Policy Consistency Group Date Approved

28/09/2009

Quality and Safety Committee 30/10/2009 Date Ratified

Reference Number CLIN Version 1 Review Date June 2011 Responsible Officer: Salaried Primary Dental Care Services Business Manager

Clinical

Protocol for Infection Control In Dentistry

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

Please retain this list in your clinic/surgery infection control folder and update as new staff join the team.

Contents

Page no 1 1 1 2 2 2

1. Introduction 2. Scope.. 3. Roles and responsibilities 4. Standard Precautions... 5. Known Carriers of Blood Borne Viruses 6. Personal Protective Equipment

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 20. References 10 Appendix 1Surgery cleaning protocol log sheet Appendix 2Protocol for manual cleaning of dental instruments Appendix 3Pre use log sheet for ultrasonic cleaning bath Appendix 4Fault record log sheet Appendix 5Daily log sheet for washer disinfector Appendix 6Weekly/monthly log sheet for washer disinfector Appendix 7Daily log sheet for non vacuum bench top sterilizer Appendix 8Transport record sheet Appendix 9A-Z Decontamination guidelines

1.

Introduction
Effective 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 in both patients and healthcare workers to ensure early and rapid diagnosis. Effective action relies on an accumulating body of evidence that takes account of current 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 Care Trust Infection Control Group and report back on Infection control and decontaminations practices which may impact on patient care and to also carry out trend 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 with patient care receive suitable and sufficient information on and training in the measures required to prevent and control risks of infection, this programme of education and information must be designed in collaboration with the Infection Prevention and Control team. All staff should be aware of infection control procedures and understand why they are necessary. New staff must be appropriately trained before undertaking decontamination duties. All dental staff working in a clinical environment are reminded of the main risks of infection 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 to personal hygiene- hand washing, masks, protective clothing to the cleaning and sterilization 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 available for external inspection. HTM01-05 also requires that dental practices produce an action plan to move from Essential quality requirements towards best practice i.e. moving from manual decontamination of instruments to a validated and automated process using washer disinfector.

2.

Scope
All employees working in the Salaried Primary Dental Care Service (Provider Services team) are required to adhere to this protocol; this includes work undertaken by PCT employees in dental clinics, dental surgeries in prisons and in domiciliary settings. 1

This protocol should be used in conjunction with the PCT Infection Control Policies and HTM 01-05: Decontamination in Primary Dental Care.

3.

Roles and Responsibilities

Local Decontamination Lead The decontamination lead for PCT Provider Services is the Head of Operations. The Clinical Director Dentistry is the local decontamination lead for the Salaried Primary Dental Care Services (SPDCS) and has overall responsibility for managing Infection Control in Dentistry for the PCT SPDCS, the standards required by HTM 01-05 and PCT Infection Control Policies. Designated Persons The local management of decontamination and infection control within the PCT SPDCS dental clinics is devolved to senior dental nurses via the SPDCS Business Manager. Users and Operators Dental care professionals are responsible for the use of decontamination equipment including daily, weekly, monthly testing and housekeeping tasks. All dental staff are responsible for compliance, and their own practice should be in accordance with national and local policies, protocols and guidelines.

4.

Standard Precautions
A wide variety of micro-organisms may be present in the saliva and blood of patients. During dental treatment infection may be transmitted through direct contact, droplets, aerosols or inoculation by contaminated instruments. These guidelines are based on the recognition that asymptomatic carriers of infectious diseases may not be identified as such. The only safe approach is to ensure that the infection control procedures are used for ALL patients ALL of the time; the principle of Standard Precautions.

5.

Known Carriers of Blood Borne Viruses

Patients with HIV (who are otherwise well) and carriers of Hepatitis and other blood borne viruses should be treated within the same Infection Control Guidelines for all other patients. If HIV patients have a raised viral load or are unwell, or have subsequently developed AIDS, advice should be sought from PCT HIV Nurse Specialist or Infection Control Team). Please refer to PCT Policy for Management of Clinical Sharps Injuries and Exposure to Blood and High Risk Body Fluids.

6.

Personal Protective Equipment

Please refer to HTM 01-05, PCT Hand Decontamination Policy and Standard Precautions and Personal Protective Equipment Policy Eye Protection and Face Masks: Patients eyes must always be protected against possible injury. 2

Operators and close support clinical staff must protect their eyes against foreign bodies, splatter and aerosols that may arise during operative procedures, especially during 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 protect against splatter. They should be close fitting and of the theatre type. Disposable masks/visors, if used, must be discarded after every patient, not pulled down and re-used. Surgery Clothing Trousers 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 in all 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 the surgery environment and changed before leaving the clinic. Footwear Shoes are to be flat or with low heels. Open toed sandals are not recommended due to the risk of injury from falling instruments or chemical spillages. N.B The above protocol may be subject to change following the ratification of the PCT uniform policy.

7.

Aerosol and saliva/blood spatter

Many infectious diseases are readily spread via aerosols e.g. TB, chickenpox and influenza. Blood splatter can spread blood borne diseases. The risk of transmission of infection by these routes will be reduced if: There is good surgery ventilation and efficient high-speed aspirators, which exhaust externally from the premises; Rubber dam isolation is used whenever practicable; High velocity aspiration is used when working without rubber dam; Appropriate protective clothing/equipment is used. 3

8. Surgery Cleaning Protocols

Surgery 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 patients using an appropriate solution or wipe Clinicians must remember that once their hands become contaminated with blood or saliva, they must not touch environmental surfaces such as light handles, unit handles, chair controls, mixers and materials, computers, keyboards or telephones etc. Surface Cleaning and Protection Surfaces 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 cleaned carefully between patients. All work surfaces, sinks, taps and splash backs including those apparently uncontaminated should be thoroughly cleaned at the end of each clinical session using an appropriate bactericidal surface disinfectant. Blood spills either from a container or as a result of an operative procedure must be dealt 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 a non-foaming disinfectant Records of surgery cleaning must be kept (see Cleaning schedule appendix 1)

9.

Use of Disposables
Local anaesthetic needles must always be disposable single-patient use. Part-used local anaesthetic cartridges must be disposed of after each patient they must never be used on a second patient. Use disposable items whenever possible. Never reuse a product or instrument if marked as single use or disposable Items that are difficult to clean should be considered single use where possible. 4

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

This is the SYMBOL FOR SINGLE USE ITEMS PLEASE ENSURE THAT YOU DO NOT RE-USE ITEMS LABELLED AS SINGLE USE

10.

Instrument Decontamination
Please refer to HTM 01-05 and PCT Decontamination Medical Devices Policy Appropriate protective clothing must be worn when cleaning, decontaminating and dismantling items of equipment. Personal protective equipment must be worn during decontamination procedures. 5

If an automated and validated washer disinfector or ultrasonic bath is not available or out of use then instruments should be decontaminated manually.

Cleaning: Manual
Use a dedicated dental instrument cleaner (accurately diluted), with a long handled brush 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 each use 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 Bath

An appropriate cleaner for use with ultrasonic baths should be used in accordance with 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. Lubricate instruments if required Ultrasonic baths should also be maintained and tested in accordance with manufacturers instructions which should be at least to HTM 01-05 requirements. They should be subject to annual, quarterly, weekly and daily testing and the results retained in a dedicated log book. This should include cleaning efficacy and protein residue tests. See Appendix 3 Any faults or concerns must be logged and reported and the machine taken out of use until the fault is identified and rectified See appendix 4 6

Cleaning: Validated Washer Disinfector

Ensure 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 with manufacturers instructions which should be at least to HTM 01-05 requirements. They should be subject to annual, quarterly, weekly and daily testing and the results retained 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 of use until the fault is identified and rectified See Appendix 4

Movement of contaminated instruments between areas

Contaminated instruments require safe movement between the treatment and decontamination areas. They should be transported in leak proof, easy to clean, rigid containers with a closable lid. The containers should be labelled accordingly and cleaned, disinfected and dried after use. When contaminated instruments are transported between sites and clinics i.e. during domiciliary visits, data collection programmes etc. the vehicle must carry a record with the instruments. The record must detail the date, details of the group of instruments, the intended destination/recipient and the vehicle details. The notice should be attached to the container holding the contaminated instruments. See appendix 8

11.

Sterilization: Non-vacuum autoclaves (Bench Top Sterilizers)

Place on clean perforated trays. Do not overload trays as this will impede the free circulation of air. Do not wrap instruments or place in pouches before autoclaving (unless a vacuum autoclave is used). Residual water must be drained from autoclave reservoir at the end of each day.

The autoclave chamber and trays should be cleaned with a damp clean cloth and left open, to dry overnight. Autoclaves should also be maintained and tested in accordance with manufacturers instructions which should be at least to HTM 01-05 requirements. They should be subject to annual, quarterly, weekly and daily testing and the results retained in a dedicated 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 as detailed in A-Z Disinfection and Sterilization Guidelines or in accordance with manufacturers instructions. See appendix 7

12.

New instruments
New instruments should be decontaminated prior to use (in accordance with manufacturers instructions) and decontamination instructions retained.

13.

Aseptic storage
Instruments should be stored dry and protected from dust, splash or aerosol contamination in closed or covered trays in closed cupboards or drawers. Packaging of decontaminated instruments should be carried out in a clean area away from contaminated instruments and decontaminating equipment. Instruments should be used within 21 days of the decontamination process or reprocessed before use.

14.

Decontamination of equipment prior to inspection service or repair

Equipment and articles which have been contaminated by contact with blood or other body fluids must be rendered safe, and a statement confirming this completed, prior to examination by third parties.

15.

Waste disposal
Please refer to PCT Policy for the Management of Healthcare Waste All waste must be segregated into correct waste streams. Staff handling clinical waste must be aware of the current policy and have received instruction on the segregation, disposal and transportation of clinical waste. contaminated dental waste is collected by a dedicated waste disposal company this includes: Waste amalgam Amalgam filled extracted teeth (N.B. Extracted teeth with no amalgam in should be disposed of in sharps box) 8

Amalgam separation units.

16.

Safe use and disposal of contaminated dental sharps

Please refer to Dental Protocol for safe handling of sharps and the PCT Policy for Management of Clinical Sharps Injuries and Exposure to Blood and High Risk Body Fluids The definition of sharps applies to: needles, teeth, burs, root canal instruments, metal matrix bands, glass ampoules/vials, scalpel blades, scissors any other contaminated sharp instrument or item. Avoid sharps usage wherever possible Never leave sharps lying around Never walk about with unguarded sharps Always request assistance when using sharps with unco-operative clients. Remove hand pieces containing contaminated burs from dental units immediately after use All sharps must be placed into an approved sharps container Ensure sharps containers are placed off the floor, out of the reach of patients and carers at all times and ensure that unauthorised people cannot gain access to them Never dispose of sharps with other clinical waste Never overfill sharps containers Never press down on the contents of the container to make more room Never attempt to retrieve items from the sharps containers. All sharps injuries must be reported immediately and an incident form completed N.B. When Dental clinicians are required to re-sheath a needle they should always use the singe-handed technique e.g. using a Jenker re-sheathing device

17.

Training
Infection control training is part of the initial structured training programmes leading to professional qualification for all clinical dental staff. `In addition to this there is a requirement to undertake an identified number of mandatory training hours in a five year period to ensure re-validation of professional registration. Infection Control Training will be accessed via the Infection Control Team arranged via the PCT training programme, or via the NHS e-learning site however specific 9

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 their training period with the PCT.

18.

Communication
From 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 clinic and added to monthly staff meetings. The amendments should be read, and signed as read, by all staff and then filed in the 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 and changing this protocol. A member of the dental team will attend PCT infection control meetings and link nurse meetings to provide feedback at the monthly dental team meetings.

19.

Monitoring
The implementation of this policy will be monitored through regular service specific audits and as required by the PCT. Audits will be registered with the PCT Clinical Audit Department and the results and action plans shared with the Dental Team

20.

References
HTM 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 and High Risk Body Fluids CLIN24 PCT Decontamination of Medical Devices Policy CLIN30

10

Surgery Cleaning Protocols Appendix 1 Clinic Location Date and time Dental Surgery No. Drawer and cupboard door handles disinfected End of session Cleaning Schedule Chair and light unit disinfected Spittoon, filters and aspirator equipment disinfected Sinks and taps cleaned Computer and key board cleaned Signed Name and designation

Work Surfaces and dental carts disinfected

Weekly schedule Date and Re-process time all un-dated instruments

Clean all drawer fronts cupboard doors

Clean operator stools

Suction/Aspirator maintenance as recommended by service engineer

Compressor maintenance as recommended by service engineer

Signed

Name and designation

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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 content and application of this protocol and associated guidance. To minimise the risk to personnel undertaking manual cleaning, the splashing and creation of aerosols should be avoided at all times. Remember: Maintaining a dirty-to-clean workflow procedure will assist in the cleaning process.

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 of water 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 the cleaning 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. 10. Visually inspect all items ensuring they are clean, functional and in good condition. 11. Lubricate any relevant items prior to sterilization with a non-oil-based lubricant. 12. Dispose of cleaning materials safely in accordance with local policy. 13. Replace cleaning solution and the rinse-water after each use. 14. Complete any relevant documentation.
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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 Date and time Daily (before use if not used recently) remove and clean strainers and/or filters Daily (before use if not used recently) fill reservoir with fresh solution After first load of the session Weekly: (before use if not used recently) Check condition of lid/door seal Weekly: (after first load of the session if not used recently) Perform a protein residue test on instruments Name and designation Signed

visually check first load to check cleaning efficacy

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FAULT RECORD
Equipment Type Date and time Nature of Fault Location Reported to Reported by Make/Model Action taken Incident form required Serial Number Outcome

Appendix 4

Name and designation

Signed

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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 manufacturers instructions. Date Clean all Check Check all Check door Replenish Record the Record the Record Name and Signed and external all hoses and seal is water pre wash disinfection the cycle designation time and filters connectors undamaged softener temperatures: temperatures: number internal and are in good and clean use the first use the first and surfaces sprays condition and print out of print out of retain the are operating the day: the day: print out. free mechanism (must start (must stay from is working debris order below 45c) above 80c)

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Appendix 6

Weekly/Monthly 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 manufacturers instructions. Perform Name and Signed Weekly residual soil designation Test test using Pro-tect Date and or equivalent time

Monthly Test
Date and time

Check all hoses are secure and no leaks Perform residual soil test using Pro-tect or equivalent

Check mains power cord undamaged

Check all internal parts for wear and damage Signed

Name and designation

Signed

Weekly Test
Date and time

Name and designation

Monthly Test
Date and time

Check all hoses are secure and no leaks

Check mains power cord undamaged

Check all internal parts for wear and damage

Name and designation

Signed

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Appendix 7

Daily (or before use) log sheet for non-vacuum bench top steriliser
Steriliser 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 and time Clean door seal, chamber, shelves and trays with a clean, damp non linting cloth Fill reservoir with fresh distilled, sterile or RO water Turn on and record cycle number in column below Record Record Temperature Pressure Record the holding time Retain print out (if available) Name and designation Signed

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Appendix 8

TRANSPORT OF CONTAMINATED DENTAL INSTRUMENTS (Low Biohazard)

Date of Transport Vehicle Registration No. Destination of Instruments Contact telephone number

Please attach this notice to the container holding the contaminated instruments in your vehicle

Retain this record in your local clinic

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Appendix 9 A - Z DECONTAMINATION GUIDELINES

Appliances orthodontic and prosthetic

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 Steel burs -disposable, Diamond -pre-clean then autoclave Tungsten Carbide -pre-clean then autoclave Acrylic Trimming Burs -pre-clean then autoclave Cover surface and use disposable instrument trays Clean with detergent/disinfectant wipe between patients Do not use alcohol based products on stainless steel. 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. Wipe and dry after each patient with detergent or disinfectant wipe. Do not use alcohol based products on stainless steel.

Burs

Bracket tables

Dental Cabinetry

Dental chair (including controls)

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Dental Instruments including hand pieces

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 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 the chuck; 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. 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

Hand pieces using manual cleaning or ultrasonic bath

Hand pieces using a washer disinfector

Impressions

Rinse under clean running water until clean.

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 Instrument containers Light cure Tip Matrix band holders Operating lights

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 Clean with detergent, rinse and dry (Do not use sodium hypochlorite)

Pre-clean and autoclave or protect with a plastic disposable cover (Check manufacturers instructions) Remove used band before decontamination process

Clean after each patient with a detergent/disinfectant wipe. Do not use alcohol wipe on stainless steel parts. 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 manufacturers recommendations 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

Spittoon

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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 Water Bottles

(Or dispose of if single use) 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. Flush for at least 2 minutes at the beginning and end of each day and flush for 20-30 seconds between each patient. Clean with detergent/disinfectant wipe between each patient and at the end of the session

Water lines Work surfaces

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