FAQ on infection control, other Cal/OSHA regulations, training, personal protective equipment and inspections. This resource is part of the Regulatory Compliance Manual. Updated Dec 2018.
Both Cal/OSHA and the Dental Board of California have regulations governing infection control practices in dental settings. Responses to the questions in this section include requirements for both agencies. You can refer to this Cal/OSHA website for more information on how Cal/OSHA enforces its blood-borne pathogens standard. In instances where neither Cal/OSHA nor the Dental Board has a regulation, a dental office should consider recommendations from the Centers for Disease Control and Prevention (CDC).
There are two separate requirements—one by the Dental Board and the other by Cal/OSHA. The Dental Board requires licensed professionals to take two hours of infection control training every license renewal period. The training should include at a minimum a discussion of the Dental Board's infection control regulations. A Dental Board-registered continuing education provider must provide training. The training course must be approved by the Dental Board.
In addition, the Dental Board requires a dentist employer to ensure that a dental assistant, who has been in continuous employment for 120 days, has successfully completed a board-approved, eight-hour infection control course.
Cal/OSHA requires employers to provide blood-borne pathogens training to occupationally exposed employees upon hire, and at least annually thereafter. (Refer to your Exposure Control Plan to identify occupationally exposed employees). Although there is no minimum time requirement, the training must include the 14 elements listed below. Many of the 14 elements are site-specific information. A person knowledgeable in the subject as it relates to the workplace must provide the training.
The Dental Board infection control course and the OSHA blood-borne pathogens training are often provided as separate educational programs. The two programs also can be combined into one educational offering because they cover similar subjects. A combined training program must be at least two hours in length, be approved by the Dental Board and be provided by a Dental Board-registered continuing education provider who is knowledgeable in blood-borne pathogens and infection control as it relates to a dental practice setting. (You can check registered providers on the Department of Consumer Affairs website ). If employees get most of their infection control training outside the office, specific office infection control policies and procedures as noted below should be reviewed in the office. The combined course must review the Dental Board infection control regulations and include these 14 elements mandated by Cal/OSHA:
Be sure to record information on employees trained, training subjects, date of training and name of trainer.
Cal/OSHA requires additional training upon the introduction of new tasks, procedures or equipment that may affect employees' occupational exposure.
The Dental Board has specific PPE requirements, whereas Cal/OSHA requires PPE to be "appropriate." The Dental Board's PPE requirements are stated clearly in the regulations you have posted in your office.
Cal/OSHA requires that PPE be "appropriate," which means PPE should not permit blood or other potential infectious materials pass through employees' underlying garments to reach the skin, eyes, mouth, etc. In a general dental office, PPE should go from the neck down to thigh length and down to the wrists, no high collars necessary. No V-necks permitted. Periodontal offices may require more elaborate PPE, orthodontic offices may allow less. Gloves, goggles, glasses with side shields or a face shield should be worn during procedures and when working with disinfectants and sterilants.
Uniforms typically are not PPE. Uniforms are not the responsibility of the employer, unless the employer requires a uniform be worn as a condition of employment. However, if the employer provides uniforms for the purpose of preventing contact with blood or other potentially infectious material, the uniforms become PPE and are subject to Cal/ OSHA requirements. During the course of the day, PPE should be changed if necessary to avoid cross contamination.
Employers are required to provide PPE for employees who come in contact with patients during treatment and who handle disinfectants/sterilants, at no cost to the employee.
Employees may NOT take home PPE. The employer is responsible for cleaning, laundering, repairing, replacing or disposing PPE and other contaminated laundry. To launder, the employer may choose one of the methods below. With each method, regulations on the handling and containment of contaminated laundry should be followed.
First, clean and treat the wound and offer an immediate confidential medical evaluation and follow-up. This is made available at no cost to the employee. Refer the employee to a health care provider who will perform all medical evaluations and procedures in accordance with current U.S. Public Health Service recommendations. These medical evaluations and procedures include the collection of the employee's blood and testing for HBV, HCV and HIV status, counseling, post-exposure prophylaxis and evaluation of reported illnesses. The U.S. Public Health Service recommends that post-exposure prophylaxis for HIV start as soon as possible even if the HIV status of the source patient is unknown (see "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV And Recommendations for Post-exposure Prophylaxis", Sept. 25, 2013, and "CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Post-exposure Management", Dec. 20, 2013). Post exposure blood testing of the employee for HIV seroconversion should occur as soon as possible after the incident, then at six weeks, 12 weeks and six months after the exposure incident. If the employee refuses the medical evaluation, document this refusal and include it as part of the Exposure Incident Report to be placed with the employee's medical records.
Determine and document how the exposure occurred. A sample Exposure Incident Report and Sharps Injury Log are included in the Records section of this manual. Both documents must be completed. A copy of the Exposure Incident Report should be provided to the health care provider and another copy placed in the employee's confidential medical record.
If a patient was treated with the same needle or instrument prior to the exposure incident, identify the patient if possible and document it in the Exposure Incident Report unless prohibited by state or local law. Contact the source patient and request his or her consent to test for HBV, HCV and HIV carrier status and to disclose the information to the employee. If consent is not obtained, have the individual sign a nonconsent form and include it as part of the Exposure Incident Report. Inform employee of test result when available.
Certain information must be provided to the health care provider who performs the medical evaluation or any follow-up treatment. These are:
The health care provider is to provide to the employer with a written opinion that is to be given to the employee within 15 days of completion of the evaluation. This written opinion must contain the following information:
All other findings remain confidential and are not included in the written report.
See Exposure Control Plan and Records sections in the CDA Regulatory Compliance Manual.
The procedures described in response to the previous question do not have to be followed because an "exposure incident" did not occur. An exposure incident is defined by Cal/OSHA as a specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious material that results from the performance of an employee's duties.
Amendments made in 1999 to Cal/OSHA's Blood-borne Pathogens standard require the use of "needleless systems, needle devices with engineered sharps injury protections and non-needle sharps with engineered sharps injury protection," subject to four (4) exceptions. These exceptions are: 1) lack of market availability, 2) information indicating that the device will jeopardize patient care or safety, 3) information indicating that the device is not more effective in reducing sharps injuries than the device currently used by the employer and 4) lack of sufficient information to determine whether a new device on the market will effectively reduce the changes of a sharps injury.
The requirements apply to dental instruments that are sharps as well as to needles. If you claim an exception to the requirement to use devices with engineered sharps injury protections, you must document it. At this time, dental offices may use exception 1 for many dental instruments. If applicable, you may use exceptions 2, 3 or 4 with regard to safety needles. Include all documentation as part of the Exposure Control Plan.
Note: Cal/OSHA's Policy and Procedures Manual states the following with regard to the utilization of Exception 4: "The effort required by the employer to keep abreast of new information will depend on the employer's size and sophistication. For small healthcare and dental offices, it will generally be sufficient if they rely on peer organizations, academic studies, and professional journals to track currently available information on devices. Larger, more sophisticated employers will be required to make more direct efforts to evaluate devices. The employer's approach to this issue must be reflected in the Exposure Control Plan."
To identify available safety needles and other sharps with engineered sharps injury protection, you can make inquiries with your dental supplier, check trade publications and trade shows or review dental journals for information.
The Oral Health Division of the Centers for Disease Control has developed sample screening and device evaluation forms.
The vaccination must be made available to employees, who are occupationally exposed, within 10 working days of initial assignment. The employee must be provided with information on its efficacy, safety, method of administration, benefits and that it is provided at no cost to the employee. Exceptions to the requirement to offer the vaccination include: 1) the employee has already received the complete vaccination series; 2) antibody testing has revealed that the employee is immune or 3) the vaccination is contraindicated for medical reasons. The employer may not require an employee to be screened for antibodies in order to receive the vaccination. An employer may not require the vaccination as a condition of employment.
Hepatitis B vaccinations are administered in three doses, with the second and third doses administered at one month and six months after the first. Vaccinations should be received intramuscularly (in the deltoid). A December 1997 update in CDC recommendations now makes mandatory postvaccination screenings for employees provided with the Hepatitis B vaccine. Serological conversion should be tested within one to two months of the last shot of the three-shot series. If the screening shows the vaccine did not work, the employer is required to offer and to pay for a second vaccine series. No additional vaccination is required if the second screening does not indicate the presence of antibodies. The U.S. Public Health Service does not recommend routine serologic testing and booster shots.
If an employee agrees to the vaccination, the employer is responsible for paying for the vaccination, postvaccination screening, and, if indicated, a second vaccination series. Check with public health clinics, outpatient clinics, hospital occupational health services departments or a physician for information where employees can receive the vaccination.
If an employee declines the vaccination, the employer must ensure the employee signs a declination form. The declination's wording must be identical to that found in the regulation (Appendix A of Section 5193, Blood-borne Pathogens). See the Records section in the manual.
If an employee initially declines the vaccination then decides to have it, the employer must pay for the vaccination, postvaccination screening and second vaccination series, if necessary.
Cal/OSHA adopted in May 2009 a regulation, Section 5199, to prevent the transmission of aerosol transmissible diseases (ATDs) at health care facilities, including nursing homes, correctional facilities, homeless shelters, drug treatment programs and among specific service providers, such as emergency responders. Aerosol transmissible diseases include all types of influenza, chicken pox, tuberculosis and several more listed in the regulation's appendix. Most dental practices and many specialty medical practices are exempt from the regulation as long as the practices comply with specific conditions. For dental practices, all of the following criteria must be met in order to claim exemption from the regulation's other requirements:
The regulation focuses on high-risk facilities such as hospitals, correctional institutions, homeless shelters, long-term care facilities and primary care clinics. Regulatory requirements include fit testing of respirators, use of airborne infection isolation rooms, regular TB testing of employees and mandatory vaccinations. Dental staff who work at these facilities would need to follow respective ATD exposure control plan.
TB testing of employees is not required for most dental practices but it is recommended by the CDC. CDC recommends all personnel in low-risk settings receive a two-step baseline tuberculin skin test (TST) at the beginning of employment. Should there be an exposure incident, post-exposure test results compared to baseline test results can identify TST conversions.
It is highly recommended for dental offices to follow the Centers for Disease Control "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Facilities, 2005" MMWR 54, (RR-17. Recommendations include prompt referral of patients to their primary care provider for suspicious symptoms, conducting periodic risk assessments in low-risk environments and requesting a patient's TB history.
Clean instruments thoroughly before sterilization or high-level disinfection. An ultrasonic cleaner can be used, but if after using the cleaner material continues to stick to the instrument, use a long-handled brush with soap and water, or a detergent, to scrub off the material. Wear heavy-duty utility gloves when cleaning instruments. Cal/OSHA forbids sharps from being stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
Cal/OSHA and the Dental Board do not specifically prohibit staff from keeping long fingernails or using artificial nails. However, if a dental office is concerned that the practice may interfere with maintaining employee and patient safety procedures, the office may adopt a policy limiting fingernail length and prohibiting artificial nails. The CDC recommends this policy.
Cal/OSHA requires floors to be free from dangerous projections or obstructions, to be maintained in good repair and to be reasonably free of oil, grease or water. If work activities necessitate working on slippery floors, mats shall be used.
Cal/OSHA and the Dental Board do not prohibit the use of carpet in the dental office. However, the CDC advises against the use of carpet in treatment areas due to difficulties in cleaning and disinfecting the area.
The regulations are in the California Code of Regulations Title 16 Section 1005. They must be posted in each dental facility. They are included in the CDA provided set of required employment posters. The regulations are based on CDC infection control recommendations.
The Dental Board regulations have specific requirements for instrument sterilization and disinfection, environmental disinfection and require written protocols for instrument processing, operatory cleanliness and injury management. The regulations require weekly biological monitoring, use of sterile coolant/irrigants for surgical procedures, flushing and purging of dental unit lines and devices and more.
Another Dental Board infection control requirement, which is not part of the regulation, requires a dentist to use sterile water or other solution containing recognized disinfecting or antibacterial properties for irrigation when dental pulp is exposed.
Failure to follow both the Dental Board and Cal/OSHA blood-borne pathogens regulations is one of the top five most common violations for which citations are issued.
Most dental offices have one emergency kit to be used for both employees and patients. For employees, Cal/OSHA does not specify what should be in a medical emergency kit, just that the employer have documentation that a physician approved the kit. For patients, it is recommended that the kit contain: oxygen, blood-pressure monitoring equipment, epinephrine, Benadryl, a quick source of glucose, nitroglycerin and a CPR pocket mask. The drugs should be checked periodically to ensure they have not expired. The ADA Council of Scientific Affairs has recommendations for office emergency kits. Dental benefit plans may require specific items be included in a medical emergency kit.
For offices where general anesthesia is used, the Dental Board of California requires specific equipment (Section 1043.3 of the Dental Practice Act).
Cal/OSHA requires a permit for the air tanks associated with air compressors if the tank is 1.5 cubic feet in volume or larger or when the safety valve is set to open at greater than 150 psi. All compressor tanks should have a nameplate with the American Society of Mechanical Engineers (ASME) code symbol (a clover leaf with a "U" or "UM" in it) to indicate compliance with the ASME code. Contact Cal/OSHA's Pressure Vessel Section to arrange inspection of your tank so it may be permitted. You will be charged for the inspection and travel time ($160/hour) and the permit ($15). A permit is issued for five years, and then the compressor must be inspected again for a new permit.
You can call the Pressure Vessel Section in Oakland, 510.622.3066, or Santa Ana, 714.567.7208.
Monitoring may be necessary if an employee expresses concern about exposure levels and the employer does not have information to substantiate that exposure levels are within allowed limits. If an employer can document, using objective data, that the presence of formaldehyde or formaldehyde-releasing products in the workplace cannot result in concentrations of airborne formaldehyde that would cause any employee to be exposed at or above the action level (AL) of 0.5 ppm, calculated as an eight-hour time-weighted average concentration, or 2 ppm, as a 15-minute short-term exposure limit, under foreseeable conditions of use, the employer is not required to provide personal formaldehyde monitors. Such objective data may be available from the manufacturer of your sterilizing unit. You could also do initial monitoring. If initial monitoring indicates an exposure level higher than either of the above limits, you must take steps to reduce it. Follow-up monitoring should be conducted every six months and may be discontinued if two consecutive measurements, taken at least one week apart, record levels below the limits.
For glutaraldehyde, an employer needs to monitor the work environment if he or she believes individual staff may be exposed to concentrations in excess of the ceiling limit or permissible exposure limit (PEL) of 0.05 ppm. The PEL is a time-weighted average for an eight-hour day. If initial monitoring indicates an exposure level higher than the above limit, you must take steps to reduce it through ventilation, covering the source, reducing amount of surface area exposed or use of another product. Follow-up monitoring should be conducted after changes are instituted and then every six months. Subsequent monitoring may be discontinued if two consecutive measurements, taken at least one week apart, record levels below the limit.
For nitrous oxide, an employer needs to monitor the work environment if he or she believes individual staff may be exposed to concentrations in excess of 50 ppm, which is a time-weighted average permissible exposure limit (PEL) for an eight-hour day. Effective scavenging equipment and periodic inspection of equipment should keep nitrous oxide exposures to within acceptable limits. The National Institute for Occupational Safety and Health (NIOSH) provides information on keeping employee exposure to nitrous oxide to a minimum.
NIOSH recommends not exceeding an average level of 25 ppm during an eight-hour day. However, Cal/OSHA has not adopted this more stringent limit. Federal OSHA has not established occupational exposure limits for nitrous oxide.
According to Title 8 of California Code of Regulations, section 5203, the use of regulated carcinogens must be reported to Cal/OSHA. Formaldehyde is one of 30 regulated carcinogens.
Obtain a "Report of Use of Regulated Carcinogens" form via email at [email protected] or by phone at 510.286.7362. It is not available on the agency's website.
Cal-OSHA requires emergency eyewash facilities be accessible in locations that require no more than 10 seconds for the injured person to reach. Plumbed or self-contained eyewash equipment must meet the requirements of sections 5, 7 or 9 of ANSI Z358.1-1981, Emergency Eyewash and Shower Equipment. Water hoses, sink faucets or showers are not acceptable eyewash facilities. Eyewash stations must be plumbed, for each eye, to provide cold water.
California's ergonomics regulation (CA Code of Regulations, Title 8, Section 5110) requires an employer to implement a repetitive motion injury prevention program when at least two employees performing the same job or work activity develop repetitive motion injuries. The program should include a worksite evaluation, control of exposures that caused the injuries and training employees. To learn more about what you can do to reduce repetitive motion injuries in the office, contact your worker's compensation company.
All employees must be provided with training on injury and illness prevention, hazard communication and fire and emergency plans. Comprehensive training must be done at the time of hire. Additional training must be provided whenever new hazardous materials or potentially hazardous procedures are introduced. Training should be specific to the hazards of the job and to the particular worksite. Unlike the blood-borne pathogens training, annual training is not required. However, annual training in these areas is recommended.
Refer to the CDA's Required Employee Training resource for more information.
Work-related incidents that lead to serious injury or illness or death must be reported immediately to the state Division of Occupational Safety and Health. Serious injury or illness is defined as any injury or illness that requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation or in which an employee suffers a loss of any member of the body or suffers any serious degree of permanent disfigurement.
Most dental offices are exempt from maintaining an OSHA Log 300. The OSHA Log 300 replaced the OSHA Log 200, which provided a summary of work-related injuries and illnesses during a calendar year.
Dental offices are required to record work-related injuries and illnesses when the business is requested to do so in writing by OSHA, the Bureau of Labor Statistics or Cal/OSHA. Any business that receives an injury and illness survey from these agencies is required to complete the survey and return it as directed.
Dental offices must continue to record sharps injuries on a sharps injury log and to document blood-borne pathogens exposure incidents.
Injury and Illness Prevention Program safety inspection logs and employee training records must be kept for one year, except for employees who have worked for less than one year and to whom records were given upon termination.
Blood-borne Pathogens/Exposure Control Plan employee training records must be kept for three years from date of training. The Sharps Injury Log must be kept for five years from the date of the exposure incident.
Employee medical records, kept in accordance with the Blood-borne Pathogens and Access to Employee Exposure and Medical Records standards, must be kept for the duration of employment plus 30 years.
Safety Data Sheets must be kept for 30 years.
CDA does not have staff to provide on-site Cal/OSHA consultations. However, CDA staff is knowledgeable and can be consulted via telephone or email.
Private consultants are available. Check with your local dental society or with colleagues.
Cal/OSHA has a consultation service, 800.963.9424, and a list of regional offices. Consultation staff can answer your questions by telephone and are available to conduct mock inspections. A mock inspection is a good way to check your safety program. However, if Cal/OSHA consultation staff determines aspects of the program are deficient, you will be asked to correct them. If you do not act on the recommendations, consultation staff will file a report with the enforcement staff and enforcement staff will follow through with an inspection.
The purpose of Cal/OSHA regulations is to protect employees at the workplace. Cal/OSHA regulates a variety of industries including construction, mining, amusement parks and manufacturing. The Cal/OSHA regulations impacting dental practices can be found in Title 8 of the California Code of Regulations. These regulations include but are not limited to:
Regulations marked with an asterisk require preparation of a written plan. Links to Cal/OSHA regulations can be found at www.dir.ca.gov/Samples/search/query.htm. Cal/OSHA's Policies and Procedures Manual is also available if you would like to review the agency's inspection procedures, enforcement guidelines, informal conference process and appeals and hearing process.
Cal/OSHA refers to this as a "dual employer" situation and discusses it in detail in its Policies and Procedures Manual. You and the employment agency have a shared responsibility for assuring the employees are protected from workplace hazards. Typically, the agency provides the required training, medical evaluations and vaccinations required by Cal/OSHA. You are responsible for providing site-specific safety instructions and personal protective equipment. You should coordinate and confirm with the agency your respective responsibilities with regard to preventing on-the-job injuries and to post-exposure or post-injury protocol.
Cal/OSHA reviews all complaints and classifies each as to whether it presents an imminent hazard, is a serious complaint or is a nonserious complaint. Complaints from self-identified employees, employee representatives and government representatives are classified as formal complaints. All formal complaints trigger an on-site inspection.
Nonformal complaints are those made by employees who do not identify themselves and non-employees. Nonformal, serious complaints are investigated by telephone first and may be followed by letter or on-site inspection. Nonformal, nonserious complaints are investigated by letter to the employer in lieu of an on-site inspection. However, Cal/OSHA district managers have some discretion to do on-site investigations of these complaints.
A complaint is invalid if the district manager determines it is willful harassment of an employer. Cal/OSHA is not obligated to provide the employer with the identity of the complainant.
Cal/OSHA also conducts "programmed inspections" when the agency is targeting an industry. For example, agriculture and the garment industry have been targets of programmed inspections. There also is a possibility of an inspection of your practice if a neighboring dental office has had frequent complaints and inspections.
Respond to Cal/OSHA's request for information to the extent possible. Provide photographs if they are useful. Once you have provided the information, do not expect Cal/OSHA to send you any notice of having satisfactorily answered its inquiries. If Cal/OSHA finds your response unsatisfactory, an unannounced, on-site inspection will occur.
Cal/OSHA may choose to investigate some nonformal, serious complaints by telephone or fax. Employers are contacted first by telephone, then by faxed letter. The employer has five working days to respond; employers who do not respond are scheduled for an on-site inspection. Follow-up inspections may be done for some of the complaints that are handled through this process.
You can find Cal/OSHA's policy and procedure for complaint evaluation and documentation online at www.dir.ca.gov/DOSHPol/P&PC-7.pdf.
Cal/OSHA prefers to have your permission to conduct the inspection. An inspector may be willing to wait while you finish treatment on a patient, but will not wait beyond a reasonable time. If you are not present at the office when the inspector arrives, Cal/OSHA staff will attempt to contact you by telephone to gain permission. If the inspector cannot contact you by telephone or other means, he or she will document the attempts to gain your permission then will commence the inspection.
If you refuse permission, the inspector will report back to the district manager who will initiate the process for obtaining a warrant or taking other appropriate action.
Complaint-based inspections are unannounced. Cal/OSHA will request the presence of the employer or a representative for the inspection. You can accompany the inspector during the walk-through of the facility, but you may not be present during the inspector's interviews with staff. An employee or employee representative also may accompany the inspector during the walk-through. The inspection starts with an opening conference where the inspector provides information on the purpose and scope of the inspection and how the inspection will be conducted. The inspector will request to see, or have a copy of, various documents such as your Injury and Illness Prevention Plan, Exposure Control Plan, Hazard Communication Plan, required posters and proof of workers' comp insurance.
The inspector will then walk through the facility, taking photographs and speaking with staff in private. At the end of the walk-through, the inspector will meet with the employer for an exit conference. If violations were observed, citations may be issued during the exit conference or the inspector will provide the employer with a preliminary report with citations to be issued at a closing conference to be scheduled later. The inspector may return for follow-up inspections.
At the closing conference, Cal/OSHA staff will review their findings with the employer. Staff also will review the nature of the violations and how they can be abated. Penalties are proposed, and the employer is informed of the requirement to post citation and other notices so employees may view them. The employer also is informed of the opportunity to have an informal conference with the district manager to discuss the citation and penalties and of the separate opportunity to appeal.
Cal/OSHA's inspection procedures are detailed in its policies and procedures manual.
At the closing conference, Cal/OSHA staff will have reviewed their findings with you or your representative. You may choose to take one of these actions:
You can also request an informal conference with the district manager. An informal conference provides an opportunity for you to present evidence, to offer explanations and to clarify issues. After an informal conference, a district manager will determine if it is appropriate to withdraw or amend citations and to revise penalties. Having an informal conference does not negate your right to a hearing before the Appeals Board. An informal conference is not the same as the prehearing conference scheduled by Appeals Board, although the scope is the same.
Request an informal conference any time before the day of the appeal hearing. Additional information on the appeals and hearing process and on informal conferences can be found in the Cal/OSHA policies and procedures manual.
Whether you need or want an attorney depends on the nature and scope of the citations. A few nonserious violations may not warrant the use of legal counsel. It is advisable to seek legal counsel for serious violations where employees have been injured or an unsafe work environment alleged.