New CDC guidelines

April 1, 2004
The recommendations update the agency's position on various contemporary issues affecting dentistry.

by Cynthia A. Chillock, CDA, RDH, and Charles John Palenik, MS, PhD

It seems like just a few months ago we were talking about new OSHA guidelines and now we have new guidelines from the CDC. Although the CDC issues recommendations — not regulations — they do carry weight in interpreting state law and standard of care.

In December 2003, the CDC issued a set of new infection control recommendations (Guidelines for Infection Control in Dental Health-Care Settings — 2003). The recommendations updated those made in 1993. The guidelines are available in print (MMWR 2003;52(RR-17):1-68) or electronically (www.cdc. gov/mmwr/preview/mmwrhtml/rr5217a1.htm). Specific practice recommendations appear on pages 39-48.

The guidelines update previous CDC recommendations, incorporating relevant infection control measures and discussing concerns not previously addressed in dentistry.

Since dental practices have long been involved with the well-known issues such as instrument sterilization, personal protective equipment, and environmental surface disinfection, compliance in these areas has generally been acceptable. However, the guidelines introduce a number of new or significantly revised infection control and prevention issues. This article will briefly discuss a limited number of these updated or additional topics.

The CDC ranks its recommendations by category on the basis of existing scientific data, theoretical rationale and applicability, and based on a system determined by the Healthcare Advisory Committee. Each recommendation made in the CDC guidelines is followed by an assigned ranking:

• Category IA — Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

• Category IB — Strongly recommended for implementation and supported by experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

• Category IC — Required for implementation as mandated by federal or state regulation or standard. (When IC is used, a second rating can be included to provide the basis for the applicability. There are state-to-state differences and we should not assume that the absence of an IC implies no state regulation.)

• Category II — Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

• Unresolved issue — No recommendation. Insufficient evidence or no consensus regarding efficacy exists.

* Universal precautions vs. standard precautions — Universal precautions, as defined by CDC, are designed to prevent transmission of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and other bloodborne pathogens when providing emergency treatment or health care. In 1996, the CDC expanded universal precautions to include standard precautions, which apply to contact with blood and all body fluids, secretions, and excretions (except sweat), regardless of whether they contain blood, nonintact skin and mucous membranes. Saliva has always been considered a potentially infectious material in dental infection control.

Bloodborne pathogens are not the only diseases that are occupational hazards in dentistry. Thus, the term standard precautions should now be used to collectively describe all the practices used to limit or prevent disease transmission within a dental practice.

* Work restrictions — The guidelines contain an extensive table that lists suggested work restrictions for HCW with or exposed to major infectious diseases in health care settings. It must be noted that the recommendations offered were made in the absence of state or local regulations.

For example, what should happen if you develop conjunctivitis? The CDC recommends that you be restricted from patient contact and even contact with the patient environment until discharges cease. The same restrictions are recommended for herpetic whitlow. Practice can resume only when all lesions have healed. Other infections, such as active tuberculosis, diarrheal diseases, active skin lesions associated with Staphylococcus aureus, and shingles cause restrictions from patient contact until lesions completely heal, symptoms resolve, or the HCW is proven to no longer be infectious.

Hepatitis C is an important viral disease that affects the liver. The hepatitis C virus (HCV) is especially troubling because over 80 percent of acute infections become chronic. The result is a dramatically higher rate years later of cirrhosis and liver cancer. Infection with HCV does not require any restrictions on professional activity. Health-care workers who are positive for HCV should follow aseptic technique and standard precautions. These recommendations are based on a lack of evidence that disease transmission occurs when correct preventive procedures are routinely applied.

* Safer sharps/safer techniques — Annually, dental practices must identify, evaluate, and select devices with engineered safety features. The goal is to regularly review new items as they are released. Examples include safer anesthetic syringes, blunt suture needles, retractable scalpels, and needleless IV systems.

All disposable sharps (syringes, needles, scalpel blades, and others) must be placed into appropriate puncture-resistant containers. Such "sharps containers" should be located as close as possible to the area in which the sharps are used, preferably in the treatment room. It is generally considered poor form to openly carry dirty instruments with used sharps out of the room and down the hall to the central sterilizing area.

Needles should never be recapped using both hands and any other technique that involves directing the point of a needle toward any part of the body. It is also recommended not to bend, break or remove needles from their bases prior to disposal. Instead, a one-handed scoop technique or a mechanical device designed for holding the needle cap should be used when recapping needles. This method would be employed between multiple injections or before removing a needle from a nondisposable aspirating syringe. If you encounter a needle that is screwed on too tightly and is difficult to remove, a hemostat can be used to loosen it at the hub. Recap it as soon as possible to remove it completely from the syringe.

Of course, the other part is evaluating safer engineering controls once a year. Be sure to include anyone who may be handling the sharps in your office — assistants, hygienists, dentists or sterilizing technicians, because non-managerial employees must be included in this evaluation meeting. The CDC have sample evaluation forms, which can be used when reviewing sharps with safety features.

* Hand hygiene — Hands are one of the most important sources of microorganisms in the spread of disease. Hand hygiene is an essential element of personal hygiene for everyone, but it is also a primary infection control and prevention procedure for HCW. Hand hygiene reduces the incidence of health-care associated infections.

Almost every study of hand hygiene indicates a lack of compliance by health-care workers. Having to wash so many times a day is problematic. Factors that negatively affect hand hygiene include irritation and dryness, sinks inconveniently located, hygiene materials not present, insufficient time, and patient priorities. Washing hands more than 40 times a day would not be exceptional for many dental personnel. Observational studies have indicated compliance to be poor. The overall average of 33 studies was about 40 percent.

Hand hygiene can be divided into three categories: routine handwashing, routine hand asepsis and surgical hand asepsis. These categories are described in the related sidebar.

* Alcohol-based hand rubs — The recent CDC guidelines reference the use of alcohol-based hand rubs (preparations containing 60 to 95 percent alcohol). These products have been shown to be effective and may improve hand hygiene compliance. The CDC guidelines state that alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting, and cause less skin irritation than antiseptic containing soaps or detergents.

Alcohol rubs are appropriate when hands are visibly clean. For routine handwashing or hand antisepsis, apply the correct amount of product into the palm of one hand and rub hands together, covering all surfaces of the hands and fingers. The amount applied varies by manufacturer. Hands should not feel dry after 10 to 15 seconds of rubbing.

Follow the advice of the product's manufacturer. Allow the rub to dry completely prior to placement of gloves. According to some studies, the rubs may also reduce the amount of time spent on hand hygiene by 92 percent per day. That should get the attention because alcohol-based hand rubs seem to not only be effective, but also quite efficient.

There are also alcohol-based hand rubs that can be used for surgical hand asepsis. They have persistent, prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms. The hands and forearms must first be washed with a nonantimicrobial soap and water and thoroughly dried. Then, a surgical hand rub is applied and rubbed in well and allowed to dry prior to gloving.

Bottom line, if you can see it, use soap and water. If you can't see it, feel free to use alcohol-based hand rubs. A couple of other things worth noting regarding hand care were the recommendation of lotion on a regular basis to prevent hand chafing, and no artificial fingernails.

The guidelines have also placed some general recommendations regarding hand hygiene in the area of contact dermatitis and latex hypersensitivity. All were considered strongly recommended or suggested and included screening patients for latex allergy, ensuring a latex-safe environment and having latex-free emergency products available at all times. It is also recommended that as a healthcare provider, if you suspect you have a latex sensitivity or any type of skin problem, you should obtain an accurate diagnosis. Latex sensitivities is now covered under the Americans with Disabilities Act.

* Dental unit waterlines — Water used in routine dental treatment (for example, dental unit and ultrasonic scalers) must meet EPA regulatory standards for drinking water — ≤500 CFU/mL of heterotrophic water bacteria. Dental manufacturers should be consulted for the appropriate methods and equipment should also identify methods for the microbial monitoring of water. Surgical procedures require the use of sterile water/irrigants.

Purging has benefits. Water and air should be discharged for two minutes at the start of the work day and for a minimum of 20 to 30 seconds after each patient from any device connected to the dental water system that enters the patient's mouth. This includes handpieces, ultrasonic scalers and air/water syringes.

Dental handpieces and other devices attached to air and waterlines are to be removed, cleaned, and heat sterilized between patients. Manufacturer's instructions for cleaning, lubrication, and sterilization of such items must be followed. There are now many products available for treatment of the water. Some of them are called point-of-entry waterline treatments, which attach close to the handpieces on the unit. Others are considered source water treatment and can be placed in the J-boxes of the unit, while others are placed where the water enters the office.

Speak to your dental supply companies. They should provide you with the necessary information regarding these systems. Of course, you will have to periodically test and maintain unit anti-retraction mechanisms.

There was one item under "special considerations" of other devices attached to air and waterlines in the guidelines worth special mention. Advise patients not to close their lips tightly around the tip of the saliva ejector when evacuating oral fluids. This creates the possibility for backflow of saliva into the service lines.

* Required reading — The new CDC guidelines concerning infection control in dentistry is an extensive document. It is imperative practitioners dedicate some time to reading it while concentrating on the recommendation section noted at the beginning of this article. It is likely that the guidelines will be discussed and debated for an extended period. They are continually changing as new research and novel technologies are developed.

To help us better understand the new guidelines, the Organization for Safety and Asepsis Procedures (OSAP) is dentistry's resource for infection control and safety. OSAP has published a book on the guidelines, From Policy to Practice OSAP's Guide to the Guidelines. The book is designed to assist dental practices to better understand the recommendations and identify effective and efficient methods for compliance.

Cynthia A. Chillock, CDA, RDH, is a clinician, author, lecturer, advanced instrumentation tutor and consultant.She is president of the Perio-Data™ company and senior consulting editor to Perio Reports Newsletter. She can be reached at (520) 323-1076. Charles John Palenik, MS, PhD, is an assistant director of Infection Control Research and Services at the Indiana University School of Dentistry. Dr. Palenik has authored numerous articles, book chapters and monographs, and is the co-author of the popular Infection Control and Management of Hazardous Materials for the Dental Team. He serves on the Executive Board of OSAP, dentistry's resource for infection control and safety.Questions about this article or any infection control issue may be directed to [email protected].

Types of hand hygiene

Routine handwashing

• Purpose: Remove soil/dirt and transient microorganisms
• Procedure: Use a nonantimicrobial soap or detergent and water for 15 seconds*
• Agents: Liquid soap dispensed using a hand-free devise; avoid the use of soap bars
• Advice: Use routine handwashing techniques when:
• Hands are visibly soiled or contaminated with materials such as blood or other body fluids
• Before and after treating patients (before gloving and after removing gloves)
• When touching barehanded objects known or likely to be contaminated with blood or saliva
• Before replacing defective gloves
• Before leaving the operatory or laboratory (for example, before eating and after using the restroom).

Routine Hand Asepsis

• Purpose: Remove or destroy transient microorganisms; may negatively affect resident flora
• Procedure #1: Use an alcohol-based hand rub; add proper amount to dry hands and then rub hands until alcohol has evaporated (hands, fingers and forearms are dry); use products with known persistent activity
• Procedure #2: Use a medicated soap or detergent and water for 15 seconds*
• Agents #1: Commonly contain 60 to 95 percent ethanol or isopropanol, or combination of alcohols; emollient additives, gel medium and antimicrobial agent, such as chlorhexidine, quaternary ammonium compounds, octenidine or triclosan
• Agents #2: Examples of active agents include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds and triclosan
• Advice: Use when hands are not visibly soiled or contaminated with blood or other body fluids. Used for routine decontamination of hands in clinic situations:
• Before and after treating patients (before gloving and after removing gloves)
• When touching barehanded objects known or likely to be contaminated with blood or saliva
• Before replacing defective gloves
• Before leaving the operatory or laboratory (for example, before eating and after using the restroom)

Surgical hand asepsis

• Purpose: Remove or destroy transient microorganisms and reduce resident flora with a persistent agent effect
• Procedure #1: Use water and antimicrobial agent or detergent and scrub for two to six minutes; use agents capable of producing persistent activity
• Procedure #2: Use a non-antimicrobial soap or detergent and water for 15 seconds, and dry hands and forearms completely; follow with the use of a surgical alcohol-based hand run; add proper amount to dry hands and then rub hands until alcohol has evaporated (hands, fingers, and forearms are dry); use products with known persistent activity#*
• Agents #1: Examples of active agents include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds and triclosan
• Agents #2: Liquid soap dispensed using a hand-free devise; avoid the use of soap bars; dry hands and forearms, then use products that contain 60 to 95 percent ethanol or isopropanol or combination of alcohols; emollient additives, gel medium and antimicrobial agent such as chlorhexidine, quaternary ammonium compounds, octenidine or triclosan
• Advice: Used prior to placement of sterile surgeons' gloves in preparation for surgical procedures

* process involves vigorous, brief rubbing together of all lathered hands and fingers, followed by an adequate rinse, then hands should be thoroughly dried
# apply prescribed amount to the palm of one hand and rub together covering all surfaces of hands and fingers until skin surfaces are dry