3.1.5 - Implementation of Various Methods of Exposure Control

All WM will be instructed on and must follow standard precautions to control infectious diseases when in direct contact with body fluids. WM must treat body fluids as if they are known to be infectious.

Body fluids are identified as blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva, urine, feces, nasal secretions, sputum, vomit, breast milk, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult to or impossible to differentiate between body fluids.

Standard precautions include:

1. WM must wash hands for 40 – 60 seconds between contact with each patient, even if gloves have been used, and after removing gloves.
2. WM must wear gloves during any patient contact when contact with body fluids is likely to occur.
3. WM are required to obtain and use the appropriate PPE based on anticipated exposure and appropriate for the procedure being performed.

• At a minimum the correct PPE should include:
  • Gloves
  • Eye Protection
  • Mask
  • Gown (optional)

4. WM are required to clean up blood and body fluids promptly with an EPA-approved disinfectant.

Transmission-based Precautions are the second tier of basic infection control and are used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission.

Transmission-based precautions include:

1. Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission.
2. Use Droplet Precautions for patients with known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, talking, or dental aerosols.
3. Use Airborne Precautions for patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., tuberculosis, measles, chickenpox, disseminated herpes zoster).

All PPE is provided to WM at no cost to the WM. PPE will be the correct size, clean, in good repair, and fit properly. PPE is designed to protect the skin and mucous membranes of the eyes, nose, and mouth from blood or OPIM. Spray and aerosol from handpieces and air-water syringes, patient coughs, and other activities in the operatory are possible sources of pathogens. 

Required PPE includes:

1. Eye protection devices, such as goggles or glasses with solid side shields or chin-length face shields, must be worn whenever splashes, sprays, splatters, or droplets of blood or OPIM may be generated, and eye contamination can be reasonably anticipated. Eyewear must be cleaned and disinfected between patients. Protective eyewear is required for the patient to protect their eyes from debris.
2. ASTM Level III surgical masks that cover both nose and mouth must be worn whenever reasonable anticipation of the production of aerosols or splatters of microorganisms exists. Masks are to be changed if wet or visibly soiled and between patients. Do not wear masks under the chin or dangling around the neck.
3. N95 respirators are optional. Respirator fit testing must be completed before wearing and annually, thereafter, if an N95 respirator is to be worn for your protection. 
4. Long-sleeve disposable over-gowns will be worn for all aerosol-generating clinical procedures. Gowns should be changed if torn or visibly soiled. Gowns should be removed before leaving the treatment areas and, under no circumstances, worn outside the clinic area, including the waiting room, patient checkout offices, or restrooms. Street clothes, work clothes, or scrubs worn under over-gowns are not considered personal protective equipment.
5. Single-use disposable, non-latex gloves will be worn for all clinical procedures when there is reasonable anticipation of encountering mucus membranes or OPIM. Patient exam gloves are worn for non-surgical procedures. Sterile surgical gloves will be worn for all surgical procedures, e.g., periodontal surgery, oral surgery, and implant placement. If leaving the operatory during patient care, gloves must be removed and discarded or protected with over gloves.
6. Head covers are optional. If worn, they must cover the entire head, and all hair must be covered. The fabric must be washable; the material cannot have inappropriate content. Head covers can only be worn for one day and WM is responsible for laundering, if not disposable.
7. Face shields are worn if eyewear does not have appropriate side shields. 
8. PPE that is soaked with blood or OPIM should be placed in a designated container labeled biohazard trash.

The following work practice controls will be used:

1. Disposable barriers will be placed whenever possible to cover contact surfaces. This includes light handles, light switches, chair controls, chair handles, patient chairs, slow-speed suction, air/water syringes, HVE, keyboards, mice, and x-ray equipment. Barriers include plastic wrap, bags, adhesive wrap, and other moisture-impervious materials. Use personal protective equipment (PPE) when disposing of contaminated barriers. Refer to the Proper Dental Unit Set-up with Barriers posters found in all clinical faculty offices.
2. A debris bag should be available at each dental unit to discard all medical waste. Waste that was generated that has significant amounts of blood or saliva (drips when squeezed) must be disposed of in the waste receptacle labeled with a RED biohazard sticker, provided in each clinic.
3. Contaminated needles and sharps will never be sheared off or purposely broken. After each use, recap needles using the one-handed scoop technique or a protector card for recapping used dental needles. Sharps must be placed in RED sharps containers located at each dental unit.
4. Disinfect using the wipe-discard-wipe technique with an Environmental Protection Agency (EPA) registered intermediate-level hospital disinfectant on all patient contact surfaces that do not have a barrier in place. If the barrier becomes compromised, then use the wipe-discard-wipe technique. Allow the disinfectant to sit on the surfaces for the manufacturer’s recommended time, usually 3 minutes. Non-sterilizable equipment used during procedures (e.g., amalgamators, torches,) must be disinfected between patients. Curing lights need to be disinfected or have a barrier put in place.
5. While wearing PPE, at the beginning of each appointment, flush air/water lines, ultrasonic scaler lines, and handpiece lines for 30 seconds.
6. Dental unit waterlines are treated to control biofilm and reduce micro-bacterial count in operatory aerosol and spatter. All dental units have self-contained water systems. Clean gloves must be worn when refilling the unit water bottle. Use ICX® treated water from the designated water sources. The ICX® tablet maintains water quality for up to two weeks.
7. Disinfect removable appliances, alginate impressions, blue bite impressions, and PVS impressions with the Clorox Healthcare Fuzion disinfectant located at each dental unit for the recommended contact time of 3 minutes. Rinse with water before transporting or working in the clinical laboratory.
8. Extracted teeth without amalgam restoratioins are considered biohazardous and are placed into the biohazard trash. Extracted teeth with amalgam restorations are placed into the amalgam waste container for proper disposal.
9. For clinical lab safety, wear proper PPE when performing laboratory procedures. Secure hair and loose clothing to minimize the potential for cross-contamination and injury. When using the polishing lathe, always use fresh pumice, a clean disposable tray, and a sterile rag wheel.
10. Hair should be secured away from the face so that it does not interfere with or become contaminated during procedures. 
11. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in areas where a reasonable likelihood of exposure to blood or OPIM can happen. Food and beverages should not be kept in refrigerators or freezers where patient products, blood, or OPIM are stored.
12. WM must adhere to good hand hygiene practices following CDC recommendations. Hand washing with soap and water for 40-60 seconds must occur before donning gloves at the beginning of the day. WM must wash their hands (if visibly soiled) or use hand sanitizers immediately after removing contaminated gloves and before donning another pair.
13. Use over-gloves or remove gloves when leaving the operatory to prevent cross-contamination.
14. All instruments must be sterilized between patients including high-speed handpieces, slow-speed attachments, dental hygiene prophy angles, ultrasonic tips, and ultrasonic handpieces. Each morning Central Sterilization (CS) performs a Bowie Dick test on the autoclaves. Every load from CS utilizes a challenge pack and is checked before releasing the load for patient use. The CS autoclaves undergo biological monitoring once a week. Each clinic's autoclave undergoes weekly biological monitoring.
15. All contaminated, reusable instruments or equipment must be turned into the “dirty” instrument tubs in each clinic. The CS staff will retrieve the tubs in a closed-case cart preventing cross-contamination. Uncovered contaminated equipment is not allowed outside of clinical areas. 
16. All checked-out student instrument kits must be turned in to CS at the end of each day. Students must not store any sterilized items in their clinic locker.

1. Contaminated sharps must be discarded immediately in puncture-resistant, sealable, leakproof containers, and adequately labeled as sharps.
2. Each dental unit is supplied with a sharps container. Containers should be kept upright and checked periodically to prevent overfill.
3. Contaminated needles and sharps shall not be sheared or purposely broken. Needles must be recapped after each use. Recapping needles is allowed for procedures requiring more than one administration of anesthesia. In such cases, a one-handed scoop technique or protector card is required.

Sharps include the following:

1. Dental needles
2. Anesthetic carpules
3. Broken glass
4. Lab blades
5. Surgical blades
6. Endodontic files
7. Burs
8. Dental Instruments
9. Gates-Glidden or any other endodontic preparatory instruments

1. A sharps injury log will consist of the required OSHA Form 300 log and a document containing information from the OU Environmental Health and Safety Office.
2. This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. 
3. If a copy of the documentation is requested, all personal identifiers must be removed from the report.

1.    Wipe instruments carefully with a damp gauze during treatment to eliminate debris from drying.
2.    Secure all instruments inside the cassette to prevent sharps exposure.
3.    Place instrument cassettes in tubs provided in each clinic.
4.    All contaminated equipment must be turned into the “dirty” tubs provided for disinfection or sterilization.
5.    Central Sterilization (CS) staff will transport all cassettes to CS in a closed instrument case cart.
6.    The transportation of open, contaminated cassettes to CS is prohibited.

1. All components of the electric handpieces must be sterilized between uses.
2. Wipe the attachments used for patient care with disinfectant wipes. Allow to stand for the appropriate contact time.
3. While wearing clean gloves, take the attachments to the dry lab for cleaning and lubrication at the designated station.
4. Dental hygiene cordless handpieces require the sleeve to be sterilized between uses. The motor has a barrier placed between the sleeve and the motor. 

The following engineering controls will be used to eliminate or minimize WM exposure to bloodborne pathogens or OPIM:

1. Autoclaves will be used to sterilize reusable sharp instruments in clinical settings.
2. Dental dams or Isovacs will be used in patient procedures when necessary to reduce aerosolization to WM.
3. Hand washing and hand sanitizing facilities are available to all WM with potential bloodborne pathogen exposure. Facilities are available at each operatory, in all clinics, dispensaries, and laboratories.
4. High-volume evacuation (HVE), dental dam or Isovac utilization, and proper patient positioning will be used to reduce exposure to blood or OPIM droplets.
5. Instrument cassettes are completely enclosed, reducing the handling of reusable contaminated sharps. WM are responsible for securing instruments inside the cassettes before turning them into CS for decontamination and sterilization.
6. Sharps containers are available at each operatory and are to be used for all disposable sharps which include, but are not limited to, needles, scalpels, files, burs, and anesthetic carpules.
7. Instrument washers/disinfectors and ultrasonic cleaners will be used to reduce WM from handling contaminated sharp instruments. Dispensary and CS personnel are responsible for monitoring the effectiveness of the equipment and reporting problems as needed.
8. Eyewash stations are available in every clinic and laboratory following ANSI and OSHA standards for workplace exposures.

WM should ensure clinical areas are maintained in a clean and sanitary manner. All equipment and patient-contact surfaces shall be decontaminated as soon as possible after contact with blood or OPIM.

The following procedures should be taken in the event of spills:

1. Standard precautions must be observed. Cleaning of spills must be limited to those people who are trained for the task.
2. Only disposable towels should be used to avoid difficulties involved with laundering.
3.  Blood or OPIM spills: 
   1. Alert people in the immediate area of the spill
   2. Put on PPE – mask, eyewear, gloves, and over-gown
   3. Cover the spill with paper towels or absorbent materials
   4. Carefully pour EPA-registered disinfectant on the surface and begin to clean up the spill
   5. Allow the disinfectant to be in contact with the surface for the manufacturer’s recommended contact time
   6. Discard all materials into a biohazard red bag for disposal

For additional information, click the link: Policy for Waste Disposal and Spills 

1. If the warning label method is selected, the warning labels shall be affixed to containers of regulated waste, refrigerators, and freezers containing blood or OPIM, and other containers used to store, transport, or ship blood or OPIM.
   1. The label shall be fluorescent orange or orange-red with lettering and symbols in a contrasting color.
   2. The label will be affixed as close to the container as possible in a manner that prevents unintentional removal.
   3. Per OSHA, red bags or red containers may be substituted for labels.
   4. Regulated waste that has been decontaminated does not need to be labeled or color-coded.
2. If the red bag or red container method is selected, the facility will need to stay consistent throughout to avoid confusion.
   1. The above items will primarily apply to the red-regulated medical waste containers located throughout the facility.
   2. Pre-labeled biohazard containers will not have the labels removed.
   3. Pre-labeled containers are primarily sharps containers and containers designed for transport.