name of the chemical, manufacturer's name and address, emergency phone number.

• Hazardous ingredients, including hazardous ingredients of the material and hazard data such as flammability and exposure limits.

• Physical characteristics, including characteristics of the chemical, such as odor and appearance and boiling point.

• Fire and explosion data, including flammability, flash point, means of extinguishing the chemical, special or unusual fire/explosion procedures.

• Reactivity data, including the chemical's stability and incompatibility with other materials (such as heat, direct sunlight, water, etc.), safe handling and storage procedures.

• Health hazard data, including routes of entry, signs and symptoms of exposure, acute

and chronic potential health hazards and emergency first aid for eye and skin contact, inhalation and ingestion.

• Spill or leak procedures, procedures for accidental spills or leaks, including necessary personal protective equipment and disposal methods.

• Special protection information, including information about protective equipment needed, as well as ventilation and respiratory protection.

• Special precautions, which may include information about labeling of containers, or warning signs, or any safety or health information not previously listed.

The manufacturer of the product creates the SDS, which the supplier sends with ordered products. If a SDS is not received, it is the responsibility of the employer to contact the manufacturer or supplier as soon as possible to obtain the SDS. Ensure all employees know the location of the SDS file and how to read and understand the information contained on the forms. Employees should review the SDS information before working with a hazardous material. The SDS instructs users regarding appropriate PPE, disposal and other precautionary measures associated with the use of the material.

3. Labeling and Other Forms of Warning

All hazardous materials require labels that contain at least the product name, the manufacturer's name and contact information and the appropriate hazard warning statement. It is the responsibility of the manufacturer to ensure a proper label is in place and that it contains correct information.

When removing a product from its original container and placing it in a secondary container, label the new container with the appropriate information. The required minimum information is the product name and the hazard warning statement. Simply copy this information from the original label. If the product is for the immediate use of the employee and the secondary container will remain in that one person's control throughout its use, no new label is required.

There are several different types of labels commercially available in addition to those that can be made on the computer or typewriter. OSHA does not require one specific style.

The National Fire Protection Association has developed a color and number system to identify hazardous ingredients in chemicals. This is one alternative to the labeling requirement, but is overly complex for the needs of most dental offices. It uses a system of color coding and numbered rankings to identify the various hazardous properties of materials.

4. Information and Training

The employer must provide all employees with information and training in the safe handling of hazardous chemicals in the office. Information and training is conducted upon initial assignment in the office, as well as when new hazardous chemicals are brought into the office.

The following information is included in the training requirement:

• A copy and explanation of the hazard communication standard and its requirements.

• The components of the hazard communication program in the office.

• Operations in the work areas where hazardous chemicals are present.

• Location of the written hazard communication program, including the SDS file.

Employee training must consist of the following:

• How the hazard communication program is implemented in the office.

• Hazards of chemicals in the work area.

• Protective measures needed in connection with hazardous materials, including use of personal protective equipment.

• Details of specific procedures developed by the employer, such as an explanation of the labeling system and other warning signs, how to read and understand a SDS, how to use personal protective equipment and emergency procedures involving hazardous chemicals.

• Methods and observations that the employee can use to detect the presence of a hazardous chemical (eg, visual appearance or smell of a chemical).

Always document details of training sessions, including who attended, what material was covered and who conducted the training.

5. The Written Hazard Communication Program.

The employer must develop, implement and maintain a written hazard communication program. Components of this program include the following:

• List of hazardous chemicals.

• Description of labeling system.

• SDS file.

• Description of employee training.

• Name of safety/compliance officer.

• Types of protective measures used.

• Emergency chemical exposure reporting.

Chapter 17: Health Hazards in the Dental Office

There are many materials and products used in the dental office with the potential to pose health hazards to the dental team. With proper knowledge and precautions, dental workers safely use these products every day in thousands of dental offices. It is important for all members of the dental team to read the manufacturer's instructions to learn how to use all products safely and to know the location of the SDS file. The following materials or products are just a sampling of hazardous materials used in the dental office.

Mercury

In the dental office, a source of mercury is dental amalgam, a common restorative material. Mercury is a metal, but exists in a liquid state and vaporizes at room temperature. Mercury poses a health hazard to dental personnel because excessive exposure to the vapors may cause mercury poisoning, or toxicity. The EPA has categorized mercury as an extremely hazardous waste. However, when bound in dental amalgam with other metals, mercury is safe for restoration of decayed teeth.

Mercury poisoning may be either acute or chronic. Acute mercury poisoning occurs when a person is exposed to a toxic level of mercury at one time; symptoms may appear in as little as a few minutes up to thirty minutes and include thirst, metallic taste in the mouth, nausea, vomiting, severe abdominal pain, bloody diarrhea and kidney failure.

Chronic mercury poisoning occurs from exposure to lower levels of mercury over an extended period of time; symptoms include irritability, excessive saliva, loosened teeth, periodontal disorders, slurred speech, tremors and staggering. Acute mercury poisoning should not be of concern to dental personnel due to the small amount and method of handling of mercury for dental amalgam. Always use pre-capsule amalgam to reduce the risk of accidental spilling of mercury.

Ways in which dental personnel are exposed to mercury and its vapors include: during trituration (mixing) and dispensing, during the polishing of amalgam restorations, during removal of an existing amalgam restoration, from contact with amalgam during a procedure, and from improper disposal of scrap amalgam.

In order to prevent the risk of mercury poisoning, it is necessary for dental personnel to handle amalgam carefully, both while working with it chairside and when disposing of excess amalgam. The following are recommendations for safe use and disposal of mercury or amalgam that contains mercury:

• Always use appropriate PPE (gloves, protective eyewear, face mask) while working with amalgam.

• Avoid direct skin contact with mercury.

• Use pre-filled amalgam capsules.

• Reassemble amalgam capsules after dispensing.

• Use an amalgamator with a cover protecting the armature.

• Work with amalgam on a surface with a lip to avoid spillage.

• Do not heat amalgam and do not heat-sterilize extracted teeth (as this emits mercury vapors).

• Use water and the high-volume evacuator when removing existing amalgam restorations or when polishing new restorations.

• Avoid carpeting the dental operatory.

• Store amalgam scraps in a closed container, dry or under a liquid (contact recycling company as to how they want scraps stored).

• Be sure that the office has a proper ventilation system.

• Maintain a mercury spill kit in the office and clean up any spills following recommended safety procedures; do not use the high-volume evacuation system for clean-up.

• Use disposable vacuum traps and collect traps for recycling with the rest of the scrap amalgam collected in the office.

• Do not dispose of unused amalgam in the trash or in the red medical waste bags.

• Use a licensed recycler to reclaim the metals in the waste amalgam.

Some locations in the United States now require the use of an amalgam separator. This is a device that collects the majority of amalgam particles in the evacuation system, reducing pollution of the wastewater stream. Check with your local public health department or wastewater management authority to determine what requirements exist in your location.

Nitrous Oxide

Nitrous oxide is an inhaled anesthetic gas used in dentistry. Nitrous oxide gas is always mixed with oxygen in healthcare settings. Nitrous oxide gas administered without oxygen is extremely dangerous and prohibited by law. The use of nitrous oxide may pose a health hazard to dental personnel. Studies have shown that excessive occupational exposure to nitrous oxide may decrease mental performance, audio-visual ability and manual dexterity; reduce fertility; cause spontaneous abortions, and neurological, renal, and liver disease.

Follow these precautions to prevent occupational exposure to nitrous oxide:

• When new equipment is installed, monitor to determine that employees are not exposed to more than 50 ppm of nitrous over an 8-hour work shift (50 ppm TWA). Monitors are available through dental, medical and lab safety supply companies.

• Leak test equipment. Deliver oxygen through the mask, occlude the mask with hand and check for air leaks in the hoses. Wiping the hose with a small amount of soapy water will help identify air leaks. Air escaping the hose will cause the soapy water to bubble.

• Install equipment that will not operate if adequate oxygen is not delivered with the nitrous oxide gas.

• Visually inspect all equipment, including hoses, connections, tubing and breathing bags daily.

• Handle gas cylinders safely, keeping them stored securely and away from heat or other flammable gases. Attach gas cylinders to structures such as walls to prevent accidental tipping over.

• Have a scavenger system in place (this removes excess nitrous oxide gases exhaled by the patient and vents it to the outside).

• Have proper ventilation in the dental office.

• Nitrous oxide can be safely used and may be a benefit to the dental patient who suffers from fear and anxiety; however, a pregnant dental assistant should not work on a patient who is under the gas because nitrous oxide crosses the placenta to the fetus and affects the central nervous system.

Restorative Materials

Some materials used for restorative procedures may contain hazardous chemicals and requiring handling with some precautions. Wear proper PPE, such as gloves, protective eyewear and a face mask when handling these materials. As always, follow the manufacturer's instructions carefully regarding preparation, use, and safety measures. Some examples of materials containing hazardous chemicals and safety measures that should be taken when using them include:

Acid Etch

• In case of eye contact, flush with cold water and seek medical attention.

• For skin contact, flush area with water and wash with soap and water.

• For spills, wear gloves and cover spill with baking soda.

BIS-GMA (found in dentin bonding systems and composite resins)

• Eye and skin irritant - avoid prolonged exposure or repeated contact.

• For spills, wear gloves and mop with hot, soapy water.

Porcelain Bonding Agents (may contain acetic acid)

• For skin contact, flush area with water and wash with soap and water.

• For spills, sweep up and place absorbent materials in container.

Laboratory Materials

Materials used in the dental laboratory may also contain materials that may be hazardous or may be irritants. Some examples include:

Alginate Impression Material

• Wear a face mask to avoid inhaling impression material; provide adequate ventilation.

• Wear protective eyewear.

• For eye contact, flush with cold water and seek medical attention.

• For skin contact, wash area with soap and water.

• For spills, mop up.

Gypsum Products

• Use protective eyewear.

• Wear a face mask to avoid breathing material; provide adequate ventilation.

• For spills, sweep up.

Polyether and Polysulfide Impression Material

• Wear gloves.

• Provide adequate ventilation.

• For skin contact, wash area with soap and water.

• For spills, wipe up with cloth or sponge and dispose in a closed container.

Radiographic Materials

Radiographic fixer and developer solutions contain hazardous chemicals and must be handled and disposed of properly.

• Wear gloves, protective eyewear, and face mask.

• For eye contact, flush eyes with cold water and seek medical attention.

• For skin contact, wash area with soap and water.

• For spills, cover with baking soda and clean up with a cloth or sponge and dispose of in a closed container.

• Provide adequate ventilation.

• Dispose of old solutions according to local and state regulations (used fixer contains silver, which is a metal regulated by most control agencies).

Disinfectants

Disinfectants are liquid chemical agents used to reduce the number of pathogens from surfaces and objects. Many disinfectants contain chemicals that may result in skin sensitivity following direct contact.

• Wear protective eyewear, gloves, and face mask.

• Provide proper ventilation.

• For eye contact, flush with water and seek medical attention.

• For spills, soak up with absorbent materials and dispose of in a closed container.

The above list is a sampling of some common materials that pose a health hazard in the dental office setting. It is not comprehensive and it is important to review materials used in each individual setting to determine appropriate precautions and the type of emergency response equipment necessary for accidental exposures. In general, all dental offices need eyewash stations either connected to existing plumbing or containing a reservoir adequate to deliver water for several minutes of flushing.

Chapter 18: Organization for Safety and Asepsis Procedures Mission

The mission of the Organization for Safety and Asepsis Procedures (OSAP) is:

" To be the world's leading source of education and information to promote evidence-based infection control and safety policies and practices in dentistry."

OSAP strives to achieve their mission in a number of ways.

What is OSAP?

Founded in 1984 and formally incorporated as a non-profit organization in 1985, OSAP is a unique group of dental practitioners, allied healthcare workers, industry representatives, and other interested persons with a collective mission to promote infection control and related science-based health and safety policies and practices. OSAP supports this commitment to the dental workers and the public through quality education and information dissemination.

OSAP also maintains the OSAP Foundation, a 501(c)(3) tax-exempt educational foundation dedicated to education, research, service, and policy development to promote safety and the control of infectious diseases in dental healthcare settings worldwide.

Who is OSAP?

OSAP's membership comprises individual dentists, hygienists, assistants, physicians, nurses, students, researchers, educators, policymakers, industry representatives, and agency and association staff members with an interest in dental infection control, occupational health, and practice safety. Anyone with such an interest is invited to join the organization's international member base. OSAP also has corporate members who provide support of the organization's endeavors through membership dues and grants that help underwrite OSAP's programs and events.

OSAP maintains a Board of Directors, which guides the organization's projects, resources, and development.

Why OSAP?

OSAP's biggest strength is its membership. The diverse backgrounds of the OSAP members afford a unique opportunity for sharing information, problems, and perspectives to create solutions

for safer dental practice everywhere.

OSAP is a valuable resource for dental offices and institutions alike. Its guidelines and position papers provide practical, scientifically sound information and recommendations on specific issues like instrument processing, surface asepsis, percutaneous injuries, and dental unit waterline contamination. OSAP's continuing-education-accredited Informational Series includes monthly OSAP newsletters containing information, charts, and resources on a specific issue of interest in dental practice as well as an opportunity to receive an hour of continuing-education for each newsletter reviewed. On-site and online OSAP Annual Symposia bring together experts from around the world to provide attendees with a heads-up on the cutting edge issues in dental infection control and safety in the United States and around the world.

Where is OSAP?

OSAP home office is in Atlanta, GA, but its reach is global. Through a grant from the Centers for Disease Control and Prevention (CDC) for "Initiatives to Promote Infection Control and Safety in Dental Care Settings," the OSAP Foundation is working to provide appropriate information about safe dental care to underserved and minority populations, refining its training modules to educate dental workers in developing countries or underserved areas, and using this website, www.osap.org, to transmit scientific information and successful prevention and intervention strategies to dental healthcare settings and the general public worldwide.

BIBLIOGRAPHY AND SELECTED REFERENCES

General Recommendations

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Latex Hypersensitivity

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Cleveland JL, Gooch BF, Shearer BG, Lyerla RL. Risk and prevention of hepatitis C virus infection: implications for dentistry. J Am Dent Assoc 1999;130:641--7.

Gruninger SE, Siew C, Azzolin KL, Meyer DM. Update of hepatitis C infection among dental professionals [Abstract 1825]. J Dent Res 2001;80:264.

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Immunization

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Needlestick Prevention and Response

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Gooch BF, Cardo DM, Marcus R, et al. Percutaneous exposures to HIV--infected blood among dental workers enrolled in the CDC needlestick study. J Am Dent Assoc 1995;126:1237--42.

CDC. National Institute for Occupational Safety and Health. Selecting, evaluating, and using sharps disposal containers. Cincinnati, OH: US Department of Health and Human Services, Public Health Service, CDC, National Institute for Occupational Safety and Health, 1998. DHHS publication no. (NIOSH) 97-111.

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Hand Hygiene

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Disinfection/Sterilization

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Regulated Waste

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Dental Waterline Contamination

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Walker JT, Marsh PD.Microbial biofilm formation in DUWS and their control using disinfectants. J Dent. 2007 Sep;35(9):721-30.

Pankhurst CL, Coulter WA.Do contaminated dental unit waterlines pose a risk of infection? J Dent. 2007 Sep;35(9):712-20.

Cross Contamination

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Lewis DL, Arens M, Appleton SS, et al. Cross-contamination potential with dental equipment. Lancet 1992;340:1252--4.

Kuehne JS, Cohen ME, Monroe SB. Performance and durability of autoclavable high-speed dental handpieces. NDRI-PR 92-03. Bethesda, MD: Naval Dental Research Institute, 1992.

Filho IB, Esberard RM, Leonardo R, del Rio CE. Microscopic evaluation of three endodontic files pre- and post instrumentation. J Endodontics 1998;24:461--4.

Laboratory Asepsis

Chau VB, Saunders TR, Pimsler M, Elfring DR. In-depth disinfection of acrylic resins. J Prosthet Dent 1995;74:309--13.

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For added information

HYPERLINK "https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-vol-30.pdf"Diagnoses of HIV infection in the United States and dependent areas, 2018pdf icon. HIV Surveillance Report 2019;30. Retrieved from: https://www.cdc.gov/hiv/statistics/overview/ataglance.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhiv%2Fstatistics%2Fbasics%2Fataglance.html

Global Health Observatory (GHO) data

Retrieved from: https://www.who.int/gho/hiv/en/

HIV and Pregnant Women, Infants, and Children Retrieved from: https://www.cdc.gov/hiv/group/gender/pregnantwomen/index.html

Dental Practice Management, (2015). Retrieved from: http://practicemanagement.dentalproductsreport.com/article/nitrous-oxide-what-dental-assistants-need-know?page=0,1

ABOUT THE AUTHORS

Eve Cuny, MS, RDA
Eve Cuny is the Director of Environmental Health and Safety and Assistant Professor in the department of Pathology and Medicine at the University of the Pacific School of Dentistry. She is a nationally recognized expert in infection control in dentistry, publishing and lecturing widely throughout North America. She was a member of the working group that developed the 2003 CDC Infection Control Guidelines for Dentistry and acts as an advisor for numerous regulatory agencies. She is past chairperson of OSAP and currently serves on its board of directors.

Charles J. Palenik, PhD, MS, MBA
Charles J. Palenik has held over the last 30 years a number of academic and administrative positions at Indiana University School of Dentistry. These include Professor of Oral Microbiology, Director/Human Health & Safety, Director/Central Sterilization Services, Director/Dental Informatics and Chairman/Infection Control and Hazardous Materials Management Committees. Currently he is Director/Infection Control Research & Services. Dr. Palenik has published 160 articles, over 300 monographs, three books and seven book chapters, the majority of which involve infection control and human safety and health. In addition, he has provided 120 continuing education courses throughout the United States and nine foreign countries. He is past chairperson of OSAP and currently serves on its board of directors.

REVIEWED AND REVISED BY ADAA COUNCIL ON EDUCATION AND PROFESSIONAL DEVELOPMENT MEMBERS:
Tracey A. Green, BS, CDA; Christina Ross, MS, EDFA, CDA; and Roxanne Terranova, MSM, CDA, RDA

Take the Accredited CE Quiz:

CREDITS: 3 SI
COST: $48.00
PROVIDER: American Dental Assistants Association
SOURCE: American Dental Assistants Association | June 2022

Learning Objectives:


  •  Describe the Hazard Communication Standard, including the responsibilities surrounding the use of Safety Data Sheets, labeling for hazardous materials, and training of dental employees in the safe handling of hazardous materials

  •  Identify hazardous materials that are used in the dental office

  •  Discuss the Organization for Safety an Asepsis Procedures (OSAP) and its role as a resource for dental offices and institutions




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Disclosures:

The author reports no conflicts of interest associated with this work.

Queries for the author may be directed to jromano@aegiscomm.com.