Current through Register Vol. 49, No. 9, September, 2024
Article XV
INFECTION CONTROL
Arkansas Code §
17-82-316(a)
-(c) and Arkansas Code §
17-82-406
provide that the Arkansas State Board of Dental Examiners is vested with the
power to revoke or suspend for any period of time, the privilege of practicing
under any license issued in the State of Arkansas to any dentist, dental
hygienist or dental assistant if the licensee fails to maintain proper
standards of sanitation or fails to otherwise maintain adequate safeguards for
the health and safety of patients.
Public
Law 102-141 passed in the First Session of the
102nd Congress of the United States of America
approved October 28, 1991 provides that the states will establish guidelines to
apply to health professionals and will determine appropriate disciplinary and
other actions to ensure compliance with those guidelines in order to prevent
the transmission of human immunodeficiency virus and hepatitis B virus during
exposure-prone invasive procedures except for an emergency situation where the
patient's life or limb is in danger.
A. Definitions as used in this Rule:
1. Dental Health Care Personnel (DHCP)
Dental health-care personnel (DHCP) refers to all paid and unpaid
personnel in the dental health-care setting who might be occupationally exposed
to infectious materials, including body substances and contaminated supplies,
equipment, environmental surfaces, water, or air.
DHCP includes dentists, dental hygienists, dental assistants,
dental laboratory technicians (in-office and commercial), students and
trainees, contractual personnel, and other persons not directly involved in
patient care but potentially exposed to infectious agents (e.g.,
administrative, clerical, housekeeping, maintenance, or volunteer
personnel).
2. HIV
The human immunodeficiency virus, whether HIV-1 or HIV-2.
3. HBV
The Hepatitis B virus.
4. HCV
The Hepatitis C virus.
5. OPIM
Other potentially infectious materials. OPIM is a term that
refers to
1) bodily fluids including
semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid,
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; and
2) any
unfixed tissue or organ (other than intact skin) from a human (living or
dead).
6. Exposure-prone
invasive procedure
Any surgical, diagnostic or therapeutic procedure involving
manual or instrumental contact with or entry into any blood, body fluids,
cavity, internal organ, subcutaneous tissue, mucous membrane or percutaneous
would of the human body in which there is a risk of contact between the blood
or OPIM of the DHCP and the blood or OPIM of the patient.
7. Standard precautions
The concept that all blood and OPIM should be treated as
infectious because patients with bloodborne infections can be asymptomatic or
unaware they are infected. Preventive practices used to reduce blood exposures,
particularly percutaneous exposures, include 1) careful handling of sharp
instruments; 2) use of rubber dams to minimize blood spattering; 3)
handwashing; and 4) use of personal protective barriers (e.g., gloves, masks,
protective eyewear, and gowns).
Standard precautions integrate and expand the elements of
universal precautions (the term used by the CDC prior to 1996) into a standard
of care designed to protect DHCP and patients from pathogens that can be spread
by blood or any other body fluid, excretion, or secretion. Standard precautions
apply to contact with 1) blood; 2) all body fluids, secretions, and excretions
(except sweat), regardless of whether they contain blood; 3) nonintact skin;
and 4) mucous membranes. Saliva has always been considered a potentially
infectious material in dental infection control; thus, no operational
difference exists in clinical dental practice between universal precautions and
standard precautions.
8.
Occupational exposure
Reasonably anticipated skin, eye, mucous membrane, or parenteral
contact with blood or OPIM that can result from the performance of an
employee's duties.
9.
Disinfection
Destruction of pathogenic and other kinds of microorganisms by
physical or chemical means. Disinfection is less lethal than sterilization,
because it destroys the majority of recognized pathogenic microorganisms, but
not necessarily all microbial forms (e.g., bacterial spores). Disinfection does
not ensure the degree of safety associated with sterilization processes.
10. Sterilization
Use of a physical or chemical procedure to destroy all
microorganisms including substantial numbers of resistant bacterial
spores.
11. Critical
instruments
Penetrates soft tissue, contacts bone, enters into or contacts
the bloodstream or other normally sterile tissue; includes surgical
instruments, periodontal scalers, scalpel blades, surgical dental burs.
12. Semicritical instruments
Contacts mucous membranes or nonintact skin; will not penetrate
soft tissue, contact bone, enter into or contact the bloodstream or other
normally sterile tissue; includes dental mouth mirror, amalgam condenser,
reusable dental impression trays.
13. Noncritical instruments
Contacts intact skin; includes radiograph head/cone, blood
pressure cuff, facebow, pulse oximeter.
B. Education and Training
1. Training in standard precautions and other
infection control standards required by OSHA and as recommended by the CDC and
set forth in this rule shall be provided to all DHCP by the employer upon
initial employment prior to direct patient care, whenever new tasks are
assigned which effects the level of occupational exposure, and at least
annually.
2. At least two (2)
continuing education hours on infection control must be reported with biennial
license renewals for all dentists, dental hygienists and registered dental
assistants.
C.
Preventing Transmission of Bloodborne Pathogens
1. All DHCPs who are at risk for occupational
exposure to blood or OPIM shall at all times use and practice standard
precautions for all patient encounters.
2. Engineering and work-practice controls
a. Consider sharp items (needles, scalers,
burs, lab knives, and wires) that are contaminated as infective.
b. Place used disposable syringes and
needles, scalpel blades, and other sharp items in appropriate
puncture-resistant containers.
a.
Do not recap used needles by using both hands or any other technique that
involves directing the point of the needle toward any part of the body. Use
either a one-handed scoop technique or a mechanical device designed for holding
the needle cap when recapping needles.
b. Do not bend or break needles prior to
disposal.
3. Follow CDC
guidelines after percutaneous, mucous membrane, or nonintact skin exposure to
blood or OPIM. Guidelines are found in the CDC publication MMWR, Dec. 19, 2003,
Volume 52, No. RR-17, pg. 13-14, "Post Exposure Management and
Prophylaxis."
D.
Personal Protective Equipment (PPE)
1. Masks,
protective eyewear, and face shields
a. A
surgical mask and eye protection with solid side shields or a surgical mask and
a face shield must be worn during procedures likely to generate splashing or
spattering of blood or OPIM.
b.
Change masks between patients. Also change masks during patient treatment if
mask becomes wet.
a. Clean with
soap and water, or if visibly soiled, clean and disinfect reusable facial
protective equipment.
2.
Protective clothing
a. Wear reusable or
disposable gowns, lab coats, or uniforms that cover personal clothing and skin
(forearms) likely to be soiled with blood or OPIM.
b. Change protective clothing if visibly
soiled.
c. Remove gloves, mask,
non-prescription protective eyewear or shields before departing clinic
area.
3. Gloves
a. Wear medical gloves when a potential
exists for contacting blood, saliva, OPIM, or mucous membranes.
b. Wash hands before donning gloves. Wear a
new pair of gloves for each patient, remove them promptly after use, and wash
hands immediately.
c. Remove gloves
that are torn, cut, or punctured and wash hands before regloving.
d. Do not wash or disinfect gloves before
use.
e. Ensure that appropriate
gloves in the correct size are readily accessible.
f. Use puncture and chemical resistant
utility gloves when cleaning instruments and performing housekeeping tasks
involving contact with chemicals and/or contaminated surfaces.
g. Ensure that non-latex gloves are available
for those patients and DHCP's with latex allergies.
E. Sterilization and disinfection
of patient-care items
1. Instrument cleaning
and sterilization
a. Clean and heat-sterilize
critical and semicritical instruments and items before each use using only
FDA-cleared medical devices for sterilization and follow the manufacturer's
instructions for correct use.
b.
Clean all visible debris from instruments and items before sterilization or
disinfection using an automated cleaning process such as an ultrasonic cleaner
or washer-disinfector.
c. Wear
puncture- and chemical-resistant/heavy duty utility gloves for instrument
cleaning and decontamination procedures.
d. Wear appropriate PPE when splashing or
spraying is anticipated during cleaning (i.e., mask, eye protection or face
shield).
e. Single-use disposable
instruments are acceptable alternatives if they are used only once and disposed
of correctly.
f. Ensure that
noncritical patient-care items are barrier protected or cleaned and disinfected
after each use with an EPA-registered hospital disinfectant.
2. Packaging of Instruments
a. Instruments should be sterilized inside
packages with color change markings or chemical indicator tape attached which
verify that the package has been exposed to the sterilization process and
required parameters of time, temperature, and the presence of steam has been
achieved.
b. Critical and
Semicritical instruments intended for immediate reuse can be heat-sterilized
unwrapped if a chemical indicator such as autoclave tape is used for each cycle
and the instruments are transported immediately and aseptically to the point of
use.
c. Do not sterilize
implantable devices unwrapped.
3. Sterilization monitoring
a. Monitor each load with mechanical (e.g.,
time, temperature, and pressure) and chemical indicators. Color change markings
on bags or autoclave tape are acceptable indicators.
b. Do not use instrument packs if mechanical
or chemical indicators indicate inadequate processing.
c. Monitor sterilizers at least monthly by
using a biological indicator (spore test) with a matching control).
d. In case of a positive spore test, remove
the sterilizer from service and retest. If the repeat spore test is negative
put the sterilizer back in service.
e. If the repeated spore test is positive,
remove the sterilizer from use until it has been inspected or repaired, recall
and reprocess all items processed since the last negative test.
f. Maintain sterilization records or
biological spore testing for three years.
4. Storing sterile items
a. Place the date or sterilization and if
multiple sterilizers are used in the facility, the sterilizer used on the
outside of the packaging material. This will be critical in case of a failed
spore test.
b. Reclean, repack, and
resterilize any instrument package that has been compromised (torn, punctured,
etc.)
c. Do not store sterile
instruments where the packages might be contaminated by contact with
non-sterile instruments or packages.
d. Do not store critical or semicritical
instruments unwrapped.
F. Environmental Infection Control
1. Clinical contact surfaces
a. Examples of clinical contact surfaces are
light handles, switches, radiograph equipment, chairside computers, drawer
handles, faucet handles, countertops, pens, doorknobs, etc.
b. Use barriers such as clear plastic wrap,
bags, sheets, tubing, and plastic-backed paper or other materials impervious to
moisture, to protect clinical contact surfaces. Barriers must be changed
between patients.
c. Clean and
disinfect clinical contact surfaces that are not barrier-protected, by using an
EPA-registered hospital disinfectant after each patient following
manufacturer's directions.
d. Use
PPE when cleaning and disinfecting environmental surfaces.
2. Regulated medical waste
a. Dispose of regulated medical waste in
accordance with federal, state, and local regulations.
b. Use color-coded or labeled containers that
prevent leakage for nonsharp regulated medical waste.
c. Place sharp items (needles, glass
anesthetic carpules, scalpel blades, ortho bands/wires, broken metal
instruments, and burs) in an appropriate sharps container. Do not
overfill.
G.
Dental Unit Water Lines and Water Quality
1.
Use water that meets EPA regulatory standards for drinking water.
2. Discharge water and air for a minimum of
20-30 seconds after each patient from any device connected to the dental water
system that enters that patient's mouth.
3. During a boil-water advisory, do not
deliver water from the public water system to the patient through the dental
operative unit, ultrasonic scaler, or other dental equipment that uses the
public water system until the boil order is lifted by the local water
utility.
H. Special
Considerations
1. Clean and heat-sterilize
handpieces and other intraoral instruments that can be removed from the air and
waterlines of dental units between patients.
2. Use heat-tolerant or disposable intraoral
devices for dental radiography which are sterilized before each use.
3. For digital radiography sensors, use
barriers (covers). If the items cannot tolerate heat sterilization.
4. Handling of extracted teeth
a. Dispose of extracted teeth as regulated
medical waste unless returned to the patient.
b. Clean and place extracted teeth in a leak
proof container, labeled with a biohazard symbol, and maintain hydration for
transport to education institutions or a dental laboratory.
5. Dental laboratory
a. Use PPE when handling items received in
the lab until they have been decontaminated.
b. Before they are handled in the lab, clean
disinfect, and rinse all dental prostheses and prosthodontic materials
(impressions, bite registrations, occlusal rims, and extracted teeth) by using
an EPA registered hospital disinfectant.
c. Clean and heat-sterilize heat tolerant
items used in the mouth such as metal impression trays.
I. Medical conditions,
work-related illness, and work restrictions
1.
A DHCP who is positive for HIV, Hepatitis B or Hepatitis C shall disclose this
fact to the board. If the DHCP is not a licensee or permit holder, the
supervising licensed dentist will report the DHCP's health status to the board.
The DHCP shall thereafter refrain from participating in any procedure which has
a potential for occupational exposure.
Said refraining will continue until such time as the board enters
an Order delineating the scope of practice permitted for the DHCP.
2. The Board will then establish
and appoint members to serve on a Review Panel to review, counsel, monitor and
recommend restrictions, when appropriate, for the practices of HIV, Hepatitis B
or Hepatitis C positive DHCPs.
3.
The Review Panel shall be appointed by the Board with its members being chosen
on a case-by-case basis.
4. The
Review Panel will conduct its review considering that exposure-prone invasive
procedures are best determined on a case-by-case basis by taking into
consideration the degree of infectivity, the specific procedure(s) as well as
the skill, technique, and possible mental and/or physical impairment of the
infected DHCP. Following its review, the Panel Chairperson will submit a report
of recommendations or restrictions of practice to the Board.
5. The Board will consider the Review Panel's
recommendations, will make the final determination of practice and/or procedure
restrictions, will develop procedures in order to monitor the compliance of the
DHCP with restrictions, and will communicate said information of any
restrictions and the monitoring of the restrictions to the DHCP or the
supervising licensed dentist by written Order.
6. Information as to the Panel's
recommendations, the Board's monitoring of restrictions and its disciplining of
the DHCP or the supervising license dentist, if necessary, will be reported in
a timely manner to the Director of the Arkansas Department of Health who will
continue to ensure the confidentiality of the infected DHCP.
7. Reports and information furnished to and
by the Board relative to the HIV, HBV or HCV infectivity of a DHCP shall not be
deemed to constituted public record but shall be deemed and maintained by the
Board as confidential and privileged as medical records.
8. At such time as there is an alleged
violation of this Rule and Regulation, the Board will proceed with its
procedures set forth in the Dental Practice Act and Rules and Regulations by
bringing a licensee before it for alleged violations of the Practice Act. At
that time, the knowledge and information pertaining to the medical condition of
the DHCP may become public knowledge.
9. The failure of a dentist, dental
hygienist, or registered dental assistant to comply with the terms of this Rule
and Regulation or the Order of the Board concerning the scope of practice as
referred to in Section
I, Paragraph 1 will be considered
a failure to maintain adequate safeguards for the health and safety of the
patient and the public, as referred to in the Dental Practice Act.
Approved 12/10/1993; 1/7/2005; 3/2/2007.
