Mohamad Hamad Infection Control in Dental

Infection Control

In The

Dental Clinic

2010

Version No. 1

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LIST OF CONTENTSLIST OF CONTENTS PAGE NO. PAGE NO. 1. INTRODUCTION 4

2. PURPOSE 4

3. TARGET AUDIENCE 4

4. RESPONSIBILITY 4

5. POLICY 4

6. TRANSMISSION OF PATHOGENS 4

7. DEFINITIONS 5

8. ABBREVIATIONS 6

9. PROCEDURES 7 INFECTION CONTROL INSIDE THE CLINIC 9.1 BEFORE RECEIVING THE PATIENT 7

A. PREPARATION OF THE DENTIST AND DENTAL NURSE 7 B. PREPARATION OF THE CLINIC BEFORE TREATMENT 9 C. PREPARATION OF THE PATIENT 12 9.2 DURING THE TREATMENT 12 9.3 PREPARATION OF THE CLINIC AFTER TREATMENT 13 9.4 FINAL CLINIC CHECK 15

10. WATER MONITORING 15 A. FLUSHING WATERLINES 15

B. WATERLINE SAMPLING 15 C. WATER SUPPLY 15

11. INFECTION CONTROL INSIDE THE CSSD 16 11.1 SINGLE USE ITEMS 16

11.2 STERILIZATION AND DISINFECTION 16 11.3 SINGLE USE ITEMS 17

11.4 STERILIZERS 1711.5 INSTRUMENT PROCESSING AREA 1711.6 STERILIZATION AREA 1811.7 STERILIZATION MONITORING 18

12. DENTAL UNIT WATERLINES, BIO-FILM AND WATER QUALITY 18

13. DENTAL HAND PIECES AND OTHER DEVICES ATTACHED TOAIR AND WATERLINES 18

14. ANTI-RETRACTION VALVES TESTING 19

15. STORAGE AREA IN CLINICS 19

16. INFECTION CONTROL IN THE DENTAL RADIOLOGY DEPARTMENTS 20

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17. IMMUNIZATION AND VACCINATION AGAINST HBV 20HEPATITIS B VIRUSHIVSTANDARD PRECAUTIONS

18. BLOOD AND BODY FLUID EXPOSURES AND POST EXPOSURE PROTOCOL 22

19. WASTE DISPOSAL AND HOUSEKEEPING 22

20. HANDLING OF BIOPSY SPECIMENS AND EXTRACTED TEETH 22

21. MISTAKES AND CORRECTIONS 23

22. EDUCATION AND TRAINING 23

23. CONCLUSION 24

24. REFERENCES 24

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Infection Control In Dental Clinic

1. INTRODUCTION:Infection control is one of the most vital and significant areas in dentistry. The protocols and procedures in this manual relate to infection control in Dental Health Care settings, they follow the guidelines of the CDC (Centre for Disease Control) for infection control in the dental health care settings.

Dental Health Care Professionals (DHCP) include dentists, dental nurses, oral hygienists, oral radiologist, dental radiographers, dental laboratory technicians, dental trainees, administrative staff, house keeping, bio-medical and maintenance staff, all of whom may be exposed to a range of infectious materials as well as contaminated supplies, air or water.

The guidelines are designed to prevent or reduce cross infection between DHCP to patient, patient to DHCP and from patient to patient. The manual sets out step by step procedures to be followed inside the clinic before, during and after treatment.Procedures are also included for infection control in CSSD, Dental Radiology Department, House Keeping and waste disposal guidelines are also detailed.

Infections:Dental patients and DHCP can be exposed to pathogenic micro-organisms and other viruses and bacteria. These include cytomegalovirus (CMV), HBV, HCV, herpes simplex virus types 1 and 2, HIV, Mycobacterium tuberculosis, staphylococci, streptococci.

2. PURPOSE: This manual consolidates recommendations for preventing and controlling infectious diseases and managing

personnel health and safety concerns related to infection control in dental settings in order to maintain high quality of infection control standards at all times.

3. TARGET AUDIENCE This is applies to all involved services of dental in the Health care facility hospital and all clinical staff should

familiarize themselves with the policy.

4. RESPONSIBILITY:It is the responsibility of each staff member of the dental services to deal and to ensure that this policy, procedures, and guidelines are implemented and followed meticulously.

5. POLICY:The key to minimize the spread of infection is to decrease opportunities for cross contamination, especially in clinic’s room where direct care is given. To be used in conjunction with Health care facility manual of Infection Control

This policy should be implemented and followed by all dental clinic staff in order to provide a safe working environment and to reduce\prevent the risk of cross- infection among patients and DHCP

6. HOW ARE PATHOGENS TRANSMITTED?In the dental settings these organisms can be transmitted through:1. Direct contact with blood\body fluids 2. Indirect contact with contaminated instruments, equipment or surfaces.3. Contact with mucosa of the eyes, nose, or mouth with droplets/splatter generated from an infected person

by coughing, sneezing or talking. 4. Inhalation of airborne micro-organisms that can remain suspended in the air for long periods.

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7. DEFINITION OF COMMON TERMS:

Alcohol- based hand rub: An alcohol containing preparation made for reducing the number of viable micro organisms on the hands.

Antimicrobial soap: A detergent containing an antiseptic agent

Antiseptic: Germicide used on skin to inhibit or destroy micro organisms (e.g. alcohols, chlorine, chlorhexidine, iodine).

Aerosols: Invisible contaminants suspended in the air. They are produced by the misuse of high speed suction, ultrasonic scalars, use of prophy jets, and high speed cooled handpieces.

Colony-forming unit (CFU): The minimum number (i.e., tens of millions) of separable cells on the surface of or in semisolid agar medium that give rise to a visible colony of progeny. CFUs can consist of pairs, chains, clusters, or as single cells and are often expressed as colony-forming units per milliliter (CFUs/mL).

Decontamination: Use of chemical or physical means to remove, inactivate or destroy pathogens on a surface or item.

Dental treatment water: Nonsterile water used during dental treatment, including irrigation of nonsurgical operative sites and cooling of high-speed rotary and ultrasonic instruments.

Disinfectant: A chemical agent used on floors, walls or sinks to destroy most microorganisms.

Disinfection: Destruction of microorganisms by physical or chemical means. Disinfection is less lethal than sterilization because it destroys the majority of pathogenic microorganisms but not necessarily all microbial forms like bacterial spores.

Droplet nuclei: Particles <5 µm in diameter formed by dehydration of airborne droplets containing microorganisms that can remain suspended in the air for long periods of time

Droplets: Small particles of moisture (spatter) generated when a person coughs or sneezes or when water is converted to a fine aerosol mist by a handpiece. These droplets can contain infectious microorganisms.

Germicide: An agent that destroys microorganisms, especially pathogenic organisms.

Hand Hygiene: General term that applies to hand washing, antiseptic hand wash, antiseptic hand rub, or surgical antisepsis.

Health-care Associated Infection (Nosocomial): Any infection associated with a medical or surgical intervention.

Hepatitis B immune globulin (HBIG): Product used for prophylaxis against HBV infection. HBIG is prepared from plasma containing high titers of hepatitis B surface antibody (anti-HBs) and provides protection for 3--6 mos.

Hepatitis B surface antigen (HBsAg): Serologic marker on the surface of HBV detected in high levels during acute or chronic hepatitis. The body normally produces antibodies to surface antigen as a normal immune response to infection.

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Hepatitis B surface antibody (anti-HBs): Protective antibody against HBsAg. Presence in the blood can indicate past infection with, and immunity to, HBV, or immune response from hepatitis B vaccine.

High-level disinfection: Disinfection process that inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores. FDA further defines a high-level disinfectant as a sterilant used for a shorter contact time.

Occupational Exposure: Skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material that can result in the daily work of a staff member.

Sterile: Free from all living microorganisms

Sterilization: Use of a physical or chemical procedure to destroy all microorganisms including substantial numbers of resistant bacterial spores.

Surfactants: Surface active agents that reduce surface tension and help cleaning by loosening, emulsifying, and holding soil in suspension, to be more readily rinsed away.

Ultrasonic cleaner: Device that removes debris by a process called cavitation.

Vaccine: Product that induces immunity, therefore protecting the body from disease. Vaccines can be given by needle injections, by mouth, or by aerosol spray

Washer- disinfector: Automatic unit that cleans and thermally disinfects instruments, by using a high-temperature cycle.

8. ABBREVIATIONSCDC : Centers for Disease Control and PreventionCSSD : Central Sterilization and Supply DepartmentDHCP : Dental Health Care ProfessionalER : Emergency RoomGP : General PracticeHIV : Human immunodeficiency virusHBV : Hepatitis B virusHVE : High volume evacuationOPG : OrthopantomographOPIM : Other potentially infectious materialsPPE : Personal protective equipmentICC : Infection Control Committee

ICM : Infection Control Manual

9. PROCEDURES Infection Control inside the Clinic 9.1 Before Receiving the Patient: A. Preparation of the Dentist and Dental Nurse A.1 Hand Hygiene and Hand Care

Hand hygiene: (e.g., hand washing, hand antisepsis, or surgical hand antisepsis). The most important factor in the prevention of infection is frequent and proper hand washing. The complete practice of this activity substantially reduces potential pathogens on the hands and is considered the single most critical measure one can take for reducing the risk of transmitting organisms between patients and DHCP.

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Hand hygiene should be performed:-Before and after treating each patient After touching inanimate contaminated objects with bare hands. When visibly soiled Before glove placement and after glove removal. Before leaving the clinic or dental laboratory. Before re-gloving after removing torn, cut or punctured gloves.

Special Hand Hygiene consideration Use hand lotions to prevent skin dryness. Consider compatibility of hand care products with gloves (e.g. mineral oils and petroleum

base may cause early glove failure. Finger nails are to be kept short – no artificial nails. No jewelry to be worn (simple wedding bands only).

Method Agent PurposeDuration (minimum)

Indication

Routine hand-wash

Water & non antimicrobial soap (e.g. plain soap)

Remove soil and transientmicroorganisms

15 seconds Before and after treating each patient (e.g., before glove placement and after glove removal). After barehanded touching of inanimate objects likely to be contaminated by blood or saliva. Before leaving the dental operatory or the dental laboratory. When visibly soiled. Before regloving after removing gloves that are torn, cut, or punctured.

Antiseptic hand-wash

Water & antimicrobial soap (e.g. chlorhexidine, iodine and iodophors,chloroxylenol, triclosan)

Remove or destroytransient microorganisms& reduce resident flora

15 seconds Same as above

Antiseptic hand rub

Alcohol-based hand rub Remove or destroytransient microorganismsand reduce resident flora

Rub hands until the agent is dry (almost 20 second)

Same as above

Surgical antisepsis

Water and antimicrobial soap (e.g. chlorhexidine, iodine and iodophors, chloroxylenol, triclosan).Water and non-antimicrobial soap (e.g. plain soap) followed by an alcohol-based surgical hand-scrub product with persistent activity

Remove or destroytransient microorganismsand reduce resident flora(persistent effect)

3 minutesFollow manufacturerinstructions forsurgical hand-scrubproduct withpersistent activity

Before donning sterile surgeon’s gloves for surgical procedures

Remember the following point: Pathogenic organisms have been found on or around bar soap during and after use. Use of liquid soap

with hands-free dispensing controls is preferable.

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Time reported as effective in removing most transient flora from the skin. For most procedures, a vigorous rubbing together of all surfaces of premoistened lathered hands and fingers for >15 seconds, followed by rinsing under a stream of cool or tepid water is recommended. Hands should always be dried thoroughly before donning gloves.

Alcohol-based hand rubs should contain 61%–95% ethanol or isopropanol and should not be used in the presence of visible soil or organic material. If using an alcohol-based hand rub, apply adequate amount to palm of one hand and rub hands together, covering all surfaces of the hands and fingers, until hands are dry. Follow manufacturer’s recommendations regarding the volume of product to use. If hands feel dry after rubbing them together for 10–15 seconds, an insufficient volume of product likely was applied.

The drying effect of alcohol can be reduced or eliminated by adding 1%–3% glycerol or other skin-conditioning agents.

After application of alcohol-based surgical hand-scrub product with persistent activity as recommended, allow hands and forearms to dry thoroughly and immediately don sterile surgeon’s gloves. Follow manufacturer instructions.

Before beginning surgical hand scrub, remove all arm jewelry and any hand jewelry that may make

A. 2. Personal Protective Equipment (PPE)PPE: Gloves, Gowns/Lab Coats, Masks, Protective Eyewear or Face-shield Use of handpieces, ultrasonic scalers, and air-water syringes create visible spray that contains

droplets of water, saliva, blood, micro-organisms and other debris. This splatter travels a short distance and settles out quickly, landing on the floor, nearby operator surfaces, DHCP, or the patient.

PPE is worn to protect the skin and mucous membranes of the eyes, nose, and mouth of the DHCP from blood or other body fluids.

The use of Personal protective clothing (PPE) is part of the routine dental treatment and should be worn when considered appropriate.

When you are selecting PPE, consider three key points:1. Anticipated exposure2. Durability and appropriateness of PPE3. Fit

PPE are placed in the following order as per CDC guidelines:1. Gown2. Mask3. Goggles/Face-shield 4. Gloves

PPE are removed in the following order:1. Gloves2. Goggles/Face-shield3. Gown4. MaskWash Hands

Re-usable PPE (e.g. face-shields and goggles) should be cleaned with soap and water when contaminated, and when visibly soiled disinfect with an intermediate- level disinfectant according to manufacturer’s directions.

Gloves and Masks must be removed before leaving the clinic. Gowns need not be removed if leaving the clinic to retrieve item/s from stock area, taking a

patient to another area or if an emergency occurs requiring the help of other staff members.

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Gowns are not to be worn outside the clinical areas (zoned).

A. 2.1 Protective Clothing- Gowns/Lab Coats/Jackets Non-sterile gowns (single use item), lab coats/jackets should be worn (unless a sterile

gown - single use item - is required) to protect your clothes and skin from contamination during procedures and patient care activities where it is anticipated blood or OPIM are likely to be generated.

Change protective clothing if it becomes visibly soiled or penetrated by blood (as soon as feasible).

No Gowns are to be worn outside the clinical area.

A.2.2 Masks, Goggles and Face-shields Wear a surgical mask and eye protection such as, goggles or face-shield during all

procedures Change mask s between patients or during patient treatment if the mask become wet Protective eye wear should be used by both HCW & patient whenever it is indicated. Goggles, face/shield should be cleaned with soap and water between patients.

A. 2.3 Gloves

All DHCP should wear clean non sterile gloves whenever

Double Gloving:The effectiveness of wearing two pairs of gloves in preventing disease transmission has not been confirmed. Studies have demonstrated a lower frequency of inner glove perforation and visible blood on the surgeons hand when double gloves are worn.

B. Preparation of the Clinic before Treatment:Protective barriers must be used to prevent cross contamination.Use barriers on any surfaces that may be faced with cross contamination. Use surface barriers to protect clinical contact surfaces, particularly those that are difficult to clean.

These barriers need to be changed between every patient regardless of how minor the treatment.• Working Services• The dental chair, the backs of the clinicians and assistants chair• The overhead light, the UV light• Hand pieces, triplex syringes• Touch control panel.• X-ray units, LED monitors• Bracket Table Handle

B.1 Working surfaces• Working surfaces are to be kept free from clutter. Only essential items used for treatment of

patients should be visible.• Restorative or exam trays placed on the bracket table. Making sure the tray is only opened in

front of the patient, to ensure patient confidence of sterility. This also includes the un-wrapping of a large quantity of trays or any other autoclaved instruments when setting up your clinic.

• Bottled materials or plastic instruments that cannot be autoclaved should be sprayed and wiped and sprayed again with a disinfectant before placing back into drawers.

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• Anything on the counters or mobile carts not required for the procedure should be removed to avoid contamination from aerosols that will be produced during treatment, which can stay suspended in the air up to 60 minutes or more.

B.2 Dental Chair:• All surfaces of the dental chair not covered with barriers should be wiped down with the

disinfectant wipes/intermediate-level disinfectant.• If barriers are used replace with a new headrest cover for each new patient.

B.3 Overhead Light• The over head light handles are covered with adhesive barrier film or plastic sleeves. If

barrier film is not available, then ensure that the handles are wiped with disinfectant wipes/intermediate-level disinfectant between each patient. After each patient, remove the plastic barrier and place new ones.

B.4 Control Panel• Touched surfaces should be covered with adhesive barrier film (e.g.: control panel and

bracket handle). If barrier film is not available, then ensure that these surfaces are wiped with disinfectant wipes/intermediate-level disinfectant between each patient. After each patient, remove the barrier film, place new ones.

B.5 Handpieces A sterilized handpiece is placed for each new patient, cover with film or plastic sleeve until

ready for use.

B.6 Air-water syringe• A new tip is placed for each patient.• Air-water syringes are covered with adhesive barrier film or a plastic sleeve, which is

changed after each patient.

B.7 Suction Tips and Saliva Ejectors A new disposable suction tip and saliva ejector is placed for each new patient. Plastic barrier cover is placed on suction tip and saliva ejector. Suction run cleaning and disinfecting solution through HVE and saliva ejector hoses (1

litre is recommended). All containers with blood or saliva (e.g., suctioned fluids) can be carefully

poured down a utility sink, drain, or toilet. Appropriate PPE (e.g., gloves, gown, mask, and protective eyewear) should be worn when performing this task. No evidence exists that bloodborne diseases have been transmitted from contact with raw or treated sewage.

B.8 Tables, Cabinets and Hard Surfaces:In the clinic, surfaces can become contaminated during patient care through direct spatter or DHCP’s contaminated gloved hands. These surfaces can act as reservoirs of microbial contamination.• All surfaces should be wiped at the start and end of the shift with disinfectant

wipes/intermediate-level disinfectant• If surfaces become contaminated with blood, the following technique should be followed:

a) Spray/wipe visible stains with disinfectant wipes/intermediate-level disinfectantb) Wipe the surface with disposable towel/gauze

c) Spray/wipe again with disinfectant wipes/intermediate-level disinfectant d) Leave to air dry.

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B.9 Dental Impression TraysDental impressions become contaminated with saliva, blood and oral bacteria. Less commonly they may become contaminated with respiratory pathogens, which are coughed up into the mouth from the lungs. Foe example, impressions taken on a patient previously diagnosed with tuberculosis were found to harbor the causative agent Mycobacterium Tuberculosis.Dental Impression

All impression must be cleaned and disinfected before being sent to the laboratory. Wear gloves, mask and eye goggles\visor. All impression should be rinsed thoroughly under running water to remove all

visible signs of contamination. Use a disinfectant that is compatible with impression material such as Virkon.

Immerse the impression in the disinfectant as per disinfectant contact time (10 minutes).avoid spray disinfectants, which are less affective and may create an inhalation risk.

Rinse off the disinfectant with water.

Impression Tray Commercially manufactured plastic impression tray is for single patient use only. Don not clean or reprocess then for subsequent reuse. After single use they should be disposed of in to clinical waste bag by the practice

or the dental laboratory.

Metal Impression Tray Metal Impression Trays are reusable and should be thoroughly cleaned Immerse in an ultrasonic bath or processed in a thermal washer disinfector and then

steam sterilized

B.10 Sterile ProceduresRoutine steps should be followed for all treatment area to maintain clinical asepsis.Shortcut should never be an option for asepsis in dentistry.The dental assistant must insure that infectious diseases are not spread from patient to patient, HCW to patient, patient to HCW.Therefore, a sterile procedure is very essential and important throughout all dental procedures. So when it is indicated it should be performed accordingly and effectively, by maintaining good hand washing before and after completion of the procedure taking in consideration the proper use of all required devices of PPE through out the procedure.

B.11 List of DisinfectantsDisinfectants Purpose\Use Contact Time Precautions MSDS

Ethyl Alcohol 70% (Ethanol)

Isopropyl Alcohol (Isopropanol)

For skin disinfection, infant incubators, x-ray equipment and thermometers

Effective and rapidly acting disinfectants (2 minutes) but they evaporate fast.

Not recommended for instrument disinfection.

Available

Chlorhexidine 4 % handwash

For skin disinfection(Hand scrub)

Invasive Procedures Theatre:-Hands should be washed for 3 minutes

Not recommended for disinfecting instrument and environmental surfaces.

Available

Hydrogen Peroxide Concentrated

"Perasafe"

It is for endoscopes and medical instrument sterilant solution

10 Minutes Have Sporicidal activity and active at 10 minutes contact time.

Available

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Hydrogen Peroxide Surfactant "Virkon"

For cleaning and Disinfecting of surfaces

10 Minutes High level surface disinfectant.Not recommended for instrument disinfection

Available

Hand Sanitizer "Purell"

Hand rub 20 -30 Seconds 62% alcoholNot recommended for instrument disinfection

Available

Hypochlorite And Sodium

Dichloroisocyanurate (N.A.D.C.)

Equipment and environment

disinfectant infant incubators and infant

feeding utensils.

30 Minutes (Never mix acids with hypochlorite since it will release chlorine gas) (not to be used for metallic surfaces and instruments),

Available

Ortho Phthal Aldhyde (OPA)

General disinfectant of instruments.

10 minutes as HLD Have no Sporicidal activity (not suitable for

cold sterilization)Use in accordance with

the manufacture’s recommendations.

Available

Detergent Solution"Biotek"

For ordinary cleaning of surfaces

5 Minutes Will remove 80% of the microorganisms

C. Preparation of the Patient:All patients are considered as potentially infectious. Therefore, you must always use Standard Precautions with all patients.

• Place a disposable, absorbent bib on the patient’s chest.• Open a new, sterile tray for each patient after the patient has been seated in the dental chair.• All surfaces are covered with adhesive film barrier or plastic cover. As mentioned previously.

9.2 During the Treatment Both the Dental Nurse and the Dentist should wear PPE when exposure to blood or may be anticipated

during treatment. Use of rubber dam: Reduction in microorganisms escaping from patients’ mouths in aerosols or spatter

can approach 100% with proper use of rubber dam, depending on the type and the site of the intraoral procedure.

Use of HVE (high-velocity evacuation): Minimizes dissemination of droplets, spatter and aerosols. If during the course of treatment other materials or instruments are required, remove gloves, or use a

pair of non-contaminated tweezers for retrieval of the item.

9.3 Preparation of the Clinic after Treatment:

A. Appointment: The Dental Nurse removes the patients bib and ensures the bracket table is pushed out of the way. The Dental Nurse removes gloves, washes hands and then gives the patient the next appointment,

(this may be done by the dentist). The Dental Nurse logs the case on the statistics sheet. The Dental Nurse then begins cleaning and preparing the clinic for the next patient by following

the procedures listed below.

B. Removal and disinfection of used instruments: Wear new clean gloves. Remove used burs from the handpieces before disassembling the handpieces from the dental unit.

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This prevents injuries with contaminated burs. Run high speed for 20-30 seconds, oil and run handpiece again before removing from the unit. Remove all instruments and place them on a tray. Remove all barriers from dental unit. If required spray any instruments with disinfectant/enzyme solution before taking to CSSD. Place instruments in covered container/tray and take to the Soiled Instrument Room (if available)

otherwise to CSSD.

C. Waste removal Dispose of used suction tips, saliva ejectors and air-water syringe tips. Place all contaminated waste in the yellow\red bags and all non contaminated waste Black\white

bag Place all needles and sharp objects in a puncture resistant sharps container, which should be filled

either up to the line or only two thirds capacity All rubbish bins should be filled to ¾ capacity only Flush through the waterlines of handpieces, ultrasonic scalers, and air-water syringes for 20-30

seconds. Flush suction through with water after every patient to clean the inside of the suction of residual

micro-organisms.

D. Wiping Down of all Surfaces. All surfaces of the dental unit that are not barrier protected must be wiped down with disinfectant

wipes/intermediate-level disinfectant including spittoon, handpiece cradle etc. If using spray disinfectant masks must be worn.

Work from clean to dirtyThis is a basic principle of infection control. In this instance it refers to touching clean body sites or surfaces before you touch dirty or heavily contaminated areas. Limit opportunities for “touch contamination” protect yourself, others, and environmental surfaces.

"Dirty to Dirty-Clean to Clean",That is, contaminated surfaces only touch other contaminated surfaces: your bare hand, which is clean, touches only clean areas e.g. inside the other glove.

Housekeeping SurfacesCDC has divided noncritical surfaces in dental offices into clinical contact and housekeeping surfaces. Clinical contact surfaces are surfaces that might be touched frequently with gloved hands during patient care or that might become contaminated with blood or other potentially infectious material and subsequently contact instruments, hands, gloves, or devices (e.g., light handles, switches, dental X-ray equipment, chair-side computers). Barrier protective coverings (e.g., clear plastic wraps) can be used for these surfaces, particularly those that are difficult to clean (e.g., light handles, chair switches). The coverings should be changed when visibly soiled or damaged and routinely (e.g., between patients). Protected surfaces should be disinfected at the end of each day or if contamination is evident. If not barrier-protected, these surfaces should be disinfected between patients with an intermediate-disinfectant (i.e., EPA-registered hospital disinfectant with tuberculocidal claim) or low-level disinfectant (i.e., EPA-registered hospital disinfectant with an HBV and HIV label claim).

Most housekeeping surfaces need to be cleaned only with a detergent and water or an EPA-registered hospital disinfectant, depending of the nature of the surface and the type and degree of contamination. When housekeeping surfaces are visibly contaminated by blood or body substances,

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however, prompt removal and surface disinfection is a sound infection control practice and required by the Occupational Safety and Health Administration (OSHA)

Clean housekeeping surfaces with a detergent and water or an EPA or CE registered hospital disinfectant /detergent on a routine basis depending on the nature of the surface and type and degree of contamination and as appropriate, based on the location in the facility, and when visibly soiled.

Clean mops and cloths after use and allow drying before reuse or using single use disposable mop heads or cloths.

Prepare fresh cleaning or EPA or CE registered disinfectant solutions daily and as instructed by the manufacturer.

Clean walls blinds and window curtains in patients care areas when they are visibly dusty or soiled.

Note:For more details refer to housekeeping manual

E. Delivery of Used Instruments to CSSD: Remove your gloves, wash hands, may use one gloved hand to carry tray to dispensary area but

not necessary. Deliver the tray/boxes to the designated dirty area. During transport to the dispensary area contaminated instruments should be carried in an enclosed

container.

Final check and leaving for the day.You have seen and discharged your last patient and you are ready to go home.

9.4 Final clinic check: Handpieces, expel water for a minimum 30 seconds, remove burs, remove handpieces and transport

to CSSD for sterilization. Dental chair and stools have been sprayed with disinfectant spray-wipe-spray and leave technique. Mobile dental cart, check for loose bottle tops, replenish stock if required and for general neatness. PPE are all in place. Suction run cleaning and disinfecting solution through HVE and saliva ejector hoses (1 litre is

recommended). Spittoon pour cleaning and disinfecting solution through system (1 litre is recommended) Amalgam clean trap thoroughly. Chair is in the raised position. Units chair and power units are switched off. Clinic check for overall neatness and cleanliness of the clinic from top to bottom. Once the Dentist and Dental Nurse are finished for the day, after infection control practices have

been completed, the Dentist and Dental Nurse may change from clinic attire into street clothes.

10. WATER MONITORING A. Flushing waterlines

Flush through the waterlines at the beginning of the clinic day to reduce the microbial load. The recommendation is to discharge water and air for a minimum of 20-30 seconds through high

/low speed handpieces, ultrasonic scalers after each patient. This procedure is intended to physically flush out patient material that might have entered the turbine,

air or waterlines.

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B. Waterline Sampling Water samples will be collected randomly from the waterlines in clinics on a quarterly basis. Bacteriology and environmental flora analysis of water samples is carried out by health care facility

Pathology Laboratory. Samples will be collected by an infection control member or their designee. Print clearly details of clinic and clinic number on the label. Remove lid of sterile container, run high speed handpiece with water on into the container until

approximately ¼ full. Replace the lid on the container and place in the appropriate collection bag. The recommendation by EPA is <500 CFU/ml

C. Water Supply Water supply is tested every two weeks for bacterial and chemical analysis. Every two weeks water supply is tested for hardness, total dissolved salts (TDS), alkalinity (pH), iron

content and conductivity.

11. INFECTION CONTROL INSIDE THE CSSDSterilization and disinfection of all instruments is done in a sterile and efficient environment in the department of CSSD. This department plays a vital role in the daily functioning of the Dental Clinic. The infection control and sterilization steps that take place are of paramount importance in the management and prevention of infection control in the whole Dental clinic.The contaminated instruments go through several steps and cycles in order to complete disinfection and sterilization. The CSSD is designed to allow the distribution of instruments during each step to take place in a specific isolated area i.e.: delivery of contaminated instruments is isolated from the area of packing and sterilization, and from the area of delivery of clean instruments.All CSSD staff should wear the appropriate PPE relevant to the different areas they are working in.

11.1 General PracticeSoiled instruments are brought to the soiled instruments room (If available otherwise to CSSD). Soiled instruments are deposited in the soiled instrument trolleys ready for collection. Every hour throughout the day Porters will pick up and transfer the instrument containers by trolley to the CSSD for processing.

11.2 Sterilization and Disinfection I. Patient-Care Items:

Scientific articles and increased publicity about the potential for transmitting infectious agents in dentistry have focused attention on dental instruments as possible agents for pathogen transmission.

The American Dental Association recommends that surgical and other instruments that normally penetrate soft tissue or bone (e.g., extraction forceps, scalpel blades, bone chisels, periodontal scalers, and surgical burs) be classified as critical devices that should be sterilized after each use or discarded. Instruments not intended to penetrate oral soft tissues or bone (e.g., amalgam condensers, and air/water syringes) but that could contact oral tissues are classified as semicritical, but sterilization after each use is recommended if the instruments are heat-tolerant. If a semicritical item is heat–sensitive, it should, at a minimum, be processed with high-level disinfection. Handpieces can be contaminated internally with patient material and should be heat sterilized after each patient. Handpieces that cannot be heat sterilized should not be used. Methods of sterilization that can be used for critical or semicritical dental instruments and materials that are heat-stable include steam under pressure (autoclave), chemical (Cidex or Perasafe ) vapor, and dry heat (e.g., 320ºF for 2 hours)

Patient-care items (dental instruments, devices, and equipment) are categorized as listed:-

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1. Critical Instruments: These are instruments used to penetrate soft tissue or bone, or have the greatest risk of transmitting infection. These should be sterilized by heat.

2. Semi-critical Instruments:These instruments touch mucous membranes or non-intact skin, and have a lower risk of transmitting micro-organism. As most instruments in dentistry are heat tolerant, they should also be sterilized by using heat.

3. Non-critical instruments:These instruments pose the least risk of transmission of infection, contacting only intact skin. These items may be immersed in a liquid chemical sterilant thus achieving high-level disinfection.

If cleaning is difficult or will damage the instrument, then use of disposable barrier protection may be considered as an alternative

Patient-Care ItemsCategory Definition Dental Instrument/ItemCritical Penetrates soft tissue, contacts bone, enters into

or contacts the bloodstream or other normally sterile tissue

Surgical instruments, periodontal scalers, scalpels, bone chisels, surgical dental burs

Semi-critical Contacts mucous membranes or nonintact skin; will not penetrate soft tissue, contact bone, enter into or contact the bloodstream or other normally sterile tissue

Dental mouth mirrors, amalgam condensers, re-useable dental impression trays, dental handpieces

Non-critical Contacts intact skin Radiograph head/cone, blood pressure cuff, facebow, pulse oximeter

11.3 Single Use ItemsA single-use device, also called a disposable device, is designed to be used on one patient and then discarded, not reprocessed for use on another patient (e.g., cleaned, disinfected, or sterilized) Single-use devices in dentistry are usually not heat-tolerant and cannot be reliably cleaned. Examples include syringe needles, prophylaxis cups and brushes, and plastic orthodontic brackets. Certain items (e.g. prophylaxis angles, saliva ejectors, high-volume evacuator tips, and air/water syringe tips) are commonly available in a disposable form and should be disposed of appropriately after each use. Single-use devices and items (e.g., cotton rolls, gauze, and irrigating syringes) for use during oral surgical procedures should be sterile at the time of use. The whole organization follows the same policy, which includes Dental Services and all the satellite

facilities. Single use means the item/device is to be used on an individual patient during a single procedure and

then disposed of. Items designed for ‘single use’ must NOT be re-processed. Single use packaging may be labeled as any of the examples listed below:-

Disposable For single use only this symbol may replace any wording and indicates ‘Do Not Re-use’

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11.4 Sterilizers

Sterilizers vary greatly in the types of indicators and their ability to provide readings on the mechanical or physical parameters of the sterilization process. (e.g. time, temperature and pressure). Consult the sterilizer manufacturer regarding the use and selection of indicators.

Steam sterilization is most widely used for wrapped and unwrapped critical and semi-critical instruments that are not sensitive to moisture or heat.

Follow the manufacturer’s instructions for proper use of sterilizers. Packages should be allowed to dry in the sterilizers before being removed.

11.5 Instrument Processing Area: In CSSD all processing areas are separate. The central area is divided into four sections:

• Receiving area• Cleaning and decontamination area• Sterilization area• Storage area

11.6 Sterilization AreaHeat tolerant dental instruments are sterilized by steam under pressureItems to be sterilized should be arranged to permit free circulation ofPlace batch monitoring device on basket with instrumentsPacks should be allowed to dry inside the sterilizer.Packs should not be touched until they are cool and dry as hot packs act as wicks, absorbing moisture

hence bacteria from hands.All items are placed in dust cover plastic bags.Instruments are then distributed to appropriate dispensing areas.

11.7 Sterilization Monitoring:Use chemical and biological monitors according to the manufacturer’s instructions to validate the effectiveness of the sterilization procedures.For more details refer to CSSD manual

12. DENTAL UNIT WATERLINES, BIO-FILM AND WATER QUALITYIn most Dental practice settings water used for dental treatment comes from the municipal water supply directly into the dental UNIT thin plastic, tubing carries water from the dental unit to the high-speed hand-piece, air water syringe, ultrasonic scaler, and subsequently to the operating field in the patient mouth. The inside surface of this dental water lines can become colonized with variety of microorganisms, including bacteria fungi and protozoa that live inside a slim layer that protects and feeds them. This phenomenon, called a bio-film allows micro-organisms to survive in the dental water lines, and raises concerns about possible health effect of exposure to dental unit water.

Recommendations Use water that meets standards for drinking water. Consult with the dental unit manufacturer for appropriate methods and equipment to maintain the

recommended quality of dental water. Discharge water and air for a minimum of 20-30 seconds after each patient from any device connected to

the dental water system that enters the patient's mouth (e.g., hand pieces, ultrasonic scalers, air/water syringes).

Maintaining and monitoring water quality

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Consult the Dental Manufacturing unit or other agencies for appropriate methods and equipment to maintain the recommended quality of Dental Water (< 500 Colony Forming Units)

Do not use Sodium hypochlorite to routinely clean dental water lines. Monitor dental water quality using commercial self contained test kits or commercial water testing

laboratories. If bacterial counts exceed 500 CFU/ml, re-evaluate the technique, re-treat the dental unit water, and retest

the dental unit immediately before the next scheduled treatment interval. Continue to monitor until acceptable water quality is achieved.

Sterile Surgical irrigations To help guard against post-surgical infections use only sterile water or sterile saline as a coolant/irrigant

for surgical procedures that present an increased opportunity for microorganisms to gain entry into the bloodstream, bone or tissue under the skin.

13. DENTAL HAND PIECES AND OTHER DEVICES ATTACHED TO AIR AND WATERLINESBecause they retract and retain patients materials, dental hand pieces and other devices used in the mouth and connected to the dental units air lines and water lines must be heat sterilize between patients. Components of these devices are prone to contamination from contact with gloves and droplet spatter should be protected with a new surface barrier for each patient and cleaned and disinfected when visibly contaminated. Clean and heat-sterilize hand pieces and other intraoral instruments that can be removed from the air and

waterlines of dental units between patients. Follow the manufacturer's instructions for cleaning, lubrication and sterilization of hand pieces and other

intraoral instruments that can be removed from the air and waterlines of dental units. Do not advise patients to close their lips tightly around the tip of the saliva ejector to evacuate oral fluids. Before removing the hand piece from the hose after treatment, with the bur still in the chuck, briefly run

the water/air system to flush water lines and airlines. Remove the bur from the hand piece, wipe visible debris from the outer surfaces of the hand piece, and

disconnect the hand piece from the hose. If the hand piece requires lubrication before heat-processing, use a hand piece cleaner recommended by

the manufacturer that will both remove the initial debris and lubricate the hand piece.- If the hand piece does not require lubrication before processing, use a cleaner that does not contain a

lubricant.- Follow the manufacturer's instructions for each type of hand piece used.- Do not over lubricate hand pieces.

Reattach the hand piece o a hose and operate the drive air system to blow excess lubricant from the rotating parts.

Failure to perform this step before heat sterilization can lead to excess lubricant accumulation in the working assembly and gumming in the rotating assemblies during the heat cycle.

14. ANTI-RETRACTION VALVE TESTING Each time the handpiece turbine is stopped while the bur is still in the patient's mouth, almost 1 ml of microbe-laden oral fluids may be aspirated into the average dental unit water line by the retraction valve present in the dental unit. This fluid may contain an average in excess of 54,000 microorganisms per milliliter, including both facultative and obligate anaerobic bacteria of medium to high virulence. Other infectious agents including hepatitis, herpes, influenza, and other upper respiratory viruses may also be present. This germ-laden water may then be sprayed into the mouth of the next patient, possibly initiating an oral or upper respiratory tract infection. Sterilizing the handpiece between appointments, although of great significance in the prevention of disease transmission, will not totally eliminate the problem discussed here as almost 95% of the oral fluid aspirated into the dental unit went past the handpiece and into the handpiece cooling water line.

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Complete elimination of the retraction valve in the unit is the most effective means of solving this problem, but, with present dental unit designs, this may result in water dripping onto the patient. A viable alternative is the installation of a check valve (anti-retraction valve) downstream from the retraction valve. Installation of a check valve resulted in an almost 4,000-fold decrease in this contamination. The attachment of a check valve will have no effect on normal less virulent bacteria already present in tap water. These bacteria colonize the water lines of the dental unit and are then continually shed into the water in numbers often as high as 1,000,000 CFU/ml. Reference:Journal of the American Dental Association, Vol 109, Issue 5, 712-716

15. STORAGE AREA IN CLINICS Storage area (if available) should contain enclosed storage for sterile items and a separate area for

disposable items. Instruments are packaged using (no EVENT RELATED STERILITY expiry date). This system

recognizes that the product remains sterile indefinitely, unless an event causes it to become compromised (e.g.: wet or torn package).

Packages containing sterile supplies should be inspected before use to make sure barrier wrap has not been compromised.

If a package is compromised, the instruments should be re-cleaned, re- packaged and re-sterilized. All used instrument are send to CSSD. No storage area for reusable instrument

16. INFECTION CONTROL IN THE DENTAL RADIOLOGY DEPARTMENTSWhen taking radiographs, the potential for cross-contamination of equipment and environmental surfaces with blood or saliva is high if aseptic techniques are not used.

15.1 Preparation of the Dental Radiology Room:• The technician must wash hands thoroughly before donning gloves.• Wear PPE.• Place barriers on all surfaces likely to be touched such as the control panel and remote control.• Barriers are often preferable because of such large areas to cover.• Daily wiping of all surfaces and equipment.

15.2 Preparation of the Patient: • Prepare a protection environment for the patient which includes plastic chair barrier, wiped lead apron,

new suction tips.• All adult female patients to be asked about the possibility of pregnancy before exposure to radiation

(first check the patient is married).• For the panoramic patients, the bite piece of the OPG is changed after every patient and sent to CSSD

for sterilization.• For the cephalometric patients, the temple support key, covered with plastic sheath and changed

between each patient as this part is inserted into the patient’s ears.• For periapical and bitewing patients, a new autoclaved film holder is used for each patient.• Films are available sheathed in a soft plastic covering, which is removed before processing and the

integrity of the film is not compromised.

17. IMMUNIZATION AND VACCINATION AGAINST HBV: DHCP are at risk for exposure to, and possible infection with, infectious organisms. Immunizations

substantially reduce both the number of DHCP susceptible to these diseases and the potential for disease transmission to other DHCP and patients. Thus, immunizations are an essential part of prevention and

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infection-control programs for DHCP, and a comprehensive immunization policy should be implemented for all dental health-care facilities

Hepatitis B virusHepatitis is an acute or chronic inflammation of the liver caused by bacterial or viral infection, parasitic infestation or chemical agents.

HBV VaccinationImmunization of DHCP before they are placed at risk for exposure remains the most efficient and effective use of vaccines in health-care settings. All DHCP should be vaccinated against Hepatitis B virus (HBV). A vaccination currently is only available

for HBV. Test dental healthcare personnel for anti-HBs 1-2 months after completion of the 3-dose vaccination

series. Provide employees appropriate education regarding the risks of HBV transmission and the availability of

the vaccine. Employees who decline the vaccination should sign a declination form to be kept on file with the

employer.

Vaccine Dose Schedule

Indications

Precautions/Contraindication

Special Consideration

HEPATITIS Brecombinant vaccine

3-dose schedule, IM inthe deltoid,2nd dose given 1 month after 1st dose, and3rd dose given 5 months after the second dose

Workers at risk of exposure to blood and body fluids

History of anaphylacticreaction to common baker'syeast. Pregnancy is not acontraindication

No therapeutic or adverse effect on HBV-infected persons.Healthcare workers who have an ongoing contact with patients or blood should be tested 1-2months after completing the vaccination series to determine serologic response if vaccinationdoes not induce adequateantibodies a second vaccine series should be given

Precautions:1. Vaccination against HBV for all DHCP.2. Standard Precautions:

These include all the procedures mentioned previously: Personal Protective Equipment (PPE) Hand hygiene before and after treatment. Disinfection of all surfaces.

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3. All procedures should be performed in a way which minimizes the formation of droplets, spatter and aerosols, utilizing high volume vacuum aspirators, rubber dams where appropriate and proper patient positioning.

4. Avoid the use of instruments which cannot be easily sterilized.5. After the procedure, all surfaces inside the clinic and equipment should be cleaned and decontaminated with

appropriate disinfectants.6. These procedures are followed for all patients, whether they are infectious or not. All patients are considered

potentially infectious.

Human Immunodeficiency Virus (HIV):Prospective studies worldwide indicate the average risk of HIV infection after a single percutaneous exposure to HIV-infected blood is 0.3% (range: 0.2%--0.5%). After an exposure of mucous membranes in the eye, nose, or mouth, the risk is approximately 0.1%. The precise risk of transmission after skin exposure remains unknown but is believed to be even smaller than that for mucous membrane exposure.

Even though the transmission of HIV in dental settings is extremely low, you should be aware of the following: Increase risk of HIV infection is associated with exposure to a relatively large volume of blood as indicated

by a deep injury with a device that was visibly contaminated with the infected patient’s blood. The risk is also increased if the exposure was to blood from patients with late stages of AIDS.

Summary of Standard Precautions: Remove all unnecessary items or materials from your area of contact which are not being used for this

patient. Place all materials needed within reach and out of drawers and packets e.g. cotton rolls, gauze, instruments. Use disposable items e.g. air syringe tips, suction tips whenever available. Place all the necessary instruments on a waterproof sheet and within easy reach of the dentist. Place protective barriers on the dental chair (disposable plastic cover), head chair cover, seat covers, light

handle cover and on all the suction and handpiece tubings or use adhesive film barriers. If you need to open a drawer, make sure you remove your gloves or use a clean pair of tweezers. Do not

touch any cabinets or drawers with contaminated gloves. Always have spare sterile gloves within easy reach, ready for you or the dentist if needed. If you need anything from the CSSD, make sure you get it before the start of the treatment. Needle stick injuries must be reported immediately for your own safety. Dispose of used needles and sharps in puncture-resistant sharps containers. Remove contaminated burs from the handpieces before disassembling the handpieces from the dental unit.

This prevents injuries with contaminated burs. Also, flush through the waterlines of hand pieces, seconds to minimize the retraction phenomenon.

Before taking the contaminated instruments to the CSSD they may be sprayed with a disinfectant/enzyme solution in the clinic. Always take them to CSSD in a covered container.

Remove your gown and change your gloves. Therefore, you will be wearing clean gloves when you leave the clinic to deliver the contaminated instruments to the CSSD.

Deliver the soiled instruments to the appropriate dispensary area. Ensure that all surfaces in the clinic are thoroughly wiped down and cleaned. Run solution through the suction apparatus and spittoon, flush through waterlines of handpieces, air/water

syringes and ultrasonic scalers with water for minimum 30 seconds.

18. BLOOD AND BODY FLUID EXPOSURES AND POST EXPOSURE PROTOCOL Refer to Infection Control Policy on blood and body fluid exposures and post exposure

19. WASTE DISPOSAL AND HOUSEKEEPING

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Floors should be cleaned regularly and any spills cleaned up immediately. Part of cleaning strategy is to minimize contamination of the cleaning solutions and cleaning tools.

Therefore, mops are heat disinfected and dried before being re-used. Single use disposable cleaning cloths are to be used to avoid spreading contamination.

Mops are all sent to be laundered each day. Fresh, cleaning solutions are to be prepared each day and then discarded as soon as cleaning has finished in

each area. At the end of the day containers are emptied allowing them to dry. A hospital cleaning and disinfection agent designed for housekeeping purposes should be used. The housekeeping personnel should wear gloves and other PPE whenever it is indicated.

20. HANDLING OF BIOPSY SPECIMENS AND EXTRACTED TEETH Handling of Extracted Teeth

• Extracted teeth (not teeth containing amalgam) are potentially infectious materials that should be disposed of in medical waste containers or puncture resistant sharps containers.

• Extracted teeth should be cleaned and placed in a leak proof container labeled with a biohazard symbol and maintain hydration (water or saline) if the teeth are to be taken to a dental laboratory or to be used for education purposes.

• Extracted teeth containing amalgam should be cleaned and placed in a separate leak proof container (water or saline) labeled with a bio-hazard symbol.

Handling of biopsy specimens: Each biopsy specimen should be placed in a clearly labeled, leak proof container Be careful not to contaminate the outside of the container when placing the specimen inside it. If the outside

of the container becomes contaminated, it should be cleaned and disinfected. If for any reason the specimen needs to be stored overnight it should be placed in the fridge. The specimen must be labeled with the biohazard symbol during storage and transport.

21. MISTAKES AND CORRECTIONSThere are certain vital mistakes that may occur in the dental clinic. These mistakes although unintentional may cause cross-contamination in the dental clinic. All staff must be aware that these mistakes must be avoided.This chapter focuses on these mistakes and the correct way to deal with them. The mistakes and corrections here are to bring to light how easily they occur and how they must be avoided and corrected.

Mistake 1: The use of both hands to recap needles, this may cause needle-stick injuryCorrection: Use a needle protector device

Mistake 2: Returning used syringe without removing needle.Correction: Remove the needle from the syringe and dispose of it in the sharps container.

Mistake 3: Touching door handles with contaminated gloves.Correction: Remove gloves, wash hands, and then touch door handle.

Mistake 4: Long fingernails and nail polish.Correction: Maintain short nails at all times while working.

Mistake 5: Using a pen to write an appointment while wearing contaminated gloves.Correction: Remove gloves, wash hands then give the appointment.

Mistake 6: Handling patient’s files with contaminated gloves.Correction: Always remove gloves first and wash hands before handling files

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Mistake 7: Carrying contaminated instruments to CSSD not in a covered trayCorrection: Contaminated instruments are carried to CSSD in a covered container

Mistake 8 : Talking on the phone in clinic with Gloves onCorrection: Remove gloves, wash hands, leave the clinic then talk on the phone

Mistake 9: Tying on mask with gloves.Correction: Tie the mask on first and then put on gloves

Mistake 10: Going into drawers with gloves onCorrection: Remove gloves before opening the drawer and touching anything, or use a pair of sterilized tweezers.

Mistake 11: Hair is lose and not tied backCorrection: Always tie long hair back while working

22. EDUCATION AND TRAININGPersonnel are more likely to comply with an infection-control program and exposure-control plan if they understand its rationale. Clearly written policies, procedures, and guidelines can help ensure consistency, efficiency, and effective coordination of activities. Provide dental healthcare personnel educational information appropriate in content and vocabulary to the educational level, literacy and language of dental healthcare personnel.

a. On initial employment.b. When new task or procedures affect the employee's occupational exposurec. Education and training regarding occupational exposure to potentially infectious agents and infection

control procedures.

23. CONCLUSIONInfection Control in the dental setting plays a vital role in total patient care. Cross- contamination can easily occur if guidelines are not set and followed.All DHCP should be informed, trained, updated and monitored regularly to ensure that all implement the Infection Control protocol.This manual will be of use in increasing infection control awareness to all DHCP in the Dental Center.DHCP should always keep in mind that total patient dental care involves a multitude of factors that all play a role in the delivery of the best care possible.

24. REFERENCESCDC Guidelines for Infection Control in Dental Health-Care Settings – December 19, 2003

Disclaimer:The contents of Guidelines for Infection Control were gathered from CDC, OSAP, ADA and OSHA. Care has been taken to confirm the accuracy of the information present.Our Resources and recommended reads· www.cdc.gov· www.osap.org· www.ada.org· www.osha.gov

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