Sterilization and Disinfection of Patient-Care Items · Sterilization and Disinfection of Patient-Care Items Patient-care items (dental instruments, devices, and equipment) are categorized

Sterilization and Disinfection of Patient-Care Items

Patient-care items (dental instruments, devices, and equipment) are categorized as critical, semi-critical, or noncritical, depending on the potential risk for infection associated with their intended use (Table 4) (242). Critical items used to penetrate soft tissue or bone, have the greatest risk of transmitting infection and should be sterilized by heat. Semi-critical items touch mucous membranes or non-intact skin and have a lower risk of transmission; because the majority of semi-critical items in dentistry are heat-tolerant, they also should be sterilized by using heat. If a semi-critical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection (2). Noncritical patient-care items pose the least risk of transmission of infection, contacting only intact skin, which can serve as an effective barrier to microorganisms. In the majority of cases, cleaning, or if visibly soiled, cleaning followed by disinfection with an EPA-registered hospital disinfectant is adequate. When the item is visibly contaminated with blood or OPIM, an EPA-registered hospital disinfectant with a tuberculocidal claim (i.e., intermediate-level disinfectant) should be used (2,243,244). Cleaning or disinfection of certain noncritical patient-care items can be difficult or damage the surfaces; therefore, use of disposable barrier protection of these surfaces might be a preferred alternative. FDA-cleared sterilant/high-level disinfectants and EPA registered disinfectants must have clear label claims for intended use, and manufacturer instructions for use must be followed (245). A more complete description of the regulatory framework in the United States by which liquid chemical germicides are evaluated and regulated is included (Appendix A).

Three levels of disinfection, high, intermediate, and low, are used for patient-care devices that do not require sterility and two levels, intermediate and low, for environmental surfaces (242). The intended use of the patient-care item should determine the recommended level of disinfection. Dental practices should follow the product manufacturer’s directions regarding concentrations and exposure time for disinfectant activity relative to the surface to be disinfected (245). A summary of sterilization and disinfection methods is included (Appendix C). Transporting and Processing Contaminated Critical and Semi-critical Patient-Care Items DHCP can be exposed to microorganisms on contaminated instruments and devices through percutaneous injury, contact with nonintact skin on the hands, or contact with mucous membranes of the eyes, nose, or mouth. Contaminated instruments should be handled carefully to prevent exposure to sharp instruments that can cause a percutaneous injury. Instruments should be placed in an appropriate container at the point of use to prevent percutaneous injuries during transport to the instrument processing area (13). Instrument processing requires multiple steps to achieve sterilization or high-level disinfection. Sterilization is a complex process requiring specialized equipment, adequate space, qualified DHCP who are provided with ongoing training, and regular monitoring for quality assurance (247). Correct cleaning,

packaging, sterilizer loading procedures, sterilization methods, or high-level disinfection methods should be followed to ensure that an instrument is adequately processed and safe for reuse on patients. Instrument Processing Area DHCP should process all instruments in a designated central processing area to more easily control quality and ensure safety (248). The central processing area should be divided into sections for 1) receiving, cleaning, and decontamination; 2) preparation and packaging; 3) sterilization; and 4) storage. Ideally, walls or partitions should separate the sections to control traffic flow and contain contaminants generated during processing. When physical separation of these sections cannot be achieved, adequate spatial separation might be satisfactory if the DHCP who process instruments are trained in work practices to prevent contamination of clean areas (248). Space should be adequate for the volume of work anticipated and the items to be stored (248). Receiving, Cleaning, and Decontamination Reusable instruments, supplies, and equipment should be received, sorted, cleaned, and decontaminated in one section of the processing area. Cleaning should precede all disinfection and sterilization processes; it should involve removal of debris as well as organic and inorganic contamination. Removal of debris and contamination is achieved either by scrubbing with a surfactant, detergent, and water, or by an automated process (e.g., ultrasonic cleaner or washer-disinfector) using chemical agents. If visible debris, whether inorganic or organic matter, is not removed, it will interfere with microbial inactivation and can compromise the disinfection or sterilization process (244,249–252). After cleaning, instruments should be rinsed with water to remove chemical or detergent residue. Splashing should be minimized during cleaning and rinsing (13). Before final disinfection or sterilization, instruments should be handled as though contaminated. Considerations in selecting cleaning methods and equipment include 1) efficacy of the method, process, and equipment; 2) compatibility with items to be cleaned; and 3) occupational health and exposure risks. Use of automated cleaning equipment (e.g., ultrasonic cleaner or washer-disinfector) does not require presoaking or scrubbing of instruments and can increase productivity, improve cleaning effectiveness, and decrease worker exposure to blood and body fluids. Thus, using automated equipment can be safer and more efficient than manually cleaning contaminated instruments (253). If manual cleaning is not performed immediately, placing instruments in a puncture-resistant container and soaking them with detergent, a disinfectant/detergent, or an enzymatic cleaner will prevent drying of patient material and make cleaning easier and less time-consuming. Use of a liquid chemical sterilant/high-level disinfectant (e.g., glutaraldehyde) as a holding solution is not recommended (244). Using work-practice controls (e.g., long-handled brush) to keep the scrubbing hand away from sharp instruments is recommended (14). To avoid injury from sharp instruments, DHCP should wear puncture resistant, heavy-duty utility gloves when handling or manually cleaning contaminated instruments and devices (6). Employees should not reach into trays or containers holding sharp instruments that cannot be seen (e.g., sinks filled with soapy water in which sharp instruments have been placed). Work-practice controls should include use of a strainer-type basket to hold instruments and forceps to remove the items. Because splashing is likely to occur, a mask, protective eyewear or face shield, and gown or jacket should be worn (13). Preparation and Packaging In another section of the processing area, cleaned instruments and other dental supplies should be inspected, assembled into sets or trays, and wrapped, packaged, or placed into container systems for sterilization. Hinged instruments should be processed open and unlocked. An internal chemical indicator

should be placed in every package. In addition, an external chemical indicator (e.g., chemical indicator tape) should be used when the internal indicator cannot be seen from outside the package. For unwrapped loads, at a minimum, an internal chemical indicator should be placed in the tray or cassette with items to be sterilized (254) (see Sterilization of Unwrapped Instruments). Dental practices should refer to the manufacturer’s instructions regarding use and correct placement of chemical indicators (see Sterilization Monitoring). Critical and semi-critical instruments that will be stored should be wrapped or placed in containers (e.g., cassettes or organizing trays) designed to maintain sterility during storage (2,247,255–257). Packaging materials (e.g., wraps or container systems) allow penetration of the sterilization agent and maintain sterility of the processed item after sterilization. Materials for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes, peel pouches of plastic or paper, and sterilization wraps (i.e., woven and nonwoven). Packaging materials should be designed for the type of sterilization process being used (256–259). Sterilization The sterilization section of the processing area should include the sterilizers and related supplies, with adequate space for loading, unloading, and cool down. The area can also include incubators for analyzing spore tests and enclosed storage for sterile items and disposable (single-use) items (260). Manufacturer and local building code specifications will determine placement and room ventilation requirements. Sterilization Procedures. Heat-tolerant dental instruments usually are sterilized by 1) steam under pressure (autoclaving), 2) dry heat, or 3) unsaturated chemical vapor. All sterilization should be performed by using medical sterilization equipment cleared by FDA. The sterilization times, temperatures, and other operating parameters recommended by the manufacturer of the equipment used, as well as instructions for correct use of containers, wraps, and chemical or biological indicators, should always be followed (243,247). Items to be sterilized should be arranged to permit free circulation of the sterilizing agent (e.g., steam, chemical vapor, or dry heat); manufacturer’s instructions for loading the sterilizer should be followed (248,260). Instrument packs should be allowed to dry inside the sterilizer chamber before removing and handling. Packs should not be touched until they are cool and dry because hot packs act as wicks, absorbing moisture, and hence, bacteria from hands (247). The ability of equipment to attain physical parameters required to achieve sterilization should be monitored by mechanical, chemical, and biological indicators. Sterilizers vary in their types of indicators and their ability to provide readings on the mechanical or physical parameters of the sterilization process (e.g., time, temperature, and pressure). Consult with the sterilizer manufacturer regarding selection and use of indicators. Steam Sterilization. Among sterilization methods, steam sterilization, which is dependable and economical, is the most widely used for wrapped and unwrapped critical and semi-critical items that are not sensitive to heat and moisture (260). Steam sterilization requires exposure of each item to direct steam contact at a required temperature and pressure for a specified time needed to kill microorganisms. Two basic types of steam sterilizers are the gravity displacement and the high-speed pre-vacuum sterilizer. The majority of tabletop sterilizers used in a dental practice are gravity displacement sterilizers, although pre-vacuum sterilizers are becoming more widely available. In gravity displacement sterilizers, steam is admitted through steam lines, a steam generator, or self-generation of steam within the chamber. Unsaturated air is forced out of the chamber through a vent in the chamber wall. Trapping of air is a concern when using saturated steam under gravity displacement; errors in packaging items or overloading the sterilizer chamber can result in cool air pockets and items not being sterilized. Pre-vacuum sterilizers are fitted with a pump to create a vacuum in the chamber and ensure air removal from the sterilizing chamber before the chamber is pressurized with steam. Relative to gravity displacement, this procedure allows faster and more positive steam penetration throughout the entire load. Pre-vacuum sterilizers should be tested periodically for adequate air removal, as recommended by the manufacturer. Air not

removed from the chamber will interfere with steam contact. If a sterilizer fails the air removal test, it should not be used until inspected by sterilizer maintenance personnel and it passes the test (243,247). Manufacturer’s instructions, with specific details regarding operation and user maintenance information, should be followed. Unsaturated Chemical-Vapor Sterilization. Unsaturated chemical-vapor sterilization involves heating a chemical solution of primarily alcohol with 0.23% formaldehyde in a closed pressurized chamber. Unsaturated chemical vapor sterilization of carbon steel instruments (e.g., dental burs) causes less corrosion than steam sterilization because of the low level of water present during the cycle. Instruments should be dry before sterilizing. State and local authorities should be consulted for hazardous waste disposal requirements for the sterilizing solution. Dry-Heat Sterilization. Dry heat is used to sterilize materials that might be damaged by moist heat (e.g., burs and certain orthodontic instruments). Although dry heat has the advantages of low operating cost and being noncorrosive, it is a prolonged process and the high temperatures required are not suitable for certain patient-care items and devices (261). Dry-heat sterilizers used in dentistry include static-air and forced-air types. • The static-air type is commonly called an oven-type sterilizer. Heating coils in the bottom or sides of the unit cause hot air to rise inside the chamber through natural convection. • The forced-air type is also known as a rapid heat-transfer sterilizer. Heated air is circulated throughout the chamber at a high velocity, permitting more rapid transfer of energy from the air to the instruments, thereby reducing the time needed for sterilization.

Sterilization of Unwrapped Instruments. An unwrapped cycle (sometimes called flash sterilization) is a method for sterilizing unwrapped patient-care items for immediate use. The time required for unwrapped sterilization cycles depends on the type of sterilizer and the type of item (i.e., porous or nonporous) to be sterilized (243). The unwrapped cycle in tabletop sterilizers is preprogrammed by the manufacturer to a specific time and temperature setting and can include a drying phase at the end to produce a dry instrument with much of the heat dissipated. If the drying phase requirements are unclear, the operation manual or manufacturer of the sterilizer should be consulted. If the unwrapped sterilization cycle in a steam sterilizer does not include a drying phase, or has only a minimal drying phase, items retrieved from the sterilizer will be hot and wet, making aseptic transport to the point of use more difficult. For dry-heat and chemical-vapor sterilizers, a drying phase is not required. Unwrapped sterilization should be used only under certain conditions: 1) thorough cleaning and drying of instruments precedes the unwrapped sterilization cycle; 2) mechanical monitors are checked and chemical indicators used for each cycle; 3) care is taken to avoid thermal injury to DHCP or patients; and 4) items are transported aseptically to the point of use to maintain sterility (134,258,262). Because all implantable devices should be quarantined after sterilization until the results of biological monitoring are known, unwrapped or flash sterilization of implantable items is not recommended (134). Critical instruments sterilized unwrapped should be transferred immediately by using aseptic technique, from the sterilizer to the actual point of use. Critical instruments should not be stored unwrapped (260). Semi-critical instruments that are sterilized unwrapped on a tray or in a container system should be used immediately or within a short time. When sterile items are open to the air, they will eventually become contaminated. Storage, even temporary, of unwrapped semi-critical instruments is discouraged because it permits exposure to dust, airborne organisms, and other unnecessary contamination before use on a patient (260). A carefully written protocol for minimizing the risk of contaminating unwrapped instruments should be prepared and followed (260).

Other Sterilization Methods. Heat-sensitive critical and semi-critical instruments and devices can be sterilized by immersing them in liquid chemical germicides registered by FDA as sterilants. When using a liquid chemical germicide for sterilization, certain post-sterilization procedures are essential. Items need to be 1) rinsed with sterile water after removal to remove toxic or irritating residues; 2) handled using sterile gloves and dried with sterile towels; and 3) delivered to the point of use in an aseptic manner. If stored before use, the instrument should not be considered sterile and should be sterilized again just before use. In addition, the sterilization process with liquid chemical sterilants cannot be verified with biological indicators (263). Because of these limitations and because liquid chemical sterilants can require approximately 12 hours of complete immersion, they are almost never used to sterilize instruments. Rather, these chemicals are more often used for high-level disinfection (249). Shorter immersion times (12–90 minutes) are used to achieve high-level disinfection of semicritical instruments or items. These powerful, sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) are highly toxic (244,264,265). Manufacturer instructions (e.g., regarding dilution, immersion time, and temperature) and safety precautions for using chemical sterilants/high-level disinfectants must be followed precisely (15,245). These chemicals should not be used for applications other than those indicated in their label instructions. Misapplications include use as an environmental surface disinfectant or instrument-holding solution. When using appropriate precautions (e.g., closed containers to limit vapor release, chemically resistant gloves and aprons, goggles, and face shields), glutaraldehyde-based products can be used without tissue irritation or adverse health effects. However, dermatologic, eye irritation, respiratory effects, and skin sensitization have been reported (266–268). Because of their lack of chemical resistance to glutaraldehydes, medical gloves are not an effective barrier (200,269,270). Other factors might apply (e.g., room exhaust ventilation or 10 air exchanges/hour) to ensure DHCP safety (266,271). For all of these reasons, using heat-sensitive semi-critical items that must be processed with liquid chemical germicides is discouraged; heat-tolerant or disposable alternatives are available for the majority of such items. Low-temperature sterilization with ethylene oxide gas (ETO) has been used extensively in larger health-care facilities. Its primary advantage is the ability to sterilize heat- and moisture-sensitive patient-care items with reduced deleterious effects. However, extended sterilization times of 10–48 hours and potential hazards to patients and DHCP requiring stringent health and safety requirements (272–274) make this method impractical for private-practice settings. Handpieces cannot be effectively sterilized with this method because of decreased penetration of ETO gas flow through a small lumen (250,275). Other types of low-temperature sterilization (e.g.,hydrogen peroxide gas plasma) exist but are not yet practical for dental offices. Bead sterilizers have been used in dentistry to sterilize small metallic instruments (e.g., endodontic files). FDA has determined that a risk of infection exists with these devices because of their potential failure to sterilize dental instruments and has required their commercial distribution cease unless the manufacturer files a premarket approval application. If a bead sterilizer is employed, DHCP assume the risk of employing a dental device FDA has deemed neither safe nor effective (276). Sterilization Monitoring. Monitoring of sterilization procedures should include a combination of process parameters, including mechanical, chemical, and biological (247,248,277). These parameters evaluate both the sterilizing conditions and the procedure’s effectiveness. Mechanical techniques for monitoring sterilization include assessing cycle time, temperature, and pressure by observing the gauges or displays on the sterilizer and noting these parameters for each load (243,248). Some tabletop sterilizers have recording devices that print out these parameters. Correct readings do not ensure sterilization, but incorrect readings can be the first indication of a problem with the sterilization cycle. Chemical indicators, internal and external, use sensitive chemicals to assess physical conditions (e.g., time and temperature) during the sterilization process. Although chemical indicators do not prove sterilization has been achieved, they allow detection of certain equipment malfunctions, and they can help identify procedural errors. External indicators applied to the outside of a package (e.g., chemical indicator tape or special markings) change color rapidly when a specific parameter is reached, and they verify that the package has been exposed to the sterilization process. Internal chemical indicators should be used inside

each package to ensure the sterilizing agent has penetrated the packaging material and actually reached the instruments inside. A single-parameter internal chemical indicator provides information regarding only one sterilization parameter (e.g., time or temperature). Multi-parameter internal chemical indicators are designed to react to >2 parameters (e.g., time and temperature; or time, temperature, and the presence of steam) and can provide a more reliable indication that sterilization conditions have been met (254). Multi-parameter internal indicators are available only for steam sterilizers (i.e., autoclaves). Because chemical indicator test results are received when the sterilization cycle is complete, they can provide an early indication of a problem and where in the process the problem might exist. If either mechanical indicators or internal or external chemical indicators indicate inadequate processing, items in the load should not be used until reprocessed (134). Biological indicators (BIs) (i.e., spore tests) are the most accepted method for monitoring the sterilization process (278,279) because they assess it directly by killing known highly resistant microorganisms (e.g., Geobacillus or Bacillus species), rather than merely testing the physical and chemical conditions necessary for sterilization (243). Because spores used in BIs are more resistant and present in greater numbers than the common microbial contaminants found on patient-care equipment, an inactivated BI indicates other potential pathogens in the load have been killed (280). Correct functioning of sterilization cycles should be verified for each sterilizer by the periodic use (at least weekly) of BIs (2,9,134,243,278,279). Every load containing implantable devices should be monitored with such indicators (248), and the items quarantined until BI results are known. However, in an emergency, placing implantable items in quarantine until spore tests are known to be negative might be impossible. Manufacturer’s directions should determine the placement and location of BI in the sterilizer. A control BI, from the same lot as the test indicator and not processed through the sterilizer, should be incubated with the test BI; the control BI should yield positive results for bacterial growth. In-office biological monitoring is available; mail-in sterilization monitoring services (e.g., from private companies or dental schools) can also be used to test both the BI and the control. Although some DHCP have expressed concern that delays caused by mailing specimens might cause false-negatives, studies have determined that mail delays have no substantial effect on final test results (281,282). Procedures to follow in the event of a positive spore test have been developed (243,247). If the mechanical (e.g., time, temperature, and pressure) and chemical (i.e., internal or external) indicators demonstrate that the sterilizer is functioning correctly, a single positive spore test probably does not indicate sterilizer malfunction. Items other than implantable devices do not necessarily need to be recalled; however the spore test should be repeated immediately after correctly loading the sterilizer and using the same cycle that produced the failure. The sterilizer should be removed from service, and all records reviewed of chemical and mechanical monitoring since the last negative BI test. Also, sterilizer operating procedures should be reviewed, including packaging, loading, and spore testing, with all persons who work with the sterilizer to determine whether operator error could be responsible (9,243,247). Overloading, failure to provide adequate package separation, and incorrect or excessive packaging material are all common reasons for a positive BI in the absence of mechanical failure of the sterilizer unit (260). A second monitored sterilizer in the office can be used, or a loaner from a sales or repair company obtained, to minimize office disruption while waiting for the repeat BI. If the repeat test is negative and chemical and mechanical monitoring indicate adequate processing, the sterilizer can be put back into service. If the repeat BI test is positive, and packaging, loading, and operating procedures have been confirmed as performing correctly, the sterilizer should remain out of service until it has been inspected, repaired, and re-challenged with BI tests in three consecutive empty chamber sterilization cycles (9,243). When possible, items from suspect loads dating back to the last negative BI should be recalled, rewrapped, and re-sterilized (9,283). A more conservative approach has been recommended (247) in which any positive spore test is assumed to represent sterilizer malfunction and requires that all materials processed in that sterilizer, dating from the sterilization cycle having the last negative biologic indicator to the next cycle indicating satisfactory biologic indicator results, should be considered non-sterile and retrieved, if possible, and reprocessed or held in quarantine until the results of the repeat BI are known. This approach is considered conservative because the margin of safety in steam sterilization is sufficient enough that infection risk, associated with items in a load indicating spore growth, is minimal, particularly if the item

was properly cleaned and the temperature was achieved (e.g., as demonstrated by acceptable chemical indicator or temperature chart) (243). Published studies are not available that document disease transmission through a non-retrieved surgical instrument after a steam sterilization cycle with a positive biological indicator (243). This more conservative approach should always be used for sterilization methods other than steam (e.g., dry heat, unsaturated chemical vapor, ETO, or hydrogen peroxide gas plasma) (243). Results of biological monitoring should be recorded and sterilization monitoring records (i.e., mechanical, chemical, and biological) retained long enough to comply with state and local regulations. Such records are a component of an overall dental infection-control program (see Program Evaluation). Storage of Sterilized Items and Clean Dental Supplies The storage area should contain enclosed storage for sterile items and disposable (single-use) items (173). Storage practices for wrapped sterilized instruments can be either date- or event-related. Packages containing sterile supplies should be inspected before use to verify barrier integrity and dryness. Although some health-care facilities continue to date every sterilized package and use shelf-life practices, other facilities have switched to event-related practices (243). This approach recognizes that the product should remain sterile indefinitely, unless an event causes it to become contaminated (e.g., torn or wet packaging) (284). Even for event-related packaging, minimally, the date of sterilization should be placed on the package, and if multiple sterilizers are used in the facility, the sterilizer used should be indicated on the outside of the packaging material to facilitate the retrieval of processed items in the event of a sterilization failure (247). If packaging is compromised, the instruments should be re-cleaned, packaged in new wrap, and sterilized again. Clean supplies and instruments should be stored in closed or covered cabinets, if possible (285). Dental supplies and instruments should not be stored under sinks or in other locations where they might become wet.

continued on page 2

IN PRACTICEInfection Control

The U.S. Centers for Disease Controland Prevention (CDC) recently re-

leased expanded recommendations for in-fection control in dental settings. Pub-lished in the December 19, 2003, editionof Morbidity and Mortality Weekly Report,“Guidelines for Infection Control in Den-tal Health-Care Settings — 2003” offersboth science-based and strong theoreticaladvice designed to prevent or reduce therisk of disease transmission from patientto dental worker, from dental worker topatient, and from patient to patient. Thedocument consolidates and updates previ-ous recommendations from CDC andother agencies and discusses concerns notaddressed in earlier recommendations fordentistry. To view the full document, visitwww.cdc.gov/OralHealth/infectioncontrol/guidelines/index.htm.

Major additions and changes to the2003 guidelines include:❍ application of standard precautions

rather than universal precautions; ❍ work restrictions for dental healthcare

personnel infected with or occupation-ally exposed to infectious diseases;

❍ management of occupational expo-sures to bloodborne pathogens such ashepatitis B virus (HBV), hepatitis Cvirus (HCV); and human immunode-ficiency virus (HIV);

❍ selection and use of devices with sharpssafety features;

❍ hand-hygiene products and surgicalhand antisepsis;

❍ contact dermatitis and latex hypersen-sitivity;

❍ sterilization of unwrapped instruments(“flash” cycles);

❍ dental water quality; ❍ dental radiography; ❍ aseptic technique for parenteral med-

ications;❍ oral surgical procedures; ❍ tuberculosis (TB); and ❍ infection control program evaluation.

The new CDC guidelines apply to allpaid or unpaid dental healthcare personnel(DHCP) who might be occupationally ex-posed to blood and body fluids by directcontact or through contact with contami-nated supplies, equipment, environmentalsurfaces, water, or air. Although the guide-lines focus mainly on outpatient dental set-tings, the recommended infection controlpractices can be applied to all settingswhere dental treatment is provided.

This month’s Infection Control In Prac-tice turns CDC’s comprehensive, 66-pageguideline into a checklist for use in yourpractice setting. If you can answer “yes” toall the questions in this list, your infectioncontrol program is up to date.

Dentistry’s Newsletter for Infection Control and Safety

OSAP Check-Up: 2003 CDC GuidelinesIs your infection control program up to date?

Contents

1-9 Charts & Checklists

10 Calendar

11 Continuing Education

12 Practice Tip

Infection Control In Practice Vol. 3, No. 1 January 2004 http://www.osap.org 1

Learning Object ives➤ Learn new and expanded recommendations for dental infection control from the Centers

for Disease Control and Prevention

➤ Be able to review your office policies, procedures, written programs, records, and training

schedules and content to ensure that they reflect the most current public health recommen-

dations for infection control dental settings

2 Infection Control In Practice Vol. 3, No. 1 January 2004 http://www.osap.org

SponsorsOSAP thanks the following companies thathelp to underwrite each issue of InfectionControl In Practice in 2004.

A-dec, Inc.

Biotrol Int'l

Clive Craig / Van R Dental Products

Cottrell, A Division of Certol Int'l

Crosstex, Inc.

DentalEZ

Dentsply Professional

Envirosystems, Inc.

GC America, Inc.

John O. Butler Co.

Miele, Inc.

Patterson Dental Co.

Rowpar Pharmaceuticals, Inc.

SciCan, Div. of Lux & Zwingenberger, Ltd.

Septodont, Inc.

SmartPractice / SmartScrubs

Sullivan-Schein Dental

Sultan Chemists

TotalCare

Infection Control In Practice is published eight times peryear by OSAP, P.O. Box 6297, Annapolis, MD 21401, USA,and is a trademark belonging to OSAP. OSAP assumes noliability for actions taken based on information herein.Contents of the issue copyright © 2004 by OSAP. All rightsreserved under international and Pan-American copyrightconventions. Printed in U.S.A. Permissions: Reproduction inwhole or in part is forbidden without prior written permis-sion. Address requests to Permissions, OSAP P.O. Box6297, Annapolis, MD 21401. Back Issues: Single copiesare available, free to members or $15 each for nonmem-bers, from OSAP, P.O. Box 6297, Annapolis, MD 21401,USA. Subscription rates: In North America, $50 for 1 year.Only the electronic version is available to subscribers out-side North America. Electronic: $50 for 1 year. Instant Ac-cess. Phone orders and subscription issues: 410-571-0003. Subscription service or change of address: Write toSubscription Director, OSAP, P.O. Box 6297, Annapolis, MD21401, USA. Attach or copy address label from a recentissue. With address change, include old and new ZIP codes.Postmaster: Send address changes to OSAP, P.O. Box6297, Annapolis, MD 21401.

OSAP Chart & Checklist

OSAP Check-Up: 2003 CDC Guidelines continued from page 1

Personnel Health Elements of an Infection Control Program ❍ Does the practice setting have a written

health program for DHCP? ❍ Does this written program specify poli-

cies, procedures, and guidelines for:❑ education and training? ❑ immunizations?❑ exposure prevention and postexpo-

sure management?❑ medical conditions, occupational

illness, and related work restrictions?❑ contact dermatitis and latex hyper-

sensitivity?❑ maintenance of records, data man-

agement, and confidentiality? ❍ Have referral arrangements been estab-

lished with a qualified healthcare pro-fessional/facility to ensure prompt andappropriate delivery of preventive serv-ices, occupationally related medicalservices, and postexposure manage-ment with any necessary medical fol-low-up?

❍ Is a list of all required and recom-mended immunizations for dentalworkers maintained? When was this list last updated? date: _________________________

❍ Is it consistent with the latest recom-mendations from public health agen-cies on appropriate immunizations forhealthcare workers?

❍ Have at-risk DHCP been referred tothe facility’s prearranged qualifiedhealthcare professional or to their ownhealthcare professional to receive ap-propriate immunizations?

❍ Is baseline tuberculin skin testing pro-vided for clinical DHCP who mighthave contact with persons with suspect-ed or confirmed infectious TB?

❍ Is a comprehensive postexposure man-agement and medical follow-up pro-gram in place?

❍ Does this program:❑ include policies and procedures for

prompt reporting, evaluation, coun-seling, treatment, and medical fol-low-up of occupational exposures?

Education and training❍ Have DHCP been educated and

trained on their risk of occupationalexposure to potentially infectiousagents and the necessary infection-con-trol procedures/protocols to safely per-form their assigned duties?

❍ Was this training provided:❑ at the time of initial employment?❑ when new tasks or procedures affect

occupational exposure?❑ at least annually?

❍ Were the training materials and proce-dures clear and easy to understand?

Postexposure management❍ Do DHCP know to report occupation-

al injuries and exposures immediately?❍ When an occupational exposure oc-

curs, is an exposure incident reportcreated listing:❑ date and time of exposure;❑ details of the procedure being per-

formed, including how and wherethe exposure occurred; if related toa sharp device, the type and brandof device and how and when the ex-posure occurred in the course ofhandling/using the device;

❑ details of the exposure, includingtype and amount of fluid or mate-rial and the severity of the expo-sure (for example, for percuta-neous exposure, the depth of theinjury and whether fluid was in-jected; for a skin or mucous mem-brane exposure, the estimated vol-ume of material and the conditionof the skin [chapped, cut, abrad-ed, intact]);

❑ details about the exposure source(whether the source material con-tained HBV, HCV, or HIV; if thesource patient is HIV-positive, thestage of disease, history of anti-retroviral medication, viral load,drug resistance, if known);

❑ details about the exposed person(vaccination and vaccine-responsestatus); and

Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 33 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org

Infection Control In Practice is a

resource prepared for clinicians

bythe Organization for Safety

and Asepsis Procedures with

the assistance and expertise of its

member-contributors. OSAP is a

nonprofit, independent organization

providing information and education

on infection control and occupation-

al health and safety to dental care

settings worldwide.

Information in this issue has been

brought to you with the help of

the following individuals:

Editorial Staff

Shannon Mills, DDSEditor-in-Chief

Therese Long, CAE, MBAExecutive Director

Karen OrtolanoManaging Editor

Editorial Review Board

Helene Bednarsh, RDH, MPH

Dee Cinner, MT

Jennifer Cleveland, DDS, MPH

James A. Cottone, DMD, MS

Eve Cuny, RDA, MS

Kathy Eklund, RDH, MHP

Richard Karpay, DDS, MPH

Ernest Lado, DDS

Mary Jane Mesmer, LDH

Chris Miller, PhD

John Molinari, PhD

Charles Palenik, Phd, MS, MBA

Ann Steiner, DMD

John Young, DDS, MSc


❑ details about counseling, postexpo-sure management, and follow-up.

❍ When an exposure incident occurs, isthe injured worker and the exposurereport immediately sent for medicalevaluation?

Medical conditions, work-relatedillness, and work restrictions ❍ Does the practice setting have compre-

hensive written policies on work re-strictions and exclusions that include astatement of authority defining whocan implement such policies?❑ Are these policies readily available

to DHCP?❑ Do these policies encourage work-

ers to seek appropriate preventiveand curative care and to report anyillnesses, medical conditions, ortreatments that can make themmore susceptible to opportunisticinfection or exposures?

❑ Do these policies protect againstlost wages, benefits, or job status inthe event of such an illness or med-ical condition?

❍ Are policies and procedures in place forevaluating, diagnosing, and managingworkers with suspected or known oc-cupational contact dermatitis?❑ Does the facility’s policy provide for

definitive diagnosis and manage-ment advice (for example, treat-ment, work restrictions, and ac-commodations) by a qualifiedhealthcare professional?

Records maintenance,data management, and confidentiality ❍ Does the practice setting establish and

keep confidential DHCP medicalrecords, such as immunization recordsand documentation of tests receivedas a result of occupational exposure?

❍ Is the practice setting in compliancewith all applicable federal, state, andlocal laws for medical recordkeepingand confidentiality?

Preventing Transmissionof Bloodborne Pathogens

HBV vaccination ❍ Have DHCP been informed of the

risks of HBV transmission and theavailability of the hepatitis B virus(HBV) vaccine?

❍ Have DHCP been offered the HBVvaccination series? ❑ Was serologic testing performed 1-

2 months after vaccination to con-firm immunity?

❍ Did DHCP who declined vaccinationsign a declination form for their med-ical record file?

Preventing exposures to blood andother potentially infectious materials ❍ Are standard precautions used during

all patient encounters? ❍ Does the practice setting have a writ-

ten, comprehensive program designedto minimize and manage DHCP expo-sures to blood and body fluids?

❍ To prevent injuries from contaminatedsharps, does the practice setting use:❑ engineering controls (such as sharps

containers, automated instrumentcleaners, safety needles, nonneedlesharps, needle recappers, and othersafer medical devices)?

❑ work practices (such as the one-handed scoop technique andplacement of sharps containersnearest their point of use in the op-eratory)?

Engineering controls❍ Does the practice setting identify, eval-

uate, and consider for use devices withengineered safety features (for example,safer anesthetic syringes, blunt sutureneedles, retractable scalpels, or needle-less IV systems):❑ at least annually?❑ as they reach the dental market?

Work practice controls❍ Are disposable syringes and needles,

scalpel blades, and other sharp items

IN PRACTICEInfection Control

continued on page 4

4 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 44 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org4 Infection Control In Practice Vol. 3, No. 1 January 2004 http://www.osap.org

placed in appropriate puncture-resist-ant containers? ❑ Are these containers located as close

as possible to the area where thesharps are used?

❍ When needles must be recapped,* areneedle recapping devices or the one-handed scoop technique used? * For example, between multiple injections

and before removing from a nondispos-able aspirating syringe.

Hand Hygiene ❍ Are hands washed with a nonantimi-

crobial or antimicrobial soap and waterwhen they are visibly dirty or contam-inated with blood or other potentiallyinfectious material?

❍ Is hand hygiene performed:❑ after accidental barehanded touch-

ing of inanimate objects likely to becontaminated by blood, saliva, orrespiratory secretions?

❑ before and after treating each patient?

❑ before donning gloves?❑ immediately after removing gloves?

❍ Before oral surgical procedures, is surgi-cal hand antisepsis performed beforedonning sterile surgeon’s gloves? (Surgi-cal hand antisepsis involves using either(a) an antimicrobial soap and water or(b) a plain soap and water handwashfollowed by an alcohol-based hand rubwith persistent activity.)

❍ Are liquid hand-care products stored ineither disposable closed containers orclosed containers that can be washedand dried before refilling?❑ Are refillable containers always

washed and dried (and not simply“topped off”) before refilling?

❍ Are hand lotions used to prevent skindryness associated with handwashing?❑ Are the lotions used during the

clinic day free of petroleum or otheroil skin softeners that degrade glovematerials?

❑ Are the lotions used during theclinic day compatible with the anti-

septics in hand hygiene products?❍ Are DHCP fingernails kept short, with

smooth, filed edges to allow thoroughcleaning and prevent glove tears?

❍ Are artificial fingernails discouragedamong DHCP in the practice setting?

❍ If it affects glove donning or fit, is handor nail jewelry removed for patient care?

Personal Protective Equipment❍ Is task-appropriate personal protective

equipment (PPE) worn when exposureto blood and body fluids is expected?

❍ Is barrier protection (including gloves,mask, eyewear, and gown) removed be-fore departing work areas such as oper-atories, the instrument processingroom, or the dental lab?

Face and eye protectionWhen performing procedures likely tocause splash or spatter:❍ Are surgical masks worn?❍ Is eye protection with solid side shields

or a face shield worn to protect mu-cous membranes of the eyes, nose, andmouth?❑ Are masks changed between patients? ❑ Are masks changed during patient

treatment if they become wet?❍ Between patients, is reusable face pro-

tection (eyewear, face shields) cleanedwith soap and water?

❍ If visibly soiled, is reusable face protec-tion (eyewear, face shields) cleaned andthen disinfected according to the disin-fectant manufacturer’s directions?

Protective clothing ❍ Is protective clothing worn over street

clothes or uniforms to protect againstsplash or spatter? ❑ Is protective clothing changed

when it is visibly soiled or penetrat-ed by blood or other potentially in-fectious fluids?

Gloves❍ Are medical gloves worn when contact

with body fluids is expected? ❍ Are sterile surgeon’s gloves worn when

performing or assisting on oral surgicalprocedures?

❍ Is a new pair of medical gloves wornfor each patient?

❍ Are gloves removed promptly after use,and is hand hygiene performed imme-diately thereafter?

❍ Are torn, cut, or punctured gloves re-moved as soon as possible and handsimmediately washed before regloving?

❍ Are gloves available in the correct sizeand readily accessible?

❍ Are puncture-/chemical-resistant utili-ty gloves worn when processing instru-ments and performing housekeepingtasks that involve contact with bodyfluids?

Contact Dermatitis and Latex Allergy❍ Have DHCP been informed of the

signs, symptoms, and diagnoses of skinreactions associated with frequent handhygiene and glove use?

❍ Are all patients in the practice settingscreened for latex allergy?

❍ Can a latex-safe environment be pro-vided for patients and DHCP withlatex allergy?

❍ Are latex-free emergency treatment kitsavailable and accessible at all times?

Sterilization and Disinfection of Patient-Care Items ❍ Are only FDA-cleared medical devices

used for heat sterilization?❑ Are manufacturer instructions for

operation always followed? (Hint:Posting procedural checklists nearthe equipment can help ensure thatdevices are used correctly.)

❍ Are all reusable critical dental instru-ments cleaned, dried, packaged, andthen heat-sterilized before use?

OSAP Chart & ChecklistOSAP Check-Up: 2003 CDC Guidelines continued from page 3

Never bend, break, or removeneedles before disposal.

❍ Are all reusable heat-tolerant semicriti-cal dental instruments cleaned andthen heat-sterilized before use?

❍ Are items and instrument packagescorrectly and loosely loaded into thesterilizer to allow penetration of thesterilizing agent?

❍ Are instrument packages allowed todry in the sterilizer before they are han-dled? (This prevents contamination.)

❍ Have heat-sensitive semicritical instru-ments been replaced with heat-tolerantor disposable versions?❑ If heat-sensitive instruments are

used in patient care, are they cleanedand then processed using an FDA-cleared sterilant/high-level disinfec-tant or an FDA-cleared low-temper-ature sterilization method? Note:Never use liquid chemical steri-lants/high-level disinfectants for en-vironmental surface disinfection oras holding solutions.

❑ Are the manufacturer’s instructionsfor preparation, use, and reuse ofchemical sterilants/high-level disin-fectants always followed?

❍ Have all DHCP been trained onOSHA guidelines for exposure tochemical disinfectants/sterilants? ❑ Have areas and tasks that have po-

tential for such exposure beenidentified?

❍ Are single-use disposable instrumentsused on only one patient and thenproperly discarded?

❍ Are all noncritical patient-care itemsbarrier-protected during use? Alterna-tively, are they cleaned (or if visiblysoiled, cleaned and disinfected) aftereach use?❑ Is an EPA-registered hospital disin-

fectant used to clean/disinfectnoncritical patient-care items thatare not barrier-protected duringuse?

❑ If noncritical patient-care items arevisibly contaminated with blood,are the items properly cleaned to re-move soil, then disinfected using an

EPA-registered hospital disinfectantwith a tuberculocidal claim?

The instrument processing area ❍ Does the practice setting have a desig-

nated central processing area?❑ Is the area divided physically, or at

least spatially, into separate areasfor:• receiving, cleaning, and deconta-

mination;• preparation and packaging; • sterilization; and • storage.

❍ Are work practice controls used to min-imize handling of loose contaminatedinstruments during transport to the in-strument processing area? For example:❑ Are instruments transported in a

covered container? ❍ Are dental team members trained to

use work practices that prevent con-tamination of clean areas? For example:❑ Are sterilized instrument packs and

clean supplies stored away from thearea where contaminated instru-ments are held or cleaned?

Receiving, cleaning, anddecontamination work area ❍ Are dental instruments and devices

cleaned of all visible blood and othercontamination before they are steril-ized or disinfected?❑ Is automated cleaning equipment

(such as an ultrasonic cleaner orwasher-disinfector) used to removedebris, improve cleaning effective-ness, and decrease worker exposureto blood?

❑ Are work practice controls (such as along-handled brush) used to mini-mize contact with sharp instrumentsif manual cleaning is necessary?

❍ Are puncture-/chemical-resistant utilitygloves worn when handling contaminat-ed instruments and performing instru-ment cleaning and decontaminationprocedures?

❍ Is appropriate PPE (a mask, protectiveeyewear, and protective clothing) worn

when splashing or spraying is antici-pated during cleaning?

Preparation and packaging ❍ After cleaning, are critical and semicrit-

ical instruments inspected for remain-ing debris?

❍ Before sterilization, are instrumentsand other patient-care items packagedusing an FDA-cleared container systemor wrap that is compatible with thetype of sterilization process used? (Pack-aging instruments in cassettes or traysbefore sterilization maintains theirsterility after the sterilization cycle.)

❍ Is an internal chemical indicator placedinside each instrument package priorto sterilization?❑ If the internal indicator is not visible

from outside the package, is an ex-ternal indicator affixed to the pack?

❍ Are packages labeled with the date andif multiple sterilizers are used withinthe facility, the sterilizer used? (Thissimplifies retrieval of processed itemsin case of a sterilization failure.)

Unwrapped instruments Although not recommended for routineinstrument processing, certain circum-stances may demand that instruments beprocessed unpackaged (for example, theonly available instrument falls to the floorduring patient care). If it is necessary tosterilize instruments without packaging,for example, using a flash cycle:❍ Are instruments cleaned and dried be-

fore the unwrapped sterilization cycle?❍ Are mechanical and chemical indica-

tors used for each unwrapped steriliza-tion cycle? (Place an internal chemicalindicator among the instruments oritems to be sterilized.)

❍ Are unwrapped instruments allowed todry and cool in the sterilizer beforethey are handled? (This prevents con-tamination and thermal injury.)

❍ Are unwrapped semicritical instru-ments sterilized on a tray or in con-tainer system?

Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 55 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 55 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 5Infection Control In Practice Vol. 3, No. 1 January 2004 http://www.osap.org 5

continued on page 6

❍ Are critical instruments that are steril-ized without packaging handled tomaintain sterility during removal fromthe sterilizer and transport to the pointof use? For example:❑ Are they transported to the opera-

tory in a sterile covered container?❍ Are sterilized, unwrapped critical in-

struments used immediately after theyhave cooled? (Do not store critical in-struments unwrapped.)

Implantable devices❍ Are implantable devices always pack-

aged for sterilization? ❍ Is a biological indicator always includ-

ed in each package containing an im-plantable device?❑ Are biological monitoring results re-

ceived and recorded before the im-plantable device is surgically placed?

Sterilization monitoring ❍ Are mechanical, chemical, and biologi-

cal monitors used according to themanufacturer’s instructions to ensurethe effectiveness of the sterilizationprocess?

❍ Is each load monitored with mechani-cal and chemical indicators?

❍ Is a chemical indicator placed on theinside of each instrument package tobe sterilized?❑ If the internal indicator is not visi-

ble from the outside, is anotherchemical indicator added to theoutside of package?

❍ If mechanical or chemical indicatorssuggest inadequate processing, are in-struments pulled from recirculation,repackaged, and sterilized again with

new indicators? ❍ Are sterilizers monitored at least week-

ly using a biological indicator and amatching control? (Using both a testand a control indicator from same lotensures that factors outside of the ster-ilization process have not affected thespores’ ability to be cultured.)❑ Is the test indicator placed within

an instrument pack and sterilizedwith a normal load?

❑ Is the control indicator — which isnot subjected to a sterilization cycle— incubated at the same time asthe test indicator?

❍ If a spore test comes back positive, areproper troubleshooting procedures im-plemented? (For a flowchart on man-aging sterilization failures, visit www.osap.org/resources/extra/sterifail.htm)

❍ Are sterilization records (mechanical,chemical, and biological) maintainedin compliance with state and local reg-ulations?

Storing patient-care items ❍ Are sterile items and dental supplies

stored in covered or closed cabinets tominimize the chance of contamination?

❍ Are wrapped packages of sterilized in-struments examined before they areopened to ensure the packaging (andsterility of the instruments inside) hasnot been compromised?❑ If packaging has been compro-

mised, are the contents recleaned,repacked, and resterilized?

❍ Does the practice setting use eitherdate- (“first in, first out”) or event-re-lated storage for wrapped, sterilized in-struments and devices? (Both methodsare considered acceptable.)

Managing Environmental Surfaces❍ Are surface barriers used to protect

clinical contact surfaces from contami-nation, especially those that are diffi-cult to clean?❑ Are surface barriers changed be-

tween patients?❍ If they are not barrier protected during

patient care, are clinical contact sur-faces cleaned and disinfected betweenpatient appointments?❑ For clinical contact surfaces that are

not visibly contaminated withblood, are surfaces cleaned and thendisinfected using an EPA-registeredhospital disinfectant with (a) HIVand HBV kill (at minimum) and/or(b) tuberculocidal activity?

❑ Are clinical contact surfaces that arevisibly contaminated with bloodcleaned and then disinfected using ahospital disinfectant with tubercu-locidal activity?

❍ Prior to disinfection, are manufacturerinstructions for precleaning surfacesclosely followed?

❍ After cleaning, is the disinfectant al-lowed to remain on the treated surfacefor the contact time stated on theproduct’s label?

❍ Is appropriate PPE in place whencleaning and disinfecting environmen-tal surfaces? For example:❑ puncture- and chemical-resistant

utility gloves,❑ protective clothing (such as a gown,

jacket, or lab coat), and ❑ face protection (protective eye-

wear/face shield with a mask). ❍ Are housekeeping surfaces such as

floors, walls, and sinks routinelycleaned using either a detergent andwater or an EPA-registered hospitaldisinfectant/detergent?

❍ Are cleaning schedules set by the na-ture of the housekeeping surface, thetype and degree of contamination, andif appropriate, location in the facility?

❍ Are housekeeping surfaces cleaned anddisinfected when visibly soiled?

❍ Are mops or cloths cleaned after use andallowed to dry before reuse, or are sin-gle-use, disposable mop heads or clothsused to clean housekeeping surfaces?

❍ Are fresh cleaning or EPA-registereddisinfecting solutions prepared daily



Do not surface-disinfect, use liquidchemical sterilants, or use ethyleneoxide on handpieces and other intraoralinstruments that can be removed fromdental unit air lines and waterlines.

and as instructed by the manufacturer?❍ Are walls, blinds, and window curtains

in patient-care areas cleaned when theyare visibly dusty or soiled?

❍ Are surfaces contaminated by spills ofblood or blood-contaminated fluidsfirst cleaned and then decontaminated?After cleaning, is an EPA-registeredhospital disinfectant with HBV andHIV label claims (minimum) and/ortuberculocidal activity used for disin-fection, depending on size of spill andsurface porosity?

Regulated Medical Waste❍ Does the practice setting have a written

medical waste management programthat outlines proper disposal of regulat-ed medical waste as dictated by federal,state, and local regulations?

❍ Are DHCP who handle and disposeof regulated medical waste trained inproper handling and disposal meth-ods?❑ Are they informed of the possible

health and safety hazards associatedwith medical waste?

❍ Are leakproof, color-coded/biohazard-labeled containers (for example, bio-hazard bags) used to contain nonsharpregulated medical waste?

❍ Are sharp items (needles, scalpel blades,orthodontic bands, broken metal in-struments, burs) placed in a puncture-resistant, leakproof, color-coded/bio-hazard-labeled sharps container? ❑ Are sharps containers closed imme-

diately before they are removed orreplaced to prevent contaminatedsharps from spilling or protruding?

❍ If allowed by state and local law, areblood, suctioned fluids, and other liquidwaste carefully poured down a drain

connected to a sanitary sewer system?❑ Are gloves, face protection (mask

with protective eyewear/faceshield), and protective clothingworn when performing this task?

Extracted teeth❍ Are extracted teeth disposed of within

the practice setting treated as regulatedmedical waste? (If the teeth are re-turned to the patient, waste disposalregulations do not apply.)

❍ Are extracted teeth containing amalgamdiscarded in regulated medical wastecontainers that will not be incinerated?(Incineration releases mercury vaporfrom amalgam, creating a hazard.)

When extracted teeth will be used in edu-cational settings or sent to a dental lab:❍ Are extracted teeth cleaned and placed

in a leakproof container with solution tomaintain hydration during transport?❑ Is the transport container labeled

with the biohazard symbol? ❍ Are teeth that do not contain amalgam

heat-sterilized before they are used foreducational purposes?

Dental Unit Waterlines, Biofilm, andWater Quality ❍ Does the water used in routine pa-

tient treatment meet EPA standardsfor drinking water (that is, less than500 CFU/mL of heterotrophic waterbacteria)?

❍ Are the products and protocols recom-mended by your dental unit manufac-turer used to maintain water quality?

❍ Are recommendations for monitoringwater quality followed? (Obtain andfollow monitoring schedules recom-mended by the dental unit manufac-turer and/or the maker of the waterlinetreatment device/chemical.)

❍ For devices that are connected to thedental water system and enter the pa-tient’s mouth, are water and air dis-charged for at least 20-30 seconds afteruse on each patient? (Such devices in-

clude handpieces, ultrasonic scalers,and air/water syringes.)

❍ If the dental unit is equipped with an-tiretraction mechanisms, are the unitmanufacturer’s recommendations forperiodic maintenance followed?

❍ Are staff aware of procedures to followin the event of a boil-water advisory?(See the OSAP Practice Tip, p. 12.)

Dental Handpieces, Other DevicesAttached to Air Lines and Waterlines❍ Are handpieces and other intraoral in-

struments that can be removed fromthe air and waterlines of dental unitscleaned and then heat-sterilized be-tween patients?

❍ Are manufacturer’s instructions forcleaning, lubrication, and sterilizationof other such intraoral instruments fol-lowed every time the instruments areprocessed for reuse? (Failure to followmanufacturer instructions can voidequipment warranties.)

Dental Radiography ❍ Are gloves worn by dental workers

when exposing radiographs and han-dling contaminated film packets?

❍ Is other PPE (such as protective eye-wear, mask, and gown) also worn ifspattering of body fluids is likely?

❍ Are heat-tolerant or disposable film-holders, positioners, and other intrao-ral devices used whenever possible?

❍ Are heat-tolerant radiographic acces-sories cleaned and then heat-sterilized?

❍ If any heat-sensitive semicritical de-vices are used, are they (at minimum)cleaned and high-level disinfected ac-


continued on page 8

Never use liquid chemical sterilants/high-level disinfectants to disinfectenvironmental surfaces.

Do not advise patients to close theirlips tightly around the tip of the salivaejector to evacuate oral fluids. It cancause oral fluids to retract.

cording to the device and germicidemanufacturer’s instructions?

❍ Are exposed radiographs films trans-ported and handled aseptically to pre-vent contamination of developingequipment?

Digital radiographyIf your practice setting uses a digital x-raysystem with intraoral sensors: ❍ Are equipment manufacturer instruc-

tions for cleaning, disinfection, and/orsterilization of digital radiology sensorsand for protection of associated com-puter hardware followed?

❍ Are FDA-cleared barriers used on sen-sors to protect them from contamina-tion during use on a patient?

❍ After use on a patient, are sensorscleaned and then either heat-steril-ized or immersed in a liquid steri-lant/high-level disinfectant for thecontact time recommended by themanufacturer?

If sensors cannot tolerate heat or liquidchemical immersion: ❍ Are FDA-cleared barriers used on sen-

sors to protect them from contamina-tion during use on a patient?

❍ Are barriers removed and sensorscleaned and then disinfected using anEPA-registered hospital disinfectantwith a tuberculocidal claim?

Aseptic Techniquefor Parenteral Medications ❍ Are IV bags, tubings, and connections

used for one patient only and disposedof appropriately?

❍ Is medication from any syringe admin-istered to only one patient?

❍ Are single-dose vials of parenteral med-ications used whenever possible?

❍ Is any medication remaining in a sin-gle-use vial discarded with the vial afteruse on one patient (rather than savedfor later use)?

If multidose vials are used: ❍ Is the access diaphragm cleansed with

70% alcohol before inserting a deviceinto the vial?

❍ Are only sterile devices used to accessmultiple-dose vials?

❍ Except by the sterile device, is contactwith the access diaphragm avoided?

❍ Are needles and syringes used to accessa multidose vial always sterile? (Neverreuse a syringe even if the needle ischanged.)

❍ Are multidose vials stored away fromthe immediate patient treatment areato prevent inadvertent contaminationby spray or spatter?

❍ Are multidose vials immediately dis-carded if their sterility is compro-mised?

Single-Use (Disposable) Devices ❍ Are single-use devices used for one pa-

tient only and then properly discarded?

Oral Surgical Procedures ❍ Is surgical hand antisepsis performed

before gloving by all dental workersparticipating in an oral surgical pro-cedure? (Surgical hand antisepsis in-volves using either (a) an antimicro-bial soap and water or (b) a plain soapand water handwash followed by al-cohol-based hand rub with persistentactivity.)

❍ Are sterile surgeon’s gloves worn whenperforming oral surgical procedures?

❍ Is sterile saline or sterile water used as acoolant/irrigant during oral surgicalprocedures?

❍ Are sterile irrigating fluids deliveredusing devices specifically designed forthat purpose, for example, a bulb orsterile irrigating syringe, single-use dis-posable products, or sterile water deliv-ery systems with disposable or steriliz-able tubing?

Biopsy Specimens ❍ Are biopsy specimens placed in a stur-

dy, leakproof container for transport?❑ Is the container labeled with the

biohazard symbol? ❍ If the outside of a biopsy specimen

container becomes visibly contaminat-ed, is it either cleaned and disinfectedor placed in an impervious bag labeledwith the biohazard symbol?

Dental Laboratory❍ Is PPE worn when handling items that

have not been decontaminated?❍ Is specific information on disinfection

(for example, solution used and dura-tion) included when laboratory casesare sent from the dental facility to anoff-site lab and back?

❍ Unless the sender indicates that theyhave been disinfected, are all dentalprostheses and prosthodontic materials(such as impressions, bite registrations,occlusal rims, and extracted teeth)cleaned, disinfected using an EPA-reg-istered hospital disinfectant with tu-berculocidal activity, and rinsed?

❍ Have material manufacturers beenconsulted on the stability of specificimpression materials relative to disin-fection procedures?

❍ Are heat-tolerant items used in themouth (such as metal impression traysand face-bow forks) clean and heat-sterilized after use on a patient?

❍ Are manufacturer instructions fol-lowed for cleaning and sterilizing ordisinfecting items that do not normal-ly contact the patient but become con-taminated during laboratory proce-dures (for example, burs, polishingpoints, rag wheels, articulators, casepans, and lathes)?

❍ If manufacturer instructions are notavailable, are items processed accordingto the degree of contamination?❑ Are heat-tolerant items cleaned and

heat-sterilized, or are they cleanedand then disinfected using an EPA-registered hospital disinfectant an



Avoid using carpeting and cloth upholstery in operatories, labs,and instrument processing areas.

HIV and HBV claim and/or a tu-berculocidal claim?

Tuberculosis and Dentistry❍ Does your practice setting have a writ-

ten TB infection-control plan? ❍ Are all dental team members trained to

know the signs and symptoms of TB aswell as how it is transmitted?

❍ Is a baseline tuberculin skin test per-formed for all dental workers whomight have contact with persons withsuspected or confirmed active TB?

❍ Is each patient assessed for history orsymptoms of TB? Are findings docu-mented on the medical history form?

If a patient with active or suspected TB ar-rives for treatment:❍ Is the patient evaluated away from

other patients and dental workers?❍ When not being evaluated, is the pa-

tient asked to wear a surgical mask andinstructed to cover his or her mouthand nose when coughing or sneezing?

❍ Is elective dental treatment deferreduntil the patient is noninfectious?

❍ Are patients in need of urgent dentalcare referred to a previously identified fa-cility with TB engineering controls anda respiratory protection program?

For DHCP who may have active TB:❍ Are personnel with a deep, productive

cough lasting longer than three weeksreferred for medical evaluation? This isespecially important when other signsor symptoms consistent with active TBare present (for example, weight loss,night sweats, fatigue, bloody sputum,anorexia, and fever).

❍ Are such DHCP instructed not to re-turn to work until a physician deter-mines that the worker does not haveTB or is no longer infectious?

❍ Has a community risk-assessment beenperformed for your practice setting?

Evaluating Your Infection ControlProgram❍ Is a plan for evaluating the practice set-

ting’s infection control program inplace? OSAP


As its title suggests, From Policy to Practice:

OSAP’s Guide to the Guidelines takes new

infection control recommendations from

the Centers for Disease Control and

Prevention (CDC) and helps you — the

dental worker — put them into practice.

OSAP has created a 170-page, all-inclusive workbook to walk users through

the new and expanded 2003 infection control guidelines. Each chapter

contains practical, how-to instructions, charts and checklists, pictures and cap-

tions, answers to common questions, and guidance for making sound clinical

judgments. Suggested retail price, $69.95. 10 hours of CE credit available.

Introducing From Policy to Practice:OSAP’s Guide to the Guidelines

• Job Categories identify who withinyour practice needs to learn andapply each chapter.

• Examining the Issues explains whyeach set of practices and procedures is important.

• A comprehensive Glossary and list of Terms You Should Know define important words and phrases you will come across in each chapter.

• Step by Step instructions explain how to perform common procedures in practice.

• Common Questions and Answersoutlines areas where clarification orclinical judgment may be needed.

•Exercises in Understanding brings recommended procedures right into your practice setting.

• Recommended Reading and Resources points you toward relatedinfo in the scientific literature and onthe World Wide Web.

• Self-Tests at the end of each chaptermake sure you’re familiar with the material before moving on.

A L OOK I N S I DE:

Contact an OSAP member dealer today

The new CDC guidelines are here.

Are you ready?

5

10 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 1010 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 10

Calendar


To help practicesstay on track,OSAP provides this calendar listing typical schedules forperiodic mainte-nance, recordkeep-ing, and infectioncontrol activities.This schedule is intended only toserve as a guide.Proper practices,procedures, andmaintenanceschedules can varyaccording to thekinds of productsused, the practicetype, and patientvolume. Alwaysfollow the device or equipment manufacturer’sinstructions for maintenance and infection control.

For a monthly dentaloffice calendar youcan customize tobest meet the needsand schedules inyour practice, visitosap.org/calendars/index.htm. (Adobe

Acrobat Reader required.)

1 2 3

4 5 6 7 8 9 10

11 12 13 14 15 16 17

18 19 20 21 22 23 24

25 26 27 28 29 30 31

JANUARY 2004

NEW YEAR’S DAY

MARTIN LUTHER KING DAY

PRESIDENTS DAY

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Monthly:check fire extinguisher

operating pressure

Monthly:foil test

ultrasonic cleaners

Weekly:spore test sterilizers




Monthly: read watertest results; retreatlines if necessary

Weekly:clean evacuation traps

Monthly: Waterlinemonitoring

Weekly: waterlinemaintenance





Monthly: Waterlinemonitoring






1 2 3 4 6 7

8 9 10 11 12 13 14

16 17 18 19 20 21

22 23 24 25 26 27 28

29

FEBRUARY 2004SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Monthly:check fire extinguisher

operating pressure

Monthly:foil test

ultrasonic cleaners






Monthly: update chemical inventory;discard expired supplies, drugs

Weekly: waterline maintenance



15

Monthly: update chemical inventory;discard expired supplies, drugsWeekly: clean evacuation traps

Annual: schedule fire suppression company to inspect and document fire extinguisher condition;

check that annual training requirements are up to date

OSAP-FEDERAL SERVICES INFECTION CONTROL & SAFETY COURSE

Monthly: read watertest results; retreat lines if necessary

Weekly: clean evacuation traps

Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 1111 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.org 1111 Infection Control In Practice Vol. 1, No. 1 May 2002 http://www.osap.orgInfection Control In Practice Vol. 3, No. 1 January 2004 http://www.osap.org 11

Cont inuing Educat ion CE Unit 1/04

If you wish to obtain one (1) hour of continuing-education (CE) credit, complete the following test and fax or mail it to theOSAP Central Office for grading. Please include a check or credit card to cover handling charges. Pending satisfactory results (at least

seven out of ten), you will be issued a letter for one (1) CE credit hour through the Academy of General Dentistry and the Dental As-sisting National Board. AGD Approved National Sponsor, FAGD/MAGD credit, 10/23/93 to 12/31/05. OSAP also is an ADA CERPRecognized Provider.

1. True or False: It is okay to administer medication from one syringe to multiple patients as long as the needle is changed.a. True b. False

2. Highspeed handpieces should be processed using:a. a liquid chemical sterilant c. an autoclave or chemical vapor sterilizerb. ethylene oxide d. a tuberculocidal hospital disinfectant

3. The 2003 CDC infection control guideline for dentisty recommends the use of ________________ to protect against expo-sures to blood and all other body fluids (except sweat, which is not infectious).a. universal precautions b. standard precautions c. healthcare worker precautions d. both a and b

4. When dental worker hands are dirty or are visibly soiled with blood or other body fluids, the worker must:a. don gloves b. use waterless antimicrobial hand rub c. thoroughly wash and dry hands d. all of the above

5. To maintain surface asepsis, clinical contact surfaces should be:a. cleaned and disinfected between patients c. both a and bb. covered with an appropriate protective barrier d. either a or b

6. When heat processing, use (a) ______________________ with each instrument pack containing an implantable device:a. biological indicator b. chemical indicator c. mechanical indicators d. all of the above

7. True or False: Flash sterilization should not be used for routine instrument processinga. True b. False

8. What schedule is recommended for spore testing heat sterilizers in dentistry?a. weekly b. monthly c. quarterly d. semi-annually

9. When performing or assisting on oral surgical procedures, you should wear:a. sterile surgeon’s gloves b. mask and eyewear c. a protective garment d. all of the above

10. During a boil-water advisory, it is acceptable to:a. use bottled water for patient rinsing c. use tap water for handwashing if you use an antimicrobial soapb. use an alcohol-based hand rub on soiled hands d. put new filters on dental unit waterlines

Mail or Fax completed test to receive (1) hour of continuing-education credit, or visit www.osap.org/training/online/ to test online.

Your Name: _____________________________________ OSAP Member Name:________________________________(if different)

Address: ____________________________________________________________________________________________street city/state zip code country

❍ VISA ❍ MASTERCARD ❍ CHECK ENCLOSED Fee: ❍ OSAP MEMBER, $5 ❍ OSAP SUBSCRIBER, $15

Name on Card: ___________________________________ Card Number: _____________________________________

Expiration Date: _______________________ Signature: ___________________________________________________MAIL TO: OSAP CE • P.O. Box 6297 • Annapolis, MD 21401 • USA FAX TO: 410.571.0028

$10

When water treatment processes failor are interrupted, or if natural disas-

ters or other circumstances compromise thewater distribution network, public drink-ing water can become contaminated.“Most notable in recent years was the out-break of cryptosporidiosis in Milwaukee,Wisconsin, where the municipal water sys-tem was contaminated with the parasiteCryptosporidium parvum,” notes ShannonMills, DDS, deputy director of the JointClinical Readiness Advisory Board. Morethan 400,000 persons became ill during theMilwaukee epidemic. Outbreaks involvingCryptosporidium and other waterborne or-ganisms also have occurred in New York,Ontario, Washington, and other areas.

Issued by the public health departmentwhen local or regional water is deemed un-safe to drink, a boil-water advisory is a no-tice to the public to boil tap water beforedrinking it. “Because dentistry relies soheavily on water — it’s used for hand-washing, patient rinsing, as a coolant ... —boil-water advisories are serious business

for dental facilities,” Dr. Mills asserts. “Tomake sure that practices and clinics canstill deliver care during these public healthadvisories, the CDC has developed a set ofguidelines that dental workers can follow.”

In the event of a boil-water advisory:❍ Do not use water from the public

water supply to treat patients. “This in-cludes water plumbed through thedental unit, ultrasonic scaler, or otherequipment that uses public water,” heexplains. Of course, if your watersource has been isolated from the mu-nicipal water system — for example, ina separate water reservoir or otherwater treatment device that has beencleared for marketing by the FDA —this restriction doesn’t apply.

❍ Avoid using water from faucets for pa-tient rinsing and handwashing. In-stead, have patients rinse with bottledwater. For hand hygiene, use alcohol-based hand rubs if hands are not visiblysoiled. If they are, use bottled waterand soap or an antiseptic-containing

towelette to clean the hands. To treat public water so it is safe for

hand hygiene or for diluting disinfectants(if necessary), bring water to a rolling boilfor at least 1 minute and cool thoroughlybefore use.

When the boil-water advisory is lifted,follow your local water utility’s recommen-dations for flushing all waterlines served bythe public water system and disinfect yourdental unit waterlines according to themanufacturer’s instructions. OSAP

FIRST-CLASS MAILU.S. POSTAGE

PAIDWoodbridge, VAPERMIT NO. 70

Pract ice Tip Doing dentistry under a boil-water advisory

Do you have a practice tip you’d like to share with other OSAP members and subscribers? Send your suggestions for enhancing dental infection control andsafety in practice to [email protected]. Be sure to include contact information, a photo, and a brief bio. Thanks!

for Infection Control & SafetyP.O. Box 6297 • Annapolis, MD 21401

Shannon Mills, DDS,is a former OSAPChairman and Editorof Infection Control

In Practice. State-ments expressed arehis own and do notreflect the officialpolicy of the U.S.Government.

Sh

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Mi

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s,

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S

ASSESSMENT OF INFECTION CONTROL PROTOCOLS IN DENTAL PRACTICES FOR PATIENT SAFETY

By Mary Govoni CDA, RDA, RDH, MBA

Learn more about NEW courses and other opportunities at FRIENDSOFHU-FRIEDY.COM

©2013 Hu-Friedy Mfg. Co., LLC. All rights reserved.

For more information visit Hu-Friedy.com or join FriendsOfHu-friedy.com

For additional Infection Control resources visit Hu-Friedy.com/Education/Infection-Prevention-Resources

©2013 Hu-Friedy Mfg. Co., LLC. All rights reserved.

• Instruments should be cleaned and inspected for cleanliness prior to sterilization

• Heat sterilize all reusable items and instruments that are heat tolerant using FDA cleared medical devices for sterilization

• Use high level disinfection/chemical sterilization on reusable items that are heat sensitive (“cold sterilization”)

• Package/wrap all instruments and/or cassettes prior to sterilization in wrapping compatible with the type of sterilization process used and that have received FDA clearance

• Use a chemical indicator in each instrument pack or cassette, or use sterilization pouches with internal and external indicators

• Monitor all heat sterilizers weekly with a biological monitor (spore test)

• Packages should be labeled with the date and, if multiple sterilizers are used within the facility, the sterilizer used should also be noted

• Keep contaminated items separated from clean/sterile items in the instrument processing area

• Use impervious barriers where appropriate to protect equipment and surfaces from contamination

• Replace equipment barriers after each patient

• Use intermediate level (tuberculocidal) disinfectants to clean and decontaminate surfaces in treatment areas

• Use personal protective equipment – gloves, safety glasses, face masks and gowns/lab coats when treating patients and reprocessing instruments

• Follow principles of aseptic technique during patient treatment, instrument processing and radiographic procedures

• Wash hands prior to donning gloves for treatment and immediately after removing gloves after treatment. If hands are not visibly soiled, an alcohol-based hand rub can also be used

• Change face masks between each patient or sooner if it becomes wet during treatment

• Wear a new pair of gloves for every patient; change gloves immediately if they become torn or punctured during a procedure

• Use sterile gloves for surgical procedures

• Segregate and dispose of contaminated sharps and waste according to state and federal guidelines

• Follow CDC prescribed protocol for follow-up after an exposure incident

• Vaccinate doctors, assistants and hygienists for Hepatitis B

• Maintain waterlines in dental units to provide water quality at 500 cfu/ml or less for treatment

• Use sterile water or sterile saline for surgical procedures

• Use single-dose medication vials whenever possible

• Prepare all medications in a clean area and use only sterile needles in multiple use medication vials

• Follow “standard precautions” (i.e. treating every patient) as if they are potentially infectious

• Screen patients for possible tuberculosis (TB) infections and provide only emergency treatment for patients who are known to have active TB or who are suspected of having TB because of symptoms that they exhibit

• Maintain a written infection control/exposure control for the practice – update annually

• Participate in or conduct annual OSHA-required infection control training updates

AFTER

WHITE

AFTER

WHITE

AFTER

WHITE

INSTRUMENT MANAGEMENT

Mary Govoni, CDA, RDA, RDH, MBA Mary Govoni brings over 40 years of experience in dentistry. She is a Certified Dental Assistant, a Registered Dental Assistant (MI) and a Registered Dental Hygienist, with experience in general and specialty practices both clinically and as an administrator. Mary is a former dental assisting educator and was a partner in a successful dental staffing service.

For the past 20 years, Mary has focused on speaking and consulting with dental teams on infection prevention, OSHA compliance, ergonomics, chairside efficiency and team communication and development. Recently Mary has added HIPAA compliance and employment law compliance to her areas of expertise. Mary has published numerous articles in professional journals. She is a life member and Past President of the American Dental Assistants Association, and serves on the ADAA Editorial Board as well as the Corporate Council for Dimensions of Dental Hygiene. Mary is also a consultant to the American Dental Association on Dental Practice (ADA) and a featured speaker on the Continuing Education and Lifelong Learning Seminar Series.

The following is a list of CDC recommended infection control protocols that every dental practice should follow to help keep their patients safe from disease transmission during dental treatment.

How effective are your practice protocols?

Preventing dental unit waterline contamination.By John A. Molinari, PhO

Dental waterlines can become contaminatedby organisms that colonize the system, rap-idly leading to the formation of biofilmsinside the lumens of the waterlines. Althoughthe water coming into dental waterlines is sanitized and meets

public health safety standards for potable quality «500 cfu

John A. Molinari, PhD. is a professor in the Department of Biomedical Sci-

ences at the University of Detroit Mercy School of Dentistry, Detroit, and

the director of Infection Control for THE DENTAL ADVISOR in Ann Arbor,

Mich. The coauthor of the textbook Practical Infection Control in Dentistry,

he has also written more than 300 articles, text chapters, and abstracts on

microbiology and immunology.

• •• 0• • 0 .

"

(colony forming units)/mL of bacteria and <1 coliform), water

coming out of dental waterlines may contain up to 1,000,000

cfu/mL of bacteria. This contamination occurs because certain

dental waterline factors (eg, system design, flow rates, materials)

promote bacterial growth and the development of biofilm.'·3

In 1995, the American Dental Association issued a state-

ment on the quality of water used in dental treatment-

encouraging industry and researchers to improve the design of

dental equipment and to provide equipment with the ability to

deliver treatment water with 200 cfu/mL or less of unfiltered

output from water lines.'·s Similar standards are in effect for

dialysate, one of the fluids used in dialysis. Standards also exist

for safe drinking water quality as established by the Environ-

mental Protection Agency (EPA), the American Public Health

... Increasing numbers of patients routinely seek

dental treatment who have weakened immunesystems and who may be periodically exposedto microbial opportunists via colonized water.

Association (APHA), and the American Water

Works Association (AWWA), which set limits of

no more than 500 cfu of heterotrophic bacte-

ria per mL of drinking water. The number of

bacteria in water used as a coolantjirrigant for

nonsurgical dental procedures should be less

than the 500 cfu/mL regulatory standard for

safe drinking water established by the EPA,

APHA, and AWWA.7.8

Many products are available that address

the composition, mechanisms of microbial

accumulation, potential health risks, and the

reduction of microbial accumulation in the

dental operatory. As a result, dental health

care workers (DHCW) are faced with many

product choices and, unfortunately, they

sometimes come upon confusing, conflict-

ing information that can make subsequent

purchasing decisions difficult.

WHAT TYPES OFMICROORGANISMS HAVE BEENISOLATED FROM COLONIZEDDENTAL WATERLINES?Research has identified multiple classes of

organisms in dental waterline samples-rang-

ing from nonpathogenic to pathogenic spec-

trums of microbes.'·3.6Types of microbes com-

monly associated with dental waterlines are

Bacterionema spp.; Corynebacterium spp.; gram

negative bacilli and cocci; Klebsiella spp.; Neis-

seria (N. catarrhalis); Pseudomonas spp., includ-

ing P.aeruginosa, P.pyogenes, and Burkholdaria

capacia; Staphylococcus epidermidis; Streptococ-

cus mutans; Streptococcus salivarius; Streptococ-

cus mitis; Actinomyces spp.; Enterococcus spp.; ()(

hemolytic streptococci; Staphylococcus aureus;

B. subtilis; E. coli; Flavobacterium; non hemolytic

streptococci; Legionella pneumophila; Mycobac-

terium spp.; Aspergillus niger; Cladosporium;

Achromobacter; and Alcaligenes faecalis. Even

small roundworms have been found in con-

taminated dental waterlines.

Most of the isolated microbes are from

the public water supply and are classified as

opportunistic pathogens, meaning they do

not usually pose a high risk of disease for

healthy persons. This fact has direct implica-

tions for dentistry because increasing num-

bers of patients routinely seek dental treat-

ment who have weakened immune systems

and who may be periodically exposed to

microbial opportunists via colonized water!

Infections in this type of patient are a prob-

lem following medical exposure to water-

borne pathogens, such as Pseudomonas, Kleb-

siella, Legionella, and nontuberculous

Mycobacterium species. Since these bacteria

have been isolated in dental water supplies,

we need to learn from the experiences of our

medical colleagues by taking steps to mini-

mize colonization and, therefore, the poten-

tial for infection and illness in immune com-

promised individuals.

Despite the presence of potentially patho-

genic bacteria in numbers greatly exceeding

levels established for drinking and recreational

waters, few cases of illness among DHCWs or

patients have been confirmed. However,

because most dental offices are located in out-

patient settings, epidemiological links between

an infection and recent exposure to contami-

nated dental water are difficult to establish. The

relatively small quantity of water entering a

patient's mouth during routine dental treat-

ment is a possible reason for the lack of docu-

mented infection. Exposure to aerosols and

entrance of contaminated water into open

wounds are also possible routes of microbial

transmission. Moreover, the widespread appli-

cation of effective, accepted infection con-

trol principles and the high level of asepsis

standards routinely exhibited in most dental

facilities reduces the risk of exposing either

patients or DHCW to water of poor microbi-

ological quality.

Biofilm is a bacterial film that tightly adheres

and liesflat against the walls of the dental water-

line. It is characterized by cells that:

1. Are irreversibly attached to a substratum

or interface with each other;

2. Are embedded in a matrix of extracellular

polymeric substances that they have produced;

and

3. Grow as a distinct community of bacteria

and other microorganisms acting as a self-per-

petuating and self-protecting unit.

Biofilms are virtually ubiquitous--existing in

all environments where there iswater and a suit-

able solid substrate for attachment. They can

harbor numerous waterborne bacteria, fungi,

protozoa, even roundworms. While at first

glance biofilms may appear as simple amor-

phous masseson water-laden sUrTaces,they can

have a surprisingly complex structure9 It is pos-

sible for clumps of biofilm to become dis-

lodged and come out as solid material when

water flows through dental waterlines, which

is of particular importance to both possible

infectious exposure and the public's percep-

tion of microbial exposure.

WHAT ARE THE CURRENTRECOMMENDATIONS FORADDRESSING DENTAL WATERASEPSIS?The most recent Centers for Disease Control

and Prevention (CDC) infection control guide-

lines recommend that potable water be used

for routine dental care and that sterile water

be used for surgical procedures that involve

exposure of bone, the vascular system, or tissue

that is normally sterile" Table 1 (page 44) lists

the CDC Recommendations for Dental Unit

Waterlines, Biofilm, and Water Quality.

Ongoing efforts by manufacturers continue

to provide DHCW with multiple choices for

controlling the quality of source water used in

patient care, including:

1. An alternate water supply that bypasses

community water systems and dental water-

lines by providing sterile or distilled water

directly into water line attachments (ie, sepa-

rate reservoir) combined with chemical treat-

ment.

2. Filtration involving in-line filters to

remove bacteria immediately before dental

unit water enters instrument attachment.

3. Chemical disinfection involving peri-

odic flushing of lines with a disinfectant fol-

step-by-step procedure for

accomplishing this removal is

essential. Minimizing sub-

sequent dental waterline

colonization may require

another seriesof protocols,

some of which may be

more time consuming

than anticipated. Thus, the

whole dental team needs

to be aware of product

costs, necessity for compli-

ance, and the time

required to reach recom-

mended dental waterline

microbial concentrations.

General Recommendations1. Use water that meets EPAregulatory standards for drinking

water (ie, <500 cfu/mL of heterotrophic water bacteria) forroutine dental treatment output water.

2. Consult with the dental unit manufacturer for appropriatemethods and equipment to maintain the recommendedquality of dental water.

3. Follow recommendations for monitoring water qualityprovided by the manufacturer of the unit or waterlinetreatment product.

4. Discharge water and air for a minimum of 20 to 30 secondsafter each patient from any device connected to the dentalwater system that enters the patient's mouth (eg, hand-pieces, ultrasonic scalers, and air/water syringes).

5. Consult with the dental unit manufacturer on the need forperiodic maintenance of anti-retraction mechanisms.

Research develop-

ments in recent years

have led to not only

greater individual

options for dental practi-

tioners, but also to the availability of com-

bination system products, which contain

separate waterline cleaning agents and

maintenance chemicals. This approach

minimizes the possible confusion that can

arise from evaluating, purchasing, and

using multiple types of products from dif-

ferent manufacturers." Remember to ask

Special Considerations for Oral Surgical Procedures1. Use sterile saline or sterile water as a coolant/irrigatant when

performing oral surgical procedures. Use devices specificallydesigned for delivering sterile irrigating fluids (eg, bulb syringe,single-use disposable products, and sterilizable tubing).

lowed by appropriate rinsing of lines with

water or a continuous release chemical disin-

fection system.

4. Thermal inactivation of facility water at

a centralized source.

5. Reverse osmosis or ozonation using

units designed for either single chair or entire

practice waterlines.

6. Ultraviolet irradiation of water before

entrance into individual unit waterlines.

Even though many choices exist for clean-

ing and maintaining waterlines, some require

a substantial commitment by personnel. One

of the more popular options is the use of

chemical agents either continuously or added

periodically to clean waterlines. While no

available chemical meets all standards, Table 2

lists the criteria that should be used to evalu-

ate the efficacy and safety of dental waterline

agents9,10

While it is fortunate that multiple options

are available, the key for accomplishing dental

waterline asepsisremains the same as for other

infection control issues:use basic infection con-

trol principles in the selection of a strategy while

ensuring personnel compliance with specified

protocols. Contaminated waterlines-like con-

taminated hands, instruments, and environ-

mental surfaces-should first be cleaned to

remove accumulated microbial and extracellular

material. Compliance with the manufacturer's

• Nontoxic to equipment or patients• Nonpyrogenic• Nonallergenic• Noncorrosive to metals• No damaging effects on rubber or

synthetic materials• Does not interfere with performance

of any dental restorative or therapeuticagents

• Rapid "cidal" (ie, lethal) antimicrobialaction

• Exhibit broad-sprectrum antimicrobialactivity against bacteria, fungi, andprotozoa

• Ability to disrupt/disperse accumulated

biofilms

• Exhibit substantivity to minimize or

prevent microbial accumulation on

treated surfaces

• Eco-friendly or "green"

the appropriate questions when discussing

available product choices with manufactur-

ers' representatives and then be certain to

evaluate what approach will work best in

your specific facility. (i)

REFERENCES1. Blake Gc. The incidence and control of bacterial infection of dental units and ultrasonicscalers. Br Med}. 1963; 115:413-416.

2. Kohn WG. Harte jA, Malvitz OM, et al. Guidelines for infection control in dental health caresettings-2003. MMWR Recomm Rep. 2003;52(RR-17):1-61.

3. Bagga BS,Murphy RA,Anderson AW, Punwani I. Contamination of dental unit cooling waterwith oral microorganisms and its prevention.) Am Dent Assoc. 1984;109:712-716.

4. Shearer BG. Biofilm and the dental office.) Am Dent Assoc. 1996;127:181-189.

5. American Dental Association statement on dental unit waterlilles. Adopted by the ADA Boardof Trustees, December 13,1995 and the ADA Council on Scientific Affairs, September 28,1995.Northwest Dent. 1996;75:25-26.

6. Mills SE.The dental unit waterline controversy: defusing the myths, defining the solutions.) Am

Dent Assoc. 2000;131:1427-1441.

7. United States Environmental Protection Agency. Part 141-National Primary Drinking WaterRegulations. Available at: http://ecfr.gpoaccess.gov/cgi/t1text/text-idx7c=ecfr&sid=39f1366979712ecaOac4e22f5f52b290&tpl=/ecfrbrowse/Title40/40cfr141_ma in_02.tpl. AccessedAugust 17, 2009.

8. American Public Health Association, American Water Works Association, Water EnvironmentFoundation. Standard methods for the examination of water and wastewater. In: Eaton RD,Clesceri LS,Greenberg AE, eds. Standard Methods for the Examination of Water and Wastewater.Washington, DC:American Public Health Association; 1999:9-41.

9. Mills SE.Dental unit water and air quality challenges. In: Molinari jA, Harte jA, eds. Cottone'sPractical Infection Control in Dentistry. 3rd ed. Philadelphia: Wolters Kluwer/ Lippincott Williams &Wilkins; 2009:63-75.

10. Molinari jA. Dental unit water contamination. Compend Cantin Ed Dent. 1999;20:358-362.

11. Molinari jA. Principles of dental waterline asepsis. Dental Economics. Available at:www.dentaleconomics.com/d isplay_articIe/363284/54/none/n one/Col um/Pri ncipies-of-denta 1-waterline-asepsis. AccessedAugust 17, 2009.

http://www.dentaleconomics.com/d

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Documents

Sterilization and Disinfection of Patient-Care Items · Sterilization and Disinfection of Patient-Care Items Patient-care items (dental instruments, devices, and equipment) are categorized