BDA advice

Infection control

Date: August 2017

 Infection control

8 Equipment
Contents Decontamination process
3 Infection control in practice Pre-sterilisation cleaning
Policies and protocols Inspection and function testing
Review your processes Sterilisation
Essential requirements and best practice Instrument packaging and storage

4 Professional responsibilities 12 Impressions, prostheses and appliances

Patient information
Health screening 13 Treatment areas
Infected dental clinicians Water supplies
Blood spillages
5 Personal protection
Training and individual responsibilities 14 Appendix 1: Common infections
Immunisation
Inoculation injuries 15 Appendix 2: National quality standards
Hand protection
Eye protection and face masks 15 Expert Solutions templates
Surgery clothing
Removing PPE
Aerosol and saliva/blood splatter

© BDA August 2017 Infection control 2

 Infection control in practice
The requirements for in-house decontamination are described in the following
guidance:
 England – HTM 01-05: Decontamination in primary care dental practices and the
Health and Social Care Act 2008: Code of practice on the prevention and control of
health associated infection and related guidance
 Scottish Dental Clinical Effectiveness Programme – Decontamination into Practice
 Northern Ireland – HTM 01-05 as amended by PEL 13-13
 Wales – WHTM 01-05: Decontamination in primary care dental practices and
community dental services
This advice provides an overview of the requirements; you should be familiar with
the guidance that is relevant to the country where you practice.
Policies and protocols
You should have an infection control policy and procedures that contain the
following information
 Minimising the risk of transmitting infection and sharps injuries, and occupational
health arrangements for staff at risk of hepatitis B
 Decontamination and storage of instruments
 Procedures for cleaning, disinfection and sterilisation of instruments
 Management and disposal of clinical waste
 Hand hygiene
 Decontamination of new reusable instruments
 Use of personal protective equipment
 Recommended disinfectants and their use, storage and disposal
 Spillage procedure
 Environmental cleaning.
Your policy and procedures should be reviewed at least every two years.
© BDA August 2017
A copy of the policy and associated protocols should be readily available to all staff.
All team members should be aware of the policy and understand their role in
ensuring that it is followed routinely. Periodic discussion at a practice meeting will
help to keep the team aware of current requirements.
Review your processes
You should undertake regular audits of your decontamination processes (six-
monthly in England and Northern Ireland and at least annually in Wales). The
results of audits should be retained for two years.
The Infection Prevention Society has produced a dental audit tool to help practices
in England and Northern Ireland self-assess compliance with HTM 01-05. For
practices in Wales, an audit tool to assess compliance with WHTM has been
developed by the School of Postgraduate Medical and Dental Education.
Essential requirements and best practice
The HTM guidance recommends compliance with essential quality requirements
and describes the benchmarks for best practice.
Essential requirements include:
 Cleaned instruments are free of visible contamination when inspected
 Instruments reprocessed (decontaminated) using a validated decontamination cycle
including cleaning/washing and a validated steam steriliser
 Reprocessed instrument stored in a way that protects them against contamination
 A detailed plan for moving towards best practice.
Best practice requirements include
 Instrument cleaning using a validated automated washer-disinfector
 Decontamination undertaken in a dedicated room away from the clinical treatment
area
 Instruments stored away from the clinical treatment area and in a facility that
reduces the likelihood of recontamination of sterilised instruments.
In Wales, essential requirements and best practice have been replaced with a
process of continuous improvement.
Infection control 3
 Professional responsibilities
You have an obligation to provide care to those in need, including those who are or
might be infected, and to offer the same high standard of care for all patients. It is
unethical to refuse dental care to patients who disclose a positive diagnosis for a
blood-borne virus (BBV) because it could expose you to personal risk. It is also
illogical as many undiagnosed carriers of BBVs attend for treatment every day and,
because they remain untreated, may present a higher risk of infection. People living
with HIV and the hepatitis viruses who are otherwise well, may be treated without
any restrictions or modification to their dental treatment.
Letting your patients know that you follow national guidelines on infection control
– for example, by including a statement on your website or in your practice
information leaflet or displaying a notice in the practice – and encouraging them to
ask questions will reassure them that you are confident about your infection control
procedures.
Patient information
You should take a detailed medical history when a patient first attends the practice
and review it at subsequent appointments; it must be retained as part of the
patient’s dental records. Direct questioning and discussion in a confidential
environment allows the patient to disclose sensitive and confidential personal
information. Using a questionnaire will ensure that you ask the same questions of
each patient.
The medical history and examination may not identify asymptomatic carriers of
infectious disease, so the same infection control procedures must be used for all
patients. Those who reveal that they are infected are providing privileged
information that should only be used to make appropriate treatment decisions that
benefit the patient and are in their best interests.
All information disclosed by a patient during medical history taking, consultation
and treatment is confidential and must not be disclosed without the patient’s
permission (including to relatives). All members of the team must be aware of the
duty of strict confidentiality and the need to keep secure any information provided
by patients. The requirement to maintain confidentiality should be included in all
contracts of employment and discussed at team meetings to ensure that all team
members understand its importance.
© BDA August 2017
Health screening
New members of the clinical team should undergo health clearance before their
appointment is confirmed. This includes checks for TB disease or immunity and
immunisation against hepatitis B. Additional checks are required for those
performing exposure prone procedures (EPPs) to establish that they are non-
infectious for:
 Hepatitis B (surface antigen negative or, if positive, e-antigen negative with a viral
load of 103 genome equivalents/ml or less)
 Hepatitis C (antibody negative or, if positive, negative for hepatitis C RNA)
 HIV (antibody negative).
EPPs are invasive procedures where injury could result in the clinician’s blood
contaminating the patient’s open tissues. They include procedures where the
worker’s gloved hands may be in contact with sharp instruments, needle tips and
sharp tissues (spicules of bone or teeth) inside a patient’s open body cavity, wound
or confined anatomical space where the hands or fingertips may not be completely
visible at all times.
Infected dental clinicians
A dental clinician who believes they may be infected with a BBV, TB or other
infection must seek medical advice and undergo any necessary testing and
counselling. Changes to clinical practice may be required and may include ceasing
or restricting practice, the exclusion of EPPs or other modifications. An infected
clinician must not rely on their own assessment of the possible risks to their patients.
Failure to obtain appropriate advice or act upon the advice given would almost
certainly lead to their fitness to practice being questioned.
Dental clinicians who are e-antigen positive carriers of hepatitis B infection must not
perform EPPs. Those who are e-antigen negative should undergo additional testing
to identify their viral loads. If the viral load exceeds 103 genome equivalents per ml,
the clinician must not perform EPPs; below this, working practices are not restricted
but the clinician should be retested at 12-monthly intervals, as viral loads may
fluctuate over time. Further advice can be obtained from your local occupational
health department.
Infection control 4
 Before performing EPPs, HIV-infected clinicians must meet the following criteria (set by UKAP):
 Be on effective combination antiretroviral therapy and have a plasma viral load <200
copies/ml; OR
 Have maintained their viral load below the limits of assay detection for at least three
measurements over 12 months, be subject to plasma viral load monitoring every
three months, be medically supervised, and be registered with the UKAP Occupational
Health Monitoring Register.
Dental nurses do not usually carry out EPPs as a part of routine work activities and can
continue working in the surgery if found to be infected with hepatitis B or other BBV.
However, personal protective equipment must be used routinely and a risk assessment
carried out to identify work activities that may pose a risk to patients.
Personal protection
Employers must ensure the personal protection of those working at the practice.
Where this requires the use of personal protective equipment (PPE), it is not sufficient
simply to provide PPE, the employer must ensure that it is being used routinely and in
the correct manner. All team members must understand the principles of personal
protection and that it is mandatory to use any PPE provided. This requirement should
be included in the employment contracts of affected employees.
Training and individual responsibilities
All members of the team must understand how infections are transmitted, the
practice policy on decontamination and infection control, what personal protection
is required and when to use it, and how to deal with accidents and personal injury.
This training should be included in the practice induction programme for new staff.
Training records should show that all staff have been appropriately trained in
decontamination procedures and know how to decontaminate the reusable dental
instruments used at the practice.
Although the practice owner has overall responsibility for the decontamination processes,
support from team members is essential. Identifying individuals to take on the following
responsibilities will help to ensure that processes are up to date and adopted routinely:
 Decontamination and infection control procedures within the practice
 Team training
 Daily and weekly periodic tests.
© BDA August 2017
Immunisation
The Green Book provides information on recommended vaccinations for health
professionals and advises that immunisation programmes be managed by
occupational health services with appropriately qualified specialists. The employing
dentist must meet any costs associated with vaccinations for work purposes. NHS
Health at Work Network lists providers of NHS occupational health services in England.
Employers must hold documentary evidence to demonstrate that all relevant members
of the dental team have been immunised and their responses to the vaccine checked;
post vaccination blood test results will show whether an adequate level of immunity has
been achieved. The employee’s consent must be obtained before the occupational
health department or GMP is approached; any information provided is confidential.
Hepatitis B
Those who have direct contact with patients’ blood or blood-stained body fluids
(including saliva) should be vaccinated against hepatitis B. This includes contact
with blood-contaminated sharp instruments. New staff who have not been
immunised should start the vaccination course as soon as possible and be fully
immunised before assisting chairside or undertaking decontamination activities.
The Green Book includes information on hepatitis B immunisation. For pre-exposure
prophylaxis, an ‘accelerated’ schedule should be used, with the vaccine given at zero,
one and two months. A ‘very rapid’ schedule is also available, with the vaccine given
at zero, seven and 21 days, plus a fourth dose administered 12 months after the
first dose.
Antibody titres for hepatitis B should be checked one to four months after completion
of a primary course of the vaccine. The results will inform decisions about post-
exposure prophylaxis following a known or suspected exposure to the virus. A single
booster dose at around five years after primary vaccination is recommended.
Non-responders (antibody titre below 10mIU/ml) must be tested for markers of
current or past infection; a repeat course of the vaccine may be required. They
should be briefed on the personal risk of working in dentistry and the importance of
following the practice inoculation injury protocol to allow timely post-exposure
prophylaxis.
Infection control 5
 Tuberculosis
Tuberculosis (TB) is spread by water droplets or by direct contact and has been
transmitted by dental procedures. Dental professionals are more likely than the
general population to come into contact with the infection and unvaccinated. Those
who are tuberculin-negative and aged under 35 years should be vaccinated.
The current shortage of the BCG vaccine has interrupted the national immunisation
programme. Where immunisation is required, you should seek advice from your
local occupation health provider.
Inoculation injuries
Inoculation injuries are the most likely route for transmission of blood borne viral
infections in dentistry and include all incidents where a contaminated object or
substance breaches the integrity of the skin or mucous membranes or comes into
contact with the eyes – for example:
 Sticking or stabbing with a used needle or other instrument
 Splashes with a contaminated substance to the eye or other open lesion
 Cuts with contaminated equipment
 Bites or scratches inflicted by patients.
Inoculation injuries must be dealt with promptly and correctly:
 Allow the wound to bleed, then wash thoroughly with running water
 Assess the risks associated with the patient and the injury. Where transmission of
infection is a possibility, contact your local occupational health service for advice on
the necessary follow-up action, including serological surveillance and post-exposure
prophylaxis (PEP). Practices without an NHS contract may need to arrange this
privately. Details of your local contact should be displayed prominently within the
practice
 When local advice is not available, you should seek advice from your local health
protection team
 Record the incident in the accident book and include details of who was injured, how
the incident occurred, what action was taken, which dentists were informed and when
and, if known, the name of the patient being treated. Both the injured person and the
dentist in charge should countersign the record.
© BDA August 2017
If the source patient is HIV infected and the injury is risk-assessed as significant,
PEP should start as soon as possible and ideally within an hour of the injury. You
should identify the local arrangements for urgent access to PEP before any incident
occurs.
Safer sharps
Guidance on the Health and Safety (Sharp Instruments in Healthcare) Regulations
2013 requires risk control measures:
 To avoid the use of sharps wherever possible
 When their use is necessary, to use safer sharps whenever practicable
 To not cap/re-sheath needles after use, unless a suitable appliance is used that
controls the risk. Some syringes include a shield that covers the needle after use
 To dispose of sharps safely.
A ‘safer sharp’ means that the medial sharps incorporate features or mechanisms
to prevent or minimise the risk of accidental injury – for example, syringes and
needles with a shield or cover that slides or pivots to cover the needle after use.
When using safer sharps, you must consider the following factors:
 The device must not compromise patient care, must be reliable and easy to use,
and must not introduce other safety hazards or exposure to other sources of
blood
 You must be able to maintain appropriate control over the procedure
 The safety mechanism should be straightforward to use, integral to the device,
and activated automatically or single-handedly; if the mechanism can be
reversed, it is not effective
 An audible, tactile or visual signal indicates that the safety mechanism has
correctly activated.
If you decide that it is not reasonably practicable to use safer sharps, you must
ensure that your procedures for working with and the disposal of sharps are safe.
Needles must not be recapped unless it is required to control a risk and an
appropriate device is used.
Infection control 6
 Hand protection
Fingernails should be kept clean, short and smooth; false nails and nail polish should
not be used. If a wedding ring is worn, the skin beneath it should be washed and
dried thoroughly. Otherwise, rings, bracelets and wrist watches should be removed
during clinical procedures. Cuts, abrasions and cracked skin can offer a portal of
entry for microorganisms and should be covered before putting on gloves.
Clean hands complement the use of gloves; neither is a substitute for the other.
Hand hygiene should take place:
 Before and after each treatment session
 Before putting on and after the removal of PPE
 Following the washing of dental instrument
 Before contact with sterilised instruments (wrapped and unwrapped)
 After cleaning or maintaining decontamination devices used on dental instruments
 At the completion of decontamination work.
A poster illustrating effective hand hygiene should be displayed above every wash-
hand basin. Mild liquid soap reduces the risk of hand irritation and disposable towels
for drying helps prevent transfer of micro-organisms. Hand cream (preferably water-based)
will help to avoid chapped or cracking skin. Ideally, a wall-mounted hand-cream dispenser
with disposable cartridges should be used.
Gloves
Gloves must be worn for all clinical procedures and a new pair used for each patient.
Suitable gloves should be manufactured to European standard BSEN 455, be well-
fitted and non-powdered; the powder from gloves can contaminate veneers and
radiographs, disperse allergenic proteins into the surgery atmosphere and interfere
with wound healing. They should also be low in extractable proteins (<50µg/g) and
low in residual chemicals. Alcohol gels should never be used on gloves. Used gloves
must be disposed of as clinical waste.
Domestic household gloves should be used when processing contaminated
instruments and equipment. They should be washed with detergent and hot water
to remove visible soil and left to dry after each use. These gloves should be replaced
weekly or more frequently if torn or visible soil cannot be removed by washing.
© BDA August 2017
Latex allergy
Allergic contact dermatitis is rare but, if it develops, it may cause the individual to
cease practice. If you suspect it, you should seek advice from a dermatologist.
Irritant contact dermatitis is more common but can be avoided by selecting good
quality gloves and meticulous hand care.
If a patient is allergic to latex or the chemicals used in glove manufacture, non-latex
gloves should be used. Additional precautions will also be needed to protect against
contact with latex through other sources – local anaesthetic cartridges, rubber dam
and eye protection, for example.
Eye protection and face masks
Eye protection is essential for all clinicians and support staff to protect against
foreign bodies, splatter and aerosols especially during scaling (manual and
ultrasonic), the use of rotary instruments, cutting and use of wires and the cleaning
of instruments.
Protective eyewear should include side protection. The lenses of many prescription
glasses may be too small to provide protection; a visor or face shield can be worn
over glasses. Patients’ eyes must always be protected against possible injury and
tinted glasses may also protect against glare from the operating light.
Masks (to EN14683) must be worn during all operative procedures to help protect
against splash and splatter; they do not protect against aerosols. Masks are single
use so must be changed after every patient. Visors can be used in addition to masks
and cleaned between patients or, if single-use, disposed of as clinical waste.
Respirators (to EN149) should be used when treating patients with active respiratory
viral infections (e.g. active TB and pandemic influenza). Filtering facepiece devices
(such as FFP2 & FFP3) provide an effective barrier to both droplets and fine aerosols.
Infection control 7
 Surgery clothing
Surgery clothing should not be worn outside the practice, so changing and storage
facilities must be provided. Short sleeves allow the forearms to be washed as part of
the handwashing routine whereas long sleeves may become contaminated during
clinical sessions.
Freshly laundered uniforms should be worn every day and, to reduce any potential
microbial contamination, laundered at the hottest temperature suitable for the
fabric. Disposable plastic aprons should be worn during decontamination processes.
Removing PPE
You should remove PPE in the following order:
 Gloves – ensuring that the gloves end up inside out and without the hands becoming
contaminated
 If they become contaminated, wash them thoroughly before removing other PPE
 Plastic disposable apron – by breaking the neck straps and gathering the apron
together touching the inside only
 Face mask – by breaking the straps or lifting over the ears, avoiding touching the outer
surface of the mask. Never allow a used mask to hang around your neck
 Face and eye protection, taking care not to touch outer surfaces.
When all PPE has been removed, you should wash your hands thoroughly.
Aerosol and saliva/blood splatter
Good surgery ventilation and efficient high-volume aspirators reduce the risk of
infection by dispersing and eliminating aerosols. Aspirators should exhaust
externally but without risk to the public or re-circulation into any building. Aspirators
and tubing should be cleaned as recommended by the manufacturer and, at the
end of each session, be flushed through with their recommended surfactant/
detergent and/or non-foaming disinfecting agent.
Rubber dam virtually abolishes saliva/blood splatter and should be used whenever
practicable. When working without rubber dam, high-volume aspiration is essential.
© BDA August 2017
Equipment
It makes good sense to purchase only equipment that is necessary and is right for
the job. Unless the equipment is designated single use, it must be able to withstand
the decontamination processes available at the practice. A practice protocol for
selecting new equipment will help to ensure that any equipment purchased meets
these criteria. You should consider the following:
 Will the equipment selected do what you need it to do?
 Is it compatible with other equipment in the surgery?
 How easy will it be to use and maintain?
 Is it CE marked?
 If the instrument requires dismantling before cleaning, are there
manufacturer’s instruction for how this is done?
 Does the manufacturer specify a limited life-cycle?
 Are the manufacturer’s recommendations for cleaning and decontamination
achievable in practice?
 Will the instrument withstand automated washer-disinfector processes?
 Avoid difficult to clean serrated handles and check that hinges are easy to clean
 If cleaning agents are recommended, will they pose a risk those using them and
will they be compatible with the washer-disinfector, ultrasonic cleaner and
instruments already in use in the practice?
 Check with the manufacturer which cleaning agents are recommended for the
dental chair covering and work surfaces to ensure that they can be regularly
decontaminated without deterioration
 Select foot controlled equipment whenever possible
 If training required, will the manufacturer provide it?
 What are the commissioning and validation requirements of the equipment?
 Are there ongoing costs?
 What is the response time in the event of a breakdown?
Infection control 8
 Single-use (disposable) items
‘Single-use’ items must be used on one patient during one treatment session and
then discarded. Items designated as single use will bear the international symbol:
Equipment that cannot be safely decontaminated for re-use must be considered
‘single-use’. Where instruments are difficult to clean, single-use alternatives (if
available) should be considered – matrix bands, saliva ejectors, aspirator tips and
three-in-one tips, for example.
Endodontic reamers and files should be treated as single-use. In England,
endodontic instruments that are designated reusable should be treated as single-
patient use to reduce the risk of prion transmission. If reusing these items on a single
patient, your practice systems must ensure that they are associated with the correct
patient. If cleaned manually, the instruments should be cleaned separately from
other instruments.
Decontamination process
At the end of each patient treatment, all instruments selected for use (used and
unused) must be cleaned and sterilised, following the manufacturer’s instructions
for decontamination. New instruments must be decontaminated before use.
You should have safe procedures for transferring contaminated instruments to the
decontamination area and for transferring sterilised instruments to the treatment
or storage area.
The decontamination process includes pre-sterilisation cleaning, disinfection,
inspection, sterilisation and storage. Where possible, these processes should be
validated. Validation shows that the process has been verified, tested and
documented and is consistently reproducible. Equipment that cannot be sterilised
must be thoroughly cleaned and disinfected in accordance with the manufacturer’s
instructions.
© BDA August 2017
Decontamination processes should be undertaken away from the clinical work are
and, wherever possible, in a separate room. If decontamination takes place in the
surgery, the reprocessing area should be as far as possible from the dental chair and
undertaken when the patient is not in the surgery. The decontamination area should
include:
 Separate hand-washing sink
 Setting-down area for dirty instruments
 Washing and rinsing sinks (or one sink with a removable bowl that can accommodate
the instruments for rinsing)
 Ultrasonic cleaner (where used)
 Washer-disinfector (where used)
 An area with a task light for instrument inspection and function testing. Where type
B or S (vacuum) sterilizers are used, this area can also be used for wrapping
instruments prior to sterilization sterilizer(s)
 An area for setting down sterilised instruments prior to placing them onto trays for
use or storage if already wrapped
A dirty-to-clean workflow should be maintained throughout to minimise the
possibility of used instruments coming into contact with sterilised instruments. Air
movement should, ideally, be from clean to dirty areas.
Pre-sterilisation cleaning
Cleaning instruments before sterilising them reduces the risk of transmission of
infectious agents and is easiest if undertaken soon after the instrument has been
used. Blood, saline and iodine are corrosive to stainless steel instruments and will
cause pitting and then rusting if allowed to remain on instruments for any length of
time. Where a delay cannot be avoided, the used instruments should be immersed
in water or an enzymatic cleaner. Lengthy periods of wet storage should be avoided,
however. Dental materials should be removed from instruments as soon as possible
after use (and before they harden) to allow effective cleaning. After cleaning,
instruments should be rinsed in water (potable, reverse osmosis or freshly distilled).
Instruments and equipment that consist of more than one component should,
where recommended by the manufacturer, be dismantled to allow each part to be
adequately cleaned.
Infection control 9
 Washer-disinfectors
Washer-disinfectors offer the best option for a validated process and remove the
need for manual cleaning; where possible, they should be used. The installation of
a washer-disinfector must comply with the Water Fittings Regulations.
A typical washer-disinfector cycle includes five stages:
1. Flush - removes gross contamination using a water temperature of less than 45OC
2. Wash - removes remaining soil using detergents specified by the manufacturer
3. Rinse(s) - removes detergents
4. Thermal disinfection - temperature raised for required time: 80OC for 10 minutes or
90OC for 1 minute, for example
5. Drying - heated air removes residual moisture.
The manufacturer’s instructions for use should be followed. Staff must understand
how to use the washer-disinfector and perform the daily tests. Records of training
should be kept.
Washer-disinfectors must be loaded correctly to ensure effective cleaning by:
 Not overloading instrument carriers or overlapping instruments
 Opening instrument hinges and joints fully
 Attaching instruments requiring irrigation to the irrigation system correctly, and
ensuring filters are in place if required (for example, for handpieces).
Washer-disinfector logbooks and records should include cycle parameters and
details of routine testing and maintenance. Automated data-loggers or interfaced
small computer-based recording systems can be used, provided the records are kept
securely and replicated (to guard against fading). Records should be kept for at least
two years.
© BDA August 2017
Ultrasonic cleaners
Ultrasonic cleaners are an effective means of cleaning dental instruments and reduce
contact with contaminated instruments. They must be maintained and tested according
to manufacturer’s recommendations. The results of all tests should be recorded.
Prior to ultrasonic cleaning, briefly immerse used instruments in cold water (with
detergent) to remove visible soiling; a container with a sealing lid is recommended.
When placing instruments in the ultrasonic cleaner:
 Place the instruments in a suspended basket, not on the floor of the cleaner
 Do not overload the basket or overlap the instruments
 Open instrument hinges and joints and, where appropriate, disassemble instruments
 Immerse fully in the cleaning solution
 Set the timer, close the lid and do not open until the cycle is complete
 Drain the basket of instruments and rinse to remove residual soil and detergent.
Where instruments require wrapping and sterilising in a vacuum steriliser, they must
be dried first using a disposable non-linting cloth.
The water/fluid must be changed at the end of the clinical session and more
frequently if it becomes heavily contaminated. At the end of each day, the
ultrasonic cleaner must be emptied, cleaned and left dry.
Manual cleaning
Manual cleaning carries a greater risk of inoculation injury than other cleaning
methods but you should have the facilities, documented procedures and trained
staff to undertake manual cleaning alongside other cleaning methods. Where
manual cleaning is necessary, you should maintain a dirty-to-clean workflow and
follow written procedures to reduce variability in cleaning.
Manual washing and rinsing requires two dedicated sinks or one sink with a
removable bowl only used for final rinsing (and not instrument washing). Always
use detergents specifically made for the manual cleaning of instruments and follow
the manufacturer’s instructions for concentration and temperature (which should
not exceed 45OC). Submerge the instruments and scrub using long-handled brushes.
Rinse the instruments after cleaning.
Where instruments require wrapping and sterilising in a vacuum steriliser, they must
be dried first using a disposable non-linting cloth.
Infection control 10
 Dental handpieces
 Washer-disinfectors are preferred if the handpiece can withstand this cleaning
method and the washer-disinfector can clean handpieces
 Dedicated handpiece-cleaners can be considered where a washer-disinfector is not
recommended
 Commercial products for decontaminating handpieces can be used where the
product can be shown to reduce the risk of infection transmission or the process can
be validated.
 Follow manufacturer’s recommendations for lubrication; separate canisters of
lubricant should be used for unclean and cleaned handpieces.
Inspection and function testing
After cleaning and before sterilisation, inspect instruments for cleanliness (using a
magnifying glass and task lighting) and checked for wear or damage. Reclean any
instruments that remain contaminated. Working parts and joints should move
freely; a non-oil-based lubricant may be necessary where hinges are stiff. The edges
of clamping instruments and scissors should meet with no overlap or rough edges;
scissor edges should move freely across each other. Screws on jointed instruments
should be tight.
You should not use faulty or damaged instruments. Clean, sterilise and label the
instruments as ‘decontaminated’ before dispatch.
Sterilisation
The preferred method of sterilisation in dentistry is saturated steam under pressure
delivered at a temperature of 134-137OC with a holding time of 3-3.5 minutes.
Three types of steriliser are suitable for use in dentistry:
 Type N (displacement): designed for unwrapped, non-hollow and non-air retentive
instruments
 Type B (vacuum): designed for hollow, air retentive and packaged loads
 Type S (vacuum): designed for specific loads (determined by the manufacturer).
Effective sterilisation requires steam to contact all surfaces of the instrument so
load instruments into the chamber to allow free circulation of steam. Avoid
overloading.
© BDA August 2017
Fill water reservoirs daily using fresh distilled or reverse osmosis (RO) water. Where
possible, Discharge the sterilizer water after each cycle, where possible, and drain
the reservoir at the end of each working session to reduce the likelihood of toxin
build up in the water supply. At the end of the day, drain, clean and dry the chamber
and ensure the door is left open.
Dental handpieces
Handpiece manufacturers will provide advice on decontamination. If cleaned using
a validated washer-disinfector (if recommended by the manufacturer), further
processing using a type B or type S steriliser is acceptable, although the presence of
lubricating product means the handpiece is unlikely to achieve sterility.
Checks, tests and record keeping
Before turning on the power at the start of the day:
 Clean the rubber door seal of the steriliser with a clean, damp non-linting cloth
 Check the chamber and shelves for cleanliness and debris
 Fill the reservoir with freshly distilled or RO water.
Daily tests include:
 Automatic control test to demonstrate that the steriliser is working
 Steam penetration test (vacuum sterilisers only)
 Where recommended by the manufacturer, a warm-up cycle before instruments can
be processed.
You should seek advice from the manufacturer on whether the daily tests can be
undertaken while instruments are being processed. The results of checks must be
recorded to demonstrate compliance. A steriliser that fails to meet any of the test
requirements should be withdrawn from service until the cause has been rectified.
When first purchased, sterilisers should be commissioned to ensure that they are
appropriately calibrated and functioning correctly; a Competent Person
(Decontamination) or service engineer must validate the steriliser to demonstrate
that the right conditions for sterilisation are achieved. The equipment must be
maintained in line with the manufacturer’s instructions and periodically examined
by a competent person.
Infection control 11
 The parameters should be monitored for each cycle. Printouts and automated data
loggers or interfaced computer-based recording systems are acceptable provided
the records are kept securely and replicated. Where automatic data production is
not available, you should keep manual records of the temperature/pressure
achieved or an absence of failure. Records should be maintained for at least two
years.
Compare readings with the recommended values. If any are outside the specified
limits, the sterilisation cycle must be checked again. If it is unsatisfactory again, the
steriliser should not be used until the problem has been rectified by an appropriately
trained engineer. Chemical indicators (TST strips, for example) demonstrate only
that instruments have been through a sterilisation cycle, not that they have been
sterilised.
Instrument packaging and storage
Sterilised instruments must be protected to reduce the possibility of
recontamination. The area used for packing prior to storage should be wiped clean
with detergent and alcohol wipes at the start of each session. Where necessary, use
disposable non-linting cloths to dry instruments; a fresh cloth for each sterilised
load.
Wrapped instruments
You can store wrapped instruments for up to one year. The steriliser used
determines when instruments should be wrapped:
 Type N (displacement): dried instruments can be wrapped after sterilisation. If you
store instruments in trays, the entire tray should be placed in a sealed pack
 Type B (vacuum): dried instruments can be pre-wrapped
 Type S (vacuum): manufacturer’s guidance should be followed
Packaging should display the date of decontamination and an expiry date.
© BDA August 2017
Unwrapped instruments
After sterilisation, unwrapped instruments should be stored dry and be protected
from contamination – in mini racks placed in cupboards or in in covered drawer
inserts, for example – not on an open work surface.
If you store instruments in the surgery (in a cupboard or drawer, for example), you
should have ready the instruments you will need for the patient before treatment
starts, eliminating the need to open cupboard doors or drawers during treatment.
If you need additional instruments, during treatment, you should ensure that your
hands are clean and put on a new pair of gloves before handling unwrapped
sterilised instruments. At the end of the working day (or at the beginning of the next
working day), you should process all unwrapped instruments regardless of whether
they have been used.
HTM 01-05 (England and Northern Ireland) recommends that instruments stored
away from the surgery (in a separate decontamination room, for example) should
be used within one week.
A storage system of first-in, first-out will help you to monitor storage times to ensure
that recommended intervals are not exceeded.
Impressions, prostheses and appliances
You are responsible for ensuring impressions, prostheses and appliances have been
cleaned and disinfected prior to dispatch to the laboratory. You should agree the
cleaning and disinfection process with the laboratory and label the device to
indicate disinfected status. This removes uncertainty and, for impressions, the
possibility of repeated disinfection, which may affect quality.
 Immediately after removal from the mouth, rinse the device under clean running
water until it is visibly clean.
 Disinfect the device using cleaning materials specified by the manufacturer, then
rinse the device. This process should occur before and after any device is placed in a
patient’s mouth.
 If the device is to be returned to a supplier/ laboratory, a label to indicate that it has
been disinfected should be affixed to the package.
Infection control 12
 Treatment areas
The layout of the surgery should be simple and uncluttered with distinct areas for
the operator and the dental nurse, each with a washbasin. The washbasins should
have sensor-controlled of elbow/foot-operated mixer taps and dispensers for
antimicrobial hand-wash solutions, liquid soap and hand rub/gel.
Work surfaces and floor coverings should be impervious and easy to clean and,
where possible, without joints. If present, joints should be sealed. Coving between
the floor and wall will help prevent accumulation of dust and dirt. The
manufacturer’s advice should be sought on the compatibility of detergents and
disinfectants.
Surfaces can be cleaned using commercial bactericidal cleaning agents and wipes.
If water with a suitable detergent is used, you should dry the surface after cleaning.
Do not refill disinfectant spray bottles as bacteria can contaminate the bottles and
grow in the spray mechanisms. Such bottles, whether supplied pre-filled or empty,
should be single use.
Defining the areas that become heavily contaminated during operative procedures
(zoning) will simplify decontamination: work surfaces, dental chair, curing lamp,
inspection light, hand controls, spittoons, and aspirator, for example. Light and chair
hand controls can be protected with disposable impervious coverings and changed
between patients or the controls cleaned.
At the end of clinical sessions, clean all work surfaces using disposable cloths or
microfibre materials, including the taps, drainage points, splashbacks, cupboard
doors and sinks. Aspirators, drains and spittoons should also be cleaned, following
the manufacturers’ instructions.
Computer keyboards should be washable or have covers that can be easily
decontaminated.
© BDA August 2017
Water supplies
Legionella
All businesses must assess the risks from legionella and prepare a course of action
for preventing or controlling the risk; you must have competent help to do this. The
HSE publication Legionnaire’s Disease: the control of legionella bacteria in water
systems (L8) provides further information.
Dental unit water lines (DUWLs)
The majority of dental units harbour biofilm – a source of microbial contamination
for the water produced by the unit. Contaminated water may harbour potentially
pathogenic organisms such as Legionella spp and Pseudomonas aeruginosa and is
a potential hazard to both patients and surgery staff. Further information can be
found in BDA advice Contaminated dental unit waterlines.
Blood spillages
Use hypochlorite at 1000 ppm available chlorine for cleaning blood spillages.
Solutions of hypochlorite can be made up freshly using hypochlorite-generating
tablets and should be used within a week. The hypochlorite solutions should be in
contact with the spill for at least five minutes.
Hypochlorite at a higher concentration of 10,000 ppm available chlorine is useful
for blood contamination. You should start the decontamination process quickly and
avoid corrosive damage to metal fittings etc. Do not use alcohol in the same
decontamination process
Infection control 13
 Appendix 1: Common infections
Herpes Simplex
Herpes simplex virus type 1 (HSV-1) is usually associated with infections of the lips,
mouth and face. It is the most common virus and is usually associated with
childhood. HSV-1 often causes lesions such as cold sores in and around the mouth
and is transmitted by contact with the lesion and infected saliva. By adulthood, up
to 90% of individuals have antibodies to HSV-1. The herpes virus can reside in the
body for years, appearing only as a cold sore when something provokes it, for
example, illness, stress, hormonal changes and sun-exposure. Individuals usually
experience a tenderness, tingling or burning before the actual sore appears, initially
as a blister which subsequently crusts over.
All stages of a herpes virus infection can be contagious although fluid-filled vesicles
are much more infectious than other stages of the herpes infection. Ideally, dental
treatment should not be undertaken but the decision lies with the individual
clinician – bearing in mind that:
 The herpes simplex virus is highly infectious and easily transmitted
 Manipulation of the facial and oral tissues can exacerbate the condition and cause
breakdown of the lesion and bleeding
 Spread of the virus to other areas of the skin can cause significant problems (new
primary lesions, for example); infection of the eyes is a rare but significantly serious
complication.
A patient requiring urgent dental care should not be denied it but, until the herpetic
lesions are healed, the dental team should take care to prevent the spread of the
virus. Reactivation of oral herpes can occur within three days of major dental
treatment (root canal treatment or surgery, for example). Dental treatment may
also cause intraoral recurrent herpes in the oral soft tissue (mucosa) adjacent to the
teeth.
Children are particularly vulnerable before they develop antibodies to HSV-1, so
extra care must be taken to avoid spreading the virus to other areas of the child’s
mouth and face. Gloves, mask, and eye protection are essential when treating a
child with an active infection.
© BDA August 2017
Influenza
Influenza is a respiratory illness characterised by rapid onset of a wide range of
symptoms including fever, cough, headache, sore throat and aching muscles and
joints. It has an average incubation time of two to three days and people are most
infectious soon after they develop symptoms.
Transmission is through close contact with an infected coughing or sneezing person.
Hand washing (with soap and water or alcohol handrub) and environmental
cleaning will deactivate the virus and help control spread through contact.
The main measures for containing the infection include:
 Standard infection control measures and droplet precautions
 A ‘stay at home’ approach for anyone with flu-like symptoms
 Separating flu-infected patients from well patients when dental care is needed
 Preventing symptomatic visitors (accompanying well patients, for example) from
attending the practice.
MRSA
No additional infection control precautions are necessary for the dental treatment
of patients colonised with Meticillin-resistant Staphylococcus aureus (MRSA).
However, members of the dental team known to be colonised with MRSA should not
undertake or assist with invasive procedures. A clinical microbiologist or
communicable disease physician will be able to provide treatment to eradicate the
MRSA colonisation.
Infection control 14
 Appendix 2: National quality standards Expert Solutions templates
The following templates relevant to this advice, are available online:
CQC inspections
The CQC will assess a dental settings against the code of practice on the prevention  Cleaning schedule example
and control of infections. The main purpose of the Code is to ensure that registered  Decontamination of laboratory items protocol
providers understand requirement for cleanliness and infection control and how to  Hand hygiene policy
comply. It also provides compliance guidance for the CQC and information for  Hepatitis B vaccine response letter
patients, commissioners and the public. Appendix B of the Code provides examples
 Infection control policy
of how the requirements might apply in dental practices.
 Infection control self-assessment audit
HIW inspections  Inoculation injuries policy
 Manual cleaning policy
Healthcare Inspectorate Wales undertakes inspections of NHS dentists and dentists  Moving instruments to and from an LDU protocol
providing private care (or both). Inspections are carried out at least every three
 Selecting new equipment protocol
years by an experienced HIW inspection manager and an external reviewer (a
dentist). The inspection will consider how practices meet the National Minimum
Standards to provide safe, quality standards. Inspectors will look for evidence of
compliance and availability of documents.

RQIA inspections
RQIA assess practices against the minimum standards for dental care and
treatment to ensure patients are not exposed to risks, including the risk of infection:

 The premises are clean

 The practice adheres to the appropriate infection control policies and procedures, in
line with current best practice and legislation
 Systems are in place, including induction and on- going training, to make sure these
policies and procedures are known, and are being appropriately applied to at all times
 The practice meets current best practice guidance on the decontamination of
reusable dental and medical instruments
 Where required, patients are informed about the need for procedures designed to
prevent and control infection
 The dental team meets CPD requirements in relation to disinfection and
decontamination.

© BDA August 2017 Infection control 15