Infection CONTROL DENTAL
It's Time To Discuss
Infection Control
Our website is dedicated to promoting awareness among dentists, orthodontists, hygienists, and the general public regarding growing health concerns within dental offices. While healthcare-associated infections are often associated with hospitals, it is vital to acknowledge that dental offices also carry the potential risk of dental cross contamination or infection for patients and dental healthcare providers.
Central to the role of dentists and their dental teams is the paramount responsibility of ensuring the safety and sterility of their practice environments. Infection control protocols serve as the cornerstone of daily operations within a dental office. However, challenges can arise, leading to lapses in adherence to these protocols.
Notable issues include instances when dental offices experience exceptionally high patient volumes, which may inadvertently result in the omission of essential infection control steps. Additionally, financial considerations can sometimes lead to cost-cutting measures that compromise safety standards. It's Time To Discuss Infection Control (It's Time To Discuss Dental Safety)
Furthermore, it is worth noting that in certain cases, the protocols followed in dental offices may not align with the current recommendations of authoritative bodies such as the CDC, FDA, ADA, and OSAP. It is important to emphasize that these concerns do not apply universally to all dental offices.
The majority of dental practices maintain rigorous safety/nfection control standards, and their dedicated staff consistently uphold these measures. Nonetheless, we believe it is essential to address these dental infection control areas of concern and engage in open dialogue to further enhance safety practices within dental offices. Understanding key terms, products, issues, and what leading health authorities recommend is essential in providing safe dental treatments to patients.
Our goal is to promote a culture of continuous improvement, ensuring that dental care remains a safe and secure experience for all patients and dental healthcare professionals. In order to do this, we first need to look at where we came from. Dentistry has seen a lot of adverse events that have helped shaped the infection control protocols that are now implemented in today's dental office.
CDC's Core Infection Prevention and
Control Practices for Safe Healthcare
Delivery in All Settings
Ensuring strict adherence to infection prevention and control protocols is paramount for delivering safe and exceptional patient care across diverse healthcare environments. Below outlines a foundational set of infection prevention and control measures imperative for all healthcare facilities, irrespective of their specialized services.
Support and Leadership
- Ensure accountability of the healthcare facility or organization's governing body for the effectiveness of infection prevention initiatives.
- Allocate ample human and material resources to infection prevention to guarantee swift and consistent measures in eliminating or mitigating infection risks, thereby halting the transmission of infections effectively.
- Appoint one or more qualified individuals with specialized training in infection prevention and control to oversee the facility's infection prevention program.
- Empower and endorse the authority of those overseeing the infection prevention program to optimize its effectiveness.
Training and Education Initiatives
- Deliver task-specific infection prevention education and training to all healthcare personnel.
- Establish procedures to ensure that all healthcare personnel comprehend and demonstrate competence in adhering to infection prevention requirements throughout the execution of their duties and responsibilities.
- Offer readily accessible, up-to-date written infection prevention policies and procedures grounded in evidence-based guidelines (e.g., CDC/HICPAC)
Education for Patients, Families, and Caregivers
- Offer pertinent infection prevention education to patients, family members, visitors, and other individuals involved in the caregiving network.
Monitoring and Feedback on Performance
- Identify and monitor compliance with infection prevention practices and control requirements.
- Monitoring and Feedback on Performance CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings
- Offer timely and consistent feedback on adherence and associated outcomes to healthcare personnel and facility leadership.
- Train personnel responsible for performance monitoring and utilize standardized tools and definitions.
- Monitor infection rates potentially linked to care provided within the facility, and utilize surveillance data to identify and respond to infectious agent transmission within the facility.
The statements made from this regulatory agency is merely stating procedures and recommendations to the dental health care professional (DHCP) from the public forum. The above core principles was written by the CDC and can be viewed in full by visiting the CDC website.
Click here to view full article on CDC website.
Standard Precautions
Ensuring strict adherence to infection prevention and control protocols is paramount for delivering safe and exceptional patient care across diverse healthcare environments. Below outlines a foundational set of infection prevention and control measures imperative for all healthcare facilities, irrespective of their specialized services.
Utilize Universal Precautions when caring for all patients across various settings. Universal Precautions encompass:
- Hand hygiene practices
- Environmental cleaning and disinfection practices
- Injection and medication safety protocols
- Perform risk assessments and utilize suitable personal protective equipment (PPE) such as gloves, gowns, and face masks tailored to the activities being conducted.
- Reducing Potential Exposures (e.g., Respiratory Hygiene and Cough Etiquette)
- Reprocessing reusable medical equipment after each patient encounter or when visibly soiled.
Hand Hygiene References and Resources
Mandate healthcare personnel to adhere to hand hygiene practices as outlined in the Centers for Disease Control and Prevention (CDC) guidelines.
Utilize alcohol-based hand rub or wash with soap and water for the following clinical scenarios:
- Right before making contact with a patient
- Before conducting an aseptic procedure (e.g., inserting an indwelling device) or handling invasive medical instruments
- Before transitioning from working on a contaminated body site to a clean body site on the same patient
- After contact with a patient or their immediate surroundings
- After coming into contact with blood, bodily fluids, or contaminated surfaces
- Immediately after removing gloves
References and Resources for Environmental Cleaning and Disinfection
Mandate regular and targeted cleaning of environmental surfaces based on the level of patient contact and extent of contamination.
- Clean and disinfect surfaces near the patient and frequently touched surfaces in the patient care environment more frequently than other surfaces.
- Immediately clean and decontaminate spills of blood or other potentially infectious materials.
Choose EPA-registered disinfectants with proven efficacy against the pathogens commonly found in the patient-care environment.
Adhere to manufacturers' guidelines for the correct usage of cleaning and disinfecting products, including dilution, contact time, material compatibility, storage, shelf-life, and safe disposal.
References and Resources for Injection and Medication Safety
Prepare medications in a designated clean medication preparation area isolated from potential sources of contamination, such as sinks or other water sources.
Utilize aseptic technique during medication preparation and administration.
Disinfect the access ports of medication vials before inserting a needle or any other device into the vial.
Use needles and syringes for single-patient use only, including manufactured prefilled syringes and cartridge devices like insulin pens.
Always use a new needle and a new syringe when accessing medication containers, even when obtaining additional doses for the same patient.
Ensure single-dose or single-use vials, ampules, and bags or bottles of parenteral solution are dedicated to use for a single patient only.
Use fluid infusion or administration sets (e.g., intravenous tubing) for single-patient use only.
Whenever possible, assign multidose vials to a single patient. If multidose vials must be shared among patients, confine them to a centralized medication area and avoid bringing them into immediate patient treatment areas (e.g., operating room, patient room/cubicle).
Wear a facemask when inserting a catheter or injecting material into the epidural or subdural space (e.g., during myelogram, epidural, or spinal anesthesia).
References and Resources for Risk Assessment and Appropriate Use of Personal Protective Equipment
Ensure correct selection and utilization of personal protective equipment (PPE) according to the nature of patient interaction and the risk of exposure to blood, bodily fluids, and/or infectious materials:
- Wear gloves when there is a reasonable anticipation of contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment.
- Wear an appropriate gown to protect the skin and prevent clothing soiling during procedures and activities that may involve contact with blood, body fluids, secretions, or excretions.
- Utilize protective eyewear and either a mask or a face shield to safeguard the mucous membranes of the eyes, nose, and mouth during procedures and activities that may generate splashes or sprays of blood, body fluids, secretions, and excretions. Choose masks, goggles, face shields, or combinations thereof based on the anticipated needs of the task at hand.
- Remove and dispose of all PPE, except for respirators, after completing a task before exiting the patient's room or care area. If a respirator is worn, remove and dispose of it (or reprocess if reusable) after leaving the patient room or care area and closing the door.
- Do not reuse the same gown or pair of gloves for the care of multiple patients. Dispose of disposable gloves once a task is completed or if they become soiled during the care process.
- Avoid washing gloves for the purpose of reuse.
Ensure that healthcare personnel have immediate access to proper training and are proficient in selecting, donning, doffing, and disposing of PPE in a manner that safeguards themselves, the patient, and others.
References and Resources for Minimizing Exposure Risks
Establish and execute protocols for the early detection and management of potentially infectious individuals at initial points of patient contact in outpatient settings (such as triage areas, emergency departments, outpatient clinics, and physician offices) and upon admission to hospitals and long-term care facilities (LTCFs). This includes the use of appropriate infection control measures, including isolation precautions and personal protective equipment (PPE).
Implement respiratory hygiene and cough etiquette practices to mitigate the spread of respiratory infections within the facility.
Encourage patients and visitors experiencing symptoms of respiratory infection to contain their respiratory secretions and practice hand hygiene after contact by providing tissues, masks, hand hygiene supplies, and informative signage or handouts at entry points and throughout the facility.
When feasible, promptly segregate patients exhibiting respiratory symptoms from others, ideally during triage or upon their arrival at the facility
References and Resources for Reprocessing of Reusable Medical Equipment
Thoroughly clean and reprocess (disinfect or sterilize) reusable medical equipment (such as blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, and endoscopes) before using them on another patient or when they become soiled.
- Consult and strictly adhere to manufacturers' instructions for reprocessing procedures
Ensure segregation between clean and soiled equipment to prevent cross-contamination
The statements made from this regulatory agency is merely stating procedures and recommendations to the dental health care professional (DHCP) from the public forum. The above core principles was written by the CDC and can be viewed in full by visiting the CDC website.
Click here to view full article on CDC website.
Occupational Health and Safety
Ensure healthcare personnel either receive immunizations or provide documented evidence of immunity against vaccine-preventable diseases as recommended by the CDC, CDC's Advisory Committee on Immunization Practices (ACIP), and mandated by federal, state, or local authorities.
Establish procedures and sick leave policies that promote healthcare personnel to remain at home upon experiencing signs or symptoms of acute infectious illness (such as fever, cough, diarrhea, vomiting, or draining skin lesions) to mitigate the spread of infections to patients and other healthcare personnel.
Implement a reporting system for healthcare personnel to notify their supervisor or designated healthcare facility staff responsible for occupational health regarding any signs, symptoms, or diagnosed illnesses that may pose a risk to their patients and colleagues.
Comply with federal and state regulations and directives aimed at safeguarding healthcare workers against the transmission of infectious agents, including OSHA's Bloodborne Pathogens Standard, Personal Protective Equipment Standard, Respiratory Protection Standard, and TB Compliance Directive.
Temporary Invasive Medical Devices for Clinical Care
Evaluate the medical necessity of any invasive medical device (such as vascular catheters, indwelling urinary catheters, feeding tubes, ventilators, surgical drains) during each healthcare encounter to pinpoint the earliest safe opportunity for removal.
Ensure healthcare personnel adhere to recommended practices for both the insertion and maintenance of invasive medical devices.
Disease-Specific Precautions
Implement additional precautions, known as Disease-Specific Precautions, for patients with confirmed or suspected diagnoses where contact with the patient, their body fluids, or their environment poses a significant transmission risk, even with adherence to Standard Precautions.
Tailor transmission-based precautions to suit the specific healthcare environment, facility design characteristics, and the nature of patient interactions.
Apply transmission-based precautions according to the patient's clinical presentation and suspected infection diagnoses (e.g., symptoms indicative of transmissible infections like diarrhea, meningitis, fever with rash, respiratory infections) as soon as the patient enters the healthcare facility (including reception or triage areas in emergency departments, ambulatory clinics, or physicians' offices), and then modify or cease precautions as additional clinical information becomes available (e.g., through confirmatory laboratory results).
Whenever feasible, assign patients who may require transmission-based precautions to singlepatient rooms while awaiting clinical assessment.
Inform both receiving facilities and the transporting agency about the necessity for transmission-based precautions due to suspected or confirmed infections or the presence of targeted multidrug-resistant pathogens when patients are transferred.
The statements made from this regulatory agency is merely stating procedures and recommendations to the dental health care professional (DHCP) from the public forum. The above core principles was written by the CDC and can be viewed in full by visiting the CDC website.
Click here to view full article on CDC website.
Implementing Universal Precautions
What are Universal Precautions?
Universal precautions are grounded on the principle that all blood and body fluids should be considered contaminated and treated as infectious, as patients with bloodborne infections may be asymptomatic or unaware of their infection. In essence, it entails treating every patient as if they are infected.
Dental healthcare professionals must prioritize both patient safety and staff protection during treatments. Adhering to the concept of universal precautions entails following these recommendations:
Hand
Hygiene
Hand hygiene stands as the foremost measure in preventing infection transmission among patients and Dental Healthcare Personnel (DHCP). Robust education and training programs should cover the indications and techniques crucial for proper hand hygiene practices, especially before performing routine and oral surgical procedures.
What to look for?
Essential supplies necessary to uphold adherence to hand hygiene protocols during routine dental procedures, such as soap, water, paper towels, and alcohol-based hand rub, are readily available to Dental Healthcare Personnel (DHCP).
Utilization of Personal Protective Equipment (PPE)
Personal Protective Equipment (PPE) includes wearable gear designed to protect Dental Healthcare Personnel (DHCP) from potential exposure to infectious agents. It is crucial to ensure a comprehensive selection of PPE suitable for various patient interactions is readily available. This equipment should effectively cover personal clothing and areas of skin vulnerable to contamination with blood, saliva, or other potentially infectious materials (OPIM).
What to look for?
Dental Healthcare Personnel (DHCP) have access to an ample supply of appropriate Personal Protective Equipment (PPE), including examination gloves, surgical face masks, protective clothing, protective eyewear/face shields, utility gloves, and sterile surgeon's gloves tailored for surgical procedures.
Respiratory hygiene and Cough Ettiquette
Infection prevention measures regarding respiratory hygiene and cough etiquette are meticulously designed to reduce the transmission of respiratory pathogens spread via droplet or airborne routes. These protocols primarily target patients and accompanying individuals who may unknowingly carry transmissible respiratory infections upon entering the dental setting. Moreover, these strategies also apply to anyone, including Dental Healthcare Personnel (DHCP), displaying symptoms such as coughing, congestion, a runny nose, or increased production of respiratory secretions.
What to look for?
Protocols and guidelines designed to control respiratory secretions in individuals exhibiting signs and symptoms of a respiratory infection are implemented from their initial arrival at the entrance of the dental setting.
Sharps Safety: Engineering and Work Practice Controls
The prevalence of percutaneous injuries, particularly needle stick incidents and sharp object cuts, among Dental Healthcare Personnel (DHCP) primarily involves burs, needles, and similar sharp instruments. The implementation of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard has significantly improved the protection of DHCP against blood exposure and sharps-related injuries. However, despite these regulatory measures, sharps injuries continue to occur, posing an ongoing risk of bloodborne pathogen transmission to both DHCP and patients. Given the preventable nature of most exposures in dentistry, it is crucial for every dental practice to have easily accessible policies and procedures addressing sharps safety.
What to look for?
Written policies, procedures, and guidelines for the prevention of exposure and management of post-exposure incidents are easily accessible.
Safe Injection Practices (including Aseptic Technique for Parenteral Medications)
Safe injection practices are designed to minimize the risk of infectious disease transmission among patients or between patients and Dental Healthcare Personnel (DHCP) during the preparation and administration of parenteral medications, such as intravenous or intramuscular injections. These practices encompass a standardized set of measures that DHCP must diligently adhere to ensure injections are performed with the highest level of safety, with patient well-being as the utmost priority. DHCP frequently encounter parenteral medications during the administration of local anesthesia, where needles and cartridges containing local anesthetics are used exclusively for individual patients, and the dental cartridge syringe is thoroughly cleaned and heat sterilized between each patient encounter.
What to look for?
Written policies, procedures, and guidelines detailing safe injection practices, including the use of aseptic techniques for administering parenteral medications, are easily accessible.
Sterilized Instruments and Equipment
Instrument processing involves a meticulous series of steps utilizing specialized equipment. It is essential for every dental practice to establish comprehensive policies and procedures governing the containment, transportation, and handling of instruments and equipment that may come into contact with blood or body fluids. Manufacturer's instructions for reprocessing reusable dental instruments and equipment should be readily accessible, preferably located within or near the reprocessing area. It is important to note that most single-use devices are explicitly labeled by the manufacturer for a single use only and lack reprocessing instructions. Such devices should be used for one patient exclusively and disposed of following appropriate protocols.
What to look for?
Accessible written policies and procedures ensure the correct cleaning and reprocessing of reusable patient care instruments and devices before their use on subsequent patients.
Policies, procedures, and manufacturer reprocessing instructions for reusable instruments and dental devices are readily accessible, ideally located in or near the designated reprocessing areas.
Clean and Disinfected Environmental Surfaces
Incorporating policies and procedures for routine cleaning and disinfection of environmental surfaces is essential within a comprehensive infection prevention plan. Cleaning effectively removes significant microbial loads from surfaces and should consistently precede disinfection procedures. While disinfection is typically less rigorous than sterilization, it involves the process of microbial inactivation, eliminating the vast majority of known pathogenic microorganisms, although not necessarily all microbial forms, such as bacterial spores.
What to look for?
Accessible written policies and procedures for the routine cleaning and disinfection of environmental surfaces, encompassing both clinical contact and housekeeping areas, are readily available.
Dental Unit Water Quality
All dental facilities are encouraged to implement water treatment systems that adhere to drinking water standards, ensuring water quality meets the criterion of ≤ 500 CFU/mL of heterotrophic water bacteria. Sole reliance on independent reservoirs, like water-bottle systems, is insufficient for this purpose. Various commercial products and devices are available to enhance the quality of water used in dental procedures. It is advisable to consult with the dental unit manufacturer for suitable water maintenance methods and recommendations for monitoring dental water quality. During surgical procedures, only sterile solutions should serve as coolants or irrigants, utilizing appropriate delivery devices such as sterile bulb syringes, sterile tubing bypassing dental unit waterlines, or sterile single-use devices.
What to look for?
Policies and procedures are in place to maintain the quality of dental unit water according to Environmental Protection Agency (EPA) standards for drinking water. This includes ensuring that the water quality levels are at or below ≤ 500 CFU/mL of heterotrophic water bacteria for routine dental treatment output water.
Policies and procedures have been implemented mandating the exclusive use of sterile water as a coolant/irrigant during surgical procedures.
Program Evaluation
A program, defined by the Centers for Disease Control and Prevention (CDC), comprises a comprehensive set of coordinated activities aimed at achieving specific outcomes in public health. These activities span from policies and interventions to environmental, systems, and media initiatives, as well as preparedness efforts, research endeavors, and capacitybuilding initiatives. Adopting a systematic approach to data collection, analysis, and utilization is crucial for evaluating program effectiveness and efficiency, while also playing a vital role in fostering continuous improvement within programs.
What to look for?
Effective policies are essential for enhancing and accounting for public health actions. Implemented programs can identify issues crucial to the health and safety of both staff and patients.
The concept of universal precautions was developed to ensure that dental healthcare professionals treat each patient as if they are highly contagious. This ensures every infection control measure is taken when treating a patient.
The statements made from this regulatory agency is merely stating procedures and recommendations to the dental health care professional (DHCP) from the public forum. The above text was taken from the CDC document, Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.
Click here to view full article on CDC website.
Understanding
Patient-Care Item
Categories
Each dental device is classified based on its potential use and the risk of disease transmission. When determining whether heat sterilization or disinfection is necessary, it's essential to understand the CDC's recommendations for each risk classification.
Critical
Items
Highest Risk of Transmitting Infection
Penetrate soft tissue or contact bone, enter into or contact the vascular system or other normally sterile tissue.
Must undergo heat sterilization between uses, or sterile single-use disposable devices must be utilized.
Device Examples:
Surgical Instruments, Periodontal Scalers
Semi-Critical
Items
Lower Risk of Transmitting Infection
Contact mucous membranes or non-intact skin (e.g., exposed skin that is chapped, abraded, or affected by dermatitis)
Should undergo heat sterilization or high-level disinfection
NOTE: For semi-critical handpieces, do not subject the handpiece to high-level disinfection, and do not simply wipe the surface with a low-level disinfectant. They should be cleaned and heat sterilized between patient uses.
Device Examples:
Amalgam Condensers, Air Water Syringes, Mouth Mirrors
Non-Critical
Items
Low Risk of Transmission Infection
Contact intact skin
Barrier protection or cleaning and disinfection using a low to intermediate-level disinfectant.
Device Examples:
X-ray head or cone, facebows, blood pressure cuff
Single-Use
Devices
Lowest Risk of Transmission Infection
Intended for single-patient use during a single procedure.
Cannot be reliably cleaned
Device Examples:
Disposable Air Water Syringe Tips, Patient Bibs, Saliva Ejectors
The statements made from this regulatory agency is merely stating procedures and recommendations to the dental health care professional (DHCP) from the public forum. The above statement from the CDC was published in the article, Disinfection of Healthcare Equipment: Guideline for Disinfection and Sterilization in Healthcare Facilities (2008).
Click here to view full article on CDC website.
Cleaning Requirements of
Healthcare Equipment
The CDC has released guidelines to distinguish between instrument risk classifications, highlighting the necessary cleaning requirements for each risk class. Healthcare professionals are expected to adhere to these recommendations to ensure proper disinfection/sterilization of instruments, thus safeguarding patient and staff safety.
Scientific literature and increased awareness of potential infectious agent transmission in dentistry have highlighted dental instruments as potential vectors for pathogen spread. The American Dental Association recommends classifying surgical and other instruments that typically penetrate soft tissue or bone (such as extraction forceps, scalpel blades, bone chisels, periodontal scalers, and surgical burs) as critical devices, requiring sterilization after each use or disposal. Instruments not meant to penetrate oral soft tissues or bone (like amalgam condensers and air/water syringes) but capable of contacting oral tissues are classified as semicritical. Sterilization after each use is advised for heat-tolerant semicritical instruments, and if heat sensitive, high-level disinfection is recommended at a minimum. Handpieces, potentially internally contaminated with patient material, should undergo heat sterilization after each use; those unable to withstand heat sterilization should not be used. Suitable sterilization methods for critical or semicritical dental instruments and heat-stable materials include steam under pressure (autoclave), chemical vapor (e.g., formaldehyde), and dry heat (e.g., 320°F for 2 hours). Steam sterilization is most commonly used in dental practices. However, all three sterilization methods carry the risk of damaging some dental instruments, including steam-sterilized handpieces. Heattolerant alternatives are preferable and widely available for most clinical dental applications.
What is the Difference between
Sterilization and Disinfection
Sterilization and disinfection are crucial procedures employed in microbial control, each fulfilling distinct purposes and demonstrating varying degrees of effectiveness.
Sterilization
Sterilization involves the complete eradication of all microbial life forms, including bacteria, viruses, fungi, and spores, from surfaces, objects, or environments. Its primary objective is to render an entity or setting entirely devoid of viable microorganisms, thereby minimizing the potential risk of infection or disease transmission. Sterilization methods encompass a range of physical techniques such as autoclaving, radiation (gamma and ultraviolet), and filtration, as well as chemical approaches like ethylene oxide gas. This rigorous process ensures an exceptionally high level of microbial control, making it indispensable for critical environments such as surgical suites, medical apparatuses, and pharmaceutical preparations.
Instruments and devices are typically sterilized using the autoclave process, which employs heat or steam under pressure.
Disinfection
Disinfection, on the other hand, involves reducing the population of viable microorganisms to a level considered safe according to prevailing public health standards, although complete elimination may not always be achievable. The primary aim of disinfection is to mitigate the risk of infection by neutralizing or incapacitating pathogenic microorganisms present on surfaces, objects, or within the surrounding environment. Disinfection techniques encompass a variety of chemical agents such as chlorine, hydrogen peroxide, alcohol, and quaternary ammonium compounds, as well as physical modalities like heat and ultraviolet radiation. Widely applied in everyday contexts including households, healthcare facilities, food processing establishments, and water treatment facilities, disinfection plays a pivotal role in curbing the spread of infectious diseases.
Instruments and devices are typically disinfected using a chemical spray or diluted solution.
As outlined by the CDC for Cleaning & Disinfection, disinfection eliminates most pathogenic and other microorganisms through physical or chemical means. In contrast, sterilization eradicates all microorganisms, including resistant bacterial spores, using heat (steam autoclave, dry heat, and unsaturated chemical vapor) or liquid chemical sterilants. Disinfection does not guarantee the same level of safety as sterilization processes.
The above statement from the CDC was published in the article, Disinfection of Healthcare Equipment: Guideline for Disinfection and Sterilization in Healthcare Facilities (2008). Click here to view the full article.
Click here to view full article on CDC website.
Dental Products
and Device Safety
Thousands of devices and products are used at dental offices. Each dental device used serves a particular purpose for each treatment. These products/devices play a major role in ensuring infection control protocols are being met. We have hand-selected a few of these products/devices for you to learn and understand their importance in the dental office.
Air Water
Syringe
As outlined by the CDC for Cleaning & Disinfection, disinfection eliminates most pathogenic and other microorganisms through physical or chemical means. In contrast, sterilization eradicates all microorganisms, including resistant bacterial spores, using heat (steam autoclave, dry heat, and unsaturated chemical vapor) or liquid chemical sterilants. Disinfection does not guarantee the same level of safety as sterilization processes.
Air Water
Syringe Tip
The air water syringe tip is a product that is used on every patient for every procedure. It is inserted into an air water syringe for a treatment and removed when the treatment is completed. The purpose of the air water syringe tip is to irrigate and dry specific areas in the oral cavity during a dental treatment. You should always be aware if an office is using a metal air water syringe tip or a disposable (plastic) air water syringe tip. Science has proven that metal air water syringe tips are impossible to clean. The micro-lumens in the metal air water syringe are smaller than a hypodermic needle, making cleaning impossible. Disposable, single-use air water syringe tips are the preferred tip for infection control best practices. Unlike metal air water syringe tips, single-use tips are thrown away after use. One tip, one patient.
Dental Unit
Waterlines
Dental unit waterlines stand as a pivotal element of infection control and patient care. Ensuring the purity and reliability of dental procedure water is paramount, safeguarding patients and dental healthcare professionals from potential health risks. The presence of biofilm within dental unit waterlines, housing diverse microorganisms such as bacteria, fungi, and protozoa, underscores the importance of proactive measures. Biofilm formation, facilitated by waterline nutrients and system design, fosters microbial accumulation. It is imperative for dental offices to establish protocols for regular testing, cleaning, and maintenance of dental unit waterlines to uphold the safety standards of water used during treatments.
Disinfectants
In dental offices, various cleaners are employed to maintain a hygienic environment by eliminating harmful germs. Known as disinfectants, these products are applied to contaminated surfaces to eradicate pathogens effectively. They come in various forms such as sprays, wipes, and solutions. The disinfection process involves two essential steps. Firstly, the surface must be thoroughly cleaned to remove all traces of blood, debris, and waste. Secondly, the surface is disinfected by applying a suitable disinfectant and allowing the chemicals to activate for the specified contact time, effectively eliminating bacteria, viruses, and potentially harmful fungi
There are three categories of disinfectants:
Low-Level
Disinfectants
Low-level disinfectants are employed for disinfecting noncritical items that have contact with skin. This category encompasses shared patient-care devices utilized by staff across multiple patients during a typical workday, as well as hard surfaces like bed rails and equipment such as blood pressure cuffs. When utilized appropriately, disinfectant wipes registered with the Environmental Protection Agency (EPA) are deemed as low-level disinfectants.
The application of an agent that eradicates all vegetative bacteria (with the exception of tubercle bacilli) and effectively neutralizes most viruses, including the Hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Provided as specific guidance by manufacturers of non-heat tolerant equipment, particularly those susceptible to damage from chemical disinfection methods (such as the lens of an intra-oral camera).
Example:
Alcohol wipes or sprays
Intermediate-Level
Disinfectants
Intermediate-level disinfectants are employed for disinfecting some semi critical items as well as certain noncritical items that may come into contact with individuals. In healthcare settings, this often includes clothing such as scrubs or workwear that could potentially encounter problematic bacteria, infectious materials, or bloodborne pathogens. Additionally, as per guidelines from the Centers for Disease Control and Prevention (CDC), noncritical clinical contact surfaces like operatory surfaces should undergo intermediate-level disinfection between patients. Regulated by the Environmental Protection Agency (EPA).
The utilization of an agent capable of eliminating a broader spectrum of pathogens compared to a low-level disinfectant, albeit without the ability to eradicate bacterial spores.
Used on operatory room equipment, hard surfaces, reception area (chairs and doorknobs), and non-critical equipment (blood pressure cuff, x-ray cone head, etc.)
Example:
Hard surface disinfectant spray and disinfectant wipes.
High-Level
Disinfectants
High-level disinfectants are employed for semicritical items that will encounter either mucous membranes or compromised skin. Typically found solely in healthcare environments, these disinfectants are designed to eliminate endospore-forming bacteria, which can propagate infections within facilities. Sporicidal disinfectant products are commonly utilized in surgical centers or facilities vulnerable to hazardous microorganisms. Additionally, they may be stocked in low-risk facilities as a precautionary measure in the event of bacterial resistance or disease outbreaks. Regulated by the FDA.
Complete eradication of all microorganisms present on or within an instrument, with the exception of minimal quantities of bacterial spores.
Instead of relying solely on high-level disinfectants, it is advisable to clean non heatsensitive dental supplies using an enzymatic cleaner to eliminate dried blood and debris. Subsequently, these items should be dried and heat-sterilized in an autoclave to eradicate all living microorganisms.
Example:
Products with a mixture of glutaraldehyde, hydrogen peroxide or orthophthalaldehyde, and peracetic acid with hydrogen peroxide.
Mask
Personal protective equipment (PPE) that is used to prevent or minimize exposure to hazards (blood, saliva, debris, aerosols). There is a lot to understand about surgical masks. Often confused with respirators, surgical masks are completely different in how they protect. The basic idea to understand is that masks protect others when you talk, cough or sneeze. Respirators protect the wearer when they breath in and offers no protection to others. For example, if a dentist is wearing a mask, they are protecting the patients and dental staff. If a dentist is wearing a respirator, he is protecting himself. In a dental office you will find staff wearing, a majority of the time, surgical masks.
Masks are available in three different levels of protection: ASTM Level 1, ASTM Level 2, ASTM Level 3
ASTM Level 1
Surgical Masks
Low barrier protection
Ideal for procedures in which there is low risk of fluid exposure (no splashes or sprays expected).
ASTM Level 2
Surgical Masks
Moderate barrier protection
Ideal for procedures in which there is moderate risk of fluid exposure (splashes or sprays can be produced).
ASTM Level 3
Surgical Masks
High barrier protection
Ideal for procedures in which there is high risk of fluid exposure (splashes or sprays will be produced).
Mask protection levels are tested based on five performance criteria
Bacterial Filtration
Efficiency (BFE):
Assesses the mask's ability to filter out bacteria larger than three microns through testing.
Particulate Filtration
Efficiency (PFE):
Evaluates the mask's capability to filter out particles larger than one micron.
Fulid Resistance
Measures the mask's resistance to penetration by approximately 2 mL of synthetic blood at high velocity, with test results indicating a pass or fail based on visual inspection.
Breathability
Tests the mask's resistance to controlled airflow, with lower breathing resistance indicating greater user comfort.
Flammability
Determines the time taken for an exposed flame to progress up the mask material at a distance of five inches, with normal flammability classified as Class One.
Once ASTM tested, masks will fall into one of the three protection categories
| TEST | LEVEL ONE MASK | LEVEL TWO MASK | LEVEL THREE MASK |
|---|---|---|---|
| ASTM F1862 (Fluid Resistance) | 80 mmHg | 120 mmHg | 160 mmHg |
| MIL-M.36954 C (Breathability) | <4 mm H20 | <5 mm H20 | <5 mm H20 |
| ASTM F2101: Bacteria Filtration Efficiency (BFE) (Filtration) | ≤ 95% | ≤ 98% | ≤ 98% |
| ASTM F2299: Particle Filtration Efficiency (BFE) (Filtration) | ≤ 95%@01 micron | ≤ 98%@01 micron | ≤ 98%@01 micron |
| 16 CFR Part 1610 (Flammability) | Class One | Class One | Class One |
At a dental office, masks should always be worn during a treatment by all dental staff. It protects you from germs present in talking, coughing, or sneezing. If a dental healthcare professional is not wearing a mask during a procedure, this is a major lack in infection control policies. For optimal protection, dental staff should be wearing N95 respirators.
Gloves
Personal protective equipment (PPE) that is used to prevent or minimize exposure to hazards (blood, saliva, debris, aerosols). Gloves should be worn by the dentist, hygienist, and dental assistant when treating a patient. New gloves should be worn for every patient. If a dental healthcare professional has to leave mid-treatment, the gloves should be removed and thrown away. Once the dental healthcare professional returns, new gloves should be worn. Upon completion of a dental treatment, gloves should be removed and placed into the proper trash receptacle. Gloves are to be used on one patient and immediately discarded. This eliminates one avenue of dental cross contamination.
Dental gloves are available in multiple sizes and colors based on operator's preference. In dentistry, there are three main materials used, latex, vinyl, and nitrile and are classified as sterile or non-sterile.
Latex Gloves
Latex is renowned as the most commonly utilized material for gloves due to its exceptional protection against chemicals and bodily fluids. With greater resistance and adaptability compared to vinyl gloves, latex gloves offer a cost-effective solution. Additionally, their superior elasticity makes them the most comfortable option available. The primary concern associated with gloves is the potential for allergies, particularly with latex gloves. Constructed from natural rubber, latex gloves can trigger allergic reactions in certain individuals.
Vinyl Gloves
Vinyl gloves exhibit higher permeability, lower resistance, and reduced adaptability compared to their counterparts. While they are more affordable than nitrile gloves, they are also less durable than both latex and nitrile options. Moreover, vinyl gloves may not conform as well to the hand, limiting the professional's dexterity and increasing the likelihood of snagging or tearing. Vinyl gloves are the least common gloves used in dentistry.
Nitrile Gloves
Nitrile gloves are renowned for their exceptional resistance to biological agents and chemical substances, boasting three times the puncture resistance of latex gloves. While a punctured nitrile glove may tear completely, this serves as a vital indicator for timely replacement, ensuring continued protection for your hands. Nitrile gloves are widely used in the dental office.
Gloves are required to be used during dental treatments to eliminate dental cross contamination. If you are being treated by a dental healthcare professional that does not wear gloves, it shows a major lack of infection control protocols.
Eyewear
Personal protective equipment (PPE) that is used to prevent or minimize exposure to hazards (blood, saliva, debris, aerosols). Eyewear is used to protect the dental staff from splashing of blood, saliva, debris, and aerosols during a treatment. Offices that understand infection control control concerns also give patients eyewear to wear during procedures due to the splashing and aerosols created during a procedure. There are many products used during a dental treatment that create large amounts of aerosolized splashes. If you have ever been to the dentist, you see this particularly when the air water syringe is being used. Protective eyewear protects your eyes this particularly when the air water syringe is being used. Protective eyewear protects your eyes from these contaminated aerosols.
Protective eyewear comes in many shapes and sizes and are available in disposable options for patients. Not all dental offices give patients protective eyewear during treatments, but it is recommended to do this for added safety during a treatment.
Dental Barriers
Dental barriers, sheaths, protective sleeves are all common names for these products. Normally these products are part of a risk management strategy to be used on high-touch surfaces and devices and are chosen for regular disinfection to minimize the risk of cross-contamination between clients. These barrier products are made to reduce cross-contamination at major points of contact in a dental office. You will notice these products everywhere in a dental office. Common places to find these products, for example, are on x-ray handles, dental chair headrests, air water syringes, dental trays, and computer keyboards. Dental barriers are disposable and should be removed and thrown in the proper trash receptacle after a patient has been seen in that operatory.
Dental barrier protection products are meant to eliminate high touch areas of dental cross contamination. If you do not notice barrier products in the dental office, this should raise a red flag with that office's infection control policies.
Safety Breaches Are
A Common Occurrence
Safety Breaches Are More Common Than You Think
The ongoing advancements in the fields of science and technology have undeniably contributed to the enhanced safety of dental procedures. However, it is crucial to recognize that there is still substantial room for further infection control improvement in ensuring the utmost safety of patients within dental settings. A significant concern persists in the continued utilization of certain dental devices, despite our well-established knowledge of the inherent safety risks they pose.
One critical challenge that warrants increased attention and scrutiny is the maintenance and treatment of dental unit water lines (DUWLs). Dental unit waterlines are becoming a hot topic in dentistry due to recent cases of patients getting sick. But this is not the only item in a dental office that is a cause for concern. There are many products/devices that need to gain more attention before it is too late. It is imperative that the public becomes informed about the potential safety risks associated with these devices, as their continued use persists within the dental profession.
At present, state-mandated health inspections often rely on whistleblowers or patient concerns to trigger investigations. This means that the responsibility for ensuring compliance with health and safety protocols predominantly falls on dentists, orthodontists, and hygienists. Unfortunately, instances of safety breaches continue to plague dental offices, with cases of gross negligence emerging worldwide. Such lapses in adherence to safety standards can directly impact the health and well-being of patients and their families.
The paramount question that emerges is what it will take to instigate the necessary changes? Must we wait until patients or their families fall ill to prompt action? It is evident that we must adopt a proactive stance by implementing infection control preventive measures rather than relying solely on reactive responses to issues.
Infection Control
Timeline
Deadly disease discovered
CDC report identifies new disease with alarming mortality rate. No safety protocols were established to deal with the new HIV epidemic.
1981
No regulations
HIV-positive dentist in Florida continues to practice. There were no regulations on infected dental practitioners. At the time practitioners were able to continue working iwth concealed illnesses. Informing the public about the inherent risks that certain dentists had was not regulated.
1987
First dentist-to-patient transmission of HIV
CDC report announces first dentist-to-patient transmission of HIV in a clinical setting. Kimberly Bergalis, age 23, died after contracting the HIV virus from dentist Dr. David J. Acer. The Bergalis case established a public outcry for public reforms in regards to the way patients were treated and how healthcare professionals should have to inform patients if they were infected. This case also sparked the need to make drastic reforms on how infection control protocols and safety equipment should be used in a medical setting.
1991
Protective equipment becomes mandatory
Personal protective equipment (gloves, masks), and barrier equipment becomes mandatory for dentists. It is important to note that eleven years lapsed between this groundbreaking rule change, and the very first AIDS case identified in San Francisco by the CDC in 1981. It took eleven years for the healthcare industry to realize gloves and masks should be mandatory operating procedure. The Dr. Acer dental scare was the only reported case during this time period. How many other cases do you think went unreported in those eleven years?
1992
First case of patient-to-patient transmission of hepatitis C
Dr. Scott Harrington's office in Oklahoma is the first case of patient-to-patient transmission of hepatitis C in a clinical setting. Due to lack of proper infection control protocols, over 7,000 patients were informed to seek medical blood testing to test for HIV, hepatitis B and C. Of the patients tested, 89 tested positive for hepatitis C, 5 for hepatitis B, and 4 for HIV.
2013
Patients at risk of infection
Five former patients of HIV-scare dentist Desmond D'Mello test positive for hepatitis C. More than 22,000 patients were called in for testing after dentist was found to be violating multiple infection control protocols. Investigations began after a young woman died weeks after being treated by Dr. Desmond D'Mello.
2015
Dental infection outbreak at Anaheim clinic
Pediatric dental infections contracted at an Anaheim clinic increased to 22 on Tuesday, as Children's Dental Group said most of the 500 children who underwent root canals there have been examined for signs of illness. Among the 22 patients, ages 3 to 9, six remain hospitalized.
2016
CDC Update 2018
CDC guidelines for infection prevention and control state that, between patients, dental health care personnel (DHCP) should clean and heat-sterilize handpieces and other intra-oral instruments that can be removed from the air and waterlines of dental units.
2018
Unsanitary sterilization practices
The Galveston County Health Department revealed an audit of CHWC's dental offices found unsanitary sterilization practices for the past three years and might have led about 9,500 former patients to have contracted hepatitis B, hepatitis C, and/or HIV.
2018
Two high-profile safety breaches
Two high-profile safety breaches have highlighted the importance of close adherence to infection control protocols in dental clinics and offices. In both recent cases, patients have been advised to undergo testing for HIV and hepatitis B and C due to possible exposure to bloodborne pathogens.
2019
COVID-19
COVID-19, an airborne virus, creates a world-wide pandemic and effectively shuts down the world for months. Dental offices are closed to prevent the spread of the disease.