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									                                Infection Control with a Twist

                        A Very Special thanks the Sponsors who make this course possible:

 This class is intended to offer general guidance to the dental professional in understanding infection control. It was developed using
CDC, DBC, OSHA, OSAP, and other various materials. Please be aware many areas of regulation are not clearly defined and must be
                                              interpreted according to the procedure or task.

                                               Time for a check-up?
 “Guidelines for Infection Control in Dental Health-Care Settings — 2003” and the new “Guideline for
Disinfection and Sterilization in Healthcare Facilities, 2008” offers both science-based and strong
theoretical advice designed to prevent or reduce the risk of disease transmission from patient to dental
worker, from dental worker to patient, from dental worker to dental worker and from patient to patient. The
document consolidates and updates previous recommendations from CDC and other agencies and discusses
concerns not addressed in earlier recommendations for dentistry. To view the full document, visit
Is it time for you to do a check up and evaluate the effectiveness of your program? Use this handout as a
guide to evaluate your current program.

Major additions and changes to the 2003 guidelines include:
❍ application of standard precautions                      hand antisepsis;
rather than universal precautions;                         ❍ contact dermatitis and latex hypersensitivity;
❍ work restrictions for dental healthcare                  ❍ sterilization of unwrapped instruments
personnel infected with or occupationally                  (“flash” cycles);
exposed to infectious diseases;                            ❍ dental water quality;
❍ management of occupational exposures to                  ❍ dental radiography;
bloodborne pathogens such as hepatitis B virus             ❍ aseptic technique for parenteral medications;
(HBV), hepatitis C                                         ❍ oral surgical procedures;
virus (HCV); and human
                                                           ❍ tuberculosis (TB); and
immunodeficiency virus (HIV);
                                                           ❍ infection control program evaluation
❍ selection and use of devices with sharps
safety features;
❍ hand-hygiene products and surgical
The CDC guidelines apply to all paid or unpaid dental healthcare personnel (DHCP) who might be
occupationally exposed to blood and body fluids by direct contact or through contact with contaminated
supplies, equipment, environmental surfaces, water, or air. Although the guideline focus mainly on
outpatient dental settings, the recommended infection control practices can be applied to all settings where
dental treatment is provided.

              Noel Kelsch RDHAP
                         Infection Control with a Twist

                                                    Personnel Health Elements of an Infection

Control program                                     treatment, and medical follow-up of occupational
❍ Does the practice setting have a written health   exposures?
program for DHCP?
❍ Does this written program specify policies,       Education and training
procedures, and guidelines for:                     ❍ Have DHCP been educated and
❑ education and training?                           trained on their risk of occupational
❑ immunizations?                                    exposure to potentially infectious
                                                    agents and the necessary infection-control
❑ exposure prevention and postexposure
                                                    procedures/protocols to safely perform their
                                                    assigned duties?
❑ medical conditions, occupational
                                                    ❍ Was this training provided:
illness, and related work restrictions?
                                                    ❑ at the time of initial employment?
❑ contact dermatitis and latex hypersensitivity?
                                                    ❑ when new tasks or procedures affect
❑ maintenance of records, data management and
                                                    occupational exposure?
                                                    ❑ at least annually?
❍ Have referral arrangements been established
with a qualified healthcare professional/facility   ❍ Were the training materials and procedures
to ensure prompt and appropriate delivery of        clear and easy to understand?
preventive services, occupationally related
medical                                             Postexposure management
services, and postexposure management               ❍ Do DHCP know to report occupational
with any necessary medical follow-                  injuries and exposures immediately?
up?                                                 ❍ When an occupational exposure occurs, is an
❍ Is a list of all required and recommended         exposure incident report
immunizations for dental                            created listing:
workers maintained? When was this list last         ❑ date and time of exposure;
updated?                                            ❑ details of the procedure being performed,
date: _________________________                     including how and where
❍ Is it consistent with the latest                  the exposure occurred; if related to
recommendations from public health agencies on      a sharp device, the type and brand
appropriate immunizations for healthcare            of device and how and when the exposure
workers?                                            occurred in the course of
❍ Have at-risk DHCP been referred to                handling/using the device;
the facility’s prearranged qualified                ❑ details of the exposure, including
healthcare professional or to their own             type and amount of fluid or material
healthcare professional to receive appropriate      and the severity of the exposure
immunizations?                                      (for example, for percutaneous
❍ Is baseline tuberculin skin testing provided      exposure, the depth of the injury and whether
for clinical DHCP who might                         fluid was injected; for a skin or mucous
have contact with persons with suspected or         membrane exposure, the estimated volume of
confirmed infectious TB?                            material and the condition of the skin [chapped,
❍ Is a comprehensive postexposure                   cut, abraded, intact]);
management and medical follow-up program in         ❑ details about the exposure source
place?                                              (whether the source material contained
❍ Does this program:                                HBV, HCV, or HIV; if the source patient is
                                                    HIV-positive, the stage of disease, history of
❑ include policies and procedures for
prompt reporting, evaluation,counseling,
                                                    medication, viral load, drug resistance, if
           Noel Kelsch RDHAP
                        Infection Control with a Twist

❑ details about the exposed person               Preventing Transmission of Bloodborne
(vaccination and vaccine-response                Pathogens
status); and ❑ details about counseling,
postexposure management, and follow-up.          HBV vaccination
❍ When an exposure incident occurs, is           ❍ Have DHCP been informed of the
the injured worker and the exposure              risks of HBV transmission and the
report immediately sent for medical              availability of the hepatitis B virus
evaluation?                                      (HBV) vaccine?
                                                 ❍ Have DHCP been offered the HBV
Medical conditions, work-related illness, and    vaccination series?
work restrictions                                ❑ Was serologic testing performed 1-
❍ Does the practice setting have comprehensive   2 months after vaccination to confirm
written policies on work restrictions and        immunity?
exclusions that include a                        ❍ Did DHCP who declined vaccination
statement of authority defining who              sign a declination form for their medical
can implement such policies?                     record file?
❑ Are these policies readily available
to DHCP?                                         Preventing exposures to blood and
❑ Do these policies encourage workers            other potentially infectious materials
to seek appropriate preventive                   ❍ Are standard precautions used during
and curative care and to report any              all patient encounters?
illnesses, medical conditions, or                ❍ Does the practice setting have a written,
treatments that can make them                    comprehensive program designed to minimize
more susceptible to opportunistic                and manage DHCP exposures to blood and body
infection or exposures?                          fluids?
❑ Do these policies protect against              ❍ To prevent injuries from contaminated sharps,
lost wages, benefits, or job status in           does the practice setting use:
the event of such an illness or medical          ❑ engineering controls (such as sharps
condition?                                       containers, automated instrument
❍ Are policies and procedures in place for       cleaners, safety needles, nonneedle
evaluating, diagnosing, and managing workers     sharps, needle recappers, and other
with suspected or known occupational contact     safer medical devices)?
dermatitis?                                      ❑ work practices (such as the one handed scoop
❑ Does the facility’s policy provide for         technique and
definitive diagnosis and management              placement of sharps containers
advice (for example, treatment,                  nearest their point of use in the operatory)?
work restrictions, and accommodations)
by a qualified healthcare professional?          Engineering controls
                                                 ❍ Does the practice setting identify, evaluate,
Records maintenance, data management, and        and consider for use devices with engineered
confidentiality                                  safety features (for example, safer anesthetic
❍ Does the practice setting establish and keep   syringes, blunt suture needles, retractable
confidential DHCP medical                        scalpels, or needleless IV systems):
records, such as immunization records            ❑ at least annually?
and documentation of tests received              ❑ as they reach the dental market?
as a result of occupational exposure?
❍ Is the practice setting in compliance          Work practice controls
with all applicable federal, state, and          ❍ Are disposable syringes and needles,
local laws for medical recordkeeping             scalpel blades, and other sharp items placed in
and confidentiality?                             appropriate puncture-resistant

           Noel Kelsch RDHAP
                         Infection Control with a Twist

containers?                                         ❍ Are DHCP fingernails kept short, with
❑ Are these containers located as close             smooth, filed edges to allow thorough cleaning
as possible to the area where the                   and prevent glove tears?
sharps are used?                                    ❍ Are artificial fingernails discouraged
❍ When needles must be recapped,* are               among DHCP in the practice setting?
needle recapping devices or the one handed          ❍ If it affects glove donning or fit, is hand or
scoop technique used?                               nail jewelry removed for patient care?
* For example, between multiple injections and
before removing from a nondisposable aspirating     Personal Protective Equipment
syringe.                                            ❍ Is task-appropriate personal protective
                                                    equipment (PPE) worn when exposure to blood
Hand Hygiene                                        and body fluids is expected?
❍ Are hands washed with a nonantimicrobial or       ❍ Is barrier protection (including gloves, mask,
antimicrobial soap and water when they are          eyewear, and gown) removed before departing
visibly dirty or contaminated with blood or other   work areas such as operatories,
potentially infectious material?                    the instrument processing room, or the dental
❍ Is hand hygiene performed:                        lab?
❑ after accidental barehanded touching
of inanimate objects likely to be                   Face and eye protection
contaminated by blood, saliva, or                   When performing procedures likely to
respiratory secretions?                             cause splash or spatter:
❑ before and after treating each                    ❍ Are surgical masks worn?
patient?                                            ❍ Is eye protection with solid side shields or a
❑ before donning gloves?                            face shield worn to protect mucous membranes
❑ immediately after removing gloves?                of the eyes, nose, and mouth?
❍ Before oral surgical procedures, is surgical      ❑ Are masks changed between patients?
hand antisepsis performed before donning sterile    ❑ Are masks changed during patient
surgeon’s gloves? (Surgical hand antisepsis         treatment if they become wet?
involves using either                               ❍ Between patients, is reusable face protection
(a) an antimicrobial soap and water or              (eyewear, face shields) cleaned
(b) a plain soap and water handwash                 with soap and water?
followed by an alcohol-based hand rub               ❍ If visibly soiled, is reusable face protection
with persistent activity.)                          (eyewear, face shields) cleaned and then
❍ Are liquid hand-care products stored in either    disinfected according to the disinfectant
disposable closed containers or                     manufacturer’s directions?
closed containers that can be washed
and dried before refilling?                         Protective clothing
❑ Are refillable containers always                  ❍ Is protective clothing worn over street
washed and dried (and not simply                    clothes or uniforms to protect against
“topped off”) before refilling?                     splash or spatter?
❍ Are hand lotions used to prevent skin             ❑ Is protective clothing changed
dryness associated with handwashing?                when it is visibly soiled or penetrated
❑ Are the lotions used during the                   by blood or other potentially infectious
clinic day free of petroleum or other               fluids?
oil skin softeners that degrade glove
materials?                                          Gloves
❑ Are the lotions used during the                   ❍ Are medical gloves worn when contact with
clinic day compatible with the antiseptics in       body fluids is expected?
hand hygiene products?

            Noel Kelsch RDHAP
                        Infection Control with a Twist

❍ Are sterile surgeon’s gloves worn when          ❍ Are instrument packages allowed to
performing or assisting on oral surgical          dry in the sterilizer before they are handled?
procedures?                                       (This prevents contamination.)
❍ Is a new pair of medical gloves worn            ❍ Have heat-sensitive semicritical instruments
for each patient?                                 been replaced with heat-tolerant or disposable
❍ Are gloves removed promptly after use, and      versions?
is hand hygiene performed immediately             ❑ If heat-sensitive instruments are
thereafter?                                       used in patient care, are they cleaned
❍ Are torn, cut, or punctured gloves removed as   and then processed using an FDAcleared
soon as possible and hands                        sterilant/high-level disinfectant
immediately washed before regloving?              or an FDA-cleared low-temperature
❍ Are gloves available in the correct size and    sterilization method? Note: Never use liquid
readily accessible?                               chemical sterilants/ high-level disinfectants for
❍ Are puncture-/chemical-resistant utility        environmental
gloves worn when processing instruments and       surface disinfection or as holding solutions.
performing housekeeping tasks that involve        ❑ Are the manufacturer’s instructions
contact with body fluids?                         for preparation, use, and reuse of
                                                  chemical sterilants/high-level disinfectants
Contact Dermatitis and Latex Allergy              always followed?
❍ Have DHCP been informed of the                  ❍ Have all DHCP been trained on
signs, symptoms, and diagnoses of skin            OSHA guidelines for exposure to
reactions associated with frequent hand           chemical disinfectants/sterilants?
hygiene and glove use?                            ❑ Have areas and tasks that have potential for
❍ Are all patients in the practice setting        such exposure been
screened for latex allergy?                       identified?
❍ Can a latex-safe environment be provided        ❍ Are single-use disposable instruments
for patients and DHCP with                        used on only one patient and then
latex allergy?                                    properly discarded?
❍ Are latex-free emergency treatment kits         ❍ Are all noncritical patient-care items
available and accessible at all times?            barrier-protected during use? Alternatively, are
                                                  they cleaned (or if visibly soiled, cleaned and
Sterilization and Disinfection of Patient-Care    disinfected) after each use?
Items                                             ❑ Is an EPA-registered hospital disinfectant
❍ Are only FDA-cleared medical devices used       used to clean/disinfect
for heat sterilization?                           noncritical patient-care items that
❑ Are manufacturer instructions for               are not barrier-protected during
operation always followed? (Hint:                 use?
Posting procedural checklists near                ❑ If noncritical patient-care items are
the equipment can help ensure that                visibly contaminated with blood,
devices are used correctly.)                      are the items properly cleaned to remove
❍ Are all reusable critical dental instruments    soil, then disinfected using an EPA-registered
cleaned, dried, packaged, and                     hospital disinfectant
                                                  with a tuberculocidal claim?
then heat-sterilized before use? ❍ Are all
reusable heat-tolerant semicritical
                                                  The instrument processing area
dental instruments cleaned and
then heat-sterilized before use?                  ❍ Does the practice setting have a designated
                                                  central processing area?
❍ Are items and instrument packages
correctly and loosely loaded into the             ❑ Is the area divided physically, or at
sterilizer to allow penetration of the            least spatially, into separate areas
sterilizing agent?                                for:
                                                  • receiving, cleaning, and decontamination;
           Noel Kelsch RDHAP
                          Infection Control with a Twist

• preparation and packaging;                       type of sterilization process used? (Packaging
• sterilization; and                               instruments in cassettes or trays before
• storage.                                         sterilization maintains their
❍ Are work practice controls used to minimize      sterility after the sterilization cycle.)
handling of loose contaminated instruments         ❍ Is an internal chemical indicator placed inside
during transport to the instrument                 each instrument package prior to sterilization?
processing area? For example:                      ❑ If the internal indicator is not visible
❑ Are instruments transported in a                 from outside the package, is an external
covered container?                                 indicator affixed to the pack?
❍ Are dental team members trained to               ❍ Are packages labeled with the date and if
use work practices that prevent contamination of   multiple sterilizers are used within
clean areas? For example:                          the facility, the sterilizer used? (This
❑ Are sterilized instrument packs and              simplifies retrieval of processed items
clean supplies stored away from the                in case of a sterilization failure.)
area where contaminated instruments
are held or cleaned?                               Unwrapped instruments
                                                   Although not recommended for routine
Receiving, cleaning, and                           instrument processing, certain circumstances
decontamination work area                          may demand that instruments be processed
❍ Are dental instruments and devices               unpackaged (for example, the only available
cleaned of all visible blood and other             instrument falls to the floor during patient care).
contamination before they are sterilized           If it is necessary to
or disinfected?                                    sterilize instruments without packaging,
❑ Is automated cleaning equipment                  for example, using a flash cycle:
(such as an ultrasonic cleaner or                  ❍ Are instruments cleaned and dried before the
washer-disinfector) used to remove                 unwrapped sterilization cycle?
debris, improve cleaning effectiveness,            ❍ Are mechanical and chemical indicators used
and decrease worker exposure                       for each unwrapped sterilization cycle? (Place an
to blood?                                          internal chemical indicator among the
❑ Are work practice controls (such as a            instruments or items to be sterilized.)
long-handled brush) used to minimize               ❍ Are unwrapped instruments allowed to dry
contact with sharp instruments if manual           and cool in the sterilizer before
cleaning is necessary?                             they are handled? (This prevents contamination
❍ Are puncture-/chemical-resistant utility         and thermal injury.)
gloves worn when handling contaminated             ❍ Are unwrapped semicritical instruments
instruments and performing instrument cleaning     sterilized on a tray or in container system?
and decontamination procedures?                    ❍ Are critical instruments that are sterilized
❍ Is appropriate PPE (a mask, protective           without packaging handled to
eyewear, and protective clothing) worn when        maintain sterility during removal from
splashing or spraying is anticipated during        the sterilizer and transport to the point
cleaning?                                          of use? For example:
                                                   ❑ Are they transported to the operatory
Preparation and packaging                          in a sterile covered container?
❍ After cleaning, are critical and semicritical    ❍ Are sterilized, unwrapped critical instruments
instruments inspected for remaining debris?        used immediately after they
❍ Before sterilization, are instruments            have cooled? (Do not store critical instruments
and other patient-care items packaged              unwrapped.)
using an FDA-cleared container system
or wrap that is compatible with the                Implantable devices
                                                   ❍ Are implantable devices always packaged for
            Noel Kelsch RDHAP
                          Infection Control with a Twist

❍ Is a biological indicator always included in        minimize the chance of contamination?
each package containing an implantable device?        ❍ Are wrapped packages of sterilized
❑ Are biological monitoring results received          instruments
and recorded before the implantable device is         examined before they are opened to ensure the
surgically placed?                                    packaging (and
                                                      sterility of the instruments inside) has
Sterilization monitoring                              not been compromised?
❍ Are mechanical, chemical, and biological            ❑ If packaging has been compromised,
monitors used according to the manufacturer’s         are the contents recleaned, repacked, and
instructions to ensure                                resterilized?
the effectiveness of the sterilization                ❍ Does the practice setting use either
process?                                              date- (“first in, first out”) or event-related storage
❍ Is each load monitored with mechanical and          for wrapped, sterilized instruments and devices?
chemical indicators?                                  (Both methods
❍ Is a chemical indicator placed on the               are considered acceptable.)
inside of each instrument package to
be sterilized?                                        Managing Environmental Surfaces
❑ Is there an internal chemical indicator and an      ❍ Are surface barriers used to protect
external chemical indicator?                          clinical contact surfaces from contamination,
chemical indicator? (2008 guidelines)                 especially those that are difficult to clean? (2008
❍ If mechanical or chemical indicators                guidelines)
suggest inadequate processing, are instruments        ❑ Are surface barriers changed between
pulled from recirculation,                            patients?
repackaged, and sterilized again with                 ❍ If they are not barrier protected during patient
new indicators?                                       care, are clinical contact surfaces cleaned and
❍ Are sterilizers monitored at least weekly           disinfected between
using a biological indicator and a                    patient appointments?
matching control? (Using both a test                  ❑ For clinical contact surfaces that are
and a control indicator from same lot                 not visibly contaminated with
ensures that factors outside of the sterilization     blood, are surfaces cleaned and then
process have not affected the                         disinfected using an EPA-registered
spores’ ability to be cultured.)                      hospital disinfectant with (a) HIV
❑ Is the test indicator placed within                 and HBV kill (at minimum) and/or
an instrument pack and sterilized                     (b) tuberculocidal activity?
with a normal load?                                   ❑ Are clinical contact surfaces that are
❑ Is the control indicator — which is                 visibly contaminated with blood
not subjected to a sterilization cycle                cleaned and then disinfected using a
— incubated at the same time as                       hospital disinfectant with tuberculocidal
the test indicator?                                   activity?
❍ If a spore test comes back positive, are proper     ❍ Prior to disinfection, are manufacturer
troubleshooting procedures implemented? (For a        instructions for precleaning surfaces closely
flowchart on managing sterilization failures, visit   followed?           ❍ After cleaning, is the disinfectant allowed to
❍ Are sterilization records (mechanical,              remain on the treated surface
chemical, and biological) maintained                  for the contact time stated on the
in compliance with state and local regulations?       product’s label?
                                                      ❍ Is appropriate PPE in place when
Storing patient-care items                            cleaning and disinfecting environmental
❍ Are sterile items and dental supplies               surfaces? For example:
stored in covered or closed cabinets to               ❑ puncture- and chemical-resistant
                                                      utility gloves,
            Noel Kelsch RDHAP
                         Infection Control with a Twist

❑ protective clothing (such as a gown,             ❍ Are sharp items (needles, scalpel blades,
jacket, or lab coat), and                          orthodontic bands, broken metal instruments,
❑ face protection (protective eyewear/             burs) placed in a punctureresistant, leakproof,
face shield with a mask).                          color-coded/biohazard-labeled sharps container?
❍ Are housekeeping surfaces such as                ❑ Are sharps containers closed immediately
floors, walls, and sinks routinely                 before they are removed or
cleaned using either a detergent and               replaced to prevent contaminated
water or an EPA-registered hospital                sharps from spilling or protruding?
disinfectant/detergent?                            ❍ If allowed by state and local law, are
❍ Are cleaning schedules set by the nature of      blood, suctioned fluids, and other liquid
the housekeeping surface, the                      waste carefully poured down a drain
type and degree of contamination, and              connected to a sanitary sewer system?
if appropriate, location in the facility?          ❑ Are gloves, face protection (mask
❍ Are housekeeping surfaces cleaned and            with protective eyewear/face shield), and
disinfected when visibly soiled?                   protective clothing worn when performing this
❍ Are mops or cloths cleaned after use and         task?
allowed to dry before reuse, or are single-use,
disposable mop heads or cloths used to clean       Extracted teeth
housekeeping surfaces?                             ❍ Are extracted teeth disposed of within
❍ Are fresh cleaning or EPA-registered             the practice setting treated as regulated
disinfecting solutions prepared daily and as       medical waste? (If the teeth are returned
instructed by the manufacturer?                    to the patient, waste disposal
❍ Are walls, blinds, and window curtains in        regulations do not apply.)
patient-care areas cleaned when they are visibly   ❍ Are extracted teeth containing amalgam
dusty or soiled?                                   discarded in regulated medical waste containers
❍ Are surfaces contaminated by spills of blood     that will not be incinerated? (Incineration
or blood-contaminated fluids                       releases mercury vapor from amalgam, creating a
first cleaned and then decontaminated?             hazard.)
After cleaning, is an EPA-registered               When extracted teeth will be used in educational
hospital disinfectant with HBV and                 settings or sent to a dental lab:
HIV label claims (minimum) and/or                  ❍ Are extracted teeth cleaned and placed in a
tuberculocidal activity used for disinfection,     leakproof container with solution to maintain
depending on size of spill and surface porosity?   hydration during transport?
                                                   ❑ Is the transport container labeled
Regulated Medical Waste                            with the biohazard symbol?
❍ Does the practice setting have a written         ❍ Are teeth that do not contain amalgam heat-
medical waste management program that              sterilized before they are used for educational
outlines proper disposal of regulated medical      purposes?
waste as dictated by federal, state, and local
regulations?                                       Dental Unit Waterlines, Biofilm, and
❍ Are DHCP who handle and dispose                  Water Quality
of regulated medical waste trained in              ❍ Does the water used in routine patient
proper handling and disposal methods?              treatment meet EPA standards
❑ Are they informed of the possible                for drinking water (that is, less than
health and safety hazards associated               500 CFU/mL of heterotrophic water
with medical waste?                                bacteria)?
❍ Are leakproof, color coded/biohazardlabeled      ❍ Are the products and protocols recommended
containers (for example, biohazard                 by your dental unit manufacturer
bags) used to contain nonsharp                     used to maintain water quality?
regulated medical waste?                           ❍ Are recommendations for monitoring
                                                   water quality followed? (Obtain and
            Noel Kelsch RDHAP
                         Infection Control with a Twist

follow monitoring schedules recommended by          ❍ Are exposed radiographs films transported
the dental unit manufacturer and/or the maker of    and handled aseptically to prevent contamination
the waterline treatment device/chemical.)           of developing
❍ For devices that are connected to the             equipment?
dental water system and enter the patient’s
mouth, are water and air discharged for at least    Digital radiography
20-30 seconds after use on each patient? (Such      If your practice setting uses a digital x-ray
devices include handpieces, ultrasonic scalers,     system with intraoral sensors:
and air/water syringes.)                            ❍ Are equipment manufacturer instructions for
❍ If the dental unit is equipped with               cleaning, disinfection, and/or sterilization of
antiretraction mechanisms, are the unit             digital radiology sensors and for protection of
manufacturer’s recommendations for                  associated computer hardware followed?
periodic maintenance followed?                      ❍ Are FDA-cleared barriers used on sensors to
❍ Are staff aware of procedures to follow in the    protect them from contamination during use on a
event of a boil-water advisory?                     patient?
                                                    ❍ After use on a patient, are sensors
Dental Handpieces, Other Devices                    cleaned and then either heat-sterilized
Attached to Air Lines and Waterlines                or immersed in a liquid sterilant/
❍ Are handpieces and other intraoral                high-level disinfectant for the
instruments that can be removed from                contact time recommended by the
the air and waterlines of dental units              manufacturer? If sensors cannot tolerate heat or
cleaned and then heat-sterilized between            liquid chemical immersion:
patients?                                           ❍ Are FDA-cleared barriers used on sensors to
❍ Are manufacturer’s instructions for               protect them from contamination during use on a
cleaning, lubrication, and sterilization            patient?
of other such intraoral instruments followed        ❍ Are barriers removed and sensors
every time the instruments are                      cleaned and then disinfected using an
processed for reuse? (Failure to follow             EPA-registered hospital disinfectant
manufacturer instructions can void                  with a tuberculocidal claim?
equipment warranties.)
❍Are all hand pieces autoclavable or removed        Aseptic Technique for Parenteral Medications
from service?(2008 guidelines)                      ❍ Are IV bags, tubings, and connections used
                                                    for one patient only and disposed of
Dental Radiography                                  appropriately?
❍ Are gloves worn by dental workers                 ❍ Is medication from any syringe administered
when exposing radiographs and handling              to only one patient?
contaminated film packets?                          ❍ Are single-dose vials of parenteral
❍ Is other PPE (such as protective eyewear,         medications used whenever possible?
mask, and gown) also worn if                        ❍ Is any medication remaining in a single-use
spattering of body fluids is likely?                vial discarded with the vial after use on one
❍ Are heat-tolerant or disposable filmholders,      patient (rather than saved for later use)?
positioners, and other intraoral devices used       If multidose vials are used:
whenever possible?                                  ❍ Is the access diaphragm cleansed with
❍ Are heat-tolerant radiographic accessories        70% alcohol before inserting a device
cleaned and then heat-sterilized?                   into the vial?
❍ If any heat-sensitive semicritical devices are    ❍ Are only sterile devices used to access
used, are they (at minimum)                         multiple-dose vials?
cleaned and high-level disinfected ac- cording to   ❍ Except by the sterile device, is contact with
the device and germicide                            the access diaphragm avoided?
manufacturer’s instructions?

            Noel Kelsch RDHAP
                          Infection Control with a Twist

❍ Are needles and syringes used to access a         ❍ Is specific information on disinfection (for
multidose vial always sterile? (Never reuse a       example, solution used and duration) included
syringe even if the needle is changed.)             when laboratory cases are sent from the dental
❍ Are multidose vials stored away from              facility to an off-site lab and back?
the immediate patient treatment area                ❍ Unless the sender indicates that they
to prevent inadvertent contamination                have been disinfected, are all dental
by spray or spatter?                                prostheses and prosthodontic materials
❍ Are multidose vials immediately discarded if      (such as impressions, bite registrations,
their sterility is compromised?                     occlusal rims, and extracted teeth)
                                                    cleaned, disinfected using an EPA-registered
Single-Use (Disposable) Devices                     hospital disinfectant with tuberculocidal activity,
❍ Are single-use devices used for one patient       and rinsed?
only and then properly discarded?                   ❍ Have material manufacturers been
                                                    consulted on the stability of specific
Oral Surgical Procedures                            impression materials relative to disinfection
❍ Is surgical hand antisepsis performed             procedures?
before gloving by all dental workers                ❍ Are heat-tolerant items used in the
participating in an oral surgical procedure?        mouth (such as metal impression trays
(Surgical hand antisepsis involves                  and face-bow forks) clean and heatsterilized after
using either (a) an antimicrobial                   use on a patient?
soap and water or (b) a plain soap                  ❍ Are manufacturer instructions followed for
and water handwash followed by alcohol-based        cleaning and sterilizing or
hand rub with persistent                            disinfecting items that do not normally
activity.)                                          contact the patient but become contaminated
❍ Are sterile surgeon’s gloves worn when            during laboratory procedures (for example, burs,
performing oral surgical procedures?                polishing
❍ Is sterile saline or sterile water used as a      points, rag wheels, articulators, case
coolant/irrigant during oral surgical               pans, and lathes)?
procedures?                                         ❍ If manufacturer instructions are not
❍ Are sterile irrigating fluids delivered           available, are items processed according
using devices specifically designed for             to the degree of contamination?
that purpose, for example, a bulb or                ❑ Are heat-tolerant items cleaned and
sterile irrigating syringe, single-use disposable   heat-sterilized, or are they cleaned
products, or sterile water delivery systems with    and then disinfected using an EPA registered
disposable or sterilizable tubing?                  hospital disinfectant an HIV and HBV claim
                                                    and/or a tuberculocidal
Biopsy Specimens                                    claim?
❍ Are biopsy specimens placed in a sturdy,          Tuberculosis and Dentistry
leakproof container for transport?                  ❍ Does your practice setting have a written TB
❑ Is the container labeled with the                 infection-control plan?
biohazard symbol?                                   ❍ Are all dental team members trained to know
❍ If the outside of a biopsy specimen               the signs and symptoms of TB as well as how it
container becomes visibly contaminated,             is transmitted?
is it either cleaned and disinfected                ❍ Is a baseline tuberculin skin test performed
or placed in an impervious bag labeled              for all dental workers who
with the biohazard symbol?                          might have contact with persons with
                                                    suspected or confirmed active TB?
Dental Laboratory                                   ❍ Is each patient assessed for history or
❍ Is PPE worn when handling items that have         symptoms of TB? Are findings documented on
not been decontaminated?                            the medical history form? If a patient with active
                                                    or suspected TB arrives for treatment:
            Noel Kelsch RDHAP
                              Infection Control with a Twist

❍ Is the patient evaluated away from                                ❍ Are personnel with a deep, productive cough
other patients and dental workers?                                  lasting longer than three weeks referred for
❍ When not being evaluated, is the patient                          medical evaluation? This is especially important
asked to wear a surgical mask and instructed to                     when other signs or symptoms consistent with
cover his or her mouth                                              activeTB are present (for example, weight loss,
and nose when coughing or sneezing?                                 night sweats, fatigue, bloody sputum, anorexia,
❍ Is elective dental treatment deferred                             and fever).
until the patient is noninfectious?                                 ❍ Are such DHCP instructed not to return to
❍ Are patients in need of urgent dental                             work until a physician determines that the
care referred to a previously identified facility                   worker does not have
with TB engineering controls and a respiratory                      TB or is no longer infectious?
protection program?                                                 ❍ Has a community risk-assessment been
For DHCP who may have active TB:                                    performed for your practice setting

Five things from the NEW guidelines:





                Infection Control Web sites (updated 3/2009) Where did she say that came from?
ADA Dental Infection Control Issues
Center for Disease Control and Prevention: Dental Infection Control
Occupational Safety and Health Administration (OSHA) Dental Safety and Health Topics
Organization for Safety an Asepsis Procedures (OSAP) Policies and Procedures Book
General Infection Control
Center for Disease Control and Prevention (CDC)                       Emerging Infectious Disease (EID)                                                
Division of Healthcare Quality Promotion                              National Immunization Program
www.cdc/gov/ncidod/dhqp/                                              National Institute for Occupational Safety and
Guidelines and Recommendations                                        Health(NIOSH                               NIOSH: Bloodborne Infectious Disease
Morbidity and Mortality Weekly Report                                                                             Division of HIV/AIDS prevention
National Nosocomial Infection Surveillance (NNIS)                     Tuberculosis Elimination
Association for Professionals in Infection Control and Epidemiology
Association for the Advancement of Medical Instrumentation(AAMI)
Joint Commission for the Accreditation of America(JCAHO)
Society for Healthcare Epidemiology of America(SHEA)
World Health Organization (WHO)

              Noel Kelsch RDHAP
                                   Infection Control with a Twist

Environmental Protection Agency
Food and Drug Administration
Center for Devices and Radiological Health www.fda.go/cdrh/index.html
Occupational Safety and Health Administration
Dental Health Safety Topics
Hiv Dent
National Alliance for the Primary Prevention of Sharps Injuries(NAPPSI)
National Institutes of Health (NIH)
National Institute for Occupational Safety and Health (NIOSH):latex allergies
National Library of Medicine (NLM)

Disease or Problem                           Work restriction                               Duration

Conjunctivitis                               Restrict from patient contact and contact      Until discharge ceases
                                             with patient’s
Cytomegalovirus infection                    No restriction

Diarrheal disease                            Restrict from patient contact, contact with    Until symptoms resolve
Acute stage (diarrhea with other             patient’s
symptoms)                                    environment, and food-handling.

Diarrheal disease                            Restrict from care of patients at high risk.   Until symptoms resolve; consult with
Convalescent stage, Salmonella species.                                                     local and state health
                                                                                            authorities regarding need for negative
                                                                                            stool cultures
Enteroviral infection                        Restrict from care of infants, neonates, and   Until symptoms resolve
                                             immunocompromised patients and their

                                             Restrict from patient contact, contact with    Until 7 days after onset of jaundice
Hepatitis A                                  patient’s
                                             environment, and food-handing.
Hepatitis B                                  No restriction; refer to state regulations.
Personnel with acute or chronic hepatitis    Standard
B                                            precautions should always be followed.
surface antigenemia who do not perform
exposure-prone procedures
Hepatitis B                                  Do not perform exposure-prone invasive         Until hepatitis B e antigen is negative
Personnel with acute or chronic hepatitis    procedures until
B                                            counsel from a review panel has been
e antigenemia who perform exposure-          sought; panel
prone                                        should review and recommend procedures
procedures                                   that personnel
                                             can perform, taking into account specific
                                             procedures as
                                             well as skill and technique. Standard
                                             precautions should
                                             always be observed. Refer to state and
                                             local regulations
                                             or recommendations.
                                             No restrictions on professional activity.
Hepatitis C                                  HCV-positive
                                             health-care personnel should follow aseptic
                                             and standard precautions.
Herpes simplex Genital                       No restriction

Herpes simplex                               Restrict from patient contact and contact      Until lesions heal
Hands (herpetic whitlow)                     with patient’s

                 Noel Kelsch RDHAP
                               Infection Control with a Twist


Herpes simplex                         Evaluate need to restrict from care of
Orofacial                              patients at high risk.
Human immunodeficiency virus;          Do not perform exposure-prone invasive
personnel who                          procedures until
perform exposure-prone procedures      counsel from an expert review panel has
                                       been sought;
                                       panel should review and recommend
                                       procedures that
                                       personnel can perform, taking into account
                                       procedures as well as skill and technique.
                                       precautions should always be observed.
                                       Refer to state
                                       and local regulations or recommendations.
Measles                                Exclude from duty                            Until 7 days after rash appears

Measles                                Exclude from duty                            From fifth day after first exposure
Postexposure (susceptible personnel)                                                through twenty-first day
                                                                                    after last exposure, or 4 days after rash
Meningococcal infection                Exclude from duty                            Until 24 hours after start of effective
Mumps                                  Exclude from duty                            Until 9 days after onset of parotitis
Mumps                                  Exclude from duty                            From twelfth day after first exposure
Postexposure (susceptible personnel)                                                through twenty-sixth
                                                                                    day after last exposure, or until 9 days
                                                                                    after onset of
Pediculosis                            Restrict from patient contact                Until treated and observed to be free of
                                                                                    adult and
                                                                                    immature lice
Pertussis                              Exclude from duty                            From beginning of catarrhal stage
Active                                                                              through third week
                                                                                    after onset of paroxysms, or until 5 days
                                                                                    after start of
                                                                                    effective antibiotic therapy
Pertussis Postexposure (asymptomatic   No restriction, prophylaxis recommended      Until 5 days after start of effective
personnel)                                                                          antibiotic therapy
Pertussis Postexposure (symptomatic    Exclude from duty
Rubella                                Exclude from duty                            Until 5 days after rash appears
Rubella                                Exclude from duty                            From seventh day after first exposure
Postexposure (susceptible personnel)                                                through twenty-first
                                                                                    day after last exposure
Staphylococcus aureus infection        Restrict from contact with patients and      Until lesions have resolved
Active, draining skin lesions          patient’s
                                       environment or food handling.

Staphylococcus aureus infection        No restriction unless personnel are
Carrier state                          epidemiologically
                                       linked to transmission of the organism
Streptococcal infection, group A       Restrict from patient care, contact with     Until 24 hours after adequate treatment
                                       patient’s                                    started
                                       environment, and food-handling.
Tuberculosis                           Exclude from duty                            Until proved noninfectious
Active disease
Tuberculosis                           No restriction
PPD converter

                 Noel Kelsch RDHAP
                                  Infection Control with a Twist

Varicella (chicken pox)                      Exclude from duty                             Until all lesions dry and crust
Varicella (chicken pox)                      Exclude from duty                             Until all lesions dry and crust
Postexposure (susceptible personnel)
Zoster (shingles)                            Cover lesions, restrict from care of          Until all lesions dry and crust
Localized, in healthy person                 patients§ at high risk
                                             Restrict from patient contact
Zoster (shingles)                            Restrict from patient contact                 From tenth day after first exposure
Generalized or localized in                                                                through twenty-first day
immunosuppressed person                                                                    (twenty-eighth day if VZIG
Postexposure (susceptible personnel)                                                       administered) after last exposure;
                                                                                           or, if varicella occurs, when lesions crust
                                                                                           and dry
Viral respiratory infection, acute febrile   Consider excluding from the care of           Until acute symptoms resolve
                                             patients at high risk¶
                                             or contact with such patients’ environments
                                             community outbreak of respiratory
                                             syncytial virus and

               Noel Kelsch RDHAP

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