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Clinical Practice Guideline for an Infection Control/Exposure Control Program in the Oral Healthcare Setting

Course Number: 342

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Medical Conditions and Work Restrictions

Oral health care facilities shall have written policies to protect patients and OHCWs with latex allergies, to protect OHCWs who are susceptible to opportunistic infections, and to protect patients from OHCWs with transmissible infections.

  1. Background

    OHCPs and patients may become susceptible to latex-related adverse reactions, OHCPs may also develop acute or chronic conditions, which may predispose them to opportunistic infections, or OHCPs may acquire potentially transmissible infections. Such individuals should discuss the problem with their personal physician or other qualified authority to determine if the condition might affect their ability to safely perform their duties.

  2. Execution/ Compliance

    1. Minimize latex allergy-related health problems among OHCPs and patients.

      1. Reduce exposure to latex-containing materials by substituting non-latex products when appropriate and using appropriate work practice controls.

      2. Train and educate OHCPs to recognize signs and symptoms of latex-related adverse effects, i.e.,

        1. Allergic contact dermatitis

        2. Urticaria

        3. Angioedema

        4. Allergic rhinitis

        5. Anaphylaxis

      3. Monitor signs and symptoms of latex sensitivity among OHCWs and patients.

      4. Refer OHCP with signs and symptoms suggestive of latex allergy to a physician to confirm diagnosis.

    2. Minimize the exposure of OHCPs with acute or chronic diseases to patients who have been diagnosed with a transmissible infectious disease.

      1. Consult with personal physician

        1. Determine if condition(s) might affect ability to safely perform duties.

    3. Minimize the exposure of patients to OHCPs who have been exposed to or have been diagnosed with an infectious disease (Tables 1, 2, 3, and 4).

      1. Restriction criteria

        1. Mode of transmission.

        2. Period of infectivity.

        3. Level of circulating viral burden.

        4. Level of risk for the transmission of a pathogen in association with a procedure.

      2. Procedure-related risk for bloodborne pathogen transmission.

        Oral healthcare-associated procedures according to the level of risk for bloodborne pathogen transmission

        1. Category I: Procedures with minimal risk of bloodborne pathogen transmission
          1. History-taking
          2. Extraoral physical examination
          3. Intraoral examination
            1. Including the use of a tongue depressor, mirror, explorer, or a periodontal probe
          4. Routine preventive dental procedures - not requiring the administration of local anesthesia
            1. Application of sealants or topical fluoride
            2. Prophylaxis – not to include subgingival scaling with a hand instrument
            3. Orthodontic procedures
            4. Prosthetic procedures
              1. Fabrication of complete dentures
            5. Hands-off supervision of surgical procedures
        1. Category II: Procedures for which bloodborne pathogen transmission is theoretically possible but unlikely
          1. Dental procedures requiring the administration of local anesthesia
            1. Operative, endodontic, and prosthetic procedures and periodontal scaling and root planing
              1. Use of ultrasonic instruments greatly reduce or eliminate the risk of percutaneous injury to the provider
              2. If significant physical force with hand instruments is anticipated to be necessary, scaling and root planing and other Category II procedures could reasonably be classified as Category III
            2. Minor surgical procedures
              1. Simple tooth extraction not requiring excessive force
              2. Soft tissue flap procedures
              3. Minor soft tissue biopsy
              4. Incision and drainage of an abscess
          2. Insertion of, maintenance of, and drug administration into arterial and central venous lines
        1. Category III: Procedures for which there is a definite risk of bloodborne pathogen transmission or that have been classified as “exposure prone”
          1. General oral surgery
            1. Surgical extractions
              1. Removal of an erupted or unerupted tooth requiring elevation of a mucoperiosteal flap, removal of bone, or sectioning of tooth and suturing
            2. Apicoectomy and root amputation
            3. Periodontal curettage, gingivectomy, and mucogingival and osseous surgery
            4. Alveoplasty and alveoectomy
            5. Endosseous implant surgery
          2. Open extensive head and neck surgery involving bone
          3. Trauma surgery, including open head injuries, facial fracture reductions, and extensive soft issue trauma
          4. Any open surgical procedure with a duration of more than 3 hours, probably necessitating glove change

      3. Criteria for recommended clinical privileges:

        1. No evidence of having transmitted infection to patients.

        2. Obtained advice from an Expert Review Panel about continued practice.

        3. Follow-up twice a year to demonstrate the maintenance of an acceptable viral burden.

        4. Follow-up by personal physician with expertise in the management of infections with bloodborne pathogens.

        5. Consulted with an expert about and strictly adhere to optimal infection control procedures.

        6. Agreed to and signed a contract or letter from the Expert Review Panel that characterizes responsibilities.

Table 1. Work Restrictions: HAV, HBV, HCV, and HIV Infections.

Infectious stateRestrictions
HAVAcute infectionRestrict from duty for seven days after onset of jaundice.
HBV and HCV
  • Circulating viral burden < 104GE/mL
    • Category I, II, and III procedures – no restrictions as long as the infected healthcare provider:
      • no evidence of having transmitted infection to patients
      • obtained advice from an Expert Review Panel about continued practice
      • follow-up twice a year to demonstrate the maintenance of a viral burden <104GE/mL
      • follow-up by a personal physician who has expertise in the management of HBV infection and who is allowed to communicate with the Expert Review Panel about the infected provider’s clinical status
      • consulted with an expert about optimal infection control procedures and strictly adheres to the recommended procedures
        • routine use of double gloving and frequent glove changes during procedures (particularly when performing tasks known to compromise glove integrity) for all instances in patient care for which gloving is recommended
        • agreed to and signs a contract or letter from the Expert Review Panel that characterizes the infected providers responsibilities
  • Circulating viral burden =104 GE/mL
    • Category I and II procedures – no restrictions as long as the infected provider meets the criteria noted above for infected providers with a viral burden of less than 104 GE/mL
      • Category III procedures – these procedures are permissible only when the viral burden is <104 GE/mL
HIV
  • Circulating viral burden <5 x 102GE/mL
    • Category I, II, and III procedures – no restrictions as long as the infected healthcare provider:
      • no evidence of having transmitted infection to patients
      • obtained advice from an Expert Review Panel about continued practice
      • follow-up twice a year to demonstrate the maintenance of a viral burden <5 x 102GE/mL
      • follow-up by a personal physician who has expertise in the management of HIV infection and who is allowed to communicate with the Expert Review Panel about the infected provider’s clinical status
      • consulted with an expert about optimal infection control procedures and strictly adheres to the recommended procedures
        • routine use of double gloving and frequent glove changes during procedures (particularly when performing tasks known to compromise glove integrity) for all instances in patient care for which gloving is recommended
      • agreed to and signs a contract or letter from the Expert Review Panel that characterizes the infected providers responsibilities
  • Circulating viral burden >=5 x 102GE/mL
    • Category I and II procedures – no restrictions as long as the infected provider meets the criteria noted above for infected providers with a viral burden of <5 x 102GE/mL
    • Category III procedures – these procedures are permissible only when the viral burden is <5 x 102GE/mL

Table 2. Work Restrictions: Measles, Mumps, and Rubella Infections.

Infectious stateRestrictions
Measles
Post-exposure

Susceptible
OHCP
Exclude from duty from the 5th day after first exposure through the 21st day after last exposure OR for 4 days after rash appears.
Acute infectionExclude from duty for 7 days after rash appears.
Mumps
Post-exposure

Susceptible
OHCP
Exclude from duty from the 12th day after first exposure through the 26th day after last exposure OR for 9 days after onset of parotitis.
Acute infectionExclude from duty for 7 days after onset of parotitis.
Rubella
Post-exposure

Susceptible
OHCP
Exclude from duty from the 7th day after first exposure through the 21st day after last exposure.
Acute infectionExclude from duty for 5 days after rash appears.

Table 3. Work Restrictions: Herpes Simplex and Varicella Infections.

Infectious stateRestrictions
Herpes simplex

Acute orofacial herpes

Evaluate the need to restrict from the care of patients at high-risk until lesions heal.
Acute herpetic whitlowExclude from duty until lesions heal.
Acute genital herpesNo Restrictions
Varicella
(chicken pox)

Post-exposure

Susceptible OHCP

Exclude from duty from the 10thday after first exposure through the 21stday after last exposure.
Acute infectionExclude from duty until all lesions dry and crust.
Varicella zoster
(shingles)

Post-exposure

Susceptible OHCP

Exclude from patient care from the 5thday after first exposure through the 21stday after last exposure.
Acute infection
Healthy OHCP		Cover lesions and restrict from the care of patients at high-risk until all lesions dry and crust.
Acute infection
Immunocompromised OHCP		Restrict from patient care until all lesions dry and crust.

Table 4. Work Restrictions: Respiratory Tract Infections.

Infectious stateRestrictions
Influenza and syncytial virusesAcute infection with feverExclude from the care of patients at high-risk until acute symptoms resolve.

Group A

streptococci

Acute infectionRestrict from duty until 24 hours after treatment is initiated.
Mycobacterium tuberculosisPPD PositiveNo Restrictions
Acute infectionExclude from duty until proven non-infectious.

On June 21, 2021, the Occupational Safety and Health Administration (OSHA) adopted a Healthcare Emergency Temporary Standard (Healthcare ETS) protecting workers from SARS-CoV-2 infection in settings where they provide healthcare or healthcare support services. As such, the Healthcare ETS attempts to maximally mitigate the airborne transmission risk associated with SARS-CoV-2 in the workplace. In addition, the Centers for Disease Control (CDC) continues to update and refine its SARS-CoV-2 mitigation guidance (Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic).

Highlights of the Healthcare ETS and CDC Guidance Pertaining to Dentistry
Develop a COVID-19 plan and assign a designated safety coordinator with authority to ensure compliance.
  • Implement a training plan to ensure all employees comprehend dental procedures associated with COVID-19 transmission and relevant office policies and procedures.
  • Implement a workforce screening plan
    • Screen employees before each workday and shift.
    • Require each employee to promptly inform the employer when the employee is COVID-19 positive, suspected of having COVID-19, or experiencing COVID-19 symptoms.
    • Notify at-risk employees within 24 hours when a person who has been in the workplace is COVID-19 positive.
    • Follow current guidance for removing employees from the workplace.
    • Provide medical removal protection benefits in accordance with the standard to workers who must isolate or quarantine.
  • Maintain a COVID-19 log (if more than 10 employees) of all employee cases of COVID-19 without regard to occupational exposure
  • Report work-related COVID-19 fatalities and in-patient hospitalizations to OSHA.
Screen and triage patients, clients and other visitors for possible COVID-19
  • Postpone all non-urgent dental treatment for: 1) patients with suspected or confirmed SARS-CoV-2 infection until they meet criteria to discontinue Transmission-Based Precautions and 2) patients who meet criteria for quarantine until they complete quarantine
    • These patients should only be provided dental care if medically necessary following
  • If a patient presents with a fever strongly associated with a dental etiology, but no other symptoms consistent with COVID-19 are present, dental care can be provided following the practices recommended for routine health care during the pandemic.
Where feasible, enforce 6-foot physical distancing
  • Install cleanable or disposable solid barriers at each fixed work location in non-patient care areas where employees are not separated from other people by at least 6 feet.
Ensure existing HVAC systems are used in accordance with manufacturer’s instructions and design specifications for the systems and that air filters are rated Minimum Efficiency Reporting Value (MERV) 13 or higher, if the system allows it.
Dental treatment should be provided in individual patient rooms whenever possible. For facilities with open floor plans, there should be:
  • At least 6 feet of space between patient chairs.
  • Physical barriers between patient chairs.
  • Consider the use of portable HEPA air filtration systems.
  • Operatories should be oriented parallel to the direction of airflow if possible.
  • Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and toward the rear wall when using vestibule-type office layouts.
  • Ensure to account for the time required to clean and disinfect operatories between patients when calculating your daily patient volume.
When performing aerosol generating procedures on patients who are not suspected or confirmed to have SARS-CoV-2 infection, ensure that DHCP correctly wear the recommended PPE (Standard Precautions) and use mitigation methods such as four-handed dentistry, high evacuation suction, and dental dams to minimize droplet spatter and aerosols.
  • When the county transmission rate is substantial or high, provide care following transmission-based precautions to mitigate airborne transmission (e.g. NIOSH-approved N95 or equivalent or higher-level respirator).

The Healthcare ETS was to be superseded by a permanent standard within 6 months. However, on December 27, 2021 OSHA announced that it had yet to complete the final rule and as a consequence withdrew the non-recordkeeping portions of the Healthcare ETS. While OSHA continues to develop its permanent regulatory solution, the dental practitioner should bear in mind that OSHA will vigorously enforce the general duty clause and its general standards, including the Personal Protective Equipment (PPE) and Respiratory Protection Standards, to help protect healthcare employees from the hazard of COVID-19. OSHA considers compliance with the terms of the Healthcare ETS as satisfying employers’ related obligations under the general duty clause, respiratory protection, and PPE standards.

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