The American Dental Institute for Continuing Education

Infection Control
925

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
Christine Wisnom, CDA, RN, BSN

Christine Wisnom is a nurse educator at the Baltimore College of Dental Surgery, where she conducts research in both the Departments of Oral Medicine and the Department of Biological Science. Chris also acts as an Infection Control 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 and

equipment that require sterilization and/or disinfection

Understand when personal protective equipment must be

surfaces, water, or air. Other Dental Health Care Providers (DHCPs) include laboratory technicians (in-office and commercial), students and trainees, contractual personnel, and other persons not directly involved in patient care who are also potentially exposed to infectious agents (e.g., administrative, clerical, housekeeping, maintenance, or volunteer personnel). Current recommendations by the Centers for Disease Control and Prevention (CDC) are designed to prevent or reduce the potential for crosstransmission 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, the recommended infection-control practices are applicable to all settings in which dental treatment is provided. The current CDC Guidelines for Infection Control in the Dental Health 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. This program presents an overview of these recommendations and regulations. The Evolution from Universal Precautions to Standard Precautions In 1993, the CDC published the last complete set of infection control recommendations for dental health care workers, which stated "Because all infected patients cannot be identified by medical history, physical examination, or laboratory tests, CDC recommends that blood and body fluid precautions be used consistently for all patients. This extension of blood and
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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, 112,000 registered dental hygienists, 218,000 dental assistants, and 53,000 dental laboratory technicians provide dental care to patients. During the provision of care, they are often occupationally exposed to infectious materials including: body substances, contaminated supplies, equipment, environmental

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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 DHCPs from Universal Precautions to Standard Precautions. Their explanation, in combination with the California Code of Regulations (CCR-100.5) Division 10, Title 16, defines Standard Precautions as "a set of combined precautions that include the major components of universal precautions (designed to reduce the risk of transmission of blood borne pathogens) and body substance isolation (designed to reduce the risk of transmission of pathogens from moist body substances). Similar to universal precautions, standard precautions are used for care of all patients regardless of their diagnoses 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 the transmission 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 infectious material in dentistry and should be handled appropriately. Other potentially infectious materials, in the laboratory setting, include HIV-containing tissue or cell cultures, organ cultures and blood or other tissues from experimental animals. In addition, 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 to minimize occupational exposures, procedures for reporting, evaluating, counseling and treating DHCPs who suffer occupational exposures. The manual must also contain protocols for instrument processing, sterilizer monitoring, operatory cleanliness, personal protective equipment (PPE), waterline management, handling and disposal of biohazard waste and contaminated sharps, educational programs and Hepatitis B vaccination or declination for employees. These policies 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 be conspicuously posted in each dental office.4
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Personal Protective Equipment (PPE) During the provision of dental care, DHCPs primarily utilize gloves, surgical masks, eyewear with side shields, face shields and protective clothing (e.g., gowns and jackets). Face protection can be achieved with either a surgical facemask in combination with either chin length face shields or protective eyewear with side shields, whenever there is the potential for splashing with blood or OPIM. The mask must be changed after each patient and during treatment if moist, torn or contaminated. Following patient care, PPE should be removed prior to leaving the clinical area. Reusable PPE (e.g., clinician or patient protective eyewear and face shields) should be cleaned with soap and water, and when visibly soiled, disinfected between patients, according to the manufacturer's directions. This recommendation is new. Previously it was a requirement that the eyewear for the operator and the patient be cleaned and disinfected regardless of any visible contamination. The new recommendation is much more practical and saves time and wear on eyewear. The use of gloves, surgical masks, protective eyewear and protective clothing in specified circumstances to reduce the risk of exposures to bloodborne pathogens is also mandated by the Bloodborne Pathogen Standard. Often, operators choose to wear scrub attire or uniforms for patient care. These items are neither intended to protect against a hazard nor are considered to be PPE; therefore, a lab coat must be worn over street clothing, work clothes, uniforms and scrub attire. The bloodborne pathogens standard also requires sleeves to be long enough to protect the forearms when the gown is worn as PPE (i.e., when spatter and spray of blood, saliva, or OPIM to the forearms is anticipated). Gowns must be changed daily or changed if they become visibly soiled or moist. 4 Reusable gowns must be laundered in accordance with California's Bloodborne Pathogen Standard. Glove Integrity Additional PPE should be worn whenever a surgical procedure is being performed. Reports indicate that different glove materials (e.g., latex, vinyl and nitrile), under different conditions, have various leakage rates and duration of usability. The frequency of perforations in surgeon's gloves used during outpatient oral surgical procedures has been determined to range from 6% to 16%. Because DHCPs are frequently unaware of minute tears in gloves that occur during use, hand washing is critical to prevent cross-transmission of pathogens from operators to patients. These studies determined that gloves developed defects in 30 minutes to 3 hours, depending on the type of glove and procedure;

Infection Control however, an optimal time for changing gloves during dental procedures has not been determined. 1 If the integrity of a glove is compromised, it should be changed as soon as possible. Washing latex gloves with plain soap, chlorhexidine or alcohol can lead to the occurrence of glove micropunctures and subsequent hand contamination. This condition is known as wicking and can allow penetration of liquids through undetected 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 dried before gloving, because hands still wet with an alcohol-based hand hygiene product can increase the risk of glove perforation, rendering the gloves an ineffective barrier.1 Sterile Surgeons Gloves and Double-Gloving During Oral Surgical Procedures Surgical procedures are defined as "the incision, excision, or reflection 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 requiring elevation of mucoperiosteal flap, removal of bone or section of tooth, and suturing if needed". The CDC recommends wearing sterile gloves for surgical procedures, despite the fact that clinical studies have detected no difference in postoperative infection rates after routine tooth extractions when surgeons wore either sterile or nonsterile gloves. This recommendation is supported by research which indicates that sterile gloves minimize transmission of microorganisms from the hands of surgical DHCP to patients and prevent contamination of the hands 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 sterile coolants/irrigants should be used and delivered using a sterile delivery system. 1 Double Gloving Increasing operator protection and decreasing disease transmission has always been the goal of an infection control program. One method that has been examined to reduce occupational exposure to blood and OPIM is the use of two pairs of gloves or "double gloving". Studies of providers wearing two pairs of gloves during oral surgery and hygiene procedures demonstrated a lower frequency of inner glove perforation and visible blood on the hands when double gloves were worn, but no data exist regarding a decrease in disease transmission from double gloving. Nevertheless, based on these studies, double gloving might provide additional protection from occupational blood contact. Operators reported that double gloving did not reduce either their manual dexterity or tactile sensitivity. Other products such as glove liners and orthopedic surgical gloves may also be helpful in reducing exposure to blood. Hand Hygiene Proper hand hygiene is the foundation of any infection control program, and is the number one method of preventing disease transmission. Operators who wear gloves should be aware that wearing gloves does not eliminate the need for handwashing. Hand hygiene should be performed immediately before donning gloves. Further, because bacteria grow quickly under gloves, hand hygiene should be performed immediately after removing gloves. The hands should also be dried thoroughly before gloving, which decreases bacterial growth. Gloves often have minute defects or holes which cannot be detected while gloves often tear or become contaminated during glove removal. These factors increase the probability of contamination of the operator's hands to microorganisms from patients; and contamination of the patient's operative site from the operator. If the integrity of the skin is compromised by weeping dermatitis or exudative lesions, the operator should refrain from all direct patient care and from handling patient care equipment until the condition resolves. Table 1 describes the proper hand hygiene recommendations. Illustration 2 lists special considerations for hand hygiene and glove use. Instrument Sterilization and Disinfection Comprehension of sterilization and disinfection protocols is critical in preventing disease transmission. Sterilization is the complete destruction of all microbial life, including spores; while disinfection has various levels of efficacy, based upon the product and use. Basic techniques for sterilization, disinfection, barrier protection, personal protective equipment, vaccinations and numerous other protocols were updated in the 2003 CDC Guidelines for Infection Control in Dentistry. In this document, items requiring sterilization were identified by category: 1. Critical items: Penetrate soft tissue and/or bone and require heat sterilization. Examples of critical items include surgical instruments, scalers, surgical burs. 2. Semi-critical items: Touch only mucous membranes and should also be heat sterilized. Examples of semi-critical items include amalgam condensers, impression trays, dental
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handpieces. 3. Non-critical items & equipment: Contact only intact skin and require only cleaning and low-level disinfection and include items 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 an autoclave (steam under pressure), dry heat or chemical vapor after each use. Items such as the dental handpiece, low-speed handpiece components used intra-orally, and other dental unit attachments such as reusable air/water syringe tips and ultrasonic scaler tips should be heat-sterilized between patients. For heat sensitive critical and semi-critical items, an FDA approved chemical sterilant/disinfectant should be used. Proper instrument storage is also a critical factor in maintaining sterility of instruments. Instruments that are not to be 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 to prevent any contamination. Items designated as "single use only", such as prophylaxis angles, prophylaxis cups and brushes, tips for the high-speed evacuators, saliva ejectors, air/water tips, etc. shall be used one time only and discarded after each patient use. 1,3 Sterilization Protocols Steam Sterilizers Heat-tolerant dental instruments are usually sterilized by steam under pressure (autoclaving), dry heat, or unsaturated chemical vapor. All sterilization should be performed by using FDA approved equipment and supplies. Manufacturer's recommendations for instrument sterilization should always be followed. 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 to dry inside the sterilizer chamber before removing and handling. Packs should not be touched until they are cool and dry because hot packs act as wicks, absorbing moisture, and hence, bacteria from hands. The ability of equipment to reach physical parameters (e.g., time, temperature, and pressure) required to achieve sterilization should be monitored by mechanical, chemical, and biological indicators. Sterilizers vary in their types of indicators and their ability to provide readings on the mechanical or physical parameters of the sterilization process.
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Consult with the sterilizer manufacturer regarding selection and use of indicators. Dry-Heat Sterilizers Dry heat is used primarily to sterilize instruments and equipment that could be damaged by moist heat (e.g., burs and certain orthodontic instruments). But while dry heat has the 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-type

sterilizer. Heating coils in the bottom or sides of the unit cause hot air to rise inside the chamber through natural convection. The forced-air type of sterilizer is also known as a rapid heat-transfer sterilizer. Heated air is circulated throughout the chamber at a high velocity, permitting more rapid transfer of energy from the air to the instruments, thereby reducing the time needed for sterilization.1 Flash Sterilization Flash Sterilization (Sterilization of Unwrapped Instruments) is used for sterilizing instruments for immediate use. It should not be used as the primary office sterilization choice. The time required for unwrapped sterilization cycles will vary with the type of sterilizer and the type of item (i.e., porous or nonporous) 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 used extensively in larger health-care facilities. Its primary advantage is the ability to sterilize heat- and moisture-sensitive patient-care items with minimal rusting and dulling of surgical edges. However, it requires 10-48 hours for sterilization and poses 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 privatepractice 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

Infection Control sterilize small metallic instruments (e.g., endodontic files). However, because there are no methods to determine appropriate times and/or temperatures, the FDA has determined that a risk of cross-contamination exists with these devices because of their potential failure to sterilize dental instruments. The FDA now requires cessation of their commercial distribution unless the manufacturer files a premarket approval application. Dental health care providers who use bead sterilizers assume the risk of using a dental device the FDA has deemed neither safe nor effective, and will be held responsible for using potentially non-sterilized instruments on patients. Sterilizer Monitoring Sterilizers can be monitoring by various methods, typically mechanical, chemical and biological processors. These processors evaluate both the sterilizing conditions and the procedure's effectiveness. Offices should regularly evaluate the mechanical aspects of their sterilizers by assessing the time cycle, temperature, and pressure by observing the gauges or displays on the sterilizer. Some tabletop sterilizers have recording devices that print out these parameters. However, they should be closely monitored because while a correct reading does not ensure sterilization, incorrect readings can be the first indication of a problem. Chemical indicators Environmental Infection Control Chemical indicators use chemicals to assess physical conditions (e.g., time and temperature) during the sterilization process. Although chemical indicators do not prove sterilization has been achieved, they detect certain equipment malfunctions. External indicators applied to the outside of a package (e.g., chemical indicator tape or special markings) change color rapidly when a specific parameter (temperature) is reached, and they verify that the package has been through the sterilization process. Internal chemical indicators should be used inside each package to ensure that the sterilizing agent has penetrated the packaging material and actually reached the instruments inside. A single-parameter internal chemical indicator provides information regarding only one sterilization parameter (e.g., time or temperature). Multiparameter internal chemical indicators are designed to react 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 been met. Steam autoclaves, commonly used in dentistry, can use a multi-parameter internal indicator which is only available for their use. It should be noted that our patients are not only at risk for contracting bloodborne pathogens from breaches of sterilizing protocols, 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 vaccinated against the acquisition of Hepatitis B virus (HBV), many of our patients are not. Blood contains the greatest proportion of HBV infectious particles of all body fluids, and is the primary vector for its transmission in the health-care setting. Although percutaneous (puncture) injuries are among the most efficient modes of HBV transmission, research demonstrates that hepatitis B outbreaks have occurred among patients treated in hemodialysis 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 the health care setting may have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces. This fact reinforces the importance of
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Because chemical indicator test results are received when the sterilization cycle is complete, they can provide an early indication of a problem and where in the process the problem might exist. If the indicators demonstrate that the sterilization cycle was inadequate, the instruments in that load should not be used for patient care. Biological indicators Biological indicators (BIs, spore tests) are the most accepted method for evaluating the sterilization process. They work by determining if the highly resistant microorganisms (e.g., Geobacillus or Bacillus species) have been destroyed, rather than merely testing the physical and chemical conditions necessary for sterilization. Because these spores are more resistant and present in greater numbers than the other contaminants found on instruments and equipment, an inactivated BI indicates other potential pathogens in the load have been inactivated.2 The CDC recommend that a spore test be used for each sterilizer in the office at least weekly. This can be achieved by sending the test to a commercial lab or testing with an in-office system. The California Code of Regulations requires that these results be kept in the office for a period of at least one year, and be available upon inspection if requested. 3 A combination of biological indicators and chemical indicators should be used by offices to closely monitor the effectiveness of their sterilizing systems.

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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 combination of both. Barrier protection of surfaces and equipment can prevent contamination of clinical contact surfaces, but is particularly effective for those that are difficult to clean. Barrier protection also prevents discoloration, drying and cracking of materials, rusting and corrosion. Barriers include clear plastic wrap, bags, sheets, tubing, and plastic-backed paper or other materials impervious to moisture. Because such coverings can become contaminated, they should be removed and discarded between patients, while DHCPs are still gloved. Clinical surfaces should be examined after removing the barrier. If the surface has become contaminated, it should be disinfected prior to placement of the next barrier. If no contamination 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 placed prior to the next patient after the contaminated gloves have been removed and the hands washed. If barriers are not used, surfaces should be cleaned and disinfected between patients by using a Cal-EPA-registered hospital disinfectant with an HIV, HBV claim (i.e., low-level disinfectant) 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 for clinical contact surfaces, dental unit surfaces, and countertops at the end of daily work activities and are required if surfaces have become contaminated since their last cleaning. To facilitate daily cleaning, treatment areas should be kept free of unnecessary equipment and supplies. Chemical- and punctureresistant utility gloves offer more protection than patient examination gloves when using hazardous chemicals. Housekeeping Surfaces No evidence exists that a nosocomial infection has been transmitted to a patient from a contaminated housekeeping surfaces (e.g., floors, walls, and sinks). These surfaces should be wiped or scrubbed regularly with a detergent and water or a Cal-EPA approved hospital disinfectant/detergent, depending on the nature of the surface and the type and degree of contamination. Schedules and methods vary according to the
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area and type of contamination. Visible contamination should be cleaned promptly. If contamination is noted in a patient care area and uncertainty exists regarding the nature of the contaminant (blood or OPIM), a Ca-EPA registered, hospital grade disinfectant/detergent should be used. Chemical- and puncture-resistant utility gloves offer more protection than patient 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 health care setting because it is less porous than carpeting and easier to clean. In addition, carpet cannot be reliably disinfected, especially after spills of blood and body substances. Studies have documented the presence of diverse microbial populations, primarily bacteria and fungi, in carpeting. Further, when selecting products for dental chair covers, cloth poses 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 flooring and fabric-upholstered furnishings in these areas should be avoided.2 Infection Control in the Dental Laboratory Infections in the dental laboratory pass from the patient to laboratory and back from the laboratory to the patient, often times infecting the DHCP in the process. Cross-transmissions of pathogens can occur when a contaminated prosthetic device, orthodontic appliance, impression tray with impressed material, or other items are removed from the patient's mouth and taken immediately into the lab for adjustment or fabrication. The bioburden from the mouth then contaminates the countertops, grinding and pouring equipment and any prosthetic equipment with which it comes in contact. The contamination remains on these surfaces often contaminating the next case that is brought into the lab. The opposite also can 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 bite registrations) are potential sources for cross-contamination and 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 an intermediate-level disinfectant after removal from mouth and

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 before returning it to the patient and placing it intra-orally. An important fact to remember is that the appliance should be rinsed thoroughly prior to intraoral placement, because acrylic materials are porous and may retain some of the chemicals, causing a chemical burn to occur. Effective communication and coordination between the commercial laboratory and the dental practice will also ensure that appropriate cleaning and disinfection procedures are performed 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 dental laboratory, written information regarding the type of disinfectant used on the case should be provided. Appliances and prostheses delivered to the patient should be free of contamination. Communication between the commercial laboratory and the dental practice is also important. When the case is returned to the office, the laboratory should also provide information regarding the disinfection method used. If such documentation is not provided, the dental office is responsible 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 the production area. Transfer of oral microorganisms into and onto impressions has been documented; therefore fresh pumice and a disinfected, sterilized or new rag wheel should be used for each patient.4 Movement of these organisms onto 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 contaminated appliances, prostheses, or other material, they should be heatsterilized, disinfected between patients, or discarded (i.e., disposable items should be used). Heat-tolerant items used in the 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, prosthetic device, or appliance but frequently become contaminated and cannot withstand heat-sterilization (e.g., articulators, case pans, or lathes) should be cleaned and disinfected between patients in accordance with the manufacturer's instructions. When working in the laboratory, splash shields and equipment guards should be used to protect the operator from contamination resulting from splatters and splashes. Waste from the laboratory and the dental practice clinical areas should 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 adapting policies and procedures that are implemented on a routine basis for their water delivery system. Staff should be trained regarding water quality, biofilm formation, water treatment methods, and appropriate maintenance. Water treatment and monitoring products require strict adherence to maintenance protocols, and noncompliance with treatment regimens has been associated with persistence of microbial contamination in treated systems. Mechanical inserts, in-line filters and antiretraction valves also prevent the flow of impurities in the lines, and should be used. At the beginning of each day, the dental unit water lines should be purged with air and/or flushed with water for at least 2 minutes prior to attaching the handpieces, scalers and other devices. The dental unit lines must also be flushed between each patient for a minimum of 20 seconds. Methods for maintaining self-contained units should 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's recommendations. 2,3 Management of Sharps Avoidance of occupational exposure from injuries with contaminated sharps is the ultimate goal of an infection control program. Numerous mechanisms exist to promote this goal 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. Used needles should never be recapped via a 2-handed needle recapping method, or any other technique, that involves directing the point of a needle toward any part of the body. Using either a one-handed scoop technique or a mechanical device designed for holding the needle cap when recapping needles (e.g., between multiple injections and before removing from 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, scalpel blades, and other sharp items should be placed in appropriate puncture-resistant containers located as close as feasible to the area 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 should be evaluated at least annually, or as they become available on the market. 2,3,5 Conclusion This program presented an overview of the "2003 CDC Recommendations for Infection Control in Dentistry" as well as the California Code of Regulations, "Minimum Standards for Infection Control'. It reviewed standard precautions, sterilization protocols and sterilizer monitoring, clinical and laboratory disinfection, PPE, specialized PPE and equipment for surgical procedures, hand hygiene, sharps management, documentation and posting requirements, dental unit water line management and numerous other items designed to reduce or prevent the transmission of bloodborne and airborne pathogens in the dental health care setting. It is hoped that adaptation of these recommendations will protect DHCPs and their patients from the acquisition of infectious diseases, while providing "State of the Art" dentistry. Acknowledgements The author would like to express her deep appreciation of the secretarial contributions that Mrs. Kathy Wisnom made to this article.

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Table 1: CDC Recommendations for Hand Hygiene in the Dental Health Care Setting
Method Routine wash Antiseptic wash Antiseptic hand rub Surgical asepsis Agent Water & soap Water & anti-microbial soap Alcohol-based hadn rub Duration 15 seconds 15 seconds Rub until dry Indicator Before & after each patient, etc. Before & after each patient, etc. Not to be used if visibly soiled

Water & anti-microbial soap or 2 - 6 minutes Before donning sterile gloves/surgery water & non-anti. Soap followed by alcohol rub

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 1. 2. 3. 4. 5. 6. Use hand lotions to prevent skin dryness associated with handwashing. Consider the compatibility of lotion and antiseptic products and the effect of petroleum or other oil emollients on the integrity of gloves during product selection and glove use. Keep fingernails short with smooth, filed edges to allow thorough cleaning and prevent glove tears. 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). Use of artificial fingernails is usually not recommended. Do not wear hand or nail jewelry if it makes donning gloves more difficult or compromises 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 blood and/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.RR8). 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.

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Questions
Infection Control 1. The 2003, CDC Guidelines for Infection Control in Dentistry have evolved from: a. Standard Precautions to Universal Precautions b. Universal Precautions to Standard Precautions c. Body fluid precautions to Standard Precautions 2. The CDC recommends the use of Standard Precautions 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 disease c. Any patient who receives clinical care regardless of their reported infectious disease status 3. Standard Precautions should be used when operators 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 in each office. Once compiled it must be updated a. Once compiled it is not necessary to update it b. It must be updated every 6 months c. It must be updated at least annually 5. Personal Protective Equipment (gloves, eyewear with side shields, mask, clothing clover) must be worn: a. For surgical procedures b. 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 torn c. After each patient and if it becomes wet or torn during a procedure 7. Recommendations for asepsis for clinical eyewear include: a. Cleaning the eyewear for the patient, and face protection for the operator should be done after each procedure, but disinfection is only necessary when visible contamination is present b. Cleaning and disinfecting the eyewear for the patient, and face protection for the operator, after each procedure regardless of the contamination c. No new recommendations have been made regarding asepsis for clinical eyewear 8. Wearing scrub attire, work clothes or uniforms alone is considered satisfactory protection when proving clinical care to patients a. True b. False c. Unsure 9. The Bloodborne Pathogen Standard states that the length of the sleeves on a lab coat be: a. Short b. Long c. 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 lunch b. Between patients c. Before leaving the clinical area

Questions
Infection Control 12. The amount of time the hands should be washed for routine patient procedures is: a. 15 seconds b. 30 seconds c. 2 minutes 13. The amount of time the hand should be washed for surgical procedures is: a. 5-10 minutes b. 2-6 minutes c. 3-5 minutes 14. A condition known as "Wicking" occurs because gloves are _________. This causes the gloves to become a ___________ barrier. a. Worn improperly, imperfect b. Torn, poor c. Washed, ineffective 15. Instruments requiring sterilization are divided into_______ categories. They are: a. Two, surgical and non-surgical b. Three, Critical, Semi-Critical and Non-critical c. Three, Semi-critical and surgical 16. ASpecial considerations for hand hygiene and glove use include: 1. Not wearing artificial fingernails 2. Filing natural nails to prevent sharp edges and punctures of gloves 3. Applying hand cream that contains petroleum each time the hands are washed a. 1 & 3 b. 2 & 3 c. 1 & 2 17. The CDC classifies a dental handpiece as a: a. Critical item b. Semi-critical item c. Non-critical item a. Large practices (hospitals), dental handpiece b. Small practices (private offices), impression tray c. Moderate practice, dental syringe 18. The CDC requires that a dental handpiece be __________________after each patient use? a. Disinfected b. Cleaned and wiped with a disinfectant c. Heat sterilized 19. Metal impression trays used for patient care must be ________________after each use? a. Heat sterilized b. Rinsed and Cleaned c. Disinfected 20. Following sterilization, instruments may be placed, unwrapped in a mobile cabinet until used. a. True b. False c. Unsure 21. When may sterilized instruments be removed from their wraps or packages and placed on a tray, covered with a fluid impervious barrier, for patient care? a. The day of use b. Two days before they are used c. Any time before they are used 22. Bead Sterilizers were previously used for sterilizing small instruments, such as ______________. They are now considered______________________. a. Surgical forceps, appropriate b. Endodontic files, inappropriate c. Prosthodontic impression trays, appropriate 23. Ethylene Oxide Gas is used primarily by _________________practices. It does not sterilize a ______________________ appropriately due to the small lumen.

Questions
Infection Control 24. Biological Indicators are the most______________method for monitoring sterilizers, because they determine if ____________________have been inactivated a. Accepted, viruses b. Accepted, bacteria c. Accepted, spores 25. Biological indicators should be used at least __________________ for sterilizers, and the results kept for at least ____________. a. Weekly, one year b. Monthly, 6 months c. Bi-weekly, 8 months 26. Hepatitis B Virus can live in _________________ at __________________ on______________ for ____________ a. Saliva, high temperatures, dental surfaces, one month b. Blood, room temperature, environmental surfaces, one week c. Body fluids, room temperatures, environmental surfaces, two weeks 27. Clinical asepsis for environment surfaces can be achieved via: a. Barrier protection b. Surface disinfection c. Combination of barrier protection and surface disinfection 28. A low-level disinfection product will not inactivate_______________ on an environmental surface a. Tuberculosis b. 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 surface c. Be removed and replaced after disinfecting the surface 30. When designing and office or redecorating an existing office, practitioners should select a. Cloth covers for chairs and hard surface flooring b. Smooth covers for chairs and carpeting for floors c. Smooth covers for chairs and hard surface flooring

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Infection Control - 925 2 CE Credits

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