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Handpiece Asepsis

Sterilization of Heat-Labile Items

Other Methods of Sterilization

Sterilization of Prion-Contaminated Instruments

Properties of Decontamination and Sterilization Equipment and Products

Review Questions

Selected Readings

14 Surface and Equipment Asepsis

Types of Environmental Surfaces

Surface Barriers

Precleaning and Disinfection

Equipment Decontamination

Aseptic Distribution of Dental Supplies

Review Questions

Selected Readings

15 Dental Unit Water Asepsis and Air Quality

Dental Unit Water

Presence of Microorganisms in Dental Unit Water

Types and Importance of Microorganisms in Dental Unit Water

Biofilm in Dental Water Lines

Need to Improve Dental Unit Water Quality

Current Infection Control Recommendations

Dental Unit Water and Infection Control

Approaches to Improve Dental Unit Water Quality

Water Quality Monitoring

Boil-Water Notices

Backflow Prevention

Dental Unit Air

Review Questions

Selected Readings

16 Aseptic Techniques

Touching of As Few Surfaces As Possible

Minimization of Dental Aerosols and Spatter

High-Volume Evaculation

Saliva Ejector

Use of the Rubber Dam

Preprocedure Mouth Rinse

Use of Disposables

Safe Injection Practices

Housekeeping and Cleaning

Other Aseptic Techniques

Review Questions

Selected Readings

17 Laboratory and Radiographic Asepsis

Laboratory Asepsis

Radiographic Asepsis

Review Questions

Selected Readings

18 Waste Management

Comprehensive Waste Management Plan

Types of Waste

Infectious Waste Management

Blood in a Liquid or Semiliquid Form

Pathogenic Waste (Teeth and Other Tissues)

Sharps

Review Questions

Selected Readings

19 Sharps Safety

Risks From Sharps Injuries

When Can Injuries Occur?

Prevention of Sharps Injuries

Safe Injection Practices

Review Questions

Selected Readings

20 Asepsis Protocols, SOPs, and Checklists

Safety Culture

Behind the Scenes

General Preparation

Before Seating the Patient

After Seating the Patient

During Patient Treatment

After Patient Treatment

Radiographic Asepsis

Laboratory Asepsis

Review Questions

Selected Readings

21 General Office Safety and Asepsis

Be Prepared

The Reception Area

Contamination From Outside

Walk Throughs

Review Questions

Selected Readings

Greener Infection Control

Going Green

Adverse Environmental Impacts

Recycling and Biodegradation

Green Indicators

Evaluating Specific Infection Control Procedures

Summary of Procedures for Greener Infection Prevention

Final Comments and Futuristic Thinking

Review Questions

Selected Readings

23 Cross-Contamination Between Work and Home

Routes of Spread From the Office to Home

Routes of Spread From Home to the Office

Review Questions

Selected Readings

Part III Office Safety

24 The Occupational Safety and Health Administration

Mission of the Occupational Safety and Health Administration

Purposes of the Occupational Safety and Health Administration

Coverage of the OSHA Act

Standards

Standards Development

State Safety and Health Programs

Department of Labor 2014 to 2018 Strategic Plan

Strategic Challenges

Review Questions

Selected Readings

25 OSHA Inspections

About OSHA

Inspection Priorities

What Does the Inspection Process Involve?

What Are the Possible Outcomes of an Inspection?

Proactive Thinking

Review Questions

Selected Readings

26 Management of the Office Safety Program

Infection Control Coordinator

Management Duties

Development of Standard Operating Procedures (SOPs)

Evaluation of the Infection Control Program

Review Questions

Selected Readings

27 Managing Chemicals Safely

Hazard Communication Program

Statement of the Problem

Occupational Safety and Health Administration

Hazard Communication Standard

Hazard Classification

Written Hazard Communication Program

Inventory and Listing of Hazardous Chemicals

Labels and Other Forms of Warning

Safety Data Sheets (Formerly Known As Material Safety Data Sheets)

Employee Information and Training

Trade Secrets

How the Occupational Safety and Health Administration Solves a Problem

Occupational Exposure to Hazardous Chemicals in Laboratories

Compliance

General Principles for Working With Laboratory Chemicals

Chemical Hygiene Responsibilities

Laboratory Facilities

Chemical Hygiene Plan

Working With Chemicals

Safety Recommendations

Review Questions

Selected Readings

28 Employee Fire Prevention and Emergency Action Plans

29 CFR Parts 1910.38 and 1910.39

Fire Prevention Plans

Emergency Action Plans

Alcohol-Based Hand Rub Solutions

Review Questions

Selected Readings

29 Infection Control Concerns During Remodeling or Construction

Statement of the Problem

Strategic Planning

Making Construction Policy

Construction and Remodeling

Moving In

Review Questions

Selected Readings

30 Transmission of Pathogens in Dental Settings

Transmission of Herpes Virus in a Dental Setting in the United States

Transmission of Pseudomonas aeruginosa to Dental Patients in England

Transmission of Legionella pneumophila to a Dental Patient in Italy

Transmission of Hepatitis B in Dental Settings

Spread of Hepatitis B From Patient to Patient in the United States

Transmission of Hepatitis C Virus From Patient to Patient in Oklahoma

Transmission of HIV to Dental Patients

Transmission of Waterborne Mycobacterium abscessus to Pediatric Dental Patients

Other Infection Control Breaches

Review Questions

Selected Readings

Appendix A Infection Control and Hazardous Materials Management Resource List

Dental-Related Organizations

Infection Control Organizations

Other Infection Control Websites

Federal Agencies

States With OSHA-Approved Programs

Appendix B CDC Guidelines for Infection Control in Dental Health Care Settings—2003

Recommendations

Reference

Appendix C CDC Guidelines for Prevention of Tuberculosis in Dental Settings

Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings, 2005‡

Appendix D Organization for Safety, Asepsis, and Prevention

Mission Statement

OSAP's Vision

OSAP's Guiding Principles

Membership

Programs and Products

Appendix E Exposure Incident Report

Appendix F Infection Control and the American Dental Association (ADA)

Summary of the ADA's Statement on Infection Control*

Appendix G The Occupational Safety and Health Administration Bloodborne Pathogens Standard*

XI The Standard Part 1910-[Amended]

Appendix H The Occupational Safety and Health Administration Hazard Communication/Globally Harmonized System Regulatory Text—2012*

Glossary

Index

Copyright

3251 Riverport Lane

St. Louis, Missouri 63043

INFECTION CONTROL AND MANAGEMEMT OF HAZARDOUS MATERIALS FOR THE DENTAL TEAM, SIXTH EDITION

ISBN: 978-0-323-40061-9

Previous editions copyrighted 2014, 2010, 2005, 1998, 1994 by Mosby, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the Publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Various materials within were reprinted with permission of Organization for Safety, Asepsis and Prevention (OSAP). OSAP is a

nonprofit organization providing information and education on dental infection control and office safety. For more information, please call 1-410-571-0003 or go to www.OSAP.org.

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Names: Miller, Chris H. (Microbiologist), author.

Title: Infection control and management of hazardous materials for the dental team / Chris H. Miller.

Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2018] | Includes bibliographical references and index.

Identifiers: LCCN 2016048959 (print) | LCCN 2016050617 (ebook) | ISBN 9780323400619 (paperback. : alk. paper) | ISBN 9780323484282 (E-book)

Classification: LCC RK52 (print) | LCC RK52 (ebook) | NLM WU 29 | DDC 617.60028/9–dc23

LC record available at https://lccn.loc.gov/2016048959

Senior Content Strategist: Kristin Wilhelm

Content Development Manager: Ellen Wurm-Cutter

Content Development Specialist: Katie Gutierrez

Publishing Services Manager: Deepthi Unni

Project Manager: Radhika Sivalingam

Designer: Patrick Ferguson

Dedication

This edition of Infection Control and Management of Hazardous Materials for the Dental Team is dedicated to my wife, Sharon, and to my brother, Dr. David Lee Miller, whose devotion to dentistry and love of life was matched by few and admired by all.

Reviewers

Kathy Eklund RDH, MHP

Director of Occupational Health and Safety

Patient Safety Advocate

The Forsyth Institute

Cambridge, Massachusetts

Therese M. Long MBA, CAE

Executive Director

Organization for Safety, Asepsis and Prevention (OSAP)

Atlanta, Georgia

Preface

Because we cannot yet cure or immunize against all infectious diseases, we must continue to rely on infection control (infection prevention) procedures to contain, interrupt the spread of, remove, or kill potentially harmful microbes. Even if we can cure a particular infectious disease, it's better to prevent it from occurring rather than risk serious primary or secondary damage to the body. Infection control also plays a key role in attempts to initially manage newly discovered microbes and emerging diseases for which cures or vaccines do not exist. Several emerging and re-emerging diseases have occurred since the first edition of this text in 1994. They include West Nile virus infection, Severe Acute Respiratory Syndrome (SARS), Ebola virus disease, Middle Eastern Respiratory Syndrome (MERSCoV), and Zika virus infection. In addition, there have been at least 19 newly discovered microbes associated with human disease in the last 23 years.

The role of infection control in dentistry continues to be of paramount importance for there have been a handful of documented incidents in dental clinics when infection control procedures were ignored and disease spread occurred. So, infection control is here to stay, and in dentistry it plays a key role in protecting the dental team from occupational diseases and in protecting patients from health care–associated infections.

New to This Edition

This edition continues to emphasize basic concepts of microbiology and infectious disease spread to facilitate a better understanding of prevention approaches and to serve as a foundation for development of new ideas. In addition to updating all chapters, I've added new items:

• Two NEW chapters:

• Chapter 9: Preparing for Patient Safety and Occupational Health includes how to develop a safety culture, how to set the stage for safe patients visits, and describes how infection control benefits the dental team and patients.

• Chapter 30: Transmission of Pathogens in Dental Settings describes how ignoring infection control procedures has led to documented disease transmissions in dental facilities.

• The updated infection control recommendations for dentistry from the Centers for Disease Control and Prevention.

• New information on hepatitis C, Ebola, Mers-CoV, “super bugs,” Zika, and emerging viruses.

• Infection control standard operating procedures and checklists for evaluating safety programs.

• Tips for the infection control coordinator to help manage and evaluate an infection control and safety program.

• New figures to help explain the chain of infection, a safety culture,

spread of pathogens from patients' mouths, and disease transmission in dentistry.

• Storytelling with more than 30 Case Scenarios that provide teaching cases of infection control and safety breaches in dental facilities.

Discussions describing related potential consequences, prevention, and regulations and recommendations are available on the related Evolve website.

Learning Aids

I've maintained several teaching/learning aids including:

• Easy-to-follow, step-by-step procedures to assist in performing infection control and safety, each having a specific goal, rationale, and a list of needed supplies and equipment.

• Summary boxes, tables, and full-color photographs to help visualize information for quick learning.

• Review questions at the end of each chapter to help ensure an understanding of the information.

• Learning objectives and selected references are given for each chapter to facilitate learning.

• Appendices include regulations and recommendations for infection control and management of hazardous materials.

• Glossary with over 450 terms.

Evolve

On the book's Evolve website, there are several ancillaries available for the instructor:

• Test Bank: Approximately 600 questions with accompanying rationales for correct and incorrect responses, page-number references for textbook remediation, and mapping to DANB's Infection Control Exam (ICE) blueprint categories

• Image Collection: All the text's images available electronically for download into PowerPoint or other classroom lecture formats

• TEACH Instructor Resource Manual: Guide for instructors featuring the following:

• TEACH Lesson Plans for each chapter with all content mapped to accreditation standards and chapter objectives

• TEACH PowerPoint presentation slides for each chapter with points for discussion

• TEACH Student Handouts with lecture summaries for distribution

• TEACH Answer Keys for chapter review questions and case scenario discussion guidelines

Additionally, for students, the following are included:

• Practice Quizzes: Approximately 300 multiple-choice questions with instant-feedback answers, rationales, page-number references for remediation, and mapping to DANB ICE blueprint categories

Acknowledgments

I thank Charles John Palenik for his excellent contributions to early editions of this text. His expertise will long be appreciated. I also thank many other colleagues for sharing their expertise with me and continuing to excite me about infection control. My interactions with dentists, dental hygienists, dental assistants, laboratory technicians, manufacturers, distributors, and government and military personnel continue to challenge me in attempts to answer their questions and concerns. My gratitude also is extended to my colleagues at Elsevier for helping to make my words come to life. I will be ever grateful to my past students who always stimulated my mind and feelings.

Chris H. Miller

PART I The Microbial World

Scope of Microbiology and Infection Control

LEARNING OBJECTIVES

After completing this chapter, the student should be able to do the following:

1. Describe the role of microorganisms in infection control.

2. Describe the early beginnings of microbiology as a science and the early procedures used to control microbes and prevent infectious diseases.

3. List the beneficial activities of microbes.

Role of Microorganisms in Infection Control

Microbiology is the study of small life forms, including bacteria, special fungi called molds and yeasts, protozoa, certain algae, and viruses. Several subdisciplines within microbiology, such as bacteriology, mycology (study of fungi), protozoology, and virology, concentrate on specific types of microorganisms or on the activities of selected microorganisms, such as those important in the fields of medical microbiology, dental microbiology, food microbiology, industrial microbiology, and environmental (aquatic, soil, sewage, and space) microbiology. Close relationships also exist between microbiology and the fields of immunology (study of the immune system) and biochemistry (the chemistry of life forms).

The field of infection control (preventing microbial contamination and infection) is seated deeply within the discipline of microbiology. In fact, microbiology had its beginnings as a science concerned with the control and identification of microorganisms in an attempt to explain and prevent disease. An understanding of the physical and chemical properties of microorganisms, where microorganisms exist, how they grow, how the environment or special physical and chemical agents influence microorganisms, and how microorganisms cause specific diseases of concern form the basis for killing microorganisms and understanding and preventing their spread from person to person. Also, a general knowledge of immunology and body defense mechanisms contributes to the understanding of disease prevention through immunization and reliance on the natural barriers of the body against infection.

Discovery of Microorganisms and Infection Control Procedures

Diseases were recognized long before their causative agents. In 1546 the Italian physician Girolamo Fracastoro is generally credited as being the first to recognize the existence of tiny living particles that cause “catching” (contagious) diseases by spreading via direct contact with human beings and animals and via indirect contact with objects. Because microorganisms are too small to see with the naked eye, their actual existence was not established until Antoni van Leeuwenhoek first observed what he called “animalcules” (bacteria, yeasts, and protozoa) in 1667. The microorganisms became visible when he observed tooth scrapings and gutter water under a simple microscope.

The relationship of these “little animals” to disease was not established until “The Golden Age of Microbiology” in the mid- to late-1800s by researchers such as Louis Pasteur (France), Robert Koch (Germany), Ignaz Semmelweis (Austria), Oliver Wendell Holmes (United States), Lord Joseph Lister (England), and Willoughby D. Miller (United States), who became known as the “Father of Oral Microbiology.” By 1900 microorganisms known as bacteria had been described and recognized as the cause of numerous diseases such as anthrax, diphtheria, tuberculosis, cholera, tetanus, leprosy, epidemic meningitis, gonorrhea, brucellosis, pneumonia, abscesses, food poisoning, dental caries, and periodontal diseases.

The Golden Age of Microbiology also brought about the basis for disease prevention through use of infection control procedures. Semmelweis in Vienna and Holmes in the United States first recognized the importance of handwashing to prevent the spread of disease agents. Pasteur and John Tyndall recognized the use of heat to destroy vegetative bacteria and resistant bacterial spores. They used boiling water to kill bacteria, and the process known as pasteurization (destroying pathogens in milk or other fluids by heating it to 63°C [145.4°F] for 30 minutes or to 72°C [161.6°F] for 15 seconds) is still

used today. As a surgeon, Lord Lister became concerned about postoperative infections and demonstrated that boiling instruments and washing his hands and surgical linens with phenol before surgery greatly reduced complications. He also proposed that infections of open wounds were caused by microorganisms in the air, so he sprayed the air around his patients with phenol before surgery. These procedures were considered bold and outrageous at the time, but they truly paved the way for the sterile and aseptic techniques that now are practiced throughout the world.

The activities of the human immune defense mechanisms were recognized about four centuries ago when it became known that some individuals who recovered from a sickness did not contract that disease a second time. Edward Jenner is credited with recognizing the concept of immunization when he realized, in the 1790s, that milkmaids who caught cowpox, a mild disease, were protected from the more serious disease of smallpox. He injected the fluid from cowpox pustules into a healthy boy and later injected the boy with fluid from human smallpox lesions. The boy did not contract smallpox because the related cowpox gave him cross-immunity to smallpox. Placing someone at risk with this type of experimentation is, of course, prohibited today.

Pasteur became known as the “Father of Immunology” for his work in developing immunization techniques against chicken cholera, anthrax in cattle, and rabies in human beings.

The viral diseases of polio, smallpox, and rabies had been described for centuries, but a microbial cause for these and other diseases was not apparent until 1898 when Friedrich Loeffler and Girolamo Fracastorius demonstrated that an agent smaller than bacteria unseen through the microscopes of the day caused foot-and-mouth disease in animals. For the next 40 years or so, a fierce scientific debate raged as to the nature of such small disease agents named viruses, the Latin word for poisons. Viruses that infected bacteria were discovered in 1915 and were named bacteriophages (“bacteria eaters”) in 1922. Then, in 1940, the electron microscope was developed, and Wendell Stanley at the Rockefeller Institute in Princeton, New Jersey,

published the first pictures of a virus magnified 35,000 times its normal size. This tobacco mosaic disease virus was first described erroneously as a large protein molecule. Today we know that viruses contain nucleic acids (RNA or DNA), a few molecules of enzymes, structural proteins, and sometimes lipids.

By 1943 viruses were described as the cause of smallpox, chickenpox, rabies, poliomyelitis, yellow fever, mumps, the common cold, hepatitis A, and influenza. Over the next 30 years, several other viruses were first isolated or seen through the electron microscope, including rubella virus, measles virus, Epstein-Barr virus, and other herpesviruses.

In 1967 Alper and Griffith proposed the existence of a new type of infectious agent composed entirely of protein as the cause of a rare degenerative brain disease in humans called Creutzfeldt-Jakob disease. Pruinser coined the term “prion” as a name for this protein in 1982. Today, we know that prions are not microorganisms but rather proteins able to induce abnormal folding of normal cellular prion proteins in the brain, leading to brain damage. Prion diseases are usually rapidly progressive and always fatal. Prions also cause brain diseases in animals such as bovine spongiform encephalopathy (“mad cow disease”).

Microbe hunters similar to Pasteur and Koch have been active throughout the history of microbiology and infection control. Within the last 40 years or so, new infectious diseases or the causative agents of recognized diseases have been discovered (see Chapter 4). Diseases will continue to emerge as new or renewed opportunities develop for microorganisms to associate with human beings and cause diseases. These diseases might result from closer interactions between the populations of the world and their unique diseases, changes in the disease-producing abilities of microorganisms, unknown factors that may enhance susceptibility of the body to microbial infections, lack of appreciation for maintenance of current vaccine programs and insect control projects, and enhanced complacency concerning personal hygiene and the general cleanliness of objects we contact.

Important Activities of Microorganisms

Microorganisms are actually more beneficial than harmful to the human race (Table 1.1), but we usually hear about or see only their harmful activities of causing diseases, spoiling food, occluding water lines, or destroying fabrics. Bacteria in the soil convert dead plants, animals, and insects into usable nutrients needed for the survival of live plants. Other soil microorganisms convert atmospheric nitrogen and carbon dioxide into forms that all plants require for growth. Bacteria also form the basis of modern sewage treatment by degrading the organic material in the sewage as it flows over or is mixed with bacterial masses in treatment plants. Also, bacteria are cultured in large vats to make several products such as vinegar, vitamins, alcohol, organic acids, enzyme cleaners, drain openers, antibiotics, insecticides, and special chemicals used in biomedical research. Microorganisms are used to make rubber products, tobacco, and spices, and are used in processing leather. Some bacteria are used to help clean up oil spills in the oceans because they can degrade the components of crude oil. Special fungi called yeasts make bread dough rise and are used in beer production. Bacteria and fungi are used to pickle cucumbers, to produce cultured dairy products such as yogurt and sour cream, and to make cheeses. Bacteria and yeasts also are used to synthesize special agents such as insulin, other hormones, and hepatitis B vaccines to treat or prevent the disease. When administered in adequate amounts, some microbes can confer a health benefit on a host. Such microbes are called probiotics. Examples of how probiotics are used include as drugs to help treat certain bacterial infections and as food ingredients and dietary supplements for humans and lower animals.

TABLE 1.1

Examples of Beneficial Activities of Microorganisms