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FOR THE CALIFORNIA DENTAL PROFESSIONAL
California Dental Provider # 4301
Course # 06-4301-07006
The Institute for Advanced Therapeutics, Inc.
P.O. Box 848152
Pembroke Pines, Florida 33084
1-954-441-9553
INFECTION CONTROL
FOR THE CALIFORNIA DENTAL PROFESSIONAL
Consultant and Editor
Mark Blum, D.D.S.
Research and Development:
Charles Edwin Cook, L.M. T., C.R. T.
By:
Renee J. Demmery, C.R.T.
©2006 Renee J. Demmery
All Rights Reserved
2
INFECTION CONTROL
FOR THE CALIFORNIA DENTAL PROFESSIONAL
Published By:
The Institute for Advanced Therapeutics, Inc.
P.O. Box 848152
Pembroke Pines, Florida 33084
1-954-441-9553 tel
1-954-432-1824 fax
This course was developed to help expand the knowledge and skills of dental
professionals with respect to the subject of Infection Control for the California
Dental Professional.
It is the responsibility of the dental professional to determine which principles and
theories contained herein are appropriate with respect to his/her personal
limitations and scope of practice.
The information in this course has been carefully researched and is generally
accepted as factual at the time of publication. The Institute for Advanced
Therapeutics, Inc. disclaims responsibility for any contradictory data prior to the
publication of the next revision of this course.
The images used herein were obtained from IMSI's MasterClips® and
MasterPhotos Premium Image Collection, 1895 Francisco Blvd. East, San
Rafael, CA 94901-5506, USA.
3
TABLE OF CONTENTS
COURSE DIRECTIONS
MAILING INSTRUCTIONS
COURSE OBJECTIVES
INTRODUCTION
COMPONENTS OF AN INFECTION CONTROL PROGRAM
STAFF EDUCATION AND TRAINING
STAFF IMMUNIZATION
EXPOSURE PREVENTION
DISPOSABLE PATIENT CARE ITEMS
BIOPSY SPECIMEN HANDLING
BIOHAZARDOUS WASTE DISPOSAL
WORK RESTRICTIONS
POSTEXPOSURE PROPHYLAXIS
STAFF RECORD MANAGEMENT
HAND HYGIENE
HAND WASHING
USE OF LOTIONS
FINGERNAILS
JEWELRY
PROTECTIVE BARRIERS
GLOVES
SURGICAL MASKS, EYEWEAR, AND FACE SHIELDS
PROTECTIVE GARMENTS
DISINFECTION AND STERILIZATION
CATEGORIES OF PATIENT CARE ITEMS
LEVELS OF DISINFECTION
ENVIRONMENTAL DISINFECTION
STERILIZATION PROCEDURES
NEEDLES AND SHARPS
INSTRUCTIONS FOR COMPLETING THE TEST
INFECTION CONTROL FOR THE CALIFORNIA DENTAL PROFESSIONAL TEST
TEST ANSWER CARD/COURSE EVALUATION
GLOSSARY
REFERENCES
4
COURSE DIRECTIONS
HOW TO BEST PROCEED WITH THIS COURSE
Each chapter should be approached systematically in a careful and
objective manner. It is important to master each chapter before going
on to the next. Relax, take your time, and go at your own pace. As 6
credits of continuing education are rewarded after successfully
completing this course, the reading of this manual and completion of
the test questions should not take less than 6 hours. Only after you
have successfully mastered all the material in the course should you
proceed to the test questions.
COMPLETING THE TEST
Before beginning, please clearly write your name, address, zip code,
and license number on your test answer card. Read each question
carefully before answering. Please use a ballpoint pen to fill-in your
answers on the answer card by completely shading your choice.
Keep in mind that each question has only one correct answer. The
test consists of 40 questions. For a passing grade, you must correctly
answer 32 questions. We encourage your input and would welcome
any suggestions to improve our course or test questions. Please feel
free to note your suggestions or comments on the course evaluation
found at the bottom of the test answer card.
INFORMATION FOR CERTIFICATION
In order to receive your 6 hours of continuing education credit, you
must be a registered purchaser of this course. Please notify us of
any address or name changes as we keep permanent records for
certification and licensure.
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MAILING INSTRUCTIONS
Please send your completed test answer card and course evaluation
to:
The Institute for Advanced Therapeutics, Inc.
P.O. Box 848152
Pembroke Pines, Florida 33084
If you have any questions regarding this course, please contact our
Customer Service Department at 1-954-441-9553 or fax us at 1-954432-1824.
6
COURSE OBJECTIVES
Upon completion of this course, you will be able to:
1.
List the conditions that must be met in order for infection to be
transmitted.
2.
Identify ways to reduce sharps injuries.
3.
Describe prophylactic measures that can be taken following
accidental exposure to hepatitis B and HIV.
4.
Discuss methods of disinfection and sterilization.
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INTRODUCTION
The reason for infection control in dentistry is to prevent transmission
of disease from patient to dental health care worker, from dental
health care worker to patient, and from patient to patient during dental
treatment.
Adhering strictly to guidelines developed in collaboration with the
California Division of Occupational Safety and Health, Centers for
Disease Control, other public agencies, academia, and private and
professional organizations, patients and dental professionals can be
protected from most pathogenic microorganisms in the dental setting.
These bacteria or viruses can be transmitted through the following:
 direct or indirect contact with blood or bodily fluids
 indirect contact with contaminated surfaces
 contact with droplets containing microorganisms
through an infected person sneezing, coughing, or
talking reaching the oral mucosa, nasal
membranes, or conjunctivae
 contact with microorganisms suspended in the air
for long periods through inhalation
The following conditions must be met in order for infection to be
transmitted.
 a means of access through which the pathogenic
microorganism can enter the host
 a host that is not immune to the pathogenic
microorganism
 a method of transmission
 a
source
that
allows
the
pathogenic
microorganism to survive and reproduce
 a pathogenic microorganism hardy enough and in
sufficient quantities to cause disease
8
An effective infection control program aims at preventing transmission
of disease by breaking the chain of cross-infection above.
Some of the diseases that present the greatest risk for dental
professionals include the following.








hepatitis B virus
hepatitis C virus
cytomegalovirus
herpes simplex viruses 1 and 2
HIV
Staphylococci
Mycobacterium tuberculosis
Streptococci
In 1996, the Centers for Disease Control and Prevention developed a
standard of care designed to prevent transmission of pathogens that
can be spread by blood or body fluids, excretion, or secretion called
Standard Precautions.
NOTES
9
COMPONENTS OF AN
INFECTION CONTROL PROGRAM
STAFF EDUCATION AND TRAINING
All dental practices should develop a written plan to prevent or reduce
the risk of transmission of infectious diseases. This program should
include ways to implement procedures to identify and help prevent
work-related cross-contamination among staff and patients and workrelated injuries. This written protocol should include information on
instrument processing, operatory cleanliness, and management of
injuries. A person to coordinate the infection control program and
provide instruction to staff regarding these procedures should be
assigned. A copy of this protocol should be posted conspicuously in
each dental office. Staff at risk for occupational exposure to
pathogens should be educated in infection control measures upon
initial employment and periodically throughout the employment
history.
STAFF IMMUNIZATION
An essential component of a dental practice’s infection control
program should be a staff immunization policy. Dental professionals
are considered high risk for acquiring vaccine-preventable diseases
such as:






hepatitis B
influenza
rubella
varicella
measles
mumps
10
Vaccinations against these diseases can provide immunity and break
the chain of infection by eliminating a susceptible host. Dental
employees identified to be at risk for exposure should be offered
immunization upon initial employment. Administrative staff can be
offered vaccinations as well.
Immunization schedules should take into consideration state and
federal regulations and U.S. Public Health Service recommendations.
The Advisory Committee on Immunization Practices (ACIP) has
issued national guidelines for health care professionals regarding
immunization including dental professionals. These guidelines can
be utilized to create a staff immunization policy.
EXPOSURE PREVENTION
As dental health professionals, there are precautions that can be
taken to reduce the risk of infection. First, treat every patient as if
they have an infectious disease. Many persons with infectious
diseases do not exhibit obvious symptoms and may appear to be
healthy. Precautions should be taken with patients who deny having
an infectious disease as they may not realize they have an infectious
disease or they may be concealing their disease for fear of
discrimination or being denied treatment.
Exposure to infection can occur through percutaneous injury such as
when a contaminated needle or sharp dental instrument punctures
the skin or through nonintact skin such as chapped hands. Infection
can also occur when infected blood, tissues, or bodily fluids come in
contact with the mucous membranes of the eyes, nose, and mouth.
11
Proper handling and disposing of sharp instruments is an important
strategy in preventing transmission of infectious diseases to dental
health care workers. Needles and sharp dental instruments should
be handled with care. Needles should never be recapped using both
hands or intentionally bent or broken by hand before disposal. The
following techniques are acceptable for recapping.
 a one-handed scoop
 specially designed needles with resheathing
mechanisms
 a device used to hold the cap while using the onehanded scoop technique
Although the risk of occupational exposure to infection can never be
completely eliminated, the following strategies can help prevent
exposure and should be part of a dental practice’s infection control
policy.
 Avoid coming in contact with blood, bodily fluids,
or tissues.
 Consistently adhere to use of protective barriers
during dental procedures.
 Comply with the dental practice’s infection control
policy.
 Consider a product’s ability to reduce accidental
percutaneous injury when choosing dental
equipment, devices, and instruments to buy.
 Vaccinate all eligible employees.
 Facilitate prompt reporting and management of
exposure incidents.
 Employ a strict policy of work restrictions.
 Train staff in infection control measures.
12
 Use appropriate sterilization and disinfection
methods.
 Wash hands frequently and thoroughly.
 Cover your mouth and nose with a tissue when
coughing or sneezing.
 Do not touch your eyes, nose, or mouth unless
your hands have just been washed or disinfected
with an alcohol-based hand rub.
DISPOSABLE PATIENT CARE ITEMS
Disposable single-use patient care items should not be cleaned,
disinfected, or sterilized for reuse at a later time. Such items should
be used only once then discarded. Some examples include:






saliva ejectors
air/water syringes
prophylaxis cups
prophylaxis brushes
prophylaxis angles
high-speed air evacuator tips
BIOPSY SPECIMEN HANDLING
Proper handling and transport of biopsy specimens is crucial to
prevent infection. All specimens should be placed in a strong
container with leak-proof lid for safe transport. The specimen should
not be allowed to come in contact with the outside of the container
during the collection process. If it does, the outside of the container
should be cleaned and disinfected appropriately.
BIOHAZARDOUS WASTE DISPOSAL
Liquid waste materials such as blood and suctioned oral fluids should
be disposed of by draining into a sanitary sewer system. Disposable
sharps should be placed in puncture-resistant appropriately-labeled
sharps containers after single-use.
13
Solid biohazardous waste materials should be sealed in impermeable
appropriately-labeled bags and handled according to local, state, or
federal requirements for disposal of biohazardous waste materials.
WORK RESTRICTIONS
Dental health employees with certain contagious illnesses pose a risk
to patients as well as other staff members while they are infectious.
These employees should not be allowed to be in the workplace until
they are asymptomatic and/or a medical physician deems them noncontagious.
POSTEXPOSURE PROPHYLAXIS
All dental practices where dental health care personnel might
experience exposures should have a written policy for management
of exposures. The policy should be based on the U.S. Public Health
Service guidelines. It should be reviewed periodically to ensure that it
is consistent with Public Health Service recommendations.
Procedures should be in place to promptly report, medically evaluate,
and record all cases of accidental occupational exposure.
Percutaneous injuries should be washed with soap and water. If the
exposure was to the eyes, nose, or mouth, the mucous membranes
should be flushed with copious amounts of water.
14
A qualified health care professional should be assigned to perform a
medical evaluation and provide first aid and counseling if necessary.
The medical evaluator should include in the chart:
 the date and time of the exposure
 details of where and how the exposure occurred
 the type, brand, and size of the dental instrument
or device involved in the exposure
 the amount of contaminant involved and what
type of injury
 details regarding the depth of the wound and
whether any potentially-infectious fluid was
injected into the body
 an estimate of the amount of potentially-infectious
fluid involved
 how long the potentially-infectious material
remained on the skin or mucous membranes
before washing or flushing of the area
 the infectious medical history of the patient from
which the exposure occurred
 the vaccination history of the exposed dental
health care professional
 details of any counseling, treatment, or
prophylaxis performed
For diseases such as hepatitis B and HIV, there are prophylactic
measures that can be taken following accidental exposure. In certain
cases, anti-retroviral agents can be administered prophylactically.
Guidelines published by the U.S. Public Health Service outline
management of occupational exposures.
Recommendations for hepatitis B virus postexposure management
include initiation of the hepatitis B vaccine series to any susceptible,
unvaccinated person who sustains an occupational blood or body
fluid exposure.
15
Postexposure prophylaxis with hepatitis B immune globulin (HBIG)
and/or hepatitis B vaccine series should be considered for
occupational exposures after evaluation of the hepatitis B surface
antigen status of the source and the vaccination and vaccineresponse status of the exposed person. Guidance is provided to
clinicians and exposed health-care personnel for selecting the
appropriate hepatitis B virus postexposure prophylaxis.
Immune globulin and antiviral agents (e.g., interferon with or without
ribavirin) are not recommended for postexposure prophylaxis of
hepatitis C. For hepatitis C virus postexposure management, the
hepatitis C virus status of the source and the exposed person should
be determined, and for health care personnel exposed to a hepatitis
C virus positive source, follow-up hepatitis C virus testing should be
performed to determine if infection develops.
Recommendations for HIV postexposure prophylaxis include a basic
4-week regimen of two drugs (zidovudine [ZDV] and lamivudine
[3TC]; 3TC and stavudine [d4T]; or didanosine [ddI] and d4T) for
most HIV exposures and an expanded regimen that includes the
addition of a third drug for HIV exposures that pose an increased risk
for transmission.
When the source person's virus is known or suspected to be resistant
to one or more of the drugs considered for the postexposure
prophylaxis regimen, the selection of drugs to which the source
person's virus is unlikely to be resistant is recommended.
STAFF RECORD MANAGEMENT
The health status of each dental health worker should be recorded in
a medical chart and properly maintained according to state and
federal laws regarding confidentiality and duration of maintenance.
16
This medical chart should contain information relating to:






immunizations
work-related medical examinations
initial screening tests
exposure incident reports
postexposure management
work restrictions
NOTES
17
HAND HYGIENE
HAND WASHING
Strict adherence to hand hygiene has been demonstrated to both
terminate outbreaks and reduce overall infection rates. There are
three methods of improving hand hygiene in the dental office –
traditional hand washing, hand asepsis, and surgical hand asepsis.
The desired method of hand washing should depend on the level of
contamination of the hands as well as the type of procedure being
performed. Dental health professionals should refrain from all direct
patient care and handling of patient care equipment if they have
exudative lesions or weeping dermatitis until the condition resolves.
Traditional hand washing involves the use of plain soap and water.
Hand asepsis involves the use of an antimicrobial soap and water or
alcohol-based hand rub. Surgical hand asepsis involves the use of
an antimicrobial soap that has a broad-spectrum of activity and longlasting antimicrobial effect.
Dental practices should take into consideration a couple of factors
when choosing which antiseptic agent to use in their facility:
 the efficacy of the product against the pathogens
likely to be encountered in the workplace
 the persistence of antiseptic activity
 the speed at which the product takes effect
 the likelihood of acceptance and compliance by
employees.
A pleasing color, smell, and moisturizing properties all can positively
influence acceptance.
18
Dental health professionals should be expected to wash their hands:
 Just before putting on gloves at the beginning of
the workday
 If the gloves are noted to have a tear or defect
 If the hands come in contact with saliva or blood
 Before a patient is seen and gloves are put on
 After a patient is seen and gloves are taken off
 Anytime gloves are removed
 If the hands are visibly soiled
 Before exiting the operatory or laboratory
 Before leaving the office for the day
The three methods of improving hand hygiene are outlined below.
1. Traditional Hand Washing – Purpose is to remove dirt,
organic material, and most transient microorganisms. Wet
hands with running water and apply soap or detergent. Rub
hands together vigorously for at least 10 to 15 seconds. Rinse
hands thoroughly and dry.
2. Hand Asepsis – The purpose is to remove or destroy transient
microorganisms. Wet hands with running water and apply
antimicrobial soap or detergent that contains an antiseptic.
Rub hands together vigorously for at least 10 to 15 seconds.
Rinse hands thoroughly and dry. An alternative when the
hands are not soiled with dirt or organic material is to use an
alcohol-based antiseptic hand rub to achieve hand antisepsis.
Apply a sufficient amount of the product to the palm of one
hand to completely cover the surfaces of both hands and
fingers when the hands are rubbed together. Continue to rub
the hands together until dry. No rinsing or towel drying is
required.
3. Surgical Hand Asepsis – The purpose is to remove or destroy
transient microorganisms and reduce resident flora when
surgery is to be performed in the event of glove tears. Wet
hands and forearms with running water and apply antimicrobial
soap or detergent that contains an antiseptic. Rub hands and
forearms vigorously for at least 120 seconds including using a
brush to clean the fingertips and under the nails.
19
USE OF LOTIONS
Frequent hand washing and use of antiseptic products can lead to
dry, chapped hands which can provide easy entry for pathogens.
Moisturizing lotion to the hands can ease dryness associated with
frequent hand washing. However, it is important to avoid petroleum
or oil-based lotion since it can break down latex gloves and increase
permeability.
FINGERNAILS
Fingernail length should be kept short since most of the bacterial flora
on the hands is found under and around the fingernails. Having
shorter fingernails can reduce infection rates by:
 allowing easier cleaning underneath the nails.
 decreasing the likelihood of glove punctures.
The use of artificial fingernails is discouraged because of the
increased incidence of fungal and bacterial infections associated with
their use. Chipped nail polish can also harbor bacteria.
JEWELRY
Although it is not known whether wearing rings while working in a
dental setting increases the risk of acquiring an infection, it may make
hand washing more difficult to perform and may increase the
likelihood of glove tears.
NOTES
20
PROTECTIVE BARRIERS
Today, health care professionals have a wide variety of physical
barrier devices available. These devices are designed to reduce or
prevent contact with blood and/or body fluids of patients who may be
infected with HIV or other communicable diseases. Some examples
of protective gear include:
1.
2.
3.
4.
Latex gloves.
Protective face shields or safety glasses.
Face masks.
Protective garments.
GLOVES
Wearing gloves prevents contamination of the hands during dental
procedures and prevents potentially infectious microorganisms on the
hands from transmitting to patients. They should be worn whenever
contact with mucous membranes, blood, or other potentially
infectious materials is possible. Gloves should be used only once on
a single patient then discarded. Contamination of the hands is
reduced by 70-80% by using gloves.
Washing gloves can cause micropunctures invisible to the naked eye
which can compromise the integrity of the gloves. This can allow
contaminated fluids to pass through the gloves.
21
Hands should be washed thoroughly before putting on each pair of
gloves and washed again once gloves are removed. If using an
alcohol-based hand rub, hands must be completely dry before putting
on gloves since alcohol-based liquid on gloved hands can increase
the risk of glove perforation.
The medical glove industry is regulated by the FDA which regulates
the following types of gloves:
 sterile surgeon’s gloves
 sterile patient examination gloves
 non-sterile patient examination gloves
Much higher standards of quality are applied to sterile surgeon’s
gloves than to patient examination gloves. Wearing sterile surgeon’s
gloves offer an increased level of protection from patient’s blood and
body fluids and reduces the risk of transmitting microorganisms from
the dental health care professional’s hands to the patient’s oral cavity.
To optimize glove performance and reduce infection rates:
 Wear gloves in the appropriate size.
 Apply gloves to completely dry hands after using
alcohol-based hand rubs.
 Follow standard precautions when dealing with
sharps.
 Keep fingernails short.
 Do not wear hand jewelry.
 Replace visibly torn or damaged gloves
immediately.
There are two forms of contact dermatitis common among dental
health care professionals:
 Irritant contact dermatitis - characterized by an
itchy, dry skin rash around the area of contact that
is generally a result of frequent hand washing with
soaps and antiseptic products.
22
 Allergic contact dermatitis - characterized by a
hypersensitivity reaction due to chemicals used in
the manufacturing of gloves. The allergic rash
usually becomes apparent a few hours after
contact.
Contact dermatitis can increase the risk of infection and transmission
of pathogens because any damage to the skin can result in more
frequent colonization by certain types of bacteria.
Some dental health care professionals develop a hypersensitivity to
the natural rubber proteins in latex. This condition is characterized by
a systemic hypersensitivity reaction and is far more serious than
irritant or allergic contact dermatitis. Symptoms range in severity and
include:












itchy burning skin
itchy eyes
scratchy throat
sneezing
runny nose
hives
difficulty breathing
wheezing
coughing
gastrointestinal tract irregularities
heart irregularities
anaphylaxis or death (rarely)
Latex protein attaches to the powder in gloves and can reach the skin
or be inhaled. When this happens, patients who are allergic can
develop adverse symptoms.
To reduce the risk of allergy to latex while using latex gloves, reduced
protein/powder-free gloves can be worn.
23
SURGICAL MASKS, EYEWEAR, AND FACE SHIELDS
Surgical masks that cover both the nose and mouth should be used
during all dental procedures in conjunction with either chin length
plastic face shields or protective eyewear where spatter of blood,
body fluids, or tissues is expected. Surgical masks are used in
conjunction with protective eyewear such as glasses with solid sides
to protect from side spatter. If a surgical mask becomes visibly soiled
or wet during a patient treatment, it should be replaced immediately.
Protective face shields or eyewear prevent blood, body fluids, or
tissues during dental procedures from getting into the eyes, nose, or
mouth which are potential gateways for infection. This gear should
be worn whenever there is a potential for spatter. After each patient,
if contaminated, they should be cleaned and disinfected.
PROTECTIVE GARMENTS
Gowns, aprons, or lab coats should be worn when splashes of blood
or bodily fluids are likely to be encountered. They protect the skin
and street clothes from contamination with blood, bodily fluids, or
tissues. For maximum protection, the sleeves should be long enough
to completely cover the forearms. Garments must be changed when
there is visible soiling or spatter. All protective garments must be
removed before leaving the workplace. Reusable garments must be
laundered in accordance with Cal-DOSH Bloodborne Pathogens
Standards.
24
DISINFECTION AND STERILIZATION
CATEGORIES OF PATIENT CARE ITEMS
There are three categories of patient care items (dental devices,
instruments, and equipment) depending on their potential risk for
transmitting infection.
 critical
 semi-critical
 non-critical
Critical patient care items are considered at highest risk for
transmitting infection because they are used to penetrate soft tissue
and bone. These items must be sterilized by autoclaving, dry heat, or
chemical vapor if they are heat-tolerant. FDA-approved chemical
sterilants and disinfectants should be used for sterilization of critical
items that are heat-sensitive.
Semi-critical patient care items are considered lower risk for
transmitting infection as they come in contact with only mucous
membranes and non-intact skin. If these items are heat-tolerant, they
should also be sterilized by autoclaving, dry heat, or chemical vapor.
If they are not heat-tolerant, they should be processed by high-level,
FDA-approved chemical sterilants/disinfectants.
Non-critical patient care items are considered low risk for transmitting
infection because they come in contact with only intact skin. These
items can be covered with a disposable barrier or cleaned with soap
and water or an intermediate-level disinfectant if visibly soiled with
blood.
25
Items that should be heat-sterilized between patients include:
1. High-speed dental hand pieces.
2. Low-speed hand piece components used intraorally.
3. Other dental attachments such as reusable air/water syringe
tips and ultrasonic scaler tips.
Items that should be used for one patient only and then discarded
include:
1.
2.
3.
4.
Disposable prophylaxis angles, cups and brushes.
Disposable tips for high-speed evacuators.
Disposable saliva ejectors.
Disposable air/water syringe tips.
If a critical or semi-critical instrument is not going to be used
immediately after being sterilized by a heat or vapor method, it should
be packaged or wrapped before sterilization and remained sealed
unless the instruments within them are placed onto a setup tray and
covered with a moisture-proof barrier on the day the instruments will
be used and stored in a manner so as to prevent contamination.
The sterilization cycle must be tested weekly for proper functioning
through the use of a biological indicator. The results of these tests
must be maintained for 12 months.
Sterile coolants/irrigants should be used for surgical procedures
involving bone or soft tissue. Sterile coolants/irrigants must be
delivered using a sterile delivery system.
LEVELS OF DISINFECTION
There are three levels of disinfection for patient care items that do not
need to be sterilized.
 high
 intermediate
 low
26
The level of disinfection required depends on the item’s intended use.
There are two levels of disinfection for environmental surfaces.
 intermediate
 low
ENVIRONMENTAL DISINFECTION
Surfaces or equipment in the dental office or operatory that do not
touch patients directly are known as environmental surfaces. The
surfaces of items such as knobs, switches, and handles can become
contaminated with microorganisms. For the purposes of disinfection,
there are two categories of environmental surfaces:
 clinical contact – (ex. countertops, switches, door
knobs).
 housekeeping – (ex. walls, floors).
Clinical contact surfaces should be disinfected with more rigorous
methods than housekeeping surfaces because they are touched
more frequently. If items or surfaces are difficult to clean and
disinfect and are likely to become contaminated, they should be
protected with disposable impervious barriers.
Following treatment of each patient and at the end of the work day,
environmental surfaces that are not protected by impervious barriers
should be cleaned with a Cal-EPA registered, hospital grade low to
intermediate level disinfectant after each patient.
Low-level
disinfectants should be labeled as effective against hepatitis B virus
and HIV and used in accordance with the manufacturers instructions.
27
Environmental surfaces that may have been contaminated with
patient debris such as floors, walls and sinks should be cleaned with
a detergent and water or a Cal-EPA registered, hospital grade
disinfectant.
Dental unit water lines should be anti-retractive. Before each
workday, the dental unit lines should be purged with air or flushed
with water for at least two minutes before attaching handpieces,
scalers, or other devices. The dental unit lines should be flushed for
a minimum of twenty seconds between each patient.
Intraoral items should be cleaned and disinfected with an
intermediate-level disinfectant before manipulation in the laboratory
or placement in the patient’s mouth. Before placement in the
patient’s mouth, the items should be thoroughly rinsed.
Splash shields and equipment guards shall be used on dental
laboratory lathes. Fresh pumice and a sterilized, disinfected or new
ragwheel should be used for each patient. Any device used to polish,
trim, or adjust contaminated intraoral devices should be properly
disinfected or sterilized.
Contaminated solid waste should be disposed of according to local,
state and federal environmental standards.
STERILIZATION PROCEDURES
Sterilization is performed to kill bacteria, viruses, fungi/mold and
spores on reusable dental instruments that might otherwise transmit
infection. There are several steps to sterilization.
1. Transport – All items for sterilization must be gathered in the
operatory and placed in a puncture-resistant sharps container
or cassette and wheeled on a mobile cart to the sterilization
area.
28
2. Cleaning – Before sterilization, all dental instruments must be
cleaned to remove excess debris. Cleaning can be achieved
by ultrasound or hand scrubbing. Ultrasound cleaning is
preferred over hand scrubbing because it reduces the risk of
cross-contamination and percutaneous injury.
3. Packaging of instruments – Dental instruments should be
drained prior to packaging. Packaging materials should be
intended for the method of sterilization used and suitable for
the items being sterilized.
4. Sterilization – The three main methods of sterilization are
steam autoclave, unsaturated chemical vapor, and dry heat.
The time and temperature required for effective sterilization
should be in the manufacturer’s instruction manual.
5. Storage – Sterilized items should not be stored loose in
drawers or cabinets and should not be stored under a sink
where they could get wet.
6. Sterilizer monitoring – Sterilizers have monitoring indicators to
ensure items are being sterilized. A biological monitor is the
only type of monitor that provides positive proof of sterilization.
It should be tested at least weekly to ensure proper functioning
of sterilization cycles.
NOTES
29
NEEDLES AND SHARPS
Disposable instruments that should be placed into a sharps container
for disposal according to all applicable regulations include:
1.
2.
3.
4.
Syringes.
Needles.
Scalpel blades.
Other sharp items and instruments.
Recapping of non-disposable needles should only be performed
using the scoop technique or a protective device. Do not bend or
break needles for the purpose of disposal.
NOTES
END OF COURSE
30
GLOSSARY
Alcohol-based hand rub: an alcohol-containing preparation designed for
application to the hands for reducing the number of viable microorganisms on the
hands.
Allergic contact dermatitis: a type IV or delayed-hypersensitivity reaction
resulting from contact with a chemical allergen (e.g. certain components of
patient care gloves), generally localized to the contact area. Reactions occur
slowly over 12-48 hours.
Anaphylaxis (immediate anaphylactic hypersensitivity): a severe and
sometimes fatal Type 1 reaction in a susceptible person after a second exposure
to a specific antigen (e.g., food, pollen, proteins in latex gloves, or penicillin) after
previous sensitization. Anaphylaxis is characterized commonly by respiratory
symptoms, itching, hives, and rarely by shock and death (anaphylactic shock).
Antimicrobial soap: a detergent containing an antiseptic agent.
Antiseptic: a germicide that is used on skin or living tissue for the purpose of
inhibiting or destroying microorganisms.
Antiseptic handwash: washing hands with water and soap or detergents
containing an antiseptic agent. Antiseptic hand rub. The process of applying an
antiseptic hand-rub product to all surfaces of the hands to reduce the number of
microorganisms present.
Asepsis: prevention from contamination with microorganisms. Includes sterile
conditions on tissues, on materials, and in rooms, as obtained by excluding,
removing, or killing organisms.
Asymptomatic: Without symptoms.
Biological indicator: a device to monitor the sterilization process that consists
of a standardized population bacterial spores known to be resistant to the mode
of sterilization being monitored. Biological indicators indicate that all the
parameters necessary for sterilization were present.
Cleaning: the removal of visible soil, organic and inorganic contamination from a
device or surface, using either the physical action of scrubbing with a surfactant
or detergent and water or an energy-based process (e.g., ultrasonic cleaners)
with appropriate chemical agents.
31
Contaminated: state of having been in contact with microorganisms. As used in
health care, it generally refers to microorganisms capable of producing disease
or infection.
Critical: the category of medical devices or instruments that are introduced
directly into the human body, either into or in contact with the bloodstream or
normally sterile areas of the body.
Disinfectant: a chemical agent used on inanimate objects to destroy virtually all
recognized pathogenic microorganisms, but not necessarily all microbial forms.
Disinfection: the destruction of pathogenic and other kinds of microorganisms
by physical or chemical means. Disinfection is less lethal than sterilization,
because it destroys most recognized pathogenic microorganisms, but not
necessarily all microbial forms, such as bacterial spores. Disinfection does not
ensure the margin of safety associated with sterilization processes.
Hand hygiene: a general term that applies to handwashing, antiseptic
handwash, antiseptic hand rub, and surgical hand antisepsis.
High-level disinfection: a disinfection process that inactivates vegetative
bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of
bacterial spores. The FDA further defines a high-level disinfectant as a sterilant
used under the same contact conditions except for a shorter contact time.
Hypersensitivity: an immune reaction (allergy) in which the body has an
exaggerated response to a specific antigen (e.g., food, pet dander, wasp venom).
See allergic contact dermatitis, anaphylxis, latex allergy.
Immunization: The process by which a person becomes immune, or protected,
against a disease. This term is often used interchangeably with vaccination or
inoculation. However, the term “vaccination” is defined as the injection of a killed
or weakened infectious organism in order to prevent the disease. Thus,
vaccination, by inoculation with a vaccine, does not always result in immunity.
Intermediate-level disinfectant: a liquid chemical germicide registered by the
EPA as hospital disinfectant and with a label claim of potency as a
tuberculocidal.
Irritant contact dermatitis: the development of dry, itchy, irritated areas on the
skin, which can result from frequent handwashing and gloving as well as
exposure to chemicals. This condition is not an allergic reaction.
Latex: a milky white fluid extracted from the rubber tree Hevea brasiliensis that
contains the rubber material cis-1,4 polyisoprene.
32
Low-level disinfectant: a liquid chemical germicide registered by the EPA as a
hospital disinfectant. OSHA requires low-level disinfectants also to have a label
claim for potency against HIV and HBV if used for disinfecting clinical contact
surfaces.
Non-critical: the category of medical items or surfaces that carry the least risk of
disease transmission. This category has been expanded to include not only
noncritical medical devices but also environmental surfaces. Noncritical medical
devices touch only unbroken (nonintact) skin (e.g., blood pressure cuff).
Noncritical environmental surfaces can be further divided into clinical contact
surfaces (e.g., light handle) and housekeeping surfaces (e.g., floors,
countertops).
Percutaneous injury: an injury that penetrates the skin.
Postexposure prophylaxis: the administration of medications following an
occupational exposure in an attempt to prevent infection.
Semi-critical: the category of medical devices or instruments that come into
contact with mucous membranes and do not ordinarily penetrate body surfaces.
Sterilization: the use of a physical or chemical procedure to destroy all
microorganisms including large numbers of resistant bacterial spores.
Ultrasonic cleaner: a device that uses waves of acoustic energy to loosen and
break up debris on instruments.
Vaccine: a product that produces immunity therefore protecting the body from
the disease. Vaccines are administered through needle injections, by mouth and
by aerosol.
33
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