GUIDELINES ON INFECTION CONTROL IN DENTAL CLINICS

1. Introduction

The unique nature of dental procedures, instrumentation and patient care settings
require specific strategies directed to the prevention of transmission of diseases among
dental health care workers and their patients. The following guidelines are written to
supplement previously published document ‘Guidelines on Infection Control Practice in
Clinics and Maternity Homes’. (Department of Health Infection Control Committee,
December 1993) All dental health care workers are advised to observe the following
recommended practices in addition to the practices and procedures outlined in the
‘Guidelines on Infection Control Practice in Clinics and Maternity Homes’.

2. Disease transmission

Infections are spread if the following criteria are satisfied:

(i) the presence of a susceptible host;

(ii) the presence of pathogenic micro-organisms;

(iii) there must be a portal of entry via which the organisms invade and colonize the
susceptible host.

Absence of any one of these requisites will prevent the transmission of an infectious
disease. Therefore, the goal of infection control is to eliminate one, two, or all of these
criteria. It should be understood that exposure to micro-organisms and infection are not
synonymous. It is impossible to avoid being exposed to micro-organisms; however,
exposure will not cause disease unless the three previously mentioned criteria are
present.

3. Routine precautions

Transmission of infection within the setting of dentistry may occur from the dental
health care worker to the patient, from the patient to the health care worker or from
patient to patient. Cases have been documented in which human immunodeficiency virus
(HIV) or hepatitis B virus (HBV) was transmitted from dental health care workers to
their patients and vice versa. Patient to patient transmission, although being reported
only in medical settings so far, may potentially occur in dental practices.

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 The major documented routes of transmission of HIV and HBV in dental settings
are (i) precutaneous inoculation and (ii) contact with an open wound, non-intact (e.g.
chapped, abraded, weeping or dermatitic) skin, or mucous membranes to blood, blood
contaminated body fluids or concentrated viruses. Blood is the single most important
source of HIV and HBV in dental practice. Protective measures against HIV and HBV
should focus primarily on preventing these types of exposures to blood as well as on
delivery of Hb vaccination.
Since it is now known that persons carrying blood-borne viruses, including both
health care workers and patients, may not have been identified and are thus not aware of
their own condition, it follows that procedures adopted routinely for ALL practices must
be adequate to prevent cross-infection.

Under current technology, it is recognized that the risks of accidental percutaneous

injury during dental procedures cannot be reduced to zero. While the risk of HBV
transmission could be eliminated by immunization, the risk of exposure to the blood of
HIV infected individual is a special concern to dental health care workers. It is
considered justifiable to apply additional infection control measures when performing
invasive procedures on individuals with known HIV infection.

Dental health care workers who consider themselves at increased risk of HIV
infection should arrange confidential testing. Those who are infected must seek
appropriate medical advice to ensure they pose no risk to patients (please refer to
Advisory Council on AIDS published document “HIV infection and the health care
workers – recommended guidelines”).

4. Medical history

A thorough medical history should be taken and up-dated at subsequent

examinations. Medical history screening is essential in alerting the clinician to medical
problems that could, in conjunction with dental treatment, adversely affect the patient.

5. Protective measures

Protection can be achieved by a combination of immunisation procedures, use of

barrier techniques and strict adherence to routine infection control procedures.

(i) Immunisation

All dental health care workers are advised to be immunized against HBV
unless immunity from natural infection or previous immunization had been

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 documented

(ii) Protective coverings

Uniforms

Uniforms should be changed regularly and whenever soiled. Gowns or aprons

should be worn during procedures that are likely to cause spattering or splashing of
blood.

Hand protection

Gloves must be worn for procedures involving contact with blood, saliva or
mucous membrane. A new pair of gloves should be used for each patient. If a glove
is damaged, it must be replaced immediately. Hands should be washed thoroughly
with a proprietary disinfectant liquid soap prior to and immediately after the use of
gloves. Disposable paper towels are recommended for drying of hands. Any cuts or
abrasions on the hands or wrists should be covered with adhesive waterproof
dressings at all times.

Protective glasses, masks or face shields

Protective glasses, masks or face shields should be worn by operators and

close-support dental surgery assistants to protect the eyes against the spatter and
aerosols which may occur during cavity preparation, scaling and the cleaning of
instruments.

(iii) Sharp instruments and needles

Sharp instruments and needle should be handled with great care to prevent
unintentional injury. Needles should never be recapped by using both hands in
direct contact or by any other technique that involves moving the point of a used
needle towards any part of the body. The needle can be recapped by laying the cap
on the tray, placing the cap in a resheathing device or holding the cap with forceps
before guiding the needle into the cap.

(iv) First aid and inoculation injuries

In the event of a skin puncture by a contaminated instrument, the wound

should be encouraged to bleed and washed thoroughly with running water.

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 All incidents should be reported to the officer i/c of the clinic. Where there is
reason to be concerned about the possible transmission of infection, advice on
appropriate serologic testing, medical evaluation and follow-up could be sought
from Accident and Emergency Department or AIDS Unit (Tel. 7808622), and the
address and contact telephone of the patient concerned should be recorded.

6. Instrument sterilization

All instruments should be cleaned thoroughly before sterilization by rinsing and

scrubbing with detergent and water. Splashing of water should be avoided. Heavy duty
gloves and, where appropriate, face protection shield, should be worn.

Items which will penetrate tissues must be sterilized in an autoclave or hot air
steriliser. Items which will touch mucous membrane but not penetrate tissues should
similarly be sterilized by heat, or, if not possible, disinfected, e.g., by immersion in 2%
glutaraldehyde solution in a closed container according to the manufacturer’s
instructions. All chemical residues must then be removed by thorough rinsing before use
or storage.

Handpieces, ultrasonic scaler inserts/tips and air-water syringe tips where

detachable should be flushed for 30 seconds, dismantled, cleaned, oiled where required,
and autoclaved between patients. (Handpieces, etc. left overnight should be allowed to
discharge water for two minutes at the beginning of the day). Handpieces which cannot
be autoclaved are disinfected with an appropriate virucidal agent.

Following sterilization, all instruments should be stored in clean containers to

prevent recontamination. Surgical and endodontic instruments should be kept in closed
containers. It may be necessary to re-sterilize them immediately before they are used and
care should be taken to ensure the instruments are cool prior to use.

7. Surface disinfection

Surfaces that are likely to become contaminated may be de-contaminated after

treatment or protected with disposable coverings before they become contaminated.

Effective cross-infection control is aided by a strict system of zoning and the use of
sterilizable trays. Procedures should be adopted which limit the areas touched and
contaminated each time a patient is treated.

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 Between clinical sessions, work surfaces should be thoroughly cleaned and
decontaminated with ethyl alcohol (70%). If there is visible blood or pus, the surface
should be cleaned and disinfected with sodium hypochorite (0.5%), followed by water
rinse. Protective gloves should be worn and care taken to minimise direct skin, mucosal
or eye contact with these disinfectants.

8. Aspiration and ventilation

The use of high volume aspiration will reduce any risk of cross-infection from
aerosols. The risk is further reduced by good ventilaton.

The tubings of high volume aspirators and saliva ejectors should be flushed with
water between patients and with disinfectant (sodium hypochlorite, 0.1%) regularly or
according to the manufacturer’s instructions.

9. Disposal of waste

Sharp items including needles and scalpels and local anaesthetic cartridges, should
be placed into puncture proof containers which should be securely sealed. These,
together with all medical waste must be disposed of in red bags, securely fastened. Red
plastic bags are to be picked up by a special collection service for hospitals and clinics.

Non infective waste should be disposed of in thick black plastic bags securely
fastened.

Liquid waste should be carefully poured into a drain and then flushed with water.
Spatter and splash should be avoided.

10. Laboratory items

Impressions and appliances should be rinsed thoroughly to remove all visible blood
and debris. Gloves should be worn when handling impressions and pouring models.
Certain types of impression material (silicone, polysulphur) can be disinfected by total
immersion in glutaraldehyde (2%) or sodium hypochlorite (0.1%). Other materials
(alginate, polyether) may be disinfected by submerging for several seconds in sodium
hypochlorite (0.1%), which should then be wrapped in a hypochlorite saturated paper
towel and kept in a closed container for the recommended disinfectant time.

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11. Additional precautions to be taken when performing invasive procedures on HIV
infected individuals

(a) If possible, schedule the patient surgery at the end of the list.

(b) The team should be limited to essential members of staff and the procedures
should be performed by experienced, fully trained staff.

(c) The operator should wear two pairs of gloves. Plastic gown, cap mask and
protective eye wear should be worn.

(d) All procedures should be performed in a way which minimizes the formation
of droplets, spatter and aerosols, utilizing high volume vacuum aspirators,
rubber dams where appropriate and proper patient positioning. Ultrasonic
scalers should be avoided.

(e) Avoid the use of instruments which cannot be easily decontaminated.

Instruments and tools used should be handled and cleansed by experienced
staff before autoclaving.

(f) After the operation, all surfaces inside the surgery and equipment should be
cleaned and decontaminated with appropriate disinfectants.

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Recommended methods of decontamination for dental items

Item Recommended Method Alternative Method

Amalgam/composite carriers Wipe with 70% ethyl alcohol

Articulators Wipe with 70% ethyl alcohol

Attachments dental units Wipe with 2% glutaraldehyde, Wipe with 70% alcohol
rinse

Bracket tables Wipe with 70% ethyl alcohol

If there is visible blood or pus,

clean and disinfect with 0.5%
sodium hypochlorite, rinse

Burs – diamond Clean with metallic brush and

detergent, autoclave
Burs - steel Clean with metallic brush and Clean with metallic brush and
tungsten-carbide detergent, rinse, dry and dry detergent, rinse, dry and
heat immerse in 2% glutaraldehyde
for 10 hours, rinse

Dental chairs Clean with detergent and

water
If there is visible blood or pus,
clean and disinfect with 0.5%
sodium hypochlorite or 2%
glutaraldehyde, rinse

Dental mirrors Clean with detergent and

water, autoclave, store in
covered pack or container

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 Item Recommended Method Alternative Method

Denture Clean with detergent and

water

If contaminated with blood,

immerse in 0.1% sodium
hypochlorite for 10 mins. and
rinse

Extraction Clean with detergent and

Forceps water, autoclave, store in
covered pack or container

Gloves Disposable

Handpieces Flush for 30 sec., Flush or 30 sec.,

Air motor for slow speed Clean with detergent and Clean with detergent and
handpieces water, oil, and autoclave water, oil, surrounding the
handpiece by a gauze pad
soaked in 2% glutaraldehyde
for 10 mins., rinse with water

Impressions –
Alginate :
(plastic trays) Rinse, get rid of excess water,
spray with 0.1% sodium
hypochlorite, put in closed
container for 10 mins.

Zinc-oxide eugenol paste : “

Alginate : Rinse, get rid of excess water,

(metallic trays) spray with 2% glutaraldehyde,
put in closed container for 10
mins.

Rubber base : Rinse, immerse in 2%

glutaraldehyde for 10 mins.,
rinse
Injection needles for Disposable
local anaesthetic

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 Item Recommended Method Alternative Method

Instrument trays Clean with detergent and

water, autoclave

Orthodontic bands Clean with detergent and

water, autoclave

Orthodontic pliers Clean with detergent and

water, autoclave

Polishing stones Clean with detergent and

water, autoclave

Prophylactic cups and brushes Disposable Clean with detergent and water
autoclave
Protective, plastic glasses and Wipe with 0.1% sodium
shields hypochlorite
Root canal instruments Clean with detergent and
water, autoclave, store in
covered container
Rubber dam clamps Clean with detergent and
water, autoclave
Rubber dam forceps Clean and autoclave Clean, immerse in 2%
glutaraldehyde for 10 mins.,
rinse

Rubber dam punches Clean with detergent and

water

Saliva ejectors Disposable

Saliva ejectors, metallic Clean with detergent and

water, and autoclave

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 Item Recommended Method Alternative Method

Scalpel blades Disposable

Stainless steel cups Clean with detergent and

water, autoclave

Stainless steel instruments Clean with detergent and Dry heat

water, autoclave, store in
covered pack or container

Suction tips Clean with detergent and

water, autoclave

Suction tube adaptors Wipe with 70% alcohol after

each use.
Autoclave weekly

Surgical instruments Clean with detergent and Dry heat

water, autoclave, store in
covered pack or container

Syringe – local anaesthetic Clean with detergent and Dry heat

water, autoclave, store in
covered pack or container

Syringe tips – detachable 3- Clean with detergent and

way water, autoclave

Ultrasonic scaler tips and Clean with detergent and

inserts water, autoclave, store in
covered pack or container

Wax bite block, wafer Rinse, immerse in 0.1%

sodium hypochlorite for 10
mins., rinse

X-ray films : Remove plastic packet and

(with disposable plastic cover) Dispose the cover and change drop the film with non-touch
gloves technique in red light.
Change gloves before
processing
(without disposable plastic Immerse in 0.1% sodium
cover) hypochlorite for 2 mins., rinse

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