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CALIFORNIA Dental Hygienist Continuing Education
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Mandatory courses included in this book: Infection Control for Dental Professionals: The California Requirement
12-Hour CE Package $72.00 ELITELEARNING.COM/BOOK
The California Dental Practice Act
INFECTION CONTROL FOR DENTAL PROFESSIONALS: THE CALIFORNIA REQUIREMENT
1
MANDATORY
2 CE HOURS
$18.00
COURSE CODE: DCA02IF
THIS COURSE SATISFIES THE CALIFORNIA INFECTION CONTROL REQUIREMENT Effective infection control techniques are critical to reducing the incidence of infections in dental facilities. Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove dental professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that dental professionals are immune or vaccinated can help decrease the availability of potential hosts. THE CALIFORNIA DENTAL PRACTICE ACT 20 MANDATORY 2 CE HOURS $18.00 COURSE CODE: DCA02CA THIS COURSE SATISFIES THE CALIFORNIA DENTAL PRACTICE ACT REQUIREMENT Although its primary objective is to safeguard the public, the California Dental Practice Act is an excellent resource for dental professionals to ensure compliance with state law. The California Dental Practice Act is the body of laws in the California Business and Professions Code and the California Code of Regulations governing dental professionals, including dentists, oral and maxillofacial surgeons, orthodontists, dental assistants, and dental hygienists. The Act is intended to serve as a legal guideline for both professionals and the public regarding all aspects of dental practice. ALLERGIC REACTIONS IN DENTAL PATIENTS 48 ELECTIVE 2 CE HOURS $18.00 COURSE CODE: DCA02AR The purpose of this course is to provide dental professionals with the information necessary to recognize, treat, and prevent allergic reactions in their patients. DENTAL TREATMENT OF PEDIATRIC AND ADOLESCENT PATIENTS 58 ELECTIVE 6 CE HOURS $54.00 COURSE CODE: DCA06DT Dental professionals are frequently involved in the care of pediatric and/or adolescent patients. The purpose of this course is to outline the oral health needs and problems unique to the pediatric and adolescent populations. Dental professionals are frequently involved in the care of pediatric and/or adolescent patients. The purpose of this course is to outline the oral health needs and problems unique to the pediatric and adolescent populations. This course will also note the debate which concerns the retention versus the extraction of impacted, but asymptomatic wisdom teeth. The course highlights some of the common surgical instruments and techniques employed for the extraction of impacted wisdom teeth. COURSE PARTICIPANT SHEET 77 Required to receive credit
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©2026: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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DENTAL HYGIENIST CONTINUING EDUCATION
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FREQUENTLY ASKED QUESTIONS What are the requirements for license renewal? LICENSES EXPIRE CONTACT HOURS
MANDATORY SUBJECTS
2 hours of CA Infection Control 2 hours of California Dental Practice Act 4 hours of basic life support (must include hands on demonstration from a certified instructor)
Licenses expire every two years on the last day of licensee’s birth month
25 (12 hours may be completed by home study) A maximum of 8 hours of CE may be granted per day.
Are you a California board-approved provider? NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply
Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Dental you will see our robust FAQ section that answers many of your questions. Simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll-free at 1-866-344-0972, Monday - Friday 9:00 am - 6:00 pm and Saturday 10:00 am - 4:00 pm EST. Important information for licensees Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a
acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.
NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994.
Are my hours reported to the California board? No. The board performs random audits at which time proof of continuing education must be provided. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable.
position to control content of the course activity. Sponsorship/commercial support and non-endorsement
It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Licensing board contact information: The Dental Hygiene Board of California Department of Consumer Affairs 2005 Evergreen Street, #1350 | Sacramento, CA 95815 Phone (916) 263-1978 | Fax (916) 623-4093 Website: https://www.dhbc.ca.gov/
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DENTAL HYGIENIST CONTINUING EDUCATION
DCA02IF Infection Control for Dental Professionals: The California Requirement ______________________ DCA02IF — 2 CE CREDIT HOURS R elease D ate : 02/01/25 E xpiration D ate : 01/31/28
Infection Control for Dental Professionals: The California Requirement
Audience This course is designed for all dentists, dental hygienists, and dental assistants in all practice settings, particularly those practicing in California. Course Objective The purpose of this course is to familiarize dental profession- als with infection control techniques in order to minimize the risks of microbial transmission in the dental healthcare setting. Learning Objectives
Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. NetCE is a Registered Provider with the Dental Board of Cali- fornia. Provider number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her permit type. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. Designations of Credit NetCE designates this activity for 2 continuing education credits. AGD Subject Code 148. This course meets the Dental Board of California’s require- ments for 2 units of continuing education. Dental Board of California course #02-3841-27452. 10/1/2021 to 9/30/2027 Provider ID #217994.
Upon completion of this course, you should be able to: 1. Outline OSHA and Cal/OSHA regulations that impact the provision of dental care. 2. Analyze potential modes of transmission and pathogens that can result in infection in dental facilities. 3. Discuss potential prevention strategies for infection control, including hand hygiene, and personal protective equipment. 4. Describe effective environmental control measures that should be applied in dental care. 5. Identify steps that should be taken to protect
dental healthcare personnel, including vaccination, education, and exposure responses.
Faculty Mark J. Szarejko, DDS, FAGD , received his dental degree from the State University of New York at Buffalo in 1985. He received fellowship from the Academy of General Dentistry in 1994. Faculty Disclosure Contributing faculty, Mark J. Szarejko, DDS, FAGD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Division Planner Mark J. Szarejko, DDS, FAGD
Mention of commercial products does not indicate endorsement.
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Special Approval This course fulfills the California requirement for 2 hours of infection control education. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.
HOW TO RECEIVE CREDIT • Read the entire course online or in print. • Depending on your state requirements you will be asked to complete: ‒ A mandatory test (a passing score of 75 percent is required). Test questions link content to learning objectives as a method to enhance individualized learning and material retention. • Provide required personal information and payment information. • A maximum of 8 hours of CE may be granted per day. Please record your completion dates on your Certificate(s) of Completion and retain for your records.
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The DBC Infection Control standards require that DHCP comply with and enforce the minimum precautions to mini- mize the transmission of pathogens in healthcare settings, as set forth by Cal/OSHA. These standards are reviewed by the DBC and Dental Hygiene Committee of California to obtain a consensus on infection control standards. A written protocol should be developed for proper instrument processing, opera- tory cleanliness, and management of injuries, and a copy of infection control regulations should be conspicuously posted in each dental office [9]. INFECTION CONTROL REGULATIONS Legal issues first began to impact infection control practices at the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic in the early 1980s. The need to protect healthcare workers from bloodborne exposures resulted in the publication of the Bloodborne Pathogens Standard by OSHA in 1991 [3]. BLOODBORNE PATHOGENS STANDARD The OSHA Standard requires employers whose employees have exposure to blood or other potentially infectious material (OPIM) to implement safe work practices, education, and barri- ers to exposure. OPIM includes saliva in dental procedures and all bodily fluid in situations where it is difficult or impossible to differentiate between bodily fluids; any unfixed tissue or organ (other than intact skin) from a human (living or dead); human immunodeficiency virus (HIV)-containing cell or tis- sue cultures, organ culture and blood, or other tissues from experimental animals [9]. The OSHA Bloodborne Pathogens Standard requires that all DHCP who may have contact on the job with blood or other bodily fluids must receive specific annual education, which includes instruction in the basics of infection control and prevention. Training must also cover bloodborne patho- gens, modes of transmission, the proper use of needles, and Transmission-Based Precautions [2; 3].
INTRODUCTION In 2023, there were more than 751,000 jobs in dental occupa- tions in the United States [1]. In California alone there are approximately 104,000 dental healthcare professionals, includ- ing dentists, dental hygienists, and dental assistants [29]. Most of these dental workers come in daily contact with a variety of infectious diseases in their workplace and are at risk for both transmitting and contracting these diseases. Universal Precautions were originally developed and recom- mended by the Centers for Disease Control and Prevention (CDC) in the 1980s as an infection control approach to protect healthcare professionals from bloodborne pathogens. Under Universal Precaution recommendations, all human blood and certain bodily fluids are treated as if they are infectious, regardless of patient or setting. In 1996, the CDC expanded these recommendations and introduced Standard Precau- tions, not only to protect healthcare workers from pathogens in human blood and body fluids but also from pathogens present in bodily fluids that are not covered under Universal Precautions, including saliva during dental procedures. Stan- dard Precautions are the minimum standard of care applied to all patients, and include hand hygiene, use of specific types of personal protective equipment (PPE) based on anticipated exposure, safe injection practices, and management of con- taminated environmental items. In addition to Standard Precautions, Transmission-Based Precautions (i.e., Contact Precautions, Droplet Precautions, and Airborne Precautions) are used to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone. The type of Transmission-Based Precaution used is based on what is known or suspected about a patient’s infection. In California, to address the issue of infection control and reduce the potential for harm, the Dental Board of California (DBC) established a requirement that licensed dental health- care professionals in California complete a course on infection control and prevention, further expanding the requirement to all dental health personnel (DHCP), defined as [9]: ...all paid and non-paid personnel in the dental healthcare setting who might be occupationally exposed to infectious materials, including body substances and contaminated supplies, equip- ment, environmental surfaces, water, or air. DHCP includes dentists, dental hygienists, dental assis- tants, dental laboratory technicians (in-office and commercial), students and trainees, contractual personnel, and other persons not directly involved in patient care but potentially exposed to infectious agents (e.g., administrative, clerical, housekeeping, maintenance, or volunteer personnel).
CALIFORNIA AEROSOL TRANSMISSIBLE DISEASE STANDARD
In 2009, Cal/OSHA adopted the nation’s first aerosol trans- missible disease (ATD) standard, which remains in effect today. The standard is designed to protect healthcare workers from diseases spread by an airborne or droplet route. The ATD standard requires employers in health care to develop expo- sure control procedures and train employees to follow those procedures [4]. Basic exposure precautions, such as source screening, infection control, hand hygiene, and cleaning and decontamination procedures, are a fundamental part of the standard. Employees must be included in the periodic review and assessment of these procedures.
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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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COMMON MODES OF INFECTION TRANSMISSION
Category
Definition
Direct contact Person-to-person transmission of pathogens (e.g., through skin, blood, or body fluid contact). Indirect contact An intermediate person or item acts as a transport between the portal of exit in one person and the portal of entry to the next person (e.g., via unwashed hands, shared equipment, needlesticks). Droplets a Large respiratory droplets propelled by an infected person coughing, sneezing, talking, or breathing heavily. Droplets settle rapidly within 6 feet of the individual on surfaces and in the upper airway of individuals exposed via the eyes, nose, or mouth.
Airborne (aerosols) a
Small particles or micro-droplets are released into the air by an infected person coughing, sneezing, talking, or breathing heavily. Airborne pathogens can linger for long periods of time and travel longer distances, landing on surfaces and being breathed in by other individuals into the lower airway. Contact with a contaminated inanimate object (e.g., used gloves, pens, used tissues, soiled laundry, keyboards, furniture). Water may be contaminated by micro-organisms in dental water unit lines, causing patient contamination as well as dispersing infected airborne particles and droplets.
Fomites
Water
a In 2024, a global consensus was reached to replace the terms droplet, airborne, and aerosol with a general umbrella term of “through the air transmission,” regardless of infected respiratory particle size and/or distance traveled. Source: [5; 6; 8] Table 1
hepatitis C or hepatitis B virus has resulted from using the same syringe or vial to administer medication to more than one patient, even if the needle was changed [5; 10]. The prevalence of hepatitis C virus infection among dentists and surgeons is similar to that among the general population, approximately 1% to 2% [5]. No studies of transmission from hepatitis C virus-infected DHCP to patients have been reported, and the risk for such transmission appears limited [10]. HIV/AIDS The average risk of HIV infection after a needlestick or cut exposure to HIV-infected blood is 0.3%; 99.7% of needle- stick or cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be 0.1%. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (i.e., a few drops of blood on skin for a short period of time) [5; 10]. In the United States, the risk of HIV transmission in dental settings is extremely low. According to surveillance data from 1981 to 2013, a total of 58 cases of HIV seroconversion had been documented among healthcare personnel after occupa- tional exposure to a known HIV-infected source, but none were among dental care personnel [12]. Certain factors affect the risk of HIV transmission after an occupational exposure. Laboratory studies have determined if needles that pass through latex gloves are solid rather than hollow-bore or are of small gauge (e.g., anesthetic needles), less blood is transferred. In a retrospective, case-control study of healthcare personnel, an increased risk for HIV infection was associated with exposure to a relatively large volume of blood, as with a deep injury with a device that was visibly
contaminated with the patient’s blood or a procedure that involved a needle placed in a vein or artery [12]. The risk was also increased if the exposure was to blood from patients with terminal illnesses, possibly reflecting the higher titer of HIV in patients with late-stage AIDS. AEROSOLS, DROPLETS, AND SPLATTER Aerosols, droplets (produced by the respiratory tract), and splat- ter contaminated with blood and bacteria are produced during many dental procedures. Devices such as dental handpieces, ultrasonic and sonic scalers, air polishers, air-water syringes, and air abrasion units produce visible aerosol clouds and possible airborne contamination. Splatter generated by dental procedures such as drilling is a primary risk for transmission of bloodborne pathogens. In general, because of their smaller size, aerosols pose the greatest risk for airborne infection [9]. Several studies have shown that airborne or droplet nuclei may extend up to 6 feet away from the source and can remain airborne for up to 30 minutes after a procedure. Tuberculosis (TB) is of special concern because it is a large particle that can remain airborne or can dry on a surface and become airborne again as part of a dust particle. In 2024, the World Health Organization (WHO) and the Centers for Disease Control and Prevention from the United States, China, Europe, and Africa, published a global consen- sus of the terminology for pathogens that transmit through the air. Key changes include [8]: • Any infected particles that are expelled from an individual through nose or mouth are referred to as “infectious respiratory particles” (IRPs). • IRPs exist on a spectrum of sizes and should no longer be distinguished as “small” (aerosol) or “large” (droplet).
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______________________ DCA02IF Infection Control for Dental Professionals: The California Requirement
• The descriptor “through the air transmission” should be used to characterize any transmission that involves a pathogen moving through the air or being suspended in the air. Two further descriptors can be used: ‒ Airborne transmission or inhalation: IRPs are expelled into the air and inhaled by another person. This can occur at short or long distances, dependent on various factors (e.g., airflow, humidity, temperature, ventilation). ‒ Direct deposition: IRPs are expelled into the air and directly deposited on the exposed mouth, nose, or eyes of another person. Due to the existing research and recommendations primarily using the terms and definitions of “aerosol” and “droplet,” these terms will continue to be used throughout this course, unless otherwise noted. The American Dental Association recommends that in addi- tion to using Universal and Standard Precautions, such as masks, gloves, and eye protection, Transmission-Based Precau- tions, including the proper sterilization of instruments and treatment of dental unit waterlines is necessary to reduce or eliminate this source of potentially contaminated dental aero- sols. Preprocedural rinsing with an antimicrobial mouthwash such as chlorhexidine is also recommended, although it is only effective for oral bacteria found in saliva and those adhering to mucous membranes. It does not penetrate subgingivally and likely has no effect on bacteria in the nasopharynx [5; 6]. Diseases known to spread by aerosols or droplet include: • TB • Pneumonic Yersinia pestis infection (plague) • Influenza • Legionellosis (Legionnaires disease) • Measles • Chickenpox • Disseminated shingles • Severe acute respiratory syndrome and coronavirus (SARS and COVID) Procedures or equipment aimed at eliminating the means of transmission include [5; 6]: • Universal preprocedural rinses • Dental dams for certain procedures • High-volume evacuator (HVE) at the treatment site (An HVE can only remove airborne contamination if it removes a large volume of air. A saliva ejector does not remove enough air to be classified as an HVE.) • High-efficiency particulate arresting and ultraviolet filters in the ventilation system
• Disposable PPE discarded after each patient (e.g., gloves, masks, gowns) • Cleaning, disinfection, and sterilization of equipment used by more than one patient • Environmental cleaning and disinfection, especially of high-touch surfaces
FOMITE TRANSMISSION Devices can transmit pathogens if they are contaminated with blood or bodily fluids or are shared without cleaning, disinfect- ing, and sterilizing between patients; these are classified as fomi- tes. Surgical instruments that are inadequately cleaned between patients or that have manufacturing defects that interfere with the effectiveness of reprocessing may transmit bacterial, fungal, and viral pathogens. Clothing, uniforms, laboratory coats, or gowns used as PPE may become contaminated with potential pathogens after care of a patient colonized or infected with an infectious agent [5; 6; 10]. WATER TRANSMISSION Dental water units and dental unit waterlines are both poten- tial sources of transmission and potential reservoirs. Routine cleaning and sterilization and adherence to the CDC’s recom- mended procedures for treating dental unit waterlines have been shown to be effective in eliminating transmission of infectious organisms via these devices. Infections known to be caused by dental-related water transmission include Pseu- domonas aeruginosa , Mycobacterium avium , and Legionella pneumophila [5; 7]. STANDARD PRECAUTIONS In 1986, California became the first state to pass a comprehen- sive bloodborne pathogen standard. The California standard provided a model for federal legislation, and in 1991, OSHA published its Bloodborne Pathogens Standard [3; 30]. Since then, regulatory and legislative activity has focused on imple- menting a hierarchy of prevention and control measures to improve infection control in healthcare settings. The gradual acceptance of various infection prevention stan- dards has changed the way we work in the provision of dental care. The DBC defines Standard Precautions as “a group of infection prevention practices that apply to all patients, regard- less of suspected or confirmed infection status, in any setting in which healthcare is delivered” [9]. The DBC mandates that Standard Precautions must be practiced in the care of all patients, and all body fluids, except sweat, are considered poten- tially infectious [9]. The use of Standard Precautions reduces the risk of infection to staff and patients and ensures that the right precautions are used with both known and unknown carriers of diseases due to bloodborne pathogens. Standard Precautions apply to contact with blood, intact or nonintact skin, mucous membranes, and all bodily fluids, secretions, and excretions (except sweat), regardless of whether they contain
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blood. A central tenet of Standard Precautions is to consider all patients to be potentially infected with a bloodborne patho- gen. Saliva has always been considered a potentially infectious material in dental infection control; thus, no operational difference exists in clinical dental practice between Universal Precautions and Standard Precautions. For organisms other than bloodborne pathogens, early identification and prompt isolation are critical. As noted, Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of health or dental care setting, and include [5]:
• When your hands feel or look dirty • After contact with contaminated things or environments, such as charts • After handling used equipment or linen • After using the bathroom • Before contact with any portal of entry, your patient’s or your own • Before and after eating
A number of conditions restrict DHCP from participating in direct patient care. These include weeping dermatitis, exuda- tive lesions, or any hand condition that increases the risk of disease transmission [9]. Good handwashing is difficult to practice, is rarely known or taught, and is one of the single most effective ways to prevent transmission of many diseases, including influenza. Everyone knows to wash their hands before eating and after using the restroom. However, few do little more than remove obvious dirt. Good handwashing involves removing the skin oils where organisms can remain even when the hands look clean. A quick pass under the water faucet and fast dry with a towel may remove visible dirt, but the oils and organisms remain. To effectively remove the oils and organisms, the process should take at least 20 seconds, or the amount of time it takes to sing “Twinkle, Twinkle Little Star.” The hands should be soaped and rubbed vigorously for 15 seconds to create a good lather and to assure that all parts of each hand are soaped and rubbed well. Then, the hands should be rinsed thoroughly and dried, preferably with a paper towel. The towel should be used to turn off the water faucet and then properly thrown away. However, 20 seconds is a long time in the busy life of a healthcare provider, and this 20 seconds has been identified as a major barrier to handwashing, particularly among those who consider themselves “too busy” to wash their hands. If there is no visible dirt or contamination, a waterless hand sanitizer with at least 60% alcohol can be used between patients. How- ever, nothing is as good as washing well with soap and water. Further, some organisms are not eliminated through the use of hand sanitizers alone (e.g., Clostridioides difficile spores). Hands should be thoroughly dried before donning gloves and washed again immediately after glove removal [9]. Some mistakenly think that hot water must be used to kill the organisms. Water hot enough to kill organisms would be too hot to touch. Warm water softens oils but mainly adds to comfort and encourages better washing technique (i.e., longer duration). Careful attention to handwashing and cleansing may result in chapped skin, so the dental professional must find effective lotions to care for his/her hands [14; 17]. Certain soaps contain stronger antiseptic compounds, such as chlorhexidine, and these soaps may be considered in cases in which exposure to potentially infectious material is likely. Antiseptic soaps or surgical preparation liquids have been found more effective than plain soap in removing bacteria
• Utilization of effective hand hygiene • Use of PPE (e.g., gloves, masks, eyewear) • Respiratory hygiene, including cough/sneeze etiquette • Sharps safety (engineering and work practice controls) • Safe injection practices (aseptic technique) • Cleaning, sterilization, and disinfection of instruments and devices • Cleaning and disinfection of environmental surfaces
HAND HYGIENE Despite the simplicity and effectiveness of hand hygiene in preventing the spread of infectious disease, adherence to hand hygiene practice remains low. Adherence varies among profes- sional categories of healthcare workers but is usually estimated at less than 50%. Healthcare providers may be required to clean their hands as many as 100 times in a 12-hour shift, depending on the number of patients and intensity of care [14; 17]. For dental healthcare workers, strict adherence to proper hand hygiene is the most important prevention strategy to protect both the patient and the worker. In one study, adherence rates to hand hygiene among postgraduate-year dentists found that overall handwashing compliance rate was 34.7%, with higher rates of compliance noted in oral surgery services (92.8%) than during work in general clinical practice (34.2%) [13]. The World Health Organization has designed the guidelines 5 Moments for Hand Hygiene as a reminder of when proper hand hygiene should be completed [11]: 1. Before touching a patient 2. Before a procedure 3. After a procedure or exposure to body fluids 4. After touching a patient 5. After touching a patient’s surroundings In general, perform hand hygiene [14]: • After contact with any bodily fluids, including your own • Before any non-invasive or invasive procedure • Each time you remove your gloves
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______________________ DCA02IF Infection Control for Dental Professionals: The California Requirement
Gloves DHCP should wear medical exam gloves to prevent contami- nation of their hands when touching mucous membranes, blood, saliva, or OPIM [9]. Gloves reduce the likelihood that micro-organisms present on the hands will be transmitted to patients during surgical or other patient-care procedures. Gloves used in the healthcare setting are subject to U.S. Food and Drug Administration (FDA) evaluation and clearance. Nonsterile, disposable medical gloves made of latex or nitrile should be available for routine patient care. Dental personnel should always use gloves when [18]: • Anticipating direct contact with blood or bodily fluids, mucous membranes, nonintact skin, and OPIM • Engaging in direct contact with patients who are colonized or infected with pathogens transmitted by the contact route, such as vancomycin-resistant enterococci or methicillin-resistant Staphylococcus aureus (MRSA) • Handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces Studies have repeatedly shown that vinyl gloves have higher failure rates than latex or nitrile gloves. For this reason, either latex or nitrile gloves are preferable for clinical procedures that require manual dexterity or those involving more than brief patient contact. Heavier, reusable utility gloves should be used for non-patient-care activities, such as handling or cleaning contaminated equipment or surfaces, handling chemicals, or disinfecting contaminated tools [9; 18]. During dental procedures, patient examination gloves com- monly contact multiple types of chemicals and materials, such as disinfectants and antiseptics, composite resins, and bonding agents, and these materials can compromise the integrity of latex, nitrile, and other synthetic glove materials. In addition, latex gloves can interfere with the setting of vinyl polysiloxane impression materials. Given the diverse selection of dental materials on the market, dental practitioners should consult glove manufacturers regarding the chemical compatibility of glove materials [5; 18]. Wearing sterile surgeon’s gloves during surgical procedures has a strong theoretical rationale. Sterile gloves minimize transmis- sion of micro-organisms from the hands of surgical personnel to patients and prevent contamination of the hands of surgical personnel with the patient’s blood and bodily fluids. In addi- tion, sterile surgeon’s gloves are more rigorously regulated by the FDA and may provide an increased level of protection for the provider if exposure to blood is likely [10; 18]. Gloves should be removed and replaced if torn or punctured and discarded between patients to prevent transmission of infectious material. They should never be washed and reused, as micro-organisms cannot be removed reliably from glove surfaces. Glove reuse has been associated with transmission of MRSA and gram-negative bacilli [9; 10].
from healthcare workers hands both pre- and postprocedure. In addition, antiseptics may be added to alcohol-based handrubs in order to achieve persistent germicidal activity. Possible side effects associated with frequent use of antiseptic hand scrubs include skin irritation, dermatitis, allergic reactions, and potential development of microbial resistances. Chlorhexidine products are considered safe for regular use in dental practice; however, if associated side effects are bothersome, they may result in decreased hand hygiene compliance [10; 14]. In summary, start and end each work day using an antibacterial soap. Gloves provide a breeding ground for microbial growth, and washing before and after use is encouraged. If hands are not visibly soiled, a waterless hand sanitizer (at least 60% alco- hol) may be used. For surgical procedures, wash hands with antimicrobial soap prior to gowning and gloving [5]. PERSONAL PROTECTIVE EQUIPMENT PPE is defined as special coverings designed to protect health- care personnel from exposure to or contact with infectious agents [18]. Cal/OSHA regulations require use of PPE in dental care settings to protect personnel from exposure to bloodborne pathogens and other OPIM [9]. Under OSHA’s General Duty Clause, PPE is also required for any potential infectious dis- ease exposure. Employers must provide their employees with appropriate PPE and ensure its proper disposal. If reusable, it must be properly cleaned or laundered, repaired, and stored after use [19]. PPE must fit the individual user, and it is up to the employer to ensure that PPE is available in sizes appropri- ate for all their workers. Employees are prohibited from taking PPE home to launder. In addition to the familiar gloves, masks, and gowns, PPE includes a variety of barriers and respirators used alone or in combination to protect skin, mucous membranes, and airways from contact with infectious agents. The selection of PPE is based on the nature of the patient/provider interaction and the likely mode of transmission. Primary PPE used in oral healthcare settings includes gloves, surgical masks, respiratory devices, protective eyewear, face shields, and protective shoes and clothing. Procedures that can generate splashes or sprays of blood, bodily fluids, secretions, excretions, or chemical agents require either a face shield (disposable or reusable) or mask and goggles. The wearing of masks, eye protection, and face shields in specified circumstances (when blood or OPIM exposures are likely to occur) is mandated by the OSHA Bloodborne Pathogens Standard. Sterile barriers for invasive procedures and masks or respirators for the prevention of droplet contamination are also required [2]. The use of PPE is not a substitute for safe work practices. Avoid contaminating yourself by keeping your hands away from your face and not touching or adjusting equipment. PPE is a poten- tial means of transmission if not changed between patients. All PPE should be removed when leaving patient care areas.
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DCA02IF Infection Control for Dental Professionals: The California Requirement ______________________
Masks, Protective Eyewear, and Face Shields In California, DHCP are required to wear surgical masks that cover both the nose and mouth, in combination with either chin-length plastic face shields or protective eyewear when there is potential for splashing or spattering of blood, droplets, chemical, or germicidal agents, or OPIM. After each patient, masks should be changed and disposed of properly. After each patient treatment, face shields and protective eyewear shall be disposed or cleaned and disinfected [9; 18]. Masks should fit snugly and fully cover the nose and mouth to prevent fluid penetration. For this reason, masks that have a flexible nose piece and can be secured to the head with string ties or elastic are preferable. Surgical masks protect against micro-organisms generated by the wearer and also protect dental personnel from large-particle droplet spatter that might contain bloodborne pathogens or OPIM. If the mask becomes wet or contaminated, it should be changed between patients or even during patient treatment. For employees at increased risk of exposure to ATDs, such as those working in endemic areas (e.g., Southeast Asia) or in areas designated for isolation or quarantine, the employer must provide a respirator at least as effective as an N95 respirator. Most surgical masks are not National Institute for Occupa- tional Safety and Health (NIOSH)-certified as respirators, do not protect the user adequately from exposure to TB, and do not satisfy OSHA requirements for respiratory protection. However, certain surgical masks (i.e., N95 respirators) do meet the requirements and are certified by NIOSH. The level of protection a respirator provides is determined by the efficiency of the filter material for incoming air (e.g., 95% for N95) and how well the face piece fits or seals to the face. N95 respirators are required to be labeled as such on the device. Respirators are used when treating patients with diseases requiring Airborne Precautions and should be used in the context of a complete respiratory protection program. This program should include training and fit testing to ensure an adequate seal between the edges of the respirator and the wearer’s face. Goggles with side shields provide barrier protection for the eyes and should fit snugly over and around the eyes or personal prescription lenses. Personal prescription lenses do not provide optimal eye protection and should not be used as a substitute for goggles. If goggles or face shields are reusable, they must be placed in a designated receptacle for subsequent reprocessing. If they are not reusable, they may be discarded in a designated waste receptacle. Face shields extending from chin to crown provide better face and eye protection from splashes and sprays than goggles. Shields that wrap around the sides may reduce splashes around the edge. Removal of a face shield, goggles, and mask can be performed safely after gloves have been removed and hand hygiene performed. The ties, earpieces, or headband used to secure the equipment to the head are considered clean and
When gloves are worn in combination with other PPE, they should be put on last. Gloves that fit snugly around the wrist are preferred for use with a gown because they will cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and hands. Removing gloves properly also prevents hand contamination. Hand hygiene following glove removal ensures that the hands will not carry poten- tially infectious material that might have penetrated through unrecognized tears or contaminated the hands during glove removal. When processing contaminated sharp instruments, needles, and devices, heavy utility gloves should be used to prevent puncture injuries [10; 18]. When adhering to Standard Precautions, always [5]: • Use good hand hygiene. • Use gloves for contact with blood, bodily fluids, nonintact skin (including rashes), mucous membranes, used equipment, linens, and trash. • Change gloves if they become heavily soiled when
working on a patient or if you must go from a potentially more infective area to a lesser one. In addition, never: • Wear artificial fingernails. • Touch a second patient with the same pair of gloves used on the first patient.
• Contaminate the environment with dirty gloves. • Wear gloves outside the treatment area unless you can say why you are wearing them. Protective Clothing Gowns are intended to protect the arms and exposed body areas and prevent contamination of clothing with blood, bodily fluids, and OPIM. The type of gown selected is based on the nature of the patient/provider interaction, including the anticipated degree of contact with infectious material and potential for blood and bodily fluid penetration of the barrier. General work clothes (e.g., uniforms, scrubs, laboratory coats, jackets) are not considered PPE. Dental personnel should change protective clothing when it becomes visibly soiled or as soon as possible if penetrated by blood or other possibly infectious fluid [18]. California regulations require that all DHCP wear reusable or disposable protective attire when their clothing or skin is likely to be exposed to aerosol spray or splashing or spattering of blood, OPIM, or chemicals and germicidal agents. Gowns must be changed daily or between patients if they become moist or visibly soiled. All PPE used during patient care shall be removed when leaving laboratories or areas of patient care activities. Reusable gowns should be laundered in accordance with Cal/OSHA Bloodborne Pathogens Standards. In addi- tion, gowns should be worn for disinfection, sterilization, and housekeeping procedures involving the use of germicides or handling contaminated items [9].
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