Infection Control Guidelines for Dental Clinics [compatibility mode]

KING KHALID HOSPITALINFECTION PREVENTION

ANDCONTROL MANUAL

DENTAL CLINIC ANDDENTAL LABORATORY

Dr. Nahla Abdel Kader, MD, PhD.Infection Control Consultant, MOHInfection Control CBAHI Surveyor

Infection Prevention Control DirectorKKH.

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DEFINITION

To provide guidelines on proper infection control practices in the Dental care setting.

COMMENTS

1. Patients and Dental Health Care Workers (DHCWs) may be exposed to a variety of infectious, viral, and bacterial agents in dental care settings.a. Routes of microbial transmission

i. Direct contact with a lesion, organisms, or potentially infectious secretions when performing intra oral procedures. E.g. practicing without wearing gloves.

ii. Indirect contact via contaminated instruments or disposable items. e.g. accidental percutaneous exposures from used needles.

iii. Aerosolization of microorganisms from patient’s blood or saliva while using devices. e.g. air water devices, dental hand pieces

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b. DHCWs and patients as modes of transmission during patients care:i. Patient to DHCW: passage of potentially infectious

microbes, can occur through breaks in the skin or through airborne exposure.

ii. DHCW to patient exposure: this transmission represents a microbial challenge, as a result of accidental bleeding into a patient’s mouth after an accidental sharps exposure or through respiratory droplets passed from DHCW to the patient.

iii. Patient to patient transmission: Can occur if instruments improperly reprocessed or improper hand hygiene

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Treat every patient and instrument as potentially infectious with a life treating

bloodborne pathogen.1. Hepatitis B Vaccination:

All susceptible DHCWs should obtain vaccination against hepatitis B. This vaccine is provided free of charge to at-risk employees by National Guard Health Affairs.

2. Standard Precautions:a. Practice standard precautions (hand hygiene, mask, gloves, goggles, face shield, gowns, or aprons). Refer to ICM – II-03b. Dispose sharps properly in puncture proof containers; do not bend or recap refer to ICM – IX-02.c. Use impervious-backed paper, aluminum foil, or plastic covers to protect items and surfaces (e.g., light handles of x-ray unit heads) that may become contaminated by blood or saliva during use and that are impossible to clean and disinfect. Between patients, remove these covers (while still gloved), discard them, and replace (after ungloving and washing hands) with clean materials.

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Care Workers.

3. Preprocedural mouth rinsing:Use it as routine for all patients to reduce the number of micro-organisms in the mouth before any procedure.

4. Unit dose concept:Dispense the sufficient amount of material to accomplish a particular procedure before patient contact.

5. Patient interview:Always obtain and determine the current health status of the patient; and always perform a through head, neck and oral examination (examination may indicate a need for medical referral for the patient (i.e. for diagnosis of active infection).

6. Management of needlestick injuries/ blood and body fluid exposure: Refer to ICM – VII-04 Management of Needlestick and Body Fluid Exposure

7. Work restriction for DHCWs:Refer to ICM – VI-04 Work Restriction for Infected Health Care Workers.

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8. Cleaning, Disinfection, and Sterilization:a. General principles

All dental and medical instruments can be classified into 3 categories reflecting their infection risk and how to process them:

i. Critical instruments penetrate soft tissue or bone and should be sterilized after each use. Examples include forceps, scalpels, bone chisels, scalers, and burs.

ii. Semicritical instruments do not penetrate soft tissues or bone but contact oral tissues and mucous membranes, and they should be sterilized; if sterilization is not feasible because heat will damage the instrument, then the item should receive a high-level disinfection. Examples include mirrors and amalgam condensers.

iii. Non critical instruments come into contact only with intact skin and may be processed with intermediate-level or low-level disinfection, or with detergent and water, depending on the nature of the surface and the degree and nature of the contamination. Examples include x-ray heads

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b. Dental instrumentsi. Wear heavy-duty (reusable utility) gloves when cleaning and

reprocessing to lessen the risk of injuries.ii. Cleaning:▪▪ Clean the instruments thoroughly to remove debris prior to

sterilization or disinfection.▪▪ Place the instruments into a container of water or disinfectant/

detergent as soon as possible after use to prevent drying of organic material and make cleaning easier.

▪▪ Scrub instruments thoroughly with soap and water or a detergent solution, or with a mechanical device such as an ultrasonic cleaner. Covered ultrasonic cleaners are recommended to increase efficiency of cleaning and to reduce handling of sharp instruments.

iii. Sterilization:▪▪ Sterilize all heat-stable critical and semicritical dental

instruments between uses by steam under pressure (autoclaving), dry heat, or chemical vapor, following manufacturer’s instructions for instruments and sterilizers

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▪▪ Package critical and semicritical instruments that will not be used immediately before sterilizing them.

▪▪Use a biological indicator (i.e., spore tests) at least weekly to verify proper functioning of sterilization cycles (see Appendix 1).

▪▪ Place a heat-sensitive chemical indicator (i.e., those that change color after exposure to heat) inside and in the center of either a load of unwrapped instruments or in each multiple instrument pack to confirm heat penetration to all instruments during each cycle.

▪▪ Follow manufacturers’ instructions for dental instruments and sterilization devices.

i. High-level disinfection:▪▪Use an U.S. Environmental Protection Agency (EPA)-registered

“sterilant/disinfectant” liquid chemical to achieve high-level disinfection of heat-sensitive semicritical dental instruments.

▪▪ Follow product manufacturer’s instructions regarding appropriate concentration and exposure time for the “sterilant/ disinfectant.”

▪▪ Check the chemical label for the “sterilant/disinfectant” designation. Liquid chemical agents that are rated less potent than the “sterilant/ disinfectant” category are not appropriate for reprocessing critical or semicritical dental instruments

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c. Dental unit and environmental surfacesi. After treatment of each patient and at the completion of daily work

activities, clean countertops and dental unit surfaces that may have become contaminated with patient material. Use paper towels, an appropriate cleaning agent, and water for cleaning.

ii. Cleaning environmental surface contaminated with patient material, with a chemical germicide registered with the U.S. EPA as a “hospital disinfectant” and labeled “tuberculocidal.” Examples of such intermediate-level disinfectants include phenolics, iodophors, and chlorine-containing compounds such as diluted household bleach (sodium hypochlorite).

iii. Prepare a fresh solution of 1:100 dilution sodium hypochlorite as an inexpensive intermediate-level disinfectant, add ¼ cup of household bleach to 1 gallon of tap water. This solution is active for only 24 hours and must be prepared fresh each day. Caution should be exercised because chlorine solutions can corrode metals such as aluminum.

iv. Clean floors, walls, and other surfaces with EPA-registered “hospital disinfectants” that are not labeled for “tuberculocidal” activity. An example of such a low-level disinfectant is a quaternary ammonium compound

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9. Use and Care of Handpieces, Anti-retraction valves, and other Intraoral Dental Devices attached to Air and Water Lines of Dental Units:

a. Heat-sterilize all high-speed dental handpieces, low-speed handpiece components used intraorally and reusable prophylaxis angles. Acceptable methods of sterilization include steam under pressure (autoclaving), dry heat, or heat/chemical vapor. It is NOT acceptable to reprocess high-speed dental handpieces, low-speed handpiece components used intraorally, and reusable prophylaxis angles by wiping or soaking these instruments in liquid chemical germicides.

b. Follow manufacturer’s instructions for cleaning, lubrication, and sterilization of handpieces and reusable prophylaxis angles to ensure effective sterilization and longevity of the instruments.

c. Install anti-retraction valves (one-way flow check valves) in dental unit water lines to prevent fluid aspiration and to reduce the risk of transfer of potentially infective material. Ensure routine maintenance of antiretraction valves.

d. Run high-speed handpieces to discharge water and air for a minimum of 20-30 seconds after use on each patient. If possible, use an enclosed container or high-velocity evacuation during discharge procedures to minimize spread of spray, spatter, and aerosols

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e. At the beginning of each clinic day, remove handpieces and allow water lines to run and discharge water for several minutes to reduce and overnight microbial accumulation.

f. Use sterile water or saline as a coolant/irrigator when surgical procedures involve cutting bone or tissues.

g. After treatment of each patient, clean and sterilize reusable intraoral instruments attached to, but removable from, the dental unit air or water lines (e.g., ultrasonic scaler tips and component parts and air/water syringe tips) in the same manner as handpieces. Follow manufacturers’ instructions for reprocessing.

h. Some dental instruments have components that are heat-sensitive or are permanently attached to dental unit water lines. Other instruments (e.g., handles or dental unit attachments of saliva ejectors, high-speed airevacuators, and air/water syringes) which do not enter the patient’s mouth can become contaminated with oral fluids during treatment procedures. Cover these instruments with impervious barriers that are changed after each use, or, if possible, clean and then disinfect with an EPA-registered “hospital disinfectant” that is labeled “tuberculocidal”.

i. Flush all water lines to all instruments thoroughly after the treatment of each patient, and at the beginning of each clinic day

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10. Water Quality:a. The Dental Unit Water System (DUWS) are contaminated

by organisms that colonize the system and water lines and soon after form biofilms inside the lumens of the water lines. Although the water coming into the system from an external source is of potable quality (<500 cfu/mL of bacteria and <1 coliforms), water coming out of the units may be contaminated to 1 million cfu/mL.

b. This contamination occurs because dental unit water line factors (e.g., system design, flow rates, materials) promote bacterial growth and development of Biofilm.

i. Successful engineering and manufacturing of these and other options for improving the ability to deliver treatment water with 200 cfu/mL or less of unfiltered output from water lines and continue to provide DHCWs with multiple choices for exerting better control over the quality of source water used in patient care. These choices are as follows:

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ii. An alternate water supply that bypasses community water systems and DUWS by providing sterile or distilled water directly into water line attachments (i.e., separate reservoir) combined with chemical treatment.

iii. Filtration involving in-line filters to remove bacteria immediately before dental unit water enters instrument attachment.

iv. Chemical disinfection involving periodic flushing of lines with a disinfectant followed by appropriate rinsing of lines with water or a continuous-release chemical disinfection system.

v. Thermal inactivation of facility water at a centralized source.

vi. Reverse osmosis or ozonation using units designed for either single-chair or entire practice water lines.

vii. Ultraviolet irradiation of water before entrance into individual unit water lines

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11. Single-Use Disposable Instruments:Use single-use disposable instruments (e.g., prophylaxis angles; prophylaxis cups and brushes; tips for high-speed air evacuators, saliva ejectors, and air/ water syringes) for one patient only and discard after use.

12. Handling of Biopsy Specimens:a. Place each biopsy specimen in a sturdy container with a secure

lid to prevent leaking during transport.b. Avoid contaminating the outside of the specimen container. If

the outside is visibly contaminated, clean and disinfect it, or place it in an impervious bag.

13. Disposal of Infectious Waste Materials:a. Pour blood, suctioned fluids, or other liquid waste into a drain

connected to a sanitary sewer system.b. Place solid waste contaminated with blood or other body fluids

in sealed, sturdy impervious bags that are leak-proof refer to ICM – IX-02 Infectious Waste Management.

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14. Practices for the Dental Laboratory:a. Separate the receiving area from the production area. Clean

and disinfect countertops and work surfaces daily.b. Clean and disinfect laboratory materials and other items

that have been used in the mouth (e.g., impressions, bite registrations, fixed and removable prostheses, orthodontic appliances) before manipulating them in the laboratory. After manipulation, clean and disinfect these items again before placing them in the patient’s mouth (see Table 1).

c. Use a chemical germicide registered with the EPA as “hospital disinfectant” and “tuberculocidal” (i.e., an intermediate-level disinfectant) to disinfect laboratory materials.

d. Disinfect all incoming cases as they are received. Sterilize or disinfect containers after each use. Discard packing materials to avoid cross contamination

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e. Production area:i. Wear a clean uniform or laboratory coat, a face mask,

protective eyewear, and disposable gloves.ii. Clean debris from work surfaces and equipment, and disinfect

daily.iii. Separate instruments, attachments, and materials to be used

with new prostheses/appliances from those to be used with prostheses/ appliances that have already been inserted in the mouth.

iv. Wash and autoclave ragwheels after each case.v. Disinfect brushes and other equipment at least daily.vi. Dispense a small amount of pumice in small disposable

containers for individual use on each case and discard the excess. A 1:20 dilution of sodium hypochlorite can be used as a mixing medium for pumice. Add 3 parts green soap to the disinfectant solution to keep the pumice suspended.

f. Disinfect each outgoing case before it is returned to the dental clinic.

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15. Dental Radiology Asepsis:a. Multiple opportunities for cross-contamination of equipment and

environmental surfaces exist when taking and developing dental radiographs.

i. Gloves should be worn when taking radiographs and handling contaminated film packets. Other PPE (e.g., mask, protective eyewear, protective clothing) is required when spatter or splashing of blood or other potentially infectious materials is anticipated.

ii. Even where there is no generation of splash or spatter, it is suggested to wear a mask when taking radiographs. Because of the close proximity to the oral cavity during the procedure, respiratory infections can be transmitted to DHCWs.

iii. After exposure of dental radiographs, care must be taken when handling the contaminated films.

b. If protective covers are used over films during exposure, the following steps are performed:i. While wearing gloves, remove and discard the covers without contaminating the film.ii. Remove gloves and perform hand hygiene.iii. Process the films

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c. If protective covers are not used over films during exposure, the following steps are performed:i. While wearing gloves, place the contaminated films into a container.

ii. Remove gloves and perform hand hygiene.iii. Don a fresh pair of gloves and transport the container to the

darkroom.iv. Carefully open the film packet and drop the films on a clean

surface.v. Discard the contaminated film packet wrappers.

vi. Remove gloves and perform hand hygiene.vii. Process the films. Surface cleaning and disinfection procedures

for radiography equipment are the same as in the dental operatory.d. Using impermeable disposable surface barriers is encouraged,

especially on surfaces that are difficult to clean and disinfect (e.g., x-ray control panels), and can be considered a timesaving procedure.

e. Lead aprons and thyroid shields should be cleaned and disinfected if they become contaminated

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