NAVY RESERVE DENTAL CORPS

INFECTION CONTROL SOP

March 1, 2017

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TABLE OF CONTENTS

CHAPTER 1- GENERAL INFORMATIONIntroductionResponsibilitiesTraining

CHAPTER 2- STANDARD PRECAUTIONSIntroductionDiscussionHBV Immunization Personal Protective Equipment and Barrier TechniquesPreparation of the DTRPatient TreatmentSecuring the DTRHousekeepingMaintenanceBio-Hazardous Waste

CHAPTER 3- HAND WASHINGIntroductionAntiseptic SoapsAlcohol Based Hand RubHand Washing Facilities and Hand Cleansing AgentsDispensersHand Washing Techniques

CHAPTER 4- STERILIZATION PROTCOL AND TRAININGIntroductionProper Central Sterilization Design of the CSRSterilization ProceduresStaff TrainingCentral Sterilization Room Training Program

CHAPTER 5- STERILIZATION MONITORING Introduction Types of Sterilization Monitoring Guidelines for Biological Monitoring Guidelines for Dosage and Process Indicators

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CHAPTER 6- DISINFECTIONIntroductionLevels of DisinfectionFactors Influencing Disinfection ProceduresChemical sterilization Chemical DisinfectionSemi-Critical Items Required Chemical DisinfectionNon-Critical Items Required Chemical Disinfection

CHAPTER 7- INFECTIOUS WASTE Introduction DefinitionsHandling of Medical WasteHandling of Amalgam WasteDocumentation and Disposal Clean-up of Infectious Waste SpillsTraining Forms

CHAPTER 8- LATEX ALLERGY/SENSITIVITY GUIDELINESIntroduction

ActionDiscussionRecognitionDiagnosisTreatmentPrevention

CHAPTER 9- RADIOLOGYIntroductionHand washingSenor DevicesNOMAD Bit PegsSemi-Critical DevicesRadiology ChairRadiology Unit Exposure Switch and Tube-head

APPENDIX A- Definitions and Suitability of Sterilization Packaging Materials

APPENDIX B- Links to References

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Chapter 1

GENERAL INFORMATION

1. Introduction. Infection control involves taking steps to prevent the spread of infectious agents. Developing a good infection control plan requires learning some of the basics about infectious diseases and the way in which they are spread in the dental environment. The Navy Reserve Dental Team practices in a myriad of unique settings. This SOP is designed to be comprehensive in order to cover all settings (MTF, NOSC or Field Setting) and all levels of treatment (T2 exams, restorative and surgical). Regardless of the setting we need to be conscious of the standard of care and hold each other accountable for the patient and our own safety. In the MTF setting you will be following established local protocols. However, in the NOSC or field setting it is incumbent on you to verify all aspects of the infection control process. This knowledge provides the background necessary for making responsible decisions about infection control work in areas where there is exposure to blood and/or other potentially infectious materials.

2. Responsibilities

a. Reserve Dental Corps Infection Control Officer

(1) Will be appointed in writing by the Deputy Dental Corps Chief, and have credentials or experience documenting the knowledge of infection control.

(2) Advise the CO and other officers on the infection control issues and practices.

(3) Address infection control functions quarterly, as part of the Navy Reserve Dental Corps Infection Control Program.

(4) Establish an on-going review and evaluation of overall local program development and monitor Reserve-wide implementation of the Infection Control Program as established by this program.

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(5) Ensure all Reserve Dental staff members receive a Navy Reserve Dental Corps orientation brief on infection control policies and infectious disease hazards in the work place.

(6) Ensure all Reserve Dental staff receive on-going training and are active participants infection control procedures.

(7) Submit a written report to the Deputy Dental Corps Chief assessing the Navy Reserve Dental Corps Infection Control Program annually.

(8) Review, revise and update this program annually to meet the guidelines of the Bureau of Medicine and Surgery (BUMED), Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), and the Environmental Protection Agency (EPA) to include:

(a) Any new procedures and employee positions that affect occupational exposure.

(b) Any changes in technology.(c) Annual consideration of safer medical devices.

b. Senior Dental Executives and Company CO’s (1) Ensure implementation and management of an infection

control program at each detachment in your command in accordance with the provisions of this program.

(2) Appoint, in writing, a Unit Infection Control Officer who will monitor, document, and manage the unit infection control program at each detachment. You will maintain copies of these appointment letters.

(3) Ensure that there are latex-free supplies in every detachment and encourage the use of non-latex products whenever practical.

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c. Unit Infection Control Officer

(1) Submit a written status report to the SDE/Company CO at the end of each quarter documenting, at a minimum, the quarterly status of the following Detachment Infection Control Program areas:

(a) Infection control indoctrination and training accomplished that quarter.

(b) Any other significant infection control items that need to be brought to leaderships attention.

(2) Assist in the management, monitoring, documentation, and oversight of all aspects of the Navy Reserve Dental Corps Infection Control Program.

(3) Conduct mandatory annual training on the Navy Reserve Dental Corps Infection Control Program.

(4) Conduct infection control training at least annually.

(5) Conduct latex sensitization training to all members of clinic staff.

(6) Ensure that all members are properly trained and have proper documentation.

3. Training

a. All staff personnel involved with dental exams or treatment at a Reserve Center or involving reserve providers, including active duty, will receive orientation training in the general principles of infection control within 90 days of joining a command, and at least annually thereafter. This information will be presented to attendees via lecture, PowerPoint, video, and/or open question/answer sessions. Indoctrination training will be documented using the Acknowledgement of Training Form. Annual training will be documented using the Report of Training form

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NAVRES 3500. The annual and indoctrination training sessions should include, but not limited to:

(1) The epidemiology and symptoms of blood-borne diseases.

(2) The modes of transmission of blood-borne pathogens and infectious diseases.

(3) An overview of the Battalion’s Infection Control Program.

(4) Recognition of tasks and activities that may involve exposure to blood and other potentially infectious material.

(5) The use and limitations of the practices that can prevent or reduce exposure, including proper engineering controls, work practice controls, and personnel protective attire and equipment.

(6) The types, basis for selection, proper use, location, removal, handling, decontamination and disposal of personal protective attire and equipment.

(7) Preparation of instruments for dry and moist heat sterilization.

(8) Mandatory information on the HBV vaccination including efficacy, safety, and administration.

b. All infection control training sessions will be documented as follows:

Date of training session Topic or summary of training conducted Names and qualifications of trainer Name and title of each attendee

c. Personnel must be offered HBV vaccination within 60 days of their initial assignment to a position involving exposure and after having received training in infection control. SDE’s/Company CO’s will ensure current immunization of personnel assigned within their commands.

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Chapter 2

STANDARD PRECAUTIONS

1. Introduction. Identifying potentially infectious patients by medical history, physical examination, and/or laboratory tests is not always possible. Several weeks may pass between the time a person becomes infected with a virus and the time when laboratory tests can detect the antigens or antibodies to it. In HIV infected individuals, this period may be months or years. Consequently, even if a patient tests negative, he or she may still be infectious. Dental personnel must assume that all body fluids and contaminated instruments and materials are infectious and must routinely use standard precautions to protect themselves and the patients.

2. HBV Immunizations and HIV Testing

a. Dental personnel who may be directly or indirectly exposed to blood and saliva will receive the HBV vaccine. Immunization against HBV involves a three-dose series of deltoid intramuscular injections.

b. Hepatitis B vaccination and HIV testing should be coordinated through the local NOSC Medical Dept.

c. All dental healthcare workers will have documented evidence in their medical record of: (1) HBV Immunization (three shot series). (2) MMR (two shot series if born after 1957). (4) HIV (Annually for all military personnel). (5) FLU (Annually for all military personnel). (6) HAV Immunization (two shot series for military only). d. The SDE/Company CO will verify each member of the dental treatment team has the proper immunizations using the Medical Readiness Recording System (MRRS) on a quarterly basis. Immunization status should be verified quarterly and reported to the Reserve Dental Infection Control Officer. The existence and location of medical record is required by OSHA.

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3. Medical History Review. Review the current medical history questionnaire with every patient prior to the initiation of any procedure or exam. A questionnaire is current if completed and signed by the patient during the past year. Obtain a medical consultation when the medical history reveals any condition that may contraindicate elective dental treatment. Patients with acute infectious diseases (TB for example) or those in the end stages of Acquired Immune Deficiency Syndrome (AIDS) require consultation with the appropriate medical specialists before elective treatment. Emergency treatment for relief of infection/pain or treatment of trauma may preclude prior medical consultation.

4. Personal Protective Equipment (PPE) and Barrier Techniques. Minimal levels of Personal Protective Equipment consist of gloves, facemask/shields, and eye protection (eyeglasses with solid side shields or a full face shield). PPE’s exposed to aerosol spray or splatter must be removed prior to entering a designated eating or lounge area. Scrubs are the ideal working uniform, to be worn under disposable gowns or linens. In the field setting the military uniform may be worn.

a. Disposable gowns will be worn by providers and Hospital Corpsmen whenever any aerosols are generated, or during any oral surgery procedures. The gown must cover the arms.Gowns must never be worn outside the Dental Treatment Room (DTR). At a minimum the gown will be changed daily, or when visibly soiled.

b. Eating, drinking, applying cosmetics, lip balm and adjusting of contact lenses in any DTR is absolutely forbidden, this also applies to DTRs not in use. Closed containers such as water bottles, coffee cups and other liquid/solid food containers cannot be stored anywhere in the DTR.

c. Gloves are worn whenever there is a chance of contact with blood, saliva, mucus membranes, or any item(s) contaminated with blood, saliva, or other potential infectious material (OPIM). They should be removed immediately following the completion of dental treatment and disposed of properly. Gloves are not authorized during record documentation, using the

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computer keyboard, or when outside the DTR, unless the contaminated instruments/packs are on route to the CSR. When a perforation occurs during patient treatment, they need to be removed immediately. Prior to donning a new set of gloves it is necessary to adhere to the hand washing protocol. Sterile gloves are used for all invasive procedures. After each patient gloves are discarded and hand washing protocol followed.

d. At the end of the work day, all contaminated linen and apparel should be place in appropriate and labeled containers.

e. Wear facemasks or full-length face shields with facemask are worn during any patient treatment and while working in dirty side CSR where aerosols or splatter are produced. Eye protection must be worn with the wrap around eye-shield facemask. Facemasks should be changed after each patient and when visibly soiled and not worn outside the DTR or CSR.

f. Protective eyewear are used when providing patient treatment or other procedures which may cause splatter or airborne particles. Eye protection is to be worn while cleaning the DTR and transporting instrument/packs to the CSR. Eyewear or goggles must have solid side shields to provide maximum protection. Patients must be provided approved protective eyewear. Patient eyewear should be disinfected after treatment.

g. Personnel must wear heavy duty rubber type gloves when handling contaminated instruments and in CSR/CSA.

6. Preparation of the Dental Treatment Room (DTR)

a. Begin each workday with hand washing for minimum of 15 seconds, or the latest CDC guidelines. Flush the dental unit handpiece hoses, three-way syringe hose, and ultrasonic line for at least one full minute at the beginning of each workday. Direct the spray into the high volume evacuator. This procedure minimizes the number of bacteria and algae in the water system due to stagnation and/or the retraction of possible residual contaminated water/saliva in the lines. Also, the system should be flushed again for 30 second at the end of each treatment session in the same manner as noted above.

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b. Dental Unit Water Lines (DUWL). DUWL monitoring and treatment must follow CDC Guidelines and EPA Standards. The water lines of ADAL units must be tested prior to shipment and must be shocked with an EPA recommended shocking agent prior to use.

c. Clear plastic barriers or impervious paper are used to cover contact surfaces that are difficult to disinfect (headrests, light handles, etc.) for each procedure. This will be a Battalion-wide procedure and indicates that the unit has been disinfected and is ready for use. Remove all barriers before removing gloves at the end of each procedure and when securing the unit. If these surfaces are not covered they must be thoroughly disinfected after each procedure and at the end of each day.

d. Unit dose is the quantity of materials or supplies required to treat a single patient. Adhere to unit dose guidelines when dispensing disposable items. Preferably, include expendable items, including cotton products in instrument packs before sterilization when possible. All items used in a patient care should be stored in closed cabinets or drawers. Sterilized packages of supplies like gauze/cotton tip applicators should be available for back up. When considering dental restorative materials, single unit dose are preferable and should be used where possible. Extra materials required during treatment should be available in packaged form, or must be retrieved without cross contamination with other materials or equipment. Cart drawers and cabinets should not be accessed with contaminated gloves. To retrieve needed items the use of the following methods; sterile cotton forceps/pliers, an over the glove barrier, etc. is recommended.

e. Mobile carts used for patient care should not be cluttered with excess materials. All mobile dental carts should have a drawer dedicated solely to store all materials needed for local anesthesia. Bulk items should not be stored in mobile carts. When absolutely necessary, bulk items may be kept in the lowest drawers away from the level of the doctor’s chest where the highest amounts of aerosols are found during a procedure. Unit dose packs should be kept in the uppermost drawers.

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f. Handpieces must be cleaned and sterilized in accordance with the manufacturer’s recommendations

g. Appropriate instruments and supplies must be readily available to begin treatment at the scheduled appointment time. Do NOT OPEN instrument packs, or supplies in advance of the patient being seated in the dental chair. Opened bulk supplies such as rolls of plastic wrap, boxes of gloves, towel packages, etc. are not to be left on the countertops. They should be stored in closed drawers. Check all sterilized instrument packs and packages to ensure they are intact and the external chemical indicator has changed to appropriate color (white to black).

h. Check all expiration dates for dental materials prior to use.

i. Once the patient has been seated, assistants may begin setting up the DTR for treatment. With clean ungloved hands, the wrap paper/towel encasing the instrument pack should be opened without directly touching the contents. Don gloves after proper hand washing. It is now permitted to handle the instruments in the instrument pack. All internal chemical indicator strips are checked for appropriate color change. Indicator strips are placed on the counter or bracket table so the dentist can verify chemical indicator color change.The chemical indicators are disposed only after the color change has been confirmed by both the dentist and the dental assistant. Instrument packs should not be open or unattended for extended periods before use.

j. The DTRs should be clutter free. Clutter free counter tops makes cleaning and disinfecting easier.

7. Patient Treatment

a. Ideally, patients should brush and/or rinse prior to dental treatment. Using a 0.12% Chlorhexidine or an over the counter mouthwash for 30 seconds significantly reduces oral microbial counts. Brushing with toothpaste also lowers the

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microbial count but is not nearly as effective. To do both is the most effective practice.

b. The use of a rubber dam is the single most important factor in reducing the microbial content of aerosols and should be used whenever possible. When used in conjunction with a high volume evacuator, the possibility of contamination during dental treatment is greatly reduced. Rubber dam is advised for use when possible and is mandatory for all endodontic procedures.

c. Instruments and handpieces are to be autoclaved. Single-use burs are recommended.

d. Dental records, radiographs, or other paper items should never be handled while wearing gloves. To prevent contamination, gloves must be removed and hands washed prior to making entries in the record or perform other tasks.

e. Strict adherence to the “one-handed scoop technique” for re-capping needles is mandatory. It is the responsibility of the dentist to re-cap needles. It is acceptable to re-cap needles using devices designed for this purpose. Bending or attempting to break or cut needles is strictly prohibited. Uncapped needles should never be left on the instrument tray, cassette or other working surfaces. Disposable plastic syringes, used dental anesthesia cartridges, scalpel blades, dull burs, suture needles, matrix bands, wedges and other “sharps” must be discarded in a sharp container.

f. Blood-borne pathogen exposure (needle/sharps or the pre-cutaneous punctures and lacerations) must be attended to immediately by washing the area with antibacterial soap. Mucous membrane/eye exposures must be flushed. Flush eyes for a minimum of five minutes. The exposed member of the team (dentist/hospital corpsman) and the source patient are then referred to the nearest medical facility. At shore this may be a Naval Hospital or facility nearest to the NOSC. Request assistance from your local NOSC. The SDE/Company CO must be notified immediately. A Management Variance Report, Supervisor Mishap Report and Safety Management Report, must be completed and

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forwarded to the unit CO and Reserve Dental Infection Control Officer, within 48 hours of the incident.

g. If a bulk supply item is needed during the procedure, use sterile cotton forceps or de-glove to retrieve the needed item(s). If de-gloving, don a pair of clean gloves after hand washing protocol is followed.

h. Upon completion of patient treatment, remove all clear plastic barriers, cassettes/instrument trays and hand pieces for cleaning and sterilization before removing gloves. Using the wipe-discard-wipe technique, clean all nearby aerosol exposed surfaces and “high touch” areas with an ADA approved high level disinfectant. Clean and disinfect patient’s, provider’s and assistants’ protective eyewear. Always wear gloves when handling contaminated materials or cleaning/disinfecting surfaces. Cover difficult to disinfect items as noted above. Remove gloves and mask then wash hands with anti-microbial soap once the room is cleaned.

i. Facemasks face shield or other coverings that are visibly soiled should be removed immediately, or as soon as possible. Never touch the soiled or splattered surfaces. Masks should be removed by the elastic strings and eye protectors by the sides of the frame.

j. Healthcare providers with weeping or bleeding skin lacerations or other lesions on the upper extremities, especially on the hands or face, must refrain from treating patients directly until the condition resolves or when cleared by a physician.

8. Securing the DTR

a. Clean and disinfect the high volume evacuator system and any other suction lines using an approved cleaning solution on a daily basis. Always follow the manufacturer’s directions.

b. Clean and disinfect patient and provider eyewear, all surrounding working surfaces and visibly spotted areas on the

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floor or walls using the spray-wipe-spray or wipe-discard-wipe technique as described in section 9

c. Remove gloves and wash hands unless performing equipment maintenance as described in section 10. Always follow the manufacturer’s directions.

9. Housekeeping

a. DTR’s must be kept neat, clean and above all, free of any items, such as personal belongings, not directly related to treatment. Items such as canisters or packages of gauze sponged should be stored in clearly marked closed drawers or in cabinets until needed. Adhere to unit dose principles and disposable items in preparing for dental procedures.

b. All surfaces and items exposed to aerosols, splatter, and high touch areas must be cleaned and disinfected between patient seating’s with an intermediate-level EPA registered disinfectant with tuberculocidal claims. These solutions are prepared in accordance with the manufacturer’s directions and are kept in stock containers bearing the expiration date of the solution, per manufacturer’s recommendation. Individual spray bottles kept in the DTR’s must also bear the correct expiration date. To be effective, the disinfectant must remain in contact with surfaces for the time recommended by the manufacturer. Avoid using gluteraldehyde products as surface disinfectants due to their caustic vapors and deleterious effects on certain materials.

c. The wipe-discard-wipe technique is recommended as to date, there are no suitable or acceptable one-step cleaner/disinfectant agents available. The wipe-discard-wipe technique is especially important for visibly splattered and stained surfaces and is accomplished between patient seating’s. The first wipe is directly on to the surface for 30 seconds. This first step constitutes the cleaning step. The second wipe is directly onto a pre-cleaned surface and allowed to remain visibly wet for three minutes before drying. This second step is the disinfection step.

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d. In addition this cleaning and disinfection procedure must be accomplished thoroughly at the end of the workday, regardless of the amount or degree of visible steps cannot be over emphasized.

e. Walls, floors and waste baskets contaminated with bodily fluids such as blood or saliva should be cleaned and disinfected as soon a practical with an approved disinfecting agent. PPE’s should be used as a minimal level of protection.

10. Maintenance

a. Using manufacturer’s direction, flush the high volume evacuator system (HVE) and saliva ejector (SE) with a non-sudsing evacuation system cleaner on a daily basis.

(1) This step is very important as several recent studies have shown that contaminated water containing saliva and debris from previously treated patients can flow backwards through the saliva ejector tubing potentially expose the patient to AIDS, Hepatitis B, tuberculosis, influenza and other diseases. This may occur when the patient closes his lips around the saliva ejector tip or actually sucks on it, especially if the vacuum is weak.

(2) Poorly maintained units decrease suction power on both the HVE and SE.

11. Bio-hazardous Waste

a. Bio-hazardous waste includes materials, such as cotton rolls and gauze sponges, generated during surgical procedures that spontaneously release blood or saliva when compressed or handled. All infectious waste will be placed in a red, leak-proof bio-hazardous waste bag, per reference (a). Small pieces of soft tissue, bone and teeth (without amalgam) are to be disposed of in a similar fashion. Extracted teeth containing amalgam should not be disposed of in regulated medical waste intended for incineration, but instead should be placed in a leak proof container intended for recycling. Teeth containing amalgam must be wiped off with either CaviCide soaked gauze for a minimum

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of three minutes or 1:10 parts bleach/water for 10 minutes. After disinfecting teeth, teeth may be placed within a contaminated amalgam scrap container. The bags are secured and placed in a covered leak proof container bearing the word biohazard and the universal biohazard symbol. Bio-hazardous waste bags may be stored for up to seven days in a designated rodent/animal proof storage room located near the pick-up point. The biohazard word and universal symbol must be placed outside of the area to designate it as an area containing such waste. Materials that do not meet the criteria noted above, such as surgical gloves, rubber dams, and patient napkins, are considered non-infectious and are handled as ordinary trash (see below).

b. Needles, scalpel blades, and other sharps, such as anesthetic cartridges, wooden wedges, matrix bands, etc., are considered infectious and are to be disposed of into closeable leak proof sharps containers colored red or marked with the universal biohazard word and symbol. Recapping must be performed using either the one handed scoop technique or a mechanical recapping device. Sharps containers must never be overfilled. Never force a sharp into a full container. When the sharps container is 3/4 full it is considered full and the container shall be closed and secured. Under no circumstance should Dental personnel transport the sharps containers after a support mission. The supported command or NOSC will take responsibility for proper securing and disposal of the sharps containers.

c. Non-infectious (Solid Medical) waste generated in procedures such as gloves, rubber dams, tongue depressors, etc. are disposed of in the same manner as ordinary trash. The use of ordinary plastic liners for trash cans is encouraged.

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Chapter 3

HANDWASHING

1. Introduction. Hand washing is considered to be one of the most important procedures in preventing health care associated infections. The purpose of hand washing is to remove resident bacterial and transient organisms acquired from contact with patients or environmental surfaces. For this reason, all jewelry such as rings, watches, and bracelets must be removed. Artificial fingernails and nail polishes are not permitted, as microorganisms are capable of growing between true and artificial nails and within cracks of nail polishes. Fingernails must be trimmed to a length not to extend beyond the fingertips and their undersurfaces must be clean.

2. Skin Flora. The skin harbors two types of flora, resident and transient. Resident organisms can survive and multiply on the skin, can be cultured repeatedly, are usually of low virulence and are not easily removed. Conversely, transient bacteria do not survive and multiply on the skin and are not firmly attached. It has been shown that the mere mechanical action of rubbing the hands together and rinsing them under running water is an important aspect in the removal of transient organisms.

3. Antiseptic Soaps. Studies have shown that soap containing chlorhexidine gluconate is unique in that it combines the broad spectrum of providone-iodine with the prolonged activity of hexachlorophene and provides the best immediate and prolonged reductions in resident and transient flora. It is also known to produce a very low incidence of secondary dermal reactions. Chlorhexidine gluconate appears to satisfy the objectives for an ideal initial hand-cleansing agent for surgical and routine clinical care (e.g., Hibiclens, Luroscrub, Excel). Soaps containing 0.75 percent povidone-iodine are also acceptable (e.g., Betadine).

4. Alcohol-Based Handrub (ABHR). Alcohol-based products can prevent the transfer of healthcare-associated pathogens. Studies have shown that alcohol based products to be more effective for standard hand washing or hand antisepsis by healthcare workers

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than soap or antimicrobial soaps. Must be at least 60% alcohol. Use ABHR between patients for routine dental care when hands are not visibly soiled. Apply ABHR to palm of one hand, rub hands together covering all surfaces for 15 seconds, until dry. Volume is based on manufacturer’s instructions.

5. Hand washing Facilities and Hand Cleansing Agent Dispensers

a. Ideally, sinks should have knee action manual faucet controls, electronic controls, or foot control lever for asepsis and ease of function. If knee-operated faucet, electronic controls, or foot control lever is not available you must follow step three under hand washing techniques. b. Hand cleansing agent dispensers should be of the non-refillable reservoir type with non-hand (knee, infra-red, or foot) operated controls to avoid potential contamination of the soap supply. Refillable foot operated dispensers may be used but as noted in reference (a), then must be emptied, disassembled and cleaned once a week. Bar soaps should never be used in clinical or common use areas. Certain microorganisms can actually thrive in certain soaps, the ingredients actually serving as a medium for them.

6. Hand washing Techniques. A rigid hand washing policy must be followed by all dental staff personnel.

a. Hand and Forearm Cleansing. At the beginning of each day, a thorough hand and forearm wash with an antiseptic soap should be accomplished. The same technique should be used throughout the day before and after patient care. Additionally, hands must be washed prior to leaving the DTR for a beak, lunch and at the end of the day before going home. The technique is as follows:

(1) Wash. Wet hands and forearms. Apply an antiseptic soap and wash hands and forearms. Clean under the fingernails using fingernails on the opposite hand.

(2) Rinse. Rinse hands and forearms thoroughly under running water. Some antiseptic soap tends to irritate the skin if not thoroughly rinsed off.

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(3) Dry. Dry hands and forearms with a clean paper towel. If a manual faucet, use a clean paper towel to turn off manual faucet. Discard the paper towel after use.

(4) Gloves. The use of gloves is required during patient care. The continued use of a single pair of gloves for all patients and glove washing is not permitted. The use of non-sterile non-surgical type of gloves is acceptable for use in non-invasive dental procedures. b. Surgical Hand/Forearm/Elbow Cleansing

(1) Wash. Wet hands, forearms, and elbows. Use an antimicrobial surgical product for the time specified by the manufacturer. Clean under the fingernails by using the fingernails of the opposite hand. Rinse thoroughly keeping the hands higher than the elbows. Dry them using a sterile towel. If a sterile towel is not available, dry with paper towel then apply ABHS following current CDC Hand Hygiene Guidelines or manufacture instructions.

(2) Gloves. Sterile gloves must be used in all invasive surgical procedures. Sterile technique must be adhered to when gloving for surgery.

Chapter 4

STERILIZATION PROTOCOL AND TRAINING

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1. Introduction. Because the handling of contaminated instruments presents a serious hazard to personnel, nearly all post-treatment/pre-sterilization handling of contaminated instruments ideally should occur in an area that is physically separate from patient treatment areas. However, when using an ADAL in a field environment, a space that is physically separated is not feasible therefore, an area will be designated for the Central Sterilization Area (CSA) as far away from patient treatment area as reasonable. The centralization of sterilization procedures improve safety and permit the standardization of sterilization procedures. Steam sterilization is preferable for all equipment and materials that can withstand high temperature. Steam sterilization is effective, easy to use, inexpensive, and readily monitored for effectiveness. Sterilization and the availability of sterile products for use in dental health care delivery depend on many factors. 2. Proper Central Sterilization Design. Critical elements of central sterilization include:

a. Dedicated Work Areas. The design and outfitting of a CSR must include areas for receiving, cleaning, processing, sterilizing, storage, and issuing.

b. Functional Flow of the Sterilization Process. A clearly established flow to minimize cross contamination hence dirty and sterile side or in the case of an ADAL dirty and sterile areas.

(1) Every effort should be made to correct any design flaws that does not promote a flow from dirty to sterile side/area. Only in the most extenuating circumstances can a field clinic make exceptions to this functional flow concept. The exceptions to the functional flow concept must be approved by the exercise OIC. Posted signs should mark the dirty side/area from the clean side/area.

c. Processing. Provide sufficient counter top space to prevent cross contamination and proper safety for personnel working in the CSA.

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d. Sterilization. The area must have proper space to allow loading and unloading the sterilizer without bumping into other structures.

e. Storage and Issuance. Provide appropriate storage and issue areas for sterile linen, instrument sets/cassettes, etc., to protect and maintain sterility. This area must be separate from contaminated or non-sterile items and labeled the Sterile Side.

3. PPE’s in the CSA. CSA personnel should wear the following at all times, when handling contaminated instruments and when processing instruments: Disposable gown, regular or non-latex gloves, facemask, safety glasses, and hair cover.

4. Clinical Protocols for Hospital Corpsman

a. Hospital Corpsman Responsibilities. Following patient care, carefully wipe gross cements. Temporary cements and blood off the instruments with a 4x4 gauze either soaked with CaviCide or alcohol. Instra-Clean an enzymatic cleaner can also be used to assist with the cleaning of instruments, in the DTR. Promptly take contaminated instruments to dirty area/side CSA/CSR. Contaminated instruments cannot be stored in the DTR while treating a different/new patient. Hospital Corpsman should inspect instruments closely for wear, breakage and cleanliness and inform the LPO if an instrument needs replacing.

b. Responsibilities in the CSA. Upon receipt of contaminated instruments, discard disposable items and place soiled linen in appropriate containers. Process instruments by: (1) Ultrasonic Cleaning. Immerse instruments in EPA registered high level disinfectant. The ultrasonic cleaning process is safer and more effective than manual scrubbing. Use baskets in ultrasonic unit to reduce instrument handling and improve cleaning efficiency. While unit is in use, keep lid in place to reduce aerosol production. Ultrasonic solution should be changed daily or when visibly soiled/cloudy.

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(2) Manual Scrubbing. This is the least desirable manner of instrument processing and should be avoided if at all possible. If necessary, scrub instruments while wearing heavy-duty nitrile gloves, facemask, eye wear, and hair cover. Keep aerosol production to a minimum.

c. Pre-sterilization Processing

(1) Inspection. Closely inspect instruments for wear, breakage, and cleanliness, sort instruments according to sets, packs or specialty departments. The less handling of instruments, the less chance of a blood-borne pathogen exposure.

(2) Packaging. Wrap and pack / or place instrument sets in approved pouches for all critical and semi-critical items prior to sterilization. Appendix A lists appropriate wrapping materials.

(3) Basic Rules for Proper Wrapping Technique

(a) Use trays when possible to prevent puncture of the packaging material and subsequent injury during handling. In the field environment instrument sets will be placed in pouches. Bulk sterilization is not authorized in the garrison or the field setting.

(b) Open hinged instruments such as forceps before sterilization so that steam may penetrate these areas.

(c) Use internal and external chemical indicators.

(d) Use appropriate wrapping material for instrument sets. Double wrap items not in heat or adhesive sealed packages. If using linen muslin wraps, launder between uses. Follow the appropriate mode of sterilization for the specific wrapping material used. See Appendix A. (e) Label all packs to show the load number, sterilization date, sterilizer number, and technician’s initials.

d. Sterilization

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(1) Sterilizer Loading. Loosely arrange packs in the sterilizer chamber so that steam may circulate freely among the packs. Cassettes should not be laid flat. Place packs on their side. (2) Steam Under Pressure Sterilization. Steam under pressure is the best means of sterilization for nearly all items found in dentistry. To ensure adequate sterilization, high temperature saturated steam must come into direct contact with all surfaces of all items for the appropriate length of time. Additional guidance includes:

(a) Proper loading of instrument packs and the use of perforated mesh trays allows air removal, steam penetration and condensate drainage.

(b) Always follow manufacturer instruction forsterilization method and sterilizing agent.

(c) Maintain a consolidated sterilization log for each sterilizer. Information in the log includes sterilizer identification number, sterilization date, duration/exposure time, temperature of cycle, Hospital Corpsman’s initials, biological monitoring results, repair and maintenance data (refer to Chapter 5).

(d) Allow sterile instruments and packs to cool before storage. Once the instruments are cooled, store them in a well-ventilated area with controlled temperature and humidity. Placing warm, wrapped, sterilized items on cool surfaces can induce condensation formation and result in contamination. Cabinets rather than open shelving are preferred.

(e) Sterilize rubber heat stable products in a steam autoclave. It is recommended to purchase pre-sterilized rubber products whenever possible.

(f) All critical items submitted for repair should be placed in a peel pack, labeled “For Repair” and sterilized. Make sure to include why the instrument is not working properly on the pack.

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(g) Never pre-load autoclave unless a load will be ran to minimize confusion of sterile vs. non-sterile instruments. e. Other Sterilization Methods

(1) Dry Heat Sterilization for Burs. Dry heat at temperatures above 320 degrees Fahrenheit will achieve sterilization. A typical dry heat cycle is 90 minutes at 340°F. Be sure to follow manufacturer’s instructions. Dry heat sterilizers must be set for 120 minutes, 30 minutes of pre-heat-up time and 90 minutes exposure time. Use chemical monitors in the bur/drill packs, conduct a biological monitor (BM) spore test weekly. Document the results for the BM spore test in the Dry-heat Biological Monitor Log.

(a) Diamond Specialized Endodontic Burs andImplant Instruments. Dry heat is the preferable way to sterilize these items. Burs should be wiped clean of debris in the DTR and returned to the CSR for processing and sterilization. Sterilize according to manufacturer’s recommendations. Use chemical monitors in each bur pack and run a spore test biological monitor weekly. Document the results for the spore test in the Biologic Monitor Log.

(b) Endodontic Files and Gates-Glidden Burs. Arrange files and burs in metal file boxes before steam sterilizing or place in glass tubes for dry-heat sterilization. If additional files or burs are necessary, use pre-sterile packs. Discard endodontic broaches (in the sharp’s container) after each single use.

(2) Liquid Chemical Sterilization. It is impossible to biologically verify chemical sterilization and is therefore not authorized for use in the 4th Dental Battalion.

(3) Sterilization Cycle Parameters. Exposure times, pressures and temperatures vary depending on the type of instruments, sterilizer and the wrapping material used to package the instruments. Personnel must follow the manufacturer’s instructions.

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5. Staff Training. All staff involved in Dental treatment will complete Sterilization and Infection Control. This program will familiarize personnel with the Navy Reserve Dental Corp’s infection control program, sterilization procedures and equipment.

6. Central Sterilization Room Training Program

a. The course curriculum is as follows:

(1) Introduction.

(a) The Central Sterilization Room and its function.

(b) Sterilization vs. Disinfection.

(c) Classification of Disinfectants.

(d) Classification of Dental Instruments

(2) The Sterilization Process.

(a) Functional Flow Concept.

(b) Instrument Processing Steps and Rationale.

(3) Occupational Hazards.

(a) Blood-borne Diseases and Transmission.

(b) Protective Attire and Standard Precautions.

(4) The Sterilization Steps.

(a) Various Sterilizing Methods.

(b) Sterilization Cycle, Time, and Temperature.

(c) Biological Monitors, their Function and Documentation.

(d) Sterilization Log Documentation.

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(5) Sterilizer Operation and Packaging.

(a) Chemical and Process Indicators.

(b) Instrument Wrapping.

(c) Dry Heat and Steam Sterilizer Operation.

(6) Medical Waste Management.

(a) Infectious vs. Non-Infectious Waste.

(b) Handling of Medical Waste.

(c) Spill cleanup.

(d) Documentation and Disposal of Waste.

Chapter 5

STERILIZATION MONITORING

1. Introduction. Chemical and biological monitoring of the sterilization process is an absolute requirement to ensure

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adequate exposure to the sterilant and proper sterilization of the processed items.

2. Types of Sterilization Monitors. These monitors are used as a quality assurance device to detect inadequate processes caused by human error or mechanical malfunction.

a. Biological Monitors (BM). The purpose is to evaluate the effectiveness of the sterilization cycle. The BM’s consist of bacterial endo-spores impregnated in paper strips or sealed in glass ampoules or plastic vials. The pre-packaged biological monitor should be placed on the bottom shelf directly over the drain. Test and Control BMs must be from the same lot number.

b. Chemical Indicators. These indicator “strips” are chemical dyes that change color when exposed to steam or dry-heat. They do not verify if sterilization has taken place, only if the pack has been exposed to steam or dry-heat.

c. Process Indicators. These indicator “tapes” are chemical dyes that change color when exposed to steam and dry-heat; and distinguish processed packages from unprocessed packages. They do not verify if sterilization has taken place.

3. Guidelines for BM. The purpose of biological monitoring is to evaluate the efficiency of specific sterilization cycles.

a. Frequency of Use.

Once per Drill WeekendFirst-three cycles after a repair For all implantable devicesWhen new packaging material is usedInitial use of a new sterilizerDuring training of new staff members

b. Specific BMs. Depending on the type of sterilizer used, the BM must consist of a microorganism that is highly resistant to the specific sterilant. For monitoring the effectiveness of steam sterilization, use a BM consisting of spores of Geo-

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bacillus stearothermophilus. For monitoring the effectiveness of dry heat sterilization, use a BM consisting of spores of Bacillus stearothermophilus. c. Test Procedures. Run all CSR loads according to this instruction and following the BM and sterilizer manufacturer’s instructions. When conducting a BM for the steam sterilizer the BM must be placed on the bottom shelf directly over the drain. For the dry-heat sterilizer BM test must be placed in the middle of the tray, on the lowest shelf.

d. Evaluation. Evaluate all results, including the control BMs, and properly document in the BM sterilization log. Results must be interpreted by a trained CSR technician. A test is satisfactory if the BM test is negative and the BM control is positive.

e. Positive BM Test Results. When a positive BM Test result occurs:

(1) Review procedures to determine if operator error could be responsible. Retest the sterilizer using biological, chemical, and mechanical monitors after correcting any procedural problems. Recall all items that were sterilized under the load number with the Positive BM test results and any other loads sterilized after the positive BM test. Secure the sterilizer from further use,

(2) If the results of the repeat BM test are negative and the chemical and mechanical tests are normal, the sterilizer can be placed back into service. All recalled items can be released for use in patient care. If the results still indicate positive growth or failure of sterilization, secure the sterilizer and notify the command for repair.

(3) Re-wrap and re-sterilize all recalled items from a positive BM test. If using a replacement sterilizer from repair, conduct a BM test on replacement sterilizer, a negative BM test result must be obtained prior to sterilizing instruments.

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(4) Make a narrative entry in the log of each action taken and the results as they occur.

(5) Once the sterilizer is repaired, retest the sterilizer. Three consecutive BM tests must be conducted in an empty chamber. Results of all three BM tests must be negative, before the sterilizer can be put back into service.

f. Disposal. After results have been read and properly recorded in consolidated log book. Dispose BMs into a sharps container.

4. Guidelines for Dosage and Process Indicatorsa. Use chemical indicators inside and process indicators

outside each instrument pack. Place chemical indicators inside the bur packs when sterilizing burs. When a chemical indicator fails to change colors notify the senior dental officer present. Closely monitor the temperature, pressure and exposure time of the load. Watch timer to be sure it does not start timing process until the correct temperature is reached. Watch for steam leaks in the sterilizer. If dosage indicator fails, notify the senior dental officer, log the results and secure sterilizer. The command should be notified so the sterilizer can be scheduled for repair.

b. Follow manufacturer’s instructions when using and reading the process indicators.

c. Biological Monitor and Sterilizer Compatibility. Bio-sign EZ-VU Test™ Packs and 3-M Rapid Read™ BM Test are used with steam sterilizers. The 3-M Rapid Read™ test are used when sterilizing implant kits, or after repairs have been conducted on the sterilizer. Spordi™, Steri-L Test™, or Ster-Spor™ are used with dry heat sterilizer. 5. Bowie-Dick test (S.M.A.R.T. test). This is a diagnostic test of a pre-vacuum sterilizer’s ability to remove air from the chamber and prevent air re-entrapment. This test must be conducted on all Pre-Vacuum steam sterilizers on a daily basis. If first test fails, conduct a second test. If second test fails, secure sterilizer, notify the senior dental officer

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present. This test cannot be conducted on a table-top sterilizer unless it is a pre-vacuum model.

6. Sterilizer Monitoring in the Field Setting

a. Beginning of exercise

(1) Perform a Bowie-Dick test (S.M.A.R.T. test) at the beginning of each exercise before seeing any patients. This will assure the sterilizer is working properly. BM should be completed 3 times if sterilizer is relocated.

(2) Perform a 3m Rapid Attest Spore test immediatelyafter the Bowie-Dick test to ensure proper sterilization.

(3) Log the results in the logbook with the Hospital Corpsman’s initials.

(4) Senior Dental Officer verifies logbook entries and initial log.

b. Middle of the exercise

(1) During the exercise, the Hospital Corpsman will perform a second test midway thru the exercise when not seeing patients. The Attest 3M, currently used in ADALs, requires 48 hours to read, treatment can continue while awaiting test results.

(2) The EXOIC must check the CSA Consolidated Log Book for proper documentation and verify each log sheet has the Hospital Corpsman initials.

c. End of the exercise

(1) Before the exercise is completely finish, the Hospital Corpsman will perform a final test to ensure the sterilizer is still good condition.

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(2) The EXOIC or senior dental officer will review the CSA logbook.

(3) Upon review of the CSA logbook, the EXOIC or senior dental officer will sign in the appropriate line to indicate that everything was done correctly and no issues where recorded. d. Documentation

(1) Consolidated Sterilization Log. This must be maintained for monitoring certain features of every cycle run by every sterilizer, monitoring the results of weekly biological (spore) testing and biological spore testing for implant kits, and monitoring the proper handling and disposal of infectious waste.

(2) Sterilization Log. Each ADAL will maintain a log depending on the exercise, to monitor all operations of each sterilizer unit, to include steam autoclaves and dry-heat claves. This also applies to table-top sterilizers. Information that must be recorded in the Sterilization Log includes: the sterilizer identification number (or name), the date each cycle is run, each day’s cycle/load number, the time the cycle was started and completed, the maximum chamber temperature, exposure time and its duration, and the Hospital Corpsman initials. For sterilizers without the capability to record their cycles, Hospital Corpsman must pay close attention to start and stop times and document the information accordingly.

(3) Spore Sterilization Log. A separate spore testSterilization log must be maintained for the steam sterilizer and the dry-heat sterilizer. Information to be recorded includes the date the test was conducted; the sterilizer ID number (or name), the cycle/load number, the temperature, exposure time, and duration of cycle, initials of Hospital Corpsman conducting the test and results of positive or negative growth in both the test and control capsules at 24 and 48 hours (one week results for Spore-test for dry-heat sterilizer).

(4)Bio-hazardous Waste Log. See Log Book for the proper content and format.

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Chapter 6

DISINFECTION

1. Introduction. No single agent is adequate for all disinfection procedures. The appropriate selection of chemical disinfectants depends on many factors, including the composition

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of the treated item, the degree of microbial kill required, and ease of use of available chemical agents. Regardless of the agent used, disinfection can occur if factors such as temperature, pH and contact time are followed as recommended by the manufacturer.

2. Levels of Disinfection. EPA classifies disinfectants as high, intermediate, or low level, based on the contact time of the solution and the bio-cidal activity of an agent against bacterial spores, mycobacterium tuberculosis, lipids and non-lipid viruses, and vegetative bacteria.

3. Factors Influencing Disinfection Procedures

a. Design. A smooth nonporous surface is relatively easy to disinfect as compared to a rough, absorbent material. Specific chemical agents may damage some materials due to their composition.

b. Bio-burden. The higher the level of microbial contamination, the longer the required exposure time. Resistant microbial sub-population will tend to control the required exposure time.

c. Amount of Organic Debris Present. Organic debris, such as blood and saliva, present on an instrument may alter the disinfection process by physically protecting the microorganisms and preventing contact with the disinfectant.

d. Concentration/Contact Time. The greater the concentration of a chemical agent, the greater its effectiveness and the shorter the exposure time required to disinfect. Altering the concentration will lead to unexpected results. The longer the disinfectant is in contact with an item the more effective the disinfection process.

4. Chemical Disinfection. More commonly used method, chemical disinfection eliminates all pathogenic organisms but not all bacterial forms.

5. Semi-Critical Items Requiring Chemical Disinfection

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a. Three-way syringe handles, light handles, dental unit controls, counter tops, and dental unit arm rest are considered semi-critical items. To properly disinfect these items read below:

(1) Thoroughly wipe clean the item with gauze saturated with an EPA registered disinfectant. Discard gauze. Re-wet the surface and allow the solution to remain in contact with the item for the time specified by the manufacturer.

(2) Covering these items with protective wrappings such as surface barriers and covers is much easier and highly recommended.

6. Non-critical Items Requiring Chemical Disinfection

a. Dental Delivery System (DDS) consists of the chair, unit, light, and dental assistant/dentist stools. To properly disinfect these items read below:

(1) Disinfect the chair daily. Change headrest covers after each patient.

(2) Disinfect hand-operated controls, and handles after each patient if these items are not covered.

(3) Follow manufacturer’s instructions when disinfecting lamp head and shield.

(4) Flush high volume evacuator and saliva ejector tubing daily with an appropriate disinfectant (e.g. Shur-Kleen, Pure Vac, and follow manufacturer’s instructions).

(5) Anesthetic Cartridges. Unused anesthetic cartridges not used during patient care must be disposed of in the sharps container. DO NOT disinfect unused cartridges and place back into the anesthesia drawer. Anesthetic cartridges are to be kept in their original containers. Do not store cartridges in disinfecting solution.

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7. Disinfection Solution. CaviCide is an ADA-approved, EPA-registered, intermediate-level disinfectant. It is a tuberculocidal, bactericidal, viricidal, and fungicidal disinfectant. For disinfecting non-instrument surfaces/counter tops, exposed to aerosols spray CaviCide directly onto instruments, counter tops, dental chair, mobile cart and handles thoroughly wetting the area. Wait 3 minutes and wipe dry using a towel or allow to air dry.

Chapter 7

INFECTIOUS WASTE

1. Introduction. At present there is an increased public awareness towards the environment concerning blood borne infectious diseases and waste generated by healthcare facilities.

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In light of these concerns, it has become increasingly important to regulate and document the handling and disposal of our waste.

2. Definitions. BUMED divides medical waste into two categories: infectious waste and non-infectious waste.

a. Infectious Waste. Infectious waste is liquid or solid waste that contains pathogens in sufficient numbers and with sufficient virulence to cause infectious disease. Examples of infectious waste are:

(1) Microbiological waste such as biological monitors.

(2) Human tissue (including extracted teeth).

(3) Blood and other body fluids.

(4) Disposable materials, such as cotton gauze or dressings saturated with blood or saliva. If blood or saliva can be expressed (drips) from the material in question upon pressure or can be flaked off when dried, consider this item as infectious.

(5) Sharps examples are syringe needles, scalpel blades, broken glass, endodontic broaches and files, anesthetic cartridges, wedges, matrix bands, and burs.

(6) Amalgam waste, such as contact amalgam (amalgam thathas been in contact with the patient). Examples are extracted teeth with amalgam restorations, carving scrap collected at chair side, and amalgam captured by chair side traps, filters, or screens. (See #4, Handling of Amalgam Waste on following page).

b. Non-infectious Waste. Examples of noninfectious waste are:

(1) Absorbent materials containing small amounts of blood or body fluid.

(2) Rubber gloves and rubber dams.

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3. Handling Infectious Waste. PPE is required when handling infectious waste.

a. Separate infectious waste from non-infectious waste in the DTR.

b. Discard sharps into sharps containers located in each DTR. DO NOT OVERFILL. Do not transport sharps. Supported command is responsible for securing and disposing of sharps.Contaminated gauze or dressings should be placed in bio-hazard bags. At the end of the day, tie the bag closed with tape.

c. If the outside of the bag/sharps container becomescontaminated, place contaminated bag/sharps container in another bio-hazard bag and secure with tape. Label tape as described above.

d. If disposable suction canisters are being used, use fluid solidifier to gel fluids. Follow manufacturer’s directions on how to use the solidifier. Once the fluids have gelled, place canister in bio-hazard bag and proceed with label.

e. If a reusable suction canister is in use, the contents of the canister must be emptied in a deep well utility sink. The sink cannot be used for hand washing.

4. Handling Amalgam Waste. Amalgam should not be disposed of in regular trash cans, infectious waste bio-hazard bags, or sharps containers. The mercury in the amalgam will volatilize and enter the atmosphere when incinerated. Amalgam should not be rinsed down the drain.

a. Amalgam waste may be mixed with body fluids or other potentially infectious material, so PPE must be used when handling it. b. After mixing the contents of the amalgam capsule, place the empty capsules in a wide-mouthed, airtight container that is marked Contact Amalgam Waste for Recycling. If the DTR does not have a wide-mouthed container, place empty capsules into a head

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rest cover and at the end of the day turn them into dirty side CSR.

c. Disinfect the disposable chair-side trap with disinfectant and allow drying. After drying, remove amalgam trap and place it directly into a wide-mouthed, airtight container that is marked Contact Amalgam Waste for Recycling. The trap can be removed on a weekly basis, or if necessary on a daily basis. d. Disinfect extracted teeth containing amalgam with soaked gauze with proper disinfection solution for a minimum of three minutes: after disinfection, place in container that is marked Contact Amalgam Waste for Recycling. Never place extracted teeth that contain amalgam in bio-hazard bags or sharps containers. 5. Documentation and Disposal

a. Document disposal of all infectious/bio-hazard waste into the Bio-hazardous Waste Log. The date of disposal, type of waste, i.e., sharps container or biohazard bag, and the identification number of each bag or container.

b. For field exercises in which Infectious/Bio-hazard waste is produced the disposal of infectious/Bio-hazard waste will be coordinated with the exercise lead and/or local Medical Treatment Facility. The person who accepts the waste will sign the log sheet accepting transfer.

6. Infectious Waste Spills. To help ensure the safety of staff and patients, take the following steps in the event of an infectious waste spill:

a. Notify the LPO and/or EXOIC immediately.

b. Always wear PPE when cleaning up spills. At a minimum, wear heavy duty rubber gloves, protective eye wear, and face mask, and shoe covers.

c. If small, promptly clean up spill with disposable absorbent material using EPA approved disinfectant.

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d. If large, block off area and secure from use. Clean up spill with disposable absorbent material using disinfectant and Blood Spill Kit or Mercury Spill Kit. Use a broom to sweep broken glass or contaminated sharps.

7. Training. The SDE/Company CO will provide annual training on the management of medical waste for respective staff members.

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Chapter 8

Latex Allergy/Sensitivity

1. Introduction. The following guidelines are used to accommodate individuals with allergic or sensitivity reactions. Use latex free options for all products when possible. To include gloves, rubber dams, mouth props, and surgical gloves.

2. Action. Any individual claiming allergy/sensitivity must provide documentation from a medical professional (Allergist). 3. Discussion. Latex allergy occurs with relatively high frequency in certain at risk populations, i.e. healthcare workers, patients with other types of allergy and generally personnel who are in contact with latex products. Natural latex is the product manufactured from a milky fluid derived mainly from the rubber tree, Hevea brasiliensis. Allergic responses can be triggered by allergens such as certain proteins in natural latex rubber or certain chemicals (e.g. thiurams and carbamates) used in the processing of the natural rubber latex and synthetic rubbers. Subjects with latex allergy or sensitivity can clinically present with irritant contact dermatitis, delayed (type IV) hypersensitivity, and immediate (type I) hypersensitivity. The following population is at higher risk for latex allergies:

a. Children with spina bifida.

b. Congenital urinary anomalies.

c. History of sensitivity to bananas, avocados, kiwi, chestnuts, potatoes, or papayas.

d. History of multiple surgical procedures.

e. History of anaphylactic reaction during anesthesia.

f. History of Atopic allergies (persons with multiple allergic conditions).

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4. Recognition

a. The patient’s health questionnaire should be reviewed prior to treatment and allergy to latex noted. Signs and symptoms of contact dermatitis are dryness, itching, burning, and irritation.

b. Patients with delayed (type IV) allergy exhibit skin redness, rash, dryness, hyperkeratosis, and edema.

c. Immediate (type I) hypersensitivity is all symptoms described for type IV plus respiratory symptoms like runny nose, sneezing, difficulty breathing, wheezing, and anaphylaxis (classic triad of hypotension, rash, and bronchi-spasm).

d. Patients with latex allergy should be referred (SF-513) to the Naval Hospital for consultation. Patients requiring treatment for life threatening dental infections who are allergic to latex should be referred to the nearest Hospital Emergency Room.

e. All healthcare workers are required to provide information as per Latex Allergy Screening Questionnaire form Appendix C and returned to the SDE/Company CO. Personnel with questionable histories are referred to the Occupational Health Department for further evaluation and proper diagnosis.

5. Diagnosis. A medical professional will make the diagnosis based on either a blood test or a skin test.

6. Treatment

a. A patient with latex allergy should be the first appointment of the day. Latex dust/powder is at its lowest levels during that time not only in the clinic but the DTR. Utilization of latex free products during set-up and patient treatment is mandatory.

b. In case of anaphylactic reaction:

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(1) Stop treatment, remove gloves and call 911 and activate a Code Blue.

(2) Maintain airway and administer 100% oxygen (make sure the nasal cannula and mask is latex free). (3) Administer epinephrine (1/1000), antihistamines (Benadryl), if a medical team has not arrived.

c. Submit an MVR and Safety Mishap Report to PI Coordinator and Safety Officer after the treatment has been rendered.

7. Prevention

a. Use non-latex products whenever practical. Latex-free products should be gloves, masks, blood pressure cuffs, rubber dams, bite blocks, prophy angles, bitewing tabs, goggles, anesthetic syringes, anesthetic cartridges and napkins. The maintenance of these items is the responsibility of the treating NOSC or military treatment facility.

b. Use appropriate work practices to reduce the chance of latex type reactions.

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Chapter 9

RADIOLOGY

1. Introduction. Infection control when taking radiographs is extremely important. Both the radiographic equipment and sensors can become contaminated and may result in the transmission of infectious agents. To protect both patients and staff, the same infection control standards maintained in the DTR apply to the dental radiology area(s).

2. Hand washing. Follow hand washing protocols as described in Chapter 3 before and after taking radiographs.

3. Sensor Devices

a. Protective Barriers. Always place a protective barrier on the sensor. Change the protective barriers between each patient. The sensor must also be cleaned anddisinfected as per the manufacturer’s instructions between patients.

b. Cleaning the Sensor and Cable. The sensor and cable must be cleaned with a disinfecting cloth. Wipe clean any visible blood, saliva or other contaminant from the sensor.

c. Disinfecting the Sensor. Disinfect the sensor head by wrapping in a disinfecting wipe and keeping it wet for three minutes. Remove wipe. Dry the sensor before placing in the newbarriers.

d. Sensor Positioning Devices. Only sterilized devices must be used. Dispose of single use positioning tabs after use.

4. Panoramic Unit Bite Pegs. Sterilize bite pegs between patients, or cover pegs with protective barrier sleeve/finger cot. Dispose of the barrier/finger cot after each patient.

5. Semi-Critical Devices. Digital radiographs, intraoral cameras, electronic periodontal probes, occlusal analyzers, and

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dental and soft tissue lasers, are considered semi-critical devices because they contact the mucous membranes. Heat sterilization is preferred method for such devices. For semi-critical devices that cannot withstand heat or chemical immersion, cover such devices with a protective sheath during patient use. Clean and disinfect with a gauze pad soaked in intermediate-level disinfectant after barrier removal.

6. Radiology Chair. Arm rests and headrests are non-criticalitems. Wipe down these areas daily with an EPA registered disinfectant to achieve intermediate-level disinfection.

7. Radiology Unit Exposure Tube Head. Cover these areas with disposable barriers and discard after use in between patients.

8. NOMAD and Portable Radiology Units. Routinely use a non- acetone based wipe (CaviWipe) to disinfect the NOMAD unit between each patient. The charging cradle and the AC power supply are not designed to be subjected to any kind of disinfection procedure.

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APPENDIX ADefinitions and Suitability of Sterilization Packaging Materials

Definitions

1. Asepsis. The process of preventing the access of microorganisms.

2. Barrier Technique. The use of rubber, plastic, paper, foil, or other fluid resistant materials to cover surfaces and protect them from contamination.

3. EXOIC. Exercise Officer in Charge.

4. Bioburden. The number of microorganisms contaminating an object, also known as the bio-load or microbial load. 5. Biological Control. An unprocessed biological monitor from the same lot as the test monitor. When cultured, serves as a control by verifying the viability of the unexposed organisms.

6. Biological Monitor. A bacterial endospore test designed to assess whether sterilization has actually occurred. Also known as a biological indicator or biological spore test. 7. Bloodborne Pathogens. Pathogenic microorganisms that are present in human blood and capable of causing disease in humans.

8. Bowie-Dick Test. A diagnostic test of a pre-vacuum sterilizer’s ability to remove air from the chamber and prevent air re-entrapment. This is not a sterility assurance test.

9. Chemical Disinfectant. The destruction or inhibition of most viruses and bacteria while in their active growth phase. The process does not necessarily kill all spores nor can it be verified by a monitor.

10. Chemical Indicator. Chemical dyes used to determine whether the conditions required for sterilization are met. Also known as a chemical monitor, dosage indicator or process indicator.

11. Clinical Contact Surfaces. Surfaces that are touched or become contaminated in other ways and will subsequently contact instruments, devices, hands, or gloves.

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12. Contaminated. The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. 13. Culture. The propagation and growth of microorganisms or living tissue cells in or on a nutrient medium.

14. Decontamination. The use of physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or item to the point where they are no capable of transmitting infectious particles and the surface item is rendered safe for handling, use or disposal.

15. Dental Item Classification. Dental Items are classified as critical, semi-critical, or non-critical based on the pathways through which cross-contamination may occur and the location and technique of instrument use.

a. Critical Item. Instruments and materials that penetrate the skin, mucous membranes or bone. These items must be sterile before use. Examples include: surgical instruments and suture needles.

b. Semi-critical Item. Instruments, equipment or materials that frequently contact mucous membranes but cannot withstand heat. At a minimum, these items require high-level disinfections. Examples: plastic positioning devices and plastic impression trays. c. Non-critical Item. Instruments, equipment or materials that do not normally penetrate or contact mucous membranes, but are exposed to splatter, spray, blood or touched by contaminated gloves or hands. These items require intermediate levels of disinfection. Examples include: the dental unit and chair.

16. Exposure Incident. A specific eye, mouth, mucous membrane, non-intact skin or parental contact with blood or other potentially infectious material that results from the performance of a person’s duty.

17. Exposure Time. The total continuous elapsed time during which the sterilizer is operating at pre-selected sterilizing parameters such as temperature and pressure.

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18. Healthcare-associated infection. Any infection associated with a medical or surgical intervention. Previously referred to as nosocomial.

19. Housekeeping surfaces. Surfaces that do not come into contact with instruments, devices, or hands used in dental procedures.

20. Infectious Microorganism. Organisms capable of producing disease in appropriate hosts. 21. Invasive Procedure. A surgical entry into the tissues, cavities, organs or repair of major traumatic injuries. This includes the manipulation, cutting or removal of any oral or peri-oral tissue during which bleeding occurs or other potential for bleeding exists. Routine restorative procedures are considered invasive procedures.

22. Microorganism. Bacteria, fungi, viruses and bacterial spores.

23. OSHA. Occupational Safety and Health Administration.

24. Personal Protective Equipment (PPE). Specialized clothing or devices worn by workers for protection against a hazard.

25. Saturated Steam Sterilization. A process that uses steam heat under pressure for sufficient length of time to kill all forms of microorganisms.

26. Spray-wipe-Spray. An acceptable method of cleaning and disinfecting. Presently there is no agent on the market with EPA registration and ADA acceptance that cleans and disinfects in one step. Therefore, the importance of cleaning as a separate step form disinfection and sterilization cannot be overemphasized.

27. Standard Precautions. A protocol for infection control that treats all human blood and body fluids as if known to be infectious for HIV, HBV, and other bloodborne pathogens. 28. Sterile. Free from all living microorganisms.

29. Unit Dose. The quantity of materials or supplies required to treat a single patient.

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30. Wipe-discard-wipe: Is the use of a saturated wipe used as An acceptable method of cleaning and disinfecting. Presently there is no agent on the market with EPA registration and ADA acceptance that cleans and disinfects in one step. Therefore, the importance of cleaning as a separate step form disinfection and sterilization cannot be overemphasized.

APPENDIX B

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REFERENCES

BUMED Instruction BUMEDINST 6220.9B, BUMED-M3/5HCS5http://navymedicine.med.navy.mil

BUMED Instruction 6280.1A http://navymedicine.med.navy.mil

OSHA Rules on Occupational Exposures to Bloodborne Pathogens, 29 CFR 1910.1030 www.osha.org

BUMEDNOTE 6230 http://navymedicine.med.navy.mil

CDC MMWR Guidelines for Infection Control in Dental Health-Care Settings, 19 Dec 03, Vol. 52, No.rr-17 http://www.cdc.gov/

OPNAVINST 5100.23F, CH-28 http://www.nablc.navy.mil/safety/Instructions/5100.23f/CH16_23F.pdf

CDC, MMWR, Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings, 30 Dec 05, Vol. 54, No. RR-17 http://www.cdc.gov/

BUMED Instruction 6200.16 http://navymedicine.med.navy.mil

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