How to Best Maximize Infection Control in Your Facilities - Assessing practice safety: an overview of basic infection control procedures published by DPR August 1999.

This report takes us back to basics, with an overview of fundamental infection control in dentistry under the following headings: personal protection, hand care, limiting the spread of contamination, instrument handling, instrument processing, sterilizer monitoring, surface asepsis, and training. Infection control and practice safety procedures are as much a part of modern dental practice as routine examinations, restorations, and prophy procedures.

Within the past 15 years in dentistry, gloving has become routine, handpiece sterilization has become the norm, and the hepatitis B vaccination has been widely accepted by dentists and staff.

So where's the next challenge? According to some infection control educators, as practitioners and staff become comfortable with the low risk of disease transmission in dentistry, the challenge lies in compliance with basic procedures. "Many people speak of emerging infectious disease challenges and express concern over ways to control them.

A more fundamental issue, however, is the extent of compliance with long-standing infection control measures that have a successful track record in preventing transmission of a wide range of disease agents," said John Molinari, PhD, of the University of Detroit Mercy School of Dentistry. "Newer generations of healthcare professionals have not seen many of the occupational infectious disease hazards that dentistry has faced.

As such, the importance of basic precautions may not be as firmly entrenched." Dentistry is safer than it has ever been because of today's standards for personal protection, instrument processing, and training. Inherent in these proven infection-control recommendations, Molinari explains, is a measure of overlap that has worked to dramatically reduce the frequency of accidental infections. "Shortcuts" in basic protocols erode this margin of overlap.

As Molinari reminds us, although occupational accidents and injuries may be less frequent today, the consequences may be no less serious.

This issue's Infection Control Report takes us back to basics, with an overview of fundamental infection control in dentistry.

The report is highlighted with 3 assessment aids suggested by national infection control consultants to evaluate infection control and safety procedures in practice.

Personal protection

Take advantage of available vaccines against hepatitis B, influenza, measles, mumps, rubella, tetanus, and varicella (chickenpox). Note:

The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard requires that employers offer hepatitis B vaccination at no cost to employees at risk of occupational exposure to blood or other potentially infectious materials.

Wear appropriate personal protective equipment (gloves, mask, eyewear, gown) when exposure to blood or other potentially infectious materials is anticipated, whether at chairside or during instrument reprocessing.

Don eyewear first, then the face mask, followed by the gloves. Conversely, remove contaminated exam gloves first and put on heavy-duty utility gloves for instrument processing. After instrument processing, remove the face mask, then the protective eyewear.

Over clean hands, don new examination gloves for each patient when contact with blood or saliva is anticipated.

Do not wash and reuse gloves. (Exposing latex gloves to detergents causes wicking, which adversely affects the material's barrier properties. Tap-water rinsing to remove excess glove powder, however, is acceptable.)

Wear inexpensive vinyl food-handlers gloves over contaminated treatment gloves when called away from chairside during a procedure. Avoid removing and re- donning the same pair of exam gloves during treatment of the same patient (for example, following an interruption in treatment), as this can strain and weaken glove material and expose the hands to infectious agents.

Wear face masks with protective eyewear or a face shield to protect mucous membranes of the eyes, nose, and mouth from exposures to potentially infectious splashes and spatter.

Use a new surgical mask for each patient, and replace a mask when it becomes moist during treatment. (Wet masks can collapse against the face, placing contaminants in direct contact with the healthcare worker's nose and mouth.)

Wear glasses, goggles, and face shields during splash- or spatter-generating procedures.

Wear protective garments with long sleeves and high necklines over street clothes or uniforms during splash- or spatter-generating procedures.

Change protective over garments daily or more frequently if visibly soiled.

When removing visibly contaminated protective clothing, fold the soiled area inside, using care not to contaminate the hands.

Place contaminated garments in a leakproof laundry bag identified as "contaminated" or marked with the universal bio hazard symbol. Remove contaminated outerwear before leaving the office or entering designated "clean areas," such as the lunch room..

OSHA defines laundering of contaminated protective garments as the responsibility of the employer, which prohibits employees from taking protective garments home for laundering. Contaminated laundry can be done on-site, by a medical laundry service, or by the employer in his/her home. Hand washing and hand care

For routine, between-patient/procedure hand washing, vigorously lather the hands and forearms with soap and water; follow with a cool-to-lukewarm water rinse. (Hot water will cause pores on the skin surface to expand.) Repeat the process; then dry hands and forearms thoroughly with disposable towels.

Use the paper towels to turn off manually operated faucets.

When using an antimicrobial handwash, read and apply the label instructions regarding contact (that is, lather) time. Healthcare workers with open sores, weeping dermatitis, or similar lesions on their hands should avoid patient contact until the condition resolves. (In addition to providing a potential portal for microorganisms, significant skin breaks may heighten a healthcare worker's risk for sensitization to glove chemicals or materials.)

Avoid using petroleum-, lanolin-, or mineral oil- based moisturizers during the clinic day. These agents can break down glove materials and compromise the integrity of the barrier.

Keep fingernails short and well manicured.

Avoid wearing rings, fingernail polish, and false nails at work. Limiting the spread of contamination whenever possible

Anticipate and make accessible the items needed for each procedure before the patient is seated. (Eliminating the need to open drawers and cabinets limits operatory contamination.)

Use disposable and unit-dose items whenever possible.

Use a pre-procedural antimicrobial mouthrinse on all patients to lower microbial counts in the oral cavity and, in turn, to reduce the quantity of microorganisms in aerosols and spatter generated during the procedure.

During treatment, use rubber dam, high-volume evacuation, and proper patient positioning to minimize spatter. Instrument handling

Always point the sharp end of the instrument away from the body.

Pass scalpels and syringes with sharp ends away from all parties.

Avoid picking up sharps instruments by the handful.

Keep arms and fingers clear of rotating instruments.

Dispose of used needles and other sharps promptly and properly, that is, in a bio hazard-labeled, leakproof, puncture-resistant container in close proximity to the point of use.

Avoid overfilling sharps containers.

Always wear puncture-resistant utility gloves during cleanup procedures. Instrument processing

Process item and or instrument depending on its use, as follows: Critical instruments penetrate soft tissue or bone. They must be heat-sterilized. Semicritical instruments do not penetrate tissue or bone but contact oral tissues. They also should be heat- sterilized, although high-level disinfection/ immersion sterilization is an acceptable compromise for heat-labile items. Noncritical instruments come into contact only with intact skin. Between-patient reprocessing with an intermediate- or low-level disinfectant is indicated.

Replace reusable heat-sensitive treatment items with heat-stable substitutes whenever possible.

Use a holding solution or presoak at chairside to prevent debris from drying on instruments, which can make cleaning more difficult. A simple water bath is an appropriate choice; a detergent or disinfectant may be used to introduce surfactant or antimicrobial activity.

Wear mask, eyewear, and protective garments during operatory cleanup, and don heavy-duty, puncture-resistant utility gloves for instrument cleaning, packaging, and sterilizer loading.

Consider using instrument cassettes, which limit staff contact with contaminated instruments during processing.

Clean instruments ultrasonically to limit staff contact with contaminated items.

Minimize handscrubbing of instruments. Routine handscrubbing following ultrasonic cleaning is usually not necessary, although stubborn debris (for example, dental composites and cements) on instrument surfaces or grooves occasionally may require postcycle handscrubbing as a supplement to ultrasonic cleaning.

When handscrubbing instruments, keep items above the waterline. (Fully immersing them in a basin of soapy water impedes visibility of the sharp ends.) Also, handle contaminated instruments only 1 or 2 at a time to enhance control.

After instruments have been cleaned, rinsed, and dried, package them for heat sterilization. Allow hinged instruments such as scissors and pliers to remain open.

Place a process indicator on the outside of the instrument pack to identify that the package has been heat- processed. Note the date on the indicator.

Add a chemical integrator (a multiparameter process indicator) to the center of each instrument pack to confirm heat penetration. In autoclaves, for example, the indicator should change color in the presence of the correct combination of time, temperature, and saturated steam. Also, place an integrator in the middle of each load of unwrapped instruments.

Process heat-stable items and instruments via autoclave-, chemical vapor-, or dry heat- (standard or rapid transfer) sterilization.

Avoid using household appliances (for example, toaster ovens, dishwashers) in instrument processing. These items are not cleared by the Food and Drug Administration for use as medical devices and may not be calibrated for optimal, reliable performance as instrument-processing tools.

Place packages vertically in the sterilizer. (Standing packages on their edges maximizes circulation and penetration of the sterilizing agent and eliminates pressure that can cause instruments to poke through the packaging material.)

Allow sufficient time for all parts of the chamber to reach the sterilization temperature before beginning the cycle.

Keep sterilized items wrapped until they are needed, and then unwrap the instruments at chairside to minimize contact with airborne contaminants. Presenting wrapped, sterile instruments at chairside offers patients a visible example of the practice's infection control efforts.

Store packages where they cannot become wet or torn. If the integrity of the sterilization packaging is compromised, repackage and subject the instruments/ items to another complete sterilization cycle. Sterilizer monitoring

Visually check sterilizer gauges during the cycle. Anomalies can indicate gross sterilizer malfunction.

Use spore suspensions (biologic indicators) in strips or vials to verify a sterilizer's effectiveness. Weekly testing is recommended by the Centers for Disease Control and Prevention (CDC), the American Dental Association (ADA), and the Organization for Safety and Asepsis Procedures (OSAP).

Use a biologic indicator (BI) that is appropriate for the method of sterilization: Bacillus stearothermophilus for autoclaves and chemical vapor sterilizers; Bacillus subtilis for dry-heat and ethylene- oxide units. Place the test indicator in the center of the instrument package least accessible to the sterilizing agent, usually the center-most package in the chamber or the package located at the top-back or bottom-front. Consult the sterilizer instructions, or contact the sterilization monitoring service to get advice on placing biologic indicators.

Use a control indicator, which is not run through the sterilization cycle but compared to the test BI to verify the presence of viable spores prior to heat processing.

Maintain records of the incubation and analysis reports provided by the testing service. Surface asepsis

Maintain surface asepsis using fluid-impervious surface covers or between- patient disinfection. Operatory surfaces that cannot be easily decontaminated (for example, light handles, manual chair controls, and suction hoses) may be barrier-protected with disposable, waterproof covers. Note: As long as the integrity of the surface cover is maintained, surfaces that are covered during patient treatment need not be disinfected before placing a clean barrier for the next patient visit. Barrier-protected surfaces, however, should be disinfected at the end of each treatment day.

Only place barriers on clean operatory surfaces.

When changing surface barriers, remove and dispose of the soiled cover with gloved hands, then remove the gloves, thoroughly wash hands, and place a clean barrier.

To effectively disinfect operatory surfaces, use a spray-wipe-spray technique: First spray and wipe to remove gross bioburden and debris; then, apply the disinfectant and allow it to remain on the surface for the contact time recommended on the label.

Save time by using a single product to both clean and disinfect operatory surfaces. Complex phenols, iodophors, and dilute sodium hypochlorite are suitable cleaner/disinfectants.

Avoid using glutaraldehydes (2.4% and 3.2%) as surface disinfectants. These high-level instrument disinfectants are inappropriate surface disinfectants. Highly toxic, they have been associated with cases of occupational asthma as well as dermal and mucosal irritation. Furthermore, their fixative properties make them ineffective cleaners and potentially damaging to some surfaces.

Maintain a list of all hazardous materials used in the practice as well as Material Safety Data Sheets (MSDSs) for each product. Training

As required by OSHA, provide employees with annual training on bloodborne disease transmission and prevention measures.

Present the rationale for various infection control and safety protocols. Understanding the rationale behind these procedures provides the building blocks for compliance.

Provide day-to-day reinforcement of proper infection control protocols and procedures.

Since the mid-1980s, the profession has made tremendous strides toward making dentistry safer for patients and staff.

With an eye toward the future, however, dental workers must remember the profession's wet-fingered past.

Ongoing staff training and self-assessments of practice safety procedures ensure that proven protocols remain in place and unchallenged by shortcuts or misunderstanding. Karen Gomolka, Contributing Editor - DPR References Centers for Disease Control and Prevention. Recommended infection-control practices for dentistry,

1993. Morbidity and Mortality Weekly Rep 1993;41(RR- 8):1-12. Cottone JA, Terezhalmy GT, Molinari JA. Practical Infection Control in Dentistry, second edition. Philadelphia:Williams & Wilkins, 1996. Miller CH.

Infection control strategies for the dental office. ADA Guide to Dental Therapeutics. Chicago:ADA Publishing Co., 1998:489-504. Miller CH, Palenik CJ.

Infection Control and Management of Hazardous Materials for the Dental Team. St. Louis:Mosby, 1998. Miller CH, Palenik CJ. Sterilization, disinfection, and asepsis in dentistry. In Block SS. Disinfection, Sterilization, and Preservation, fourth edition. Malvern:Lea & Febiger, 1991:676-695. Organization for Safety and Asepsis Procedures.

The dental infection control program: from basic principles to fine- tuning. OSAP Monthly Focus 1998 (No. 2). Safety Checkpoint 1 Mary Govoni, CDA, RDA, RDH Clinical Dynamics Okemos, Mich.

Have the clinical staff do a walk-through of the office to identify and correct any potential threats to patient or provider safety and health.

For example, ensure that biohazard signs appear on contaminated waste containers, all chemical containers (including spray bottles) are properly labeled, utility gloves are available in treatment- room and instrument-processing areas, and sharps containers are not overfilled.

Encourage team members to take note of each other's infection control and safety practices and to issue reminders when necessary (for example, when personal protective equipment may be lacking).

Safety Checkpoint 2 Dr. Mary Quinn Quinn Associates Shorewood, Wis.

In training new and existing staff, feedback is key.

To stimulate discussion and identify areas for improvement, issue quizzes on protocols and procedures. For a more interactive approach, have staff members demonstrate various infection control and safety procedures, as, for example, operatory cleanup, instrument processing, and chairside transfer of instruments between staff.

Such assessment measures allow the lead infection control staffer not only to target the training sessions to the areas of greatest need but also to assist team members in understanding the rationale behind various infection control and safety procedures.

Safety Checkpoint 3 Doni L. Bird, RDH, MA Dr. William F. Bird D.B. Bird Management Glen Ellen, Calif.

Schedule time to routinely update the office's chemical inventory and Material Safety Data Sheet (MSDS) binder. Although product information may be rather easily added to the inventory and binder, the demands of a busy practice often preclude thorough review to remove information on products no longer used in the practice.

The result: an MSDS binder that looks like a copy of the Yellow Pages for a major metropolitan area. At least annually, leaf through the MSDS book to ensure it is current and of a reasonable size.

Keep MSDSs for all hazardous products in the practices and remove MSDSs for products not used in the office. Maintain a separate file of MSDSs for discontinued products (with a note indicating their years in use) to address any questions that might arise regarding specific chemicals.