II. BEFORE PATIENT TREATMENT

A. Medical History

A thorough medical history from patients will always be obtained and reviewed. It should be updated at each subsequent visit. Specific questions may be included concerning medications, current and recurrent illness, unintentional weight loss, oral soft tissue lesions, lymphadenopathy, other infections, history of hepatitis and alcohol/drug abuse, coughing lasting more than 2 weeks (T13), etc.

B. Personal Protective Equipment (PPE)

Techniques that are used to interfere with the initial step in the infectious disease process are called barrier techniques. These protective barriers include gloves, masks, eyewear, and protective clothing.

1. Gloves

Handwashing is considered the most important single procedure for the prevention of cross-contamination. However, blood has been found under the fingernails for periods up to five days. Therefore, gloves are a necessity even with proper handwashing. Refer to Appendix A.

A surgical scrub is recommended with rapid antimicrobial activity plus residual action as the initial scrub of the day. Hands will be washed and dried well after removing or changing gloves. A lotion may be necessary 3 or 4 times a day to prevent chapped hands. Preferably a lotion low in microbes, no petroleum base, and non-sticky after applying. All jewelry should be removed and nails kept short in order to prevent punctures in the glove material.

Gloves should fit the hand snugly but allow the hand to move comfortably. Gloves will be changed for every patient, when they become tacky or damaged, or every hour, whichever comes first,- nor will gloves be removed and re-donned for the same patient.

If breaking the aseptic chain, such as acquiring supplies or exposing radiographs, a pair of overgloves may be donned and removed before resuming procedures. Gloves will be removed or covered with an overglove before handling a patient's chart. Exam gloves should not be worn out of the treatment area unless covered with overgloves.

2. Masks

The highest concentration of microorganisms in dental aerosols are found 2 feet in front of the patient. When aerosols or splatters are being generated, it is necessary to wear a mask even if wearing a face shield. The mask should be routinely changed every hour, or more frequently in the presence of heavy aerosol contamination. The mask will be put on while the hands are clean and before gloving for the patient. It should fit over the ridge of the nose so that the glasses will fit over the top edge of the mask to reduce fogging. The mask should not be handled during dental procedures.

Face masks with layers achieve the highest filtration. The mask should not fit flat on the face but should fit close around the edges. Do not wear the mask on the neck or forehead.

It should be remembered that masks are also necessary during pre and post-operative cleaning or when generating dust such as trimming models. If lasers are used in the practice, higher filtration type masks are needed.

3. Protective eyewear

Debris ejected toward the operator while performing dental procedures may contain large concentrations of bacteria or can physically damage the eyes. Protective eyewear with side shields is necessary for most dental procedures. If prescription lenses are worn, side shields can be added to the frames or goggles worn over the glasses.

Eyewear should be able to tolerate cleaning. Eyewear that has both side shields and a top shield offer the most protection. A face shield may be worn in place of glasses but it does not replace a mask.

Protective eyewear is also recommended for the patient. All eyewear should be cleaned with soap and water and should not be handled during dental procedures.

4. Clothing

Clothing worn by dental personnel can become contaminated from aerosols and splatters during dental procedures. Protective clothing is chosen according to the anticipation of splash and spatter. In some cases, short sleeves would be appropriate. The idea is that the skin will not come into contact with body fluids. The protective clothing should I be changed at the end of the day or when visibly soiled. Contaminated clothing should not be worn out of the clinic.

At the end of the day, the contaminated protective clothing will be placed in the designated container in the sterilization area. This container (a plastic bag is acceptable), will have a biohazard symbol on it.

Protective clothing will be worn anytime there is a chance of contamination from blood or potentially infectious fluid (which includes dental saliva).

5. Hair

Hair is another concern for potential contamination. Surgical caps or hoods may be worn to prevent contamination by potentially infectious material such as occurs from Cavitrons or high speed drills.

C. Preparing the Operatory

1. Initial Handwashing

The hands will be washed:*

A.      At the beginning of the day, following the recommended "initial handwashing" procedures. (Otherwise using "between nonsurgical patient" procedures.)

B.       Immediately after gloves are removed

C.       Before gloving

Refer to Appendix A.

2. Surface disinfecting

The operator, while wearing utility gloves, masks, and protective eyewear, will disinfect all surfaces except electrical switches, with the spray-wipe-spray method (Refer to Appendix B). Barriers are recommended, reducing the amount of surface disinfectant. The water lines will be flushed in the air/water syringe and the handpiece hoses for 1-2 minutes at the beginning of the day (and any other water equipment such as the Cavitron). This is done before the handpiece or air/water tip is added. Between patients, flush hoses 10-15 seconds and a minute after long breaks. Wash and remove utility gloves; then wash hands. Cover light handles, air/water syringe, and switches on chairs, units and x-ray machines with plastic or foil. These will be replaced after every patient. It is not necessary to disinfect those areas covered with barriers except at the end of the day.

The bracket table or tray should be covered with plastic wrap or plastic cleaner's bags, which covers the entire surface including the holders. Paper tray covers or surgical wraps are placed on top. Under no conditions should there be more than one tray cover on the bracket table or tray at a time. A disposable tray is another alternative. -

3. Instruments

Tray "setups" or individual instruments that have been sterilized are placed on the bracket table along with needed supplies and covered with a clean patient napkin. Instruments should be opened in the patient's presence. If tray setups are used, the individual tray should also be covered with plastic.

All instruments that can possibly be sterilized, will be. (Refer to Appendix C). There are several methods that can accomplish sterilization, i.e., steam, dry heat, chemical heat and ethylene oxide.

The CDC and ADA has suggested weekly monitoring of dental sterilizers for verification of sterilization. Color indicators such as autoclave tape are useful but they only tell that a certain temperature was reached. It does not tell if the temperature was held long enough to kill spores. Chemical indicator strips will be placed inside each cassette.

Sterilized instruments should be wrapped and stored in clean boxes or drawers until ready to be used. Drawers should also be cleaned routinely. Most wraps are capable of maintaining sterility up to 2 months. Do not get wraps wet. It is not acceptable to remove sterilized instruments from a package and place them in a drawer for later use. There should be no loose instruments in drawers.

4. Tray Armamentarium

Place a sterilized or disposable tip on the air/water syringe. Place a sterilized handpiece on the unit. All handpieces and prophy angles will be sterilized or disposable. Slow speed motors and other not sterilized handpieces will be covered with plastic sleeves.

Never reuse rubber cups or brushes on prophy angles. Brushes tend to cause more splatter and should not be used unless absolutely necessary.