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OSHA Program For The Dental Office

Robert Cooley, DMD, MS Email bobcooley@sbcglobal.net

Forms For Documenting Training

BLOODBORNE PATHOGENS TRAINING RECORD Name of Office Date of Training Session Person Conducting Training Session Dr. Robert Cooley Name of Persons Attending

Hazard Communication Training Record

Name of Office: Date of Training Session: Person Conducting Training Session: Dr. Robert Cooley Name of Persons Attending

Summary of Training Session •Hazard Communication Plan – New Globally Harmonized Rules •Signal Words •Pictograms •Labels - Primary and Secondary •MSDS

EMPLOYEE INPUT FOR SAFETY NEEDLES & SYRINGES

Products Reviewed and Suggestions For Safer Devices Or Synopsis of Article Reviewed

DATE:

Employee Names

HypoSafety Syringe

Safe Mate Safety Needle

Sandel Safety Scalpel Futura Safety Scalpel Employee’s Input For Safety Devices

Dental Assistant Certificates

• State Board Certificates for dental assistants must be posted in the office where employed.

• Certificates must be originals. Copying of the certificates is forbidden by the State Board Rules.

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Internet Course For Dental Assistant Registration

Texas Academy Of General Dentistry

www.tagd.org

OSHA New Reporting Requirements For Work Related Deaths and Hospitalizations

• Death must be reported within 8 hours

• In-patient hospitalization, amputation, or loss of an eye must be reported within 24 hours.

• Dallas Area Office (972) 952-1330

• Call 1-800-321-OSHA (6742)

• Visit http//:www.osha.gov/report_online

Texas State Board Dental Examiners RULE §108.6 Report of Patient Death or Injury Requiring Hospitalization

• Death of a dental patient which may have occurred as a consequence of the receipt of dental services – 72 Hours.

• Hospitalization of a dental patient, as a possible consequence of receiving dental services – 30 Days.

OSHA Training Involves 3 Areas

• Bloodborne Pathogens

• Hazard Communication

• Building, Equipment, Fire Safety

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Posters Required By Texas

Payday

Workers Compensation

Unemployment Insurance

Notice To Injured Employee - Ombudsman Program

Posters Required By Federal Government

OSHA

Equal Employment Opportunity

Federal Minimum Wage

Family & Medical Leave Act

Employee Polygraph Protection Act

Americans With Disabilities (may be included in the EEO section)

Uniformed Services Employment and Reemployment Rights Act (USERRA)

These posters are available in laminated form from:

• Compliance Pro 1-800-997-5545

• G. Neil Company 1-800-999-9111

Other Requirements From State of Texas

• Texas Bureau Of Radiation Control requires a Radiation Poster entitled:

Notice To Employees Poster

http://www.dshs.state.tx.us/radiation/pdffiles/Rules/232-1frm_10_08.pdf

• State Board Of Dental Examiners requires that the Consumer Information Sign

be posted where visible to patients. This can be ordered from the State

Board or you can make one on your computer.

http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_

dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=5&ch=108&rl=3

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Other Requirements From State of Texas

• Texas Bureau Of Radiation Control requires a Radiation Poster entitled:

Notice To Employees Poster

http://www.dshs.state.tx.us/radiation/pdffiles/Rules/232-1frm_10_08.pdf

• State Board Of Dental Examiners requires that the Consumer Information Sign

be posted where visible to patients. This can be ordered from the State

Board or you can make one on your computer.

http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_

dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=5&ch=108&rl=3

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The Practice Of Dentistry is Regulated by the Texas Dental Practice Act and the

Rules of the State Board of Dental Examiners (SBDE).

The mission of the SBDE is to assure that the people of the State of Texas receive

the highest quality dental care.

For Information, Concerns or Complaints, contact the:

State Board Of Dental Examiners

333 Guadalupe, Tower 3, Suite 800

Austin, Texas 78701

Phone 1-800-821-3205

512- 463-6400

Fire Safety Plan

When To Do Training On Bloodborne Pathogens

1. At the time of initial assignment.

2. When there are changes in duties or job assignments.

3. At least annually thereafter.

Exposure Control Plan For The Office Of

12.

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Exposure Determination Form

EXAMPLE OF ENTRIES

All employees in the following jobs have occupational exposure:

Job Classification

Dentist (if the practice is incorporated)

Dental Assistant

Dental Hygienist

Dental Technician

Some employees in the following jobs have occupational exposure:

Job Task or Procedure

Secretary Dental Assisting

Receptionist Cleaning Operatories

Office Manager Cleaning Instruments

14.

EXPOSURE DETERMINATION FORM

All employees in the following jobs have occupational exposure:

Job Classification

Some employees in the following jobs have occupational exposure:

Job Task or Procedure

15.

Procedures For Employees With Occasional Exposure

Tasks Involving Exposure to Blood, Saliva or Tissues

Task or Procedure Protective Equipment Required

Assisting With Patient Procedures Gloves, Mask, Glasses, Protective Gown

Cleaning Operatories Gloves, Mask, Glasses, Protective Gown

Cleaning and Sterilizing Instruments Gloves, Mask, Glasses, Protective Gown

16.

Procedures For Employees With Occasional Exposure

Tasks Involving Exposure to Blood, Saliva, or Tissues

Tasks or Procedures Protective Equipment Required

17.

UNIVERSAL PRECAUTIONS

Because not all patients with infectious diseases can be identified by medical

history, physical examination, or laboratory tests, the blood and saliva of all dental

patients should be treated as if they were infective.

ENGINEERING CONTROLS

These are physical things that remove or isolate a hazard from the workplace.

Examples of engineering controls are sharps containers and high volume evacuators.

The following engineering controls will be used in this office:

Sharps Containers

EXAMINATION AND MAINTENANCE OF ENGINEERING CONTROLS

Engineering controls will be examined every to

ensure that they are present and in good condition, including the following items:

• Sharps containers will be examined to determine if they are located in the proper

location and that they are being replaced at sufficiently frequent intervals to prevent

over filling. Sharps containers should be replaced when filled to the "Fill Line" below

the opening. Sharps containers must be closed when moved from one place to

another. When full, the sharps container should be placed in the regulated waste

container for disposal.

• High volume evacuator will be examined on the same schedule to determine that

it is in good working condition and the filters are clean.

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Consideration of Safety Needles: These devices will be considered or evaluated

each year by reviewing safety products and with discussions with employees. Some

publications indicate that they are unacceptable and can cause more incidents than

conventional needles.

Eve Cuny et al. Safety Needles......... CDA Journal 27:525, 1999.

Eve Cuny et al. Dental Safety Needles .....JADA 11:1443, October, 2000

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Hypo Safety Syringe

Safe Mate Safety Needle

Safety Scalpels

Futura Safety Scalpel Sandel Safety Scalpel

EMPLOYEE INPUT FOR SAFETY NEEDLES & SYRINGES

Safety Devices Discussed

Date:

Employee Name MedPro Safe-Mate

HypoSafety Syringe

Sandel Safety Scalpel

Futura Safety Scalpel

____________________________________________________________________

Employee’s Comments and Suggestions For Devices

Needlestick Log

For Offices or Clinics With 11 or More Employees

To Be Used Until January, 2002 - Then Use OSHA Log 300

Date Brand of Device Work Area Explanation Of How Incident Occurred

21.

This Log Not Required In Dentistry At This Time

WORK PRACTICE CONTROLS

This is changing or altering a task or procedure to reduce the likelihood of

exposure to bloodborne pathogens. Examples of work practice controls are

prohibiting recapping of needles by a two-handed technique and prohibiting eating

and drinking in work areas.

HANDWASHING

• Hands should be washed immediately or as soon as feasible after removal of

gloves or other personal protective equipment.

• Hands and any other skin should be washed with soap and water immediately

following contact with blood or other potentially infectious materials.

• Flush mucous membranes with water immediately or as soon as feasible following

exposure to blood or saliva. An eyewash station is located in .

SHARPS

• Contaminated sharps are considered to be any object that can penetrate the skin.

Sharps include needles, scalpels, broken glass and exposed ends of dental wires.

• Immediately or as soon as feasible after use, contaminated sharps must be placed

in a sharps container.

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RECAPPING OF NEEDLES

Recapping of needles is permitted for procedures when there is no feasible

alternative to recapping. In this office, frequently it is necessary to administer

incremental doses of an anesthetic to the same patient. There is no feasible

alternative to recapping of the needle. Recapping will be accomplished with

resheathing instruments, forceps, or a one- handed scoop technique.

EATING AND DRINKING

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact

lenses in the work areas where there is a reasonable likelihood of occupational

exposure is prohibited. This is not to restrict use of hand cream or lotion. No

food or drinks will be stored in refrigerators, freezers, shelves, cabinets or on

countertops or bench tops where blood or other potentially infectious materials are

present.

MINIMIZE SPLASHING AND SPRAYING

• All procedures involving blood or saliva must be performed in a way to minimize

splashing, spraying, spattering, and generation of droplets.

• The high volume evacuator should be used with all procedures involving blood

and saliva to minimize exposure.

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One Hand Scoop Technique Needle Recapping Devices

RECAPPING OF NEEDLES

Recapping of needles is permitted for procedures when there is no feasible

alternative to recapping. In this office, frequently it is necessary to administer

incremental doses of an anesthetic to the same patient. There is no feasible

alternative to recapping of the needle. Recapping will be accomplished with

resheathing instruments, forceps, or a one- handed scoop technique.

EATING AND DRINKING

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact

lenses in the work areas where there is a reasonable likelihood of occupational

exposure is prohibited. This is not to restrict use of hand cream or lotion. No

food or drinks will be stored in refrigerators, freezers, shelves, cabinets or on

countertops or bench tops where blood or other potentially infectious materials are

present.

MINIMIZE SPLASHING AND SPRAYING

• All procedures involving blood or saliva must be performed in a way to minimize

splashing, spraying, spattering, and generation of droplets.

• The high volume evacuator should be used with all procedures involving blood

and saliva to minimize exposure.

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EQUIPMENT TO BE REPAIRED

Equipment that becomes contaminated with blood or other potentially infectious

materials should be examined prior to servicing or shipping and should be

decontaminated. If the equipment cannot be decontaminated, a label should be

attached to the equipment stating which portions remain contaminated.

PERSONAL PROTECTIVE EQUIPMENT

• When there is a potential for occupational exposure, the employee should use

appropriate personal protective equipment.

• PPE used will depend on the tasks and amount of anticipated exposure. Use PPE

that will prevent blood or saliva from contacting the employee's skin, street clothes,

eyes, mouth, or mucous membranes as well as underwear.

GLOVES

WHEN TO WEAR

Gloves should be worn when the employee has the potential for the hands to have

direct skin contact with blood, other potentially infectious materials.

WHEN TO REPLACE

Disposable (single-use) gloves, such as surgical or examination gloves, should be

replaced as soon as possible when visibly soiled, torn, punctured, or when they are

compromised. They should not be washed or disinfected for reuse.

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MASKS, EYE PROTECTION, AND FACE SHIELDS

Masks and eye protection OR chin-length face shields must be worn whenever

splashes, spray, spatter, droplets, or aerosols of blood or other potentially infectious

materials may be generated and there is a potential for eye, nose, or mouth

contamination. A chin-length face shield may be worn in place of a mask and eyewear.

GOWNS

• Appropriate protective clothing should be worn when the employee has a potential for

occupational exposure. The clothing selected should form an effective barrier.

• Gowns, lab coats, clinic jackets, or similar clothing should be worn if there is a

potential for soiling of clothes with blood or other potentially infectious materials.

• Garments that become penetrated by blood or saliva will be removed immediately or

as soon as feasible.

• These protective garments should not be worn outside the office or taken home.

They should be placed in the laundry bags which have been provided for

contaminated laundry.

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LAUNDRY

Contaminated laundry is that which has been soiled with blood or other potentially

infectious materials or may contain sharps. It will be handled as little as possible, bagged

where it is used, not be sorted or rinsed where it is used, placed and transported in bags

that are labeled with biohazard label or color-coded red.

Laundry will be cleaned by (circle one)

• Outside laundry service.

• Washer and dryer on site.

• Unincorporated dentist does cleaning.

• Designated employee does cleaning at Laundromat using PPE. (Employee must be trained, use PPE, and carry laundry in labeled bag).

REGULATED WASTE

All containers of regulated waste (infectious or biomedical) will be labeled with an

orange or orange-red label with the Biohazard Symbol and the word Biohazard.

The 3 categories of regulated waste are:

• Sharps

• Items saturated with blood or saliva.

• Tissues removed from the patient.

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Contaminated Laundry Container should have Biohazard Label & label

with wording “Contaminated Laundry”.

Washing Machine As Laundry Container

LAUNDRY

Contaminated laundry is that which has been soiled with blood or other potentially

infectious materials or may contain sharps. It will be handled as little as possible, bagged

where it is used, not be sorted or rinsed where it is used, placed and transported in bags

that are labeled with biohazard label or color-coded red.

Laundry will be cleaned by (circle one)

• Outside laundry service.

• Washer and dryer on site.

• Unincorporated dentist does cleaning.

• Designated employee does cleaning at Laundromat using PPE. (Employee must be trained, use PPE, and carry laundry in labeled bag).

REGULATED WASTE

All containers of regulated waste (infectious or biomedical) will be labeled with an

orange or orange-red label with the Biohazard Symbol and the word Biohazard.

The 3 categories of regulated waste are:

• Sharps

• Items saturated with blood or saliva.

• Tissues removed from the patient.

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Amarillo

A local TV station sent a reported out to dig through the dumpster of a dental office looking for medical waste. The reporter found bloody gauze and called the dentist requesting a statement and informing him that this would be part

of a TV report.

• Commission on Environmental Quality Writes Medical Waste Rules

Gauze with blood is OK in regular waste

• What Cannot Go Into The Regular Trash? Sharps

Tissues, such as teeth

Isolyzer Sharps Container Texas Regulations on Medical Waste

Effective Date April 30, 2012

TCEQ REGULATORY GUIDANCE

RG-001 Revised January 2012

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Requirements for Generators of Medical Waste

• Generators of medical waste that ship their waste off-site for treatment are required to properly package and label it.

• The rules require generators to list the weight of each medical-waste container on the generator label. Prior to transportation off-site.

• TCEQ is allowing transporters to assist in the labeling of medical waste containers including weighing the containers for the generator before the waste leaves the point of generation.

Medical Waste Regulations

• Generators are required to obtain a signed shipping receipt from a registered transporter.

• Maintain records of all shipments of untreated medical waste sent off-site for three years.

• Make the records available for inspection by the TCEQ.

• Generators must also obtain a receipt from the medical-waste treatment facility certifying that the waste has been properly treated and must also maintain these records.

Generators That Treat Their Own Medical Waste On-site

Less Than 50 lbs/month

• Required to notify the TCEQ of the operation as specified in 30 TAC 330.11(f).

• Required to maintain records of each load of medical waste treated.

• Maintain records such as the date and method of treatment, the amount of waste treated, the name of the person performing the treatment.

Encapsulation Of Sharps Letter Of Notification To TCEQ

TCEQ Christine Bergren, Section Manager Municipal Solid Waste Permits MC -124, Building F P.O. Box 13087 Austin, Texas 78711-3087

Maintain The Following Records

(A) Date of treatment (B) Amount of waste treated (C) Method of treatment (encapsulation) (D) Name (printed) and initials of the person(s) performing treatment; and (E) If applicable, name, address, telephone number, and registration number of the entity providing treatment.

Biohazard Symbol Used on sharp containers, regulated waste,

contaminated laundry or where there is blood or body fluids.

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HOUSEKEEPING

The safety and health manager, will assure that this office is maintained in a clean

and sanitary condition. The safety and health manager will determine and implement the

appropriate schedule for cleaning and method of disinfection.

Our disinfectants are chemical germicides that have:

• EPA Number

• Effective against TB OR HIV and HBV. (Will be on the label)

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CLEANING AND DISINFECTION SCHEDULE

Work surfaces should be decontaminated with an appropriate disinfectant after

completion of procedures; when surfaces are overtly contaminated; immediately after

any spill of blood; and at the end of the work shift.

Protective coverings such as plastic wrap, aluminum foil, or imperviously backed

absorbent paper may be used to cover equipment and environmental surfaces.

Bins, Pails, Cans, and similar receptacles intended for reuse that have a potential

for becoming contaminated with blood or other potentially infectious materials should be

inspected and cleaned daily. Decontamination can be done with soap and water.

Broken glassware that may be contaminated must not be picked up directly with

the hands. It should be cleaned up using mechanical means, such as a dust pan and

tongs.

Reusable Sharps (such as explorers and scalers) must be placed in appropriate

containers immediately or as soon as feasible after contamination. Reusable sharps

that are contaminated with blood or other infectious materials will not be stored or

processed in a manner that requires reaching by hand into the container

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HBV VACCINATION AND POSTEXPOSURE EVALUATION AND FOLLOW-UP

All employees identified in the "Exposure Determination" as having possible

exposure to blood and other potentially infectious materials will be offered the

hepatitis B Vaccination free of charge. Any employee who declines to take the

vaccination must sign the declination form as required by the Bloodborne Pathogens

Standard. Additional information on the hepatitis B vaccine is provided under the "HBV

Vaccination" section of this manual.

Antibody Test: The hepatitis B antibody (anti-HB) test will be offered one to two

months after the last injection of the vaccine to determine if seroconversion has taken

place (development of antibodies in blood).

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The Location of Personal Protective Equipment in Our Office is as Follows:

Personal Protective Equipment Location

Gloves, Non-sterile

Gloves, Sterile

Gloves, Utility

Masks

Protective Eyewear

Protective Gowns

Resuscitation Equipment

THE BASIS FOR SELECTION OF PERSONAL PROTECTIVE EQUIPMENT

Selection of personal protective equipment will depend on the degree of anticipated

exposure and the procedure to be performed. For example, an oral examination may

simply require gloves. However, the use of a rotary instrument (high or low speed),

ultrasonic scaler, or air prophy will require gloves, mask, protective eyewear, and

gowns.

26.

Pocket Masks Ambu-Bag

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SEPARATE MEDICAL RECORDS FOR EACH EMPLOYEE

(CONFIDENTIAL)

• Employee's Name and Social Security Number.

• Employee's Hepatitis B vaccination status including dates of

vaccination.

• Signed statement refusing Hepatitis B Vaccine.

If an exposure incident occurs, the following must be in the medical record.

• Exposure Incident Report.

• A copy of all results, examinations, medical testing, and follow-up

procedures.

• A copy of the health care professional's written opinion.

NOTE: All medical records must be maintained for the duration of employment

plus 30 years.

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TRAINING RECORDS

Training records should include:

• Dates of the training sessions.

• Summary of the training sessions.

• Names of the person conducting the training.

• Names of all persons attending the training session.

NOTE: These records must be maintained for 3 years.

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EMPLOYEE MEDICAL RECORD FORM CONFIDENTIAL

Employee Medical Record Form

Employee name

Employee social security number

History of HBV vaccination

(Date vaccination received or Declination Statement)

Exposure Incidents – Needlestick or Splash of Blood Onto Mucous Membranes

(List Date and Describe What Happened)

Medical Follow-Up Procedures

(Was medical evaluation offered, was it accepted by employee, was employee informed

of blood test results, was hepatitis B vaccine offered and was it accepted)

Medical Records must be maintained for the duration of employment plus 30

years.

28.

HEPATITIS B VACCINATION

WHO: Any employee who has exposure to bloodborne pathogens. Full time, part

time, temporary, and probationary employees.

WHEN: Within 10 working days of initial assignment.

COST: Must be made available at no cost to employees with occupational exposure.

May not use health insurance unless employer pays all costs of insurance.

REFUSAL: Employees may refuse to be vaccinated, but must sign "Informed Refusal

For Hepatitis B Vaccination" form. That form is included in this section.

BOOSTER: The US. Public Health Service guidelines do not currently recommend

"booster" doses. If a "booster" is recommended, it must be provided at no cost.

ANTIBODY TEST: Done to determine if seroconversion has taken place, that is, if

antibodies have developed and the person is now immune to hepatitis B. One to two

months after the last vaccination injection, the hepatitis B antibody test is offered.

RECORDS: Documentation of the Hepatitis B Vaccination should be placed in the

employee's medical record.

PROCEDURES: The procedures to follow for Hepatitis B Vaccination are illustrated on

the following page. This includes refusals and pre-vaccination evaluations.

29.

30.

HEALTHCARE PROFESSIONALS WRITTEN

OPINION FOR HEPATITIS B VACCINATION

Please Return This Form To The Office Of:

Name Of The Employee

Is the hepatitis B vaccine indicated

Was the hepatitis B vaccine received

If so, dates the vaccine was received

Signature Of The Health Care Provider

Date:

31.

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INFORMED REFUSAL FOR HEPATITIS B VACCINATION

CONFIDENTIAL

I understand that due to my occupational exposure to blood or

other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV)

infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at

no charge to myself. However, I decline hepatitis B vaccination at this time. I understand

that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious

disease. If in the future I continue to have occupational exposure to blood or other

potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can

receive the vaccination series at no charge to me.

Signature

Witness Name

Address

City State Zip Code

Date

32.

POSTEXPOSURE EVALUATION AND FOLLOW-UP

WHO Any employee who has an exposure incident (needlestick or

blood splash on mucous membranes) must be provided a

confidential medical evaluation and follow-up

WHEN: Immediately after the exposure incident, the confidential medical evaluation

and follow-up shall be made available.

PROCEDURES: The procedures to follow are illustrated in the chart on the following

page.

DOCUMENTATION: Documents and information that are to be sent to the Health

Care Professional are listed on the chart on the following page. Documentation to be

returned from the Health Care Professional is also listed.

FORMS: One form is provided in this section to document the employee's

refusal for medical evaluation and follow-up (Employee Informed Refusal Of

Postexposure Medical Evaluation). Another form is provided to assist in getting the

required information to and from the Health Care Provider.

33.

34.

HEALTHCARE PROFESSIONALS WRITTEN OPINION FOR POST-

EXPOSURE EVALUATION

Name Of The Employee

Date Of Exposure

Location of Exposure

Circumstances, description, and route of exposure

Was employee informed of evaluation results

and need for any further follow-up:

Is the hepatitis B vaccine indicated:

Was the hepatitis B vaccine received:

If so, dates the vaccine was received:

Signature Of The Health Care Provider Date

35.

REFUSAL OF POSTEXPOSURE MEDICAL EVALUATION

Name:

Date:

Job:

Describe Exposure Incidence:

On the above date, I had an Exposure Incident and was offered a medical evaluation.

I understand that the Bloodborne Pathogens Standard requires that I be offered a

medical evaluation to determine if I have been exposed to or contracted a bloodborne

disease. However, I have decided to not to go for the medical evaluation for personal

reasons.

Signature ____________________________

36.

Needlestick Package

37.

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Needlestick Instructions 1. First Aid: Wash the needlestick wound. For a splash, go to the eyewash station and wash the eyes

until all the material is removed. 2. Report the exposure to the Doctor or Office Manager. 3. Offer the employee a medical evaluation. The employee is

not required to go, but the medical evaluation must be offered. Take the Needlestick Package. Three blood test should be run on the employee: HBV, HCV, HIV.

4. Explain to the source patient what has happened and obtain their permission for blood testing for HBV, HBC and HIV. Patient can agree or not agree to go for testing.

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Needlestick Instructions

5. During the medical evaluation, give the form “Health Care Professionals Written Opinion” to the physician or other health care staff. Ask them to fill out this form and return it to your office as this form is required by OSHA.

6. Ensure that the employee is informed of all blood test results from both the employee and the source patient. Ensure that the injured employee receives counseling on the risk of becoming infected.

7. After the initial medical evaluation, report any flu-like illnesses to the health care professional for follow-up.

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HEALTHCARE PROFESSIONALS WRITTEN OPINION FOR POST-

EXPOSURE EVALUATION

Name Of The Employee

Date Of Exposure

Location of Exposure

Circumstances, description, and route of exposure

Was employee informed of evaluation results

and need for any further follow-up:

Is the hepatitis B vaccine indicated:

Was the hepatitis B vaccine received:

If so, dates the vaccine was received:

Signature Of The Health Care Provider Date

39.

Occupational Safety & Health Administration Regulations (Standards - 29 CFR)

Bloodborne pathogens. - 1910.1030

• Part Number:1910

• Part Title: Occupational Safety and Health Standards • Subpart's• Subpart Title: Toxic and Hazardous Substances

• Standard Number:1910.1030 • Title: Bloodborne pathogens.

Only the Post Exposure Evaluation and Follow-Up section of the Bloodborne Pathogens Standard will be included in the Needlestick Package

40.

EXPOSURE INCIDENT EVALUATION

1. Type of exposure and location in Office.

2. Explain the type of device being used and procedure being performed .

3. Evaluation of policies, engineering controls, work practices and personal

protective equipment used at the time of the exposure incident.

4. Comments on how this could be prevented:

42.

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EXPOSURE CONTROL CHECKLIST

Date:

Initials:

PERFORM THE EXPOSURE DETERMINATION.

Identify and document all positions with potential for occupational

exposure.

Perform exposure determinations without regard to the use of personal

protective equipment.

ESTABLISH AN EXPOSURE CONTROL PLAN.

Use the Bloodborne Pathogens Rule to establish a written exposure

control plan.

Specify the schedule of implementation for each of the requirements of

the exposure control plan.

Review and update the exposure control plan yearly or as necessary to

reflect significant changes in tasks or procedures.

Make sure that this exposure control plan is readily available for review

by employees and OSHA inspectors.

MAINTAIN MEDICAL AND TRAINING RECORDS

Establish a medical record for each employee.

Establish training records for each employee.

43.

HAZARD COMMUNICATION PLAN

45.

Changes To Hazard Communication

• Globally Harmonized System developed by United Nations.

• This GHS is a world wide plan.

• Employees must be trained on this plan by December 1, 2013.

Three Areas of Change In HazCom

• Hazard Classification

• Labels

• SDS (use to be MSDS)

• Manufacturers are still required to provide a label with:

1. Name of product or chemical

2. Hazardous warning

3. Manufacturers name and address

Hazard Classification

• The definition of hazard has been changed

to provide specific criteria for classification of health and physical hazards. These specific criteria will help to ensure that evaluations of hazardous effects are consistent across manufacturers.

• This will make labels and safety data sheets more accurate.

Labels

• Chemical manufacturers and importers will be required to provide a label that includes a harmonized:

Signal Word

Pictogram

Hazard statement for each hazard class and category.

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Signal Word

• A single word used to indicate the relative level of severity of hazard and alert the reader to a potential hazard on the label:

Danger - used for the more severe hazards.

Warning - used for less severe hazards

Secondary Labels Used In Your Office

Can use a copy of original label that came on container or,

Color coded labels – as long as the information supplied on these labels are consistent with the revised Haz Com Standard, e.g., no conflicting hazard warnings or pictograms.

OSHA Secondary Labels

Glutaraldehyde

Skin Irritant

Eye Irritant

Respiratory Irritant

0

0

3

N

0

0

3

N

Standard Format Of The 16 Section SDS

• Section 1. Identification Section 2. Hazard(s) identification Section 3. Composition/information on ingredients Section 4. First-Aid measures Section 5. Fire-fighting measures Section 6. Accidental release measures Section 7. Handling and storage Section 8. Exposure controls/personal protection Section 9. Physical and chemical properties Section 10. Stability and reactivity Section 11. Toxicological information Section 12. Ecological information Section 13. Disposal considerations Section 14. Transport information Section 15. Regulatory information Section 16. Other information, including date of preparation.

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When do we need the new Safety Data Sheets

June 1, 2015

Compliance with all modified provisions of the final rule.

Replace Your Hazard Communication Plan and Standard

• Remove the old Hazard Communication Plan and Standard from your OSHA Manual.

• Take the new Globally Harmonized Hazard Communication Plan and Standard from your handouts and place them in your OSHA Manual.

HAZARD COMMUNICATION PLAN

GENERAL

In order to comply with 29 CFR 1910.1200, the following written Hazard

Communication Plan (HCP) is to be implemented for personnel of this office.

It will be used by ALL personnel. The Safety & Health Manager will be responsible

for ensuring the program is current and enforced.

A copy of this plan is to be made available to an employees upon hiring, and a copy

will be supplied to any employees upon request. The Safety & Health Manager will be

contacted when a copy of the program is needed.

The plan will be updated when new chemicals or hazards are introduced into the

working environment, and reviewed annually.

46. Top

CONTAINER LABELING:

Primary Container Labels

The Safety & Health Manager will be responsible for all containers of hazardous

chemicals or dental products entering the workplace and will assure that the

chemical containers are properly labeled with:

• Product Name

• Hazard warnings to include target organ

• Name and address of the manufacturer,

importer, or responsible party.

No containers shall be used until they have been checked by the Safety Manager.

46. Bottom

Secondary Container Labels

If the chemical or dental product is to be transferred to a separate container,

the Safety & Health Manager will ensure that the new container is properly

labeled; i.e., that all secondary containers are labeled with a reproduced copy

of the original manufacturer's label or with generic labels which have a block

for:

1. Product Name

2. Hazard Warning to include target organ

Containers To Check In Your Office:

Spray Bottles

Cold Sterilization Tubs

Ultrasonic Cleaner

47. Top

OSHA Secondary Containers

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OSHA Secondary Labels

Glutaraldehyde

Skin Irritant

Eye Irritant

Respiratory Irritant

0

0

3

N

SAFETY DATA SHEETS (SDS):

The Safety and Health Manager will be responsible for the following duties;

• Obtaining and Maintaining the SDS system,

• Review incoming data sheets for new and significant health/safety

information and ENSURE that this new information is given to employees.

• Annually review the SDS system for accuracy and completeness.

The SDS system shall include:

• Current list of all SDS indexed by numerical number which is then placed

on that Safety Data Sheet (SDS).

• The identity used on the SDS shall be the same as used on the container

label.

• The chemical and common name of all ingredients determined to present a

hazard shall appear on all SDS.

47. Bottom

EMPLOYEE TRAINING AND INFORMATION:

Before starting work, the Safety and Health Manager will give go over the Hazard

Communication Plan (HCP) with the new employee and each MSDS applicable to

their job. This instruction will be accomplished with hand-outs an verbal instruction.

The following videos or manuals were used for training:

Before any new chemical or dental product is used, all employees will be informed of

its use, will be instructed on safe use, and will be trained on hazards associated with

the new chemical. All employees will attend additional training, as appropriate, to

review the HCP and MSDS. Appropriate library reference material will also be

discussed during the training sessions.

48. Bottom

The minimum orientation and training for a new employee is:

1. An overview of the requirements contained in the Hazard

Communication Standard, 29 CFR 1910.1200.

2. Chemicals present in their workplace operations and this office.

3. Location of Hazard Communication Plan and availability.

4. Physical and health effects of the hazardous chemicals listed on the

inventory list of this program.

5. Methods and observation techniques used to determine the

presence or release of hazardous chemicals in the work area.

6. How to lessen or prevent exposure to these hazardous chemicals

through usage of engineering controls, work practices and personal

protective equipment.

7. Steps taken by our office to lessen or prevent exposure to the

chemicals listed on the inventory list.

8. Emergency procedures to follow if exposed to any chemicals.

9. Location of SDS file and location of hazardous inventory list.

49. Top

INVENTORY LIST OF HAZARDOUS Dental Products:

A list of the hazardous dental products and chemicals used in this

workplace is located in the front of the SDS notebook. Further

information can be obtained from the MSDS attached with this program or

from the Safety and Health Manager.

49. Middle

SAMPLE LIST OF SOME SAFETY DATA SHEETS

SDS INDEX # PRODUCT (TRADE NAME)

1 Vital Defense S

2 MARATHON

3 VISAR-SEAL

4 LIGHTEN BLEACH

5 DRY BOND

6 TENURE KIT

7 IONOMER LIQUID

8 ZIONOMER POWDER

9 PAINT-ON DAM

10 COE-CIDE XL

11 LYSOL SPRAY

12 DYCAL

13 TRAY PLASTIC LIQUID

14 RAY PLASTIC POWDER

15 TOOTH POWDER

Not In The Handout

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NON-ROUTINE TASKS:

No non-routine tasks are known to exist at the time of preparation of

this program.

However, if any non-routine task is performed, employees shall be advised

they must contact the Safety & Health Manager for special precautions to

follow and then the Safety & Health Manager shall inform any other

personnel who could be exposed.

In the event such tasks are required, the Safety & Health Manager will

provide the following information about such activity as it relates to the

specific chemicals expected to be encountered:

Specific chemical names and hazards.

Personal protective equipment required and safety measures to

be taken.

Measures that have been taken to lessen the hazards, including

ventilation, respirators, presence of other employees.

49. Bottom

Disposable Plaster Trap

OTHER PERSONNEL EXPOSURE (CONTRACTORS):

It will be the responsibility of the Safety & Health Manager to provide other personnel

or outside contractors with the following information:

• Hazardous chemicals to which they may be exposed.

• Measures to lessen the possibility of exposure.

• Location of SDS for all hazardous chemicals.

• Procedures to follow if they are exposed.

The Safety & Health Manager will also be responsible for contacting each contractor

before work is started to gather and disseminate any information concerning chemical

hazards the contractor is bringing into the workplace.

50. Bottom

EXPOSURE TO HAZARDOUS MATERIALS

1. Determine hazard from material label.

2. First aid or emergency procedures indicated on SDS.

3. If serious, medical evaluation by physician.

4. Continuous medical re-evaluation if necessary.

CHEMICAL SPILL

1. Determine hazard from material label.

2. Wear appropriate protective clothing (Usually gloves, mask, eye

wear, and gown).

3. Contain and remove chemicals with a chemical spill kit.

4. Place contaminated materials in appropriate containers.

5. Label containers.

6. Notify waste collector as to what chemical is contained.

7. If spill is of a very hazardous nature, call manufacturer.

MERCURY SPILL

1. Open the Mercury Spill Kit.

2. Put on protective clothing (gloves, eyewear, masks).

3. Collect the spilled mercury in the dust pan using the scraper.

4. Place the collected mercury in the amalgam waste container.

5. Use mercury sponges to clean up residual mercury spill.

51.

EXAMPLES OF SECONDARY CONTAINERS REQUIRING LABELING

X-RAY PROCESSOR TANKS

DISINFECTING TUBS or COLD STERILE TUBS

PLASTER & STONE BINS

SPRAY BOTTLES

ULTRASONIC CLEANER

AMALGAM CAPSULES PLACED IN OPERATORIES

ANY UNLABELED BOTTLES OR CONTAINERS

MAKING YOUR OWN CHEMICAL SPILL KIT

• USE A CONTAINER SUCH AS A PAIL THAT HAS A LABEL

"CHEMICAL SPILL KIT"

• CHEMICAL SPILL INSTRUCTIONS

• UTILITY GLOVES & PROTECTIVE EYE WEAR

• KITTY LITTER

• BAKING SODA

• DUST PAN & WHISK BROOM & SPONGES

52.

CHECKLIST FOR HAZARD COMMUNICATION Plan

Date:

Initials:

The key elements that each employer must implement are a written program,

employee training, and program availability.

1. Have you prepared a written list or inventory of all the hazardous

dental products or chemicals present in the workplace?

2. Are you prepared to update your hazardous chemical list?

3. Do you have up-to-date Material Safety Data Sheets (MSDS) for those

materials on your hazardous chemical lists?

4. Is the list of hazardous chemicals cross-referenced (have an MSDS index

number) so that identifiers on the list refer to the MSDS ?

5. Have you developed a system to ensure that all incoming hazardous

products or chemicals are received with proper labels and MSDS?

6. Do you have procedures in your workplace to ensure proper labeling for

secondary containers that hold hazardous products or chemicals?

53.

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Enamel Etchant Dropper Bottles Calcium Hydroxide Paste And Dentist Doing Endo

pH is 12.5

Calcium Hydroxide Injury With Loss of Vision

Infection Control

vs

Infection Prevention

Major Infection Control Failure In Tulsa, Oklahoma

March 2013

Oklahoma Dentist Exposes 7000 Patients To HIV, Hepatitis B, Hepatitis C

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Dr. Scott Harrington Tulsa, OK Dr. Scott Harrington

• Practiced in Tulsa for 35 years

• Had 2 offices in the area

• Had never had a compliant to State Board

• Sued for malpractice twice, both settled out of court

• When the State Board issued its Compliant, it called him "a menace to the public health”

Violations

• Practice was unsafe and unsanitary

• Lack of sterilization checks

• Committing gross negligence

• No display of licenses and certifications

• Failure to keep records of drugs

• Allowing dental assistants to practice dentistry

• Unsanitary dental materials in an unclean environment

• Open vials of medications

• Expired medications, one expired in 1993

Dr. Harrington Compliant Dr. Harrington Compliant

2/4/2015

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Dr. Harrington Compliant

Check out Mailman Vs Cat

Oklahoma Board Of Dentistry

• Has 6 employees – state law limit

• 3 investigators

• To Monitor 2200 dentists

• Oklahoma law prevents surprise inspections

• Legislature has said it will not increase funding for the State Board.

Comments From Susan Rodgers On Her Office Visit

• I had a very sick feeling because I knew what was coming. When the initial investigators went there, they were physically sick by what they found. I was literally sick the whole weekend from what I heard.

• I couldn’t imagine that there was a dentist stupid enough to allow his dental assistants to do anesthesia. . Let’s be clear about this … dental assistants can’t insert a needle into a patient in Oklahoma.

• I think we’ll be doing more of a lockdown on dental assistants who are in the operatory area. You may see dental assistants coming to get permits before they can be in the operatory.

Comments From The Readers Of This Article

• Unless I missed something, this whole incident will be

blamed on the dental assistants. There is no mention of the

dentist loosing his license, being fined, or jail time. Please

give me a break. Unless some, any or all of this happens,

this dentist will continue to practice in the same way. And,

I believe, the dentist already had settled two malpractice

suits. Let's put the responsibility on the person with the

power to practice independently. Please, I practice dental

hygiene for over 30 years and had to be very, very careful

for whom I worked.

Comments From Readers

• I have been a registered dental hygienist for over 30 years. I have worked in dentistry prior to dental school since I was 15, started in co-op. I have worked for dentists in all aspects of care. I was very shocked to hear this story .99.9 percent of dental offices go above and beyond to protect our patients. It only takes one story like this to set off fear in patients. You must have trust and a good relationship with your caregivers. Be observant and ask questions about sterilization procedures. We who have the best standards of care and always welcome any question. The entire office staff should be prosecuted to the fullest extent of the law. These patient's placed their full trust in these UNPROFESSIONALS . I will now have to spend weeks easing the minds of my patient's because of this office.I will pray for the patient's of this office.Please know as a whole dentistry holds the highest standards of care for our patients safety and also OSHA safety for our staff. All autoclaves in a proper practice are spore tested. I am proud of the sterilization protocol we use, we would NEVER compromise that. This case is VERY unusual and is not the standard of care.

2/4/2015

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• I personally feel all staff in that practice needs to be held accountable. There are no excuses for anyone letting this go for so long, common sense tells you an instrument contaminated with bodily fluids is DIRTY and can't be used until cleaned and sterilized!!! Come on!! Don't tell me they didn't know any better, were not properly trained or ignored hygienic practices.

• I managed 25 employees including: oral surgeon, periodontist, orthodontist, general dentist and dental assistants. If I find a dirty instrument or something not to my standards of clean, it does not get used on a patient!!! Plain and simple. Reason #1 it's unethical , reason #2 a law suit will closed down the business and therefore affect 25 families and thousand of our patients.

• In my office I get visits by the dental insurance companies we participate ever single year, they check spore testing logs, emergency kit, nitrous oxide units, CPR , credentials of all licensed practitioners and patient records. Maybe all states need to enforce yearly reviews.

Free Blood Testing For Patients

Oklahoma Department of Health Interim Report

• 4202 Patents tested

• 89 + for HCV, 5 + for HBC, 5 + for HIV

• One event of patient to patient transmission of HCV

• Genetic testing by CDC confirmed the HCV transmission

• $710,000 cost to federal & state agencies

Surrender Of Dr. Harrington’s License August, 2014

Surrender Of Dr. Harrington’s License At State Board Meeting

• Did not admit to doing anything wrong

• No Penalties and No Fines

• State Board of Dentistry said that the case is closed.

• Local District Attorney said that there would be on criminal charges.

Malpractice Lawsuits

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Colorado Oral Surgeon May Have Infected 8000 Patients

Accusations Against Dr. Stein

• Accused of reusing needles and syringes on patients receiving IV sedation for 12 years

• Needles and syringes were saved and reused on other patient IV lines.

• Denver Police Dept has an active on-going investigation for prescription fraud

• Saved unused portions of Vicodin to be used on other patients

Accusations Against Dr. Stein

• Wrote prescriptions for Vicodin, had patient bring Vicodin to next appointment, then diverted the Vicodin to his own use.

• Admitted to long battle with drug dependency and voluntarily surrendered his license.

• Will be eligible for new license in 2 years

Aftermath of Harrington Incidence

• State Dental Board

• Legislature

Oral Maxillofacial Surgery Assistant Oklahoma passed

a new law in the 2013 legislative session creating an oral maxillofacial surgery assistant in Oklahoma. The Oklahoma Board of Dentistry has not yet defined requirements and scope of practice for the oral maxillofacial surgery assistant.

• Malpractice Lawsuits

• Will It Happen Again

2/4/2015

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These Two Cases Are Not The First Time This Has Happened

• New York ( 2 offices in New York City )

• Nebraska Oncology Clinic –Cluster of 10 Hep C infections. Resulted in 99 patients infected with Hep C

• Oklahoma Pain Clinic – Cluster of 6 Hep C infections, CRNA infected 69 HCV and 31 HBV patients.

POSSIBLE EXPOSURE TO HEPATITIS &

HIV: Endoscopy clinic shut down City serves suspension order, locks center's doors

Mar. 01, 2008 Las Vegas Review-Journal

According to investigators, clinic staff regularly reused syringes and vials of medication on multiple patients, a practice that risked spreading communicable diseases. Six people who were treated at the clinic -- five on the same day -- have been diagnosed with hepatitis C. Up to 40,000 may have been exposed to Hepatitis and HIV.

Transmission Of HBV, HCV or HIV From Patient to Patient

• Multi-Dose Vials of Drugs

Multi-Dose Drug Vials

IV Line With Injection Port Aseptic Technique For Parenteral

Medications

1. Do not administer medications from syringe to to multiple patients. (IA)

2. Use single dose vials when possible. (II)

3. Do not combine leftover contents of single dose vials for later use. (IA)

2/4/2015

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Aseptic Technique For Parenteral Medications When Multi-dose Vials Are Used

1. Clean the diaphragm with 70% alcohol. (IA)

2. Use a sterile needle to access the multiple-dose vial and avoid touching the diaphragm. Both needle and syringe should be sterile. (IA)

3. Keep multi-dose vials away from operatories to prevent contamination from spray or spatter. (II)

4. Discard vial if sterility is compromised. (IA)

5. Use IV bags and tubing for only one patient. (IB)

Single Use Disposable Devices

Suction Tips, Saliva Ejectors, Impression Trays Propy Angles and Cups

• Use single use disposable devices for one patient only and dispose of them. (IC)

How Long Can Virus Survive On A Surface ?

• HIV

• HBV

• HCV

HIV How Long Can Virus Survive On A Surface ?

• HIV - several weeks under certain conditions

• Which body fluid it is in, volume of the body fluid, concentration of the virus within it, temperature, acidity, and exposure to sunlight

• HIV may survive for up to four weeks in syringes after HIV-infected blood has been drawn up into the syringe and then flushed out

HBV How Long Can Virus Survive On A Surface ?

• HBV can survive outside the body for months depending on the conditions

HCV How Long Can HCV Survive On A Surface ?

• HCV - Dried spots of blood contaminated with hepatitis C virus (HCV) can remain infectious for up to six weeks at normal room temperatures

• Commercially available disinfectants were highly effective against the HCV-contaminated blood spots. One minute of exposure to bleach (diluted to a ratio of 1:10) was 100% effective, whereas Cavicide at a similar concentration was 94% effective and ethanol (70%) eliminated HCV in 87% of blood spots

2/4/2015

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Dental Town Poll

Infection Control Practices

60 Offices Responded

Who is the primary infection control coordinator in

your practice?

18% Hygienist

32% Dental assistant

2% Practice manager

20% Dentist

28% There is no designated coordinator

Does your staff use a separate internal processing indicator in each of your sterilization

pouches when processing your instruments?

• 34% Yes

• 66% No

Preparation & Packaging Use internal chemical indicator in each package. If

cannot be seen from outside, use external indicator.

Internal/External Chemical Indicators

Do you perform spore testing on a

regular basis?

• 90% Yes

• 10% No

2/4/2015

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Monitor Effectiveness of Sterilization Process

• Spore test the sterilizer once a week. Use a matching control. Spore Test is the only way to determine if sterilization process is successful.

• Place a chemical indicator (color change device) on the inside of each package.

• Monitor each load with mechanical indicators:

Timer

Pressure Gauge

Temperature Gauge

How Long Should You Keep Spore Test Results

• ADA Recommendations - Check your state regulations.

• CDC Recommendations - retained long enough to comply with state regulations.

• State Board of Dentistry - Check with OSHA.

• OSHA Requirements - Nothing found on the OSHA website.

Department of State Health Services Title 25 Texas Administrative Code

Chapter 133 Hospital Licensing Rules Effective June 21, 2007

• (i) Performance records for all sterilizers shall be maintained for each cycle.

• These records shall be retained and available for review for a minimum of five years.

How do you sterilize the majority of your hand instruments?

• 62% Disposable Bags/Pouches

• 27% Wrapped Cassettes

• 12% Unwrapped

• 0% Other

Preparation & Packaging

Use wrapping compatible with type of sterilization and has FDA Clearance.

Before sterilization, inspect instruments for cleanliness and then wrap or place in containers designed to maintain sterility.

Internal & External Chemical Indicators

2/4/2015

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On average, how much do you think infection control procedures cost per patient visit? (e.g.,

gloves, masks, gowns, disinfectants and instrument sterilization)

• 28% $0 - $5

• 40% $6 - $10

• 20% $11 - $15

• 8% $16 - $20

• 3% More than $20

On average, how much time does your staff spend turning over a room per patient visit? (including

instrument recycling and environmental asepsis)

61% 8-10 minutes

• 25% 10-12 minutes

• 10% 12-15 minutes

• 3% 15 minutes or more

How often do you wash your hands?

• 0% Hygiene exams only

• 5% Dental procedures only

• 68% Every time I enter a room

• 27% As needed during the day

How would you rate the compliance with infection control procedures in your

practice?

• 23% Excellent

• 57% Very good

• 18% Good

• 0% Poor

• 2% Very Poor

In your opinion, which of the following is the prime factor that limits compliance with infection

control procedures in your practice?

• 55% Time limitations

• 4% Material availability

• 5% Cost

• 13% Inadequate training

• 24% Lack of enforcement

How often do patients ask you about the infection control procedures used in your

practice?

• 0% Once a week

• 2% More than once a week

• 8% Several times a month

• 90% Rarely to never

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How do you explain infection control

procedures to your patients?

• 53% Verbally

• 8% Written information sheet

• 12% Signs displayed in office

• 27% I do not explain it to patients

Do you disinfect your dental unit waterlines?

• 931 responded to this poll

• 48% Currently disinfect water lines

• 52% Do not

What is reason you do NOT disinfect the dental unit waterlines ?

• 6% Cost

• 14% Requires too much time

• 38% It is not important

• 9% Lack of enforcement

2/4/2015

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ICX by Adec

• Effervescing Tablet

• Non corrosive to unit

• Silver Nitrate

• Sodium percarbonate

• Effective for 2 weeks

• Continuous use product

• No purging water lines at night

Denta Pure Iodine Impregnated Tube

Last 40 Working Days

Approximately $70

Denta Pure In-line Iodine Cartridges

Sterisil PureTube Silver Impregnated Tube & Bottle

Lasts One Year

Approximately $340

Water must be soft

and pH below 8 or

use Distilled Water

Sterilix

• Ammonium chloride

• Corrosive to eyes/skin

• Once A Week Use

• Overnight Soak

• Flush lines next day

• Pink Color

Should Scrubs Be Worn In Public Places

On The Street

Restaurants

2/4/2015

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Should Scrubs Be Worn In Public Places

Doctors sound off -- loudly -- about wearing scrubs on the street

Dr. David C. Martin may be onto something.

In three Antidote posts last week, he made the case that health care workers should not wear

surgical scrubs out in public and that, if they are seen doing so, they should be confronted.

Scrubs Have Not Been Shown To Be Involved In Disease Transmission

• Seems to be a hospital related issue

• Dr. Harry Greenspun, chief medical officer at

Dell Services healthcare group.

"Given the choice between focusing on hand

hygiene, an issue that has very clear data

documenting transmission of infectious agents,

and scrubs outside the hospital, a practice that

has not been shown to be involved in disease

transmission, most organizations would focus

on the hands.

Scrubs

• Perception Problem

• Public Relations Problem

TEXAS STATE BOARD OF DENTAL EXAMINERS

Rules and Regulations CHAPTER 108

PROFESSIONAL CONDUCT

CHAPTER 108

PROFESSIONAL CONDUCT

SUBCHAPTER B

SANITATION AND INFECTION CONTROL

Rule 108.20 Purpose

The purpose of rules contained in this subchapter is to establish proper

sterilization, disinfection, and other infection control procedures in the

practice of dentistry. Failure of a dental health care worker to practice and

maintain these procedures constitutes a significant danger to public health

and safety. Any violation of these rules regarding infection control in this subchapter and other applicable statutes, rules, or regulations that may

be incorporated by reference herein or that may apply otherwise through

federal or state mandate or regulation shall be considered a failure to

safeguard the public interest and thus shall constitute, at a minimum,

negligence in the performance of dental services and failure to use proper

diligence in the conduct of a dental practice, pursuant to Section 263.002,

Dental Practice Act.

2/4/2015

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Rule 108.21 Requirements

A person practicing dentistry in the State of Texas must maintain the entire dental

office in a clean and sanitary condition, and such premises shall be maintained

in full compliance with all health requirements of the city or county, or both, in which

such office or premises is located and in conformity with the health laws of the

State of Texas; further, a dentist shall provide restroom facilities for staff and

patients and use properly sterilized instruments and clean supplies.

SOURCE: The provisions of rule 108.21 adopted to be effective February 20,

2001.

Rule 108.23 Definitions

(1) Barrier techniques - the use of protective items against infection-transmission

during any intraoral or invasive procedure to include appropriate gloves for the

procedure performed. This definition shall include protective eye wear and

nasal/oral masks when "splash, spatter, or aerosol" of body fluids is possible or

expected.

(2) Disinfection - the partial elimination of active growth stage bacteria and the

inactivation of some viruses. The potential for infections remains after disinfection,

including infection with M. tuberculosis, hepatitis A virus (HAV) and hepatitis B virus

(HBV). The human immunodeficiency virus (HIV) may also remain active following

disinfection.

(3) Sterilization - a process by which all forms of life within a defined environment

are completely destroyed.

Rule 108.24 Required Sterilization and Disinfection

(a) Sterilization is required for all surgical and other instruments that may be

used intraorally or extraorally, where these instruments may be used invasively or

in contact with or penetration of soft tissue, bone or other hard tissue. Other

nonsurgical instruments, such as plastic instruments, that may come into contact

with tissue must be disinfected with an American Dental Association-registered

solution that is tuberculocidal.

(b) All instruments subject to sterilization must undergo at least one of the

following procedures:

(1) Steam autoclave

(2) Chemical Vapor

(3) Dry-heat oven

(4) Ethylene oxide

(5) Chemical sterilant (used in dilution amounts and time periods according to

manufacturer's recommendations or accepted OSHA standards). Sterilization

equipment and its adequacy shall be tested and verified in accord with American

Dental Association (ADA) recommendations

Chemical Sterilization

• Glutaraldehydes – 10 Hours • Sporox – 6 Hours • How do you keep the instruments sterile after they

come out of the chemicals?? 1. Everything they touch must be sterile. 2. Sterile Gloves 3.. Sterile Tongs 4. Sterile Rinse Water 5. Sterile Towels 6. Sterile Trays

Ethylene Oxide Sterilizer EtO Gas

EtO is toxic and a

potent carcinogen.

Contact Time is 4-8 hrs.

Off Gas Time is 8-12 hrs

(c) Following a dental procedure, all instruments and operatory equipment

that may have become contaminated with blood, saliva, or tissue debris must be,

at a minimum, disinfected and preferably sterilized by a CDC or ADA-

approved method before utilization again for patient care.

(d) Prior to sterilization, all instruments must be free of any visible debris

and must be either scrubbed thoroughly with a detergent and water solution or

debrided in an ultrasonic device containing cleaning solution.

(e) Oral prosthetic appliances and devices from a dental laboratory must be

washed with a detergent and water solution, rinsed, disinfected, and rinsed

before the appliance or device is placed into patient's mouth.

2/4/2015

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(f) Disposable (non-resterilizable) items, including but not limited to gloves,

needles, intravenous fluids, intravenous administration tubing, intravenous

catheters/needles, and like items, shall not be used in the treatment of more

than one patient.

(g) All items contaminated by body fluids during patient care must be treated as

biohazardous material. Before extracted teeth are returned to a patient or other

party, the teeth must be rendered non-biohazardous. All contaminated single-

use items must be disposed of through established OSHA guidelines for such

disposal. Teeth or tissue fragments to be used for microscopic, testing, or

educational purposes must be sterilized prior to use. Such tissues must be handled

and stored as biohazardous material until sterilization is performed.

(h) When it is necessary to send items (including but not limited to impressions,

bites, working casts, prosthetic appliances or devices) to a dental laboratory

for fabrication on repair, those items that are contaminated by body fluids must be

considered biohazardous. Before such items are delivered to the dental

laboratory or technician, they must be rendered non-biohazardous according

to established OSHA guidelines.

(i) When it is necessary to return items (including but not limited to impressions,

bites, working casts, prosthetic appliances or devices) to a dental office from a

dental laboratory which item has been fabricated or repaired, those items that have

been potentially contaminated shall be rendered non-biohazardous. Before return

to the dentist by the dental laboratory or technician, the item must be

rendered non-biohazardous according to established OSHA guidelines.

Rule 108.25 Dental Health Care Workers

(a) All dental health care workers shall comply with the universal precautions,

as recommended for dentistry by the Centers for Disease Control and required by

THSC, §85.202, et seq,1991, as amended, in the care, handling, and treatment of

patients in the dental office or other setting where dental procedures of any type

may be performed.

(b) All dental health care workers who have exudative lesions or weeping

dermatitis shall refrain from contact with equipment, devices, and appliances

that may be used for or during patient care, where such contact holds potential for

blood or body fluid contamination, and shall refrain from all patient care and

contact until condition(s) resolves unless barrier techniques would prevent

patient contact with the dental health care worker's blood or body fluid.

(c) A dental health care worker(s) who knows he/she is infected with HIV

or HBV and who knows he/she is HbeAg positive shall report his/her health

status to an expert review panel, pursuant to provisions of THSC, §85.204, et

seq,1991, as amended. (Texas Health & Safety Code).

(d) A dental health care worker who is infected with HIV or HBV and is

HbeAg positive shall notify a prospective patient of the dental health care

worker's seropositive status and obtain the patient's consent before the

patient undergoes an exposure-prone procedure performed by the notifying

dental health care worker.

(e) All dental health care workers should receive a tuberculin skin test at

least annually.

Updated CDC Recommendations for the Management of Hepatitis B Virus–Infected Health-Care Providers and Students

• Defining exposure-prone procedures in dentistry and oral surgery has been particularly difficult. Many intra-oral procedures (e.g., injection or scaling) occur in a confined cavity and might lead to injuries to the operator , so some institutions have considered these procedures to be exposure-prone. However, no transmission of HBV from a U.S. dentist to a patient has been reported since 1987, and no transmission has ever been reported from a dental or medical student. Thus, Category I Procedures include only major oral surgery, and do not include the procedures that medical and dental students or most dentists would be performing or assisting.

Category II. All other invasive and noninvasive procedures

• These and similar procedures are not included in Category I as they pose low or no risk for percutaneous injury to a health-care provider

• dental procedures other than major oral or maxillofacial surgery;

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(c) A dental health care worker(s) who knows he/she is infected with HIV

or HBV and who knows he/she is HbeAg positive shall report his/her health

status to an expert review panel, pursuant to provisions of THSC, §85.204, et

seq,1991, as amended.

(d) A dental health care worker who is infected with HIV or HBV and is

HbeAg positive shall notify a prospective patient of the dental health care

worker's seropositive status and obtain the patient's consent before the

patient undergoes an exposure-prone procedure performed by the notifying

dental health care worker.

(e) All dental health care workers should receive a tuberculin skin test at

least annually.

Guidelines for Infection Control In Dental Health-Care Settings – 2003

December 19, 2003

Purpose Of Infection Control Program

Break The Chain Of Infection From

Patient To Patient Patient To Dental Staff Dental Staff To Patient

Infectious Diseases In The Dental Office

• Dental Assistant may come into contact with a number of infectious diseases in the dental office.

• These diseases fall into 4 categories depending on their mode of transmission.

Modes Of Disease Transmission In Dental Offices

1. Direct contact with infectious lesion

2. Indirect transmission via contaminated object

3. Bloodborne by splatter of blood, saliva or nasal secretions onto broken skin or mucosa

4. Airborne by aerosolization of microbes

Modes Of Disease Transmission Examples Of Each Mode

• Airborne - TB, Measles, Chickenpox

Precautions: Do not treat until disease is resolved.

• Bloodborne - Hepatitis & HIV

Precautions: (1) Standard Precautions (2) PPE

(3) Work Practice Controls

• Direct Contact - Herpes

Precautions: Do not treat until disease resolves.

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Herpes Of The Finger Herpetic Whitlow

Herpes Of The Eye Ocular Herpes

Hepatitis Viruses

Spread By Fecal-Oral Not Occupational Disease

Hepatitis A

Hepatitis E

Spread By Blood Occupational Disease

Hepatitis B

Hepatitis C

Hepatitis D

Hepatitis F

Hepatitis G

Vaccinations Recommended by CDC For Dental Staff

• Hepatitis B

• Flu

• Measles

• Mumps

• Rubella or German Measles

• Varicella-Zoster or Chickenpox

No Vaccination For Following Diseases

• HIV or AIDS

• Hepatitis C

• TB or Tuberculosis

Work Restrictions For Health Care Personnel Recommended By CDC

• Conjunctivitis

• Diarrhea

• Hepatitis A

• Herpes (on hands)

• Measles

• Mumps

• Pertussis

• Rubella

• Staphylococcus aureus

• TB

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HCW Works With Pertussis

Morbidity and Mortality Weekly Report

(MMWR)

Notes from the Field: Investigation of Contacts

of a Health Care Worker Who Worked While Ill

with Pertussis — Maryland, August–September

2014

HCW Becomes Ill with Suspected Pertussis

• Consulted a colleague who started tests and advised against patient contact

• Infected HCW continued to see patients and met with other hospital personnel

• Exposed 31 patients and 15 HCW

• Patients placed on antibiotics and screened by public health investigators

• Cause a major disruption in the hospital

Staphylococcus aureus Rash, Impetigo, Boil or Skin Abscess

Methicillin Resistant Staphylococcus aureus

MRSA – “Flesh Eating Bacteria”

Sterilization & Disinfection

1. Use only FDA cleared devices for sterilization. (IB)

Fry Baby Barnstead Autoclave

Chemical Vapor Autoclave or Chemiclave

What Is The Main Advantage

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VapoSteril Solution Glass Bead Sterilizer FDA Says Is Not Safe or Effective

Autoclave Sterilization

• Temperature: 121oC (250oF)

• Pressure: 15 psi

• Cycle Time: 30 minutes

Commercial Autoclaves MidMark Ultraclave

1. Unwrapped 1320C for 3 minutes

2. Pouches 1320C for 5 minutes

3. Handpieces 1320C for 6 minutes

4. Packs 1210C for 30 minutes

Instrument Classification Dr. Earle Spaulding

• Critical – will penetrate tissue and come in contact with bone or blood vessels.

• Semi-Critical – will come in contact with mucous membranes and non-intact skin.

• Non-Critical – will come in contact with intact skin.

Preventing Cross-Contamination & Disease Transmission In The Dental Office

• Perform Proper Hand Washing

• Use Disposable Items Wherever Possible

• Unit Dose Concept

• Utilize Barrier Techniques and PPE

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Proper Hand Washing CDC Recommendations

Alcohol based hand rubs (hand sanitizers) if the hands are NOT visibly soilded.

If the hands are visibly soiled, use regular soap OR antimicrobial soap and water.

Recommended wash time is 15 seconds.

Surgery Procedures – wash hands with antimicrobial soap and water for 2 to 6 min.

Hand Sanitizers

Hand Washing

Soap Containers: CDC Recommendations

(1) Use disposable containers OR

(2) Wash and dry containers before refilling.

(3) Do not “top off” containers.

Fingernails Fingernails are the dirtiest part of the hands

Keep fingernails short with smooth edges for (1) thorough cleaning and (2) prevent glove tears.

Use of artificial fingernails is usually not recommended

Do not wear hand or nail jewelry IF it makes donning gloves difficult or compromises fit or integrity of glove.

When To Wash Hands CDC Recommendations

1. When hands are visibly soiled with blood or infectious matter.

2. After touching items contaminated by blood, saliva or respiratory secretions.

3. Before and after treating patients.

4. Before and after glove use.

• Hand washing is the MOST important step in

preventing cross contamination.

Use Of Disposable Items

• Use disposable items whenever possible to prevent cross-contamination.

• Disposable items include:

Gloves

Saliva Ejector

High Volume Suction Tips

Prophy Angles & Propy Cups

Air-Water Syringe Tips

Impression Trays

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Disposable Items Cannot be reliably cleaned

• State Board Rules state that disposable items shall not be used in the treatment of more than one patient.

• CDC recommends that disposable items not be used in the treatment of more than one patient.

Unit Dose Concept

• Dispensing the amount of material needed for a given procedure.

• Done before the patient procedure.

• Excess is discarded.

• Examples: cotton balls, cotton rolls, 2x2s, waxes, compound, Vaseline, cements.

• Unit dosing prevents cross contamination of cabinets and drawers.

• To get supplies out of cabinet: (1) Remove gloves or (2) Use over-gloves over latex gloves.

Utilize Barrier Techniques and PPE To Prevent Cross-Contamination

• Barrier techniques include plastic wrap, impervious paper and aluminum foil.

• These can be placed over work surfaces and difficult to clean items such as electrical switches.

• Work surfaces that can be barrier wrapped include light switches, light handle, air water syringe, bracket table, x-ray equipment and any surface that is touched or comes in contact with contaminated items.

PPE Can Be Use To Prevent Cross-Contamination and Disease Transmission

• Gloves – Should Be Changed After Each Patient

• Masks – When To Change 1. Between Patients 2. When Wet 3. Splashed With Blood

• Eyewear – Face Shield or Glasses 1. Wash Between Patients

• Protective Gowns 1. Change if splattered with blood. 2. Long sleeves 3. Disposable or reusable cotton or cotton polyester

Changing Surgical Masks CDC Recommendations

• Change between patients.

• Change when wet.

• Change when contaminated with blood.

SARS Or Flu Epidemic

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N-95 Masks

• N – means normal air with no oil in the air.

• 95 – means that it will filter 95% of the particles down to .3 microns.

N-95 Masks

Protective Eyewear

• Safety Glasses

• Goggles

• Face Shields

• Prescription glasses with side shields

Utility Gloves – When To Use CDC Recommendations

• Decontaminating the operatory

• Cleaning instruments

• Handling chemicals such as disinfectants

Performing Disinfection Procedures

1. Select appropriate PPE.

2. Select, prepare and use chemical agents following manufacturers instructions.

3. Prepare surfaces for disinfection.

4. After treating the patient, disinfect:

Treatment room

Darkroom

Instrument Processing Area

All associated equipment

Selecting PPE For Disinfection Procedures CDC Recommendations

Wear the complete ensemble to include gloves, mask, eyewear, and gown.

Use puncture resistant utility gloves.

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Select And Prepare Chemical Disinfectants

Follow the manufacturer’s instructions for correct use of disinfecting products.

If using bleach, must be mixed daily.

Do not use Chemical Sterilants (such as glutaraldehydes) on surfaces.

Clinical Contact Surfaces Light Switch, Light Handle, Bracket Table, Mobile Cabinet

CDC Recommendations

Use an EPA registered hospital disinfectant

* Low level activity (HBV and HIV claims)

* Intermediate level activity (TB claim)

Use Intermediate Level disinfectant if visibly contaminated with blood.

Chemicals That Can Be Used Disinfectants For Surfaces

Chlorine, phenols and iodophors

Alcohol should not be used.

Glutaraldehydes should not be use.

EPA or Environmental Protection Agency is the agency that registers disinfectants in the USA. Your disinfectant should have an EPA Number on the label.

Housekeeping Surfaces Floors, Walls & Sinks CDC Recommendations

Soap and Water

OR

EPA Registered Hospital Disinfectant

Clean blinds and window curtains in patient care areas when visibly dusty or soiled.

Prepare Surfaces For Disinfection

Surfaces must be clean before disinfecting. Any debris may protect microorganisms from the disinfectant.

Surfaces may be cleaned and disinfected with a “Spray-Wipe- Spray” procedure. The disinfectant is sprayed on the surface and then wiped off as a cleaning procedure. Then the disinfectant is again sprayed and left for the contact time listed on the label.

Disinfecting Items Going To Lab Short Contact Time Disinfectants

1 Minute Contact Time 1 Minute Contact Time

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Short Contact Time Disinfectants One Minute Contact Time

DisCide Ultra

CaviCide 1 One Minute Contact Time

Performing Sterilization Procedures

1. Select appropriate PPE Wear the complete ensemble of PPE

Wear utility gloves when cleaning instruments

2. Prepare dental instruments for sterilization

3. Apply appropriate method for sterilization of dental instruments and equipment.

4. Label and store all instruments properly

5. Monitor effectiveness of sterilization process

Properly Prepare Instruments For Sterilization

• Clean all blood or debris from instruments

State Board Rules require all visible debris removed before sterilizing

• Use Ultrasonic Cleaner OR Instrument Washer

• If Hand Scrubbing, use long handle brush

Miele Instrument Washer Long Handle Scrub Brush

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Ultrasonic Cleaner Bubble Cleaning Action

Ultrasonic Cleaner Test Ultrasonic Cleaner Test

Apply Appropriate Sterilization Method CDC Recommendations

• Heat sterilize all Critical and Semi-critical

instruments. Autoclave

Chemiclave

Dry Heat Sterilizer

• Heat sensitive items (plastic instruments) can be

processed with high level disinfectant or chemical sterilant.

Label & Store Instruments Properly

• Wrap instruments or place in containers designed to maintain sterility (cassettes or trays)

• Place sterilization date on wraps or containers. In event of sterilizer failure, packs can be re-sterilized.

• Store in covered or closed cabinets

• Do not store under a sink

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Sterilization of Unwrapped Instruments

• Semi-critical instruments that will used immediately can be sterilized unwrapped provided that they are handled aseptically.

• Critical instruments for immediate use can be sterilized unwrapped if maintained sterile (transported in a sterile covered container)

Sterilization of Unwrapped Instruments

Do not sterilize implants unwrapped.

Do not store critical instruments unwrapped.

Dental Handpieces & Other Devices Attached To Air & Waterlines

1. Clean & heat sterilize handpieces and other waterline instruments between patients.

2. Do NOT surface disinfect, use chemical sterilants or ethylene oxide on handpieces.

3. Any device attached to the waterlines should be flushed for 20 to 30 seconds.

4. Do NOT tell patients to close their lips tightly around the tip of the saliva ejector.

Turbines Sent In For Repair

Identify Conditions For Potential Cross-Contamination

• Bare hands touching contaminated instruments or equipment.

• Removing bulk items (cotton rolls) with contaminated gloves.

• Taking contaminated oral prosthesis into the dental lab without disinfection.

• While working in the instrument processing area, going from the dirty side to the clean side with contaminated PPE.

• Touching paper records with contaminated gloves.

Computer Keyboard Contamination

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Bacterial Contamination Of Keyboards: Impact Of Disinfectants Bill Rutala et al

• Several studies show bacterial contamination.

• Keyboards have more microorganisms than toilet seats.

• This study found Staphylococci, Diptheroids, Micrococcus, and Bacillus on keyboards.

• Keyboards were contaminated with 3 organisms.

• Keyboards were treated with 6 disinfectants: alcohol, phenol, chlorine and quaternary ammonium. Also sterile water.

Bacterial Contamination Of Keyboards: Impact Of Disinfectants Bill Rutala et al

• All disinfectants, as well as the sterile water control, were effective at removing or inactivating more than 95% of the test bacteria.

• No functional or cosmetic damage to the computer keyboards was observed after 300 disinfection cycles.

Covering With Plastic Wrap Disinfecting The Keyboard

Keyboard Skins Washable Keyboards

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Practicon Dental www.practicon.com

Indestructible Keyboard

Utilize And Maintain A Quality Assurance Program For Infection Control

• Develop a written Infection Control Manual.

• As part of this manual, develop a checklist of the Infection Control Procedures discussed in this lecture.

• At least once a year, review the checklist to ensure these procedures are being done correctly in your office.

OSAP National Infection Control Organization

• Questions to ask your dentist about their infection control procedures.

• What should a patient look for in a dental office for assurance that the dentist and staff are taking proper precautions to prevent cross infection.

5 Questions For Patient To Ask

1. Do you heat-sterilize all your instruments, including

handpieces ("dental drills"), between patients?

2. How do you know that the sterilizer is working properly?

3. Do you change your gloves for every patient?

4. Do you disinfect the surfaces in the operatory between

patients?

5. If you are unclear on or uncomfortable with the

precautions your dental practice takes to protect you

during treatment, talk to your dentist or dental team

member about your concerns and ask to see the office's

instrument processing area.