_______________________________ Infection Control for Dental Professionals: The California Requirement
and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions should be available for each instrument, medical device, and equipment reprocessed. The FDA has issued guidance on ensuring the safety of reusable medical devices [23]. All procedures involving blood or OPIM must be performed in such a manner as to minimize splashing, spraying, spatter- ing, and generation of droplets of these substances. Splatter shields should be used on medical equipment associated with risk-prone procedures. Equipment that may become contaminated with blood or OPIM must be examined before servicing or shipping and should be decontaminated as necessary, unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible. A readily observ- able label should be attached to the equipment stating which portions remain contaminated. The employer must ensure that this information is conveyed to all affected employees, the servicing representative, and the manufacturer before handling, servicing, or shipping, so appropriate precautions may be taken. Single-Use Devices A single-use device is a device that is intended for use on a single patient during a single procedure. An unused single-use device is referred to as an original device. A reprocessed single- use device is an original device that has previously been used on a patient and has been subjected to additional processing and manufacturing for the purpose of an additional single use on a patient [22]. Dental Unit Waterlines, Biofilm, and Water Quality Studies have shown that dental unit waterlines, such as narrow-bore plastic tubing that carries water to high-speed handpieces, air/water syringes, and ultrasonic scalers, can become colonized with micro-organisms, including bacteria, fungi, and protozoa. Protected by a polysaccharide layer known as a glycocalyx, these micro-organisms colonize and replicate on the interior surfaces of the tubing and form a biofilm. This biofilm serves as a reservoir that can increase the number of micro-organisms in the water used during dental treatment [10]. California regulations require that dental unit water lines be anti-retractive, to prevent patient material, such as oral micro- organisms, blood, and saliva, from entering a dental water system during treatment. These dental unit lines and devices should be purged with air or flushed with water at the begin- ning of the clinic day for at least two minutes prior to attaching handpieces, scalers, air water syringe tips, or other devices [9]. The dental unit lines and devices should be flushed between each patient for a minimum of 20 seconds [9]. Commercial devices and procedures shown to improve the quality of water used in dental treatment include self-contained water systems
with chemical treatment, in-line microfilters, and combinations of these treatments. Simply using tap, distilled, or sterile water will not eliminate bacterial contamination in treatment water if biofilms in the system are not controlled. Microbial load should be less than or equal to 500 colony-forming units of heterotrophic bacteria per milliliter (≤500 CFU/mL) of water, the standard set for drinking water by the EPA [7]. Removal or inactivation of dental waterline biofilms requires use of chemical germicides. California law defines “germicide” as a chemical agent that can be used to disinfect items and surfaces based on the level of contamination. All germicides must be used in accordance with intended use and label instructions [9]. Regarding irrigation, if a surgical procedure involves soft tissue or bone, California regulations require the use of sterile cool- ants or irrigants, delivered using a sterile delivery system [9]. In addition, a new infection control standard that took effect in 2019, requires that water or other methods for irrigation must be sterile or contain recognized disinfecting or antibacterial properties when performing procedures on exposed dental pulp. Appropriate oral irrigants include chlorhexidine, BioPure MTAD, and sodium hypochlorite [33]. This requirement was in response to a 2016 outbreak of mycobacterial infection from a Southern California dental clinic that led to the hospitaliza- tion of more than 60 children. The cause was determined to be bacteria introduced through water during pulpotomies [33].
CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES
As discussed, contaminated surfaces and objects can serve as the means of transmission for potential pathogens. The trans- fer of a micro-organism from an environmental surface to a patient is largely via hand contact with the surface. Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces is fundamental in reducing their potential contribution to the incidence of infections [10]. All work areas, including contact surfaces and barriers, must be maintained in a clean and sanitary condition. Employers are required to determine and implement a written schedule for cleaning and disinfection based on the location, type of surface to be cleaned, type of soil present, and tasks or pro- cedures being performed. All equipment and environmental and working surfaces must be properly cleaned and disinfected after contact with blood or OPIM. If non-critical items or surfaces likely to be contaminated are manufactured in a manner preventing cleaning and disinfec- tion, they should be protected with disposable impervious barriers. Disposable barriers should be changed when visibly soiled or damaged and between patients. Products used to clean items or surfaces prior to disinfection procedures shall be clearly labeled and follow all material safety data sheet (MSDS) handling and storage instructions. Clean and dis- infect all clinical contact surfaces that are not protected by impervious barriers using a CalEPA-registered, hospital grade
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