Chapter 3 – Health Care Operations

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental staff shall adhere to the Centers for Disease Control and Prevention, Guidelines for Infection Control in Dental Health-Care Settings, as well as the occupational safety and health standards established by the Occupational Safety and Health Administration (OSHA), in the provision of dental care to patients.

Purpose

• To promote a safe and healthy work environment in which dental services are provided to patients; minimize the possibility of the transmission of infection to patients or dental personnel by establishing procedures to ensure that patients and staff infected with communicable diseases receive prompt care and treatment; and provide guidelines for the completion and filing of all reports consistent with local, state and federal laws and regulations regarding infectious and communicable diseases.

Procedure Overview

• The infection control program consists of written policies, procedures and practices designed to prevent or reduce the risk of disease transmission and to effectively monitor the incidence of infectious and communicable diseases among patients and staff.

• A successful infection control program requires a collaborative effort among all stakeholders. The Quality Management Committee (QMC), including subcommittees responsible for infection control activities, and Infection Control Nurse can be valuable assets in implementing and maintaining such a program.

• Standard precautions require that health care workers:

  • Consider all patients as potentially infected with bloodborne pathogens.

  • Follow infection control protocols to minimize the risk of exposure to blood and body fluids (secretions and excretions [except sweat], regardless of whether they contain blood) which come in contact with non-intact skin or mucous membranes.

Procedure

• The Dental Health Program Manager (DHPM) III at each Correctional Facility shall ensure that:

  • Requirements for the management of occupational exposures to bloodborne pathogens including post exposure prophylaxis for work exposures are followed.

  • All clinical dental employees at their institution receive annual training on dental clinic and dental laboratory infection control procedures. 

  • Each new clinical dental department employee is provided training on infection control procedures prior to assignments involving direct or indirect patient care duties.

  • Documentation of training provided to dental staff on infection control procedures includes the following information:

    • Date(s) of training.

    • Duration of training.

    • Contents of training.

    • Name(s) and signature(s) of person(s) conducting the training.

    • Names and signatures of all employees attending the training.

  • Documentation of training on infection control procedures is maintained for a period of six years.

• The Supervising Dentist at each Correctional Facility shall:

  • Monitor clinical procedures to ensure that dental staff adheres to dental clinic and dental laboratory infection control procedures.

  • Ensure that each staff dentist is responsible for compliance with infection control procedures in their clinic.

• Program Support Team staff shall monitor the institution infection control program at least every six months and work with local quality committees to ensure improvement plans are instituted, appropriate, and progressing at an acceptable pace.

• Any unusual or accidental employee exposure to potentially infectious matter shall be reported to the DHPM III and the institution’s exposure control personnel or designee.  The DHPM III shall ensure that an incident report as well as all required Workers Compensation documents and any other required forms are completed and properly filed. The DHPM III and exposure control personnel shall maintain a record of unusual or accidental exposures and any corrective action plans that result from such exposures.

• Infection Control Procedures in Dental Clinics

  • Health History

    • A thorough health history shall be compiled for all patients. (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.6.1(c)(2)(E)).

    • Patients with a suspected undiagnosed infectious disease shall be referred to a physician for a follow-up medical evaluation. (Reference the HCDOM, Section 3.3.4.5(c)(5)).

  • Personal Protective Equipment (PPE)

    • Protective clothing, gloves, masks, respirators, protective eyewear, head and shoe covers, as well as other PPE shall be made available for use by dental staff and shall be removed prior to leaving laboratories or patient care areas.

      • Disposable masks, respirators, and head and shoe covers must be disposed of after each patient encounter.

      • Disposable gowns are to be disposed of when visibly soiled or at the end of the work day.

    • Dental staff shall wear PPE for any surgical procedure, when decontaminating and disinfecting environmental surfaces and at all times when splashes, spray, spatter, aerosols, or droplets of blood, or other potentially infectious materials (OPIM) may be generated. In addition, dental personnel who clean instruments or other soiled items shall wear puncture and chemical resistant/heavy-duty utility gloves to minimize health risks. (Reference Section (d)(5)(H)3.b.).

  • Minimizing Potentially Infectious Droplets, Spatters, and Aerosols

    • To achieve maximum reduction in hazardous aerosol production during treatment, the following measures shall be utilized:

      • Four-handed dentistry where available.

      • High volume evacuation.

      • Supplemental high volume evacuation where feasible.

      • Dental dams where feasible.

      • HEPA air filtration units where available.

      • Patient pre-procedural oral rinse with 1.5% hydrogen peroxide or 0.5% iodine.

  • Malfunction of High Volume Evacuation Equipment

    • Invasive dental procedures shall be suspended until malfunctioning high volume evacuation equipment is repaired.

  • Latex Allergy

    • All patients shall be screened for latex allergy, (i.e., take a health history and refer for medical consultation when latex allergy is suspected). (Reference the HCDOM, Section 3.3.6.1(c)(2)(E) of this policy).

    • The DHPM III shall ensure a latex-safe environment for staff and patients with latex allergies, and shall ensure that emergency treatment kits with latex-free products are available at all times. Patients with latex allergies should receive treatment at the beginning of the day (first patient of the day) to allow latex allergens to dissipate from the environment.

  • Handling Sharp Instruments

    • The DHPM III shall ensure that engineering controls and work practices are in place to prevent injuries when staff is handling sharp instruments.

    • Where engineering controls are not available, work-practice controls that result in safer behavior, (e.g., one-handed needle recapping or not using fingers for cheek retraction while using sharp instruments or suturing), shall be utilized.

  • General Work Practice Requirements

    • Flush mucous membranes immediately, or as soon as feasible, when they are exposed, or potentially exposed, to blood or OPIM.

    • Eating, drinking, applying cosmetics and handling contact lenses are prohibited in occupational exposure areas (e.g., dental operatories, dental laboratories, sterilization areas).

    • Storing or placing food or beverages in refrigerators, cabinets, or on shelves or countertops where blood or OPIM are present shall not be permitted.

    • Dental staff who directly assist with or provide patient care shall:

      • Employ appropriate hand hygiene techniques as outlined in the “Hand Hygiene” sections of the Centers for Disease Control and Prevention, Guidelines for Infection Control in Dental Health-Care Settings – 2003, as well as the Centers for Disease Control and Prevention, Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health; March 2016.

      • Maintain their fingernails short enough to allow thorough cleaning underneath them.

      • Refrain from having long artificial or natural nails.

  • Sterilization Requirements

    • Items used for patient care (dental instruments, devices and equipment) are classified as critical, semicritical, or noncritical, depending on the possible risk for infection related to their intended use.

      • Critical items are those objects or instruments that penetrate soft tissue or bone and have the greatest risk of transmitting infection.  All critical patient care items shall be sterilized by heat after being cleaned.

      • Semicritical items touch mucous membranes or non-intact skin during their use and have a lower risk of transmitting infection. The majority of semicritical items used in dentistry are heat-tolerant and shall also be sterilized by using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection.

      • Noncritical Items are objects or equipment that contact only intact skin. These include dental operating light handles, dental radiographic equipment, dental operatory computer hardware surfaces and peripherals, operating cart/unit hoses and surfaces, dental chair surfaces, counter tops, etc. For most noncritical items, cleaning, or if visibly soiled, cleaning followed by disinfection with an Environmental Protection Agency (EPA)-registered hospital disinfectant is acceptable. When the item is visibly contaminated with blood or OPIM, an EPA-registered hospital disinfectant with a tuberculocidal claim (e.g., Centers for Disease Control and Prevention intermediate-level disinfectant) should be used.

    • Instrument Processing Area

      • A designated central instrument processing area shall be established in all dental clinics. The area shall be divided physically or, at a minimum, spatially, into distinct areas for:

        • Receiving, cleaning and decontamination.

        • Preparation and packaging.

        • Sterilization.

        • Storage.

      • Contaminated instruments shall be transported to the instrument processing area in a secure, puncture resistant container with a locking lid, and a biohazard label affixed.

    • Cleaning Instruments or Other Items Prior to Sterilization

      • Instruments or items used in the delivery of dental treatment shall be cleaned thoroughly to remove debris prior to sterilization.

      • Hand scrubbing of instruments or items shall be avoided and automated cleaning equipment such as ultrasonic cleaners shall be used whenever possible. (Reference Section (d)(5)(B)2.). Ultrasonic cleaning units shall be tested according to manufacturer’s recommendations or at least monthly to ensure proper functioning.

      • If instruments are not able to be processed immediately after use, in order to keep biological matter from drying and adhering to instrument surfaces, the instruments shall be covered with or immersed in enzymatic presoaking detergent until placement in the ultrasonic cleaner.

    • Packaging Instruments or Other Items for Sterilization

      • Critical and semicritical items shall be packaged prior to sterilization in a self or manual sealing pouch, sterilization wrap, or a sterilization cassette.

      • The outside of the pouch or wrap shall be labeled with the sterilizer identification number, operator’s initials and the date of sterilization. The contents shall be considered sterile indefinitely if the pouch is sealed appropriately and the integrity of the pouch or wrap is not compromised.

    • Sterilization of Instruments or Other Items

      • All metal or heat-stable, reusable, critical and semicritical items including instruments attached to, but removable from, the dental unit air and water lines, such as ultrasonic scaler tips and components or parts of air/water syringes, etc., shall be cleaned and sterilized after each use.

      • Items being sterilized shall be arranged in the chamber to allow free circulation of the sterilizing agent. Manufacturer’s guidelines for loading the chamber shall be followed.

    • Instrument Storage

      • Sterilized instruments and burs shall not be stored unwrapped.

      • Un-sterilized instruments or other items that require overnight storage shall be cleaned and prepackaged before storage in preparation for sterilization the next business day. These instruments shall be stored separately from sterilized instruments and items.

      • All instruments and other items shall be stored as outlined in the HCDOM, Section 3.3.3.2(c)(2).

    • Sterilizer Monitoring, Cleaning and Maintenance (including “back-up” sterilizers)

      • Proper functioning of sterilizers shall be verified by the use of mechanical, chemical, and biological indicators.

        • Mechanical indicator – assessing the cycle time, temperature, and pressure of sterilization equipment by observing the gauges or displays on the sterilizer.

        • Chemical indicator – sensitive chemicals used to assess physical conditions such as temperature during the sterilization process. These indicators can be internal (inside the sterilization pouch) or external (on the outside of the sterilization pouch).

        • Biological indicator (BI) – used to determine whether resistant microorganisms (e.g., Geobacillus or Bacillus species) were successfully inactivated. These indicators are also referred to as spore testing.

      • All sterilizers shall be identified by an identification number (e.g., an arbitrary number or the serial number) to facilitate documentation of spore test results and to aid in tracking instruments or items that need to be re-sterilized in the event a sterilizer has a positive spore test result.

      • All sterilizers shall be monitored at least once a week using a BI with a matching control, (i.e., one BI that is run through a sterilization cycle and one control BI from the same lot number that is not sterilized). The spore tests shall be sent to a commercial monitoring service for verification and documentation of the proper operation of each sterilizer.

        • Dental staff may continue to use a sterilizer as long as the spore test results are “negative for growth.”

        • If the spore test comes back “positive for growth” the following procedures shall be followed:

          • The sterilizer shall be removed from service and sterilization procedures reviewed, (i.e., work practices and use of mechanical and chemical indicators), to determine whether operator error could be responsible.

          • All items from suspect loads dating back to the last negative BI test shall be recalled, re-wrapped, and re-sterilized.

          • All items in contact with a recalled package shall be re-wrapped and re-sterilized.

          • After any identified procedural problems have been corrected, the sterilizer shall be retested using the same type of sterilization cycle that produced the positive BI. Biological, mechanical, and chemical indicators shall be used during this sterilization cycle.

          • If the repeat spore test is negative and mechanical and chemical indicators are within normal limits, the sterilizer may be returned to service.

          • If the repeat spore test is positive:

            • The sterilizer shall not be used until it has been inspected or repaired and the reason for the positive test has been determined and corrected.

            • The sterilizer shall be retested with BI tests in three consecutive empty chamber sterilization cycles and may be returned to service if all three tests are negative.

      • The Supervising Dentist Assistants shall review all BI test results upon receipt and shall maintain the monitoring records of all sterilizers for a period of three years.

      • Dental staff shall follow the manufacturer’s recommendations for use prior to cleaning and maintenance of sterilizers.

  • Sterile Water Use

    • As mandated by the Dental Board of California in the Dental Practice Act, sterile water shall be used in all CDCR dental clinics for invasive oral surgical procedures. 

    • In the absence of commercially available devices that bypass the dental unit to deliver sterile water, delivery devices (e.g., bulb syringe or sterile, single-use disposable products) shall be used to deliver sterile water.

    • Sterile water shall be procured from a vendor and kept in the dental clinic storage area for ease of availability.

  • Flushing Water Lines

    • Dental unit lines shall be purged with air or flushed with water for at least two minutes at the beginning of the day before connecting the sterilized handpiece or other devices to the dental unit, and at the end of each work shift.

    • Dental unit lines shall be purged with air or flushed with water for a minimum of 20-30 seconds between each patient treated.

    • Dental staff shall follow the manufacturer’s recommendations for cleaning, disinfecting, and testing dental unit water lines.

  • Disposal of Regulated Medical Waste

    • Examples of regulated medical waste found in dental-practice settings are solid waste soaked or saturated with blood or saliva (e.g., gauze saturated with blood after surgery), extracted teeth, surgically removed hard and soft tissues, and contaminated sharp items (e.g., needles, scalpel blades, burs, root canal files, and orthodontic wires).

    • Contaminated sharp items shall be placed intact into a leak proof, puncture-resistant, red or labeled sharps container prior to disposal.

    • The container shall be located as close as feasible to the area in which the disposable item is used.

    • Sharps containers shall be easily accessible to staff, mounted securely at a height of 52″-56″, maintained upright so the contents are not easily accessible to patients, and not allowed to overfill. 

    • When the sharps container is 3/4 full, the lid shall be tightly closed or taped shut to prevent loss prior to disposal. Once sealed, dental staff shall transport the sharps container to the medical waste accumulation area where it shall be segregated from other types of waste containers and placed on the floor of the storage area for the medical waste transporter to pick up.

    • Extracted teeth (including crowns), surgically removed hard and soft tissues, and solid waste soaked or saturated with blood or saliva, shall be placed into a biohazard waste container that is visibly labeled and lined with a red biohazard bag.

    • When the biohazard waste container lined with a red biohazard bag is 3/4 full or at the end of a clinic day in which patient care is provided, the red biohazard bag shall be twisted and secured with a single knot. Dental staff shall transport the secured red biohazard bag, in a biohazard waste transport container, to the medical waste accumulation area where it is to be placed in a rigid biohazardous waste container for the medical waste transporter to pick up.

    • Blood, suctioned fluids, or other liquid waste may be carefully poured into a drain connected to a sanitary sewer closed system.

  • Dental Vacuum System Cleaning, Disinfection and Maintenance

    • Dental staff shall follow the manufacturer’s recommendations for cleaning, disinfection and maintenance of vacuum systems and amalgam collector/separator systems.

  • Mycobacterium tuberculosis (TB)

    • All dental staff shall receive annual training and testing regarding the recognition of signs, symptoms, and transmission of TB.

    • Dentists shall interview patients to check for a history of TB as well as symptoms indicative of TB as outlined in the HCDOM, Section 3.3.6.1(c)(2)(E) and document their findings as outlined in the HCDOM, Section 3.3.6.1(c)(1)(F) through (H).

• Infection Control Procedures In Dental Laboratories

  • Infection control can be accomplished most efficiently in the dental laboratory by:

    • Disinfecting all material coming into and going out of the laboratory.

    • Using mechanical barriers that inhibit passage of infectious diseases between the dental clinic and the dental laboratory or vice versa.

  • Dental personnel or dental technician trainees performing disinfection procedures or handling incoming or outgoing cases shall wear PPE as outlined in Section (d)(5)(B).

  • All casts and intraoral items such as impressions, bite registrations and prosthetic appliances sent from dental clinics to a dental laboratory or vice versa shall be enclosed in sealed plastic bags or plastic wrap (e.g., Polyethylene cling wrap) to avoid contamination of packing materials.

  • Cleaning, Disinfecting and Sterilizing Items in Dental Laboratories:

    • Laboratory personnel shall transfer incoming casts, prostheses, impression trays, jaw relation records and all other submitted materials to a disinfection area, such as a sink with an overlying drain board, before they are placed in laboratory case pans.

    • All surfaces of submitted materials shall be sprayed with an EPA-registered hospital disinfectant with a tuberculocidal claim (e.g., Centers for Disease Control and Prevention intermediate-level disinfectant capabilities).

    • The solution shall be permitted to remain on the materials in accordance with the manufacturer’s instructions before rinsing with water.

    • The submitted materials shall be placed on the drain board with the prosthesis or cast standing on end so that the disinfectant will not pool in the palatal and lingual areas.

    • Casts, prosthetic appliances (after being removed from the cast), non-metal impression trays, jaw relation records and other materials leaving the laboratory for the dental clinics shall be disinfected prior to being returned to the dental clinics.

    • Heat-tolerant items used in the mouth, (e.g., metal impression trays, face-bow forks), shall be cleaned and heat-sterilized prior to being returned to the dental clinics.

    • Manufacturer’s instructions shall be followed for cleaning, sterilizing, or disinfecting items used in dental laboratories that become contaminated but do not normally contact the patient, (e.g., lab burs, polishing points, rag wheels, articulators, case pans, and lathes). 

    • If the manufacturer’s instructions are unavailable after contacting the manufacturer, items shall be cleaned and heat sterilized (if heat-tolerant) or cleaned and soaked overnight in an EPA-registered hospital disinfectant with a tuberculocidal claim (e.g., Centers for Disease Control and Prevention intermediate-level disinfectant capabilities).

    • When returning laboratory cases to the dental clinics, dental laboratory technicians shall include specific information regarding disinfection techniques used (e.g., solution used and duration).

  • Shipping and Receiving Benches

    • Shipping and receiving benches shall be cleaned and disinfected daily with an EPA-registered hospital disinfectant with a tuberculocidal claim (e.g., Centers for Disease Control and Prevention intermediate-level disinfectant capabilities).

    • Dental laboratory staff shall follow manufacturer’s instructions when utilizing disinfectant products.

    • Identical procedures shall be used to disinfect laboratory case pans.

  • Mechanical Barriers on Laboratory Equipment

    • Splash shields and equipment guards shall be used on all dental laboratory lathes.

    • Pumice pans that are used for polishing prostheses immediately following clinical adjustment shall have disposable plastic liners (Polyethylene cling wrap or polyethylene tray covers).

    • Disposable plastic liners, rag wheels, and pumice used on all dental laboratory lathes shall be changed after each patient.

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental staff shall maintain control of and provide accountability for dental instruments, sharps and other equipment items that pose a threat to persons or to the security of the institution.

Purpose

• To establish guidelines and procedures that will ensure that all CDCR dental staff maintains proper control of and accountability for dental instruments.

Procedure

• CDCR dentists shall be held accountable for and maintain an ongoing inventory of all instruments, tools and dental sharps in the dental clinics. Dental sharps are defined as needles, scalpels, and wires.

• When not in use, all dental instruments, syringes, tools and sharps shall be kept in secured cabinets in the dental operatory or other secure storage area in each dental facility.

• An inventory sheet of the instruments, syringes, tools or sharps in the cabinet shall be listed on the Tool Control Inventory Report form and posted in each cabinet.

• Dentists, dental hygienists and dental assistants shall work in partnership to count all dental instruments, syringes, tools, and sharps at the beginning and end of each work shift, and before and after any midday break in which all dental staff leave the clinic. 

• Dental staff shall document the count on the Tool Control Inventory Report form by initialing the date and the watch on which the counts were performed. A legend shall be present on the Tool Control Inventory Report with each dental staff member providing documentation showing their name and corresponding initials.

• A visual accounting of dental instruments and sharps shall be completed before and after each dental treatment, (e.g., prior to dismissing the patient).

• Dental instruments and tools shall not be engraved or have their surfaces altered in any way that may compromise the ability to be effectively sterilized. All other associated safety and security requirements of Department Operations Manual (DOM), Section 52040.5 and local institution policy shall be followed.

• In the dental laboratories and dental clinics, incarcerated workers shall only have access to dental equipment, instruments, or tools as outlined in the Health Care Department Operations Manual, Section 3.3.4.8, Incarcerated Dental Workers.

• All damaged, broken, or worn instruments, including digital radiographic sensors, shall be disposed of according to the institution’s Local Operating Procedures (LOP) and reported to the Dental Health Program Manager (DHPM) III, Supervising Dentist (SD) and the Supervising Dentist Assistant (SDA) for inventory control and re-order purposes. The disposition of such instruments or tools shall be noted appropriately on the tool inventory sheet and in accordance with each institution’s LOP.

• Tool inventory reports shall be routed in accordance with the institution’s tool control operational procedures by the Office Technician (OT) or designated dental staff.

• Tool inventory reports shall be maintained on file for three years by the OT or designated dental staff.

• The loss of any instrument or tool shall be immediately reported to the DHPM III, SD, SDA and the Watch Commander at the facility. The DHPM III, SD and SDA shall follow the institution’s LOP and shall ensure that, after a thorough search of the dental facility has been conducted, a “Lost Tool Report” is prepared and hand carried to the Watch Commander by the dental staff member reporting the lost or missing tool.

• The SD and SDA shall be responsible for ensuring that dental impression materials and waxes are stored in a secure location and never left unattended while in use.

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental staff shall comply with all applicable safety and regulatory standards when operating radiation producing devices utilized by the CDCR.

Purpose

• To establish procedures and guidelines that ensure the safety of staff, patients and the workspace environment during all phases of the dental radiography process.

Procedure

• The Health Program Manager (HPM) III and Supervising Dentist (SD) shall establish a Radiation Safety Program (RSP) for all dental clinics that contain dental radiographic equipment to monitor staff compliance with all applicable local, state and federal laws and safety regulations when capturing dental radiographic images. All clinical dental staff shall receive annual training on the RSP and shall demonstrate proper use of the procedures at all times. The HPM III shall maintain RSP training records for a period of three years. The RSP shall:

  • Ensure coordination and scheduling of preventive maintenance for dental radiographic units by qualified service technicians.

  • Ensure staff and patients do not receive unnecessary radiation exposure.

  • Be reviewed annually by the HPM III and SD regarding content.

• The following procedures are designed to provide radiation protection for all occupationally and non-occupationally exposed persons within the dental clinics, with the goal of reducing radiation exposure to as low as reasonably achievable (ALARA).  Some methods of protection may not be practical at all locations or in all instances, but the safety and operating procedures designed to reduce the risk of radiation exposure must be strictly followed to achieve the ALARA objectives.

  • Only the following individuals shall be allowed to operate dental radiographic equipment:

    • Dental staff licensed in accordance with the Dental Board of California, Dental Practice Act, Chapter 4 Dentistry, Article 3, and Section 1656, Radiation Safety Requirements.

    • Radiologic technologists certified or granted a permit to use diagnostic or therapeutic X-rays on human beings pursuant to the California Health and Safety Code, Section 114870, subdivision (b) or (c), or Section 114885.

  • Dental assistants, dental hygienists, and radiologic technologists shall operate dental radiographic equipment and take patient dental radiographs only upon the authorization of a dentist.

  • All operators of radiographic equipment are responsible for following radiation safety guidelines.

  • Radiation Exposure Monitoring

    • Federal regulations state that monitoring of individual employees for exposure to radiation is necessary if the employee is likely to receive more than ten percent of the allowable annual occupational dose limit. (The allowable annual occupational dose limit is 5000 milliroentgens [mR]). (Reference Code of Federal Regulations Title 10 (Energy), Chapter 1 (Nuclear Regulatory Commission), Part 20 (Standards for Protection Against Radiation), Subpart F (Surveys and Monitoring) Sec. 20.1502).

    • Beginning on January 1, 2024, and on January 1 every four years thereafter, the HPM III shall implement Section (c)(2)(D)3. and 4.

    • The HPM III shall ensure that radiation dosimetry badges are provided for all dental staff working within the vicinity of radiographic equipment.

      • Monitoring shall be performed for a period of 12 consecutive months.

      • Radiation monitoring badges shall be worn at chest level by participating staff.

      • The badges are not to be worn outside the dental treatment area.

    • The monitoring reports shall be reviewed monthly and/or quarterly as well as at the end of 12 consecutive months.   Radiation exposure is within allowable limits  if the result  is less than 500 mR at the end of the 12 consecutive months.

    • In the event the result of an employee’s dosimetry badge monitoring report exceeds ten percent of the allowable annual occupational dose limits, the HPM III shall have the dental radiographic unit(s) in the area(s) where the employee works inspected and corrected to be within standards.

    • The HPM III shall maintain a file of radiation monitoring reports for a period of four years.

    • Radiation dosimetry badges shall be provided on a monthly or quarterly basis to declared pregnant dental staff.

    • The HPM III shall report to the California Department of Public Health (CDPH), Radiologic Health Branch (RHB) any radiation exposure of dental personnel in excess of the allowable occupational dose limits.

  • Lead Protective Equipment

    • The safety and welfare of patients must be considered at all times. Appropriate shielding devices, such as gonad shielding, lead aprons, thyroid shields, portable shields, etc., shall be used at all times for all patients when dental radiographs are taken.

    • A thyroid shield shall be utilized on all patients unless it interferes with the examination.  (This is not a regulatory requirement, but is a statement of accepted good practice in keeping exposure to a minimum).

    • All protective lead aprons shall contain 0.25 millimeters or more of lead equivalence. All aprons shall be stored on an apron rack or on hangers (not folded) to prevent bending or cracking of the protective lead lining. 

    • At a minimum, lead protective equipment shall be inspected annually by performing a manual and visual check to look for obvious cuts, rips, holes, cracks or tears.

    • When a lead apron is found to be defective, staff shall cease using the apron and notify the Supervising Dentist Assistant (SDA) or SD to obtain a replacement.

  • All dental radiographic equipment shall have devices to limit the radiation exposure to patients and employees.  These devices include filters that reduce unnecessary low energy radiation from the primary beam and collimators, which restrict the size of the X-ray beam.  Staff shall not alter, remove, tamper with, or defeat these devices, or in any way cause needless radiation exposure.

  • All dental staff shall make every reasonable effort to maintain radiation exposure at the lowest possible dosage.

  • All dental staff exposing radiographs must comply with the CDPH, RHB, guidelines on dental radiology quality assurance.

  • All dental radiographic units shall be inspected and calibrated annually in accordance with CDPH, RHB requirements.

  • Dental personnel shall not hold a radiographic sensor in the patient’s mouth while exposing a radiograph.

  • Dental staff shall immediately report to the SD and/or SDA any incidental equipment malfunction or condition that may cause any unnecessary radiation exposure.

  • During each exposure, only the patient shall be in the useful beam. All other individuals in the vicinity of the radiographic unit shall remain at least six feet from the useful beam or behind a protective barrier.

  • Mechanical support of the tube head and cone shall maintain the exposure position without drift or vibration.

    • Dental staff or patients shall never hold the tube housing or suspension arm of intraoral radiographic units during any exposure.

    • If a problem with stability of the tube housing or suspension arm develops, the radiographic unit shall be taken out of service.

    • The SDA, or designee, shall be notified immediately, and they shall arrange for service as soon as possible.

  • Areas or rooms that contain permanently installed X-ray machines as the only source of radiation shall be posted with a sign or signs stating “Caution X-ray.”

• A copy of radiographic certificates, rules and regulations, as required by the CDPH, RHB, shall be posted in each dental clinic in full view of all patients and staff.

• External Imaging for Panoramic Radiographic Units

  • Position the patient following the instructions in the operator’s manual.

  • If the processed image appears misaligned and it is determined that operator error was not a contributing factor, the unit shall be taken out of service and the SD and/or SDA shall be notified.  The SDA, or designee, shall arrange for service as soon as possible.

Policy

• All California Department of Corrections and Rehabilitation (CDCR) dental staff shall manage hazardous materials and waste generated in each dental facility in compliance with all applicable standards mandated by the Environmental Protection Agency; the Occupational Safety and Health Administration (OSHA), Occupational Safety and Health Standards, Title 29 of the Code of Federal Regulations; and in accordance with each institution’s Medical Waste Management Plan and Local Operating Procedures.  The Division of Health Care Services, Adult Correctional Dental Care shall ensure that all dental facilities have implemented and are in compliance with these regulations.

Purpose

• To develop a comprehensive environmental health program, (e.g., a Hazardous Communication Program), in consultation with the local prison administration and the Chief Executive Officer or designee, as a standard to maintain and protect the health and welfare of all patients and staff and establish procedures and regulations for the safe handling and disposal of hazardous materials and waste generated in the CDCR dental facilities.

Procedure

• Required training and documentation

  • All hazardous materials and dental medicaments utilized in each dental clinic shall have an individual Safety Data Sheet (SDS), on file in a visible location in the dental clinic.

  • The Health Program Manager (HPM) III shall ensure that all dental staff receives SDS orientation and training.  This training shall be conducted at least annually or as frequently as required.

  • All dental staff SDS training records shall be kept on file by the HPM III for a period of three years.

  • The HPM III shall ensure that all dental staff receives Regulated Waste Training upon hire and annually thereafter.  All dental staff Regulated Waste Training records shall be kept on file by the HPM III for a period of three years.

  • To ensure compliance with these standards, environmental inspections or parts of the inspections may be conducted by health services staff, correctional staff, an outside agency, (e.g., a local or state health department), or any combination of the above.

  • Inspections with written reports shall be submitted to the prison administration and the responsible health authority as required by local institutional policy, or more frequently as appropriate to ensure that patients are receiving dental care in a clean, safe and healthy environment.

  • All dental departments shall procure the least toxic and environmentally adverse materials to perform a required task.

  • The storage and disposal of toxic materials shall be performed in accordance with manufacturer’s and institutional regulations and in a safe and environmentally sound manner.

  • All dental departments shall implement required emergency procedures in the event of a chemical spill or accident.

  • Emergency eye wash stations shall be installed in all dental clinics and dental laboratories and shall be connected to tepid water (60 – 100°F).

  • Dental staff shall utilize standard precautions when handling hazardous materials and waste.

• Amalgam Waste and Empty Amalgam Capsules

  • All dental clinics shall utilize individually dosed amalgam capsules and covered amalgamators. Dental departments shall not formulate amalgam, (e.g., utilizing bulk liquid mercury and metal powder or tablets to make the amalgam alloy).

  • A licensed commercial waste disposal service or amalgam waste recycler shall be used to dispose of or recycle contact or non-contact amalgam waste and empty amalgam capsules.

  • Proper protocol for the storage, disinfection and disposal of empty amalgam capsules and contact or non-contact amalgam waste shall involve consultation with local city and county regulatory agencies, commercial waste disposal services or amalgam waste recyclers and the institution’s HazMat Specialist.

  • Containers shall be kept for no longer than the legally allowed period of time until removal by the institution’s HazMat Specialist, or shipping of the waste container by the institution dental department to the respective recycler.

• Waste Containers and Waste Disposal

  • All dental facilities shall have separate waste containers for general waste, (i.e., non-infectious waste) and for Regulated Medical Waste. (Reference the Health Care Department Operations Manual, Section 3.3.3.1(d)(5)(K)1.).

  • All waste shall be handled, stored and disposed of in a safe and sanitary manner consistent with local, state and federal regulations and in accordance with institutional operating procedures.

• Pharmaceutical Waste

  • The following items are considered as non-hazardous pharmaceutical waste under the Resource Conservation and Recovery Act (RCRA) and shall be placed in a special white container with blue top, clearly labeled with the words “For Incineration Only” on the lid and on the sides.

    • Unused, expired carpules of local anesthetic.

    • Partially spent and empty local anesthetic carpules.

    • Partially used injectables including plastic disposable syringes, (after the needle has been removed), that were utilized to administer medications from the dental clinic’s emergency kit to a patient.

    • Used ointments.

    • Unidentifiable pills.

  • Hazardous pharmaceutical waste, both RCRA and non-RCRA shall be placed in special black containers with a sealable top, clearly labeled with the words “Hazardous Waste” on the lid and on the sides.  All hazardous pharmaceutical waste shall be placed in different black containers based upon the characteristics of the waste material.  The different types of Hazardous Wastes are:

    • RCRA inhalants (full or partially used ammonia ampules).

    • Non-RCRA hazardous inhaler canisters (e.g., pressurized aerosol hydro-fluoroalkane-HFA containers like asthma inhalers).

    • Non-RCRA universal hazardous waste (e.g., dental amalgam).  Dental staff shall place contact or non-contact amalgam waste in a hazardous waste container as described in Section (c)(4)(B) or in a container provided by a licensed commercial waste disposal service or amalgam waste recycler contracted to dispose of or recycle amalgam waste.

  • With the exception of hazardous waste containers for Non-RCRA hazardous inhaler canisters, all other hazardous waste containers shall have a Hazardous Waste Container Log attached that must be completed with each addition to the container.  Each container must have a completed Hazardous Waste label that includes the date upon which hazardous waste was first placed in the container.

  • Pharmaceutical waste containers shall be:

    • Obtained through the institution’s Medical Waste Administrator (e.g., Chief Support Executive or Correctional Health Safety Administrator II) or, if necessary, directly from a medical waste hauler or a medical supply company.

    • Clearly marked with the first date of use, known as the “accumulation start date.” The Medical Waste Administrator shall be notified to remove the containers when they are 3/4 full or prior to 275 calendar days from the accumulation start date, whichever occurs first.

• Laundry

  • Laundry services, whether on-site or contracted, shall assure the availability of a sufficient supply of clean linen, (e.g., scrubs, protective gowns, towels), for all dental facilities.

  • Laundry contaminated with infectious materials, (e.g., scrubs, protective gowns, towels), shall be handled using standard precautions and appropriately processed according to institution local operating procedures.

  • The Office Technician or designated dental staff shall coordinate pickup and delivery of all laundry.

• Risk Exposure Mitigation

  • Hazardous dental materials include, but are not limited to, flammable, toxic and caustic materials.

  • The HPM III shall be responsible for ensuring that:

    • All hazardous dental materials deemed to be flammable (e.g., butane gas containers, alcohols) are stored in approved, fireproof, locked storage cabinets, in accordance with local and state fire codes, manufacturers’ and OSHA guidelines and in secure areas that are inaccessible to incarcerated persons.

    • An inventory and accountability system is implemented for distribution of flammable, toxic or caustic materials.

    • Incarcerated persons have access to flammable, toxic or caustic materials only under the direct supervision of qualified staff.

• Inspections

  • All dental equipment (e.g., radiographic equipment; dental operatory units; Heating, Ventilation, and Air Conditioning [HVAC] units) shall be inspected and serviced regularly, consistent with manufacturer’s specifications and state regulations, to ensure that all systems continue to function properly.

  • Any negative pressure areas for the control of infectious disease shall be regularly monitored for air quality.