Infection control practice guidelines in dental hygiene

2008; 42, no.2: 63-103 63

BACKGROUND

n the broader health system, infection control has

become a significant issue for government, health

professionals and the public, given national public health

issues, such as severe acute respiratory syndrome (SARS),

pandemic influenza and global problems with multi

resistant bacteria, such as Methicillin-resistant

Staphylococcus aureus (MRSA). The media reflects public

concerns with recent information regarding patient

infections, poor hand hygiene, and improper sterilization

of equipment in hospitals.

1,2

Infection control in dental

hygiene practices has also grown to a level of considerable

importance, and given the pace of population ageing,

dental hygienists are considering how their infection

control practices will affect a client population with

potentially increased susceptibility to infection.

In the 1980s, Universal Precautions were designed to

protect against bloodborne pathogens such as hepatitis B

virus (HBV), human immunodeficiency virus (HIV), and

hepatitis C virus (HCV). In 1996, the Centers for Disease

Control (CDC) published “Standard Precautions” which

expanded upon Universal Precautions by covering more

bodily fluids and sites, including blood, body fluids, secre-

tions, excretions (except sweat), non-intact skin and

mucous membranes. The new Standard Precautions

incorporated body substance isolation (BSI) practices.

Standard Precautions are meant to be used with all clients,

regardless of age, gender, diagnosis, or whether they are

under isolation for a specific disease. Dental hygiene

clients may appear clinically healthy according to a physi-

cal examination and medical history. Therefore, Standard

Precautions should be applied to all clients, regardless of

their infection status.

Within the context of this paper, guidelines for infec-

tion control are defined as systematically developed

statements to assist dental hygienists make decisions

ABSTRACT

The paper on infection control is divided into two parts. Part I, in this issue, compares several infection control practice guideline docu-

ments from the Centers for Disease Control, the Canadian Dental Association, the Canadian Forces Dental Services, the United States Air Force,

and several relevant documents from the Organization for Safety and Asepsis Procedures.

Part II entitled, “Current Issues in Infection Control” in volume 42.3, discusses four current issues including compliance with infection con-

trol practices, HIV, HBV and HCV, dental unit water lines, and aerosols. Part II provides recommendations for dental hygienists, educational

institutions, several dental hygiene organizations, the National Dental Hygiene Certification Board, the Commission on Dental Accreditation

Canada, and researchers.

RÉSUMÉ

L’article sur la prévention des infections comprend deux volets. Le premier compare plusieurs guides pratiques de prévention des infections,

ceux de Centers for Disease Control, (centres américains de prévention des maladies), de l’Association dentaire canadienne, des Services den-

taires des Forces canadiennes et de la force aérienne des États-Unis, ainsi que plusieurs documents pertinents de l’Organization for Safety and

Asepsis Procedures (organisation pour la sécurité et les procédures d’asepsie).

Le deuxième volet qui traite des problèmes courants dans la prévention des infections, se penche sur quatre problèmes actuels, notam-

ment: l’observance des pratiques de prévention, le VIH, le VHB et le VHC, les conduites d’eau des unités dentaires et les aérosols. Le deuxième

volet formule des recommandations destinées aux hygiénistes dentaires, aux établissements de formation, à plusieurs organismes d’hygiène

dentaire, au Bureau national de la certification en hygiène dentaire, à la Commission d’agrément dentaire du Canada et aux chercheurs.

about appropriate health care for specific clinical circum-

stances. Dental hygiene clients can also use guidelines for

infection control to obtain a better understanding of how

dental hygienists incorporate infection control into their

dental hygiene care. They are meant to be used by dental

hygienists in a daily routine, as an integral part of the

clinical decision-making process and as part of a quality

assurance process. Guidelines for infection control provide

a baseline for infection control procedures and provide

protocols to minimize the risk of injury or disease for den-

tal hygiene clients, and dental hygienists. The guidelines

do not attempt to provide procedures for every situation,

or every dental hygiene setting. Clinical judgment regard-

ing the most appropriate protection for a specific

procedure should be based upon the dental hygienists

knowledge of the principles of infection control. In some

instances, dental hygienists may set their own more strin-

gent guidelines, or their workplace may set guidelines that

are more stringent. For example, some larger health

facilities may require head and shoe covers during all

procedures that may generate spray or spatter of blood or

Other Potentially Infectious Material (OPIM), and other

facilities may require daily spore sterilizer testing.

The legislative regulation of infection control falls with-

in the mandate of provincial or territorial dental hygiene

regulatory bodies. These regulatory bodies may adopt or

modify existing guidelines and use them in the context of

complaints, discipline, quality assurance processes and

informal resolution agreements. Therefore, dental hygien-

Infection control practice guidelines in dental hygiene - Part 1

Judy Lux, MSW

Canadian Dental Hygienists Association, Ottawa

Submitted 22 Oct. 2007; Revised 10 Dec. 2007; Accepted 15 Jan. 2008.

This is a peer reviewed article.

Correspondence to: J Lux, 96 Centrepointe Drive, Ottawa, ON K2G 6B1;

[email protected]

EVIDENCE FOR PRACTICE

64 2008; 42, no.2: 63-103

ists must follow the standards or guidelines developed by

their regulatory bodies in order to maintain their registra-

tion and ability to practice.

All of the self-regulating dental hygiene colleges

include some varying degree of reference to infection con-

trol in their dental hygiene standards documents.

4,5,6

British Columbia refers to guidelines published by the

CDC, Alberta refers to the guidelines from CDC, Canadian

Dental Association and Health Canada and Ontario refers

to scientifically accepted infection control procedures.

This paper has two main purposes. First, to gather com-

prehensive background information on infection control

that is pertinent to the Canadian Dental Hygienists

Association (CDHA), its members, oral health practition-

ers, educators, researchers, policy-makers and the public.

Second, the paper examines the infection control litera-

ture in order to explain issues in some detail and to permit

the CDHA to base its guideline statement on in depth

analyses.

METHODOLOGY

The methodological approach in this paper is a compre-

hensive review and comparison of the major features of

several guidelines for infection control for oral health

practitioners in Canada and the USA. The author also

reviews and analyzes current scientific literature on a

selected list of topics on infection control for dental

hygiene practice, including compliance with infection

control practices to prevent transmission of Human

immunodeficiency virus (HIV), Hepatitis C virus (HCV),

Hepatitis B virus (HBV), aerosols, and Dental Unit Water

Lines (DUWL). Topics were chosen for their recent nation-

al or global significance, and/or for the large number of

studies conducted on some of the topics.

The literature search was limited to English language

studies in MedLine, Cochrane controlled trials register, the

CINAHL Database and Google Scholar, from 2003 to 2007.

Additional articles were identified from reference lists of

published studies. The search also included “grey” litera-

ture (information not reported in the published scientific

literature), and web sites known to contain information

on this topic. Topic experts were consulted at several

development stages, and input on the draft paper was

obtained from CDHA members and other dental hygiene

organizations.

A REVIEW AND COMPARSION OF INFECTION CONTROL

GUIDELINE DOCUMENTS

The highlights of several guidelines for infection control

for oral health practitioners in Canada and the USA are

listed in Table 1. The table highlights major features of the

original documents that should be consulted for details.

The documents reviewed are:

• Centers for Disease Control (CDC) in the USA:

Guidelines for Infection Control in Dental Health-Care

Settings-2003.

(No comparable Canadian govern-

ment document exists specifically for dental health

care settings).

• Canadian Dental Association (CDA): Infection

Prevention and Control in the Dental Office: An opportu-

nity to improve safety and compliance, 2006.

• Canadian Forces Dental Services (CFDS): Infection

Control Guidelines, 2006.

• United States Air Force (USAF): Guidelines for Infection

Control in Dentistry, 2004.

• Organization for Safety and Asepsis Procedures

(OSAP), A Global Dental Safety Organization: OSAP

Position Paper: Percutaneous Injury Prevention, 2002.

Dental Unit Waterlines: OSAP Recommendations to

Clinicians.

Issue Focus: Anthrax and Dental

Practice.

and Issue Focus: Severe Acute Respiratory

Syndrome: SARS and the Dental Office.

The American Dental Hygienists Association (ADHA)

has not developed an infection control document; howev-

er, their web site recommends that dental hygienists

consult with CDC’s guidelines. The Public Health Agency

of Canada (PHAC) does not have an infection control doc-

ument that pertains specifically to dental or dental

hygiene practice settings; however, the organization is in

the process of developing occupational health guidelines.

A comparison of these guidelines is found in Appendix

A. The infection control document of the CDC, the most

comprehensive document available on this issue, is com-

pared with the four other guideline documents. The

comparative information is classified as supplemental,

more rigorous, and less rigorous. The supplemental catego-

ry represents information that was not included in the

CDC document. The two “rigorous” classifications repre-

sent recommendations that were either more or less

rigorous in comparison to the CDC document. Appendix

A also includes a brief background and purpose of the

guidelines.

The comparison shows that three infection control

documents of the CDA, the CFDS and the USAF contain

guidelines that are supplemental, more rigorous and less

rigorous than the infection control document of the CDC.

The documents of OSAP provide only supplemental infor-

mation. The areas in which the three documents are more

rigorous than the infection control document of CDC

primarily pertain to immunization programs, personal

protective clothing, and sterilization and disinfection of

patient-care items, and DUWL. For instance, the following

issue is found in the more rigorous category: the CDA and

the USAF call for preprocedural mouth rinse in order to

reduce aerosol production. However, the CDC indicates

that the use of preprocedural mouth rinse is an unresolved

issue, since there is a need for more research to confirm its

efficacy. A second example is the CDA’s call for oral health

professionals to include medical history questions regard-

ing dura mater transplantation, and familial history of

Creutzfeldt-Jakob Disease (CJD) and variant Creutzfeldt-

Jakob Disease (vCJD). Dental instruments and devices

touching pulpal tissue (e.g. endodontic broaches and files,

access opening burs) of these clients should be discarded

in sharps containers after each client use. CJD is thought

to be caused by infection with a prion, which is not

inactivated by the standard sterilization methods used in

oral health care settings. In contrast, CDC reports this is an

unresolved issue and therefore makes no recommenda-

tions.

The areas where the documents were less rigorous than

CDC’s guidelines pertain mostly to sterilization and disin-

Lux

2008; 42, no.2: 63-103 65

Infection control in DH - Part 1

fection of patient care items. For example, the USAF rec-

ommends cleaning digital sensors with intermediate to

level disinfectant, whereas the CDC recommends high

level disinfectant for digital sensors. The CFDS calls for

monthly biological monitoring of a sterilizer for semi crit-

ical care items and weekly monitoring of a sterilizer for

critical care items. In contrast, CDC calls for all heat steril-

izers of critical and semi critical instruments to be

monitored with biological indicators weekly.

Part II of Infection Control, entitled “Current issues in

infection control”, will be published in volume 42 no.3

(May-June 2008).

APPENDIX A

A COMPARISON OF INFECTION CONTROL

DOCUMENTS

The Centers for Disease Control and Prevention (CDC)

Infection Control Guidelines in Dental Health-Care –

2003 document is compared with infection control

information from four other organizations. The infor-

mation is classified as follows:

• supplemental (information that was not included

in the CDC document),

• more rigorous (though the issue is mentioned in

the CDC document, the information in this cate-

gory is more rigorous), and

• less rigorous (though the issue is mentioned in the

CDC document, the information is less rigorous).

Centers for Disease Control and Prevention (CDC):

Infection Control Guidelines in Dental Health-Care

Settings – 2003

These guidelines apply to all oral health settings and are

intended for clinicians, public health practitioners and

the public. The guidelines are based on a range of ration-

ale from systematic reviews to expert opinion, and each

recommendation is rated for its strength. The CDC rat-

ing scheme is located at the bottom of Table 1.

Canadian Forces Dental Services (CFDS)

Infection Control Guidelines, 2006

This document is based on infection control protocols

developed by the Laboratory Centre for Disease Control

(LCDC) of the Public Health Agency of Canada and the

CDC of the USA. It provides a baseline for standard

infection control procedures throughout the CFDS.

Similar to the Canadian Dental Association (CDA) docu-

ment, the CFDS document highlights the lack of strong

scientific evidence from clinical trials to support infec-

tion contol procedures for oral health professionals.

Therefore, many of the recommendations are based on

opinions of respected authorities on the basis of clinical

experience, descriptive studies, or reports of expert com-

mittees, and not from clinical trials. This document uses

the term “routine practices”, a term adopted from the

Public Health Agency of Canada for the standards of

practice that should be followed for the care of all

patients at all times. Agencies such as the CDC use the

term “standard precautions” with the same meaning.

Information that supplements the CDC document on

infection control:

• CFDS guidelines include a call for vaccinations

against polio, tetanus/diphtheria and influenza,

which are not included in the CDC guideline.

• For HIV prophylaxis to be effective treatment

must begin within two hours of exposure. CDC

confirms the importance of this timing in the

2005 CDC’s guidelines for the management of

occupational exposure to HIV

• Sinks for hand washing should not be used for any

other purpose.

• Consider the use of hair covers and do not allow

hair to contact the client.

• Employ a rubber dam whenever possible to reduce

exposure of the dental personnel to microorgan-

isms.

• All oral health professionals must wear a reusable

or disposable uniform, which must remain at the

clinic, where access to separate external launder-

ing facilities are available. Do not launder with

family wash.

• Wash utility gloves in disinfectant soap and reuse.

• Discard contaminated disposable items in the

operatory waste container, which should be

cleared on a daily basis.

• Use of a DUWL conditioner is recommended.

More rigorous guidelines than the CDC document on

infection control:

• Clients in the supine position should also wear

protective eyewear. CDC states that protective eye-

wear for patients shields their eyes from spatter or

debris, but there is no specific directive for provid-

ing eyewear.

• Areas such as switches, headrests and bracket

trays, chair adjustment controls, light handles,

air/water syringe handles, saliva ejector and vacu-

um couplings, unit switches and handles, mobile

cart or operatory counter surfaces, and operatory

sink hand-operated valves require intermediate or

high level disinfectant. CDC’s guidelines call for a

low or intermediate level disinfectant.

• Reduce the aerosol production by the following:

consider asking clients to brush their teeth and/or

rinse their mouth with a mouthwash prior to

dental treatment. Three 10-second rinses can tem-

porarily reduce a client’s oral microbial count by

up to 97 per cent. CDC reports this is an unre-

solved issue.

• Specific Creutzfeldt-Jakob Disease (CJD) infection

control precautions, in addition to standard pre-

cautions are recommended for clients who have

developed, are suspected of having developed, or

are at substantially increased risk of developing

CJD. These precautions include the following:

Lux

66 2008; 42, no.2: 63-103

a. use single-use disposable items and equipment

whenever possible,

b. consider difficult to clean items (e.g. diamond

burs) as single use disposable and discard after

use,

c. keep the instrument moist until cleaned and

decontaminated to minimize the drying of tis-

sues and body fluids on a device,

d. clean instruments thoroughly and steam-auto-

clave at 134°C for 18 minutes,

e. do not use flash sterilization for processing

instruments or devices. CDC’s guidelines report

that this is an unresolved issue and therefore

there are no recommendations.

Less rigorous guidelines than the CDC document on

infection control:

• After removing the barrier from the digital sensor,

clean and disinfect with an intermediate level

activity. CDC’s guidelines recommend a high level

disinfectant.

• Biological monitoring of a sterilizer for semi criti-

cal care items should take place monthly and for

critical care items the sterilizer should be tested

weekly. CDC’s guidelines call for weekly monitor-

ing of sterilizers of critical and semi critical care

items.

Canadian Dental Association (CDA)

Infection Prevention and Control in the Dental

Office: An opportunity to improve safety and com-

pliance, 2006

Scientific evidence supporting the CDA document

comes primarily from CDC’s guidelines and documents,

CDA documents, published research papers, U.S.

Department of Labour documents, and position papers

from the Association for Professionals in Infection

Control and Epidemiology (APIC). The CDA document

points out that there is a lack of strong scientific evi-

dence from clinical trials to support infection control

procedures. The evidence is drawn from respected

authorities on the basis of clinical experience, descrip-

tive studies, or reports of expert committees.

Supplemental information:

• Proper disposal of single use masks.

• An eyewash station should be available and staff

training on location, function and indications for

use.

• Personal Protective Equipment (PPE) designed for

re-use can be washed with soap and water.

Infected PPEs can be disinfected according to the

manufacturer’s directions. Disposable PPE items

should be discarded following use.

• Use dental rubber dams and high volume/high

velocity suction whenever the creation of droplets,

spatter, spray and aerosol occurs.

• Utility gloves should be disinfected or sterilized at

the end of the day.

• Don’t expose gloves to heat sources, such as x-ray

unit controllers, lasers, fans, electrical generators,

suction machines or motors.

• Don’t use waterline heaters. Flush lines for at least

2-3 minutes at the beginning of the day, without

handpieces, air-water syringe tips and ultrasonic

tips detached.

• DUWL should be cleaned at least once a week with

an enzymatic cleaner. CDC recommends follow-

ing manufacturer’s instructions for cleaning.

More rigorous guidelines than the CDC document on

infection control:

• Double gloving may be used for procedures

involving the handling of multiple sharp metal

instruments or during longer procedures. CDC

reports this is an unresolved issue.

• Low-temperature sterilization using ethylene

oxide gas (EtO) may be used in larger healthcare

facilities, such as hospitals, but the hazardous

vapours produced make it impractical for private

practice settings. CDC’s guidelines list EtO as a low

temperature sterilization method.

• Antimicrobial mouth rinses should be used by a

client prior to a dental procedure. CDC reports

this is an unresolved issue.

• OHP’s should include medical history questions

regarding dura mater transplantation, and familial

history of CJD and variant Creutzfeldt-Jakob

Disease (vCJD). Dental instruments and devices

touching pulpal tissue (e.g. endodontic broaches

and files, access opening burs) should be discarded

in sharps containers after each client use. CJD is

thought to be caused by infection with a prion,

which is not inactivated by the standard steriliza-

tion methods used in oral health care settings.

CDC reports this is an unresolved issue and there-

fore makes no recommendations.

Less rigorous guidelines than the CDC document on

infection control:

• The film packet should be disinfected using a

hospital-grade tuberculocidal intermediate-level

disinfectant. CDC calls for a high-level disinfec-

tant for film holding and positioning devices.

• Dispose extracted teeth in general waste. CDC

calls for treatment as regulated medical waste.

United States Air Force (USAF)

Guidelines for Infection Control in Dentistry, 2004

The United States Air Force (USAF) document on infec-

tion control appears to incorporate a broader range of

regulatory documents, compared with those of CDA

and the CFDS. The goals of the USAF infection control

guidelines are to comply with applicable federal, state,

and local regulations governing infection control, job

safety, and management of regulated medical waste. The

US federal regulations include those issued by the

Occupational Safety and Health Administration (OSHA),

Infection control in DH - Part 1

2008; 42, no.2: 63-103

the Food and Drug Administration (FDA), and the

Environmental Protection Agency (EPA). The USAF

infection control guidelines also incorporate recommen-

dations made by non-regulatory agencies including the

American Dental Association (ADA), the CDC and the

Joint Commission for the Accreditation of Health Care

Organizations.

Supplemental information:

• For a period of 3 years, maintain training records

documenting each training session provided by

the dental service in accordance with current

OSHA and medical treatment facility guidelines.

• Label package with: sterilizer identification

number, load number, operator’s initials, and

indefinite shelf life label. The use of self-adhesive

labels or tapes is preferred. Labelling makers

should be indelible, nonbleeding and nontoxic.

• In the absence of manufacturer recommendations

for monitoring dental unit water quality, test

water from each unit monthly for three months. If

the unit meets standards during this period, then

monitor water from the dental unit quarterly at a

minimum. It is recommended to use a rotating

schedule, testing several units each month. If test

remains positive, a “shock-treatment of the water-

lines may be indicated. CDC calls for following

manufacturer’s directions.

• Decontaminate extracted teeth: clean and place

extracted teeth in a leak proof container labeled

with a biohazard symbol; place amalgam-free

teeth in a heat resistant glass container; fill the

container no more than half-way with de-ionized

or distilled water or saline, and loosely cover;

process through a steam sterilizer at 121° C for 40

minutes using a fluid or liquid cycle. At the end of

the cycle, remove the container slowly without

shaking to avoid the boiling over of the fluid.

• At a minimum, clean and disinfect rag wheels and,

clean and surface disinfect lathes daily. Clean and

disinfect case pans and articulators when visibly

soiled, and after each case is completed. CDC calls

for following manufacturer’s instructions.

• Inspections: Conduct and document routine

scheduled or unscheduled inspections of dental

treatment rooms, dental laboratory and radiology

areas, decontamination and sterilization areas,

and locations where sterile and/or patient-care

items are stored.

• Waterline Monitoring: Implement a waterline-

monitoring program as described in this

document.

• Health-Care Associated Infections (HAI):

Surveillance for HAI provides data useful for iden-

tifying infected patients, determining the site of

infection, and identifying the factors that con-

tribute to HAI. Information containing patient

identifiers or patient care staff should be carefully

handled. Data should not be used for punitive pur-

poses, but should be viewed as an opportunity to

improve patient/ employee/ process outcome.

Surveillance goals should include:

• providing objective assessment of dental HAI

rates, reducing morbidity and cost, establishing

baseline infection rates based on well defined

case definition criteria,

• educating DHCP concerning data relevant to

their practices,

• evaluating control measures designed to reduce

infection rates,

• complying with accreditation standards,

defending malpractice claims through imple-

mentation of an active surveillance program,

and

• providing data useful in clinical research.

More rigorous guidelines than the CDC document on

infection control:

• Clean and disinfect clinical contact surfaces that

are not barrier protected with at least an interme-

diate-level disinfectant. CDC calls for a low or

intermediate level disinfectant.

• Do not install EtO sterilization equipment in

dental clinics. CDC lists EtO as a low temperature

sterilization method.

• The use of a preprocedural antimicrobial mouth

rinse is optional, but should be considered to

reduce the level of microorganisms in aerosols.

CDC reports this is an unresolved issue.

Less rigorous guidelines than the CDC document on

infection control:

• Digital radiography sensors – use barriers and dis-

infectant with an intermediate level activity. CDC

recommends a high level disinfectant for digital

sensors.

Organization for Safety and Asepsis Procedures

(OSAP)

a. Position Paper: Percutaneous Injury Prevention,

2002; Dental Unit Waterlines.

b. OSAP Recommendations to Clinicians; Issue

Focus: Anthrax and Dental Practice.

c. Issue Focus: Severe Acute Respiratory Syndrome:

SARS and the Dental Office.

http://www.osap.org/index.cfm

Supplemental information:

• Avoid heating dental unit water.

• Consider using a separate water reservoir system to

eliminate the inflow of municipal water into the

dental unit.

• Monitor scientific and technological develop-

ments in the area of DUWL to identify improved

technical approaches as they become available.

• Cooperate with the oral healthcare industry to

develop and validate standard protocols for main-

taining and monitoring dental unit waterlines.

• It is important to ensure that the sterile water sys-

tem or device marketed to improve dental water

Lux
68 2008; 42, no.2: 63-103
quality has been cleared for market by the U.S.
Food and Drug Administration.
• SARS and the dental office: CDC recommends that
clinicians evaluating suspected cases should apply
standard precautions - air borne precautions (e.g.,
N-95 respirator), and contact precautions (e.g.,
gowns and gloves). Until the mode of transmis-
sion had been positively identified and precisely
defined, eye protection also should be worn for all
patient contact.
Dental Personnel Protection: 
• Disposable gloves which must be changed after
every patient. 
• Chin length plastic face shields or surgical
masks and protective eyewear.
• Make sure the mask covers the mouth and the
nose. 
• Reusable or disposable gowns. 
• Cleaning and disinfection - use a hospital grade
disinfectant or 1:100 dilution of household
bleach. Make sure the disinfectant is compatible
with your dental equipment.
CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT
Centers for Disease Control and 
Prevention (CDC): Guidelines for 
Infection Control in Dental Health-
Care Settings
7
 - 2003.
http://www.cdc.gov/mmwr/pre-
view/mmwrhtml/rr5217a1.htm#top
http://www.guideline.gov/
summary/summary.aspx?doc_
id=4540andnbr=003354andstring=
infection+AND+control+AND+dental
+AND+health+AND+care+AND+
settings+AND+2003
http://www.cdc.gov/mmwr/
preview/mmwrhtml/rr5217a1.htm 
Canadian Dental Association 
(CDA): Infection Prevention and 
Control in the Dental Ofﬁ ce: An 
opportunity to improve safety and 
compliance
8
, 2006.
http://www.cda-adc.ca/_ﬁ les/
members/clinical_information/
infection
_control/ infection_control_manual
_06.pdf
United States Air Force (USAF): 
Guidelines for Infection Control in 
Dentistry
10
, 2004.
decs.nhgl.med.navy.mil
or
https://decs.nhgl.med.navy.mil/ 
1QTR05/usaﬁ cguidelinesjanuary06
.pdf
Canadian Forces Dental Services 
(CFDS): Infection Control Guide-
lines
9
, 2006.
Available only in printed format.
Organization for Safety 
and Asepsis Procedures 
(OSAP): Position Pa-
pers: Percutaneous In-
jury Prevention
11
,2002; 
Dental Unit Waterlines: 
OSAP Recommenda-
tions to Clinicians
12
; Is-
sue Focus: Anthrax and 
Dental Practice
13
; Issue 
Focus: Severe Acute 
Respiratory Syndrome: 
SARS and the Dental 
Ofﬁ ce.
14
http://www.osap.org/
index.cfm
I. PERSONNEL HEALTH ELEMENTS OF AN INFECTION PREVENTION AND CONTROL PROGRAM
A. General Recommendations
1. Develop a written health program 
for DHCP that includes policies, 
procedures, and guidelines for 
education and training; immuniza-
tions; exposure prevention and post 
exposure management; medical 
conditions, work-related illness, and 
associated work restrictions; contact 
dermatitis and latex hypersensitivity; 
and maintenance of records, data 
management, and conﬁ dentiality.
Supporting evidence: 1B
A written ofﬁ ce infection prevention 
and control program should be 
developed to maintain and improve 
the health of all DHCP including a 
manual of policies, procedures and 
practices, identiﬁ cation of an IPC 
ofﬁ cer, guidelines for education and 
training, immunizations, exposure 
prevention and post exposure 
management, special consider-
ations i.e. medical conditions, latex 
allergies, maintenance of records, 
maintenance of equipment.
Supporting evidence: IPC-02-01 
CDC Guidelines for IC in Dental 
Health-Care Settings - 2003
Same as CDC document.    
2. Establish referral arrangements 
with qualiﬁ ed health care profession-
als to ensure prompt and appropri-
ate provision of preventive services, 
occupationally related medical 
services, and post exposure manage-
ment with medical follow-up.
Supporting evidence: 1B, 1C
Identify referral arrangements with 
IPC services from external health 
care facilities and providers prior to 
exposure.
Supporting evidence: IPC-02-01 
CDC Guidelines for IC in Dental 
Health-Care Settings - 2003
Same as CDC document.    
B. Education and Training
1. Provide DHCP 1) on initial 
employment, 2) when new tasks or 
procedures affect the employee’s 
occupational exposure, and 3) at a 
minimum, annually, with education 
and training regarding occupational 
exposure to potentially infectious 
agents and infection-control proce-
dures/protocols appropriate for and 
speciﬁ c to their assigned duties.
Supporting evidence: 1B, 1C
DHCP should receive infection-
control training upon hire, when 
given new tasks /procedures, and 
annually. Training should include: 
exposure risks, prevention strategies 
and IC policies and procedures, how 
to manage work-related illness and 
injuries, including post exposure 
prophylaxis, work restrictions for the 
exposure or infection.
Supporting evidence: IPC-02-02 
Chapter 2, B 1. Same as CDC 
document.
  
Continued …
TABLE 1: INFECTION CONTROL PRACTICE GUIDELINES
Highlights from infection control documents. Follow the web site links to access the complete document. Acronyms and rating definitions are
listed in “Legends for Table 1” on page 102.

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

2. Provide educational information

appropriate in content and vocabu-

lary to the educational level, literacy,

and language of DHCP.

Supporting evidence: 1B, 1C

Educational materials should be ap-

propriate for the DHCP’s educational

level, literacy and language, as well

as consistent with existing federal/

provincial/municipal regulations.

Supporting evidence: PC-02-02

Chapter 2, B 2. Same as CDC

document.

Provide training for DHCP who

perform tasks likely to result in

occupational exposure to infectious

agents that includes: a) a description

of the exposure risks; b) a review of

prevention strategies and infection-

control policies and procedures; c)

discussion regarding how to man-

age work-related illness and injuries,

including post exposure prophylaxis;

d) review of work restrictions for the

exposure.

Same as CDC and provide training

for DHCP who perform tasks likely

to result in occupational exposure

to infectious agents that includes:

a) description of the exposure risks;

b) review of prevention strategies

and infection-control policies and

procedures; c) discussion regarding

how to manage work-related illness

and injuries, including post exposure

prophylaxis; d) review of work

restrictions if exposed to or infected

with certain pathogens.

Inclusion of DHCP with minimal

exposure risks (e.g. administrative

employees) in educational and

training programs might enhance

facility wide understanding on

infection control principles and the

importance of the program.

Provide newcomer’s orientation

training for all DHCP, including

administrative employees.

For a period of 3 years, maintain

training records documenting each

training session provided by the

dental service in accordance with

current OSHA and medical treat-

ment facility (MTF) guidelines.

C. Immunization Programs

1. Develop a written immunization

policy, including a list of required

and recommended immunizations,

including Hep.B, Inﬂ uenza, measles,

mumps, rubella, varicella-zoster.

Supporting evidence: The Advi-

sory Committee on Immunization

Practices (ACIP) provides national

guidelines for immunization of HCP,

which includes HDCP.

Supporting evidence: 1B

DHCP should be immunized against:

Hep.B, measles, mumps, rubella,

varicella, inﬂ uenza. IPC-02-04 Fol-

lowing Hep.B vaccination, if the

anti-HBs is <10mIU/mL a second

vaccine should be completed and if

this occurs again, following a third

round of vaccination then testing

for HBs AG should be completed.

Those with HBs AG-negative are

susceptible to HBV infection and

should obtain prophylaxis.

Supporting evidence: IPC-02-03

DHCP APIC position paper and CDC

APIC recommendations

IPC-02-04 CDC documents 1987,

1989, 1999, 2001.

Ensure DHCP receive all appropri-

ate immunizations (e.g. varicella,

measles, mumps, rubella, inﬂ uenza)

based on internal policies as well as

DHCP’s medical history and risk for

occupational exposure.

Current vaccinations against

tetanus, Hep.B, Hep.A, rubella,

measles, mumps, polio, tetanus/

diphtheria and inﬂ uenza. Baseline

testing for tuberculosis for new OHP.

Testing may be required following

a suspected exposure. Post Hep.B

vaccination serology performed at

recommended intervals to ensure

continued immunity. (Immuniza-

tion schedule can be found at CFHS

Policy and Guidance 4400-40)

Civilian staff should be encouraged

to receive the recommended im-

munizations.

Offer the HBV vaccination series

to all DHCP with potential oc-

cupational exposure to blood or

Other Potentially Infectious Material.

(OPIM). Follow U.S. Public Health

Service/CDC recommendations for

Hep.B vaccination, serologic test-

ing, follow-up and booster dosing.

Provide employees appropriate

education regarding the risks of HBV

transmission and have employees

who decline the vaccination sign a

declination form.

2. Refer DHCP to a prearranged

qualiﬁ ed healthcare professional or

own health care professional.

Supporting evidence: 1B

Continued …

Infection control in DH - Part 1

2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

D. Exposure Prevention and Post Exposure Management

1. Develop a comprehensive post

exposure management and medical

follow-up program.

a. Include policies and procedures

for prompt reporting, evaluation,

counseling, treatment, and medical

follow-up of occupational exposures.

(1B, 1C).

b. Establish mechanisms for referral

to a qualiﬁ ed health care profes-

sional for medical evaluation and

follow-up. (1B).

c. Conduct a baseline TST, prefer-

ably by using a two-step test, for all

DHCP who might have contact with

persons with suspected or conﬁ rmed

infectious TB, regardless of the risk

classiﬁ cation of the setting.

For prevention use Standard precau-

tions (PPE - gloves, masks, protective

eyewear or face shields and protec-

tive clothing), engineering controls

(e.g. needle guards, self-sheathing

needles, shielded burs, aspirating

anesthetic syringes), work-practice

controls (extreme caution in passing

sharps, remove burs before hand-

piece, not using ﬁ ngers in tissue

retraction or palpation during sutur-

ing and administration of anesthesia,

remove sharps from instrument tray

before cleaning, place disposable

syringes, needles, scalpel blades in

puncture-resistant containers, do not

bend or manipulate needles by hand

or point them towards the OHCP’s

body, re-cap needles as soon as pos-

sible after use, using a one-handed

scoop technique- before removing

the needles from the syringe for

disposal. If the same needle is used

for multiple injections, needle

should be re-caped in between use.

Use extreme caution when passing

contaminated sharps.

Supporting evidence: IPC-02-04

CDC. Public Health Service

guidelines for the management of

occupational exposures to HBV, HCV

and HIV and recommendations for

postexposure prophylaxis, MMWR

2001.

CDC Guidelines for prevention of

transmission of human immuno-

deﬁ ciency virus and Hep.B virus to

health care and public-safety work-

ers: a response to P.L. 100-607. The

Health Omnibus Programs Extension

Act of 1988. MMWR 1989;38(no.

S6).

CDC NIOSH. Selecting, evaluating

and using sharps disposal contain-

ers. Cincinnati, OH: US Department

of Health and Human Services,

Public Health Service, CDC NIOSH,

1998. DHHW publication. NIOSH

97-111.

CDC NIOSH alert: Preventing

needlestick injuries in health care

settings. Cincinnati, OH: US Depart-

ment of Health and Human Services,

Public Health Service, CDC, NIOSH

1999.

Same as CDC document 1a. and 1b.

But not c.

Continued …

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70 2008; 42, no.2: 63-103

Infection control in DH - Part 1

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

Percutaneous injury - assess injury;

administer ﬁ rst-aid; wash the area

with antimicrobial soap and water.

Flush eye, mouth or nose mucosa

with water. Report injury to the Of-

ﬁ ce Infection Prevention and Control

ofﬁ cer, who will document the injury

and contact the appropriate health

care professional for a referral. Docu-

mentation should include exposed

persons medical history, procedure

being performed, extent of the

exposure, and follow-up-care.

Supporting evidence: IPC-02-05

CDC, Updated U.S. Public health

Service guidelines for the manage-

ment of occupational exposures to

HBV, HCV, and HIV and recommen-

dations for post exposure prophy-

laxis. MMWR 2001;50(RR-11).

Guidelines for personnel with ac-

quired disease: a. dermatitis - cover

dermatitis with occlusive bandages,

and wear gloves b. Immuno-com-

promised staff - may be at increased

risk of acquiring or have more severe

consequences from acquiring infec-

tion from clients. These staff may

also be at risk of shedding viruses.

Therefore tailor job descriptions and

potential exposures accordingly.

OSAP Position Paper:

Percutaneous Injury

Prevention

Recommendations:

Communicate the

importance of preven-

tion and management

of PI to all OHP. Train

employees in the safe

handling of instruments

and devices. Review

procedures and consider

devices (as they become

commercially available)

that may reduce the

risk of PI. Seek the input

of non-managerial

members of the clinical

dental team in selecting

appropriate and effec-

tive safety devices for

the practice. Manage

all injuries as indicated

by OSHA regulations

and U.S. Public Health

Service Recommenda-

tions; Comply with all

OSHA requirements for

documentation; convey

the needs of the end us-

ers - the dental team - to

the research, develop-

ment, and manufactur-

ing sectors.

Conclusions: OSAP

encourages all dental

practices to establish a

written, comprehensive

program that includes

strategies to avoid oc-

cupational exposures to

bloodborne pathogens.

OSAP encourages the

use of appropriate,

effective devices that

isolate sharps or provide

a non-sharp alternative.

OSAP discourages inap-

propriate manipulation

of sharps by hand. OSAP

encourages research

into risk assessment of

speciﬁ c instruments and

devices, prioritization of

risk, product evaluation,

and other mechanisms

for OHPs to assess

the safety of devices.

OSAP reminds OHPs

that products have an

intended use and that

manufacturer’s instruc-

tions must be reviewed

and followed. In the

event of product failure,

an immediate report

should be ﬁ led with the

Food and Drug Admin-

istration’s Medwatch

program.

Continued …

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

E. Medical Conditions, Work-Related Illness, and Work Restrictions

1. Develop and have readily avail-

able to all DHCP comprehensive

written policies regarding work re-

striction and exclusion that include a

statement of authority deﬁ ning who

can implement such policies.

Supporting evidence: 1B

Develop work restriction and exclu-

sion policies for DHCP with certain

illnesses or infection.

Guidelines for some commonly

acquired diseases: a. common cold-

practice hand hygiene after contact

with nasal secretions. Avoid seeing

immuno-compromised clients. Wear

a surgical mask and wash hands

frequently. b. inﬂ uenza - refrain from

working. c. herpes simplex virus

infections 1. cold sore - if possible

keep the lesion covered. 2. herpetic

whitlow (herpetic ﬁ nger infection)

- no client contact until the lesion is

resolved. 3. Shingles - a susceptible

client exposed to a health care work-

er with shingles may get chicken-

pox. Cover the lesions and practice

good hand washing techniques.

Don’t work with high-risk clients

(newborns, immuno-compromised

clients) until the lesions are crusted.

d. Enteric infection - excluded from

work. e. Tuberculosis - excluded

from work, until 3 consecutive

sputum specimens have negative

results.

2. Develop policies for work restric-

tion and exclusion that encourage

DHCP to seek appropriate preven-

tive and curative care and report

their illnesses, medical conditions,

or treatments that can render them

more susceptible to opportunistic

infection or exposures; do not

penalize DHCP with loss of wages,

beneﬁ ts, or job status.

Supporting evidence: 1B

Encourage DHCP to seek appropri-

ate preventive and curative care

and report their illnesses or medical

conditions. Follow MTF guidance

and recommendation in the CDC

Guideline for Infection Control in

Healthcare Personnel (www.cdc.

gov/ncidod/dhqp/guidelines.html)

3. Develop policies and procedures

for evaluation, diagnosis, and man-

agement of DHCP with suspected

or known occupational contact

dermatitis.

Supporting evidence: 1B

4. Seek deﬁ nitive diagnosis by a

qualiﬁ ed health care professional

for any DHCP with suspected latex

allergy to carefully determine its

speciﬁ c etiology and appropriate

treatment as well as work restrictions

and accommodations.

Supporting evidence: 1B

F. Records Maintenance, Data Management, and Conﬁ dentiality

1. Establish and maintain conﬁ den-

tial medical records (e.g. immuniza-

tion records and documentation of

tests received as a result of occupa-

tional exposure) for all DHCP.

Supporting evidence: 1B, 1C

2. Ensure that the practice complies

with all applicable federal, state, and

local laws regarding medical record-

keeping and conﬁ dentiality.

Supporting evidence: 1C

II. PREVENTING TRANSMISSION OF BLOODBORNE PATHOGENS

A. HBV Vaccination

Ensure DHCP receive all appropri-

ate immunizations (e.g. varicella,

measles, mumps, rubella, inﬂ uenza)

based on USAF policy, the latest

recommendations from the Advisory

Committee on Immunization Prac-

tices (ACIP) and the HICPAC as well

as their medical history and risk for

occupational exposure.

1. Offer the HBV vaccination series

to all DHCP with potential occupa-

tional exposure to blood or OPIM.

Supporting evidence: 1A, 1C

Same as CDC.

Continued …

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72 2008; 42, no.2: 63-103

Infection control in DH - Part 1

2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

2. Always follow U.S. Public Health

Service/CDC recommendations for

Hep.B vaccination, serologic testing,

follow-up, and booster dosing.

Supporting evidence: 1A, 1C

Same as CDC.

3. Test DHCP for anti-HBs 1-2

months after completion of the

3-dose vaccination series.

Supporting evidence: 1C, 1B

4. DHCP should complete a second

3-dose vaccine series or be evaluated

to determine if they are HBsAg-pos-

itive if no antibody response occurs

to the primary vaccine series.

Supporting evidence: 1A, 1C

5. Retest for anti-HBs at the comple-

tion of the second vaccine series. If

no response to the second 3-dose

series occurs, nonresponders should

be tested for HBsAg.

Supporting evidence: 1C

6. Counsel non responders to vac-

cination who are HBsAg-negative

regarding their susceptibility to HBV

infection and precautions to take.

Supporting evidence: 1A, 1C

7. Provide employees appropriate

education regarding the risks of HBV

transmission and the availability of

the vaccine. Employees who decline

the vaccination should sign a decli-

nation form to be kept on ﬁ le with

the employer.

Supporting evidence: 1C

Same as CDC. Have employees

who decline the Hep.B vaccination

sign a declination form using the

wording found in the appendix A of

the OSHA bloodborne pathogens

standard [1910.1030] to be kept on

ﬁ le with the employer.

B. Preventing Exposures to Blood and OPIM

a. Use standard precautions (OSHA’s

bloodborne pathogen standard re-

tains the term universal precautions)

for all patient encounters.

Supporting evidence: 1A, 1C

Same as CDC.

b. Consider sharp items (e.g.

needles, scalers, burs, lab knives,

and wires) that are contaminated

with patient blood and saliva as

potentially infective and establish

engineering controls and work

practices to prevent injuries.

Supporting evidence: 1B, 1C

Same as CDC.

c. Implement a written, comprehen-

sive program designed to minimize

and manage DHCP exposures to

blood and body ﬂ uids.

Supporting evidence: 1B, 1C

Same as CDC.

C. Engineering and Work-Practice Controls

a. Identify, evaluate, and select

devices with engineered safety

features at least annually and as they

become available on the market

e.g. safer anesthetic syringes, blunt

suture needle, retractable scalpel, or

needleless IV systems.

Supporting evidence: 1C

The Dental Infection Control Ofﬁ cer

(ICO) must be knowledgeable about

available devices, e.g. safety anes-

thetic syringes, be able to discuss

the advantages/disadvantages of

each device the with the Medical

Treatment Facility (MTF)

Controls include the following:

Remove burs immediately after use,

don’t use ﬁ ngers in tissue retraction

during suturing or administration of

anesthesia, and minimize potentially

uncontrolled movements of instru-

ments such as scalers or laboratory

knives.

b. Place used disposable syringes

and needles, scalpel blades, and

other sharp items in appropriate

puncture-resistant containers located

as close as feasible to the area in

which the items are used.

Supporting evidence: 1A, 1C

Same as CDC. Dispose of sharp instruments

by placing them directly into a

designated, puncture proof disposal

container.

c. Do not recap used needles by

using both hands or any other

technique that involves directing the

point of a needle toward any part

of the body. Do not bend, break, or

remove needles before disposal.

Supporting evidence: 1A, 1C

Do not pass syringes with un-

sheathed needles. Same as CDC.

Never re-cap needles, manipulate by

using both hands, or point toward

your body.

Continued …

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

d. Use either a one-handed scoop

technique or a mechanical device

designed for holding the needle

cap when recapping needles (e.g.

between multiple injections and

before removing from a nondispos-

able aspirating syringe).

Supporting evidence: 1A, 1C

Same as CDC. Use the following methods: one

hand scoop, hold the sheath with

a hemostat, use a syringe stand or

use safety syringes. Do not bend or

break used needles. Re-cap needles

on non-disposable aspirating

syringes prior to their removal, for

multiple injections, recap the needle

between injections. Avoid passing a

syringe with an unsheathed needle.

D. Post Exposure Management and Prophylaxis

a. Follow CDC recommendations

after percutaneous, mucous mem-

brane, or nonintact skin exposure to

blood or OPIM. Report all exposures

to blood or OPIM as soon as pos-

sible, because certain interventions

have to be initiated promptly to be

effective. Policy should be consistent

with OSHA and current PHS recom-

mendations.

Supporting evidence: 1A, 1C

Post exposure Prophylaxis (PEP)

- should be consistent with the

current infection prevention and

control guidelines recommended by

the Public Health Agency of Canada

or the U.S. Public Health Service.

Supporting evidence: IPC-02-07

CDC, Updated U.S. Public Health

Service guidelines for the manage-

ment of occupational exposures to

HBV, HCV, and HIV and recommen-

dations for post exposure prophy-

laxis. MMWR 2001;50(RR-11).

PHAC Public Health Agency of Can-

ada: An integrated protocol to man-

age health care workers exposed to

bloodborne pathogens.1997;23S2

Same as CDC.

Promptly report, evaluate and docu-

ment any occupational exposure

incidents to blood or OPIM (includ-

ing saliva, regardless of whether

blood is visible).

A qualiﬁ ed health care professional

should evaluate any occupational

exposure incident to blood or OPIM.

After each exposure, review the cir-

cumstances surrounding the injury

and the postexposure management

plan to ensure the plan’s effective-

ness. Provide education and training

and implement practice changes as

appropriate.

Injured person should immediately

report the incident and seek medi-

cal attention. For HIV prophylaxis

to be effective treatment must

begin within 2 hours of exposure.

Remove contaminated clothing.

Wash affected area with soap and

water. Flush eyes, nose or mouth

with water. OHP should see a

medical provider to discuss risks and

interventions. If the client who is the

known source of the blood exposure

is present, the person should be ap-

proached to provide a blood sample

to be checked for bloodborne

pathogens. The name of the injured

worker should not be entered in the

client’s chart.

OHP who are PSAC employees

should submit a Workers’ Compen-

sation Form.

III. HAND HYGIENE

A. General Considerations

1. Perform hand hygiene with either

a non antimicrobial or antimicrobial

soap and water when hands are

visibly dirty or contaminated with

blood or OPIM. If hands are not

visibly soiled, an alcohol-based hand

rub can also be used. Follow the

manufacturer’s instructions. After

using dry alcohol-based hand rub

ensure hands are dried before glov-

ing as hands still wet with alcohol

based products can increase the risk

of glove perforation.

Supporting evidence: 1A

Hands of OHP that contact clients

should be washed: at beginning

of day, after eating, after using the

washroom, when hands become

contaminated. Wash hands with

anti-microbial soap with persistent

activity (e.g. chlorhexidine, choroxy-

lenol, octenidine, or triclosan), cool

or warm (not hot) water, and single

use towels. Thoroughly dry hands.

Same as CDC. Components of good hand washing

include using an adequate amount

of soap, rubbing the hands together

to create some friction, and rinsing

under running water.

There is mixed evidence regarding

the efﬁ cacy of air hand dryers.

Controlled trials have not docu-

mented decreased infection with

the use of an antiseptic agent over

plain soap for routine hand washing

in the general health care setting. A

few studies suggest that antiseptic

agents may be preferable if there

is a possibility of encountering

antimicrobial-resistant organisms,

such as in intensive care units; in the

presence of known antimicrobial-

resistant organisms; and under con-

ditions of heavy microbial soiling.

See Appendix B for “Characteristics

of Antiseptic Agents”.

Several studies show efﬁ cacy of

waterless hand scrubs compared

to hand washing with soap and

water or with chlorhexidine. Further

studies are needed to determine

efﬁ cacy of waterless hand scrubs in

the presence of large amounts of

organic matter.

Wash hands with antiseptic agent

for the following: a. heavy microbial

soiling, e.g. in the presence of infec-

tion, b. prior to performing invasive

procedures, c. before contact with

immune deﬁ cient clients, d. before

and after direct contact with clients

who have antimicrobial-resistant

organisms.

The absolute indications for, and

the ideal frequency of hand wash-

ing have not been well studied.

See Annex C for hand washing

technique. Avoid potential microbial

contamination by splashing of cloth-

ing, other skin surfaces or inanimate

items during washing.

Continued …

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74 2008; 42, no.2: 63-103

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

2. Indications for hand hygiene

include:

For hand antisepsis use an alcohol

hand-rub, between clients and after

removing gloves. Alcohol hand-rub

must be dry when applying gloves,

as the alcohol can cause glove mate-

rial degradation and loss of glove

integrity.

Same as CDC. Hand washing with waterless/

alcohol-based agents is equivalent to

hand washing with soap and water.

If heavy microbial soiling, hands

must be washed with soap and wa-

ter ﬁ rst. Hands must be dry before

applying alcohol-based agent.

a. When hands are visibly soiled,

after barehanded touching of inani-

mate objects likely to be contami-

nated by blood, saliva, or respiratory

secretions. (1A, 1C).

b. After barehanded touching

of inanimate objects likely to be

contaminated by blood, saliva, or

respiratory secretions. (1A, 1C).

Same as CDC. Hands must be washed: 1. before

and after treating each client (before

glove placement and after glove

removal) and before leaving any

client-care, laboratory or instrument

processing area or after any other

situation or procedure in which

microbial of blood contamination

of hands is likely. 2. when hands are

visibly soiled. 3. before preparing,

handling, serving or eating food,

and 4. after personal body functions,

such as using the toilet or blowing

one’s nose. Plain soap is indicated

for washing hands soiled with dirt,

blood or other organic material. It

will remove most transient organ-

isms.

c. before and after treating each

patient.

Supporting evidence 1B

Same as CDC.

d. before donning gloves.

Supporting evidence: 1B

Same as CDC.

e. immediately after removing

gloves.

Supporting evidence 1B, 1C

Same as CDC.

3. For oral surgical procedures,

perform surgical hand antisepsis

before donning sterile surgeon’s

gloves. Follow the manufacturer’s

instructions by using either an an-

timicrobial soap and water, or soap

and water followed by drying hands

and application of an alcohol-based

surgical hand-scrub product with

persistent activity.

Supporting evidence: 1B

Same as CDC. Surgical Scrub: Follow the protocol

of the institution where the surgical

scrub is required. Generally no rea-

son to perform this in a dental clinic.

4. Store liquid hand-care products in

either disposable closed containers

or closed containers that can be

washed and dried before reﬁ lling.

Do not add soap or lotion to (i.e.,

top off) a partially empty dispenser.

Supporting evidence: 1A

Same as CDC.

B. Special Considerations for Hand Hygiene and Glove Use

1. Soap should not be added to

partially empty dispenser due to

potential bacterial contamination.

Lotions should be dispensed in

small, individual-use containers

or pump dispensers that are not

opened or reﬁ lled to reduce contam-

inants and bacterial growth.

Sinks for hand washing should not

be used for any other purpose. At

least one sink per dental operatory.

To prevent decontaminating hands,

use sink with hand-foot, wrist or

knee operated handles, electric eye,

or make use of single use towels to

turn off faucets. Use non-reﬁ llable

lotion containers to avoid product

contamination. Liquid hand wash

products should be stored in closed

containers and if the container

is reusable, then wash and dry it

thoroughly before reﬁ lling.

Continued …

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

2. Consider the compatibility of

lotion and antiseptic products and

the effect of petroleum or other

oil emollients on the integrity of

gloves during product selection and

glove use.

Supporting evidence: 1B

Consider emollient hand lotions to

prevent hand irritation and derma-

titis. Consult lotion manufacturers

to ensure products to ensure no

negative interaction between lo-

tions, antimicrobial soaps or alcohol

hand-rubs, and other dental materi-

als e.g. chlorhexidine hand hygiene

products should be used with

anionic hand lotions to avoid loss

in persistence of the antimicrobial

action of the solution.

Supporting evidence: IPC-02-08

CDC. Guideline for hand hygiene

in health care settings: recom-

mendations of the HICPAC and

the HICPAAC/SHEA/APIC/IDSA

hand Hygiene Task Force. MMWR

2002/51(RR-16).

Consider the compatibility between

lotion and antiseptic products and

potential for lotion’s effect on glove

integrity.

3. Keep ﬁ ngernails short with

smooth, ﬁ led edges to allow thor-

ough cleaning and prevent glove

tears .

Keep ﬁ ngernails short to thoroughly

clean underneath and prevent glove

tears. Avoid artiﬁ cial nails. Nail polish

without chips is acceptable.

Same as CDC.

4. Do not wear artiﬁ cial ﬁ ngernails

or extenders when having direct

contact with patients at high risk

e.g. those in intensive care units or

operating rooms.

Supporting evidence: 1A

5. Use of artiﬁ cial ﬁ ngernails is usu-

ally not recommended.

Supporting evidence: II

Same as CDC.

6. Do not wear hand or nail jewelry

if it makes donning gloves more

difﬁ cult or compromises the ﬁ t and

integrity of the glove.

Avoid jewelry as it may prevent hand

hygiene, make donning gloves difﬁ -

cult and can cause tearing of gloves.

Alternately, arm and wrist jewelry

and watches should be covered by

the cuffs and long sleeves of protec-

tive clothing.

Same as CDC.

Chipped nail polish can harbour

added bacteria.

Unchipped nail polish on short

natural nails is acceptable.

All cases of hand dermatitis should

be evaluated for treatment and

follow-up. If open sores or weeping

dermatitis exists, refrain from direct

patient contact and handling of

patient-care equipment until the

condition is resolved.

Consider the use of hair covers and

do not allow hair to contact the

client.

IV. PERSONAL PROTECTIVE EQUIPMENT (PPE)

A. Masks, Protective Eyewear, and Face Shields

1. Wear a surgical mask and eye

protection with solid side shields

or a face shield to protect mucous

membranes of the eyes, nose, and

mouth during procedures likely to

generate splashing or spattering of

blood or other body ﬂ uids.

Protective eyewear for patients

shields their eyes from spatter or

debris generated during dental

procedures.

Supporting evidence: 1B, 1C

Wear a mask during procedures

which produce aerosol, or splashes,

sprays, or spatter of blood, saliva

other body ﬂ uids, or water contami-

nated with blood, saliva or other

body ﬂ uids. Ensure mask ﬁ ts tightly

over nose and mouth.

DHCP should wear protective eye-

wear with solid side shields or a face

shield a face shield should be worn

during procedures likely to generate

splashes, sprays or spatter of blood,

saliva, other body ﬂ uids, or water

contaminated with blood, saliva or

other body ﬂ uids may be produced.

Eye protection for patients should

also be used to protect their eyes

from spatter of debris.

Supporting evidence: IPC-03-04

CDC. NIOSH. TB respiratory protec-

tion program in health care facilities:

administrator’s guide. Cincinnati,

OH: US Department of Health and

Human Services, Public Health

Service, CDC, NIOSH 99-143.

CDC Guidelines for preventing the

transmission of Mycobacterium

tuberculosis in health care facilities,

1994. MMWR 1994;43(RR-13).

Wear scrub suits during patient

care and instrument processing.

Supplement scrub suits with PPE

when exposure to blood or OPIM is

reasonably anticipated.

Wear a surgical mask and eye pro-

tection with solid side shields (e.g.

glasses, face shield) to protect mu-

cous membranes of the eyes, nose,

and mouth during procedures likely

to generate splashing or spattering

of blood or other body ﬂ uids.

Eye protection is essential. Employ

eyeglasses, goggles or a face shield

to deﬂ ect the splatter of blood,

saliva and airborne debris. Every day

eyewear is not sufﬁ cient.

Clients in the supine position should

also wear protective eyewear. For

clients, everyday corrective lenses

provide adequate protection.

Remove masks when leaving the

dental operatory or laboratory.

Continued …

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2. Change masks between patients

or during patient treatment if the

mask becomes wet.

Supporting evidence: 1B

Change masks when they become

contaminated or wet (from splash,

spray or spatter), or from the OHP’s

exhaled moist air.

Supporting evidence: IPC-03-04

CDC. NIOSH. TB respiratory protec-

tion program in health care facilities:

administrator’s guide. Cincinnati,

OH: US Department of Health and

Human Services, Public Health

Service, CDC, NIOSH 99-143.

CDC Guidelines for preventing the

transmission of Mycobacterium

tuberculosis in health care facilities,

1994. MMWR 1994;43(RR-13).

Same as CDC. Change masks between patients

and if the mask becomes saturated

with moisture. Wash hands after re-

positioning a mask, unless a gloved

hand contacted only the mask.

Remove a mask by holding onto the

ties and the side of the mask.

3. Clean with soap and water, or

if visibly soiled, clean and disinfect

reusable facial protective equipment

(e.g. clinician and patient protective

eyewear or face shields) between

patients.

Supporting evidence: II

Properly dispose of single use masks.

Supporting evidence: IPC-03-04

CDC. NIOSH. TB respiratory

protection program in health care

facilities: administrator’s guide.

Cincinnati, OH: US Department

of Health and Human Services,

Public Health Service, CDC, national

Institute for Occupational Safety and

Health, 1999. DHHS publication no.

(NIOSH) 99-143.

CDC Guidelines for preventing the

transmission of Mycobacterium

tuberculosis in health care facilities,

1994. MMWR 1994;43(RR-13).

Same as CDC.

Surgical masks should be NIOSH

certiﬁ ed (e.g. N95 respirators).

The surgical mask should have more

than 95% ﬁ ltration efﬁ ciency for

particles 3-5 microns.

Supporting evidence: IPC-03-04

CDC. NIOSH. TB respiratory protec-

tion program in health care facilities:

administrator’s guide. Cincinnati,

OH: US Department of Health and

Human Services, Public Health

Service, CDC, NIOSH, 1999. DHHS

publication no. (NIOSH) 99-143.

CDC Guidelines for preventing the

transmission of Mycobacterium

tuberculosis in health care facilities,

1994. MMWR 1994;43(RR-13).

When respirators are used in treating

patients with diseases requiring

airborne transmission precautions

(e.g. TB) they should be used in

the context of a complete respira-

tory protection program (e.g. test

ﬁ tting).

When respiratory infection isolation

precautions are necessary (e.g.. Cli-

ents with active tuberculosis) wear a

particulate-ﬁ lter respirator or mask

(e.g. N95, N99 or N100). The use of

these masks should be accompanied

by training and ﬁ t-testing of the

respirator or mask.

Supporting evidence: IPC-03-04

CDC. NIOSH. TB respiratory protec-

tion program in health care facilities:

administrator’s guide. Cincinnati,

OH: US Department of Health and

Human Services, Public Health

Service, CDC, NIOSH 99-143.

CDC Guidelines for preventing the

transmission of Mycobacterium

tuberculosis in health care facilities,

1994. MMWR 1994;43(RR-13).

Masks should have small particle

ﬁ ltration efﬁ ciency ≥95% ﬁ ltration of

3.0 to 3.5 micron particles). Public

health authorities may mandate the

use of N-95 masks, which must be

ﬁ t tested and ﬁ t checked each time

the mask is put on.

An eye-wash station should be avail-

able and staff training on location,

function and indications for use.

Supporting evidence: IPC-03-04

CDC. NIOSH. TB respiratory protec-

tion program in health care facilities:

administrator’s guide. Cincinnati,

OH: US Department of Health and

Human Services, Public Health

Service, CDC, NIOSH 99-143.

CDC Guidelines for preventing the

transmission of Mycobacterium

tuberculosis in health care facilities,

1994. MMWR 1994;43(RR-13).

Continued …

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B. Protective Clothing

Use dental rubber dams and high

volume/high velocity suction when-

ever the creation of droplets, spatter,

spray and aerosol occurs.

Supporting evidence: IPC-03-01

CDC Guidelines for Infection Control

In Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Employ a rubber dam whenever

possible to reduce exposure of the

dental personnel to microorganisms.

Protective clothing and equipment

should be worn e.g. reusable or

disposable gown, laboratory coat,

or uniform that covers personal

clothing and skin (e.g. forearms)

likely to be soiled with blood, saliva,

or OPIM.

Supporting evidence: 1B,1C

Re-usable PPE designed for re-use

can be washed with soap and water.

Infected PPE’s can be disinfected ac-

cording to the manufacturer’s direc-

tions. Disposable PPE items should

be discarded following use.

Supporting evidence: IPC-03-01

CDC Guidelines for Infection Control

In Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Wear protective clothing (e.g.

long-sleeved reusable or disposable

gown, clinic jacket) that covers

clothing and skin (e.g. forearms)

likely to be soiled with blood, saliva

or OPIM. PPE does not have to be

ﬂ uid impervious or ﬂ uid resistant

to meet OSHA standards, but must

prevent contamination of clothing

or skin.

Procedures likely to result in spatter-

ing of blood or OPIM that require

the use of long-sleeved protective

clothing include but are not limited

to, the following: the use of high-or

low-speed handpieces or sonic or

ultrasonic scalers; manipulation

with sharp cutting instruments

during periodontal and prophylaxis

treatments; spraying water and air

into a patient’s mouth; oral surgical

procedures; and manual instrument

cleaning.

2. Change protective clothing if

visibly soiled; change immediately or

as soon as feasible if penetrated by

blood or other potentially infectious

ﬂ uids. OSHA bloodborne pathogens

standards require sleeves to be long

enough to protect forearms.

Supporting evidence: 1B, 1C

Protective clothing including gowns

and lab-coasts are meant to be worn

over uniforms, scrubs or street cloth-

ing. If short sleeve protective cloth-

ing is used, hand hygiene protocols

should extend up the arms, past the

wrists. Change protective clothing

at least daily, or if it becomes visibly

soiled or signiﬁ cantly contaminated,

as soon as feasible if penetrated by

blood or potentially infectious ﬂ uids.

Supporting evidence: IPC-03-06

Same as CDC. All OHP must wear a reusable or dis-

posable uniform, which must remain

in the clinic, where access to sepa-

rate, external laundering facilities are

available. Do not launder with family

wash. For personnel with breaks

in the skin integrity, long sleeves

gowns should be provided and the

gloves should cover the cuffs.

3. Remove barrier protection, includ-

ing gloves, mask, eyewear, and

gown before departing work area,

e.g. dental patient care, instrument

processing, or laboratory areas.

Supporting evidence: 1C

Remove PPE prior to leaving the

client care area.

Supporting evidence: IPC-03-06

Same as CDC.

C. Gloves

Wear medical gloves when a poten-

tial exists for contacting blood, sa-

liva, OPIM, or mucous membranes.

2. Wear a new pair of medical gloves

for each patient, remove them

promptly after use, and wash hands

immediately to avoid transfer of

microorganisms to other patients or

environments.

Supporting evidence: 1B

Gloves should be discarded after

each client, or if the gloves are torn

or punctured. Perform appropriate

hand hygiene before applying and

after removing gloves.

Supporting evidence: IPC-03-02

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC. Wear gloves to treat all patients

when hand contact with blood,

saliva, mucous membranes or blood-

contaminated objects or surfaces is

anticipated. Discard gloves between

patients.

Gloves are not a substitute for hand

washing.

3. Remove gloves that are torn, cut,

or punctured as soon as feasible and

wash hands before regloving.

Supporting evidence: 1B, 1C

Monitor integrity of gloves and

replace as soon as possible if there

is a manufacturing defect, puncture

or tear.

Supporting evidence: ICP-03-02

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

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4. Do not wash surgeon or patient’s

examination gloves before use or

wash, disinfect, or sterilize gloves

for reuse.

Supporting evidence: 1B, 1C

Patient-examining gloves and sterile

surgical gloves are for one client

only and are discarded after use.

Gloves should not be washed, as

soaps, and alcohols can compromise

the surface of latex and synthetic

materials, leading to loss of integrity.

Micro-porosities in glove material

can lead to wicking of water, blood

or saliva to the hand surface.

Supporting evidence: IPC-03-02

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

5. Ensure that appropriate gloves

in the correct size are readily ac-

cessible.

Supporting evidence: 1C

Same as CDC.

6. Use appropriate gloves (e.g.

puncture- and chemical-resistant

utility gloves) when cleaning instru-

ments and performing housekeep-

ing tasks involving contact with

blood or OPIM.

Supporting evidence: 1B, 1C

Glove selection is dependent upon

the task performed. Patient examin-

ing gloves are used for routine client

care. Sterile surgical gloves are used

with an open surgical wound. Utility

gloves are used for cleaning and

disinfection procedures and should

be puncture and chemical resistant.

They should be disinfected or steril-

ized at the end of the day.

Supporting evidence: IPC-03-02

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC. Use heavy-duty utility gloves, for

clean up and disinfection; wash

them in disinfectant soap and reuse.

7. Consult with glove manufacturers

regarding the chemical compat-

ibility of glove material and dental

materials used.

Supporting evidence: II

Do not expose gloves to heat sourc-

es, such as x-ray unit controllers,

lasers, fans, electrical generators,

suction machines or motors.

Supporting evidence: IPC-03-02

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

Health Canada recommends pur-

chasing gloves with the Canadian

General Standards Board (CGSB)

certiﬁ cation mark.

There is no evidence based docu-

mentation of a latex/non-latex glove

type offering better protection than

another.

D. Sterile Surgeon’s Gloves and Double Gloving During Oral Surgical Procedures

Wear sterile surgeon’s gloves when

performing oral surgical procedures.

2. No recommendation is offered

regarding the effectiveness of wear-

ing two pairs of gloves to prevent

disease transmission during oral

surgical procedures. The majority of

studies among HCP and DHCP have

demonstrated a lower frequency of

inner glove perforation and visible

blood on the surgeon’s hands when

double gloves are worn; however,

the effectiveness of wearing two

pairs of gloves in preventing disease

transmission has not been demon-

strated.

Supporting evidence: Unresolved

issue

Double-gloving may be used for

procedures involving the handling

of multiple sharp metal instru-

ments or during longer procedures.

Double gloving should be procedure

speciﬁ c, not client speciﬁ c. It may

affect manual dexterity and tactile

sensitivity.

Supporting evidence: IPC-03-02

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

Continued …

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

V. CONTACT DERMITITIS AND LATEX HYPER-SENSITIVITY

A. General Recommendations

1. Educate DHCP regarding the

signs, symptoms, and diagnoses of

skin reactions associated with fre-

quent hand hygiene and glove use.

When powdered gloves are worn

more latex protein reaches the skin

and powder particles become aero-

solyzed and can be inhaled.

Supporting evidence: 1B

Same as CDC.

Develop policies and procedures for

evaluation, diagnosis, and manage-

ment of DHCP with suspected or

known latex allergy or occupational

contact dermatitis. Seek deﬁ nitive

diagnosis by a qualiﬁ ed health care

professional for any DHCP with

suspected latex allergy to carefully

determine its speciﬁ c etiology and

appropriate treatment as well as

work restrictions and accommoda-

tions.

Latex products are being removed

on a gradual basis from the clinical

environment. Powder-free latex

gloves are strongly encouraged

due to the dermatitis caused by the

powder.

OHP who have demonstrated

an allergy or sensitivity to latex

shall be provided with a latex-free

alternative.

OHP shall utilize latex-free gloves

when treating clients with a history

of latex sensitivity.

It is imperative that sensitivities to

latex products be investigated an

accurate diagnosis made.

A supply of latex free dams shall be

maintained for clients with sensitiv-

ity to latex.

2. Screen all patients for latex allergy

(e.g. take health history and refer

for medical consultation when latex

allergy is suspected).

Supporting evidence: 1B

Medical histories for clients and OHP

should include questions relating to

possible latex allergy, predisposing

conditions for latex allergy, including

previous history of allergies, a history

of early latex exposure or related

allergies to certain fruits and nuts.

Supporting evidence: IPC-03-03

CDC. NIOSH Alert: preventing aller-

gic reactions to natural rubber latex

in the workplace. Cincinnati, OH: US

Department of health and Human

Services, Public Health Service, CDC,

NIOSH 1997.

If using latex gloves, use reduced

protein, powder-free gloves to

reduce exposure to latex allergens.

Clients at risk of anaphylactic shock

due to a documented latex allergy

shall be referred to a civilian latex-

free practice. If treated in a DCFDS

facility: 1. they should be the ﬁ rst

client of the day. 2. use no latex in

the facility until they have left.

3. Ensure a latex-safe environment

for patients and DHCP with latex al-

lergy. Dental patients with a history

of latex allergy can be at risk from

dental products e.g. prophylaxis

cups, rubber dams, ortho elastics

and medication vials.

Clients with latex allergy (type 1

immunologic reactions which are

IgE antibody mediated and result

in respiratory and anaphylactic

reactions) should be treated in an

environment where contact with

latex proteins, either directly or

airborne, is kept as low as reason-

ably achievable (ALARA). Remove

or cover latex-containing materials

or devices from the treatment area.

The following precautions should

also be taken: the operatory and the

sterilization of instruments should be

done by an OHP wearing only non-

latex gloves. Instruments should not

come in contact with any other in-

struments that may have contacted

latex. Schedule appointments at

the beginning of the day to reduce

exposure to airborne allergens.

Supporting evidence: IPC-03-03

CDC NIOSH Alert: preventing aller-

gic reactions to natural rubber latex

in the workplace. Cincinnati, OH: US

Department of health and Human

Services, Public health Service, CDC,

NIOSH 1997.

Same as CDC. 3. “No latex” includes latex in

the following items: gloves, masks

with latex straps, local anesthetic

carpules, prophy cups.

4. Have emergency treatment kits

with latex-free products available at

all times.

Supporting evidence: II

Keep latex-free emergency treat-

ment kits available.

Supporting evidence: IPC-03-03

CDC. NIOSH Alert: preventing aller-

gic reactions to natural rubber latex

in the workplace. Cincinnati, OH: US

Department of health and Human

Services, Public health Service, CDC,

NIOSH, 1997.

Same as CDC.

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VI. STERILIZATION AND DISINFECTION OF PATIENT CARE ITEMS

A. General Recommendations

1. Use only FDA-cleared medical

devices for sterilization and follow

the manufacturer’s instructions for

correct use.

Supporting evidence: 1B

The following methods of heat

sterilization are acceptable:

steam autoclave (either gravity

displacement or prevacuum type);

unsaturated chemical vapor sterilizer

(chemiclave); or dry heat sterilizers

(either static or forced air). Assure

that scheduled maintenance and

calibration are performed on all

decontamination and sterilization

equipment according to manufac-

turer recommendations and MTF

guidance.

2. Clean and heat-sterilize critical

dental instruments before each use.

Supporting evidence: 1A

Critical care items are used to

penetrate soft tissue or bone, and

should be heat sterilized.

Supporting evidence: IPC-04-01

Same as CDC. Clean instruments prior to disinfec-

tion or sterilization to remove blood,

saliva, tissue, and adherent dental

materials, which act as barriers

to disinfection/sterilization. Clean

using manual scrubbing, ultrasonic

cleaning, or by using an instrument

washer.

3. Clean and heat-sterilize semi criti-

cal items before each use.

Supporting evidence: 1B

Semi critical care items only touch

mucous membranes or non-intact

skin. They should be heat sterilized,

or if health-sensitive disinfected with

high-level disinfection.

Supporting evidence: IPC-04-01

Same as CDC.

4. Allow packages to dry in the

sterilizer before they are handled to

avoid contamination.

Supporting evidence: 1B

5. Use of heat-stable semi critical

alternatives is encouraged.

Supporting evidence: 1B

6. Reprocess heat-sensitive critical

and semi critical instruments by

using FDA-cleared sterilant/high-

level disinfectants or an FDA-cleared

low-temperature sterilization

method (e.g. ethylene oxide). Fol-

low manufacturer’s instructions for

use of chemical sterilants/high-level

disinfectants.

Supporting evidence: 1B

Low-temperature sterilization using

ethylene oxide gas (ETO) may be

used in larger health care facilities,

such as hospitals, but the hazardous

vapours produced, make it impracti-

cal for private practice settings.

Same as CDC.

Using heat sensitive, semi critical

items that must be processed

with liquid chemical germicides is

discouraged.

Do not install ethylene oxide steril-

ization equipment in dental clinics.

7. Single-use disposable instruments

are acceptable alternatives if they

are used only once and disposed of

correctly.

Supporting evidence: 1B, 1C

Single-use devices are for one

patient only, and must be disposed

of appropriately.

Do not use intermediate or low-level

disinfectants intended for use on

environmental surfaces to clean and

disinfect dental instruments.

8. Do not use liquid chemical

sterilants/high-level disinfectants for

environmental surface disinfection

or as holding solutions.

Supporting evidence: 1B, 1C

Same as CDC. There are 4 classes of chemical

disinfectants: chlorides, iodine,

combination synthetic phenolics and

glutaraldehydes. All of these disin-

fectants, except the glutaraldehydes,

are acceptable for both surface and

immersion disinfection. In some

provinces (e.g. British Columbia)

there are limits on workers’ exposure

to glutaraldehyde fumes. B.C.

requires the use of fume hoods and

extraction fans in health care set-

tings using glutaraldehyde.

Do not use alcohol, the quaternary

ammonium compounds and simple

or single phenols.

9. Ensure that non critical patient-

care items are barrier-protected or

cleaned, or if visibly soiled, cleaned

and disinfected after each use with

an EPA-registered hospital disinfec-

tant. If visibly contaminated with

blood, use an EPA-registered hospital

disinfectant with a tuberculocidal

claim (i.e. intermediate level).

Supporting evidence: 1B

Non critical care items contact only

intact skin. These items can be

barrier protected or cleaned and if

contaminated by blood, saliva or

other body ﬂ uid, cleaning followed

by disinfection.

Supporting evidence: IPC-04-01

Same as CDC.

Continued …

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10. Inform DHCP of all OSHA

guidelines for exposure to chemical

agents used for disinfection and ster-

ilization. Using this report, identify

areas and tasks that have potential

for exposure.

Supporting evidence: 1C

Same as CDC.

Clean, lubricate, and heat-sterilize

all dental handpieces, including

prophy angles and motors between

patients.

B. Instrument Processing Area

2. Train DHCP to employ work prac-

tices that prevent contamination of

clean areas.

Supporting evidence: II

Same as CDC.

C. Receiving, Cleaning, and Decontamination Work Area

Process instruments in a designated

central processing area. If manual

cleaning is not performed im-

mediately, place instruments in a

puncture resistant container and

soak with detergent, disinfectant/

detergent or enzymatic cleaner.

Central processing areas should have

clear sections for receiving, cleaning

and decontamination; preparation

and packaging; sterilization; storage

of processed instruments (or storage

in the operatory). Decontamination

and cleaning should precede all dis-

infection and sterilization processes.

Supporting evidence: IPC-04-02

Designate a central processing area.

Divide the area physically, or at a

minimum spatially, into distinct

areas for receiving, cleaning, and

decontamination; preparation

and packaging; sterilization; and

storage. Do not store sterile or

clean instruments in an area where

contaminated instruments are held

or cleaned.

Clean all visible blood and other

contamination from instruments

and devices before sterilization or

disinfection. The use of holding

solutions are optional, but should be

considered to prevent hardening of

bioburden.

Sorting and Soaking: If instruments

and small items cannot be cleaned

immediately, submerge in water

and/or detergent. Heavy non im-

mersible items should be wrapped in

or covered with a wet towel.

2. Use automated cleaning equip-

ment (e.g. ultrasonic cleaner or

washer-disinfector) to remove debris

to improve cleaning effectiveness

and decrease worker exposure to

blood.

Supporting evidence: 1B

An automated process for cleaning

instruments (e.g. ultrasonic cleaner

or washer-disinfector) is preferable

to hand scrubbing to reduce risk of

injury. Rinse instruments after clean-

ing to remove chemical or detergent

residue. If cleaning is not done

immediately, use a holding solution.

Holding solutions with ﬁ xative and

toxic natures should not be used

(e.g. glutaraldehyde and high level

disinfectants).

Supporting evidence: IPC-04-02

Same as CDC. The cleaning detergent must be

compatible with the disinfection

process. An enzymatic solution may

be used. Combination low-level

disinfectant-detergent products

(germicidal detergents) can be used

to clean items that do not require

further disinfection or sterilization

(e.g. intravenous IV poles, articula-

tors).

Rinse and dry after cleaning.

Dental handpieces must be cleaned

by hand or with speciﬁ c devices

designed for handpiece cleaning.

Ultrasonic cleaning is usually more

effective than manual scrubbing

and decreases the likelihood of

PI to staff. Instruments should be

suspended in the ultra sonic cleaner

and not placed on the bottom of the

chamber ﬂ oor. Follow instructions

for the ultrasonic cleaner, including

the appropriate detergents and test

the cleaner once a month according

to instructions.

Instrument washers automatically

wash, clean, rinse and dry instru-

ments and they may also sanitize,

disinfect and sterilize. They minimize

handling and reduce the possibility

of PI.

Manual scrubbing is generally

less effective than other cleaning

methods and it jeopardizes worker

safety. It should be reserved for

items that remain visibly soiled after

automated cleaning. Thorough

rinsing is necessary. Drying prevents

microbial growth.

Inspect items for traces of organic

soil, oil, grease and other matter

prior to sterilization.

3. Use work-practice controls that

minimize contact with sharp instru-

ments if manual cleaning is neces-

sary (e.g. long-handled brush).

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4. Wear puncture- and chemical-

resistant/heavy-duty utility gloves for

instrument cleaning and decontami-

nation procedures.

The following workplace controls

should be used for instrument/de-

vice decontamination and operatory

clean-up:

- Wear puncture-resistant gloves.

- Transport used instruments in a

rigid or puncture-resistant container.

- Use a long-handled brush for

manual cleaning.

- Use strainer -type basket to hold

instruments and forceps to remove

instruments from containers.

- Wear PPE during instrument

decontamination.

Supporting evidence: IPC 04-02

Same as CDC. Heavy rubber gloves should be worn

and scrub instruments below the

water surface to prevent aerosoliza-

tion and splashing.

5. Wear appropriate PPE (e.g. mask,

protective eyewear, and gown)

when splashing or spraying is antici-

pated during cleaning.

Supporting evidence: 1C

Same as CDC. Instrument cleaning and steriliza-

tion/disinfection staff must be

properly trained, wear personal

protective equipment, appropriate

to the task, in order to protect them-

selves from exposure to pathogens

and chemical. These employees

should be immunized.

Minimize handling of loose contami-

nated instruments during transport

to the instrument processing area.

Table-top ultrasonic cleaning

equipment should be periodically

tested according to manufacturer’s

instructions.

D. Preparation and Packaging

All instruments that can withstand

high heat should be heat sterilized.

Glass bead sterilizers and microwave

ovens are not acceptable for

sterilization.

2. Use a container system or wrap-

ping compatible with the type of

sterilization process used and that

has received FDA clearance.

Supporting evidence: 1B

For semi critical and critical instru-

ments, inspect for cleanliness, wrap

and place in containers designed

to maintain sterility during storage.

Immerse hinged instruments in a

rust inhibitor and process opened

and unlocked. Place a chemical in-

dicator on the outside of instrument

package. Use packaging materials

speciﬁ cally designed for the type of

sterilization process used.

Supporting evidence: IPC-04-02

Use an FDA-cleared container system

or wrapping compatible with the

type of sterilization process used.

Items to be sterilized should be ar-

ranged to permit free circulation of

the sterilizing agent. Hinged instru-

ments should be left open.

Arrange packs loosely in the

sterilization chamber. Open or disas-

semble hinged or other complex

instruments to permit exposure to

sterilizing agents.

3. Before sterilization of critical

and semi critical care instruments,

inspect instruments for cleanliness,

then wrap or place them in contain-

ers designed to maintain sterility

during storage (e.g. cassettes and

organizing trays).

Supporting evidence: 1A

Same as CDC.

Processing Critical Care Items

Critical care items should be heat

sterilized.

Critical care items should be steril-

ized by heat.

Supporting evidence: IPC-04-02

Continued …

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2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

Processing Semi Critical Care Items

Semi critical care items should be

heat sterilized. If the semi critical

care item is heat sensitive it should

at a minimum be processed with

high-level disinfection.

Processing semi critical care items

using heat. Items that cannot be

sterilized should receive high-level

disinfection (which does not neces-

sarily destroy high levels of bacterial

spores) by liquid immersion and

then rinsing with sterile water. Due

to toxicity of disinfection liquids use

closed containers and chemically

resistant gloves and aprons, goggles

and face shields.

Supporting evidence: IPC-04-03

CDC. Epidemiologic notes and

reports: symptoms of irritation

associated with exposure to

glutaraldehyde-colourado. MMWR

1987;36:190-1.

CDC Guidelines for environmental

infection control in health care

facilities: recommendations of

CDC and the HICPAC. MMWR

2003;52(RR-10).

Processing Non-Critical Care Items

Non-critical care items should

be cleaned, or, if contaminated,

cleaned and then disinfected with

a hospital-grade tuberculocidal

intermediate-level disinfectant. If

cleaning and disinfection damages

the surfaces, use disposable barriers.

Supporting evidence: IPC-04-05.

CDC Guidelines for Environmental

Infection Control in health care

Facilities: Recommendations of

CDC and the HICPAC. MMWR

2003;52(RR-10).

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

E. Sterilization of Unwrapped Instruments

1. Clean and dry instruments before

the unwrapped sterilization cycle.

Supporting evidence: 1B

Same as CDC.

2. Use mechanical and chemical

indicators for each unwrapped

sterilization cycle (i.e., place an

internal chemical indicator among

the instruments or items to be

sterilized).

Supporting evidence: 1B

Same as CDC.

3. Allow unwrapped instruments to

dry and cool in the sterilizer before

they are handled to avoid contami-

nation and thermal injury.

Supporting evidence: II

Same as CDC.

4. Semi critical instruments that

will be used immediately or within

a short time can be sterilized un-

wrapped on a tray or in a container

system, provided that the instru-

ments are handled aseptically during

removal from the sterilizer and trans-

port to the point of use.

Supporting evidence: II

Same as CDC.

5. Critical instruments intended for

immediate reuse can be sterilized

unwrapped if the instruments are

maintained sterile during removal

from the sterilizer and transport to

the point of use (e.g. transported in

a sterile covered container).

Supporting evidence: 1B

Same as CDC.

6. Do not sterilize implantable

devices unwrapped.

Supporting evidence: 1B

Same as CDC.

7. Do not store critical instruments

unwrapped.

Supporting evidence: 1B

Continued …

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

Allow instruments to dry and cool

before handling.

Flash Sterilization Cycles: Do not use

ﬂ ash sterilization for convenience,

as an alternative to purchasing ad-

ditional instrument sets, or to save

time. Clean and dry instruments

before the ﬂ ash sterilization cycle.

Do not package or wrap instruments

used during ﬂ ash sterilization unless

the sterilizer is speciﬁ cally designed

and labelled for this use. Use

mechanical, chemical and biological

indicators. Allow instruments to dry

and cool before they are handled.

Critical instruments intended for

immediate reuse can undergo ﬂ ash

sterilization if the instruments are

maintained sterile during removal

from the sterilizer and transport to

the point of use in a sterile covered

container. Semi critical instruments

that will be used immediately or

within a short time can undergo

ﬂ ash sterilization on a tray or in a

container system, provided that the

instruments are handled aseptically

during removal from the sterilizer

and transported to the point of use.

Do not ﬂ ash-sterilize implantable

devices.

F. Sterilization Monitoring

1. Use mechanical, chemical, and

biological monitors according to the

manufacturer’s instructions to ensure

the effectiveness of the sterilization

process.

Supporting evidence: 1B

Monitor sterilization procedures

and equipment using mechanical,

chemical and biological indicators.

Reprocesses if any of these methods

fails.

Supporting evidence: IPC-04-04

Same as CDC. Follow manufacturer’s instructions.

Any malfunction should be noted

and action taken for reprocessing.

Clinic should have a protocol to fol-

low if monitoring shows equipment

failure.

Monitor equipment’s ability to

achieve sterilization, through

mechanical, chemical and biological

indicators.

Do not use “liquid chemical steri-

lants” to sterilize critical and semi

critical care instruments.

Bead sterilizers may be used when

the instruments is being used mid-

procedure on the same individual.

Label package with: sterilizer identiﬁ -

cation number; load number; opera-

tor’s initials, and indeﬁ nite shelf-life

label. The use of self-adhesive labels

or tapes is preferred. Labelling

markers should be indelible, non

bleeding and non toxic.

2. Monitor each load with mechani-

cal (e.g. time, temperature, and

pressure) and chemical indicators.

Chemical indicators do not guaran-

tee that sterilization has taken place,

they allow determination of certain

equipment malfunctions. Biological

indicators are the accepted method

for monitoring sterilization. Me-

chanical indicators do not ensure

sterilization, but indicate a problem

with the sterilization cycle.

Supporting evidence: II

Mechanical monitoring includes

observing cycle time, temperature,

and pressure by observing the

gauges. Correct readings don’t en-

sure sterilization, however, incorrect

readings may indicate a problem

with equipment.

Supporting evidence: IPC-04-04

Monitor with chemical, mechanical

and biological indicators.

Chemical indicators including time/

temp/ and/or humidity sensitive

tape, strips or pellets should be used

on every package. Indicators should

also be used inside each large pack-

age wrapped in cloth. Chemical

indicators do not guarantee that

sterilization has taken place.

Mechanical indicators, such as

thermometers, time indicators

and pressure monitors must be

monitored for every load. They do

not guarantee that sterilization has

taken place.

Biological indicators (spore tests)

are the only accurate tests that

monitor the actual effectiveness of

the sterilization process and conﬁ rm

that sterilization has taken place.

All sterilizers must be monitored

with a spore test at least monthly.

Critical care items should be placed

in a sterilizer that is tested weekly.

If the spore test is positive, the

equipment should be checked and if

the repeated test is positive and the

device should be serviced. Maintain

records for a period of two years in-

cluding sterilizer serial number, date

of testing, test results, temperature

conditions and the operator.

Continued …

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2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

3. Place a chemical indicator on

the inside of each package. If the

internal indicator is not visible from

the outside, also place an exterior

chemical indicator on the package.

Chemical indicators (tape or special

markings) do not prove steriliza-

tion has been achieved, they detect

certain equipment malfunctions and

help identify procedural errors.

Supporting evidence: IPC-04-04

Use an internal chemical indicator

in each package. If the indicator

cannot be seen from the outside of

the package, also use an external

indicator.

4. Place items/packages correctly

and loosely into the sterilizer so as

not to impede penetration of the

sterilant.

Supporting evidence: 1B

Biological indicators (BI), i.e. spore

tests, verify the sterilization process

directly. Periodically use BI, at least

weekly.

Supporting evidence: IPC-04-04

5. Do not use instrument packs if

mechanical or chemical indicators

indicate inadequate processing.

Supporting evidence: 1B

Same as CDC.

6. Monitor sterilizers at least weekly

by using a biological indicator with

a matching control (i.e., biological

indicator and control from same lot

number).

Supporting evidence: 1B

A control BI, from the same lot as

the test indicator and not processed

through the sterilizer, should b in-

cubated with the test BI; the control

BI should yield positive results for

bacterial growth.

Supporting evidence: IPC-04-04

Same as CDC.

7. Use a biological indicator for

every sterilizer load that contains

an implantable device. Verify results

before using the implantable device,

whenever possible.

Supporting evidence: 1B

Perform air removal testing on pre-

vacuum steam autoclaves according

to manufacturer’s instructions.

8. The following are recommended

in the case of a positive spore test:

In the event of a positive spore test:

Supporting evidence: IPC-04-04

Recommendations for a positive

spore test:

a) Repeat the BI test immediately

after correctly loading the sterilizer

and using the same cycle that pro-

duced the failure.

Supporting evidence: IPC-04-04

Items other than implantable

devices do not necessarily need to

be recalled.

a. Remove the sterilizer from service

and review sterilization procedures

(e.g. work practices and use of

mechanical and chemical indicators)

to determine whether operator error

could be responsible.

Supporting evidence: II

b) Remove the sterilizer from service,

and all records reviewed of chemical

and mechanical monitoring since

the last negative BI test.

Supporting evidence: IPC-04-04

Same as CDC.

b. Retest the sterilizer by using

biological, mechanical, and chemical

indicators after correcting any iden-

tiﬁ ed procedural problems.

Supporting evidence: II

c) Common reasons for a positive BI

in the absence of mechanical failure

include:

overloading, failure to provide ad-

equate package separation, incorrect

or excessive packaging material.

Supporting evidence: IPC-04-04

Same as CDC.

c. If the repeat spore test is negative,

and mechanical and chemical indi-

cators are within normal limits, put

the sterilizer back in service.

Supporting evidence: II

d) Put sterilizer back into service

if the BI test is negative and the

chemical and mechanical monitor-

ing indicates adequate processing.

Same as CDC.

e) Retain results of biological

monitoring.

9. The following are recommended

if the repeat spore test is positive:

Recommendations if the repeat

spore test is positive:

a. Do not use the sterilizer until it

has been inspected or repaired or

the exact reason for the positive test

has been determined.

Supporting evidence: II

Same as CDC.

b. Recall, to the extent possible, and

reprocess all items processed since

the last negative spore test.

Supporting evidence: II

Same as CDC.

c. Before placing the sterilizer back

in service, rechallenge the sterilizer

with biological indicator tests in

three consecutive empty chamber

sterilization cycles after the cause

of the sterilizer failure has been

determined and corrected.

Supporting evidence: II

Same as CDC.

Continued …

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

10. Maintain sterilization records

(i.e. mechanical, chemical, and

biological) in compliance with state

and local regulations.

Supporting evidence: 1B

Maintain sterilization records for a

period dictated by local statutes and

MTF policy or two years, whichever

is longer. Minimum documentation

includes: date and time of test; b.

sterilizer ID #; sterilizer conditions -

temperature and exposure period, if

available; individual conducting the

test; results of the test and control

and nature and date of any malfunc-

tions or repairs.

G. Storage Area for Sterilized Items and Clean Dental Supplies

1. Implement practices on the basis

of date- or event-related shelf-life for

storage of wrapped, sterilized instru-

ments and devices.

Supporting evidence: 1B

Same as CDC.

2. Even for event-related packaging,

at a minimum, place the date of

sterilization, and if multiple sterilizers

are used in the facility, the sterilizer

used, on the outside of the packag-

ing material to facilitate the retrieval

of processed items in the event of a

sterilization failure.

Supporting evidence: 1B

Label packages as discussed in the

Preparation and Packaging section.

3. Examine wrapped packages of

sterilized instruments before open-

ing them to ensure the barrier wrap

has not been compromised during

storage.

Supporting evidence: II

Same as CDC.

4. Reclean, repack, and resterilize

any instrument package that has

been compromised.

Supporting evidence: II

Same as CDC.

5. Store sterile items and dental sup-

plies in covered or closed cabinets,

if possible. Do not store under sinks

or other locations where they might

become wet.

Supporting evidence: II

Store sterile items and dental sup-

plies in clean, dry, and dust/lint-free

areas with limited access. Covered or

closed cabinets are recommended. If

sterile items are stored in a patient-

care area, they must be in covered

or closed cabinets.

Do not store sterile supplies or

patient-care items under the sink

(or any location where they may be-

come wet), on the ﬂ oor, windowsill,

or any area other than designated

shelving or cabinets.

Do not store sterile items with items

not intended for clinical use.

As a general rule, keep like items

together.

To allow for adequate air circulation,

cleaning and compliance with local

ﬁ re codes, follow MTF guidelines. In

the absence of such guidance store

clean and sterile materials at least

8 to 10 inches above the ﬂ oor,

18 inches below the ceiling, and

2 inches from the outside walls.

Maintain stock rotation according to

the “ﬁ rst in, ﬁ rst out” principle.

Only handle packages when abso-

lutely necessary. Do not use ship-

ping cartons to dispense sterile or

clean patient treatment items. Sterile

supplies should be trans ported in a

covered or enclosed cart.

VII. ENVIRONMENTAL INFECTION CONTROL

A. General Recommendations

Do not use bleach as a primary hos-

pital-grade environmental surface

disinfectant in the dental clinic. A

manufacturer-recommended diluted

bleach solution maybe e used to

clean DUWLs

1. Follow the manufacturer’s instruc-

tions for correct use of cleaning and

EPA-registered hospital disinfecting

products.

Supporting evidence: 1B, 1C

Same as CDC.

Continued

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

2. Do not use liquid chemical steri-

lants/high-level disinfectants for dis-

infection of environmental surfaces

(clinical contact or housekeeping).

Supporting evidence: 1B, 1C

Same as CDC.

3. Use PPE, as appropriate, when

cleaning and disinfecting environ-

mental surfaces. Such equipment

might include gloves (e.g. puncture-

and chemical-resistant utility),

protective clothing (e.g. gown,

jacket, or lab coat), and protective

eyewear/face shield, and mask.

Supporting evidence: 1C

Same as CDC.

Do not use low-or intermediate-level

disinfectants on critical or semi criti-

cal dental instruments or materials.

Avoid the use of spray bottles that

generate mists or aerosols. Do not

immerse gauze in disinfectants

or wrap items in disinfectant to

minimize the spray. To facilitate

daily cleaning, keep treatment areas

free of unnecessary equipment and

supplies.

B. Clinical Contact Surfaces

1. Use surface barriers to protect

clinical contact surfaces, particularly

those that are difﬁ cult to clean (e.g.

switches on dental chairs) and

change surface barriers between

patients.

Supporting evidence: II

Environmental surfaces such

as clinical contact surfaces and

housekeeping surfaces typically need

to be cleaned only. Whenever the

environmental surface is suspected

to be contaminated with blood,

saliva, or other bodily ﬂ uids or water

containing any bodily ﬂ uid, then it

should be cleaned and disinfected.

These surfaces can also be barrier

protected. Clinical contact surfaces

that may have been contaminated

should be cleaned and disinfected

between clients and at the end of

the workday using a hospital-grade

tuberculocidal intermediate-level

disinfectant.

Supporting evidence: IPC-05-01

CDC Guidelines for Environmental

Infection Control in health care Facil-

ities: recommendations for CDC and

HICPAC. MMWR 2003;52(RR-10).

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

Clean and disinfect surfaces between

patients only when the integrity of

physical barriers has been compro-

mised or when visibly soiled. Clean

and disinfect environmental surfaces

that have been covered with barriers

at the end of each clinical day.

2. Clean and disinfect clinical

contact surfaces that are not barrier-

protected, by using an EPA-regis-

tered hospital disinfectant with a

low- (i.e., HIV and HBV label claims)

to intermediate-level (i.e., tuber-

culocidal claim) activity after each

patient. Use an intermediate-level

disinfectant if visibly contaminated

with blood.

Supporting evidence: 1B

Barrier protection for clinical

contact surfaces and equipment

include: clear plastic wrap, plastic

bags, plastic sheets, plastic tubing,

plastic-backed paper, materials that

are impervious to moisture. Remove

and discard between clients, using

gloves. If the surface below became

contaminated, it should be cleaned

and disinfected. Discard gloves fol-

lowing removal of the barrier.

Supporting evidence: IPC-05-02

CDC Guidelines for Environmen-

tal Infection Control In health

care Facilities: recommendations

of CDC and HISPAC. MMWR

2003;52(RR-10).

Same as CDC, except that the

disinfectant is required to be at least

intermediate-level.

Most surfaces are classiﬁ ed as non

critical with respect to transmission

of disease; however, CDC does not

consider low-level disinfectants to be

adequate for cleaning these surfaces;

instead, intermediate level agents

are the minimum to be used.

Clean and dry surfaces prior to

disinfection.

Differs from CDC - Parts of the

dental unit and chair require daily

sanitization with a low or intermedi-

ate level disinfection agent. how-

ever, other areas, such as switches,

headrests and brackets trays, chair

adjustment controls, light handles,

air/water syringe handles, saliva

ejector and vacuum couplings, unit

switches and handles, mobile cart

or operatory counter surfaces, and

operatory sink hand-operated valves

require intermediate to high-level

agents.

Continued …

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

General cleaning and disinfection

are recommended for clinical con-

tact surfaces, dental unit surfaces,

and countertops at the end of daily

work activities and are required if

surfaces have become contaminated

since their last cleaning.

C. Housekeeping Surfaces

1. Clean housekeeping surfaces (e.g.

ﬂ oors, walls, and sinks) with a deter-

gent and water or an EPA-registered

hospital disinfectant/detergent on

a routine basis, depending on the

nature of the surface and type and

degree of contamination, and as ap-

propriate, based on the location in

the facility, and when visibly soiled.

Supporting evidence: 1B

Housekeeping surfaces should be

periodically cleaned with dilute

detergents or household low-

level disinfectants. If the surface is

contaminated with blood, saliva

or other bodily ﬂ uids, the surface

should be cleaned promptly and

then disinfected with a hospital-

grade tuberculocidal intermediate-

level disinfectant. Visible organic

material should be removed with

absorbent material and discarded

in a leak-proof container. If tubercu-

locidal disinfectant is not available,

use a 1:100 dilution of sodium

hypochlorite e.g. approximately 60

ml. or 1/4 cup of 5.25% household

chlorine bleach in 4 litres [1 gallon]

of water.

Supporting evidence: IPC-05-03

CDC Guidelines for Environmen-

tal Infection Control In health

care Facilities: recommendations

of CDC and HISPAC. MMWR

2003;52(RR-10).

Same as CDC. Clean walls, blinds,

and window curtains in patient-care

areas when they are visibly dusty

or soiled.

Floors should be washed daily

with a low or intermediate level

disinfectant and walls should be

washed monthly. No carpets on the

operatory ﬂ oors.

2. Clean mops and cloths after use

and allow to dry before reuse; or use

single-use, disposable mop heads

or cloths.

Supporting evidence: II

Cleaning tools, such as mop heads

of cloths should be cleaned after

use and allowed to dry before reuse.

Single use items avoid spreading

contamination. Fresh cleaning solu-

tion should be made each day. Allow

the container to dry between uses.

3. Prepare fresh cleaning or EPA-

registered disinfecting solutions

daily and as instructed by the

manufacturer.

Supporting evidence: II

4. Clean walls, blinds, and window

curtains in patient-care areas when

they are visibly dusty or soiled.

Supporting evidence: II

D. Spills of Blood and Body Substances

1. Clean spills of blood or OPIM and

decontaminate surface with an EPA-

registered hospital disinfectant with

low- (i.e., HBV and HIV label claims)

to intermediate-level (i.e., tubercu-

locidal claim) activity, depending on

size of spill and surface porosity.

Supporting evidence: 1B, 1C

Same as CDC. Use of commercially

available spill kits is recommended.

E. Carpet and Cloth Furnishings

1. Avoid using carpeting and cloth-

upholstered furnishings in dental

operatories, laboratories, and instru-

ment processing areas.

Supporting evidence: II

Do not use carpeting and cloth fur-

nishings in client care areas, as they

cannot be reliably disinfected.

Supporting evidence: CDC Guide-

lines for Environmental Infection

Control In health care Facilities: rec-

ommendations of CDC and HISPAC.

MMWR 2003;52(RR-10).

Same as CDC.

F. Regulated Medical Waste

1. General Recommendations

a. Develop a medical waste manage-

ment program. Disposal of regulated

medical waste must follow federal,

state, and local regulations.

Supporting evidence: 1C

Develop a plan for management of

medical waste (that includes stor-

age, handling, neutralization and

disposal) that complies with local

provincial and municipal regulations.

Supporting evidence: IPC-05-04

Follow federal, state and local

regulations for disposal of regulated

medical waste. Deﬁ nitions of regu-

lated medical waste vary by locality.

Continued …

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b. Ensure that DHCP who handle

and dispose of regulated medical

waste are trained in appropriate

handling and disposal methods and

informed of the possible health and

safety hazards.

Supporting evidence: 1C

Same as CDC.

2. Management of Regulated Medical Waste in Dental Health Care Facilities

a. Use a colour-coded or labelled

container that prevents leakage (e.g.

biohazard bag) to contain nonsharp

regulated medical waste.

Supporting evidence: 1C

Place non-sharp medical waste in a

leak-resistant sturdy bag, which is

securely closed.

Supporting evidence: IPC-05-04

Same as CDC. Discard contaminated disposable

items (cotton rolls, rubber dams,

paper products by containerization

immediately after each client. Place

them in a small plastic bag and tie it

off and then discard in the operatory

waste container, which should be

discarded on a daily basis. Employ

heavy-duty garbage bags or double

bagging to prevent inadvertent

littering. Some jurisdictions require

auto claving of this waste before it

can be legally discarded in municipal

sanitation dumpsites.

b. Place sharp items (e.g. needles,

scalpel blades, orthodontic bands,

broken metal instruments, and

burs) in an appropriate sharps

container (e.g. puncture resistant,

colour-coded, and leak proof).

Close container immediately before

removal or replacement to prevent

spillage or protrusion of contents

during handling, storage, transport,

or shipping.

Supporting evidence: 1C

Keep puncture resistant sharps

containers near point of use.

Same as CDC. Discard needles, suture needles, burs

and scalpel blades in a puncture-re-

sistant, colour-coded and leak proof

sharps containers. Close after each

use and do not ﬁ ll past the ﬁ ll line.

c. Pour blood, suctioned ﬂ uids or

other liquid waste carefully into a

drain connected to a sanitary sewer

system, if local sewage discharge

requirements are met and the state

has declared this an acceptable

method of disposal. Wear appropri-

ate PPE while performing this task.

Supporting evidence: 1C

The OHP wearing appropriate PPE

can pour containers with blood or

saliva can be poured into a utility

sink, drain or toilet.

Supporting evidence: IPC-05-04

Same as CDC. Pour blood and other body ﬂ uids

carefully down a drain connected

to a sanitary sewer (e.g. toilet, most

sinks). Some jurisdictions require

pretreatment of biomedical liquid

waste (including efﬂ uent from saliva

ejector) with an intermediate to

high-level disinfectant before they

are discharged into the municipal

sewer system.

VIII. DENTAL UNIT WATERLINES (DUWL), BIOFILM, AND WATER QUALITY

A. General Recommendations

1. Use water that meets EPA regula-

tory standards for drinking water

(i.e., <500 CFU/mL of heterotrophic

water bacteria) for routine dental

treatment output water.

Supporting evidence: 1B, 1C

Follow regular waterline mainte-

nance procedures outlined below to

reduce the DUWL microorganisms

to less than 500 CFU/mL.

Supporting evidence: IPC-05-05

Same as CDC. The minimum quality of water that

should be delivered by the DUWL

should have less than 500 colony

forming units of bacteria per mil-

liliter (<500 CFU/ml).

2. Consult with the dental unit

manufacturer for appropriate meth-

ods and equipment to maintain

the recommended quality of dental

water.

Supporting evidence: II

Do not use waterline heaters.

Do not touch the tubing with ﬁ n-

gers or gloved hand when changing

the water coolant bottle of a closed

water system.

Use a bulb syringe or sterile, single-

use disposable products for irrigat-

ing open vascular sites and invasive

surgical procedures.

Follow manufacturer’s instructions

of the DUWL for daily and weekly

maintenance in a closed or special

water system.

Supporting evidence: IPC-05-05

Use a DUWL maintenance protocol

that is consistent with the manufac-

turer’s recommendations.

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3. Follow recommendations for

monitoring water quality provided

by the manufacturer of the unit or

waterline treatment product.

Supporting evidence: II

Supporting evidence: IPC-05-06

CDC. Assessing the public health

threat associated with waterborne

cryptosporidiosis: report of a work-

shop. MMWR 1995;44(RR-6).

CDC. Working Group on Water-

borne Cryptosporidiosis. Cryptospo-

ridium and water: a Public Health

Handbook. Atlanta, GA: US Depart-

ment of Health and Human Services,

Public Health Service. CDC. 1997.

In the absence of manufacturer’s

recommendations for monitor-

ing dental unit water quality, test

water from each unit monthly for 3

months. If the unit meets standards

during this period, then monitor

water from the dental unit quarterly

at a minimum. It is recommended

to use a rotating schedule testing

several units each month.

If standards are not met (ie≥500

CFU/ml), review work practices,

waterline treatment protocols, and

waterline treatment and monitoring

records. Correct any procedural

problems, retreat the waterlines, and

retest. If the test remains positive, a

“shock- treatment of the waterlines

may be indicated. Acceptable moni-

toring methods include: submitting

water samples to the microbiology

lab or using an in-ofﬁ ce self-con-

tained system. Maintain records for

a minimum of 2 years.

Same as CDC.

4. Discharge water and air for a

minimum of 20-30 seconds after

each patient, from any device con-

nected to the dental water system

that enters the patient’s mouth (e.g.

handpieces, ultrasonic scalers, and

air/water syringes).

Supporting evidence: II

All waterlines should be purged at

the beginning of each workday by

ﬂ ushing with water for 2-3 minutes.

Handpieces utilizing water coolant

should be run for 20-30 seconds

after patient care.

Same as CDC. CDC recommends that water and

air be discarded for a minimum of

20-30 seconds after each client,

from any device connected to the

dental water system that enters

the client’s mouth (handpieces,

ultrasonic scalers, and air/water

syringes). Use of a CUWl conditioner

is recommended.

Follow current OSAP,

ADA, and CDC recom-

mendations to ﬂ ush lines

for several minutes each

morning. Flush hand-

pieces with air/water for

20-30 seconds between

patient appointments.

Installing sterilized

handpieces and sterile or

disposable syringe tips

after ﬂ ushing will reduce

cross-contamination.

5. Consult with the dental unit

manufacturer on the need for peri-

odic maintenance of antiretraction

mechanisms.

Supporting evidence: 1B

Same as CDC. Periodic testing to conﬁ rm the

efﬁ cacy of the clinic DUWL

maintenance protocols is highly

recommended.

If recommended by the

dental unit manufactur-

er, install and maintain

anti retraction valves to

prevent oral ﬂ uids from

being drawn into dental

waterlines.

Sterile solutions should be used as a

coolant/irrigation in the perfor-

mance of oral surgical procedures.

CDC recommends sterile solutions

be used as a coolant/irrigation in

the performance or oral surgical

procedures.

Use sterile solutions for

all surgical irrigations.

Additionally, ensure that

only heat-sterilized/

sterile-disposable bulb

syringes or sterile water

delivery devices are

employed to deliver the

sterile water.

Dental unit water that remains

untreated or unﬁ ltered is unlikely

to meet drinking water standards.

Commercial devices and procedures

designed to improve the quality of

water used in dental treatment are

available; methods demonstrated to

be effective include self contained

water systems combined with

chemical treatment, in line micro-

ﬁ lters, and combinations of these

treatments. Removal or inactivation

of dental waterline bioﬁ lms requires

use of chemical germicides.

Clean high-volume evacuator and

low-volume suction lines and traps

daily using an evacuation system

cleaner.

Avoid heating dental

unit water as it may am-

plify bioﬁ lm formation

and select organisms

preadapted to growth in

a human host.

Continued …

Infection control in DH - Part 1

2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

Use of independent reservoirs with-

out use of a germicidal treatment

will have no effect on waterline bio-

ﬁ lms. Follow the unit manufacturer’s

recommended maintenance regi-

mens to control bioﬁ lm formation.

Handle the water reservoir with care

to avoid cross contamination.

Consider using a

separate water reservoir

system to eliminate

the inﬂ ow of municipal

water into the dental

unit. In addition to hav-

ing better control over

the quality of the source

water, it would eliminate

interruptions in care

when “boil-water”

notices are issued by

local health authorities.

Contact the manufac-

turer of the dental unit

for a compatible system

and treatment protocols

before undertaking this

step.

Educate and train OHP

on effective treatment

measures to ensure

compliance and mini-

mize risks to equipment

and personnel.

Monitor scientiﬁ c and

technological develop-

ments in this area to

identify improved tech-

nical approaches as they

become available.

Cooperate with the oral

healthcare industry to

develop and validate

standard protocols

for maintaining and

monitoring dental unit

waterlines.

It is important to ensure

that the sterile water

system or device mar-

keted to improve dental

water quality has been

cleared for market by

the U.S. Food and Drug

Administration.

B. Boil-Water Advisories

1. The following apply while a boil-

water advisory is in effect:

During a boil water advisory, the fol-

lowing precautions should be taken:

Supporting evidence: IPC-05-06

CDC. Assessing the public health

threat associated with waterborne

cryptosporidiosis: report of a work-

shop. MMWR 1995;44(RR-6).

CDC. Working Group on Water-

borne Cryptosporidiosis. Cryptospo-

ridium and water: a public health

handbook. Atlanta, GA: US Depart-

ment of Health and Human Services,

Public Health Service. CDC. 1997.

The following apply during a boil-

water advisory:

a. Do not deliver water from the

public water system to the patient

through the dental operative unit,

ultrasonic scaler, or other dental

equipment that uses the public

water system.

Supporting evidence: 1B, 1C

a. Do not deliver public water

through the dental unit, ultrasonic

scaler or other devices or equip-

ment. Use alternative closed delivery

systems.

Supporting evidence: IPC-05-06

CDC. Assessing the public health

threat associated with waterborne

cryptosporidiosis: report of a work-

shop. MMWR 1995;44(RR-6).

CDC. Working Group on Water-

borne Cryptosporidiosis. Cryptospo-

ridium and water: a public health

handbook. Atlanta, GA: US Depart-

ment of Health and Human Services,

Public Health Service. CDC. 1997.

Same as CDC.

Continued …

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92 2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

b. Do not use water from the public

water system for dental treatment,

patient rinsing, or handwashing.

Supporting evidence: 1B, 1C

b. Clients should not use tap water

for mouth rinsing. Bottled or dis-

tilled water should be used.

Supporting evidence: IPC-05-06

CDC. Assessing the public health

threat associated with waterborne

cryptosporidiosis: report of a work-

shop. MMWR 1995;44(RR-6).

CDC. Working Group on Water-

borne Cryptosporidiosis. Cryptospo-

ridium and water: a public health

handbook. Atlanta, GA: US Depart-

ment of Health and Human Services,

Public Health Service. CDC. 1997.

Same as CDC.

c. For handwashing, use

antimicrobial-containing products

that do not require water for use

(e.g. alcohol-based hand rubs). If

hands are visibly contaminated, use

bottled water, if available, and soap

for handwashing or an antiseptic

towelette.

Supporting evidence: 1B, 1C

c. Do not use tap water for hand

hygiene, use antimicrobial products

that don’t require water. If hands

are known to be contaminated, they

should be washed with bottled or

distilled water and an antimicrobial

soap.

Supporting evidence: IPC-05-06

CDC. Assessing the public health

threat associated with waterborne

cryptosporidiosis: report of a work-

shop. MMWR 1995;44(RR-6).

CDC. Working Group on Water-

borne Cryptosporidiosis. Cryptospo-

ridium and water: a public health

handbook. Atlanta, GA: US Depart-

ment of Health and Human Services,

Public Health Service. CDC. 1997.

Same as CDC.

2. The following apply when the

boil-water advisory is cancelled:

When the boil water advisory is

cancelled:

Supporting evidence: IPC-05-06

The following apply when the boil-

water advisory is cancelled:

a. Follow guidance given by the lo-

cal water utility regarding adequate

ﬂ ushing of waterlines. If no guidance

is provided, ﬂ ush dental waterlines

and faucets for 1-5 minutes before

using for patient care.

Supporting evidence: 1C

a. Incoming public water system

lines, including taps or other

waterlines should be ﬂ ushed for 1-5

minutes.

Supporting evidence: IPC-05-06

Same as CDC.

b. Disinfect dental waterlines as

recommended by the dental unit

manufacturer.

Supporting evidence: II

b. Disinfect DUWL and equipment

according to the manufacturer’s

instructions.

Supporting evidence: IPC-05-06

Same as CDC.

IX. SPECIAL CONSIDERATIONS

A. Dental Handpieces and Other Devices Attached to Air and Waterlines

1. Clean and heat-sterilize hand-

pieces and other intra oral instru-

ments that can be removed from

the air and waterlines of dental units

between patients.

Supporting evidence: 1B, 1C

Any dental device connected to

the dental air/water system that

enters the client’s mouth should be

run to discharge water and air for

a minimum of 20-30 seconds after

each client.

Dental handpieces and other

intra oral devices attached to air or

waterlines should be sterilized after

client care use. Ethylene oxide gas

cannot adequately sterilize internal

components of handpieces.

Supporting evidence: IPC-06-01

Same as CDC.

2. Follow the manufacturer’s instruc-

tions for cleaning, lubrication, and

sterilization of handpieces and other

intra oral instruments that can be

removed from the air and waterlines

of dental units.

Supporting evidence: 1B

Follow the manufacturer’s instruc-

tions closely for cleaning, lubrication

and sterilization.

Supporting evidence: IPC-06-01

Same as CDC.

3. Do not surface-disinfect, use liq-

uid chemical sterilants, or ethylene

oxide on handpieces and other

intra oral instruments that can be

removed from the air and waterlines

of dental units.

Supporting evidence: 1C

Components of dental devices and

equipment permanently attached to

DUWL should be treated as clinical

contact surfaces. Components

such as electric handpiece motors,

handles for ultrasonic devices or

dental unit attachments of saliva

ejectors) should be covered with

barriers that are changed after each

use. If suspicion of contamination

exists, clean and disinfect it with a

hospital grade intermediate-level

disinfectant.

Supporting evidence: IPC-06-01

Same as CDC.

Continued …

Infection control in DH - Part 1

2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

4. Advise patients not to close their

lips tightly around the tip of the

saliva ejector to evacuate oral ﬂ uids.

Supporting evidence: II

Do not allow clients to seal their

mouths over the saliva ejector tip.

Engineering controls exist which

prevent negative pressure to form

around the tip of the saliva ejector.

This prevents backﬂ ow from the line

into the client’s mouth. Rinse suc-

tion lines with water or appropriate

cleaning or disinfecting solution

between clients. Lines should be

cleaned at least once a week with an

enzymatic cleaner.

Supporting evidence: IPC-06-02

Consider advising patients not to

close their lips tightly around the tip

of the saliva ejector when evacuat-

ing oral ﬂ uids due to the potential

for backﬂ ow.

B. Dental Radiology

Follow hand hygiene outlined in

this paper.

1. Wear gloves when exposing

radiographs and handling contami-

nated ﬁ lm packets. Use other PPE

(e.g. protective eyewear, mask, and

gown) as appropriate if spattering of

blood or other body ﬂ uids is likely.

Supporting evidence: 1A, 1C

Wear gloves and other PPE when

taking radiographs and handling

contaminated ﬁ lm packets.

Supporting evidence: IP-06-03

Same as CDC. Wear gloves when taking radio-

graphs and handling contaminated

ﬁ lm packets. Radiography equip-

ment should be protected with

surface barriers that are changed

after each client. If barriers are not

used, thoroughly wipe the head and

the exposure buttons with an inter-

mediate to high-level disinfectant

following each client visit.

2. Use heat-tolerant or disposable

intra oral devices whenever possible

(e.g. ﬁ lm-holding and positioning

devices). Clean and heat-sterilize

heat-tolerant devices between

patients. At a minimum, high-level

disinfect semi critical heat-sensitive

devices, according to manufacturer’s

instructions.

Supporting evidence: 1B

Heat sensitive radiograph acces-

sories exist and should be heat

sterilized between clients. The ﬁ lm

packet should be disinfected using

a hospital-grade tuberculocidal

intermediate-level disinfectant.

Then rinse and dry and open to

develop the ﬁ lm. Alternately, open

contaminated packet using gloved

hands, drop ﬁ lm onto a clean sur-

face without touching and dispose

of the empty packets. Remove

gloves and process ﬁ lm. Alternatively

ﬁ lm barrier pouches may be used.

Carefully remove from the pouch

to avoid contamination of the inner

ﬁ lm packet.

Supporting evidence: IP-06-03

Same as CDC. Whenever possible, treat ﬁ lm hold-

ing devices as semi critical and heat

sterilize them between clients. If this

is not possible, employ high-level

disinfection.

Disposable bite block covers should

be used for each client. If these

disposable covers are not available,

then sterilize them.

Intra-oral ﬁ lm packets are semi criti-

cal care items.

3. Transport and handle exposed

radiographs in an aseptic manner to

prevent contamination of develop-

ing equipment.

Supporting evidence: II

Avoid contamination of developing

equipment. Use protective barriers

or clean and disinfect contaminated

surfaces using a hospital-grade

tuberculocidal intermediate-level

disinfectant.

Supporting evidence: IP-06-03

Same as CDC. It is no longer acceptable to contam-

inate processor rooms or daylight

loaders by introducing ﬁ lm packs or

gloves still coated in saliva.

4. The following apply for digital

radiography sensors:

Digital radiography:

After radiograph exposure and

before glove removal rinse and

dry ﬁ lm.

Supporting evidence: IPC-06-03

Change surface barriers on radio-

graph equipment, or clean and

disinfect between clients.

Supporting evidence: IPC-06-03

a. Use FDA-cleared barriers.

Supporting evidence: 1B

Radiographic sensors and other as-

sociated instruments are semi critical

devices and therefore should be

cleaned and heat sterilized or disin-

fected between clients. Alternatively

use barrier protection; however, if

they are contaminated they should

be cleaned and disinfected prior to

next client use. Follow manufac-

turer’s instruction carefully for

barrier and disinfection/sterilization

procedures for these devices.

Supporting evidence: IPC-06-03

Use barriers on all intra oral sensors.

Continued …

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94 2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

b. Clean and heat-sterilize, or high-

level disinfect, between patients,

barrier-protected semi critical items.

If the item cannot tolerate these

procedures then, at a minimum,

protect with an FDA-cleared barrier

and clean and disinfect with an EPA-

registered hospital disinfectant with

intermediate-level (i.e.tuberculocidal

claim) activity, between patients.

Consult with the manufacturer for

methods of disinfection and steriliza-

tion of digital radiology sensors

and for protection of associated

computer hardware.

Supporting evidence: 1B

Differs slightly from CDC.

Dental radiography sensors and

other high-technology instruments

(e.g. intra oral camera, electronic

periodontal probe, occlusal analyz-

ers, and lasers) come into contact

with mucous membranes and are

considered semi critical devices.

They should be cleaned and ideally

heat-sterilized or high-level disin-

fected between patients. However,

these items vary by manufacturer or

type of device in their ability to be

sterilized or high-level disinfected.

The following apply for digital radi-

ography sensors: a) Use FDA-cleared

barriers. b) To minimize the poten-

tial for device-associated infections,

after removing the barrier, clean and

disinfect using an EPA-registered

hospital disinfectant with an

intermediate-level activity after each

patient. c) Follow manufacturer’s

recommendations for cleaning and

disinfecting computer equipment.

Use surface barriers if the equipment

is likely to be contacted or contami-

nated during patient-care activities.

After removing the barrier, clean and

disinfect with an intermediate-level

disinfectant after each client.

Differs slightly from CDC.

Use surface barriers to protect clini-

cal contact surfaces (e.g. x-ray tube

head, switches, control panels) and

change surface barriers between

patients. Clean and disinfect surfaces

between patients only when the

integrity of the barrier has been

compromised or when visibly soiled.

Clean and disinfect environmental

surfaces that have been covered

with barriers at the end of each

clinical day.

Follow manufacturer recommenda-

tions for cleaning and disinfecting

computer equipment. Use surface

barriers if the equipment is likely to

be contacted or contaminated dur-

ing client-care activities.

C. Aseptic Technique for Parenteral Medications

1. Do not administer medication

from a syringe to multiple patients,

even if the needle on the syringe is

changed. (IA)

Handle containers of medication

with aseptic techniques. Single dose

vials should be used for parenteral

medications whenever possible. If a

multi-dose vial must be used, then

clean the access diaphragm with

70% alcohol prior to inserting a ster-

ile device. Medication vials, syringes,

or supplies should not be carried in

uniform or clothing pockets.

2. Use single-dose vials for paren-

teral medications when possible.

The access diaphragm in multi-dose

vials should be cleansed with 70%

alcohol before inserting a sterile

device.

Supporting evidence: II

3. Do not combine the leftover con-

tents of single-use vials for later use.

Supporting evidence: 1A

Same as CDC.

4. The following apply if multidose

vials are used:

a. Cleanse the access diaphragm

with 70% alcohol before inserting a

device into the vial.

Supporting evidence: 1A

Same as CDC.

b. Use a sterile device to access a

multiple-dose vial and avoid touch-

ing the access diaphragm. Both the

needle and syringe used to access

the multidose vial should be sterile.

Do not reuse a syringe even if the

needle is changed.

Supporting evidence: 1A

Same as CDC.

c. Keep multidose vials away from

the immediate patient treatment

area to prevent inadvertent contami-

nation by spray or spatter.

Supporting evidence: II

Same as CDC.

Continued …

Infection control in DH - Part 1

2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

d. Discard the multidose vial if steril-

ity is compromised.

Supporting evidence: 1A

Same as CDC.

Follow manufacturer’s guidelines

for storage, use and disposal of

pharmaceuticals or MTF policies if

more stringent.

5. Use ﬂ uid infusion and administra-

tion sets (i.e., IV bags, tubings and

connections) for one patient only

and dispose of appropriately.

Supporting evidence: 1B

Same as CDC.

D. Single-Use (Disposable) Devices

1. Use single-use devices for one

patient only and dispose of them

appropriately.

Supporting evidence: 1C

Use single-use devices on one client

and then discard.

Supporting evidence: IP-06-04

E. Preprocedural Mouth Rinses

1. No recommendation is offered

regarding use of preprocedural an-

timicrobial mouth rinses to prevent

clinical infections among DHCP

or patients. Although studies have

demonstrated that a preprocedural

antimicrobial rinse (e.g. chlorhexi-

dine gluconate, essential oils, or

povidone-iodine) can reduce the

level of oral microorganisms in aero-

sols and spatter generated during

routine dental procedures and can

decrease the number of microor-

ganisms introduced in the patient’s

bloodstream during invasive dental

procedures , the scientiﬁ c evidence

is inconclusive that using these rins-

es prevents clinical infections among

DHCP or patients (see discussion,

Preprocedural Mouth Rinses).

Supporting evidence: Unresolved

issue

Anti microbial mouth rinses should

be used by a client prior to a dental

procedure in order to a) reduce the

number of microorganisms that

might be released from the client’s

mouth in the form of aerosols or

spatter b) decrease the number of

microorganisms introduced in the

clients bloodstream or transient

bacteremias. In clients that cannot

spit or rinse consideration may be

given to brushing or swabbing the

antimicrobial solution in the mouth

prior to care.

Supporting evidence: IPC-06-05

The use of preprocedural

antimicrobial mouth rinses (e.g.

chlorhexidine gluconate, essential

oils, or povidone-iodine) is optional,

but should be considered to reduce

the level of oral microorganisms in

aerosols and spatter generated dur-

ing routine dental procedures and to

decrease the number of microor-

ganisms introduced in the patient’s

bloodstream during invasive dental

procedures. The scientiﬁ c evidence is

inconclusive that using these rinses

prevents clinical infections among

OHP or patients.

Reduce the aerosol production by

the following: Consider asking cli-

ents to brush their teeth and/or rinse

their mouth with a mouthwash prior

to dental treatment. Three 10 sec-

ond rinses can temporarily reduce a

client’s oral microbial count by up to

97%. Use a rubber dam whenever

possible to reduce the microbial

level with the aerosol produced. Use

high-volume evacuation systems,

clean tooth preparations with water

alone, instead of a combination of

air and water spray, polish restora-

tions with rubber points and ﬁ nish-

ing burs instead of bristle brushes,

cover ultrasonic cleaners with lids to

reduce the spread of aerosols.

F. Oral Surgical Procedures

1. The following apply when per-

forming oral surgical procedures:

a. Perform surgical hand antisepsis

by using an antimicrobial product

(e.g. antimicrobial soap and water,

or soap and water followed by

alcohol-based hand scrub with

persistent activity) before donning

sterile surgeon’s gloves. (1B)

b. Use sterile surgeon’s gloves.

Supporting evidence: 1B

Same as CDC.

c. Use sterile saline or sterile water as

a coolant/irrigant when performing

oral surgical procedures. Use devices

speciﬁ cally designed for delivering

sterile irrigating ﬂ uids (e.g. bulb

syringe, single-use disposable prod-

ucts, and sterilizable tubing).

Supporting evidence: 1B

Same as CDC.

Place the date opened on all sterile

irrigating solutions. Discard at the

end of the day or sooner if contami-

nated or contamination is suspected.

G. Handling of Biopsy Specimens

1. During transport, place biopsy

specimens in a sturdy, leak proof

container labelled with the biohaz-

ard symbol.

Supporting evidence: 1C

Place biopsy specimens in a sturdy,

leak-proof container with a secure

lid for transportation.

Supporting evidence: IPC-06-06

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

Continued …

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96 2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

2. If a biopsy specimen container

is visibly contaminated, clean and

disinfect the outside of a container

or place it in an impervious bag

labelled with the biohazard symbol.

Supporting evidence: 1C

Take care to avoid contaminating

the outside of the container. If this

occurs, clean and disinfect or place

in an impervious bag. Provincial/mu-

nicipal regulations may require con-

tainer labeling with the biohazard

symbol during storage, transport,

shipment and disposal.

Supporting evidence: IPC-06-06

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

H. Handling of Extracted Teeth

1. Dispose of extracted teeth as

regulated medical waste unless

returned to the patient.

Supporting evidence: 1C

Dispose of extracted teeth in general

waste.

Supporting evidence: IPC-06-07

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

2. Do not dispose of extracted teeth

containing amalgam in regulated

medical waste intended for incinera-

tion.

Supporting evidence: II

Do not dispose of teeth containing

dental amalgam in waste that may

be incinerated.

Supporting evidence: IPC-06-07

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Same as CDC.

3. Clean and place extracted teeth

in a leak proof container, labelled

with a biohazard symbol, and

maintain hydration for transport to

educational institutions or a dental

laboratory.

Supporting evidence: 1C

Extracted teeth to be sent to a den-

tal laboratory should be cleaned and

surface-disinfected with a hospital-

grade tuberculocidal intermediate-

level disinfectant.

Supporting evidence: IPC-06-07

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

4. Heat-sterilize teeth that do not

contain amalgam before they are

used for educational purposes.

Supporting evidence: 1B

Teeth collected for preclinical edu-

cational training should be cleaned

and maintained in a hydrated state

in a closed container. Local regula-

tions may require labeling with the

biohazard symbol. Prior to educa-

tional use, teeth without amalgam

should be autoclaved. Teeth with

amalgam restorations should be im-

mersed in a 10% formalin solution

for at least 2 weeks.

Supporting evidence: IPC-06-07

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

Using extracted teeth in educa-

tional settings: a) clean and place

extracted teeth in a leak proof

container labelled with a biohazard

symbol. b) place amalgam-free teeth

in a heat-resistant glass container.

c) Fill the container no more than

half-way with deionized or distilled

water or saline, and loosely cover. d)

Process through a steam sterilizer at

121 degrees C for 40 minutes using

a ﬂ uid or liquid cycle. At the end

of the cycle, remove the container

slowly without shaking to avoid

the boiling over of the ﬂ uid. e) If

using extracted teeth containing

amalgam, immerse in 10% formalin

for two weeks before use in an edu-

cational setting.

Return extracted teeth to client

without any special considerations

for infection prevention and control.

Supporting evidence: IPC-06-07

CDC Guidelines for Infection Control

in Dental Health-Care Settings -

2003. MMWR 2003;52(RR-17).

I. Dental Laboratory

Communication between the

dental practice and the laboratory

is important to ensure appropri-

ate cleaning and disinfection and

to avoid damaging materials due

to disinfectant overexposure. If no

indication has been made on the

transported materials, then clean

and disinfect the material.

Follow hand-hygiene recommenda-

tions in this paper.

Continued …

Infection control in DH - Part 1

2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

1. Use PPE when handling items

received in the laboratory until

they have been decontaminated.

(1A, 1C)

2. Before they are handled in the

laboratory, clean, disinfect, and

rinse all dental prostheses and prost-

hodontic materials (e.g. impressions,

bite registrations, occlusal rims,

and extracted teeth) by using an

EPA-registered hospital disinfectant

having at least an intermediate-level

(i.e. tuberculocidal claim) activity.

Supporting evidence: 1B

Use PPE until cleaning and disinfec-

tion is completed. Dental prostheses,

impressions, orthodontic appliances

and other prosthodontic materials

should be cleaned, disinfected with

a hospital-grade tuberculocidal

intermediate-level disinfectant and

thoroughly rinsed before being

handled. Clean as soon as possible

after removal from the client’s

mouth. Wet impressions should be

placed in an impervious bag.

Supporting evidence: IPC-06-08

Same as CDC.

Use appropriate protection (e.g.

mask, protective eyewear) from pro-

jectile and particulate hazards when

lathes and other rotary instruments

are used.

Sanitize or disinfect all impressions

and prostheses/devices prior to

transfer to the lab. Send items to lab

in a sealed plastic bag or container

that is clearly labelled to indicate the

contents were disinfected and the

procedures used.

3. Consult with manufacturers

regarding the stability of speciﬁ c

materials (e.g. impression materials)

relative to disinfection procedures.

Supporting evidence: II

Consult with manufacturers instruc-

tions regarding the stability of

speciﬁ c materials during disinfection.

Supporting evidence: IPC-06-08

Same as CDC.

4. Include speciﬁ c information

regarding disinfection techniques

used (e.g. solution used and dura-

tion), when laboratory cases are sent

off-site and on their return.

Supporting evidence: II

Transporting of non-decontaminated

clinical materials may be subject to

provincial and municipal regulations.

Supporting evidence: IPC-06-08

Same as CDC.

5. Clean and heat-sterilize heat-

tolerant items used in the mouth

(e.g. metal impression trays and

face-bow forks).

Supporting evidence: 1B

Heat-tolerant items used in the

mouth (e.g. metal impression trays)

should be cleaned and heat steril-

ized between clients.

Same as CDC.

6. Follow manufacturer’s instructions

for cleaning and sterilizing or disin-

fecting items that become contami-

nated but do not normally contact

the patient (e.g. burs, polishing

points, rag wheels, articulators, case

pans, and lathes). If manufacturer’s

instructions are unavailable, clean

and heat-sterilize heat-tolerant items

or clean and disinfect with an EPA-

registered hospital disinfectant with

low- (HIV, HBV effectiveness claim)

to intermediate-level (tuberculocidal

claim activity, depending on the

degree of contamination.

Supporting evidence: II

Items that do not normally contact

the client, but become contami-

nated and cannot withstand heat

sterilization should be cleaned and

disinfected between clients using

manufacturer’s instructions. If labo-

ratory items (burs, polishing points,

etc.) are used on contaminated

appliances, prostheses or other

material, they should be heat steril-

ized and disinfected between clients

or discarded.

Supporting evidence: IPC-06-08

At a minimum, clean and disinfect

rag wheels daily. At a minimum

clean and surface disinfect lathes

daily. Clean and disinfect case pans

and articulators when visibly soiled

and after each case is completed.

Clean and disinfect countertops and

lab benches when visibly soiled and

at the end of daily work activities.

Before they are handled in the

laboratory, clean, disinfect, and

rinse all dental prostheses and prost-

hodontic materials (e.g. impressions,

bite registrations, occlusal rims,

and extracted teeth) by using an

EPA-registered hospital disinfectant

having at least an intermediate-level

(i.e., tuberculocidal claim) activity.

Establish a separate receiving

and disinfecting area to reduce

contamination. Clean and disinfect

environmental surfaces in the same

manner as in the dental treatment

area (see IPC-05-01).

Supporting evidence: IPC-06-08

When using ultrasonic cleaners,

place the item in a sealed, dispos-

able plastic bag (ﬁ lled with cleaning

solution) into the ultrasonic machine

and process. Following removal

from the ultrasonic cleaner, dispose

of the cleaning solution and disinfect

the item before returning it to the

patient.

Impressions: Rinse and follow

manufacturer’s recommendations

for disinfectant. With impression ma-

terials that incorporate a disinfectant

within the material itself, the tray

still requires disinfection.

Prostheses/devices: manually

scrub the appliances with a brush,

detergent or bactericidal soap and

water, then use a disinfection solu-

tion. If copious amounts of calculus

is present, immerse the appliance

in a beaker or plastic bag ﬁ lled with

some and plaster removal solution

or ultrasonic cleaner liquid and pro-

cess it in an ultrasonic cleaner.

Casts: should be made from disin-

fected impressions, and all items

(e.g. wax rims) should be disinfected

prior to contacting the casts.

Articulators, case pans, water

baths: disinfect these items with an

intermediate to a high-level surface

disinfectant prior to shipment to the

lab or storing.

Waste in the dental laboratory (e.g.

disposable trays or impression mate-

rials) may be discarded with general

waste. Dispose of sharp items (burs,

and blades) in puncture-resistant

containers.

Supporting evidence: IPC-06-08

Prior to reuse, clean and disinfect

items used on appliances previously

worn by the patient, even if the ap-

pliance was cleaned and disinfected

before the adjustment/repair.

Continued …

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98 2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

Appliances and prostheses for

patients should be free of contami-

nation. If dental lab staff disinfect,

a hospital-grade tuberculocidal

intermediate-level disinfectant

should be used and the item placed

in a tamper-evident container.

Supporting evidence IPC-06-08

Mix pumice with clean water and

dilute 1: 10 bleach or other appro-

priate disinfectant, and change daily

at a minimum.

J. Laser/Electrosurgery Plumes/Surgical Smoke

1. No recommendation is offered

regarding practices to reduce DHCP

exposure to laser plumes/surgical

smoke when using lasers in dental

practice. Practices to reduce HCP

exposure to laser plumes/surgical

smoke have been suggested, includ-

ing use of a) standard precautions

(e.g. high-ﬁ ltration surgical masks

and possibly full face shields); b)

central room suction units with

in-line ﬁ lters to collect particulate

matter from minimal plumes; and

c) dedicated mechanical smoke ex-

haust systems with a high-efﬁ ciency

ﬁ lter to remove substantial amounts

of laser-plume particles. The effect of

the exposure (e.g. disease transmis-

sion or adverse respiratory effects)

on DHCP from dental applications

of lasers has not been adequately

evaluated (see previous discussion,

Laser/Electrosurgery Plumes or

Surgical Smoke).

Supporting evidence: Unresolved

issue.

To avoid inhaling or coming in con-

tact with laser and electrosurgical

plumes and surgical smoke use:

standard precautions (e.g. high-

ﬁ ltration surgical masks and possibly

full face shields) central room suc-

tion units with in-line ﬁ lters dedi-

cated mechanical smoke exhaust

systems with high-efﬁ ciency ﬁ lters,

local smoke evacuation systems.

Supporting evidence: IPC-06-09.

CDC. NIOSH Control of smoke from

laser/electric surgical procedures.

Cincinnati. OH: US Department of

Health and Human Services, Public

Health Service, CDC,NIOSH 1996.

DHHS publication no. (NIOSH)

96-128.

At a minimum: a) follow manu-

facturer’s instructions regarding

use and safety precautions b) use

standard precautions when working

in the laser environment. c) Wear

appropriate PPE including N-95 or

N-100 respirators to minimize expo-

sure to laser plumes. d) Wear protec-

tive laser eyewear. e) Implement lo-

cal exhaust ventilation controls that

may include but are not limited to

wall suction units with in-line ﬁ lters

and smoke evacuation units.

K. Mycobacterium Tuberculosis

1. General Recommendations

a. Educate all DHCP regarding the

recognition of signs, symptoms, and

transmission of TB.

Supporting evidence: 1B

OHP treating clients infected

with M. tuberculosis (TB) should

understand the pathogenesis of

the development of TB to help

determine how to manage such

clients, and to recognize signs and

symptoms to help with prompt

detection of TB in clients. Develop a

TB control program appropriate for

their level of risk.

Supporting evidence: IPC-06-10

CDC. Prevention and treatment of

tuberculosis among patients infected

with human immunodeﬁ ciency

virus: Principles of therapy and

revised recommendations. MMWR

1998;47(RR-20)

Educate OHP regarding the rec-

ognition of signs, symptoms, and

transmission of TB.

b. Conduct a baseline TST, prefer-

ably by using a two-step test, for all

DHCP who might have contact with

persons with suspected or conﬁ rmed

active TB, regardless of the risk clas-

siﬁ cation of the setting.

Supporting evidence: 1B

OHP with client contact should have

a baseline TST (tuberculin skin test) -

preferably 2 step test, upon employ-

ment. The facilities level of exposure

to clients at risk of TB will determine

the need for routine follow-up TST.

Supporting evidence: IPC-06-10

CDC. Prevention and treatment of

tuberculosis among patients infected

with human immunodeﬁ ciency

virus: Principles of therapy and

revised recommendations. MMWR

1998;47(RR-20).

Ensure OHP, who might have

contact with persons with suspected

or conﬁ rmed active TB, have had

a baseline TST according to MTF

policy.

c. Assess each patient for a history

of TB as well as symptoms indicative

of TB and document on the medical

history form.

Supporting evidence: 1B

OHP should ask all patients if they

have a history of TB disease or symp-

toms indicative of TB. Clients with

symptoms indicative of undiagnosed

active TB should be referred prompt-

ly for medical evaluation.

Supporting evidence: IPC-06-10

CDC. Prevention and treatment of

tuberculosis among patients infected

with human immunodeﬁ ciency

virus: Principles of therapy and

revised recommendations. MMWR

1998;47(RR-20).

Same as CDC.

Continued …

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2008; 42, no.2: 63-103

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

d. Follow CDC recommendations

for 1) developing, maintaining,

and implementing a written TB

infection-control plan; 2) managing

a patient with suspected or active

TB; 3) completing a community risk-

assessment to guide employee TSTs

and follow-up; and 4) managing

DHCP with TB disease.

Supporting evidence: 1B

Follow MTF guidance and current

CDC recommendations www.cdc.

gov/nchstp/tb/default.htm) for:

developing, maintaining, and imple-

menting a written TB infection-con-

trol plan; managing a patient with

suspected or active TB; completing a

community risk-assessment to guide

employee tuberculin skin tests (TST)

and follow-up; and

2. The following apply for patients

known or suspected to have active

TB:

Follow MTF guidelines for patients

known or suspected to have active

TB:

a. Evaluate the patient away from

other patients and DHCP. When

not being evaluated, the patient

should wear a surgical mask or be

instructed to cover mouth and nose

when coughing or sneezing.

Supporting evidence: 1B

Clients suspected of having active TB

should be isolated from other clients

and other OHP, and should wear

a surgical mask when not being

evaluated and should be instructed

to cover their mouth and nose when

coughing or sneezing.

Supporting evidence: IPC-06-10

CDC. Prevention and treatment of

tuberculosis among patients infected

with human immunodeﬁ ciency

virus: Principles of therapy and

revised recommendations. MMWR

1998;47(RR-20).

Same as CDC.

b. Defer elective dental treatment

until the patient is noninfectious.

Supporting evidence: 1B

Elective dental treatment should be

deferred until there is conﬁ rmation

that client does not have infectious

TB, or if the client is diagnosed with

active TB disease, until conﬁ rmed

the client is no longer infectious.

Supporting evidence: IPC-06-10

CDC. Prevention and treatment of

tuberculosis among patients infected

with human immunodeﬁ ciency

virus: Principles of therapy and

revised recommendations. MMWR

1998;47(RR-20).

Same as CDC.

c. Refer patients requiring urgent

dental treatment to a previously

identiﬁ ed facility with TB engineer-

ing controls and a respiratory

protection program.

Supporting evidence: 1B

Oral health care should be provided

in a facility that provides airborne

infection isolation (e.g. engineering

controls such as TB isolation rooms,

negatively pressured relative to the

corridors). OHP treating clients with

active TB should use respiratory

protection (e.g. ﬁ t-tested, dispos-

able N-95 respirators), as surgical

facemasks do not protect against TB

transmission.

Supporting evidence: IPC-06-10

CDC. Prevention and treatment of

tuberculosis among patients infected

with human immunodeﬁ ciency

virus: Principles of therapy and

revised recommendations. MMWR

1998;47(RR-20).

Follow MTF guidance when emer-

gency dental treatment is performed

on a patient with active or suspected

TB (e.g. wear a ﬁ t-tested, disposable

N-95 respirator).

L. Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases

1. No recommendation is offered

regarding use of special precautions

in addition to standard precautions

when treating known CJD or vCJD

(variant CJD) patients. Potential

infectivity of oral tissues in CJD or

vCJD patients is an unresolved issue.

Scientiﬁ c data indicate the risk, if

any, of sporadic CJD transmission

during dental and oral surgical

procedures is low to nil. Until ad-

ditional information exists regarding

the transmissibility of CJD or vCJD

during dental procedures, special

precautions in addition to standard

precautions might be indicated

when treating known CJD or vCJD

patients; a list of such precautions is

provided for consideration without

recommendation (see Creutzfeldt-

Jakob Disease and Other Prion

Diseases).

Supporting evidence: Unresolved

issue

OHP’s should include medical his-

tory questions regarding dura mater

transplantation, and familial history

of CJD and vCJD. Dental instruments

and devices touching pulpal tissue

(e.g. endodontic broaches and ﬁ les,

access opening burs) should be

discarded in sharps containers after

each client use. CJD is thought to

be caused by infection with a prion,

which is not inactivated by the

standard sterilization methods used

in oral health care settings.

Supporting evidence: IPC-06-11

Same as CDC.

A list of special precautions is

provided for consideration without

recommendation at: www.cdc.

gov/ncidod/diseases/submenuus/

sub_bse.htm

Speciﬁ c CJD-speciﬁ c infection con-

trol precautions, in addition to stan-

dard precautions are recommended

for clients who have developed, are

suspected of having developed, or

are at substantially increased risk of

developing CJD. These precautions

include the following:

a. use single-use disposable items

and equipment whenever possible;

b. consider difﬁ cult to clean items

(e.g. diamond burs) as single-use

disposable and discard after use;

c. keep the instrument moist until

cleaned and decontaminated to

minimize the drying of tissues and

body ﬂ uids on a device; d. clean

instruments thoroughly and steam-

autoclave at 134 degrees C for 18

minutes; e. do not use ﬂ ash steriliza-

tion for processing instruments or

devices.

Continued …

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CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

Anthrax and Dental

Practice: OSAP sup-

ported Guidelines

No special precautions

are needed. Tissue and

other material from

a patient potentially

infected with anthrax

may contain sensitive

vegetative cells of the

microorganism, but not

be resistant spore forms.

Standard precautions

(“universal precautions”)

intended to prevent the

transmission of diseases

also prevent the spread

of anthrax.

SARS and the Dental

Ofﬁ ce.

CDC recommends that

clinicians evaluat-

ing suspected cases

should apply standard

precautions, airborne

precautions (e.g. N-95

respirator), and contact

precautions (e.g. gowns

and gloves) precau-

tions. Until the mode of

transmission had been

positively identiﬁ ed and

precisely deﬁ ned, eye

protection also should

be worn for all patient

contact.

Dental Personnel Protec-

tion - disposable gloves

which must be changed

after every patient.

Chin-length plastic face

shields or surgical masks

and protective eyewear.

Make sure the mask

covers the mouth and

the nose. Reusable or

disposable gowns.

Cleaning and disinfec-

tion - use a hospital

grade disinfectant

or 1:100 dilution of

household bleach. Make

sure the disinfectant is

compatible with your

dental equipment.

M. Program Evaluation

1. Establish routine evaluation of the

infection-control program, including

evaluation of performance indica-

tors, at an established frequency.

Supporting evidence: II

Program evaluation should be prac-

ticed consistently across program

areas, and integrated into the day-

to-day management of the infection

prevention and control program.

A successful infection, prevention

and control program depends on

developing standard operating

procedures, evaluating practices,

routinely documenting adverse

outcomes and work-related illnesses

in OHP’s and monitoring health care

associated infections in clients. Strat-

egies and tools can include: periodic

observational assessments, checklists

to document procedures, routine

review of occupational exposures

to bloodborne pathogens. Effective

implementation requires the OHP to

monitor the scientiﬁ c literature.

Supporting evidence: IPC-06-12

CDC. Framework for program

evaluation in public health. MMWR

1999;48(RR-11).

A. Sterilization Monitoring

Implement a sterilizer-monitoring

program as described in this docu-

ment.

Every clinic must have an infection

control Standard of Practice that

documents the equipment, infection

control products and staff respon-

sibilities particular to that clinic. A

template is provided.

Continued …

Infection control in DH - Part 1

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101

Infection control in DH - Part 1

CDC DOCUMENT CDA DOCUMENT USAF DOCUMENT CFDS DOCUMENT OSAP DOCUMENT

B. Inspections

Conduct and document routine

scheduled or unscheduled inspec-

tions of dental treatment rooms,

dental laboratory and radiology

areas, decontamination and steriliza-

tion areas, and locations where

sterile and/or patient-care items are

stored.

C. Waterline Monitoring

Implement a waterline-monitoring

program as described in this docu-

ment.

D. Healthcare Associated Infections

(HAI)

Surveillance for HAI provides data

useful for identifying infected

patients, determining the site of

infection, and identifying the factors

that contribute to HAI. Information

containing patient identiﬁ ers or

patient care staff should be carefully

handled. Data should not be used

for punitive purposes, but should

be viewed as an opportunity to

improve patient/employee/process

outcome. Surveillance goals should

include: providing objective assess-

ment of dental HAI rates, reducing

morbidity and cost, establishing

baseline infection n rates based on

well deﬁ ned case deﬁ nition criteria,

educating DHCP concerning data

relevant to their practices, evaluating

control measures designed to reduce

infection rates, complying with

accreditation standards, defending

malpractice claims through imple-

mentation of an active surveillance

program, and providing data useful

in clinical research.

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102 2008; 42, no.2: 63-103

Lux

LEGENDS FOR TABLE 1

Acronyms

APIC - Association for Professionals in Infection

Control

BI - Biological Indicator

DHCP - Dental Health Care Professional

HAI - Health-Care-Associated Infection

HBsAG - Hepatitis B surface antigen

HBV - Hepatitis B Vaccination

Hep A - Hepatitis A

Hep B - Hepatitis B

HICPAC - Healthcare Infection Control Practices

Advisory Committee

ICO - Infection Control Officer

IPC officer - Infection Prevention and Control Officer

MTF - Medical Treatment Facility

NIOSH - National Institute for Occupational Safety

and Health

OHP - Oral Health Professional

OPIM - Other Potentially Infectious Materials

PI - Percutaneous Injuries

PPE - Personal Protective Equipment

SARS - Severe Acute Respiratory Syndrome

Definitions

Supporting evidence. Supporting evidence and

strength of recommendation rating / reference #

CDC Recommendation Rating Scheme

Category IA. Strongly recommended for implementa-

tion and strongly supported by well-designed experi-

mental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementa-

tion and supported by experimental, clinical, or epi-

demiologic studies and a strong theoretical rationale.

Category IC. Required for implementation as mandated

by federal or state regulation or standard. When IC is

used, a second rating can be included to provide the

basis of existing scientific data, theoretical rationale,

and applicability. Because of state differences, the reader

should not assume that the absence of an IC implies the

absence of state regulations.

Category II. Suggested for implementation and support-

ed by suggestive clinical or epidemiologic studies or a

theoretical rationale.

Unresolved issue. No recommendation. Insufficient

evidence or no consensus regarding efficacy exists.

Footnote for Table 1: the serial numbers used within a

cell are indicative of the numbers assigned in the organi-

zation’s documents.

Infection control in DH - Part 1

2008; 42, no.2: 63-103

103

ACKNOWLEDGEMENT

The author is grateful for the review, inputs, and com-

ments of CDHA Research Advisory Committee members

(Barbara Long, Indu Dhir, Dianne Gallagher and Dr.

Susanne Sunell), Dr. Doug Waterfield (UBC), Dr. Jennifer

Cleveland (Centers for Disease Control), Lexie Martin

(UBC), Susan Schmit (Vancouver Community College),

Maria Tigner (Algonquin College), Simone Wartman,

College of Dental Hygienists of Ontario, College of

Registered Dental Hygienists of Alberta, Saskatchewan

Dental Hygienists Association, thirteen CDHA members

who responded to the anonymous web site consultation,

and the American Dental Hygienists Association in prepar-

ing this document.

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4. College of Registered Dental Hygienists of Alberta. Practice

Standards. 2007 Jun.

5. College of Dental Hygienists of British Columbia. Registrants

Handbook. 2004.

6. College of Dental Hygienists of Ontario. Dental Hygiene

Standards of Practice. 1996.

7. Centers for Disease Control and Prevention - Federal

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Control in the Dental Office: An opportunity to improve safety and

compliance. 2006 June.

9. Canadian Forces Dental Services. Infection Control Guidelines.

2006 Oct.

10. United States Air Force. Guidelines for Infection Control in

Dentistry. 2004 Sep.

11. Organization for Safety and Asepsis Procedures (OSAP). OSAP

Position Paper: Percutaneous Injury Prevention. 2002 Nov.

12. Organization for Safety and Asepsis Procedures (OSAP). Dental

Unit Waterlines: OSAP Recommendations to Clinicians. 2007.

13. Organization for Safety and Asepsis Procedures. Issue Focus:

Anthrax and Dental Practice. 2007.

14. Organization for Safety and Asepsis Procedures. Issue Focus:

Severe Acute Respiratory Syndrome: SARS and the Dental Office.

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