Healthcare-Associated Infections: Infection Prevention in Oral Health Settings

Regular cleaning and disinfection of environmental surfaces is important to help prevent the spread of infectious diseases within the oral health care setting.

Cleaning and disinfection tips

• Ensure products used for cleaning and disinfection are Environmental Protection Agency (EPA) approved.
• Develop cleaning and disinfection checklists for clinical contact surfaces (such as light handles and computers) as well as housekeeping surfaces (such as floors and sinks).
• While cleaning operatories after patient care, use utility gloves when handling sharp instruments to protect against accidental pokes.
• Dilute any concentrated disinfection solutions properly, according to the manufacturer’s instructions for use (IFU). Wear appropriate personal protective equipment (PPE), and label the diluted solution appropriately, including the modified expiration date.
  • Note: Do not "top off" bottles of diluted solutions. The remaining product should be discarded and the container rinsed. Then, the bottle can be refilled with new diluted solution.

Resources

• CDC (Centers for Disease Control and Prevention) Basic Expectations for Safe Care Training Module 8 – Environmental Infection Prevention and Control Presentation (PDF)
• CDC Basic Expectations for Safe Care Training Module 8 – Environmental Infection Prevention and Control Presenter's Script (PDF)
• CDC Best Practices for Environmental Infection Prevention and Control

Adequate sterilization requires a series of steps, all of which must be performed properly. Improperly sterilized dental instruments can lead to the transmission of illnesses, such as Hepatitis B, Hepatitis C, and HIV.

Dental Instrument Cleaning, Disinfection, and Sterilization Toolkit

The DHS Dental Instrument Cleaning, Disinfection, and Sterilization Toolkit is intended to help support oral health clinics in achieving proper sterilization of instruments and devices. This toolkit includes background on the sterilization process and describes recommended processes for sterilizing instruments and devices, according to evidence-based guidance. This toolkit also includes sample sterilization audit tools and a monitoring log.

Access the toolkit, P-03640 (PDF)

Hand hygiene refers to either washing hands with soap and water, using alcohol-based hand rub (ABHR), or in some cases performing surgical hand scrubs. In most cases, ABHR is the preferred method for performing hand hygiene. However, some situations warrant hand washing with soap and water.

Hand hygiene methods

Refer to the following list for situations that require hand hygiene and the method which is most appropriate.

 ABHR

Perform hand hygiene using an alcohol-based hand rub for the following situations:

• Prior to performing a clean task.
• Moving from a soiled task to a clean task.
• After touching instruments, equipment, materials, and other objects likely to be contaminated by blood, saliva, or respiratory secretions with bare hands.
• Before and after treating each patient.
• Before putting on gloves and again immediately after removing gloves.

 Soap and water

Perform hand hygiene using soap and water for the following situations:

• Before eating.
• After using the restroom.
• When hands are visibly soiled or dirty (for example, with blood or bodily fluids).

 Surgical hand scrub

Perform a surgical hand scrub prior to surgical procedures. Visit the CDC website to learn more about what procedures are considered oral surgery.

For step-by-step instructions on cleaning your hands, using either soap and water or ABHR, visit the CDC's hand hygiene webpage for health care providers.

Other considerations

Keep natural fingernails short, less than ¼ inch long. Artificial nails and extenders should not be worn by direct caregivers.

Resources

• World Health Organization Hand Hygiene Training Tools
• CDC Basic Expectations for Safe Care Module 2 – Hand Hygiene Presentation (PDF)
• CDC Basic Expectations for Safe Care Module 2 – Hand Hygiene Presenter's Script (PDF)
• CDC Clean Hands in Healthcare Training

PPE is equipment that is worn to help protect staff from injuries and exposures to infectious agents. While there are many similarities in PPE worn in the oral health setting compared to other health care settings, there are some differences as well. Many of these differences can be attributed to the standard precautions that are necessary for the type of work that occurs in the oral health setting.

Types of PPE

 Surgical masks

Surgical masks are worn to protect the mouth and nose from splashes and sprays. They should be used whenever splashes and sprays can be expected. They should be changed between every patient encounter and whenever they become wet.

 Protective eyewear

Safety glasses or a face shield are worn to protect the eyes against splashes and sprays. They should be used whenever splashes and sprays can be expected. Reusable eyewear should be cleaned and disinfected between patients.

 Exam gloves

These are worn to protect the skin on the hands from bloodborne pathogen exposure during routine care. They should be used for all care and other housekeeping duties whenever hands may come in contact with blood, body fluid, non-intact skin, and when handling potentially infectious material. Gloves should be changed after caring for each patient, if they become torn or punctured, and after handling contaminated material. Gloves are never to be washed to extend their use.

 Sterile surgical gloves

Sterile surgical gloves are worn for oral surgical procedures in order to reduce the chance of introducing harmful bacteria and other pathogens to an operative wound. Oral surgical procedures involve incision, excision, or reflection of tissue, exposing normally sterile parts of the oral cavity. These procedures include biopsies, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth.

 Utility gloves

Utility gloves are worn to protect against pokes and other skin injuries when cleaning operatories and reprocessing instruments. Never use utility gloves for patient care. Utility gloves should be dedicated to one staff member for use. The exterior of the utility gloves should be washed with soap and water after each use. Replace utility gloves when they are punctured, torn, or become otherwise unsuitable for continued use.

 Protective clothing

Gowns or cover jackets with long sleeves are worn to protect clothing and skin from bloodborne pathogen exposure. They should be worn whenever clothing may come in contact with blood or body fluids, or other contaminated material. Reusable gowns and cover jackets should be changed and laundered at the end of the workday and when they become visibly soiled. Remove them when leaving the building for lunch or entering a clean break room space. Protective clothing must be provided and laundered by the employer and never taken home by employees.

Resources

• CDC Basic Expectations for Safe Care Training Module 3 – Personal Protective Equipment Presentation (PDF)
• CDC Basic Expectations for Safe Care Training Module 3 – Personal Protective Equipment Presenter's Script (PDF)
• CDC PPE Donning and Doffing Instructional Videos
• CDC PPE Frequently Asked Questions

Implement respiratory hygiene (cough etiquette) practices as part of standard precautions in your clinic.

Resources

• CDC Basic Expectations for Safe Care Training Module 4 – Respiratory Hygiene and Cough Etiquette Presentation (PDF)
• CDC Basic Expectations for Safe Care Training Module 4 – Respiratory Hygiene and Cough Etiquette Presenter's Script (PDF)

To prevent transmission of infectious diseases, implement safe injection practices as part of standard precautions in your clinic.

Safe injection practices for oral health clinics

• Use aseptic technique
• Use needles and syringes only one time(on a single patient)
• Use single-dose vials instead of multi-dose vials whenever possible
• When using dental cartridge syringes, ensure they are cleaned, disinfected, and sterilized appropriately between uses, according to the manufacturer’s instructions for use (IFU).

Resources

• CDC Basic Expectations for Safe Care Training Module 6 – Safe Injection Practices Presentation (PDF)
• CDC Basic Expectations for Safe Care Training Module 6 – Safe Injection Practices Presenter's Script (PDF)
• CDC Best Practices for Safe Injections in Dental Settings

Sharps in the oral health setting include needles, scalpel blades, burs, and other sharp instruments that can easily puncture the skin and soft tissue. They must be sterile and never reused without following manufacturer’s instructions for use (IFUs). The majority of these items are labeled for single use only.

Care must be taken to prevent accidental cuts, scrapes or punctures. Used disposable sharps must be placed in a puncture-resistant container (for example, a red sharps disposal box) as close to the point of use as possible. Items that can be reprocessed, such as dental instruments, must be carefully transported to the sterilization area in a covered, puncture-resistant container that is labeled as biohazardous.

Knowing where the sharps are, careful handling, and not reaching over or handing off instruments will reduce the incidence of exposure or puncture wounds. In the event of a puncture wound, proceed to post exposure management. Additional information can be found under the employee health section of this webpage.

Resources

• Organization for Safety, Asepsis, and Prevention (OSAP) Needlestick Safety webpage
• CDC Basic Expectations for Safe Care Training Module 5 – Sharps Safety Presentation (PDF)
• CDC Basic Expectations for Safe Care Training Module 5 – Sharps Safety Presenter's Script (PDF)
• Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard

Oral health clinics should routinely evaluate the effectiveness of the infection prevention and control program. This includes periodic audits of processes or incidents such as:

• Proper hand hygiene practices.
• Appropriate PPE usage.
• Disinfection and sterilization practices.
• Adherence to sharps safety practices.
• Operatory turnover and environmental cleaning and disinfection.
• Occupational bloodborne pathogen exposures.

Auditing resources

Clinics may create their own audit tools based on their unique policies and procedures. Additionally, clinics may use the following online resources to evaluate the effectiveness of their infection prevention and control program, such as the following resources:

• DHS Hand Hygiene Observations Template for Oral Health Settings (PDF)
• DHS Hand Hygiene and PPE Observations audit form F-02726 (PDF)
• Infection Control in Dental Settings, P-01808 (PDF)
• CDC Infection Prevention Checklist for Dental Settings – Basic Expectations for Safe Care (PDF)
• CDC Dental Check Mobile App

Oral surgical procedures involve incision, excision, or reflection of tissue, and expose normally sterile parts of the oral cavity. Oral surgical procedures include biopsies, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth. By opening tissues that are not normally exposed, oral surgical procedures can allow microorganisms from the mouth and elsewhere to enter the patient’s blood stream, increasing the chance of local or systemic infection.

Considerations when performing oral surgical procedures

• Perform surgical hand antisepsis using an antimicrobial agent that is fast-acting, has a broad spectrum of activity, and has a persistent effect. For step-by-step instructions on cleaning your hands, using either soap and water or ABHR, visit the CDC's hand hygiene webpage for health care providers.
• Wear surgical gloves to reduce the chance of introducing harmful bacteria and other pathogens to an operative wound. Sterile gloves are packaged to maintain sterility.
• Use sterile irrigating solutions, such as sterile water or sterile saline. Note that sterile solutions cannot flow through standard dental unit waterlines because standard waterlines are non-sterile. Instead, use an appropriate delivery device, such as:
  • A sterile bulb syringe. Designate the bottle of sterile saline or sterile water as single patient use only. Discard the bottle at the end of the procedure. Do not reserve remaining solution for another patient.
  • Pre-filled sterile irrigating syringes.
  • Sterile tubing that bypasses dental unit waterlines. This is a special delivery system that consists of single-use disposable or autoclavable waterline tubing that access a sterile water bottle. Most offices do not use this method to deliver sterile irrigating solution.

Additional information on best practices for oral surgical procedures can be found on the CDC website.

The dark, narrow tubing that supplies water to dental instruments and patients can become a breeding ground for bacteria and create biofilm. It is important to stay proactive in water treatment and testing to help mitigate risks associated with dental unit waterlines.

Considerations for maintaining safe water quality in oral health clinics

• Ensure water used in dental unit waterlines meets the EPA’s minimum standards for safe drinking water (≤ 500 CFU/mL). This is done through testing.
• Develop a procedure for treating water.
• Have a plan in place in the event of a boil water advisory. Under a boil water advisory, avoid using the water for dental procedures or in dental unit waterlines. Other activities, such as performing hand hygiene and environmental cleaning or instrument sterilization should also be avoided. Alcohol-based hand rub is an appropriate alternative if hands are not visibly soiled. Bottled and distilled water can be during this time. See the CDC Guidelines for Infection Control in Dental Health Care Settings (2003) and Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities for more information.

Dental Unit Waterlines Toolkit

For more information on maintaining dental unit waterlines, view the DHS Dental Unit Waterlines Toolkit, P-03664 (PDF). The toolkit includes background on dental water treatment and describes recommended processes for ensuring water used in dental units is safe, according to evidence-based guidance.

Resources

• American Dental Association Dental Unit Waterlines: Message to My Patients
• CDC Basic Expectations for Safe Care in Dentistry
• CDC Summary of Infection Prevention in Dental Settings: Basic Expectations for Safe Care, Module 9: Dental Unit Water Quality
• CDC Summary of Infection Prevention in Dental Settings: Basic Expectations for Safe Care, Module 9: Dental Unit Water Quality Presenter Script
• DHS Legionella webpage

Dentists account for 1 in 10 antibiotic prescriptions in the outpatient setting, which makes them the third to fourth highest antibiotic prescribers by volume.

Learn more about trends in dental antibiotic prescribing in Wisconsin, P-03383a (PDF) and antibiotic stewardship in dental and oral health by visiting the DHS Antimicrobial Stewardship webpage.

CDC Basic Expectations of Safe Care Training Modules

CDC has developed Basic Expectations of Safe Care Training Modules to increase infection prevention knowledge and skills for oral health care providers. These can be used to provide foundational training for oral health clinic staff.

CDC Foundations: Building the Safest Dental Visit

CDC designed Foundations: Building the Safest Dental Visit for oral health care staff to help increase awareness and adherence to established infection prevention and control guidelines. Continuing education units are available.

In addition to these modules, staff should be trained upon hire, annually, and when changes are made on the clinic’s individual policies, procedures, and expectations. Be sure to include temporary or contracted staff in these trainings.

An important point to consider is the health and safety of the dental health care personnel (DHCP). DHCP refers to all paid and unpaid personnel in the oral health care setting who might be occupationally exposed to infectious materials, including body substances and contaminated supplies, equipment, environmental surfaces, water, or air.

 Examples of DHCP

• Dentists
• Dental hygienists
• Dental assistants
• Dental laboratory technicians
• Students and trainees
• Contracted personnel
• Others not directly involved in patient care but potentially exposed to infectious agents such as administrative and clerical staff, housekeeping, maintenance, and volunteers

All DHCP must have the ability to call in sick if not feeling well, without penalty. An office policy outlining communicable diseases is recommended.

Illnesses or injuries that might prevent a DHCP from performing hand hygiene or wearing PPE properly may be cause to exclude those DHCP from working in their patient care duties until a resolution is reached. Consult with the local or Tribal health department or the Wisconsin HAI Prevention Program for further guidance.

 Return to work

Return to work guidance for SARS-CoV-2 (COVID-19) can be found on the CDC website.

Staff with acute respiratory illness (ARI) who are tested and do not have COVID-19 should be excluded from work until at least 24 hours after they no longer have a fever (without the use of fever-reducing medicines, such as acetaminophen or ibuprofen).

In addition, DHCP with a gastrointestinal (GI) illness can return to work after 48 hours with no GI symptoms, without the use of antidiarrheal or anti-nausea medication.

 DHCP immunizations

DHCP are at risk for exposure to infectious disease, including hepatitis B, influenza, measles, mumps, rubella, and varicella. Fortunately, vaccinations are available to protect DHCP from these illnesses. A brief summary of the guidance for DHCP vaccination is available.

The Occupational Health and Safety Administration (OSHA) requires that a hepatitis B immunization is offered to all DHCP who may have contact with blood or other potentially infectious material (OPIM) within 10 days of employment, at no cost to the DHCP. Most individuals have received this vaccine either as a part of their general health care or from a former employer or school affiliation.

Post-vaccination screening for protective levels of hepatitis B surface antibody should be conducted one to two months after completion of the vaccination series in order to document immunity.

DHCPs who decline a hepatitis B vaccination are required to sign a declination statement or provide proof of immunity. DHCP may still choose to receive the vaccination at a later time.

 Post-exposure prophylaxis

If an exposure to blood or other potentially infectious material (OPIM) such as a needle stick or puncture from a used instrument occurs, the following steps should be taken:

1. Wash the area thoroughly with soap and water.
2. Immediately report to a medical provider who can provide post-exposure prophylaxis (PEP).
3. Ask the source patient (if known) to have their blood drawn to check their hepatitis and HIV status.
4. Your clinic should have an agreement with a medical provider prior to any exposures occurring. The medical provider should be qualified to provide counseling and perform all medical evaluations and procedures in accordance with current recommendations of the U.S. Public Health Service (PHS), including PEP when indicated. If indicated, PEP must be started within 72 hours after an exposure.

Clinicians caring for workers who’ve had a possible exposure can call the CDC PEPline (888-448-4911) for advice on managing occupational exposures to HIV. Exposed workers may also call the PEPline, but they should seek local medical attention first.

 Tuberculosis (TB)

Screening for latent TB infection (LTBI) and TB disease should be performed before assumption of duties in which DHCP will have direct contact with patients. The Wisconsin TB Program has developed a decision tree, P-02530 (PDF) to assist with screening health care personnel and caregivers upon hire, as well as a worksheet, F-02314e (PDF) to determine the need for repeat TB testing after baseline testing for DHCP. Wisconsin screening and testing guidance, P-02382 (PDF) is also available.