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T R E N D S

Standard and Transmission-Based

Precautions
An update for dentistry
Jennifer A. Harte, DDS, MS

n 1996, the Centers for Dis-

I ease Control and Prevention

(CDC) introduced Standard
Precautions, which combined
and expanded on the elements
of Universal Precautions to create a
standard of care designed to protect
all health care personnel (HCP)
ABSTRACT
Background. Standard Precautions are the foundation of all infection
control programs and include infection control practices that apply to all
patients and situations regardless of whether the infection status is sus-
pected, confirmed or unknown.
Methods. The author reviewed Standard Precautions, including two
from pathogens that can be spread
new elements introduced by the Centers for Disease Control and Preven-
by blood or any other body fluid,
tion in 2007: safe injection practices and respiratory hygiene and cough
excretion or secretion. Standard
etiquette. Standard Precautions sometimes are referred to as the first
Precautions also include three sub-
tier of precautions because for some diseases and circumstances, trans-
sets of precautions, known as
mission cannot be interrupted completely with Standard Precautions
“Transmission-Based Precautions,”
alone and it is necessary to use second-tier Transmission-Based Precau-
that are based on the routes of dis-
tions. The author reviewed the three categories of Transmission-Based
ease transmission for a smaller
Precautions—Airborne, Droplet and Contact—with an emphasis on their
number of patients who are known
use in dental health care outpatient settings.
or suspected to be infected or colo-
Conclusions and Clinical Implications. Dental health care per-
nized with highly transmissible or
sonnel (DHCP) should update their infection control programs to ensure
epidemiologically important patho-
that safe injection practices and respiratory hygiene and cough etiquette
gens. Transmission-Based Precau-
measures are used routinely. In addition, with the emergence of new
tions are designed to reduce the risk
pathogens, re-emergence of variant organisms and more patients seeking
of airborne, droplet and contact
care in ambulatory care facilities, DHCP need to be aware of additional
transmission and always are used in
measures to take when treating patients in their offices who are actively
addition to Standard Precautions.
infected with certain organisms to protect fully other patients, their staff
Since the publication of the Guide-
members and themselves.
lines for Infection Control in Dental
Key Words. Infection control; Standard Precautions; Transmission-
Health-Care Settings—2003,1 the
Based Precautions; Contact Precautions; Droplet Precautions; Airborne
CDC has published updated isolation
Precautions.
guidelines, which have introduced
JADA 2010;141(5):572-581.
new elements of Standard Precau-
tions and provided more detailed
information about Transmission- Dr. Harte is a colonel, U.S. Air Force Dental Corps, and the chief military consultant, United States Air
Based Precautions. Force Surgeon General for Dental Infection Control, United States Air Force Dental Evaluation and
Consultation Service, Great Lakes, Ill. Address reprint requests to Dr. Harte at United States Air Force
In this article, I review Standard Dental Evaluation and Consultation Service, 310C B St., Building 1H, Great Lakes, Ill. 60088, e-mail
Precautions, including the new ele- “[Link]@[Link]”.

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 T R E N D S

ments applicable to dentistry, and the importance term “Standard Precautions,” which was intro-
and relevance of Transmission-Based Precautions duced in the Guideline for Isolation Precautions
in dental settings. in Hospitals.7
Standard Precautions combined and expanded
STANDARD PRECAUTIONS the elements of Universal Precautions and BSI
Overview. Because patients with blood-borne into a standard of care designed to protect HCP
infections can be asymptomatic or unaware that and patients from pathogens that can be spread
they are infected, in 1985 the Centers for Disease by blood or any other body fluid, excretion or
Control (now the Centers for Disease Control and secretion (Table 1).1,8 Standard Precautions apply
Prevention) introduced the concept that all blood to contact with blood; all body fluids, secretions
and body fluids that might be contaminated with and excretions (except sweat), regardless of
blood should be treated as infectious.2 Infection whether they contain blood; nonintact skin; and
control precautions were introduced largely mucous membranes. While the term “Universal
because of the human immunodeficiency virus Precautions” still is used in OSHA’s blood-borne
(HIV) epidemic and were updated and revised pathogens standard and other documents, no
across the years. They eventually became known operational difference exists in clinical dental
as Universal Precautions and were designed to practice between Universal Precautions and
prevent transmission of HIV, hepatitis B virus Standard Precautions, because even when blood
(HBV), hepatitis C virus (HCV) and other blood- is not visible, saliva has been considered a poten-
borne diseases.3,4 The Occupational Safety and tially infectious material in dentistry.1
Health Administration (OSHA) based its blood- Standard Precautions are the foundation of a
borne pathogens standard on the concept of Uni- comprehensive infection control program and
versal Precautions.5 include a group of infection control practices that
Many fluids, secretions and excretions from apply to all patients, regardless of suspected or
patients not covered under Universal Precautions confirmed infection status, in any setting in
are colonized with organisms (that often are resis- which health care is delivered, including dental
tant to antimicrobial therapy) before any symp- settings. Although Standard Precautions apply to
toms of illness become apparent, and they are all patient encounters, the application of
potential sources of hospital- and community- Standard Precautions during patient care is
acquired infections. Therefore, infection control determined by the task being performed and the
personnel at the Harborview Medical Center, type of exposure to blood, body fluid or pathogens
Seattle, and the University of San Diego intro- that is anticipated. In other words, infection con-
duced Body Substance Isolation (BSI) guidelines trol procedures are determined according to the
in 1987. These guidelines concentrate on isolating procedure, not the patient. In OSHA terminology,
all moist and potentially infectious body sub- they are performance-based standards because
stances (blood, feces, urine, sputum, saliva, they are applied to the level necessary to provide
wound drainage and other body fluids) primarily exposure protection relative to the procedure per-
by wearing gloves.6 Although these guidelines formed and the given circumstances. For example,
were accepted, there was some confusion only gloves may be needed when obtaining dental
regarding which body fluids or substances radiographs, whereas protective eyewear and
required HCP to use precautions under Universal
Precautions and BSI. Also, it was becoming nec-
essary to address droplet transmission and ABBREVIATION KEY. AIIR: Airborne infection
emerging multidrug–resistant organisms isolation room. BSI: Body Substance Isolation. CDC:
(MDROs) such as Clostridium difficile and Centers for Disease Control and Prevention. DHCP:
vancomycin-resistant enterococci; direct or indi- Dental health care personnel. HBV: Hepatitis B virus.
HCP: Health care personnel. HCV: Hepatitis C virus.
rect contact transmission of some infectious
HIV: Human immunodeficiency virus. MDROs:
microorganisms from dry skin or environmental Multidrug–resistant organisms. MRSA: Methicillin-
sources (for example, C. difficile and vancomycin- resistant Staphylococcus aureus. NIOSH: National
resistant enterococci); and airborne transmission Institute for Occupational Safety and Health. OSHA:
of infections across long distances by floating Occupational Safety and Health Administration. PPE:
droplet nuclei. CDC expanded the concept of Uni- Personal protective equipment. SARS: Severe acute
versal Precautions in 1996 and began using the respiratory syndrome. TB: Tuberculosis.

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T R E N D S

TABLE 1 hygiene and cough

etiquette—focus on protec-
Elements of Standard Precautions.* tion of patients, as well as
ELEMENT REPRESENTATIVE EXAMPLES that of HCP.
Hand Hygiene Hand washing or using hand antisepsis or surgical hand In 2006, CDC also pub-
antisepsis to reduce potential pathogens on the hands
lished a comprehensive
Using PPE † Wearing gloves, mask, eye protection with solid side review and recommenda-
shields and protective clothing to protect the skin and the
mucous membranes of the eyes, nose and mouth from tions for prevention of
exposure to blood or other potentially infectious transmission of MDROs.9
materials (for example, saliva)
Like the 2007 isolation
Handling Contaminated Materials Cleaning and heat sterilizing instruments before reuse
or Equipment to Prevent on patients; cleaning and disinfecting environmental guideline, this guideline
Cross-contamination surfaces; using appropriate PPE; and containing heavily addresses a variety of
soiled items or areas to prevent cross-contamination
health care settings, not
Using Engineering and Work Examples may include, but are not limited to, minimizing only hospitals. Even
Practice Controls or eliminating employee exposure by using sharps
containers, not using two hands to recap needles, or not though this document is a
bending or breaking needles before disposal separate publication, it is
Respiratory Hygiene and Cough Applying measures at the first point of contact with a considered a part of CDC’s
Etiquette potentially infected patient to minimize the transmission
of respiratory infections, including influenza, in health 2007 isolation guidelines.
care settings Safe injection prac-
Safe Injection Practices Using aseptic technique (box) when handling parenteral tices. Across the years, the
medications and associated items to avoid contamination
of sterile injection equipment and supplies results of various infectious
disease outbreak investiga-
* For a complete discussion of the elements of Standard Precautions, refer to Kohn and colleagues1 and
Siegel and colleagues. 8 tions indicated that reuse
† PPE: Personal protective equipment. of syringes or the use of
single-dose medication
BOX
vials or bags of saline solutions for
Summary of Centers for Disease Control and multiple patients caused numerous
transmissions of HBV and HCV.
Prevention’s Recommendations for Aseptic These findings led to increased atten-
Technique for Parenteral Medications.* tion to aseptic technique during the
d Do not administer medication from a syringe to multiple patients, even if the handling of parenteral medications.8,10
needle on the syringe is changed. The conclusions of the investigations
dUse single-dose vials for parenteral medications when possible. stated that these transmissions could
dDo not combine the leftover contents of single-use vials for later use.
dIf multidose vials are used, cleanse the access diaphragm with 70 percent have been prevented if HCP had
alcohol before inserting a device into the vial, use a sterile device to access a adhered to basic principles of aseptic
multiple-dose vial and avoid touching the access diaphragm. Both the needle
and syringe used to access the multidose vial should be sterile. Do not reuse a technique for the preparation and
syringe even if the needle is changed. administration of parenteral medica-
dKeep multidose vials away from the immediate patient treatment area to pre- tions. Safe handling of parenteral
vent inadvertent contamination by spray or spatter.
dDiscard the multidose vial if sterility is compromised. medications, including dental local
d Use fluid infusion and administration sets (that is, intravenous bags, tubing anesthetics, and fluid infusion systems
and connections) for one patient only and dispose of them appropriately. is required to prevent health care–
* Source: Kohn and colleagues. 1(pp31,32,46) associated infections among patients.
These recommendations were included
clothing, gloves and masks are necessary when in the special considerations section of the Guide-
placing restorations. lines for Infection Control in Dental Health-Care
Update. In 2007, CDC updated and expanded Settings—20031 (Box). Although these safe injec-
the 1996 Guideline for Isolation Precautions in tion practices and associated recommendations
Hospitals7 with the 2007 Guideline for Isolation are not new, they are considered elements of
Precautions: Preventing Transmission of Infec- Standard Precautions.
tious Agents in Health Care Settings.8 The 2007 Respiratory hygiene and cough etiquette.
isolation guideline introduced several new ele- The recommendation for respiratory hygiene and
ments of Standard Precautions. The new addi- cough etiquette grew out of observations during
tions—safe injection practices and respiratory the 2003 outbreaks of severe acute respiratory

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 T R E N D S

Figure. Centers for Disease Control and Prevention posters with tips to prevent the spread of germs from coughing and a notice for
patients to report influenza symptoms, emphasizing covering coughs and sneezes and hand hygiene. These posters are available at
“[Link]/flu/protect/[Link]” and “[Link]/ncidod/dhqp/pdf/Infdis/[Link]”, respectively.

syndrome (SARS), in which failure to implement dturning the head away from others and main-
simple source-control measures with patients, vis- taining spatial separation, ideally more than
itors and HCP with respiratory symptoms may three feet, when coughing.8
have contributed to SARS coronavirus transmis- Respiratory hygiene and cough etiquette meas-
sion. Respiratory hygiene and cough etiquette are ures are considered a component of Standard Pre-
a combination of infection control measures cautions and should be practiced routinely in
designed to minimize the transmission of respira- dental settings. Posters that promote these meas-
tory pathogens via droplet or airborne routes in ures are available, at no charge, from CDC’s Web
health care settings. These measures apply not site (Figure). These posters can be downloaded,
only to SARS, but also to any respiratory illness— printed and placed in waiting areas or at reception
such as influenza, respiratory syncytial virus and desks to increase awareness of the importance of
whooping cough—and are targeted at all patients respiratory hygiene and cough etiquette. Dental
with symptoms of respiratory infection and their office staff members should ensure that tissues,
accompanying family members or friends. These receptacles for used tissue disposal and hand
infection control measures begin at the point of hygiene agents (for example, alcohol-based hand-
the patient’s initial encounter with a health care rub dispensers or soap and disposable towels if
setting, such as the reception area in the dental sinks are available) are available to patients, visi-
office. The primary components of respiratory tors and staff members so they can comply with
hygiene and cough etiquette are as follows: respiratory hygiene and cough etiquette.
dcovering the mouth and nose during coughing
and sneezing; TRANSMISSION-BASED PRECAUTIONS
dusing tissues to contain respiratory secretions In some circumstances, patients have a docu-
and promptly disposing of them; mented infection or are suspected of having an
doffering a surgical mask to people who are infection with specified highly transmissible
coughing to decrease contamination of the sur- pathogens for which Standard Precautions cannot
rounding environment; interrupt completely airborne or droplet trans-
dperforming hand hygiene after contact with mission or transmission by contact with dry skin
respiratory secretions; or contaminated surfaces. A second tier of precau-

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T R E N D S

tions, referred to as Transmission-Based Precau- might become infected with these diseases.1 Also,
tions, is necessary to prevent the potential spread recently, several diseases requiring precautions
of these diseases. There are three categories of beyond Standard Precautions (for example,
Transmission-Based Precautions: Airborne, Droplet MRSA or 2009 H1N1 influenza) have received
and Contact.7,8 More than one Transmission-Based extensive media coverage, and some dental
Precaution category may apply at a time because professionals have inquired why there were not
some diseases are transmitted via multiple routes, specific infection control recommendations to
and Transmission-Based Precautions sometimes cover these conditions in ambulatory care dental
are recommended for use on an empiric, temporary settings.
basis until a diagnosis can be made. When used The purpose of infection control procedures is
alone or in combination, Transmission-Based to interrupt the spread of diseases. Therefore,
Precautions always should be used in addition to applying Standard Precautions and, if indicated,
Standard Precautions. the additional measures of Transmission-Based
CDC’s 2007 isolation guideline addresses the Precautions, is essential in preventing disease
changing patterns of health care delivery, as well transmission.
as those of emerging and evolving Categories. The names of the
pathogens such as SARS and com- three categories of Transmission-
munity-associated methicillin- Applying Standard Based Precautions—Airborne,
resistant Staphylococcus aureus Precautions and, Droplet and Contact—mirror their
(MRSA).8 A primary difference in if indicated, the modes of disease transmission.
this guideline from previous CDC additional measures Some diseases have multiple routes
isolation precautions is the inclu- of transmission and require using
of Transmission-
sion of recommendations for a more than one Transmission-Based
broader spectrum of health care Based Precautions, Precautions category.8 In Table 2,8.9
delivery settings than found in the is essential in I present examples of diseases
previous guidelines for hospitals preventing disease requiring Transmission-Based Pre-
only. Specifically, CDC makes rec- transmission. cautions in addition to Standard Pre-
ommendations for ambulatory care cautions. I also present recommenda-
settings that include dental offices. tions for duration of the precautions
Challenges may exist when adapting Transmis- because, unlike Standard Precautions that are used
sion-Based Precautions to dental offices rather for every patient, Transmission-Based Precautions
than to inpatient facilities. For example, dental typically remain in effect only while there is risk
office staff members may not be able to identify of the infectious agent being transmitted or for
patients with infections immediately, patients the duration of the illness.8 DHCP will notice that,
frequently remain in common waiting areas for in some instances primarily with Contact and
prolonged periods and treatment rooms may be Droplet Precautions, the recommended precautions
turned around quickly with limited cleaning.8 do not differ much from the infection control prac-
Transmission-Based Precautions were men- tices they normally use. For example, DHCP rou-
tioned in CDC’s 2003 infection control guidelines tinely wear gloves, protective eyewear, masks and
for dental health care settings,1 but not to any gowns because they frequently are exposed to blood
great extent. The same is true for dental infection and blood-contaminated saliva during dental
control textbooks and journal articles; the main procedures, and OSHA requires them to wear
focus generally is on Standard Precautions. This personal protective equipment (PPE). On the
may be because patients usually do not seek rou- other hand, nurses or physicians may not always
tine dental outpatient care when they are acutely wear a complete ensemble of PPE for all patient
ill with diseases that require Transmission-Based interactions.
Precautions.1 Nonetheless, a general under- Below, I summarize the recommendations for
standing of precautions for diseases transmitted PPE, patient placement and patient transport for
via all routes is important, because some dental those treating patients in hospitals and for those
health care personnel (DHCP) are hospital based treating patients in ambulatory care or outpa-
or work part time in hospital settings, patients tient settings such as a dental office or a hospital-
infected with these diseases might seek urgent based outpatient clinic. I emphasize the differ-
treatment at outpatient dental offices, and DHCP ences between recommendations for inpatient

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 T R E N D S

TABLE 2

Select conditions and diseases requiring Transmission-Based

Precautions.*†
DISEASE/CONDITION CONTACT DROPLET AIRBORNE DURATION OF
PRECAUTIONS PRECAUTIONS PRECAUTIONS PRECAUTIONS
Clostridium difficile X‡ NA§ NA DI¶
Herpes Simplex (Mucocutaneous, X NA NA Until lesions are dry and crusted
Disseminated or Primary, Severe)
Influenza Human (Seasonal) NA X NA Five days, except DI in people who
are immunocompromised
2009 H1N1 Influenza X X X Seven days from symptom onset or
until the resolution of symptoms,
whichever is longer
Head Lice (Pediculosis) X NA NA U# four hours
Measles (Rubeola) NA NA X Four days after onset of rash,
except DI in people who are
immunocompromised

Methicillin-Resistant X NA NA Unresolved issue

Staphylococcus aureus
Mumps NA X NA U nine days
Pertussis NA X NA U five days
Rubella NA X NA U seven days after onset of rash
Severe Acute Respiratory X X X DI plus 10 days after resolution of
Syndrome fever, provided respiratory symptoms
are absent or improving
Smallpox (Variola) X NA X DI until all scabs have crusted and
separated (three-four weeks)

Tuberculosis (Confirmed NA NA X Discontinue precautions only when

Pulmonary or Laryngeal) the patient receiving effective
therapy is improving clinically and has
three consecutive sputum smears
negative for acid-fast bacilli collected
on separate days
Varicella Zoster (Chicken Pox) X NA X Until lesions are dry and crusted
* Transmission-Based Precautions always are used in addition to Standard Precautions.
† Sources: Siegel and colleagues8 and Siegel and colleagues.9
‡ X: Use or apply the precaution.
§ NA: Not applicable.
¶ DI: Duration of illness (with wound lesions, DI means until wounds stop draining).
# U: Until time specified in hours or days after initiation of effective therapy.

(hospital) and ambulatory care settings. Special care settings are touching, contact with oral
or additional procedures for cleaning and disin- secretions or contact with body lesions. Infectious
fecting environmental surfaces or instrument microorganisms also can be transferred indirectly
processing, which are available in CDC’s 2003 via a contaminated intermediate object or person.
infection control guidelines for dental health care Contaminated hands frequently are cited as a sig-
settings,1 are not indicated after treating patients nificant source of indirect contact transmission.11
requiring Transmission-Based Precautions. It is Other modes of indirect contact transmission
beyond the scope of this article to review specific include percutaneous injuries sustained via a con-
diseases; however, I mention some briefly as taminated needle or other sharp object and
examples. instruments, surfaces and equipment that are not
Contact Precautions. Contact is the most properly cleaned and disinfected or sterilized
common mode of transmission.8 Infections are between patients.8,12,13
spread directly when disease-causing microorgan- Contact Precautions are intended to prevent
isms pass from an infected person to a healthy transmission of infectious agents that are spread
person via direct physical contact with blood or by direct or indirect contact with the patient or
body fluids. Examples of direct contact in health the patient’s environment. Examples of conditions

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T R E N D S

requiring Contact Precautions include, but are nities for disease transmission to staff members
not limited to, herpes simplex (mucocutaneous, and other patients. If a patient in any health care
disseminated, or primary or severe) and MRSA. setting must be transported to another area in
Recurrent oral herpetic lesions only require the facility or office, all infected or colonized
Standard Precautions.8 CDC’s MDROs guideline areas of the patient’s body should be contained
covers patients colonized or infected with or covered.8
MDROs, such as MRSA.9 Contact Precautions are Droplet Precautions. Droplet Precautions
recommended for inpatients known to be infected should be followed to prevent the transmission of
or colonized with MDROs and for patients in pathogens spread through close respiratory or
ambulatory care settings who have uncontrolled mucous membrane contact with respiratory secre-
wound drainage or other syndromes representing tions. Person-to-person transmission can occur
increased risk of contact transmission.9 when an infected person coughs, sneezes or talks
PPE. HCP caring for patients requiring Con- and generates large-particle droplets (> 5 microm-
tact Precautions should wear protective clothing eters). Blood and saliva frequently spatter during
and gloves whenever contacting the patient or dental treatment, and disease transmission may
potentially contaminated areas surrounding the occur if these fluids from an infected patient con-
patient. To contain pathogens, PPE should be tact unprotected broken skin or mucous mem-
donned when HCP enter the room. This is dis- branes.8,12,13 Generally, special ventilation require-
tinctly different from Standard Precautions, for ments are not required to prevent droplet
which protective clothing is worn only if contact transmission because these pathogens do not
with blood or body fluid is anticipated. Also, to remain infectious across long distances in a
prevent environmental contamination outside of health care facility. Three feet is considered the
the treatment room, PPE should be removed in a definition of a “short distance”; however, the
manner that prevents contamination of under- results from some studies have shown that
lying clothing and skin and discarded before droplets traveled six feet or more with emerging
exiting the room, and hand hygiene should be and highly virulent pathogens (for example,
performed.8,9 SARS or smallpox).8 Technically, droplet trans-
In ambulatory care clinics, such as a dental mission is considered a form of contact transmis-
clinic, Contact Precautions are indicated only for sion because some infectious agents transmitted
patients who have uncontrolled wound drainage via this route also may be transmitted by direct
or other syndromes representing increased risk of or indirect contact.8
contact transmission. Strict enforcement of Influenza is a contagious respiratory illness
Standard Precautions, including wearing gloves caused by influenza viruses and commonly is
and protective clothing when contact with uncon- referred to as “seasonal” influenza because it typi-
trolled secretions and other potentially infectious cally occurs in winter. It can cause mild to severe
body fluids is anticipated, is considered adequate illness, but sometimes it can lead to death.
in most situations to prevent the transmission of Influenza is spread from person to person pri-
MRSA and other MDROs.9,14 marily when an infected person coughs and
Patient placement. In acute care hospitals, it is sneezes, so it is a good example of a condition
preferred that each inpatient is placed in a single- requiring Droplet Precautions. As I previously
patient room to limit the opportunities for trans- mentioned, sometimes people become infected by
mission. In some cases, cohorting (grouping touching something with influenza viruses on it
patients infected or colonized with the same infec- and then touching their mouths or noses. There-
tious agent together in one area to limit further fore, frequent hand hygiene is critical in pre-
transmission) may be acceptable after assessing venting further spread of influenza. Patients with
the risks associated with this type of patient acute respiratory illnesses often visit their den-
placement. In dental care settings, place patients tists, and, as with any patient, the goal of infec-
requiring Contact Precautions in a treatment tion control is to prevent transmission of the dis-
room or operatory as soon as possible after they ease. Other examples of diseases spread through
arrive at the dental office to limit the number of droplets include pertussis, mumps and rubella.
people exposed in the waiting area.8 Implementing respiratory hygiene and cough eti-
Patient transport. Transporting patients should quette measures at the first point of contact with
be limited as much as possible to reduce opportu- a potentially infected person is vital with diseases

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 T R E N D S

spread by droplets. virus (measles) and Mycobacterium tuberculosis.

PPE. HCP should wear a mask that preferably PPE. Because surgical masks protect the
is donned when entering a room before engaging mouth and nose only from splashes, spray and
in close contact with infective patients. CDC’s spatter from large-particle droplets and not the
2007 isolation guideline does not make a recom- smaller aerosol particles, they cannot be used
mendation for routinely wearing eye protection in when Airborne Precautions are indicated. When
addition to a mask for close contact with patients breathing with a surgical mask in place, much of
who require Droplet Precautions.8 Nevertheless, the inhaled air comes in around the sides of the
protective eyewear is indicated for DHCP because mask, along with airborne organisms. According
rotary dental and surgical instruments (for to CDC’s 2007 isolation guideline, HCP should
example, handpieces and ultrasonic scalers) and don fit-tested N95 respirators approved by CDC’s
air-water syringes primarily generate a large-par- National Institute for Occupational Safety and
ticle spatter of water, saliva, blood, microorgan- Health (NIOSH) when entering the room of a
isms and other debris that may contact unpro- patient who has confirmed or suspected infectious
tected mucous membranes of the eyes, leading to pulmonary or laryngeal tuberculosis (TB) or who
microorganisms entering the body.1,4 is suspected of having TB when infectious skin
Patient placement. As with Contact Precau- lesions are present and for aerosol-generating
tions, placing each patient in a procedures.8 This recommendation
single-patient room is preferable so also applies when treating patients
that opportunities for transmission Airborne Precautions with smallpox.
are limited. In some cases, When HCP use respirators while
are used to prevent
cohorting may be acceptable after treating patients with diseases
assessing the risks associated with transmission of requiring Airborne Precautions,
this type of patient placement. infectious agents that they should use the respirators in
Instruct patients receiving treat- remain infectious the context of a complete respira-
ment in dental ambulatory care across long distances tory protection program. This pro-
settings to follow respiratory when suspended in gram should include training and fit
hygiene and cough etiquette and testing to ensure an adequate seal
the air.
place them in an examination room between the edges of the respirator
promptly after arriving at the and the wearer’s face.1,8,15,16 Because
dental office to limit exposure to other people in it is not likely that patients with confirmed TB or
the waiting area.8 who are suspected of having TB will be treated in
Patient transport. Transporting of patients who nonhospital–based dental clinics, a respiratory
require Droplet Precautions should be limited. If protection program is not always necessary for
a patient requires transport to another area of ambulatory care settings. Health care settings in
the facility, the patient should wear a mask and which HCP do not treat patients with TB need
follow respiratory hygiene and cough etiquette to only written protocols for recognizing the signs
reduce opportunities for transmission.8 and symptoms of TB and for referring patients to
Airborne Precautions. Airborne transmis- a setting in which they can be treated.17
sion involves particles that are smaller (< 5 μm) Patient placement. A patient requiring Air-
and are called “droplet nuclei” or “aerosols.” borne Precautions should be in an airborne infec-
Transmission occurs when these particles, which tion isolation room (AIIR), which is a single-
can remain suspended in the air for long periods, patient room with special air-handling and
are inhaled by DHCP or patients. Exposure to ventilation capacity. If the facility has an AIIR,
aerosols containing microorganisms from a a respiratory protection program is required.
patient’s blood or saliva may occur during a use of Elements of a respiratory protection program
rotary dental and surgical instruments, including include education about use of respirators, fit
dental handpieces and ultrasonic scalers.8,13 Air- testing and user seal checks with each use of an
borne Precautions are used to prevent transmis- N95 respirator.8
sion of infectious agents that remain infectious In dental offices or other medical settings in
across long distances when suspended in the air. which Airborne Precautions cannot be imple-
Examples of diseases transmitted via the airborne mented because of limited engineering resources,
route may include, but are not limited to, rubeola having the patient wear a mask, placing the

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T R E N D S

patient in a private room (for example, an exami- inhalation of aerosols near an infected person.18,19
nation room) with the door closed and providing CDC has published specific 2009 H1N1
N95 or better respirators (or masks, if respirators influenza infection control recommendations for
are not available) to HCP will reduce the likeli- dentistry on its Web site.19 With respect to the
hood of airborne transmission until the patient is Standard and Transmission-Based Precautions
either transferred to a facility with an AIIR or infection control guidance I reviewed in this article,
returned to the home environment, as deemed the following precautions are recommended.
medically appropriate.1,8,16,17 If a patient has TB or dUse patient-reminder calls to identify patients
is suspected of having TB, CDC recommends post- reporting influenzalike illness. If the patient
poning any nonurgent dental treatment until the reports influenzalike illness, reschedule nonur-
patient does not have TB or is not infectious. If gent visits for 24 hours after the patient is free of
treatment cannot be postponed, it should be per- fever without the use of fever-reducing medicine.
formed in an AIIR, and DHCP should wear at dIdentify patients with influenzalike illness at
least a fit-tested N95 disposable respirator.1,16,17 check-in. Offer a face mask or tissues to patients
Patient transport. In hospitals, transport of with symptoms, ask them to follow respiratory
patients requiring Airborne Precautions should hygiene and cough etiquette, and reschedule
be limited. If a patient must be moved outside of nonurgent care. When evaluating patients for
the AIIR, the patient should wear a surgical urgent care, separate ill patients from others
mask, if possible, and observe respiratory hygiene whenever possible.
and cough etiquette.8,16 If the patient has skin dUrgent dental treatment can be performed
lesions, such as with varicella zoster (chicken pox) without the use of an AIIR because transmission
or smallpox, the affected areas should be covered of 2009 H1N1 influenza is thought not to occur
to prevent aerosolization or anyone coming into across long distances through the air, such as
contact with any infectious agents in the skin from one patient room to another.
lesions. If the patient is wearing a mask and skin dUse a treatment room with a closed door, if
lesions are covered, the HCP transporting the available. If one is not available, use the one that
patient is not required to wear a mask.8 is the farthest away from other patients and
Special considerations. I have presented lim- personnel.
ited examples of conditions requiring Transmission- dWear recommended PPE before entering the
Based Precautions. Many conditions (for example, treatment room.
SARS, smallpox, varicella zoster, 2009 H1N1 dDHCP should wear a NIOSH fit-tested,
influenza) can be transmitted via multiple routes disposable N95 respirator when entering
and, therefore, require the use of more than one the patient’s room and when performing
type of Transmission-Based Precaution in addi- dental procedures in patients with con-
tion to Standard Precautions. Also, as with firmed or suspected 2009 H1N1 influenza.
MDROs, additional precautions may be indicated. dIf N95 respirators, fit testing services or both
Additional information can be found in CDC’s are not available despite reasonable attempts to
2007 isolation guideline8 and CDC’s MDROs obtain them, the dental office should transition to
guideline.9 In addition, as new diseases emerge, a prioritized use mode (that is, nonfit–tested dis-
infection control guidance and information about posable N95 respirators or surgical face masks
any special considerations for various practice can be considered a lower level of protection for
settings can be found at CDC’s Web site personnel at lower risk of exposure or lower risk
(“[Link]”). A relevant example of this is of complications resulting from influenza than
2009 H1N1 influenza.18,19 personnel at the highest risk of experiencing
Sometimes called “swine flu,” the 2009 H1N1 influenza exposure until fit-tested N95 respira-
influenza is an influenza virus that was first tors are available). Detailed information is avail-
detected in people in the United States in April able in CDC’s Interim Guidance on Infection Con-
2009. 2009 H1N1 is an example of a disease that trol Measures for 2009 H1N1 Influenza in
requires more than one category of Transmission- Healthcare Settings, Including Protection of
Based Precautions be followed because transmis- Healthcare Personnel.18
sion is thought to occur through droplet exposure The recommendation for using an N95 respi-
of mucosal surfaces, indirect contact via contami- rator when treating patients with 2009 H1N1
nated hands or environmental surfaces, and influenza differs from current infection control

580 JADA, Vol. 141 [Link] May 2010

Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.
 T R E N D S

guidance for seasonal influenza, which recom- type III/lymphadenopathy-associated virus in the workplace. MMWR
Morb Mortal Wkly Rep 1985;34(45):681-686, 691-695.
mends that HCP wear surgical masks for patient 3. Centers for Disease Control (CDC). Recommendations for preven-
care.18 Since the 2009 H1N1 influenza situation is tion of HIV transmission in health-care settings. MMWR Morb Mortal
Wkly Rep 1987;36(suppl 2):1S-18S.
evolving, guidance may change as additional 4. Centers for Disease Control (CDC). Update: universal precautions
information becomes available. CDC’s Web site for prevention of transmission of human immunodeficiency virus,
hepatitis B virus, and other bloodborne pathogens in health-care set-
will have the most current infection control tings. MMWR Morb Mortal Wkly Rep 1988;37(24):377-382, 387-388.
recommendations. 5. U.S. Department of Labor, Occupational Safety and Health Admin-
istration. 29 CFR Part 1910.1030: Occupational exposure to bloodborne
pathogens—OSHA, final rule. Fed Regist 1991;56:64004-64182.
CONCLUSIONS “[Link]/pls/oshaweb/owadisp.show_document?p_table=
STANDARDS&p_id=10051”. Accessed March 23, 2010.
In this article, I reviewed the importance of using 6. Lynch P, Jackson MM, Cummings MJ, Stamm WE. Rethinking the
Standard Precautions and introduced two new role of isolation practices in the prevention of nosocomial infections.
Ann Intern Med 1987;107(2):243-246.
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tion Control Practices Advisory Committee. 2007 Guideline for isola-
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was designed to use when treating all patients, care settings. Am J Infect Control 2007;35(10 suppl 2):S65-S164.
“[Link]/hicpac/pdf/isolation/[Link]”. Accessed March
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tion Control Practices Advisory Committee. Management of multidrug-
cannot be interrupted completely with Standard resistant organisms in healthcare settings, 2006. Am J Infect Control
Precautions alone, it is necessary to use 2007;35(10 suppl 2):S165-S193. “[Link]/ncidod/dhqp/pdf/ar/
[Link]”. Accessed March 16, 2010.
Transmission-Based Precautions. I reviewed the 10. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital
three categories of Transmission-Based Precau- health care-associated hepatitis B and C virus transmission: United
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use of these measures as well as Standard Pre- mittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Recomm Rep 2002;51(RR-16):1-45. “[Link]/mmwr/PDF/
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15. U.S. Department of Labor, Occupational Safety and Health
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The views expressed in this article are those of the author and do not 17. Cleveland JL, Robison VA, Panlilio AL. Tuberculosis epidemi-
reflect the official policy of the U.S. Department of Defense or other ology, diagnosis and infection control recommendations for dental set-
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The author thanks Dr. William G. Kohn for his contributions to this 18. Centers for Disease Control and Prevention. Interim guidance on
manuscript. infection control measures for 2009 H1N1 influenza in healthcare set-
tings, including protection of healthcare personnel. Miss RN 2009;
1. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection 71(4):13-18, “[Link]/h1n1flu/guidelines_infection_control.htm”.
control in dental health-care settings—2003. MMWR Recomm Rep Accessed March 16, 2010.
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2. Centers for Disease Control (CDC). Recommendations for pre- gov/oralhealth/infectioncontrol/factsheets/2009_h1n1.htm”. Accessed
venting transmission of infection with human T-lymphotropic virus March 16, 2009.

JADA, Vol. 141 [Link] May 2010 581

Copyright © 2010 American Dental Association. All rights reserved. Reprinted by permission.