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The American

Dental Institute

for

Continuing Education

Copyright © 2003, The American Dental Institute, All Rights Reserved

This document may not be reproduced in any form without written permission of the copyright owner.

Infection Control

925



Christine Wisnom is a nurse educator at the BaltimoreCollege of Dental Surgery, where she conducts research inboth the Departments of Oral Medicine and the Department of Biological Science. Chris also acts as an InfectionControl consultant to the Maryland State Board of Dental Examiners.

Learning Objectives

At the completion of this program the participant will:

• Comprehend the concept of Standard Precautions•

Be able to identify the 3 categories of instruments andequipment that require sterilization and/or disinfection• Understand when personal protective equipment must be

worn, how it is handled and when it must be changed• Implement the recommendations for appropriate hand

hygiene• Integrate the CDC recommendations for management of

contaminated sharps into clinical care• Understand the various requirements for safety equipment in

both the clinical and laboratory setting• Comprehend the requirements for management of

occupational exposures

Introduction

In the United States, an estimated 168,000 dentists, 112,000registered dental hygienists, 218,000 dental assistants, and53,000 dental laboratory technicians provide dental care topatients. During the provision of care, they are oftenoccupationally exposed to infectious materials including: body substances, contaminated supplies, equipment, environmental

surfaces, water, or air. Other Dental Health Care Providers(DHCPs) include laboratory technicians (in-office andcommercial), students and trainees, contractual personnel,and other persons not directly involved in patient care who arealso potentially exposed to infectious agents (e.g.,administrative, clerical, housekeeping, maintenance, or volunteer personnel). Current recommendations by theCenters for Disease Control and Prevention (CDC) aredesigned to prevent or reduce the potential for cross-transmission of pathogens from all of these health care workers to patients, from patients to DHCPs, and from patient to patient. Although these guidelines focus mainly on

outpatient, ambulatory dental health-care settings, therecommended infection-control practices are applicable to allsettings in which dental treatment is provided.

The current CDC Guidelines for Infection Control in the DentalHealth Care Setting 2003, in combination with the California Code of Regulations and the California Division of Occupational Safety and Health (Cal-DOSH), provides a framework for "safe practice" for the California DHCP. Thisprogram presents an overview of these recommendations andregulations.

The Evolution from Universal Precautions to Standard Precautions

In 1993, the CDC published the last complete set of infectioncontrol recommendations for dental health care workers, which stated "Because all infected patients cannot be identifiedby medical history, physical examination, or laboratory tests,CDC recommends that blood and body fluid precautions beused consistently for all patients. This extension of blood and

Infection ControlChristine Wisnom, CDA, RN, BSN

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AMERICAN DENTAL INSTITUTE

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Personal Protective Equipment (PPE)

During the provision of dental care, DHCPs primarily utilizegloves, surgical masks, eyewear with side shields, face shieldsand protective clothing (e.g., gowns and jackets). Face

protection can be achieved with either a surgical facemask incombination with either chin length face shields or protectiveeyewear with side shields, whenever there is the potential forsplashing with blood or OPIM. The mask must be changedafter each patient and during treatment if moist, torn orcontaminated. Following patient care, PPE should be removedprior to leaving the clinical area. Reusable PPE (e.g., clinicianor patient protective eyewear and face shields) should becleaned with soap and water, and when visibly soiled,disinfected between patients, according to the manufacturer'sdirections. This recommendation is new.

Previously it was a requirement that the eyewear for theoperator and the patient be cleaned and disinfected regardlessof any visible contamination. The new recommendation ismuch more practical and saves time and wear on eyewear. Theuse of gloves, surgical masks, protective eyewear andprotective clothing in specified circumstances to reduce therisk of exposures to bloodborne pathogens is also mandatedby the Bloodborne Pathogen Standard. Often, operatorschoose to wear scrub attire or uniforms for patient care.These items are neither intended to protect against a hazardnor are considered to be PPE; therefore, a lab coat must be worn over street clothing, work clothes, uniforms and scrubattire. The bloodborne pathogens standard also requires

sleeves to be long enough to protect the forearms when thegown is worn as PPE (i.e., when spatter and spray of blood,saliva, or OPIM to the forearms is anticipated). Gowns must bechanged daily or changed if they become visibly soiled ormoist. 4 Reusable gowns must be laundered in accordance with California's Bloodborne Pathogen Standard.

Glove Integrity

Additional PPE should be worn whenever a surgical procedureis being performed. Reports indicate that different glovematerials (e.g., latex, vinyl and nitrile), under different

conditions, have various leakage rates and duration of usability. The frequency of perforations in surgeon's glovesused during outpatient oral surgical procedures has beendetermined to range from 6% to 16%. Because DHCPs arefrequently unaware of minute tears in gloves that occur duringuse, hand washing is critical to prevent cross-transmission of pathogens from operators to patients. These studiesdetermined that gloves developed defects in 30 minutes to 3hours, depending on the type of glove and procedure;

body fluid precautions, referred to as "universal precautions",must be observed routinely in the care of all dental patients". 1

In 2003, the CDC changed the recommendations for DHCPsfrom Universal Precautions to Standard Precautions. Their

explanation, in combination with the California Code of Regulations (CCR-100.5) Division 10, Title 16, definesStandard Precautions as "a set of combined precautions that include the major components of universal precautions(designed to reduce the risk of transmission of blood bornepathogens) and body substance isolation (designed to reducethe risk of transmission of pathogens from moist body substances). Similar to universal precautions, standardprecautions are used for care of all patients regardless of theirdiagnoses or personal infectious status." 2

Specifically, Standard Precautions should be utilized for any contact with blood or "Other Potentially Infectious Materials(OPIM)" which includes body fluids, secretions and excretions(except sweat, which has never been associated with thetransmission of a blood-borne pathogen), regardless of whether they contain blood. They also protect against contamination of non-intact skin and mucous membranes.Saliva has always been considered a potentially infectiousmaterial in dentistry and should be handled appropriately.Other potentially infectious materials, in the laboratory setting,include HIV-containing tissue or cell cultures, organ culturesand blood or other tissues from experimental animals. Inaddition, any unfixed tissues or organs (other than intact skin), from a human, who is alive or dead, should be

considered to be potentially infectious.3

Documentation

Utilization of Standard Precautions, however, is only one aspect of disease prevention. Other required items include developing written policies and procedures to include engineering, work practice, and administrative controls. These are designed tominimize occupational exposures, procedures for reporting,evaluating, counseling and treating DHCPs who sufferoccupational exposures. The manual must also containprotocols for instrument processing, sterilizer monitoring,

operatory cleanliness, personal protective equipment (PPE), waterline management, handling and disposal of biohazard waste and contaminated sharps, educational programs andHepatitis B vaccination or declination for employees. Thesepolicies should be updated at least annually or more often if necessary. In addition, a copy of the California Division of Occupational Safety and Health (Cal-DOSH) must beconspicuously posted in each dental office.4



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however, an optimal time for changing gloves during dentalprocedures has not been determined. 1 If the integrity of a glove is compromised, it should be changed as soon aspossible. Washing latex gloves with plain soap, chlorhexidineor alcohol can lead to the occurrence of glove micropunctures

and subsequent hand contamination. This condition is knownas wicking and can allow penetration of liquids throughundetected holes and, consequently, washing of gloves is not recommended. Currently, alcohol-based hand washes are very popular but when used, the hands should be thoroughly driedbefore gloving, because hands still wet with an alcohol-basedhand hygiene product can increase the risk of gloveperforation, rendering the gloves an ineffective barrier.1

Sterile Surgeon’s Gloves and Double-Gloving During Oral Surgical Procedures

Surgical procedures are defined as "the incision, excision, orreflection of tissue that exposes the normally sterile areas of the oral cavity. Examples include biopsy, periodontal surgery,apical surgery, implant surgery, and surgical extractions of teeth (e.g., removal of erupted or nonerupted tooth requiringelevation of mucoperiosteal flap, removal of bone or section of tooth, and suturing if needed". The CDC recommends wearingsterile gloves for surgical procedures, despite the fact that clinical studies have detected no difference in postoperativeinfection rates after routine tooth extractions when surgeons wore either sterile or nonsterile gloves. This recommendationis supported by research which indicates that sterile gloves

minimize transmission of microorganisms from the hands of surgical DHCP to patients and prevent contamination of thehands of surgical DHCP with the patient's blood and body fluids, because they are more rigorously regulated by the FDA for lower permeability. During surgical procedures sterilecoolants/irrigants should be used and delivered using a steriledelivery system. 1

Double Gloving

Increasing operator protection and decreasing diseasetransmission has always been the goal of an infection control

program. One method that has been examined to reduceoccupational exposure to blood and OPIM is the use of twopairs of gloves or "double gloving". Studies of providers wearing two pairs of gloves during oral surgery and hygieneprocedures demonstrated a lower frequency of inner gloveperforation and visible blood on the hands when doublegloves were worn, but no data exist regarding a decrease indisease transmission from double gloving. Nevertheless, basedon these studies, double gloving might provide additional

protection from occupational blood contact. Operatorsreported that double gloving did not reduce either theirmanual dexterity or tactile sensitivity. Other products such asglove liners and orthopedic surgical gloves may also be helpfulin reducing exposure to blood.

Hand Hygiene

Proper hand hygiene is the foundation of any infection controlprogram, and is the number one method of preventing diseasetransmission. Operators who wear gloves should be aware that wearing gloves does not eliminate the need for handwashing.Hand hygiene should be performed immediately beforedonning gloves. Further, because bacteria grow quickly undergloves, hand hygiene should be performed immediately afterremoving gloves. The hands should also be dried thoroughly before gloving, which decreases bacterial growth. Gloves oftenhave minute defects or holes which cannot be detected whilegloves often tear or become contaminated during gloveremoval. These factors increase the probability of contamination of the operator's hands to microorganismsfrom patients; and contamination of the patient's operative sitefrom the operator. If the integrity of the skin is compromisedby weeping dermatitis or exudative lesions, the operatorshould refrain from all direct patient care and from handlingpatient care equipment until the condition resolves. Table 1describes the proper hand hygiene recommendations.Illustration 2 lists special considerations for hand hygiene andglove use.

Instrument Sterilization and Disinfection

Comprehension of sterilization and disinfection protocols iscritical in preventing disease transmission. Sterilization is thecomplete destruction of all microbial life, including spores; while disinfection has various levels of efficacy, based upon theproduct and use. Basic techniques for sterilization,disinfection, barrier protection, personal protectiveequipment, vaccinations and numerous other protocols wereupdated in the 2003 CDC Guidelines for Infection Control inDentistry. In this document, items requiring sterilization were

identified by category:

1. Critical items: Penetrate soft tissue and/or bone and requireheat sterilization. Examples of critical items include surgicalinstruments, scalers, surgical burs.

2. Semi-critical items: Touch only mucous membranes andshould also be heat sterilized. Examples of semi-critical itemsinclude amalgam condensers, impression trays, dental




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handpieces.

3. Non-critical items & equipment: Contact only intact skin andrequire only cleaning and low-level disinfection and includeitems such as blood pressure cuffs, stethoscopes, etc.

Both critical and semi-critical instruments that are able to withstand heat should be cleaned and sterilized via anautoclave (steam under pressure), dry heat or chemical vaporafter each use. Items such as the dental handpiece, low-speedhandpiece components used intra-orally, and other dental unit attachments such as reusable air/water syringe tips andultrasonic scaler tips should be heat-sterilized betweenpatients. For heat sensitive critical and semi-critical items, anFDA approved chemical sterilant/disinfectant should be used.

Proper instrument storage is also a critical factor in

maintaining sterility of instruments. Instruments that are not tobe used immediately after sterilization must be packaged or wrapped. The packages or wraps must remain intact.Instruments may be removed from packages on the day of use,but must be covered with a moisture-impervious barrier toprevent any contamination. Items designated as "single useonly", such as prophylaxis angles, prophylaxis cups andbrushes, tips for the high-speed evacuators, saliva ejectors,air/water tips, etc. shall be used one time only and discardedafter each patient use. 1,3

Sterilization Protocols

Steam Sterilizers

Heat-tolerant dental instruments are usually sterilized by steamunder pressure (autoclaving), dry heat, or unsaturatedchemical vapor. All sterilization should be performed by usingFDA approved equipment and supplies. Manufacturer'srecommendations for instrument sterilization should always befollowed. Items to be sterilized should be arranged to permit circulation of the sterilizing agent (e.g., steam, chemical vapor, or dry heat). Instrument packs should be allowed todry inside the sterilizer chamber before removing andhandling. Packs should not be touched until they are cool and

dry because hot packs act as wicks, absorbing moisture, andhence, bacteria from hands.

The ability of equipment to reach physical parameters (e.g.,time, temperature, and pressure) required to achievesterilization should be monitored by mechanical, chemical,and biological indicators. Sterilizers vary in their types of indicators and their ability to provide readings on themechanical or physical parameters of the sterilization process.

Consult with the sterilizer manufacturer regarding selectionand use of indicators.

Dry-Heat Sterilizers

Dry heat is used primarily to sterilize instruments andequipment that could be damaged by moist heat (e.g., bursand certain orthodontic instruments). But while dry heat hasthe advantages of low operating cost and being non-corrosive,it takes much longer than steam to complete sterilization.Further, because a very high temperature is required, it is not suitable for certain patient-care items and devices.

Two primary types of dry-heat sterilizers used in dentistry:

• The static-air type is commonly called an oven-typesterilizer. Heating coils in the bottom or sides of the unit cause hot air to rise inside the chamber through naturalconvection.

• The forced-air type of sterilizer is also known as a rapidheat-transfer sterilizer. Heated air is circulated throughout the chamber at a high velocity, permitting more rapidtransfer of energy from the air to the instruments, thereby reducing the time needed for sterilization.1

Flash Sterilization

Flash Sterilization (Sterilization of Unwrapped Instruments) isused for sterilizing instruments for immediate use. It shouldnot be used as the primary office sterilization choice. The time

required for unwrapped sterilization cycles will vary with thetype of sterilizer and the type of item (i.e., porous ornonporous) to be sterilized. Each machine must be used only in accordance with the manufacturer's directions.

Ethylene oxide gas sterilization

Ethylene oxide gas sterilization (ETO) has been usedextensively in larger health-care facilities. Its primary advantage is the ability to sterilize heat- and moisture-sensitivepatient-care items with minimal rusting and dulling of surgicaledges. However, it requires 10-48 hours for sterilization andposes potential hazards to patients and DHCPs from exposure

to the gas, requiring stringent health and safety requirements. As a result, this sterilization method is impractical for private-practice settings. In addition, handpieces cannot be effectively sterilized with this method because of the decreased flow of gas flow through the small lumen of the handpiece.

Bead sterilizers

Bead sterilizers traditionally have been used in dentistry to



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sterilize small metallic instruments (e.g., endodontic files).However, because there are no methods to determineappropriate times and/or temperatures, the FDA hasdetermined that a risk of cross-contamination exists with thesedevices because of their potential failure to sterilize dental

instruments. The FDA now requires cessation of theircommercial distribution unless the manufacturer files a pre-market approval application. Dental health care providers whouse bead sterilizers assume the risk of using a dental devicethe FDA has deemed neither safe nor effective, and will beheld responsible for using potentially non-sterilizedinstruments on patients.

Sterilizer Monitoring

Sterilizers can be monitoring by various methods, typically mechanical, chemical and biological processors. Theseprocessors evaluate both the sterilizing conditions and theprocedure's effectiveness. Offices should regularly evaluate themechanical aspects of their sterilizers by assessing the timecycle, temperature, and pressure by observing the gauges ordisplays on the sterilizer. Some tabletop sterilizers haverecording devices that print out these parameters. However,they should be closely monitored because while a correct reading does not ensure sterilization, incorrect readings canbe the first indication of a problem.

Chemical indicators

Chemical indicators use chemicals to assess physicalconditions (e.g., time and temperature) during thesterilization process. Although chemical indicators do not prove sterilization has been achieved, they detect certainequipment malfunctions. External indicators applied to theoutside of a package (e.g., chemical indicator tape or specialmarkings) change color rapidly when a specific parameter(temperature) is reached, and they verify that the package hasbeen through the sterilization process. Internal chemicalindicators should be used inside each package to ensure that the sterilizing agent has penetrated the packaging material andactually reached the instruments inside. A single-parameterinternal chemical indicator provides information regarding

only one sterilization parameter (e.g., time or temperature).Multiparameter internal chemical indicators are designed toreact to > 2 parameters (e.g., time and temperature; or time,temperature, and the presence of steam) and can provide a more reliable indication that sterilization conditions have beenmet. Steam autoclaves, commonly used in dentistry, can use a multi-parameter internal indicator which is only available fortheir use.

Because chemical indicator test results are received when thesterilization cycle is complete, they can provide an early indication of a problem and where in the process the problemmight exist. If the indicators demonstrate that the sterilizationcycle was inadequate, the instruments in that load should not

be used for patient care.

Biological indicators

Biological indicators (BIs, spore tests) are the most acceptedmethod for evaluating the sterilization process. They work by determining if the highly resistant microorganisms (e.g.,Geobacillus or Bacillus species) have been destroyed, ratherthan merely testing the physical and chemical conditionsnecessary for sterilization. Because these spores are moreresistant and present in greater numbers than the othercontaminants found on instruments and equipment, aninactivated BI indicates other potential pathogens in the loadhave been inactivated.2 The CDC recommend that a sporetest be used for each sterilizer in the office at least weekly. Thiscan be achieved by sending the test to a commercial lab ortesting with an in-office system. The California Code of Regulations requires that these results be kept in the office fora period of at least one year, and be available upon inspectionif requested. 3 A combination of biological indicators andchemical indicators should be used by offices to closely monitor the effectiveness of their sterilizing systems.

Environmental Infection Control

It should be noted that our patients are not only at risk forcontracting bloodborne pathogens from breaches of sterilizingprotocols, poor hand hygiene and/or improper use of PPE,they are also at risk for contracting disease from a contaminated environment. While most DHCPs are vaccinatedagainst the acquisition of Hepatitis B virus (HBV), many of ourpatients are not.

Blood contains the greatest proportion of HBV infectiousparticles of all body fluids, and is the primary vector for itstransmission in the health-care setting. Although percutaneous(puncture) injuries are among the most efficient modes of

HBV transmission, research demonstrates that hepatitis Boutbreaks have occurred among patients treated inhemodialysis units, because HBV can survive in dried blood at room temperature on environmental surfaces for <1 week.Thus, HBV infections that occur in patients treated in thehealth care setting may have resulted from direct or indirect blood or body fluid exposures that inoculated HBV intocutaneous scratches, abrasions, burns, other lesions, or onmucosal surfaces. This fact reinforces the importance of



rigorous environmental infection control protocols.2

Clinical surfaces

Clinical surfaces are divided into 2 categories, Clinical Contract Surfaces and Housekeeping Surfaces. Illustration 2 describes various clinical contact surfaces. Clinical asepsis is achieved via barrier protection or surface disinfection, or a combinationof both. Barrier protection of surfaces and equipment canprevent contamination of clinical contact surfaces, but isparticularly effective for those that are difficult to clean.Barrier protection also prevents discoloration, drying andcracking of materials, rusting and corrosion. Barriers includeclear plastic wrap, bags, sheets, tubing, and plastic-backedpaper or other materials impervious to moisture. Becausesuch coverings can become contaminated, they should beremoved and discarded between patients, while DHCPs are still

gloved. Clinical surfaces should be examined after removingthe barrier. If the surface has become contaminated, it shouldbe disinfected prior to placement of the next barrier. If nocontamination has occurred, a new barrier may be applied.The surface needs to be cleaned and disinfected only if contamination is evident. A clean barrier should be placedprior to the next patient after the contaminated gloves havebeen removed and the hands washed.

If barriers are not used, surfaces should be cleaned anddisinfected between patients by using a Cal-EPA-registeredhospital disinfectant with an HIV, HBV claim (i.e., low-leveldisinfectant) or a tuberculocidal claim (i.e., intermediate-level

disinfectant). Intermediate-level disinfectant should be used when the surface is visibly contaminated with blood or OPIM. A high-level disinfectant kills some but not all bacterial spores,but does inactivate tuberculosis, bacteria, fungi and viruses. Also, general cleaning and disinfection are recommended forclinical contact surfaces, dental unit surfaces, and countertopsat the end of daily work activities and are required if surfaceshave become contaminated since their last cleaning. Tofacilitate daily cleaning, treatment areas should be kept free of unnecessary equipment and supplies. Chemical- and puncture-resistant utility gloves offer more protection than patient examination gloves when using hazardous chemicals.

Housekeeping Surfaces

No evidence exists that a nosocomial infection has beentransmitted to a patient from a contaminated housekeepingsurfaces (e.g., floors, walls, and sinks). These surfaces shouldbe wiped or scrubbed regularly with a detergent and water ora Cal-EPA approved hospital disinfectant/detergent, dependingon the nature of the surface and the type and degree of contamination. Schedules and methods vary according to the

area and type of contamination. Visible contamination shouldbe cleaned promptly. If contamination is noted in a patient care area and uncertainty exists regarding the nature of thecontaminant (blood or OPIM), a Ca-EPA registered, hospitalgrade disinfectant/detergent should be used. Chemical- and

puncture-resistant utility gloves offer more protection thanpatient examination gloves when using hazardous chemicals.4

Carpeting and Cloth Furnishings

When designing an office, or redecorating an existing office,practitioners should select hard flooring instead of carpeting.Hard surface flooring has always been preferred in the healthcare setting because it is less porous than carpeting and easierto clean. In addition, carpet cannot be reliably disinfected,especially after spills of blood and body substances. Studieshave documented the presence of diverse microbialpopulations, primarily bacteria and fungi, in carpeting.Further, when selecting products for dental chair covers, clothposes similar contamination risks in areas of direct patient care and places where contaminated materials are managed(e.g., the dental operatory, laboratory, or instrument processing areas). For these reasons, use of carpeted flooringand fabric-upholstered furnishings in these areas should beavoided.2

Infection Control in the Dental Laboratory

Infections in the dental laboratory pass from the patient tolaboratory and back from the laboratory to the patient, oftentimes infecting the DHCP in the process. Cross-transmissionsof pathogens can occur when a contaminated prostheticdevice, orthodontic appliance, impression tray with impressedmaterial, or other items are removed from the patient's mouthand taken immediately into the lab for adjustment orfabrication. The bioburden from the mouth then contaminatesthe countertops, grinding and pouring equipment and any prosthetic equipment with which it comes in contact. Thecontamination remains on these surfaces often contaminatingthe next case that is brought into the lab. The opposite alsocan occur, typically when an item is fabricated in the

laboratory, returned to the patient and placed intra-orally without appropriate cleaning and disinfection. In addition,appliances, and items used in their fabrication (e.g.,impressions and impression trays, occlusal rims, and biteregistrations) are potential sources for cross-contaminationand should be handled in a manner that prevents exposure of DHCPs, patients, or the office environment to infectious agents.These items should be cleaned and disinfected with anintermediate-level disinfectant after removal from mouth and

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Infection Control

prior to manipulation in the laboratory. It is better to do it immediately, before saliva and/or blood can dry on the device,making it more difficult to remove.

When the procedure is completed in the laboratory, the

appliance must be cleaned and disinfected once again beforereturning it to the patient and placing it intra-orally. Animportant fact to remember is that the appliance should berinsed thoroughly prior to intraoral placement, becauseacrylic materials are porous and may retain some of thechemicals, causing a chemical burn to occur. Effectivecommunication and coordination between the commerciallaboratory and the dental practice will also ensure that appropriate cleaning and disinfection procedures areperformed in the dental office or laboratory, materials are not damaged or distorted because of disinfectant overexposure,and that effective disinfection procedures are not unnecessarily duplicated.

When a prosthetic case is sent to a commercial dentallaboratory, written information regarding the type of disinfectant used on the case should be provided. Appliancesand prostheses delivered to the patient should be free of contamination. Communication between the commerciallaboratory and the dental practice is also important. When thecase is returned to the office, the laboratory should alsoprovide information regarding the disinfection method used. If such documentation is not provided, the dental office isresponsible for the final disinfection procedures to ensure that no contaminated appliances or devices are returned to the

patient.

In the laboratory, a separate receiving and disinfecting area should be established to reduce contamination in theproduction area. Transfer of oral microorganisms into andonto impressions has been documented; therefore freshpumice and a disinfected, sterilized or new rag wheel shouldbe used for each patient.4 Movement of these organismsonto dental casts has also been demonstrated. If laboratory items (e.g., burs, polishing points, rag wheels, or laboratory knives) are used on contaminated or potentially contaminatedappliances, prostheses, or other material, they should be heat-sterilized, disinfected between patients, or discarded (i.e.,

disposable items should be used). Heat-tolerant items used inthe mouth (e.g., a metal impression tray or face bow fork)should be heat-sterilized before being used on another patient.Items that do not normally contact the patient, prostheticdevice, or appliance but frequently become contaminated andcannot withstand heat-sterilization (e.g., articulators, casepans, or lathes) should be cleaned and disinfected betweenpatients in accordance with the manufacturer's instructions. When working in the laboratory, splash shields and equipment

guards should be used to protect the operator fromcontamination resulting from splatters and splashes. Wastefrom the laboratory and the dental practice clinical areasshould be disposed of in accordance with the applicable local,state and environmental standards.2,3,5

Waterline Management

DHCPs should attempt to maintain acceptable water quality (i.e., < 500 CFU/mL) as prescribed by the American Dental Association (ADA), CDC, Cal-DOSH and other regulatory organizations. Compliance can be achieved by adaptingpolicies and procedures that are implemented on a routinebasis for their water delivery system. Staff should be trainedregarding water quality, biofilm formation, water treatment methods, and appropriate maintenance. Water treatment andmonitoring products require strict adherence to maintenanceprotocols, and noncompliance with treatment regimens hasbeen associated with persistence of microbial contamination intreated systems. Mechanical inserts, in-line filters and anti-retraction valves also prevent the flow of impurities in thelines, and should be used. At the beginning of each day, thedental unit water lines should be purged with air and/orflushed with water for at least 2 minutes prior to attaching thehandpieces, scalers and other devices. The dental unit linesmust also be flushed between each patient for a minimum of 20 seconds. Methods for maintaining self-contained unitsshould be obtained from the manufacturer and diligently followed. Clinical monitoring of water quality can ensure that

procedures are correctly performed and that devices are working in accordance with the manufacturer'srecommendations. 2,3

Management of Sharps

Avoidance of occupational exposure from injuries withcontaminated sharps is the ultimate goal of an infectioncontrol program. Numerous mechanisms exist to promote thisgoal and include the use of standard precautions for all patient encounters. Sharp items, such as needles, scalers, burs and wires that are contaminated with patient blood and saliva

should be considered as being potentially infectious. Usedneedles should never be recapped via a 2-handed needlerecapping method, or any other technique, that involvesdirecting the point of a needle toward any part of the body.Using either a one-handed scoop technique or a mechanicaldevice designed for holding the needle cap when recappingneedles (e.g., between multiple injections and before removingfrom a non-disposable aspirating syringe) is prescribed.Contaminated needles must never be bent or broken before

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discarding them. Used disposable syringes and needles, scalpelblades, and other sharp items should be placed in appropriatepuncture-resistant containers located as close as feasible to thearea in which the items are used. In addition, the office must have a written, comprehensive program designed to minimize

and manage DHCP exposures to blood and body fluids and which describes the items used. Further, as per the Needlestick Safety Prevention Act, new devices with safety features shouldbe evaluated at least annually, or as they become available onthe market. 2,3,5

Conclusion

This program presented an overview of the "2003 CDCRecommendations for Infection Control in Dentistry" as well asthe California Code of Regulations, "Minimum Standards for

Infection Control'. It reviewed standard precautions,sterilization protocols and sterilizer monitoring, clinical andlaboratory disinfection, PPE, specialized PPE and equipment for surgical procedures, hand hygiene, sharps management,documentation and posting requirements, dental unit waterline management and numerous other items designed toreduce or prevent the transmission of bloodborne andairborne pathogens in the dental health care setting. It ishoped that adaptation of these recommendations will protect DHCPs and their patients from the acquisition of infectiousdiseases, while providing "State of the Art" dentistry.

Acknowledgements

The author would like to express her deep appreciation of thesecretarial contributions that Mrs. Kathy Wisnom made to thisarticle.

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Table 1: CDC Recommendations for Hand Hygiene in the Dental Health Care Setting

Ref: CDC, Guidelines for Infection Control in Dental Health Care Setting, 2003. MMWR 2003; 52 (No. RR17):1-61

Illustration 1: Special Considerations for Hand Hygiene and Glove Use

Method Agent Duration IndicatorRoutine wash Water & soap 15 seconds Before & after each patient, etc.

Antiseptic wash Water & anti-microbial soap 15 seconds Before & after each patient, etc. Antiseptic handrub

Alcohol-based hadn rub Rub until dry Not to be used if visibly soiled

Surgical asepsis Water & anti-microbial soap or water & non-anti. Soap followedby alcohol rub

2 - 6 minutes Before donning sterile gloves/surgery

1. Use hand lotions to prevent skin dryness associated with handwashing.

2. Consider the compatibility of lotion and antiseptic products and the effect of petroleum orother oil emollients on the integrity of gloves during product selection and glove use.

3. Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears.

4. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive care units or operating rooms).

5. Use of artificial fingernails is usually not recommended.

6. Do not wear hand or nail jewelry if it makes donning gloves more difficult orcompromises the fit and integrity of the glove.

[Ref: CDC, Guidelines for Infection Control in Dental Health Care Setting, 2003. MMWR 2003; 52 (No. RR17):1-61.]



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Illustration 2: Clinical Contact Surfaces

Contamination of clinical contact surfaces can occur directly from splatters or splashes of bloodand/or OPIM from patients, or indirectly from contact with the contaminated hands or gloves of DHCPs. These surfaces can subsequently contaminate other instruments, devices, or individuals.Examples of such surfaces include:

• dental chairside computers, keyboards high contamination• light handles• switches on dental chair and x-ray equipment • dental radiograph equipment (standard and digital)• reusable containers of dental materials• drawer handles in clinical and laboratory areas• faucet handles• clinical and laboratory countertops• pens• telephones, and• doorknobs

[Ref: CDC, Guidelines for Infection Control in Dental Health Care Setting, 2003. MMWR 2003; 52 (No. RR17):1-61]



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References

1. CDC, Guidelines for Infection Control in Dental Health Care Setting, 2003. MMWR 2003;52(No. RR17):1-61.2. CDC, Recommended Infection Control Practices in Dentistry, 1993. MMWR 1993;42(No.RR-

8).3. California Codes of Regulations (CCR)-1005. Minimum Standards for Infection Control.

Amended Section/Division 10:Title 16, July 21, 2004.4. California Codes of Regulations (CCR)-Section 5193, Title 8.5. California Business and Professional Code. Section 1680, July 21, 2004.



QuestionsInfection Control

1. The 2003, CDC Guidelines for Infection Control inDentistry have evolved from:

a. Standard Precautions to Universal Precautionsb. Universal Precautions to Standard Precautionsc. Body fluid precautions to Standard Precautions

2. The CDC recommends the use of StandardPrecautions for:

a. Patients who report that they are infected with a bloodborne pathogen

b. Patients who report that they are healthy and

currently do not have an infectious diseasec. Any patient who receives clinical care regardless

of their reported infectious disease status

3. Standard Precautions should be used whenoperators have exposure to:

a. Blood only b. Blood and other potentially infectious materials

(OPIM)c. Human sweat

4. A written Infection Control Program is required ineach office. Once compiled it must be updated

a. Once compiled it is not necessary to update it b. It must be updated every 6 monthsc. It must be updated at least annually

5. Personal Protective Equipment (gloves, eyewear withside shields, mask, clothing clover) must be worn:

a. For surgical proceduresb. For any procedure where it is anticipated that an

exposure to blood or OPIM may occur

c. For routine procedures

6. A face mask must be changed:

a. After each patient b. During a procedure if it becomes wet or tornc. After each patient and if it becomes wet or torn

during a procedure

7. Recommendations for asepsis for clinical eyewearinclude:

a. Cleaning the eyewear for the patient, and faceprotection for the operator should be doneafter each procedure, but disinfection is only necessary when visible contamination ispresent

b. Cleaning and disinfecting the eyewear for thepatient, and face protection for the operator,after each procedure regardless of thecontamination

c. No new recommendations have been made

regarding asepsis for clinical eyewear

8. Wearing scrub attire, work clothes or uniformsalone is considered satisfactory protection whenproving clinical care to patients

a. Trueb. Falsec. Unsure

9. The Bloodborne Pathogen Standard states that thelength of the sleeves on a lab coat be:

a. Short b. Longc. Long enough to protect the forearms when the

gown is worn as PPE

10. Gowns must be changed:

a. Daily or more often if they become soiled,contaminated or moist

b. With each patient c. At the end of the week

11. All PPE must be changed:

a. Before going to lunchb. Between patientsc. Before leaving the clinical area




12. The amount of time the hands should be washed forroutine patient procedures is:

a. 15 secondsb. 30 secondsc. 2 minutes

13. The amount of time the hand should be washed forsurgical procedures is:

a. 5-10 minutesb. 2-6 minutesc. 3-5 minutes

14. A condition known as "Wicking" occurs becausegloves are _________. This causes the gloves tobecome a ___________ barrier.

a. Worn improperly, imperfect b. Torn, poorc. Washed, ineffective

15. Instruments requiring sterilization are dividedinto_______ categories. They are:

a. Two, surgical and non-surgicalb. Three, Critical, Semi-Critical and Non-criticalc. Three, Semi-critical and surgical

16. ASpecial considerations for hand hygiene and gloveuse include:1. Not wearing artificial fingernails2. Filing natural nails to prevent sharp edges and

punctures of gloves3. Applying hand cream that contains petroleum

each time the hands are washed

a. 1 & 3

b. 2 & 3c. 1 & 2

17. The CDC classifies a dental handpiece as a:

a. Critical itemb. Semi-critical itemc. Non-critical item

18. The CDC requires that a dental handpiece be__________________after each patient use?

a. Disinfectedb. Cleaned and wiped with a disinfectant c. Heat sterilized

19. Metal impression trays used for patient care must be________________after each use?

a. Heat sterilizedb. Rinsed and Cleanedc. Disinfected

20. Following sterilization, instruments may be placed,unwrapped in a mobile cabinet until used.

a. Trueb. Falsec. Unsure

21. When may sterilized instruments be removed fromtheir wraps or packages and placed on a tray, covered with a fluid impervious barrier, for patient care?

a. The day of useb. Two days before they are usedc. Any time before they are used

22. Bead Sterilizers were previously used for sterilizingsmall instruments, such as ______________. They are now considered______________________.

a. Surgical forceps, appropriateb. Endodontic files, inappropriatec. Prosthodontic impression trays, appropriate

23. Ethylene Oxide Gas is used primarily by

_________________practices. It does not sterilizea ______________________ appropriately dueto the small lumen.

a. Large practices (hospitals), dental handpieceb. Small practices (private offices), impression tray c. Moderate practice, dental syringe




16

24. Biological Indicators are themost______________method for monitoringsterilizers, because they determine if ____________________have been inactivated

a. Accepted, virusesb. Accepted, bacteria c. Accepted, spores

25. Biological indicators should be used at least __________________ for sterilizers, and theresults kept for at least ____________.

a. Weekly, one yearb. Monthly, 6 monthsc. Bi-weekly, 8 months

26. Hepatitis B Virus can live in _________________at __________________ on______________for ____________

a. Saliva, high temperatures, dental surfaces, onemonth

b. Blood, room temperature, environmentalsurfaces, one week

c. Body fluids, room temperatures, environmental

surfaces, two weeks

27. Clinical asepsis for environment surfaces can beachieved via:

a. Barrier protectionb. Surface disinfectionc. Combination of barrier protection and surface

disinfection

28. A low-level disinfection product will not inactivate_______________ on an environmental

surface

a. Tuberculosisb. HIV c. HBV

29. If barrier protection is used on a clinical contact surface and it has not been disturbed it may

a. Be used for the next patient b. Be removed and replaced without disinfecting the

surfacec. Be removed and replaced after disinfecting the

surface

30. When designing and office or redecorating an existingoffice, practitioners should select

a. Cloth covers for chairs and hard surface flooring

b. Smooth covers for chairs and carpeting for floorsc. Smooth covers for chairs and hard surface

flooring



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Infection Control - 925

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