Infection Control During Clinical Procedure

Infection Control practices for use during clinical activities will help reduce the exposure to infectious agents.

Infection Control Practices-Chair side

• Use care when receiving, handling or passing sharp instruments. Many dental instruments can easily cut gloves and skin.
• Take special precautions with syringes and needles. Needle stick injuries are a major cause of infection in health care personnel. Needles should not be recapped, bent, broken or otherwise manipulated by hand.
• Never recap a needle using a two-handed technique. Instead, use one of the commercially available sheath holders or the "scoop" technique. In this technique, the cap is scooped up from the tray with the needle tip using only one hand. As an additional protection against needle sticks, do not allow uncovered needles to remain on the instrument tray. It is far safer to dispose of them immediately after use in a puncture- proof container
• Disposable needles should not be bent or broken after use.
• Needles should not be removed manually from disposable syringes or otherwise handled manually.
• Forceps or other appropriate instruments may be used to handle sharp items.
• Disposable syringes, needles, scalpel blades and other sharp items should be discarded into puncture-resistant biohazard (sharps) containers that are easily accessible.
• Use a rubber dam whenever possible. Rubber dams limit the splash and spatter of blood and saliva and should be used whenever possible .
• Avoid touching unprotected switches, handles and other equipment after gloves have become contaminated. If objects are touched or handled, they should be carefully cleaned and disinfected at the end of the procedure.
• Avoid opening drawers or cabinets once gloves have become contaminated.
• If it becomes necessary, you may simply ask another person for assistance; or you may use another barrier, such as prepackaged aluminum foil squares or plastic gloves, to grasp the cabinet or drawer handle.
• However, if these options are not available, you must remove the contaminated gloves, wash hands before opening a drawer or cabinet, and then reglove before resuming patient treatment.
• Extracted teeth should be considered as potentially infectious material and should be disposed in medical waste containers.

Pre-procedural Mouth Rinses

• Anti-microbial mouth rinses (e.g. chlorhexidine gluconate, essential oils, or povidone- iodine) used by patients before a dental procedure are intended to reduce the number of microorganisms the patient might release in the form of aerosols or spatter that subsequently can contaminate dental practitioner and equipment operatory surfaces.

The infection control process continues after the patient leaves the office. Although effective pretreatment planning will simplify your task, there are a number of tasks that should be done following patient care to further reduce the risk for transmission of infectious agents.

Infection Control Procedures-Post treatment

• Continue to wear personal protective equipment during cleanup. Begin the cleaning and disinfection process by removing contaminated gloves used during treatment.
• Next, wash your hands and put on a pair of utility gloves before beginning clean-up. Continue to wear protective eyewear, mask and gown.
• Remove all disposable barriers. All barriers placed before treatment, including light handle covers, polyethylene tubing and counter-top barriers, should be removed. These should be placed into a leak-proof waste bag inside a trash container.
• Dispose of blood and suctioned fluids that have accumulated in the collection bottles during treatment.
• Identify a utility sink, drain or toilet connected to a sanitary sewer that can be used solely for the disposal of blood, liquid wastes and suctioned fluids.
• After the blood and suctioned fluids are poured into the sink, use a 1 : 100 dilution of household bleach (or other appropriate intermediate-level disinfectant) and tap water to disinfect the dental unit collection bottle. 
• The bottle should be completely filled and the solution should be kept in the bottle for 10 minutes (or according to manufacturer's instructions) before emptying and rinsing with fresh water.
• Clean and disinfect all items not protected by barriers. All clinical contact surfaces that were not protected by barriers must be cleaned and then disinfected with an intermediate-level surface disinfectant- for example iodophor, phenolic solution, or diluted household bleach (sodium hypochlorite).
• Remove personal protective equipment. The proper method of removing a mask is to grasp it only by the cloth or elastic strings, not by the mask itself.
• Reusable protective eyewear and face shields should be cleaned with soap and water as necessary and, if visibly soiled, disinfected between patients according to manufacturer's instructions.
• Remember not to touch the eyewear or face shield with ungloved hands, because it may have become contaminated with spatter of blood and saliva during patient care.
• Protective clothing should be changed when it becomes visibly soiled and as soon as feasible if penetrated by blood or OPIM.
• Soiled protective gowns should be placed in a soiled linen container.
• Gowns may be washed using the normal laundry cycle.
• Utility gloves should be washed with soap before removal. 
• Finally, thoroughly wash your hands for at least 15 seconds, using soap or anti microbial hand wash.
• Clean the instruments and prepare them for sterilization. Remove the tray with all instruments to the receiving and clean-up section of the central processing area.
• Instruments should be picked up individually. Never pick up a handful of instruments because this greatly increases the risk of cuts or punctures.
• Special care should be used when handling double-ended instruments. Don't reach into trays or containers holding sharp instruments that are not clearly visible. Use strainer- type baskets to remove them.
• Dental instruments should be scrubbed carefully using a long- handled brush with soap and water and rinsed thoroughly. As an alternative, instruments may be cleaned in an ultrasonic cleaner or washer- disinfector. After drying, the clean instruments are ready for sterilization.
• Sterilize devices connected to the air or waterlines of the dental unit between each patient. Any device connected to the dental unit air or water system that enters the patient's mouth (e.g., handpieces, prophylaxis angles, air abrasion devices) should be run to discharge water and/or air for 20-30 seconds after each patient.
• Follow the manufacturer's recommendations for proper flushing of devices and for the use and maintenance of waterlines and check valves as appropriate.
• An ultrasonic cleaner should be used to remove any adherent material, but only if recommended by the device's manufacturer.
• Otherwise, scrub devices thoroughly with a detergent and hot water and dry. Finally, sterilize it according to the manufacturer's instructions.
• Disposal of any general medical waste (e.g. gloves, masks, lightly soiled cotton balls, protective barriers) classified as non-regulated medical waste and can be disposed of along with ordinary waste.
• A single leak-resistant biohazard bag is usually adequate for non-sharp regulated medical waste. Sharp items, such as needles and scalpel blades, should be placed intact into puncture- resistant biohazard containers and disposed.
• Disposal of regulated medical waste. (e.g. solid waste soaked or saturated with blood and saliva, surgically removed hard and soft tissues, and contaminated sharp items). A single leak- resistant biohazard bag is usually adequate for non-sharp regulated medical waste. Sharp items, such as needles and scalpel blades, should be placed intact into puncture- resistant biohazard containers and disposed.

Appropriate procedures for handling sharp instruments include the following

• Wear sturdy utility gloves when cleaning contaminated instruments or other sharp items.
• Dispose of needles and other sharp items promptly and appropriately.
• When handling sharp instruments, avoid any quick motions that would bring one hand toward the other or the instrument across any part of your body.

Dental Radiology

• When taking radiographs, the potential to cross-contaminate equipment and environmental surfaces with blood or saliva is high if aseptic technique is not practiced.
• Gloves should be worn when taking radiographs and handling contaminated film packets.
• Other PPE (e.g. mask, protective eyewear and gowns) should be used if spattering of blood or other body fluids is likely to occur.
• Heat-tolerant versions of intraoral radiograph accessories are available and these semicritical items (e.g. film-holding and positioning devices) should be heat-sterilized before patient use.
• After exposure of the radiograph and before glove removal, the film should be dried with disposable gauze or a paper towel to remove blood or excess saliva and placed in a container (e.g. disposable cup) for transport to the developing area.
• However, care should be taken to avoid contamination of the developing equipment.
• Protective barriers should be used, or any surfaces that become contaminated should be cleaned and disinfected with a disinfectant (intermediate-level).
• Radiography equipment (e.g. radiograph tubehead and control panel) should be protected with surface barriers that are changed after each patient.
• If barriers are not used, equipment that has come into contact with dental practitioners gloved hands or contaminated film packets should be cleaned and then disinfected after each patient use.

For Digital Radiography

• Digital radiography sensors and other high-technology instruments (e.g. intraoral camera, electronic periodontal probe, occlusal analyzers and lasers) come into contact with mucous membranes and are considered semicritical devices.
• They should be cleaned and ideally heat-sterilized or high- level disinfected between patients.
• Semicritical items that cannot be reprocessed by heat sterilization or high- level disinfection should, at a minimum, be barrier protected to reduce gross contamination during use.
• To minimize the potential for device-associated infections, after removing the barrier, the device should be cleaned and disinfected with a disinfectant (intermediate-level) after each patient.
• Manufacturers should be consulted regarding appropriate barrier and disinfection/sterilization procedures for digital radiography sensors, other high-technology intraoral devices and computer components.

Steps to be followed:

• Keep operatory free of unnecessary items.
• Set up all supplies and instruments for a procedure in advance.
• Use disposable items whenever appropriate.
• Use individualized, sterilized bur blocks.
• Set up radiographs and review patient records before treatment.
• Flush waterlines between patients. Wear gown, protective eyewear, masks and gloves during procedures involving spatter.
• Use proper handwashing techniques.
• Use rubber dams.
• Use high-volume evacuation.
• Use barriers to protect equipment (including digital radiographic equipment) from contamination whenever possible.
• Keep radiographs and records protected during treatment.
• Use a safe method for recapping needles.
• Disinfect all unprotected clinical contact surfaces in dental operatory.
• Use appropriate methods of handling and passing sharp items.
• Use safe procedures for exposing and developing radiographs.
• Wear protective gear during post treatment clean-up.
• Proper disposal of regulated medical waste.