Free Online CME: HIV and Oral Health Care

Updated April 2010

Recommendations in the New York State Department of Health AIDS Institute guidelines are assigned an evidence-based rating and use the rating scheme developed by the US Department of Health and Human Services. The category rating of expert opinion can mean the collective opinions of experts in HIV management, or a requirement of a regulatory agency such as the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH), the Centers for Disease Control and Prevention (CDC), or the New York State Department of Health (NYSDOH).
 

I. GENERAL INFECTION CONTROL: OVERVIEW

Recommendations:

Dentists and dental hygienists in New York State must complete course work or training in infection control every 4 years, with particular emphasis on the modes and risks of HIV and hepatitis B virus (HBV) transmission.¹ (AIII)

All dental healthcare settings must have a written infection control program that includes postexposure management and tuberculosis infection control (see Table 1). (AIII) 

Healthcare settings must meet the Occupational Safety and Health Administration (OSHA) requirements to eliminate or minimize employee exposure to bloodborne pathogens.² The requirements include the following: (AIII)

• A written Exposure Control Plan (ECP) that addresses exposure to blood and other potentially infectious material, such as droplets, spills, splashes, and aerosols
• Review and update of the ECP at least annually
• Annual employee training about bloodborne pathogen transmission, and
• Free-of-charge immunization against hepatitis B virus. Employees who choose not to be immunized must sign a declination statement³

In New York State, approved courses for training in infection control are offered by the State Education Department and the Department of Health. Oral health professionals may choose from a list of approved training providers from which to take required courses appropriate to their practice. Some courses are also available online. A list of these providers is available from the NYSDOH Bureau of Communicable Diseases (1-518-486-2938) and online at: www.health.state.ny.us/professionals/diseases/reporting/communicable/infection/hcp_training.htm 

Guidelines for Infection Control in Dental Health-Care Settings – 2003 from the Centers for Disease Control and Prevention (CDC) replaces the 1997 dental infection control guidelines and consolidates recommendations from other CDC guidelines (see Table 1 for a listing of the infection control topics that are addressed). In the CDC’s guidelines, the nomenclature universal precautions, which are measures to prevent exposures to blood, is replaced with the more encompassing term standard precautions, which are procedures to safeguard against exposures to blood, other body fluids, including saliva, mucous membranes, and broken skin.⁴

The CDC guidelines for use with all dental patients and all dental procedures are intended to reduce the risk of inadvertent disease transmission, control cross-contamination, and ensure a safe working environment for all dental personnel. All patients are considered to be potentially infected with a bloodborne pathogen, thereby standardizing the approach to treatment and eliminating the need for special precautions.⁴

Except where noted, these guidelines are a summary of the CDC’s Guidelines for Infection Control in Dental Health-Care Settings – 2003. The New York State Department of Health AIDS Institute’s (NYSDOH AI) Dental Standards of Care Committee has emphasized HIV-specific information in these guidelines. Infection control guidance that does not specifically pertain to HIV is included in Appendix A.

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II. GENERAL INFECTION CONTROL PRACTICES

Recommendations:

Dental healthcare workers (DHCWs) should adhere to the following four principles recommended by the CDC in order to achieve a safe working environment: (AIII)

• Take action to stay healthy
• Avoid contact with blood and body fluids
• Limit the spread of contamination
• Make objects safer for use 

All dental healthcare settings should have, and implement, an immunization policy that includes up-to-date state, federal, and United States Public Health Service regulations, and recommendations from professional organizations.⁴ (AIII)

All DHCWs should perform proper hand hygiene using an FDA-approved agent before and after treating each patient to prevent the spread of infection. The hand hygiene technique chosen is determined by treatment procedure, degree of contamination, and desired persistence of antimicrobial action. (AII)

All dental healthcare settings must develop, implement, and review, on an annual basis, a program to prevent sharps injuries.⁵ (AII)

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A. Taking Action to Stay Healthy

1. Staff Training and Education

To comply with OSHA requirements, staff must be trained, at least annually, on risks associated with office-specific policies, procedures performed, and methods to reduce associated risks. This is in addition to the New York State Infection Control training required every 4 years for re-licensure of healthcare professionals.

See OSHA training requirements for DHCWs, available at: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051

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2. Immunizations

Immunizations are the primary defense against the spread of vaccine-preventable diseases, such as hepatitis B virus (HBV), in the dental setting. Childhood vaccinations should be updated, as well as disease-specific vaccinations depending on potential risk of exposure, such as influenza.⁴ Because adult chicken pox is associated with high morbidity, employees who do not have evidence of immunity should be encouraged to receive immunization against the varicella zoster virus (VZV). Recommended immunizations for HCWs are shown in Table 2.

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3. Work-Related Illness and Restriction

DHCWs are responsible for monitoring their own health; however, there may be circumstances under which work restrictions need to be implemented. Work restrictions should be based on mode of transmission and period of potential infectivity.⁴ Exclusion policies should be clearly written and discussed with DHCWs through training and education.⁴

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4. Hand Hygiene and Hand Health

Hand hygiene is a general term related to routine handwashing, antiseptic handwashing, alcohol-based handrubs, or surgical hand hygiene/antisepsis.^4,6 The method of hand hygiene selected is determined by the treatment procedure, the degree of contamination, and the desired persistence of antimicrobial action.⁴

Frequent hand washing with soaps and antiseptics can minimize transmission of pathogens but also can cause chronic irritant contact dermatitis. The primary defense against infection and transmission of pathogens is healthy unbroken skin. Lotions are often recommended to ease the dryness resulting from frequent hand washing and, more recently, to prevent dermatitis resulting from glove use.⁴ Petroleum-based lotions can weaken latex gloves and increase permeability. If lotions are used during the workday, a water-based product should be used.

For more information about hand hygiene, refer to the CDC’s Guidelines for Hand Hygiene, available at: www.cdc.gov/OralHealth/infectioncontrol/faq/hand.htm

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5. Programs to Prevent Sharps Injuries

Engineering controls, such as self-sheathing anesthetic needles, and work practice controls, such as putting used disposable sharps in nearby puncture-resistant containers, are important in the dental healthcare setting because sharps are the primary source of percutaneous injuries. A program to prevent sharps injuries in dental personnel and patients must be developed, implemented, and reviewed annually. A staff person knowledgeable about or willing to be trained in injury prevention (i.e., a safety coordinator) should be assigned to perform the following: 

• Promote safety awareness
• Facilitate prompt reporting and post-exposure management of injuries
• Identify unsafe work practices and devices
• Coordinate the selection and evaluation of safer dental devices, including seeking advice and input from employees
• Organize staff education and training
• Complete the necessary reporting forms and documentation
• Monitor safety performance

These activities must be described in the healthcare setting’s written bloodborne pathogens exposure control plan. A mechanism for staff feedback should be available. This feedback will assist the safety coordinator in reviewing the effectiveness of the plan and making necessary modifications.

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6. Reporting Occupational Exposure to Blood

DHCWs should be instructed to report occupational exposures to blood as soon as possible so that appropriate post-exposure management can be executed. See HIV Prophylaxis Following Occupational Exposure.

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B. Avoiding Contact with Blood and Body Fluids

Recommendation:

DHCWs should use personal protection equipment (PPE) to decrease the risk of acquiring or transmitting diseases. PPE should be used according to the manufacturers’ instructions. (AIII)

The term standard precautions includes universal precautions, but also encompasses contact with blood, all body fluids (except sweat) regardless of whether they contain visible blood, non-intact skin, and mucous membranes. In the context of dental practice, saliva is considered a potentially infectious material because it is frequently contaminated with blood after manipulation.^7,8 Accordingly, no operational difference exists in clinical dental practice between universal and standard precautions.³ Standard precautions include transmission-based precautions when indicated, including airborne precautions for tuberculosis (TB).⁴

Minimizing sprays and splashes is critical for limiting the spread of contamination.⁴ To prevent contact with droplets and splashes, use of barrier precautions such as face shields, surgical masks, and gowns, appropriate use of rubber dams, high-velocity air evacuation, and proper patient positioning are recommended. Personal protection equipment (PPE), such as masks, protective eyewear/face shields, protective clothing, and gloves, should be used to protect skin and mucous membranes from exposure to transmissible diseases.⁴ Allergy or hypersensitivity to materials used, such as latex gloves, should be considered when ordering PPE to ensure that all employees are provided with adequate protection.⁴ At the time of product selection, information should be obtained from the manufacturer regarding interaction between gloves, lotions, dental materials, and antimicrobial products.⁴ All PPE should be used according to manufacturers’ directions.⁴ PPE should be removed and may be disposed of with other non-medical waste before leaving patient care area. Gloves must be changed between each patient and when compromised.

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C. Limiting the Spread of Contamination

Proper management of environmental surfaces, along with good hand hygiene, is essential for preventing or limiting contamination.4 Although environmental surfaces have not been directly associated with disease transmission, they have the potential to become contaminated during patient care and may serve as reservoirs for microorganisms.4 Environmental surfaces are divided into two general groups: 1) clinical contact surfaces, and 2) housekeeping surfaces.

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1. Clinical Contact Surfaces

Recommendation:

Areas of high probability of contamination with pathogenic microorganisms from oral secretions, such as light handles, dental chair switches, or other frequently touched surfaces, must either have a disposable barrier or be cleaned and then disinfected between patients with an approved disinfectant. (AII)

Contact surfaces, such as instrument trays, light handles, switches on dental chairs, and cabinet knobs, are areas of high probability of contamination with pathogenic microorganisms, including hepatitis B and C viruses, herpes simplex virus, cytomegalovirus, Mycobacterium tuberculosis, staphylococci, streptococci, and other viruses and bacteria that colonize or infect the oral cavity and respiratory tract.^4,6,9,10 Contamination occurs when an object, such as a gloved hand, comes in contact with saliva/blood during dental procedures then touches these surfaces. Contact surfaces must either have a disposable barrier or be cleaned and then disinfected with either an Environmental Protection Agency (EPA) -registered hospital disinfectant with an HIV/HBV claim (low-level disinfectant) or a tuberculocidal claim (intermediate-level disinfectant).⁴ Surfaces visibly contaminated with blood or other potentially infectious material should be cleaned with an intermediate-level disinfectant. Surfaces that cannot be adequately cleaned should have a barrier placed over them. Table 3 lists differences between FDA- and EPA-regulated disinfectants.

See Appendix B for a list of websites that review contact surface disinfectants that can be used in the dental office.

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III. WATERBORNE INFECTION CONTROL

Recommendation:

All dental healthcare settings should follow CDC dental water quality recommendations. (BIII)

Immunocompromised individuals may be at increased risk for a range of opportunistic infections acquired by the ingestion of contaminated water. Although contamination of dental treatment water may be a concern, no clinical reports or current evidence of widespread public health problems have been reported.⁴ Concern about dental treatment water has increased in part because of 1) a general increase in awareness on the part of both oral healthcare workers and patients regarding infection control issues in dentistry, 2) reports of relatively high levels of potentially pathogenic microorganisms in the dental treatment water,⁴ and 3) disclosure of anecdotal case reports associating illness with dental water contamination. 

Water delivered through dental unit waterlines for use as a coolant/irrigant for nonsurgical dental procedures should be of safe drinking water quality – less than 500 colony forming units (CFU) per milliliter of heterotrophic bacteria. Maintaining this standard is difficult because higher microbial contamination can occur due to the nature of dental unit waterlines (e.g., system design, flow rates, and materials) which promotes both bacterial growth and development of biofilm. However, the majority of organisms recovered from dental waterlines are common heterotrophic water bacteria.⁴ When a boil-water alert is issued to the public, water from the public water supply should not be used and dental care should be discontinued on all units connected to the public water supply.⁴ NYS county health departments are responsible for disseminating information locally. 

The CDC previously recommended flushing dental waterlines at the beginning of the clinic day to reduce microbial load; however, studies have shown that this practice did not affect biofilm or reliably improve the quality of water.⁴ Therefore, other strategies should be used to achieve the recommended value of <500 CFU/mL of bacteria in safe drinking water. To achieve this, commercial devices and procedures designed for this purpose should be used. Some effective methods include the following ⁴: 

• Self-contained water systems combined with chemical treatment
• In-line microfilters
• Combination of these treatments

Dental healthcare providers who wish to obtain more information on public water supply should contact the New York State Department of Health (NYSDOH) Bureau of Public Water Supply Protection at the Center for Environmental Health (phone: 1-800-458-1158, extension 27650).

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IV. HEALTHCARE WORKERS WITH BLOODBORNE OR OTHER INFECTIOUS DISEASES

Recommendations:

DHCWs should be counseled about the importance of learning their bloodborne disease status (HIV, HBV, HCV).⁴ (BIII)

DHCWs with acute or chronic medical conditions should consult with a qualified clinician to determine if their condition(s) would affect their ability to safely perform their work.⁴ (BIII)

DHCWs should follow New York State and local recommendations for work restrictions for HCWs infected with or exposed to major infectious diseases in healthcare settings. (AIII) (Additional suggested work restrictions can be found in Table 1 of the CDC Guidelines for Infection Control in Dental Health-Care Settings – 2003.)

Being HIV-infected is not sufficient justification to limit the professional duties of healthcare professionals unless specific factors compromise a worker’s ability to meet infection control standards or to provide appropriate patient care.^11,12 The theoretical risk of transmitting HIV infection by HCWs with HIV is significantly small.¹³ As part of the infection control process, healthcare facilities are responsible for establishing a mechanism for evaluating HCWs with HIV or HBV infection and monitoring all HCWs whose compromised function or health condition poses a significant risk to patients at the facility. For more information, see the NYSDOH Policy Statement and Guidelines to Prevent Transmission of HIV and Hepatitis B Through Medical/Dental Procedures. Additional information regarding resources for dentists infected with infectious diseases is available through the ADA Dentist Health and Wellness Program.

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V. AIRBORNE INFECTION CONTROL (TUBERCULOSIS)

Tuberculosis (TB) is a significant public health problem in New York State; however, the risk of transmission of Mycobacterium tuberculosis in routine dental settings remains quite low.

Recommendations:

All dental healthcare settings must have a written TB control plan. The following should be included in the plan:

• An annual TB risk assessment; TB infection control policies for each dental setting should be based on the setting’s risk assessment.^4,14 (AIII)
• A baseline TB screening with an FDA-approved test for diagnosis of latent TB infection (LTBI) for all DHCWs. Those who do not have documentation of TB screening should be screened for TB with any FDA-approved test, such as the tuberculin skin test (TST), or one of the whole blood interferon-gamma release assays (IGRAs). DHCWs who have recently been exposed to TB should be tested as soon as possible. (AII) The frequency of retesting of DHCWs is based on the risk assessment of the setting in which they practice.^4,14 (AIII)
• Deferral of all non-emergency dental treatment in patients with suspected pulmonary or laryngeal TB disease until the patients are confirmed by a qualified clinician to be non-infectious. (AII) Emergency dental treatment should be referred to a facility with isolation capability and infectious disease management. (BII)

HIV-infected DHCWs who are exposed to TB should be aware of their increased risk for developing active TB and should observe appropriate precautions.¹⁵ (BII)

In New York State, all healthcare employees in hospitals and diagnostic and treatment centers are required to undergo TB screening with any FDA-approved test, such as the tuberculin skin test (TST), or one of the whole blood interferon-gamma release assays (IGRAs), to detect M. tuberculosis infection.¹⁶ Currently, approved IGRAs include QuantiFERON-TB Gold, 2005; QuantiFERON-TB Gold In-Tube, 2007; and TSpot.TB, 2008. This Committee recommends that employees in medical and dental outpatient offices follow these same TB screening guidelines.
 

HIV-infected patients who have pulmonary TB are no more infectious than non–HIV-infected persons with pulmonary TB. Hence, the same infection control principles apply to all patients with pulmonary TB. Knowledge of HIV status is not required for determination of an individual patient’s potential TB infectivity; however, DHCWs should be aware that TB is a known HIV-related opportunistic infection.
 

TB is transmitted via airborne droplets, in particular from the coughing and sneezing of patients with active pulmonary or laryngeal TB. TB “infection” is synonymous with latent infection (LTBI). Patients with LTBI have been exposed to TB and have a reactive tuberculin skin test: these asymptomatic patients are non-infectious. TB “disease” is synonymous with symptoms of active infection, and these patients are considered potentially infectious. Although HIV-infected patients with LTBI have a higher rate of reactivation to TB disease, while asymptomatic they remain, like HIV-negative persons, non-infectious. 

Extrapulmonary TB, which may be present in a small percentage of patients, is not infectious via the respiratory route, although isolated cases of transmission from ulcerating lesions have occurred after percutaneous injury.^17,18 Persons diagnosed with LTBI (e.g., reactive tuberculin skin tests and negative chest x-rays) are not infectious. Reviews of TB management in a dental practice are available for further reading.¹⁹ See Mycobacterial Infections for further information on HIV/TB co-infection, including strains of M. tuberculosis that are resistant to anti-tuberculosis medications. See the Division of Tuberculosis Elimination site for CDC guidelines and information.^14,20

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VI. RESOURCES FOR CONSULTATION

The following online resources are available for more information about infection control in dental settings: 

• Centers for Disease Control and Prevention (CDC) – www.cdc.gov/OralHealth/infectioncontrol
• Occupational Safety and Health Administration (OSHA) – www.osha.gov/SLTC/dentistry/control.html
• National Institute for Occupational Safety and Health (NIOSH) – www.cdc.gov/niosh/topics/bbp
• American Dental Association (ADA) – www.ada.org/1857.aspx
• Organization for Safety and Asepsis and Procedures (OSAP) – www.osap.org 

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REFERENCES

1. Office of the Professions. New York State Education Requirement. Mandated Training Related to Infection Control. Available at: www.op.nysed.gov/training/icmemo.htm 

2. US Department of Labor, Occupational Safety and Health Administration. Regulations (Standards – 29 CFR) Bloodborne pathogens – 1910.1030. Available at: www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 

3. US Department of Labor, Occupational Safety and Health Administration. Model Plans and Programs for OSHA Bloodborne Pathogens and Hazard Communications Standard. 2003. Publication 3186. Available at: www.osha.gov/Publications/osha3186.pdf 

4. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings — 2003. MMWR Recomm Rep 2003;52(RR-17):1-66. Available at: www.cdc.gov/mmwr/PDF/rr/rr5217.pdf and www.cdc.gov/OralHealth/infectioncontrol/guidelines/index.htm 

5. Centers for Disease Control and Prevention. Infection Control in Dental Settings: Device screening and evaluation forms. Available at: www.cdc.gov/Oralhealth/infectioncontrol/forms.htm 

6. Kohn WG, Harte JA, Malvitz DM, et al. Guidelines for infection control in dental settings-2003. J Am Dent Assoc 2004;135:33-47. [PubMed] 

7. Centers for Disease Control and Prevention. Updated Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001;50(RR-11):1-42. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm 

8. Harte JA. Looking inside the 2003 CDC Infection Control Guidelines. J Calif Dent Assoc 2004;32:919-930. [PubMed] 

9. Reams GJ, Baumgartner JC, Kulild JC. Practical application of infection control in endodontics. J Endod 1995;21:281-284. Review. 

10. New York State Human Rights Law, § 292(21); 296(2). 

11. Americans with Disabilities Act, 4 USC, § 401 (1990). Available at: www.ada.gov 

12. New York State Department of Health Policy Statement and Guidelines to Prevent Transmission of HIV and Hepatitis B Through Medical/Dental Procedures. New York, NY: New York State Department of Health; 1992. Available at: www.health.state.ny.us/professionals/protocols_and_guidelines/docs/guidelines_prevent_hiv_medical-dental_procedures.pdf

13. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities. MMWR Recomm Rep 1994;43(RR-13):1-132. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm 

14. Kramer F, Sasse SA, Simms JC, et al. Primary cutaneous tuberculosis after a needlestick injury from a patient with AIDS and undiagnosed tuberculosis. Ann Intern Med 1993;119:594-595. [PubMed] 

15. Centers for Disease Control and Prevention. TB and HIV Coinfection. Available at: www.cdc.gov/tb/topic/TBHIVcoinfection/default.htm

16. New York State Department of Health. TB Screening. Letter to Chief Executive Officer. Available at: www.health.state.ny.us/professionals/hospital_administrator/letters/2009/2009-01-08_tb_screening.htm

17. Genné D, Siegrist HH. Tuberculosis of the thumb following a needlestick injury [see comments]. Clin Infect Dis 1998;26:210-211.

18. Phelan JA, Jimenez V, Tompkins DC. Tuberculosis. Dent Clin North Am 1996;40:327-339. [PubMed]

19. Cleveland JL, Robinson VA, Panlilio JA. Tuberculosis epidemiology, diagnosis and infection control recommendations for dental settings: An update of the Centers for Disease Control and Prevention guidelines. J Am Dent Assoc 2009;140:1092-1099. [PubMed]

20. Centers for Disease Control and Prevention. Aerosols and HIV. Available at: www.cdc.gov/ncidod/dhqp/bp_hiv_aerosol.html

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FURTHER READING

Szymańska J. Microbiological risk factors in dentistry. Current status of knowledge. Ann Agric Environ Med 2005;12:157-63. Review. [PubMed]

Walker J, Marsh P. Microbial biofilm formation in DUWS and their control using disinfectants. J Dent 2007;35:721-730. [PubMed]

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APPENDIX A

GENERAL INFORMATION FOR ALL DENTAL PRACTICES

The following information pertains to all dental facilities to ensure a safe working environment for dental personnel and is not unique to practices that provide care for HIV-infected patients.
 

A. Housekeeping Surfaces

Housekeeping surfaces such as floors, walls, and sinks have little potential for disease transmission in dental healthcare settings; therefore, they may be cleaned and decontaminated with soap and water or with an EPA-registered hospital disinfectant. In the event of a blood spill, housekeeping surfaces should be cleaned immediately and disinfected with an EPA-registered hospital disinfectant with an HIV, HBV, or tuberculocidal claim (see Appendix B).
 

Aerosols

Aerosols are invisible particles, <10 microns in diameter, generated by both human and environmental sources that require considerable energy to generate and have the capability to remain airborne for extended periods, although they are not likely to be present in most clinical settings. Aerosols are not the large-particle spatter that is the dominant spray from handpieces and ultrasonic scalers in dental settings. There is no clear evidence that the use of rotary dental and surgical instruments can generate aerosols containing infective bloodborne pathogens. Bloodborne pathogens can be transmitted through mucous membrane exposure, but transmission of bloodborne pathogens through aerosols has not been documented.¹
 

Medical Waste

Special caution is needed for handling and disposal of medical waste, including sharps (even if non-contaminated). There is no evidence linking disease transmission to non-infectious medical waste. Regulated medical waste (potentially infectious), such as sharps or discarded materials saturated with blood or blood products or other potentially infectious material, must be appropriately labeled, packaged, and disposed of in accordance with Federal and State EPA regulations and in compliance with any local regulations.

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B. Making Objects Safer for Use

Recommendations:

Critical and semicritical instruments should be cleaned and heat sterilized, or they should be single-use disposable instruments (SUDS).² SUDS should not be reused or re-sterilized. (AII)

Manufacturers’ directions should be followed for all cleaning and sterilization procedures. (AIII)

Use of clean and/or sterilized objects reduces the potential for disease transmission among both staff and patients. The CDC recommends that critical instruments (e.g., periodontal scalers, scalpel blades) and semi-critical instruments (e.g., dental mouth mirrors, reusable dental impression trays) be heat sterilized or that single-use disposable (SUDS) instruments are used. SUDS are intended for use on one patient only and during a single procedure and should not be reused or re-sterilized.² 

Sterilization Monitoring

A variety of factors can hinder proper sterilization. The CDC recommends using a combination of process parameters, including mechanical, chemical, and biological, to monitor in-office sterilization (see Table A-1).² Instruments should be in sufficient supply to ensure that the results of sterilization procedures are known prior to reusing those instruments. Chemical indicators, such as indicator tapes, should be used with each instrument sterilization cycle. A color change will indicate that the instruments have been exposed to the proper sterilization conditions; when the color fails to change, the instruments need to be re-sterilized. In addition, sterilizers should be monitored at least weekly with biological indicators. Biological monitoring can be done in-house or through a mail-in monitoring program. 

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C. Engineering Controls

Use of engineering controls can also reduce the risk of disease transmission. An example of an engineering control is a safety device, such as a self-sheathing needle, scalpel, or a blunt suture. Safe work habits can be used where engineering controls are not available or appropriate and include using a sharps disposal container, avoiding recapping needles by hand, restricting the use of fingers for palpation or retraction of tissue in the presence of a sharp or needle, and creating a neutral zone for four-handed procedures.

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D. Safer Dental Devices

Information on specific brands and products of safer dental devices can be obtained from vendors, purchasing agents, scientific literature, lists published on the Internet (e.g., www.healthsystem.virginia.edu/internet/epinet/safetydevice.cfm; www.ada.org/2737.aspx?currentTab=2) or in trade journals, and other healthcare facilities or by contacting the Organization for Safety and Asepsis Procedures (OSAP) Research Foundation,³ OSHA, and the American Dental Association (ADA). OSHA requires employers to involve employees in identifying and choosing effective safer medical devices.⁴

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APPENDIX A

REFERENCES

1. Centers for Disease Control and Prevention. Aerosols and HIV. Available at: www.cdc.gov/ncidod/dhqp/bp_hiv_aerosol.html 

2. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings — 2003. MMWR Recomm Rep 2003;52(RR-17):1-66. Available at: www.cdc.gov/mmwr/PDF/rr/rr5217.pdf and www.cdc.gov/OralHealth/infectioncontrol/guidelines/index.htm 

3. Organization for Safety and Asepsis Procedures. Infection Control Guidelines. Available at: http://osap.org 

4. US Department of Labor, Occupational Safety and Health Administration. Model Plans and Programs for OSHA Bloodborne Pathogens and Hazard Communications Standard. 2003. Publication 3186. Available at: www.osha.gov/Publications/osha3186.pdf

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APPENDIX B

DENTAL OFFICE CONTACT SURFACE DISINFECTANTS AND STERILANTS

To obtain updated information about contact surface disinfectants and sterilants, visit any of the following websites:

• American Dental Association (ADA) – www.ada.org/1013.aspx#steam
• Food and Drug Administration (FDA) – www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/ReprocessingofSingle-UseDevices/UCM133514
• Environmental Protection Agency (EPA) – www.epa.gov/oppad001/chemregindex.htm
• Organization for Safety and Asepsis and Procedures (OSAP) – www.osap.org/

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