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home > about > cross infection control policy
The mouth carries a large number of potentially infective micro-organisms. Saliva and blood are known vectors (carriers) of infection and both can be transferred from the mouth to instruments, hands, etc during dental treatment. It is therefore essential that we operate cross infection control procedures to minimise the risk of infection passing from patient to patient; or from patient to team members or vice versa. The practice operates thorough, universal cross infection control procedures. These procedures are “universal” because they apply equally to all patients and personnel. Additional precautions are only taken when patients or team members are known to be high-risk because they are carriers (or in some cases likely to be carriers) of certain infectious diseases (see below). This document contains the practice’s written cross infection control policies and procedures. Additional detail is also given in the relevant “checklists”. Cross-references are given where appropriate. All members of the dental team (both clinical personnel and others) are expected to know and routinely observe all cross infection policies and procedures. It is the responsibility of individual practitioners (ie dentists and hygienists) to ensure that these procedures are followed in the surgeries. They must monitor themselves and their DSAs to check that this is done. Failure to employ adequate methods of cross infection control may result in the General Dental Council bringing proceedings for misconduct against a dentist or hygienist. If any member of the dental team is uncertain about any aspect of cross infection control, they are required to seek clarification from the clinical director or practice director immediately. Cross infection control is discussed at practice meetings. All members of the team are encouraged to contribute their observations and ideas to ensure that cross infection control policies and procedures are operated correctly and efficiently and that improvements are made where possible. training a) appropriate training for all new personnel prior to working unsupervised or unassisted in the
surgeries* * New clinical personnel must, of course, work in the surgeries in order to be properly trained. However, they must either shadow or be shadowed by a member of the team (this can include the dentist themselves – it need not be an additional DSA) who has been trained in cross infection control procedures. This will continue until the dentist with whom they are training is satisfied that they are competent in these procedures. New members of the team are also required to study the practice’s written cross infection control policies and procedures. immunisation requirements Clinical personnel must, when asked to do so, provide (or authorise their GPs to provide) written confirmation to the practice that their immunisation is still current and the practice keeps written records of this. Records of immunity are reviewed and team members are issued with reminders to update their immunity or to have their immunity checked as appropriate. infected clinical personnel If infection is confirmed, they must notify the clinical director or practice director immediately. This information will be treated in the strictest confidence, as are all matters relating to the health of individual team members. The practice will seek advice from an appropriate agency on the necessary steps to be taken. Appropriate agencies may include the General Dental Council, British Dental Association, Dental Defence Union, Department of Health, Area Health Authority or Trust or any other competent body. It may be necessary for the team member concerned to cease working in the clinical environment (ie surgery). If this occurs, the team member concerned will (whenever possible and in accordance with practice staffing and operational requirements) be offered the opportunity to retrain to fulfill other non-clinical functions within the practice. treatment of high-risk patients Man of the high-risk patients that we treat probably do not tell us that they are carriers of such a disease, so we are unaware that they are high-risk. This is not necessarily because patients deliberately conceal these facts from us but far more likely that they do not themselves know that they are infected. Many serious diseases do not cause the patient to suffer any symptoms for a very long time and even when symptoms do appear, it may take some time for the disease to be diagnosed. However, such a person is a “carrier” of the infection and may be capable of passing it on to others. This is why we operate thorough universal cross infection control procedures for all patients. Everyone who enters the surgery for treatment is a potential source of infection to others in the surgery – both to other patients and the dental team alike. However, where we know that someone is high-risk, it is logical that we take additional precautions. The most effective precaution is to treat the person at the end of the working day. If they are the last patient of the day then they are being treated immediately before the surgery receives its most comprehensive cleaning of the day – the “closing down” procedure (see DSAs’ checklist 2). This further reduces the risk of any infection being passed from the high-risk patient to the next patient treated in that surgery. Where a patient is in a high-risk group for new variant CJD, further precautions are taken. New variant CJD is transmitted from one person to another by Prions, a type of protein. Prions are very difficult to neutralise. However, according to recent guidance from the Department of Health, Prions can be denatured by repeat autoclaving. We ensure that all re-usable instruments that have been infected or potentially infected with bodily fluids from a patient who is in a high-risk group for new variant CJD are cleaned separately from our other instruments. They are cleaned manually and in the ultrasonic bath in the usual way before autoclaving. The solutions used to clean them are discarded (as they will be anyway since the patient is treated at the end of the day). The instruments are then autoclaved at maximum temperature (134 degrees Celsius) six times. Other universal cross infection control procedures are followed in the usual way. Admission of carrier status by a patient is always subject to the strictest confidentiality. We will not refuse to provide dental care to a patient solely because they are known or suspected to be a carrier of an infectious disease. opening the surgery zoning To minimise the risk of infection being passed from one patient to another, each surgery is divided into “clean” and “dirty” zones. The dirty zones are those routinely used or touched in the course of treating patients. Of course, the dirty zones do not stay dirty. Dirty zones are only dirty while “in use” (i.e. while the dentist is working on a patient in the chair). They are cleaned between every patient, whether or not they appear to be contaminated – remember, you can’t see bacteria and viruses. The dirty zones are identified in DSAs’ checklist 3 as those that must be cleaned between every patient. Gloved hands are a dirty zone once a team member begins to participate in patient treatment. Discarding and replacing your gloves is the only reliable way to make your hands clean again. The clean zones in each surgery are: a) on top of the autoclave By observing the following rules we therefore eliminate some of the possible pathways by which infection can be spread from one person to another: a) We never touch a clean zone during treatment of a patient. For example, if we find that an additional
instrument or material is needed during the course of treatment, we DO NOT open a drawer or cupboard to
get it unless we have first removed and discarded our examination gloves. The gloves are dirty. The drawer
and cupboard handles are clean. They must not meet. Removing potentially contaminated gloves removes the
risk of contamination being passed to a clean zone (that isn’t necessarily cleaned between patients) and
therefore to the next patient. Alternatively, we may use a clean pair of tweezers to open the drawer,
pick up what we need from the drawer and place it where we need it; the same tweezers are used to close the
drawer again. use of gloves, masks & eye protection
a) an effective barrier to the passage of infection from patients to the dental team and vice versa; While examination gloves are thin and easily perforated by sharp instruments they still help to protect team members from infection through inoculation injuries (i.e. sticking themselves with a used needle or instrument). This is because as the needle or other sharp object passes through the glove, the latex “wipes it clean”, removing the majority of any potentially infected material. It is important not to underestimate the protection that gloves provide just because they are thin. Nonetheless, dentists should where possible wear two pairs of examination gloves while carrying out minor oral surgery procedures. Recent studies show that about 16% of examination gloves are perforated during minor oral surgery. Double-gloving gives additional protection to the hands. Furthermore, by throwing away gloves after treating a patient and putting on a clean pair, we ensure that we have truly “clean hands” each time we begin work on another person. Simply washing hands with soap or disinfectant between patients does not make them completely clean (in any event, hand washing can cause skin problems if it is done too frequently). It is better to cover the hands with a thin membrane like an examination glove and to throw it away after use. This makes sure that any bacteria, viruses, etc. that got onto our hands from the last patient do not find their way to the next. All clinical personnel wear a clean pair of examination gloves while working on, or assisting with work on, a patient. These are discarded (by placing them in the clinical waste bin) when that patient’s appointment ends. A clean pair is put on before work begins on the next patient. It is not acceptable to wash or clean the gloves between patients: they are thrown away. Gloves worn while cleaning the surgery are also potentially contaminated and are removed, discarded and replaced with a clean pair before a team member begins to assist with the treatment of a patient. We never wear our examination gloves outside the surgery. If we have to leave the room during treatment, we remove our gloves and discard them. We put on a fresh pair when we re-enter the room and before continuing to work on, or assist with work on, a patient. Once treatment has begun, we never go back into cupboards or drawers for additional materials or instruments while still wearing our gloves. We do not even open a drawer or cupboard with our gloves on – since this may contaminate the handle and if it is touched again later, spread an infection. Generally, all necessary instruments and materials will have been laid out before work begins. However, if something is forgotten or if a procedure changes part way through so that additional instruments and/or materials are required, we remove and discard our examination gloves before reaching into drawers or cupboards. We put on a clean pair of gloves, take out what we need and continue with the treatment (alternatively, we may use tweezers – see “zoning”, above). Drawers and cupboards are clean zones (see above) and must never be touched with dirty gloves. Cuts and abrasions on our hands and arms are covered with waterproof plasters. Jewellery and watches are not worn during clinical sessions. Hands are washed before donning gloves using an alcohol-based surgical hand disinfectant (Desderman "N"). Hands are also moisturised regularly during the working day. Personnel who experience any skin reactions to their gloves, are required to inform the clinical director or practice director immediately.
The heavy-duty gloves are thicker and stronger than examination gloves and offer significant protection against inoculation injuries. However, sharp clinical instruments can still perforate these gloves. If the gloves become perforated, it is the responsibility of the person wearing them at the time to discard them and replace them with a new pair from the stock cupboard. The heavy-duty gloves are used because it is widely recognised (and this is confirmed by our own experience at the practice) that the most likely time for a member of the dental team to suffer an inoculation injury is while they are cleaning dirty instruments. This is also one of the worst times to suffer an inoculation injury because it is likely that the object is contaminated with biological material (though it is, of course, far from certain that this will cause any harm). It is therefore mandatory for all members of the clinical team to use these gloves when cleaning dirty instruments. After use the gloves are cleaned and disinfected. The heavy-duty gloves are never used in place of examination gloves and vice-versa. We do not pick up a hand full of instruments at the same time; for example, when emptying the wash basin or ultrasonic bath. We pick them up individually. This further reduces the risk of an inoculation injury while cleaning instruments. Heavy-duty gloves may be worn in place of examination gloves when handling irritant chemicals, but we thoroughly rinse and disinfect the gloves afterwards.
Dental treatment inevitably results in the release of biological material into the surgery air. For example, the use of dental burrs creates a fine aerosol spray that can carry bacteria, etc. Masks help to reduce the amount of this aerosol being breathed in by the dental team. Aerosols are also removed from the surgery air by the air conditioning system. The air conditioning units in each surgery are fitted with special “bio-filters” that remove tiny particulates from the air as small as individual bacteria. We do not open surgery windows because this reduces the effectiveness of the air conditioning system and allows contamination (insects, dust, air borne microbials, etc) to enter the surgery environment. Nonetheless, we always wear a mask when a patient is being treated. We do not wear our masks on our faces outside the surgery. The appearance of clinical personnel wearing masks outside the surgeries can be intimidating for patients, so we take our masks off or pull them down around our necks before leaving the room. We change our masks regularly during the day - and always remove and discard masks that have become contaminated with blood, etc. Personnel who develop skin reactions to their masks are required to inform the clinical director or practice director immediately.
a) improve cross infection control by protecting the eyes from spray and other biological debris
(called “dental splatter”) leaving the patient’s mouth The spectacles are worn by all members of the dental team and by the patient at all times during treatment. They are put in place before any work begins. They are also worn by members of the dental team while cleaning the surgery or sterilising instruments. Dentists need not wear the protective spectacles when working with magnifiers. Similarly, any member of the dental team who wears prescription glasses need not wear the protective spectacles in addition to these, but they must ensure that side shields are fitted. If in doubt, they must speak to the clinical director or practice director. The spectacles are re-usable and are cleaned and disinfected between every patient. This also applies to prescription glasses. We never wear our protective spectacles on our faces outside the surgery. Aside from considerations of cross infection control, the appearance of clinical personnel wearing protective spectacles outside the surgeries can be intimidating and worrying for patients, so we take them off and set them down before leaving the surgery. Magnifiers (loupes) with fibre optic illuminators do not need to be removed by the dentist or hygienist every time they leave the room, but they should be taken down off the face and worn around the neck while not in use. clinical dress code
food use of rubber dam Recent studies have demonstrated that the use of rubber dam during dental treatment reduces quantity of aerosols produced. The number of culturable bacteria on surfaces in the surgery falls by over 90%. dental unit water lines Accordingly, hygeia uses a system called Alpron to kill these micro-organisms and break up the biofilms they will otherwise form. This ensures that the water flowing through the dental units is of an acceptable quality. The Alpron system works by periodic flushing of the dental unit water lines and the use of specially formulated chemicals to remove, and inhibit the formation of, biofilm. cleaning between patients sterilisation of instruments We assume that all new re-usable instruments are dirty/contaminated and must be sterilised before use, regardless of who supplied them. All disposables are supplied clean, so we do not sterilise them. If they are obviously dirty or contaminated, we throw them away (unless a large quantity or batch appear to have been supplied contaminated, in which case they are passed to the practice director who may then return them to the supplier or dispose of them, as appropriate). If we are uncertain as to whether an instrument is sterile, WE DO NOT USE IT. If it is re-usable, we sterilise it again. If it is disposable, we throw it away (unless a large quantity or batch appear to have been supplied contaminated, in which case they are passed to the practice director who may then return them to the supplier or dispose of them, as appropriate). Before beginning to clean any instruments, we put on an apron and heavy duty gloves. We keep our safety spectacles on, too. We take great care when handling dirty instruments – particularly reusable sharps: refer to the guidance in the section above titled “heavy duty gloves”. We always ensure that instruments being sterilised move in the same direction:
We always make sure that instruments move in the same direction and never vice-versa because then the paths of clean and dirty instruments do not cross. If they did, it can result in cross infection between patients. Used instruments are often heavily contaminated with blood, etc. and must be cleaned by immersion in the ultrasonic bath before autoclaving (nb – not hand pieces – see below). The ultrasonic bath is kept three-quarters full with detergent (not disinfectant) solution. When it becomes dirty, we replace it. The solution is changed at least once every day (more often if it becomes too contaminated). The bath is emptied, cleaned and left to dry at the end of every day – refer to DSAs’ checklist 2 and DSAs' checklist 3. We always use the basket in the bath to hold the instruments (it does not matter if small items like burrs fall through the mesh). The timer is set to five minutes and the bath switched on. When it has completed its cycle, we remove the instruments and rinse them in clean water to remove the cleaning solution. After cleaning the instruments in the ultrasonic bath, we make a visual inspection to ensure that all debris have been removed. If any of the instruments are still dirty, we scrub them in detergent (not disinfectant) in the DSAs’ wash basin. We use a long handled plastic brush for this (nb – we do not immerse hand pieces – see below). Once we have removed any gross debris from the instruments, they are placed onto metal autoclave trays. A piece of autoclave indicator tape is attached to one of the trays in each load. We place the trays inside the autoclave, close the autoclave door and press the uppermost program selector button (134 degrees Celsius, without drying cycle). When the autoclave cycle is finished, the door is opened. The operator must be very careful not to put their hands or arms above the door as they do this or immediately afterwards since the escaping steam may burn. We make sure that the escaping steam has subsided before reaching above/on to the top of the autoclave. The trays of instruments are removed from the autoclave using the plastic tray carrier handle provided. The trays are placed on top of the autoclave. Then we check that the autoclave indicator tape has changed colour – if it has not, the autoclave may not be functioning correctly. In this case, the clinical director or practice director are informed immediately. The autoclave is not used again until it has been confirmed (by an engineer, if necessary) that it is safe to do so. The trays of instruments that have just been put through the autoclave are sterilised again using the autoclave in the other surgery. When the sterilised instruments have cooled, they are put away in their normal places. Sterilised instruments are not left on top of the autoclave (or anywhere else) after they have cooled. When instruments need to be sent away for servicing or repair (eg hand pieces or ultrasonic tips) they must be sterilised before dispatch. When autoclaving these instruments, we wrap a piece of autoclave indicator tape around each one. This helps to identify the instrument that needs to be sent away (so that it is not mixed up with the others). It also confirms that the instrument has been sterilised. The instruments are passed to the practice director for dispatch to the relevant maintainer/repairer. The practice director will ensure that the instruments are dispatched with relevant documentation to confirm that they have been sterilised. cleaning and lubrication of hand pieces Next, the burr is removed from the hand piece and set it aside. The hand piece is connected to the Assistina and the cycle is started. The Assistina is always allowed to completely finish its cycle before the hand piece is removed – otherwise the instrument may not be thoroughly lubricated, resulting in damage. Next, the hand pieces are placed on an instrument tray and put into the autoclave. They are autoclaved on the high temperature program (134 degrees Celsius) but we DO NOT use the drying cycle. Use of the drying cycle can cause the temperature to far exceed 134 degrees and cause the oil to bake inside the hand pieces. This will result in damage to the bearings. Hand pieces are very expensive to repair or replace. There are laminated W&H (manufacturer's) hand piece lubrication and sterilisation guides next to the autoclave in each surgery. Before using a clean hand piece, we run it (with the water spray switched on) into the sink for a few seconds. This removes excess oil that may have been introduced during the cleaning process. When attaching clean hand pieces to their outlets at the beginning of each working day or removing them at the end of the day, we run the hand piece (with the water spray switched on) into the sink for 1 minute. This significantly reduces any overnight accumulation of microbials in the water lines. sharps To pass an unsheathed sharp instrument to someone else, always hold it with the sharp surface toward yourself and the handle/blunt surface toward the person you are handing it to. The practice no longer uses disposable needles. We use a disposable syringe system instead. This is because recent research has proven that the disposable syringe system is much safer in that it practically eliminates preventable needle-stick (inoculation) injuries, which are one of the most common causes of injury to clinical personnel. Full instructions for the use and disposal of Safety Plus disposable syringes can be found on the practice computers. There are both short and long form versions – either may be used. If in doubt about the use of the system, DSAs must ask the dentist or hygienist they are working with. For guidance on handling re-usable sharps during cleaning, see also the section on heavy-duty gloves (above). procedure for inoculation injuries It is essential that inoculation injuries are dealt with promptly and correctly. If the skin is punctured with a contaminated sharp, wash the injury with soap and water but avoid scrubbing the wound. The wound must then be encouraged to bleed freely and cleaned again under running water. Dry the wound, apply disinfectant and a dressing. If the eyes are exposed, flood them with plain water. If there is reason to be concerned about the transmission of infection, the clinician supervising the surgery at the time must inform the clinical director or practice director immediately. This applies where, for example, the patient whose bodily fluids caused the contamination is known or suspected to be a carrier of an infectious disease or is in a high-risk group. The clinical director or practice director will seek guidance from an expert in communicable disease control on appropriate post-exposure prophylaxis and serological surveillance. If the clinical director and practice director are absent, this responsibility falls to the clinician supervising the surgery at the time. The Primary Care Trust has a designated specialist - contact the offices at Shinners Bridge, Dartington 01803 866665 or Torbay Hospital 01803 614567. Alternatively, advice can be obtained from the duty doctor at the PHLS Communicable Disease Surveillance Centre, 61 Colindale Avenue, London on 020 8200 6868. All inoculation injuries are recorded in the accident report book, which is kept at reception. There are notes inside the front cover of the book confirming what must be recorded. We record not only the name of the person who is the recipient of the inoculation injury but also the name of the person who was the source of any infected material, if known. prosthodontic appliances and impressions Impressions are cleaned under running water to remove saliva, blood and debris until it is visibly clean. What happens next depends on the type of impression material being used:
Appliances are cleaned under running water and then soaked in dilute bleach for 10 minutes. They are washed under running water again before despatch to the laboratory. If they are grossly contaminated, appliances (not impressions) are be cleaned in the ultrasonic bath and rinsed in clean water before soaking in bleach. The bleach solution to soak appliances or impressions is prepared as follows: 5% bleach is diluted 1:5 with water; 10% bleach is diluted 1:10 with water. Fresh solution is made up every day. clinical waste The practice produces a variety of different types of waste, many of which may be contaminated, and all requiring different disposal techniques. This is a complicated area and so a separate written policy is devoted to it – refer to the practice waste disposal policy. The golden rule is this – all waste produced in the surgeries is potentially contaminated and must be treated as such. No waste produced in the surgeries, of whatever kind, is discarded with the normal commercial waste. closing down the surgery spring cleaning Important Notice: Remember that the advice and information in this website is not intended to be a substitute for a visit to your own dentist - always seek the advice of a dental professional. The advice and information is provided for your interest and entertainment only. Hygeia cannot accept responsibility for any loss, damage or injury arising from reliance on the advice or information in this website. |
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Cross infection control