This course was written for dentists, dental hygienists, and assistants.

4 CEUs

Earn

Breaking the Chain of Infection:

Practical and Effective Infection Control
A Peer-Reviewed Publication Written by Nancy Andrews, RDH, BS

The Academy of Dental Therapeutics and Stomatology is an ADA CERP Recognized Provider

TM

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This course has been made possible through an unrestricted educational grant from Kerr TotalCare . The cost of this CE course is $59.00 for 4 CEUs. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.

Educational Objectives
At the completion of this course, the dental healthcare professional (DHCP) will be able to: 1. Understand the chain of infection and how infection control strategies break that chain or prevent infection transmission. 2. Discuss the roles of the following methods in breaking the chain of infection: hand hygiene, instrument processing, environmental asepsis, and personal protective barriers. 3. Describe the concept of cleaning prior to disinfection or sterilization relative to hand hygiene, instrument processing, environmental asepsis, and personal protective barriers. 4. Understand how to select and use appropriate products correctly.

procedures have been found to pose a serious exposure hazard for DHCPs.1

Infection Control Program Strategies

A well-structured infection control program provides maximum protection for patients and staff while enabling the ofce to operate efciently, but does not eliminate the risk of exposure. Infection control strategies attempt to break the chain of infection in many places along the pathway of disease transmission, with an emphasis on the earliest opportunities to control pathogen contamination. Controlling the spread of pathogens at the source rather than allowing pathogen dispersal makes infection control more manageable and probably more successful. The strategy of breaking the chain of infection before exposure occurs is proactive and requires planning, training, and a commitment to avoiding exposure. If contamination has already occurred, cleaning followed by disinfection or sterilization is necessary. Infection control programs should be clearly written, must adhere to legal requirements, and should be well-monitored on a dayto-day basis.2

Introduction
All dental procedures provide an opportunity to transmit infectious pathogens directly or indirectly between patients and workers. The pathway of disease transmission between people is referred to as the chain of infection, and infection control programs focus on breaking this chain. This educational course addresses hand hygiene, instrument processing, environmental asepsis, and use of personal protective barriers relative to breaking the chain of infection, undertaking sequenced processes of cleaning prior to disinfection or sterilization, and using appropriate products correctly. Single-dose and disposable products as alternatives to bulk or re-usable items and their roles in addressing the goals of safety and efciency are also considered. Disease transmission requires a source of microbes, a method of transmission and exposure, an entry portal, and a susceptible host. Microbial exposure can be direct or indirect. Direct exposure may occur through injury or contact with non-intact skin, mucosal tissue, or ocular tissue or through ingestion. Examples of direct and indirect transmission are shown in Table 1. Hand contact with contaminated surfaces is an example of indirect contact and can result in cross-contamination, endangering patients and staff alike. Both contaminated surfaces and aerosols generated during dental Table 1. Direct transmission primary exposure Needle-stick and sharps injuries Injury from an instrument during a procedure Spray or debris entering the eye Bacterial aerosol and splatter during a procedure Unprotected skin Indirect transmission secondary exposure Contaminated instruments Contaminated surfaces and equipment Bacterial aerosol
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Breaking the chain of infection and preventing disease transmission

Hand Hygiene One of the most common methods for microbial transmission is through contamination by hands as a result of poor hand hygiene, which has been linked to healthcare-associated infections. These ndings were a major motivation for CDC Infection Control Recommendations in 2003. Appropriate hand hygiene has been found to be the single most critical procedure in the infection control program.3 Normal human skin is colonized with millions of bacteria. Resident ora, found in the deeper layers of the skin, is unique to each individual and is less likely than the more supercial transient ora to be removed during hand antisepsis. Transient ora is acquired through contact with microbes on people, items, or surfaces, and is more commonly associated with healthcarerelated infections, including pathogenic coagulase-resistant Staphylococcus aureus.

Hand hygiene is the single most critical procedure in the infection control program.
Personal and Surface Barriers Barriers are designed to prevent exposure. Intact skin is the rst line of defense against infection. The second line of defense is the use of personal protection barriers. Avoiding personal exposure is preferable to the stress, time, and cost of responding to an exposure incident. Routine use of personal barriers to prevent pathogens from contacting mucosal tissues of the eyes, oronasal mucosa, or any openings in skin has been
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very successful in reducing DHCP exposure to infections, and is now standard practice. However, if workers become lax in their use of barriers such as wearing them out of position, wearing them past their lifespan, re-using single-use items, or failing to wear them, then infection is more likely to occur. Masks were originally designed to protect the patient from contamination caused by the operator coughing, speaking, etc. Face shields, eyewear, and masks protect DHCPs from exposure to potentially infectious uids and debris, as well as from injury due to ying particles. Patient treatment masks and respirators also lter breathed air. Dental professionals have been found to have higher rates of conjunctivitis than the non-dental population,4 highlighting the importance of protective eyewear.

Surface Cleaning and Disinfection Any exposed clinical contact surface should be rst cleaned and must then be disinfected using intermediate-level disinfectants (those that are effective against Mycobacterium tuberculosis a highly resistant organism used to test surface disinfectants) between patients. Cultures of operatory surfaces have yielded a variety of microorganisms, including methicillin-resistant Staphylococcus aureus, and the transmission of this pathogen to a number of patients occurred during dental procedures in one study.5 Hepatitis B transmission between patients has been documented, and the investigators speculated that a lapse in environmental asepsis procedures was the most likely mechanism of transmission.6 Both studies highlight the importance of effective surface barriers and decontamination. Instrument Processing Instrument processing must be appropriate to the procedures for which the instrument or component is used. Heat-sterilizable and disposable items offer the highest level of asepsis to reliably prevent disease transmission and are required for critical instruments (those that penetrate the mucosa). For semi-critical instruments (those that contact the mucosa), immersion in high-level disinfectant/sterilants may be acceptable if the instrument is heat-sensitive and cannot be otherwise sterilized.7 (Figure 1) Breaking the chain of infection requires a sequence of steps. Instrument processing is quicker, more controlled, and less error-prone with automated devices and processes such as instrument washers, ultrasonic cleaners, and current-model sterilizers thereby reducing risk.

Routine use of personal barriers is standard practice.

Surface/Environmental Barriers Operatory surface barriers prevent surface contamination by touch, contact, or airborne contaminants. Clinical contact surfaces frequently touched (such as light handles), and complex surfaces that are difcult or time-consuming to clean, can be covered with impermeable single-use barriers. The benets of surface barriers include: less time spent performing environmental asepsis, more reliable asepsis, and visible barriers that communicate asepsis to patients. Aseptic techniques are needed to handle and change barriers, and uncovered clinical contact surfaces must still be cleaned and disinfected between patients. Figure 1. Breaking the chain of of infection: Instrument Processing Breaking the chain infection: Instrument Processing

Perform the procedure: single-use disposable and sterilized instruments Discard all sharps into sharps container; discard all single-use items

Spray enzymatic foam onto non-disposable instruments and trays to start cleaning process Heat-sterilize all critical instruments, all heat-resistant semi-critical and non-critical instruments

Remove all non-disposable instruments to the instrument processing area

Store packaged, sterile instruments Clean all non-disposable instruments Chemical-sterilize all heat-sensitive semi-critical and non-critical instruments

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Single-use Disposable and Unit-dose Items Disposable and unit-dose products are becoming more available and economical. These offer time-saving alternatives to the sequential steps required in the processing of re-usable dental items and should avoid potential cross-contamination. Single-use disposable items cannot be sterilized or safely disinfected and must be discarded after one use and disposed of appropriately. Single-use sharps, such as needles and scalpels, should be placed in an approved sharps container in the operatory immediately after use, for later collection and disposal. (Figure 2) Other single-use disposable items should also be disposed of in the operatory. Figure 2.

or non-visible debris or organic substances may interfere with disinfection and sterilization. This concept applies to hand hygiene, environmental asepsis, and reprocessing reusable instruments and items. Cleaning and Sanitizing Hands The CDC recommends a combined regimen of both handwashing to clean hands and use of waterless hand sanitizers to kill organisms throughout the day. Handwashing with soap and water removes organisms and physical matter from hands, and may also kill organisms if antimicrobial soaps are used. If hands are visibly soiled, handwashing is always required. Waterless hand sanitizers are poor cleaners but excellent antiseptics, and have been found to be signicantly more effective than handwashing with antiseptic soap or plain soap at killing organisms.8,9 For surgical procedures, antimicrobial soap or an alcohol-based hand-rub with substantivity is required10 this will reduce hand ora and provide a residual antimicrobial effect under gloves, thus reducing bacterial regrowth. (Figure 3) Wearing gloves does not nullify the need for hand hygiene gloves may be compromised or may have undetected defects that allow hand contamination. Hand hygiene is necessary prior to donning gloves, and hands must also be decontaminated after glove removal to remove pathogens and to reduce the ora that may have multiplied in the warm, moist environment under gloves.

Proper techniques and sequencing of procedures

Cleaning Prior to Disinfection or Sterilization Cleaning to remove all debris is the essential rst step in proper disinfection or sterilization. The presence of visible Figure 3. Hand hygiene

Wearing Personal Barriers

Gloves Single-use gloves are vital elements of infection control programs. While they are not 100% reliable, they are essential barriers to protect patients and DHCPs. Aseptic

Prior to donning gloves

Non-surgical procedures

Surgical procedures

Instrument cleaning

Hands visibly soiled: Wash with water and plain or antimicrobial soap

Hands not visibly soiled: Wash with water and plain or antimicrobial soap OR use an alcohol-based hand-rub

Wash with antimicrobial soap OR wash with plain soap and use an alcohol-based hand-rub with substantivity

Wash hands with water and plain or antimicrobial soap OR apply waterless hand sanitizer

Don medical gloves

Don sterile surgical gloves

Don thick utility gloves

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For handwashing: 1. Wet hands with water. 2. Apply soap. 3. Lather for at least 15 seconds. 4. Thoroughly rinse with water, and dry hands using disposable towels. Plain soap and water effectively clean hands; they do not destroy pathogens. For alcohol-based hand-rubs or solutions: Follow the manufacturers recommendations for application and length of use. Alcohol-based products destroy pathogens; they do not effectively clean hands. technique must be observed; gloves must be removed when compromised, and after each patient, and hand hygiene performed immediately after removing gloves. Fresh gloves from the end of an open box in the operatory have been found to be contaminated with microorganisms prior to use11; therefore, gloves should ideally be stored in a closed container prior to use. Sharp-edged jewelry, and long or ragged fingernails are contraindicated as they may harbor organisms, tear and compromise gloves, as well as make gloves difficult to don. Instrument Processing Instrument cleaning can be achieved by using enzymatic solutions and ultrasonic cleaning, by using instrument washers/disinfectors, or by hand scrubbing. Closedcassette systems involve the use of operatory cassettes as trays that can be closed and locked after use and prior to cleaning, and can also be placed in a mechanical instrument cleaner prior to being sterilized. (Figure 4) This automates the process and minimizes the risk of personal injury. Figure 4.

be carried out wearing heavy-duty utility gloves to reduce the risk of puncture (masks, protective eyewear, and gowns should also be worn), scrubbing one instrument at a time, low down in the sink to minimize the risk of injury.12 Hand scrubbing after instruments have been treated with enzymatic cleaner (Figure 5) and/or ultrasonic cleaning is safer, as the organic matter and most of the debris have already been removed. Figure 5.

Eyewear, Masks and Gowns Protective eyewear should be lightweight, clear, and distortion-free. Protective eyewear and face shields should be washed and disinfected between patients, following the manufacturers instructions. Surgical masks should be worn for all dental procedures and should ideally be stored in a protected container to prevent contamination prior to use. If a mask becomes damaged or damp during a procedure, it should be changed out for a new mask. Clinical uniforms should protect all personal clothing and exposed skin, including the arms. If soiled, a clean gown should be donned. Single-use disposable gowns and shoe/foot shields are also available.

Gloves and masks should ideally be stored in a closed container prior to use.
Appropriate Product Selection and Use
Infection control products should be selected based on the anticipated level of contamination exposure and the type of procedure being performed. Consult manufacturers to understand the uses and limitations of all infection control products, and communicate that information to all DHCPs. Hand Hygiene Hand hygiene compliance is affected by perceptions that there is a low risk of cross-infection and that gloves are enough; compliance is also affected by perceived time
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Hand scrubbing heavily contaminated instruments is unwise. If hand scrubbing must be performed, it should
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pressures and by irritated and dry skin.13 Non-compliance is a large contributing factor to disease outbreaks.14 Hand hygiene must be practical, routine, non-irritating and convenient. Liquid- or foam-dispensed soaps in closed containers offer convenience and a reduced likelihood of contamination; however, they should not be topped-off, as this increases the risk of contamination. Bar soaps are exposed to microbial contaminants and are therefore less suitable; in public settings, these have been found to be a potential source of cross-infection.15 Available antimicrobial soaps include VioNex Antimicrobial Liquid Soap (Kerr TotalCare), which contains chloroxylenol, skin conditioners and emollients; Sani-Sept (Crosstex), which contains 0.3% triclosan, aloe vera and vitamin E; and Hibiclens (GC America) which contains chlorhexidine. Foam-dispensed, closed-container soaps offer superior coverage using the minimum amount of product, reducing the potential for skin reactions. (Figure 6) Antimicrobial soaps are available with chloroxylenol, chlorhexidine gluconate, quaternary ammonium, povidone-iodine, hexachlorophene, or triclosan. Note that povidone-iodine is most commonly associated with allergic reactions; hexachlorophene is contraindicated in pregnant women and on denuded skin; and the effectiveness of quaternary ammonium products is impacted by exposure to organic materials. Chloroxylenol, chlorhexidine gluconate, and triclosan are well-tolerated, effective skin antimicrobials that are minimally affected by the presence of organic matter. Antimicrobial Foaming Soaps include VioNexus (Kerr TotalCare) and Alcare (Vestal). The routine use of hand lotions containing emollients helps reduce irritation and drying of skin. Petroleum- and mineral oilbased emollients are unsuitable in lotions and alcoholbased hand sanitizers, as they affect glove integrity.

Figure 6.

hand antisepsis. An example is Sani-Tyze (Crosstex), with aloe- and water-based emollients. Available products containing both alcohol and an antimicrobial agent required for surgical alcohol-based hand products include VioNexus No Rinse Spray Antiseptic Handwash, which contains 66% ethanol, 0.10% benzalkonium chloride, and emollients; VioNex Towelette; VioNex No-Rinse Gel Antiseptic Handwash (Kerr TotalCare), formulated with chloroxylenol, cleansers, and skin conditioners; and SaniDex (PDI). Since waterless sanitizers are to be used on clean hands, non-powdered gloves are recommended. The emollients in these products make donning gloves so easy that powder is not necessary. Gloves, Eyewear and Masks Glove selection must consider the need for sterility, length of the procedure, chemical exposure, fit, latex and manufacturing allergies (alternatives to latex include nitrile and polychloroprene; nitrile provides superior chemical resistance). Eye shields must provide wraparound protection to avoid exposure from the sides of the eyes. Prescription glasses typically do not wrap around the sides of the eyes and therefore provide insufficient barrier protection; if these are used, side shields should be fitted over the legs of the eyeglasses, or an eyeshield or a full face shield should be used over them. A full face shield such as Googles (Kerr TotalCare) protects the whole face and can be worn over eyeglasses and loupes. (Figure 7) Key selection criteria for masks include the t, uid resistance, and ltration value (based on the size and percentage of particles present particle ltration efciency). (Figure 8) Regular molded and tie-on masks have been found in one study to be only 85% to 86% effective, compared with 95% to 96% efcacy for a personal respirator that lters out particulate matter.17 Masks should provide American Societty for Testing Materials (ASTM) low-, moderate-, or high-barrier protection, as appropriate to the exposure risk of an activity. High-barrier protection masks
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Foam-dispensed, closed-container soaps offer superior coverage using the minimum amount of product, reducing the potential for skin reactions.
Alcohol-based solutions, gels, and towelettes are increasingly available to the public. For maximum effectiveness balanced with skin protection and glove compatibility, only medical-quality, FDA- or EPA-approved hand sanitizers should be used. Alcohol-based hand-rubs have been found to be more cost-effective and less timeconsuming than handwashing.16 Concentrations should be 60% to 95%; ethanol-based products are more effective against viruses than isopropanol-based products (which are also more drying to skin). Dispensers or towelettes offer convenience and ease-of-use without requiring a sink. Many waterless sanitizers contain only alcohol as the active ingredient and are recommended for non-surgical
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should be available for procedures that can result in higher levels of moisture and/or dust exposure, and moderateand low-barrier protection masks should be available for lower-exposure procedures. For easy selection, Patterson masks are named according to ASTM level of protection. Crosstex clearly communicates the level of protection of their masks on the boxes, and the company offers training in selection. N95 National Institute of Occupational Safety and Health (NIOSH) respirators provide respiratory protection above that required for daily use and are recommended for transmission-based precautions, such as exposure to inuenza. Figure 7.

boards in the clinical setting should also receive the same impermeable wrap. Figure 9.

Disposable and Single-use Items

Single-use disposable items include suction tips, saliva ejectors, X-ray holders, as well as trap filters for evacuation units and bite-blocks for panoramic radiographs. (Figure 10) Figure 10.

Figure 8.

Environmental (surface) barriers

Fitted, plastic, single-use disposable barriers are easy and quick to apply and remove, and are more likely to remain in position than plastic sheets or drapes. Fitted plastic barriers are available as slip-over sleeves for chairs, headrests, lights, light-curing units, digital X-ray sensors, airwater syringe handles, impression guns, dental waterline units, and X-ray units. (Figure 9) For other items, impermeable plastic wrap can be used. Computer keyboards have also been found to be a source of pathogenic bacteria in healthcare settings,18 suggesting that computer keywww.ineedce.com

Air-water syringe tips are an example of successful replacement of re-usable items by disposable products. Cleaning non-disposable metal air-water syringe tips is difficult and time-consuming due to their narrow lumens. The problem is compounded by the retraction of materials into the lumen. To break the chain of infection, disposable air-water syringes are a recommended alternative. They are compatible with standard non-disposable fittings, are cost-effective, and are made of plastic with or without a metal tip insert to the handle of the syringe. (Figure 11) Other variants include plastic syringes with rubber O-ring seals and push-button converters for quick, user-friendly, tip changing (Seal-Tight Disposable Air-Water Syringe Tips, Kerr TotalCare). In addition to single-use disposable accessories and instruments, unit-dose products help reduce the risk of microbial contamination when handled aseptically, saving both time and money.
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Figure 11.

Choosing a product with a shorter TB kill time reduces the time the product must remain on the surface, and thereby reduces associated costs.
Figure 12.

Surface Cleaners and Disinfectants: Product Selection

The following factors should be considered: The products ability to serve as both a high-performing cleaner and a disinfectant, reducing inventory requirements and making compliance easier (Products with high alcohol content are effective at disinfecting but poor at cleaning, requiring the use of a separate compatible product for cleaning. Choice of pre-mixed product or product that must be mixed (consider time, risk of spillage or mistakes in mixing, and product shelf-life after being opened or mixed). TB kill time choosing a product that takes less time to kill TB, the most resistant organism, reduces the time the product must remain on the surface, which in turn reduces costs associated with room turnaround time. Choice of aerosol, pump, or spray applicators (consider over-spray and aerosolization of chemicals). Propensity to stain, corrode, or rust materials. Toxicity (such as likelihood of inhalation problems or allergies). Vehicle (whether the product is available as a solution, spray, foam, and/or wipes). Surface cleaners and disinfectants include those available containing quaternary ammonium, phenolics, hydrogen peroxide, EGME, iodophor, or citric acid. Wipes, sprays (such as CaviCide, Kerr TotalCare; Citrex Hospital Spray Disinfectant, Caltech), and foams typically use less volume of product than solutions do. (Figure 12) This reduces exposure to chemicals. Available wipes include CaviWipes (Kerr TotalCare), Sporicidin, Asepti-wipe (Ecolab) and Clorox wipes (Bosworth). Wipes use the least product, are quick to use, and are less likely to cause aerosolization, splatter, or dripping of the product. A typical protocol for a pre-impregnated wipe cleaner and disinfectant such as CaviWipes or Patterson PDCare wipes would be as follows: 1. Clean the surface by wiping. 2. Discard the used wipe. 3. Select a new pre-impregnated towelette, and wipe the surface. 4. Leave the surface undisturbed for the length of time of the TB kill (five minutes for CaviWipes). If unsure about the toxicity, handling, or surface effects of a surface cleaner or disinfectant, the manufacturer should be contacted for more information prior to use.
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Instrument Sterilization, Disinfection, and Pre-cleaning

Enzymatic foam cleaners speed up cleaning and debris removal. The foam is sprayed on the instruments and tray prior to taking them to the instrument processing area. This starts the dissolution of organic matter and the loosening of gross debris, without giving these contaminants a chance to dry on the instruments. Enzymatic foams currently available include EmPower Foam (Kerr TotalCare), Zymex (Sultan), ProEZ Foam (Certol) and Prezyme (L&R). Pre-cleaning the instruments with enzymatic foam to remove debris increases the lifespan of ultrasonic solutions, which should be changed at least once a day (and more often if heavily-contaminated instruments are placed in it). Some enzymatics, such as EmPower, can be used as a pre-soak solution, an ultrasonic solution, and an evacuation solution. Ultrasonic solutions should be used in accordance with the manufacturers recommendations. In selecting these solutions, consider both cleaning ability and the potential for damage to instruments exposed to them. Solutions containing enzymes, detergents, and rust inhibitors are particularly effective and help prevent rust and corrosion damage to instruments. After cleaning, instruments and trays must be dried and appropriately packaged prior to sterilization. Instrument sterilization can be performed using an FDA-cleared steam autoclave, a dry-heat sterilizer, a forced-air convection sterilizer, or an unsaturated chemical vapor sterilizer.19 If the instrument is heat-sensitive and is semi-critical or non-critical, it can be sterilized by immersing in a high-level disinfectant/sterilant such as ProCide-D Plus (Kerr TotalCare), which contains 3.4% buffered glutaraldehyde solution and can be used to sterilize immersible instruments by soaking them for 10 hours at 77 F. (Figure 13) Other high-level disinfectant/sterilants include Omnicide (Cardinal) and Sporicidin. Surface (intermediate-level) disinfectants may not be used in place of a high-level disinfectant/sterilant; this would result in inadequate infection control, would not meet EPA requirements, and would be a violation of federal law. Heat sterilizable or disposable items are preferred. Some manufacturers provide excellent training resources for their products based on recommended safe practices.
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Figure 13.
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Summary
Successful infection control breaks the chain of infection by applying the concept of cleaning prior to disinfection or sterilization and by following recommended steps in the logical and appropriate sequences. This strategy applies to hand hygiene, instrument re-processing, environmental asepsis, and use of personal protective barriers, and should be central to establishing ofce protocol and safety product selection. New single-use disposable items, as well as quicker and safer chemical and physical treatments, have become key components of an appropriate infection control program.

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recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16). Kabara JJ, Brady MB. Contamination of bar soaps under in-use conditions. J Environ Pathol Toxicol Oncol. 1984;5:114. Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7(2):3745. Checchi L, Montevecchi M, Moreschi A, Graziosi F, Taddei P, Violante FS. Efcacy of three face masks in preventing inhalation of airborne contaminants in dental practice. J Am Dent Assoc. 2005;136(7):877882. Bures S, Fishbain JT, Uyehara CF, Parker JM, Berg BW. Computer keyboards and faucet handles as reservoirs of nosocomial pathogens in the intensive care unit. Am J Infect Control. 2000;28(6):465471. Miller CH, Palenik CJ. Sterilization, disinfection, and asepsis in dentistry. In: Block SS, ed. Disinfection, Sterilization, and Preservation. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins. 2001:1053.

Author Profile
Nancy Andrews, RDH, BS Ms. Andrews is a nationally recognized speaker, author and educational consultant and has written more than 80 peer-reviewed articles. She received her B.S.D.H. from University of Southern California, where she was later a clinical instructor. Ms. Andrews practiced clinical Dental Hygiene for 20 years. She has consulted with individual and large dental facilities, dental laboratories and dental corporations on clinical safety and OSHA compliance. She has given seminars nationally and internationally on topics including Diseases and Infection Prevention, Biolms, and Dental Waterlines and also participated in the drafting of the OSAP Position Paper on Dental Unit Waterlines. Ms. Andrews is an active member of OSAP, ADHA, and CDHA. She can be reached at Nancyandrewsrdh.com.

References
1 Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contamination during dental procedures. J Am Dent Assoc. 1994;125(5):579584. Morbidity and Mortality Weekly Report. Recommendations and Reports. Guidelines for Infection Control in Dental Health-Care Settings 2003; 52(No.RR-17). Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7(2):3745. Lonnroth EC, Shahnavaz H. Adverse health reactions in skin, eyes, and respiratory tract among dental personnel in Sweden. Swed Dent J. 1998;22(12):3345. Kurita H, Kurashina K, Honda T. Nosocomial transmission of methicillin-resistant Staphylococcus aureus via the surfaces of the dental operatory. Br Dent J. 2006 Sep 9;201(5):297300. Redd JT, Baumbach J, Kohn W, Nainan O, Khristova M, Williams I. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. J Infect Dis. 2007;195(9):13111314. CDC. Recommended infection-control practices for dentistry, 1993. MMWR. 1993;42(No. RR-8). Girou E, Loyeau S, Legrand P, Oppein F, Brun-Buisson C. Efcacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. BMJ. 2002;325(7360):362. Kac G, Podglajen I, Gueneret M, Vaupre S, Bissery A, Meyer G. Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. J Hosp Infect. 2005 May;60(1):3239. Morbidity and Mortality Weekly Report. Recommendations and Reports. Guidelines for Infection Control in Dental Health-Care Settings 2003;52(RR-17). Luckey JB, Bareld RD, Eleazer PD. Bacterial count comparisons on examination gloves from freshly opened boxes versus nearly empty boxes and from examination gloves before treatment versus after dental dam isolation. J Endod. 2006;32(7):646648. www.osha.gov/SLTC/dentistry/index.html. Accessed 2007. Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. J Contemp Dent Pract. 2006;7(2):3745. CDC. Guideline for hand hygiene in health-care settings:

Disclaimer
The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

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Non-Educational Content
TotalCare, a division of Kerr, offers an extensive array of infection control products for the dental industry. TotalCare features the brand names Pinnacle and Metrex. Pinnacle products include barrier protection accessories and single-use disposables for the dental operatory. Metrex infection control products serve to protect staff and patients with products for surface disinfection, instrument sterilization and hand care. All TotalCare products are available from authorized dealers.
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Questions
1. The pathway of disease transmission is referred to as the _______________.
a. b. c. d. a. b. c. d. chain of affection chain of infection infection linkages All of the above.

11. An alcohol-based hand-rub is acceptable as the sole hand hygiene procedure _______________.
a. for non-surgical procedures if hands are visibly soiled b. for surgical procedures c. for non-surgical procedures if hands are not visibly soiled d. b and c.

21. Non-disposable metal air-water syringe tips _______________.

2. Disease transmission requires__________.

a susceptible host and entry portal a source of microbes a method of transmission and exposure All of the above.

a. are difcult and time-consuming to clean b. are required and there is no suitable substitute c. can be substituted by plastic single-use disposable air-water syringe tips d. a and c.

12. Handwashing after glove removal is important because ____________.

22. In considering surface cleaners, important factors include _______________.

3. Hand contact with contaminated surfaces is an example of _______________.

a. b. c. d. indirect transmission direct transmission contamination prevention a and b.

a. pathogens may have gained entry through defects in the gloves during the procedure b. ora may have multiplied in the warm, moist environment under the gloves c. hands will feel dry after removing gloves d. a and b. a. b. c. d. are required for all procedures are required for surgical procedures are required for instrument cleaning All of the above.

a. the ability of the product to serve as both a cleaner and disinfectant b. the TB kill time c. the ability of the solution to dry rapidly d. a and b.

13. Sterile surgical gloves _______________.

23. Compared to surface cleaning solutions, wipes_______________ .

a. use the least product, are quick to use and less likely to result in dripping of the product b. use more product to ensure better surface coverage c. use the same amount of product as solutions but are signicantly more effective at cleaning d. All of the above.

4. Transient ora is more commonly associated with healthcare-related infections than resident ora.
a. True. b. False.

14. Hand hygiene compliance is affected by _______________.

a. the perception that there is a low risk of cross-infection b. the perception that gloves are enough c. irritated and dry skin d. All of the above.

5. The routine use of personal barriers by DHCPs _______________.

a. is now standard practice b. is only required in high-risk situations c. has been very successful in reducing DHCP exposure to infections d. a and c.

24. The same wipe can be used for cleaning and disinfecting, without a fresh one being required.
a. True. b. False.

15. With respect to liquid and foam soaps dispensed from closed containers, _______________.

25. Enzymatic foam cleaners ____________.

a. speed up bacterial resistance b. speed up cleaning and debris removal c. should be sprayed on instruments only in the instrument processing area d. b and c.

6. Impermeable single-use environmental (surface) barriers _______________.

a. result in less time being spent on environmental asepsis b. result in more reliable asepsis c. provide a visual image for patients that communicates asepsis d. All of the above.

a. the soap dispenser containers can be topped-off b. they are more convenient than bar soaps and reduce the risk of contamination c. they do not contain emollients d. All of the above.

16. Foam-dispensed soaps offer superior coverage using the minimum amount of product.
a. True. b. False.

26. Pre-cleaning instruments with enzymatic foam prior to ultrasonic cleaning _______________.

7. Cultures of operatory surfaces have yielded organisms including methicillinresistant Staphylococcus aureus.
a. True. b. False.

17. Active ingredients used in antimicrobial soaps include _______________.

8. _______________ may interfere with thorough disinfection and sterilization.

a. b. c. d. The presence of visible debris The presence of invisible debris The presence of organic substances All of the above.

a. chloroxylenol, chlorhexidine gluconate, triclosan, povidone-iodine b. triglycerides, iodophones and chlorhexidine c. quaternary ammonium, hexachlorophene d. a and c.

a. increases the lifespan of ultrasonic solutions b. decreases the likelihood of corrosion of the ultrasonic bath c. increases the concentration of ultrasonic cleaning solution required d. All of the above.

27. Critical instruments that penetrate the mucosa _______________.

a. b. c. d. can be single-use disposable can be re-usable and heat-sensitive can be re-usable and heat-resistant a and c.

9. Instrument cleaning, the essential rst step in instrument processing can be carried out with _______________.
a. b. c. d. ultrasonic cleaners enzymatic solutions instrument washers All of the above.

18. Of the antimicrobials that can be included in soaps, ____________ is most commonly associated with allergic reactions and ___________ is contraindicated in pregnant women.
a. b. c. d.

povidone-iodine, hexachlorophene povidone-iodine, chloroxylenol chlorhexidine gluconate, quaternary ammonium None of the above.

28. Re-usable critical instruments must be cleaned and then heat-sterilized.

a. True. b. False.

19. Alcohol-based hand-rubs ___________ .

a. offer convenience b. do not require a sink c. are more cost-effective and less time-consuming than handwashing d. All of the above.

29. Semi-critical instruments, if heatsensitive, can be chemical-sterilized using glutaraldehyde.

a. True. b. False.

10. Hand scrubbing instruments _______________.

a. should only be performed wearing heavy-duty utility gloves b. can be performed wearing light surgical gloves c. is safer if the instruments have been pre-treated with an enzymatic cleaners or cleaned ultrasonically d. a and c.

20. Eyewear used for protection should be _______________ .

a. lightweight b. clear c. able to wrap-around the eyes to offer full protection d. All of the above.

30. For chemical-sterilization of instruments,_____________.

a. use of intermediate-level disinfectant is acceptable b. only high-level disinfectants can be used c. use of intermediate-level disinfectant would meet EPA guidelines d. All of the above. www.ineedce.com

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Breaking the Chain of Infection: Practical and Eective Infection Control

Name: Title: Address: City: Telephone: Home ( ) Specialty: E-mail: State: Oce ( ) ZIP:

ANSWER SHEET

Instructions to obtain dental continuing education credits: 1) Complete all information above. 2) Complete answer sheets in either pen or pencil. 3) Mark only one answer for each question. 4) Successful completion of this course will earn you 4 CEUs. 5) A blank duplicate answer sheet may be copied for additional course participants.

Mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology

P.O. Box 116, Chesterland, OH 44026 (216) 398-7822

Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. How would you rate the objectives and educational methods? 5 4 3 2 1 0 2. To what extent were the course objectives accomplished? 5 4 3 2 1 0 3. Please rate the course content. 5 4 3 2 1 0 4. Please rate the instructors eectiveness. 5 4 3 2 1 0 5. Was the overall administration of the course eective? 5 4 3 2 1 0 6. How do you rate the authors grasp of the topic? 5 4 3 2 1 0 7. Do you feel that the references were adequate? Yes No 8. Do you feel that the educational objectives were met? Yes No 9. If any of the continuing education questions were unclear or ambiguous, please list them. __________________________________________________ 10. Was there any subject matter you found confusing? Please describe. __________________________________________________ 11. Would you participate in a program similar to this one in the future on a dierent topic? Yes No 12. What additional continuing dental education topics would you like to see? __________________________________________________

For IMMEDIATE results, go to www.ineedce.com and click on the button ENTER Answers Online. Answer sheets can be faxed with credit card payment to (216) 255-6619, (440) 845-3447, or (216) 398-7922. Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MasterCard Visa AmEx Discover Acct. Number: _______________________________ Exp. Date: _____________________

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AGD Code 148

AUTHOR DISCLAIMER The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. INSTRUCTIONS Each question should have only one answer. Grading of this examination is done manually. Participants will receive verication in the mail within three to four weeks after taking an examination. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from Kerr TotalCare. No manufacturer or 3rd party has had any input into the development of course content. All content has been derived from the references listed and the opinions of clinicians. Please direct all questions pertaining to the ADTS or the administration of this course to the program director: P.O. Box 116, Chesterland, OH 44026, or e-mail aeagle@ineedce.com. PARTICIPANT FEEDBACK Questions can be e-mailed to aeagle@ineedce.com or faxed to (216) 255-6619, (440) 845-3447, or (216) 398-7922.

COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive verication of 4 CEUs. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. For current terms of acceptance, please contact the ADTS. DANB Approval indicates that a continuing education course appears to meet certain specications as described in the DANB Recertication Guidelines. DANB does not, however, endorse or recommend any particular continuing education course and is not responsible for the quality of any course content. Participants are urged to contact their state dental boards for continuing education requirements. The cost of this course is $59.00. EDUCATIONAL DISCLAIMER The information presented here is for educational purposes only. It may not be possible to present all information required to utilize or apply this knowledge to practice. It is therefore recommended that additional knowledge be sought before attempting a new procedure or incorporating a new technique or therapy. The opinions of ecacy or the perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the courses and do not necessarily reect those of the ADTS.

RECORD KEEPING The ADTS maintains records of your successful completion of any exam. Please contact our oces for a copy of your continuing education credits report. This report, which lists all credits earned to date, will be generated and mailed to you within ve business days of receipt of your request. CANCELLATION/REFUND POLICY Any participant who is not 100% satised with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing. COURSE EVALUATION We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included within the answer sheet. 2007 by the Academy of Dental Therapeutics and Stomatology

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