cdc gudelines 2003

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Guidelines for Infection Control in Dental

Health-Care Settings --- 2003

Prepared by%illiam &. 'ohn, (.(.).*

#my ). +ollins, .P..*

ennifer /. +leveland, (.(.).

*

ennifer #. arte, (.(.).0 'athy . 12lund, ..P.3

(olores . alvit4, (r.P..*1 Division of Oral Health National Center for Chronic Disease Prevention and Health Promotion, CDC2United States Air Force Dental Investigation Service

reat !a"es, Illinois#$he Fors%th Instit&te

'oston, (assach&setts

The material in this report originated in the 5ational +enter for +hronic (isease Prevention and ealth

Promotion, ames ). ar2s, .(., .P.., (irector6 and the (ivision of 7ral ealth, %illiam 8. aas,

(.(.)., .P.., (irector.

Summary

$his re)ort consolidates )revio&s recommendations and adds ne* ones for infection

control in dental settings+ ecommendations are )rovided regarding 1- ed&cating and )rotecting dental health.care )ersonnel/ 2- )reventing transmission of 0lood0orne

)athogens/ #- hand h%giene/ - )ersonal )rotective e&i)ment/ 3- contact dermatitis and

late4 h%)ersensitivit%/ 5- sterili6ation and disinfection of )atient.care items/ 7-environmental infection control/ 8- dental &nit *aterlines, 0iofilm, and *ater &alit%/ and

9- s)ecial considerations :e+g+, dental hand)ieces and other devices, radiolog%, )arenteral medications, oral s&rgical )roced&res, and dental la0oratories-+ $heserecommendations *ere develo)ed in colla0oration *ith and after revie* 0% a&thorities

on infection control from CDC and other )&0lic agencies, academia, and )rivate and

)rofessional organi6ations+

Introduction

mailto:[email protected]:[email protected]


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This report consolidates recommendations for preventing and controlling infectious

diseases and managing personnel health and safety concerns related to infection control in

dental settings. This report *9 updates and revises previous +(+ recommendationsregarding infection control in dental settings 1 ,296 09 incorporates relevant infection-

control measures from other +(+ guidelines6 and 39 discusses concerns not addressed in previous recommendations for dentistry. These updates and additional topics include the

following:

• application of standard precautions rather than universal precautions6

• wor2 restrictions for health-care personnel +P9 infected with or occupationally

e;posed to infectious diseases6

• management of occupational e;posures to bloodborne pathogens, including

poste;posure prophyla;is P1P9 for wor2 e;posures to hepatitis < virus =96

• selection and use of devices with features designed to prevent sharps in$ury6

• hand-hygiene products and surgical hand antisepsis6

• contact dermatitis and late; hypersensitivity6

• sterili4ation of unwrapped instruments6

•

dental water-quality concerns e.g., dental unit waterline biofilms6 delivery ofwater of acceptable biological quality for patient care6 usefulness of flushing

waterlines6 use of sterile irrigating solutions for oral surgical procedures6 handling

of community boil-water advisories96

• dental radiology6

• aseptic technique for parenteral medications6

• preprocedural mouth rinsing for patients6

• oral surgical procedures6

• laser?electrosurgery plumes6

• tuberculosis T


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• +reut4feldt-a2ob disease +(9 and other prion-related diseases6

• infection-control program evaluation6 and

• research considerations.

These guidelines were developed by +(+ staff members in collaboration with other

authorities on infection control. (raft documents were reviewed by other federal agencies

and professional organi4ations from the fields of dental health care, public health, andhospital epidemiology and infection control. # Federal egister notice elicited public

comments that were considered in the decision-ma2ing process. 1;isting guidelines and

published research pertinent to dental infection-control principles and practices werereviewed. %herever possible, recommendations are based on data from well-designed

scientific studies. owever, only a limited number of studies have characteri4ed ris2

factors and the effectiveness of prevention measures for infections associated with dental

health-care practices.

)ome infection-control practices routinely used by health-care practitioners cannot be

rigorously e;amined for ethical or logistical reasons. >n the absence of scientific evidence

for such practices, certain recommendations are based on strong theoretical rationale,suggestive evidence, or opinions of respected authorities based on clinical e;perience,

descriptive studies, or committee reports. >n addition, some recommendations are derived

from federal regulations. 5o recommendations are offered for practices for which

insufficient scientific evidence or lac2 of consensus supporting their effectiveness e;ists.

Background

>n the nited )tates, an estimated A million persons wor2 in health-care professions,including appro;imately *B",!!! dentists, **0,!!! registered dental hygienists, 0*",!!!

dental assistants #9, and 3,!!! dental laboratory technicians 9. >n this report, dental

health-care personnel (+P9 refers to all paid and unpaid personnel in the dental health-

care setting who might be occupationally e;posed to infectious materials, including bodysubstances and contaminated supplies, equipment, environmental surfaces, water, or air.

(+P include dentists, dental hygienists, dental assistants, dental laboratory technicians

in-office and commercial9, students and trainees, contractual personnel, and other persons not directly involved in patient care but potentially e;posed to infectious agents

e.g., administrative, clerical, house2eeping, maintenance, or volunteer personnel9.

8ecommendations in this report are designed to prevent or reduce potential for diseasetransmission from patient to (+P, from (+P to patient, and from patient to patient.

#lthough these guidelines focus mainly on outpatient, ambulatory dental health-care

settings, the recommended infection-control practices are applicable to all settings in

which dental treatment is provided.

(ental patients and (+P can be e;posed to pathogenic microorganisms including

cytomegalovirus +=9, =,


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(%co0acteri&m t&0erc&losis, staphylococci, streptococci, and other viruses and bacteria

that coloni4e or infect the oral cavity and respiratory tract. These organisms can be

transmitted in dental settings through *9 direct contact with blood, oral fluids, or other patient materials6 09 indirect contact with contaminated ob$ects e.g., instruments,

equipment, or environmental surfaces96 39 contact of con$unctival, nasal, or oral mucosawith droplets e.g., spatter9 containing microorganisms generated from an infected person

and propelled a short distance e.g., by coughing, snee4ing, or tal2ing96 and C9 inhalationof airborne microorganisms that can remain suspended in the air for long periods 39.

>nfection through any of these routes requires that all of the following conditions be

present:

• a pathogenic organism of sufficient virulence and in adequate numbers to cause

disease6

• a reservoir or source that allows the pathogen to survive and multiply e.g., blood96

• a mode of transmission from the source to the host6

• a portal of entry through which the pathogen can enter the host6 and

• a susceptible host i.e., one who is not immune9.

7ccurrence of these events provides the chain of infection 5 9. 1ffective infection-control

strategies prevent disease transmission by interrupting one or more lin2s in the chain.

Previous +(+ recommendations regarding infection control for dentistry focused

primarily on the ris2 of transmission of bloodborne pathogens among (+P and patients

and use of universal precautions to reduce that ris2 1 ,2 ,7 ,89. niversal precautions were

based on the concept that all blood and body fluids that might be contaminated with blood should be treated as infectious because patients with bloodborne infections can be

asymptomatic or unaware they are infected 9,1;9. Preventive practices used to reduce

blood e;posures, particularly percutaneous e;posures, include *9 careful handling ofsharp instruments, 09 use of rubber dams to minimi4e blood spattering6 39 handwashing6

and C9 use of protective barriers e.g., gloves, mas2s, protective eyewear, and gowns9.

The relevance of universal precautions to other aspects of disease transmission wasrecogni4ed, and in *AAB, +(+ e;panded the concept and changed the term to standard )reca&tions. )tandard precautions integrate and e;pand the elements of universal

precautions into a standard of care designed to protect +P and patients from pathogens

that can be spread by blood or any other body fluid, e;cretion, or secretion 119. )tandard precautions apply to contact with *9 blood6 09 all body fluids, secretions, and e;cretions

e;cept sweat9, regardless of whether they contain blood6 39 nonintact s2in6 and C9

mucous membranes. )aliva has always been considered a potentially infectious material

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in dental infection control6 thus, no operational difference e;ists in clinical dental practice

between universal precautions and standard precautions.

>n addition to standard precautions, other measures e.g., e;panded or transmission-based

precautions9 might be necessary to prevent potential spread of certain diseases e.g., Tn addition,

administrative controls e.g., policies, procedures, and enforcement measures targeted at

reducing the ris2 of e;posure to infectious persons9 are a priority for certain pathogens

e.g., (+ t&0erc&losis9, particularly those spread by airborne or droplet routes.

(ental practices should develop a written infection-control program to prevent or reduce

the ris2 of disease transmission. )uch a program should include establishment and

implementation of policies, procedures, and practices in con$unction with selection anduse of technologies and products9 to prevent wor2-related in$uries and illnesses among

(+P as well as health-care--associated infections among patients. The program should

embody principles of infection control and occupational health, reflect current science,and adhere to relevant federal, state, and local regulations and statutes. #n infection-

control coordinator e.g., dentist or other (+P9 2nowledgeable or willing to be trained

should be assigned responsibility for coordinating the program. The effectiveness of the

infection-control program should be evaluated on a day-to-day basis and over time tohelp ensure that policies, procedures, and practices are useful, efficient, and successful

see Program 1valuation9.

#lthough the infection-control coordinator remains responsible for overall managementof the program, creating and maintaining a safe wor2 environment ultimately requires the

commitment and accountability of all (+P. This report is designed to provide guidance

to (+P for preventing disease transmission in dental health-care settings, for promoting


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a safe wor2ing environment, and for assisting dental practices in developing and

implementing infection-control programs. These programs should be followed in addition

to practices and procedures for wor2er protection required by the 7ccupational )afetyand ealth #dministrationDs 7)#9 standards for occupational e;posure to bloodborne

pathogens 1#9, including instituting controls to protect employees from e;posure to blood or other potentially infectious materials 7P>9, and requiring implementation of a

written e;posure-control plan, annual employee training, nterpretations and enforcement procedures are available to

help (+P apply this 7)# standard in practice 19. #lso, manufacturerDs aterial

)afety (ata )heets )()9 should be consulted regarding correct procedures forhandling or wor2ing with ha4ardous chemicals 139.

Previous Recoendations

This report includes relevant infection-control measures from the following previously

published +(+ guidelines and recommendations:

• +(+. &uideline for disinfection and sterili4ation in health-care facilities:

recommendations of +(+ and the ealthcare >nfection +ontrol Practices

#dvisory +ommittee >+P#+9. %8 in press9.

• +(+. &uidelines for environmental infection control in health-care facilities:

recommendations of +(+ and the ealthcare >nfection +ontrol Practices

#dvisory +ommittee >+P#+9. %8 0!!3605o. 88-*!9.

• +(+. &uidelines for the prevention of intravascular catheter-related infections.

%8 0!!06*5o. 88-*!9.

• +(+. &uideline for hand hygiene in health-care settings: recommendations of the

ealthcare >nfection +ontrol Practices #dvisory +ommittee and the

>+P#+?)1#?#P>+?>()# and ygiene Tas2 Force. %8 0!!06* 5o.88-*B9.

• +(+. pdated .). Public ealth )ervice guidelines for the management of

occupational e;posures to = and recommendations for

poste;posure prophyla;is. %8 0!!*6!5o. 88-**9.

• angram #, oran T+, Pearson /, )ilver /+, arvis %8, ospital >nfection

+ontrol Practices #dvisory +ommittee. &uideline for prevention of surgical site

infection, *AAA. >nfect +ontrol osp 1pidemiol *AAA60!:0!--E".

• nfection +ontrol Practices #dvisory +ommittee. &uideline forinfection control in health care personnel, *AA". #m >nfect +ontrol


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*AA"60B:0"A--3C.

• +(+. >mmuni4ation of health-care wor2ers: recommendations of the #dvisory

+ommittee on >mmuni4ation Practices #+>P9 and the ospital >nfection +ontrol

Practices #dvisory +ommittee >+P#+9. %8 *AAE6CB5o. 88-*"9.

• 8utala %#, #ssociation for Professionals in >nfection +ontrol and 1pidemiology,

>nc. #P>+ guideline for selection and use of disinfectants. #m >nfect +ontrol

*AAB60C:3*3--C0.

• &arner ), ospital >nfection +ontrol Practices #dvisory +ommittee. &uideline

for isolation precautions in hospitals. >nfect +ontrol osp 1pidemiol *AAB6*E:3--"!.

• /arson 1/, *AA0, *AA3, and *AAC &uidelines +ommittee. #P>+ guideline for

handwashing and hand antisepsis in health-care settings. #m >nfect +ontrol*AA603:0*--BA.

• +(+. &uidelines for preventing the transmission of (%co0acteri&m t&0erc&losis

in health-care facilities, *AAC. %8 *AAC6C35o. 88-*39.

• +(+. 8ecommendations for preventing transmission of human

immunodeficiency virus and hepatitis < virus to patients during e;posure-prone

invasive procedures. %8 *AA*6C!5o. 88-"9.

• &arner ). +(+ guideline for prevention of surgical wound infections, *A".

)upersedes guideline for prevention of surgical wound infections published in*A"0. 7riginally published in 5ovember *A"9. 8evised. >nfect +ontrol

*A"B6E:*A3--0!!.

• &arner ), Favero ). +(+ guideline for handwashing and hospital

environmental control, *A". >nfect +ontrol *A"B6E:03*--C3.

Selected Definitions

Alcohol.0ased hand r&0


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'ead sterili6er


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e;posed to their bacterial component.

ermicide


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complication of treatment.

Imm&ni6ation


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OPI( is an 7)# term that refers to *9

body fluids including semen, vaginal secretions, cerebrospinal fluid, synovial fluid,

pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures6 any body fluid visibly contaminated with blood6 and all body fluids in

situations where differentiating between body fluids is difficult or impossible6 09 anyunfi;ed tissue or organ other than intact s2in9 from a human living or dead96 and 39

>=-containing cell or tissue cultures, organ cultures6 >=- or = or


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=accines are administered through needle in$ections, by mouth, and by aerosol.

?asher.disinfectorn such

settings, the infection-control coordinator should establish programs that arrange for site-specific infection-control services from e;ternal health-care facilities and providers

before (+P are placed at ris2 for e;posure. 8eferral arrangements can be made with

qualified health-care professionals in an occupational health program of a hospital, with

educational institutions, or with health-care facilities that offer personnel health services.

"ducation and #raining

Personnel are more li2ely to comply with an infection-control program and e;posure-

control plan if they understand its rationale 3,1#,15 9. +learly written policies, procedures, and guidelines can help ensure consistency, efficiency, and effective

coordination of activities. Personnel sub$ect to occupational e;posure should receive

infection-control training on initial assignment, when new tas2s or procedures affect their

occupational e;posure, and at a minimum, annually 1#9. 1ducation and training should be appropriate to the assigned duties of specific (+P e.g., techniques to prevent cross-

contamination or instrument sterili4ation9. For (+P who perform tas2s or proceduresli2ely to result in occupational e;posure to infectious agents, training should include *9 adescription of their e;posure ris2s6 09 review of prevention strategies and infection-

control policies and procedures6 39 discussion regarding how to manage wor2-related

illness and in$uries, including P1P6 and C9 review of wor2 restrictions for the e;posure orinfection. >nclusion of (+P with minimal e;posure ris2s e.g., administrative

employees9 in education and training programs might enhance facilitywide understanding

of infection-control principles and the importance of the program. 1ducational materials


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should be appropriate in content and vocabulary for each personDs educational level,

literacy, and language, as well as be consistent with e;isting federal, state, and local

regulations 3,1#9.

Iuni$ation Progras

(+P are at ris2 for e;posure to, and possible infection with, infectious organisms.

>mmuni4ations substantially reduce both the number of (+P susceptible to these

diseases and the potential for disease transmission to other (+P and patients 3,17 9.

Thus, immuni4ations are an essential part of prevention and infection-control programsfor (+P, and a comprehensive immuni4ation policy should be implemented for all

dental health-care facilities 17 ,189. The #dvisory +ommittee on >mmuni4ation Practices

#+>P9 provides national guidelines for immuni4ation of +P, which includes (+P17 9. (ental practice immuni4ation policies should incorporate current state and federal

regulations as well as recommendations from the .). Public ealth )ervice and

professional organi4ations 17 9 #ppendi; Pdoes not recommend routine immuni4ation of +P against T< i.e., inoculation with

bacille +almette-&uMrin vaccine9 or hepatitis # 17 9. 5o vaccine e;ists for +=. #+>P

guidelines also provide recommendations regarding immuni4ation of +P with specialconditions e.g., pregnancy, >= infection, or diabetes9 3 ,17 9.

>mmuni4ation of (+P before they are placed at ris2 for e;posure remains the mostefficient and effective use of vaccines in health-care settings. )ome educational

institutions and infection-control programs provide immuni4ation schedules for studentsand (+P. 7)# requires that employers ma2e hepatitis < vaccination available to all

employees who have potential contact with blood or 7P>. 1mployers are also required

to follow +(+ recommendations for vaccinations, evaluation, and follow-up procedures

1#9. 5onpatient-care staff e.g., administrative or house2eeping9 might be included,depending on their potential ris2 of coming into contact with blood or 7P>. 1mployers

are also required to ensure that employees who decline to accept hepatitis < vaccination

sign an appropriate declination statement 1#9. (+P unable or unwilling to bevaccinated as required or recommended should be educated regarding their e;posure

ris2s, infection-control policies and procedures for the facility, and the management of

wor2-related illness and wor2 restrictions if appropriate9 for e;posed or infected (+P.

"%&osure Prevention and Poste%&osure 'anageent

#voiding e;posure to blood and 7P>, as well as protection by immuni4ation, remain

primary strategies for reducing occupationally acquired infections, but occupational

e;posures can still occur 199. # combination of standard precautions, engineering, wor2

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practice, and administrative controls is the best means to minimi4e occupational

e;posures. %ritten policies and procedures to facilitate prompt reporting, evaluation,

counseling, treatment, and medical follow-up of all occupational e;posures should beavailable to all (+P. %ritten policies and procedures should be consistent with federal,

state, and local requirements addressing education and training, poste;posuremanagement, and e;posure reporting see Preventing Transmission of


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#29 see +ontact (ermatitis and /ate; ypersensitivity9.

'aintenance of Records( Data 'anageent( and Confidentialit*

The health status of (+P can be monitored by maintaining records of wor2-relatedmedical evaluations, screening tests, immuni4ations, e;posures, and poste;posuremanagement. )uch records must be 2ept in accordance with all applicable state and

federal laws. 1;amples of laws that might apply include the Privacy 8ule of the ealth

>nsurance Portability and #ccountability #ct >P##9 of *AAB, C +F8 *B! and *BC, and

the 7)# 7ccupational 1;posure to P## Privacy 8ule applies to covered entities,

including certain defined health providers, health-care clearinghouses, and health plans.

7)# requires employers to ensure that certain information contained in employeemedical records is *9 2ept confidential6 09 not disclosed or reported without the

employeeDs e;press written consent to any person within or outside the wor2place e;cept

as required by the 7)# standard6 and 39 maintained by the employer for at least theduration of employment plus 3! years. (ental practices that coordinate their infection-

control program with off-site providers might consult 7)#Ds = transmission from (+P to patients has been reported, and the last


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prevalence in the patient population and the nature and frequency of contact with blood

and body fluids through percutaneous or permucosal routes of e;posure. The ris2 of

infection after e;posure to a bloodborne virus is influenced by inoculum si4e, route ofe;posure, and susceptibility of the e;posed +P 129. The ma$ority of attention has been

placed on the bloodborne pathogens =, and these pathogens presentdifferent levels of ris2 to (+P.

He&atitis B ,irus


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vaccine use and adherence to universal precautions 319. #mong .). dentists, LA!N

have been vaccinated, and serologic evidence of past llinois, personal communication, une 0!!39. >nfection rates can be e;pected to decline further as vaccination rates remain high among young dentists and

as older dentists with lower vaccination rates and higher rates of infection retire.

#lthough the potential for transmission of bloodborne infections from (+P to patients

is considered limited 3#..339, precise ris2s have not been quantified by carefully

designed epidemiologic studies 3# ,35 ,37 9. 8eports published during *AE!--*A"Edescribe nine clusters in which patients were thought to be infected with


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respond to vaccination will lose detectable antibodies over *0 years. 1ven so, immunity

continues to prevent clinical disease or detectable viral infection 17 9.


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has been reported, but the mode of transmission could not be determined 2 ,92,9#9. #s of

)eptember 3!, *AA3, +(+ had information regarding test results of L00,!!! patients of

B3 >=-infected +P, including 33 dentists or dental students 33 ,9#9. 5o additionalcases of transmission were documented.

Prospective studies worldwide indicate the average ris2 of >= infection after a single

percutaneous e;posure to >=-infected blood is !.3N range: !.0N--!.N9 99. #fter an

e;posure of mucous membranes in the eye, nose, or mouth, the ris2 is appro;imately!.*N 75 9. The precise ris2 of transmission after s2in e;posure remains un2nown but is

believed to be even smaller than that for mucous membrane e;posure.

+ertain factors affect the ris2 of >= transmission after an occupational e;posure.

/aboratory studies have determined if needles that pass through late; gloves are solidrather than hollow-bore, or are of small gauge e.g., anesthetic needles commonly used in

dentistry9, they transfer less blood #5 9. >n a retrospective case-control study of +P, an

increased ris2 for >= infection was associated with e;posure to a relatively large volumeof blood, as indicated by a deep in$ury with a device that was visibly contaminated with

the patientDs blood, or a procedure that involved a needle placed in a vein or artery 939.

The ris2 was also increased if the e;posure was to blood from patients with terminal

illnesses, possibly reflecting the higher titer of >= in late-stage #>().

"%&osure Prevention 'ethods

#voiding occupational e;posures to blood is the primary way to prevent transmission of

=, to +P in health-care settings 19 ,95,97 9. 1;posures occur through

percutaneous in$ury e.g., a needlestic2 or cut with a sharp ob$ect9, as well as through

contact between potentially infectious blood, tissues, or other body fluids and mucousmembranes of the eye, nose, mouth, or nonintact s2in e.g., e;posed s2in that is chapped,

abraded, or shows signs of dermatitis9.

7bservational studies and surveys indicate that percutaneous in$uries among generaldentists and oral surgeons occur less frequently than among general and orthopedic

surgeons and have decreased in frequency since the mid-*A"!s 98..1;29. This decline

has been attributed to safer wor2 practices, safer instrumentation or design, and continued(+P education 1;#,1;9. Percutaneous in$uries among (+P usually *9 occur outside

the patientDs mouth, thereby posing less ris2 for recontact with patient tissues6 09 involve

limited amounts of blood6 and 39 are caused by burs, syringe needles, laboratory 2nives,

and other sharp instruments 99..1;2,1;3,1;5 9. >n$uries among oral surgeons might occur more frequently during fracture reductions using wires 1;,1;7 9. 1;perience, as

measured by years in practice, does not appear to affect the ris2 of in$ury among general

dentists or oral surgeons 1;;,1;,1;7 9.

The ma$ority of e;posures in dentistry are preventable, and methods to reduce the ris2 of

blood contacts have included use of standard precautions, use of devices with features

engineered to prevent sharp in$uries, and modifications of wor2 practices. These

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approaches might have contributed to the decrease in percutaneous in$uries among

dentists during recent years 98..1;;,1;#9. owever, needlestic2s and other blood

contacts continue to occur, which is a concern because percutaneous in$uries pose thegreatest ris2 of transmission.

)tandard precautions include use of PP1 e.g., gloves, mas2s, protective eyewear or face

shield, and gowns9 intended to prevent s2in and mucous membrane e;posures. 7ther

protective equipment e.g., finger guards while suturing9 might also reduce in$uriesduring dental procedures 1;9.

1ngineering controls are the primary method to reduce e;posures to blood and 7P>

from sharp instruments and needles. These controls are frequently technology-based and

often incorporate safer designs of instruments and devices e.g., self-sheathing anestheticneedles and dental units designed to shield burs in handpieces9 to reduce percutaneous

in$uries 1;1,1;#,1;89.

%or2-practice controls establish practices to protect (+P whose responsibilities include

handling, using, assembling, or processing sharp devices e.g., needles, scalers,laboratory utility 2nives, burs, e;plorers, and endodontic files9 or sharps disposal

containers. %or2-practice controls can include removing burs before disassembling the

handpiece from the dental unit, restricting use of fingers in tissue retraction or palpationduring suturing and administration of anesthesia, and minimi4ing potentially uncontrolled

movements of such instruments as scalers or laboratory 2nives 1;1,1;39.

#s indicated, needles are a substantial source of percutaneous in$ury in dental practice,

and engineering and wor2-practice controls for needle handling are of particular

importance. >n 0!!*, revisions to 7)#Ds bloodborne pathogens standard as mandated bythe 5eedlestic2 )afety and Prevention #ct of 0!!! became effective. These revisions

clarify the need for employers to consider safer needle devices as they become availableand to involve employees directly responsible for patient care e.g., dentists, hygienists,

and dental assistants9 in identifying and choosing such devices 1;99. )afer versions of

sharp devices used in hospital settings have become available e.g., blunt suture needles,

phlebotomy devices, and butterfly needles9, and their impact on reducing in$uries has been documented 11;..1129. #spirating anesthetic syringes that incorporate safety

features have been developed for dental procedures, but the low in$ury rates in dentistry

limit assessment of their effect on reducing in$uries among (+P.

%or2-practice controls for needles and other sharps include placing used disposablesyringes and needles, scalpel blades, and other sharp items in appropriate puncture-

resistant containers located as close as feasible to where the items were used

2 ,7 ,1#,11#..1139. >n addition, used needles should never be recapped or otherwisemanipulated by using both hands, or any other technique that involves directing the point

of a needle toward any part of the body 2 ,7 ,1#,97 ,11# ,119. # one-handed scoop

technique, a mechanical device designed for holding the needle cap to facilitate one-handed recapping, or an engineered sharps in$ury protection device e.g., needles with

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resheathing mechanisms9 should be employed for recapping needles between uses and

before disposal 2 ,7 ,1#,11# ,119. (+P should never bend or brea2 needles before

disposal because this practice requires unnecessary manipulation.


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Puncture wounds and other in$uries to the s2in should be washed with soap and water6

mucous membranes should be flushed with water. 5o evidence e;ists that using

antiseptics for wound care or e;pressing fluid by squee4ing the wound further reduces theris2 of bloodborne pathogen transmission6 however, use of antiseptics is not

contraindicated. The application of caustic agents e.g., bleach9 or the in$ection ofantiseptics or disinfectants into the wound is not recommended 199. 1;posed (+P

should immediately report the e;posure to the infection-control coordinator or otherdesignated person, who should initiate referral to the qualified health-care professional

and complete necessary reports. = or other bloodborne pathogens, and, if the source was infected with >=, the stage ofdisease, history of antiretroviral therapy, and viral load, if 2nown.

• (etails regarding the e;posed person e.g., hepatitis < vaccination and vaccine-

response status9.

• (etails regarding counseling, poste;posure management, and follow-up.

1ach occupational e;posure should be evaluated individually for its potential to transmit

=, based on the following:

• The type and amount of body substance involved.

• The type of e;posure e.g., percutaneous in$ury, mucous membrane or nonintact

s2in e;posure, or bites resulting in blood e;posure to either person involved9.

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• The infection status of the source.

• The susceptibility of the e;posed person 199.

#ll of these factors should be considered in assessing the ris2 for infection and the needfor further follow-up e.g., P1P9.

(uring *AA!--*AA", P) published guidelines for P1P and other management of health-

care wor2er e;posures to = 59 ,115 ..1199. >n 0!!*, theserecommendations were updated and consolidated into one set of P) guidelines 199.

The new guidelines reflect the availability of new antiretroviral agents, new information

regarding the use and safety of >= P1P, and considerations regarding employing >=P1P when resistance of the source patientDs virus to antiretroviral agents is 2nown or

suspected. >n addition, the 0!!* guidelines provide guidance to clinicians and e;posed

+P regarding when to consider >= P1P and recommendations for P1P regimens 199.

Hand H*giene

and hygiene e.g., handwashing, hand antisepsis, or surgical hand antisepsis9substantially reduces potential pathogens on the hands and is considered the single most

critical measure for reducing the ris2 of transmitting organisms to patients and +P

12;..12#9. ospital-based studies have demonstrated that noncompliance with handhygiene practices is associated with health-care--associated infections and the spread of

multiresistant organisms. 5oncompliance also has been a ma$or contributor to outbrea2s

12#9. The prevalence of health-care--associated infections decreases as adherence of+P to recommended hand hygiene measures improves 12..125 9.

The microbial flora of the s2in, first described in *A3", consist of transient and resident

microorganisms 127 9. Transient flora, which coloni4e the superficial layers of the s2in,

are easier to remove by routine handwashing. They are often acquired by +P duringdirect contact with patients or contaminated environmental surfaces6 these organisms are

most frequently associated with health-care--associated infections. 8esident flora

attached to deeper layers of the s2in are more resistant to removal and less li2ely to beassociated with such infections.

The preferred method for hand hygiene depends on the type of procedure, the degree of

contamination, and the desired persistence of antimicrobial action on the s2in Table 09.

For routine dental e;aminations and nonsurgical procedures, handwashing and handantisepsis is achieved by using either a plain or antimicrobial soap and water. >f the hands

are not visibly soiled, an alcohol-based hand rub is adequate.

The purpose of surgical hand antisepsis is to eliminate transient flora and reduce resident

flora for the duration of a procedure to prevent introduction of organisms in the operativewound, if gloves become punctured or torn. )2in bacteria can rapidly multiply under

surgical gloves if hands are washed with soap that is not antimicrobial 127,1289. Thus,

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an antimicrobial soap or alcohol hand rub with persistent activity should be used before

surgical procedures 129..1#19.

#gents used for surgical hand antisepsis should substantially reduce microorganisms on

intact s2in, contain a nonirritating antimicrobial preparation, have a broad spectrum ofactivity, be fast-acting, and have a persistent effect 121,1#2..1#39. Persistence i.e.,

e;tended antimicrobial activity that prevents or inhibits survival of microorganisms after

the product is applied9 is critical because microorganisms can coloni4e on hands in themoist environment underneath gloves 1229.

#lcohol hand rubs are rapidly germicidal when applied to the s2in but should include

such antiseptics as chlorhe;idine, quaternary ammonium compounds, octenidine, or

triclosan to achieve persistent activity 1#;9. Factors that can influence the effectivenessof the surgical hand antisepsis in addition to the choice of antiseptic agent include

duration and technique of scrubbing, as well as condition of the hands, and techniques

used for drying and gloving. +(+Ds 0!!0 guideline on hand hygiene in health-caresettings provides more complete information 12#9.

Selection of ntise&tic gents

)electing the most appropriate antiseptic agent for hand hygiene requires consideration of

multiple factors. 1ssential performance characteristics of a product e.g., the spectrum

and persistence of activity and whether or not the agent is fast-acting9 should bedetermined before selecting a product. (elivery system, cost per use, reliable vendor

support and supply are also considerations.


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The primary defense against infection and transmission of pathogens is healthy, unbro2en

s2in. Frequent handwashing with soaps and antiseptic agents can cause chronic irritant

contact dermatitis among (+P. (amage to the s2in changes s2in flora, resulting in morefrequent coloni4ation by staphylococci and gram-negative bacteria 131,1329. The

potential of detergents to cause s2in irritation varies considerably, but can be reduced byadding emollients. /otions are often recommended to ease the dryness resulting from

frequent handwashing and to prevent dermatitis from glove use 13#,139. owever, petroleum-based lotion formulations can wea2en late; gloves and increase permeability.

For that reason, lotions that contain petroleum or other oil emollients should only be used

at the end of the wor2 day 122,1339. (ental practitioners should obtain information fromlotion manufacturers regarding interaction between lotions, gloves, dental materials, and

antimicrobial products.

/ingernails and rtificial ails

#lthough the relationship between fingernail length and wound infection is un2nown,2eeping nails short is considered 2ey because the ma$ority of flora on the hands are found

under and around the fingernails 135 9. Fingernails should be short enough to allow

(+P to thoroughly clean underneath them and prevent glove tears 1229. )harp nail

edges or bro2en nails are also li2ely to increase glove failure. /ong artificial or naturalnails can ma2e donning gloves more difficult and can cause gloves to tear more readily.

and carriage of gram-negative organisms has been determined to be greater among

wearers of artificial nails than among nonwearers, both before and after handwashing137..15;9. >n addition, artificial fingernails or e;tenders have been epidemiologically

implicated in multiple outbrea2s involving fungal and bacterial infections in hospital

intensive-care units and operating rooms 151..159. Freshly applied nail polish on

natural nails does not increase the microbial load from periungual s2in if fingernails areshort6 however, chipped nail polish can harbor added bacteria 153,155 9.

1e!elr*

)tudies have demonstrated that s2in underneath rings is more heavily coloni4ed than

comparable areas of s2in on fingers without rings 157..17;9. >n a study of intensive-carenurses, multivariable analysis determined rings were the only substantial ris2 factor for

carriage of gram-negative bacilli and Sta)h%lococc&s a&re&s, and the concentration of

organisms correlated with the number of rings worn 17;9. owever, two other studiesdemonstrated that mean bacterial colony counts on hands after handwashing were similar

among persons wearing rings and those not wearing rings 159,1719. %hether wearing

rings increases the li2elihood of transmitting a pathogen is un2nown6 further studies areneeded to establish whether rings result in higher transmission of pathogens in health-

care settings. owever, rings and decorative nail $ewelry can ma2e donning gloves more

difficult and cause gloves to tear more readily 12,1#9. Thus, $ewelry should notinterfere with glove use e.g., impair ability to wear the correct-si4ed glove or alter glove

integrity9.


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Personal Protective "ui&ent

PP1 is designed to protect the s2in and the mucous membranes of the eyes, nose, and

mouth of (+P from e;posure to blood or 7P>. se of rotary dental and surgical

instruments e.g., handpieces or ultrasonic scalers9 and air-water syringes creates a visiblespray that contains primarily large-particle droplets of water, saliva, blood,

microorganisms, and other debris. This spatter travels only a short distance and settles out

quic2ly, landing on the floor, nearby operatory surfaces, (+P, or the patient. The sprayalso might contain certain aerosols i.e., particles of respirable si4e, J*! Km9. #erosols

can remain airborne for e;tended periods and can be inhaled. owever, they should not

be confused with the large-particle spatter that ma2es up the bul2 of the spray fromhandpieces and ultrasonic scalers. #ppropriate wor2 practices, including use of dental

dams 1729 and high-velocity air evacuation, should minimi4e dissemination of droplets,

spatter, and aerosols 29.

Primary PP1 used in oral health-care settings includes gloves, surgical mas2s, protectiveeyewear, face shields, and protective clothing e.g., gowns and $ac2ets9. #ll PP1 should

be removed before (+P leave patient-care areas 1#9. 8eusable PP1 e.g., clinician or

patient protective eyewear and face shields9 should be cleaned with soap and water, and

when visibly soiled, disinfected between patients, according to the manufacturerDsdirections 2 ,1#9. %earing gloves, surgical mas2s, protective eyewear, and protective

clothing in specified circumstances to reduce the ris2 of e;posures to bloodborne

pathogens is mandated by 7)# 1#9. &eneral wor2 clothes e.g., uniforms, scrubs, pants, and shirts9 are neither intended to protect against a ha4ard nor considered PP1.

'asks( Protective "*e!ear( /ace Shields

# surgical mas2 that covers both the nose and mouth and protective eyewear with solid

side shields or a face shield should be worn by (+P during procedures and patient-careactivities li2ely to generate splashes or sprays of blood or body fluids. Protective eyewear

for patients shields their eyes from spatter or debris generated during dental procedures. #

surgical mas2 protects against microorganisms generated by the wearer, with LAN

bacterial filtration efficiency, and also protects (+P from large-particle droplet spatterthat might contain bloodborne pathogens or other infectious microorganisms 17#9. The

mas2Ds outer surface can become contaminated with infectious droplets from spray of oral

fluids or from touching the mas2 with contaminated fingers. #lso, when a mas2 becomeswet from e;haled moist air, the resistance to airflow through the mas2 increases, causing

more airflow to pass around edges of the mas2. >f the mas2 becomes wet, it should be

changed between patients or even during patient treatment, when possible 2 ,179.

%hen airborne infection isolation precautions e;panded or transmission-based9 arenecessary e.g., for T< patients9, a 5ational >nstitute for 7ccupational )afety and ealth

5>7)9-certified particulate-filter respirator e.g., 5A, 5AA, or 5*!!9 should be used

2;9. N93 refers to the ability to filter *-Km particles in the unloaded state with a filterefficiency of LAN i.e., filter lea2age JN9, given flow rates of J! /?min i.e.,

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appro;imate ma;imum airflow rate of +P during breathing9. #vailable data indicate

infectious droplet nuclei measure *-- Km6 therefore, respirators used in health-care

settings should be able to efficiently filter the smallest particles in this range.

The ma$ority of surgical mas2s are not 5>7)-certified as respirators, do not protect theuser adequately from e;posure to T7) as respirators. The levelof protection a respirator provides is determined by the efficiency of the filter material for

incoming air and how well the face piece fits or seals to the face e.g., qualitatively or

quantitatively tested in a reliable way to obtain a face-seal lea2age of J*!N and to fit thedifferent facial si4es and characteristics of +P9.

%hen respirators are used while treating patients with diseases requiring airborne-

transmission precautions e.g., T to the forearms is anticipated9 1#,19. (+P should

change protective clothing when it becomes visibly soiled and as soon as feasible if penetrated by blood or other potentially infectious fluids 2 ,1#,1,1#7 9. #ll protective

clothing should be removed before leaving the wor2 area 1#9.

Gloves and Gloving

(+P wear gloves to prevent contamination of their hands when touching mucous

membranes, blood, saliva, or 7P>, and also to reduce the li2elihood thatmicroorganisms present on the hands of (+P will be transmitted to patients during

surgical or other patient-care procedures 1 ,2 ,7 ,1;9. edical gloves, both patiente;amination and surgeonDs gloves, are manufactured as single-use disposable items thatshould be used for only one patient, then discarded. &loves should be changed between

patients and when torn or punctured.

%earing gloves does not eliminate the need for handwashing. and hygiene should be

performed immediately before donning gloves. &loves can have small, unapparentdefects or can be torn during use, and hands can become contaminated during glove

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removal 122,177..187 9. These circumstances increase the ris2 of operative wound

contamination and e;posure of the (+PDs hands to microorganisms from patients. >n

addition, bacteria can multiply rapidly in the moist environments underneath gloves, andthus, the hands should be dried thoroughly before donning gloves and washed again

immediately after glove removal.

#*&es of Gloves

nvestigators did not determine an optimal time for changing gloves during procedures.

(uring dental procedures, patient e;amination and surgeonDs gloves commonly contact

multiple types of chemicals and materials e.g., disinfectants and antiseptics, composite

resins, and bonding agents9 that can compromise the integrity of late; as well as vinyl,nitrile, and other synthetic glove materials 198..2;5 9. >n addition, late; gloves can

interfere with the setting of vinyl polysilo;ane impression materials 2;7..2;99, although

the setting is apparently not adversely affected by synthetic vinyl gloves 2;7,2;89. &iven

the diverse selection of dental materials on the mar2et, dental practitioners should consultglove manufacturers regarding the chemical compatibility of glove materials.

>f the integrity of a glove is compromised e.g., punctured9, it should be changed as soon

as possible 1#,21;,2119. %ashing late; gloves with plain soap, chlorhe;idine, or alcohol

can lead to the formation of glove micropunctures 177,212,21#9 and subsequent handcontamination 1#89.


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1929.

F(# regulates the medical glove industry, which includes gloves mar2eted as sterile

surgeonDs and sterile or nonsterile patient e;amination gloves. &eneral-purpose utility

gloves are also used in dental health-care settings but are not regulated by F(# becausethey are not promoted for medical use. ore rigorous standards are applied to surgeonDs

than to e;amination gloves. F(# has identified acceptable quality levels e.g., ma;imum

defects allowed9 for glove manufacturers 219, but even intact gloves eventually failwith e;posure to mechanical e.g., sharps, fingernails, or $ewelry9 and chemical e.g.,

dimethyacrylates9 ha4ards and over time. These variables can be controlled, ultimately

optimi4ing glove performance, by *9 maintaining short fingernails, 09 minimi4ing oreliminating hand $ewelry, and 39 using engineering and wor2-practice controls to avoid

in$uries with sharps.

Sterile Surgeons Gloves and Dou+le-Gloving During 4ral Surgical Procedures

+ertain limited studies have determined no difference in postoperative infection rates

after routine tooth e;tractions when surgeons wore either sterile or nonsterile gloves213,215 9. owever, wearing sterile surgeonDs gloves during surgical procedures is

supported by a strong theoretical rationale 2 ,7 ,1#7 9. )terile gloves minimi4e

transmission of microorganisms from the hands of surgical (+P to patients and preventcontamination of the hands of surgical (+P with the patientDs blood and body fluids

1#7 9. >n addition, sterile surgeonDs gloves are more rigorously regulated by F(# and

therefore might provide an increased level of protection for the provider if e;posure to blood is li2ely.

#lthough the effectiveness of wearing two pairs of gloves in preventing diseasetransmission has not been demonstrated, the ma$ority of studies among +P and (+P

have demonstrated a lower frequency of inner glove perforation and visible blood on thesurgeonDs hands when double gloves are worn 181,183,193,195,198,217..2199. >n one

study evaluating double gloves during oral surgical and dental hygiene procedures, the

perforation of outer late; gloves was greater during longer procedures i.e., LC minutes9,

with the highest rate *!N9 of perforation occurring during oral surgery procedures 195 9.rritant contact dermatitis is common, nonallergic,

and develops as dry, itchy, irritated areas on the s2in around the area of contact.


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comparison, allergic contact dermatitis type >= hypersensitivity9 can result from

e;posure to accelerators and other chemicals used in the manufacture of rubber gloves

e.g., natural rubber late;, nitrile, and neoprene9, as well as from other chemicals found inthe dental practice setting e.g., methacrylates and glutaraldehyde9. #llergic contact

dermatitis often manifests as a rash beginning hours after contact and, similar to irritantdermatitis, is usually confined to the area of contact.

/ate; allergy type > hypersensitivity to late; proteins9 can be a more serious systemicallergic reaction, usually beginning within minutes of e;posure but sometimes occurring

hours later and producing varied symptoms. ore common reactions include runny nose,

snee4ing, itchy eyes, scratchy throat, hives, and itchy burning s2in sensations. oresevere symptoms include asthma mar2ed by difficult breathing, coughing spells, and

whee4ing6 cardiovascular and gastrointestinal ailments6 and in rare cases, anaphyla;is and

death #2,2239. The #merican (ental #ssociation #(#9 began investigating the

prevalence of type > late; hypersensitivity among (+P at the #(# annual meeting in

*AAC. >n *AAC and *AA, appro;imately 0,!!! dentists, hygienists, and assistantsvolunteered for s2in-pric2 testing. (ata demonstrated that B.0N of those tested were

positive for type > late; hypersensitivity 225 9. (ata from the subsequent years of thisongoing cross-sectional study indicated a decline in prevalence from ".N to C.3N 227 9.

This downward trend is similar to that reported by other studies and might be related to

use of late; gloves with lower allergen content 228..2#;9.

5atural rubber late; proteins responsible for late; allergy are attached to glove powder.%hen powdered late; gloves are worn, more late; protein reaches the s2in. >n addition,

when powdered late; gloves are donned or removed, late; protein?powder particles

become aerosoli4ed and can be inhaled, contacting mucous membranes 2#19. #s a result,

allergic patients and (+P can e;perience cutaneous, respiratory, and con$unctivalsymptoms related to late; protein e;posure. (+P can become sensiti4ed to late; protein

with repeated e;posure 2#2..2#5 9. %or2 areas where only powder-free, low-allergenlate; gloves are used demonstrate low or undetectable amounts of late; allergy-causing

proteins 2#7..2#99 and fewer symptoms among +P related to natural rubber late;

allergy. 7)

recommends that if late; gloves are chosen, +P should be provided with reduced protein, powder-free gloves #29. 5onlate; e.g., nitrile or vinyl9 powder-free and low-

protein gloves are also available #1,2;9. #lthough rare, potentially life-threatening

anaphylactic reactions to late; can occur6 dental practices should be appropriatelyequipped and have procedures in place to respond to such emergencies.

(+P and dental patients with late; allergy should not have direct contact with late;-

containing materials and should be in a late;-safe environment with all late;-containing

products removed from their vicinity #19. (ental patients with histories of late; allergycan be at ris2 from dental products e.g., prophyla;is cups, rubber dams, orthodontic

elastics, and medication vials9 219. #ny late;-containing devices that cannot be

removed from the treatment environment should be adequately covered or isolated.Persons might also be allergic to chemicals used in the manufacture of natural rubber


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late; and synthetic rubber gloves as well as metals, plastics, or other materials used in

dental care. Ta2ing thorough health histories for both patients and (+P, followed by

avoidance of contact with potential allergens can minimi4e the possibility of adversereactions. +ertain common predisposing conditions for late; allergy include previous

history of allergies, a history of spina bifida, urogenital anomalies, or allergies toavocados, 2iwis, nuts, or bananas. The following precautions should be considered to

ensure safe treatment for patients who have possible or documented late; allergy:

• f late;-related complications occur during or after a procedure, manage the

reaction and see2 emergency assistance as indicated. Follow current medicalemergency response recommendations for management of anaphyla;is #29.

Sterili$ation and Disinfection of Patient-Care Ites

Patient-care items dental instruments, devices, and equipment9 are categori4ed as

critical, semicritical, or noncritical, depending on the potential ris2 for infectionassociated with their intended use Table C9 229. +ritical items used to penetrate soft

tissue or bone have the greatest ris2 of transmitting infection and should be sterili4ed by

heat. )emicritical items touch mucous membranes or nonintact s2in and have a lower ris2 of transmission6 because the ma$ority of semicritical items in dentistry are heat-tolerant,

they also should be sterili4ed by using heat. >f a semicritical item is heat-sensitive, it

should, at a minimum, be processed with high-level disinfection 29.

5oncritical patient-care items pose the least ris2 of transmission of infection, contacting

only intact s2in, which can serve as an effective barrier to microorganisms. >n thema$ority of cases, cleaning, or if visibly soiled, cleaning followed by disinfection with an

1P#-registered hospital disinfectant is adequate. %hen the item is visibly contaminated

with blood or 7P>, an 1P#-registered hospital disinfectant with a tuberculocidal claimi.e., intermediate-level disinfectant9 should be used 2 ,2#,29. +leaning or disinfection

of certain noncritical patient-care items can be difficult or damage the surfaces6 therefore,

use of disposable barrier protection of these surfaces might be a preferred alternative.

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F(#-cleared sterilant?high-level disinfectants and 1P#-registered disinfectants must have

clear label claims for intended use, and manufacturer instructions for use must be

followed 239. # more complete description of the regulatory framewor2 in the nited)tates by which liquid chemical germicides are evaluated and regulated is included

#ppendi; #9.

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 environmentalsurfaces 229. The intended use of the patient-care item should determine the

recommended level of disinfection. (ental practices should follow the product

manufacturerDs directions regarding concentrations and e;posure time for disinfectantactivity relative to the surface to be disinfected 239. # summary of sterili4ation and

disinfection methods is included #ppendi; +9.

#rans&orting and Processing Containated Critical and Seicritical Patient-Care

Ites

(+P can be e;posed to microorganisms on contaminated instruments and devicesthrough percutaneous in$ury, contact with nonintact s2in on the hands, or contact with

mucous membranes of the eyes, nose, or mouth. +ontaminated instruments should be

handled carefully to prevent e;posure to sharp instruments that can cause a percutaneousin$ury. >nstruments should be placed in an appropriate container at the point of use to

prevent percutaneous in$uries during transport to the instrument processing area 1#9.

>nstrument processing requires multiple steps to achieve sterili4ation or high-level

disinfection. )terili4ation is a comple; process requiring speciali4ed equipment, adequate

space, qualified (+P who are provided with ongoing training, and regular monitoringfor quality assurance 27 9. +orrect cleaning, pac2aging, sterili4er loading procedures,

sterili4ation methods, or high-level disinfection methods should be followed to ensurethat an instrument is adequately processed and safe for reuse on patients.

Instruent Processing rea

(+P should process all instruments in a designated central processing area to more

easily control quality and ensure safety 289. The central processing area should be

divided into sections for *9 receiving, cleaning, and decontamination6 09 preparation and pac2aging6 39 sterili4ation6 and C9 storage. >deally, walls or partitions should separate the

sections to control traffic flow and contain contaminants generated during processing.%hen physical separation of these sections cannot be achieved, adequate spatialseparation might be satisfactory if the (+P who process instruments are trained in wor2

practices to prevent contamination of clean areas 289. )pace should be adequate for the

volume of wor2 anticipated and the items to be stored 289.

Receiving( Cleaning( and Decontaination

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8eusable instruments, supplies, and equipment should be received, sorted, cleaned, and

decontaminated in one section of the processing area. +leaning should precede all

disinfection and sterili4ation processes6 it should involve removal of debris as well asorganic and inorganic contamination. 8emoval of debris and contamination is achieved

either by scrubbing with a surfactant, detergent, and water, or by an automated processe.g., ultrasonic cleaner or washer-disinfector9 using chemical agents. >f visible debris,

whether inorganic or organic matter, is not removed, it will interfere with microbialinactivation and can compromise the disinfection or sterili4ation process 2 ,29..2329.

#fter cleaning, instruments should be rinsed with water to remove chemical or detergent

residue. )plashing should be minimi4ed during cleaning and rinsing 1#9. f manual cleaning is not performed immediately, placing instruments in a puncture-

resistant container and soa2ing them with detergent, a disinfectant?detergent, or an

en4ymatic cleaner will prevent drying of patient material and ma2e cleaning easier andless time-consuming. se of a liquid chemical sterilant?high-level disinfectant e.g.,

glutaraldehyde9 as a holding solution is not recommended 29. sing wor2-practice

controls e.g., long-handled brush9 to 2eep the scrubbing hand away from sharp

instruments is recommended 19. To avoid in$ury from sharp instruments, (+P shouldwear puncture-resistant, heavy-duty utility gloves when handling or manually cleaning

contaminated instruments and devices 5 9. 1mployees should not reach into trays orcontainers holding sharp instruments that cannot be seen e.g., sin2s filled with soapy

water in which sharp instruments have been placed9. %or2-practice controls should

include use of a strainer-type bas2et to hold instruments and forceps to remove the items.

n another section of the processing area, cleaned instruments and other dental supplies

should be inspected, assembled into sets or trays, and wrapped, pac2aged, or placed intocontainer systems for sterili4ation. inged instruments should be processed open and

unloc2ed. #n internal chemical indicator should be placed in every pac2age. >n addition,

an e;ternal chemical indicator e.g., chemical indicator tape9 should be used when theinternal indicator cannot be seen from outside the pac2age. For unwrapped loads, at a

minimum, an internal chemical indicator should be placed in the tray or cassette with

items to be sterili4ed 239 see )terili4ation of nwrapped >nstruments9. (ental practices

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should refer to the manufacturerDs instructions regarding use and correct placement of

chemical indicators see )terili4ation onitoring9. +ritical and semicritical instruments

that will be stored should be wrapped or placed in containers e.g., cassettes or organi4ingtrays9 designed to maintain sterility during storage 2 ,27,233..237 9.

Pac2aging materials e.g., wraps or container systems9 allow penetration of the

sterili4ation agent and maintain sterility of the processed item after sterili4ation. aterials

for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes, peel pouches of plastic or paper, and sterili4ation wraps

i.e., woven and nonwoven9. Pac2aging materials should be designed for the type of

sterili4ation process being used 235..2399.

Sterili$ation

The sterili4ation section of the processing area should include the sterili4ers and related

supplies, with adequate space for loading, unloading, and cool down. The area can alsoinclude incubators for analy4ing spore tests and enclosed storage for sterile items and

disposable single-use9 items 25;9. anufacturer and local building code specificationswill determine placement and room ventilation requirements.

)terili4ation Procedures. eat-tolerant dental instruments usually are sterili4ed by *9

steam under pressure autoclaving9, 09 dry heat, or 39 unsaturated chemical vapor. #ll

sterili4ation should be performed by using medical sterili4ation equipment cleared byF(#. The sterili4ation 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

2#,27 9.

>tems to be sterili4ed should be arranged to permit free circulation of the sterili4ing agent

e.g., steam, chemical vapor, or dry heat96 manufacturerDs instructions for loading the

sterili4er should be followed 28,25;9. >nstrument pac2s should be allowed to dry insidethe sterili4er chamber before removing and handling. Pac2s should not be touched until

they are cool and dry because hot pac2s act as wic2s, absorbing moisture, and hence,

bacteria from hands 27 9. The ability of equipment to attain physical parametersrequired to achieve sterili4ation should be monitored by mechanical, chemical, and

biological indicators. )terili4ers vary in their types of indicators and their ability to

provide readings on the mechanical or physical parameters of the sterili4ation process

e.g., time, temperature, and pressure9. +onsult with the sterili4er manufacturer regardingselection and use of indicators.

)team )terili4ation. #mong sterili4ation methods, steam sterili4ation, which is

dependable and economical, is the most widely used for wrapped and unwrapped criticaland semicritical items that are not sensitive to heat and moisture 25;9. )team

sterili4ation requires e;posure of each item to direct steam contact at a required

temperature and pressure for a specified time needed to 2ill microorganisms. Two basic

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types of steam sterili4ers are the gravity displacement and the high-speed prevacuum

sterili4er.

The ma$ority of tabletop sterili4ers used in a dental practice are gravity displacement

sterili4ers, although prevacuum sterili4ers are becoming more widely available. >n gravitydisplacement sterili4ers, steam is admitted through steam lines, a steam generator, or self-

generation of steam within the chamber. nsaturated air is forced out of the chamber

through a vent in the chamber wall. Trapping of air is a concern when using saturatedsteam under gravity displacement6 errors in pac2aging items or overloading the sterili4er

chamber can result in cool air poc2ets and items not being sterili4ed.

Prevacuum sterili4ers are fitted with a pump to create a vacuum in the chamber and

ensure air removal from the sterili4ing chamber before the chamber is pressuri4ed withsteam. 8elative to gravity displacement, this procedure allows faster and more positive

steam penetration throughout the entire load. Prevacuum sterili4ers should be tested

periodically for adequate air removal, as recommended by the manufacturer. #ir notremoved from the chamber will interfere with steam contact. >f a sterili4er fails the air

removal test, it should not be used until inspected by sterili4er maintenance personnel and

it passes the test 2#,27 9. anufacturerDs instructions, with specific details regarding

operation and user maintenance information, should be followed.

nsaturated +hemical-=apor )terili4ation. nsaturated chemical-vapor sterili4ation

involves heating a chemical solution of primarily alcohol with !.03N formaldehyde in a

closed pressuri4ed chamber. nsaturated chemical vapor sterili4ation of carbon steelinstruments e.g., dental burs9 causes less corrosion than steam sterili4ation because of

the low level of water present during the cycle. >nstruments should be dry before

sterili4ing. )tate and local authorities should be consulted for ha4ardous waste disposalrequirements for the sterili4ing solution.

(ry-eat )terili4ation. (ry heat is used to sterili4e materials that might be damaged by

moist heat e.g., burs and certain orthodontic instruments9. #lthough 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 devices2519.

(ry-heat sterili4ers used in dentistry include static-air and forced-air types.

•

The static-air type is commonly called an oven-type sterili4er. eating coils in the bottom or sides of the unit cause hot air to rise inside the chamber through naturalconvection.

• The forced-air type is also 2nown as a rapid heat-transfer sterili4er. eated 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


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needed for sterili4ation.

)terili4ation of nwrapped >nstruments. #n unwrapped cycle sometimes called flash

sterili6ation9 is a method for sterili4ing unwrapped patient-care items for immediate use.

The time required for unwrapped sterili4ation cycles depends on the type of sterili4er andthe type of item i.e., porous or nonporous9 to be sterili4ed 2#9. The unwrapped cycle in

tabletop sterili4ers 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 instrumentwith much of the heat dissipated. >f the drying phase requirements are unclear, the

operation manual or manufacturer of the sterili4er should be consulted. >f the unwrapped

sterili4ation cycle in a steam sterili4er does not include a drying phase, or has only aminimal drying phase, items retrieved from the sterili4er will be hot and wet, ma2ing

aseptic transport to the point of use more difficult. For dry-heat and chemical-vapor

sterili4ers, a drying phase is not required.

nwrapped sterili4ation should be used only under certain conditions: *9 thoroughcleaning and drying of instruments precedes the unwrapped sterili4ation cycle6 09

mechanical monitors are chec2ed and chemical indicators used for each cycle6 39 care is

ta2en to avoid thermal in$ury to (+P or patients6 and C9 items are transported

aseptically to the point of use to maintain sterility 1#,238,2529. tems need to be *9 rinsed with sterile water

after removal to remove to;ic or irritating residues6 09 handled using sterile gloves anddried with sterile towels6 and 39 delivered to the point of use in an aseptic manner. >f

stored before use, the instrument should not be considered sterile and should be sterili4ed

again $ust before use. >n addition, the sterili4ation process with liquid chemical sterilantscannot be verified with biological indicators 25#9.


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appro;imately *0 hours of complete immersion, they are almost never used to sterili4e

instruments. 8ather, these chemicals are more often used for high-level disinfection

299. )horter immersion times *0--A! minutes9 are used to achieve high-leveldisinfection of semicritical instruments or items. These powerful, sporicidal chemicals

e.g., glutaraldehyde, peracetic acid, and hydrogen pero;ide9 are highly to;ic2 ,25,2539. anufacturer instructions e.g., regarding dilution, immersion time, and

temperature9 and safety precautions for using chemical sterilants?high-level disinfectantsmust be followed precisely 13,239. These chemicals should not be used for applications

other than those indicated in their label instructions. isapplications include use as an

environmental surface disinfectant or instrument-holding solution.

%hen using appropriate precautions e.g., closed containers to limit vapor release,

chemically resistant gloves and aprons, goggles, and face shields9, glutaraldehyde-based

products can be used without tissue irritation or adverse health effects. owever,

dermatologic, eye irritation, respiratory effects, and s2in sensiti4ation have been reported

255..2589. ts primary advantage is the ability to sterili4e heat- and

moisture-sensitive patient-care items with reduced deleterious effects. owever, e;tended

sterili4ation times of *!--C" hours and potential ha4ards to patients and (+P requiring

stringent health and safety requirements 272..279 ma2e this method impractical for private-practice settings. andpieces cannot be effectively sterili4ed with this method

because of decreased penetration of 1T7 gas flow through a small lumen 23;,2739.7ther types of low-temperature sterili4ation e.g., hydrogen pero;ide gas plasma9 e;ist

but are not yet practical for dental offices.

f a bead sterili4er is employed, (+P assume the ris2 of employing a dental

device F(# has deemed neither safe nor effective 275 9.

)terili4ation onitoring. onitoring of sterili4ation procedures should include a

combination of process parameters, including mechanical, chemical, and biological

27,28,277 9. These parameters evaluate both the sterili4ing conditions and the procedureDs effectiveness.

echanical techniques for monitoring sterili4ation include assessing cycle time,

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temperature, and pressure by observing the gauges or displays on the sterili4er and noting

these parameters for each load 2#,289. )ome tabletop sterili4ers have recording

devices that print out these parameters. +orrect readings do not ensure sterili4ation, butincorrect readings can be the first indication of a problem with the sterili4ation cycle.

+hemical indicators, internal and e;ternal, use sensitive chemicals to assess physical

conditions e.g., time and temperature9 during the sterili4ation process. #lthough

chemical indicators do not prove sterili4ation has been achieved, they allow detection ofcertain equipment malfunctions, and they can help identify procedural errors. 1;ternal

indicators applied to the outside of a pac2age e.g., chemical indicator tape or special

mar2ings9 change color rapidly when a specific parameter is reached, and they verify thatthe pac2age has been e;posed to the sterili4ation process. >nternal chemical indicators

should be used inside each pac2age to ensure the sterili4ing agent has penetrated the

pac2aging material and actually reached the instruments inside. # single-parameter

internal chemical indicator provides information regarding only one sterili4ation

parameter e.g., time or temperature9. ultiparameter internal chemical indicators aredesigned to react to L0 parameters e.g., time and temperature6 or time, temperature, and

the presence of steam9 and can provide a more reliable indication that sterili4ationconditions have been met 239. ultiparameter internal indicators are available only for

steam sterili4ers i.e., autoclaves9.

f either mechanical indicators or internal or e;ternal chemical

indicators indicate inadequate processing, items in the load should not be used until

reprocessed 1#9.


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results for bacterial growth.

>n-office biological monitoring is available6 mail-in sterili4ation monitoring services e.g.,

from private companies or dental schools9 can also be used to test both the and the

control. #lthough some (+P have e;pressed concern that delays caused by mailingspecimens might cause false-negatives, studies have determined that mail delays have no

substantial effect on final test results 281,2829.

Procedures to follow in the event of a positive spore test have been developed 2#,27 9.

>f the mechanical e.g., time, temperature, and pressure9 and chemical i.e., internal ore;ternal9 indicators demonstrate that the sterili4er is functioning correctly, a single

positive spore test probably does not indicate sterili4er malfunction. >tems other than

implantable devices do not necessarily need to be recalled6 however the spore test should be repeated immediately after correctly loading the sterili4er and using the same cycle

that produced the failure. The sterili4er should be removed from service, and all records

reviewed of chemical and mechanical monitoring since the last negative test. #lso,sterili4er operating procedures should be reviewed, including pac2aging, loading, and

spore testing, with all persons who wor2 with the sterili4er to determine whether operator

error could be responsible 9,2#,27 9. 7verloading, failure to provide adequate pac2age

separation, and incorrect or e;cessive pac2aging material are all common reasons for a positive in the absence of mechanical failure of the sterili4er unit 25;9. # second

monitored sterili4er in the office can be used, or a loaner from a sales or repair company

obtained, to minimi4e office disruption while waiting for the repeat .

>f the repeat test is negative and chemical and mechanical monitoring indicate adequate

processing, the sterili4er can be put bac2 into service. >f the repeat test is positive, and

pac2aging, loading, and operating procedures have been confirmed as performingcorrectly, the sterili4er should remain out of service until it has been inspected, repaired,and rechallenged with tests in three consecutive empty chamber sterili4ation cycles

9,2#9. %hen possible, items from suspect loads dating bac2 to the last negative

should be recalled, rewrapped, and resterili4ed 9,28#9.

# more conservative approach has been recommended 27 9 in which any positive sporetest is assumed to represent sterili4er malfunction and requires that all materials processed

in that sterili4er, dating from the sterili4ation cycle having the last negative biologic

indicator to the ne;t cycle indicating satisfactory biologic indicator results, should beconsidered nonsterile and retrieved, if possible, and reprocessed or held in quarantine

until the results of the repeat are 2nown. This approach is considered conservative

because the margin of safety in steam sterili4ation is sufficient enough that infection ris2,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 chart9 2#9. Published studies are notavailable that document disease transmission through a nonretrieved surgical instrument

after a steam sterili4ation cycle with a positive biological indicator 2#9. This more

conservative approach should always be used for sterili4ation methods other than steam


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e.g., dry heat, unsaturated chemical vapor, 1T7, or hydrogen pero;ide gas plasma9

2#9.

8esults of biological monitoring should be recorded and sterili4ation monitoring records

i.e., mechanical, chemical, and biological9 retained long enough to comply with state andlocal regulations. )uch records are a component of an overall dental infection-control

program see Program 1valuation9.

Storage of Sterili$ed Ites and Clean Dental Su&&lies

The storage area should contain enclosed storage for sterile items and disposable single-use9 items 17#9. )torage practices for wrapped sterili4ed instruments can be either date-

or event-related. Pac2ages containing sterile supplies should be inspected before use to

verify barrier integrity and dryness. #lthough some health-care facilities continue to date

every sterili4ed pac2age and use shelf-life practices, other facilities have switched to

event-related practices 2#9. This approach recogni4es that the product should remainsterile indefinitely, unless an event causes it to become contaminated e.g., torn or wet

pac2aging9 289. 1ven for event-related pac2aging, minimally, the date of sterili4ationshould be placed on the pac2age, and if multiple sterili4ers are used in the facility, the

sterili4er used should be indicated on the outside of

cdc gudelines 2003

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