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The way to infection control in dental clinics
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.
Disease: impairment of normal functioning, manifested by signs and symptoms.
Infection: state produced by an infected agent in or on a suitable host, host may be or may not
have signs or symptoms.
Carrier: individual harbors the agent but does not have symptoms (person can infect others).
Factors that allow or aid infection:
= The presence of pathogenic micro-organisms.
= There must be a portal of entry via which the organisms invade and colonize the susceptible
host.
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.
Protective measures
Protection can be achieved by a combination of immunization procedures, use of barrier
techniques and strict adherence to routine infection control procedures.
(a) Immunization:
All dental health care workers are advised to be immunized against HBV unless immunity
from natural infection or previous immunization had been documented
(b) 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 gloves 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 o abrasions on the hands or wrists should be covered with adhesive waterproof
dressings at all times.

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=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.
(c) 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 indirect 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 re-
sheathing device or holding the cap with forceps before guiding the needle into the cap.
(d) 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
All incidents should be reported to 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
Successful infection prevention program
A successful infection prevention program depends on:
1-Developing standard operating procedures.
2- Evaluating practices and providing feedback to dental health care personnel (DHCP).
3- Routinely documenting adverse outcomes (e.g., occupational exposures to blood) and work-
related illnesses in DHCP.
4- Monitoring health care associated infections in patients.
Standard Precautions
Standard Precautions: are the minimum infection prevention practices that apply to all
patient care, regardless of suspected or confirmed infection status of the patient, in any setting
where health care is delivered. These practices are designed to both protect DHCP and prevent
DHCP from spreading infections among patients.
Standard Precautions include:
1- Hand hygiene.
2- Use of personal protective equipment (e.g., gloves, masks, eyewear).
3- Respiratory hygiene / cough etiquette.
4- Sharps safety.
5- Safe injection practices (i.e., aseptic technique for parenteral medications).
6- Sterile instruments and devices.
7- Clean and disinfected environmental surfaces.

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Each element of Standard Precautions is described in the following sections. Education and
training are critical elements of Standard Precautions, because they help DHCP make
appropriate decisions and comply with recommended practices.
1- HAND HYGIENE:
1- Perform hand hygiene.
a. When hands are visibly soiled.
b. After bare hand touching of instruments, equipment, materials, and other objects likely to be
contaminated by blood, saliva, or respiratory secretions.
C. Before and after treating each patient.
d. Before putting on gloves and again immediately after removing gloves.
2. Use soap and water when hands are visibly soiled (e.g., blood, body fluids); otherwise, an
alcohol-based hand rub may be used.
2- PERSONAL PROTECTIVE EQUIPMENT (PPE):
1- Provide sufficient and appropriate PPE and ensure it is accessible to DHCP.
2- Educate all DHCP on proper selection and use of PPE.
3- Wear gloves whenever there is potential for contact with blood, body fluids, mucous
membranes, non-intact skin or contaminated equipment.
a- Do not wear the same pair of gloves for the care of more than one patient.
b- Do not wash gloves. Gloves cannot be reused.
c- Perform hand hygiene immediately after removing gloves.
4- Wear protective clothing that covers skin and personal clothing during procedures or
activities where contact with blood, saliva, or OPIM (other potential infectious materials) is
anticipated.
5- Wear mouth, nose, and eye protection during procedures that are likely to generate splashes
or spattering of blood or other body fluids.
6- Remove PPE before leaving the work area.
3- RESPIRATORY HYGIENE / COUGH ETIQUETTE:
1- Implement measures to contain respiratory secretions in patients and accompanying
individuals who have signs and symptoms of a respiratory infection, beginning at point of entry
to the facility and continuing throughout the visit.
a. Post signs at entrances with instructions to patients with symptoms of respiratory
infection to:
I. Cover their mouths / noses when coughing or sneezing.
ii. Use and dispose of tissues.
iii. Perform hand hygiene after hands have been in contact with respiratory secretions.
b. Provide tissues and no-touch receptacles for disposal of tissues.
c. Provide resources for performing hand hygiene in or near waiting areas.
d. Offer masks to coughing patients and other symptomatic persons when they enter the
dental setting.

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e. Provide space and encourage persons with symptoms of respiratory infections to sit as far
away from others as possible. If available, facilities may wish to place these patients in a
separate area while waiting for care.
2- Educate DHCP on the importance of infection prevention measures to contain
respiratory secretions to prevent the spread of respiratory pathogens when examining and
caring for patients with signs and symptoms of a respiratory infection.
4- SHARPS SAFETY:
Consider sharp items (e.g., needles, scalars, burs, lab knives, and wires) that are
contaminated with patient blood and saliva as potentially infective and establish engineering
controls and work practices to prevent injuries.
Do not recap used needles by using either hands or any other technique that involves
directing the point of a needle toward any part of the body. Use either a one-handed scoop
technique or a mechanical device designed for holding the needle cap when recapping needles
(e.g., between multiple injections and before removing from a non-disposable aspirating
syringe).
Place used disposable syringes and needles, scalpel blades, and other sharp items in
appropriate puncture-resistant containers located as close as possible to the area where the
items are used.
5- SAFE INJECTION PRACTICES:
1- Prepare injections using aseptic technique in a clean area.
2- Disinfect the rubber septum on a medication vial with alcohol before piercing.
3- Do not use needles or syringes for more than one patient (this includes manufactured
prefilled syringes and other devices such as insulin pens).
4- Medication containers (single and multi-dose vials, ampules, and bags) are entered with a
new needle and new syringe, even when obtaining additional doses for the same patient.
5- Use single-dose vials for parenteral medications when possible.
6- Do not use single-dose (single-use) medication vials, ampules, and bags or bottles of
intravenous solution for more than one patient.
7- Do not combine the leftover contents of single-use vials for later use.
8- The following apply if multi-dose vials are used:
a. Dedicate multi-dose vials to a single patient whenever possible.
b- If multi-dose vials will be used for more than one patient, they should be restricted to a
centralized medication area and should not enter the immediate patient treatment area (e.g.,
dental operatory) to prevent inadvertent contamination.
c. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated for
single-patient use and discarded immediately after use.
d. Date multi-dose vials when first opened and discard within 28 days, unless the manufacturer
specifies a shorter or longer date for that opened vial.
9- Do not use fluid infusion or administration sets (e.g., IV bags, tubings, connection) for more
than one patient.

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6- STERILIZATION AND DISINFECTION:
1- Clean and reprocess (disinfect or sterilize) reusable dental equipment appropriately
before use on another patient.
2- Clean and reprocess reusable dental equipment according to manufacturer instructions. If
the manufacturer does not provide such instructions, the device may not be suitable for multi-
patient use.
a. Have manufacturer instructions for reprocessing reusable dental instruments / equipment
readily available, ideally in or near the reprocessing area.
3- Assign responsibilities for reprocessing of dental equipment to DHCP with appropriate
training.
4-Wear appropriate PPE when handling and reprocessing contaminated patient equipment.
4- Use mechanical, chemical, and biological monitors according to manufacturer
instructions to ensure the effectiveness of the sterilization process. Maintain sterilization
records in accord
7- ENVIRONMENTAL INFECTION PREVENTION AND CONTROL:
1- Establish policies and procedures for routine cleaning and disinfection of environmental
surfaces in dental health care settings.
a- Use surface barriers to protect clinical contact surfaces, particularly those that are
difficult to clean (e.g., switches on dental chairs, computer equipment) and change surface
barriers between patients.
b- Clean and disinfect clinical contact surfaces that are not barrier-protected after each
patient.

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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 sterilizer. 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. Hand
pieces, ultrasonic scalar inserts/tips and air-water syringe tips where detachable should be
flushed for 30 seconds, dismantled, cleaned, oiled where required, and autoclaved between
patients. Hand pieces which cannot be autoclaved are disinfected with an appropriate verucidal
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.
1. 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.
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 hypochlorite (0.5%), followed by water rinse. Protective gloves should
be worn and care taken to minimize direct skin, mucosal or eye contact with these disinfectants.
2. 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 changed between patients or using (sodium hypochlorite, 0.1%) regularly or
according to the manufacturer’s instructions.
3. Disposal of waste:
Sharp items including needles and scalpels 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.

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4. 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 hypo chloride (0.1%). Other materials (alginate, polyether) may
be disinfected by submerging for several seconds in sodium hypo chloride (0.1%), which should
then be wrapped in a hypochloride saturated paper towel and kept in a closed container for the
recommended disinfectant time.
5. 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.
d. The operator should wear two pairs of gloves. Plastic gown, cap mask and protective eye
wear should be worn.
c. 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 scalars should be avoided.
d. Avoid the use of instruments which cannot be easily decontaminated. Instruments and tools
used should be handled and cleansed by experienced staff before autoclaving.
e. After the operation, all surfaces inside the surgery and equipment should be cleaned and
decontaminated with appropriate disinfectants.

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Recommended methods for dental items
Item Recommended method Alternative method
Amalgam/composite carrier Wipe with70% ethyl alcohol
articulators Wipe with70% ethyl alcohol
Attachment dental units Wipe 2% glutaraldehyde, rinse Wipe with 70% alcohol
Bracket table Wipe with 70% ethyl alcohol. But if
there is invisible blood or pus, clean
and disinfect with 0.2% of sodium
hypochloride, rinse
Burs-- diamond Clean with metallic brush and
detergent, autoclave.
Burs: steel, tungsten, carbide. Clean with metallic brush and
detergent, rinse, dry, and dry heat
Clean with metallic
brush and detergent,
rinse, dry, 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% of sodium
hypochloride or 2% glutaraldehyde,
rinse
Dental mirrors Clean with detergent and water,
autoclave, store in covered pack or
container.
Denture Clean with detergent and water, if
contaminated with blood immerse in
0.1% sodium hypochloride for 10
minutes, and rinse.
Extraction forceps Clean with detergent and water,
autoclave, store in covered pack or
container.
Gloves Disposable
Hand pieces, air motor for
low speed hand pieces
Flush for 30 seconds, clean with
detergent and water, oil, and
autoclave. 0
Flush for 30 seconds,
clean with detergent
and water, oil,
surrounded the hand
piece by a gauze pack
soaked in 2%
glutaraldehyde for 10
minutes, rinse with
water

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Item Recommended method Alternative method
Alginate: with plastic trays Rinse get a rid of excess
water, spray with 0.1%
sodium hypochloride, put in
closed container for10
minutes
Alginate with metals trays Rinse get a rid of excess
water, spray with 2%
glutaraldehyde, put in closed
container for10 minutes
Rubber base materials Rinse, immerse in 2%
glutaraldehyde for 10
minutes, rinse.
Injection needles for local
anesthesia
disposable
Instrument trays Clean with detergent and
water, autoclave.
Orthodontic bands and pliers Clean with detergent and
water, autoclave.
Polishing stone Clean with detergent and
water, autoclave.
Cups and brushes disposable
Protective plastic glasses and
shield
Wipe with 0.1% sodium
hypochloride
Root canal instruments Clean with detergent and
water
Rubber dam clamps Clean with detergent and
water, autoclave.
Rubber dam forceps Clean and autoclave Clean, immerse in 2%
glutaraldehyde for 10
minutes, 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 instruments Clean with detergent and
water, autoclave, stored in
covered pack or container
Dry heat
Suction tips disposable
Suction tube adaptor Wipe with 70% alcohol each
use, autoclave weekly.
Surgical instruments Clean with detergent and
water, autoclave, stored in
covered pack or container
Dry heat
Syringe, local anesthesia Clean with detergent and
water, autoclave, stored in
covered pack or container
Dry heat
Ultrasonic scalar tips and
inserts
Clean with detergent and
water, autoclave, stored in
covered pack or container
Wax bit block, and wafer Rinse, immerse in 0.1%
sodium hypochloride for 10
minutes, rinse.

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Notes:
1- Role of nurses to doctors: firstly, to protect patient, secondly, help doctors
2- All areas that surrounds doctor and may will be touch, must be covered
3- Do not touch desk, door, cabinet, telephone, dental chair, basin, your lab coat, and
tap, while you wearing the infected or non-infected gloves.
4- If it urgently to touch anything should remove the gloves firstly or covering it firstly.
5- How many contra angle in each clinic? (How many patients come to each clinic per-
day?)
6- Air tip should be disposable (preferable) and if it is metal must have a lot of number
to accommodate all patients per-day
7- Suction tips must be disposable.
8- The drawer’s hands of cabinet must be covered between patients or only touch by
cleaned glove.
9- During alginate mixing, take care about touching spatula or rubber bowel by infected
glove.
10- For example, during composite restoration: composite syringe, itch and bond
bottle should be touch by new gloves or nurse can help doctor for that.
11- Keep in your mind that the patient’s relatives observe everything in the clinic
during any procedure.
12- Nurse and doctor should be mindful for everything doing to the patient.
13- Must be respect the patient’s privacy when present in the clinic so do not open the
door more than one time under any situation.
14- Do not talking with the nurse about another patient’s behavior (respect privacy)
15- Take care for the following when the patients in your clinic:
Cough, running nose, burping, hum, hiccough. Also the doctor and nurse must be:
presentable, have good smell, have good manner, honest, faithful and reasonable all
the times