Purpose

This procedure outlines the steps to be taken in order to assure control over transmission of infection and cross-contamination of patients treated in the ETSU Dental Hygiene Clinic.

Policy:

In an effort to comply with the Tennessee Department of Labor, Division of Occupational Safety and Health (TOSHA) infection control guidelines (TOSHA Instruction: CPL 2-2.36A), the following infection control plan has been written. Infection control is a high priority at East Tennessee State University, Department of Dental Hygiene, and is addressed throughout this clinical policy, which is available on this Web site.

Infection control at the department is a team effort. The students, faculty and staff all play an important function in maintaining the chain of asepsis. It is imperative that each team member be familiar with his/her role, and execute it responsibly.

I. Departmental Risk Level

A. High Risk

1. Faculty Members

• Rebecca Nunley, Chair, Associate Professor
• Gail Barnes, Assistant Professor
• Charles Faust, Associate Professor
• Frieda Pickett, Associate Professor
• Victor Hopson, Associate Professor
• The clinical faculty are at a high risk of contracting a bloodborne virus (i.e., HBV and HIV) due to their exposure to blood, saliva, gingival fluids and mucous membranes as well as their potential contact with aerosols.

2. Students

• The dental hygiene students are classified at a high risk level due to their knowledge level as well as their exposure to blood, saliva, gingival fluids, mucous membranes and aerosols.

B. Moderate Risk

1. Dental Equipment Service Technician - Tandy Phillips

• The Service Technician is at moderate risk of being exposed to bloodborne pathogens through contact with contaminated equipment, and precleansed, wrapped instruments.

2. Clinical Safety Supervisor - Christy Hoffman

• While the supervisor has no direct patient contact, his/her clinical responsibilities place the supervisor in contact with precleansed, wrapped instruments. The supervisor is also in potential contact with blood from the suction system, on contaminated equipment or surfaces, and aerosols.

C. Moderate/Low Risk - Ralph Coffman

• Because of the large quantity of items to be autoclaved following the clinic sessions, and the dental hygiene department's limited autoclaving capacity, some of the items to be autoclaved are transported by cart to the third floor, Department of Health Sciences to be sterilized. Mr. Coffman supervises the sterilization of the instruments on the third floor, and while he maintains that he does not handle the instrument packages, there is always the potential for him to be exposed parenterally.

D. Low Risk

1. Custodians

• On a day to day basis, the custodians are at low risk of being exposed to blood since the infectious waste generated within the department is separated from the non-infectious waste. The custodians will not be exposed to the infectious waste as they will only be required to collect the non-infectious waste from the trash receptacles on the clinic floor. The custodians will wear gloves when emptying the clinic floor trash.

2. Executive Aid

• The Executive Aid has no exposure to blood, mucous membranes, body fluids or aerosols.

3. Student Workers

• The student workers have no exposure to blood, mucous membranes, body fluids or aerosols. Student workers who have contact with clinical instruments have the same risk level as the Clinic Safety Supervisor.

II. Immuunizations

• Hepatitis B (HBV), a bloodborne virus, has long been a dental health concern since contracting the disease can cause an individual to be a chronic carrier of the virus. Due to the safety and the effectiveness of the Hepatitis B vaccine, all dental hygiene students, faculty and staff who are at risk of contacting blood or other infectious materials are required to be vaccinated if they are not already immune. This guideline follows the recommendations of the Council on Dental Therapeutics, and the Immunization Practices Advisory Committee of the Centers for Disease Control. The department will provide the immunization for their employees; however, students will be responsible for the payment of their vaccination. A record of each employee's hepatitis B vaccination will be kept in the personnel records. Employees refusing to be vaccinated will sign an "Informed Refusal for Hepatitis B Vaccination Form" which will be kept in their confidential personnel file.

III. Universal Precautions

• While every effort is made to obtain a thorough medical history on each patient, it is recognized that not all patients with an infectious disease may be identified. Therefore, all patients will be treated as though they may be infectious, and the same infection control practices will be utilized with each patient.

IV. Personal Protective Equipment

A. Gloves

• Students, faculty and staff will wear gloves when there is a potential for exposure to blood, mucous membranes, body fluids, or blood contaminated objects or surfaces.

1. Type

• Utility Gloves - General purpose utility gloves will be utilized when cleaning and disinfecting the operatory, when cleaning and disinfecting a blood spill, and when handling and scrubbing contaminated instruments. Following use, the gloves will be washed with an antimicrobial handwash, rinsed thoroughly, and dried and sprayed with disinfectant prior to removal. The utility gloves will be replaced at the first signs of cracking or deterioration.
• Nitrile or Vinyl Gloves - The students, faculty and staff will wear nitrile or vinyl examination gloves during all procedures that involve contact with blood, body fluids or mucous membranes. Sterile gloves will be available for Dr. Nunley and her assistant in the event that a surgical procedure must be performed.

2. Provider

• Faculty/Staff - Gloves will be provided by the university.
• Students - The dental hygiene students will be responsible for purchasing their own gloves from a dental supplier. The department will provide vinyl gloves for the students to wear during the development of radiographs.

B. Masks

• In order to protect the mucous membranes of the mouth and nose from blood and saliva, students, faculty and staff will wear a mask during all patient contact. The mask will fit snugly against the face, and will be changed between patients. It will be handled by the elastic or strings during removal. The mask will not be worn outside of the operatory.
• The masks will be provided by the university for the faculty and staff. Students will purchase masks from a dental supplier.

C. Protective Eyewear

• To protect the eyes from injury and infection, shatter resistant glasses with side shields, goggles or chin-length face shields will be worn by students, faculty, staff and patients during clinical procedures.

D. Clinic Attire

• Faculty/Staff - The dental hygiene faculty and staff may wear street clothes that are covered by a long sleeved lab coat or scrub gown. The lab coat or scrub gown will be changed following exposure to aerosols, when visibly soiled or at the end of the day. The lab coat will be buttoned during procedures involving production of aerosols or spatter.
• Pre-Clinic students will wear a clean, long sleeved lab coat over their street clothes. The lab coat will be buttoned during procedures that involve the production of aerosols or spatter. The lab coat will be changed at the end of the day, when visibly soiled or following exposure to aerosols. Lab coat will be removed upon leaving cubicle.
• Clinic students will wear a clean, regulation uniform. A lab coat will be worn in the operatory. Upon leaving the operatory the lab coat will be removed. Following the clinic session and before leaving the department, the clinic attire will be removed and placed in a laundry bag.
• Laundering - Faculty and staff will utilize the departmental laundry service to launder their lab coats. Students are responsible for laundering their own uniforms and lab coats. Clinic attire should be washed separate from street clothes. In situations in which the water temperature is questionable, a laundry sanitizer should be considered (e.g. Lysol or bleach).

E. Resuscitation Equipment

• Resuscitator Bag-located back in X-ray. Contains a large and a small mask.
• Disposable CP Reviver^TM-located in the red tackle box on the bookcase in the clinic center common area.
• Portable Oxygen Tanks-2 tanks are located at the center common area in the clinic.

V. Infection Control Procedures

1. Handwashing

• The day will begin with two consecutive 15 second handwashes with an antimicrobial handwash. Visible soil will be removed from under fingernails with a rile orangewood stick, and a sterile handbrush. The handbrush will only be used to remove visible soil from around the fingernail area. Fingernails will be kept short and nail polish will not be worn. Jewelry will not be worn during treatment. During the day, hands will be washed at the following times for 15 seconds with an antimicrobial handwash.

1. Between patients
2. Before gloving
3. After removal of gloves
4. Before leaving the operatory
5. Upon return to the operatory
6. Wash gloves before disposal if visible blood is present.
7. As necessary to maintain the aseptic chain

• A surgical procedure will require scrubbing hands and arms up to the elbows for 5 minutes with a surgical antimicrobial handwashing product. Hands will be dried with a sterile towel.

2. Pretreatment Phase

1. All unnecessary items will be removed from the operatory or placed in the cabinet drawers.
2. Utilizing the following procedures, the operatory and all the items that cannot be sterilized will be disinfected.

• Spray with an Environmental Protection Agency (EPA) approved disinfectant.
• Scrub irregular surfaces with a clean hard brush, and smooth surfaces with a paper towel.
• Wipe all items clean and dry with a paper towel.
• Spray again with a disinfectant and leave wet for 10 minutes before each appointment and at the end of the clinic session.
• Care will be taken to identify the items that will be contaminated during treatment. Disposable covers (i.e. impervious-backed paper, plastic wrap or foil) will be utilized as necessary to prevent contamination of items that are not easily disinfected (i.e. handpiece, air/water syringe, x-rays placed on view box, light handles/switch, ultrasonic handle, cubical lights, stool handles.
• The dental chair and operator stool will be covered with a polyethylene bag or disinfected with an EPA approved disinfectant.
• Handpieces, ultrasonic scalers, suction system and air/water syringes will be flushed for 3 minutes at the beginning of each day, and 30 seconds between patients.
• To prevent the need to leave the operatory or go into cabinets during treatment, the operator will determine the materials that will be needed and set them out in the unit.
• Disposable items will be used whenever possible.

3. Treatment Phase

• To maintain the aseptic chain, the hands will be washed and gloved as previously outlined.
• Sterile instruments and supplies will be utilized.
• Instruments, supplies and equipment will be handled to prevent cross-contamination. Instrument packages will be opened in the presence of the patient. If sharpening before patient arrives is necessary make sure instruments are wiped with wet gauze and covered before patient is seated.
• A careful medical history will be taken on new patients and updated on each reappointment. The operator will consult with the supervising dentist and patient's physician when a serious systemic infection is suspected. Patients with transmissible oral lesions in their acute phase (e.g. herpes) will not be treated.
• Clean and prepare external facial tissues if indicated to prevent contamination of gloves by the patient's skin.
• Protect patients' eyes during any treatment that may make them vulnerable to splatter or debris, or to injury by sharp instruments.

• Patients judged to have an increased risk of bacterial endocarditis or other systemic infection should be medicated prophylactically according to the most recent American Heart Association guidelines, unless they are already protected by clinically equivalent antibiotic therapy for an active infection.

• Before treatment, the patient will rinse with an antiseptic mouthwash to reduce the spread of microorganisms.
• During the data collection phase of the appointment, students will use laminated charts and transfer data after patient dismissal. Meticulous care should be taken to prevent contamination of the records. During screening sessions an assistant will record data.
• Instruments will be wiped with wet gauze after sharpening (when sharpening before or during the appointment).
• During treatment, instruments will be wiped on gauze squares. Soiled gauze squares will be placed in a plastic cup on the bracket table.
• When rinsing the treatment area, water followed by air spray should be used rather than a combined air-water spray.
• The high-velocity evacuation system will be utilized for ultrasonic, air-polishing and turbine procedures.
• A rubber dam will be used whenever possible.
• The operator will avoid entering drawers or cabinets, and leaving the operatory once the gloves have been contaminated.
• Gloves may be rinsed with water alone to remove blood during treatment.
• Care will be used when passing and receiving sharp instruments.
• Needles will not be bent, broken or otherwise manipulated by hand. When recapping the needle, the "scoop" method will be utilized. Uncapped needles will not remain on the instrument tray. Using hemostats, the capped needle will be removed from the syringe and placed in the red puncture-resistant container located in Dr. Nunley's cubicle or in the sterilization cubicle.

4. Posttreatment Phase

• Contaminated (visible blood) gloves will be washed, previously indicated, and removed. Upon completion of a handwash, the operator will don utility gloves.
• All disposable barriers and or instruments will be used only once and disposed following use in the appropriate container.
• All items not protected by barriers, will be cleaned and disinfected as prescribed in V.2. of this plan.
• Contaminated instruments will be placed in a 2% glutaraldehyde solution located in the unit bard parker. The instruments will remain in the solution for 20 minutes in order to disinfect before scrubbing with detergent to remove debris. The instruments will then be rinsed, thoroughly dried, and packaged for sterilization or when instrument trays are used they will be run in the ultrasonic for 16 minutes with instrument cleaner then rinsed, wrapped and autoclaved.
• If not covered with the polyethylene bag, the dental chair including arm rest and operator stool will be disinfected with an EPA approved disinfectant, and conditioned with Tannery^TM.
• All handpieces, handpiece sleeves, air/water syringes, suction hose ends, and unit controls that cannot be autoclaved will be sprayed and scrubbed with an EPA approved disinfectant/sterilant and left wet.
• All non-autoclavable, non-disposable items will be scrubbed with an EPA approved disinfectant, rinsed, dried and soaked in a 2% glutaraldehyde solution for 10 hours.
• Water lines of the dental unit and ultrasonic scalers will be flushed for 3 minutes.
• Bag covering the unit foot controls will be changed daily.
• Suction hoses used during treatment will be flushed with water for 3 minutes, the suction basket will be removed and scrubbed clean, and the saliva ejector screen will be cleaned in the ultrasonic. Or-Evac^TM, the suction system cleaner, will be run through the suction hoses weekly.
• When decontamination and disinfection of cubicle and all contaminated areas is complete, operator will wash and dry utility gloves and wet with surface disinfectant prior to removal of utility gloves. In preparation for a second patient operator performs a 15 second handwash and begins cubicle set up.

5. Radiology

• Students will remove contaminated gloves and wash hands before leaving the operatory to take the patient back to x-ray.
• The patient's medical history will be evaluated for indications of infectious disease.
• Personal protective equipment will be worn during placement, exposure and development of radiographs.
• Hands will be washed prior to donning gloves.
• Students will remove the prepackaged films from the lead lined box using an aseptic technique.
• The tray setup for the patient will include the appropriate number and type of films, and sterilized x-ray equipment. The tray will be covered until used.
• The patient's charts and forms will be kept away from the work area. Entries in the charts and forms will not be made with contaminated gloves.
• The control panel, chair adjustments, tubehead, and positioning indicating device will be covered with plastic wrap or a polyethylene bag, or cleaned and disinfected as outlined above.
• The arms, rings and biteblocks will be autoclaved.
• Contaminated films will be placed in a plastic cup immediately following exposure.
• Vinyl gloves, provided by the dental hygiene department, will be worn in the darkroom when handling contaminated films. Packets will be opened and films will be spilled out onto a clean surface. After all packets have been emptied, gloves will be removed and films will be placed on the film holder. Hands will be washed upon leaving the darkroom.
• Vinyl gloves, provided by the department, will be worn when using the automatic developer. The plastic cup containing the exposed films will be placed inside the loader and the lid will be closed. Clean gloved hands will be inserted through the light shield, films will be unwrapped and spilled onto the clean surface inside the loader. Waste from the film package will be placed in the plastic cup. Gloves will be removed leaving them inside out, and put in the plastic cup. Films will then be placed in the loader for developing. Hands will be removed from the automatic processor, the lid will be removed and the cup of waste placed in the trash. Hands will be washed.
• Processed x-rays will be handled with clean hands.

6. Dental Laboratory

• Students will use disposable or autoclavable impression trays.
• Patients will rinse with an antiseptic mouthwash prior to inserting the impression trays.
• Alginate impressions and wax bites will be rinsed free of blood, saliva and debris, sprayed with disinfectant, wrapped and left wet for 10 minutes.
• Other impression materials will be disinfected according to the manufacturer's instructions.
• All metal impression trays, knives and waxing instruments will be cleaned (wax removed with steam) and autoclaved.

VI. Sterilization and Disinfection

1. Sterilization

• Critical and semi-critical items (penetrate soft tissue or contact mucous membranes) are autoclaved whenever possible. Instruments that are heat sensitive will be prepared for sterilization and immersed in an EPA approved disinfectant/sterilant solution for the contact time specified by the manufacturer.
• The dental hygiene department currently has a small autoclave in the supply room. A larger autoclave in the Department of Health Sciences is also utilized to sterilize the instruments in a timely manner. Safety Supervisor, Halvie Miller, Ralph Coffman, and the student clinic assistants are responsible for autoclaving the instruments and supplies.
• As recommended by the American Dental Association and the Centers for Disease Control, sterilization will be verified weekly using a biological indicator. A biological indicator will be utilized to test each autoclave that is routinely used for sterilization to ascertain that the equipment is functioning properly. Manufacturer's instructions will be carefully followed to ensure accurate test results. Verification records will be kept on each autoclave that is routinely used by the department.

2. Disinfection

• An EPA registered disinfectant/sterilant will be used for high-level disinfection. An EPA approved hospital disinfectant with a claim for tuberculocidal activity will be utilized for intermediate-level disinfection. The mixing, dilution, replenishing, monitoring and changing of the solutions will be performed by the student clinic assistants under the supervision of Kathy Shorter. The concentration of the glutaraldehyde solutions will be tested weekly by the clinic assistants.

VII. Monitoring Sterilization and Disinfection

1. Faculty

• The clinical faculty will be responsible for monitoring and assuring compliance of the this infection control plan within their respective sections on a daily basis.

2. Clinical Safety Supervisor

• The Safety Supervisor will supervise the sterilization of instruments and supplies, as well as the verification of sterilization. Additionally, the supervisor will supervise the mixing, monitoring and replenishing of chemical solutions used for sterilization and disinfection, the daily maintenance of the operatory suction systems, and the students' unit disinfection procedures.

VIII. Housekeeping

1. The window sills and operatory ledges will be dusted daily. Operatory ledges will not be used as storage areas.
2. The cubical walls will be scrubbed clean approximately every 6 months or when visibly soiled.
3. The cubicals will be cleaned and disinfected daily. The trash receptacle area is to be considered contaminated at all times.
4. At the end of each semester, the cubicals, x-ray units, supply room and common areas will be thoroughly cleaned, disinfected and restocked following the daily protocol in Dental Hygiene Clinical Handbook, 3rd ed..
5. Non-infectious departmental trash will be emptied daily by the custodians.
6. Departmental restrooms will be routinely cleaned by the custodians.
7. The clinic floor will be mopped by the custodians as warranted.
8. Blood Spills will be cleaned as follows:

• Fluid-resistant clothing, mask, utility gloves and glasses will be worn by persons cleaning the spill.
• The spill will be decontaminated for 10 minutes with an EPA approved chemical germicide, cleaned up with disposable paper towels, and contaminated again with a chemical germicide.

IX. Non-Routine Tasks

• The faculty, staff and/or students performing non-routine tasks will evaluate the risk of contacting blood or body fluids during the task, and don the personal protective equipment necessary to prevent an occupational exposure.

X. Follow-up Procedures After Possible Exposure to HIV/HBV

1. HIV (as recommended by the Centers for Disease Control)

• Following a mucous membrane, percutaneous or cutaneous exposure to blood or body fluids, Dr. Rebecca Nunley will be notified and she will inform the source patient of the incident. Department of Dental Hygiene Protocol for Post-
• Exposure Potential HIV (AIDS) Virus Infection in Employees, Students, and Trainees form will be utilized.
• Dr. Nunley, will question the patient to determine whether there are any risk factors for HIV. The information obtained from the interview will be confidential.
• If the interview with the patient reveals any potential risk factors for HIV, Dr. Nunley will request that the patient be serologically tested for HIV. If the patient does not agree to the testing or tests positive for HIV, the exposed individual will be serologically tested as soon as possible after the exposure. The Regional Health Department will perform the serological tests.
• If the interview does not disclose any risk factors for HIV, the decision about serological testing will be left to the exposed individual.
• The exposed individual should report and seek a medical evaluation for any acute febrile illness (characterized by fever, rash or lymphadenopathy) that occurs within 12 weeks following the exposure.
• Seronegative individuals should be retested 6 weeks post-exposure and on a periodic basis thereafter (e.g., 12 weeks and 6 months after exposure).
• If the source patient cannot be identified, the decision regarding proper follow-up care will be individualized.
• The same procedures will be followed in the event that the patient is exposed to the blood or body fluids of the health-care worker.

2. HBV

• Since all students, faculty and staff involved in patient care have been immunized against Hepatitis B, the treatment following a percutaneous exposure to blood will be dependent on the source of exposure and on whether the vaccinated person has developed anti-HB's following vaccination. The recommendations of the Immunization Practices Advisory Committee of the Centers for Disease Control (June 7, 1985, Morbidity and Mortality Weekly) will be followed.

XI. Waste Disposal

1. Infectious Waste

• Sharps will be placed in the red sharps container currently located in the supply room. Since few sharps are currently utilized in the department, a sharps container takes many months to fill. Therefore, the sharps in the container will periodically be covered with dental plaster to prevent an accidental injury. The filled sharps container will be closed, and transported to the ETSU, Student Health Clinic for disposal with their infectious waste.
• During the appointment, contaminated gauze or cotton rolls will be placed in a plastic cup on the bracket table. Care should be taken to avoid gauze saturation.

2. Non-Infectious Waste

• Non-infectious waste will be placed in the operatory waste receptacle. Following treatment, the operatory waste should be emptied into one large waste receptacle located on the clinic floor. The large can will be emptied daily by a gloved custodian.

XII. Miscellaneous Considerations

• Never return anything to the bracket table that has fallen on the floor or the patient.
• Do not allow patients to handle instruments from the bracket table, top of the mobile cart, or instrument tray.
• Never place non-sterile items such as hand mirrors, pencils. audio-visual aids, toothbrush kits etc. on the bracket table.
• During the day take a moment to sit in the dental chair any survey the cubicle. Does it look neat and clean to you? Personal items such as purses and books are allowed in the cubicle.
• Place the suction tips on their hoses in the patient's presence. Open all sterile packages in the presence of the patient, including the handpiece.
• Set out all the necessary instruments and supplies for your first procedure. All disposable supplies are to be dispensed prior to patient treatment and discarded at the end of the appointment.

XIII. Enforcement and Compliance

• It is the responsibility of the dental hygiene faculty in the respective sections to monitor, maintain and assure compliance of the sterilization and infection control procedures set forth in this policy.
• There can be no exceptions to these policies. A 30 day period will be allowed for all those engaged in patient care to become familiar with and comply with regulations. Thereafter, continued patient care privileges will be contingent upon compliance.