In reviewing the available literature, there are no well-documented cases of serious bleeding problems from dental surgery in patients receiving therapeutic levels of continuous warfarin sodium therapy, but there were several documented cases of serious embolic complications in patients whose warfarin therapy was withdrawn for dental treatment. Many authorities state that dental extractions can be performed with minimal risk in patients who are at or above therapeutic levels of anticoagulation. There are sound legal reasons to continue therapeutic levels of warfarin for dental treatment.
Although there is a theoretical risk of hemorrhage after dental surgery in patients who are at therapeutic levels of anticoagulation, the risk appears to be minimal, the bleeding usually can be easily treated with local measures, and this risk may be greatly outweighed by the risk of thromboembolism after withdrawal of anticoagulant therapy. Continuous oral anticoagulant therapy has been used to decrease the risk of thromboembolism for more than 50 years, prolonging the lives of thousands of patients.
Dental treatment on continuously anticoagulated patients has been controversial, 1 - 4 and physicians must weigh the risks of hemorrhage from the dental procedure against the risks of emboli from withdrawing anticoagulation treatment. Some recommend no change in anticoagulation for dental treatment. In a review of the English-language literature using computerized searches and authors' references , there have been more than dental surgical procedures including more than dental extractions documented in 26 case reports and studies of more than patients receiving continuous oral anticoagulant therapy.
These procedures include both single and multiple simple extractions, surgical extractions, full mouth extractions, alveoectomies, and other surgical procedures. Nonsurgical dental procedures were not included in this review. Many of the patients had levels of warfarin above recommended levels on the day of surgery.
In , the American College of Chest Physicians stated that the recommended therapeutic range of warfarin is an international normalized ratio INR of 2. Cannegieter et al 15 have suggested a higher therapeutic range, an INR of 3. Therefore, for the purposes of this review, the therapeutic level of warfarin in all patients is no higher than an INR of 4. The studies of reported cases of dental surgery on patients receiving continuous oral anticoagulant therapy are summarized in Table 1.
Because of variations in study designs and differences in measuring the intensity of anticoagulant therapy between the more recent and the older reports, these studies do not lend themselves to a conventional meta-analysis or even systematic review. Still, of the more than dental surgical procedures reported in more than patients receiving continuous warfarin therapy, the following observations can be made:. Many of these procedures were performed in patients with warfarin levels above present recommended therapeutic levels of anticoagulation.
Many procedures were extensive, including multiple and full mouth extractions, alveoectomies, and surgical extractions. But after examining these 12 cases closely, none makes a good case for withdrawal of warfarin for dental surgery. In 5 of the 12 cases, 30 , 32 , 41 the PT ratios were above therapeutic levels. In 3 cases 21 , 39 in which patients were administered concomitant antibiotics, the preoperative INR was within the therapeutic range, and bleeding was initially controlled in all 3 cases by local measures. After 2 consecutive days contrary to American Heart Association guidelines to prevent endocarditis 44 of high-dose prophylactic erythromycin treatment, 1 of these patients developed bleeding 2 days after the extraction when his INR was 4.
The authors speculated that the antibiotics caused the increase in INR and subsequent bleeding and oozing, although there may have been other causes, including warfarin overdose. In the third case, the patient had a therapeutic preoperative INR of 3. On the fourth postsurgical day, the patient was bleeding. The INR was then 9. Warfarin Coumadin was withheld, and the patient underwent transfusion of fresh-frozen plasma, then packed red blood cells, and ultimately vitamin K. The authors concluded that the elevated PT was from an interaction with amoxicillin, and that the amoxicillin was probably unnecessary.
Ramstrom et al 31 and Sindet-Pedersen et al 34 conducted separate studies comparing results of dental surgery on patients taking anticoagulants who rinsed 4 times a day for 7 days with a tranexamic acid mouthwash with those of patients who rinsed with a placebo mouthwash. Only 1 patient in each study each in the placebo group developed postoperative bleeding that was treated by more than local measures.
Unfortunately, the authors did not report these patients' INRs, although they reported an INR range of all patients, the upper level of which in the study by Sindet-Pedersen was above recommended therapeutic levels. More important, the study design was poor: patients should not rinse at all after dental extractions until a hemostatic clot has formed. A more fair comparison would have been comparing tranexamic acid with no mouthwash at all. Kwapis 28 reported in that 3 of 60 treated patients had "prolonged bleeding" after dental extractions. The PT ratio was reported for only 2 of these patients, and it was less than 1.
These patients were administered vitamin K, but it was not reported if local measures to control hemostasis were attempted before administering vitamin K. Although there is a theoretical risk of hemorrhage after dental surgery, the literature indicates that the risk is very small. Some investigators recommend consideration of replacement heparin for especially high-risk patients undergoing extensive dental surgery.
In addition to the high cost-benefit ratio for intravenous administration of heparin, 47 the cases documented above include many extensive surgical procedures and argue against any withdrawal of anticoagulant therapy, including heparin replacement. In reviewing the English-language literature, there are no well-documented cases of serious bleeding problems from dental surgery in patients receiving therapeutic levels of continuous anticoagulant therapy.
Many practitioners believe that there is minimal risk of thromboembolism in patients whose anticoagulant therapy is interrupted for surgery. There have been several documented cases of serious embolic complications, including deaths, after withdrawing continuous warfarin therapy. Three of these embolisms occurred within 5 days of the interruption of therapy. In documented cases in patients of withdrawing continuous anticoagulation specifically for dental procedures, 5 1. Table 2 presents the reported cases of withdrawal of continuous oral anticoagulation for dental procedures patients receiving heparin replacement are not included.
Unfortunately, there are several documented cases of serious embolic complications in patients whose warfarin therapy has been withdrawn for dental treatment. There are limitations in comparing the results of dental surgery in patients receiving continuous anticoagulant therapy with those of patients whose anticoagulation treatment is withdrawn. There was not necessarily a direct cause-and-effect relationship between the embolic complications and the withdrawal of warfarin therapy for dental treatment since these complications sometimes occur even if the patient continues warfarin therapy.
On the other hand, some of the bleeding complications in patients who continued warfarin therapy for dental surgery may have also been coincidental since patients who have normal coagulation sometimes have postoperative bleeding. OPIM is an OSHA term that refers to 1 body fluids including semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures; any body fluid visibly contaminated with blood; and all body fluids in situations where differentiating between body fluids is difficult or impossible; 2 any unfixed tissue or organ other than intact skin from a human living or dead ; and 3 HIV-containing cell or tissue cultures, organ cultures; HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Parenteral: Means of piercing mucous membranes or skin barrier through such events as needlesticks, human bites, cuts, and abrasions. Persistent activity: Prolonged or extended activity that prevents or inhibits proliferation or survival of microorganisms after application of a product. This activity can be demonstrated by sampling a site minutes or hours after application and demonstrating bacterial antimicrobial effectiveness when compared with a baseline level.
Previously, this property was sometimes termed residual activity. Prion: Protein particle lacking nucleic acid that has been implicated as the cause of certain neurodegenerative diseases e. Retraction: Entry of oral fluids and microorganisms into waterlines through negative water pressure. Seroconversion: The change of a serological test from negative to positive indicating the development of antibodies in response to infection or immunization.
Sterile: Free from all living microorganisms; usually described as a probability e. Sterilization: Use of a physical or chemical procedure to destroy all microorganisms including substantial numbers of resistant bacterial spores.
Surfactants: Surface-active agents that reduce surface tension and help cleaning by loosening, emulsifying, and holding soil in suspension, to be more readily rinsed away. Ultrasonic cleaner: Device that removes debris by a process called cavitation, in which waves of acoustic energy are propagated in aqueous solutions to disrupt the bonds that hold particulate matter to surfaces. Vaccine: Product that induces immunity, therefore protecting the body from the disease.
Vaccines are administered through needle injections, by mouth, and by aerosol. Washer-disinfector: Automatic unit that cleans and thermally disinfects instruments, by using a high-temperature cycle rather than a chemical bath. Wicking: Absorption of a liquid by capillary action along a thread or through the material e. The objectives are to educate DHCP regarding the principles of infection control, identify work-related infection risks, institute preventive measures, and ensure prompt exposure management and medical follow-up.
Coordination between the dental practice's infection-control coordinator and other qualified health-care professionals is necessary to provide DHCP with appropriate services. Dental programs in institutional settings, e. However, the majority of dental practices are in ambulatory, private settings that do not have licensed medical staff and facilities to provide complete on-site health service programs.
In such settings, the infection-control coordinator should establish programs that arrange for site-specific infection-control services from external health-care facilities and providers before DHCP are placed at risk for exposure. Referral arrangements can be made with qualified health-care professionals in an occupational health program of a hospital, with educational institutions, or with health-care facilities that offer personnel health services. Personnel are more likely to comply with an infection-control program and exposure-control plan if they understand its rationale 5,13, Clearly written policies, procedures, and guidelines can help ensure consistency, efficiency, and effective coordination of activities.
Personnel subject to occupational exposure should receive infection-control training on initial assignment, when new tasks or procedures affect their occupational exposure, and at a minimum, annually Education and training should be appropriate to the assigned duties of specific DHCP e.
For DHCP who perform tasks or procedures likely to result in occupational exposure to infectious agents, training should include 1 a description of their exposure risks; 2 review of prevention strategies and infection-control policies and procedures; 3 discussion regarding how to manage work-related illness and injuries, including PEP; and 4 review of work restrictions for the exposure or infection. Inclusion of DHCP with minimal exposure risks e. Educational materials should be appropriate in content and vocabulary for each person's educational level, literacy, and language, as well as be consistent with existing federal, state, and local regulations 5, DHCP are at risk for exposure to, and possible infection with, infectious organisms.
Immunizations substantially reduce both the number of DHCP susceptible to these diseases and the potential for disease transmission to other DHCP and patients 5, Thus, immunizations are an essential part of prevention and infection-control programs for DHCP, and a comprehensive immunization policy should be implemented for all dental health-care facilities 17 , Dental practice immunization policies should incorporate current state and federal regulations as well as recommendations from the U.
Public Health Service and professional organizations 17 Appendix B. On the basis of documented health-care--associated transmission, HCP are considered to be at substantial risk for acquiring or transmitting hepatitis B, influenza, measles, mumps, rubella, and varicella. All of these diseases are vaccine-preventable. No vaccine exists for HCV. Immunization of DHCP before they are placed at risk for exposure remains the most efficient and effective use of vaccines in health-care settings. Some educational institutions and infection-control programs provide immunization schedules for students and DHCP.
Employers are also required to follow CDC recommendations for vaccinations, evaluation, and follow-up procedures Nonpatient-care staff e. Employers are also required to ensure that employees who decline to accept hepatitis B vaccination sign an appropriate declination statement DHCP unable or unwilling to be vaccinated as required or recommended should be educated regarding their exposure risks, infection-control policies and procedures for the facility, and the management of work-related illness and work restrictions if appropriate for exposed or infected DHCP.
Avoiding exposure to blood and OPIM, as well as protection by immunization, remain primary strategies for reducing occupationally acquired infections, but occupational exposures can still occur A combination of standard precautions, engineering, work practice, and administrative controls is the best means to minimize occupational exposures.
Written policies and procedures to facilitate prompt reporting, evaluation, counseling, treatment, and medical follow-up of all occupational exposures should be available to all DHCP. Written policies and procedures should be consistent with federal, state, and local requirements addressing education and training, postexposure management, and exposure reporting see Preventing Transmission of Bloodborne Pathogens.
DHCP who have contact with patients can also be exposed to persons with infectious TB, and should have a baseline tuberculin skin test TST , preferably by using a two-step test, at the beginning of employment Thus, if an unprotected occupational exposure occurs, TST conversions can be distinguished from positive TST results caused by previous exposures 20 , DHCP are responsible for monitoring their own health status.
DHCP who have acute or chronic medical conditions that render them susceptible to opportunistic infection should discuss with their personal physicians or other qualified authority whether the condition might affect their ability to safely perform their duties. However, under certain circumstances, health-care facility managers might need to exclude DHCP from work or patient contact to prevent further transmission of infection Decisions concerning work restrictions are based on the mode of transmission and the period of infectivity of the disease 5 Table 1.
Exclusion policies should 1 be written, 2 include a statement of authority that defines who can exclude DHCP e. Policies should also encourage DHCP to report illnesses or exposures without jeopardizing wages, benefits, or job status. With increasing concerns regarding bloodborne pathogens and introduction of universal precautions, use of latex gloves among HCP has increased markedly 7 , Increased use of these gloves has been accompanied by increased reports of allergic reactions to natural rubber latex among HCP, DHCP, and patients , as well as increased reports of irritant and allergic contact dermatitis from frequent and repeated use of hand-hygiene products, exposure to chemicals, and glove use.
DHCP should be familiar with the signs and symptoms of latex sensitivity 5, A physician should evaluate DHCP exhibiting symptoms of latex allergy, because further exposure could result in a serious allergic reaction. A diagnosis is made through medical history, physical examination, and diagnostic tests. Procedures should be in place for minimizing latex-related health problems among DHCP and patients while protecting them from infectious materials.
These procedures should include 1 reducing exposures to latex-containing materials by using appropriate work practices, 2 training and educating DHCP, 3 monitoring symptoms, and 4 substituting nonlatex products where appropriate 32 see Contact Dermatitis and Latex Hypersensitivity. The health status of DHCP can be monitored by maintaining records of work-related medical evaluations, screening tests, immunizations, exposures, and postexposure management.
Such records must be kept in accordance with all applicable state and federal laws. The HIPAA Privacy Rule applies to covered entities, including certain defined health providers, health-care clearinghouses, and health plans. OSHA requires employers to ensure that certain information contained in employee medical records is 1 kept confidential; 2 not disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by the OSHA standard; and 3 maintained by the employer for at least the duration of employment plus 30 years. Dental practices that coordinate their infection-control program with off-site providers might consult OSHA's Bloodborne Pathogen standard and employee Access to Medical and Exposure Records standard, as well as other applicable local, state, and federal laws, to determine a location for storing health records 13, Preventing Transmission of Bloodborne Pathogens Although transmission of bloodborne pathogens e.
The opportunity for transmission is greatest from patient to DHCP, who frequently encounter patient blood and blood-contaminated saliva during dental procedures. The majority of DHCP infected with a bloodborne virus do not pose a risk to patients because they do not perform activities meeting the necessary conditions for transmission.
Although an infected DHCP might be viremic, unless the second and third conditions are also met, transmission cannot occur. The risk of occupational exposure to bloodborne viruses is largely determined by their prevalence in the patient population and the nature and frequency of contact with blood and body fluids through percutaneous or permucosal routes of exposure. The risk of infection after exposure to a bloodborne virus is influenced by inoculum size, route of exposure, and susceptibility of the exposed HCP HBV is transmitted by percutaneous or mucosal exposure to blood or body fluids of a person with either acute or chronic HBV infection.
Blood contains the greatest proportion of HBV infectious particle titers of all body fluids and is the most critical vehicle of transmission in the health-care setting. HBsAg is also found in multiple other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, the majority of body fluids are not efficient vehicles for transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg The concentration of HBsAg in body fluids can be ,fold greater than the concentration of infectious HBV particles Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among HCP.
In multiple investigations of nosocomial hepatitis B outbreaks, the majority of infected HCP could not recall an overt percutaneous injury 40,41 , although in certain studies, approximately one third of infected HCP recalled caring for a patient who was HBsAg-positive 42, Thus, HBV infections that occur in HCP with no history of nonoccupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces The potential for HBV transmission through contact with environmental surfaces has been demonstrated in investigations of HBV outbreaks among patients and HCP in hemodialysis units Since the early s, occupational infections among HCP have declined because of vaccine use and adherence to universal precautions Among U.
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During , levels remained relatively unchanged Chakwan Siew, Ph. Infection rates can be expected to decline further as vaccination rates remain high among young dentists and as older dentists with lower vaccination rates and higher rates of infection retire. Although the potential for transmission of bloodborne infections from DHCP to patients is considered limited 53 , precise risks have not been quantified by carefully designed epidemiologic studies 53 , 56 , Reports published during describe nine clusters in which patients were thought to be infected with HBV through treatment by an infected DHCP However, transmission of HBV from dentist to patient has not been reported since , possibly reflecting such factors as 1 adoption of universal precautions, 2 routine glove use, 3 increased levels of immunity as a result of hepatitis B vaccination of DHCP, 4 implementation of the OSHA bloodborne pathogen standard 68 , and 5 incomplete ascertainment and reporting.
Only one case of patient-to-patient transmission of HBV in the dental setting has been documented CDC, unpublished data, In this case, appropriate office infection-control procedures were being followed, and the exact mechanism of transmission was undetermined. Because of the high risk of HBV infection among HCP, DHCP who perform tasks that might involve contact with blood, blood-contaminated body substances, other body fluids, or sharps should be vaccinated 2 ,13, 17 , 19 , Prevaccination serological testing for previous infection is not indicated, although it can be cost-effective where prevalence of infection is expected to be high in a group of potential vacinees e.
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DHCP who do not develop an adequate antibody response i. Revaccinated persons should be retested for anti-HBs at the completion of the second vaccine series. Approximately half of nonresponders to the primary series will respond to a second 3-dose series. If no antibody response occurs after the second series, testing for HBsAg should be performed Persons who prove to be HBsAg-positive should be counseled regarding how to prevent HBV transmission to others and regarding the need for medical evaluation.
Even so, immunity continues to prevent clinical disease or detectable viral infection Booster doses of vaccine and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series are not necessary for vaccine responders Hepatitis C virus appears not to be transmitted efficiently through occupational exposures to blood.
Follow-up studies of HCP exposed to HCV-infected blood through percutaneous or other sharps injuries have determined a low incidence of seroconversion mean: 1. One study determined transmission occurred from hollow-bore needles but not other sharps Although these studies have not documented seroconversion associated with mucous membrane or nonintact skin exposure, at least two cases of HCV transmission from a blood splash to the conjunctiva 75,76 and one case of simultaneous transmission of HCV and HIV after nonintact skin exposure have been reported In a study that evaluated risk factors for infection, a history of unintentional needlesticks was the only occupational risk factor independently associated with HCV infection Multiple reports have been published describing transmission from HCV-infected surgeons, which apparently occurred during performance of invasive procedures; the overall risk for infection averaged 0.
Transmission of HIV to six patients of a single dentist with AIDS has been reported, but the mode of transmission could not be determined 2 ,92, No additional cases of transmission were documented. Prospective studies worldwide indicate the average risk of HIV infection after a single percutaneous exposure to HIV-infected blood is 0. After an exposure of mucous membranes in the eye, nose, or mouth, the risk is approximately 0.
The precise risk of transmission after skin exposure remains unknown but is believed to be even smaller than that for mucous membrane exposure. Certain factors affect the risk of HIV transmission after an occupational exposure. Laboratory studies have determined if needles that pass through latex gloves are solid rather than hollow-bore, or are of small gauge e.
In a retrospective case-control study of HCP, an increased risk for HIV infection was associated with exposure to a relatively large volume of blood, as indicated by a deep injury with a device that was visibly contaminated with the patient's blood, or a procedure that involved a needle placed in a vein or artery The risk was also increased if the exposure was to blood from patients with terminal illnesses, possibly reflecting the higher titer of HIV in late-stage AIDS. Exposures occur through percutaneous injury e. Observational studies and surveys indicate that percutaneous injuries among general dentists and oral surgeons occur less frequently than among general and orthopedic surgeons and have decreased in frequency since the mids This decline has been attributed to safer work practices, safer instrumentation or design, and continued DHCP education , Percutaneous injuries among DHCP usually 1 occur outside the patient's mouth, thereby posing less risk for recontact with patient tissues; 2 involve limited amounts of blood; and 3 are caused by burs, syringe needles, laboratory knives, and other sharp instruments ,, Injuries among oral surgeons might occur more frequently during fracture reductions using wires , Experience, as measured by years in practice, does not appear to affect the risk of injury among general dentists or oral surgeons ,, The majority of exposures in dentistry are preventable, and methods to reduce the risk of blood contacts have included use of standard precautions, use of devices with features engineered to prevent sharp injuries, and modifications of work practices.
These approaches might have contributed to the decrease in percutaneous injuries among dentists during recent years , However, needlesticks and other blood contacts continue to occur, which is a concern because percutaneous injuries pose the greatest risk of transmission. Standard precautions include use of PPE e. Other protective equipment e. Engineering controls are the primary method to reduce exposures to blood and OPIM from sharp instruments and needles. These controls are frequently technology-based and often incorporate safer designs of instruments and devices e.
Work-practice controls establish practices to protect DHCP whose responsibilities include handling, using, assembling, or processing sharp devices e. Work-practice controls can include removing burs before disassembling the handpiece from the dental unit, restricting use of fingers in tissue retraction or palpation during suturing and administration of anesthesia, and minimizing potentially uncontrolled movements of such instruments as scalers or laboratory knives , As indicated, needles are a substantial source of percutaneous injury in dental practice, and engineering and work-practice controls for needle handling are of particular importance.
These revisions clarify the need for employers to consider safer needle devices as they become available and to involve employees directly responsible for patient care e. Safer versions of sharp devices used in hospital settings have become available e. Aspirating anesthetic syringes that incorporate safety features have been developed for dental procedures, but the low injury rates in dentistry limit assessment of their effect on reducing injuries among DHCP.
Work-practice controls for needles and other sharps include placing used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as feasible to where the items were used 2 , 7 ,13, In addition, used needles should never be recapped or otherwise manipulated by using both hands, or any other technique that involves directing the point of a needle toward any part of the body 2 , 7 ,13,97, , A one-handed scoop technique, a mechanical device designed for holding the needle cap to facilitate one-handed recapping, or an engineered sharps injury protection device e.
DHCP should never bend or break needles before disposal because this practice requires unnecessary manipulation. Before attempting to remove needles from nondisposable aspirating syringes, DHCP should recap them to prevent injuries. For procedures involving multiple injections with a single needle, the practitioner should recap the needle between injections by using a one-handed technique or use a device with a needle-resheathing mechanism. Passing a syringe with an unsheathed needle should be avoided because of the potential for injury. Additional information for developing a safety program and for identifying and evaluating safer dental devices is available at.
Postexposure management is an integral component of a complete program to prevent infection after an occupational exposure to blood. During dental procedures, saliva is predictably contaminated with blood 7 , Even when blood is not visible, it can still be present in limited quantities and therefore is considered a potentially infectious material by OSHA 13, A qualified health-care professional should evaluate any occupational exposure incident to blood or OPIM, including saliva, regardless of whether blood is visible, in dental settings Dental practices and laboratories should establish written, comprehensive programs that include hepatitis B vaccination and postexposure management protocols that 1 describe the types of contact with blood or OPIM that can place DHCP at risk for infection; 2 describe procedures for promptly reporting and evaluating such exposures; and 3 identify a health-care professional who is qualified to provide counseling and perform all medical evaluations and procedures in accordance with current recommendations of the U.
DHCP, including students, who might reasonably be considered at risk for occupational exposure to blood or OPIM should be taught strategies to prevent contact with blood or OPIM and the principles of postexposure management, including PEP options, as part of their job orientation and training. Educational programs for DHCP and students should emphasize reporting all exposures to blood or OPIM as soon as possible, because certain interventions have to be initiated promptly to be effective.
Policies should be consistent with the practices and procedures for worker protection required by OSHA and with current PHS recommendations for managing occupational exposures to blood 13, After an occupational blood exposure, first aid should be administered as necessary. Puncture wounds and other injuries to the skin should be washed with soap and water; mucous membranes should be flushed with water.
No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, use of antiseptics is not contraindicated. The application of caustic agents e. Exposed DHCP should immediately report the exposure to the infection-control coordinator or other designated person, who should initiate referral to the qualified health-care professional and complete necessary reports.
Because multiple factors contribute to the risk of infection after an occupational exposure to blood, the following information should be included in the exposure report, recorded in the exposed person's confidential medical record, and provided to the qualified health-care professional:. All of these factors should be considered in assessing the risk for infection and the need for further follow-up e.
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In , these recommendations were updated and consolidated into one set of PHS guidelines The new guidelines reflect the availability of new antiretroviral agents, new information regarding the use and safety of HIV PEP, and considerations regarding employing HIV PEP when resistance of the source patient's virus to antiretroviral agents is known or suspected. Hand Hygiene Hand hygiene e. Hospital-based studies have demonstrated that noncompliance with hand hygiene practices is associated with health-care--associated infections and the spread of multiresistant organisms.
Noncompliance also has been a major contributor to outbreaks The prevalence of health-care--associated infections decreases as adherence of HCP to recommended hand hygiene measures improves The microbial flora of the skin, first described in , consist of transient and resident microorganisms Transient flora, which colonize the superficial layers of the skin, are easier to remove by routine handwashing. They are often acquired by HCP during direct contact with patients or contaminated environmental surfaces; these organisms are most frequently associated with health-care--associated infections.
Resident flora attached to deeper layers of the skin are more resistant to removal and less likely to be associated with such infections. The preferred method for hand hygiene depends on the type of procedure, the degree of contamination, and the desired persistence of antimicrobial action on the skin Table 2. For routine dental examinations and nonsurgical procedures, handwashing and hand antisepsis is achieved by using either a plain or antimicrobial soap and water. If the hands are not visibly soiled, an alcohol-based hand rub is adequate. The purpose of surgical hand antisepsis is to eliminate transient flora and reduce resident flora for the duration of a procedure to prevent introduction of organisms in the operative wound, if gloves become punctured or torn.
Skin bacteria can rapidly multiply under surgical gloves if hands are washed with soap that is not antimicrobial , Thus, an antimicrobial soap or alcohol hand rub with persistent activity should be used before surgical procedures Agents used for surgical hand antisepsis should substantially reduce microorganisms on intact skin, contain a nonirritating antimicrobial preparation, have a broad spectrum of activity, be fast-acting, and have a persistent effect , Persistence i.
Alcohol hand rubs are rapidly germicidal when applied to the skin but should include such antiseptics as chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan to achieve persistent activity Factors that can influence the effectiveness of the surgical hand antisepsis in addition to the choice of antiseptic agent include duration and technique of scrubbing, as well as condition of the hands, and techniques used for drying and gloving. CDC's guideline on hand hygiene in health-care settings provides more complete information Selecting the most appropriate antiseptic agent for hand hygiene requires consideration of multiple factors.
Essential performance characteristics of a product e. Delivery system, cost per use, reliable vendor support and supply are also considerations. Because HCP acceptance is a major factor regarding compliance with recommended hand hygiene protocols , ,, , considering DHCP needs is critical and should include possible chemical allergies, skin integrity after repeated use, compatibility with lotions used, and offensive agent ingredients e.
Discussing specific preparations or ingredients used for hand antisepsis is beyond the scope of this report. DHCP should choose from commercially available HCP handwashes when selecting agents for hand antisepsis or surgical hand antisepsis. Handwashing products, including plain i.
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Liquid products should be stored in closed containers and dispensed from either disposable containers or containers that are washed and dried thoroughly before refilling. Soap should not be added to a partially empty dispenser, because this practice of topping off might lead to bacterial contamination , Store and dispense products according to manufacturers' directions. The primary defense against infection and transmission of pathogens is healthy, unbroken skin.
Frequent handwashing with soaps and antiseptic agents can cause chronic irritant contact dermatitis among DHCP. Damage to the skin changes skin flora, resulting in more frequent colonization by staphylococci and gram-negative bacteria , The potential of detergents to cause skin irritation varies considerably, but can be reduced by adding emollients.
Lotions are often recommended to ease the dryness resulting from frequent handwashing and to prevent dermatitis from glove use , However, petroleum-based lotion formulations can weaken latex gloves and increase permeability. For that reason, lotions that contain petroleum or other oil emollients should only be used at the end of the work day , Dental practitioners should obtain information from lotion manufacturers regarding interaction between lotions, gloves, dental materials, and antimicrobial products. Although the relationship between fingernail length and wound infection is unknown, keeping nails short is considered key because the majority of flora on the hands are found under and around the fingernails Fingernails should be short enough to allow DHCP to thoroughly clean underneath them and prevent glove tears Sharp nail edges or broken nails are also likely to increase glove failure.
Long artificial or natural nails can make donning gloves more difficult and can cause gloves to tear more readily. Hand carriage of gram-negative organisms has been determined to be greater among wearers of artificial nails than among nonwearers, both before and after handwashing In addition, artificial fingernails or extenders have been epidemiologically implicated in multiple outbreaks involving fungal and bacterial infections in hospital intensive-care units and operating rooms Freshly applied nail polish on natural nails does not increase the microbial load from periungual skin if fingernails are short; however, chipped nail polish can harbor added bacteria , Studies have demonstrated that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings In a study of intensive-care nurses, multivariable analysis determined rings were the only substantial risk factor for carriage of gram-negative bacilli and Staphylococcus aureus, and the concentration of organisms correlated with the number of rings worn However, two other studies demonstrated that mean bacterial colony counts on hands after handwashing were similar among persons wearing rings and those not wearing rings , Whether wearing rings increases the likelihood of transmitting a pathogen is unknown; further studies are needed to establish whether rings result in higher transmission of pathogens in health-care settings.
However, rings and decorative nail jewelry can make donning gloves more difficult and cause gloves to tear more readily , Thus, jewelry should not interfere with glove use e. Use of rotary dental and surgical instruments e. This spatter travels only a short distance and settles out quickly, landing on the floor, nearby operatory surfaces, DHCP, or the patient. The spray also might contain certain aerosols i. Aerosols can remain airborne for extended periods and can be inhaled.
However, they should not be confused with the large-particle spatter that makes up the bulk of the spray from handpieces and ultrasonic scalers. Appropriate work practices, including use of dental dams and high-velocity air evacuation, should minimize dissemination of droplets, spatter, and aerosols 2. Primary PPE used in oral health-care settings includes gloves, surgical masks, protective eyewear, face shields, and protective clothing e.
Reusable PPE e. Wearing gloves, surgical masks, protective eyewear, and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens is mandated by OSHA General work clothes e. A surgical mask that covers both the nose and mouth and protective eyewear with solid side shields or a face shield should be worn by DHCP during procedures and patient-care activities likely to generate splashes or sprays of blood or body fluids.
Protective eyewear for patients shields their eyes from spatter or debris generated during dental procedures. The mask's outer surface can become contaminated with infectious droplets from spray of oral fluids or from touching the mask with contaminated fingers. Also, when a mask becomes wet from exhaled moist air, the resistance to airflow through the mask increases, causing more airflow to pass around edges of the mask.
If the mask becomes wet, it should be changed between patients or even during patient treatment, when possible 2 , When airborne infection isolation precautions expanded or transmission-based are necessary e. However, certain surgical masks i.
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The level of protection a respirator provides is determined by the efficiency of the filter material for incoming air and how well the face piece fits or seals to the face e. When respirators are used while treating patients with diseases requiring airborne-transmission precautions e. This program should include training and fit testing to ensure an adequate seal between the edges of the respirator and the wearer's face. Protective clothing and equipment e. OSHA bloodborne pathogens standard requires sleeves to be long enough to protect the forearms when the gown is worn as PPE i.
DHCP should change protective clothing when it becomes visibly soiled and as soon as feasible if penetrated by blood or other potentially infectious fluids 2 ,13,14, All protective clothing should be removed before leaving the work area DHCP wear gloves to prevent contamination of their hands when touching mucous membranes, blood, saliva, or OPIM, and also to reduce the likelihood that microorganisms present on the hands of DHCP will be transmitted to patients during surgical or other patient-care procedures 1 , 2 , 7 , Medical gloves, both patient examination and surgeon's gloves, are manufactured as single-use disposable items that should be used for only one patient, then discarded.
Gloves should be changed between patients and when torn or punctured. Wearing gloves does not eliminate the need for handwashing. Hand hygiene should be performed immediately before donning gloves. Pulmonary Disease 43 4. Endocrine and Metabolic Disorders 69 5. Renal and Urinary Tract Disease 95 6. Hepatic Disease 7.