advicesheet infectioncontrolindentistry A › resources › bda-cross-infection.pdf · infection control routine is adopted for all patients. The following recommendations for infection

advicesheet

A12infectioncontrolindentistry

infectioncontrolindentistryadvicesheet

contentsIntroductionRoutine proceduresPatient perceptionAcceptance of patientsConfidentialityThe infected dental health care worker

Infection control in dentistryTraining in infection controlSurgery designChoice of equipmentDecontamination of instruments and equipmentSingle use (disposable) itemsSurface cleaning and disinfectionDecontamination of instruments and equipmentprior to service or repairDecontamination of impression materials andprosthetic and orthodontic appliancesDisposal of clinical wasteBlood spillagesBiopsy specimens sent through the post

Personal protectionImmunisationHand protectionEye protection and face masksSurgery clothingAerosol and saliva/blood splatterInoculation injuries

Emerging infectionsTransmissible Spongiform EncephalopathiesMethycillin-resistant Staphylococcus aureus(MRSA)Tuberculosis

Infection control policyChecklist

Useful website addresses for informationSources of further information

This advice sheet hasbeen developed withthe Department of

Health in England and isconsistent with current

infection control policiesin the National HealthService. Its production

and distribution todentists in the UK hasbeen financed by the

English Department ofHealth.

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IntroductionInfection control in health carecontinues to be the subject ofintensive research and debate. Thisadvice sheet condenses currentknowledge and recommendations ina practical form for the dentalpractitioner.

Implementing safe and realisticinfection control procedures requiresthe full compliance of the wholedental team. These proceduresshould be regularly monitoredduring clinical sessions anddiscussed at practice meetings. Theindividual practitioner must ensurethat all members of the dental teamunderstand and practise theseprocedures routinely.

Every practice must have a writteninfection control policy, which istailored to the routines of theindividual practice and regularlyupdated. The policy should be keptreadily available so that staff canrefer to it when necessary.

Routine procedures

A thorough medical history shouldbe obtained for all patients at thefirst visit and updated regularly.Medical history questionnairesalongside direct questioning anddiscussion between the dentist andthe patient are recommended.Discussions should be conducted inan environment that permits thedisclosure of sensitive personalinformation. The medical historyinformation should be retained aspart of the patient's dental records.

The medical history and examinationmay not identify asymptomaticcarriers of infectious disease anduniversal precautions must beadopted. This means that the sameinfection control procedures must beused for all patients.

All dentists have a duty of care totheir patients to ensure adequateinfection control procedures arefollowed. "Failure to employadequate methods of cross-infectioncontrol would almost certainlyrender a dentist liable to a charge ofserious professional misconduct"

(GDC. Maintaining standards.November 1997, as amended May2001).

Patient perception

As a result of frequent mediacoverage, the public is now far moreaware of the need for dentists topractise good infection control.Displaying an infection controlstatement may be appropriate inyour practice to help allay patientanxiety and gain their confidence. Itmay encourage them to askquestions, so never be too busy togive an answer. Ensure all themembers of your practice staff areconfident and competent to answerpatients' queries or know who torefer to when necessary.

Acceptance of patients

Whilst a health professional has theright to accept or refuse to treat apatient, it is important that thedental profession accepts theresponsibility of providing dentaltreatment to all members of thecommunity. Dental clinicians have ageneral obligation to provide care tothose in need and this should extendto infected patients who should beoffered the same high standard ofcare available to any other patient.

Those with human immuno-deficiency viruses (HIV), who areotherwise well, and carriers of thehepatitis viruses may be treated

routinely in a primary care setting(general dental practice, communitydental service, for example). Theevidence indicates that, in theabsence of an inoculation injury, therisk of infection to a dental healthcare worker during the dentaltreatment of HIV-infectedindividuals is negligible. HIV-infected individuals need a highstandard of dental care when theyare asymptomatic to minimisedental problems. If theysubsequently develop AcquiredImmune Deficiency Syndrome(AIDS) it may be appropriate forthem to be referred for specialistadvice and care.

It is unethical to refuse dental care tothose patients with a potentiallyinfectious disease on the groundsthat it could expose the dentalclinician to personal risk. It is alsoillogical as many undiagnosedcarriers of infectious diseases passundetected through practices andclinics every day. If patients arerefused treatment because they areknown carriers of an infectiousdisease, they may not report theirconditions honestly or abandonseeking treatment; both results areunacceptable. Those who reveal thatthey are infected are providingprivileged information.

Confidentiality

All information disclosed by apatient in the course of medical

© BDA February 2003

Infection control in dentistry bda advice sheet A124

‘the sameinfectioncontrol

proceduresmust be

used for allpatients’

bda advice sheet A12 Infection control in dentistry 5

history taking, consultation andtreatment is confidential. No part ofthe information obtained shouldever be disclosed to any third party,including relatives, without thepatient's permission. Dentists areresponsible for the security ofinformation given by patients,whether it is written on record cardsor held on computer. All membersof the dental team should be awareof the duty of strict confidentialityand seek to ensure it at all times. It isstrongly recommended thatpractices have a confidentialitypolicy in place and that contracts ofemployment for dental staff includea statement on the need to maintainconfidentiality.

The infected dental health careworker

All health care workers have anoverriding ethical and legal duty toprotect the health and safety of theirpatients and those who carry outexposure-prone procedures shouldbe immune to or non-infectious forhepatitis B (page 11). A dentalclinician who believes he or she maybe infected with a blood borne virusor other infection has an ethicalresponsibility to obtain medicaladvice, including any necessarytesting. If a clinician is found to beinfected, further medical advice andcounselling must be sought. Changesto clinical practice may be requiredand may include ceasing orrestricting practice, the exclusion ofexposure-prone procedures or othermodifications. An infected clinicianmust not rely on his/her ownassessment of the possible risks totheir patients. Failure to obtainappropriate advice or act upon theadvice given would almost certainlylead to a charge of seriousprofessional misconduct (GDC.Maintaining standards. November1997, as amended May 2001).

Exposure-prone procedures arethose invasive procedures wherethere is a risk that injury to theworker may result in exposure of thepatient's open tissues to the blood ofthe worker. These includeprocedures where the worker'sgloved hands may be in contact withsharp instruments, needle tips and

sharp tissues (spicules of bone orteeth) inside a patient's open bodycavity, wound or confinedanatomical space where the hands orfingertips may not be completelyvisible at all times.

A dentist who employs a dentalnurse who is subsequently found tobe infected with a blood borne virusmust undertake a risk assessment todetermine whether there is a risk topatients and whether the dentalnurse should be redeployed withinthe practice. The risk assessmentmust take into account the dutiesperformed by the dental nurse andthe likelihood that the infectioncould be transmitted to a patient oranother member of staff. An infecteddental nurse must not undertakeexposure prone procedures in orderto remove, as far as is possible, therisk of transmitting infection. Theremay be employment issues that needto be considered and advice shouldbe sought from the employmentadvisers at the BDA.

Infection controlin dentistryMembers of the dental team have aduty to ensure that infection controlprocedures are followed routinely.The mouth carries a large number ofpotentially infective micro-organisms; saliva and blood areknown vectors of infection. Mostcarriers of latent infection areunaware of their condition and it isimportant, therefore, that the sameinfection control routine is adoptedfor all patients.

The following recommendations forinfection control procedures inroutine dental practice are made inlight of current knowledge and maybe subject to revision, as furtherinformation becomes available.

Training in infection control

All dental staff must be aware of theprocedures required to prevent thetransmission of infection and shouldunderstand why these procedures arenecessary. Regular monitoring of theprocedures is essential and the

infection control policy for thepractice should be reviewed regularlyand updated when necessary.

All new staff must be appropriatelytrained in infection controlprocedures prior to working in thepractice. Training should equip staffto understand –

•• how infections are transmitted

•• the practice policy ondecontamination and infectioncontrol

•• what personal protection isrequired and when to use it

•• what to do in the event ofaccidents or personal injury.

Surgery design

The layout of the surgery, whichshould be simple and uncluttered, isan important aspect of infectioncontrol. There should be two distinctareas: one for the operator and onefor the dental nurse, each with awashbasin, which should haveelbow- or foot-operated taps, andliquid soap dispensers. Theoperator's area would have access tothe turbines, three-in-one syringe,slow handpiece, bracket table andoperating light. The dental nurse'sarea would contain the suction lines,perhaps the three-in-one syringe,curing light, all the cabinetrycontaining dental materials and adesignated area for clinical wastedisposal and the decontamination ofinstruments.

Clean and dirty areas within thesurgery should be clearly defined.Where possible, instruments shouldbe decontaminated away from thesurgery in a room containing theautoclave(s), ultrasonic bath(s),instrument washer(s) and sinks anda separate hand wash basin. Ifinstruments are cleaned manuallybefore sterilisation, the sink must beof sufficient depth to enableinstruments to be fully covered withwater during cleaning to minimisethe risk of splashing.

Ventilation •• the surgery should be well

ventilated; usually an openwindow will suffice but, in somecases, it might be appropriate to


‘All membersof the dentalteam shouldbe aware ofthe duty of

strictconfidentiality’

install an extraction fan

•• ventilation systems shouldexhaust to the outside of thebuilding without risk to thepublic or re-circulation into anypublic building

•• the recommended fresh airsupply rate of ventilation systemsshould not fall below 5-8 litresper second per occupant andshould not create uncomfortabledraughts

•• mechanical ventilation systemsmust be regularly cleaned, testedand maintained according to themanufacturer's recommend-ations to ensure they are freefrom anything that maycontaminate the air

•• recycling air conditioningsystems are not recommended.

Floor covering•• the floor covering should be

impervious and non-slip.Carpeting must be avoided

•• the floor covering should beseam-free; where seams arepresent, they should be sealed

•• the junctions between the floorand wall and the floor andcabinetry should cove or besealed to prevent inaccessibleareas where cleaning might bedifficult.

Work surfaces•• work surfaces should be

impervious and easy to clean anddisinfect – check withmanufacturers on suitableproducts for decontamination

•• work surface joins should besealed to prevent theaccumulation of contaminatedmatter and aid cleaning

•• all work surface junctions shouldbe rounded or coved to aidcleaning.

Choice of equipment

When selecting new equipment, youshould think about –

•• what you want the equipment todo – will the equipment selectedbe fit for this purpose? Is thereany evidence? Is it compatiblewith other equipment in thesurgery?

•• how easy it will be to use andmaintain – is it CE marked (todemonstrate compliance withMedical Devices Regulations)?

•• how easy it is to decontaminate -what are the manufacturer'srecommendations? Whenselecting new hand instrumentsavoid difficult to clean serratedhandles and check that hingesare easy to clean

•• can the material covering thedental chair and worksurfaces becleaned and disinfected regularlywithout deterioration? Checkwith the manufacturer

•• selecting foot controlledequipment whenever possible

•• training – is it required? Will themanufacturer provide it?

Water supplies All water lines and air lines shouldbe fitted with anti-retraction valvesto help prevent contamination of thelines but these valves cannot berelied upon to prevent infectedmaterial being aspirated back intothe tubing.

Most dental unit waterlines willharbour biofilm, which acts as areservoir of microbial contaminationand may be a source of knownpathogens (Legionella spp, forexample). A bottled water systemcan help to control microbialcontamination – disinfectants can beintroduced into the water supply toreduce the microbial load. Themanufacturer's advice on the typeand strength of disinfectant shouldbe followed.

The design of some dentalequipment requiring a water supplymeans that it is possible forcontaminated water to be drawnback through the waterlines to themains water supply (backflow/backsiphonage). Interrupting thewater supply to the surgery by aphysical break (air gap) will preventthe possibility of backflow. Someequipment requiring a water supplyis now manufactured to incorporatean air gap – check this with themanufacturer.

Decontamination of instrumentsand equipment

All instruments contaminated withoral and other body fluids must bethoroughly cleaned and sterilisedafter use. Instruments selected for atreatment session but not used mustbe regarded as contaminated. Thereare three stages to the decontamin-ation process: pre-sterilisationcleaning, sterilisation and storage.Manufacturers are now required toprovide instructions for thedecontamination of their equipment- these instructions should befollowed. It is worth checking withthe manufacturers prior to purchasethat equipment can be used for thepurpose intended anddecontaminated by the methods usedin the practice.

A systematic approach to thedecontamination of instrumentsafter use will ensure that dirtyinstruments are segregated fromclean. The flow diagram (right)shows a possible approach.



‘worksurfaces

should beimperviousand easy toclean anddisinfect’


Pre-sterilisation cleaning

Used instruments are often heavilycontaminated with blood and salivaand must be completely cleanedbefore sterilisation. Instruments canbe cleaned by hand, in an ultrasonicbath or using an instrumentwasher/disinfector – do check withthe manufacturer that instrumentscan withstand ultrasonic cleaningand automated processing.Ultrasonic cleaners and washer/disinfectors are preferred over handcleaning instruments as they aremore efficient and contact withcontaminated instruments is kept toa minimum thereby reducing thelikelihood of inoculation injuries.

After cleaning, all instruments mustbe examined thoroughly and, ifthere is residual debris, re-cleaned.

Hand cleaning of dentalinstruments is the least efficientcleaning method. If this method isused, however, the instrumentsshould be fully immersed in a sinkpre-filled with warm water anddetergent and a long-handledkitchen-type brush used to removedebris. Instruments should bewashed under water with the sharpend of the instrument held awayfrom the body; extra care must betaken when cleaning instrumentsthat are sharp at both ends. Thickwaterproof household gloves mustbe worn to protect against accidentalinjury and protective eyewear toshield against splashing. The brushused to remove debris from theinstruments should be cleaned andautoclaved at regular intervals – atthe end of each clinical session, forexample. Cleaned brushes should bestored dry.

Ultrasonic cleaners should be usedand serviced according to themanufacturer's instructions andshould contain a detergent not adisinfectant – disinfectant solutionsalone can precipitate proteins andmake them resistant to removal. Docheck the manufacturer'srecommendations. The liquid in theultrasonic cleaners should bedisposed of at the end of eachclinical session and more often if itappears heavily contaminated.Ultrasonic cleaners with baskets are

preferred. The cleaning cycle shouldnot be interrupted to add furtherinstruments. At the end of each day,the ultrasonic cleaner must beemptied, cleaned and left dry.

Washer/disinfectors designed forcleaning instruments are nowavailable and, if used, themanufacturer's instructions shouldbe followed. Washer/disinfectors aremore efficient at pre-sterilisationcleaning than ultrasonic cleanersand hand cleaning but must not beused as a substitute for sterilisationprocedures.

Sterilisation

The method of choice for thesterilisation of all dental instrumentsis autoclaving. Sterilisation should beperformed at the highest temperaturecompatible with the instruments inthe load. For dental instruments andequipment, autoclaves should reach atemperature of 134-137oC for threeminutes. New autoclaves should havean integral printer to allow theparameters reached during thesterilisation cycle to be recorded forroutine monitoring. Hot air ovens,ultra violet light, boiling water andchemiclaves are not recommendedfor sterilising dental instruments andequipment.

Effective sterilisation depends onsteam condensing on all surfaces ofthe instruments in the load to be

autoclaved, so it is essential thatinstruments be placed to allow freecirculation of steam; the autoclavechamber must not be overloaded.The sterilisation process is impairedor prevented by air remaining in thechamber or trapped in the loaditems. Air is removed from theautoclave chamber by either beingdisplaced downwards by steam orby evacuating the air to create avacuum before steam is introducedinto the chamber. For many years,downward displacement autoclaveswere the only autoclaves used in adental surgery; they are stillconsidered an acceptable means ofsterilising dental instruments andequipment.

More recently, however, vacuum-phase autoclaves have becomeavailable to dentists in generalpractice. Dentists consideringpurchasing a vacuum-phaseautoclave should ensure that it iscapable of sterilising the intendedload items (various types areavailable and not all are suitable forprocessing dental equipment). Theautoclave should be equipped onlywith cycles providing a pre-sterilisation vacuum stage tominimise the possibility of anincorrect cycle being selected – and aconsequent failure to sterilise theload.

Processing wrapped instruments in aconventional downward


Procedure for the decontamination of instruments

contaminated instrument

initial cleaning (by hand, ultrasonic bath or washer/disinfector)

INSPECT

debris visible clean

sterilise

store clean

displacement autoclave may result ininadequate air removal and failure tosterilise. Wrapped instruments andinstruments in pouches must besterilised using a vacuum-phaseautoclave.

There continues to be some debateabout the effective decontaminationof handpieces. In theory, a vacuum-phase autoclave will remove the airfrom the lumen of a dentalhandpiece, allowing steam topenetrate. The presence oflubricating oil, however, maycompromise the sterilisation process.Current opinion is that effective pre-sterilisation cleaning of dentalhandpieces and subsequentprocessing in a properly functioningdownward displacement autoclave isacceptable.

All autoclaves must be regularlyserviced and maintained accordingto the manufacturer's recommen-dations and periodically inspected(usually annually) to ensure theintegrity of the associated pipework.Vacuum-phase autoclaves are morecomplicated than conventionalsteam sterilisers and require morerigorous testing by the user todemonstrate that they functioncorrectly (MDA, October 2000, DB2002/06 gives more detail on this). Ifyou are considering purchasing avacuum-phase autoclave, you mustbe aware of all the user tests that youwill be required to perform andrecord on a regular basis. Yourservice and maintenance agreementshould cover the anticipatedresponse time in the event that theautoclave breaks down ormalfunctions.

At the end of each day, the residualwater should be drained from theautoclave chamber and reservoir,which should then be cleaned andleft open to dry overnight. Manyautoclaves now incorporate a facilityfor draining residual water. A drainvalve can be retro-fitted to manyautoclaves that do not have anintegral drainage device. As a lastresort, the high volume suction unitmay be used (if it is convenientlyplaced). If this is necessary, theautoclave should not be moved orlifted unless it can be done safely andwithout risk of injury.

It is important that the water used inthe autoclave should contain nominerals that may cause damageand, to ensure the integrity of thesterilisation cycle, it should be free ofpathogens and endotoxins (pyrogenfree).

Successful sterilisation dependsupon the consistent reproducibilityof sterilising conditions –

•• autoclaves must be validatedbefore use and theirperformance monitoredroutinely (by periodic testing,including daily and weekly usertests)

•• the equipment must be properlymaintained according to themanufacturer's instructions

•• correct operation of theautoclave must be checkedwhenever the autoclave is usedby recording the readings(physical parameters) on theautoclave's instruments orprintout at the beginning of eachclinical session

•• the readings should becompared with therecommended values – if anyreading is outside its specifiedlimits, the sterilisation cyclemust be regarded asunsatisfactory, irrespective of theresults obtained from chemicalindicators, and the autoclavecycle checked again. If thesecond cycle is unsatisfactory,

the autoclave should not be useduntil the problem has beenrectified by an engineer

•• autoclave logs and printoutsshould be retained forinspection and monitoring - todemonstrate that the autoclave isperforming within therecommended parameters.

Chemical and biological indicatorsdo not demonstrate sterility of theload. Chemical indicators serve onlyto distinguish loads that have beenprocessed in an autoclave from thosethat have not. Biological indicatorsare of limited value in moist heatsterilisation and can only be regardedas additional to the measurement ofphysical parameters.

Handpieces must be cleaned andautoclaved after each patient. Pre-sterilisation cleaning machines arerecommended. Those using analcohol/disinfectant combination ora washing cycle must only be used todisinfect handpieces on themanufacturer's advice. Thesemachines do not replace thesterilisation process.

Decontamination of handpiecesIf a cleaning machine is not used, thefollowing protocol should beadopted for the pre-sterilisationcleaning of handpieces:

•• leave the bur in place duringcleaning to preventcontamination of the handpiece



‘Allautoclavesmust beregularlyserviced

andmaintained’


bearing

•• clean the outside of thehandpiece with detergent andwater – never clean or immersethe handpiece in disinfectant

•• remove the bur

•• if recommended by themanufacturer, lubricate thehandpiece with pressurised oiluntil clean oil appears out of thechuck and clean off excess oil

•• sterilise in an autoclave

•• if recommended by themanufacturer, lubricate thehandpiece after sterilisation andrun it briefly before use to clearexcess lubricant

•• the oil used for pre-sterilisationcleaning/lubrication should notbe the same as used for post-sterilisation lubrication; eithertwo canisters should be used orthe nozzle changed betweenapplications.

Instrument storage

Sterilised instruments should bestored in dry, covered conditions –trays with lids are now available forthis purpose. Sterilised instrumentsshould not be stored in a

disinfectant or antiseptic solution.Pouches can be useful for storinginfrequently used instruments suchas extraction forceps and elevators.Pouches with a clear side allowinstruments to be easily identifiedbefore opening.

The instruments necessary fortreatment should be selected prior tothe treatment session. If additionalinstruments are needed duringtreatment, care must be taken toavoid the cross contamination ofother instruments. Tray systems canhelp with this.

Single use (disposable) items

Equipment that is described by themanufacturer as 'single use' shouldbe used whenever possible anddiscarded after use, never reused.'Single use' means that a device canbe used on a patient during onetreatment session and thendiscarded. These items include, butare not limited to, local anaestheticneedles and cartridges, scalpel blades,saliva ejectors, matrix bands,impression trays and beakers.Disposable towels are recommended.Items such as three-in-one tips aredifficult to decontaminate effectivelyand can now be bought as disposableitems.

Surface cleaning and disinfection

Surfaces of dental units must beimpervious as they may becomecontaminated with potentiallyinfective material. When selectingequipment, consider the ease withwhich the surfaces can be cleanedand disinfected. Check with themanufacturer that the surfaces areresistant to common disinfectants.The manufacturer may recommendthe use of a particular disinfectant;ensure that it will destroy ordeactivate all viruses, bacteria andfungi.

Protect light and chair hand controlswith disposable imperviouscoverings and change betweenpatients. If these are not used, thecontrols must be effectivelydecontaminated between patients asdescribed below.

A strict system of zoning aids andsimplifies the decontamination

process. In practice, this meansdefining the areas, which willbecome contaminated duringoperative procedures; only theseareas need to be cleaned anddisinfected between patients. Asurgery can, as a result, be cleanedrapidly. In addition, between clinicalsessions, all work surfaces, includingthose apparently uncontaminated,should be thoroughly cleaned anddisinfected.

Effective surface decontamination isa two-stage process of cleaning anddisinfection to reduce the microbialload to a minimum –

•• clear the work surface ofinstruments, materials, patients'notes etc

•• cleaning is achieved by applyinga detergent liquid to the surfaceand physically wiping the areawith a generous application ofelbow grease!

•• the surface can then bedisinfected with a disinfectantthat will destroy or deactivate allmicrobes. Disinfectant solutionsmust be made up and usedaccording to the manufacturer'sinstructions

•• disinfectants containing alcoholmay be flammable and shouldnot be used near a naked flame

•• protective gloves must be wornand eyes must be protected

•• good general ventilation willhelp to minimise inhalation.

All aspirators, drains and spittoonsshould be cleaned after every sessionwith a surfactant/detergent (to breakdown the biofilm) and a non-foaming disinfectant. Portableaspirators with reservoir bottles arenot recommended; they are notfitted with filters and pose aconsiderable hazard when disposingof the contents.

Decontamination of instrumentsand equipment prior to serviceor repair

There is a statutory duty to ensureinstruments and equipment are safefor repair. In practice, this meansthat handpieces and otherinstruments must be cleaned andsterilised before being sent for repairand a statement confirming thismust accompany the equipment.


‘'single use'should be

usedwheneverpossible’


Equipment that cannot be sterilisedmust be thoroughly cleaned anddisinfected in accordance with themanufacturer's instructions.

Decontamination of impressionmaterials and prosthetic andorthodontic appliances

The responsibility for ensuringimpressions and appliances havebeen cleaned and disinfected prior todispatch to the laboratory lies solelywith the dentist –

•• immediately on removal fromthe mouth, the impression orappliance should be rinsed underrunning water to remove saliva,blood and debris

•• continue the process until it isvisibly clean. If an appliance isgrossly contaminated, it shouldbe cleaned in an ultrasonic bathcontaining detergent and thenrinsed

•• the impression or applianceshould be disinfected accordingto the manufacturer'srecommendations. Genericmaterials such as sodiumhypochlorite (household bleach)may no longer be suitable fordisinfecting impressions unlessspecifically recommended by themanufacturer

•• disinfectants should not besprayed onto the surface of theimpression; it lessens theeffectiveness and creates aninhalation risk. Immersion of theimpression is recommended

•• the impression or applianceshould be rinsed again in waterbefore sending to the laboratoryaccompanied by a confirmationthat it has been disinfected.

Products that are suitable for thedisinfection of impressions orappliances are CE marked todemonstrate conformity toEuropean Directives. Themanufacturer's recommendationsfor the dilution of the disinfectantand immersion time must befollowed.

Disposal of clinical waste

All waste in the practice should besegregated into clinical and non-clinical waste –

•• clinical waste is waste that iscontaminated with blood, salivaor other body fluids and mayprove hazardous to any personcoming into contact with it

•• clinical waste sacks must be nomore than three-quarters full,have the air gently squeezed outto avoid bursting when handledby others, labelled and tied at theneck, not knotted

•• sharps waste (needles and scalpelblades) must be sealed in UNtype approved puncture-proofcontainers (to BS 7320), whichmust be labelled before disposal

•• local anaesthetic cartridges,whether partially discharged(hazardous) or fully dischargedmust always be disposed of viathe sharps container

•• sharps containers should bedisposed of when no more thantwo-thirds full

•• clinical waste and sharps wastemust be stored securely beforecollection for final disposal -usually by high temperatureincineration

•• clinical waste must only becollected for disposal by aregistered waste carrier whoholds a certificate of registration

•• when waste is collected fordisposal, a transfer note must becompleted and signed by bothparties. The transfer noteprovides the dentist withevidence that the waste will bedisposed of in the correctmanner

•• repeated transfers of the samekind of waste between the sameparties can be covered by onetransfer note for up to one yearbut a copy must be kept for twoyears.

Some primary care trusts have localarrangements for the collection anddisposal of clinical waste; otherwisearrangements for the collection ofclinical waste should be made with aprivate contractor.

Partially used local anaestheticcartridges are regarded as hazardouswaste and are subject to additionaldisposal controls; when the waste iscollected, consignment notes mustbe completed and kept for three

years. If a local anaesthetic cartridgeis fully discharged, however, it is notregarded as hazardous waste and canbe disposed of as clinical waste viathe sharps container. If partiallydischarged local anaestheticcartridges are disposed of via thesharps container, the container mustbe disposed of as hazardous waste.

Amalgam filled extracted teethcannot be discarded via the sharpscontainer, as amalgam must not beincinerated. These teeth should bedisposed of with waste amalgam butcare should be taken as the teeth willbe contaminated with blood. Wastecollection agencies often producespecial containers for the disposal ofamalgam filled teeth. It is possible tosend amalgam filled teeth (and nonfilled teeth) through the post touniversities for teaching and researchpurposes but the patient's consentmust be obtained first (and recordedin the clinical records). It isimportant to ensure that extractedteeth that are sent through the postare first decontaminated andpackaged securely to avoid thepackage being split open duringtransit. Some dental schools providea container and disinfectant suitablefor decontamination, storage andtransport.

A dentist who fails to dispose ofwaste in a safe manner will faceprosecution by the authorities(Environmental HealthDepartments, Health and SafetyExecutive etc) and may be liable toproceedings for serious professionalmisconduct before the GeneralDental Council. Clinical waste andhazardous waste must never bedisposed of at local refuse tips orlandfill sites.

Blood spillages

If blood is spilled – either from acontainer or as a result of anoperative procedure – the spillageshould be dealt with as soon aspossible. The spilled blood should becompletely covered either bydisposable towels, which are thentreated with 10,000 ppm sodiumhypochlorite solution or by sodiumdichloroisocyanurate granules. Atleast 5 minutes must elapse beforethe towels etc are cleared and


‘All waste inthe practiceshould be

segregated’


disposed of as clinical waste. Thedental health care worker who dealswith the spillage must wearappropriate protective clothing,which will include household gloves,protective eyewear and a disposableapron and, in the case of anextensive floor spillage, protectivefootwear. Good ventilation isessential.

Biopsy specimens sent throughthe post

Dentists using Royal Mail to sendpatients' non-fixed specimens topathology laboratories fordiagnostic opinion or tests mustcomply with the UN 602 packagingrequirements. The 602 packagingrequirements ensure that strictperformance tests (including dropand puncture tests) have been met.In practice this means –

•• the outer shipping package mustbear the UN packagingspecification marking. Only firstclass letter post, special deliveryor data post services must beused. The parcel post must notbe used

•• every pathological specimenmust be enclosed in a primarycontainer that is watertight andleakproof

•• the primary container must bewrapped in sufficient absorbentmaterial to absorb all fluid incase of breakage

•• the primary container shouldthen be protected by placing it ina second durable watertight,leakproof container

•• several wrapped primarycontainers may be placed in onesecondary container providedsufficient additional absorbentmaterial is used to cushion theprimary containers

•• finally the secondary containershould be placed in an outershipping package which protectsit and its contents from physicaldamage and water whilst intransit

•• the shipping package must beconspicuously labelled 'PACKEDIN COMPLIANCE WITH THEPOST OFFICE INLANDLETTER POST SCHEME'


•• the sender must also sign anddate the package in the spaceprovided

•• information concerning thesample, such as data forms,letters and descriptiveinformation should be taped tothe outside of the secondarycontainer.

A dentist sending a pathologicalspecimen through the post withoutcomplying with the aboverequirements may be liable toprosecution.

Specimens that are 'fixed' are notcovered by these requirements. Thismeans that –

•• specimens should be enclosed ina primary container and sealedsecurely

•• the container must be wrappedin sufficient absorbent materialto absorb all leakage if it isdamaged, and then sealed in aleakproof plastic bag

•• the specimen should then beplaced in a padded bag andlabelled 'PATHOLOGICALSPECIMEN – FRAGILE WITHCARE'

•• the bag must show the name andaddress of the sender to becontacted in case of damage orleakage.

PersonalprotectionThe employing dentist has a duty ofcare towards employees to provide asafe place of work. It is not sufficientsimply to provide personal protectiveequipment such as gloves andglasses; the employer must ensurethat it is being used in the correctmanner. It is important that all staffunderstand the principles ofpersonal protection and thatcompliance is part of their contractsof employment.

Immunisation

All clinical staff should be vaccinatedagainst the common illnesses. Allthose involved in clinical proceduresmust be vaccinated against hepatitisB. If an inoculation injury issustained before completion of thecourse, follow up action, includingboosters and tests for hepatitis Bmarkers, is essential. The hepatitis Bvaccine is effective in preventinginfection in individuals who producespecific antibodies to the hepatitis Bsurface antigen (anti-HBs). UKexperts recommend that anti-HBslevel of >100 mIU/ml will provideprotection against hepatitis Binfection. It is now clear thatimmunological memory is produced

‘all staffunderstand

theprinciples

of personalprotection’

in those who respond to the primarycourse of the vaccine(>100mIU/ml). Protection againstinfection is maintained even ifantibody concentrations at the timeof exposure have declined.

Anti-HBs levels must be measured2-4 months after completion of theimmunisation course.

A single booster dose five years aftercompletion of the primary course isrecommended for all health careworkers who have contact withblood, blood stained fluids andpatients' tissues. Pre- and post-testing at the time of a booster is notrequired if the individual respondedto the primary course of the vaccine.

Not everyone will respond to thevaccine, however, some because theyare true non-responders, othersbecause they carry the virus. Thosewho fail to respond should undergofurther investigation to establish iftest markers of hepatitis B infection

are present. Investigation toestablish infection should take placebefore booster doses of the vaccineare given in an attempt to achieveanti-HBs levels of at least 100mIU/ml. True vaccine non-responders may remain susceptibleto infection and it is essential thatinoculation injuries be followed upwith tests for hepatitis B markerswhere appropriate.

Dental clinicians and their staffmust have documentary evidence todemonstrate that they have beenimmunised and their response tothe vaccine checked. Where theyhave failed to respond they mustundergo further investigation toexclude the possibility of being highrisk carriers of the hepatitis B virus.The employing dentists must holdevidence of hepatitis B immun-isation; post vaccination blood testresults will show whether anadequate level of immunity hasbeen achieved. The letter (left) maybe helpful, if you are requesting thisinformation from your employee'sgeneral medical practitioner. Doremember that you must have theconsent of your employee beforeyou approach his/her GMP and thatany information provided isconfidential and should be storedappropriately.

Hepatitis B infection in pregnantwomen may result in severe diseasefor the mother and chronic infectionin the new-born. Although infantscan receive active/passiveimmunisation at birth, vaccinationshould not be withheld from apregnant woman if she is likely to beat risk from contracting hepatitis Binfection. Many women havediscovered at a later date that, at thetime of receiving the vaccine, theywere pregnant. In these instances,the vaccine caused no harm tothemselves or their children. Thevaccine also does not affect fertilityand does not prevent breast-feeding.

Hand protection

The care of hands is vital to infectioncontrol; lacerated, abraded andcracked skin can offer a portal ofentry for micro-organisms. Glovesmust be worn for all clinicalprocedures and treated as single use

items so a new pair of gloves must beused for each patient. Gloves shouldbe donned immediately beforecontact with the patient andremoved as soon as clinicaltreatment is complete. Used glovesmust be disposed of as clinical waste.

Recommendations for hand careduring clinical sessions include –

•• removal of rings, jewellery andwatches

•• covering all cuts and abrasionswith waterproof adhesivedressings

•• methodical handwashing using agood quality liquid soappreferably containing adisinfectant – a full handwashand thorough drying isrecommended before donninggloves

•• removing gloves and washinghands after each patient (givesthe hands time to recover frombeing covered)

•• regular use of an emollient handcream to prevent the skin fromdrying, especially after everyclinical session.

There is a variety of gloves available.Those selected should be –

•• good quality non-sterile medicalgloves (to European standardBSEN 455, parts 1 and 2, medicalgloves for single use), worn forall clinical procedures andchanged after every patient

•• well fitting and non-powdered.The powder from gloves cancontaminate veneers andradiographs, disperse allergenicproteins into the surgeryatmosphere and interfere withwound healing

•• ‘hypoallergenic’ and ‘low protein’to reduce the possibility ofallergy.

Allergic contact dermatitis is rarebut, if it develops, it may be seriousenough to cause the person to ceasepractice. If it is suspected, theadvice of a dermatologist should besought. Irritant contact dermatitisis more common and can beavoided by careful choice of gloveand hand disinfectant andmeticulous hand care.

Dear Dr Jones,

You have kindly immunised Jane Smith against

hepatitis B, in line with current recommendations.

As employers, we need to know if Jane has

responded to the vaccine (>100 mIU/ml) and is

protected against hepatitis B. If she failed to

respond, we should know if she is a true non-

responder or if she carries the infection (as this may

affect her day to day duties). In her work routines,

Jane is exposed to blood and saliva and although

we use barrier techniques, it is possible that she

could sustain an inoculation injury from an

instrument used on an infected patient. Knowing

her immune status will allow us to take the most

appropriate action.

Would it be possible for you to confirm her response

to the vaccine or provide us with a copy of her blood

test results, please? Jane has given her consent for

you to release this information to us and has

countersigned the letter.

I look forward to hearing from you in due course.

Yours sincerely,




Increasingly, dentists areencountering patients who areallergic to latex or the chemicalsused in glove manufacture. Non-latex gloves are available butadditional precautions will beneeded to protect the allergic patientagainst contact with latex throughother sources in the surgery – localanaesthetic cartridges, rubber damand protective glasses, for example.A Fact File on Hand dermatitis andlatex allergy is available from theBDA. The advice of a consultantimmunologist may need to besought on the treatment of thepatient.

Eye protection and face masks

Operators and close support clinicalstaff must protect their eyes againstforeign bodies, splatter and aerosolsthat may arise during operativedentistry, especially during scaling(manual and ultrasonic), the use ofrotary instruments, cutting and useof wires and the cleaning ofinstruments. Ideally, protectiveglasses should have side protection.Many modern prescription glasseshave small lenses, which wouldmake them unsuitable for use as eyeprotection. Patients' eyes mustalways be protected against possibleinjury; tinted glasses may alsoprotect against glare from theoperating light.

Masks do not confer completemicrobiological protection but theydo stop splatter from contaminatingthe face. Masks or visors arerecommended for all operativeprocedures and should be changedafter every patient, not pulled downor re-used.

Surgery clothing

A wide variety of clothing is worn indental surgeries and in manypractices is used to reinforce thecorporate image. There is noconsensus view on whether surgeryclothing should have short or longsleeves. Shortsleeves will allow theforearms to be washed as part of thehandwashing routine. Longsleevedcoats or tunics will protect the skinof the arms against splatter. This isimportant if skin is cracked orabraded (as a result of eczema, for

example). Long sleeves, however, aremore likely to become contaminatedduring clinical sessions and couldcause a breach in infection control.Surgery clothing should be made of amaterial that can be machine-washed with a suitable detergent at atemperature of 65oC to eradicate anypotential microbial contamination.

Aerosol and saliva/blood splatter

Good surgery ventilation andefficient high-volume aspirators,which exhaust externally from thepremises, will reduce the risk ofinfection by dispersing andeliminating aerosols. External ventsshould discharge without risk to thepublic or re-circulation into anybuilding. Aspirators and tubingshould be cleaned and disinfectedregularly in accordance with themanufacturer's instructions and thesystem should be flushed through atthe end of each session with theirrecommended surfactant/detergentand/or non-foaming disinfectingagent.

Rubber dam isolation of teeth alsooffers substantial advantages andshould be used whenever practicable.

It enhances the quality of theoperative environment and virtuallyabolishes saliva/blood splatter andaerosols. When working withoutrubber dam, the use of high-volumeaspiration is essential.

Inoculation injuries

Inoculation injuries are the mostlikely route for transmission of bloodborne viral infections in dentistry.The definition of an inoculationinjury includes all incidents where acontaminated object or substancebreaches the integrity of the skin ormucous membranes or comes intocontact with the eyes. The followingare typical examples –

•• sticking or stabbing with a usedneedle or other instrument

•• splashes with a contaminatedsubstance to the eye or otheropen lesion

•• cuts with contaminatedequipment

•• bites or scratches inflicted bypatients.

Inoculation injuries must be dealtwith promptly and correctly –

•• the wound should be allowed tobleed and washed thoroughlywith running water

•• where there is reason to beconcerned about the possibletransmission of infection, theinjured person should seekurgent advice according to thelocal arrangements in place onwhat follow up action, includingserological surveillance, isnecessary. Ideally all practicesshould have formal links with anoccupational health service, sothat management of sharpsinjuries is undertaken promptlyand according to acceptednational protocols

•• every primary care trust will haveat least one designated specialist,for example the Consultant inCommunicable Disease Controlor Consultant MedicalMicrobiologist, who can becontacted for advice on post-exposure prophylaxis. Everypractice should have details ofthe local contact displayedprominently


‘Inoculationinjuriesmust be

dealt withpromptly’


•• when local advice cannot beobtained, advice should beobtained from the followingsources

England: the duty doctor at thePHLS Communicable DiseaseSurveillance Centre, 61 ColindaleAvenue, London NW9 5EQ (Tel: 0208200 6868)

Scotland: Scottish Centre forInfection and Environmental Health(SCIEH), Clifton House, CliftonPlace, Glasgow G3 7LN (Tel: 0141300 1100)

Wales: PHL Cardiff, The UniversityHospital of Wales, Heath Park,Cardiff CF14 4XW (Tel: 02920742718)

Northern Ireland: Director ofPublic Health at your local Healthand Social Services Board

•• a full record of the incidentshould be made in the accidentbook and include details of whowas injured, how the incidentoccurred, what action was taken,which dentists were informedand when and, if known, thename of the patient beingtreated. Both the injured personand the dentist in charge shouldcountersign the record.

The risk of acquiring HIV infectionfollowing an inoculation injury issmall. If the injury is risk-assessed assignificant for transmission of HIV(see Table) and the source patient isHIV infected, the use of anti-retroviral drugs taken prophylac-tically as soon as possible afterexposure – ideally within one hour –is recommended. Post-exposure

prophylaxis (PEP) involves the use ofa short course (four weeks) oftreatment with anti-retroviral drugsin an attempt to reduce even furtherthe risk of infection with HIVfollowing exposure. Dentists shouldclarify local arrangements for urgentaccess to PEP, with the help of anoccupational health department or aconsultant in communicable diseases,before any incident occurs.

EmerginginfectionsTransmissible SpongiformEncephalopathies

Creutzfeldt-Jakob disease (CJD),including sporadic, familial,iatrogenic and variant CJD, belongsto the family of diseases known asTransmissible SpongiformEncephalopathies (TSEs), along withthe related conditions Gerstmann-Straussler-Scheinker disease (GSS),kuru and fatal familial insomnia.TSEs are a very rare cause of a formof dementia, which is generally rapidin its progression. The incubationperiod of CJD is unknown but datafrom kuru suggests that TSEs canhave very long incubation periods(up to several decades).

Early in 1996, the National CJDSurveillance Unit in Edinburghidentified a form of CJD that

differed from previouslyrecognised types of the disease.The patients affected were usuallyyounger, their symptoms weredifferent and the appearance oftheir brain tissue after death wasdifferent from that seen with otherforms of CJD. The disease wasinitially labelled "new variant CJD"(nvCJD) and is now known as"variant CJD" (vCJD). TheSpongiform EncephalopathyAdvisory Committee (SEAC)concluded that the most likelyexplanation for the emergence ofvCJD was that it had beentransmitted to people throughexposure to Bovine SpongiformEncephalopathy (BSE).

Transmission of a form of CJD(not vCJD) has also beenassociated with human derivedpituitary growth hormones anddura mater brain grafts.

Dental interest in Creutzfeldt-Jakobdisease and the related conditionscentres on the risk of theirtransmission from patient to patientin the course of dental treatmentthrough contaminated instruments.There is no known case of thishappening and appropriate dentalinfection control precautions willreduce the scope of the theoreticalrisk. It is not yet known whetherCJD can be transmitted via blood orother tissues encountered duringdental surgery.

Procedure for dealing with sharps injuries

Record incident in accident book

INJURY

allow wound to bleed but do not scrub allow wound to bleed but do not scrub

wash thoroughly in ruwater and cover a waterproof plar

wash thoroughly in runningwater and cover with a waterproof plaster

assess hepatitus B antistatus of victim and estviral carriage status of sc patient. If reason for con

assess hepatitus B antibody status of victim and establish viral carriage status of sourcepatient. If reason for concern

refer to infectious disease physician or consultant microbiologistrefer to infectious disease physician or consultant microbiologist

Factors associated with HIV transmission

Deep injury to the health care worker

Visible blood on the device causing injury

Device previously placed in source�patient's vein or artery

Source patient within last 60 days of life�(i.e. late stage AIDS)



CJD and related conditions raisenew infection control questionsbecause 'prions', the infectiousagents that cause them, are muchmore difficult to destroy thanconventional micro-organisms, sooptimal decontaminationstandards need to be observed. Asa universal precaution, allinstruments should be thoroughlycleaned before autoclaving, inorder to remove as much matter aspossible.

Guidance on the prevention oftransmission is available in thedocument Transmissible SpongiformEncephalopathy Agents: safe workingand the prevention of infectionproduced by the AdvisoryCommittee on Dangerous Patho-gens. This guidance will be availableon the Department of Healthwebsite http://www.doh.gov.uk/cjd/and will be updated as necessary.Dentists will be informed ofsignificant changes through theChief Dental Officer's Digest, whichis sent to all dentists in England andis also available on the Departmentof Health website.

Methicillin-resistantStaphylococcus aureus (MRSA)

Methicillin-resistantStaphylococcus aureus (MRSA) is abacterium that is resistant tocommon antibiotics but is notmore pathogenic than otherstrains of S. aureus. MRSA doesnot colonise normal skin. Itcolonises the nose, axillae andperineum, and abnormal skin(wounds, ulcers and eczematousskin, for example). MRSA may befound in patients who arehospitalised or who have beendischarged from hospital into thecommunity. It is not normallyfound in the oral cavity but mayoccasionally be isolated from oralinfections.

No special infection controlprecautions are necessary for thedental treatment of patientscolonised with MRSA. However,dentists or ancillary staff colonisedwith MRSA should not undertakeor assist with invasive procedures.A microbiologist or communicabledisease physician will be able to

provide treatment to eradicate theMRSA colonisation.

Tuberculosis

The incidence of all forms oftuberculosis (TB) is rising and nowapproximately one third of theworld's population is infected. Thedisease is spread by droplets or bydirect contact and has beentransmitted by dental procedures.Although Mycobacterium tuberculosisis the usual cause of TB, other speciesof mycobacterium can also cause thedisease. The infection controlprocedures described in thisdocument should be adequateprotection against transmission ofTB.

Infection controlpolicyEach practice must have a writteninfection control policy. The policyshould describe the practice policy forall aspects of infection control andprovide a useful guide to the trainingnecessary for each member of staff tobe competent and confident in itsimplementation. All members of thedental team must know who is

responsible for ensuring certainactivities are carried out and to whomto report any accidents or incidents.Accidents and incidents should alwaysbe recorded in the accident book.Some accidents and incidents must bereported to the Health and SafetyExecutive; for further information onthis see the BDA's advice sheet onHealth and Safety Law for DentalPractice (A3). Accidents and incidentsinvolving the failure of dentalinstruments or equipment should bereported to the MDA.

Although a policy will describe theprocedure for the practice as a whole,it is useful for each member of staff toreceive a copy and to sign adeclaration to confirm that the policyhas been received and trainingprovided – for example, "I confirmthat I have read the practice InfectionControl Policy and have receivedtraining in all its aspects". A copy ofthe policy should be displayed in eachsurgery.

It is a good idea to discuss infectioncontrol at practice staff meetings.Open discussion will allowmisunderstandings to be addressedand ensure everyone in the practiceapproaches infection control in thesame way.


‘discussinfectioncontrol atpractice

staffmeetings’


Practice infection control policyInfection control is of prime importance in this practice. It is essential to the safety of our patients, ourfamilies and us. Every member of staff will receive training in all aspects of infection control, includingdecontamination of dental instruments and equipment, and the following policy must be adhered to atall times. If there is any aspect that is not clear, please ask .......................................................

You might not be the only person who is unclear and it is useful to discuss the policy frequently toensure that we all understand its implications. Remember, any of our patients might ask you about thepolicy, so make sure you understand it.

1 All staff must be immunised against hepatitis B and a record of their hepatitis B seroconversion held by thepractice owner. For those who do not seroconvert or cannot be immunised medical advice and counsellingwill be sought. In these cases it may be necessary to restrict their clinical activities.

2 The practice provides protective clothing, gloves, eyewear and masks that must be worn by dentists andPCDs during all operative procedures. Protective clothing worn in the surgery should not be worn outsidethe practice premises.

3 Before donning gloves, hands must be washed using ................…….. Any glove that becomes damaged mustbe replaced and a new pair of gloves must be used for each patient.

4 Before sterilisation, re-usable instruments should be cleaned either by placing in the ultrasonic cleaner orwasher/disinfector or washed in a designated area by hand under water using a long-handled brush. Inspectinstruments for residual debris and re-clean if necessary. Instruments are then rinsed under running waterbefore being sterilised using an autoclave. Heavy-duty gloves and eye protection must be worn whenhandling and cleaning used instruments. All instruments that have been potentially contaminated must besterilised. Single-use items must not be decontaminated and re-used.

5 Sterilised instruments should be stored in covered trays / pouches.

6 Working areas that have instruments placed on them during treatment will be kept to a minimum, clearlyidentified and, after each patient, cleaned with ………….……. (detergent) and disinfected using......................................

7 Needles should be re-sheathed only using the re-sheathing device provided. Needles, scalpel blades, LAcartridges, burs, matrix bands etc shall be disposed of in the yellow sharps container. This must never bemore than two-thirds full.

8 All clinical waste must be placed in the appropriate sacks or bins provided in each surgery. The sack must besecurely fastened when three quarters full and stored in the designated area.

9 All dental impressions must be rinsed until visibly clean and disinfected using ………………...……… (asrecommended by the manufacturer) and labelled as 'disinfected' before being sent to the laboratory.Technical work being returned to the laboratory should also be disinfected and labelled.

10 In the event of an inoculation injury, the wound should be allowed to bleed, washed thoroughly underrunning water and covered with a waterproof dressing. The incident should be immediately discussed with…………................ to assess whether further action is needed. Advice on post-exposure prophylaxis can beobtained from……………………………….. Record the incident in the accident book.

11 Any spillages involving blood or saliva or mercury will be reported to ................................

12 Anyone developing a reaction to protective gloves or a chemical must inform ................ immediately

13 ALL STAFF WILL OBSERVE TOTAL CONFIDENTIALITY OF ALL INFORMATION RELATING TOPATIENTS OF THE PRACTICE

Date................................................................Review date................................................................


Infection control checklist


At start of day/session

Fill the autoclave reservoir andrun the autoclave for a completecycle

Record the sterilisationparameters reached in yourautoclave logbook

Compare these with themanufacturer's recommendedparameters

Before patient treatment

Ensure that all equipment hasbeen sterilised or adequatelydisinfected (if it cannot besterilised)

Put disposable coverings in placewhere necessary

Place only the appropriateinstruments on bracket table

Set out all materials and otheressential instruments

Update patient's medical history

During patient treatment

Treat all patients as potentiallyinfectious

Wear gloves, masks and

protective eyewear andprotective clothing

Provide eye protection forpatient

Wash hands before gloving; anew pair of gloves must be usedfor each patient

Change gloves immediately ifthey are torn, cut or punctured

Use rubber dam to isolate whereappropriate

Use high-volume aspiration

Ensure good general ventilationof the treatment area

Handle sharps carefully and onlyre-sheath needles using asuitable device

After patient treatment

Dispose of sharps via the sharpscontainer

Segregate and dispose of clinicalwaste

Clean and inspect allinstruments to ensure visiblyclean before placing in anultrasonic cleaning machine orwasher/disinfector

Sterilise cleaned instrumentsusing an autoclave and storecovered

Clean and disinfect allcontaminated work surfaces

Clean and disinfect impressionsand other dental appliancesbefore sending to laboratory

Prepare surgery for next patient

At the end of each session

Dispose of all clinical waste fromthe surgery area

Clean and disinfect all worksurfaces thoroughly

Disinfect the aspirator, its tubingand the spittoon

Clean the chair and the unit

Empty and clean ultrasoniccleaning machine and leave todry.

At the end of the day

Drain autoclave chamber andwater reservoir to remove allresidual water and leave to dry



The following websites provide informationabout decontamination and associated subjects:

http://www.bda-dentistry.org.uk/The British Dental Association website

http://www.gdc-uk.org/The General Dental Council website details the ethicalobligations of UK dental practitioners

http://www.doh.gov.uk/The Department of Health's website on which you willfind information on health and social care guidance,publications and policy

http://www.nhsestates.gov.uk/NHS Estates website. NHS Estates is an executiveagency of the Department of Health

www.decontamination.nhsestates.gov.uk/Recently established site to develop the NHS Estatesdecontamination agenda

http://www.show.scot.nhs.uk/On line health information from NHS Scotland

http://www.wales.gov.uk/subihealth/index.htm The Health of Wales Information Service (HOWIS) onthe National Assembly for Wales Internet site

www.dhsspsni.gov.uk/The Northern Ireland Health Department Website

http://www.medical-devices.gov.uk/The Medical Devices Agency Website. Essential readingfor hazard notices and warnings

http://www.defra.gov.uk/ Department for Environment Food and Rural Affairs isthe government department that deals with food, air,land, water and people. Useful information about BSE

http://www.bse.org.uk/The BSE Inquiry website contains the full version of thePhillips report BSE and vCJD

http://www.hse.gov.ukThe Health and Safety Executive website

http://www.ada.org/American Dental Association Website, up-to-date anduseful information

http://www.fdiworldental.org/The FDI World Dental Federation has policy statementson infection control developed for a world audience

http://www.who.int/en/The World Health Organisation site

http://www.immunize.org/index.htmNon-profit organisation to boost immunisation rates andprevent disease. Promotes physician, community, andfamily awareness of, and responsibility for, appropriateimmunisation of all children and adults against all vaccine-preventable diseases

http://www.hepnet.comThe Hepatitis Information Network

http://www.fda.gov/The FDA Website has information about regulatedproducts and agency policies of interest to the medicalcommunity

http://www.cdc.gov/The USA Centres for Disease Control and Prevention(CDC) is responsible for disease prevention and control,environmental health, and health promotion andeducation activities for the United States

http://www.osap.org/ Founded in 1984, OSAP is a group of dentalpractitioners, allied healthcare workers, industryrepresentatives, and other interested persons with acollective mission to promote infection control andrelated science-based health and safety policies andpractices

http://www.apic.org/The USA based Association for Professionals in InfectionControl and Epidemiology. Its purpose is to “influence,support and improve the quality of healthcare throughthe practice and management of infection control andthe application of epidemiology in all health settings”

http://www.icna.co.uk/New UK site for the Infection Control NursesAssociation is now generating some useful informationabout current concerns such as hepatitis C

Useful websites



Hepatitis B Infected Health Care Workers:Guidance on Implementation of Health ServiceCircular 2000/020 -23 June 2000http://www.doh.gov.uk/nhsexec/hepatitisb.htm Issued under cover of Health Service Circular HSC2000/020 http://www.doh.gov.uk/agh/020hsc.pdf

Addendum to HSG(93)40: Protecting health careworkers and patients from hepatitis B (issued undercover of Executive Letter EL(96)77)) 26 September1996. Available from: Blood-borne Viruses Unit,Room 631B, Department of Health, Skipton House,80 London Road, London SE1 6LH

Protecting health care workers and patients fromhepatitis B. Recommendations of the AdvisoryGroup on Hepatitis (issued under cover of HealthService Guidelines HSG(93)40 ) August 1993.Available from: Blood-borne Viruses Unit, Room631B, Department of Health, Skipton House, 80London Road, London SE1 6LH

PHLS Hepatitis Subcommittee. Exposure tohepatitis B virus: guidance on post-exposureprophylaxis. CDR Review Number 9, Volume 2. 14August 1992 pages R97-R103. Available athttp://www.phls.org.uk/publications/cdr/CDRreview/1992/cdrr0992.pdf

Hepatitis C infected health care workers (issuedunder cover of Health Service Circular HSC2002/010. http://www.doh.gov.uk/coinh.htm). 14August 2002. http://www.doh.gov.uk/hepatitisc

Ramsay ME. Guidance on the investigation andmanagement of occupational exposure to hepatitisC. Commun Dis Public Health 1999; 2: 258-262.http://www.phls.co.uk/advice/HepCguidelines.pdf

HIV post-exposure prophylaxis: Guidance from theUK Chief Medical Officers' Expert Advisory Groupon AIDS. July 2000. Available athttp://www.doh.gov.uk/eaga/index.htm

Guidance on the management of AIDS/HIV infectedhealth care workers and patient notification.December 1998 (issued under cover of HealthService Circular HSC 1998/226). [Note: Aconsultation on revised guidance has recently beencompleted. See http://www.doh.gov.uk/aids.htm]

Guidance for clinical health care workers:protection against infection with blood-borneviruses. Recommendations of the Expert AdvisoryGroup on AIDS and the Advisory Group on Hepatitis(issued under cover of Health Service Circular HSC1998/063). 15 April 1998. Available athttp://www.doh.gov.uk/pub/docs/doh/chcguid1.pdfand from: Blood-borne Viruses Unit Room 631B,Department of Health, Skipton House, 80 LondonRoad, London SE1 6LH

Immunisation against Infectious Disease 1996:Department of Health, Welsh Office, Scottish OfficeDepartment of Health, DHSS (Northern Ireland)(Green Book). September 1996. Available athttp://www.doh.gov.uk/greenbook/index.htm andfrom HMSO - ISBN 0-11-321815-X.

Sources of further information


British Dental Association ● 64 Wimpole Street ● London W1G 8YS ● Tel: 020 7563 4563 ● Fax: 020 7487 5232

● E-mail: [email protected] ● © BDA February 2003


Documents

advicesheet infectioncontrolindentistry A › resources › bda-cross-infection.pdf · infection control routine is adopted for all patients. The following recommendations for infection