Infection Prevention

College of Dental Hygienists
of British Columbia
Infection Prevention and Control Guidelines

July 2012
Introduction
Patient Safety
Dental Health Care Providers’ Responsibilities and Safety
Cleaning, Disinfection and Sterilization of Patient Care Items
Office Cleaning, Housekeeping and Management of Waste
Equipment and Area Specific Practice Guidelines
Additional Considerations for Alternative Practice Settings
Glossary of IPAC Terms
Appendices
Development of Infection Prevention and Control Guidelines for B.C. Dental Professionals
Developed in collaboration with the College of Dental Surgeons of BC and

based on: Guidelines on Infection Control in the Dental Office (revised –
February 2010) published by the Royal C
ollege of Dental Surgeons of Ontario.
Development of Infection Prevention and Control Guidelines

for B.C. Dental Professionals
The development of the Infection Prevention and Control This document is intended to serve as a “living document”
Guidelines has been a collaborative project between the that will be updated over time to reflect changes called
College of Dental Hygienists of BC and the College of for as a result of research and developments in the field
Dental Surgeons of BC. The intent of the project was to of infection prevention and control. As a result, static
develop a document that will serve as a practice resource referenced-to specific publications are not provided.
for all dental assistants, dentists and dental hygienists in However, Appendix 2 provides a listing of additional
British Columbia. In addition, this project is in accordance resources available online.
with the mandate of public protection that is common to The content contained in these Infection Prevention and
both Colleges. Control Guidelines is the same in the version that has
A consultative working group was established in order been published by each of the two Colleges. The context
to include the infection control perspectives of dental is framed from the perspective of each regulatory College,
professionals in diverse areas of practice including as the target audience is different oral health professionals.
private practice, residential care, research and education. Each College commits to the ongoing collaborative nature
Staff from both Colleges reviewed a number of credible of this document and will undertake future revisions with
resources on infection prevention and control, including input and consultation with the other College.
infection control documents currently in use in other
jurisdictions. Many resources were utilized in the
development of these guidelines, most significantly
Guidelines on Infection Prevention and Control in the
Dental Office published by the Royal College of Dental
Surgeons of Ontario.
2 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Contents
Contents

Introduction 5
Purpose of the Document 6
Professional and Regulatory Considerations 7
Transmission of Microorganisms and Principles of Infection Prevention
and Control (IPAC) 7
Part A: Patient Safety

1. Screening of Patients 9
2. Routine Practices 9
3. Risk Assessment 10
4. Hand Hygiene 10
5. Personal Protective Equipment for Patient Safety 13
• General considerations
• Protective eyewear
• Protective draping
• Use of rubber dam and high-volume suction
• Latex sensitivity and allergies
6. Safe Handling and Disposal of Sharps 14
7. Additional Precautions 14
8. Human Rights and Confidentiality 15
Part B: Dental Health Care Providers’ Responsibilities and Safety

1. Education and Training 16
2. Immunization 16
3. Illness and Work Restrictions 17
4. Exposure Prevention 18
• Safety-Engineered Needles
5. Personal Protective Equipment for Dental Hygienists 19
• General considerations
• Gloves
• Protective eyewear
• Masks
• Protective clothing
• Latex sensitivity and allergies
6. Minimizing Droplet Spatter 21
7. Exposure Management 21
8. Occupational Health and Safety Requirements and WHMIS 22
9. Prohibition of Eating and Drinking in Non-Designated Areas 22
Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 3

Part C: Cleaning, Disinfection and Sterilization of Patient Care Items
Contents
Introduction
1. General Considerations 23
• Sterilization
2. Processing of Critical and Semi-Critical Items 24
• Receiving, cleaning and decontamination
• Preparation and packaging
• Storage
3. Sterilization of Unpackaged Instruments 27
4. Processing of Heat-Sensitive Items 27
5. Processing of Non-Critical Items 28
6. Equipment Use and Preventive Maintenance 28
Part D: Office Cleaning, Housekeeping and Management of Waste

1. General Considerations 30
2. Clinical Contact Surfaces 30
3. Housekeeping Surfaces 31
4. Management of Waste 31
• Biomedical waste
• General office waste
• Handling of extracted teeth
Part E: Equipment and Area Specific Practice Guidelines

1. Dental Unit Waterlines 34
2. Dental Handpieces 35
3. Saliva Ejectors 35
4. Single-Use Devices 35
5. Dental Radiography Equipment 36
6. Digital Radiography Sensors and Intraoral Cameras 36
7. Lasers and Electrosurgery Equipment 37
8. Dental Laboratory Asepsis 37
9. Handling of Biopsy Specimens 38
10. General and Surgical Aseptic Technique 38
Part F: Additional Considerations for Alternative Practice Settings 40
Part G: Glossary of Infection Prevention and Control Terms 42
Appendix 1
Methods for Cleaning, Disinfection and Sterilization of Patient Care
Items and Environmental Surfaces 45
Appendix 2
Additional Resources and Reference Materials available on the Internet 46

Introduction
Introduction
Infection prevention and control is an important • The term “dental office” includes any facility in
part of safe patient care. Concerns about the which oral health care is provided, such as tradi-
possible spread of blood-borne diseases, and the tional dental practices, dental hygiene practices,
impact of emerging, highly contagious respiratory community and school-based dental clinics, and
and other illnesses, require practitioners to estab- residential care centres and other institutional
lish, evaluate, continually update and monitor their settings.
infection prevention and control strategies and
• These Guidelines contain practice parameters
protocols.
and standards, but respect the autonomy of
These Guidelines are significantly broader than each dental office. Guidelines, by definition, are
previous documents, and they reflect current directing principles, and indications or outlines
knowledge of the transmission of infection, and of policy and conduct.
how to prevent and control it.
• Dental hygienists are trained to take precautions
IM P O RTA N T in order to protect patients and staff. In addition
to previous instruction, it is important that
In this document, the following assumptions have
all dental hygienists receive office-specific
been made:
training in infection prevention and control as
• The terms “dental health care provider” (DHCP) part of their orientation, and whenever new
and “staff” are used interchangeably. “Staff” tasks, procedures or equipment are introduced.
encompasses all persons conducting activities It is recommended that one staff person
within, or associated with, dental offices and be appointed to manage the dental office’s
includes dentists, dental hygienists, dental infection prevention and control program and
assistants, anaesthetists and other support ensure that it remains current. While infection
persons. prevention and control is the responsibility of all
dental hygienists, implementation and oversight
rests with the principal practice owner(s).

Purpose of the Document
Purpose of the Document
This document is not a step-by-step manual on how

to implement specific infection control p
ractices The words “must” and “should” are used
or procedures, nor does it endorse the use of throughout this document:
specific infection control products or manufactur- • “Must” indicates the minimum standards
ers. Rather, it is intended to provide all DHCPs that are mandatory.
with the k nowledge of principles and standards to
• “Should” indicates a recommendation
inform and properly implement necessary infection
that is not mandatory.
prevention and control m
easures in a safe and
effective manner, including standards of practice
that must be met. These are reflected throughout Wherever possible, recommendations are based
the body of the document by the use of “must” on data from well-designed scientific studies.
statements rather than “should” statements. However, some infection prevention and control
This document consolidates published recom- practices routinely used by health care practitioners
mendations from government and other agencies, cannot be rigorously examined for ethical or logisti-
regulatory bodies and professional associations. cal reasons. In the absence of scientific evidence
for such practices, certain recommendations are
based on strong theoretical rationale, suggestive
evidence or opinions of respected authorities. In
addition, some recommendations are derived from
provincial and federal regulations.
Accordingly, this document presents “best
practices,” reflecting the best evidence and expert
opinion available at the time of writing.

Professional and Regulatory Considerations
Professional and Regulatory Considerations • Transmission of Microorganisms and Principles of IPAC

Practice owners have an obligation to maintain prevention and control procedures, and that the
the standards of practice of the profession and, necessary supplies and equipment are available,
accordingly, must ensure that recommended fully operational, up-to-date and routinely monitored
infection prevention and control procedures are for efficacy.
carried out in their offices. In addition to professional obligations, practice
Dental hygienists must maintain current owners also have an ethical duty to maintain a
knowledge of infection prevention and c ontrol safe and healthy office environment for both
procedures, and apply and maintain them patients and staff, and to adhere to all rules and
appropriately and c onsistently. To this end, it is regulations related to the operation of a dental
the practice owner’s responsibility to ensure practice, including workplace health and safety,
that staff are adequately trained in infection and environmental protection.
Transmission of Microorganisms and Principles

of Infection Prevention and Control (IPAC)
In order to transmit an organism or infection, three
elements must be present: Break any link to break the
1. A microorganism chain of infection
2. A susceptible host
3. A way for the microorganism to be
transmitted Infectious
Agent
Understanding the modes of transmission of infec-
tion is necessary for designing and implementing Susceptible
Reservoir
effective infection prevention and control strate- Host
gies. Dental patients and DHCPs can be exposed
to pathogenic microorganisms, including viruses
(e.g. HBV, HCV, HIV, human herpes viruses, human
papillomavirus), bacteria (e.g. Mycobacterium Portal of Portal of
tuberculosis, staphylococci, streptococci) and other Entry Exit
microbes that colonize or infect the oral cavity and
respiratory tract. Transmission

In the dental office, the main modes of IPAC principles include:
Transmission of Microorganisms and Principles of IPAC
transmission of microorganisms are: • patient assessment;

• direct transmission – direct physical contact • following Routine Practices;
with blood, oral fluids or other materials
• using barrier techniques to protect both patients
• indirect transmission – contact with an and dental hygienists;
intermediate contaminated object, such
• applying the principles of cleaning, disinfection,
as a dental instrument, equipment or an
sterilization and storage of dental instruments;
environmental surface
• environmental cleaning;
• droplet – contact of oral, nasal or conjunctival
mucosa with droplets, spatter or spray contain- • care of the overall office setting;
ing microorganisms generated from an infected • safe handling and disposal of wastes.
person, such as by coughing, sneezing or talking
An overall IPAC program should focus on strategies
• aerosol – particles of respirable size (<10um) to reduce the risk of transmission.
generated by both humans and environmental
These strategies include:
sources that can remain viable and airborne for
extended periods in the indoor environment. In a) identifying, communicating and implementing
dentistry, aerosols are commonly generated by standards and guidelines by setting specific
the use of handpieces, ultrasonic scalers and policies and procedures;
air/water syringes. b) effective occupational health and safety
The risk of infection as a result of a dental programs for all dental hygienists, such as
procedure is extremely low, but it represents written procedures for the workplace and
an important patient safety consideration. By guidance on immunization;
understanding how diseases are transmitted, and c) educating dental hygienists, as well as patients
applying infection prevention and control (IPAC) and their families, about everyone’s role in
principles, dental hygienists can develop s trategies infection prevention;
to interrupt the transmission of microorganisms
d) ongoing review of policies and procedures, and
among patients and dental hygienists, and from
evaluation of the IPAC program.
dental instruments, handpieces, devices and
equipment.
KEY PRINCIPLE: Dental hygienists must
maintain current knowledge of best
practices in infection prevention and
control, and apply it appropriately and
consistently to ensure protection of staff
and patients.


1. Screening of Patients 2. Routine Practices
From time to time, patients who are unwell may Health Canada uses the term “Routine Practices”
attend at a dental office. Their health condition may to describe basic standards of infection prevention
relate to a dental problem, such as an oral infection and control that are required for safe patient care.
or a postoperative complication, but it may also A similar term, “Standard Precautions,” is used by
relate to a non-dental problem, such as a severe the Centers for Disease Control and Prevention in
respiratory illness (e.g. influenza) or simply a the United States. Routine Practices synthesize
bad cold. the major principles of “universal precautions,”
which are designed to reduce the risk of transmit-
In order to protect other patients and dental
ting pathogens that are blood-borne, and those of
hygienists from the spread of microorganisms,
“body substance precautions,” which are designed
patients who appear to be ill should be r escheduled
to reduce the risk of transmitting pathogens from
if at all p
ossible. If their dental condition is of an
moist body substances.
urgent nature, every effort should be made to
separate them from other patients by seating them Routine Practices are based on the concept that
in a secluded operatory as soon as possible. In this all patients are potentially infective, even when
way, the spread of m
icroorganisms by direct or asymptomatic, and that the same safe standards
droplet transmission can be minimized. of practice should routinely apply to contact with
blood, body fluids and secretions (e.g. saliva),
Another opportunity to screen for ill patients
mucous membranes and non-intact skin. In addi-
is when confirming dental appointments in
tion, instruments in direct contact with these fluids
advance. If staff learn that a particular patient has
and tissues are potentially contaminated with
a fever or cough, dental appointments should be
infectious agents.
rescheduled.
Adherence to Routine Practices protects both
dental hygienists and patients.
There are four principles that are inherent in
Routine Practices:
1. risk assessment
2. hand hygiene
3. use of personal protective equipment
4. safe handling and disposal of sharps and
contaminated waste

3. Risk Assessment 4. Hand Hygiene
The first step in the effective use of Routine Hand hygiene is the single most important measure
Practices is to perform a risk assessment. for preventing the transmission of microorganisms.
This must be done before each interaction with The term “hand hygiene” has replaced handwash-
the patient in order to determine the interventions ing and includes the use of plain or antimicrobial
that are required to prevent the transmission of soap with running water, as well as alcohol-based
infection. hand rub.
The risk of transmission of microorganisms will When should hand hygiene occur and with
vary, depending on the type of dental procedure what type of product?
to be performed and the likelihood of exposure Hand hygiene should be performed by washing
to blood, body fluids and secretions, mucous with plain or antimicrobial soap and running
membranes and non-intact skin. Additional water, or by using a 70-90% alcohol-based hand
factors to consider include: rub. Both methods are equally effective, unless
• the health status of the patient; hands are visibly soiled (including with powder
from gloves) or contaminated with body
• the characteristics of the patient, such as level
fluids, in which case hands should be washed
of cooperativeness;
with soap and water. Hand hygiene should be
• the physical environment and resources performed:
available;
• following personal body functions (e.g. blowing
• the immune status of the dental hygienist. nose or using washroom);
Procedures involving exposure to blood, body fluids • before and after direct contact with individual
and secretions, mucous membranes and non-intact patients;
skin require the use of appropriate personal protec-
• before putting on and after removing gloves;
tive equipment. On the other hand, procedures
involving no anticipated exposure may require • after contact with environmental surfaces,
fewer precautions. instruments or other equipment in the dental
operatory;
I M P O RTA NT
• after contact with dental laboratory materials or
Perform a risk assessment before each interaction equipment;
with the patient in order to determine the interven-
• before and after eating or drinking.
tions that are required to prevent the transmission
of infection. I M P ORTANT
Contamination may involve areas beyond the
hands (e.g. forearms). Use professional judgment
regarding the extent of contamination and ensure
affected areas are decontaminated appropriately.
If you think your hands or other skin surfaces have
become contaminated with body fluids, wash with
soap and water to remove organic matter.

Liquid soap should be provided in disposable I M P ORTANT

pump dispensers. Bar soap should not be used. Avoid the use of hand jewellery and artificial nails.
Hand lotion to prevent dry or cracked skin also Jewellery interferes with proper hand hygiene, can
should be available in disposable pump dispensers. make donning gloves more difficult and increases
Petroleum-based hand lotions should not be used the risk of gloves tearing. Artificial nails have been
because they can affect glove integrity. To avoid implicated in hospital outbreaks involving fungal
contamination, disposable pump dispensers of and bacterial infections.
liquid products should be discarded when empty
When using antimicrobial soap and water for
and not “topped-up” or refilled. Reports have been
surgical procedures:
documented in the scientific literature of dispos-
able soap dispensers becoming contaminated with • Remove all hand and wrist jewellery.
gram-negative bacterial species. • Clean under nails. A disposable manicure stick
Despite perceptions to the contrary, alcohol-based may be used, but nailbrushes are not recom-
hand rubs have been shown to be less irritating mended, as they can become contaminated and
to skin than soap and water. Select a product that damage the skin around the nails. Nails should
contains emollients. be short enough to allow thorough cleaning
underneath and not cause glove tears.
IM P O RTA N T
• Wash hands and forearms to the elbows
There is sufficient evidence that alcohol-based thoroughly for the length of time recommended
hand rubs are equally effective as washing with by the manufacturer (usually two to five
soap and water, except in cases where the hands minutes).
are visibly soiled or contaminated with body fluids.
• Rinse off soap and dry hands thoroughly before
In this case, handwashing with soap and water is
donning sterile gloves.
necessary to remove organic matter.
When using an alcohol-based hand rub for
How should hand hygiene be done?
routine care:
When using soap and water for routine care:
• Apply the product to one palm and rub both
• Wet hands with warm, not hot, water. hands together for at least the minimum time
• Apply adequate amount of soap to achieve interval indicated by the manufacturer, covering
lather. all surfaces of hands and fingers, until they
• Rub vigorously for a minimum of 15 seconds, are dry.
covering all surfaces of hands and fingers.

Pay particular attention to fingertips, between
fingers, backs of hands and base of thumbs,
which are the most commonly missed areas.
• Rinse well with running water.
• Dry thoroughly with a disposable paper towel.
Turn off taps with towel and discard towel
in a bin.

When using an alcohol-based surgical hand rub In addition:
for surgical procedures: • Soap dispensers should be placed at every sink.

• Remove all hand and wrist jewellery. • Alcohol-based hand rub dispensers should be
• Ensure that the alcohol-based hand rub strategically located for ease of use.
selected has been approved for surgical hand • Disposable towels should be readily available at
disinfection. each facility.
• Apply the product to dry hands only and follow • Taps should be turned off with the aid of a paper
the manufacturer’s instructions. towel to avoid recontamination of hands. If reno-
• Allow hands to dry thoroughly before donning vating, consider installing hands-free faucets.
sterile gloves. • A hand wash sink should not be used for any
Hand hygiene facilities should be located as other purpose.
close as possible to all dental operatories and
I M P ORTANT
preferably in clear sight of patients. If they are
out of sight, patients should be made aware The use of gloves does not preclude the need for
that hand hygiene is taking or has taken place. careful hand hygiene.

Use of rubber dam and high-volume

5. Personal Protective suction
Equipment for Patients Appropriate efforts should be made to minimize
the spread of droplets, spatter and spray created
General considerations during dental procedures. Accordingly, a rubber
Dental hygienists wear personal protective dam should be used whenever feasible, and
equipment (PPE) to shield their own tissues from high-volume suction should be used whenever the
exposure to potentially infectious material. This creation of droplets, spatter and spray is possible.
also protects patients by preventing the dental The use of rubber dam and high-volume suction
hygienist from becoming a vector for the transmis- also minimizes the ingestion or inhalation of
sion of microorganisms from patient to patient. contaminated material and debris.
Additional protective barriers and techniques Latex sensitivity and allergies
should be employed to shield patients from
Dental patients with true latex allergy may react to
potentially infectious material.
common dental products, such as gloves, rubber
Protective eyewear dams, prophylaxis cups, orthodontic elastics
Large particle droplets of water, saliva, blood, and some medication vials. As part of taking
microorganisms and other debris are created by the the medical history, patients should be asked
use of dental handpieces, ultrasonic instruments questions relating to possible latex allergy. This
and air/water syringes. includes asking whether true latex allergy has been
diagnosed. Additional questions should probe for
This visible spray typically travels only a short
a history of common predisposing conditions for
distance and settles out quickly, landing on nearby
latex allergy, such as other allergies (e.g. avocados,
surfaces, including the operatory countertops
kiwis, hazelnuts, bananas) or early latex exposure
and equipment, as well as the dental hygienist
related to medical treatment (e.g. spina bifida,
and patient.
urogenital anomalies).
Patients should be provided with protective eye-
Patients with true latex allergy should be treated in
wear to shield their eyes from spatter and debris
an environment where contact with latex proteins,
created during dental procedures. Protective
either directly or airborne, is kept as low as reason-
eyewear should be worn throughout the dental
ably achievable. When performing hand hygiene,
appointment, then cleaned and disinfected after
alcohol-based sanitizers are not sufficient for
use and whenever visibly contaminated.
removing latex particles; therefore, hands should
Protective draping be thoroughly washed with soap and water prior to
Single-use bibs or drapes should be used to protect contact with latex-sensitive patients.
the patient’s clothing, and reduce their exposure All latex-containing materials or devices should be
to spatter and debris created during dental pro removed from the operatory or adequately covered
cedures. Single-use strips may be used to secure and isolated.
bibs and drapes, in place of reusable daisy chains.
I M P ORTANT
Check labels of dental products for latex content.
Many items are available in latex-free forms.

These Additional Precautions are of particular
6. Safe Handling and Disposal relevance in health care institutions, where they
of Sharps may be determined by local infection preven-
tion and control committees and monitors. For
Extreme care must be taken at all times to ensure example, in an institutional setting, patients may be
patients are protected from injuries involving at increased risk of becoming infected or colonized
sharp objects. Sharps should be kept out of the with methicillin-resistant Staphylococcus aureus
reach of patients and safely collected in a clearly (MRSA), vancomycin-resistant enterococcus (VRE)
labelled puncture-resistant container. These sharps or respiratory tract viruses (e.g. influenza).
containers should be placed immediately adjacent In an ambulatory setting, such as a dental office,
to the point of use. Sharps should be disposed Additional Precautions are required for patients
of immediately following use at the end of the who are known or suspected of having an infec-
procedure. (See “Exposure Prevention” on p. 18 tion that can be transmitted by large respiratory
for more about sharps handling.) droplets. Examples of microorganisms that can be
transmitted in this fashion include respiratory tract
viruses, rubella, mumps and Bordetella pertussis.
7. Additional Precautions
Patients who are known or suspected of having an
infection that can be transmitted by large respira-
Routine Practices may not be sufficient for
tory droplets should be offered a mask and hand
patients who are infected or colonized with certain
hygiene upon presentation, maintain a two-metre
microorganisms that pose special problems in
separation from other persons, and be removed
blocking their transmission. The term “Additional
from the reception/waiting area and seated in a
Precautions” is used to describe measures that are
secluded operatory as soon as possible. In this
taken in addition to Routine Practices in order to
way, the spread of such microorganisms by droplet
interrupt the transmission of such microorganisms.
transmission can be minimized.
They include the physical separation of infected
or c olonized patients from other individuals and
the use of protective barriers (e.g. gowns, gloves, KEY PRINCIPLE: Dental hygienists must
masks) to prevent or limit the transmission of the ensure that recommended infection pre
infectious agent. vention and control procedures, including
Routine Practices, are applied in all aspects
of their practice.

The information contained in patient records is

8. Human Rights and confidential and must not be released to anyone
Confidentiality without the consent of the patient, or his/her
authorized representative, or as required or allowed
The BC Human Rights Code (the Code) provides for by law. Therefore, it is important to remember that
equal rights and opportunities, and freedom from patient records should be stored securely and not
discrimination. It prohibits discrimination based on left unattended or in public areas of the office.
race, ancestry, place of origin, colour, religion, sex, Sensitive medical information should not be
sexual orientation, age (19 and over), criminal con- recorded on the front of the patient’s chart, where
viction (in employment only), marital status, family it could easily be seen by others. A medical alert
status, political belief (in employment only), lawful should be coded in such a way that only staff
source of income (in employment only) or mental recognize the significance of the information,
or physical disability (including HIV or AIDS). while the exact nature of the condition should
Dental hygienists are prohibited from discriminating be documented within the patient’s chart.
against patients. This includes using extraordinary If patient records are computerized, login and
and unnecessary infection control or other mea- password protection should be used to prevent
sures that are not used for other patients. Dental unauthorized access. In addition, screen savers
hygienists may require modifications to Routine and other measures should be employed to ensure
Practices based on the risks associated with certain information on computer screens is not visible to
dental procedures, provided that they are employed other patients in the office.
for all patients undergoing the same procedures.
It is the practice owner’s responsibility to ensure
that all staff are knowledgeable about and take
appropriate steps to protect patient confidentiality.

Part B: Dental Health Care Providers’
Responsibilities and Safety

All dental hygienists should be adequately
1. Education and Training immunized against the following diseases:
• hepatitis B • influenza
Dental hygienists are more likely to comply with
• measles • diphtheria
infection p
revention and control protocols if they
• mumps • pertussis
understand the rationale for them. It is important
• rubella • tetanus
that all dental hygienists receive office-specific
training in infection prevention and control as • varicella • polio
part of their o
rientation, and whenever new It is important that all dental hygienists know their
tasks, p
rocedures or equipment are introduced. personal immunization status and ensure that it is
This t raining should be s upplemented whenever up to date. In this regard, dental hygienists should
necessary and reviewed at least a nnually by means consult with their family physician about the need
of staff m
eetings, a ttendance at c ontinuing educa- for immunizations, as well as baseline and annual
tion courses and through s elf-learning programs. tuberculosis skin testing. In addition, the Canadian
All dental hygienists should receive training that Immunization Guide sets out recommendations
includes information about their exposure risks, and schedules for adults, including those engaged
infection prevention and control strategies specific in the provision of health care.
to their occupational tasks, and the management Hepatitis B is the most important vaccine-prevent-
of any work-related illness or injury. able infectious disease for all workers engaged
It is also recommended that this document, as in health care. The risk of being infected is a
well as key reference materials identified in it, form consequence of the prevalence of virus carriers
part of an in-office infection prevention and control in the population receiving care, the frequency
manual. of exposure to blood and other body fluids, and
the contagiousness of hepatitis B virus (HBV).
Therefore, immunization against HBV is strongly
2. Immunization recommended for all dental hygienists who may
be exposed to blood, body fluids or injury
Immunizations substantially reduce the number involving sharps.
of dental hygienists susceptible to infectious Serological testing for anti-HBs should be
diseases, as well as the potential for disease conducted 1 to 2 months after completion of the
transmission to other staff and patients. Therefore, 3-dose vaccination series to establish antibody
immunizations are an essential part of infection response. Dental hygienists who fail to develop
prevention and control programs. an adequate antibody response should complete a
second vaccination series, followed by retesting
for anti-HBs. Dental hygienists who fail to respond
to the second vaccination series should be tested
for HBsAg.

Non-responders to vaccination who are HBsAg- As already noted, hand hygiene is the single most

negative should be counselled regarding important measure for preventing the transmission
precautions to prevent HBV infection and the of microorganisms, protecting both dental hygienists
need to obtain immunoglobulin prophylaxis for and patients. Please refer to Part A: Patient Safety
any known or probable parenteral exposure to for detailed information regarding recommended
HBsAg-positive blood. hand hygiene procedures.
Dental hygienists who are HBsAg-positive should Unique situations that might warrant particular
seek guidance from CDHBC regarding necessary attention by a dental hygienist include:
and reasonable steps to prevent HBV transmission • Dermatitis – When the protective skin barrier
to others and the need for medical evaluation. is broken, as occurs with chapped hands or
In particular, dental hygienists who might perform eczema, the dental hygienist is at increased risk
exposure-prone procedures should be assessed of acquiring and transmitting infection through
on a case-by-case basis regarding the need for the exposed area. Good skin care should always
possible work restrictions. be practised. Any areas of dermatitis should be
covered with bandages, in addition to wearing
KEY PRINCIPLE: Dental hygienists gloves.
who might perform exposure-prone • Immunocompromised staff – These dental
procedures have an ethical obligation to hygienists are at increased risk of becoming
know their s erologic status. If infected, infected and may suffer more severe
dental hygienists must seek guidance consequences. They might also be at risk of
from the College with respect to the shedding viruses (e.g. influenza) for prolonged
potential for transmission of their periods. Where f easible, job functions and
infection to their patients. associated exposure risks should be considered.
Dental hygienists who have an upper respiratory
illness (e.g. common cold) should take the n
ecessary
3. Illness and Work Restrictions precautions to prevent the transmission of micro-
organisms to patients and other staff. This includes
practicing respiratory etiquette by covering their
Dental hygienists are usually concerned about
coughs and sneezes with their elbow or a tissue
contracting illnesses in the dental office.
rather than with their hands, and discarding used
Such occurrences can be minimized by practis- tissues immediately. Additionally, continuous diligent
ing the principles discussed in this document, hand hygiene is especially important. Dental hygien-
including: ists who have a severe respiratory illness with fever
• ensuring adequate and appropriate (e.g. influenza), acute viral gastroenteritis with vomit-
immunization of all dental hygienists; ing and/or diarrhea, or acute conjunctivitis should
stay at home until their symptoms have subsided.
• triaging patients and rescheduling those who
are ill; Dental hygienists who have oral and/or nasal
herpes simplex infections (i.e. cold sores) should
• adhering to Routine Practices, including
pay particular attention to hand hygiene and not
effective hand hygiene before and after each
touch the affected area. In this situation, the use
patient contact.
of a mask might help to remind the worker not to
touch the lesions.

Percutaneous injuries pose the greatest risk
4. Exposure Prevention of transmission of blood-borne pathogens to

dental hygienists. Best practices to prevent
The primary method of preventing the transmission such injuries include the following:
of blood-borne pathogens (e.g. HBV, HCV and HIV) • Always use extreme caution when passing
to dental hygienists is by avoiding occupational sharps during four-handed dentistry. Consider
exposures to blood, saliva and other bodily fluids. the use of a “safe zone” for transferring
In the dental office, exposure may occur through instruments rather than passing instruments
percutaneous injuries (e.g. needle-sticks or cuts hand to hand.
with sharp objects), by contact with the mucous
• Needles should remain capped prior to use.
membranes of the eyes, nose and mouth, or by
contact with non-intact skin (e.g. exposed skin that • Needles should not be bent, recapped or other-
is abraded, chapped or has signs of dermatitis). wise manipulated by using both hands.
The majority of exposures are preventable by • Following use, needles should be recapped as
following Routine Practices, which include the soon as possible by using a one-handed scoop
use of personal protective equipment (PPE), such technique or a commercial recapping device.
as gloves, protective eyewear, masks, closed-toe • When suturing, tissues should be retracted
shoes and protective clothing, and safe work habits using appropriate instruments (e.g. retractor,
for the handling and disposal of sharps. dental mirror), rather than fingers.
PPE should be used consistently during the treat- • Remove burs from handpieces immediately
ment of patients, as well as the care of instruments following the procedure.
and equipment. Cuts, abrasions or dermatitis
• Identify and remove all sharps from trays before
constitute a breach in the skin’s protective barrier.
processing instruments.
During work, non-intact skin should be covered
with a waterproof bandage or protective dressing • Used sharps must be collected in a clearly
(e.g. Opsite, Tegaderm), which should be changed labelled puncture-resistant container which
as needed. Large cuts might require medical should be located at the point of use.
assessment and re-evaluation of work duties. • When removing debris from contaminated
instruments by hand, heavy-duty utility gloves,
appropriate clothing and long-handled brushes
should be used.
I M P ORTANT
Where a syringe and needle are being used
multiple times on the same patient, safe recapping
of a needle is preferred to prolonged exposure to
an unprotected needle.

Safety-Engineered Needles should not be worn outside of the office. Single-

use barriers, such as gloves and masks, should be
Some instruments and equipment have been
discarded immediately after use.
designed to increase safety, such as self-sheathing
anaesthetic needles* (also known as safety- I M P ORTANT
engineered syringes) and dental units that shield
Gloves, protective eyewear and masks should
burs in handpieces. WorkSafeBC’s Occupational
be task- and patient-specific and discarded
Health and Safety Regulation (OHSR G6.36)
immediately after use.
currently stipulates that safety-engineered hollow
bore needles must be used for the administration Gloves
of medications or fluids, unless the use of such a Gloves are worn to protect the hands of the dental
required device is not clinically appropriate in the hygienist from contamination. Since gloves are
particular circumstances. Research concluded that not completely free from leaks and may tear, their
additional design modifications are required use does not replace the need for hand hygiene.
prior to recommending universal use of Therefore, effective hand hygiene protocols should
currently available models of safety-engineered be followed before donning gloves and after
syringes/needles. However, they can be consid- removing them.
ered for optional use and safer versions of sharp
In the dental office:
devices should be considered as they become
• Gloves must be worn when contact with
available in the dental marketplace.
mucous membranes, non-intact skin or body
*For further information, see Appendix 2 for a link
fluids is anticipated.
to “WorkSafeBC Preventing Needle-stick Injuries
• The same pair of gloves must not be used for
and the Use of Dental Safety Syringes.”
more than one patient.
• Gloves should be put on immediately before the
5. Personal Protective activity for which they are indicated.
Equipment for Dental • Gloves must be removed and discarded imme-
Hygienists diately after the activity for which they were

used, and hand hygiene must be performed.
General considerations • Gloves should not be worn outside any room

or area where they are required for personal
Personal protective equipment (PPE) is worn to
protection.
shield the exposed tissues of dental hygienists
from exposure to potentially infectious material. • Gloves must not be washed and reused.
PPE serves as a barrier to protect the skin of the • Double-gloving may be utilized for some specific
hands and arms from exposure to splashing, spray- procedures, which may involve the handling
ing or spatter of blood, saliva or other body fluids, of multiple sharp instruments or during longer
and from introducing microorganisms into deeper appointments.
tissues by traumatic injuries. Such equipment also
• The issue of protocol for double-gloving is unre-
protects the conjunctival mucosa of the eyes, as
solved as the body of evidence for this practice
well as the lining mucosa of the respiratory tract.
is small. Professional judgment should be used
Primary barriers include gloves, protective eyewear, when assessing the risk of a procedure and
masks and protective clothing. Protective clothing whether double-gloving may be appropriate.

Protective eyewear It is the practice owner’s responsibility to develop a
policy that uniforms and scrubs worn during patient

The conjunctival mucosa of dental hygienists
care procedures should not be worn outside the
should be protected from spatter and debris
dental office.
created during dental procedures by wearing
appropriate eyewear or face shields. P
rotective Latex sensitivity and allergies
eyewear should be cleaned and disinfected Latex is commonly used in the manufacture of
between patients and whenever it becomes gloves and in dental products, including rubber
noticeably contaminated. An eye-wash station dams, prophylaxis cups, orthodontic elastics
should be available in the dental office for both and some medication vials. Skin irritations can
dental hygienists and patients to aid in m
anaging be confused with true allergy to latex. The vast
contact with any body fluid or dental chemical/ majority of skin reactions involving gloves are, in
solvent. fact, irritant contact dermatitis, and not allergic
Masks reactions to latex.
Appropriate masks that cover the nose and mouth Adverse reactions involving latex gloves range
should be worn during dental procedures to protect from mild to serious and can include:
the respiratory mucosa of dental h
ygienists from • irritant contact dermatitis;
contact with potentially contaminated droplet
• delayed hypersensitivity reactions (allergic
material. Masks lose efficiency over time, as
contact dermatitis);
they become moist from the dental hygienist’s
breathing. A
ccordingly, masks should be changed • immediate allergic reactions.
between each patient or sooner if they become Mild contact dermatitis can be managed by
visibly soiled. Face shields are not an appropriate changing the types or brands of soap, towels or
substitute for masks. gloves, rinsing hands thoroughly after washing, use
Protective clothing of lotions, and performing proper hand hygiene.
Spatter or spray from dental procedures can Delayed hypersensitivity reactions require referral
contaminate fabric of long-sleeved garments and to a medical dermatologist, and using washed
lead to cloth-borne transmission of pathogens. (powderless) low-protein latex gloves or non-latex
Provided that the skin of a dental hygienist’s fore- gloves.
arms is unbroken and intact, short-sleeved scrubs Powder-free gloves reduce the lifetime exposure
should be worn to prevent cross-contamination risk to latex allergy for patients and practitioners,
between patients and when exposed to spatter or and are therefore preferred. Immediate allergic
spray, forearms should be washed with soap and reactions necessitate emergency medical care and
water. Long sleeved garments are intended to be subsequent referral to a medical dermatologist, as
patient-specific items of protective clothing and well as using only non-latex, powder-free gloves
should be removed prior to seeing the next patient. and avoiding all latex products in the workplace and
This includes gowns and lab coats. If the skin of at home.
the dental hygienist’s forearms is not intact, long-
sleeved garments are recommended. This includes
gowns and lab coats, which are meant to be worn
over regular clinic clothing,
such as uniforms, scrubs or street clothing.

In the event of a significant exposure, immedi-

6. Minimizing Droplet Spatter ate first-aid measures should be instituted:
• For percutaneous injuries, allow the wound to
By their very nature, the provision of dental bleed briefly and freely. Then, gently wash the
services can involve the creation of droplets, wound with soap and water, and bandage as
spatter and spray contaminated with blood, saliva, needed.
other body fluids and debris.
• For exposures involving the eyes, nose or
As previously noted, a rubber dam should be used mouth, flush the area with copious amounts
whenever feasible, and high-volume suction should of water.
be used whenever the creation of droplets, spatter
• For exposures involving non-intact skin, wash
and spray is possible.
the site with soap and water.
Any kind of occupational injury should be reported
7. Exposure Management to the owner of the practice or designate. However,
in all cases involving a significant exposure, the
Blood-borne pathogens, such as HBV, HCV and HIV, practice owner should assess the source patient’s
can be transmitted to dental hygienists through status and risk for blood-borne illnesses by
occupational exposures to blood, saliva and other reviewing the medical history and, if necessary,
body fluids. Significant exposures must be handled asking her/him additional questions.
in a prompt and organized fashion. For this reason,
If the patient’s HBV, HCV or HIV status is unknown,
an exposure management protocol is an important
or if the patient presents with known risk factors,
component of an in-office infection prevention and
then her/his co-operation should be sought to
control manual.
clarify such information. Every reasonable effort
IM P O RTA N T should be made to obtain the patient’s informed
consent to be tested for HBV, HCV and HIV. This
All dental practices must have an exposure
can be accomplished by referring the patient to
management protocol in place. It should be
her/his family physician for consultation, assess-
reviewed periodically to ensure it is familiar to
ment of risk factors and any blood tests that are
all dental hygienists. WorkSafeBC has resources
considered necessary.
available to assist with developing an exposure
management protocol. At the same time, the injured dental hygienist
should be immediately referred to her/his family
Significant exposures include percutaneous injuries
physician, an infectious disease specialist or
with contaminated needles, burs or other sharp
hospital emergency department for counselling,
instruments, as well as accidents in which blood,
baseline blood tests and, if deemed necessary,
saliva or other body fluids are splashed onto
post-exposure prophylaxis.
non-intact skin or the mucosa of the eyes, nose
or mouth. However, percutaneous injuries pose If necessary, post-exposure prophylaxis should be
the greatest risk of transmission of blood-borne administered as soon as possible. For example, in
pathogens to dental hygienists. the event of a high-risk exposure to HIV infection,
antiretroviral drugs should be administered
within hours.

All cases involving a significant exposure WHMIS is a national communication standard
should be documented, including: that deals with hazardous materials in the

• name of the exposed dental hygienist and workplace. Any workplace, including a
details r egarding her/his vaccination status; dental office that uses materials classified as
controlled products under federal legislation,
• date and time of the exposure;
is required to:
• nature of the exposure, including the dental
• supply labels for all controlled products that do
procedure being performed, extent of the
not have them;
exposure and the immediate action taken;
• ensure material safety data sheets (MSDS) are
• name of the source and details regarding
available for these products;
known or suspected status related to blood-
borne pathogens; • educate and train workers about hazardous
materials in the workplace.
• follow-up counselling and post-exposure
management. Employers are obligated to uphold WHMIS
standards in their workplace; accordingly, every
practice owner should be familiar with the
8. Occupational Health and legislation.
Safety Requirements and

Workplace Hazardous 9. Prohibition of Eating and
Materials Information Drinking in Non-Designated
System (WHMIS) Areas
Under Occupational Health and Safety The consumption of all foods and beverages should
Regulation, there is a general duty for an be restricted to designated areas (e.g. lunch area,
employer to establish written procedures for staff lounge) or outside the dental office.
the health and safety of employees. These
Eating and drinking in operatories, instrument
procedures may include, but are not limited to,
processing areas and in-office dental laboratories
the following:
should be prohibited.
• safe work practices and working conditions;
• proper hygiene practices and the use of hygiene
KEY PRINCIPLE: Dental hygienists must
facilities;
continually update their knowledge and
• control of infections. education about exposure prevention and
Employees must work in compliance with the management in order to preserve their
legislation, and use or wear any equipment, personal health and safety and that of
protective devices or clothing required by the their patients and colleagues.
employer.

Part C: Cleaning, Disinfection and

Sterilization of Patient Care Items
Cleaning* entails the removal of debris (e.g.
1. General Considerations organic and inorganic matter). This is achieved
either by scrubbing with a surfactant, detergent
The goals of safe processing of reusable patient and water, or by an automated process (e.g. ultra-
care items (dental instruments, hand pieces, sonic cleaner or washer with a cleaning solution).
devices and equipment) include: This step is essential, as residual organic debris
• preventing transmission of microorganisms to will compromise the disinfection and sterilization
dental hygienists and patients; process. After cleaning, instruments should be rinsed
with water to remove detergent residue and visually
• minimizing damage to patient care items from
inspected to ensure all debris has been removed.
foreign material or inappropriate handling;
Patient care items are categorized as critical,
• safe handling of chemical disinfectants.
semi-critical or non-critical, depending on the
Contaminated instruments should be handled care- potential risk for infection associated with their
fully at all times to prevent percutaneous injuries. intended use. This classification determines their
All instruments must be properly cleaned, rinsed processing requirements.
and dried prior to either disinfection or s terilization.
Risk Classification Table (see glossary for additional examples)
Category Definition Processing
Critical Items Items that penetrate soft tissue or bone, Cleaning* followed by
enter into or contact normally sterile sterilization
tissue or the bloodstream (e.g. surgical
instruments and surgical burs, implantable
devices, periodontal instruments)
Semi-critical items Items that contact mucous membranes or Cleaning* followed by
non-intact skin (e.g. mouth mirrors, amal- sterilization or high-level disinfec-
gam condensers, facebow forks, reusable tion (as a minimum). Sterilization
impression trays, X-ray film holders) is the preferred method.†
Non-critical items Items that contact intact skin, but not Cleaning* followed by low- or
mucous membranes, or do not directly intermediate-level disinfection
contact the patient (e.g. radiograph head/
cone, blood p
ressure cuff, pulse oximeter,
patient safety glasses)
† The majority of semi-critical items used in dentistry are heat-tolerant and should always be heat-sterilized between uses.
If a semi-critical item is heat-sensitive, at a minimum it should be processed using high-level disinfection

If a product is received from the manufacturer chemical agent to which a worker is exposed at
who has guaranteed the instrument’s sterility, any time. If control measures are not available
it need not be sterilized prior to initial use. during reprocessing involving a chemical agent,
Newly purchased non-sterile critical and semi- air sampling shall be required to ensure that the
critical items must be inspected and processed regulated limit has not been exceeded for the
according to m
anufacturer’s instructions prior to chemical being used.
use. Any product that comes in a clean state that The health care setting should have air
the m
anufacturer indicates is ready for use does changes; temperature and humidity appropriate
not need to be s terilized provided that it is used to the process/product being used (refer to CSA
directly from the new package. standards and manufacturer’s recommenda-
Sterilization tions for products).
The sterilization section of the processing area
should include the sterilizer and related supplies,
with adequate space for loading, unloading and
2. Processing of Critical and
cool down. The area may also include biological Semi-Critical Items
indicators and incubators for conducting spore
tests, as well as enclosed storage for sterile Instrument sterilization requires multiple steps.
and single-use disposable items. Heat-tolerant Sterilization is a complex process requiring
instruments are usually sterilized by steam under specialized equipment, adequate space, qualified
pressure (i.e. autoclaving), which is dependable staff and regular monitoring for quality assurance.
and economical. Other means include dry heat or Correct sorting, cleaning, drying, packaging, steril-
*unsaturated chemical vapor. All sterilization should izer loading procedures and sterilization methods
be performed by using medical sterilization equip- should be followed to ensure that all instruments
ment registered with Health Canada. Sterilization are adequately processed and safe for reuse on
times, temperatures and other operating param- patients. Processing of specialized instruments
eters recommended by the manufacturer of the (e.g. channelled or bored instruments) should
equipment used, as well as instructions for correct be completed according to the manufacturer’s
use of containers, wraps, and chemical or biological instructions.
indicators, should always be followed.
All instruments should be processed in a central
* Excerpt from Best Practice Guidelines for area of the dental office that is designed to
Cleaning, Disinfection and Sterilization of facilitate quality control and ensure safety.
Critical and Semi-Critical Medical Devices in BC The instrument processing area should have
Health Authorities (Dec 2011) clear separation of clean and dirty areas with
Air Quality separate sections for:
The Occupational Health and Safety Regulation • receiving, cleaning and decontamination;
respecting control of exposure to biological and • preparation and packaging;
chemical agents made under the Workers Com-
• sterilization;
pensation Act provides occupational exposure
• drying/cooling;
limits such as ceiling exposure value (CEV) for
chemical agents (e.g. gluteraldehyde). A CEV • storage.
is the maximum airborne concentration of a

Care must be taken to avoid cross-contamination as holding solutions, due to the fixative nature of

when using sterilizer equipment (e.g. controls, these chemicals making surfaces more difficult to
buttons, cassette handles, exterior surfaces). clean, as well as their general toxicity.
Receiving, cleaning and To avoid injury from sharp instruments, the
decontamination following precautions should be taken:
To prevent percutaneous injuries, contaminated • Wear puncture-resistant, heavy-duty utility
instruments should be placed in a puncture-resis- gloves when handling or manually cleaning
tant container at the point of use and then trans- contaminated instruments.
ported to the instrument processing area. Reusable • Do not reach into trays or containers holding
instruments should be received, sorted, cleaned sharp instruments that cannot be seen (e.g.
and rinsed in one section of the processing area. sinks filled with soapy water in which sharp
The use of automated cleaning equipment can instruments have been placed). Instead, use a
increase productivity, improve cleaning effective- strainer-type basket to hold instruments, as well
ness and decrease worker exposure to blood as forceps to remove them.
and body fluids provided that the manufacturer’s • Wear a mask, protective eyewear or face shield,
instructions are strictly followed. Thus, using auto- and gown or jacket to protect from splashing.
mated equipment can be safer and more efficient
than manually cleaning contaminated instruments.
Preparation and packaging
In another section of the processing area, cleaned
Gross debris should be removed from instruments
instruments should be inspected, assembled into
prior to placement in an ultrasonic cleaner. In
sets or trays, and packaged for sterilization. Critical
addition, ultrasonic cleaning solutions should be
and semi-critical instruments (refer to p. 24) should
changed daily, and more frequently if they become
be processed in a manner that will maintain sterility
visibly soiled. Automated washers do not require
during storage. Suitable packaging materials
presoaking or scrubbing of most instruments.
include wrapped perforated instrument cassettes,
If cleaning cannot be performed immediately, peel pouches of plastic or paper, and woven or
instruments should be placed in a puncture-resis- nonwoven sterilization wraps. Packaging materials
tant holding container and soaked with a detergent should be designed for the type of sterilization
or an enzymatic cleaner to prevent drying of process being used. Hinged instruments should
organic material. This makes subsequent cleaning be processed open and unlocked.
easier and less time-consuming. Liquid chemical
sterilants or high-level disinfectants (e.g. glutaral-
dehyde, ortho-phthalaldehyde) should not be used

In the event of a positive BI (i.e. failed spore Storage
test):
Sterile and single-use disposable items should
• Remove the sterilizer from service. be stored in an enclosed space, such as closed
• Review all records of mechanical and chemical or covered cabinets. They should not be stored
indicators since the last negative BI, as well as under sinks or in other locations where they might
sterilization procedures to determine whether become wet and contaminated.
operator error could be responsible. In the Storage practices for packaged sterilized instru-
absence of a mechanical failure, common rea- ments may be either date- or event-related. Dating
sons for a positive BI include overloading, failing assists in the recall of instruments should concerns
to provide adequate package separation and arise with the results of sterilization tests. Some
using incorrect or excessive packaging material. healthcare facilities date every sterilized package
• Repeat the spore test immediately. This should and use shelf-life practices (e.g. “first in, first out”).
be done after addressing any procedural prob- Others use event-related practices. The latter
lems and correctly loading the sterilizer, and by approach recognizes that the packaged instruments
using the same cycle that produced the failure. should remain sterile indefinitely, unless an event
While waiting for the repeat test results, the causes them to become contaminated (e.g. torn or
sterilizer should remain out of service. If the wet packaging).
dental office does not have a second sterilizer, Packages containing sterile instruments should
a colleague may be able to assist or a dental be inspected before use to verify barrier integrity
supply company may lend one. and dryness. If packaging is compromised, the
• If the repeat spore test is negative, and instruments must be cleaned, packaged and
mechanical and chemical indicators demon- sterilized again.
strate adequate processing, then the sterilizer
I M P ORTANT
may be put back into service.
Critical instruments must be processed in a
• If the repeat spore test is positive, and all
manner that will maintain sterility during storage.
sterilization procedures have been performed
This includes ensuring that the integrity of the
correctly, then the sterilizer should remain out of
package is maintained.
service until it has been inspected, repaired and
successfully re-challenged with BI tests in three
consecutive empty chamber sterilization cycles.
In addition, all items from suspect loads dating
back to the last negative BI should be recalled,
to the extent possible, and reprocessed.

All implantable devices should be quarantined after

3. Sterilization of Unpackaged sterilization until the results of biological monitor-
Instruments ing are known. Accordingly, unpackaged or flash
sterilization of implantable items is inadequate and
An unpackaged cycle (sometimes called flash must not be used. Flash sterilization should not
sterilization) is a method for sterilizing patient care be routinely used in the dental office or healthcare
items for urgent or unplanned use. Flash steriliza- settings.
tion should be used only under certain conditions
I M P ORTANT
as outlined in the Best Practice Guidelines for
Cleaning, Disinfection and Sterilization of Critical Historically, bead sterilizers have been used in
and Semi-critical Medical Devices in BC Health dentistry to treat small metallic instruments, such
Authorities (Dec. 2011): as endodontic files. These devices cannot assure

sterility, creating the risk of cross-contamination if
• thorough cleaning and drying of instruments
instruments are used between patients. Therefore,
precedes the unpackaged cycle;
the use of bead sterilizers is not an acceptable
• mechanical parameters are checked and an method of sterilization.
internal chemical indicator is used for each
cycle;
• care is taken to avoid thermal injury to staff or 4. Processing of Heat-Sensitive
patients; Items
• items are transported aseptically to the point of
use to maintain sterility. The majority of semi-critical items (refer to p. 23)
used in dentistry are available in heat-tolerant
When sterile items are left open to the air, they can
or disposable alternatives. If the use of a heat-
quickly become contaminated. Therefore, critical
sensitive semi-critical item is unavoidable, then
instruments that are sterilized unpackaged should
such items should be cleaned and then receive
be used immediately and not stored. Sufficient
high-level disinfection, which may be achieved by
inventories of critical instruments should be main-
immersion in a liquid chemical germicide (e.g. 2%
tained to avoid the need for flash sterilization.
glutaraldehyde, 7% accelerated hydrogen peroxide,
Semi-critical instruments that are sterilized unpack-
6% hydrogen peroxide, 0.2% peracetic acid and
aged on a tray or in a container system must be
0.55% ortho-phthalaldehyde).
used immediately or within a short time. S
torage,
even temporary, of unpackaged semi-critical
instruments is not acceptable because it permits
exposure to dust, airborne organisms and other
unnecessary contamination before use on patients.

Liquid chemical germicides are highly toxic
and their effectiveness cannot be verified with 5. Processing of Non-Critical

biological indicators. Accordingly, the manufac- Items
turer’s instructions regarding dilution, instrument
preparation, immersion time, temperature and the Non-critical items (refer to p. 23) pose the least risk
changing of solutions should be followed care- of transmission of infection, as they either have
fully. In addition, appropriate precautions should no contact with the patient or contact only intact
be taken to safeguard staff, including the use of skin, which serves as an effective barrier to micro
closed c ontainers to limit vapour release, adequate organisms. Non-critical items should be cleaned
ventilation and chemically resistant gloves, aprons, after use or, if contaminated, cleaned and then dis-
goggles and face shields. Following liquid immer- infected with an appropriate low-level disinfectant
sion, instruments should be thoroughly rinsed with (e.g. chlorine-based products, 0.5% accelerated
sterile water to remove toxic or irritating residues hydrogen peroxide, 3% hydrogen peroxide, 60 to
and then dried with clean towels. Liquid chemical 95% alcohols, iodophors, phenolics and quaternary
germicides should not be used for applications ammonium compounds).
other than those indicated in their label instructions,
Cleaning and disinfection of some non-critical items
and they should not be used as an e
nvironmental
may be difficult or could damage surfaces. It may
surface disinfectant or instrument-holding solution.
be preferable to use disposable barriers to protect
NOTE: When using liquid chemical germicides, the these surfaces.
use of liquid germicide test strips should be used
to confirm that the minimum effective concentra-
tion is within the potency range present to achieve 6. Equipment Use and
sterilization.
Preventive Maintenance
Tabletop sterilizers undergo frequent use, and wear

and tear. The manufacturer’s recommendations
should be consulted for guidance on a preventive
maintenance program, including regular inspection
of gaskets and seals.
I M P ORTANT
The information in this section of the Guidelines
represents best practices for the monitoring of
sterilization in the dental office.

1. Mechanical indicators are the gauges or NOTE: Mechanical and chemical indicators do

displays on the sterilizer for cycle time, tem- not ensure that sterilization has been achieved.
perature and pressure. Some tabletop sterilizers They merely offer verification that the necessary
have recording devices that print out these conditions have been met. However, they can
parameters, which is preferred. All new steril- also provide an early warning of a problem. If
izers should have this feature. either mechanical or chemical indicators demon-
Mechanical indicators should be checked and strate inadequate processing, then none of the
recorded for each load, to the extent possible. items in the load should be used until they are
reprocessed.
2. Chemical indicators (i.e. internal and external)
use sensitive chemicals to assess physical 3. Biological indicators (BIs or spore tests)
conditions during the sterilization process. For are the most accepted means for monitoring
example, heat-sensitive tape, applied to the out- sterilization because they directly assess the
side of a package, changes colour rapidly when procedure’s effectiveness in killing the most
a given temperature is reached. This signifies resistant microorganisms. The spores used are
that the package has undergone a sterilization more resistant and present in greater numbers
cycle, although it does not ensure that steriliza- than the common microbial contaminants found
tion has been achieved. on patient care items. Therefore, an inactivated
BI signifies that other potential pathogens in
A sterilizing agent has more difficulty penetrat-
the load have been killed. BIs must be used at
ing a hollow object, such as a handpiece, than it
least once a week for each sterilizer used.
does a solid object, such as a dental mirror. Air
that is trapped inside these hollow areas cannot Spore tests may be conducted using an
be easily removed, thus hindering the sterilizing in-office system available through most dental
agent’s contact with the internal surface of the suppliers or by submitting the indicator to a
instrument. testing facility.
In addition, when items are packaged, the In addition, if a load contains implantable
sterilizing agent takes longer to penetrate to devices, it must be monitored with a BI, and
the instruments. The packaging envelops the these items should be quarantined until the test
instruments, creating a hollow area into which results are known. Follow the manufacturer’s
the sterilizing agent must be drawn or forced in. directions concerning the appropriate placement
of the BI in the sterilizer.
For these reasons, each package must have
external chemical indicators. In addition, it is I M P ORTANT
recommended that both internal and external The daily operation of every sterilizer must be
chemical indicators be used to detect pen- reviewed and documented. A record must be
etration into the package. Please refer to the kept for this purpose indicating “operating as
Glossary for further information on chemical required”, or noting any malfunctions and
indicator classifications. follow-up action taken.

Part D: Office Cleaning, Housekeeping
and Management of Waste
1. General Considerations 2. Clinical Contact Surfaces
Generally speaking, environmental surfaces in Clinical contact surfaces are frequently touched
the dental operatory do not come into contact in the course of patient care. They can become
with the patient and do not pose a direct risk contaminated by direct spray or spatter gener-
to their safety. However, surfaces such as light ated during dental procedures, or by contact
handles and drawer knobs can become contami- with a dental hygienist’s gloved hands or
nated during patient care, acting as reservoirs of contaminated instruments. Examples of clinical
microorganisms. Transmission usually occurs contact surfaces include:
through hand contact or by touching the surface • chair controls and switches
with a c ontaminated instrument. When this
• drawer and faucet handles
happens, microorganisms can be transferred to
other instruments, other environmental surfaces, • light handles and switches
or to the hands, nose, mouth and eyes of patients • countertops
and dental hygienists. • radiography equipment
Proper hand hygiene and the use of personal pro- • pens
tective equipment are essential to minimizing the
• chairside computers
transfer of microorganisms. In addition, the use of
• keyboards and monitors
barriers or cleaning and disinfection of environmen-
tal surfaces will guard against such transferral. • telephones
Dental hygienists should take particular care in the • doorknobs

handling of patient’s charts to ensure that they do • reusable containers of dental materials
not become vehicles for cross-contamination. This
Clinical contact surfaces should be cleaned and
is particularly important because paper charts are
disinfected between patients and at the end of
transported by staff members to numerous areas
the workday using an appropriate low-level disin-
in an office and are difficult to effectively clean
fectant. To facilitate this, treatment areas should
and disinfect.
be well-organized and kept free of unnecessary
Environmental surfaces are divided into clinical equipment and supplies, especially on countertops.
contact surfaces and housekeeping surfaces. Staff should take appropriate precautions, including
wearing gloves, while cleaning and disinfecting
surfaces to prevent occupational exposure to
infectious agents and hazardous chemicals.

Alternatively, clinical contact surfaces and From a general housekeeping point of view, floors

equipment can be protected from contami- should be cleaned regularly and spills should be
nation by the use of barriers. Barriers are cleaned up promptly. Cleaning tools, such as mop
particularly effective for those surfaces that heads, should be rinsed after use and allowed to
are difficult to clean and disinfect, due to their dry before they are used. Fresh cleaning solutions
shape, surface or material characteristics. should be made each day, discarding any that
Suitable barrier materials include: remain and allowing the container to dry between
• clear plastic wrap uses. In this way, the risk of these solutions
becoming reservoirs for microorganisms can
• plastic tubing
be minimized.
• plastic bags
I MP ORTANT
• plastic-backed paper
Carpeting and cloth furnishings are difficult to clean
• plastic sheets
and cannot be reliably disinfected. They should
• other moisture-proof materials
not be used in patient treatment or instrument
• overgloves preparation areas.
Since barriers can become contaminated during
dental procedures, they should be discarded (using
4. Management of Waste
gloves) on a routine basis (e.g. between patients)
and when visibly soiled or damaged. At a minimum,
For the purposes of infection control, waste from
following barrier removal, the underlying surfaces
dental offices can be divided into two categories:
should be examined to ensure they did not inadver-
biomedical waste and general office waste.
tently become contaminated. Those that did should
B.C. legislation dictates that biomedical waste
be cleaned and disinfected. Otherwise, clean
must be handled and disposed of in a manner
barriers should be placed prior to the next patient.
that avoids transmission of potential infections.
Therefore, it is necessary to understand the
3. Housekeeping Surfaces differences between these types of waste, so
that they can be separated, stored and disposed
Housekeeping surfaces, such as floors and of in an appropriate manner.
walls, have a limited risk of disease t ransmission.
Accordingly, these surfaces usually require
only periodic cleaning with dilute detergents.
If a surface is s uspected to have become
contaminated with blood, saliva or other bodily
fluids, it should be cleaned first and then disin-
fected with an a ppropriate low-level disinfectant
(e.g. household bleach diluted 1:50 or accelerated
hydrogen p
eroxide). Dental hygienists should take
appropriate precautions, including wearing gloves,
for this purpose.

Biomedical Waste ii) Non-anatomical waste (i.e. sharps and blood-
soaked materials)
Biomedical waste is classified as hazardous
waste and must not be disposed with regular Sharps (e.g. needles, syringes with needles,
garbage. It must be handled safely to protect scalpel blades, clinical glass) must be separated
human health and the environment. In general, and collected in a yellow puncture-resistant, leak-
all biomedical waste must be: proof container that is specifically designed for
their management and labelled with the universal
• stored in colour-coded containers that are
biohazard symbol. Once the container has reached
marked with the universal biohazard symbol;
the designated capacity, it must only be released to
• released to an approved biomedical waste an approved biomedical waste carrier for disposal.
carrier for disposal.
Non-anatomical waste includes blood-soaked
Biomedical waste can be further divided into materials that release liquid or semi-liquid blood if
anatomical and non-anatomical waste. compressed. It must be separated and collected in
i) Anatomical waste (i.e. human tissue) a yellow liner bag that is labelled with the universal
The generation of anatomical waste is normally biohazard symbol. If blood-soaked materials are to
limited to oral surgeons and periodontists, such remain on site for more than four days, they must
as in the course of harvesting human tissue for be stored like anatomical waste in a refrigerated
treatment. Anatomical waste must be separated storage area that is marked “Biomedical Waste
and collected in a red liner bag that is labelled Storage Area” and displays the universal biohazard
with the universal biohazard symbol. This waste symbol. Once accumulated, blood-soaked materials
must then be stored in an enclosed storage area, must only be released to an approved biomedical
such as a stand-alone refrigeration/freezer unit, waste carrier for disposal.
that is marked “Biomedical Waste Storage Area” In most instances, items such as gauze, cotton
and d
isplays the universal biohazard symbol. This rolls and examination gloves that have come in
storage area must be separate from other supply contact with blood, saliva or other bodily fluids are
areas, locked and maintained at a temperature at not classified as biomedical waste. Provided that
or below 4 degrees Celsius. Once accumulated, the item does not release liquid or semi-liquid blood
anatomical waste must only be released to an if compressed, it should be considered as general
approved biomedical waste carrier for disposal. office waste.
NOTE: Extracted teeth are not classified as bio-

medical waste and should be handled differently.
Please refer to the section on p. 33.

General Office Waste Handling of extracted teeth

General office waste is no more infective than Extracted teeth may be returned to the patient
residential waste. Therefore, the majority of without any special considerations for infection
soiled items generated in dental offices do prevention and control, other than simple cleaning
not require any special disposal methods, of visible blood and gross debris.
other than careful containment and removal. If being discarded, extracted teeth without
Recommendations for all types of general office amalgam fillings may be disposed as general
waste include: office waste. Extracted teeth with amalgam fillings
• Ensure all garbage containers are waterproof should be treated as mercury-containing waste and
and have tight-fitting lids, preferably operated disposed accordingly. Patients should be advised
by a foot pedal. Open wastebaskets might be that extracted teeth with amalgam fillings may
dangerous if children are around them. be returned to the dental office for appropriate
• Use plastic bags to line the garbage containers. disposal.
The use of double-bagging is not necessary, If being sent to a dental laboratory for shade or size
unless the integrity of the bag is jeopardized or comparisons, extracted teeth should be cleaned
the outside is visibly soiled. and surface disinfected with an appropriate low-
• Do not overfill garbage containers. level disinfectant. Extracted teeth being collected
for use in pre-clinical education training should
• Do not place sharp, hard or heavy objects into
be cleaned of visible blood and gross debris, and
plastic bags that could cause them to burst.
maintained in a hydrated state in a closed container
Certain types of waste generated in dental offices during transportation.
can be detrimental to the environment if not
properly handled, and their disposal is subject to
provincial regulations and municipal bylaws. In addi-
tion to biomedical waste, this includes waste that
contains mercury, silver, lead and other chemicals.
For further information regarding the disposal of
these types of waste, refer to the requirements or
bylaws in your area.

Part E: Equipment and Area Specific
Practice Guidelines
• Handpieces using water coolant should be run
1. Dental Unit Waterlines for 20 to 30 seconds after patient care in order
to purge all potentially contaminated air and
Dental unit waterlines are made of narrow-bore water. The handpiece should then be removed
plastic tubing that carry water to handpieces, ultra- and, following cleaning and disinfection of
sonic instruments and air/water syringes. They can clinical contact surfaces, another sterilized
become heavily colonized with waterborne micro handpiece may be attached for use with the
organisms, including bacteria, fungi and protozoa, next patient.
which form a biofilm on the interior surface of NOTE: Sterile water or sterile saline delivered
the waterline. However, they are not a supportive through a sterilized device should be used when
environment for bacteria commonly found in the irrigating open surgical sites and whenever bone is
oral cavity. cut during invasive surgical procedures. Appropriate
High numbers of these opportunistic micro devices, such as bulb syringes or single-use dispos-
organisms are not necessarily dangerous to the able products, should be used to deliver sterile
general population, unless the patient or dental irrigation solutions since general waterline sterility
hygienist is a susceptible host. This includes per- cannot be ensured.
sons who are immunocompromised (e.g. persons For offices using closed or other water delivery
living with HIV, persons undergoing oncology systems:
treatment or organ transplantation procedures) and
• The manufacturer’s instructions related to dental
those with cystic fibrosis, chronic bronchitis and
units and equipment should be followed for
bronchiectasis.
daily and weekly maintenance.
The use of monitoring systems can help to ensure
Backflow Prevention Valves
dental waterline quality. The potential risk of infec-
tion from dental unit waterline microorganisms can Many areas within B.C. now have requirements
be effectively reduced to counts similar to those that backflow prevention valves be installed to pre-
in potable water standards by following regular vent a backflow of water and potential contamina-
waterline m
aintenance procedures. tion in the event of a disruption of the office water
supply. For further information on this, refer to the
For offices using communal water supplies:
municipal requirements or bylaws in your area.
• Waterline heaters should not be used, as the
heat encourages the growth of microorganisms.
• All waterlines should be purged at the beginning
of each workday by flushing them thoroughly
with water for at least two to three minutes.
Before purging is carried out, handpieces, air/
water syringe tips and ultrasonic tips should be
removed from the waterlines.

2. Dental Handpieces and Other 3. Saliva Ejectors
Intraoral Devices
Backflow from a low-volume saliva ejector can
Several dental devices that contact mucous occur when a patient closes his or her lips around
membranes are attached to the air or water- the tip, forming a seal that creates a partial vacuum.
lines of the dental unit, including: This backflow can result in microorganisms from
the suction lines entering the patient’s mouth, a
• high- and low-speed handpieces;
potential source of cross-contamination. Therefore,
• prophylaxis angles; dental hygienists should not allow patients
• ultrasonic and sonic instruments; to close their mouths over the saliva ejector
• air abrasion devices; tip. In addition, specially designed saliva ejectors
exist that do not allow a negative pressure to form
• air/water syringe tips.
around the tip.
These devices have the potential of becoming con-
Suction lines should be purged between patients
taminated by retracting oral fluids into their internal
by aspirating water or an appropriate cleaning
compartments. Such fluids can then be expelled
solution, thereby removing loosely adherent
into the oral cavity of another patient during
debris and microorganisms. At least once per
subsequent use. In order to flush out any patient
week, suction lines should be flushed out with an
material that might have entered the turbine or air
enzymatic cleaner or appropriate cleaning solution.
and waterlines, these devices should be activated
to discharge air and water for a minimum of 20 to
30 seconds after each patient use. 4. Single-Use Devices
Dental handpieces and other intraoral devices that
are attached to air or waterlines must be sterilized Single-use (i.e. disposable) devices are designed
after each patient use. The manufacturer’s instruc- to be used on one patient and then discarded and
tions for cleaning, lubricating and sterilizing these not to be reprocessed and used on another patient.
devices should be strictly followed. Examples include syringe needles, prophylaxis
Some instrument components are permanently cups and brushes, and certain orthodontic brackets.
attached to dental unit waterlines (e.g. electric Some items, such as prophylaxis angles, high-
handpiece motors, handles for ultrasonic devices, volume suction tips and air/water syringe tips are
and attachments for saliva ejectors, high-volume commonly available in single-use forms.
suction and air/water syringes). Such components Single-use devices are usually not heat-tolerant
should be covered with barriers that are changed and cannot be reliably cleaned or disinfected.
after each patient use. If the item is contaminated Therefore, they should be disposed of appropriately
or suspected to have been contaminated, it must after use.
be cleaned and disinfected with an appropriate
low-level disinfectant, or barriers placed, before the
next patient is seated in the operatory.

Another option is to use a barrier pouch to prevent
5. Dental Radiography contamination of the film packet. If used, the

Equipment film packet should be carefully removed from the
pouch to avoid contamination and then placed in a
When taking radiographs, appropriate steps should container for transport to the developing area.
be taken to prevent cross-contamination of equip- Care should be taken to avoid contamination of the
ment and environmental surfaces with blood or developing equipment. Protective barriers should
saliva. This includes the use of gloves when taking be used or, alternatively, any surfaces that become
radiographs and handling contaminated film pack- contaminated should be cleaned and disinfected
ets. Accessories for taking intraoral radiographs with an appropriate low-level disinfectant.
(e.g. film-holders and positioning devices) must be
sterilized between patients. Care should be taken
to avoid placing or removing a lead apron with 6. Digital Radiography Sensors
contaminated gloves. The use of overgloves or de-
and Intraoral Cameras
gloving followed by hand hygiene is recommended.
Radiography equipment (e.g. tube heads and Digital radiography sensors and intraoral cameras
control panels) should be protected with surface come into contact with mucous membranes.
barriers that are changed after each patient use. Accordingly, these devices should be cleaned and
If barriers are not used, equipment that has come disinfected between patients. Manufacturer’s
into contact with the dental hygienist’s gloved instructions should be followed for the disinfection
hands or contaminated film packets should be of phosphor plates. Alternatively, digital radiography
cleaned and disinfected after each patient use. sensors and intraoral cameras should be protected
After a radiograph is exposed, the film packet with barriers to reduce gross contamination.
should be dried with disposable gauze or a paper However, following barrier removal, the underlying
towel to remove blood or excess saliva and then surfaces should be examined and if found contami-
placed in a container, such as a disposable cup, for nated, they should be cleaned and disinfected.
transport to the developing area. As with other dental equipment, the manufacturer’s
The film packet may be disinfected with an instructions should be followed regarding the use
appropriate low-level disinfectant before opening of appropriate barriers and recommended steriliza-
to develop the film. Alternatively, a contaminated tion and disinfection procedures for these devices.
film packet may be opened using gloves. The film
should be dropped onto a clean surface w
ithout
touching it and the empty packet should be
discarded, being careful to avoid contamination.
Gloves should then be removed before developing
the film.

Effective communication and coordination

7. Lasers and Electrosurgery between the dental office and the commercial
Equipment dental laboratory will ensure that:
• appropriate cleaning and disinfection procedures
During surgical procedures, the use of lasers and are performed in the dental office or the com-
electrosurgery equipment causes thermal destruc- mercial dental laboratory;
tion of tissues, creating a smoke by-product that
• materials are not damaged or distorted because
may contain viable microorganisms. In addition,
of overexposure to disinfectants;
lasers transfer electromagnetic energy into the
tissues, resulting in the release of a heated plume • disinfection procedures are not unnecessarily
that includes particles, gases, tissue debris, viruses duplicated.
and offensive odours. Impressions, prostheses or appliances should be
Dental hygienists should take appropriate cleaned and disinfected as soon as possible after
precautions to avoid inhaling or otherwise removal from the patient’s mouth, before drying of
coming into contact with laser plumes and blood or other organic debris. The manufacturer’s
electrosurgery smoke, including the use of: instructions regarding the stability of specific
materials during disinfection should be consulted.
• Routine Practices (e.g. appropriate masks and
Wet impressions or appliances should be placed
face shields);
in an impervious bag prior to transportation to a
• central room suction units with in-line filters to commercial dental laboratory.
collect particulate matter;
Heat-tolerant semi-critical items used in the mouth,
• dedicated mechanical smoke exhaust systems such as impression trays or facebow forks, should
with a high-efficiency filter to remove substan- be sterilized after each patient use. Other items
tial amounts of laser plume particles. that do not normally come in contact with the
patient, but frequently become contaminated, such
as articulators and case pans, should be cleaned
8. Dental Laboratory Asepsis and disinfected according to the manufacturer’s
instructions. Items used in the typical in-office
Dental prostheses and appliances, as well as dental laboratory, such as burs, polishing
items used in their fabrication (e.g. impressions, points, rag wheels, laboratory knives and dental
occlusion rims, bite registrations), are potential lathes, frequently become contaminated during
sources for cross-contamination. They should be adjustments to prostheses and appliances. These
handled in a manner that prevents exposure of items should be sterilized, cleaned and disinfected
patients, dental hygienists or the office environ- or discarded after use.
ment to infectious agents.
Finished prostheses and appliances delivered to
the patient should be free of contamination. This
can be accomplished with an appropriate low-
level disinfectant by either the commercial dental
laboratory or dental office.

Surgical aseptic technique refers to practices that
9. Handling of Biopsy render and maintain objects and the surrounding

Specimens area maximally free of microorganisms, prevent
contamination of a wound, isolate the opera-
To protect persons handling and transporting biopsy tive site from the surrounding unsterile physical
specimens, they must be placed in a sturdy, leak- environment, and create a sterile field in order to
proof container that has a secure lid and is clearly perform surgery as safely as possible (e.g. draping
labelled with the universal biohazard symbol. Care where appropriate).
should be taken when collecting the specimen to For minor dental procedures, hand hygiene is
avoid contaminating the outside of the container. If performed, sterile instruments are placed at a clean
the outside of the container is suspected to be or chair-side area and care is taken to avoid placing
has been contaminated, it should be cleaned and unsterile equipment near sterile items. Depending
disinfected or placed in an impervious bag prior to on the complexity of the procedure, the chair-
transportation. side area is separated into clean or sterile versus
contaminated areas. Once the procedure begins,
items are no longer sterile due to contamination
10. General and Surgical with organisms from the patient’s mouth, but the
Aseptic Technique goal is to keep the tray and instruments as clean
as possible, and to avoid contamination from other
sources. When hands or gloves contact certain
The mouth is considered a clean-contaminated
surfaces that are frequently touched by others,
environment and the patient’s own defenses
microorganisms can be transferred to instruments
(e.g. antibacterial enzymes in saliva and immune
or other environmental surfaces, and to the eyes,
responses) play a large role in healing and prevent-
nose or mouth.
ing infection after a dental procedure. Infection is
usually the result of the patient’s own oral flora. For major dental procedures (similar to other
surgical procedures), the patient is prepared, hand
Aseptic technique is a term used to describe prac-
hygiene is performed, sterile gloves are worn,
tices that prevent microbial contamination. These
and all items that go onto the sterile field are
practices include environmental cleaning, effective
kept sterile, including instruments, materials and
hand hygiene, wearing appropriate clinical attire
supplies that come in contact with the surgical
(e.g. gloves, protective eyewear, masks, gowns),
site. Every item handled by the operator should be
proper handling of clean instruments, wrapping and
sterile or have a protective sterile covering.
sterilization, proper handling of sterile instruments
as they are unwrapped, preventing sterile instru-
ments from being contaminated from environmen-
tal sources, and properly administering medicines.

In addition to following routine practices, I M P ORTANT

and performing appropriate disinfection and If an item is needed for a procedure, but not on the
sterilization of dental instruments and devices, procedure tray, it should only be retrieved using
dental hygienists reduce the risk of transferring transfer forceps or by first ensuring that the dental
bacteria from the environment to patients by hygienist’s hands are clean. Transfer forceps should
adhering to some basic steps: be readily available at all times.
1. Prepare and organize work procedures so that
all of the required equipment is gathered for
KEY PRINCIPLE: Dental hygienists
the task.
must utilize appropriate equipment and
2. Sterile instruments and devices should be employ routine cleaning, disinfection and
stored in an enclosed space, such as closed or sterilization techniques to prevent disease
covered cabinets. They should remain wrapped transmission and ensure patient safety.
until ready for use.
3. Spatially separate work areas and equipment
into clean versus contaminated, sterile versus
unsterile.
4. Use protective covers and barriers according to
approved office-specific work procedures.
5. If an item is needed for a procedure, but not on
the procedure tray, it should only be retrieved
using transfer forceps or by first ensuring that
the dental hygienist’s hands are clean.
6. Gloves should be put on immediately before
initiating the procedure for the patient.
7. If you observe or suspect that gloves have
become torn or perforated, remove them,
perform hand hygiene and re-glove where
appropriate.
Maintaining aseptic technique is a co-operative
responsibility of the entire dental team. Each
member must develop a professional conscience
for infection prevention and control, as well as
a willingness to supervise and be supervised by
others regarding aseptic technique.

Part F: Additional Considerations for
Part F: Additional Considerations for Alternative Practice Settings
Alternative Practice Settings

Alternative practice settings include any setting The following topics should be carefully considered
where dental or dental hygiene services may be when providing oral care in alternative care
provided that are not confined to a conventional settings:
clinical operatory. These settings may include, but Disposal of biomedical waste
are not limited to, the following:
Biomedical waste is classified as hazardous waste
• Group homes and must not be disposed with regular garbage. It
• Long term care/residential care facilities must be handled safely to protect human health
• Rehabilitation facilities and the environment. In general, all biomedical
waste must be:
• Private residences
• stored in colour-coded containers that are
• Community centres
marked with the universal biohazard symbol;
• Educational facilities
• released to an approved biomedical waste
• Hospitals
carrier for disposal.
Due to the lack of standardized dental e
quipment
Biomedical waste can be further divided into
and patient care equipment (dental units, dedicated
anatomical and non-anatomical waste. Refer
waterlines and suction, etc) available in many
to “Management of Waste” section (p.31) for
of these settings, dental hygienists must take
instructions on disposal of biomedical waste items.
appropriate measures to ensure that infection
control protocols are followed and patient safety
is maintained. It is the responsibility of the dental
hygienist to check with any alternative practice
setting/institution to review sterilizing policy before
practice begins.

Disposal of environmentally hazardous waste Transportation of contaminated and sterile
Part F: Additional Considerations for Alternative Practice Settings

Certain types of waste generated in dental offices equipment
can be detrimental to the environment if not When transporting instruments between practice
properly handled, and their disposal is subject to settings, contaminated instruments must be
federal and provincial regulations and municipal packaged in sealed, sturdy, leak-proof containers
bylaws. In addition to biomedical waste, this to prevent cross-contamination. Similarly, sterile
includes waste that contains mercury, silver, lead instruments must be transported in sealed pack-
and other chemicals. Mercury-containing items ages to maintain sterility until opened for use on
should be treated as h
azardous materials and site. Disposable sharps such as needles and blades
should not be thrown in the garbage and liquid should be removed and disposed of in an appropri-
mercury should never be poured down the drain. ate puncture-resistant sharps container at point
Disposal of sharps of use, prior to transportation. Soiled instruments
must be handled in a manner that reduces the risk
Sharps (e.g. needles, syringes with needles, scalpel
of exposure and/or injury to personnel and clients/
blades, clinical glass) must be separated and col-
patients/residents, or contamination of environmen-
lected in a puncture-resistant, leak-proof container
tal surfaces. A process should be in place to ensure
that is specifically designed for their management
that instruments that have been reprocessed
and labelled with the universal biohazard symbol.
(sterilized) can be differentiated from those that
Once the container has reached the designated
have not been reprocessed (e.g. colour coding).
capacity, it must only be released to an approved
biomedical waste carrier for disposal.

Part G: Glossary of Infection Prevention
Part G: Glossary of Infection Prevention and Control Terms
and Control Terms

Additional precautions: A term used to describe on the outside of packages (e.g. sterilization tape
infection prevention and control interventions that or packaging printed with colour-changing inks).
are taken in addition to Routine Precautions for Class 1 CIs are directly exposed to the sterilization
certain pathogens or clinical presentations, based environment, so they usually fail only when there is
on the method of transmission (e.g. contact, a gross malfunction of the sterilizer.
droplet, airborne). Specialty indicator (Class 2): An indicator that is
Aerosol: Particles of respirable size (<10um) designed for use in specific test procedures in spe-
generated by both humans and environmental cial sterilizers (e.g. dynamic air-removal sterilizers).
sources that can remain viable and airborne for Examples of Class 2 CIs include Bowie Dick and
extended periods; commonly generated in dentistry Dart products, which are used for steam sterilizers.
during use of hand pieces, ultrasonic scalers, and Single-parameter indicator (Class 3): An internal
air/water syringes. indicator that responds to only one critical
Asepsis: The absence of pathogenic (i.e. disease- parameter of the sterilization process, usually
producing) microorganisms. time or temperature. It is important to note that
Aseptic technique: A term used to describe the sterilization process has more than one critical
practices that prevent microbial contamination. parameter, and all of them must be reached for
sterilization to occur.
Biological indicator (BI): A device that is used to
monitor the sterilization process, which consists Multi-parameter indicator (Class 4): An internal
of a standardized population of bacterial spores indicator that responds to two or more critical
known to be resistant to the mode of sterilization parameters of the sterilization process.
being monitored. BIs indicate that all the param- Integrating indicator (Class 5): An internal indica-
eters necessary for sterilization were present. tor that responds to all critical parameters of the
Chemical indicator (CI): A monitoring device that sterilization process. Class 5 CIs are correlated to
is designed to respond with a chemical or physical the performance of biological indicators (BIs).
change to one or more of the sterilization process Cleaning: The physical removal of foreign material
parameters. CIs do not verify sterility, but they (i.e. organic and inorganic matter) from an object
do assist in the detection of potential sterilization or item using water and mechanical action, with or
failures, which could result from incorrect packag- without detergents. Cleaning removes rather than
ing, incorrect loading of the sterilizer or equipment kills microorganisms. Cleaning and then rinsing is
malfunction. There are several classes of CIs: performed before further processing.
Process indicator (Class 1): An external indica- Decontamination: A process of cleaning, followed
tor that is used to demonstrate that an item has by inactivation of pathogenic microorganisms from
been exposed to a sterilization process, and to objects to render them safe to handle.
distinguish between processed and non-processed DHCP: Dental health care provider.
items. Class 1 CIs are usually applied to or visible

Disinfection: A process that kills most pathogenic risk of disease transmission is generally limited to

microorganisms, but rarely kills all b
acterial spores. persons and surfaces in close proximity to the
Disinfection is achieved through p
asteurization droplet source.
or the use of some chemical agents (i.e. Exposure-prone procedures: A term used for
disinfectants). The term falls between physical the purpose of managing the risk of transmitting
cleaning and sterilization. There are various levels blood-borne pathogens. They are procedures dur-
of disinfection: ing which transmission of HBV, HCV or HIV from
High-level disinfection (HLD): A process capable of a health care worker to patients is most likely to
killing vegetative bacteria, mycobacteria (including occur. Exposure-prone procedures include:
Mycobacterium tuberculosis), fungi, and enveloped • digital palpation of a needle tip in a body cavity,
and non-enveloped viruses, as well as some, but or the simultaneous presence of the health
not necessarily all, bacterial spores. HLD is consid- care worker’s fingers and a needle or other
ered to be the minimum level of decontamination sharp object in a blind or highly confined
required for semi-critical patient care items. HLD anatomic site;
is performed after items are thoroughly cleaned
• repair of major traumatic injuries;
and rinsed. HLDs include 2% glutaraldehyde, 7%
accelerated hydrogen peroxide, 6% hydrogen • major cutting or removal of any oral or perioral
peroxide, 0.2% peracetic acid and 0.55% ortho- tissue, including tooth structures.
phthalaldehyde. Implantable devices: Implantable devices
Intermediate Level Disinfection (ILD): A process that have been prepared and packaged by the
that kills all microbial pathogens, except bacterial manufacturer and are received pre-sterilized do
endospores, when used according to labelling. not require re-sterilization. Implantable devices are
ILDs include ethyl alcohol or isopropyl alcohol, not intended for reuse. If an implantable device
hypochlorites, iodine and iodophors. has been used in a patient’s mouth it must not
be reused.
Low-level disinfection (LLD): A process capable of
killing most vegetative bacteria, as well as some Personal protective equipment (PPE): Specialized
fungi and enveloped viruses. LLD is the minimum clothing or equipment worn by staff and patients
level of decontamination required for non-critical for protection against hazards.
patient care items and some environmental sur- Reusable device: A device that has been designed
faces. LLD is performed after items are thoroughly by the manufacturer, through the selection of
cleaned and rinsed. LLDs include chlorine-based materials and/or components, to be reused.
products (e.g. diluted household bleach), 0.5%
Risk class: The class assigned to patient care
accelerated hydrogen peroxide, 3% hydrogen
items based on the potential risk for infection
peroxide, 60 to 95% alcohols, iodophors, phenolics
associated with their intended use. The risk class
and quaternary ammonium compounds.
determines the processing requirements of an
Droplets: Small particles of moisture (e.g. spatter) item. The risk classes are as follows:
generated when a person coughs or sneezes, or
Critical items: Items that penetrate soft tissue or
when water is converted to a fine mist by an aera-
bone, enter into or contact normally sterile tissue or
tor or shower head. Intermediate in size between
the bloodstream. Critical items present a high risk
drops and droplet nuclei, these particles, although
of infection if the item is contaminated with any
they may still contain infectious microorganisms,
type of microorganism, including bacterial spores.
tend to quickly settle out from the air so that any

Processing of critical items involves meticulous • Nasal hoods (e.g. for use with nitrous oxide)
cleaning followed by sterilization. • Orthodontic pliers

Examples of instruments that are considered • Rubber dam frame and clamp forceps
critical include (note this is not an exhaustive list):
• Suction tips other than for surgery (does not
• Air/water syringe tips include single-use saliva ejectors)
• Anesthetic syringes Non-critical items: Items that contact intact skin,
• Endodontic instruments, including files, but not mucous membranes, or do not directly
reamers, broaches contact the patient. Processing of non-critical items
involves cleaning followed by low-level disinfection.
• Handpieces
• Metal matrix bands Examples of instruments that are considered non-
critical include (note this is not an exhaustive list):
• Periodontal instruments including ultrasonic tips
• Curing lights
• Polishing cups, points and mandrels
• Laboratory knives and spatulas
• Restorative and operative instruments
• Rubber dam punch
• Rotary burs and diamonds
• Rubber dam clamps • Shade guides
• Stainless steel crowns Routine practices: A term used to describe basic

standards of infection prevention and control that
• Surgical suction tips
are required for safe patient care. Routine Practices
Semi-critical items: Items that contact mucous are based on the concept that all patients are
membranes or non-intact skin, but ordinarily do potentially infective, even when asymptomatic, and
not penetrate them. Processing of semi-critical that the same safe standards of practice should
items involves meticulous cleaning followed by routinely apply to contact with blood, body fluids
sterilization (preferred) or high-level disinfection and secretions (e.g. saliva), mucous membranes
(minimum). Semi-critical instruments or devices and non-intact skin.
that have been exposed to blood or have the
Single-use/disposable device: A device that has
potential to be exposed to blood must be treated
been designed by the manufacturer for single-use
as critical. Dental hygienists must use their profes-
only.
sional judgment for every instrument, device and
surface for their specific practices to ensure that Spatter: Visible drops of liquid or body fluid that are
these Guidelines are being met. expelled forcibly into the air and settle out quickly,
as distinguished from particles of an aerosol, which
Examples of instruments that are c onsidered semi-
remain airborne indefinitely.
critical include (note this is not an e
xhaustive list):
Sterilization: A validated process that kills all
• Articulating paper holders
pathogenic microorganisms, including bacteria,
• Crown removing instruments fungi, viruses and spores.
• Impression trays
Ultrasonic cleaner: A machine that cleans
• Lab burs patient care items by the cavitations produced by
• Mixing spatulas ultrasound waves.

Appendix 1 Methods for Cleaning, Disinfection and Sterilization
Appendix 1
of Patient Care Items and Environmental Surfaces
Process Result Examples for Specific Comments

Dentistry Indications
Sterilization Kills all forms of patho- Steam Critical and Steam sterilization is the preferred method.
genic microorganisms, Dry Heat semi-critical Sterilization process must be audited and
including bacteria, fungi, items monitored with mechanical, chemical and
viruses and spores biological indicators.
High-level Kills vegetative bacteria, 2% glutaraldehyde Heat-sensitive, Not for use on environmental surfaces.
disinfection (HLD) mycobacteria, fungi, 7% accelerated semi-critical Follow manufacturer’s instructions regarding
All disinfectants enveloped and non- hydrogen peroxide, items dilution, instrument preparation, immersion
must have a Drug enveloped viruses, but 6% hydrogen peroxide time, temperature and changing of solutions.
Identification not necessarily bacterial
0.2% peracetic acid Glutaraldehyde is non-corrosive to metals
Number (DIN) from spores.
and compatible with most materials.
Health Canada Extremely irritating to skin and mucous
membranes. Use in well-ventilated areas.
0.55% ortho- Hydrogen peroxide is active in presence of

pthalaldehyde organic matter, but is corrosive to aluminum,
brass, copper and zinc.
Low-level Kills most vegetative Chlorine-based Non-critical Follow manufacturer’s instructions regarding
disinfection (LLD) bacteria, as well products (e.g. diluted items and concentration and contact time.
All disinfectants as some fungi and sodium hypochlorite or environmental Diluted household bleach is inexpensive and
(except household enveloped viruses. household bleach – 1:50 surfaces readily available, but must be prepared daily.
bleach) must have Cannot be relied on or 1000 PPM) Items and surfaces must be cleaned first, as
a Drug Identifica- to kill mycobacteria, chlorine-based products are inactivated by
tion Number including Mycobacterium organic material. Corrosive to metals and
(DIN) from Health tuberculosis or bacterial may destroy fabrics.
Canada spores. 0.5% accelerated Hydrogen peroxide is active in presence of
hydrogen peroxide, organic matter, but is corrosive to aluminum,
3% hydrogen peroxide brass, copper and zinc.
60 to 95% alcohols Alcohols are fast-acting, but are flammable
and evaporate quickly. Items and surfaces
must be cleaned first, as alcohols are
inactivated by organic material. May harden
plastic and rubber.
Some iodophors, Quaternary ammonium compounds are used
phenolics and quaternary for disinfecting non-critical equipment and
ammonium compounds environmental surfaces, but not instruments.
They require careful dilution, as they may
support microbial growth.
Cleaning Physical removal of Soap and water, All reusable Follow manufacturer’s instructions regarding
soil, dust and foreign detergents and items concentration and contact time.
material. enzymatic cleaners
0.5% accelerated
hydrogen peroxide
Quaternary ammonium
compounds

Appendix 2 Additional Resources and Reference Materials
Part A: Patient
Appendix
Note: URLs are provided for convenience only and were correct at the time of printing.
2
Dental Wastes Best Management Practices in Ontario, 2003

Safety
Royal College of Dental Surgeons of Ontario

www.rcdso.org/pubs_resources/practice_resources/amalgam_waste.html
Best Practice Guidelines for Cleaning, Disinfection, and Sterilization of Critical and Semi-critical Medical
Devices in BC Health Authorities, 2011
www.health.gov.bc.ca/library/publications/year/2011/Best-practice-guidelines-cleaning.pdf
Best Practices for Hand Hygiene in All Health Care Settings, 2009
Provincial Infection Diseases Advisory Committee
Ontario Ministry of Health and Long-Term Care
www.ontla.on.ca/library/repository/mon/25009/312519.pdf
Canadian Immunization Guide for 2006

Public Health Agency of Canada
www.phac-aspc.gc.ca/publicat/cig-gci/pdf/cig-gci-2006_e.pdf
Decontamination of Reusable Medical Devices (CSA Z314.8-08), 2008

Canadian Standards Association
http://shop.csa.ca/en/canada/sterilization/cancsa-z3148-08/invt/27010632008/
Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

Centers for Disease Control and Prevention
www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf
Guidelines for Infection Control in Dental Health-Care Settings, 2003

Centers for Disease Control and Prevention
www.cdc.gov/mmwr/PDF/rr/rr5217.pdf
Infection Control in the Physician’s Office, 2004

College of Physicians and Surgeons of Ontario
www.cpso.on.ca/uploadedFiles/policies/guidelines/office/Infection_Controlv2.pdf
Routine Practices and Additional Precautions in All Health Care Settings, 2009
Provincial Infection Diseases Advisory Committee
Ontario Ministry of Health and Long-Term Care
www.oahpp.ca/resources/documents/pidac/Routine%20Practices%20and%20Additional%20Precautions.pdf
Workplace Hazardous Material Information System (WHMIS): A Guide to the Legislation, 2008
Ontario Ministry of Labour
www.labour.gov.on.ca/english/hs/pdf/whmis.pdf
Preventing Needle-stick Injuries and the Use of Dental Safety Syringes, 2010
WorkSafeBC
www.worksafebc.com/contact_us/research/research_results/res_60_10_1080.asp

Notes

College of Dental Hygienists
of British Columbia
Suite 219 – Yarrow Building

645 Fort Street
Victoria, BC V8W 1G2
Phone: 250-383-4101
Toll Free within B.C.: 800-778-8277
Fax: 250-383-4144
Email: [email protected]
www.cdhbc.com

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College of Dental Hygienists

Infection ­Prevention and Control Guidelines

Dental Health Care Providers’ Responsibilities and Safety

Cleaning, Disinfection and Sterilization of Patient Care Items

Office Cleaning, Housekeeping and Management of Waste

Equipment and Area Specific Practice Guidelines

Additional Considerations for Alternative Practice Settings

Glossary of IPAC Terms

Developed in collaboration with the College of Dental Surgeons of BC and

Development of Infection Prevention and Control Guidelines

2 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part A: Patient Safety

Part B: Dental Health Care Providers’ Responsibilities and Safety

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 3

Part D: Office Cleaning, Housekeeping and Management of Waste

Part E: Equipment and Area Specific Practice Guidelines

Part F: Additional Considerations for Alternative Practice Settings 40

Part G: Glossary of Infection Prevention and Control Terms 42

4 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 5

This document is not a step-by-step manual on how

6 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Professional and Regulatory Considerations • Transmission of Microorganisms and Principles of IPAC

Transmission of Microorganisms and Principles

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 7

­transmission of microorganisms are: • patient assessment;

8 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part A: Patient Safety

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 9

3. Risk Assessment 4. Hand Hygiene

10 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part A: Patient Safety

• Rub vigorously for a minimum of 15 seconds, are dry.

covering all surfaces of hands and fingers.

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 11

for surgical procedures: • Soap dispensers should be placed at every sink.

12 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part A: Patient Safety

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 13

14 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part A: Patient Safety

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 15

Responsibilities and Safety

16 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part B: Dental Health Care Providers’ Responsibilities and Safety

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 17

4. Exposure Prevention of transmission of blood-borne pathogens to

18 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part B: Dental Health Care Providers’ Responsibilities and Safety

Hygienists diately after the activity for which they were

General considerations • Gloves should not be worn outside any room

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 19

policy that uniforms and scrubs worn during patient

20 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Part B: Dental Health Care Providers’ Responsibilities and Safety

Infection Prevention and Control Guidelines – College of Dental Hygienists of BC 21

should be documented, including: that deals with hazardous materials in the

Safety Requirements and ­

22 Infection Prevention and Control Guidelines – College of Dental Hygienists of BC

Infection Prevention and Control Guidelines

transmission of microorganisms are: • patient assessment;

Safety Requirements and

Authorities (Dec. 2011): as endodontic files. These devices cannot assure

5. Dental Radiography contamination of the film packet. If used, the

0.55% ortho- Hydrogen peroxide is active in presence of