I n f e c t i o n C o n t ro l in th e

D ental O ff i c e
a, b a
Francesco R. Sebastiani, DMD *, Harry Dym, DDS , Tarun Kirpalani, DDS

KEYWORDS
 Hand hygiene  Blood-borne pathogens  Personal protective equipment
 Sterilization and disinfection  Environmental infection control

KEY POINTS
 The Centers for Disease Control and Prevention (CDC) has developed infection control
guidelines intended to improve the effectiveness and impact of public health interventions
and inform clinicians, public health practitioners, and the public.
 This article highlights current scientific rationale and technique for performing proper
infection control practices in the dental office.
 Although the principles of infection control remain unchanged, new technologies, mate-
rials, equipment, and data require continuous evaluation of current infection control
practices.

WHY IS INFECTION CONTROL IMPORTANT IN THE DENTAL OFFICE?

During dental treatment, both patients and dental health care personnel (DHCP) can
be exposed to pathogens through contact with blood, oral and respiratory secretions,
and contaminated equipment. Following recommended infection control protocols
described in the 2003 CDC guidelines and 2016 CDC summary can prevent transmis-
sion of infectious organisms among both patients and DHCP.1 Dental patients and
DHCP may be exposed to a variety of disease-causing microorganisms that are
present within the oral cavity and respiratory tract. These pathogens include
cytomegalovirus, hepatitis B virus (HBV), hepatitis C virus (HCV), herpes simplex virus
types 1 and 2, HIV, tuberculosis (TB), staphylococci including methicillin-resistant
Staphylococcus aureus, and streptococci, among others. The modes of infection of
these organisms in dental settings are through multiple routes:
1. Direct contact of blood, saliva, teeth, or other potentially infectious patient mate-
rials with intact or nonintact skin

a
Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb
Avenue, Brooklyn, NY 11201, USA; b Department of Dentistry and Oral Maxillofacial Surgery,
The Brooklyn Hospital Center, 121 Dekalb Avenue, Box 187, Brooklyn, NY 11201, USA
* Corresponding author.
E-mail address: fsebastiani@tbh.org

Dent Clin N Am 61 (2017) 435–457

http://dx.doi.org/10.1016/j.cden.2016.12.008 dental.theclinics.com
0011-8532/17/ª 2016 Elsevier Inc. All rights reserved.
436 Sebastiani et al

2. Indirect contact with a contaminated object, such as instruments, operatory equip-

ment, or environmental surfaces
3. Direct contact of conjunctival, nasal, or oral mucosa with droplets containing
microorganisms
4. Inhalation of airborne microorganisms that can remain suspended in the air for long
periods of time
Infection through any of these routes requires that all of the following conditions be
present:
 An adequate number of pathogens, or disease-causing organisms, to cause
disease
 A reservoir or source, such as blood, that allows the pathogen to survive and
multiply
 A mode of transmission from the source to the host
 An entrance through which the pathogen may enter the host
 A susceptible host, one who is not immune
The occurrence of all these events is the chain of infection (Fig. 1). Effective infection
control strategies prevent disease transmission by interrupting 1 or more links in the
chain of infection.
The CDC is widely recognized as the leading national public health institute of the
United States. Previous CDC recommendations on infection control for dentistry in
1986 and 1993 described the use of universal precautions to prevent transmission
of blood-borne pathogens. Universal precautions were based on the concept that
all blood and certain body fluids should be treated as infectious because it is impos-
sible to know who may be carrying a blood-borne virus. Thus, universal precautions
should apply to all patients.
The relevance of universal precautions applied to other potentially infectious mate-
rials was recognized, and in 1996, the CDC replaced universal precautions with stan-
dard precautions.1 Standard precautions integrate and expand universal precautions
to include organisms spread by

Fig. 1. The chain of infection.

 Infection Control in the Dental Office 437

 Blood
 All body fluids, secretions, and excretions except sweat, regardless of whether
they contain blood
 Nonintact skin
 Mucous membranes
Standard precautions include respiratory hygiene with cough etiquette, sharp
safety, safe injection practices, sterile instruments and devices, clean and disinfected
environmental surfaces, and the use of personal protective equipment (PPE). Saliva
has always been considered a potentially infectious material in dental infection control;
thus, no operational difference exists in clinical dental practice between universal pre-
cautions and standard precautions.
When standard precautions alone cannot prevent transmission, they are supple-
mented with transmission-based precautions. This second tier of infection prevention
is used when patients have diseases that can spread through contact, droplet or
airborne routes in addition to standard precautions. Despite that most dental practices
are not designed to carry out all transmission-based precautions, DHCP should carry
out systems for early detection and management of potentially infectious patients at
initial points of entry into the dental setting.
Standard precautions include
 Hand washing
 The use of PPE, such as gloves, masks, eye protection, and gowns, intended to
prevent the exposure of skin and mucous membranes to blood and other poten-
tially infectious materials
 Proper cleaning and decontamination of patient care equipment
 Cleaning and disinfection of environmental surfaces
 Injury prevention through engineering controls or safer work practices
The Occupational Safety and Health Administration (OSHA) retains the use of the
term, universal precautions, because they are concerned primarily with transmission
of blood-borne pathogens.

IS HAND HYGIENE THE SINGLE MOST IMPORTANT FACTOR IN PREVENTING THE

SPREAD OF PATHOGENS IN HEALTH CARE SETTINGS?

The CDC estimates that each year approximately 2 million patients in the United
States acquire infections in hospitals, and approximately 90,000 of these infections
result in patient mortalities.1 The hands are the most common mode of pathogen
transmission. Hand hygiene is a general term that applies to routine hand washing,
antiseptic hand wash, antiseptic hand rub, and surgical hand antisepsis.
 Hand washing refers to washing hands with plain soap and water.
 Antiseptic hand wash refers to washing hands with water and soap or other de-
tergents containing an antiseptic agent, such as triclosan or chlorhexidine.
 Using a waterless agent containing 60% to 95% ethanol or isopropanol alcohol-
containing preparation is referred to as an alcohol hand rub.2 These agents are a
new addition to the dental guidelines and have become more frequently used in
the United States to improve compliance with hand washing in hospitals. In
dental practices, however, sinks are readily available and the need for alcohol
preparations is not as great.
 Surgical antisepsis refers to an antiseptic hand wash or alcohol-based hand rub
(if using an alcohol-based hand rub, the hands should first be washed with soap
438 Sebastiani et al

and water) performed preoperatively by surgical personnel to eliminate microor-

ganisms on hands. Antiseptic preparations for surgical hand hygiene should have
persistent (long-lasting) antimicrobial activity.2
Hand washing can reduce the spread of antibiotic resistance in health care settings
and the likelihood of health care–associated infections (Table 1).

Table 1
Methods of hand hygiene

Duration
Method Agent Purpose Area (Minimum)
Routine Water and Remove soil and All surfaces of 15 sb
hand nonantimicrobial transient the hands and
wash soapa (plain soap) microorganisms fingers
Antiseptic Water and Remove or destroy Remove or destroy 15 sb
hand antimicrobial soap transient transient
wash (chlorhexidine, microorganisms microorganisms
iodine and and reduce and reduce
iodophors, resident flora resident flora
chloroxylenol (persistent (persistent
[PCMX], triclosan) activity) activity)
Antiseptic Alcohol-based hand Remove or destroy All surfaces of Until the hands
hand rub rub transient the hands and are dry
microorganisms fingersc
and reduce
resident flora
(persistent
activity)
Surgical Water and Remove or destroy Hands and 2–6 min
antisepsis antimicrobial soap transient forearms
(chlorhexidine, microorganisms
iodine and and reduce
iodophors, resident flora
chloroxylenol (persistent
[PCMX], triclosan) activity)
Water and — — Follow
nonantimicrobial manufacturer
soap (plain soap) instructions for
followed by an surgical hand
alcohol-based scrub product
surgical hand with persistent
scrub product activity
with persistent
activity
a
Use of liquid soap with hands-free dispenser is preferred. Pathogenic organisms have been found
on/or around bar soap during and after use.
b
Reported effective time in removing most transient bacteria flora from skin. A vigorous rubbing
together of all surfaces of premoistened lathered hands and fingers for 15 seconds, followed by
rinsing under a stream of cool water is recommended. Dry hands thoroughly before donning
gloves.
c
Alcohol-based hand rubs should contain 60% to 95% ethanol or isopropanol and should not be
used with visible soil or organic material.
Adapted from Centers for Disease Control and Prevention (CDC). Guidelines for infection control
in dental health-care settings — 2003. MMWR Morb Mortal Wkly Rep 2003;52:161.
 Infection Control in the Dental Office 439

WHAT ARE INDICATIONS FOR HAND HYGIENE?

Hand hygiene substantially reduces potential pathogens on the hands and is consid-
ered a primary measure for reducing the risk of transmitting organisms to patients and
health care personnel (HCP). Hospital-based studies have shown that noncompliance
with hand hygiene practices is associated with health care–associated infections and
the spread of multiresistant organisms and has been a major contributor to out-
breaks.1 Studies also have shown that the prevalence of health care–associated infec-
tions decreased as hand hygiene measures improved.2
Specific indications for hand hygiene include
 Before and after treating each patient (before glove placement and after glove
removal)
 After bare hand touching of inanimate objects likely contaminated by blood,
saliva, or respiratory secretions
 Before leaving the dental operatory
 When hands are visibly soiled; before regloving, after removing gloves that are
torn, cut, or punctured
 For oral surgical procedures, perform surgical hand antisepsis before donning
sterile surgical gloves.
Alcohol-based hand sanitizers are the most effective products for reducing the
number of germs on the hands of health care providers.2 Antiseptic soaps and deter-
gents are the next most effective and nonantimicrobial soaps are the least effective.
When hands are not visibly dirty, alcohol-based hand sanitizers are the preferred
method of cleaning a provider’s hands in the health care setting. Soap and water
are recommended for cleaning visibly dirty hands (Table 2).

POTENTIAL INFECTIOUS DISEASES IN THE DENTAL OFFICE

Blood-borne viruses, such as HBV, HCV, and HIV, are of particular concern to DHCP.
These viruses
 Can be transmitted to patients and HCP in health care settings
 Can produce chronic infection
 Are often carried by persons unaware of their infection

Table 2
Centers for Disease Control and Prevention recommendations during routine dental care

Wash with Soap and Water Use an Alcohol-Based Hand Sanitizer

 When hands are visibly dirty  For everything else
 After known or suspected exposure to Clostridium
difficile if facility is experiencing an outbreak or
higher endemic rates
 After known or suspected exposure to patients with
infectious diarrhea during norovirus outbreaks
 If exposure to Bacillus anthracis is suspected or
proved
 Before eating
 After using a restroom

From Centers for Disease Control and Prevention (CDC). Hand hygiene in healthcare settings. Avail-
able at: http://www.cdc.gov/handhygiene/providers/index.html. Accessed April 2, 2016.
440 Sebastiani et al

The risk of infection with a blood-borne virus is largely determined by

 Its prevalence, or frequency, in the patient population
 The risk of transmission after an exposure to blood (risk varies by type of virus)
 The type and frequency of blood contacts. If HCP are frequently exposed to
blood, especially if they are working with sharp objects, such as needles, their
risk of exposure to a blood-borne virus would be higher than if they rarely
come into contact with blood.
OSHA requires that all dental practitioners receive training in standard precaution
practices at the time of employment and annually thereafter.3
Table 3 highlights the average risk of transmission after a single needlestick from an
infected patient by type of blood-borne virus. As displayed, risk varies greatly by the
type of virus.
The risk of HBV transmission after a needlestick to HBV-infected blood varies from
1% to 62%, depending on the hepatitis B e antigen (HBeAg) status of a source
patient. If a source patient’s blood is positive for HBeAg, a marker of increased infec-
tivity, the risk of transmission can be as high as 62%.1 If the patient’s blood is
hepatitis B surface antigen (HBsAg) positive but HBeAg negative, the risk varies
from 1% to 37%.
The average risk of HCV transmission after a percutaneous exposure to HCV-
infected blood is 1.8%. The average risk of HIV infection after a percutaneous
exposure to HIV-infected blood is 0.3%.1 Thus, 1 in 3 needlesticks from an HBeAg-
positive source patient results in infection compared with only 1 in 300 needlesticks
from an HIV-infected patient.
The critical 2011 recommendations from the CDC regarding HBV vaccination and
influenza control for infection control in dental health care settings are discussed.
Each recommendation is categorized on the basis of existing scientific data, theoretic
rationale, and applicability. Rankings are based on the system used by the CDC and
the Healthcare Infection Control Practices Advisory Committee to categorize recom-
mendations (Boxes 1–3).

CONTROL OF 2009 H1N1 INFLUENZA

A hierarchy of control measures should be applied to prevent transmission of 2009

H1N1 influenza in all health care settings. To apply the hierarchy of control measures,

Table 3
Percutaneous exposure risk in dental practice

Source Risk
HBV
HBsAg1 and HBeAg1 22.0%–31.0% clinical hepatitis; 37%–62% serologic evidence
of HBV infection
HBsAg1 and HBeAg 1.0%–6.0% clinical hepatitis; 23%–37% serologic evidence of
HBV infection
HCV 1.8% (0%–7% range)
HIV 0.3% (0.2%–0.5% range)

Data from Centers for Disease Control and Prevention (CDC). Division of Oral Health. Infection pre-
vention & control in dental settings. Questions & Answers: Occupational Exposure to Blood. Avail-
able at: http://www.cdc.gov/oralhealth/infectioncontrol/questions/occupational-exposure.html.
Accessed April 2, 2016.
 Infection Control in the Dental Office 441

Box 1
Categories for recommendations on infection control in dental health care settings

 Category IA—strongly recommended for implementation and strongly supported by well-

designed experimental, clinical, or epidemiologic studies
 Category IB—strongly recommended for implementation and supported by experimental,
clinical, or epidemiologic studies and a strong theoretic rationale
 Category IC—required for implementation as mandated by federal or state regulations or
standards. When category IC is used, a second rating can be included to provide the basis
of existing scientific data, theoretic rationale, and applicability. Because of state differences,
readers should not assume that the absence of a IC recommendation implies the absence of
any state regulations.
 Category II—suggested for implementation and supported by suggestive clinical or
epidemiologic studies or a theoretic rationale

Adapted from Centers for Disease Control and Prevention (CDC). Guidelines for infection con-
trol in dental health-care settings — 2003. MMWR Morb Mortal Wkly Rep 2003;52:1–61.

facilities should take the following steps, ranked according to their likely
effectiveness:
1. Elimination of potential exposures (deferral of treatment of ill patients and source
control by masking persons who are coughing)
2. Engineering controls that reduce or eliminate exposure at the source without
placing primary responsibility of implementation on individual employees
3. Administrative controls, including sick leave policies and vaccination, that depend
on consistent implementation by management and employees
4. PPE for exposures that cannot otherwise be eliminated or controlled (PPE includes
gloves, surgical face masks, respirators, protective eyewear, and protective
clothing, such as gowns.)

Box 2
Hepatitis B virus vaccination

Offer the HBV vaccination series to all DHCP with potential occupational exposure to blood or
other potentially infectious material (category IA or IC).
Always follow US Public Health Service/CDC recommendations for hepatitis B vaccination,
serologic testing, follow-up, and booster dosing (category IA or IC).
Test DHCP for anti-HBs 1 to 2 months after completion of the 3-dose vaccination series
(category IA or IC).
DHCP should complete a second 3-dose vaccine series or be evaluated to determine if HBsAg
positive if no antibody response occurs to the primary vaccine series (category IA or IC).
Retest for anti-HBs at completion of the second vaccine series. If no response to the second 3-
dose series, nonresponders should be tested for HBsAg (category IC).
Counsel nonresponders to vaccination who are HBsAg negative regarding their susceptibility
to HBV infection and precautions to take (category IA or IC).
Provide employees appropriate education regarding the risks of HBV transmission and
availability of the vaccine. Employees who decline the vaccination should sign a declination
form to be kept on file with the employer (category IC).

Adapted from Centers for Disease Control and Prevention (CDC). Guidelines for infection con-
trol in dental health-care settings — 2003. MMWR Morb Mortal Wkly Rep 2003;52:1–61.
442 Sebastiani et al

Box 3
Preventing exposures to blood and other potentially infectious material

General recommendations
Use standard precautions (OSHA blood-borne pathogen standard retains the term universal
precautions) for all patient encounters (category IA or IC).
Consider sharp items (eg, needles, scalers, burs, laboratory knives, and wires) that are
contaminated with patient blood and saliva as potentially infective, and establish engineering
controls and work practices to prevent injuries (category IB or IC).
Implement a written, comprehensive program designed to minimize and manage DHCP
exposures to blood and body fluids (category IB or IC).
Engineering and work practice controls
Identify, evaluate, and consider devices with engineered safety features at least annually and as
they become available on the market (eg, safer anesthetic syringes, blunt suture needle,
retractable scalpel, or needleless intravenous systems) (category IC).
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 (category IA or IC).
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 (category IA or IC).
Use a 1-handed scoop technique or a mechanical device designed for holding the needle cap
when recapping needles (eg, between multiple injections, before removing from a
nondisposable aspirating syringe) (category IA or IC).
Postexposure management and prophylaxis
Follow current CDC recommendations after percutaneous, mucous membrane, or nonintact
skin exposure to blood or other potentially infectious material.
Handling of biopsy specimens
During transport, place biopsy specimens in a sturdy, leak-proof container labeled with the
biohazard symbol (category IC).
If a biopsy specimen container is visibly contaminated, clean and disinfect the outside of a
container, or place it in an impervious bag labeled with the biohazard symbol (category IC).
Handling of extracted teeth
Dispose of extracted teeth as regulated medical waste unless returned to the patient
(category IC).
Do not dispose of extracted teeth containing amalgam in regulated medical waste intended
for incineration (category II).
Clean and place extracted teeth in a leakproof container, labeled with a biohazard symbol, and
maintain hydration, for transport to educational institutions or a dental laboratory category
(IB or IC).
Heat-sterilize teeth that do not contain amalgam, before they are used for educational
purposes (category IB).

Adapted from Centers for Disease Control and Prevention (CDC). Guidelines for infection con-
trol in dental health-care settings—2003. MMWR Morb Mortal Wkly Rep 2003;52:1–61.
 Infection Control in the Dental Office 443

Vaccination
Vaccination, an administrative control, is one of the most important interventions for
preventing transmission of influenza to HCP. More information on this hierarchy of
controls is available in the CDC Interim Guidance on Infection Control Measures for
2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare
Personnel (CDC: H1N1 Flue Clinical and Public Health Guidance, http://www.cdc.
gov/h1n1flu/guidance/).

Specific Recommendations for Dental Health Care

 Encourage all DHCP to receive seasonal influenza and 2009 H1N1 influenza
vaccinations.
 Use patient reminder calls to identify patients reporting influenza-like illness, and
reschedule nonurgent visits until 24 hours after patients are free of fever without
the use of fever-reducing medicine.
 Identify patients with influenza-like illness at check-in; offer a face mask or tis-
sues to symptomatic patients; follow respiratory hygiene/cough etiquette and
reschedule nonurgent care. Separate ill patients from others whenever possible
if evaluating for urgent care.
 Urgent dental treatment can be performed without the use of an airborne infection
isolation room, because transmission of 2009 H1N1 influenza is thought not to occur
over longer distances through the air, such as from one patient room to another.
 Use a treatment room with a closed door, if available. If not, use one that is
farthest from other patients and personnel.
 Wear recommended PPE before entering the treatment room.
 DHCP should wear a National Institute for Occupational Safety and Health fit-
tested, disposable N95 respirator when entering the patient room and when per-
forming dental procedures on patients with suspected or confirmed 2009 H1N1
influenza.
 As customary, minimize spray and spatter (eg, use a dental dam and high-
volume evacuator).

Dental Health Care Personnel

 DHCP should self-assess daily for symptoms of febrile respiratory illness (fever
plus 1 or more of the following: nasal congestion or runny nose, sore throat, or
cough).
 Personnel who develop fever and respiratory symptoms should promptly notify
their supervisor and should not report to work.
 Personnel should remain at home until at least 24 hours after they are free of fever
(100 F/37.8 C), or signs of a fever, without the use of fever-reducing medications.
 Personnel with a family member who is diagnosed with 2009 H1N1 influenza can
still go to work but should self-monitor for symptoms so that any illness is recog-
nized promptly.

TRANSMISSION RISK OF MYCOBACTERIUM TUBERCULOSIS IN DENTISTRY

Mycobacterium TB is spread from person to person through the air. When a person
with pulmonary or laryngeal TB coughs or sneezes, tiny particles, known as droplet
nuclei, are expelled into the air. The particles are an estimated 1 mm to 5 mm in size,
and normal air currents can keep them airborne for prolonged periods of time and
spread them throughout a room or building.4 Infection may occur when a person in-
hales droplet nuclei containing TB organisms.
444 Sebastiani et al

During the first few weeks after infection, organisms can spread from the initial loca-
tion in the lungs to the lymph nodes in the center of the chest and then to other parts of
the body by way of the bloodstream. Within 2 to 12 weeks, the body’s immune system
usually prevents further multiplication and spread, although they can remain alive in
the lungs for years.3 This condition is referred to as latent TB infection. Overall, the
risk for transmission of TB in most dental settings is low.
Table 4 lists the CDC recommendations on work restrictions for HCP infected with
or exposed to major infectious diseases at work in the absence of state and local
regulations.

PERCUTANEOUS INJURIES AMONG DENTAL HEALTH CARE PROVIDERS

Current literature substantiates that percutaneous injuries among dentists have

declined from an average rate of 11 injuries per year in 1987 to fewer than 3 injuries
per year in 1993.1 Most injuries among general dentists were found to be caused by
burs, followed by syringe needles and other sharp instruments. Injuries are found to
occur while a dentist’s hands are outside a patient’s mouth. The frequency of percu-
taneous injuries among oral surgeons is similar to that reported among US dentists.
Injuries among oral surgeons may occur more frequently during procedures using sur-
gical wire, such as during fracture reductions.
Primary methods used to prevent occupational exposures to blood in health care
settings include standard precautions, engineering controls, work practice controls,
and administrative controls.2

EXPOSURE PREVENTION STRATEGIES

Engineering Controls
Engineering controls are the primary method to reduce exposures to blood, such as
sharps containers and self-sheathing needles. Safe practices include handling, using,
or processing sharp devices.2 OSHA code mandates that employees be given the op-
portunity to review and help select needlestick prevention devices. In addition, em-
ployers are responsible for maintaining a log of needlestick exposures to help in the
annual review so that the workplace protocol may be modified to reduce the number
of exposures.5

Work Practice Controls

Work practice controls are behavior based and are intended to reduce the risk of
blood exposure by changing the manner in which a task is done. These include using
instruments instead of fingers to retract or palpate tissue during suturing and anes-
thesia administration, 1-handed needle recapping, and not passing an unsheathed
needle to another dental health care provider.2

Administrative Controls
Administrative controls include policies, procedures, and enforcement measures to
prevent exposure to disease-causing organisms. The placement in the hierarchy
varies by the problem addressed, such as early identification and referral of a patient
suspected of having TB.2

Personal Protective Equipment

PPE, or barrier precautions, is a major component of standard precautions. It is essen-
tial to protect the skin and mucous membranes of personnel from exposure to
 Infection Control in the Dental Office 445

Table 4
Work restrictions for health care personnel exposed to infectious diseases

Disease/Problem Work Restriction Duration

Conjunctivitis Restrict from patient contact Until discharge ceases
and contact with patient’s
environment.
Cytomegalovirus infection No restriction
Diarrheal disease
Acute-stage (diarrhea with Restrict from patient contact Until symptoms resolve
other symptoms) and contact with patient’s
environment.
Convalescent stage, Restrict from care of patients Until symptoms resolve;
Salmonella species at high risk. consult with local and state
health authorities
regarding need for
negative stool cultures.
Enteroviral infection Restrict from care of infants, Until symptoms resolve
neonates, and
immunocompromised
patients and their
environment.
Hepatitis A virus Restrict from patient contact Until 7 d after onset of
and contact with patient’s jaundice
environment.
HBV
Personnel with acute or No restrictiona; refer to state
chronic hepatitis B regulations. Standard
surface antigenemia precautions should always
who do not perform be followed.
exposure-prone
procedures
Personnel with acute or Do not perform exposure- Until HBeAg is negative
chronic hepatitis B e prone invasive procedures
antigenemia who until counsel from a review
perform exposure-prone panel has been sought;
procedures panel should review and
recommend procedures
that personnel can
perform, taking into
account specific
procedures as well as skill
and technique. Standard
precautions should always
be observed. Refer to state
and local regulations or
recommendations.
HCV No restrictions on
professional activity.a HCV-
positive HCP should follow
aseptic technique and
standard precautions.

(continued on next page)

446 Sebastiani et al

Table 4
(continued )
Disease/Problem Work Restriction Duration
Herpes simplex virus
Genital No restriction
Hands (herpetic whitlow) Restrict from patient contact Until lesions heal
and contact with patient’s
environment.
Orofacial Evaluate need to restrict
from care of patients at
high risk.
HIV; personnel who perform Do not perform exposure-
exposure-prone prone invasive procedures
procedures until counsel from an
expert review panel has
been sought; panel should
review and recommend
procedures that personnel
can perform, taking into
account specific
procedures as well as skill
and technique. Standard
precautions should always
be observed. Refer to state
and local regulations or
recommendations.
Measles
Active Exclude from duty Until 7 d after the rash
appears
Postexposure (susceptible Exclude from duty From 5th day after first
personnel) exposure through 21st day
after last exposure, or 4 d
after rash appears
Meningococcal infection Exclude from duty Until 24 h after start of
effective therapy
Mumps
Active Exclude from duty Until 9 d after onset of
parotitis
Pediculosis Restrict from patient contact Until treated and observed to
be free of adult and
immature lice
Pertussis
Active Exclude from duty From beginning of catarrhal
stage through 3rd week
after onset of paroxysms,
or until 5 d after start of
effective antibiotic therapy
Postexposure No restriction; prophylaxis
(asymptomatic recommended
personnel)
Postexposure Exclude from duty Until 5 d after start of
(symptomatic personnel) effective antibiotic therapy

(continued on next page)

 Infection Control in the Dental Office 447

Table 4
(continued )
Disease/Problem Work Restriction Duration
Rubella
Active Exclude from duty Until 5 d after rash appears
Postexposure (susceptible Exclude from duty From 7th day after first
personnel) exposure through 21st day
after last exposure
Staphylococcus aureus infection
Active, draining skin Restrict from contact with Until lesions have resolved
lesions patients and patients’
environment or food
handling.
Carrier state No restriction unless
personnel are
epidemiologically linked to
transmission of organism.
Streptococcal infection, Restrict from patient care, Until 24 h after adequate
group A contact with parent’s treatment started
environment, and food
handling.
Tuberculosis
Active disease Exclude from duty Until proved noninfectious
Purified protein derivative No restriction
(PPD) converter
Varicella (chicken pox)
Active Exclude from duty Until all lesions dry and crust
Postexposure (susceptible Exclude from duty From 10th day after first
personnel) exposure through 21st day
(28th day if varicella-zoster
immune globulin
administered) after last
exposure
Zoster (shingles)
Localized; in healthy Cover lesions; restrict from Until all lesions are dry and
person care of patientsb at high crust
risk.
Generalized or localized in Restrict from patient contact Until all lesions are dry and
immunosuppressed crust
person
Postexposure (susceptible Exclude from duty From 10th day after first
personnel) exposure through 21st day
(28th day if varicella-zoster
immune globulin
administered) after last
exposure or, if varicella
occurs, when lesions crust
and dry

(continued on next page)

448 Sebastiani et al

Table 4
(continued )
Disease/Problem Work Restriction Duration
Viral respiratory infection, Consider excluding from the Until acute symptoms resolve
acute febrile care of patients at high
riskc or contact with such
patients’ environments
during community
outbreak of respiratory
syncytial virus and
influenza.
a
Unless epidemiologically linked to transmission of infection.
b
Those susceptible to varicella and who are at increased risk of complications of varicella (eg, ne-
onates and immunocompromised persons of any age).
c
Patients at high risk as defined by ACIP for complications of influenza.
Adapted from Weissfeld AS. Infection control in the dental office. Clin Microbiol Newsl
2014;36(11):81, 82; with permission.

infectious or potentially infectious materials in spray or spatter and the should be

removed when leaving treatment areas. The various barriers available include5
1. Gloves – these include powder-free latex gloves, vinyl gloves, and nitrile gloves.
These minimize the risk of HCP acquiring infections from patients or of transmis-
sion from HCP to patients. Wearing gloves does not eliminate nor replace the
need for hand washing. Gloves that are torn, cut, or punctured should obviously
be removed. Gloves should also not be washed, disinfected, or sterilized for reuse.
Maintaining short fingernails and not wearing jewelry can minimize the risk of punc-
ture.3 Lastly, wearing sterile gloves or double gloving has not been mandated. After
wearing gloves for a period of time, glove juice collects that is laden with skin flora.
It is important to prevent glove juice from contacting instruments, for instance,
when changing gloves during a long procedure. It is recommended that clinicians
remove gloves slowly and deliberately, with their hands as far away from the instru-
ment setup as possible.6
2. Masks – these include surgical masks that are fluid-resistant and isolation masks
that cover the nose and mouth. Layers include an outer layer, a microfiber middle
layer, and a soft inner layer that absorbs moisture.
3. Protective eyewear for dentist and patient – with side shields, this protects from
aerosols and spatter that transmit infection, from debris projected from the mouth,
and from injuries caused by sharp instruments. Face shields can be considered for
procedures that involve a great potential for splatter or aerosol generation.6
4. Surgical head caps
5. Protective clothing – this include cotton gowns, if contamination of clothing is antic-
ipated, and fluid-resistant isolation gowns, if contamination by significant volumes
of blood or body fluids is anticipated. It should completely cover personal clothing
and any skin likely to come in contact with blood-borne pathogens.6

Respiratory Hygiene/Cough Etiquette

Respiratory hygiene/cough etiquette infection prevention measures are designed to
limit the transmission of respiratory pathogens spread by droplets or airborne routes.
These were added to standard precautions in 2007. They include implementing mea-
sures to contain respiratory secretions in patients with signs and symptoms of a
 Infection Control in the Dental Office 449

respiratory infection (eg, signs with instructions to cover their mouth/noses when
coughing or sneezing), providing tissues and no touch receptacles for disposal of tis-
sues, providing resources for performing hand hygiene in or near waiting areas, offer-
ing masks to coughing patients, and encouraging persons with symptoms of
respiratory infections to sit as far from others as possible. Lastly, DHCP should be
educated on the importance of infection prevention measures to contain respiratory
secretions.7

POSTEXPOSURE MANAGEMENT

Despite best efforts, blood exposures will likely continue to occur. Postexposure man-
agement remains an important component of a complete program to prevent infection
following exposure to blood. Elements of an effective postexposure management pro-
gram include
 Policies and procedures that clearly state how to manage exposures
 Education of DHCP in prevention strategies (including evaluation of safety de-
vices), principles of postexposure management, the importance of prompt re-
porting, and postexposure prophylaxis efficacy and toxicity
 Resources for rapid access to clinical care, postexposure prophylaxis, and
testing of both source patients and exposed HCP (preferably with a rapid HIV test)
Except for institutional settings, coordination with off-site infection control or occupa-
tional health services likely is necessary. A health care professional who is qualified to
manage, counsel, and provide medical follow-up should be selected before staff are
placed at risk. Ensure that this person is familiar with the dental application of risk
assessment and management. The key elements of postexposure management include
wound management and exposure reporting. After a puncture wound, such as a needle-
stick, the area should immediately be thoroughly washed with soap and water. If blood
or saliva contacts mucous membranes, immediate flushing with water is necessary.3
The evaluating health care professional should assess the risk of infection by examining
the type and severity of exposure, the blood-borne status of the source person, and the
susceptibility (immune status) of the exposed person. All these factors should be
considered in assessing the risk of infection and the need for further follow-up.

DISINFECTION VERSUS STERILIZATION

Disinfection and sterilization are both decontamination processes. Although disinfec-

tion is the process of eliminating most harmful microorganisms from inanimate objects
and surfaces, sterilization is the process of killing all microorganisms, including a sub-
stantial number of resistant bacterial spores (Table 5).
Disinfection
Disinfection is a 2-step process — the initial step involves vigorous scrubbing of the
surfaces to be disinfected and wiping them clean; the second step involves wetting
the surface with a disinfectant and leaving it wet for the time prescribed by the manu-
facturer. The spray-wipe-spray technique enhances decontamination through me-
chanical cleansing with a paper towel followed by the chemical action of the
disinfectant solution. The same process occurs when using the disinfectant wipes in
the wipe-discard-wipe technique; the first wipe removes microbes and the second
wipe provides disinfection.8 The ideal disinfectant has a broad spectrum of activity;
acts rapidly; is noncorrosive, environmentally friendly, free of volatile organic com-
pounds, and nontoxic; and does not stain.9
450 Sebastiani et al

Table 5
Categories of patient care items

Category Definition Dental Instrument Management

Critical  Penetrates soft Surgical instruments,  Heat sterilize between
tissue periodontal scalers, use.
 Contacts bone scalpel blades, burs
 Enters bloodstream
Semicritical  Contacts mucous Mouth mirror, amalgam  For heat tolerant — heat
membranes or condenser, impression sterilize.
nonintact skin trays, hand pieces  For heat sensitive10 —
 Do not penetrate replace with a heat
soft tissue tolerant or disposable
alternative. If not, then
high-level disinfection
(glutaraldehyde,
peracetic acid, hydrogen
peroxide).
Noncritical  Contacts intact Radiograph head and  Clean and disinfect using
skin cone, pressure cuff, a low- to intermediate-
facebow, pulse oximeter level disinfectant. If low-
level disinfection, OSHA
requires a label claim for
killing HIV and HBV. If
bloody, an intermediate
level disinfectant should
be used. Protecting
these surfaces with
disposable barriers is an
alternative.

Modified from Centers for Disease Control and Prevention (CDC). Guidelines for infection control
in dental health-care settings — 2003. MMWR Morb Mortal Wkly Rep 2003;52:1–61.

Sterilization
Sterilization stages include presoaking, cleaning, corrosion control and lubrication,
packaging, sterilization, handling sterile instruments, storage, and distribution. The
physical agents used in sterilization can include sunlight, drying, dry heat, moist
heat, filtration, radiation, ultrasonic and sonic vibrations. The chemical agents used
can be alcohols, aldehydes, dyes, halogens, phenols, surface-active agents, metallic
salts, and gases.10

DECONTAMINATION AND DISINFECTION METHODS

Cleaning is the first step in the decontamination process, which involves the physical
removal of debris and reducing the number of microorganisms on the instrument. If
visible debris or organic matter is not removed, it may interfere with the disinfection
or sterilization process. This may be achieved by manual cleaning, or automated
cleaning, and the Environmental Protection Agency (EPA) Web site lists registered
approved cleansers.5

Manual Cleaning
The instruments should be soaked in a rigid container filled with disinfectant. This pre-
vents drying of patient material and makes cleaning easier and less time consuming.
 Infection Control in the Dental Office 451

The disinfectant to hold the instruments should not be high level, such as glutaralde-
hyde. To avoid injury, it is recommended that personnel wear puncture-resistant,
heavy-duty gloves.2

Automated Cleaning
a. Ultrasonic cleaner: involves the use of sound waves to form oscillating bubbles, a
process referred to as cavitation. Instruments are kept in a perforated cassette
where the bubbles act on remaining debris to remove it from the instruments.
They are then rinsed and then carefully inspected for debris. Instruments likely to
rust are dipped in a rust inhibitor solution and are then dried using an absorbent
towel.10
b. Instrument washer: uses high-velocity hot water and a detergent; there is a clean-
ing and drying cycle in this process. Thermal disinfectors may also be used, which
are similar to instrument washers except that it is the high temperatures of the wa-
ter and chemical additives that are used to disinfect the instruments.10

STERILIZATION METHODS

In dentistry, the 4 accepted methods of sterilization include steam pressure steriliza-

tion (autoclave), unsaturated chemical vapor pressure sterilization (chemiclave), dry
heat sterilization (dryclave), and ethylene oxide sterilization.

Autoclaving
Autoclaving usually involves a temperature of 121 C at 15 lb of pressure for
20 minutes.6 It is the most rapid and effective method for sterilizing cloth surgical
packs and towel packs, is dependable and economic, and the sterilization is verifiable.
Items sensitive to elevated temperatures cannot be autoclaved, however, this process
tends to rust carbon steel instruments and burs, and the instruments must be air dried
at cycle completion. Types of autoclaves include downward displacement, positive
pressure displacement, negative pressure displacement, a triple vacuum, and prevac-
uum.10 In the commonly used gravity displacement sterilizers, steam enters the cham-
ber and unsaturated air is forced out through a vent. Prevacuum sterilizers are fitted
with a vacuum pump to create a vacuum in the chamber before the chamber is pres-
surized with steam to improve the speed and efficiency of the process.

Chemiclave
Chemiclave involves the use of an unsaturated chemical vapor system of alcohol and
formaldehyde. This process is quick, the load comes out dry, the sterilization is verifi-
able, and corrosion-sensitive instruments do not rust. Items sensitive to elevated
temperatures are damaged, however, must be dried before processing; aeration is
needed due to offensive vapors; and heavy cloth wrappings of surgical instruments
may not be penetrated.10

Dry Heat Sterilization

Dry heat sterilization involves the use of conventional dry heat ovens with a short cycle
and high temperatures for items that cannot be subject to moist heat; either static air
or forced air is used. Advantages include no corrosion (if instruments are dried well
prior to the cycle), rapid cycles, low cost, and verifiable sterilization and it can be per-
formed at a larger capacity with industrial hot air ovens. Disadvantages include that
sterilization cycles are prolonged at lower temperatures, ovens must be calibrated,
452 Sebastiani et al

and the high temperatures may damage heat-sensitive items, including rubbers and
plastics.10

Ethylene Oxide Sterilization

Ethylene oxide sterilization involves the use of a fumigator. It operates effectively at
low temperatures, the gas is penetrative and can be used for sensitive equipment
such as hand pieces, and the sterilization is verifiable. On the other hand, this method
can be mutagenic and carcinogenic, requires an aeration chamber, and is usually only
available at hospitals.11
Newer methods of sterilization under research and development include peroxide va-
por sterilization, ultraviolet light, and ozone sterilization. Peroxide vapor sterilization in-
volves an aqueous hydrogen peroxide solution boiled in a heat vaporizer and flowed as
a vapor into a sterilization chamber containing instruments at low temperature and pres-
sure. Ultraviolet light exposes the contaminants with a lethal dose of energy in the form
of light at 240 nm to 280 nm, which results in the destruction of nucleic acid through the
induction of thymine dimers (not effective against RNA viruses). Ozone sterilization is the
newest low-temperature sterilization method suitable for many heat sensitive, moisture
sensitive, and stainless steel devices. The sterilizer creates its sterilant internally from
United States Pharmacopoeia–grade oxygen, steam-quality water, and electricity;
the sterilant is converted back to oxygen and water vapor at the end of the cycle by a
passing through a catalyst before being exhausted into the sterilization room. The ozone
cycle parameters are approximately 4 hours and 15 minutes at 30 C to 35 C.12
Flash sterilization was originally defined as sterilization of an unwrapped object at
132 C for 3 minutes at 28 lb of pressure in a gravity displacement sterilizer for imme-
diate use. It is acceptable for processing cleaned patient care items that cannot be
packaged, sterilized, or stored before use. It is also used when there is insufficient
time to sterilize an item by the preferred package method. This type of sterilization cy-
cle should only be used after instruments have been thoroughly cleaned.10

INSTRUMENT PROCESSING

To prevent cross-contamination, the instrument processing area should be physically

and spatially divided into areas for2
1. Cleaning – reusable contaminated instruments are received, cleaned, decontami-
nated, and sorted.
2. Packaging – for inspecting, assembling, and packaging clean instruments in prep-
aration for sterilization. Critical and semicritical items should be wrapped or placed
in containers before sterilization, and hinged instruments should be opened and
unlocked so that all surfaces are exposed. Lastly, a chemical indicator should be
placed inside each wrapped package.
3. Sterilization – contains sterilizers and incubators for analyzing spore tests.
4. Storage – should be dust proof, dry, well ventilated, and easily accessible for
routine dental use. Sterile instruments must be at least 8 inches from the floor,
18 inches from the ceiling, and 2 inches from the walls. Items should be positioned
so that packaged items are not crushed, bent, compressed, or punctured. Ultravi-
olet and formalin chambers can be used for storage.9

SPORE TESTING AND DUAL-MONITORING STRIPS IN STERILIZATION BAGS

The 3 methods for monitoring sterilization include mechanical techniques, chemical

indicators (internal/external), and biological indicators. The mechanical and chemical
 Infection Control in the Dental Office 453

techniques do not guarantee sterilization but help detect procedural errors and equip-
ment malfunction.
Mechanical techniques
Mechanical techniques involve assessment of cycle time, temperature, and pressure
by observing gauges on the sterilizer. Because these parameters can be observed
during the sterilization cycle, this might be the first indication of a problem.
Chemical Techniques
Chemical techniques use sensitive chemicals that change color when a given param-
eter is reached, usually a heat-sensitive external tape or an internal chemical indicator
strip. A chemical indicator should be used in every package to verify that the steriliza-
tion agent penetrated the package and reached the instruments inside. If the internal
chemical indicator is not visible from the outside of the package, an external indicator
should be used. These indicators can also help differentiate between processed and
unprocessed items, eliminating the possibility of using instruments that have not been
sterilized. It is recommended to use multiparameter internal chemical indicators that
react to time, temperature, and presence of steam.7
Biological Techniques
Biological techniques, or a biological spore test, is the most valid process because it
assesses the process directly by using the most heat-resistant microorganism, which
is contingent on the sterilization method. A control biological indicator from the same
lot, which has not been sterilized, should be incubated along with the test indicator.
The control should show a positive result and the test should yield a negative result
(Box 4).3

PROPER DISINFECTION OF HAND PIECES, IMPRESSIONS, AND ENVIRONMENTAL

SURFACES

Operatory asepsis is important because environmental surfaces can be contaminated

during patient care. These surfaces include light handles, unit switches, counter tops,
bracket trays, dental chairs, door handles, and drawer knobs that can serve as reser-
voirs of microbial contamination. The transfer of microorganisms from contaminated

Box 4
Protocol for positive spore text

 Recall and resterilize affected instruments.

 Remove autoclave from service.
 Review process to identify possible operator error (eg, packaging, loading, or monitoring).
 Retest unit with biological indicator and control.
 If unit fails a second test, affected instruments should be resterilized with an alternate
autoclave.
 If second test is negative and chemical/mechanical indicators are satisfactory, place unit back
in service.
 Incident should be documented in sterilization log.

Modified from Thomas MV, Jarboe G, Frazer RQ. Infection control in the dental office. Dent
Clin N Am 2008;52(3):624; with permission.
454 Sebastiani et al

environmental surfaces to patients occurs primarily through personal hand contact.

These do not require as stringent decontamination procedures, and surface barriers
can be used and changed between patients. If surface barriers cannot be used, clean
and disinfect the surface with an EPA-registered hospital disinfectant effective against
HIV and HBV.
Housekeeping surfaces, such as walls, floors, and sinks, must be cleaned with wa-
ter and soap or a registered hospital detergent on a regular basis. They must be
cleaned if visibly soiled. Treatment rooms should be free of extraneous materials to
facilitate cleaning and disinfection. Loose items should be placed in draws or storage.6
Strategies for decontaminating spills of blood and other body fluids differ by setting
and volume of the spill. The person assigned to clean the spill should wear PPE as
needed. Visible organic material should be removed with absorbent material, such
as disposable paper towels, and the manufacturer’s instructions for proper use of in-
termediate level disinfectants with a tuberculocidal claim should be followed. If such
products are unavailable, a 1:100 dilution of sodium hypochlorite could be used.9
Because of their toxic nature, however, high-level disinfectants on environmental sur-
faces are not recommended.
Hand pieces are considered semicritical devices, but they must be heat sterilized
between patients because studies have shown that their internal surfaces can become
contaminated with patient materials during use.7 Hand piece surface decontamination
includes running it under the sink, scrubbing it thoroughly, cleaning the fiberoptic ends
with alcohol, placing it in a clear view sterilization pouch, and then sterilizing the hand
piece.10 Because it is difficult for chemical germicides to reach the internal parts of the
hand pieces, they should be heat sterilized with a steam autoclave or chemical vapor
sterilizer.2 This includes the associated attachments, including low-speed motors and
reusable prophylaxis angles. Surface disinfection, liquid germicides, and ethylene ox-
ide are not acceptable.
For ultrasonic scalers, inserts must be soaked in a container with 70% isopropyl
alcohol to remove organic debris. The inserts must then be rinsed in warm water to
remove all chemicals and can then run the scaler hand piece with the insert to flush
out any remaining chemicals. The inserts are then dried thoroughly and packaged
with spore tests and chemical indicators. Ethylene oxide is the preferred method of
choice, with dry heat and chemical vapor considered ineffective with risk of damage
to materials.13
Dental prosthesis and orthodontic appliances are also potential sources of contam-
ination and should be handled in a manner that protects patients and DHCP from
exposure to microorganisms. They should be disinfected with an intermediate-level
disinfectant before sent to a laboratory or before delivery to a patient. Heat-tolerant
items used in the mouth should be heat sterilized and appropriate PPE worn until disin-
fection has been completed.2 According to a study by Omidkohda and colleagues,14
autoclave and glutaraldehyde solution were the best methods for disinfection of ortho-
dontic marking pencils but could also be disinfected with Deconex solution if the 2
aforementioned methods were not available. Laboratory equipment, such as pumice
and buff wheels, should also be disinfected between patients. If ultrasonic cleaners
are used to clean prostheses or other items that are going to be inserted into a pa-
tient’s mouth, the prosthesis must first be placed in a sealed, impervious receptacle
containing cleaner.6
Dental impression handguns are also easily contaminated during clinical use. A
study by Westergard and colleagues8 concluded that to minimize the cross-
contamination with these items, the use of steam sterilization combined with plastic
impression gun covers and disinfection was recommended.
 Infection Control in the Dental Office 455

Digital radiography sensors are also considered semicritical and should be pro-
tected with a Food and Drug Administration–cleared barrier to reduce contamination
during use, followed by cleaning and heat sterilization or high-level disinfection be-
tween patients. These items vary by manufacturer and their ability to be sterilized or
high-level disinfected also vary. The manufacturer’s instructions for reprocessing
should be referred to.7

MEDICAL WASTE MANAGEMENT

A majority of waste generated in a dental office is considered noninfectious and can be

discarded in regular trash. This includes gloves, masks, and lightly bloodied gauze.
Regulated medical waste, however, including needles, extracted teeth, and gauze
soaked in blood, may pose a potential risk of infection. A leak-resistant biohazard
bag is adequate to contain nonsharp regulated medical waste. Puncture-resistant
containers with a biohazard label, such as sharps containers, are used as containment
for scalpel blades, needles, syringes, and unused sterile sharps. Medical wastes are
stored and disposed of in accordance with state and local EPA regulations. For regu-
lated waste, this may involve autoclaving and incineration.2
To protect those handling and transporting biopsy specimens, the specimens
should be placed in a leak-proof container with a secure lid to prevent leakage during
transport. Contaminating the outside of the container should be avoided by placing it
in a leak-proof bag. The container must also be labeled with a biohazard symbol.
Extracted teeth are considered regulated medical waste. Those containing
amalgam should not be incinerated. Those to be used for shade comparison or given
back to the patient on request should be cleaned and disinfected. Teeth to be used for
educational settings and preclinical training should be cleaned, autoclaved, and hy-
drated in tap water or saline. Those containing amalgam should not be autoclaved
because harmful mercury favors are released; they should be soaked in formalin
instead.
The American Dental Association has published recommendations and guidelines
for amalgam management in dental offices. In 2006, the American National Standards
Institute and American Dental Association developed specifications describing the
procedures for storing and preparing amalgam waste for delivery to recyclers. Con-
tainers for amalgam waste must have a silver or gray label and must be marked,
“Amalgam Waste for Recycling.” Containers must have a sealable closure and meet
requirements set by the Department of Transportation and the International Safe
Transportation Association. Some states require dental practices to install amalgam
separators.5

DENTAL UNIT WATERLINES

Dental unit water systems are classified as open or closed based on the water source;
open units are connected to a municipal water supply whereas closed units use a refill-
able reservoir attached to the unit. Studies have shown that biofilms can form inside
the tubing that transport water within the dental unit to hand pieces and air/water
syringes. A few pathogenic bacteria, such as Legionella species, Pseudomonas
aeruginosa, and nontuberculous mycobacterium have been isolated from water sys-
tems, but a majority of them are heterotrophic bacteria with limited pathogenic poten-
tial. Regardless, untreated dental units cannot reliably produce water that meets
drinking water standards of less than 500 colony-forming units/mL of heterotrophic
water bacteria. Hence, removal of dental waterline biofilms is required to meet CDC
standards. Using independent reservoirs, chemical treatment, microfilters, or sterile
456 Sebastiani et al

water delivery systems can do this. Monitoring of dental water quality may be per-
formed by using commercial self-contained test kits. In-office water-testing systems
are available that work at room temperature to culture medium to reveal bacteria col-
onies. Dentists should, however, follow recommendations provided by the manufac-
turer of the dental unit or waterline treatment protocol to monitor the water quality and
disinfecting the waterlines.2 For open water systems, it has been recommended that
these units be flushed for varying periods. If no guidance is provided, then flush all
dental unit waterlines for 5 minutes before patient care.6
For components of devices permanently attached to the air and water lines, water-
proof barriers must be used and changed between uses. Examples include attach-
ments of saliva ejectors, high-speed air evacuators, and air/water syringes. If an
item becomes visibly soiled, an intermediate-level disinfectant with tuberculocidal
claim must be used. With saliva ejectors, patients should be instructed to not close
their lips tightly around the tips because this can cause reverse flow, potentially
causing material from the mouth of the previous patient to be aspirated into the mouth
of the next patient. Saliva ejectors and high-volume evacuation valves should be
removed and sterilized, especially if the unit is used for surgical procedures. If this
is not feasible, the valves should be cleaned thoroughly with an intermediate level
disinfectant.6

INFECTION CONTROL PROGRAM PLAN AND GOALS

Each dental office should have a written plan for an infection control program that in-
cludes elements to protect personnel. These elements include
 Education programs for staff members
 Immunization plan for vaccine preventable diseases
 Exposure prevention and postexposure management, with follow-up of staff
exposed to infectious organisms or potentially harmful materials
 Medical condition management and work-related illnesses and restrictions
 Maintenance of health records in accordance with all applicable state and federal
laws

REFERENCES

1. Centers for Disease Control and Prevention. Division of Oral Health, Infection
Control in Dental Settings. Available at: https://www.cdc.gov/oralhealth/
infectioncontrol/index.html. Accessed April 2, 2016.
2. Centers for Disease Control and Prevention. Guidelines for infection control in
dental health-care settings—2003. MMWR Morb Mortal Wkly Rep 2003;52:
1–61. Available at: http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr5217a1.htm.
3. Weissfeld AS. Infection control in the dental office. Clin Microbiol Newsl 2014;
36(11):79–84.
4. Little JW, Falace DA, Miller CS, et al. Guidelines for infection control in dental
health care settings. Little and Falace’s dental management of the medically
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pendix B.
5. Boyce R, Mull J. Complying with the Occupational Safety and Health Administra-
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6. Thomas MV, Jarboe G, Frazer RQ, et al. Infection control in the dental practice.
Dent Clin North Am 2008;52:609–28.
 Infection Control in the Dental Office 457

7. Centers for Disease Control and Prevention. Summary of infection prevention

practices in dental settings: basic expectations for safe care. Atlanta (GA): US
Department of Health and Human Services, Centers for Disease Control and Pre-
vention, National Center for Chronic Disease Prevention and Health Promotion,
Division of Oral Health; 2016.
8. Westergard EJ, Romito LM, Kowolik MJ, et al. Controlling bacterial contamination
of dental impression guns. J Am Dent Assoc 2011;142(11):1269–74.
9. Mante F. “Infection control,” lecture. Philadelphia: University of Pennsylvania
School of Dental Medicine; 2012.
10. Shanker S. “Sterilization in dentistry & infection control,” lecture. Telangana (In-
dia): Mamata Dental College; 2013.
11. Gardner JF, Peel MM. Introduction to sterilization, disinfection and infection con-
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12. Rutala WA, Weber DJ, the Healthcare Infection Control Practices Advisory Com-
mittee (HICPAC). Guidelines for disinfection and sterilization in healthcare facil-
ities. Atlanta (GA): Center for Disease Control and Prevention; 2008.
13. Parkes RB, Kolstad RA. Effects of sterilization on periodontal instruments.
J Periodontol 1982;53(7):434–8.
14. Omidkhoda M, Rashed R, Bagheri Z, et al. Comparison of three different sterili-
zation and disinfection methods on orthodontic markers. J Orthod Sci 2016;
5(1):14–7.