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Protocol for
Infection ControlIn Dentistry
Policy Consistency GroupDate Approved 28/09/2009
Quality and Safety Committee 30/10/2009Date Ratified
Clinica
l
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Please read this protocol and sign your name below.
I confirm that I have read and understood the Infection Control in Dentistry Protocol.
Name (please print) Designation Signature Date and Time
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Contents Page no
1. Introduction 1
2. Scope.. 1
3. Roles and responsibilities 1
4. Standard Precautions... 2
5. Known Carriers of Blood Borne Viruses 2
6. Personal Protective Equipment 2
7. Aerosol and Splatter... 3
8. Surgery Cleaning Protocols 3
9. Use of Disposables. 4
10. Instrument Decontamination. 5
11. Sterilization... 7
12. New Instruments 8
13. Aseptic Storage.. 8
14. Decontamination of equipment prior to repair 8
15. Waste Disposal.. 8
16. Safe use and disposal of sharps...... 8
17. Training. 9
18. Communication 9
19. Monitoring. 10
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1. IntroductionEffective prevention and control of healthcare associated infections has to be
embedded into everyday practice and applied consistently by everyone.
It is particularly important to have a high awareness of the possibility of HCAI inboth patients and healthcare workers to ensure early and rapid diagnosis.
Effective action relies on an accumulating body of evidence that takes account ofcurrent practices. Together with this evidence multidisciplinary working between the
Dental department and the Infection Prevent and Control Team is essential.
Provider Dental services must be represented on the South Staffs Primary CareTrust Infection Control Group and report back on Infection control anddecontaminations practices which may impact on patient care and to also carry outtrend analysis for infections and compliance with audit programmes.
Working with the Infection Prevention and Control Team, Dental Managers and
senior Dental nurses must ensure that staff directly and in directly concerned withpatient care receive suitable and sufficient information on and training in themeasures required to prevent and control risks of infection, this programme ofeducation and information must be designed in collaboration with the InfectionPrevention and Control team.
All staff should be aware of infection control procedures and understand why theyare necessary. New staff must be appropriately trained before undertakingdecontamination duties.
All dental staff working in a clinical environment are reminded of the main risks ofinfection i.e. through sharps injuries, aerosol spray from high speed hand pieces,triple syringes, ultrasonic scalers and the routes of infection through eyes, mouth,nose and skin abrasions.
Infection Control needs to include all aspects of dental practice from attention topersonal hygiene- hand washing, masks, protective clothing to the cleaning andsterilization of instruments and maintenance of the equipment(HTM 01-05 Decontamination in primary Dental Care April 2009)
HTM01-05 requires that all dental practices have an infection control policy
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This protocol should be used in conjunction with the PCT Infection Control Policiesand HTM 01-05: Decontamination in Primary Dental Care.
3. Roles and ResponsibilitiesLocal Decontamination LeadThe decontamination lead for PCT Provider Services is the Head of Operations.The Clinical Director Dentistry is the local decontamination lead for the SalariedPrimary Dental Care Services (SPDCS) and has overall responsibility for managingInfection Control in Dentistry for the PCT SPDCS, the standards required by HTM01-05 and PCT Infection Control Policies.
Designated PersonsThe local management of decontamination and infection control within the PCTSPDCS dental clinics is devolved to senior dental nurses via the SPDCS BusinessManager.
Users and OperatorsDental care professionals are responsible for the use of decontamination equipment
including daily, weekly, monthly testing and housekeeping tasks. All dental staff areresponsible for compliance, and their own practice should be in accordance withnational and local policies, protocols and guidelines.
4. Standard PrecautionsA wide variety of micro-organisms may be present in the saliva and blood of
patients. During dental treatment infection may be transmitted through directcontact, droplets, aerosols or inoculation by contaminated instruments.
These guidelines are based on the recognition that asymptomatic carriers ofinfectious diseases may not be identified as such. The only safe approach is toensure that the infection control procedures are used for ALL patients ALL of thetime; the principle of Standard Precautions.
5. Known Carriers of Blood Borne VirusesPatients with HIV (who are otherwise well) and carriers of Hepatitis and other bloodborne viruses should be treated within the same Infection Control Guidelines for allother patients.
If HIV patients have a raised viral load or are unwell or have subsequently
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Operators and close support clinical staff must protect their eyes against foreignbodies, splatter and aerosols that may arise during operative procedures, especiallyduring scaling (manual and ultra-sonic), the use of rotary instruments, cutting and
use of wires, and during the cleaning of instruments.
Masks and visors/goggles must be worn for all operative procedures to protectagainst splatter. They should be close fitting and of the theatre type.
Disposable masks/visors, if used, must be discarded after every patient, not pulleddown and re-used.
Surgery ClothingTrousers and tunics are the uniform of choice.
Long sleeved tunics are recommended only if exposed skin is cracked or abraded.
All uniforms should be laundered at 60C
Uniforms visibly contaminated with blood/body fluids must be changed immediately.
Uniforms should be changed daily.
Disposable white plastic aprons should be worn when handling all body fluids and inall aspects of direct patient care including cleaning and disinfection procedures(where aerosol is generated).
Aprons must be changed between patients and following cleaning tasks.
N.B. - if aprons are not worn for the tasks then uniforms should only be worn in thesurgery environment and changed before leaving the clinic.
Footwear
Shoes are to be flat or with low heels. Open toed sandals are not recommendeddue to the risk of injury from falling instruments or chemical spillages.
N.B The above protocol may be subject to change following the ratification ofthe PCT uniform policy.
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8. Surgery Cleaning ProtocolsSurgery zoning
A zoning system should be utilised with clean and dirty areas being clearly defined.
To facilitate cleaning, the surgery should be kept simple and uncluttered
All unnecessary items must be removed from the surgery environment
Defining the areas, which may be contaminated during operative procedures is
imperative as these areas should be cleaned and disinfected between patientsusing an appropriate solution or wipe
Clinicians must remember that once their hands become contaminated with bloodor saliva, they must not touch environmental surfaces such as light handles, unithandles, chair controls, mixers and materials, computers, keyboards or telephonesetc.
Surface Cleaning and ProtectionSurfaces should be smooth, impervious and washable.
Prior to session ensure all surfaces areas and equipment are clean and dust free
Surfaces and equipment should be protected from contamination or cleanedcarefully between patients.
All work surfaces, sinks, taps and splash backs including those apparentlyuncontaminated should be thoroughly cleaned at the end of each clinical sessionusing an appropriate bactericidal surface disinfectant.
Blood spills either from a container or as a result of an operative procedure must bedealt with as soon as possible. All clinics have a blood spillage kit available.
All aspirators, drains and spittoons should be cleaned after every session with anon-foaming disinfectant
Records of surgery cleaning must be kept
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The SPDCS has identified the following dental items and instruments as single use:
- all root canal files, reamers and broaches
- plastic impression trays
- matrix bands
- plastic dappens dishes
- plastic suction tubes
- prophy brushes and cups
- plastic saliva ejectors
- steel burs
- toothbrushes
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If an automated and validated washer disinfector or ultrasonic bath is not availableor out of use then instruments should be decontaminated manually.
Cleaning: ManualUse a dedicated dental instrument cleaner (accurately diluted), with a long handledbrush under water to avoid splashing.
Cleaning by hand using a brush should only be done when absolutely necessary.
Brushes should be autoclaved between each use or washed thoroughly after eachuse with hot water and detergent.
Sharp ends of the instruments should be held away from the body
Rinse in clean water
Visually check to ensure all debris is removed.
Lubricate if required
See appendix 2 for details of manual cleaning procedure
Cleaning: Validated Ultrasonic BathAn appropriate cleaner for use with ultrasonic baths should be used in accordancewith manufacturers instructions.
Immerse briefly in cold water and detergent to remove visible debris
Rinse in clean water
Open joints or hinges and immerse fully in ultrasonic bath
Set the timer (according to manufacturers instructions and close the lid).
Do not open lid during cycle.
Rinse in clean water
Visually check to ensure all debris is removed.
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Cleaning: Validated Washer DisinfectorEnsure dental cement is removed
Do not lubricate hand pieces
Place instruments on trays in accordance with manufacturers instructions
Complete the cycle
Lubricate hand pieces after washer disinfector cycle
Washer Disinfectors should also be maintained and tested in accordance withmanufacturers instructions which should be at least to HTM 01-05 requirements.They should be subject to annual, quarterly, weekly and daily testing and the resultsretained in a dedicated log book.
This should include cleaning efficacy and protein residue tests.
See appendix 5 & 6
Any faults or concerns must be logged and reported and the machine taken out ofuse until the fault is identified and rectifiedSee Appendix 4
Movement of contaminated instruments between areasContaminated instruments require safe movement between the treatment anddecontamination areas.
They should be transported in leak proof, easy to clean, rigid containers with aclosable lid.
The containers should be labelled accordingly and cleaned, disinfected and driedafter use.
When contaminated instruments are transported between sites and clinics i.e.during domiciliary visits, data collection programmes etc. the vehicle must carry arecord with the instruments. The record must detail the date, details of the group ofinstruments, the intended destination/recipient and the vehicle details. The noticeshould be attached to the container holding the contaminated instruments
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The autoclave chamber and trays should be cleaned with a damp clean cloth andleft open, to dry overnight.
Autoclaves should also be maintained and tested in accordance with manufacturersinstructions which should be at least to HTM 01-05 requirements. They should besubject to annual, quarterly, weekly and daily testing and the results retained in adedicated log book.
This should include daily tests to check the temperature, pressure and holding time,as well as housekeeping tasks.
See appendix 6
All dental instruments and equipment must be cleaned and sterilized after use asdetailed in A-Z Disinfection and Sterilization Guidelines or in accordance withmanufacturers instructions.See appendix 7
12. New instrumentsNew instruments should be decontaminated prior to use (in accordance withmanufacturers instructions) and decontamination instructions retained.
13. Aseptic storageInstruments should be stored dry and protected from dust, splash or aerosolcontamination in closed or covered trays in closed cupboards or drawers.
Packaging of decontaminated instruments should be carried out in a clean areaaway from contaminated instruments and decontaminating equipment.
Instruments should be used within 21 days of the decontamination process or re-processed before use.
14. Decontamination of equipment prior to inspection service or repairEquipment and articles which have been contaminated by contact with blood orother body fluids must be rendered safe, and a statement confirming thiscompleted, prior to examination by third parties.
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training relating to infection control in dentistry will be provided in addition to this,arranged by the Senior Dental Nurse with a training facilitator role.
Trainee Dental Nurses will be trained infection control measures during theirtraining period with the PCT.
18. CommunicationFrom time to time additions, amendments and policies are issued via the BDA,Department of Health or the PCT. This information will be forwarded to each clinicand added to monthly staff meetings.
The amendments should be read, and signed as read, by all staff and then filed inthe clinics Infection Control File.
New employees will be informed of this protocol at the local induction process.Existing employees will be part of the discussion process in formulating andchanging this protocol.
A member of the dental team will attend PCT infection control meetings and linknurse meetings to provide feedback at the monthly dental team meetings.
19. MonitoringThe implementation of this policy will be monitored through regular service specificaudits and as required by the PCT.
Audits will be registered with the PCT Clinical Audit Department and the results andaction plans shared with the Dental Team
20. ReferencesHTM 01-05 Decontamination in Primary Dental Care April 2009
HTM 2010 Part 3 Validation and Verification- Sterilization NHS Estates
PCT Hand Decontamination Policy CLIN18
PCT Standard Precautions and Personal Protective Equipment Policy CLIN37
PCT Policy for Management of Clinical Sharps Injuries and Exposure to Blood andHigh Risk Body Fluids CLIN24
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Surgery Cleaning ProtocolsAppendix 1
End of session Cleaning Schedule
Date andtime
WorkSurfacesand dentalcartsdisinfected
Drawer andcupboarddoor handlesdisinfected
Chair andlight unitdisinfected
Spittoon, filtersand aspiratorequipmentdisinfected
Sinks andtaps cleaned
Computerand keyboardcleaned
Signed Name anddesignation
Weekly scheduleDate andtime
Re-processall un-datedinstruments
Clean alldrawer frontscupboarddoors
Cleanoperatorstools
Suction/Aspiratormaintenance asrecommended byservice engineer
Compressormaintenance asrecommended byservice engineer
Signed Name anddesignation
Clinic Location Dental Surgery No.
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Appendix 2
Protocol for the Manual Cleaning of Dental Instruments
All personnel involved in the decontamination of dental instruments should be trained in the contentand application of this protocol and associated guidance.
To minimise the risk to personnel undertaking manual cleaning, the splashing and creation ofaerosols should be avoidedat all times.
Remember: Maintaining a dirty-to-clean workflow procedure will assist in the cleaningprocess.
Immersion Method
1. Wash hands.
2. Put on personal protective clothing (PPE)
3. Ensure sinks, equipment and setting-down areas are free from extraneous
items
4. Dismantle and open the instruments, as required, ready for immersion
5. Fill the clean sink (NOT wash-hand basin) with the appropriate amount ofwater and detergent (specified for the purpose). Note: ensure correct
temperature as recommended by the detergent manufacturer is maintained.
6. Fully immerse the instruments in the solution and keep under water during thecleaning process to prevent aerosols.
7. Agitate/scrub the instruments using long-handled brushes with soft plastic
bristles.
8. Drain any excess cleaning solution prior to rinsing.
9. Rinse in clean water.
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Appendix 3
Pre-use log sheet for Ultrasonic Cleaning Bath
Ultrasonic Cleaning Bath Location Make/Model Serial Number
Please undertake the following tests and tasks before using the above piece of equipment or according to manufacturers instructions
Dateand
time
Daily(before use
if not usedrecently)
remove andcleanstrainersand/or filters
Daily(before use
if not usedrecently)
fill reservoirwith freshsolution
After first load ofthe session
visually check firstload to checkcleaning efficacy
Weekly:(before use if not
used recently)
Check condition oflid/door seal
Weekly:(after first load of
the session if notused recently)
Perform a proteinresidue test oninstruments
Name anddesignation
Signed
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FAULT RECORD Appendix 4
Date andtime
Nature of Fault Reported to Reported by Action taken Incidentform
required
Outcome Name anddesignation
Signed
Equipment Type Location Make/Model Serial Number
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Appendix 5
Daily (or before each session) log sheet for washer disinfector
Washer Disinfector Location Make/Model Serial Number
Please undertake the following tests and tasks before using the above piece of equipment or in accordance with manufacturersinstructions.
Dateandtime
Clean allexternalandinternal
surfaces
Checkallfiltersand
spraysarefreefromdebris
Check allhoses andconnectorsare in good
condition
Check doorseal isundamagedand clean
andoperatingmechanismis workingorder
Replenishwatersoftener
Record thepre washtemperatures:use the first
print out ofthe day:
(must startbelow 45c)
Record thedisinfectiontemperatures:use the first
print out ofthe day:
(must stayabove 80c)
Recordthe cyclenumberand
retain theprint out.
Name anddesignation
Signed
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Appendix 6
Weekly/Monthly log sheet for Washer DisinfectorWasher Disinfector Location Make/Model Serial Number
Please undertake the following tests and tasks before using the above piece of equipment orin accordance with manufacturers instructions.
WeeklyTest
Date andtime
Performresidual soiltest usingPro-tect
or equivalent
Name anddesignation
Signed
MonthlyTest
Date andtime
Check allhoses aresecure andno leaks
Check mainspower cordundamaged
Check allinternal partsfor wear anddamage
Name anddesignation
Signed
WeeklyTest
Date andtime
Performresidual soiltest usingPro-tect orequivalent
Name anddesignation
Signed
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Appendix 7
Daily (or before use) log sheet for non-vacuum bench top steriliserSteriliser Location Make/Model Serial Number
Please undertake the following tests and tasks before using the above piece of equipment or according to manufacturers instructions
Date andtime
Cleandoor seal,chamber,shelves
and trayswith aclean,damp nonlintingcloth
Fillreservoirwith freshdistilled,
sterile orRO water
Turn onandrecordcycle
number incolumnbelow
RecordTemperature
RecordPressure
Recordtheholdingtime
Retainprint out(ifavailable)
Name anddesignation
Signed
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Appendix 8
TRANSPORT OF CONTAMINATED DENTAL INSTRUMENTS(Low Biohazard)
Please attach this notice to the container holding the contaminated instrumentsin your vehicle
Retain this record in your local clinic
Date ofTransport
Vehicle Registration No. Destination of Instruments Contact telephone number
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Appendix 9
Appliances
orthodontic andprosthetic
Rinse under clean running water until clean.
Use an appropriate disinfectant according to manufacturers instructions.
Rinse thoroughly.
If returning to laboratory ensure a label is attached to indicate that a decontamination process has taken place
Burs Steel burs -disposable,
Diamond -pre-clean then autoclave
Tungsten Carbide -pre-clean then autoclave
Acrylic Trimming Burs -pre-clean then autoclave
Bracket tables
Cover surface and use disposable instrument trays Clean with detergent/disinfectant wipe between patients
Do not use alcohol based products on stainless steel.
DentalCabinetry
Wipe cupboard doors, drawer fronts and handles at the end of each session with a detergent/disinfectant wipe
Do not use alcohol based products on stainless steel.
Dental chair
(includingcontrols)
Wipe and dry after each patient with detergent or disinfectant wipe.
Do not use alcohol based products on stainless steel.
A - Z DECONTAMINATION GUIDELINES
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DentalInstruments
including handpieces
Clean (using a validated process)
Inspect
Autoclave and inspect again
Dry Store in clean, dry covered conditions.
N.B Use within 21 days or re-process
Hand pieces
using
manual cleaningor ultrasonic bath
In addition to above:
Leave bur in place during cleaning to prevent contamination of hand piece bearing
DO NOT IMMERSE IN WATER
Remove bur
Lubricate hand piece with pressurised oil as recommended by the manufacturer, until clean oil appears out of thechuck;
Clean off excess oil
Sterilise in autoclave
If post sterilization lubrication is required then either separate canisters must be used or the nozzles changed.
Run hand piece briefly with bur in place before use, to clear excess lubricant.
Hand pieces
using a washerdisinfector
Clean outside of hand piece
Remove bur
Do not lubricate
Place in the displacement device in the washer disinfector
Lubricate before placing in the autoclave
If post sterilization lubrication is required then either separate canisters must be used or the nozzles changed. Run hand piece briefly with bur in place before use, to clear excess lubricant
Impressions Rinse under clean running water until clean.
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Use an appropriate disinfectant according to manufacturers instructions.
Rinse thoroughly.
If returning to laboratory ensure a label is attached to indicate that a decontamination process has taken place
Instrumentcontainers
Clean with detergent, rinse and dry (Do not use sodium hypochlorite)
Light cure Tip Pre-clean and autoclave or protect with a plastic disposable cover (Check manufacturers instructions)
Matrix bandholders
Remove used band before decontamination process
Operating lights
Clean after each patient with a detergent/disinfectant wipe.
Do not use alcohol wipe on stainless steel parts.
Spittoon Flush between each patient and clean with detergent/disinfectant wipe
Do not use alcohol based products on stainless steel.
Remove debris from the trap at the end of the session and system clean according to manufacturersrecommendations
Sinks Clean at the end of each session with cream cleaner and detergent wipe and leave dry.
Do not use alcohol base wipes or solution on stainless steel sinks
Suction
apparatus
Aspirator tubing and drainage system should be cleaned at the end of each sessions according to manufacturers
instructions
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(Or dispose of if single use)
Water Bottles Empty residual water at the end of each session.
Rinse with sterile water.
Leave a little clean water in the bottom of the bottle to prevent air locks.
Before use empty remaining water
Rinse again and re-fill with sterile water.
Water lines Flush for at least 2 minutes at the beginning and end of each day and flush for 20-30 seconds between each patient.
Work surfaces Clean with detergent/disinfectant wipe between each patient and at the end of the session