_______________________________ Infection Control for Dental Professionals: The California Requirement
According to the California ATD Standard, California dental offices whose patients have suspected or confirmed illnesses that require Airborne or Droplet Precautions, such as tuber- culosis (TB) or other respiratory illnesses, must comply with the ATD standards [4]. Key points include: • Dental employees must be trained to screen patients for ATDs. • The screening process must be described in a written office procedure.
Diseases at https://www.dir.ca.gov/dosh/dosh_publications/ ATD-Guide.pdf [4].
MODES OF TRANSMISSION Almost all pathogens are transmitted by being carried from one place to another. The mode or means of transmission is the weakest link in the chain of infection, and it is the only link that can be eliminated entirely. Most infection control efforts are aimed at preventing transmission of pathogens from a reservoir to a susceptible host. Both Standard and Transmission-Based Precautions are designed to interrupt the mode of transmission. Table 1 details the most common modes of infection transmission in dentistry [5; 6; 8]. DIRECT AND INDIRECT CONTACT The most common modes of transmission in the healthcare setting are through contact, both direct and indirect. Because it addresses the weakest link in the chain of transmission, hand hygiene is the single most important procedure for preventing the spread of infection. Items moving between patients should be cleaned and sterilized after each use to avoid indirect trans- mission of pathogens. Standard Precautions in conjunction with identified Contact Precautions are often used in the dental setting. Bloodborne Pathogens Healthcare employees can be exposed to blood through needle- stick and other sharps injuries, damaged mucous membranes, and broken skin exposures. The pathogens of primary concern to dental professions are HIV, hepatitis B virus, and hepatitis C virus. Hepatitis B Virus Healthcare personnel who have received the hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection. For a susceptible person, the risk from a single needlestick or cut exposure to hepatitis B-infected blood ranges from 6% to 30%, depending on the hepatitis B antigen status of the source individual. While there is a risk for hepatitis B infection from exposures of mucous membranes or nonintact skin, there is no known risk for infection from exposure to
• Screening must be consistently implemented. • Elective dental treatment should be deferred until the patient is non-infectious for TB or other diseases requiring Airborne or Droplet Precautions.
A simple screening procedure can be done by the first person who comes in contact with a patient. For example, the patient may be asked “How are you feeling today?” or “Do you have any coughs, fever, or flu-like symptoms?” If the patient is not feeling well or gives a positive answer to any part of the second question, the dental treatment should be rescheduled. Outpatient dental clinics or offices are not required to comply with this standard if they meet all of the following conditions [4; 21]: • Dental procedures are not performed on patients identified as ATD cases or suspected ATD cases (e.g., persons with TB or other respiratory illnesses). • The clinic’s injury and illness prevention program includes a written procedure for screening patients for ATDs that is consistent with the CDC guidelines for infection control in dental settings. This procedure must be followed before performing any dental work on a patient. • Employees have been trained in the screening procedure in accordance with state law. • Aerosol-generating dental procedures are not performed on a patient identified through the screening procedure as presenting a possible ATD exposure risk unless a licensed physician determines that the patient does not currently have an ATD. As of 2024, California remains the only state with such a per- manent standard; however, the coronavirus disease (COVID) pandemic of 2019–2022 highlighted the need for a standard addressing infectious pathogens spread by aerosols or droplets. During the pandemic, OSHA did issue interim guidance for safe workplaces, and some states issued emergency temporary standards. Experts have called for these requirements to be codified in order to ensure the safety of professions and patients, but this has not yet been accomplished [15]. Full guidance on aerosol-transmissible diseases can be found in the 2023 California Workplace Guide to Aerosol Transmissible
intact skin [5; 10]. Hepatitis C Virus
Hepatitis C is transmitted primarily through percutaneous exposure to infected blood. The average risk for infection after a needlestick or cut exposure to hepatitis C virus-infected blood is approximately 1.8%. The risk following a blood exposure to the eye, nose, or mouth is unknown but is believed to be very small; however, hepatitis C virus infection from blood splashes to the eye has been reported. There also has been a report of hepatitis C virus transmission that may have resulted from exposure to nonintact skin, but there is no known risk from exposure to intact skin. Documented transmission of
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