Guidelines for Infection Control in Dental Health Care Settings

Presented in this appendix are the most recent (2011) recommendations from the Centers for Disease Control and Prevention (CDC) for infection control in dental health care settings. Most of these recommendations are essentially the same as in the 2003 guidelines, with some updates in the prevention of H1N1 influenza transmission in dental health care settings, which were updated in 2009. Also included are a few summary statements (and tables) regarding recommendations for tuberculosis (TB) infection control (2009).

The CDC believes that dental offices that follow these new recommendations will strengthen an already admirable record of safe dental practice. Patients and providers alike can be assured that oral health care can be delivered and received in a safe manner.

Overview

Although the principles of infection control remain unchanged, new technologies, materials, equipment, and data require continuous evaluation of current infection control practices. The unique nature of many dental procedures, instrumentation, and patient care settings also may require use of specific strategies directed at preventing the transmission of pathogens among dental health care workers and their patients. Recommended infection control practices are applicable to all settings in which dental treatment is provided.

Prevention of 2009 H1N1 Influenza Transmission in Dental Health Care Settings (Updated on November 23, 2009)

CDC provides updated guidance on preventing 2009 H1N1 influenza transmission in dental health care settings. Guidance includes new recommendations on using airborne infection isolation rooms, N95 respirators (i.e., those that filter at least 95% of airborne particles), and infection control measures for personnel with influenza-like illness.

Tuberculosis Infection Control Recommendations

The changing epidemiology of TB and discovery of new diagnostic methods prompted a revision of CDC’s Guidelines to Prevent TB Transmission in Healthcare Settings. The revised CDC’s TB infection control recommendations for dental settings, as well as information on how they should be incorporated into an infection control program, are available online (see “ Additional Resources ” later on).

Educational Materials

Slide Presentation for Infection Control Guidelines

A slide set and accompanying speaker notes that provide an overview of many of the basic principles of infection control in the CDC’s Guidelines for Infection Control in Dental Health-Care Settings can be downloaded as a PowerPoint presentation or viewed on the CDC Web site.

If Saliva Were Red: A Visual Lesson on Infection Control. *

The video training system If Saliva Were Red features an 8-minute video (VHS, CD-ROM) that shows dental professionals at work to highlight common infection control and safety flaws; the cross-contamination in everyday clinical practice that would be evident if saliva were red; and how controlling contamination by using personal barrier protection, safe work practices, and effective infection control products reduces the risk of exposure.

From Policy to Practice: OSAP’s Guide to the Guidelines *

The Organization for Safety & Asepsis Procedures (OSAP) has produced a 170-page workbook that contains practical information to help health care professionals put the infection control recommendations into practice. These resources were produced by OSAP through a CDC cooperative agreement.

Related Organizations

  • American Dental Association Infection Control Resources *

  • National Institute for Occupational Safety and Health

  • Organization for Safety and Asepsis Procedures *

  • Safety and Health Topics for Dentistry from the Occupational Safety and Health Administration (OSHA)

  • U.S. Air Force (USAF) Dental Evaluation and Consultation Service

* Links to nonfederal organizations do not constitute an endorsement of any organization by CDC or the federal government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at such links.

Prevention of H1N1 Influenza Transmission in Dental Health Care Settings

Exposures to 2009 H1N1 influenza virus occurs in household, community, and occupational settings, and transmission is thought to occur through droplet exposure of mucosal surfaces; through indirect contact, usually via the hands, with respiratory secretions from an infectious patient or contaminated surface; and through inhalation of small particle aerosols in the vicinity of the infectious individual.

Symptoms of Influenza

Persons with influenza, including 2009 H1N1 influenza, may have some or all of these symptoms * :

  • Fever

    Note: not everyone with a influenza will have a fever.

  • Cough

  • Sore throat

  • Runny or stuffy nose

  • Body aches

  • Headache

  • Chills

  • Fatigue

  • Sometimes diarrhea and vomiting

Control of 2009 H1N1 Influenza

A hierarchy of control measures should be applied to prevent transmission of 2009 H1N1 influenza in all health care settings. To apply the hierarchy of control measures, facilities should take the following steps, ranked according to their likely effectiveness:

  • 1

    Elimination of potential exposures (e.g., deferral of treatment for ill patients and source control by masking persons who are coughing)

  • 2

    Engineering controls that reduce or eliminate exposure at the source without placing primary responsibility of implementation on individual employees

  • 3

    Administrative controls including sick leave policies and vaccination that depend on consistent implementation by management and employees

  • 4

    Personal protective equipment (PPE) for exposures that cannot otherwise be eliminated or controlled

(PPE includes gloves, surgical face masks, respirators, protective eyewear, and protective clothing such as gowns.)

Vaccination

Vaccination, an administrative control, is one of the most important interventions for preventing transmission of influenza to health care personnel. More information on this hierarchy of controls is available in the CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel (see CDC: H1N1 Flue Clinical and Public Health Guidance, www.cdc.gov/h1n1flu/guidance/ ).

Specific Recommendations for Dental Health Care

  • Encourage all dental health care personnel to receive seasonal influenza and 2009 H1N1 influenza vaccinations.

  • Use patient reminder calls to identify patients reporting influenza-like illness, and reschedule nonurgent visits until 24 hours after the patient is free of fever without the use of fever-reducing medicine.

  • Identify patients with influenza-like illness at check-in; offer a face mask or tissues to symptomatic patients; follow respiratory hygiene/cough etiquette and reschedule nonurgent care. Separate ill patients from others whenever possible if evaluating for urgent care.

  • Urgent dental treatment can be performed without the use of an airborne infection isolation (AII) room, because transmission of 2009 H1N1 influenza is thought not to occur over longer distances through the air, such as from one patient room to another.

  • Use a treatment room with a closed door, if available. If not, use one that is farthest from other patients and personnel.

  • Wear recommended PPE before entering the treatment room.

  • Dental health care personnel should wear a NIOSH fit-tested, disposable N95 respirator when entering the patient room and when performing dental procedures on patients with suspected or confirmed 2009 H1N1 influenza.

  • If N95 respirators and/or fit-testing is not available despite reasonable attempts to obtain, the dental office should switch over to a prioritized use mode (i.e., non–fit-tested disposable N95 respirators or surgical face masks can be considered as a lower level of protection for personnel at lower risk of exposure or lower risk of complication from influenza until fit-tested N95 respirators are available). Detailed information can be found in the CDC’s Interim Guidance on Infection Control Measures for H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel (see later under “ Additional Resources ”). Additional guidance, including recommendations regarding fit-testing issues, can be found in the related question and answer document regarding respiratory protection (see under “ Additional Resources ”).

  • As customary, minimize spray and spatter (e.g., use a dental dam and high-volume evacuator).

Dental Health Care Personnel

  • Dental health care personnel should self-assess daily for symptoms of febrile respiratory illness (fever plus one or more of the following: nasal congestion or runny nose, sore throat, or cough).

  • Personnel who develop fever and respiratory symptoms should promptly notify their supervisor and should not report to work.

  • Personnel should remain at home until at least 24 hours after they are free of fever (100° F/37.8° C), or signs of a fever, without the use of fever-reducing medications.

  • Personnel with a family member who is diagnosed with 2009 H1N1 influenza can still go to work but should self-monitor for symptoms so that any illness is recognized promptly.

Additional Resources

For comprehensive information on CDC 2009 H1N1 influenza infection control guidelines, visit Infection Control and Clinician Guidance at www.cdc.gov/h1n1flu/guidance/ , for access to the following:

  • Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

  • Questions and Answers about CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

  • Questions and Answers Regarding Respiratory Protection for Infection Control Measures for 2009 H1N1 Influenza Among Healthcare Personnel

  • 10 Steps You Can Take: Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities

Information on swine flu also is available at this Web site:

Prevention of H1N1 Influenza Transmission in Dental Health Care Settings

Exposures to 2009 H1N1 influenza virus occurs in household, community, and occupational settings, and transmission is thought to occur through droplet exposure of mucosal surfaces; through indirect contact, usually via the hands, with respiratory secretions from an infectious patient or contaminated surface; and through inhalation of small particle aerosols in the vicinity of the infectious individual.

Symptoms of Influenza

Persons with influenza, including 2009 H1N1 influenza, may have some or all of these symptoms * :

  • Fever

    Note: not everyone with a influenza will have a fever.

  • Cough

  • Sore throat

  • Runny or stuffy nose

  • Body aches

  • Headache

  • Chills

  • Fatigue

  • Sometimes diarrhea and vomiting

Control of 2009 H1N1 Influenza

A hierarchy of control measures should be applied to prevent transmission of 2009 H1N1 influenza in all health care settings. To apply the hierarchy of control measures, facilities should take the following steps, ranked according to their likely effectiveness:

  • 1

    Elimination of potential exposures (e.g., deferral of treatment for ill patients and source control by masking persons who are coughing)

  • 2

    Engineering controls that reduce or eliminate exposure at the source without placing primary responsibility of implementation on individual employees

  • 3

    Administrative controls including sick leave policies and vaccination that depend on consistent implementation by management and employees

  • 4

    Personal protective equipment (PPE) for exposures that cannot otherwise be eliminated or controlled

(PPE includes gloves, surgical face masks, respirators, protective eyewear, and protective clothing such as gowns.)

Vaccination

Vaccination, an administrative control, is one of the most important interventions for preventing transmission of influenza to health care personnel. More information on this hierarchy of controls is available in the CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel (see CDC: H1N1 Flue Clinical and Public Health Guidance, www.cdc.gov/h1n1flu/guidance/ ).

Specific Recommendations for Dental Health Care

  • Encourage all dental health care personnel to receive seasonal influenza and 2009 H1N1 influenza vaccinations.

  • Use patient reminder calls to identify patients reporting influenza-like illness, and reschedule nonurgent visits until 24 hours after the patient is free of fever without the use of fever-reducing medicine.

  • Identify patients with influenza-like illness at check-in; offer a face mask or tissues to symptomatic patients; follow respiratory hygiene/cough etiquette and reschedule nonurgent care. Separate ill patients from others whenever possible if evaluating for urgent care.

  • Urgent dental treatment can be performed without the use of an airborne infection isolation (AII) room, because transmission of 2009 H1N1 influenza is thought not to occur over longer distances through the air, such as from one patient room to another.

  • Use a treatment room with a closed door, if available. If not, use one that is farthest from other patients and personnel.

  • Wear recommended PPE before entering the treatment room.

  • Dental health care personnel should wear a NIOSH fit-tested, disposable N95 respirator when entering the patient room and when performing dental procedures on patients with suspected or confirmed 2009 H1N1 influenza.

  • If N95 respirators and/or fit-testing is not available despite reasonable attempts to obtain, the dental office should switch over to a prioritized use mode (i.e., non–fit-tested disposable N95 respirators or surgical face masks can be considered as a lower level of protection for personnel at lower risk of exposure or lower risk of complication from influenza until fit-tested N95 respirators are available). Detailed information can be found in the CDC’s Interim Guidance on Infection Control Measures for H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel (see later under “ Additional Resources ”). Additional guidance, including recommendations regarding fit-testing issues, can be found in the related question and answer document regarding respiratory protection (see under “ Additional Resources ”).

  • As customary, minimize spray and spatter (e.g., use a dental dam and high-volume evacuator).

Dental Health Care Personnel

  • Dental health care personnel should self-assess daily for symptoms of febrile respiratory illness (fever plus one or more of the following: nasal congestion or runny nose, sore throat, or cough).

  • Personnel who develop fever and respiratory symptoms should promptly notify their supervisor and should not report to work.

  • Personnel should remain at home until at least 24 hours after they are free of fever (100° F/37.8° C), or signs of a fever, without the use of fever-reducing medications.

  • Personnel with a family member who is diagnosed with 2009 H1N1 influenza can still go to work but should self-monitor for symptoms so that any illness is recognized promptly.

Additional Resources

For comprehensive information on CDC 2009 H1N1 influenza infection control guidelines, visit Infection Control and Clinician Guidance at www.cdc.gov/h1n1flu/guidance/ , for access to the following:

  • Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

  • Questions and Answers about CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel

  • Questions and Answers Regarding Respiratory Protection for Infection Control Measures for 2009 H1N1 Influenza Among Healthcare Personnel

  • 10 Steps You Can Take: Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities

Information on swine flu also is available at this Web site:

Comparison of Selected Changes Between 1994 and 2005 Editions of Cdc Guidelines for Preventing Tuberculosis in Dental Health Care Settings

Although rates of tuberculosis (TB) in the United States have decreased in recent years, disparities in TB incidence still exist between U.S.-born and foreign-born people (people living in the United States but born outside it) and between white people and nonwhite people. In addition, the number of TB outbreaks among health care personnel and patients has decreased since the implementation of the 1994 CDC guidelines to prevent transmission of Mycobacterium tuberculosis. Therefore, there are a few updates on the epidemiology of TB, advances in TB diagnostic methods and TB infection control guidelines for dental settings.

Clinical Implications

Although the principles of TB infection control have remained the same, the changing epidemiology of TB and the advent of new diagnostic methods for TB led to the development of the 2005 update to the 1994 guidelines. Dental health care personnel should be aware of the modifications that are pertinent to dental settings and incorporate them into their overall infection control programs.

Tuberculosis Risk Categories and Recommended Testing Frequency

  • Low —fewer than three patients with unrecognized TB treated in past year: Baseline screening at hiring; further testing not needed unless exposure occurs

  • Medium —three or more patients with unrecognized TB treated in past year: Baseline screening, then annual testing

  • Potential of ongoing transmission —evidence of ongoing person-to-person transmission: Baseline screening, then testing every 8 to 10 weeks until evidence of transmission has ceased

Baseline screening should be conducted by a qualified health care professional using a two-step tuberculin skin test or a single blood assay for interferon gamma release

Tuberculosis Precautions for Outpatient Dental Settings

Administrative Controls

  • Assign responsibility for managing TB infection control program.

  • Conduct annual risk assessment.

  • Develop written TB infection control policies for promptly identifying and isolating patients with suspected or confirmed TB disease for medical evaluation or urgent dental treatment.

  • Instruct patients to cover mouth when coughing and/or wear a surgical mask.

  • Ensure that dental health care personnel (DHCP) are educated regarding signs and symptoms of TB.

  • When hiring DHCP, ensure that they are screened for latent TB infection and TB disease.

  • Postpone urgent dental treatment.

Environmental Controls

  • Use airborne infection isolation room to provide urgent dental treatment to patients with suspected or confirmed infectious TB.

  • In settings with high volume of patients with suspected or confirmed TB, use high-efficiency particulate air filters or ultraviolet germicidal irradiation.

Respiratory Protection Controls

  • Use respiratory protection—at least an N95 filtering face piece (disposable)—for DHCP when they are providing urgent dental treatment to patients with suspected or confirmed TB.

  • Instruct patients with TB to cover the mouth when coughing and to wear a surgical mask.

  • Respiratory hygiene and cough etiquette measures :

    • Use tissues to cover the nose and mouth and to contain respiratory secretions when coughing or sneezing.

    • Dispose of tissues in no-touch receptacles (such as those with foot pedal–operated lids or an open, plastic-lined wastebasket).

    • When coughing or sneezing, if tissues are not available, cover the mouth and nose with the inner surface of the arm and forearm, to keep pathogenic organisms away from the hands; although Mycobacterium tuberculosis cannot be spread by the hands, other respiratory pathogens such as rhinoviruses can be spread in this manner.

    • Practice hand hygiene (such as hand washing with nonantimicrobial soap and water, alcohol-based hand rub or antiseptic hand wash) after contact with respiratory secretions or contaminated objects and materials; hand hygiene is recommended to prevent transmission of all respiratory illnesses in general but will not affect TB transmission.

Clinical Implications

The CDC Guidelines for Infection Control in Dental Health Care Settings—2003 is a major update and revision of the CDC’s Recommended Infection Control Practices for Dentistry—1993. As of 2011, these guidelines still apply (along with the previous updates on H1N1 and TB). As the nation’s disease prevention agency, the CDC develops a broad range of guidelines intended to improve the effect and effectiveness of public health interventions and to inform key audiences, most often clinicians, public health practitioners, and the public, about applicable findings.

Why are guidelines needed that are specific for dentistry? More than a half-million dental health care personnel (DHCP) work in the United States—approximately 168,000 dentists, 112,000 registered dental hygienists, 218,000 dental assistants, and 53,000 dental laboratory technicians. Most dentists are solo practitioners who work in outpatient, ambulatory care facilities. In these settings, no epidemiologists or other hospital infection control experts track possible health care–associated (i.e., nosocomial) infections or monitor and recommend safe practices. Instruments frequently used in dental practice generate spatter, mists, aerosols, or particulate matter. Unless precautions are taken, the possibility is great that patients and DHCP will be exposed to blood and other potentially pathogenic infectious material. Fortunately, by understanding certain principles of disease transmission and using infection control practices based on those principles, dental personnel can prevent disease transmission.

The CDC’s first set of infection control recommendations for dentistry was published as an article in the Morbidity and Mortality Weekly Report in 1986. At that time, a position paper from the American Association of Public Health Dentistry commented on the state of dental infection control, noting: “Dental practitioners are virtually the only health care providers who routinely place an ungloved hand into a body cavity.” Reports published from 1970 through 1987 described nine clusters of patients who were believed to be infected with hepatitis B virus (HBV) through treatment by an infected DHCP. However, since 1987, no transmission of HBV from dentist to patient has been reported. This good statistic possibly is the result of widespread acceptance of the hepatitis B vaccine and the adoption of standard (formerly universal) precautions, including routine glove use. HBV seroprevalence among dentists has fallen from about 14% in 1983 to about 9% today—a proportion that is expected to decline to below that for the general population as older dentists retire (because older dentists are more likely than young dentists to be infected) (personal communication, C. Siew, PhD, American Dental Association, 2003).

In early 1988, a published report described a dentist who was seropositive for human immunodeficiency virus (HIV) but had no admitted risk factors for HIV infection, which suggests the possibility of occupational transmission. In addition, during the early 1990s, the health care community was shaken when six cases of transmission from an HIV-infected dentist to his patients were reported. No additional reports have described HIV transmission from HIV-infected DHCP to patients, and since the CDC began surveillance for occupationally acquired HIV, no cases of occupationally acquired HIV have been documented among DHCP.

In 1991, OSHA released the bloodborne pathogen standard that mandated certain practices for all dental offices. For example, employers must provide hepatitis B vaccine for their employees, and all employees must use appropriate personal protective equipment (e.g., gloves, protective eyewear, gowns). After OSHA published its standards, the CDC published Recommended Infection Control Practices for Dentistry in 1993. Those recommendations, which focused on preventing transmission of disease due to bloodborne pathogens, were based primarily on health care precedent, theoretical rationale, and expert opinion. In contrast with OSHA (which is a regulatory agency), the CDC cannot mandate certain practices; it can only recommend. Nevertheless, many dental licensing boards have adopted the CDC’s recommendations, or variations of them, as the infection control standard for dental practice in their states.

The following introductory commentary has been adapted from Kohn WG, et al: Guidelines for infection control in dental health care settings—2003,

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