INFECTION CONTROL

GUIDELINES
FOR THE
COLLEGE OF DENTISTRY
K ING SAUD UNIVERSITY

2013G (1434H)
 Contributors
Asma’a A. Al-Ekrish BDS, MDS, Cert. in Diag. Sci.
Assistant Professor,
Department of Oral Medicine and Diagnostic Sciences
College of Dentistry, King Saud University
Reem A. Al-Mishari BDS, SSCRD
Consultant, Advanced Restorative Dentistry
College of Dentistry, King Saud University
Aziza F. Mobeirik BDS, MDS, Cert. in Diag. Sci.
Associate Professor, Department of Oral Medicine and Diagnostic Sci-
ences
College of Dentistry, King Saud University
Maha A. Al-Sarheed BDS, MSc, MPh-PhD
Associate Professor, Department of Pediatric Dentistry and Orthodon-
tics
College of Dentistry, King Saud University

Editors
Asma’a A Al-Ekrish BDS, MDS, Cert. in Diag. Sci.
Assistant Professor,
Department of Oral Medicine and Diagnostic Sciences
College of Dentistry, King Saud University
Reem A Al-Mishari BDS, SSCRD
Consultant, Advanced Restorative Dentistry
College of Dentistry, King Saud University

This publication was commissioned, reviewed and approved by the In-

fection Control Unit at the College of Dentistry, King Saud University in
2012.

This document was approved by the College of Dentistry Board in the

19th meeting for the academic year 2011-2012 held on 10 Jun 2012.

2
 Members of the Infection Control Unit
(for the academic years 2010-2011 and 2011-2012):
Chairman:
Samer Abdullah Al Jetaily, BDS, MSc Cert. in Prosthodontics, PhD
Assistant Professor, and Consultant
Dept. of Prosthetic Dental Science
Vice-Dean for Administrative Affairs
College of Dentistry, King Saud University
Members:
1. Nasir Hamad Al-Bagieh , B.S , M.A , PhD
Professor of Microbiology
Head of Oral Pathology, Oral Biology, Microbiology and Immunology Divi-
sion
Department of Oral Medicine and Diagnostic Science
College of Dentistry, King Saud University
2. Sulieman Al-Johany, BDS, MSD Cert. in Prosthodontics, DABP,
FACP
Associate Professor, Dept. of Prosthetic Dental Science
Director of Clinics, DUC
College of Dentistry, King Saud University
3. Nasrien Z. Ateyah, B.D.S., MSc., Cert. in Restorative Dentistry
Associate Professor, and Consultant
Dept. of Restorative Dental Science
Director of Clinics, MUC
College of Dentistry, King Saud University
4. Naif A. Bindayel, BDS,MS, Ortho-Cert
Assistant Professor, Dept. of Pediatric Dentistry and Orthodontics
Assistant Director of the Clinics
College of Dentistry, King Saud University
5. Reem A. Al-Mishari BDS, SBARD
Consultant, Advanced Restorative Dentistry
College of Dentistry, King Saud University

3
 6. Fe A. Estanislao ,DMD
Chief DASD, MUC
7. Nestor F. Santiago IV, DMD, MBA
Chief DASD, DUC
Trustee:
Asma’a A. Al-Ekrish, BDS, MDS, Cert. in Diag. Sci.
Assistant Professor,
Dept. of Oral Medicine and Diagnostic Science
College of Dentistry, King Saud University

Expert Reviewer:
Eng. Mohammed S. AL-Qarni, BS (Biomedical Engineering)
Biomedical Technologist
Assistant Director of Engineering Department
College of Medicine & King Khalid University Hospital
King Saud University

All Copy Rights Reserved for

College of Dentistry, King Saud University

PO Box 60169 Riyadh 11545 Saudi Arabia

4
 TABLE OF CONTENTS

INTRODUCTION 16
DISEASE TRANSMISSION 17
UNIVERSAL PRECAUTIONS AND STANDARD PRECAUTIONS 23
TRANSMISSION –BASED ISOLATION PRECAUTIONS 26
INFECTIOUS DISEASES OF MAJOR CONCERN TO
DENTAL HEALTH CARE PERSONNEL 34
HEPATITIS 36
HUMAN IMMUNODEFICIENCY VIRUS 61
RESPIRATORY INFECTIONS 71
HERPETOVIRUSES 99
OTHER INFECTIOUS DISEASES OF CONCERN IN DENTISTRY 112
VACCINATION 132
OCCUPATIONAL EXPOSURE, EXPOSURE INCIDENT AND DOCUMENTATION 161
WORK RESTRICTION AND MANAGEMENT OF JOB-RELATED ILLNESSES 171
NOTIFICATION OF INFECTIOUS DISEASES 178
HAND HYGIENE 180
PERSONAL PROTECTIVE EQUIPMENT 208
DESIGN OF CLINICS AND DENTAL UNITS 221
DENTAL TREATMENT WATER 227
CHEMICALS USED FOR DISINFECTION AND STERILIZATION 235
ENVIRONMENTAL INFECTION CONTROL 258
CLINICAL PRECAUTIONS DURING OPERATION 266
INFECTION CONTROL IN RADIOLOGY 277
INFECTION CONTROL IN PROSTHODONTICS AND IN DENTAL LABORATORY 283
INFECTION CONTROL IN RESEARCH ANIMAL FACILITIES 308
CENTRAL STERILIZATION AND SUPPLY DEPARTMENT (CSSD) 316

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 ACQUISITION OF DEVICES AND MATERIALS 357
MANAGEMENT OF MEDICAL WASTE 359
APPENDICES 390
REFERENCES 395

6
 LIST OF TABLES
Table 1: Conditions and Diseases Requiring Transmission- Based Precautions 27

Table 2: Representative Infectious Diseases in Dentistry 35

Table 3: Hepatitis B Terminology 40

Table 4: Interpretation of the Hepatitis B Serological Profiles 45

Table 5: Recommended HIV Postexposure Prophylaxis For

Percutaneous Injuries 70

Table 6: Tuberculosis (TB) Risk Categories And Recommended

Testing Frequency 97

Table 7: Immunizing Agents Recommended for Health Care Personnel 153

Table 8: Important Recommendations and Suggested Work Restrictions

for Personnel with Selected Infectious Diseases 174

Table 9: Hand Hygiene Methods and Indications Within the Clinic 185

Table 10: Anti-microbial Spectrum of Selected Hand Hygiene Agents 205

Table 11: Glove Types and Indications 211

Table 12: Comparison of Eye Protection Devices 216

Table 13: Categories of Disinfectants/ Sterilants and Recommended

Uses in Dentistry 242

Table 14: Effect Of Disinfectant Treatment on Cast Dimensions as

Compared with Room Temperature Controls 295

Table 15: Recommendations for Disinfection of Polysulfide and

Silicon Rubber Impressions 297

Table 16: Recommendations for Disinfection Of Polyether Impressions 298

Table 17: Recommendations for Disinfection of Hydrocolloid Impressions 300

Table 18: Recommendations for Disinfection of ZOE 301

Table 19: Recommendations for Disinfection of Stone Casts and

Custom Impression Trays (Acrylic) 302

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 Table 20: Recommendations for Disinfection of Prosthodontic
and Orthodontic Appliances 305

Table 21: Examples of Diseases Associated with Zoonotic Transmission 309

Table 22: Color Coding Recommended for Waste Bags or Containers 388

Table 23: Common Techniques to Treat Hazardous Medical Waste 389

LIST OF FIGURES

Figure 1: Technique for Rubbing Hands During Handwashing 188

Figure 2: Decreasing Order of Resistance of Microorganisms to

Germicidal Chemicals 239

Figure 3: Diagrams of Recommended CSSD Work-Flow Patterns 317

Figure 4: The Bio- hazard Logo 367

8
 List of Used Abbreviations
ACIP: Advisory Committee on Immunization Practices
ACH: Air Changes/Hour
ADA: American Dental Association
AFB: Acid-Fast Bacilli
AIA: American Institute of Architects
AIDS: Acquired Immune Deficiency Syndrome
AIIR : Airborne Infection Isolation Room
ALT: Alanine Aminotransferase (test)
Anti-HBc: Antibody to Hepatitis B Core Antigen
Anti-HBe: Antibody to Hepatitis Be Antigen
Anti-HBs: Antibody to Hepatitis B Surface Antigen
Anti- HCV: Antibody to Hepatitis C
Anti-HEV: Antibody to Hepatitis E
ART: Antiretroviral Therapy
BAMT: Blood Assays For Mycobacterium Tuberculosis
BCG: Bacillus Calmette-Guérin (vaccine)
BIs: Biologic Indicators
BSE: Bovine Spongiform Encephalopathy
CDC: The Centers for Disease Control and Prevention
cfu: colony-forming unit
CJD: Creutzfeldt-Jakob Disease
CMV: Cytomegalovirus
CSSD: Central Sterilization and Supply Department
DHCP: Dental Health Care Personnel
DNA: Deoxyribonucleic Acid
DUWLs: Dental Unit Waterlines
DTP: Diphtheria-Tetanus-Pertussis
DT: Diphtheria-Tetanus (vaccine)

9
 DTaP: Diphtheria-Tetanus-acellular Pertussis (vaccine)
EBV: Epstein-Barr virus
EHC: Employee Health Clinic
EPA: Environmental Protection Agency
EPP: Exposure Prone Procedures
ER: Emergency Room
EU: Endotoxin Unit
FDA: Food and Drug Administration
GABHS: Group A Beta-Hemolytic Streptococci
GNB: Gram-Negative Bacilli
HAART: Highly Active Antiretroviral Therapy
HAV: Hepatitis Virus type A
HBV: Hepatitis Virus type B
HBcAg: Hepatitis B core Antigen
HBeAg: Hepatitis Be Antigen
HBsAg: Hepatitis B Surface Antigen
HCP: Health Care Personnel
HCV: Hepatitis Virus Type C
HDV: Hepatitis Delta Virus
HEPA: High Efficiency Particulate Air (filter)
HEV: Hepatitis Virus Type E
Hib: Haemophilus influenzae type b
HIV: Human Immunodeficiency Virus
HSV: Herpes Simplex Virus
HSV 1: Herpes Simplex Virus Type 1
HSV 2: Her¬pes Simplex Virus Type 2
HVAC: Heating, Ventilation, and Air Conditioning
HVE: High-Volume Evacuator
HZV: Herpes Zoster Virus

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ICD: Irritative Contact Dermatitis
Ig: Immunoglobulin
IgG: Immunoglobulin class G
IgM: Immunoglobulin class M
IgM Anti-HBc: Immunoglobulin class M Antibody to HBcAg
IGRA: Interferon Gamma Release Assay (test)
IM: Intra- Muscular
IPV: Inactivated Polio Vaccine
IV: Intra-Venous
KDF: Kinetic Degradation Fluxion
LAA: Laboratory Animal Allergy
LAIV: Live Attenuated Influenza Vaccine
LFT: Liver Function Test
LTB1: Latent TB Infection
MCV4: Quadrivalent Meningococcal Conjugate Vaccine
MDR: Multi-Drug Resistant
MDRTB: Multi-Drug-Resistant Tuberculosis
MDROs: Multi-Drug Resistant Organisms
MEC: Minimum Effective Concentration
MMR: Measles, Mumps And Rubella (vaccine)
MOH: Ministry of Health
MPSV: Meningococcal Polysaccharide Vaccine
MRSA: Methicillin Resistant Staphylococcus Aureus
MSDS: Material Safety Data Sheet
NADL: National Association of Dental Laboratories
Ni/Cd: Nickel/ Cadmium
NIOSH: National Institute of Occupational Safety and Health
OI: Opportunistic Infections
OPIM: Other Potentially Infectious Materials

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 OPV: Oral Polio Vaccine
OSHA: The Occupational Safety and Health Administration
PCR: Polymerase Chain Reaction (test)
PEP: Post-Exposure Prophylaxis
PHN: Post Herpetic Neuralgia
PI: Protease Inhibitors
PME: Presidency of Meteorology and Environment
PPE: Personal Protective Equipment
PSGN: Post-Streptococcal Glomerulonephritis
RNA: Ribonucleic Acid
RSV: Respiratory Syncytial Virus
SARS: Severe Acute Respiratory Syndrome
SC: Sub-Cutaneous
SP: Standard Precautions
TB: Tuberculosis
Td: Tetanus –diphtheria (vaccine)
Tdap: Tetanus-diphtheria-acellular pertussis (vaccine)
TEWL: Transepidermal Water Loss
TFM: Tentative Final Monograph (FDA testing criteria)
TIG: Tetanus Immune Globulin
TIV: Trivalent Influenza Vaccine
TST: Tuberculin Skin Test
VAPP: Vaccine-Associated Paralytic Poliomyelitis
vCJD: variant Creutzfeldt-Jakob Disease
VRE: Vancomycin-Resistant Enterococci
VZIG: Varicella-Zoster Immune Globulin
VZV: Varicella-Zoster Virus
WHO: World Health Organization
ZOE: Zinc Oxide Eugenol

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 EXECUTIVE SUMMARY
The Infection Control Guidelines for the College of Dentistry, King
Saud University, 2012, present the requirements for the practice of infec-
tion control in the various departments of the College, as approved by the
College Board of the College of Dentistry. These guidelines aim to guide
policy makers and educators within the College of Dentistry in formulat-
ing the policies and procedures for the various clinics and departments,
and in determining the content of infection control educational material.
This document supercedes any previous infection control documents
published by the College of Dentistry. It has updated the information in
previous guidelines and expanded their scope to provide more compre-
hensive coverage of infection control issues, and provides more detailed
guidance on most aspects of the topics covered.
These guidelines address the requirements for protection of dental
health care personnel and patients from cross-contamination, through
providing information on the use of standard precautions and isolation-
based precautions, as well as providing guidance on control measures of
different infectious diseases of major concern in dentistry, vaccination of
dental healthcare personnel (DHCP), management and documentation
of occupational exposure, work restriction and management of job-re-
lated illnesses, hand hygiene, the use of personal protective equipment,
acceptable methods of decontamination of the various classes of patient
care items, environmental infection control, work practice controls, engi-
neering controls, and the management of medical waste.
The guidelines for acceptable design of the dental clinics and dental
units from an infection control perspective are also presented, as well
as approved methods for maintaining acceptable quality of dental treat-
ment water. Specific issues of clinical precautions during operation are
also addressed, as well as guidelines for infection control in the specific
practices of radiology and prosthodontics and the specific areas of the
dental laboratory, and research animal facilities. Detailed guidelines are
also presented regarding the design of the central sterilization and supply
department (CSSD), attire of the CSSD staff, workflow, and instrument
processing and monitoring. Guidelines are also presented for a standard-

13
 ized program for acquisition of devices and materials.
In formulation of these guidelines, relevant resources issued by the
Centers for Disease Control and Prevention (CDC) were referred to ex-
tensively. Such resources included, but were not limited to, guidelines for
infection control in dental health-care settings, disinfection and steriliza-
tion in healthcare facilities, environmental infection control, infection pre-
vention in outpatient settings, and hand hygiene in health care settings,
as well as recommendations on immunization of health-care personnel,
preventing needlestick injuries in health care settings, and management
of occupational exposures. The Bloodborne Pathogens Standard of the
Occupational Safety and Health Administration (OSHA) was also referred
to. In matters not fully addressed by the CDC or OSHA, information was
supplemented from guidelines, directives, or resources published by oth-
er national and international governmental bodies and academic institu-
tions. Information was also obtained from resources published by the
World Health Organization (WHO), and professional associations such
as the American Dental Association (ADA), Organization for Safety and
Asepsis Procedures (OSAP), Infection Control Nurses Association, and
the American Academy of Oral and Maxillofacial Radiology.
Due to the time lapse since many of the guidelines, articles published
in peer-reviewed journals were also referred to in matters which were not
controversial. To the extent possible, papers published within the past ten
years were used. However, older articles were also referred to in order
to highlight their findings if they were of continued relevance, such as the
demonstration of interactions between disinfectants and dental materi-
als or the demonstration of spread of contamination by particular routes.
The latest editions of established textbooks in the field were also used if
they provided useful information not available in the latest guidelines. If
conflicting recommendations were encountered, guidelines were given
precedence over individual published papers or books.
For matters of national significance, information relating to epidemiol-
ogy of disease in Saudi Arabia was obtained from the most recent ar-
ticles published in peer-reviewed journals or from WHO or Saudi Arabian
Ministry of Health (MOH) resources. For guidelines on work restrictions
applied to DHCP and waste management, the directives of the MOH

14
and the Infection Control and Prevention Manual of the Gulf Cooperation
Council (GCC) and Center for Infection Control (2009) were the main
resources.
In matters which the developers of the guidelines felt were not suf-
ficiently addressed in the published literature (wearing of head covers
in the clinics and acceptable length of nails for DHCP), the available in-
formation regarding the topics was presented to the members of the In-
fection Control Unit and, after open discussion within the Unit, the Unit
reached its conclusions which were included in these guidelines.
For dissemination of these guidelines, this document is to be made
available on the College of Dentistry website. Based upon the informa-
tion contained within this document, policies and procedures relevant to
the various clinics, departments, or laboratories are to be developed by
the Legislative Committee of the Infection Control Unit in conjunction with
the respective administrative heads. The policies and procedures will
then need to be approved by the Infection Control Unit. Subsequently,
every staff member, student, or employee within the College of Dentistry
is to receive a copy of the policies and procedures pertaining to their work
situation. The policies and procedures are then to be stressed by periodic
lectures or workshops which highlight their content.
These guidelines are to be submitted for external review and are to be
updated by the Legislative Committee of the Infection Control Unit of the
College of Dentistry within two years of the publication date. For this task,
the legislative committee is to include as internal consultants representa-
tives from the various departments of the College, including all academic
departments. External consultants may also be referred to for expert or
professional advice within their area of expertise.

15
 INTRODUCTION
Infections present a significant hazard in the dental environment. Pa-
tients and all dental health care personnel (DHCP), including dentists,
hygienists, assistants, and laboratory personnel, are at significant risk of
being exposed to potentially life-threatening pathogenic bacteria, viruses
and fungi as consequence of cross-infection during dental treatment.
Many sources of cross-infection exist in the dental office. Saliva,
blood, nasal secretions, and other contaminated body fluids may be
transmitted between patients via dental instruments and equipment
and hands. Dust, contaminated waterlines, clothing, and hair may
also harbor pathogenic microorganisms which may be transmitted to
patients and DHCP. All such sources of cross-contamination must be
considered during implementation of infection control practices in the
healthcare environment. Practicing the current methods of sterilization
and infection control in the dental office and laboratory will significant-
ly decrease the risk of infectious disease for the patient, dentist, and
staff.
Each department and clinic of the College of Dentistry is unique in
its working conditions and infection control requirements. Dental health
care personnel, therefore, may encounter varying situations and chal-
lenges. Hence, even if particular situations are not specified in these
guidelines, DHCP are required to exercise their judgment and apply
appropriate infection control practices to all situations in which they
come in contact with patients, patient materials, instruments, or de-
vices used in patient care.
Although an infection control program cannot guarantee against oc-
cupational exposure/transmission, implementation of a well-researched
infection control policy, based on the most up to date guidelines and
scientific evidence, may aid in reducing the risk of serious infections,
and even death, that could result from less careful attention to the criti-
cal details of dental asepsis. For this reason, the importance of ad-
herence to the following infection control guidelines in dental practice
cannot be overemphasized.

16
 DISEASE TRANSMISSION
[1 -11]
An infectious disease is one that is communicable or contagious
which means that the disease can be transmitted (spread) in some way
from one host to another. Infection control procedures are designed to
prevent disease transmission in the dental practice. An understanding
of the modes of disease transmission is important in order to prevent
such transmission.
Transmission of Infection in the Dental Environment
(Entry of Infections)
Infections may be transmitted in the dental environment via different
modes:

A. Parenteral Routes
(Transmission via Skin and Mucosa)

1. Contact Transmission:
Contact transmission requires physical contact between an infected
person or a contaminated surface and a susceptible person (via mu-
cous membrane or non-intact skin-e.g., exposed skin that is chapped,
abraded, or shows signs of dermatitis), and the physical transfer of
microorganisms. Contact transmission is divided into two subgroups:
a. Direct contact transmission occurs when microorganisms pass
from the infected person to the healthy person via direct physical
contact with blood or body fluids. Examples of direct contact are
touching, kissing, sexual contact, contact with oral secretions, or
contact with body lesions (example is herpetic whitlow caused by
transmission of herpes simplex virus).
b. Indirect transmission involves the transfer of an infectious agent
through a contaminated intermediate object or person. Examples
include transmission of pathogens to susceptible persons via

17
 the hands or gloves of DHCP which have touched contaminated
dental instruments, devices or surfaces, or touched infected tis-
sues, fluids, or colonized body sites of an infected patient. Con-
taminated dental instruments, and devices may also transmit
pathogens indirectly if they are used for another patients without
appropriate decontamination.

2. Percutaneous Transmission:
The introduction of a microorganism or an agent of disease into an
host through the skin by needle stick or sharps injuries, human bites,
or cuts.

3. Permucosal Transmission:
The introduction of a microorganism or an agent of disease into an
host through the mucosa by mucous membrane exposure in the eye,
nose, or mouth (e.g. spatter to the eye or mouth).
Bloodborne Pathogens are certain pathogens which are carried
in the blood and body fluids (such as saliva) of infected individuals,
and can be transmitted to others through the above mentioned routes
(i.e. contact, percutaneous, and permucosal transmission). Saliva is of
particular concern during dental treatment because it frequently is con-
taminated with blood. Although blood is not visible in the saliva, it may
be present. Because dental treatment often involves contact with blood
and always with saliva, bloodborne diseases are of major concern in the
dental office. Bloodborne diseases include, but are not limited to, hepa-
titis B, hepatitis C and acquired immune deficiency syndrome (AIDS).

4. Airborne Transmission (transmission by inhalation)

The smaller particles of an aerosol (0.5 to 10 μm in diameter) and
droplet nuclei (see - Definitions of contaminated airborne particles as
sources of infection in dental settings) have the potential to penetrate
and lodge in the smaller passages of the lungs and are thought to car-
ry the greatest potential for transmitting infections (Aerosol Infection).
These fine airborne particles containing pathogens are able to remain
infective and may transmit infections over long distances, requiring
airborne infection isolation room (AIIR) (see Airborne Precautions) to

18
prevent its dissemination within a facility. They can also pass through
the filters of surgical masks which are not designed to protect against
this mode of transmission. A particular respirator (e.g., N-95 respirator)
would be needed to afford protection against such transmission. Ex-
amples of diseases that are spread through the airborne route include
tuberculosis, influenza, pneumonic plague, measles, varicella zoster,
severe acute respiratory syndrome (SARS), smallpox (i.e., variola ma-
jor) and legionnaires disease.

B. Enteral Routes
(Transmission via the Gastrointestinal Tract)

1. Fecal-oral Transmission:
Ingestion of food or water contaminated with fecal matter. If proper
sanitation (such as handwashing) after use of the toilet are not fol-
lowed, many pathogens present in fecal matter may be transmitted to
others directly or indirectly (contaminated surfaces or food).

2. Dental Unit Waterlines:

Ingestion of water containing pathogenic microorganisms released
from the biofilm within dental unit waterlines (transmission of diseases
from waterlines could also be through inhalation).

Transmission could also be:

1. Perinatal Transmission:
The transmission of pathogen from mother to baby during the peri-
natal period, the period immediately before and after birth. This occurs
through the placenta (permucosal transmission) or by ingestion from
the breast milk (enteral route of transmission). Perinatal route is also
called vertical transmission.

2. Droplet Transmission:
(see - De�initions of Contaminated Airborne Particles)

19
 Droplets are generated when an infected person coughs, sneezes,
or talks, or during procedures which involve the use of air-water syring-
es, handpieces and ultrasonic scalers. Droplets containing pathogenic
microorganisms have the potential to transmit disease if they contact
mucous membranes or unprotected skin (Droplet Infection). Droplet
transmission is, technically, a form of contact transmission. However,
in contrast to contact transmission, respiratory droplets carrying infec-
tious pathogens transmit infection when they travel directly from the
respiratory tract of the infectious individual to susceptible mucosal sur-
faces of the recipient, generally over short distances.
The maximum distance for droplet transmission is currently unre-
solved, although pathogens transmitted by the droplet route have not
been transmitted through the air over long distances, in contrast to
the airborne pathogens. Historically, the area of defined risk has been
a distance of less than 3 feet around the patient. However, studies
of smallpox and SARS suggest that droplets from patients with these
two infections could reach persons located 6 feet or more from their
source. It is likely that the distance droplets travel depends on the ve-
locity and mechanism by which respiratory droplets are propelled from
the source, the density of respiratory secretions, environmental factors
such as temperature and humidity, and the ability of the pathogen to
maintain infectivity over that distance.
Organisms transmitted by the droplet route do not remain infective
over long distances, and therefore do not require special air handling
and ventilation. Surgical masks, eye glasses, gowns and face shields
interrupt this mode of transmission. Examples of infectious agents that
are transmitted via the droplet route include Bordetella pertussis , influ-
enza virus, adenovirus, rhinovirus, Mycoplasma pneumoniae, SARS-
associated coronavirus, group A streptococcus, Neisseria meningitides
and respiratory syncytial virus (RSV).

Definitions of Contaminated Airborne Particles

The main potential sources of airborne contamination during dental
treatment are saliva, respiratory secretions and the water from den-
tal unit waterlines. Visible spray created during the use of air-water

20
syringes, dental rotary instruments, and ultrasonic scalers and drop-
let generated when an infected person coughs, sneezes, or talks may
contain blood, saliva, nasopharyngeal (nasal) secretions, and infec-
tious microorganisms. Contaminated airborne particles could be in the
form of droplets, droplet nuclei, spatter, or aerosols.
Droplets
Droplets are small particles of moisture larger than 5 μm and less
than 500 μm in size (intermediate in size between drops and droplet
nuclei). These droplets could be projected from the patient by cough-
ing, sneezing, talking, or by splatter from a dental procedure. As the
droplet begins to evaporate, the size of the droplet becomes smaller,
and it then has the potential to stay airborne or to become reairborne
as a dust particle. Dehydration of airborne droplets containing microor-
ganisms leads to formation of Droplet nuclei.
Droplet Nuclei
Droplet nuclei are the residuals of droplets that, when suspended in
air, subsequently dry and produce particles ranging in size from 1–5 μm
in diameter. Droplet nuclei can remain suspended in the air indefinitely
for long periods of time, and may reach beyond 3 feet of the source of
these particles, and even be transported over long distances through
the air and ventilation system. These particles can contain potentially
viable microorganisms which are protected by a coat of dry secretions.
The microorganisms in droplet nuclei persist in favorable conditions
(e.g., a dry, cool atmosphere with little or no direct exposure to sunlight
or other sources of radiation).
Spatter
Spatter are visible large-particle droplet of water, saliva, blood, mi-
croorganisms, and other debris that makes up the bulk of the spray
generated in dental settings. They form airborne particles larger than
50 mm in diameter, and settles out quickly, landing either on the floor,
nearby operatory surfaces, dental personnel providing care, or the pa-
tient. Spatter particles behave in a ballistic manner when they are gen-
erated, i.e. they are ejected forcibly from the operating site and arc in

21
 a trajectory similar to that of a bullet until they contact a surface or fall
to the floor. These particles are too large to become suspended in the
air and are airborne only briefly. They fall onto surfaces within a 60 cm
range of the point of origin.
Aerosols
Aerosols are small airborne particles that take considerable energy
to generate and can stay airborne for an extended periods of time be-
fore they settle on environmental surfaces or enter the respiratory tract.
Aerosols consist of particles less than 10 microns in diameter, and are
not typically visible to the naked eye. However, aerosol droplets can
reach up to 50 μm in diameter. Due to their ability to stay airborne, and
potential to enter respiratory passages, the greatest airborne infection
threat in dentistry comes from aerosols.

22
UNIVERSAL PRECAUTIONS AND STANDARD PRE-
CAUTIONS [10, 12-16]
Universal Precautions is defined as an approach to infection con-
trol. According to the concept of universal precautions, all human blood
and certain human body fluids are treated as if known to be infectious
for human immunodeficiency virus (HIV), hepatitis virus types B (HBV),
and other bloodborne pathogens. The Centers for Disease Control and
Prevention (CDC) introduced its universal precautions document in
1986. This was later expanded in scope and referred to as standard
precautions. However, The Occupational Safety and Health Adminis-
tration’s (OSHA’s) bloodborne pathogen standard retains the term uni-
versal precautions.
Standard precautions is the term used now by CDC and is de-
fined as the minimum infection prevention practices that apply to all
patient care in any setting where healthcare is delivered, regardless
of suspected or confirmed infection status of the patient. Standard
precautions combine the features of universal precautions and body
substance isolation. These precautions are designed to both protect
health care personnel (HCP) and prevent HCP from spreading infec-
tions among patients, and are intended to prevent skin and mucous
membrane exposures. Standard precautions are based on the as-
sumption that every person potentially is infected or colonized with an
organism that could be transmitted in a health care setting.

Standard precautions apply to the following:

1. Blood
2. All body fluids, secretions and excretions (except sweat) regard-
less of whether they contain blood

3. Non-intact skin
4. Mucous membranes
Standard precautions include the following:
1. Hand hygiene.

23
 2. Use of personal protective equipments.
3. Safe handling of potentially contaminated instruments and equip-
ments to avoid cross contamination.
4. Environmental control.
5. Proper handling of textiles and laundry.
6. Engineering controls and work practice controls:
a. Engineering controls are the primary method to reduce ex-
posures to blood and other potentially infectious materials
(OPIM: tissues, or other body fluids) from sharp instruments
and needles. These controls are frequently technology-based
and often incorporate safer designs of instruments and de-
vices (e.g., self-sheathing anesthetic needles and dental units
designed to shield burs in handpieces) to reduce percutane-
ous injuries.
b. Work-practice controls establish practices to protect DHCP
whose responsibilities include handling, using, assembling,
or processing sharp devices (e.g., needles, scalers, labora-
tory utility knives, burs, explorers, and endodontic files) or
sharps disposal containers. Work-practice controls can include
removing burs before disassembling the handpiece from the
dental unit, restricting use of fingers in tissue retraction or pal-
pation during suturing and administration of anesthesia, and
minimizing potentially uncontrolled movements of such instru-
ments as scalers or laboratory knives.
7. Avoiding occupational exposures.
8. Safe injection practices.
9. Safe disposal of waste.
10. Respiratory hygiene/cough etiquette. The primary components of
respiratory hygiene and cough etiquette are as follows:
a. covering the mouth and nose during coughing and sneezing;
b. using tissues to contain respiratory secretions and promptly

24
 disposing of them;
c. offering a surgical mask to people who are coughing to de-
crease contamination of the surrounding environment;
d. performing hand hygiene after contact with respiratory secre-
tions; and
e. turning the head away from others and maintaining spatial
separation, ideally more than three feet, when coughing.

25
 TRANSMISSION– BASED ISOLATION PRECAUTIONS
[3, 10, 12-14, 17-18]
In addition to standard precautions, other measures (e.g., expand-
ed or transmission-based precautions) might be necessary to prevent
potential spread of certain diseases (e.g., tuberculosis, influenza, and
varicella) that are transmitted through airborne, droplet, or contact
transmission (e.g., sneezing, coughing, and contact with skin). When
acutely ill with these diseases, patients do not usually seek routine
dental outpatient care. Nonetheless, a general understanding of pre-
cautions for diseases transmitted by all routes is critical because:
1. some DHCP are hospital-based or work part-time in hospital
settings;
2. patients infected with these diseases might seek urgent treat-
ment at outpatient dental offices; and
3. dental health care personnel might become infected with
these diseases.
Necessary transmission-based precautions might include patient
placement (e.g., isolation), adequate room ventilation, respiratory pro-
tection (e.g., N-95 masks) for DHCP, or postponement of nonemer-
gency dental procedures.
While standard precautions (SP) applies to all patients, transmis-
sion–based isolation precautions apply to selected patients, based on
either a suspected or confirmed clinical diagnosis. It must also be not-
ed that transmission– based isolation precautions are designed to be
used in combination with standard precautions. Furthermore, in many
instances, the risk of nosocomial transmission of infection may be
highest before a definitive diagnosis can be implemented. Therefore,
patients with certain signs and symptoms should be isolated while a
definitive diagnosis is pending.
Transmission– based isolation precautions are divided into three
categories that reflect the major modes of transmission of infectious
agents within the health care setting: contact; droplet; and airborne.
These isolation categories are to be combined for diseases that have

26
multiple routes of transmission (Table 1).
Table 1
Conditions and Diseases Requiring Transmission-Based Precautions
CONTACT DROPLET AIRBORNE DURATION OF
DISEASE/CONDITION
PRECAUTIONS PRECAUTIONS PRECAUTIONS PRECAUTIONS

Clostridium difficile
+ NA NA DI

Herpes Simplex (Mucocutane-

ous,
Disseminated or Primary, Se- + NA NA Until lesions are dry and crust

vere)

Five days
Influenza Human (Seasonal) NA
+ NA DI in people who are immunocompro-
mised

Seven days from symptom onset or

2009 H1N1 Influenza
+ + + until the resolution of symptoms,
whichever is longer

Head Lice (Pediculosis)

+ NA NA U four hours

Four days after onset of rash,

Measles (Rubeola) NA NA
+ except DI in people who are
immunocompromised

Methicillin-Resistant
Staphylococcus aureus + NA NA Unresolved issue

Mumps NA
+ NA U nine days

Pertussis NA
+ NA U five days

Rubella NA
+ NA U seven days after onset of rash

DI plus 10 days after resolution of

Severe Acute Respiratory
Syndrome (SARS) + + + fever, provided respiratory symptoms
are absent or improving

DI until all scabs have crust and

Smallpox (Variola)
+ NA
+ separated (three-four weeks)

Discontinue precautions only when

the patient receiving effective
therapy is improving clinically and has
Tuberculosis (Confirmed) NA NA
+ three consecutive sputum smears
negative for acid-fast bacilli collected
on separate days

Varicella Zoster (Chicken Pox)

+ NA
+ Until lesions are dry and crust

+: Use or apply the precaution.

NA: Not applicable.
DI: Duration of illness (with wound lesions, DI means until wounds stop draining).
U: Until time specified in hours or days after initiation of effective therapy.

Source: Siegel, et al. [3], Siegel, et al. [19]

27
 A. Contact Precautions
Contact precautions are used in addition to standard precautions for
specified patients who have poorly controlled body fluids, respiratory
secretions or are known or suspected to be infected or colonized with
epidemiologically significant microorganisms transmitted by direct or
indirect contact. Examples of such infections include:
• Infections or colonization with multi-drug resistant bacteria (e.g.
methicillin resistant staphylococcus aureus (MRSA)).
• Enteric infections with a low infectious dose or prolonged envi-
ronmental survival, including Clostridium difficile.
• Patients infected with: Enterohemorrhagic Escherichia coli,
Shigella, hepatitis A, or rotavirus.
• Respiratory syncytial virus, para-influenza virus, enteroviral in-
fections in infants and young children.
• Skin infections that are highly contagious or that may occur on
dry skin, including: diphtheria (cutaneous); herpes simplex virus
(neonatal or mucocutaneous); impetigo; major (noncontained)
abscess, cellulites, or decubiti; pediculosis (lice); scabies; staph-
ylococcal furunculosis in infant and young children; zoster; viral
/hemorrhagic conjunctivitis; viral hemorrhagic fevers and group
A streptococcal major skin, burn, or wound infection.
• In dental clinic, contact precautions are applied for patients who
have uncontrolled wound drainage.
Patient Isolation Requirements
• Patients should be treated in a private room or clinic when avail-
able, or grouped as roommates with other patients who are infected
or colonized with the same pathogen.
• Patients must be physically separated (greater than one meter
apart) from each other.
• Patients on contact precautions should not be placed in the same
room or clinic with patients who have conditions that may increase

28
 the risk of adverse outcome from infection (i.e., those who are im-
munocompromised or have open wounds).
• All standard precautions should be applied.
• Personal protective equipment (PPE) (gown and gloves) should be
worn upon entry to the clinic or room and whenever contacting the
patient or potentially contaminated areas surrounding the patient.
Before exiting the clinic or room of the patient, PPE should be re-
moved in a manner that prevents contamination of underlying cloth-
ing and skin, and discarded. Appropriate hand hygiene should then
be immediately performed (see sections on “HAND HYGIENE” and
“PERSONAL PROTECTIVE EQUIPMENT”).
• Movement and transport of the patient from the clinic or room
should be undertaken for medically essential purposes only.
• If the patient is transported out of the clinic or room, the necessary
precautions must be maintained to minimize the risk of transmission
of microorganisms to DHCP and other patients, or contamination of
environmental surfaces or equipments (infected or colonized areas
of the patient’s body should be contained and covered).
• Prior to transporting patients on contact precautions, any contami-
nated PPE should be removed and disposed of appropriately, and
appropriate hand hygiene performed.
• When possible, patient care equipment should be restricted to a sin-
gle patient. If use of common equipment or items is unavoidable, then
the same guidelines governing sterilization and disinfection of reus-
able items in the dental setting apply (see section on “CHEMICALS
USED FOR DISINFECTION AND STERILIZATION IN DENTISTRY-
Classification of Items and Surfaces for Decontamination”).
• Clinics and rooms of patients subject to contact precautions should
be prioritized for frequent cleaning and disinfection.
Discontinuing Contact Precautions
Contact precautions may be discontinued under the following conditions:
1. The patient is no longer considered infectious based on clinical

29
 and/or laboratory data.
2. The patient meets specific decolonization criteria.
3. The isolation is discontinued by the infection control team.

B. Droplet Precautions
In addition to standard precautions, droplet precautions should be
applied for patients known or suspected to have serious illnesses trans-
mitted by large particle droplets. Examples of such illnesses include:
• Invasive haemophillus influenza type b disease, including menin-
gitis, pneumonia, and sepsis
• Invasive Neisseria meningitides disease, including meningitis,
pneumonia, and sepsis.
• Other serious bacterial respiratory infections spread by droplet
transmission, including: diphtheria (pharyngeal); Mycoplasma
pneumonia; pertussis; pneumonic plague; streptococcal (group
a) pharyngitis; pneumonia, or scarlet fever in infants and young
children.
• Serious viral infections spread by droplet transmission including:
adenovirus infection; influenza; mumps; parvovirus b19 infec-
tion; and rubella.
Droplet precautions must be implemented to prevent the transmis-
sion of pathogens spread through close respiratory or mucous mem-
brane contact with respiratory secretions. Generally, special ventila-
tion requirements are not required to prevent droplet transmission.
Patient Isolation Requirements
• Patient should be placed in a private room when available.
• Patients on droplet precautions should not be placed in the same
room with patients who have conditions that may increase the risk
of adverse outcome from infection (i.e., those who are immuno-
compromised or have open wounds).
• Patients should be physically separated (i.e., greater than one me-

30
 ter apart from each other.
• All standard precautions should be applied, including having the
patient follow respiratory hygiene/cough etiquette.
• A surgical mask should be worn when working within one meter of
the patients.
• Movement and transport of the patient from the room should be
undertaken for medically essential purposes only.
• If transport or movement is necessary, dispersal of droplet nuclei
from the patient should be minimized by placing face mask on the
patient, if possible.
Discontinuing Droplet Precautions:
Droplet Precautions may be discontinued under the following conditions:
1. The patient is no longer considered infectious based on clinical
and/or laboratory data.

2. The isolation is discontinued by the Infection Control team.

C. Airborne Precautions
Airborne precautions are implemented to prevent transmission of in-
fectious agents that remain infectious across long distances when sus-
pended in the air, through aerosolization. Airborne precautions should
be used, in addition to standard precautions, when treating patients
known or suspected to have serious illnesses transmitted by airborne
droplet nuclei. Examples of such illnesses include:
• Measles (Rubeola).
• Varicella (including disseminated zoster).
• Tuberculosis (including pulmonary & laryngeal tb).
Patient Isolation Requirements:
1. Patient should be placed in an airborne infection isolation room (AIIR)
that has been constructed in accordance with current guidelines

31
 • At least six 6 or 12 air changes per hour should take place.
• Room should be supplied with negative pressure (air flows
under the door gap into the room).
• Exhaust of air should be directly from the room to the out-
side of the building or recirculation of air should take place
through a high efficiency particulate air (HEPA) filter. The
AIIR door should be kept closed when not required for en-
try and exit.
• When an AIIR is not available, the patient should not be
treated and should be referred to a facility that has an avail-
able AIIR.

2. Respiratory Protection:
• A fit tested respiratory protection (N95 or higher level respi-
rator) should be worn when entering the room.

Ø N95 disposable respirators are nonpowered, air-

purifying, particulate-filter respirators.

Ø The N (not resistant to oil) series respirators are

available with filtration efficiencies of 95% (N95), 99%
(N99), and 99.7% (N100) when challenged with 0.3 µm
particles.
• To assure a good seal of the mask with the face, a deep
breath should be taken. Mask should collapse during inha-
lation and expand during exhalation.
• Susceptible persons should not enter the room of patients
known or suspected to have measles (Rubeola) or Vari-
cella (chickenpox) if other immune caregiver is available.

• Masks should only be removed AFTER leaving the room.

3. Movement and transport of the patient from the room should be

limited to essential purposes only. If transport or movement is nec-
essary, dispersal of patient droplet nuclei should be minimized by
placing a surgical mask on the patient, if possible.

32
4. All standard precautions should be applied, including having the
patient follow respiratory hygiene/cough etiquette.
Discontinuing Airborne Precautions
Airborne precautions may be discontinued under the following conditions:
1. The patient is no longer considered infectious based on clinical
and/or laboratory data.
2. For pulmonary TB patients, three (3) negative sputum smears
are obtained usually after 2 weeks from starting effective treat-
ment.

3. The isolation is discontinued by the infection control team.

NOTE: For patients with diseases transmitted by multiple routes, ad-

ditional isolation requirements should be followed in addition to
airborne precautions. For example, for varicella zoster (chicken
pox) or disseminated varicella zoster (shingles), contact pre-
cautions should be followed as well as airborne precautions.

33
 INFECTIOUS DISEASES OF MAJOR CONCERN TO
DENTAL HEALTH CARE PERSONNEL
[6, 10, 20-21]
Various infectious diseases may be transmitted In the dental envi-
ronment (Table 2). Microorganisms of concern include hepatitis virus
types A, B, and C, herpes simplex virus types 1 and 2, human immuno-
deficiency virus (HIV), Mycobacterium tuberculosis, cytomegalovirus,
staphylococci, streptococci, and a number of other viruses and bac-
teria. A thorough medical history should be obtained from all patients.
Specific questions about medications, current illnesses, hepatitis, re-
current illnesses, unintentional weight loss, lymphadenopathy, oral soft
tissue lesions, or other infections should be included. Medical consul-
tation may be indicated when a history of active infection or systemic
disease is elicited
Transmission of bloodborne pathogens (e.g., HBV, HCV, and HIV)
in dental health-care settings can have serious consequences. Expo-
sure to infected blood can result in transmission from patient to DHCP,
from DHCP to patient, and from one patient to another. The opportu-
nity for transmission is greatest from patient to DHCP, who frequently
encounter patient blood and blood-contaminated saliva during dental
procedures.
For DHCP to pose a risk for bloodborne virus transmission to pa-
tients, DHCP must 1) be viremic (i.e., have infectious virus circulating
in the bloodstream); 2) be injured or have a condition (e.g., weeping
dermatitis) that allows direct exposure to their blood or other infectious
body fluids; and 3) enable their blood or infectious body fluid to gain
direct access to a patient’s wound, traumatized tissue, mucous mem-
branes, or similar portal of entry. Although an infected DHCP might be
viremic, unless the second and third conditions are also met, transmis-
sion cannot occur.

34
Table 2
Representative Infectious Diseases in Dentistry

Estimated Sur-
Incubation vival
Agent/ Disease Routes
Period at Room Tem-
perature
Bacterial
Mycobacterium tuber- Saliva
To 6 mo Months
culosis Sputum
Staphylococcus aureus Saliva
Staphylococcal infec- Exudates 4-10 days Days
tions Skin
Streptococcus pyo-
genes
Open wound
Streptococcal 1 day-1 wk Hours-days
Bloodborne
Wound infections
Endocarditis
Treponema pallidum Direct contact
1-10 wk Seconds
Syphilis with lesions
Viral
Respiratory viruses Saliva
1-14 days Hours
Flu colds Secretions
Feces
Hepatitis A virus
Saliva 15-40 days Days
Hepatitis A
Blood
Blood
Hepatitis B virus 50-180 days
Saliva Months
Hepatitis B
Semen
Blood
HCV Saliva
30-150 days Hours-days
Sexual con-
tact
Blood
HIV
Semen To 11 yr Days
Secretions
Herpes simplex I and II
Recurrent herpes Saliva
2 wk Minutes
Whitlow Secretions
Conjunctivitis

Source: modified from Nisengard and Newman [21]

35
 Hepatitis [4]
Hepatitis, which is an inflammation of the liver, varies in seriousness
from a minor flulike illness to a fatal liver disease. The severity of the
disease depends on the type of hepatitis virus involved and the abil-
ity of the host to resist the disease. Early symptoms of hepatitis often
include loss of appetite, nausea and vomiting, jaundice (a yellowish
discoloration of the skin and eyes, caused by the color of excess liver
bile in the blood), and fever.
There are at least four types of viral hepatitis, each of which is caused
by a different virus: hepatitis A virus, hepatitis B virus (HBV), hepatitis C
virus (HCV), hepatitis D virus (HDV), and hepatitis E virus (HEV).

Hepatitis A
[4, 6-7, 13, 22-24]
Hepatitis A , formally known as infectious hepatitis, is caused by
Hepatitis A virus (HAV) which is a small (27 nm) RNA virus. This is one
of the less serious forms of hepatitis.

Epidemiology:
Hepatitis A commonly occurs in developing countries where sewage
disposal measures and food hygiene is unsatisfactory. Children and young
people are most often infected. In the Saudi population, it has been report-
ed to range from 52.4% in young children to 80.0% in adults with a steady
increase with increasing age. Other factors associated with significant in-
crease in prevalence were found to be low level of education of parents,
low socio-economic status, and rural dwelling (vs. urban)
Characteristic Features of the Causative Microorganism:
Humans are the only natural host. The incubation period of Hepatitis A
is 15-40 days. Depending on the environmental conditions, the virus can
be stable in the environment for months. It can remain stable and infec-
tious at low ph and moderate temperatures, and is inactivated by ultravio-
let light, high temperatures, formalin and chlorine.

36
Transmission of the Disease:
Hepatitis A is not a bloodborne infection. It is spread via the fecal/oral
route, most commonly through contaminated food and water and by direct
person to person contact. It is rarely transmitted by needlestick injuries.

High Risk Groups:

• Inhabitants of day care centers.
• International travelers.
• Intravenous drug users.
• Homosexuals.
• Persons with chronic liver disease.
• Persons drinking contaminated water or eating raw or inad-
equately cooked shellfish.

Clinical Features:
Patients with Hepatitis A may manifest sudden onset of fever, mal-
aise, anorexia, nausea, abdominal discomfort, inflammation of the liver
and jaundice. Infections with HAV are either asymptomatic or mild in
young children. In contrast, approximately 70% of adults and older chil-
dren manifest jaundice and other symptoms. Chronic infection does
not occur. No HAV carrier state exists. Patients are infectious before
the onset of symptoms during the prodromal phase and just before the
onset of clinical disease.
Some patients continue to excrete HAV in stool during weeks 1-3 of
illness, and HAV may also be present in saliva throughout this period.
HAV infection is self limiting and recovery provides lifelong protection
against recurrent disease.

Diagnosis:
The diagnosis of acute Hepatitis A is confirmed by finding anti HAV
of immunoglobulin M (IgM) in serum collected during the acute or early
phase of the disease. The antibodies persist for 4-6 weeks and are then
replaced by high concentration of IgG antibodies which remain detect-
able in serum thereafter confirming lifelong protection against disease.

37
 Prophylaxis:
• Passive immunization (post exposure use of Immunoglob-
ulin-Ig): In health care setting, immunoglobulin can be giv-
en, preferably within 2 weeks after exposure.
• Active immunization (vaccination): Vaccine is available for
long term prevention of hepatitis A infection in person two
(2) years of age and older. It is given in two (2) doses within
6-12 months interval.

Control Measures:
In addition to standard precautions, contact precautions are recom-
mended for diapered and incontinent patient for one week after the
onset of symptoms. Health care personnel with Hepatitis A should be
restricted from patient contact and contact with patient’s environment
for 7 days after onset of jaundice.

Management of Exposures to HAV:

Personnel who have had direct fecal-oral exposure to excretions
from a patient incubating hepatitis A should be given a single dose
of immunoglobulin (0.02 ml/kg up to 2ml) intramuscularly as soon as
possible after exposure. Administration 14 days after an exposure is
unlikely to be beneficial and hence is not indicated. Prophylaxis with Ig
for all personnel who take care of patients with hepatitis A, other than
as suggested above, should not be given.

Hepatitis B
[4-7, 10, 13, 16, 21-22, 25-37]
Hepatitis B is a serious disease that may result in prolonged illness.
It is caused by hepatitis B virus (HBV) which is a 42 nm enveloped
DNA virus that infects and multiples in human liver cells and is released
during the course of an infection in high numbers into the bloodstream
and other body fluids. A variety of ultimate outcomes of this disease
exist, including a carrier state, liver cirrhosis, acute hepatitis, primary
liver cancer, and death.

38
 Careful medical histories will usually reveal approximately 20 per-
cent of individuals who have had hepatitis B. It is strongly suggested
that all patients be presumed to be active hepatitis B carriers. The ethi-
cal, legal and financial costs of a dentist developing hepatitis B are
very serious, including transmission to spouses, vertical transmission
to newborn offspring, as well as transmission to patients and staff.

Epidemiology:
Hepatitis B is a major health problem worldwide. Hepatitis B has
high endemicity with about 10% to 20% in Southeast Asia, China, parts
of the Middle East, and sub Saharan Africa. In contrast, the endemicity
is low in Western Europe, the United States, Canada, New Zealand,
and Australia, with only a 0.1% to 2%. Globally, approximately 2 billion
people have been infected with about 350-400 million people being
chronic carrier of the virus. Approximately 90% of HBV carriers live in
less developed countries. HBV is the most frequent cause of chronic
hepatitis in the world HBV is also associated with about 80% of the
cases of primary liver cancer. There are about 1-1.5 million deaths at-
tributable to hepatitis B sequelae each year. Overall mortality rates for
reported cases generally do not exceed 2%.
In the past 15 years, studies have shown reductions in the prev-
alence of hepatitis B in Saudi Arabia. Reported prevalence rates in
adults varied from 1.5 - 9.7 % . The results varied according to age,
and nationality of the subjects, as well as region of residence. Patients
attending a hospital in the Jizan region (for any reason) had the highest
prevalence reaching 9.7 % , and Yemeni and Pakistani nationals were
found to have the highest prevalence rates among the different nation-
alities. Prevalence among foreign nationals was found to be lower than
in their respective countries probably due to mandatory screening of
all expatriates.
Prevalence rates tended to increase with increasing age. In chil-
dren, the prevalence rate was reported as 0.3- 0.9 % (down from ear-
lier reports of 6.7 %). The rate dropped between 1989-1997 (after
implementation of vaccination). The low prevalence of hepatitis B sur-
face antigen (HBsAg) in children, provides evidence for the effective-

39
 ness and efficacy of the integration of hepatitis B vaccination into the
extended program of immunization in Saudi Arabia.
Characteristic Features of the Causative Microorganism:
Humans are the only natural host. The incubation period of Hepatitis
B virus is long: 50-180 days. The virus has three components that are
important antigens; one on its surface (HBsAg) and two on the inside
(HBcAg and HBeAg). Several well-defined antigen-antibody systems
have been described for HBV infection (Table 3). Hepatitis B virus has
been demonstrated to survive in dried blood at room temperature on
environmental surfaces for one week and longer.
The virus can be killed or inactivated by commonly used methods of
sterilization and disinfection provided that the killing agent comes into
direct contact with the virus. Such methods include:
• Steam autoclave.
• Ten (10) minutes exposure to 1:100 diluted bleach.
• Exposure to 1:16 diluted phenolic glutaraldehyde.
• Exposure to 75 ppm iodophor.
• Exposure to 70% isopropyl alcohol.
(see section on CHEMICALS USED FOR DISINFECTION
AND STERILIZATION)

Table 3
Hepatitis B Terminology

Abbreviation Term Comments

Etiologic agent of “serum” or

HBV Hepatitis B virus “long-incubation” hepatitis; also
known as Dane particle
Surface antigen(s) of HBV detect-
Hepatitis B surface an-
HBsAg able in large quantity in serum;
tigen
several subtypes

40
 Abbreviation Term Comments

Soluble antigen; antigen corre-

lates with HBV replication, higher
HBeAg Hepatitis Be antigen
titer HBV in serum, and high in-
fectivity of serum
Hepatitis B core anti-
HBcAg No commercial test available
gen
Indicates past infection with, and
immunity to HBV, passive anti-
Anti-HBs Antibody to HBsAg
body from HBIg, or immune re-
sponse from hepatitis B vaccine
Presence in serum of HBsAg car-
rier suggests lower titer of HBV
Anti-HBe Antibody to HBeAg
and lower infectiousness of the
patient
Indicates past infection with HBV
Anti-HBc Antibody to HBcAg
at some undefined time
Indicates recent infection with
IgM class antibody to
IgM Anti-HBc HBV; tests positive for 4-6 months
HBcAg
after infection

Source: modified from Molinari and Harte [6]

Transmission of the Disease:

Hepatitis B is a bloodborne disease that is transmitted by percutane-
ous or permucosal exposure to blood or body fluids (including saliva )
of a person with either acute or chronic HBV infection. Persons infected
with HBV can transmit the virus for as long as they are HBsAg-positive.
Although, the degree of infectivity is best correlated with positive re-
sults for HBeAg. The risk of HBV infection is more a factor of exposure
to blood than of exposure to general patient contact. However, HBsAg
has been detected in 76% of salivary samples of known carriers.
The virus can be transmitted by a human bite and can be detected
in nasopharyngeal secretions and gingival crevicular fluid. Blood con-
tains the greatest proportion of HBV infectious particle titers of all body
fluids and is the most critical vehicle of transmission in the health-care
setting. HBsAg is also found in multiple other body fluids, including
breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings,

41
 saliva, semen, sweat, and synovial fluid. However, the majority of body
fluids are not efficient vehicles for transmission because they contain
low quantities of infectious HBV, despite the presence of HBsAg. A mil-
limeter of blood from an infected person may contain as many as 100
millions virus particles, meaning that only a small amount of blood is
necessary to transmit the disease to others.
The potential for HBV transmission through contact with environ-
mental surfaces has been demonstrated in investigations of HBV out-
breaks among patients and HCP in hemodialysis units. Hepatitis B vi-
rus is capable of being transmitted by:

1. Parenteral route, through either:

a. Percutaneous contact (e.g. sharps injuries with contami-
nated instruments, or exposure of non intact skin to blood
or body fluids of infected person); or
b. Permucosal contact (e.g. exposure of mucous mem-
branes to blood, saliva, or other body fluids of a person
with either acute or chronic HBV infection).

Examples of such routes include dental and surgical

treatments, sexual activities, and frequent intimate con-
tact which leads to contaminated fluids from one person
contacting the mucous membranes or non-intact skin of
another person, either directly or indirectly. In the dental
operatory, parenteral transmission may occur from patient
to DHCP, and less often from patient to patient, and from
DHCP to patient.

2. Perinatal route:
When a pregnant woman is chronically infected with HBV,
there can be as high as 80%-90% risk of infection for the
newborn, of which 90% of those children become chronic
HBV carrier with increased risk for having cirrhosis or
hepatocellular carcinoma as they age.

In studies of HCP who sustained injuries from needles

42
 contaminated with blood containing HBV, the risk of de-
veloping clinical hepatitis if the blood was positive for both
HBsAg and HBeAg was 22 - 31%; the risk of developing
serologic evidence of HBV infection was 37- 62%. By
comparison, the risk of developing clinical hepatitis from a
needle contaminated with HBsAg-positive, HBeAg-nega-
tive blood was 1- 6%, and the risk of developing serologic
evidence of HBV infection, 23- 37%.
Hepatitis B Virus Carrier State:
A carrier is defined as a person who has HBsAg-positive results on
at least two occasions at least 2 months apart or being HBsAg-positive
and immunoglobulin M anti-HBc-negative at a single test. The HBV car-
rier is central in the epidemiology of HBV transmission. About 90% of
those infected with HBV undergo complete recovery without developing
a carrier state. About 2%-10% become carriers of the virus, with about
one half eliminating the virus from their bodies within 5 years. The other
half become chronic carriers and about 25% of these develop chronic
active hepatitis with greater chance of developing liver cancer.
Anyone who has developed the disease, and some persons who
have been exposed but have not been actively ill, may be carriers of
HBV. The HBV carrier state develops more commonly via asymptom-
atic subclinical HBV infection versus acute infection. This means that
even patients who appear to be healthy and have no history of the dis-
ease may be a source of infection. This presents a high risk for dental
personnel because dental treatment brings them into contact with sa-
liva and blood. Additionally, carriers with an asymptomatic subclinical
infection are more likely to be HBeAg positive, indicating that they are
in a more infectious, contagious state, and therefore are more liable to
transmit the disease.
High Risk Groups:
• Health care providers.
• Patients in hemodialysis and hematology / oncology units.
• Clients and staff of institutions for developmentally disabled

43
 persons.
• Newborns of hepatitis B carrier mothers.
• Intravenous drug abusers.
• Sexual partners of infected persons.
Risk in the Dental Operatory:
Hepatitis B remains the most important occupationally acquired dis-
ease for dental professionals. Studies indicate that, for dentists, the
risk for acquiring hepatitis B is three to six times that of the general
population. That risk seems to be related to the frequency of contact
with patient’s blood.
The greatest dental occupational risk for exposure are the following:
a. Injuries from contaminated sharps.
b. Blood and saliva contamination of cuts and cracks on the
skin or ungloved hands or hands with torn gloves.
c. Spraying of blood and saliva onto open lesions of the skin
or onto mucous membranes.
It has been shown that, for non-immune persons disease transmis-
sion from a needlestick exposure is up to 100 times more likely for
exposure to hepatitis B e antigen (HBeAg)–positive blood than to HIV-
positive blood. In hepatitis B there are over 100 million viral particles
per mL of blood, whereas in AIDS there are only up to 100 viruses per
mL of blood.
Although the potential for transmission of bloodborne infections from
DHCP to patients is considered limited, precise risks have not been
quantified by carefully designed epidemiologic studies. Transmission
of HBV from dentist to patient has not been reported from1987-2007,
possibly reflecting such factors as:
a. adoption of standard precautions,
b. routine glove use,
c. increased levels of immunity as a result of hepatitis B vac-
cination of DHCP,
d. implementation of the 1991 OSHA bloodborne pathogen
standard, and

44
 e. incomplete ascertainment and reporting.
Clinical Features:
Hepatitis B virus infection may result in clinical symptoms in about
one third of the cases and no symptoms or unrecognized symptoms in
about two third of the cases. The clinical sign and symptoms in acute
cases include combination of malaise, anorexia, nausea, vomiting, ab-
dominal pain, jaundice, light colored stool, dark urine, and fever. Skin
rashes, arthralgia, and arthritis also can occur. Jaundice, the sign most
believed to be pathognomonic of hepatitis, is rarely evident.
Diagnosis:
Diagnosis of HBV is complicated by the variety of serological mark-
ers and the complex sequelae of the disease itself. Table 4 summa-
rizes the significance of the serological markers HBV.

Table 4
Interpretation of the Hepatitis B Serological Profiles

Test Result Interpretation

HBsAg Negative
Anti-HBc Negative - Susceptible
Anti-HBs Negative
HBsAg Negative
- Immune because of natural
Anti-HBc Positive
infection
Anti-HBs Positive
HBsAg Negative
- Immune because of hepatitis B
Anti-HBc Negative
vaccination
Anti-HBs Positive
HBsAg Positive
Anti-HBc Positive
- Acutely infected
IgM Anti-HBc Positive
Anti-HBs Negative
HBsAg Positive
Anti-HBc Positive
- Chronically infected
IgM Anti-HBc Negative
Anti-HBs Negative

45
 - Recovering from acute infection,
or
- Immune and test is not sensitive
HBsAg Negative enough to detect low level of
Anti-HBc Positive Anti-HBs, or
Anti-HBs Negative - Susceptible with false positive of
Anti-HBc, or
- Carrier and undetectable level of
HBsAg present in the serum

Source: Molinari and Harte [6]

Prophylaxis:
Because no successful medical treatment exists to cure this dis-
ease, prevention is of paramount importance. Safe and effective vac-
cines for hepatitis B are available. Vaccination can protect both DHCP
and patients from HBV infection and, whenever possible, should be
completed when dentists or other DHCP are in training, before they
come into contact with blood. The Saudi Arabian Ministry of Health
requires serologic screening before immunization to identify positive
cases and instruct them about preventive measures.
Because no vaccine is 100% effective, the CDC recommends that
healthcare personnel who have contact with blood and are at risk for
sharps injuries be tested for antibody response 1 to 2 months after the
third dose of the vaccine series. Approximately half of nonresponders
to the primary series will respond to a second 3-dose series. Nonre-
sponders to vaccination who are HBsAg-negative should be consid-
ered susceptible to HBV infection.
Vaccine-induced antibodies decline gradually over time, and 60% of
persons who initially respond to vaccination will lose detectable anti-
bodies over 12 years. Even so, immunity continues to prevent clinical
disease or detectable viral infection. Booster doses of vaccine and pe-
riodic serologic testing to monitor antibody concentrations after comple-
tion of the vaccine series are not necessary for vaccine responders.
Control Measures:
• Serologic screening before immunization is required to identify

46
 positive cases and instruct them about preventive measures.
• All body fluids except sweat (e.g. Blood, saliva, gingival fluid and
pus), from all dental patients should be considered infective.
• All sharp items (e.g., needles, scalers, burs, lab knives, and
wires) that are contaminated with fluid or material, regardless of
whether it is visible or not, are considered as potentially infec-
tive.
• standard precautions , engineering controls and work practices
are established, and must be observed, to prevent injuries.
• The written, comprehensive program designed to minimize and
manage DHCP exposures to blood and body fluids must be im-
plemented.
• Dental Health Care Personnel:
- All DHCP must follow the recommended standard precau-
tions for all patients.
- All DHCP will be screened for HBV (HBsAg).
- Non-Saudi DHCP will be screened for HBV before recruit-
ment and travelling to the Kingdom and again on arrival.
- Only DHCP with negative HBsAg or positive HBsAg and
positive Anti- HBs should be accepted to work in the King-
dom. (with the exception of those with rare qualifications,
such as professors in universities and institutes of higher
education).
- If those tests shows intermediate results, PCR test should
be performed.
- HBsAg screening will also be repeated every two years for
iqama renewal for non-Saudi DHCP.
- Those with negative hepatitis B virus (HBsAg –ve) should
receive hepatitis B vaccine series. For non-Saudi DHCP,
the first dose of vaccine should be received before iqama
application.
- Vaccination is encouraged within 10 days of initial assign-

47
 ment unless: 1) documentation exists that the DHCP has
previously received the series; 2) antibody testing reveals
that the DHCP is immune; or 3) medical evaluation shows
that vaccination is contraindicated.
- Dental students and residents will be screened for HBV be-
fore starting the pre-clinical courses. They must have proof
of immunity, either through previous exposure to vaccina-
tion (by demonstrating a titer level greater than ten interna-
tional units (IU) of Anti-HBs), or by beginning the series of
Hepatitis B vaccinations (for those with HBsAg –ve) before
they may start patient treatment.
- All DHCP will be tested for anti-HBs 1-2 months after com-
pletion of the 3-dose vaccination series.
- DHCP who do not develop an adequate antibody response
(i.e., anti-HBs <10 mIU/mL) to the primary vaccine series
should complete a second 3-dose vaccine series or be
evaluated to determine if they are HBsAg-positive.
- Another test for anti-HBs at the completion of the second
vaccine series should be done and if no response to the
second 3-dose series occurs, non-responders should be
tested for HBsAg.
- Non-responders to vaccination who are HBsAg-negative
should be considered susceptible to HBV infection and
should be counseled regarding precautions to prevent
HBV infection and the need to obtain HB immunoglobulin
prophylaxis for any known or probable parenteral exposure
to HBsAg-positive blood.
- Persons who prove to be HBsAg-positive should be coun-
seled regarding how to prevent HBV transmission to others
and regarding the need for medical evaluation.
- According to MOH regulations, DHCP with viral load more
than100,000 copy/ml should be restricted from performing
exposure prone invasive procedures (see section on Work
Restrictions).

48
Management of Exposures to HBV:
1. Treatment of the exposure site.
a. Bleeding of the site should be encouraged.
b. The site should be washed with plenty of water.
c. Exposure site should be disinfected.
d. Dressing should be placed on exposure site.
2. Making an exposure report.
a. An incidence form should be filled and sent to the Infec-
tion Control Officer for further management, and a copy of
the form should be kept in the Infection Control Office (see
Policies and Procedures Manual).
b. The source individual should be identified and document-
ed. Arrangements should be done to have the source indi-
vidual tested as soon as possible to determine HIV, HCV,
and HBV infectivity.
c. If the source individual is already known to be HIV, HCV
and/or HBV positive, new testing need not be performed.
d. The following details of the occupational exposure should
be documented for every incident, and the incidence report
kept within the confidential medical records of the DHCP
in the Infection Control Office (for at least the duration of
employment plus 30 years) and provided to the necessary
qualified health-care professional:
i. Date and time of exposure.
ii. The routes of exposure (e.g., percutaneous injury,
mucous membrane, or non-intact skin exposure, or
bites resulting in blood exposure to either person
involved).
iii. Details of the exposure, including its severity and the
type and amount of fluid or material. For a percutane-
ous injury, severity might be measured by the depth
of the wound, gauge of the needle, and whether fluid
was injected; for a skin or mucous membrane expo-

49
 sure, the estimated volume of material, duration of
contact, and the condition of the skin (e.g., chapped,
abraded, or intact).
iv. Details of the procedure being performed when the
incident occurred.
v. Type and brand of the device involved (syringe,
suture needle).
vi. Location of the incident (clinic, operation room, pa-
tient room, etc.)
vii. Explanation of how the incident occurred.
viii. Details regarding whether the source material was
known to contain bloodborne pathogens (HBV, HCV
or HIV). And, if the source was infected, the stage of
disease, history of therapy, and viral load, if known.
ix. Details regarding the exposed person (e.g., hepatitis
B vaccination and vaccine-response status).
x. Engineering controls in use at the time.
xi. Work practices followed.
xii. Protective equipment or clothing that was used at the
time of the exposure incident (gloves, eye shields,
etc.).
xiii. The affected DHCP’s training.
xiv. Details regarding counseling, post-exposure man-
agement, and follow-up.
e. This information should be also be recorded in sharps
injury log and reviewed as part of the annual infection
control program evaluation and maintained for at least five
years.
3. Evaluation of the exposure source.
The patient should be asked to have his/her blood drawn for
testing for HBV or other infectious diseases unless the patient’s
serostatus is already known. The source individual’s blood shall
be tested as soon as feasible and consent is obtained in order
to screen for hepatitis B markers and determine HBV infectiv-

50
ity.
a. If the source is HBsAg positive:
i. If DHCP is unvaccinated: Passive immunization with
Hepatitis B Immunoglobulin (HBIg: 0.06 ml/kg intra-
muscularly) should be instituted within 48 hours (its
effectiveness is unknown if given later than 7 days
after exposure). This should be followed by a com-
plete course of the hepatitis B vaccine, the first dose
of which may administered immediately or within 7
days of the accident.
ii. If DHCP is vaccinated: determine if he/she is a good
responder or non-responder.
iii. If DHCP is a good responder (anti-HBs level is >10IU/
ml), no treatment is necessary.
iv. If DHCP is a non-responder (anti-HBs level is <10
IU/ml), HBIg is given as soon as possible preferably
within 24 hours (but not later than 7 days) after ex-
posure and hepatitis B vaccine series started at the
same time.
v. If DHCP refused to be revaccinated, a second dose
of HBIg should be given one month later.
b. If the source HBsAg status is unknown:
i. The DHCP should be managed as if the source is
positive.
ii. If DHCP’s antibody response status is unknown: the
DHCP should be screened for anti- HBs and man-
aged as a non-responder until the laboratory screen-
ing results are available.
c. If the source is negative for HBsAg:
i. Check the DHCP immune status.
ii. If immune against HBV, no further management is
necessary.
iii. If non-immune, the DHCP should be advised to re-
ceive hepatitis B vaccine series.

51
 iv.If not vaccinated, the DHCP should be advised to re-
ceive hepatitis B vaccine series.
4. Evaluating the DHCP
a. The DHCP shall be screened for hepatitis B markers.
b. The DHCP should be followed-up to determine if they have
received the 3 doses of hepatitis B vaccine.
i. If the DHCP has not been vaccinated or has not com-
pleted the 3 doses, they should be advised to com-
plete the vaccine series (0,1,6).
ii. If DHCP received 3 doses of Hepatitis B vaccine and he
/she does not know their immune status, advise to
check anti-HBs level.
Hepatitis C
[6, 10, 13, 25, 28, 32-35, 37-42]
Hepatitis C is a bloodborne disease that is caused by Hepatitis C
virus (HCV). The virus is a single stranded RNA virus which has 6 gen-
otypes and more than 90 subtypes. Hepatitis C was previously termed
parenterally transmitted non-A, non-B (NANB) hepatitis.
Epidemiology:
Prevalence of hepatitis C in Saudi Arabia among blood donors is
1.5%, and the overall prevalence of hepatitis C among hemodialysis
patients in different centers is 68% (range 16-94%).
In the past 15 years, studies have shown reductions in the preva-
lence of hepatitis C in Saudi Arabia. The prevalence rates in Saudi
Arabia have been reported to be between 0.4%- 3.88 %, the results
varied according to age, and nationality of the subjects, as well as re-
gion of residence. Drug users, however, had a much higher prevalence
of HCV, 37.7%, compared to the general population.
Patients attending a hospital in Jizan region (for any reason) had
among the highest prevalence rates (3.8 %) by region. Foreign nation-
als had a higher prevalence rates than Saudis (1.6-3.3 % vs. 0.2- 0.98
% respectively) . Egyptian nationals have been reported with the highest
prevalence (8.1-14.6 %) followed by Pakistanis (3.6- 3.8 %). Preva-

52
lence among foreign nationals was reportedly lower than in their respec-
tive countries, probably due to mandatory screening of all expatriates.
Prevalence rates of anti-HCV tend to increase with increasing age.
Children younger than 15 years of age were reported to have a lower
prevalence rate compared to adults, 0.012 vs. 0.202%, respectively.
The overall prevalence in hemodialysis patients was reported as
72.6 %, with the rate increasing with the number of years the patient
has been on dialysis. A prevalence rate of 16.4 % has been reported
for patients on dialysis for one year and 94.5 % for patients on dialysis
for 3 years or more.
Characteristic Features of the Causative Microorganism:
The incubation period of Hepatitis C is 30-150 days. The HCV RNA
can be detected in the blood as soon as 1 week after initial exposure
and antibodies to HCV can be detected within 3 months after onset of
infection.
The virus is different from other hepatitis viruses in that it has the
ability to mutate and modify viral surface components, which is a major
factor in the very high rate of chronic HCV infection.
Transmission of the Disease:
The primary route of transmission of HCV is via the blood. However,
in recent years, less than 5% of the reported cases have been related to
blood transfusions. It is most efficiently transmitted via percutaneous ex-
posure (through skin) to blood by the sharing of contaminated needles
among injection drug users. This illegal intravenous drug use accounts
for the majority (60%) of reported cases of acute HCV infections.
Perinatal and familial transmissions have also been documented.
However, the lower number of HCV infections reported in children com-
pared with those reported in adults suggested that perinatal and child-
hood transmission was not a major mode of infection and that other
modes of transmission, such as unscreened blood transfusion before
1990 and intravenous drug use, were likely to be the main modes of
infection. In contrast to HBV transmission, sexual transmission of HCV
appears less efficient.

53
 The risk of HCV infection is more a factor of exposure to blood than
of exposure to general patient contact. However, HCV RNA is found in
the saliva of approximately 50% of patient with chronic HCV, but the
rate of transmission through saliva is low.
Hepatitis C Virus Carrier State:
The carrier rate associated with HCV is higher than that associated
with HBV. An estimated 75%-85% of those infected with HCV become
chronic carriers. Chronic hepatitis C can take as long as 20 years to de-
velop, and may progress without signs or symptoms. An estimated 20%
of chronic carriers develop chronic liver disease such as cirrhosis and
liver cancer. Death from cirrhosis may occur in 1%-5% of those infected.
High Risk Groups:
• Intravenous drug abusers.
• Recipients of clotting factors.
• Patients on hemodialysis
• Recipients of blood or solid organs
• Newborns of hepatitis C carrier mothers.
• Health care providers.
• Sexual partners of infected persons.
Risk in the Dental Operatory:
Health care personnel are at risk for exposure to patient blood
and possible subsequent infection from bloodborne diseases includ-
ing HCV. However, HCV does not appear to be transmitted efficiently
through occupational exposures to blood. The majority of studies indi-
cate the prevalence of HCV infection among dentists, surgeons and
hospital based HCP has declined and is currently similar to that among
the general population, approximately 1% to 2%.
A history of unintentional needle-sticks was the only occupational
risk factor independently associated with HCV infection. Follow-up
studies of HCP exposed to HCV-infected blood through percutaneous
or other sharps injuries have determined a low incidence of serocon-
version (mean: 1.8%; range, 0%--7%). One study determined trans-

54
mission occurred from hollow-bore needles but not other sharps.
At least two cases of HCV transmission from a blood splash to the
conjunctiva and one case of simultaneous transmission of HCV and
HIV after non-intact skin exposure have been reported.
No studies of transmission from HCV-infected DHCP to patients
have been reported, and the risk for such transmission appears lim-
ited. Multiple reports have been published describing transmission from
HCV-infected surgeons, which apparently occurred during performance
of invasive procedures; the overall risk for infection averaged 0.17% .
Clinical Features:
Since hepatitis C virus infection often induces less hepatic inflam-
matory reactions than the HBV, most (60%-70%) individuals with acute
HCV infection are asymptomatic or have non- specific symptoms.
More than 85% of hepatitis C cases progress to chronic HCV infection.
Chronic HCV can take as long as 20 years to develop and progresses
without sign and symptoms until the liver disease has progressed to
the advanced stages. Almost 80% of chronic cases are stable with mild
to moderate histological disease. The other 20% eventually develop to
cirrhosis or liver cancer.
Diagnosis:
HCV can be diagnosed by blood testing for antibodies to HCV. The
polymerase chain reaction (PCR) test is an advanced RNA technology
test used to detect ribonucleic acid from the virus, and may be an indi-
cator of the transmission potential of the virus. A positive antibody and
negative PCR test may indicate a previously cleared infection. Patients
who are antibody positive but PCR negative should have a second
PCR test after 4-6 weeks to confirm their negative status.
Prophylaxis:
There is no vaccine against hepatitis C. However, effective treat-
ments are available to control the effect of the disease.
Control Measures:
• All body fluids except sweat (e.g. blood, saliva, gingival fluid and

55
 pus), from all dental patients should be considered infective.
• All sharp items (e.g., needles, scalers, burs, lab knives, and
wires) that are contaminated with fluid or material, regardless of
whether it is visible or not, are considered as potentially infec-
tive.
• standard precautions, engineering controls and work practices
are established, and must be observed, to prevent injuries.
• The written, comprehensive program designed to minimize and
manage DHCP exposures to blood and body fluids must be im-
plemented.
• Dental Health Care Personnel:
- All DHCP should follow the recommended standard pre-
cautions for all patients.
- All DHCP will be screened for HCV (Anti-HCV).
- Non-Saudi DHCP will be screened for Anti-HCV before re-
cruitment and travelling to the Kingdom and again on ar-
rival.
- Only DHCP with negative Anti-HCV should be accepted to
work in the Kingdom (with the exception of those with rare
qualifications, such as professors in universities and insti-
tutes of higher education).
- If Anti-HCV test shows intermediate results, PCR test
should be performed.
- Anti-HCV screening will also be repeated every two years
for iqama renewal for non-Saudi DHCP.
- Dental student and residents will be screened for HCV be-
fore starting the preclinical courses.
- Persons who prove to be HCV positive should be coun-
seled regarding how to prevent HCV transmission to others
and regarding the need for medical evaluation.
- DHCP who prove to be HCV positive should not perform
exposure-prone invasive procedures (see Work Restric-
tions).

56
Management of Exposures to HCV:
1. Treatment of exposure site (as in Hepatitis B)
2. Making an exposure report (as in Hepatitis B)
3. Evaluation of the exposure source
The source individual’s blood shall be tested for anti-HCV.
a. If the source is negative for hepatitis C, no further man-
agement will be done.
b. If the source is positive for hepatitis C, early diagnosis of
HCV infection for DHCP is important.
i. The DHCP should be tested for HCV PCR after 2-8
weeks.
ii. Follow-up testing (e.g. 4-6 months) for anti-HCV and
ALT activity (alanine aminotransferase blood test,
typically used to detect liver injury).
iii. If HCV infection is identified, a short course of inter-
feron is initiated.
iv. Immunoglobulin is not recommended for post-
exposure prophylaxis (PEP) after exposure to HCV
positive blood.
4. Evaluating the DHCP
The DHCP shall be screened for anti- HCV and liver function
tests (LFTs).
Delta Hepatitis
[4, 6, 10, 13, 43]
Hepatitis delta virus (HDV) is a defective bloodborne virus requiring
the presence of HBV to replicate. Patients co-infected with HBV and
HDV have substantially higher mortality rates than those infected with
HBV alone. An estimated 4% of persons with acute HBV infection are
also infected with HDV.
Epidemiology:
Delta hepatitis is worldwide in distribution. It is endemic in Mediter-
ranean countries such as southern Italy, the Middle East and parts of

57
 Africa, as it is in parts of South America.
In 2004, the prevalence rate in hospital- and clinic-based HBsAg
positive patients in Saudi Arabia was reported as 8.6%. In healthy blood
donors who were HBsAg positive the rate was 3.3%, and in healthy
blood donors was 0.06%.

Characteristic Features of the Causative Microorganism:

Delta hepatitis is unique and distinct from HBV. However, HDV de-
pends on HBV for clinical expression. HDV requires HBV as a helper
virus for an outer protein coat (HBsAg) and thus for replication.
Transmission of the Disease:
Transmission is similar to that of HBV (i.e., percutaneous or permu-
cosal). The HDV can be transmitted by blood or blood products, and
sexual contact, as long as HBsAg is found in the patient’s blood. Fre-
quent percutaneous exposures (such as those occurring with intrave-
nous drug users and hemophiliacs) are considered as high risk factors.
Non-percutaneous transmission of HDV is believed to occur primarily
by intimate contact and transmucosal exchange of body fluids.
High Risk Groups:
Similar to that of HBV.

Clinical Features:
Hepatitis relating to delta infection occurs in two primary modes.
The fist mode is simultaneous infection with HBV and HDV. When si-
multaneous infection occurs, the acute clinical course of hepatitis of-
ten is limited, with resolution of both HBV and delta infections, although
fulminant hepatitis may develop.
The second mode involves acute delta super-infection in HBsAg
carriers. These patients are more likely to have a serious and possible
acute fulminant form of hepatitis that more often leads to chronic HDV
infection.
Prophylaxis:
Dental health care personnel who are immune to HBV following
hepatitis B vaccinations or who have developed natural active immu-

58
nity against HBV following viral infection are also protected against
clinical exposure to HDV infection. Vaccination against HBV will also
prevent infection with HDV.

Control Measures and Management of Exposures to HDV:

• The same control and preventive measures as for HBV infection
are indicated.
• HBV carriers should take extreme care in avoiding exposure to
HDV as no currently immunobiologic product exists for preven-
tion of HDV super-infection.
• Immunization to prevent HBV infection, through either pre- or
post-exposure prophylaxis, can also prevent HDV infection.

Hepatitis E Virus [4, 6, 24, 44]

Hepatitis E, which is not bloodborne, is most frequently transmitted
via fecal/oral routes through contaminated food or water. The disease
occurs most frequently in the form of an epidemic in developing coun-
tries. Transmission risks have been found for people who live or travel
to an endemic area; with the greatest risks being for those individuals
having close personal contact with HEV infected persons, and those
who consume contaminated food or water.
Most outbreaks have occurred in India, Asia, portions of Africa, and
Mexico and none have been reported in Europe, the United States,
and Australia. In Saudi Arabia, studies published within the past 15
years reported the prevalence of anti- HEV to range between 8.37 -
33.3 %, with non-Saudi nationals having double the rate of Saudis. The
rate was found to increase with age , and there was a significant as-
sociation between anti-HCV and anti-HEV. Donors positive to anti-HCV
were five times more likely to be positive for anti-HEV.
Transmission of HEV is not a major concern in a standard den-
tal setting; HEV is not considered a routine occupational infection for
healthcare providers in particular because parenteral transmissions
are at most very rare occurrences.
When viral infection is followed by symptomatic disease, onset is

59
 acute with an incubation period ranging from 15-70 days. While most
cases of HEV disease are self-limiting with no resultant chronic carrier
state, pregnant women are at a much greater risk for developing fatal
fulminant hepatitis.
Treatment for infection is supportive and an effective vaccine is not
available.

60
 Human Immunodeficiency Virus
[4-5, 7, 10, 13, 21, 28, 31-35, 45-48]
Infection by human immunodeficiency virus (HIV) is extremely seri-
ous. Even the best informed and conscientious practitioners are chal-
lenged by the fact that hepatitis B and acquired immune deficiency
syndrome (AIDS), caused by HIV, follow very long incubation periods
and most infected individuals are not identifiable.
Epidemiology:
The UNAIDS 2010 report estimates the worldwide HIV prevalence
to be between 0.7 - 0.8 %, with the highest prevalence being in the
sub-Saharan Africa and the Carribean region (5.0 % and 1.0 %, re-
spectively). It is estimated that more than 45 million persons worldwide
are infected with HIV. Since the first reports of AIDS in 1981, more than
25 million people have died of the disease. In 2007 there were about
2.5 million deaths that were directly attributable to AIDS. More than
96% of the cases are in low and middle income countries. Women ac-
count for almost 50% of cases and 40% are among young people.
Sixty-eight percent of all people living with HIV live in sub-Saharan
Africa. This region alone suffered 76% of all AIDS deaths in 2007. Asia
also bears a very large burden of HIV/AIDS with an estimated 4.9 mil-
lion people living with HIV infection in 2007. However, the annual num-
ber of new HIV infections globally has been steadily declining since the
late 1990s. The decline in AIDS cases may correspond to the introduc-
tion of highly active antiretroviral therapy (HAART) and protease inhibi-
tors (PI) to the antiretroviral therapy (ART) regimens.
Several countries and regions, however, are showing increasing
incidences of new HIV infections. The Middle East and North Africa
are estimated to have an increasing incidence of HIV infections, with
a prevalence rate of 0.2 %. During the last few years, Saudi Arabia
also has had a significant increase in the reported annual new HIV-
positive cases, and hence total number of cases. Studies published
within the past 11 years have reported a prevalence of seropositivity for
HIV among blood donors in Saudi Arabia to range between 0- 0.2 %.

61
 An estimated 67- 76 % of affected persons in Saudi Arabia are male
expatriates. The HIV prevalence in Saudi nationals has been calcu-
lated as 0.02% .
Most people infected with HIV are asymptomatic and are unaware
that they are HIV-positive. Regardless of the stage of disease, howev-
er, all HIV -infected persons are potentially infectious. Once HIV infects
a host, that person remains infected for the rest of his or her life.
Characteristic Features of the Causative Microorganism:
HIV is a ribonucleic acid (RNA) virus and is classified as a retrovi-
rus. Retroviruses are unique because they contain the enzyme reverse
transcriptase. This enzyme is essential in performing a retrograde step,
converting viral RNA into an intermediary DNA to reproduce new, infec-
tious virions.
The uniqueness of HIV infection is based upon the fact that HIV
attacks cells of the immune system primarily, specifically lymphocytes
(CD41) and macrophages. As the infection progresses, HIV slowly
damages the immune system and weakens the defenses of the body
against other diseases such as tuberculosis, hepatitis, cancer, and op-
portunistic diseases.
When the HIV-positive individual becomes symptomatic (has clini-
cally defined symptoms), he/she will be classified as having AIDS. AIDS
is a term given to a group of disorders characterized by a profound cell-
mediated immunodeficiency consequential to irreversible suppression
of T lymphocyte by the HIV. It is the clinical endpoint of the HIV infec-
tion and is essentially a 100% lethal infection.
The incubation period from the time of infection to the development
of signs and symptoms of AIDS is long; the present mean time is ap-
proximately 11 years. Thus, many years are available for HIV-infected
individuals to spread the virus to partners who share drug-abuse habits
and/or sex. Additionally, this “reservoir” of time creates prolonged peri-
ods during which medical and dental care must be provided for these
HIV-positive individuals.
Current knowledge continues to show that this retrovirus does not

62
survive well in the environment, is unable to replicate outside of the
body, and is rapidly inactivated. Thus, the possibility of environmental
transmission is considered remote.
Studies have shown that HIV is inactivated rapidly after being ex-
posed to commonly used chemical germicides at concentrations that
are much lower than used in practice. In addition to commercially avail-
able chemical germicides, a solution of sodium hypochlorite (house-
hold bleach; Clorox) prepared daily is an inexpensive and effective ger-
micide. Concentrations ranging from approximately 500 ppm sodium
hypochlorite (1:100 dilution of household bleach) to 5,000 ppm (1:10
dilution of household bleach) are effective depending on the amount
of organic material (e.g. blood, mucous) present on the surface to be
cleaned and disinfected.
Transmission of the Disease:
The HIV is not a virulent virus. It is bloodborne, and there is no
scientific evidence to suggest or support possible HIV transmission by
casual contact, air, water, insects, or animal bites. It is transmitted most
easily through blood, semen, and vaginal secretions during sexual in-
tercourse. Sexual contact accounts for the majority of cases in adults.
Mucosal linings of the vagina, penis, rectum, or the oral cavity are lined
with immune system cells (dentritic cells) and present receptors on
which HIV can bind. These cells then migrate to the regional lymph
nodes, initiating HIV infection.
HIV is also transmitted through exposure to shared needles (for
drug use), through tattoo needles, accidental exposure to blood that
occurs in occupational settings, organ donation, transfusion of con-
taminated blood or blood products, and by infected mother to her child
during birth or through breast-feeding. The transmission of HIV itself
is a concern, but not a major threat, in the dental setting. However,
patients who are HIV positive often have other diseases that can be
transmitted more easily through dental treatment, particularly tubercu-
losis and hepatitis B.
When careful personal barrier techniques (gloves being the most
important) and appropriate disinfection and sterilization principles are

63
 followed, practitioners, staff, and patients should feel safe from con-
tracting the disease. Prospective studies worldwide indicate the aver-
age risk of HIV infection after a single percutaneous exposure to HIV-
infected blood is 0.3% (range: 0.2- 0.5%). After an exposure of mucous
membranes in the eye, nose, or mouth, the risk is approximately 0.1%.
The precise risk of transmission after skin exposure remains unknown
but is believed to be even smaller than that for mucous membrane
exposure.
Several factors may increase the risk of transmission:
• If HCP is exposed to a large quantity of blood.
• A procedure that involved a needle which is placed directly in a
vein or artery or a deep injury.
• If the source patient is in the terminal illness (possibly reflecting
the higher titer of HIV in late-stage AIDS).
• If the injury is deep with hollow-bore needles or penetrating
sharps related event. Laboratory studies have determined that
if needles that pass through latex gloves are solid rather than
hollow-bore, or are of small gauge (e.g., anesthetic needles com-
monly used in dentistry), they transfer less blood.
High Risk Groups:
• Sexual partners of an infected person.
• Intravenous drug abusers.
• Patients exposed to blood/blood products though transfusion or
infusion, or through organ transplantation.
• Patients on hemodialysis.
• Newborns of infected mothers.
• Children breast feeding from infected mother.
• Health care providers.
Risk in the Dental Operatory:
HIV-infected persons are being treated in dental offices; and many
times, both the dental professional and the patient are unaware of the
infections. Clinical and scientific evidence supports the belief that the
risk of HIV transmission after percutaneous exposure of HCP to HIV-

64
infected blood is quite low. The reported incidence of infection following
needle stick or cut with item contaminated with HIV-infected blood or
serum is 0 to 0.5 percent. In the United States, only two dental profes-
sionals have been known to seroconvert from possible occupational
infection; both of these professionals were dentists. As of December
2002, CDC had confirmed 57 cases of American HCP (none were
DHCP) with documented HIV seroconversion resulting from accidental
occupational exposures. Routes of exposure in these cases included
percutaneous (puncture / cut injury) exposure (48 cases), mucocuta-
neous exposure, and unknown.
Transmission of HIV to six patients of a single dentist with AIDS has
been reported, but the mode of transmission could not be determined.
Clinical Features:
Because of oral signs and symptoms of HIV infection, dental pro-
fessionals may be the first to either refer or make the diagnosis of
HIV infection and/or AIDS. Common oral findings caused by HIV may
include:
1. Candidiasis.
This may be the first sign or symptom of HIV infection.
Intraoral infection is frequently accompanied by angular
chelitis.
2. Hairy leukoplakia (HL).
A common manifestation of AIDS, HL appears as corru-
gated white lesions, nearly always occurring on the lateral
borders of the tongue.
3. Periodontal disease.
Progressive and premature periodontal disease is a rela-
tively frequent finding in HIV-infected individuals. HIV-as-
sociated periodontal disease is often rapidly progressive
and painful.
Other relatively common oral findings include:
4. Warts associated with human papilloma virus types.
5. Herpetic infections, which appear to be related to factors

65
 permitting more frequent and severe activation of herpes
simplex virus.
6. Recurrent aphthae.
7. Autoimmune xerostomia.
Diagnosis:
History and clinical criteria are of the essence in the provisional di-
agnosis of HIV infection but laboratory investigations are required for
confirmation of the disease. A blood test can be used to determine the
presence of antibodies to HIV before symptoms appear. A negative
test, also known as a seronegative result, means that no infection was
present at the time of the test. However, negative result does not rule
out the possibility of HIV infection, because there is a ‘window’ period
between acquisition of infection and the development of antibodies,
and most people develop detectable antibodies within 6 months of in-
fection. The test should be repeated few months later.
More recent technical improvements in testing have resulted to the
ability to quantify the viral load in the blood. The use of PCR test (poly-
merase chain reaction test that is used to detect ribonucleic acid from
the HIV virus) and viral load testing have improved the possibility of di-
agnosing early HIV infection, predicting the probability of transmission,
predicting the progression in the chronically infected and assessing the
need for antiviral therapy.
Prophylaxis and Treatment:
The HIV has a characteristic of mutating, increasing the difficulty
of development of effective drugs and vaccines for the virus. Because
there is no effective vaccine, education and behavioral change are the
main methods of controlling the spread of the disease.
Animal studies have found that post-exposure prophylaxis (PEP)
prevented retroviral infection or decreased its rate in some cases; ef-
ficacy was lower with delayed time to treatment, shorter duration of
therapy, or decreased dose. It is largely unknown, however, how much
these animal studies can be extrapolated to humans. In a retrospec-
tive case-control study among HCP, PEP was associated with an 81%

66
decrease in the risk of HIV seroconversion after percutaneous expo-
sure to HIV-infected blood. Failure of PEP to prevent HIV infection in
HCP has been reported in at least 21 instances. Possible factors have
included exposure to a resistant strain, high titer of large inoculum, de-
layed initiation or short duration of the regimen, and host factors such
as diminished cellular immune response.
Currently, two or three drugs are recommended for PEP regimes.
Zidovudine (ZDV) and Lamiduvine (3TC) for 4 weeks is the recom-
mended regime. If the risk of transmission is high, a third drug, notably
protease inhibitor, for instance Indinavir, can be added to the regimen,
over the four week course of treatment.
In the event of contraction of the disease, there are medical thera-
pies that may delay its progression; however, there is no cure. The
current standard of care is using primary and secondary chemoprophy-
laxis for the prevention of opportunistic infections (OI), which continue
to be frequent causes of death in people infected with HIV. Maintaining
a CD4 cell count above 200 is considered a primary strategy in pre-
vention of OIs. Controlled clinical trials have shown the use of HAART
to inhibit HIV replication, suppress the viral load, sustain this suppres-
sion, significantly improve immune function, markedly reduce morbid-
ity and mortality of HIV/AIDS, reduce the incidence of OI, and reduce
deaths by 60% to 80%.
Control Measures:
• All body fluids except sweat (e.g. blood, saliva, gingival fluid and
pus), from all dental patients should be considered infective.
• All sharp items (e.g., needles, scalers, burs, lab knives, and
wires) that are contaminated with fluid or material, regardless of
whether it is visible or not, are considered as potentially infec-
tive.
• Standard precautions , engineering controls and work practices
are established, and must be observed, to prevent injuries.
• The written, comprehensive program designed to minimize and
manage DHCP exposures to blood and body fluids must be im-
plemented.

67
 • Dental Health Care Personnel:
- All DHCP must follow the recommended standard precau-
tions for all patients.
- All DHCP will be screened for HIV before recruitment.
Non-Saudi DHCP will be screened for HIV before recruit-
ment and travelling to the Kingdom and again on arrival.
HIV screening is done every two years for iqama renewal
for DHCP coming from Ethiopia, Eritrea, Kenya, Somalia,
Djibouti, Thailand, Nigeria, Sudan, Nepal, and Vietnam..
- Any DHCP who become HIV positive should notify the
employer immediately so a decision can be made regard-
ing whether this individual will continue to provide patient
care. Decisions are made on the basis of a case-by-case
evaluation of the circumstances.
- Any DHCP who is HIV positive should not perform expo-
sure-prone invasive procedures (see Work Restrictions).
Management of Exposures to HIV:
Management of the health-care worker who has had a parenteral
(e.g., needle stick or cut) or mucous membrane (e.g., spatter to the
eye or mouth) exposure to blood or bloody secretions from an HIV
positive patient should include the following:
1. Hands, mucous membrane and other skin surfaces that are
contaminated with blood or bloody fluids or secretions should
be washed immediately and thoroughly. A skin puncture
should be encouraged to bleed and the wound should then be
washed thoroughly.
2. An incident report should be written including information of
the location and medical file number of the source (patient)
and health care worker.
3. Confirmation that the source patient is HIV positive should be
made.
4. Dental health care personnel should be evaluated serologi-

68
 cally for HIV antibody as soon as possible after the exposure
to establish serostatus before exposure. If DHCP is seronega-
tive, he/she should be tested at six weeks, and again at three,
six, and 12 months following exposure to determine whether
transmission has occurred. Most exposed persons who have
been infected will seroconvert during the first 12 weeks after
exposure.
5. No further follow-up of DHCP as described above is neces-
sary if the source patient is seronegative, unless the source
patient is at high risk of HIV infection.
6. Because most occupational exposures to HIV do not result in
transmission, the decision to recommend PEP must balance
the risk of infection (represented by details of the exposure
itself and information about the exposure source) with the ef-
ficacy and adverse side effects of PEP.
7. If a decision is made to use post-exposure prophylaxis, it
should be initiated as soon as possible preferably within 24-36
hours (Table 5).

69
 Table 5
Recommended HIV Postexposure Prophylaxis for Percutaneous Injuries:
Infection status of source
Exposure Source has HIV
type HIV positive HIV positive Unknown
unknown nega-
class 1a class 2a sourcec
HIV statusb tive
Generally,
Gener-
no PEP war-
ally, no PEP
ranted, but
warranted,
consider
but con-
Recom- Recommend basic 2-drug No PEP
sider basic
Less severed mend basic expanded PEPe in set- war-
2-drug
2-drug PEP 3-drug PEP tings where ranted
PEPe for
exposure in
source with
HIV-infected
HIV risk
persons is
factorsf
likely
Generally,
Gener-
no PEP war-
ally, no PEP
ranted, but
warranted,
consider
Recom- but con-
Recommend basic 2-drug No PEP
mend sider basic
More severe g
expanded PEPe in set- war-
expanded 2-drug
3-drug PEP tings where ranted
3-drug PEP PEPe for
exposure to
source with
HIV infected
HIV risk
persons is
factorf
likely
a
HIV positive, class I – asymptomatic HIV infection or known low viral load (<1,500 RNA copies mL) HIV
positive, class 2 –symptomatic HIV infection.
b
Source of unknown HIV status (e.g. deceased source person with no samples available for HIV test-
ing)
c
Unknown source (e.g. a needle for a sharps disposal container)
d
Less severe (e.g. a solid needle and superficial injury)
e
“Consider PEP” indicates that PEP is optional and should be based on an individualized decision by
the exposed person in consultation with the treating clinician.
f
If PEP is taken and the source is less determined to be HIV negative, PEP should be discontinued.
g
More severe (e.g. large-bore hollow needle, deep puncture, visible blood on device, or needle used in
patient’s artery or vein).

Source: Cleveland and Cardo [28]

70
 Respiratory Infections

Respiratory infections are the most common microbial disease found

in humans. Diseases resulting from acute respiratory illness such as
influenza, tuberculosis and pneumonia, are responsible for over 10%
of the global deaths following microbial infection. Etiologies of respira-
tory infections are quite varied, as numerous viruses, bacteria, fungi,
and parasitic microbes are involved. [6]

General Features of Microbial Respiratory

Infections [6]
Bacterial Infections
Noninvasive bacterial infections lead to inflammation of the site of
the local infection. More severe invasive diseases are associated with
fever and white cell infiltration. Syndromes range from localized infec-
tions to aggressive pneumonias. Examples of bacterial respiratory in-
fections include tuberculosis, pneumococcal pneumonia, legionelosis,
tularemia, plague, anthrax. Most can be effectively treated with appro-
priately administered antibiotics.
Viral Infections
Viral respiratory infections are the leading cause of human disease,
hospitalization, and mortality. Syndromes range in severity from mild
colds to acute and chronic pneumonias, and most cannot be treat-
ed with antimicrobial chemotherapy. These infections are the leading
cause of inappropriate antibiotic use.
Mycotic and Parasitic Infections
Many mycotic and parasitic infections are associated with chronic
infection and pneumonias. Increased susceptibility to such diseases
are found with immune compromised persons.

71
 Upper Respiratory Tract Infections

It is conventional to divide the respiratory tract into two parts; upper

and lower. The upper respiratory tract is comprised of the nasal cavity,
nasopharynx, and larynx. The trachea, bronchi, and lungs constitute
the lower respiratory tract.
Infections of the upper respiratory tract are more common than
any other microbial disease. Many infections are self-limiting but can
lead to more serious secondary sequelae in certain susceptible indi-
viduals. Many of the microorganisms responsible for upper respiratory
tract infections have been isolated in dental aerosols. Dental students
have been shown to experience a consistently higher incidence of up-
per respiratory tract infections than their counterparts in medical and
pharmacy schools. A positive correlation also has been demonstrated
between the incidence of common cold epidemics in patients and in
DHCP who treated them. [6]

Common Cold [6, 12-13]

Causative Microorganism:
Several viruses can cause the common cold, but rhinoviruses are
by far the most common. Rhinoviruses are RNA viruses that have an
incubation period of 1 to 4 days leading to onset of acute symptoms.
Transmission of the Disease:
Actual shedding of the virus usually precedes the onset of clinical
symptoms by 1 to 2 days, but peak viral secretion occurs during the
symptomatic phase. Rhinoviruses are spread by aerosols and direct
person to person contact via contaminated hands. Viruses from infect-
ed people are airborne in droplet nuclei that are emitted during respira-
tion, talking, sneezing, and coughing. These viruses are also able to
remain viable on skin and environmental surfaces for hours.
High Risk Groups:
Predisposing factors for susceptibility include physical and emotion-
al stress, and allergic nasopharyngeal disorders.

72
Clinical Features:
Signs and symptoms include profuse nasal discharge, sneezing,
headache, fever malaise, dryness, soreness, hoarseness, and tick-
ling of the throat. Nasal secretions during the symptomatic period are
clear or mucoid in appearance. As the illness progresses a cough may
appear as an increasingly prominent symptom lasting up to 2 weeks.
Smell and taste are frequently impaired.
In the absence of complications, signs and symptoms resolve in 4
to 10 days. Secondary bacterial infections are frequent and consist of
suppuration in the nasopharynx with involvement by direct extension
from the nose to the paranasal sinuses, ears, mastoids, pharynx, lar-
ynx, trachea, bronchi and lungs.
Diagnosis:
Diagnosis is usually presumptive. When a specific diagnosis is need-
ed, biochemical and molecular biological procedures are available.
Prophylaxis and Treatment:
Treatment of the common cold includes rest, sufficient fluids to pre-
vent dehydration, and a light, palatable, well balanced diet.
Nasal decongestants may provide temporary relief. An analgesic/
antipyretic agent may be given. Cough may be reduced by stream in-
halation, with cough-suppressant syrups, or with an expectorant, an
agent that promotes the ejection of mucus or exudates from the tra-
chea, bronchi, and lungs.
Control Measures:
• The application of standard precautions including respiratory
hygiene/cough etiquette may reduce the spread of infection.
• It is neither necessary nor feasible to restrict all personnel with
acute upper respiratory infection from taking care of patients
who are not in high-risk groups.
• Dental health care personnel with respiratory infections should
not treat high– risk groups such as the elderly, patients with
chronic underlying illness, or immunocompromised patients.

73
 Influenza [6, 12-13, 27, 49-50]
Causative Microorganism:
Influenza is an acute respiratory infection caused by influenza vi-
ruses. These viruses are single stranded, helical shaped RNA viruses
classified in the family Orthomyxoviridae.
The typical incubation period for influenza is 1- 4 days. In most cas-
es infection results in self-limited disease. However, some viral strains
have the capacity to cause more severe disease, thereby leading to
potentially life-threatening pneumonia in susceptible people.
There are three influenza virus types, termed A, B, and C, which
are distinguished by specific antigenic differences in viral components.
Influenza A and B viruses cause seasonal epidemics. Influenza type
C infections cause a mild respiratory illness and are not thought to
cause epidemics. Influenza A viruses are divided into subtypes based
on two proteins on the surface of the virus: the hemagglutinin (H) and
the neuraminidase (N). There are 16 different hemagglutinin subtypes
and 9 different neuraminidase subtypes. Influenza A viruses can be
further broken down into different strains.
New viral strains may evolve through antigenic shift (a sudden shift
in the antigenicity of a virus resulting from the recombination of the ge-
nomes of two viral strains, and seen only with influenza A viruses), and/
or antigenic drift (mutation of viruses and their antibody-binding sites
which may occur in both influenza A and influenza B viruses). The
current subtypes of influenza A viruses found in humans are A (H1N1)
and A (H3N2).
Swine flu, which is a respiratory disease of pigs, is caused by a
type A influenza virus that regularly causes outbreaks of influenza in
pigs. Like all influenza viruses, the swine flu virus changes constantly.
Through antigenic shift, the different species of influenza viruses that
infect pigs can evolve into new viruses that are a mix of swine, human
and/or avian flu viruses. Such novel H1N1 virus can be transmitted
from one human to another.

74
Comparison of Influenza Types
1. Type A
• Natural hosts are wild birds.
• Can infect birds, people, pigs, and other animals.
• Subtypes based on antigenic differences of hemagglutinin
(HA) and neuraminidase (NA) surface proteins.
• Can cause moderate to severe disease.
• Can undergo antigenic shift and antigenic drift.
• Can cause large pandemics with high mortality.
2. Type B
• Human infection only.
• Primarily infects children.
• Generally cause milder disease than type A viruses.
• Severe cases of flu generally found in elderly or high-risk
persons.
• Can undergo antigenic drift.
• Do not cause pandemics, only seasonal epidemics.
3. Type C
• Rarely reported as cause of human influenza.
• Most infections are asymptomatic.
• No epidemics seen.
Transmission of the Disease:
Influenza viruses are spread from person to person primarily through
large-particle (≥ 5 µm) respiratory droplet remission when an infected
person coughs and sneezes near a susceptible person. Transmission
via large-particle droplets requires close contact between source and
recipient persons, because droplets do not remain suspended in the
air and generally travel only a short distance (1 meter) through the air.
Contact with respiratory droplet contaminated surfaces is another po-
tential source of transmission.
Adults can be infectious from the day before symptoms begin

75
 through approximately 5 days after onset of illness. Children can be
infectious for ≥10 days after onset of symptoms.
Clinical Features:
Uncomplicated influenza illness is characterized by the abrupt onset
of fever, myalgia, headache, nonproductive cough, sore throat, and
rhinitis.
In children otitis media, nausea, and vomiting are also common.
Cough and malaise can persist for more than 2 weeks.
Influenza virus infections can cause primary influenza viral pneu-
monia, exacerbate underlying pulmonary or cardiac disease, lead to
secondary bacterial sinusitis, otitis, and pneumonia, or predispose to
co-infections with other viral and bacterial pathogens. Rarely, enceph-
alopathy, myositis, myocarditis, pericarditis and Reye syndrome (fatal
disease that causes numerous detrimental effects to many organs, es-
pecially the brain and liver, as well as causing a lower than usual level
of blood sugar) have been reported.
Diagnosis:
In the absence of laboratory confirmation, it is difficult to distinguish
between influenza and illnesses caused by other respiratory patho-
gens based on signs and symptoms alone. The diagnosis of influenza
should be considered in any patient with respiratory symptoms or fever
during the influenza season.
Prophylaxis and Treatment:
Annual vaccination against current influenza A and B subtypes is
the most effective method of preventing infection and has been shown
to reduce associated complications. Preventing influenza among HCP
who might serve as sources of influenza virus transmission provides
additional protection to patients at risk for influenza complications. An-
nual vaccination has been strongly recommended for HCP by the U.S.
Centers for Disease Control, Advisory Committee on Immunization
Practices (ACIP).
Antiviral agents with activity against influenza viruses can be effec-

76
tive for the chemoprophylaxis and treatment of influenza.
Control Measures:
• The application of standard precautions, including respiratory
hygiene/cough etiquette, in addition to droplet precautions
may reduce the spread of infection. The droplet precautions
could be terminated after 5 days from onset of symptoms.
• The application of airborne, droplet and contact precautions in
addition to standard precautions are needed for patients with
H1N1 infection.
• Dental health care personnel with fever and upper respiratory
infection during atypical flu outbreaks should take a sick leave
for two (2) days until laboratory results are available. If H1N1
infection is confirmed, sick leave should be extended up to 7
days from the first day of fever.
• It is neither necessary nor feasible to restrict all personnel with
acute upper respiratory infection from taking care of patients
who are not in high-risk groups.
• Dental health care personnel with respiratory infections should
not treat high– risk groups such as the elderly, patients with
chronic underlying illness, or immunocompromised patients.

Rhinosinusitis [6, 12-13, 51-52]

Causative Microorganism:
Rhinosinusitis is characterized by inflammation of the paranasal si-
nuses because of viral, bacterial, or fungal infections, or allergic condi-
tions.
The most common bacterial organisms in community-acquired acute
bacterial rhinosinusitis are Streptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus aureus, and Moraxella catarrhalis. The
most common viruses in acute viral rhinosinusitis are rhinovirus, ad-
enovirus, influenza virus, and parainfluenza virus. Respiratory viruses
cause most cases of acute rhinosinusitis, and the initial viral infection
may be followed by a secondary bacterial infection. Anaerobe bacteria
may play a role in chronic rhinosinusitis.

77
 Transmission of the Disease:
Rhinosinusitis can be transmitted in hospitals and dental settings
by droplet and contact transmission. S. pneumonia, H. influenza, and
anaerobes have been identified in dental aerosols and contaminated
water lines.
Clinical Features:
Acute and chronic rhinosinusitis produce similar clinical signs and
symptoms. Maxillary sinusitis produces pain over the affected sinus,
toothache, and a frontal headache. Frontal sinusitis produces pain
over the frontal sinus and a frontal headache. Ethmoid sinusitis pro-
duces pain behind the eyes and a frontal headache. Sphenoid sinusitis
is characterized by malaise and pain referred to the frontal and or oc-
cipital areas.
Diagnosis:
Acute bacterial rhinosinusitis is correctly diagnosed about half the
time based on clinical impressions. Acute bacterial rhinosinusitis and
viral rhinosinusitis are difficult to differentiate. Bacterial rhinosinusitis
may be present if symptoms have been present for more than 7 days
and there is localization to the maxillary sinus. Bacterial culture of se-
cretions may be used when resistant pathogens are suspected or if the
patient is immunocompromised.
In both acute and chronic rhinosinusitis, the edematous mucous
membrane and retained exudates cause the affected sinus to appear
radiographically radiopaque. However, sinus radiography is not recom-
mended for routine evaluation of acute, uncomplicated bacterial rhi-
nosinusitis.
Prophylaxis and Treatment:
Symptoms usually resolve within 7–11 days, and most people re-
cover without medical treatment.
Symptomatic treatment is recommended for patients with acute viral
rhinosinusitis; however, if a patient has acute bacterial rhinosinusitis,
symptomatic and antibiotic treatment is recommended. Symptomatic

78
treatment may include antipyretics, analgesics, decongestants, anti-
histamines mucolytics, intranasal corticosteroids, and saline nasal ir-
rigation.
Antibiotics may be considered in patients with symptoms or signs
of acute rhinosinusitis that do not improve within seven days or that
worsen at any time; in those with moderate to severe pain or a temper-
ature of 101°F (38.3°C) or higher; and in those who are immunocom-
promised. For patients allergic to penicillin, trimethoprim/sulfamethox-
azole (Bactrim, Septra) or a macrolide may be used. Rhinosinusitis not
responding to antibiotic therapy may require surgical intervention.
Control Measures:
• The application of standard precautions including respiratory
hygiene/cough etiquette may reduce the spread of infection.
• Dental health care personnel with fever and upper respiratory
infection should take a sick leave for two (2) days and may
return to work after initiation of appropriate chemotherapy, de-
pending on their clinical status.
• It is neither necessary nor feasible to restrict all personnel with
acute upper respiratory infection from taking care of patients
who are not in high-risk groups.
• Dental health care personnel with respiratory infections should
not treat high –risk groups such as the elderly, patients with
chronic underlying illness, or immunocompromised patients.

Pharyngitis [6, 13, 53]

Causative Microorganism:
Acute pharyngitis is usually of viral origin (i.e. rhinovirus, coronavi-
rus, influenza A and B viruses, parainfluenza virus, enterovirus, adeno-
virus, Epstein Barr virus, herpes simplex virus (HSV), cytomegalovirus,
and HIV), but it may also be caused by group A beta-hemolytic strep-
tococci (GABHS), Mycoplasma pneumonia, Chlamydia pneumonia, or
other bacteria. Streptococcus pyogenes is the most common bacterial
cause of acute pharyngitis.

79
 The incubation period for GABHS is 2-5 days, and that for viral phar-
yngitis can reach up to 2 weeks.
Transmission of the Disease:
Viral pharyngitis, and bacterial pharyngitis caused by streptococcus
pyogenes (which have been isolated from dental aerosols) are spread
by droplet and contact transmission.
Patients with GABHS are considered noncontagious 24 hours after
starting therapy.
Clinical Features:
The hallmark of pharyngitis is a sore throat and pain when swallow-
ing. The pharyngeal mucosa is erthyematous and edematous and may
be covered by pseudomembraneous purulent exudates. Fever and
cervical lymphadenopathy are present.
If untreated, a patient with S. pyogenes pharyngitis can develop sup-
purative and nonsuppurative complications. Suppurative complications
include otitis media, sinusitis, peritonsillar/ retropharyngeal abcesses,
or mastoiditis. The major nonsuppurative complication is rheumatic fe-
ver, a complication that is more likely to occur in children with S. pyo-
genes pharyngitis than in adults with this bacterial infection.
Signs and symptoms of recent fever, tender anterior cervical lymph-
adenopathy, red pharynx and/or tonsillar swelling or exudate, and no
cough indicate a higher probability of GABHS for both adults and chil-
dren. In addition to rheumatic fever, post-streptococcal glomerulone-
phritis (PSGN) may occur following GABHS infection (usually occurs
after a streptococcal skin infection). Treating GABHS pharyngitis does
not appear to diminish the risk of PSGN.
Diagnosis:
Definitive diagnosis requires culture and susceptibility testing.
Prophylaxis and Treatment:
Treatment includes rest and the administration of acetaminophen to
relieve pain. A regimen of penicillin or erythromycin is initiated to pre-
vent rheumatic fever for those patients with clinical evidence of bacte-

80
rial pharyngitis, while awaiting the results of culture and susceptibility
testing.
Control Measures:
• The application of standard precautions including respiratory
hygiene/cough etiquette may reduce the spread of infection.
• Dental health care personnel with fever and upper respiratory
infection should take a sick leave for two (2) days and may
return to work after initiation of appropriate chemotherapy, de-
pending on their clinical status.
• It is neither necessary nor feasible to restrict all personnel with
acute upper respiratory infection from taking care of patients
who are not in high-risk groups.
• Dental health care personnel with respiratory infections should
not treat high –risk groups such as the elderly, patients with
chronic underlying illness, or immunocompromised patients.

Laryngitis [6, 13, 54]

Laryngitis is defined as inflammation of the larynx. Acute laryngitis
may occur during the course of a common cold and influenza or as a
complication of measles, pertussis, bronchitis, or pneumonia. Exces-
sive talking or singing, allergies and breathing substances such as to-
bacco smoke and certain chemicals also can cause acute laryngitis.
Transmission of the Disease:
Laryngitis is transmitted by contact and droplet transmission.
Clinical Features:
In acute laryngitis, the throat is sore and the voice is hoarse. Lat-
er the patient may lose his or her voice altogether. A hoarse or weak
voice associated with the common cold may be differentiated from that
caused by layngitis by the duration; hoarseness associated with the
common cold will usually disappear after 2 or 3 days. A cough is usu-
ally present but is nonproductive unless there is associated tracheitis
and bronchitis. Malaise, fever, and/ or dysphasia may be present in
more severe infections. Pain is absent or minimal.

81
 Diagnosis:
Direct laryngoscopy may reveal mild or moderate erythema and
edema of the mucous membranes. In chronic laryngitis, the vocal cords
may be thickened and red.
Prophylaxis and Treatment:
Resting the voice, use of steam inhalations and drinking plenty of
water promote relief of symptoms associated with acute viral laryngitis.
Control Measures:
• The application of standard precautions including respiratory
hygiene/cough etiquette may reduce the spread of infection.
• Dental health care personnel with fever and upper respiratory
infection should take a sick leave for two (2) days and may
return to work after initiation of appropriate chemotherapy, de-
pending on their clinical status.
• It is neither necessary nor feasible to restrict all personnel with
acute upper respiratory infection from taking care of patients
who are not in high-risk groups.
• Dental health care personnel with respiratory infections should
not treat high –risk groups such as the elderly, patients with
chronic underlying illness, or immunocompromised patients.

Pertussis [13, 27, 55]

Pertussis, a respiratory illness commonly known as whooping
cough, is a highly contagious infection.
Causative Microorganism:
Pertussis is caused by a type of bacteria called Bordetella pertussis.
These bacteria attach to the cilia that line part of the upper respiratory
system. The bacteria release toxins, which damage the cilia and cause
inflammation. The incubation period is generally 7–10 days but can be
as long as 21 days.

Transmission of the Disease:

Transmission occurs by direct contact with respiratory secretions or

82
large aerosolized droplets from the respiratory tract of infected persons
(by coughing or sneezing). The period of communicability starts with
the onset of the catarrhal stage and extends into the paroxysmal stage
(see Clinical Features).. The disease can be transmitted from adults to
close contacts, especially unvaccinated children. Vaccinated adoles-
cents and adults, whose immunity from childhood vaccinations wanes
5–10 years after the most recent dose of vaccine (usually administered
at age 4–6 years), are an important source of pertussis infection for
susceptible infants.
In hospital settings, transmission of pertussis has occurred from
hospital visitors to patients, from HCP to patients, and from patients
to HCP.
Clinical Features:
Symptoms of early pertussis (catarrhal phase) are indistinguish-
able from other upper respiratory infections. These early symptoms
(catarrhal stage) can last for 1 to 2 weeks and usually include: runny
nose; low-grade fever (generally minimal throughout the course of the
disease), mild and occasional cough; and apnea in infants. Because
pertussis in its early stages appears to be nothing more than the com-
mon cold, it is often not suspected or diagnosed until the more severe
symptoms appear. Infected people are most contagious during this
time, up to about 2 weeks after the cough begins.
As the disease progresses, the traditional symptoms (paroxysmal
stage) of pertussis appear and include: paroxysms (fits) of many rapid
coughs followed by a high-pitched “whoop” that continues for weeks;
vomiting; exhaustion (very tired) after coughing fits. Paroxysmal stage
lasts for 1-6 weeks and may extend up to 10 weeks. Coughing fits
generally become more common and severe as the illness continues,
and can occur more often at night. Pertussis can cause serious and
sometimes life-threatening complications in infants and young chil-
dren, especially those who are not fully vaccinated. Infants too young
to be vaccinated are at greatest risk for severe pertussis, including
hospitalization and death.
The illness can be milder (less severe) and the typical “whoop” ab-

83
 sent in children, teens, and adults who have been vaccinated.
Recovery from pertussis can happen slowly. The cough becomes
less severe and less common. However, coughing fits can return with
other respiratory infections for many months after pertussis started.
Prophylaxis and Treatment:
Pertussis is generally treated with antibiotics and early treatment is
very important. Treatment may make the infection less severe if it is
started early, before coughing fits begin, and it may shorten the amount
of time someone is contagious.
Vaccinations are available for children for diphtheria, tetanus toxoids
and acellular pertussis (DTaP vaccine). The pertussis booster vaccine
for adolescents and adults is called Tdap.
Control Measures:
• The application of standard precautions including respiratory
hygiene/cough etiquette in addition to droplet precautions may
reduce the spread of infection.
• The droplet precautions could be terminated after 5 days of
starting effective antimicrobial therapy.
• Postexposure prophylaxis is necessary for HCP in contact
with persons at risk for severe disease.
• Other HCP either should receive postexposure prophylaxis or
be monitored for 21 days after pertussis exposure and treated
at the onset of signs and symptoms of pertussis.
• Recommended postexposure prophylaxis antibiotics for HCP
exposed to pertussis include azithromycin, clarithroymycin, or
erythromycin.
• Dental health care personnel with active Pertussis and ex-
posed symptomatic DHCP should be excluded from duty from
the beginning of the catarrhal stage through 3rd week after
onset of paroxysms (active DHCP) or until 5days after start of
effective antimicrobial therapy (active and exposed symptom-
atic DHCP).

84
 Lower Respiratory Tract Infections
Acute Tracheobronchitis [6, 56]
It is an inflammatory response of the tracheobronchial tree to infec-
tions. Acute bronchitis usually follows an upper respiratory tract infec-
tion that extends into the trachea and bronchi, and results in cough
and sputum production. Environmental pollutants and the inhalation of
various allergens are predisposing or contributory factors.
Causative Microorganism:
Viruses are by far the most common etiologies (i.e. Respiratory syn-
cytial virus (RSV), Adenovirus, Influenza, and Parainfluenza viruses).
In young adults acute bronchitis may be associated with Mycoplasma
pneumonia, Bordetella pertussis, and Chlamydia pneumonia infections.
Transmission of the Disease:
Tracheobronchitis is spread by droplet and contact transmission.
Clinical Features:
The disease causes soreness behind the sternum and a dry, painful,
nonproductive cough. The patient wheezes and has difficulty breath-
ing. Acute tracheobronchitis is a self-limiting disease in healthy adults
and most symptoms resolves within 2 weeks, but the cough can last for
up to 8 weeks in some people.
As secondary bacterial infection occurs, thick purulent sputum is
produced. Malaise and fever for up to 5 days is common. Persistent
fever suggests complicating pneumonia.
Diagnosis:
Diagnosis is usually based on clinical signs and symptoms. Gram
stain and culture should be performed to identity the causative organ-
ism. A chest x-ray is also indicated to rule out other diseases for pa-
tients presenting with severe disease symptoms.
Prophylaxis and Treatment:
Rest, oral fluids, and an antipyretic are indicated. Antibiotics are in-

85
 dicted when purulent sputum is present, when high fever persists, and
in patients with chronic obstructive pulmonary disease.
Control Measures:
• The application of standard precautions including respiratory
hygiene/cough etiquette may reduce the spread of infection.
• Dental health care personnel with fever and respiratory infec-
tion should take a sick leave for two (2) days and may return
to work after initiation of appropriate chemotherapy, depend-
ing on their clinical status.
• It is neither necessary nor feasible to restrict all personnel with
acute respiratory infection from taking care of patients who
are not in high-risk groups.
• Dental health care personnel with respiratory infections should
not treat high –risk groups such as the elderly, patients with
chronic underlying illness, or immunocompromised patients.

Pneumonia [6, 13]

Staphylococcal pneumonia occurs primarily in children, patients
with altered pulmonary function, and hospitalized patients. This life-
threatening secondary infection is frequently noted during influenza
epidemics.
Causative Microorganism:
Bacteria are the most common causes of pneumonia. Defective leu-
kocyte activity predisposes patients to infections with pneumococci,
streptococci, Haemophilus influenza, and Pneumocystic carinii. Strep-
tococcus penumoniae (pneumococci) strains are responsible for 98%
of the infections, with staphylococci accounting for 1%.
Transmission of the Disease:
The organisms are spread by droplet nuclei (inhalation) and by as-
piration from the upper respiratory tract.
Clinical Features:
Signs and symptoms include a rapidly rising fever, a painful cough,
and the production of purulent sputum sometimes mixed with blood

86
(hemoptysis). The patient experiences pain on respiration, and as a
result, breathing becomes rapid and shallow.
Diagnosis:
Diagnosis is based on clinical signs and symptoms in conjunction
with the radiographic distribution of the infiltrate. Culturing expectorated
sputum is the most practical method of identifying bacterial pathogens. A
lung biopsy may be required to determine a specific etiological agent.
Prophylaxis and Treatment:
Treatment consists of respiratory support and the administration of
appropriate antimicrobial agents.
Control Measures:
• The application of standard precautions including respiratory hy-
giene/cough etiquette in addition to droplet precaution (in case
of pneumonia caused by Haemophillus influenza type b and
Neisseria Meningitidis ) may reduce the spread of infection.
• Dental health care personnel with fever and respiratory infec-
tion should take a sick leave for two (2) days and may return
to work after initiation of appropriate chemotherapy, depend-
ing on their clinical status.
• It is neither necessary nor feasible to restrict all personnel with
acute respiratory infection from taking care of patients who
are not in high-risk groups.

Legionnaire’s Disease [4, 57]

Causative Microorganism:
The Legionella pneumophila bacterium is responsible for two acute
bacterial diseases: Pontiac fever and Legionnaires’ disease. The L.
pneumophila bacteria have been found to thrive in lakes, air-condition-
ing systems, shower heads, water distillation systems, and the biofilm
found in dental unit water lines.
Transmission of the Disease:
The bacteria are transmitted through aerosolization and aspiration

87
 of contaminated water and it is not transmitted from person to person.
Clinical Features:
The least serious form of infection is called Pontiac fever and causes
acute flu like symptoms with headache, high fever, dry cough, chills,
diarrhea, and pleural and abdominal pain. The more serious form of in-
fection is called Legionnaire’s disease and causes a very severe pneu-
monia. In individuals who are already immunocompromised or elderly,
the disease can be fatal.
Control Measures:
• Application of standard precautions.
• Regular cleaning and maintenance of different water lines.
• Regular cleaning and maintenance of air conditioning sys-
tems.

Tuberculosis [4, 6, 10, 13, 58-59]

Tuberculosis (TB), which is caused by the bacterium Mycobacte-
rium tuberculosis, is the leading cause of death worldwide from infec-
tious diseases. Although it involves primarily the lungs, it can affect any
organ or tissue, including the oral cavity.
Patients infected with Mycobacterium tuberculosis occasionally
seek urgent dental treatment at outpatient dental settings. Understand-
ing the pathogenesis of the development of TB will help DHCP deter-
mine how to manage such patients. Although the risk of transmission
of M. tuberculosis in dental settings is low, it is important for DHCP to
include protocols for TB infection control in their offices’ written infec-
tion control program.
Infection is most likely to occur when a patient has unsuspected pul-
monary or laryngeal TB, has bacillus-laden sputum or respiratory secre-
tions, and is coughing or sneezing into air that remains in circulation.
Epidemiology:
An estimated 2 billion persons (one-third of the world’s population)
are infected globally with M. tuberculosis. Most infections do not lead
to symptomatic TB.

88
 Active symptomatic disease is curable, yet TB kills 5,000 people
every day. This chronic infection is the single most frequent cause of
death in the world from one infectious agent. One symptomatic person
infects 10-15 others each year.
Causative Microorganism:
Mycobacterium tuberculosis is a rod-shaped tubercle bacillus car-
ried in airborne infective droplet nuclei. These small particles (1-5 µm)
can stay suspended in the air for hours and can be carried in normal
air currents throughout a room or building.
Transmission of the Disease:
Tuberculosis is not a highly contagious disease in that M. tubercu-
losis requires prolonged or frequent close contact with an infectious
source for transmission to a susceptible host. Infection occurs when a
susceptible person inhales droplet nuclei containing M. tuberculosis,
which then travel to the alveoli of the lungs. These droplet nuclei can
be generated when persons with pulmonary or laryngeal TB sneeze,
cough, speak, or sing. The probability that a person who is exposed to
M. tuberculosis will become infected depends on the concentration of
infectious droplet nuclei in the air and the duration of the exposure to
a person with infectious, active disease. Environmental factors such
as exposure in confined spaces, inadequate ventilation, and recircula-
tion of air containing infectious droplet nuclei further increase the likeli-
hood of transmission. Persons at highest risk for exposure to and infec-
tions with M. tuberculosis are close contacts (who share air space in a
household or other enclosed environment) of persons with pulmonary
tuberculosis.
Usually within 2-12 weeks after initial infection with M. tuberculosis,
immune response prevents further spread of the TB bacteria, although
they can remain alive in the lungs for years, a condition termed la-
tent TB infection (LTB1). Reactivation of these bacteria can occur fre-
quently as the result of malnutrition, debilitation, immunosuppression
(AIDS, immunosuppressive therapy, Diabetes Mellitus) or other forms
of stress. Persons with latent TB infection usually exhibit a reactive
tuberculin skin test (TST), have no symptoms of active disease, no

89
 radiographic abnormalities, no positive culture test, and are not infec-
tious. However, they can develop active disease later in life if they do
not receive treatment for their latent infection.
Ninety percent of people who are exposed to tuberculosis have la-
tent TB infection. They carry the microorganism without active symp-
toms. They do not transmit the disease at this stage; however, if resis-
tance is weakened, the tuberculosis may become active.
Risk in the Dental Operatory:
Tuberculosis is a great health risk for healthcare workers. One rea-
son for this is that the bacteria are able to withstand disinfectants that
kill many other bacteria. But, overall, the risk borne by DHCP for ex-
posure to a patient with active TB disease is probably low and TST
conversions among DHCP are also low.
While there is a paucity of data linking dental instrumentation to the
generation of droplet nuclei containing Mycobacterium tuberculosis, it
can be anticipated that DHCP and patients with infectious tuberculosis
(TB) will generate droplet nuclei by coughing, sneezing, laughing and
talking. The probable transmission of multiple drug-resistant tuberculo-
sis (MDRTB) disease from patients to 2 DHCP has been documented
and there is evidence of TB disease transmission from an oral surgeon
to 15 patients following extractions.
Clinical Features:
Symptoms of active TB disease include a productive and persis-
tent cough, bloody sputum, night sweats, fatigue, malaise, unexplained
weight loss, fever or anorexia or a combination of these. Infected spu-
tum may cause tuberculous tracheitis, laryngitis, and tuberculous ul-
cers on the tonsils, nasal and oral cavities.
Certain immunocompromising medical conditions (e.g., HIV) in-
crease the risk that TB infection will progress to active disease at a
faster rate. So, if any of the following signs are present, it may be nec-
essary to refer the patient for diagnosis and treatment before providing
dental care:
• A productive cough lasting longer than 3 weeks.

90
 • Unexplained fever, fatigue, night sweats, hoarseness or chest
pain.
• Unexplained weight loss and anorexia (loss of appetite).
• Being a member of a high-risk group.
Diagnosis:
Definitive diagnosis of active TB disease requires the demonstration
of bacteria in the patient’s tissues or secretions. Bacteriologic exami-
nation includes obtaining a specimen of sputum. Detection of acid-fast
bacilli (AFB) in stained smears examined microscopically can provide
the first bacteriologic clue to clinical disease. DNA probes specific for
the genus mycobacterium now are used routinely to identify specific
bacteria.
Presumptive diagnosis of M. tuberculosis infection clinically relies
on conversion of the infected person to a positive type IV( delayed)
hypersensitivity state as shown by the Tuberculin Skin Test (TST). Two
steps tuberculin skin test may be indicated annually for clinical person-
nel who risk exposure to this disease, but test results are not always
accurate. When there is any doubt concerning these test results, radio-
graphs and laboratory tests are necessary to establish a more defini-
tive diagnosis. The CDC recommends that persons with a positive TST
undergo further evaluation, including a chest radiograph to determine
whether the person has TB disease.
In some people infected with TB in the past, the body loses its ability
to react to the tuberculin antigen. When these people receive a TST
many years after the initial infection, they may have a negative reac-
tion. However, if they are tested a second time, they may have a posi-
tive reaction owing to a boosted response to the tuberculin solution. At
baseline testing, if the results of the first and second tests are negative,
the person is considered uninfected. If the first test result is positive
or the first test result is negative and the second result is positive, the
person should be evaluated by a physician for latent TB infection or
active disease.
New blood assays for M. tuberculosis (BAMTs), called “interferon

91
 gamma release assays” (IGRAs), have been developed for use as an
aid in diagnosing LTBI infection and TB disease. IGRAs can be used in
all circumstances in which the TST is currently used. The advantages
of the BAMT versus the TST are that:
1. it requires a single patient visit to draw a blood sample;
results can be available within 24 hours;
2. it does not boost responses (as measured by means
of subsequent tests), as can happen with the TST;
3. it is not subject to the reader bias that can occur with
the TST;
4. it is not affected by prior BCG vaccination (Bacillus
Calmette-Guérin, vaccine against Mycobacterium tu-
berculosis- see vaccination section).

The CDC 2005 revision of the TB infection control guidelines in-

cludes general recommendations regarding the use of blood assays
for M. tuberculosis as part of the infection control program in health
care settings.
Prophylaxis and Treatment:
The two most effective drugs that are used to treat the disease are
isoniazid and rifampin. However, multidrug resistant (MDR) TB is resis-
tant to the most effective first-line therapeutic drugs. The prevalence of
MDR TB has increased globally owing to the misuse and mismanage-
ment of anti-TB drugs, incomplete treatment, and an inadequate drug
supply.
There is no effective form of protective immunization against tuber-
culosis.
Control Measures:
• While standard precautions reduce the risk of occupational
exposure to most organisms responsible for upper respiratory
tract infections, they are inadequate to prevent the spread of
M. tuberculosis. Surgical masks do not prevent inhalation of
M. tuberculosis droplet nuclei. To prevent the cross infection
in these instances, transmission based precautions (airborne

92
 precautions) are necessary.
• The primary risk of exposure to M. tuberculosis in the dental
healthcare setting is contact with patients with undiagnosed or
unsuspected infectious disease.
• Minimum requirements in a community based dental health-
care setting is implementation and enforcement of a TB infec-
tion control protocol that provides for prompt: (a) identification
of patients with suspected or confirmed infectious TB disease,
(b) isolation of patients with suspected and confirmed TB dis-
ease from other patients and DHCP, and (c) referral of pa-
tients with suspected or confirmed symptomatic disease who
require dental healthcare to a facility with appropriate environ-
mental controls and respiratory protection controls.
• Dental health care personnel should be trained to recognize
signs and symptoms to help with prompt detection.
• While taking patients’ initial medical histories and at peri-
odic updates, dental DHCP should routinely ask all patients
whether they have a history of TB disease, symptoms indica-
tive of TB or medical conditions that increase the risk of TB
disease.
• Patients with a medical history or symptoms indicative of un-
diagnosed active TB should be referred promptly for medical
evaluation to determine possible infectiousness. Such pa-
tients should not remain in the dental-care facility any longer
than required to evaluate their dental condition and arrange
a referral. While in the dental health-care facility, the patient
should be isolated from other patients and DHCP, instructed
to observe strict respiratory hygiene and cough etiquette pro-
cedure and wear a surgical mask when not being evaluated.
When coughing or sneezing they should turn their heads away
from other persons and cover their mouth and nose with their
hands or preferably a cloth or tissue.
• Routine dental care should be postponed until a physician
confirms that the patient does not have infectious TB disease
or if the patient is diagnosed with active TB disease, until con-

93
 firmed the patient is no longer infectious.
• If urgent dental care is provided for a patient who has, or is
suspected of having active TB disease, the care should be
provided in a facility (e.g., hospital) that provides airborne in-
fection isolation.
• Dental Health Care Personnel:
- A tuberculosis screening and prevention program for
DHCP is important in protecting personnel and patients.
The facility’s level of TB risk will determine the need for
routine follow-up screening (Table 6).
- Screening Program:
• All newly arrived DHCP should have a chest x-ray, and
a two-step tuberculin skin test or single blood assay,
interferon gamma release assay prior to employment.
Those already known to have significant reactions
need not be retested.
• Any DHCP with a persistent cough (i.e., lasting>3
weeks), especially in the presence of other signs or
symptoms compatible with active TB (e.g., weight loss,
night sweats, fatigue, bloody sputum, anorexia, or fe-
ver), should be evaluated promptly.
• A two-step procedure can be used to minimize the like-
lihood of misinterpreting a boosted reaction as a true
conversion due to a recent infection. In the two-step
procedure, an initial tuberculin skin-test is given. If this
test result is 0-9 mm of induration, a second test is
given at least one week and no more than three weeks
after the first. The result of the second test is used as
the base line test in determining treatment and follow-
up of these personnel.
• For DHCP with documented negative tuberculin skin
tests and considered to be at significant risk, repeat
skin tests will be necessary on a yearly basis.
• Skin-test reaction after BCG vaccination may be quite

94
 variable, and it cannot be distinguished from that due
to virulent tuberculous infection. Caution is necessary
in attributing a significant skin-test reaction to previous
BCG vaccination, especially if the person vaccinated
has recently been exposed to infective tuberculosis.
Skin test reactivity tends to diminish with time, and by
10 years after BCG vaccination, most recipients do not
have a significant reaction (i.e., 10 mm or more of in-
duration). At any time, a reaction greater than 15 mm
is not likely to be due to BCG. It is prudent to manage
a significant reaction in BCG-vaccinated persons as a
possible tuberculous infection.
• All DHCP with positive test results should be evalu-
ated promptly for active disease. A thorough history
of exposure to M. tuberculosis should be obtained
to determine whether the infection is occupational or
community acquired. Baseline positive and newly pos-
itive DHCP (significant skin-test reaction), those who
have pulmonary symptoms that may be due to TB,
and those with documented treatment for LTB1 or TB
disease should receive one chest radiograph as part
of the evaluation to rule out TB disease. If the result
of the initial radiographic examination is negative no
further radiographs are necessary unless symptoms
suggestive of TB disease develop. Periodically, DHCP
with positive test results should be reminded about the
signs and symptoms of TB disease and the need for
prompt evaluation of any pulmonary symptoms.
- According to CDC guidelines, all dental settings, regard-
less of risk category, should develop a written TB infec-
tion control plan as part of their overall infection control
programs. Specifics of TB infection control programs will
differ, depending on whether patients with suspected or
confirmed TB are likely to seek treatment in each setting.
- According to CDC guidelines, all dental settings should

95
 also conduct an initial and annual assessment of the risk
of TB transmission, regardless of the likelihood of en-
countering people with TB disease.
- A dental setting’s TB infection control program should be
based on a three-level hierarchy of TB infection control
measures: administrative controls, environmental con-
trols and respiratory protection (RP) controls.

a. Administrative Controls
1. Assigning responsibility for managing TB infec-
tion control program.
2. Annual risk assessment should be conducted.
3. Written TB infection control policies should be
developed for promptly identifying and isolat-
ing patients with suspected or confirmed TB
disease for medical evaluation or urgent dental
treatment.
4. Patients should be instructed to cover mouth
when coughing and/or wear a surgical mask
5. Ensuring that DHCP are educated regarding
signs and symptoms of TB.
6. Ensuring that all newly hired DHCP are screened
for latent TB infection and TB disease.
7. Postponing of routine dental treatment.
b. Environmental Controls
1. Airborne infection isolation room should be
used to provide urgent dental treatment to pa-
tients with suspected or confirmed infectious
TB.
2. In settings with high volume of patients with
suspected or confirmed TB, high-efficiency
particulate air filters or ultraviolet germicidal ir-
radiation should be used.

96
 c. Respiratory Protection Controls
1. N95 (at a minimum) disposable respirators
should be used by DHCP when they are pro-
viding urgent dental treatment to patients with
suspected or confirmed TB.
2. TB patients should be instructed to cover
mouth when coughing and to wear a surgical
mask.

Table 6
Tuberculosis (TB) Risk Categories and Recommended Testing Fre-
quency

Risk Category Risk Classification TB Testing Frequency

Baseline, at hiring*;
Further testing not needed un-
People with TB disease
less exposure occurs
unlikely to be seen
Newly hired DHCP working in a
Low Fewer than three patients
low-risk setting
with unrecognized TB
should receive a baseline two-
treated in past year
step TST or a single
BAMT.
People with TB disease
likely to be seen
Medium Three or more patients Baseline*, then annually
with unrecognized TB
treated in past year
Evidence of ongoing Baseline*, then every 8 -10
Potential Ongoing
person-to-person weeks until evidence of transmis-
Transmission
transmission sion has ceased

Baseline screening should be conducted using a two-step tuberculin skin test or

single blood assay, interferon gamma release assay.
Source: Jensen, et al. [59]

Management of Exposure to M. tuberculosis:

1. As soon as possible after an exposure to M. tuberculosis
for whom proper isolation precautions have not been imple-
mented, TST or blood assay for M. tuberculosis (BAMT) test-

97
 ing should be done on DHCP known to have had negative
results from previous testing. If the initial post-exposure test
is negative, repeat the test 10-12 weeks after exposure ( the
upper limit of time required for an infected person to develop
hypersensitivity to tuberculin).
2. Those that have significant reactions on testing need chest
X-rays to exclude the possibility of tuberculous pulmonary
disease. If chest films are normal, these persons can be ad-
vised to receive preventive therapy (i.e., chemoprophylaxis
with oral isoniazid (INH) 300 mg and pyridoxine 25 mg daily
for 9-12 months). If the chest film has abnormalities compat-
ible with pulmonary TB, these personnel need evaluation to
rule out the possibility of active disease.
3. All DHCP with active TB disease should be excluded from
the workplace until documentation is provided from their
healthcare provider that they are: a) receiving adequate
therapy, (b) their cough has resolved and (c) that they have
had three consecutive sputum smears collected with nega-
tive results for AFB. After returning to work, they should
obtain periodic documentation from their healthcare provider
that effective drug therapy has been maintained for the rec-
ommended period of time and that sputum smears remain
negative for AFB.
4. Household contacts of DHCP who develops active pulmo-
nary tuberculosis will be screened and, if indicated, treated.

98
 Herpetoviruses [4, 7, 60]

A herpesvirus is a double-stranded DNA virus that causes infec-

tions. Of the many herpesviruses that have been identified, eight are
known to affect human:
1. Herpes Simplex Virus Type 1 (HSV 1), which causes primar-
ily oral lesions
2. Herpes Simplex Virus Type 2 (HSV 2), which causes primar-
ily genital lesions.
3. Herpes Zoster or Varicella-Zoster Virus (HZV) causes her-
pes zoster, shingles, and chickenpox.
4. The Cytomegalovirus (CMV) is normally latent (does not
produce disease) but may become active when the immune
system is damaged (once active, it is highly contagious and is
transmitted by most body fluids).
5. The Epstein-Barr virus (EBV) causes infectious mononucle-
osis and Burkitt’s lymphoma, which is a malignant neoplasm
involving lymphatic tissues.
6. Herpes Lymphotrophic Virus
7. Human Herpes Virus 7
8. Kaposi’s Sarcoma Related Virus

Herpes Simplex Virus Type I

Causative Microorganism:
This disease, which is highly contagious, makes its first appearance
in very young children (1 to 3 years of age) and is known as primary
herpes.
After this initial childhood infection, the virus of herpes simplex lies
dormant (residing in the neurons of either the trigeminal ganglion or
the sacral ganglia ) and reappears later in life. Recurrences tend to

99
 take place when the patient’s general resistance is lowered as a result
of stress, fever, illness, injury, and exposure to the sun. Care must be
taken by the patient because autoinfection (to the eye, nose, or geni-
tals, for example) is possible, as is infection of other people.
Clinical Features:
When clinical disease is evident, gingivostomatitis and pharyngitis are
the most frequent manifestation. The child may have a slight fever, pain in
the mouth, increased salivation, and bad breath. The inside of the mouth be-
comes swollen, and the gingivae are inflamed. Before the appearance of local
lesions, there may be burning sensation with slight swelling as prodrome.
Subsequently, a variable number of vesicles develop on the oral mucosa,
the tongue and gingiva. These vesicles eventually rupture and coalesce, and
crusting follows. The lesions are infectious, with viral shedding. The lesions
then develop into small round or irregular superficial ulcers with erythematous
halos and grayish-yellow bases. Healing begins naturally within 3 days, and
the illness is usually over in 7 to 14 days.
In the second stage of the disease, the characteristic sore usually appears
at the mucocutaneous junction of the lip or on the skin adjacent to the nostrils.
This manifestation is known as recurrent herpes labialis. As in the case of
primary herpes, recurrent herpes labialis sores heal by themselves in 7 to 10
days, leaving no scar.
Herpes simplex virus has been implicated in Bell’s palsy and in oral cancer.

Herpes Simplex Virus Type 2 [4, 13, 21, 60]

Causative Microorganism:
Herpes simplex virus type 2 is also known as genital herpes, but it
also occurs as an oral and perioral infection.
Herpes Transmission:
The major transmission route for the herpetovirus is through direct
contact either with primary or recurrent lesions or with secretions, such
as saliva, vaginal secretions or infected amniotic fluid, that contain the
virus when no lesions are obvious.

100
Risk in the Dental Operatory:
Herpes simplex viruses I and II are frequently in the mouth of dental
patients and may lead to serious infection for the dentist or staff. Den-
tists may develop an infection of the fingers (herpetic whitlow) which can
also be a primary or recurrent infection of HSV, causing severe pain on
pressure and inability to practice dentistry. Transmission results from
direct contact with a vesicular lesion on a patient’s lip or with saliva that
contains the viruses. Avoidance of direct contact with lesions, wearing
gloves for all contact with oral secretions, and thorough handwashing
after patient contact will protect DHCP from such infections.
Dental health care personnel with herpetic whitlow should not have
direct contact with patients until their lesions have healed. A dental
hygienist with herpes simplex virus I infection on her fingers reportedly
transmitted herpes gingivostomatitis to 20 patients.
Protective eyewear is particularly important because the most seri-
ous infection, ocular herpes, which can be a primary or recurrent infec-
tion of HSV, may lead to blindness. Transmission results from splashing
saliva or fluid from a vesicular lesion directly into unprotected eyes.
Clinical Features:
Within 1 week, clusters of painful blisters develop on the mucosal
tissue of the genital area. Once a person is infected, outbreaks will
recur even without reinfection. The disease can be transmitted only
during these recurrences.
A mother with active vaginal or cervical herpetic lesions at the time
of delivery can pass the virus to her newborn. Of the infants infected,
at least 85% may be born with severe health problems or deformities,
or killed by the virus.
Prophylaxis and Treatment:
Antiviral therapy can suppress HSV2 lesions. Acyclovir, an antiviral
drug, has been used in topical, oral, and intravenous forms. Acyclovir
is a selective inhibitor of replication of HSV and varicella-zoster virus.
It is established as the drug of choice for treatment of a wide range of
infections caused by HCV and VZV.

101
 Control Measures:
• Standard precautions should be applied to reduce the spread
of infection.
• When oral lesions are present, the patient may be asked to
reschedule his/ her appointment for a time after the lesions
have healed.
• If urgent dental care is provided for a patient with oral lesions,
contact precautions in addition to standard precautions should
be applied to reduce the spread of infection.
• Even when there are no active lesions, there is still the possi-
bility of transmission through saliva or the aerosol spray from
the dental handpiece.
• Because there is no preventive vaccine to protect against her-
pes, it is essential that precautions be taken to prevent expo-
sure.
• Dental health care personnel with herpetic whitlow should be
restricted from patient contact and contact with the patient’s
environment until lesions heal.
• For DHCP with orofacial lesion, restriction from care of high-
risk patients should be considered.

Herpes Zoster or Varicella-Zoster Virus [13, 27, 60-62]

Infection with varicella zoster virus (VZV) causes two distinct clinical
conditions.
1. Primary VZV infection causes varicella (i.e., chickenpox).
2. Herpes zoster (zoster) (i.e., shingles).

Varicella (Chickenpox)
Chickenpox is a highly contagious rash illness that typically oc-
curs among children. It is occasionally found in adults not previously
exposed. Chickenpox may be life threatening in children who are im-
munocompromised, such as children with HIV infection. When primary
maternal VZV occurs during pregnancy or during the peripartum pe-

102
riod, fetal infection may result in congenital malformations.
Causative Microorganism:
The varicella zoster virus gains access to epidermal cells, causing
the typical varicella rash. The virus then enters sensory nerves in mu-
cocutaneous sites and travels to the sensory dorsal root ganglia adja-
cent to the spinal cord where the virus establishes permanent latency
in neuronal cell bodies.
Transmission of the Disease:
Chickenpox may be transmitted by direct contact, by droplet (pos-
sibly airborne), by inhalation of aerosols from vesicular fluid of skin le-
sions, or by indirect contact with articles soiled by discharges from the
vesicles and respiratory tract. The average incubation period is 14–16
days after exposure to rash (range: 10–21 days). Infected persons are
contagious an estimated 1–2 days before rash onset until all lesions
are crust, typically 4–7 days after rash onset. Contagiousness is more
prolonged in patients with altered immunity. Susceptible individuals
should be considered infectious for 10-21 days following exposure.
Clinical Features:
The disease is characterized by a maculopapular rash that becomes
vesicular in a few days and then scabs. If the itchy, crusted lesions of the
skin are scratched, a secondary bacterial infection can result. When oral
lesions occur, they may spread into the upper respiratory tract.
Prophylaxis and Treatment:
A vaccine for preventing initial VZV infection has been available since
1995. The CDC- ACIP recommends routine varicella vaccination for all
persons aged >12 months who lack evidence of immunity. Varicella vac-
cination has dramatically reduced chickenpox cases among children.
Control Measures:
• In addition to standard precautions, airborne and contact pre-
cautions should be applied to reduce the spread of infection.
• Airborne and contact precautions could be terminated when
lesions dry.

103
 • Susceptible DHCP (not immune) should not treat patients
known or suspected to have varicella if other immune DHCP
is available. If susceptible DHCP must treat patients known
or suspected to have varicella, DHCP should wear respiratory
protection (N95 respirator). DHCP immune to varicella need
not wear respiratory protection when dealing with varicella pa-
tients.
• Dental health care personnel with varicella should be exclud-
ed from work facility until all lesions are dry and crusted. If
only lesions that do not crust (i.e., macules and papules) are
present, the work restriction should stay in effect until no new
lesions appear within a 24-hour period.
• For susceptible exposed DHCP, post-exposure vaccine within
120 hours or varicella zoster immunoglobulin (VZIG) within
96 hours should be provided:
1. Dental health care personnel who have received 2
doses of vaccine and who are exposed to VZV should
be monitored daily during days 8–21 after exposure for
fever, skin lesions, and systemic symptoms suggestive
of varicella.

- Dental health care personnel can be monitored di-

rectly or instructed to report fever, headache, or other
constitutional symptoms and any atypical skin lesions
immediately.

- If symptoms occur, DHCP should be excluded from

work facility immediately until all lesions are dry and
crusted. If only lesions that do not crust (i.e., macules
and papules) are present, the work restriction should
stay in effect until no new lesions appear within a 24-
hour period.

- If illness occurs, with or without postexposure vac-

cination, antiviral treatment (e.g., acyclovir) can be
considered for adolescents and adults.

104
2. Dental health care personnel who have received 1 dose
of vaccine and who are exposed to VZV should receive
the second dose within 3–5 days after exposure to rash
(provided 4 weeks have elapsed after the first dose).

- After vaccination, management is similar to that of

2-dose vaccine recipients.

- Those who did not receive a second dose or who

received the second dose more than 5 days after ex-
posure should be excluded from work from 8th day
after 1st exposure through 21st day (28th day if vari-
cella-zoster immune globulin administered) after the
last exposure to the virus. And if varicella occurs, the
work restriction applies until all lesions are dry and
crusted or, if only lesions that do not crust (i.e., ma-
cules and papules) are present, until no new lesions
appear within a 24-hour period.

3. Unvaccinated DHCP who have no other evidence of im-

munity and are exposed to VZV are potentially infective
from 8th day through 21st day after exposure and should
be excluded from the facility during this period.
- They should receive postexposure vaccination as
soon as possible.
- Vaccination within 3–5 days of exposure to rash might
modify the disease if infection occurred.
- Vaccination after 5 days of exposure is still indicated
because it induces protection against subsequent
exposures (if the current exposure did not cause in-
fection).
- For DHCP at risk for severe disease, for whom vari-
cella vaccination is contraindicated, administration
of varicella-zoster immune globulin (VZIG) is recom-
mended after exposure.

105
 - VZIG is expected to provide maximum benefit when
administered as soon as possible after exposure, al-
though it can be effective if administered as late as
96 hours after exposure; treatment after 96 hours is
of uncertain value. VZIG should be administered in-
tramuscularly as directed by the manufacturer.
- Any patient who receives VZIG to prevent varicella
subsequently should receive varicella vaccine, pro-
vided the vaccine is not contraindicated.
- Varicella vaccination should be delayed until 5
months after VZIG administration. Varicella vaccine
is not needed if the patient has varicella after admin-
istration of VZIG.
- The patient groups recommended by ACIP to receive
VZIG include the following:
1. Pregnant women.
2. Neonates whose mothers have signs and symp-
toms of varicella around the time of delivery.
3. All premature infants born to susceptible
mothers.
4. Infants born at <28 weeks’ gestation or who
weigh <1000 g.
5. Immunocompromised persons of all ages.

Zoster (Shingles)
VZV can reactivate clinically decades after initial infection to cause
herpes zoster ( shingles), a localized and generally painful cutaneous
eruption that occurs most frequently among older adults.
Causative Microorganism:
Latent VZV is present in approximately 1%-7% of sensory ganglion neu-
rons. As with other members of the herpesvirus family, VZV is noninfectious
in its latent form but can reactivate at a later time to form intact virions in the
involved sensory neurons. These virions then migrate to the skin through
axons, spread from cell to cell, and penetrate the epidermis. Reactivation in

106
adulthood may result from immunosuppression, such as from drug therapy
or from HIV infection, and in people with advanced neoplastic disease. Ap-
proximately one in three persons will develop zoster during their lifetime.
Transmission of the Disease:
Zoster lesions contain high concentrations of VZV that can be spread
by the airborne and contact routes, and cause primary varicella in ex-
posed susceptible persons. Localized zoster is transmitted by contact
route: direct skin to skin contact with vesicular fluid from patients with
zoster lesions. Localized zoster is only contagious after the rash erupts
and until the lesions crust.
Zoster has a lower rate of transmission than varicella, unless it is dis-
seminated (Generalized) which usually occurs in immunocompromised
patients. In hospital settings, transmission has been documented be-
tween patients or from patients to health-care personnel, but transmis-
sion from health-care personnel to patients has not been documented.
Persons with localized zoster are less likely to transmit VZV to sus-
ceptible persons in their household or occupational settings if their le-
sions are covered.
Clinical Features:
Zoster is a localized, generally painful cutaneous eruption that occurs
most frequently among older adults and immunocompromised persons.
In its full clinical expression, zoster causes pain, which is followed by a
localized unilateral vesicular rash associated with the nerve endings of
the area innervated by the infected sensory nerves. When the second
division of the trigeminal nerve is involved, intraoral lesions may occur.
The clinical course of acute zoster is variable. It is usually less se-
vere in children and younger adults. Typically, zoster begins with a pro-
drome. Headache, photophobia, and malaise might occur, with fever
being less common. Abnormal skin sensations and pain of varying se-
verity are the most common symptoms. These symptoms can precede
the zoster rash by days to weeks and rarely might be the only clinical
manifestation of VZV reactivation. Pain is described as aching, burn-
ing, stabbing, or shock-like. Altered sensitivity to touch, pain provoked

107
 by trivial stimuli, and unbearable itching are all frequently reported.
Zoster rash is typically unilateral and does not cross the mid-line.
The rash is initially erythematous and maculopapular but progresses
to form coalescing clusters of clear vesicles containing high concen-
trations of VZV. The vesicles form over several days and then evolve
through pustular, ulcer, and crust stages. The rash usually lasts 7--10
days, with complete healing within 2-4 weeks. However, pigmentation
changes and scarring might be permanent.
Idiopathic facial palsy (Bell’s palsy) might be caused by inappar-
ent VZV reactivation. A common complication of zoster is postherpetic
neuralgia (PHN), a chronic, often debilitating pain condition that can
last months or even years. The risk for PHN in patients with zoster is
10%--18%. Another complication of zoster is eye involvement, which
occurs in 10%-25% of zoster episodes and can result in prolonged or
permanent pain, facial scarring, and loss of vision.
Diagnosis:
Diagnosis might not be possible in the absence of rash. In its classi-
cal manifestation, the signs and symptoms of zoster are usually distinc-
tive enough to make an accurate clinical diagnosis once the rash has
appeared. The accuracy of diagnosis is lower for children and younger
adults in whom zoster incidence is lower and its symptoms less often
classic. Laboratory testing might clarify the diagnosis. Smear test can
be used to detect multinucleated giant cells in lesion specimens, but
they do not distinguish between infections with VZV and HSV.
Prophylaxis and Treatment:
Prompt treatment with the oral antiviral agents decreases the sever-
ity and duration of acute pain from zoster. Additional pain control can be
achieved in certain patients by supplementing antiviral agents with corti-
costeroids and with analgesics. Established PHN can be managed in cer-
tain patients with analgesics, tricyclic antidepressants, and other agents.
The CDC- ACIP recommends routine zoster vaccination with 1 dose
for all persons aged >60 years who have no contraindications, in-
cluding persons who report a previous episode of zoster or who have

108
chronic medical conditions. Licensed zoster vaccine is a lyophilized
preparation of a live, attenuated strain of VZV, the same strain used in
the varicella vaccines.
In a large clinical trial, zoster vaccine was partially efficacious at pre-
venting zoster. It also was partially efficacious at reducing the severity and
duration of pain and at preventing PHN among those developing zoster.
Control Measures:
• The application of standard and contact precautions, in addi-
tion to covering the lesion, may reduce the spread of infection
of localized zoster lesions.
• For generalized (disseminated zoster) and localized zoster
with an uncontained/uncovered lesion, or localized zoster in
immunocompromised patients (until disseminated infection
is ruled out), the control measures of varicella (chickenpox)
should be followed.
• Immunocompetent DHCP with localized zoster should cover
the lesion and avoid contact with susceptible persons at high
risk for severe varicella in their household and occupational
settings until lesions are dry and crusted.
• For susceptible DHCP who are exposed to localized zoster
with a contained/covered lesion, post-exposure vaccine within
120 hours or varicella zoster immunoglobulin (VZIG) within
96 hours should be considered:
a. Dental health care personnel who have received 1 dose
of vaccine should receive the second dose within 3–5
days after exposure to the rash (provided 4 weeks have
elapsed after the first dose). Dental health care person-
nel who have received 1-2 doses of vaccine should not
be excluded from work.
b. Susceptible DHCP who have never received doses of
varicella vaccine should receive postexposure vaccina-
tion as soon as possible. They should also be excluded
from work from 8th day after 1st exposure through 21st
day (28th day if varicella-zoster immune globulin admin-

109
 istered) after the last exposure to the virus. And if vari-
cella occurs, the work restriction applies until all lesions
are dry and crusted or, if only lesions that do not crust
(i.e., macules and papules) are present, until no new le-
sions appear within a 24-hour period.

Epstein-Barr Virus (EBV) [13, 60]

Infectious Mononucleosis
Infectious mononucleosis is generally a disease of adolescents and
young adults.
Causative Microorganism:
One type of infectious mononucleosis is caused by infection with the EBV.
Transmission of the Disease:
The disease is transmitted orally by direct contact with saliva and by
droplet. Viruses are excreted through the saliva even when the patient
has no symptoms of disease, so there may be a long period of com-
municability or a lasting carrier state.
Clinical Features:
It is characterized by fever, lymphadenopathy, and sore throat and is
identified by specific atypical lymphocytes called mononucleosis cells.
Control Measures:
The application of standard precautions may reduce the spread of
infection

Cytomegalovirus (CMV) Infection [60]

Causative Microorganism:
Cytomegalovirus infections are widespread and appear in various
forms. The most severe form develops in infants infected in utero.

Transmission of the Disease:

The virus is excreted in urine, saliva, cervical secretions, and se-

110
men. The virus from the mother’s primary or recurrent infection may
infect the infant in utero, in the birth canal, or through breast milk. Cy-
tomegalovirus infection in a fetus may lead to a child that is premature,
is anemic, and has mental retardation, microcephaly, motor disabilities,
deafness, and chronic liver disease.
High Risk Groups:
• Blood transfusion
• Transplantation of solid organ and bone marrow.
• Sexual transmission through semen, vaginal fluid, or saliva.
• Children attending day-care centers have a high prevalence
of CMV infection (due to spread of respiratory droplet, espe-
cially among children).
Clinical Features:
Symptomatic infection is relatively rare, but infectious mononucleo-
sis, pneumonitis, and other infections may be caused by CMV. Primary
and reactivated infections in immunodeficient or immunosuppressed
patients is commonly caused by CMV, which is an opportunistic agent.
Infection with CMV is a serious complication of the acquired immuno-
deficiency syndrome.
Control Measures:
The application of standard precautions and personal hygiene
(handwashing) may reduce the spread of infection.

111
 Other Infectious Diseases of Concern in Dentistry
Tetanus [4, 6, 13, 27, 63]
Causative Microorganism:
Tetanus is an extremely dangerous and often fatal disease that is
caused by spore-forming bacillus found in soil, dust, or animal or hu-
man feces.

Transmission of the Disease:

This microbe is not transmitted from person to person. It is usually
introduced into the body through a wound or break in the skin (as in a
puncture wound from a soiled instrument). Health care personnel are
not at greater risk for tetanus than the general population.
Clinical Features:
The organism causing tetanus produces the severe muscle spasms
and rigidity that give the disease its popular name of lockjaw.
Prophylaxis:
The disease can be prevented by the administration of a vaccine;
however, immunity must be kept current through booster doses (It is im-
portant that dental personnel keep all of the immunizations current).
Tetanus immune globulin (TIG) contains antibody to tetanus toxin.
It can bind to the toxin and deactivate it. TIG may be administered (in
addition to a tetanus booster) to those who are not up-to-date with their
tetanus vaccinations.
Control Measures:
The application of standard precautions and personal hygiene
(handwashing) reduce the spread of infection.
Management of Exposures to Tetanus:
• Dental health care personnel younger than age 65 years with
direct patient contact should receive a single dose of Tdap
if they have not previously received it (see section on Vac-
cination). After receipt of Tdap, DHCP should receive Td for

112
 routine booster every 10 years.
• In case of puncture wounds or lacerations, previously vacci-
nated DHCP should receive a Td booster at the time of injury if
more than 5 years have elapsed since their last booster. Those
with severely or heavily contaminated wounds may require hu-
man tetanus immunoglobulin in addition to vaccine if their his-
tory of previous primary tetanus immunizations is not definite.

Diphtheria [7, 13, 64]

Causative Microorganism:
Diphtheria is a serious bacterial disease caused by Corynebacte-
rium. It usually affects the mucosa of the upper respiratory tract, and
sometimes the skin. Corynebacteria can also produce a powerful exo-
toxin which is cardiotoxic and neurotoxic.

Transmission of the Disease:

Transmission is via respiratory droplets and direct person- to-per-
son contact with cutaneous lesions (highly contagious). Patients carry
toxigenic organisms up to 3 months after infection.
Clinical Features:
Respiratory diphtheria presents as a sore throat with low-grade fe-
ver and an adherent pseudomembrane of the tonsils, pharynx, or nose.
Neck swelling is usually present in severe disease. Nasal diphtheria
is often milder than laryngeal diphtheria, which is serious because of
respiratory tract obstruction. Myocarditis, polyneuritis, and airway ob-
struction are common complications of respiratory diphtheria; death
occurs in 5%-10% of respiratory cases.
Cutaneous diphtheria presents as infected skin lesions which lack
a characteristic appearance. Complications and deaths occur less fre-
quently from cutaneous diphtheria.
Prophylaxis and Treatment:
The disease can be prevented by the administration of a vaccine;
however, immunity must be kept current through booster doses.

113
 Treatment of the disease requires the use of an antitoxin in addition
to penicillin or erythromycin.
Control Measures:
• In addition to standard precautions, droplet precautions (in
cases of respiratory diphtheria) and contact precautions (in
cases of cutaneous diphtheria) should be applied to reduce
the spread of infection.
• Droplet and contact precautions could be terminated when
antimicrobial treatment is completed and two cultures taken
24 hours apart shows negative results.
• Dental health care personnel with active diphtheria and ex-
posed DHCP should be excluded from duty until antimicrobial
therapy is completed and two cultures taken more than 24
hours apart shows negative results.
• Dental health care personnel younger than age 65 years with
direct patient contact should receive a single dose of Tdap
if they have not previously received it. After receipt of Tdap,
DHCP should receive Td for routine booster every 10 years
(see section on Vaccination).

Measles [7, 13, 27]

Causative Microorganism:
Measles is a potentially serious disease caused by the rubeola virus.

Transmission of the Disease:

It is a highly contagious rash illness that is transmitted by respira-
tory droplets and airborne spread and has an incubation period of 10-
12 days. Because of the greater opportunity for exposure, HCP are
at higher risk than the general population for becoming infected with
measles. A study conducted in 1996 in medical facilities indicated that
HCP were 19 times more likely to develop measles than other adults.
Clinical Features:
The disease is characterized by a characteristic exanthematous
rash.

114
 The prodromal symptoms are conjunctivitis, nasal discharge, head-
ache, fever and sore throat. Three to 4 days before the appearance of
the rash, patches called Koplik’s spots may appear in the oral cavity.
These patches are small, irregular in shape, and red with bluish-white
specks and are located on the mucosa of the cheeks. The disease is
highly contagious at this stage.
Severe complications, which might result in death, include pneumo-
nia and encephalitis.
Prophylaxis:
Measles can be prevented by the administration of a vaccine. Mea-
sles vaccine is administered in combination with the mumps and rubella
components as the MMR vaccine. Health care personnel who have an
“indeterminate” level of immunity upon testing should be considered non-
immune. Nonpregnant, susceptible people exposed to the rubeola virus
may receive protection if immunized within 72 hours after exposure.
Control Measures:
• In addition to standard precautions, airborne precautions
should be applied to reduce the spread of infection.
• Airborne precautions may be terminated 4 days after the on-
set of rashes.
• Susceptible DHCP (not immune) should not treat patients
known or suspected to have measles if other immune DHCP
are available. If susceptible DHCP must treat patients known
or suspected to have measles, DHCP should wear respiratory
protection (N95 respirator). DHCP immune to measles need not
wear an N95 respirator when dealing with measles patients.
• For exposed DHCP, post-exposure vaccine within 72 hrs or
immunoglobulin within 6 days should be provided.
• Dental health care personnel with active measles and exposed
DHCP should be excluded from duty from day 5 after first ex-
posure to day 21 after last exposure (exposed personnel) or
for 4 days after rash appears (active and exposed personnel),
regardless of post-exposure management.

115
 Rubella [7, 13, 27, 57]
Causative Microorganism:
Rubella, also known as German measles, is a mild viral disease
caused by the Rubella Virus.

Transmission of the Disease:

Rubella virus can be transmitted via droplet and perinatal (through
placenta) routes of transmission. During outbreaks, transmission oc-
curred from HCP to susceptible coworkers and patients, as well as
from patients to HCP and other patients. Health care personnel may
also transmit the disease to associates some of whom might be preg-
nant. However, no data are available on whether HCP are at increased
risk for acquiring rubella compared with other professions.
Clinical Features:
Rubella is characterized by a slight rash, low-grade fever, lymph-
adenopathy, and malaise. Although rubella is considered a benign
disease, transient arthralgia and arthritis are observed commonly in
infected adults, particularly among postpubertal females. Other compli-
cations that occur infrequently are thrombocytopenia and encephalitis.
Infection is asymptomatic in 25%–50% of cases.
The danger from rubella is to women, particularly during the first
trimester of pregnancy. If the mother has rubella, she runs the risk
of miscarriages, stillbirths, giving birth to a child who is severely de-
formed, mentally retarded, deaf, blind, or has congenital heart defects.
Fetal infection with rubella (from infected mother) can occur in as many
as 80% of fetuses during the first trimester of pregnancy and to some
extent in the second trimester.
Clinical diagnosis of rubella is unreliable and should not be consid-
ered in assessing immune status.
Prophylaxis:
Rubella may be prevented by the administration of a vaccine.
Rubella vaccine is administered in combination with the mumps and
measles components as the MMR vaccine. Neither rubella-containing

116
vaccine nor immune globulin (Ig) is effective for postexposure prophy-
laxis of rubella. Although intramuscular administration of 20 mL of im-
munoglobulin within 72 hours of rubella exposure might reduce the risk
for rubella, but it will not eliminate it.
Control Measures:
• In addition to standard precautions, droplet precautions
should be applied to reduce the spread of infection.
• Droplet precautions may be terminated 7 days after onset of
rashes.
• Susceptible DHCP (not immune) should not treat patients
known or suspected to have rubella if other immune DHCP
are available.
• Pregnant women who are not immune should not treat pa-
tients known or suspected to have rubella.
• For exposed DHCP, vaccine should be administered within three
days of exposure to non-pregnant susceptible individuals.
• Dental health care personnel with active rubella and exposed
DHCP should be excluded from duty from day 7 after first ex-
posure to day 21 after last exposure (exposed personnel) or
for 7 days after rash appears (active and exposed personnel),
regardless of post-exposure vaccine.

Mumps [7, 13, 27, 65]

Causative Microorganism:
Mumps is an acute systemic infection caused by a paramyxovirus.

Transmission of the Disease:

Mumps virus can be transmitted via droplet and contact routes of
transmission. The mean incubation period for mumps is 18 days, and
the virus has been isolated from saliva from infected people 7 days
before parotitis develops. Mumps can be transmitted before the de-
velopment of symptoms and the disease is most contagious 1–2 days
before the onset of parotitis. Mumps can also be transmitted by people
with subclinical infection.

117
 Probability of mumps virus shedding decreases rapidly after the on-
set of symptoms. However, patients will still be shedding the virus 5-9
days after the onset of symptoms and, thus, may still be contagious
during this period.
Although health-care–associated transmission of mumps is infre-
quent, it might be underreported because of the high percentage (20%–
40%) of infected persons who might be asymptomatic. In a survey of
9,299 adults in different professions conducted in 1968, before vacci-
nation was used routinely, the rate of mumps acquisition was highest
among dentists and HCP, with rates of 18% among dentists and 15%
among physicians.
Clinical Features:
Mumps is a viral infection that causes inflammation and swelling of
the parotid glands and sometimes the submandibular salivary glands. It
is accompanied by headache, fever, sore throat, trismus, furred tongue,
earache, and pain on chewing and during salivation. The spectrum
of illness ranges from subclinical infection (20%–40%) to nonspecific
respiratory illness, sialadenitis including classic parotitis, deafness, or-
chitis, and meningoencephalitis; severity increases with age.
Prophylaxis:
Mumps can be prevented by the administration of a vaccine.
Control Measures:
• In addition to standard precautions, droplet precautions
should be applied to reduce the spread of infection.
• Droplet precautions may be terminated 5 days after onset of
swelling.
• Susceptible DHCP (not immune) should not treat patients
known or suspected to have mumps if other immune DHCP
are available.
• Dental health care personnel with active mumps and exposed
DHCP should be excluded from duty from day 12 after ex-
posure to day 25 after exposure (exposed personnel) or for 5
days after onset of parotitis (active and exposed personnel).

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 Poliomyelitis [13, 27, 66]
Causative Microorganism:
Poliomyelitis (polio) is a highly infectious disease caused by polivi-
rus, an enterovirus that invades the nervous system.

Transmission of the Disease:

Polio affects humans only, and it is spread by person-to-person con-
tact (contact transmission)and by fecal-oral route of transmission. Polio-
virus can be recovered from infected persons, including from pharyngeal
specimens, feces, urine, and (rarely) saliva and cerebrospinal fluid.
High Risk Groups:
In general, three groups of adults are at higher risk and should con-
sider polio vaccination in the following situations:
1. Persons traveling to polio-endemic or high-risk areas
of the world.
2. Health care personnel working in a laboratory and
handling specimens that might contain polioviruses.
3. Health care personnel treating patients who could have
polio or have close contact with a person who could be
infected with poliovirus.
Clinical Features:
It is potentially fatal disease that can strike at any age.
Approximately 95% of persons infected with polio will have no symp-
toms. About 4-8% of infected persons have minor symptoms, such as
fever, fatigue, nausea, headache, flu-like symptoms, stiffness in the
neck and back, and pain in the limbs, which often resolve completely.
Less than 1% of polio cases result in permanent paralysis of the limbs
(usually the legs). Of those paralyzed, 5-10% die when the paralysis
strikes the respiratory muscles. The death rate increases with increas-
ing age.
Prophylaxis and Treatment:
There is no cure, but there are safe and effective vaccines. There-
fore, the strategy to eradicate polio is based on preventing infection by

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 immunizing every child to stop transmission.
Control Measures:
In addition to standard precautions, contact precautions should be
applied to reduce the spread of infection.

Syphilis [4, 7, 13, 22, 67]

Causative Microorganism:
Syphilis is caused by Treponema pallidum spirochetes.
Transmission of the Disease:
Syphilis is a sexually transmitted disease that can also be transmit-
ted through any other direct contact with a syphilis sore and through
perinatal routes (placenta). Sores occur mainly on the external geni-
tals, vagina, anus, or in the rectum. Sores also can occur on the lips
and in the mouth. Syphilis cannot be transmitted by indirect contact
because Treponema pallidum spirochetes are quite fragile outside the
body. In the dental operatory, the danger of cross-infection is through
contact with oral lesions.
Although transmission occurs from persons with sores who are in
the primary or secondary stage, many of these sores are unrecog-
nized. Thus, transmission may occur from persons who are unaware
of their infection.
Clinical Features:
Syphilis may be asymptomatic. However, if not treated, persons infect-
ed with syphilis remain at risk for developing late stage complications.
The first stage of syphilis is the presence (at the inoculation site of
spirochaete) of a painless flat, red, indurated ulcer with serous exudate,
known as a chancre, which is highly infectious on contact. When it oc-
curs on the lip, it may resemble herpes, but the crusting is darker. The
time between infection with syphilis and the start of the first symptom
can range from 10 to 90 days (average 21 days). The chancre lasts 3 to
6 weeks, and it heals without treatment. However, if adequate treatment
is not administered, the infection progresses to the secondary stage.

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 The second stage is characterized by skin rash and mucous mem-
brane lesions. This stage is also infectious, and immediate infection may
occur through contact with an open sore. The rash can appear as the
chancre is healing or several weeks after the chancre has healed. The
characteristic rash of secondary syphilis may appear as rough, red, or
reddish brown spots (oozing sores) both on the palms of the hands and
the bottoms of the feet. Sometimes rashes associated with secondary
syphilis are so faint that they are not noticed. In addition to rashes, symp-
toms of secondary syphilis may include fever, swollen lymph glands,
sore throat, patchy hair loss, headaches, weight loss, muscle aches,
and fatigue. Signs of special interest to dental personnel are:
1. Split papules at the corners of the mouth.
2. Grayish-white, moist, so-called mucous patches on the
tongue, tonsils or inner surfaces of the lips (these are high-
ly infectious).
The signs and symptoms of secondary syphilis will resolve with or
without treatment, but without treatment, the infection will progress to
the latent and possibly late stages of disease.
The third stage, is usually fatal, and it may occur after the disease
has been dormant for 20 years. In this late stage of syphilis, the disease
may damage the internal organs, including the brain, nerves, eyes,
heart, blood vessels, liver, bones, and joints. Signs and symptoms of
the late stage of syphilis include difficulty coordinating muscle move-
ments, paralysis, numbness, gradual blindness, and dementia. Gumma
nodules may form on the palate lips or tongue. A pattern of ulceration
and healing of the hard palate may eventually lead to perforation.
Diagnosis:
Treponema pallidum cannot be cultured in vitro. However, a sero-
logical test to detect specific antibodies can be used to diagnose syphi-
lis. Dark ground microscopy of tissue fluid from primary and secondary
clinical lesions helps in identifying the microorganism.
Prophylaxis and Treatment:
Syphilis is easy to cure in its early stages. A single intramuscular in-

121
 jection of penicillin, an antibiotic, will cure a person who has had syphi-
lis for less than a year. Additional doses are needed to treat someone
who has had syphilis for longer than a year. For people who are allergic
to penicillin, other antibiotics are available to treat syphilis. Treatment
will kill the syphilis bacterium and prevent further damage, but it will not
repair damage already done.
Having syphilis once does not protect a person from getting it again.
Following successful treatment, people can still be susceptible to re-
infection.
Control Measures:
• The application of standard precautions reduce the spread of
infection
• Dental Health Care Personnel:
- For infection control purposes, pre-employment
evaluation including serologic tests for syphilis must
be performed.
- Non-Saudi staff will be screened for syphilis before
recruitment and travelling to the Kingdom and again
on arrival.
- According to a Saudi Arabian Ministry of Health
Regulation, applicants who have established syphilis
infection will be considered as non fit to work.

Meningitis [13, 27, 68-70]

Causative Microorganism:
Meningitis is a disease caused by the inflammation of the protec-
tive membranes covering the brain and spinal cord (“meninges”). The
inflammation is usually caused by an infection of the fluid surrounding
the brain and spinal cord.
Viral infections are the most common cause of meningitis; bacterial
infections are the second most common cause. Other, rarer, causes
of meningitis include fungi, parasites, and non-infectious causes, in-
cluding physical injury, certain diseases like AIDS, cancer, diabetes, or

122
certain drugs that weaken the body’s immune system.
For bacterial meningitis, it is important to know which type of bacte-
ria is causing the disease because antibiotics can prevent some types
from spreading and infecting other people. Before the 1990s, Haemo-
philus influenzae type b (Hib) was the leading cause of bacterial men-
ingitis. Meningitis caused by Hib occurs mostly in children under the
age of 5 years.
Hib vaccine is given to all children as part of their routine immuni-
zations. This vaccine has reduced the number of cases of Hib infec-
tion and the number of related meningitis cases. Today, Streptococ-
cus pneumoniae and Neisseria meningitidis are the leading causes of
bacterial meningitis. Meningitis in individuals at the extremes of age,
infants, young children and the elderly, is commonly caused by S.
pneumoniae.
During epidemics, children and young adults are most commonly
affected. The highest rates of endemic or sporadic disease occur in
children less than 2 years of age.
Different viral infections can lead to viral meningitis, but most cases
are caused by enteroviruses (which include enteroviruses, coxsacki-
eviruses, and echoviruses). The incubation period is usually between
3 and 7 days for enteroviruses. Other viral infections that can lead to
meningitis include mumps, herpesvirus (such as Epstein-Barr virus,
herpes simplex viruses, and varicella-zoster virus), measles, and in-
fluenza. Arboviruses, which mosquitoes and other insects spread, can
also cause infections that can lead to viral meningitis. Lymphocytic
choriomeningitis virus, which is spread by rodents, is a rare cause of
viral meningitis.
The incubation period of meningococcal disease is 3 to 4 days, with
a range of 2 to 10 days.
Transmission of the Disease:
Some forms of bacterial meningitis are contagious. Haemophilus
influenza, Streptococcus pneumoniae and Neisseria meningitides are
respiratory pathogens and can mainly be spread from person to per-

123
 son through the exchange of respiratory and throat secretions (droplets
and contact transmission). This can occur through coughing, kissing,
and sneezing.
Following acquisition of bacterial meningitis, illness results when
the organism is able to colonize the mucosa of the nasopharynx and
oropharynx and enters the blood stream. Subsequently the organism
gains access to the cerebrospinal fluid, where infection is established
and inflammation occurs.
People in the same household or daycare center, or anyone with di-
rect contact with a patient’s oral secretions would be considered at in-
creased risk of getting the infection. People at high risk should receive
prophylactic antibiotics to prevent them from getting the disease.
Viral meningitis is also contagious. The viruses that most often
cause viral meningitis are spread from person to person through fecal
contamination (such as by someone who uses the toilet or changes a
baby’s diaper and does not wash her/his hands well afterward).
Infection may also be transmitted from patient to HCP and from HCP
to patient during the blood-taking procedure.
Clinical Features:
Often, the symptoms of viral meningitis and bacterial meningitis are
the same. Sudden onset of high fever, headache, and stiff neck are
common symptoms of meningitis in anyone over the age of 2 years.
These symptoms can develop over several hours, or they may take 1
to 2 days. Other symptoms may include nausea, vomiting, photopho-
bia (sensitivity to bright light), altered mental status, lack of appetite
and sleepiness. Infants with meningitis may appear slow or inactive,
have vomiting, be irritable, or be feeding poorly. As the disease pro-
gresses, patients of any age may have seizures.
Viral (sometimes called “aseptic”) meningitis is serious but rarely
fatal in people with normal immune systems. Usually, the symptoms
last from 7 to 10 days and the patient recovers completely.
Bacterial meningitis, on the other hand, can be very serious and
may result in brain damage, hearing loss, or learning disabilities if not

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treated promptly. Fatality rates vary with age at the time of illness and
the species of bacterium causing infection, but typically range from 3 to
19% in developed countries. Higher case-fatality rates (37-60%) have
been reported in developing countries. Up to 54% of survivors are left
with disability due to bacterial meningitis, including deafness, mental
retardation, and neurological sequelae.
Diagnosis:
Early diagnosis and treatment are very important. The diagnosis
is usually made by laboratory tests of a patient’s spinal fluid. The test
can reveal whether the patient is infected with a virus or a bacterium.
However, blood test can be done when collecting patient’s spinal fluid
is contraindicated, cannot be performed for technical reasons, or when
bacteremia is suspected.
If bacteria are present, they can be grown (cultured) to identify the
specific type of bacteria that is causing the infection and to select the
proper antibiotic.
The specific causes of viral meningitis may be determined by tests
used to identify the virus in samples collected from the patient. How-
ever, identifying the exact virus causing meningitis may be difficult.
Prophylaxis and Treatment:
Bacterial meningitis can be treated with a number of effective anti-
biotics. It is important, however, that treatment be started early in the
course of the disease. Appropriate antibiotic treatment of most com-
mon types of bacterial meningitis can prevent severe illness, reduce
the spread of infection from person to person and reduce the mortality
to below 15%, although the risk is higher among the elderly.
There is no specific treatment for viral meningitis. Most patients
completely recover on their own within 2 weeks. Doctors often will
recommend bed rest, plenty of fluids, and medicine to relieve fever and
headache.
There are vaccines against Hib, against some serogroups of N.
meningitidis and many types of Streptococcus pneumoniae. The vac-
cines are safe and highly effective.

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 Control Measures:
• In addition to standard precautions, droplet precautions should
be applied to reduce the spread of infection.
• Postexposure prophylaxis is advised for all persons who have
had intensive, unprotected contact (i.e., without wearing a
mask) with infected patients (e.g., via mouth-to-mouth resus-
citation, endotracheal intubation, or endotracheal tube man-
agement), including HCP who have been vaccinated.
• Antimicrobial prophylaxis can eradicate carriage of N. men-
ingitidis and prevent infections in persons who have unpro-
tected exposure to patients with meningococcal infections.
• Antimicrobial prophylaxis (Rifampicin 600 mg twice a day for
2 days, Ciprofloxacin 500 mg orally as a single dose or Ceftri-
axone 250 mg IM single dose) are effective in eradicating na-
sopharyngeal carriage of N. meningitides and should be offered
immediately to personnel who have had intensive direct contact
with an infected patient without using proper precautions.
• Postexposure prophylaxis should be administered within 24
hours of exposure when feasible; postexposure prophylaxis
administered >14 days after exposure is of limited or no value.

Methicillin-Resistant Staphylococcus Aureus

[13-14, 19]
Staphylococcal infection or carriage occurs frequently in humans.
There are two sources of nosocomial transmission; persons with le-
sions and asymptomatic carriers. The anterior nares are one of the
most commonly colonized sites, but carriage of S. aureus may occur at
other sites (e.g., draining or crusted lesion, nasopharynx and orophar-
ynx, and the skin of the axilla, fingers, and perineum). Outbreaks of
methicillin-resistant-staphylococci tend to occur more frequently in in-
tensive care and burn units.
Causative Microorganism:
Multidrug-resistant organisms (MDROs) are defined as microorgan-
isms, predominantly bacteria, that are resistant to one or more classes

126
of antimicrobial agents. Such organisms, including methicillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant enterococci
(VRE) and certain gram-negative bacilli (GNB), have important infec-
tion control implications.
Staphylococcus aureus is a gram-positive coccus that frequently
colonizes the nose and skin of healthy people, and it can cause a vari-
ety of localized and invasive syndromes, ranging from superficial skin
infections to life-threatening pneumonia and bloodstream infections.
MRSA refers to S. aureus that is resistant to all currently available
β-lactam antimicrobial agents, including antistaphylococcal penicillins
(methicillin, oxacillin, nafcillin) and cephalosporins. In health care set-
tings, MRSA frequently affects people with chronic illness, frequently
causes invasive disease, and resists multiple classes of antimicrobial
agents. While, in the community, MRSA frequently affects young, oth-
erwise healthy people, and predominantly causes skin and soft-tissue
infection and it is susceptible to most classes of antimicrobial agents
other than β-lactams.

Transmission of the Disease:

In the community, outbreaks of MRSA infections have been report-
ed in settings in which people are crowded, have frequent skin-to-skin
contact, have compromised skin (cuts and abrasions), lack adequate
hygiene practices, and share personal items. Draining lesions are high-
ly infectious and represent the most common source of transmission.
In health care settings, S. aureus most often is spread indirectly
from person to person on the transiently contaminated hands. MRSA
has been isolated from environmental surfaces in health care facili-
ties, but contaminated environmental surfaces and objects likely play
a relatively minor role in MRSA transmission. Frequent exposure to
antimicrobial agents may facilitate acquisition of MRSA.

Risk in the Dental Operatory:

In a study of S. aureus in a dental school clinic, investigators isolat-
ed MRSA from samples collected from the emergency treatment area:
dental chair push buttons, light handles, air-and-water syringes and a

127
 computer keyboard. MRSA has also been found in the oral cavity and
on dentures, more frequently in elderly people. A risk factor for oral
carriage of MRSA among older people is related to antibiotic use, low
serum albumin levels, and poor nutrition.
There has been one documented transmission of MRSA from a Brit-
ish dental practitioner to patients. Two patients undergoing oral surgical
procedures within three weeks of each other developed MRSA infec-
tions of the same type. The dentist was identified as the only staff mem-
ber with the same type of MRSA isolated from his fingers and nares.

Clinical Features:
Health care–associated MRSA infections most commonly manifest
as surgical site infections, pneumonia or bloodstream infections, and
they require treatment with systemic antimicrobial agents.
About 77 percent of community-associated MRSA infections are
localized in the skin in the form of pustules, boils or abscesses and
typically can be treated in outpatient settings, often without antibiotics.
However, less frequently, community strains of MRSA can lead to se-
vere infections and potentially to invasive disease that can be fatal.

Treatment and Prophylaxis:

Vancomycin remains an agent of choice for treatment of invasive
MRSA infections. However, increased use of vancomycin has contrib-
uted to a rapid increase in the incidence of colonization and infection
with vancomycin-resistant enterococci. Coexistence of vancomycin re-
sistant enterococci and MRSA in the same host was shown to facilitate
the transfer of vancomycin resistance to S. aureus. Antimicrobial treat-
ment options exist for vancomycin resistant S. aureus infections but
are limited.
No S. aureus vaccines are available, although such products are
being developed.

Control Measures:
• The CDC’s Healthcare Infection Control Practices Advisory
Committee developed measures to control the spread of mul-

128
 tidrug-resistant organisms (MDROs) of epidemiologic impor-
tance, such as MRSA, in health care settings.
• Prevention of MRSA and other MDRO transmission in these
settings requires a comprehensive strategy that includes ad-
ministrative measures such as:
1. Use of standard precautions for all patients.
2. Use of contact precautions for patients known to be in-
fected or colonized with these organisms.
3. Implement systems to designate patients known to be
colonized or infected with MDRO and to notify receiving
healthcare facilities and personnel prior to transfer of such
patients within or between facilities.
4. Provide education and training on risks and prevention of
MDRO transmission during orientation and periodic edu-
cational updates for DHCP.
5. Judicious use of antimicrobial agents.
6. Ongoing monitoring of trends through time to measure
progress in prevention and control.
• Few studies have been conducted to determine whether any
additional actions can improve prevention of MRSA in dental
settings: Investigators in one such study described the elim-
ination of MRSA from patients' dentures by use of common
denture-cleansing solutions, and researchers in another study
found that the rate of bacteremia occurring within one hour
after a tooth extraction can be reduced by means of a preop-
erative rinse with an oral chlorhexidine solution.
• Infected persons should be restricted from work if wound drain-
age cannot be contained.

Creutzfeldt-Jakob Disease (CJD) and Other Prion Diseases

[10, 71-73]
Classic CJD is a human prion disease. It is a neurodegenerative
disorder with characteristic clinical and diagnostic features. The most
common form of classic CJD is believed to occur sporadically, caused

129
 by the spontaneous transformation of normal prion proteins into abnor-
mal prions.
Classic CJD has been recognized since the early 1920s. This dis-
ease occurs worldwide, at a rate of approximately one case per 1 mil-
lion populations per year, although rates of up to two cases per million
are not unusual. The risk of CJD increases with age, and in persons
aged over 50 years of age, the annual rate is approximately 3.4 cases
per million.
Variant Creutzfeldt-Jakob disease (vCJD) is a very rare, degenera-
tive, fatal disease that can infect persons for many years before mak-
ing them sick by destroying brain cells.
Epidemiology:
Since variant CJD was first reported in 1996, a total of 217 patients
(as of October 2009) with this disease from 11 countries have been
identified (including one case from Saudi Arabia). This variant form of
CJD should not be confused with the classic form of CJD that is en-
demic throughout the world.
Both vCJD and CJD cause progressive degeneration of the brain
leading to death. However, the variant form usually affects persons
much younger than other forms of CJD.
Transmission of the Disease:
Eating beef and beef products contaminated with the infectious
agent of bovine spongiform encephalopathy (BSE) is the main cause of
vCJD. Although experience with this new disease is limited, evidence
to date indicates that there has never been a case of vCJD transmitted
through direct contact of one person with another. A case of probable
transmission of vCJD through transfusion of blood components from
an asymptomatic donor who subsequently developed the disease has
been reported.
Potential infectivity of oral tissues in CJD or vCJD patients is an un-
resolved issue. Scientific data indicate the risk, if any, of sporadic CJD
transmission during dental and oral surgical procedures is low to nil.

130
Clinical Features:
Classic CJD is rapidly progressive and always fatal (usually within 1
year of onset of illness), whereas variant CJD has a longer survival after
onset of illness (the majority of illnesses lasting more than one year).
The median age at death for vCJD patients is 28 years, compared
with 68 years for patients with classic CJD. The median duration of ill-
ness for vCJD is 14 months, compared to 5 months for classic CJD.
Variant CJD also has somewhat different clinical symptoms than
classic CJD. Classic CJD is characterized by dementia and early neuro-
logic signs whereas vCJD is characterized by prominent psychiatric/be-
havioral symptoms; painful dysthesiasis and delayed neurologic signs.
Diagnosis:
Using brain biopsy, variant CJD produces a characteristic abnor-
mality in brain tissue called florid plaques; rounded deposits of abnor-
mal proteins surrounded by vacuoles, rarely if ever seen in the other
forms.

Control Measures:
No recommendation is offered by CDC regarding use of special pre-
cautions in addition to standard precautions when treating known CJD
or vCJD patients.

131
 VACCINATION

The Immune System [4, 6, 74]

The immune system plays an extremely important role in the ability
of the body to resist pathogens. Immunity is a condition of an organism
that allows it to successfully resist a specific infection. An individual
who produces a large number of antibodies against a bacterium is said
to be resistant, or immune, to infection from that bacterium. There are
two main categories of immunity: inherited and acquired.
• Inherited immunity is immunity with which a person is born.
• Acquired immunity is immunity that is developed during per-
son’s life time. It is subdivided into two groups: naturally ac-
quired immunity is obtained naturally, and artificially acquired
immunity is obtained through vaccination.

Naturally Acquired Immunity

1. Active Immunity:
When the body was fighting the invading pathogen it formed anti-
bodies that provide future resistance against that particular pathogen.

2. Passive Immunity:
Occur during pregnancy or breastfeeding when the fetus or infant
receives antibodies from the mother.

Artificially Acquired Immunity

Artificially acquired immunity could be obtained through:

1. Active immunization:
Use of an antigen substance to induce immunity by stimulating an
immune response:
• Vaccine: A suspension of live (usually attenuated) or inactivat-
ed microorganisms, or fractions thereof.
• Toxoid: A modified (nontoxic) bacterial toxin that is capable of

132
 stimulating antitoxin formation.

2. Passive immunization
Use of an antibody containing preparation to prevent onset of infec-
tion.
• Immune globulin (Ig): A sterile solution containing antibodies
from human blood.
• Antitoxin: A solution of antibodies derived from the serum of
animals immunized with specific antigens.

Vaccination
A vaccine contains weakened disease causing organisms or ge-
netically engineered organisms. Harmful characteristic of the disease
producing organisms are eliminated from the vaccine to make them
less likely to cause the disease. The body then produces antibodies in
response to the vaccine.
Vaccines may be one of the following types:
1. Monovalent: A vaccine consisting of a single strain or
type of organism.
2. Bivalent: A vaccine consisting of a two strains or types
of organism.
3. Trivalent: A vaccine consisting of three types of strains
of a single organism (influenza vaccine) or three differ-
ent organisms (DPT vaccine).
4. Polyvalent: Multiple strains or types of organisms in
the vaccine (23-valent pneumococcal vaccine).
It is extremely important that dental healthcare workers be immu-
nized against vaccine-preventable diseases. After a period of time,
the number of antibodies against a particular antigen may decrease. A
booster is an additional dose of vaccine administered to increase the
number of antibodies.

133
 Immunization of Dental Health Care Personnel
[6, 13, 25, 29, 74-75]

Maintenance of immunity is an important part of disease prevention

and infection control in dental offices and hospital-based oral health
programs. Optimal use of immunizing agents will safeguard the health
of DHCP, obviate unnecessary work restrictions, and protect patients
from becoming infected by DHCP.
Although there is a chance that dentists can infect their patients,
dentists are at a greater risk for contracting diseases from their pa-
tients than patients are from their dentists. Indications for use of rec-
ommended routine vaccines are generally the same for DHCP as for
the general population; however, immunity to some diseases, such as
hepatitis B, may be more important for DHCP.
Although the OSHA bloodborne pathogens standard focuses on
HBV and HIV infection, there are many other infectious diseases that
can cause HCP devastating or fatal illness. Childhood diseases, sexu-
ally transmitted diseases, and tuberculosis are but a few of these infec-
tious diseases. Therefore, any HCP who has patient contact or contact
with infectious materials should be sure they have had these diseases
or have been vaccinated against them.
The ACIP recommends for HCP immunoprophylaxis for hepatitis B,
influenza, measles, mumps, rubella, tetanus, diphtheria, pertussis and
varicella. There are other diseases, such as tuberculosis, for which
immunization of DHCP may or may not be indicated based on special
health care delivery situations. Meningococcal disease is another dis-
order characterized by the ACIP as possibly indicated for immunization
of HCP in special circumstances. Transmission of Neisseria menin-
gitidis in the health care delivery settings is rare. Dentists might be at
risk for contracting Neisseria meningitides because they are usually in
close proximity to the oropharynx of patients.
A history of immunization should be obtained carefully from DHCP
at the time of initial employment. This history should be updated peri-
odically. Health care institutions should provide all recommended vac-
cines for all DHCP (Table 7). Each time a DHCP receives a dose of

134
vaccine, a notation should be made in the medical record on a special
immunization form. The information recorded should include the type
of vaccine; the dose, route, and site of administration; the name of
the person who gave the vaccine; the date the vaccine was given; the
manufacturer and lot number; and the date the next dose is due.

Hepatitis B Vaccine
[4, 6-7, 21-22, 27]

Plasma-Derived Vaccine:
Approximately 5.6 million people worldwide received the plasma-
derived vaccine before it was discontinued in 1989.
Organism:
A 1:10 dilution of hepatitis B infective serum (strain MS-2) lost infec-
tivity but retained its antigenicity when boiled for 1 minute.
Administration:
The vaccine is given in three separate intramuscular injections; the
first two doses are administered 1 month apart and the third dose is
given 6 months after the first dose.

Protection:
After the first dose, approximately 30% of normal, healthy, young
adult vaccine recipients respond by the formation of antibodies. The
response rate increases to 75% after the second dose, rising to a cur-
rent response rate 90% to 95% after the third dose.
Continued clinical monitoring of vaccine recipients by the CDC
through 1984 and current monitoring by the Food and Drug Administra-
tion (FDA) indicate that there is no increased incidence of any severe
side effects associated with the hepatitis B vaccine.

Recombinant DNA Vaccines:

In July 1986 the first vaccine made using recombinant DNA technol-
ogy was licensed.

135
 Organism:
The surface antigen of the hepatitis B virus, HBsAg, manufactured
in yeasts by genetic recombination and absorbed on to aluminium salt.
Successful vaccination also offers protection against delta hepatitis
(hepatitis D).

Administration:
Three doses (two doses at an interval of 1 month, followed by a third
6 months later) intramuscularly in the deltoid not in the fatty tissue.

Protection and Safety:

• Post-testing:
Post-vaccination testing for the anti-HBV antibodies is recommend-
ed. Serologic testing within 6 months of competing the primary series
will differentiate people who respond to vaccine from those who fail to
respond; however, the results of testing performed more than 6 months
after completion of the primary series are more difficult to interpret.
Therefore, post-testing should be scheduled soon after the last inocu-
lation, preferably within 1-2 months. The formation of antibodies indi-
cates that the individual has developed immunity.
The 3-dose vaccine series administered intramuscularly at 0, 1, and
6 months produces a protective antibody response in approximately
30%–55% of healthy adults aged ≤40 years after the first dose, 75% af-
ter the second dose, and >90% after the third dose. After age 40 years,
<90% of persons vaccinated with 3 doses have a protective antibody
response, and by age 60 years, protective levels of antibody develop
in approximately 75% of vaccinated persons.
• Nonresponders:
Individuals who have been vaccinated but do not develop antibod-
ies are known as nonresponders. A vaccine recipient who has nega-
tive results for anti-HBs several years after vaccination can also be a
primary nonresponder who remains susceptible to HBV or a vaccine
responder whose antibody levels have decreased below detectability
yet he or she is still protected against clinical disease. The three-dose

136
series should be repeated for nonresponders.
Among nonresponders, 25%–50% respond to an additional vaccine
dose, and 44%–100% respond to a 3-dose revaccination series. Per-
sons who do not have protective levels of anti-HBs1–2 months after re-
vaccination either are infected with HBV or can be considered primary
nonresponders. For the latter group, genetic factors might be associ-
ated with nonresponse to hepatitis B vaccination. The ACIP does not
recommend more than two vaccine series in nonresponders.
Smoking, obesity, genetic factors, and immune suppression are as-
sociated with diminished immune response to hepatitis B vaccination.
• Antibody Persistence and Booster Dose:
There is controversy over the necessity for booster doses.
Some advocate boosters after 3 – 5 years, whereas others,
contend that booster doses are unnecessary because of the
anamnestic response of the immune system (renewed rapid
production of an antibody on the second (or subsequent) en-
counter with the same antigen).
Ongoing studies have shown that immunological memory in
persons who have responded to vaccination with >10 U/mL of
anti-HBs lasts for at least 23 years, and probably much longer.
People who had demonstrable anti-HBs when initially tested,
yet lost detectable anti-HBs on a subsequent blood test, have
demonstrated a secondary anamnestic response that was pro-
tective against clinical infection when challenged with HBV.
According to the CDC, it is not necessary to test routinely for
anti-HBs each year after vaccination.
• Hepatitis B vaccines have been demonstrated to be safe when
administered to infants, children, adolescents, and adults.
These vaccines are considered safe for pregnant women.
Recommendation by ACIP 2011:
• HCP and trainees in certain populations at high risk for chronic
hepatitis B (e.g., those born in countries with high and interme-
diate endemicity) should be tested for HBsAg and anti-HBc/

137
 anti-HBs to determine infection status.
• Hepatitis B vaccine is strongly recommended for all health-
care personnel who are occupationally exposed to blood or
other potentially infectious materials (2 doses 4 weeks apart;
third dose 5 months after second; booster doses not neces-
sary; all doses should be administered IM in the deltoid).
• Postvaccination testing for antibody to hepatitis B surface anti-
gen (anti-HBs) response is indicated for HCP who have blood
or patient contact and are at ongoing risk for injuries with sharp
instruments or needlesticks including DHCP. This will aid in
determining appropriate postexposure prophylaxis.
• Periodic serologic testing to monitor antibody concentrations
after completion of the three-dose series is not recommend-
ed.
• For postexposure prophylaxis, 0.06 mL/kg Hepatitis B immu-
noglobulin is given IM as soon as possible after exposure.

Measles-Mumps-Rubella (MMR) Vaccine

[6-7, 13, 22, 27, 74]
Organisms:
Live-attenuated strains of measles, mumps and rubella viruses.

Administration:
• Two doses subcutaneous 28 days apart.
• Universal immunization against rubeola (Measles) is recom-
mended (two doses) for all young adults particularly HCP born
after 1956.
• Universal immunization against the rubella virus generally is
recommended (one dose) for all HCP , but particularly for pre-
viously nonimmunized women of childbearing age who do not
have laboratory evidence of immunity.
• Immunization against mumps viruses is also recommended
(two doses) for health care workers because they are likely to
be exposed to mumps and experience the consequences of

138
 infection, characterized by the involvement of major salivary
glands, possibly meningitis.
• The vaccine is usually administered in combination form
(Measles-mumps-rubella-MMR vaccine).
• Adequate rubella vaccination for HCP consists of 1 dose of
MMR vaccine. However, because of the 2-dose vaccination
requirements for measles and mumps, the use of the com-
bined MMR vaccine will result in the majority of HCP receiving
2 doses of rubella-containing vaccine, which should provide an
additional safeguard against primary rubella vaccine failure.
• Women should receive the vaccine only if they are not preg-
nant and must be counseled not to become pregnant for 3
months after immunization.
• It is safe to give rubeola vaccine to a person who is already im-
mune, either from natural infection or previous vaccination.
• In approximately 5% to 15% of Rubeola vaccine recipients,
symptoms of attenuated measles, characterized by fever, be-
gin to develop 5 to 12 days after vaccination. A transient rash
may occur in approximately 5% of vaccinated patients
• Reactions to the mump vaccine are rare. MMR vaccine has
1-dose vaccine effectiveness in preventing mumps of 80%–
85% and a 2-dose vaccine effectiveness of 79%–95%.
• The most common complication with rubella vaccine is joint
pain, usually of the small distal joints, reported by as many as
40% of adult vaccine recipients.

Protection and Safety:

• Protection is good and booster is not needed. Two doses of
live measles vaccine are considered to provide long-lasting
immunity
• MMR vaccine is highly effective in preventing measles with a
1-dose vaccine effectiveness of 95% when administered on
or after age 12 months and a 2-dose vaccine effectiveness of
99%.
• Although antibody levels decline following vaccination, a study

139
 examining antibody levels up to 10 years following the second
dose of MMR vaccine in children indicates that antibodies re-
main above the level considered protective.
• MMR vaccine has 1-dose vaccine effectiveness in preventing
mumps of 80%–85% and a 2-dose vaccine effectiveness of
79%–95%.
• MMR vaccine is also highly effective in preventing rubella with
vaccine effectiveness of >99%.
• Fever can occur in up to 15% of recipients and transient rash-
es occur in up to 5% of recipients.
• Adolescents and adult women appeared at increased risk of
developing arthralgias and arthritis after rubella immunization.
The risk is small and generally of short duration. Chronic arthri-
tis has been rarely reported.
• Peripheral neuritis of short duration have also been reported
with rubella immunization
• Rare cases of optic neuritis, encephalitis, viral meningitis, paro-
titis and orchitis were reported following mumps immunization.

Recommendation by ACIP 2011:

• All persons who work in health-care facilities should have evi-
dence of immunity to measles, mumps and rubella. This in-
formation should be documented and readily available at the
work location.
• Evidence of immunity to measles, mumps and rubella for per-
sons who work in health-care facilities includes any of the fol-
lowing:
a. written documentation of vaccination with 2 doses of
live measles and mumps and 1 dose of live rubella, or 2
doses of MMR vaccine (the two doses administered at
least 28 days apart),
a. laboratory evidence of immunity,
b. laboratory confirmation of disease, or

140
 c. birth before 1957 (presumed immune from natural dis-
ease in childhood).
• Note: Although birth before 1957 generally is considered ac-
ceptable evidence of measles, mumps, and rubella immunity,
a dose of MMR vaccine is recommended (two doses during a
mumps outbreak) to unvaccinated HCP born before 1957.

Influenza Vaccine
[6-7, 12-13, 22, 27, 74]
Organism:
Usually contains strains of influenza viruses that are antigenically
equivalent to one influenza A (H3N2) virus, another influenza A (H1N1)
virus, and one influenza B virus. Because of the phenomenon of the
antigenic ‘drift’ and ‘shift’ seen in influenza viruses, the vaccine compo-
sition needs to be reviewed and altered each year.

Administration:
• One dose by injection, repeated each winter, which is the usual
period of outbreak.
• Adult immunization with the influenza virus vaccine consists of
one 0.5-ml intramuscular dose of vaccine.
• It is strongly recommended for health care providers to mini-
mize the transmission of influenza from health care providers
to patients and reduce time lost from work.
• Annual immunization is recommended, particularly for health
care providers with diabetes and other metabolic diseases; pro-
viders with severe anemia, hemoglobinopathies, or immuno-
suppression; providers with chronic pulmonary, cardiovascular,
or renal disease; providers older than 65 years of age; and all
other health care providers who may have contact with high-
risk patients (such as neonates, infants, elderly, patients with
chronic underlying illness, or immunocompromised patients).
• Two types of influenza vaccines are available: trivalent (Inac-
tivated) influenza vaccine (TIV), which may be given to any
HCP; and live attenuated influenza vaccine (LAIV), which may

141
 be given to any non-pregnant healthy HCP age 49 years and
younger.

Protection and Safety:

• Effectiveness of influenza vaccines varies from year to year
and depends on the age and health status of the person get-
ting the vaccine and the similarity or “match” between the vi-
ruses or virus in the vaccine and those in circulation.
• The protection is relatively short (approximately one year). An-
nual vaccination is recommended because the predominant cir-
culating influenza viruses typically change from season to sea-
son and, because immunity declines postvaccination with time.
• The vaccine is generally safe and cannot cause influenza.
• The most frequent side effect of vaccination is mild soreness at
the vaccination site (affecting 10%–64% of patients) which lasts
for less than 2 days. Malaise and low grade fever for as long as
48 hours are infrequent, and hypersensitivity reactions are rare.
• A history of Guillain-Barré syndrome (an acute polyneuropa-
thy, a disorder affecting the peripheral nervous system caus-
ing ascending paralysis, weakness, change in sensation or
dysfunction of the autonomic nervous system) within 6 weeks
following a previous dose of influenza vaccine is considered to
be a precaution for use of influenza vaccines.

Recommendation by ACIP 2011:

• All HCP who have no contraindications, not just those with di-
rect patient care duties, should receive an annual influenza
vaccination.
• Vaccination with the current season’s formulation is recom-
mended.
• Influenza vaccination rates among HCP within facilities should
be measured and reported regularly.
• When vaccine supply is limited, HCP should be among the
groups considered for prioritized receipt of influenza vac-
cines.

142
 Diphtheria-Tetanus-Pertussis (DTP)
[6-7, 22, 27, 74, 76]
Organism:
This vaccine is a three-in-one vaccine for prevention against diphthe-
ria caused by Corynebacterium diphtheriae, whooping cough caused
by Bordetella pertussis and tetanus caused by Clostridium tetani. The
vaccine contains killed Bordetella pertussis (acellular pertussis) and
diphtheria and tetanus toxoid.
There are four combination vaccines: DTaP, Tdap, DT, and Td. Two
of these (DTaP and DT) are given to children younger than 7 years of
age, and two (Tdap and Td) are given to older children and adults. DT
does not contain acellular pertussis, and is used as a substitute for
DTaP for children who cannot tolerate pertussis vaccine. Td is a teta-
nus-diphtheria vaccine given to adolescents and adults as a booster
shot every 10 years, or after an exposure to tetanus. Tdap is similar to
Td but also containing protection against pertussis.
Adult preparations have less diphtheria toxoid component compared
to pediatric preparations.

Administration:
• Five spaced doses of DTaP by intra-muscular injection for in-
fants and children, one dose at each of the following ages: 2, 4,
6, and 15-18 months and 4-6 years. For children who receive
DT as a substitute for DTaP, because they cannot tolerate the
pertussis vaccine, subsequent booster doses of diphtheria and
tetanus toxoids is needed.
• Health care providers not previously immunized should receive
a series of two doses of tetanus-diphtheria (Td) vaccine 4 to 8
weeks apart, followed by a booster 6 to 12 months later. Sub-
sequent to the primary series of immunizations, a Td (Tetanus-
Diphtheria) booster should be administered every 10 years.
• Adolescents 11-18 years of age (preferably at age 11-12 years)
and adults 19 through 64 years of age should receive a single
dose of Tdap. For adults 65 and older who have close con-

143
 tact with an infant and have not previously received Tdap, one
dose should be received. Tdap should also be given to 7-10
year olds who are not fully immunized against pertussis. Tdap
can be given no matter when Td was last received.
• Previously vaccinated health care providers with puncture
wounds or lacerations should receive a Td booster if more
than 5 years have elapsed since their last booster. Those with
severely or heavily contaminated wounds may require human
tetanus immunoglobulin in addition to vaccine if their history of
previous primary tetanus immunizations is not definite.
• If boosters are given too often, tetanus toxoid can cause se-
vere local pain and swelling.

Protection:
• Estimated vaccine efficacy is 92%
• Duration of immunity from vaccination has yet to be evalu-
ated.
• Data from many studies support the safety of Tdap in adoles-
cents and adults.
• Booster doses of tetanus and diphtheria are required to main-
tain immunity.

Recommendation by ACIP 2011:

• Regardless of age, HCP should receive a single dose of Tdap
(intramuscular) as soon as feasible if they have not previously
received Tdap and regardless of the time since their most re-
cent Td vaccination. After receipt of Tdap, HCP should receive
Td for routine booster every 10 years.
• Vaccinating HCP with Tdap will protect them against pertussis
and is expected to reduce transmission to patients, other HCP,
household members, and persons in the community.
• Tdap is not licensed for multiple administrations; therefore, af-
ter receipt of Tdap, HCP should receive Td for future booster
vaccination against tetanus and diphtheria.

144
 Varicella – Zoster
[6, 13, 22, 27, 74]
Organisms:
The varicella zoster vaccine is an attenuated viral preparation in a
lyophilized preparation.

Administration:
• One dose subcutaneous for persons ages 12 months to 12
years.
• Two 0.5 ml doses subcutaneous 4–8 weeks apart for those
ages 13 and up.
• It is intended for non-immune children and health profession-
als without a reliable history of chickenpox or serologic labora-
tory evidence of immunity against varicella.
• Both children and adults should receive two injections of the
vaccine given at least 28 days apart.
• A minority of vaccine recipients may develop a mild case of
chickenpox from the first vaccine dose.
• The vaccine is not recommended for pregnant women and
immune-compromised individuals.

Protection and Safety:

• The vaccine provides 70- 90% protection against varicella in-
fection and 95% protection against severe disease for 5-10
years after vaccination. Serious complications caused by vari-
cella are also reduced.
• Vaccines may potentially be capable of transmitting vaccine
virus to close contacts. Vaccinated health care workers should
therefore avoid close contact with susceptible high-risk indi-
viduals (e.g. newborns, pregnant women and immunocompro-
mised persons).
• The varicella vaccine has an excellent safety profile.
• The most common adverse events among adolescents and
adults were injection-site complaints. Varicella-like rash at the

145
 injection site occurred in 1- 3% of vaccine recipients. A non-
localized rash occurred in 0.9%-5.5% of vaccine recipients.

Recommendation by ACIP 2011:

• Health-care institutions should ensure that all HCP have evi-
dence of immunity to varicella.
• Evidence of immunity for HCP includes any of the following:
- written documentation of vaccination with 2 doses of vari-
cella vaccine,

- laboratory evidence of immunity or laboratory confirmation

of disease,

- diagnosis or verification of a history of varicella disease by

a health-care provider, or

- diagnosis or verification of a history of HZ by a health-

care provider.

• This information should be documented in the medical record

of HCP.
• Health care personnel without evidence of immunity to vari-
cella should receive 2 doses of varicella vaccine administered
4–8 weeks apart (subcutaneous). If >8 weeks elapse after the
first dose, the second dose may be administered without re-
starting the schedule.
• Varicella-zoster immunoglobulin (125U/10 kg IM) should be
given to persons without evidence of immunity who have con-
traindications for varicella vaccination, who are at risk for severe
disease and complications, and who have direct, non-transient
exposure to an infectious hospital staff worker or patient.
• Health care personnel who develop a vaccine-related rash
after vaccination should avoid contact with persons without
evidence of immunity to varicella who are at risk for severe
disease and complications until all lesions resolve (i.e., are
crusted over) or, if they develop lesions that do not crust (ma-
cules and papules only), until no new lesions appear within a

146
 24-hour period.
• Serologic screening before vaccination of HCP without evi-
dence of immunity is likely to be cost effective.
• A vaccine to prevent HZ is available and recommended for all per-
sons aged ≥60 years without contraindications to vaccination.
• The HZ vaccine is not indicated for HCP for the prevention of
nosocomial transmission, but HCP aged ≥60 years may re-
ceive the vaccine on the basis of the general recommendation
for HZ vaccination, to reduce their individual risk for HZ.

Vaccinations Which Might be Indicated in Certain

Circumstances [27]
Health-care institutions should consider including in their vaccination
programs other vaccines to prevent some diseases (such as meningococ-
cal disease and polio) for HCP who have certain health conditions or who
work in laboratories where the risk for work-related exposure exists.

Poliomyelitis Vaccine
[6-7, 22, 27, 66, 74]
Organism:
Live poliovirus types 1, 2 and 3 – Sabin vaccine or killed (inacti-
vated) poliovirus – Salk vaccine.

Administration:
• There are two types of vaccine that can prevent polio: inacti-
vated polio vaccine (IPV) and oral polio vaccine (OPV).
• Inactivated poliovirus vaccine (IPV): 2 doses should be admin-
istered at intervals of 4–8 weeks; a third dose should be ad-
ministered 6–12 months after the second dose. IPV is given in
the leg or arm, depending on age.
• Inactivated poliovirus vaccine (IPV) was indicated only in peo-
ple older than 18 years of age because of the slightly increased
risk of vaccine-associated paralysis in adults after administra-

147
 tion of live poliovirus (OPV).
• Now, there is a complete transition from use of oral poliovi-
rus vaccine (OPV) to inactivated poliovirus vaccine (IPV) for
all ages in USA and vaccine-associated paralytic poliomyelitis
(VAPP) attributable to OPV is also avoidable.

Protection and Safety:

• Both vaccines are highly effective in polio prevention, 98% to
100% seroconversion occurs after two doses of vaccination.
• Booster doses are recommended for fully immunized health
care providers only if there has been direct contact with oral
secretions or feces of a person with poliomyelitis.
• Adults are slightly at increased risk for vaccine-associated pa-
ralysis (oral polio). The risk is one case for 1.2 million doses.

Recommendation by ACIP 2011:

• Most adults do not need polio vaccine because they were al-
ready vaccinated as children.
• The childhood recommendation for poliovirus vaccine consists
of 4 doses at ages 2, 4, and 6–18 months and 4–6 years.
• Occasional cases of poliomyelitis still occur; therefore, health
care providers need to be vaccinated against this virus:
1. Vaccination is recommended for HCP who are at greater
risk for exposure to polioviruses than the general popu-
lation, including laboratory workers who handle speci-
mens that might contain polioviruses and HCP who
have close contact with patients who might be excreting
polioviruses, including HCP who travel to work in areas
where polioviruses are circulating.
2. Adults at higher risk who have never been vaccinated
against polio should get 3 doses of IPV: the first dose at
any time, the second dose 1 to 2 months later, and the
third dose 6 to 12 months after the second.
3. Adults at higher risk who have had 1 or 2 doses of

148
 polio vaccine in the past should get the remaining 1 or
2 doses, regardless of how long it has been since the
earlier dose(s).
4. Adults who are at increased risk of exposure to poliovi-
rus and who have previously completed a routine series
of polio vaccine (IPV or OPV) can receive one lifetime
booster dose of IPV.

Meningococcal Vaccine
[13, 22, 27, 69]
Organism:
Various preparations are available containing either: monovalent vac-
cine (containing group A immunogens), bivalent vaccine (containing group
A & C immunogens), trivalent vaccine (containing group A, C & Y immuno-
gens), or quadrivalent meningococcal conjugate vaccine-tetravalent vac-
cine (MCV4) (containing group A, C, Y & W135 immunogens). In 2010
a new meningococcal conjugate vaccine was licensed, pre-qualified by
WHO. Conjugate vaccines generally result in higher levels of protection,
longer duration of protection, protection of children less than 2 years of
age, and may interrupt nasopharyngeal carriage and transmission.

Administration:
• Use of MCV4 is preferred for persons younger than age 56
years (IM).
• If MCV4 is unavailable, the MPSV (quadrivalent meningococ-
cal polysaccharide vaccine) is an acceptable alternative for
HCP younger than age 56 years.
• Use of MPSV is recommended for HCP older than age
55(SC).

Protection and Safety:

The vaccine is generally safe and effective for a 3-year duration in adults.

Recommendation by ACIP 2011:

• MCV4 is not recommended routinely for all HCP.

149
 • However, HCP may become infected after direct contact with
respiratory secretions of infected persons and in a laboratory
setting (HCP can decrease the risk for infection by taking an-
timicrobial chemoprophylaxis if exposed directly to respiratory
secretions):
1. A 2-dose vaccine series is recommended for HCP with
known asplenia or persistent complement component de-
ficiencies, because these conditions increase the risk for
meningococcal disease.
2. Health care personnel traveling to countries in which
meningococcal disease is hyperendemic or epidemic also
are at increased risk for infection and should receive vac-
cine. They should receive a single dose of MCV4 before
travel if they have never received it or if they received it
more than 5 years previously.
3. Clinical microbiologists and research microbiologists who
might be exposed routinely to isolates of N. meningitides
should receive a single dose of MCV4 and receive a boost-
er dose every 5 years if they remain at increased risk.
4. Health-care personnel aged more than 55 years who have
any of the above risk factors for meningococcal disease
should be vaccinated with MPSV4.
5. Health care personnel who receive the 2 doses MCV4
vaccine series and/or remain in a group at increased risk
should receive a booster dose every 5 years.
6. Health care personnel not otherwise indicated for vac-
cination may be recommended to be vaccinated with
meningococcal vaccine in the setting of a community or
institutional outbreak of meningococcal disease caused
by a serogroup contained in the vaccine.

150
 Hepatitis A Vaccine
[22, 27]
Organism:
The currently licensed hepatitis A vaccine is an inactivated vaccine
and cannot cause hepatitis A.

Administration:
• Hepatitis A immunization requires a single dose in adults with a
later booster dose 6 to 12 months to achieve maximum titers.
• Health care personnel have not been demonstrated to be at
increased risk for hepatitis A virus infection because of occu-
pational exposure, including persons exposed to sewage.
• Hepatitis A vaccine is recommended for person with chronic
liver disease, and certain other groups at increased risk for
exposure to hepatitis A (day care workers, HCP having contact
with active cases, laboratory workers who handle live hepatitis
A virus, food handlers, staff of institutions for mentally handi-
capped, chronic carriers of hepatitis B, persons with other
chronic liver diseases, and international travelers).
• The vaccine should be given during pregnancy only if clearly
needed.
• There are no other contraindications other than hypersensitiv-
ity to any of the known components of the vaccine.

Protection and Safety:

• All studies to date indicate that this vaccine is highly immuno-
genic with excellent safety profiles.
• After a single dose 80% to 90% have protective levels of antibody
after 15 days and more than 96% seroconvert after 30 days.
• When a booster dose is given 6 months later, essentially 100%
of recipients seroconvert.
• Protective antibody titers develop within 15-30 days after vac-
cination and persists for 5-10 years, and preliminary data sug-
gest protective antibody levels may persist for between 16-25

151
 years.
• Post-vaccination serologic testing is not typically performed or
required.

Pneumococcal Vaccine
[22, 27]
Organism:
A polyvalent vaccine containing 23 strains.

Administration:
• The vaccine is given either intramuscularly or subcutaneously
in a dose of 0.5 ml.
• It is recommended for healthy persons aged ≥65 years. It is
also recommended for persons aged <65 years with certain
underlying medical conditions, including anatomic or function-
al asplenia, compromised immunity (including HIV infection),
chronic lung, heart or kidney diseases, and diabetes.

Protection and Safety:

• Efficacy rate ranges between 50 -70%.
• The vaccine is generally safe.
• Soreness and erythema at local injection sites occurs in 50%
of recipients, and lasts for no more than 48 hours.
• Anaphylaxis was reported among persons frequently receiv-
ing the vaccine more than indicated (a minimum of 6 years is
recommended between repeated doses).

BCG Vaccine (Bacillus Calmette-Guérin)

[6-7, 74]
Organism:
The vaccine contains live M. bovis attenuated by propagation in a
bile-potato medium, and is active against Mycobacterium tuberculosis.

Administration:
Single dose intradermally in the deltoid muscle.

152
Table 7
Immunizing Agents Recommended for Health Care Personnel
Primary
Generic
Recommen- booster Indications Contraindica-
name Special considerations
dation dose tions
schedule
Hepati- REQUIRED Two doses ACIP: All History of ana- According to the Ministry
tis B According to IM Health care phylactic reaction of Health Regulation, se-
recombi- the Ministry in the personnel at to common rologic screening is neces-
nant of Health deltoid risk of expo- baker’s yeast. sary before immunization
vaccine Regulation muscle 4 sure to blood Not contraindi- (to identify positive cases
immunization weeks and body cated in pregnan- and instruct them about
against hepa- apart; 3rd fluids. cy ( no apparent preventive measures).
titis B should dose 5 adverse effects The CDC recommends
be completed months MOH: All to developing that health care person-
during health after 2nd; persons at risk fetuses); nel who have ongoing
professional booster of contact with contact with patients or
training be- dose is blood, blood blood should be tested
cause the risk not neces- products, or 1-2 months after complet-
for infection is sary other body ing the vaccination series
thought to be secretions. to determine serologic re-
highest at this sponse
time Vaccine immunogenicity
If an DHCP is related to several fac-
declines the tors such as concomitant
vaccination, medical conditions. gen-
the DHCP der, age, body weight, and
must sign a smoking status
declination
form
Influenza RECCOM- An- ACIP: All HCP. History of ana- Side effects:
vaccine MENDED nual with phylactic hyper- Low-grade fever, soreness
(inacti- current MOH: All sensitivity after at the vaccination site (af-
vated seasonal health care egg ingestion fecting 10%–64% of pa-
whole or vaccine workers caring Known hyper- tients) that lasted <2 days.
split virus) -single for high-risk sensitivity to egg Rarely Guillain-Bare syn-
dose vac- persons*. proteins. drome (GBS) may occur
cination Persons who especially among adults
IM (either developed <65 years
whole or (Guillain-Barrè Influenza vaccination is
split-virus) Syndrome) or recommended for women
Give TIV other neurologic who are or will be preg-
intramus- syndromes re- nant during influenza sea-
cularly or lated to influenza son because of increased
intrad- immunization. risk for hospitalization and
ermally; No evidence of death.
or LAIV maternal or fetal LAIV is recommended only
intrana- risk when vac- for healthy, non–pregnant
sally. cine was given to persons aged 2–49 years.
pregnant women Intradermal vaccine is in-
with underlying dicated for persons aged
conditions that 18–64 years. HCP who
render them care for severely immuno-
at high risk for suppressed persons who
serious influenza require a protective envi-
complications. ronment should receive
TIV rather than LAIV.

153
 Measles RECCOM- 2 doses ACIP: All Pregnancy; MMR is the vaccine of
live virus MENDED SC; ≥28 HCP who lack immunocompro- choice if recipients are
vaccine days apart evidence of mised** state; also likely to be suscep-
immunity history of tible to rubella and/or
MOH: All anaphylactic mumps; give 2 doses of
health care reactions after MMR, 4 weeks apart.
workers at gelatin ingestion HCP vaccinated during
risk of contact or receipt of 1963–1967 with a killed
with patients neomycin; measles vaccine alone,
with measles, hypersensitivity killed vaccine followed by
or are likely to egg; live vaccine, or a vaccine
to have direct or recent receipt of unknown type should be
contact with of immuneo- revaccinated with 2 doses
pregnant globulin of live measles virus vac-
women. cine.
Side effects:
Fever can occur in up to
15% of recipients.
Transient rashes occur in
up to 5% of recipients.
Mumps RECCOM- 2 doses ACIP: All Pregnancy; MMR is the vaccine of
live virus MENDED SC; ≥28 HCP who lack immunocompro- choice if recipients are
vaccine days apart evidence of mised persons,** also likely to be suscepti-
immunity anaphylaxis to ble to measles and rubella
MOH: All gelatin or gelatin- give 2 doses of MMR, 4
health care containing prod- weeks apart.
workers at risk ucts; anaphylaxis HCP vaccinated before
of contact with to neomycin; 1979 with either killed
patients with hypersensitivity mumps vaccine or mumps
mumps or are to egg vaccine of unknown type
likely to have should consider revac-
direct contact cination with 2 doses of
with pregnant MMR vaccine.
women.
Side effects:
Fever can occur in up to
15% of recipients.
Transient rashes occur in
up to 5% of recipients.
Parotitis and encephalitis
have rarely been report-
ed.

154
Rubella RECCOM- 1 dose ACIP: All Pregnancy; Women who are pregnant
live virus MENDED SC; HCP who lack immunocompro- when vaccinated or who
vaccine (However, evidence of mised** state; become pregnant within 3
due to the immunity history of ana- mo of vaccination
2-dose MOH: All phylactic reaction should be counseled on
require- health care after the theoretic risks to the
ments for workers at risk receipt of neomy- fetus, the risk of rubella
measles of contact with cin; hypersensi- vaccine- associated mal-
and patients with tivity to egg; formations in these wom-
mumps rubella or are en is negligible;
vaccines, likely to have MMR is the vaccine of
the use of direct contact choice if recipients are
MMR vac- with pregnant also likely to be suscepti-
cine will women. ble to measles or mumps;
result in give 2 doses of MMR, 4
most HCP weeks apart.
receiving
2 doses of Side effects:
rubella- Fever can occur in up to
containing 15% of recipients.
vaccine.) Transient rashes occur in
up to 5% of recipients.
Transient arthralgias or
arthritis may occur among
40% of susceptible adult
women.
Peripheral neuritis of short
duration has been report-
ed.
Varicella RECCOM- Two 0.5 ACIP: All HCP Pregnancy, Because 71%-93% of
vaccine MENDED ml doses who do not immunocompro- persons without a history
(varicella SC 4–8 have evidence mised** state, of varicella are immune,
zoster weeks of immunity. history of ana- serologic testing before
virus apart if MOH: Suscep- phylactic reaction vaccination may be cost
live-virus aged ≥13 tible persons after receipt of effective.
vaccine) years. working in neomycin or
close contact gelatin; Persons
with high risk with blood dysc-
groups*; and rasis; malignant
day care work- neoplasms
ers and staff affecting bone
of institutional marrow or lym-
settings. phatics; during
febrile respiratory
illness; persons
with active
untreated tuber-
culosis. Vaccina-
tion should be
avoided for at
least five months
following blood
or plasma trans-
fusions. Salicy-
late use should
be avoided for 6
weeks after vac-
cination.

155
 Tetanus RECCOM- One dose ACIP: All HCP, History of serious Tetanus prophylaxis in-
and diph- MENDED IM as regardless of allergic reaction cluded in wound man-
theria (tox- soon as age. (i.e., anaphy- agement if Tdap not yet
oids) and feasible if MOH: Health laxis) to any received.
acellular Tdap not care work- component of
pertussis already ers during Tdap. Because
(Tdap) received outbreaks of of the importance
and diphtheria of tetanus vac-
regardless especially cination, persons
of interval those working with history of
from last in contact with anaphylaxis to
Td. After persons travel- components
receipt ing form newly in Tdap or
of Tdap, independent Td should be
routine Russian states referred to an
booster of allergist to de-
Td every termine whether
10 years. they have a
specific allergy
to tetanus toxoid
and can safely
receive tetanus
toxoid (TT) vac-
cine. Persons
with history of
encephalopathy
(e.g., coma
or prolonged
seizures) not
attributable to an
identifiable cause
within 7 days of
administration
of a vaccine
with pertussis
components
should receive
Td instead of
Tdap.

156
Quadri- RECCOM- One dose ACIP: Clinical Acute infectious
valent MENDED either IM and research diseases;
menin- in special cir- or SC in microbiologists Current evolving
gococcal cumstances 0.5 ml who might diseases (acute
conjugate dose routinely be or chronic).
vaccine- 10days exposed to Vaccine safety
tetravalent before isolates of Neis- in pregnant
(MCV4)for expected seria meningiti- women has not
HCP ages exposure; des; HCP with been evaluated;
19–54 booster known asplenia vaccine should
years, dose in or persistent not be given
Quadri- 5 years complement during pregnancy
valent if person component unless risk of
menin- remains at deficiencies; infection is high.
gococcal increased HCP traveling
polysac- risk to countries in
charide which meningo-
vaccine coccal disease
(MPSV4) is hyperendem-
for HCP ic or epidemic,
age >55 and clinical
years microbiologists
and research
microbiologists
who might
be exposed
routinely to
isolates of N.
meningitides.
HCP in a
community or
institutional
outbreak of
meningococcal
disease.
MOH: All health
care workers
during epidem-
ics outbreaks or
those working
in endemic
regions; all
health care
workers in high-
risk conditions
(during AI-Hajj
season).

157
 Inactivated RECCOM- For unvac- ACIP: Vac- Immunocompro-
poliovirus MENDED cinated cination is mised** persons;
vaccine in special cir- adults, recommended hypersensitivity
(IPV) cumstances 2 doses for adults at or anaphylactic
should be increased risk reactions to IPV
adminis- for exposure or antibiotics
tered at to polioviruses contained in IPV.
intervals including labo- IPV contains
of 4–8 ratory workers trace amounts
weeks; a who handle of streptomycin,
third dose specimens that polymyxin B, and
should be might contain neomycin.
adminis- polioviruses
tered 6–12 and HCP
months who have
after the close contact
second with patients
dose. who might
be excreting
polioviruses,
including HCP
who travel to
work in areas
where polio-
viruses are
circulating.
Adults who
have previ-
ously received
a complete
course of po-
liovirus vaccine
may receive
one lifetime
booster if they
remain at
increased risk
for exposure.
MOH: Health
care workers
at increased
risk of
exposure to
poliovirus.

158
 Hepatitis A RECCOM- Hepatitis A ACIP:HCP The vaccine Post-vaccination serologic
MENDED immu- have not been should be given testing not typically per-
in special cir- nization demonstrated during pregnancy formed or required.
cumstances requires to be at only if clearly
a single increased risk needed
dose in for hepatitis A There are no
adults with virus infection. other contrain-
a later Hepatitis A dications other
booster vaccine is than hypersen-
dose 6 to recommended sitivity to any
12 months for person of the known
to achieve with chronic components of
maximum liver disease, the vaccine
titers. international
travelers,
and certain
other groups at
increased risk
for exposure to
hepatitis A.
MOH: Hepatitis
A vaccine is
indicated for
pre-exposure
prophylaxis
against hepa-
titis A infection
for day care
workers,
HCP having
contact with
active cases
and labora-
tory workers
who handle
live hepatitis
A virus, food
handlers, staff
of institutions
for mentally
handicapped,
chronic carri-
ers of hepatitis
B, persons
with other
chronic liver
diseases

IM, Intramuscularly; SC, subcutaneously.MMR, Measles Mumps Rubella

* high risk groups: such as neonates, infants, elderly, patients with chronic underlying illness, or
immunocompromised patients.
**Persons are immunocompromised because of immune deficiencies, HIV infection, leukemia,
lymphoma, generalized malignancy, or immunosuppressive therapy with corticosteroids, al-
kylating drugs, antimetabolites, or radiation.
Source: KKUH Infection Control Department [13], Saudi Arabian MOH [22], CWRU School Of
Dental Medicine [25], CDC [27], Dalhousie University [29]

159
 Contraindications to Immunization
[6-7, 74]

• Adverse reactions to vaccines almost always are caused by hy-

persensitivity to one or more vaccine components such as re-
sidual animal proteins, antibiotics, preservatives, or stabilizers.
• The most common allergenic component is egg protein found
in vaccines prepared in embryonated chicken eggs or chicken
embryonal cultures (i.e., measles, mumps, and influenza).
• People who can eat eggs or egg-containing products can re-
ceive these vaccines, but vaccination is contraindicated for
people with a history of anaphylactic reaction to eggs or egg
proteins.
• On rare occasions, patients will have an anaphylactic reaction
to neomycin found in trace amounts in the measles, mumps,
and rubella vaccine and streptomycin found in the oral polio
vaccine.
• In general, immunizations with live virus vaccines should be
avoided in immunocompromised patients and during pregnancy.

160
OCCUPATIONAL EXPOSURE, EXPOSURE INCIDENT
AND DOCUMENTATION
[10, 25, 27]
Avoiding occupational exposures to blood is the primary way to pre-
vent transmission of hepatitis B virus (HBV), hepatitis C virus (HCV),
and human immunodeficiency virus (HIV), to DHCP in health-care
settings. An exposure incident refers to percutaneous injury (e.g., a
needlestick or cut with a sharp object such as a scalpel blade, bur, or
scaler) or contact of specific mucous membranes (eye, nose, mouth) or
non-intact skin (e.g., exposed skin that is chapped, abraded, or shows
signs of dermatitis) with blood or OPIM that results from the perfor-
mance of one’s duties or tasks.
Dental Health-Care Personnel (DHCP)
[10, 13, 16, 28]
Persons who have direct contact with patients, including dentists,
hygienists, dental assistants, clinical faculty, technicians, residents and
dental students, are more likely to be involved in disease transmission.
These persons may become infected through exposure to infected pa-
tients or exposure outside the facility. In either case they may transmit
the infection to patients, other DHCP, members of their household, or
other community contacts.
All DHCP are responsible for monitoring their own health status.
Those who have acute or chronic medical conditions that render them
susceptible to opportunistic infection should discuss with their person-
al physicians whether the condition might affect their ability to safely
perform their duties. The health status of DHCP can be monitored by
maintaining records of work-related medical evaluations, screening
tests, immunizations, exposures, and postexposure management. It
is the responsibility of all DHCP at risk of exposure to blood or body
fluids to secure receipt of a full course of the Hepatitis B vaccine and to
observe standard precautions.
Those DHCP who might reasonably be considered at risk of occu-
pational exposure to blood or other potentially infectious fluids should
be taught strategies to prevent exposures and the principles of post

161
 exposure management, including options for post exposure prophy-
laxis, as part of their job orientation and ongoing training. Under cer-
tain circumstances, dental health-care facility managers might need to
exclude DHCP from work or patient contact to prevent further transmis-
sion of infection.

Tasks and Procedures which may Result in

Occupational Exposure in the Dental Facility
Tasks and procedures which may result in occupational exposure in
the dental facility include the following:
1. Patient treatment procedures.
2. Radiographic procedures.
3. Cleaning, disinfection and sterilization of instruments.
4. Environmental surface and equipment disinfection.
5. Dental laboratory procedures.
6. Handling contaminated laundry.
7. Handling infectious waste.
8. Repairing dental equipment.
9. Handling infectious tissues and body fluids in different labora-
tories.
Dental Health Care Personnel at Risk of Occupational Exposures
Dental health care personnel at risk of occupational exposures in-
clude the following:
1. Dental health care providers (including: Dentists; hygienists;
students; residents; and trainees).
2. Dental assistants.
3. Radiology department technicians.
4. Sterilization center technicians.
5. Dental laboratory technicians.

162
 6. Microbiology laboratory technicians.
7. Histopathology laboratory technicians.
8. Research laboratory technicians.
9. Maintenance technicians.
10. Janitorial personnel.

Employee Health Services

[13, 22]
The following infection control activities of a personnel health ser-
vice must be observed before and during the placement of all DHCP:
1. Pre-employment Evaluation: All potential staff members must
have a medical examination and certain screening procedures
in their country of recruitment and on arrival. This pre-em-
ployment medical check-up will ensure that persons are not
placed in jobs that would pose undue risk of infection to them,
other personnel, patients, or visitors.
2. For infection control purposes, the following screening labora-
tory tests must be performed:
a. Serologic tests for syphilis, hepatitis B, C, and HIV
infections.
b. Tuberculin (TB) skin test and chest X-ray.
c. Urinalysis including pregnancy test.
d. Stool screening for parasites and enteropathogenic
bacteria.
e. Varicella antibody screening.
3. According to the Saudi Arabian Ministry of Health Regula-
tions, applicants who have an established infection, such as
tuberculosis or syphilis, or are carriers of HBV or HIV will be
considered as non fit to work.
4. Before signing the employment contract, all potential DHCP
irrespective of their recruitment origin must have an initial

163
 evaluation by the Employee Health Department which in-
cludes the following:
a. Complete history. History taking should enquire re-
garding any communicable disease the person may
have had, and any chronic infection or skin disease.
b. Psychological requirements. According to the Ministry
of Health Regulation, health employees should be
free from any psychological or mental troubles that
can affect their full work capacity.
c. General physical examination.
d. Screening laboratory tests. Lab investigations should
include complete blood count; biochemistry laboratory
tests, serologic tests for syphilis, hepatitis B, C, and
HIV; tuberculin skin test; chest X-ray, taken within the
previous 3 months; urinalysis; pregnancy test; and
stool screen for parasites and enteric pathogens.
e. Varicella screening. Enquiries should be made re-
garding history of varicella infection. Those with
doubtful or no history of infection should be screened.
If negative for antivaricella IgG, they should receive
the varicella vaccine.
f. Hepatits B screening. Personnel with negative anti
HBs should receive hepatitis B vaccine series.
g. Medical requirements: According to the Ministry of
Health Regulations, health care workers should be
free from the following health problems if they affect
their full work capacity or render them at high risk of
nosocomial infections:
i. Any incapacitating congenital anomalies.
ii. Cardiac diseases.
iii. Uncontrolled Hypertension.
iv. Uncontrolled Diabetes, Chronic chest diseases.

164
 v. Chronic liver diseases.
vi. Tumors.
vii. History of major surgical operations which may
affect physical and/or mental capacity.
viii. Renal disorders.
ix. Diseases needing major surgical operations.
x. Hearing, visual and/or speech disorders which
can affect work performance.
xi. Locomotor deficits, which can affect his work
performance.
xii. Lab tests should prove freedom from:
a. Hepatitis B & C
b. Sexually transmitted diseases including
AIDS.
c. Carriage of salmonella organisms causing
typhoid fever.
d. Carriage of vibrio cholera
e. Parasitic infections which include: Ma-
laria, Bilharziasis, Filriasis, Intestinal
parasites.

Management of Needlestick Injuries/Blood And

Body Fluid Exposure
[13, 28, 77]
I. First Aid:
Percutaneous Injuries (Needlestick/ Sharp Injury)
1. Allow the site to bleed.
2. Wash generously with soap and water.
3. Cleanse with alcohol wipes. However, there is no evidence
that using antiseptics or expressing fluid by squeezing the

165
 wound reduces the risk of transmission. Extraordinary mea-
sures, such as soaking injured tissues in bleach, excessive
scrubbing, or doing anything else that challenges the integrity
of skin, should be avoided.
4. Cover with appropriate bandages.
Mucocutaneous Exposures (Body Fluid Exposure)
1. Remove contaminated clothing (if necessary).
2. Irrigate affected area with copious amounts of water (10 min-
utes).
II. Reporting of Exposures:
All percutaneous injuries and mucocutaneous exposures must be
reported. The incident report should include:
a. Time and date of incident.
b. Location.
c. Source patient if known: Risk factors for the source
patient include:
• High-risk sexual behavior
• Intravenous drug use
• Tattoo/body piercing
• Transfusion of blood and blood product before
1990
• Origin in developing country
• Dialysis
d. Description of incident (including first aid measures)
Exposed personnel should attend the employee health clinic (EHC)
during normal working hours or the emergency room (ER) after hours.
It is the responsibility of the Employee Health physician to take the his-
tory from the DHCP and document the details. History to include:
a. Mechanism of injury.

166
 b. Site of injury.
c. Amount and type of blood/body fluid, and an indica-
tion of the severity of the exposure e.g. degree of
penetration of the needle, inoculation.
d. Immediate action taken (first aid).
e. Source patient serology status.
It is the responsibility of the EHC/ER physician to request the follow-
ing baseline lab investigations (as required) on the DHCP after obtain-
ing consent and/or counseling:
a. HBsAg
b. Anti-HBs
c. Anti-HCV
d. Anti-HIV.
NOTE:
1. The incident report should be taken for physician
documentation.
2. The injury should be reported within 24 hours of the
incident for risk assessment and prophylaxis where
indicated. Since documentation of any exposure man-
agement is essential to support future compensation
claims, notification must be made within 72 hours.
3. All DHCP should report to the employee health clinic
despite attendance at emergency room, as the EHC
physician is responsible for determining the need and
type of follow–up.
III. Evaluating The Exposure:
Each occupational exposure should be evaluated individually. This
evaluation should be based on:
a. the type and amount of body substance involved;
b. the type of exposure (e.g. percutaneous injury, expo-

167
 sure of mucous membranes or nonintact skin, bites
resulting in blood exposure to either person involved);
c. the infection status of the source; and
d. the susceptibility of the exposed person.
All of these factors should be considered in assessing the risk of
infection and the need for further follow-up.
IV.Prophylactic Treatment:
• When prophylactic treatment with drugs, vaccines, or immune
globulins is necessary, it should be offered and personnel
should be informed of risk of infection, alternative means of
prophylaxis, degree of protection provided by the therapy, and
potential side-effects.
• Hepatitis B (HBV) prophylaxis, when indicated, should be initi-
ated within 48 hours of the exposure incident and no later than
7 days.
• No post exposure prophylaxis or vaccination is available for
Hepatitis C (HCV).
• HIV prophylaxis when indicated should be initiated as soon as
possible following exposure and no later than 24 hours.
V. Documentation:
The incidence should be properly documented in the confidential
medical records of the DHCP.

Documentation
[16, 25]
Certain records, including medical records and training records,
should be kept for documentation and as part of infection control and
exposure control programs.

Medical Records
An accurate record should be established and maintained for each
DHCP with occupational exposure. This record shall include the fol-

168
lowing:
1. Demographic data including basic information such as the
DHCP’s name, identification card (ID) number, age, gender,
nationality, marital status, address, and phone number.
2. General health history updated regularly including health prob-
lems that may affect DHCP’s full work capacity or render them
at high risk of nosocomial infections.
3. The results of all pre-employment evaluation and screening
laboratory tests (see section on Employee Health Services).
4. A list of all vaccinations received (and to be received) by the
DHCP, documented by a physician.
5. A copy of the DHCP’s Hepatitis B vaccinations and any
medical records relative to the health care worker’s ability to
receive vaccination as required by the section on Hepatitis
B vaccination. If the staff member declines the vaccination,
documentation of refusal is kept in the file.
6. A copy of the following information (provided previously to
DHCP) signed by DHCP:
a. A description of the DHCP’s job description.
b. A document signed by the DHCP stating that they
have received a copy of the applied policies and pro-
cedures related to his/her duties.
7. In case of exposure incident, the following should be included
in the medical record:
a. A copy of all results of examinations and medical
testing as required by the section on Management of
Needlestick Injuries and Management of Exposures
(of different infectious diseases).
b. A description of the DHCP’s duties as they relate to
the exposure incident.
c. A copy of Incident Report Form.

169
 d. Results of the source individual’s blood testing, if
available.
e. Details regarding counseling, postexposure manage-
ment, and follow-up including vaccination status.

Confidentiality
The administration of the dental facility shall ensure that the required
health care worker medical records are:
1. Kept confidential.
2. Not disclosed or reported without the health care worker’s
express written consent to any person within or outside the
workplace except as required by law.
3. Maintained for at least the duration of employment plus 30
years.

Training Records
Training records of the DHCP shall include the following information:
1. The dates of the training sessions;
2. The contents or a summary of the training sessions;
3. The names and qualifications of persons conducting the train-
ing;
4. The names and job titles of all persons attending the training
sessions.
Training records shall be maintained for three years from the date
on which the training occurred.

170
 WORK RESTRICTION AND MANAGEMENT OF
JOB-RELATED ILLNESSES
[3, 10, 13, 37, 75, 78-80]
A major function of the personnel health service is to arrange for
prompt diagnosis and management of job-related illnesses and pro-
vide prophylaxis for certain preventable diseases to which personnel
may be exposed. It is the responsibility of the health care organiza-
tion to implement measures to prevent transmission of infection, which
sometimes warrants exclusion of personnel from work or patient con-
tact. Decisions concerning work restrictions are based on the mode of
transmission and the period of infectivity of the disease (Table 8).
Health care organization should develop and have readily available
to all DHCP comprehensive written policies regarding work restriction
and exclusion that include a statement of authority defining who can
implement such policies. The policies for work restriction and exclusion
should encourage DHCP to seek appropriate preventive and curative
care and report their illnesses, medical conditions, or treatments that
can render them more susceptible to opportunistic infection or expo-
sures; and should not penalize DHCP with loss of wages, benefits, or
job status.
The term exclude from duty in this document should be interpreted
as exclusion from the health care facility and from health care activities
outside the facility. Personnel who are excluded should avoid contact
with susceptible persons both in the facility and in the community.
According to USA Advisory Committee on Immunization Practices
(ACIP) 2011, HCP positive for HBsAg (e.g., acute or chronic hepatitis B
infection) should not perform exposure-prone invasive procedures until
they have sought counsel from an expert review panel, which should
review and recommend the procedures the worker can perform, taking
into account the specific procedure as well as the skill and technique
of the worker. Exposure prone procedures (EPP) have been character-
ized by the CDC as those procedures which “include digital palpation
of a needle tip in a body cavity or the simultaneous presence of the
HCP’s fingers and a needle or other sharp instrument or object in a

171
 poorly visualized or highly confined anatomic site.” The UK Dept. of
Health, defines EPPs as procedures in which “there is a risk that injury
to the worker may result in exposure of the patient’s open tissues to the
blood of the worker. These procedures include those where the work-
er’s gloved hands may be in contact with sharp instruments, needle
tips or 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.” It further states
that “The majority of procedures in dentistry are exposure prone”. Fur-
thermore, the Saudi Arabian Ministry of Health classifies dental proce-
dures as risk procedures.

Work Restriction According to the Ministry of Health

Regulation (Regarding Hepatitis B and C) [37]

• All DHCP should be screened for markers of HBV (HBsAg)

and HCV (Anti-HCV).
• PCR test for HBV and HCV should also be done for all DHCP
performing exposure prone procedures
• DHCP (performing exposure prone procedures) with posi-
tive HBsAg and positive PCR and the viral load is more than
100,000 copy/ml should be restricted from performing expo-
sure prone invasive procedures and they should work in an
area where transmission of the infection to patients could be
avoided.
• DHCP (performing exposure prone procedures) with posi-
tive HBsAg and negative PCR or the viral load is less than
100,000 copy/ml on two tests one month apart should not be
restricted from work, provided that the test is repeated yearly.
Once the viral load becomes more than 100,000 copy/ml,
work restriction applies.
• DHCP (performing exposure prone procedures) with positive
Anti-HCV and positive PCR should be restricted from per-
forming exposure prone invasive procedures and they should

172
 work in an area where transmission of the infection to patients
could be avoided.
• DHCP (performing exposure prone procedures) with posi-
tive Anti-HCV and negative PCR should not be restricted from
work.
• All health care workers with negative PCR for HCV tested
twice, at least one month apart, are considered free of the
disease.
• All health care workers receiving treatment for HCV and
proven to be cured from the disease with negative PCR for
6 months after receiving the treatment are considered free of
the disease.

173
 Table 8
Important Recommendations and Suggested Work Restrictions for
Personnel with Selected Infectious Diseases

Disease/problem Work Restriction Duration

Conjunctivitis (infectious) Restrict from patient con- Until discharge ceases
tact and contact with the
patient’s environment
Diphtheria Exclude from duty Until antimicrobial therapy
completed and 2 cultures
obtained >24 hours apart
are negative
Hepatitis A Restrict from patient con- Until 7 days after onset of
tact, contact with patients’ jaundice.
environment, and food-
handling
Hepatitis B (According to
MOH Regulation dated
18.02.1427)

a. Viral load < 100,000 a. No restriction, but viral

copy/ml load must be checked
with PCR yearly. If
becomes > 100,000
copy/ml, the following
restriction applies.

b. Viral load > 100,000 b. Restriction from per- Council may be sought
copy/ml forming exposure from an expert review
prone invasive proce- panel, which should re-
dures. view and recommend the
procedures the worker
can perform, taking into
account the specific pro-
cedure.
Hepatitis C diagnosed Restrict from performing
by PCR (According to exposure prone invasive
MOH Regulation dated procedures.
18.02.1427)
Human immune deficien- Restrict from performing
cy exposure prone invasive
Virus (HIV) procedures.

174
Herpes simplex Restrict from patient con- Until lesions heal.
Hands (herpetic whitlow) tact and contact with the
patient’s environment
Herpes simplex Evaluate the need to re-
Orofacial strict from care of high-risk
patients
Measles Exclude from duty Until 4 days after the rash
Active appears
Measles Exclude from duty From the 5th day after ex-
Post exposure (suscep- posure through 21st day
tible after exposure and/or 4
personnel) days after rash appears.

Mumps Exclude from duty Until 5 days after onset of

Active parotitis

Mumps Exclude from duty From 12th day after ex-

Post exposure (suscep- posure through 25th day
tible after exposure and/or until
personnel) 5 days after onset of paro-
titis.
Rubella Exclude from duty Until 7 days after rash ap-
Active pears
Rubella Exclude from duty From 7th day after through
Post-exposure (suscep- 21st day after exposure
tible personnel) and/or 7 days after rash
appears
Meningococcal infection Exclude from duty Until 24 hours after the
start of effective therapy.
Pertussis Exclude from duty From the beginning of the
Active catarrhal stage through
3rd week after onset of
paroxysms or until 5days
after start of effective anti-
microbial therapy.
Pertussis No restriction, prophylaxis
Post exposure (asymp- recommended
tomatic
personnel)
Pertussis Exclude from duty Until 5days after start of
Post exposure (symptom- effective antimicrobial
atic therapy.
personnel)

175
 Staphylococcus aureus in- Restrict from contact with Until lesions have re-
fection patients and patient’s envi- solved.
Active, draining skin le- ronment or food handling
sions
Staphylococcus aureus in- No restriction, unless per- until documented to be
fection sonnel are epidemiologi- negative from MRSA.
Carrier state cally linked to transmission
of the organism or
outbreak of MRSA infec-
tion. These personnel
should be cultured and,
if positive, removed from
patient
contact and undergo de-
colonization therapy.
Streptococcal infection, Restrict from patient care, Until 24 hours after ade-
group A contact with patient’s envi- quate treatment started.
ronment or food handling
Tuberculosis Exclude from duty Until proved noninfectious
Active disease
Tuberculosis No restriction
PPD converter
Varicella Exclude from duty Until all lesions dry and
Active crust. If only lesions that
do not crust (i.e., macules
and papules), until no new
lesions appear within a 24-
hour period
Varicella Exclude from duty unless From the 8th day after 1st
Post-exposure (suscep- receipt of the second dose exposure through 21st day
tible within 3-5 days after expo- (28th day if VZIG given)
personnel) sure after the last exposure; if
varicella occurs, until all
lesions dry and crust or,
if only lesions that do not
crust (i.e., macules and
papules), until no new le-
sions appear within a 24-
hour period
Zoster Cover lesions; restrict from Until all lesions dry and
Localized, in healthy per- care of high-risk patients crust
son

176
Zoster Exclude from duty Until all lesions dry and
Generalized or localized crust
in immunosuppressed
person until generalized
infection is ruled out
Zoster Exclude from duty unless From the 8th day after 1st
Post-exposure (suscep- receipt of the second dose exposure through 21st day
tible of varicella vaccine within (28th day if VZIG given)
personnel) 3–5 days after exposure after the last exposure; if
Generalized zoster or lo- varicella occurs, until all
calized zoster with uncon- lesions dry and crust or,
tained/uncovered lesions if only lesions that do not
crust (i.e., macules and
papules), until no new le-
sions appear within a 24-
hour period
Zoster For HCP with at least From the 8th day after 1st
Post-exposure (suscep- 1dose of varicella vaccine, exposure through 21st day
tible no work restrictions. (28th day if VZIG given)
personnel) For HCP with no doses of after the last exposure; if
Localized zoster with con- varicella vaccine, restrict varicella occurs, until all
tained/covered lesions from patient contact lesions dry and crust or,
if only lesions that do not
crust (i.e., macules and
papules), until no new le-
sions appear within a 24-
hour period
Viral respiratory infections, Consider excluding from Until acute symptoms re-
acute febrile the care of high risk pa- solve
tients or contact with their
environment during com-
munity outbreak of Re-
spiratory Syncytial Virus
RSV and influenza

Source: CDC [10], KKUH [13], CDC [27], Bolyard , et al. [75], MOH [37]

177
 NOTIFICATION OF INFECTIOUS DISEASES [13]
Notification of infectious diseases is one of the basic element of the
surveillance system which is the corner stone in the control and pre-
vention of infectious diseases. Notification is the process of informing
the Health Authorities (Ministry of Health) about the occurrence of a
disease that should be notified.
All patients diagnosed with one of the diseases that should be noti-
fied must be recorded by the Infection Control Officer who will forward
that information to the Chairman of Infection Control Unit.
Objectives of Notification:
1. To identify the public health problems.
2. To take preventive and control measures against infectious dis-
eases.
3. To allocate the necessary resources to solve major health prob-
lems.
4. To identify the epidemiological change for the disease.
5. To help eradication of some diseases.
Examples of infectious diseases that should be notified:
1. Tetanus
2. Polio cases
3. Hepatitis A
4. Hepatitis B
5. Hepatitis C
6. Unspecified Hepatitis
7. HIV
8. Syphilis
9. Diphtheria
10. Measles

178
11. Mumps
12. Rubella
13. Pertussis (whooping cough)
14. Meningitis
15. Varicella (chicken pox)

179
 HAND HYGIENE
Hand hygiene is an important component of any infection control
program. Its primary purpose is the mechanical removal of transient mi-
croorganisms from the skin of HCP, preventing cross infection from con-
taminated hands [6]. Increased frequency of hand hygiene procedures
is associated with decreased transmission of micro-organisms and a
reduction in the incidence of health-care-associated infections [81].

Selected Definitions [81-82]

• Alcohol-based hand rub: An alcohol-containing preparation
designed for application to the hands for reducing the number
of viable microorganisms on the hands. In the United States,
such preparations usually contain 60%–95% ethanol or iso-
propanol.
• Antimicrobial soap: Soap (i.e., detergent) containing an anti-
septic agent.
• Antiseptic agent: Antimicrobial substances that are applied
to the skin to reduce the number of microbial flora. Examples
include alcohols, chlorhexidine, chlorine, hexachlorophene,
iodine, chloroxylenol (PCMX), quaternary ammonium com-
pounds, and triclosan.
• Antiseptic handwash: Washing hands with water and soap or
other detergents containing an antiseptic agent.
• Antiseptic hand rub: Applying an antiseptic hand-rub product
to all surfaces of the hands to reduce the number of microor-
ganisms present.
• Bacteriostatic: Inhibit bacterial growth (the suffix “-static” fol-
lowing the name of an organism or group of organisms indi-
cates prevention of growth of such organisms).
• Bacteriocidal: Has the ability to kill bacteria (the suffix “-ci-
dal” following the name of an organism or group of organisms
indicates the ability to kill such organisms).
• Cumulative effect: A progressive decrease in the numbers of
microorganisms recovered after repeated applications of a

180
 hygiene product.
• Decontaminate hands: To Reduce bacterial counts on hands
by performing antiseptic hand rub or antiseptic handwash.
• Detergent or soap: i.e., surfactants, are compounds that pos-
sess a cleaning action.
• Hand antisepsis: Refers to either antiseptic handwash or anti-
septic hand rub.
• Hand hygiene: A general term that applies to either handwash-
ing, antiseptic handwash, antiseptic hand rub, or surgical hand
antisepsis.
• Handwashing: Washing hands with plain (i.e., non-antimicrobi-
al) soap and water.
• Persistent or residual activity: The prolonged or extended an-
timicrobial activity that prevents or inhibits the proliferation or
survival of microorganisms after application of the product.
• Surgical hand antisepsis: Antiseptic handwash or antiseptic
hand rub performed preoperatively by surgical personnel to
eliminate transient and reduce resident hand flora using Anti-
septic detergent preparations which have persistent antimicro-
bial activity.
• Visibly soiled hands: Hands showing visible dirt or visibly contam-
inated with proteinaceous material, blood, or other body fluids.

Hand Hygiene Product Categories [81]

The following is the Food and Drug Administration (FDA) (of the
United States Government) hand hygiene product categories:
• Patient preoperative skin preparation:
A fast-acting, broad spectrum, and persistent antiseptic-contain-
ing preparation that substantially reduces the number of microor-
ganisms on intact skin.
• Antiseptic handwash or HCP handwash:
An antiseptic-containing preparation designed for frequent use; it
reduces the number of microorganisms on intact skin to an initial

181
 baseline level after adequate washing, rinsing, and drying; it is
broad-spectrum, fast-acting, and if possible, persistent.

• Surgical hand scrub:

An antiseptic-containing preparation that substantially reduces
the number of microorganisms on intact skin; it is broad-spec-
trum, fast-acting, and persistent.

Transmission of Pathogens Through Hands [81, 83]

Transmission of health-care-associated pathogens from one patient
to another via the hands of HCP requires the following:
1. Organisms present on the patient’s skin, or that have been shed
on objects, must be transferred to the hands of HCP.
2. These organisms must be able to survive for at least several
minutes on the hands of the HCP.
3. Health care personnel’s handwashing or hand antisepsis is in-
adequate or omitted, or the antiseptic agent used is inappropri-
ate.
4. The contaminated hands of the HCP must come in direct con-
tact with another patient, or with an inanimate object that will
come into direct contact with the patient.
Touching intact areas of moist skin of the patient transfer organisms
to the hands more than dry surfaces. Wet hands have been described
to significantly increase the risk of cross-transmission, indicating that
hands should always be thoroughly dried.
Thus, to break the chain of transmission of potential pathogens via
the hands of HCP, hand hygiene must be performed when indicated (see
below) following the appropriate technique, with adequate hand drying.

Types of Skin Flora [6, 10, 81, 83]

The main types of microbial flora on the skin are resident (normal)
flora and the transient flora. Most of the hand flora are found under and
around the fingernails.

182
 Resident Flora
Consists of microorganisms that normally reside on the skin. They
may include bacteria and fungi, but viruses are not usually a part of
resident flora.
They are mainly attached to deeper layers of the skin and are less
likely to be associated with health-care–associated infections. They
are not regarded as pathogens on intact skin but may cause infections
in the eyes, or on nonintact skin.
Resident flora are more resistant to removal than transient flora
(see below). They are difficult to be removed mechanically, but hand
washing may reduce their numbers. And if disrupted by hand hygiene
methods, they re-establish themselves at the same site on the skin.
This normal resident flora serves a protective function against colo-
nization by pathogenic microorganisms. Long-term changes may oc-
cur to resident flora after contact with disinfectants, antibiotics therapy,
or disease.
Transient Flora
Consists of microorganisms that may be found on the skin only at
times, and occasionally multiply and cause disease. They may come
from patients (blood, saliva, or dental plaque) or inanimate surfaces.
They colonize the superficial layers of the skin and are the organisms
most often associated with health-care–associated infections.
They are easier to be removed mechanically by routine hand wash-
ing or by other proper hand hygiene practices than resident flora.

Hand Hygiene Methods and Indications

[6, 10, 81, 83-86]

The preferred method for hand hygiene depends on the type of pro-
cedure, the degree of contamination, and the desired persistence of
antimicrobial action on the skin.
Hand hygiene methods and their indications within the clinic are
listed in Table 9. From the table, it may be summarized that for routine

183
 dental examinations and nonsurgical procedures, handwashing and
hand antisepsis is achieved by using either a plain or antimicrobial
soap and water. If the hands are not visibly soiled, an alcohol-based
hand rub is adequate.
Furthermore, the following should be taken into consideration when
choosing the method of hand hygiene:
1. If the hands are known to be or are suspected of being contami-
nated, an antiseptic hand wash or antiseptic hand rub (after
washing off visible soil) should be performed with a an anti-
septic which has bactericidal, fungicidal, and virucidal (coated
viruses) activity.
2. Residual powder left on the hands by powdered gloves may in-
terfere with the antimicrobial action of alcohol based products.
Therefore, if alcohol based products are to be used following
removal of gloves, powder-free gloves should be used.
3. Antimicrobial-impregnated wipes may be considered as an al-
ternative to washing hands with plain soap and water, in the
absence of visible debris. However, such wipes should not be
used as a substitute for using an alcohol-based hand rub or an-
timicrobial soap because they are not as effective for reducing
bacterial counts on the hands of HCP.
4. However, if exposure to bacterial spores is suspected or prov-
en, hands should be washed with soap (antimicrobial or plain)
and water. The physical action of washing and rinsing hands
under such circumstances is recommended because alcohols,
and other antiseptic agents have poor activity against spores.
5. Also, the following non-clinical situations are all indications for
washing hands with soap (antimicrobial or plain) and water:
a. Before preparing or eating food.
b. After going to the bathroom.
c. After handling uncooked foods, particularly raw meat, poul-
try, or fish.

184
 d. After blowing the nose, coughing, or sneezing.
e. After handling an animal or animal waste.
f. After handling garbage.
g. Before and after treating a cut or wound.
h. After handling items contaminated by sewage.
Table 9
Hand Hygiene Methods and Indications Within the Clinic
Duration
Method Agent Purpose Indication
(minimum)
R o u t i n e Water and plain Remove soil 15 seconds –Before and after
handwash soap and transient contacting or treat-
micro-organ- ing each patient
isms (e.g. before glove
placement and af-
ter glove removal).
–After barehanded
touching of inani-
mate objects likely
A n t i s e p t i c Water and anti- Remove or de- 15 seconds to be contaminated
handwash microbial soap stroy transient by blood or saliva.
(e.g. chlorhexi- micro-organ-
dine, iodine isms and re- –Before leaving the
and iodophors, duce resident dental operatory or
chloroxylenol flora the dental labora-
[PCMX], triclo- tory.
san) –When hands are
A n t i s e p t i c Alcohol-based Remove or de- Rub hands visibly soiled (but
hand rub hand rub¶ stroy transient until the alcohol hand rubs
m i c r o - o r g a n - agent is dry not indicated in this
isms and re- situation).
duce resident –Before reglov-
flora ing after removing
gloves that are torn,
cut or punctured.

185
 Surgical an- Water and anti- Remove or de- 2-6 minutes Before donning
tisepsis microbial soap stroy transient sterile surgeon’s
(e.g. chlorhexi- microorgan- gloves for the fol-
dine, iodine isms and re- lowing procedures:
and iodophors, duce resident
–biopsy
chloroxylenol flora (persistent
[PCMX], triclo- effect) –periodontal sur-
san) gery
Water and plain Follow man- –apical surgery
soap followed ufacturer
by an alcohol- –implant surgery
instructions
based surgi- for surgical –surgical extraction
cal hand-scrub hand-scrub of teeth
product with per- product with
sistent activity persistent
activity

Source: CDC [10], and CDC [81]

The following is an outline of the effects, advantages, disadvantag-

es, and technique for the various hand hygiene methods.

Hand washing
Washing the hands with unmedicated soap and water removes dirt
and loosely adhering microbial skin flora (most of the transient and a
small part of the resident flora) through the physical action of scrubbing
the skin in the presence of a detergent. However, handwashing with
plain soap does not inactivate the microorganisms. This method does
not guarantee prevention of hand transmission of microorganisms.
The cleaning efficiency depends on the time and technique of washing.
Scrubbing the hands with the cleaning agent should be performed for 15-20
seconds, and the whole procedure should not take less than 30 seconds.
Advantages:
1. Can use plain soap
2. Effectiveness not affected by organic matter.
3. Familiar technique

Disadvantages:
1. Frequent handwashing with soaps and antiseptic agents (or

186
 even with water alone) can cause chronic irritant contact der-
matitis.
a. Skin damage causes changes in skin flora, resulting in
more frequent bacterial colonization (staphylococci and
gram-negative bacteria).
b. Adding emollients to the detergents reduce skin damage.
c. Water-based lotions recommended to ease the dryness re-
sulting from frequent handwashing and to prevent derma-
titis from glove use.
d. Petroleum-based lotions can weaken latex gloves and in-
crease permeability, thus should only be used at the end of
the work day.
e. Using hot water leads to greater skin irritation and scaling
of the skin, which may be due to increased penetration of
detergents into the epidermis.
2. Compliance with recommended handwashing protocol is tradi-
tionally low.
3. Requires fully equipped handwashing facilities.
4. Takes more time than antiseptic hand rubs.
5. Time and technique are critical.
6. Strong fragrances and other ingredients may be poorly toler-
ated by some HCP.
7. Washing with non-medicated soap may lead to contamination
of hands by the washing process per se.
a. A possible source is the sink itself, when splashes of con-
taminated water come in contact with the hand of the health
care worker. The reason is that the microorganisms are not
killed during the hand wash but only removed and distrib-
uted in the immediate surroundings of the person, includ-
ing the clothes.
b. Also, occasionally, plain soaps may become contaminat-
ed, which may lead to colonization of hands of personnel
with gram-negative bacilli.

187
 Technique:
1. Remove jewelry (rings and watches).
2. Adjust the water flow and temperature.
3. Wet hands with water.
4. Apply an amount of product recommended by the manufacturer
to hands.
5. Rub hands together vigorously, without splashing, for at least
15 seconds covering all surfaces of the hands and fingers (see
Figure 1 for technique to ensure all surfaces are covered).
6. Rinse hands with water.
7. Dry hands thoroughly with a disposable towel.
8. Use towel to turn off the faucet.
9. Apply hand lotion as necessary.
Figure 1
Technique for Rubbing Hands During Handwashing

Source: WHO [86]

188
Requirements of Handwashing Facilities:
1. Wash basin should be placed in a convenient place to increase
the compliance.
2. Sinks should be constructed of a smooth, highly polished mate-
rial, such as stainless steel or porcelain, which is amenable to
repeated disinfection procedures.
3. Sinks should be large enough and faucets placed in such a way
to allow washing of hands without contacting the faucet or sink.
4. Faucet controls, soap and lotion dispensers, should allow
hands-free operation so as to avoid their contamination by un-
washed hands. Sensor- operated or foot controls may be uti-
lized as well as elbow-controlled faucet handles.
5. A mixer tap helps to provide comfortable temperature.
6. Liquid soap dispensers should be either disposable or easily
removable and heat resistant for thermal reprocessing.
7. Liquid soap from refillable containers should be bacteriostatic
to prevent microbial growth.
8. Soap should not be added to a partially empty dispenser, be-
cause this can lead to bacterial contamination of the soap.
9. For plain soap, the following forms are acceptable: liquid, leaf-
let or powdered forms.
10. Products should be stored and dispensed according to the
manufacturers’ directions
11. Paper towel dispensers should be designed and positioned to
allow paper towels to be pulled out individually without contami-
nation of the dispenser or the remaining contents.
12. There must be a container for used towels.

Antiseptic Hand Rub

The objective of this method is to reduce the microbial release with
maximum efficiency and speed.
Alcohol hand rubs are rapidly germicidal when applied to the skin.
So the agent of choice for waterless hand rubs should be alcohol based

189
 (60%–95% ethanol or isopropanol) and should not be used in the pres-
ence of visible soil or organic material. Alcohol formulations which con-
tain chlorhexidine, quaternary ammonium compounds, octenidine, or
triclosan should be used if persistent activity is required.
In the absence of visible soil, it is acceptable to apply waterless han-
drubs repeatedly without washing hands with soap and water. How-
ever, washing hands is recommended after 5-10 applications because
of buildup of the handrub product.
Repeated use of an alcohol hand rub may causes some dryness of
the skin. However, such dryness is significantly less than that caused
by washing hands with detergent. Furthermore, the drying effect of al-
cohol can be reduced or eliminated by adding 1%–3% glycerol or other
skin-conditioning agents.

Advantages:
• Alcohol based antiseptic hand-rubs provide more effective an-
tiseptic action on visibly clean hands than washing with plain
or antimicrobial soaps.
• Faster protocol than the handwashing protocol.
• May be used without handwashing facilities.
• Allergic reactions rare.

Disadvantages:
• Not indicated when hands visibly soiled.
• Frequent use may cause skin dryness or irritation if product
lacks effective emollients/skin conditioners.
• Agent may temporarily sting compromised skin.
• Strong fragerances may be poorly tolerated by some HCP.
• Alcohol products are flammable, so should be stored away
from flames.
• Residual powders following removal of powdered gloves may
interfere with effectiveness of antiseptic rub.
• Handwashing stations must still be accessible for times when

190
 the use of waterless sanitizers are not appropriate.
Technique:
1. Hands must be dry before agent is applied.
2. The manufacturer’s recommendations should be followed re-
garding the volume of product to use.
3. The product should be applied to the palm of one hand and
the hands rubbed together, covering all surfaces of hands and
fingers, until hands are dry.
4. If hands feel dry after rubbing them together for 10–15 seconds,
an insufficient volume of product likely was applied.

Antiseptic Hand Wash

The aim of this method is to reduce the microbial release using a
washing procedure that is more effective than ordinary hand washing.
The washing technique is illustrated in Figure 1. Agents to be used de-
pend on the use (similar to hygienic rub). The most commonly used are
detergent preparations containing iodophors, chlorahexidine glucnate,
triclosan.
Alcohol-based products are more effective for use in antiseptic
handwashes than other antimicrobial formulations.

Surgical Hand Disinfection

The invasive nature of the following oral procedures: biopsy, peri-
odontal surgery, apical surgery, implant surgery, and surgical extraction
of teeth, indicates a need for a heightened level of pre-operative hand hy-
giene for DHCP. The objective of surgical hand disinfection is to reduce
the release of skin bacteria (transient and resident flora) from the hands
of the surgical team for the duration of an operation in case the surgical
glove is punctured or torn. Thus, agents used for surgical hand antisepsis
must be fast-acting, and have a persistent effect. They should also sub-
stantially reduce microorganisms on intact skin, contain a nonirritating
antimicrobial preparation, and have a broad spectrum of activity.

The recommended protocol for surgical hand antisepsis involves either:

191
 a. Water and anti-microbial soap, or
b. Water and plain soap followed by an alcohol-based surgi-
cal hand-scrub product with persistent activity.
The most active agents in reducing microbial counts post-scrubbing
are formulations containing 60%–95% alcohol alone or 50%–95%
when combined with limited amounts of a quaternary ammonium com-
pound, hexachlorophene, or chlorhexidine gluconate. The next most
active agents (in order of decreasing activity) are chlorhexidine glucon-
ate, iodophors, triclosan, and plain soap.
Hexachlorophene is absorbed into the blood after repeated use,
therefore it should not be used as a surgical scrub.

Technique:
1. Remove rings, watches, and bracelets before beginning the
surgical hand scrub.
2. Remove debris from underneath fingernails using a nail cleaner
under running water.
3. If using an antimicrobial soap:
a. Scrub hands and forearms for the length of time recom-
mended by the manufacturer, usually 2–6 minutes.
b. Fingertips should always point upward, with elbows down,
to avoid recontamination of clean fingers and hands by wa-
ter running down from contaminated proximal areas.
c. Long scrub times (e.g., 10 minutes) are not necessary and
frequently lead to skin damage.
d. Dry hands well using sterile towels, starting at the tips of
the fingers, followed by the hands, then the forearms.
4. If using an alcohol-based surgical hand-scrub product with per-
sistent activity:
a. Before applying the alcohol solution, prewash hands and
forearms with either plain or antimicrobial soap (4% chlor-
hexidine gluconate or povidone- iodine) for 1- or 2-minutes,
taking care that fingertips point upward.

192
 b. After washing, dry hands and forearms completely.
c. Apply the alcohol-based product as recommended by the
manufacturer.
d. Rub the product onto the entire surface of the fingertips,
hands and forearms, keeping them wet for the recom-
mended time by adding further portions as necessary, and
carrying out wash movements.
e. A hand rub should never be followed by a hand wash, be-
cause this has been shown to considerably lessen the ef-
fect of the rub.
f. Allow hands and forearms to dry thoroughly before don-
ning sterile gloves.
5. Scrubbing with a brush is not recommended as it can damage
the skin of personnel and result in increased shedding of bac-
teria from the hand.

Selection of Hand Hygiene Agents [6, 10, 81]

Only hand hygiene products approved by the FDA should be used.
And when selecting from FDA approved products, selection should be
based on the kind of procedure being done and the level of exposure
anticipated. Personnel should be provided with hand hygiene products
with appropriate spectrum of activity for their intended use. Persistence
of activity and speed of activity must also be taken into consideration
when selecting a product. Delivery system, reliable vendor support and
supply are also considerations. Low irritancy potential of an agent also
must be sought, particularly when these products are used multiple
times per shift. The cost of hand hygiene products should not be the
primary factor influencing product selection.
Because HCP acceptance is a major factor regarding compliance
with recommended hand hygiene protocols, end users should have
an input during evaluation and selection of hand-hygiene products.
Such input should include possible chemical allergies, skin integrity
after repeated use, compatibility with lotions used, and offensive agent
ingredients (e.g., scent).

193
 When selecting hand hygiene agents, information should be ob-
tained from manufacturers regarding any known interactions between
products used to clean hands, skin care products, and the types of
gloves used. Also, the dispenser systems of the various products
should be evaluated to ensure that dispensers function adequately and
deliver an appropriate volume of product.
Also, lotions or creams should be provided for HCP to minimize the
occurrence of irritant contact dermatitis associated with hand antisep-
sis or handwashing. Information should be obtained from manufactur-
ers regarding any effects that hand lotions, creams, or alcohol-based
hand antiseptics may have on the persistent effects of antimicrobial
soaps being used.

Storage of Hand Hygiene Products [81]

Hand hygiene products should be stored in closed containers which
are either disposable, or that can be washed and dried before refilling.
Fresh products should never be added to remaining amounts within
the container, due to the possibility of contamination and overgrowth of
microorganisms.
Supplies of alcohol-based hand rubs should be stored in cabinets or
areas approved for flammable materials.

Agents Used for Hand Hygiene [10, 81, 83]

Plain (Non-Antimicrobial) Soap

Soaps are detergent-based products that are available in various
forms. Their cleaning activity can be attributed to their detergent proper-
ties, which result in removal of dirt, soil, and various organic substances
from the hands. Plain soaps have minimal, if any, antimicrobial activity.
Handwashing with plain soap can remove loosely adherent transient
flora. However, in several studies, handwashing with plain soap failed
to remove pathogens from the hands of hospital personnel.

Effect on human skin:

Non-antimicrobial soaps may be associated with considerable skin

194
irritation and dryness, although adding emollients to soap preparations
may reduce their propensity to cause irritation.
A single hand wash already significantly reduces the dermal sebum
content; the reduction lasts for 1 h. If hands are washed four times with-
in 1 h, the skin does not recover to its normal state within this period.
Frequent hand washing induces irritative contact dermatitis (ICD) and
dry skin, which may become colonized with nosocomial pathogens.
Furthermore, each hand wash detrimentally alters the water-lipid
layer of the superficial skin, resulting in a loss of various protective
agents such as antimicrobial protective factors. Regeneration of the
protective film may be insufficient if many hand washes are carried out
in a row. This may lead to damage of the barrier function of the stratum
corneum, the transepidermal water loss (TEWL) increases, and the
skin becomes more permeable for toxic agents.
Alcohols
The majority of alcohol-based hand antiseptics contain either isopro-
panol, ethanol, n-propanol, or a combination. N-propanol is not an FDA-
approved active agent for HCP hand washes or surgical hand-scrub
preparations. The antimicrobial activity of alcohols can be attributed
to their ability to denature proteins. Alcohol solutions containing 60%--
95% alcohol are most effective. Higher concentrations are less potent
because proteins are not denatured easily in the absence of water.
Alcohol hand rubs are rapidly germicidal when applied to the skin;
and the regrowth of bacteria on the skin after use of alcohol-based
hand antiseptics is slow. So the agent of choice for waterless hand rubs
should be alcohol based. However, alcohols have no persistent activ-
ity; therefore, such hand rubs should include other antiseptics such as
chlorhexidine, quaternary ammonium compounds, octenidine, or triclo-
san to achieve persistent activity.

Effect on micro-organisms:
Alcohols have excellent in vitro germicidal activity against gram-pos-
itive and gram-negative vegetative bacteria, including multidrug-resis-
tant pathogens, Mycobacterium tuberculosis, and various fungi. Cer-

195
 tain enveloped (lipophilic) viruses (e.g., herpes simplex virus, human
immunodeficiency virus [HIV], influenza virus and respiratory virus are
susceptible to alcohols. Hepatitis B virus is somewhat less susceptible
but is killed by 60%–70% alcohol. Hepatitis C virus also is likely killed
by this percentage of alcohol. Alcohols have very poor activity against
bacterial spores and some non-enveloped (non-lipophilic) viruses.
In the presence of heavy microbial contamination (without visible
debris or proteinaceous material) an antiseptic hand rub using an alco-
hol-based rinse may be more effective at preventing pathogen trans-
mission than handwashing with plain soap and water. Also, alcohol-
based products are more effective for standard handwashing or hand
antisepsis by HCP than soap or other antimicrobial soaps.
Ethanol 60%--95% is classified by the FDA as a Category I agent
(i.e., generally safe and effective for use in antiseptic handwash or HCP
hand-wash products). However, isopropanol 70%–91.3% was classi-
fied as category IIIE (i.e., insufficient data to classify as effective).
Alcohols are effective for preoperative cleaning of the hands of sur-
gical personnel. The majority of alcohol-based preparations have been
found to be more effective than povidone-iodine or chlorhexidine. No
acquired bacterial resistance to alcohols has been reported to date.
The efficacy of alcohol-based hand-hygiene products is affected by
several factors :
• Type of alcohol used.
• Concentration of alcohol.
• Contact time.
• Whether the hands are wet when the alcohol is applied.
• Volume of alcohol used: Applying small volumes (i.e., 0.2--0.5
ml) of alcohol to the hands is not effective. The ideal volume
of product to apply to the hands is not known and may vary for
different formulations. However, if hands feel dry after rubbing
hands together for 10-15 seconds, an insufficient volume of
product likely was applied. Because alcohol-impregnated tow-
elettes contain a limited amount of alcohol, their effectiveness

196
 is comparable to that of soap and water.

Effect on skin :
Alcohols are considered to be among the safest antiseptics avail-
able and generally have no toxic effect on human skin. The skin barrier
remains intact, dermal hydration does not change significantly, and the
dermal sebum content remains unchanged.
Repeated exposure to alcohol or a moderately formulated product
can cause or maintain skin dryness and irritation. Adding glycerol,
humectants, emollients, or other skin-conditioning agents can reduce
or eliminate the drying effects of alcohol. Alcohol-based hand rubs con-
taining emollients may cause significantly less skin dryness and irrita-
tion than washing hands with liquid detergents.
When alcohol-based hand rubs are used following prolonged peri-
ods of hand washing with plain soap or antimicrobial soap and water,
burning or stinging of the skin may be experienced when applying the
alcohol. This is usually due to the presence of underlying, detergent-
associated irritant contact dermatitis (ICD). Skin that has been dam-
aged by preexisting exposure to detergents may be more susceptible
to irritation by alcohols than are non-damaged skin areas. As the skin
condition improves with continued use of alcohol-based hand rubs, the
burning and stinging associated with applying alcohol invariably disap-
pears.
Allergic reactions to alcohols are very rare.

Disadvantages:
• Organic matter diminishes the antimicrobial activity of alcohols
slightly. Alcohols are not appropriate for use when hands are
visibly dirty or contaminated with proteinaceous materials.
• Alcohols are flammable and require special storage conditions
for liquids with flash points ranging between 21°C- 24°C (“eas-
ily flammable”). Handling items such as polyester may create
a substantial amount of static electricity which could ignite
unevaporated alcohol, therefore hands should be rubbed to-
gether after application of alcohol-based products until all the

197
 alcohol has evaporated.
• Frequent use of alcohol-based formulations for hand anti-
sepsis can cause drying of the skin unless emollients, hu-
mectants, or other skin-conditioning agents are added to the
formulations. The drying effect of alcohol can be reduced or
eliminated by adding 1%--3% glycerol or other skin-condition-
ing agents.
• Alcohol hand rubs containing emollients may cause a tran-
sient stinging sensation at the site of any broken skin (e.g.,
cuts and abrasions).
• Alcohol-based hand-rub preparations with strong fragrances
may be poorly tolerated by HCP with respiratory allergies.
• Allergic contact dermatitis or contact urticaria syndrome
caused by hypersensitivity to alcohol or to various additives
present in certain alcohol hand rubs (occurs only rarely).
• Alcohols are volatile, therefore containers should be designed
to minimize evaporation.
• Residual powder left on the hands by powdered gloves may
interfere with the antimicrobial action of alcohol based prod-
ucts. Therefore, if alcohol based products are to be used fol-
lowing removal of gloves, powder-free gloves should be used.

Chlorhexidine
Chlorhexidine gluconate is commonly used either at 0.5 to 0.75%
in aqueous solutions and detergent preparations or at 2 to 4% in other
detergent preparations.
Chlorhexidine’s antimicrobial activity is slower than that of alcohols,
but it seems to have good residual activity. Its residual effect is prob-
ably the best of any antiseptic available. Thus, it has been added to
alcohol-based preparations for surgical hand disinfection to extend the
antimicrobial activity of alcohols under the glove.

Effect on micro-organisms:
The antimicrobial activity of chlorhexidine is likely attributable to at-

198
tachment to, and subsequent disruption of, cytoplasmic membranes,
resulting in precipitation or coaagulation of cellular contents. Chlorhexi-
dine also prevents the outgrowth, but not the germination, of bacterial
spores.
The antimicrobial activity of chlorhexidine is dependent on its con-
centration. When used in a liquid soap, chlorhexidine usually has a
concentration of 4% and exhibits a bactericidal activity against vari-
ous gram-positive and, to a lesser extent, gram-negative bacteria and
fungi. It has only minimal activity against tubercle bacilli. Chlorhexidine
is not sporicidal. It is active against enveloped viruses (e.g., herpes
simplex virus, HIV, cytomegalovirus, influenza, and RSV) but substan-
tially less activity against nonenveloped viruses.
In a comparison with a nonmedicated hand wash product, a chlor-
hexidine-based scrub yielded a lower reduction of different antibiotic-
resistant bacteria such as MRSA and vancomycine resistant entero-
cocci (VRE). Furthermore, chlorhexidine has been described to be less
effective in vitro against various nosocomial pathogens than is ben-
zalkonium chloride or povidone iodine.
Recurrent exposure of bacteria to chlorhexidine may lead to ad-
aptation and may enhance their resistance. The potential for cross-
resistance between antiseptic agents and antibiotics must be given
careful consideration. Resistance to chlorhexidine may even result in
nosocomial infections. Occasional outbreaks of nosocomial infections
have been traced to contaminated solutions of chlorhexidine.

Effect on Skin :
When used as recommended, chlorhexidine is safe for the skin. De-
tergents containing chlorhexidine were reported to cause skin dam-
age less frequently than was nonantimicrobial soap or other detergents
containing antimicrobial agents. However, skin irritation may occur with
high-concentration products (containing 4%) when used frequently for
antiseptic handwashing.
Allergic reactions to chlorhexidine gluconate are uncommon. How-
ever, there is a potential for sensitization and allergic contact derma-

199
 titis during frequent use of chlorhexidine. Allergic reactions to the use
of detergents containing chlorhexidine gluconate on intact skin have
been reported and can be severe, including dyspnea and anaphylactic
shock. Some cases of contact urticaria have also occurred as a result
of chlorhexidine use.
Furthermore, care must be taken to avoid contact with the eyes
when using preparations >1% chlorhexidine, because the agent can
cause conjunctivitis and severe corneal damage.

Disadvantages:
• The antimicrobial activity of chlorhexidine can be reduced by
natural soaps, various inorganic anions, nonionic surfactants,
and hand creams containing anionic emulsifying agents.
• Inactivation of chlorhexidine may result in contamination of
solutions containing 0.1% chlorhexidine.
• Chlorhexidine’s antimicrobial activity is slower than that of
alcohols.
• Recurrent exposure of bacteria to chlorhexidine may enhance
their resistance.
• Resistance to chlorhexidine may even result in nosocomial in-
fections. Occasional outbreaks of nosocomial infections have
been traced to contaminated solutions of chlorhexidine.
• The use of detergents containing chlorhexidine gluconate can
cause allergic reactions on the skin which can be severe.
• Preparations containing more than 1% chlorhexidine can
cause conjunctivitis and severe corneal damage when come
in contact with eye.

Iodine and Iodophors

Iodine is an effective antiseptic. However, iodine often causes irrita-
tion and discoloring of skin, therefore, iodophors have replaced iodine
as the active ingredient in antiseptics. Povidone-iodine 5%–10% has
been tentatively classified by FDA TFM as a Category I agent (i.e., a
safe and effective agent for use as an antiseptic handwash and an

200
HCP handwash).
The amount of molecular iodine present (so-called “free” iodine) de-
termines the level of antimicrobial activity of iodophors. Combining io-
dine with various polymers increases the solubility of iodine, promotes
sustained release of iodine, and reduces skin irritation.

Effect on Micro-organisms:
The antimicrobial spectrum of iodine preparations is wide, even
including bacterial spores. Efficacy against spores is too slow to be
useful in hand disinfection. Iodine and iodophors have bactericidal ac-
tivity against gram-positive, gram-negative, and certain spore-forming
bacteria (e.g., clostridia and Bacillus spp.) and are active against my-
cobacteria, viruses, and fungi. However, in concentrations used in an-
tiseptics, iodophors are not usually sporicidal.
An aqueous solution of povidone-iodine, the most commonly used
iodophor, is approximately as effective in reducing skin flora as 60%
isopropanol, but preparations in liquid soap are much less active. The
majority of iodophor preparations used for hand hygiene contain 7.5%-
-10% povidone-iodine. Lower concentrations also have good antimi-
crobial activity because dilution can increase free iodine concentra-
tions. However, as the amount of free iodine increases, the degree of
skin irritation also may increase.
The sustained effect is short.
The antimicrobial activity of iodophors is substantially reduced in
the presence of organic substances (e.g., blood or sputum). Organic
matter reduces antimicrobial activity slightly, but blood may abolish the
antimicrobial effect. The antimicrobial activity of iodophors also can
be affected by pH, temperature, exposure time, concentration of total
available iodine, and the amount and type of organic and inorganic
compounds present (e.g., alcohols and detergents). Unless special
precautions are taken, the antimicrobial efficacy of povidone prepara-
tions wanes during storage.
Iodophor antiseptics may become contaminated with gram-negative
bacilli as a result of poor manufacturing processes.

201
 Effect on Skin:
Iodine is absorbed through the intact skin across mucous mem-
branes, the use of iodine-containing, preparations may be associated
with undesired side effects such as allergic reactions. Skin irritation
and damage occur rather often and may thus adversely influence com-
pliance with hand disinfection. Iodophors cause more irritant contact
dermatitis than other antiseptics commonly used for hand hygiene.

Disadvantages:
• The antimicrobial activity of iodophors is affected by organic
substances (e.g., blood or sputum), pH, temperature, ex-
posure time, concentration of total available iodine, and the
amount and type of organic and inorganic compounds present
(e.g., alcohols and detergents).
• The antimicrobial efficacy of povidone preparations might
wane during storage.
• Iodine often causes skin irritation and damage and iodophors
cause more irritant contact dermatitis than other antiseptics.

Quaternary Ammonium Compounds

Quaternary ammonium compounds are a large group of compounds
which vary in their structure and complexity, but derive their name from
their shared chemical composition of a nitrogen atom linked to four
alkyl groups. Of these compounds, alkyl benzalkonium chlorides are
the most widely used as antiseptics. Other compounds that have been
used as antiseptics include benzethonium chloride, cetrimide, and
cetylpyridium chloride.
FDA tentatively classifies benzalkonium chloride and benzethonium
chloride as Category IIISE active agents (i.e., insufficient data exists
to classify them as safe and effective for use as an antiseptic hand-
wash).
For skin and hand disinfection quaternary ammonium compounds
present are in combination with other antiseptics such as alcohols.
They are not compatible with anionic detergents.

202
Effect on Micro-organisms:
Quaternary ammonium compounds are mainly bacteriostatic and
fungistatic and microbiocidal in high concentrations. They are more ac-
tive against gram-positive bacteria than against gram-negative bacilli.
They have weak activity against mycobacteria and fungi, but are active
against some viruses (lipophilic viruses), especially in combination with
alcohols.
Because of weak activity against gram-negative bacteria, benzalko-
nium chloride is prone to contamination by these organisms.
Their antimicrobial activity is adversely affected by the presence of
organic material and ion-rich water.

Effect on Skin:
Quaternary ammonium compounds have low allergenic and toxicity
potentials, but are three to ten times higher than the phenols deriva-
tives.

Disadvantages:
• Quaternary ammonium compounds have weak activity against
gram-negative bacteria and they are prone to contamination
by these organisms.
• Their antimicrobial activity is affected by the presence of or-
ganic material and ion-rich water.

Triclosan
Triclosan is an antimicrobial incorporated into soaps for use by HCP
and the public. The commonly used concentration in antiseptic soaps
is 1%. The FDA TFM tentatively classified triclosan <1.0% as a Cate-
gory IIISE active agent (i.e., insufficient data exist to classify this agent
as safe and effective for use as an antiseptic handwash).

Effect on Micro-organisms:
Triclosan achieves its antimicrobial effect by blocking lipid synthe-
sis. It has a broad range of antimicrobial activity, but it is often bacterio-
static. Triclosan’s activity against gram-positive organisms (including

203
 MRSA) is greater than against gram-negative bacilli. The agent pos-
sesses reasonable activity against mycobacterial and Candida spp.,
but it has limited activity against filamentous fungi.
Triclosan has persistent activity on the skin. However, it has been
shown to be less effective at microbial reduction compared to chlorhex-
idine, iodophors, or alcohol-based products. The amount of bacterial
reduction achieved with triclosan appear to be similar to that achieved
with nonmedicated soap. Furthermore, microbial resistance to triclo-
san is of concern, with evidence of microorganisms developing multi-
resistance to various antibiotics following exposure to triclosan.
Triclosan’s activity is not substantially affected by organic matter,
but it can be inhibited by surfactants present in certain formulations.
Furthermore, triclosan’s lack of potent activity against gram-negative
bacilli has resulted in occasional reports of contamination.

Effect on skin:
The majority of formulations containing <2% triclosan are well-toler-
ated and seldom cause allergic reactions.

Disadvantages:
• The amount of bacterial reduction achieved with triclosan
is less than that achieved with chlorhexidine, iodophors, or
alcohol-based products.
• Triclosan lack potent activity against gram-negative bacteria
and they are prone to contamination by these organisms.
• Their antimicrobial activity can be inhibited by surfactants
present in certain formulations.
• There is evidence of microorganisms developing multi-resis-
tance to various antibiotics following exposure to triclosan.
Table 10 is a summary of the antimicrobial spectrum of selected hand
hygiene agents.

204
Table 10
Anti-microbial Spectrum of Selected Hand Hygiene Agents
Gram- Gram- Speed
Myco- Virus- Com-
AGENT Positive Negative Fungi of Ac-
bacteria es ments
Bacteria Bacteria tion
Optimum
concen-
tration
Alcohols +++ +++ +++ +++ +++ Fast 60%-
95%; no
persistent
activity
Persistent
Chlor-
activ-
hexidine Inter-
+++ ++ + + +++ ity, rare
(2% and mediate
allergic
4%)
reactions
Less
Iodo- Inter- irrita-
+++ +++ + ++ ++
phors mediate tion than
iodine
Neutral-
ized by
Pheno- Inter-
+++ + + + + non-ionic
lics mediate
surfac-
tants
Accept-
Triclo- Inter- ability on
+++ ++ + - +++
san mediate hands
varies
Quater-
Used
nary
only in
ammo-
combina-
nium + ++ - - + Slow
tion with
com-
alcohols
pounds
+++ Excellent
++ Good but does not include the entire bacterial spectrum
+ Fair
- No activity

Source: adapted from CDC [81]

205
 Skin Reactions to Hand Hygiene Products [81]
Irritant Contact Dermatitis
Frequent and repeated use of hand-hygiene products, particularly
soaps and other detergents, is a primary cause of chronic irritant con-
tact dermatitis among HCP. Affected persons often complain of a feeling
of dryness or burning; skin that feels “rough;” and erythema, scaling, or
fissures. Such damage to the skin may change skin flora, resulting in
more frequent colonization by staphylococci and gram-negative bacilli.
Iodophors are the most commonly reported antiseptic causing irritant
contact dermatitis. Other antiseptic agents that can cause irritant contact
dermatitis (in order of decreasing frequency) include chlorhexidine, tri-
closan, and alcohol-based products. Skin that is damaged by repeated
exposure to detergents may be more susceptible to irritation by alcohol-
based preparations. Routinely washing hands with soap and water im-
mediately after using an alcohol hand rub may also lead to dermatitis.
Other factors that can contribute to dermatitis associated with fre-
quent handwashing include using hot water for handwashing, low rela-
tive humidity (most common in winter months), failure to use supple-
mentary hand lotion or cream, and the quality of paper towels. Shear
forces associated with wearing or removing gloves and allergy to latex
proteins may also contribute to dermatitis of the hands of HCP.
Irritant contact dermatitis may be reduced by replacing products with
high irritation potential with preparations that cause less damage to the
skin. Exposure of personnel to irritating soaps and detergents may be
reduced through the use of alcohol-based hand rubs containing various
emollients. Also, HCP may be educating regarding the risks of irritant
contact dermatitis, and provided with moisturizing skin-care products.
Regular use (e.g., twice a day) of moisterizers can help prevent and
treat irritant contact dermatitis caused by hand-hygiene products.

Allergic Contact Dermatitis

Liquid soaps and hand lotions or creams may contain ingredients
that cause contact allergies among HCP. Allergic reactions to products

206
applied to the skin (i.e., contact allergies) may present as delayed type
reactions (i.e., allergic contact dermatitis) or less commonly as immedi-
ate reactions (i.e., contact urticaria).
Allergic contact dermatitis associated with alcohol-based hand rubs
is uncommon. Allergic reactions to alcohol-based products may repre-
sent true allergy to alcohol or may be caused by compounds that may
be present as inactive ingredients in alcohol-based hand rubs.

Other Hand Hygiene Considerations [6, 10, 81]

Fingernails
Subungual areas (areas beneath the nails) of the hand harbor high
concentrations of bacteria. Even after careful handwashing or the use
of surgical scrubs, personnel often harbor substantial numbers of po-
tential pathogens in the subungual spaces. And although freshly ap-
plied nail polish does not increase the number of bacteria recovered
from the skin around the nails, chipped nail polish may support the
growth of larger numbers of organisms on fingernails.
Therefore, fingernails should be kept short with smooth, filed edges
to allow the skin beneath the nails to be cleaned with routine hand-
washing, and prevent glove tears. Furthermore, artificial fingernails
should not be worn.

Jewelry
Rings, watches, and bracelets should be removed prior to hand hy-
giene and should not be worn if they make donning gloves more dif-
ficult or compromises the fit and integrity of the glove.

207
 PERSONAL PROTECTIVE EQUIPMENT
[2, 5-6, 10, 13, 81, 87-93]
Personal protective equipment (PPE) such as protective clothing
and eyewear, face shields and disposable gloves are designed to pro-
tect the skin and mucous membranes of the eyes, nose, and mouth of
dental healthcare practitioners. Therefore, they are worn as a barrier
to prevent the transmission of microorganisms between patients and
the dental team. Gloves also reduce the likelihood that microorganisms
present on DHCP hands will be transmitted to patients during surgery
or patient-care procedures.
PPE must be easily accessible for DHCP and should be stored in
clean areas away from potential contamination. Contaminated PPE
should be disposed of as hazardous dental healthcare waste.

Gloves
Gloves protect DHCP from direct contact with microorganisms pres-
ent in the patient’s mouth and on contaminated surfaces. Also, they pro-
tect patients from microorganisms on the hands of the dental team.

Indications of Wearing Gloves

1. To provide a barrier to protect the wearer from contamination
when a potential exists for contacting patient’s blood, saliva,
mucous membranes, or other potentially infectious materials.
2. To reduce the risk of transmission of microbes from dentist to
patient
3. Gloves should be worn for all routine dental treatment and dis-
carded between patients
4. Preventing heavy contamination of the hands through use of
gloves is considered important, because handwashing or hand
antisepsis may not remove all potential pathogens when hands
are heavily contaminated.

Precautions to be Taken When Wearing Gloves

1. Fingernails should be short

208
2. Hands must be washed immediately before donning gloves.
Never consider gloves to be an alternative to hand washing.
3. Use of petroleum-based hand lotions or creams may adversely
affect the integrity of latex gloves.
4. After a hand rub with alcohol, the hands should be thoroughly
dried before gloving, because hands still wet with an alcohol-
based hand hygiene product can increase the risk of glove per-
foration.
5. Never re-use single use disposable gloves.
6. Changing gloves between patients prevents cross-infection be-
tween patients and contamination of hard surfaces in the sur-
gery.
7. Gloves should be changed during patient care if the hands will
move from a contaminated body site to a clean body site.
8. Unprotected surfaces such as patients’ files, pens, telephones,
computer keyboards, door or drawer handles, or face should
not be touched with gloved hands.
9. Gloves that are torn, cut or punctured should be removed as
soon as feasible, and hands washed before re-gloving.
10. Gloves should be changed during very long procedures, as up
to 40% of gloves develop tears after prolonged use and may
leak. Gloves also become porous during prolonged use due to
hydration of the latex. Also, by changing gloves excess sweat-
ing can be prevented, reducing the risk of dermal infections or
inflammation.
11. Gloves must only be worn whilst treating the patient and re-
moved at the end of the procedure and should be disposed of
as hazardous waste.
12. Gloves should not be washed, and no attempts should be made
to disinfect or sterilize gloves.
13. Hands should not be considered clean because gloves have
been worn.
a. Gloves do not provide complete protection against hand
contamination. Bacterial flora colonizing patients may be

209
 recovered from the hands of < 30% of HCP who wear
gloves during patient contact.
b. When removing gloves the patient’s microorganisms can
be transmitted from the external surface of the glove to the
dentist’s hands and need to be removed by hand hygiene.
14. Gloves do not prevent sharps injuries.

Choosing a Suitable Glove for the Task

Disposable gloves are manufactured in a variety of materials and must
conform to acceptable safety levels and performance. The most common
type of glove used for clinical procedures is natural rubber latex gloves
which permit manual dexterity and are impermeable to microbes.
1. Gloves should be FDA approved.
2. Sterile surgical gloves should be used for all dental procedures
performed by dentist or hygienist, other than patient examina-
tion and radiograph taking.
3. A glove should have a correct fit. Gloves that are too small,
especially if worn for prolonged periods of time, will produce
muscle fatigue in fingers and hands. If they are excessively
tight over the wrists it can exacerbate the symptoms of carpal
tunnel syndrome
4. Heavy duty, lined utility gloves should be used for general en-
vironmental cleaning and handling sharp items. These gloves
are reusable, and should be washed while on the hands and
dried. If excess sweating under the gloves becomes a problem,
cotton glove liners can be worn. They need to be checked regu-
larly for small tears, and discarded accordingly.
5. Double gloving is recommended in the following situations:
a. When the operator has dermatological condition.
b. With high risk patients to reduce risk of punctures.
c. When handling sharp objects such as crowns or wires.
6. Disposable clinical gloves should not be used for scrubbing in-
struments.

210
 Types of Gloves
Different glove types and their indications are listed in Table 11.
Table 11
Glove Types and Indications

Glove Indication Comment Material

Patient ex- Patient exami- Medical device reg- –Natural-rubber latex (NRL)
a m i n a t i o n nations, Radio- ulated by the Food –Nitrile
gloves graph taking, and and Drug Adminis-
laboratory proce- tration (FDA). –Nitrile and chloroprene
dures. (neoprene) blends
Non-sterile and
Double gloves sterile single-use –Nitrile and NRL blends
should be used disposable. Use –Butadiene methyl meth-
when cleaning for one patient and acrylate
or handling con- discard appropri- –Polyvinyl chloride (PVC,
taminated sharp ately. vinyl)
items. –Polyurethane
–Styrene-based copolymer
–Powder-less gloves
–Flavored gloves
–Low-protein gloves
S u r g e o n Surgical proce- Medical device reg- –NRL
gloves dures ulated by the FDA. –Nitrile
(all dental proce- Sterile and single-
dures performed –Chloroprene (neoprene)
use disposable.
by dentist or Use for one patient –NRL and nitrile or chloro-
hygienist, other and discard appro- prene blends
than patient ex- priately. –Synthetic polyisoprene
amination and ra- –Styrene-based copolymer
diograph taking).
–Polyurethane
Non-medi- Cleaning and dis- Commonly referred –NRL and nitrile or chloro-
cal gloves infection. to as utility, indus- prene blends
Handling con- trial or general pur- –Chloroprene (neoprene)
taminated sharps pose gloves.
or chemicals. Should be punc- –Nitrile
ture or chemical- –Butyl rubber
resistant, depend- –Fluoroelastomer
ing on the task. –Polyethylene and ethylene
Latex gloves do not vinyl alcohol copolymer
provide adequate
chemical protec-
tion.
Sanitize after use.
Source: Modified from CDC [10]

211
 Contact Dermatitis and Latex Hypersensitivity
Occupationally related contact dermatitis can develop from frequent
and repeated use of hand hygiene products, exposure to chemicals,
and glove use. Contact dermatitis is classified as either irritant or al-
lergic. Irritant contact dermatitis is common, non-allergic, and develops
as dry, itchy, irritated areas on the skin around the area of contact. By
comparison, allergic contact dermatitis (type IV hypersensitivity) can
result from exposure to accelerators and other chemicals used in the
manufacture of rubber gloves (e.g., natural rubber latex, nitrile, and
neoprene), as well as from other chemicals found in the dental practice
setting (e.g., methacrylates and glutaraldehyde).
Allergic contact dermatitis often manifests as a rash beginning hours
after contact and, similar to irritant dermatitis, is usually confined to the
area of contact. The use of hand lotions or creams may reduce derma-
titis associated with frequent handwashing. DHCP should be educated
regarding the signs, symptoms and diagnosis of skin reactions associ-
ated with frequent hand hygiene and glove use.
Latex allergy (type I hypersensitivity to latex proteins), on the other
hand, can be a more serious systemic allergic reaction, usually begin-
ning within minutes of contact with natural rubber latex, but sometimes
occuring hours later, and producing varied symptoms. The symptoms
of a latex allergy reaction may be skin reactions of urticaria (hives),
redness, burning and itching. More severe reactions may involve re-
spiratory symptoms such as runny nose, sneezing, watery itchy eyes,
scratchy throat and asthma, marked by difficult breathing, coughing
spells, and wheezing. Cardiovascular and gastrointestinal ailments
may also develop, and in rare cases, anaphylaxis and death. Anaphy-
lactic shock rarely occurs as the first sign of latex allergy but could oc-
cur with subsequent exposures.
Natural rubber latex proteins responsible for latex allergy are attached
to latex glove powder. When powdered latex gloves are worn, more la-
tex protein reaches the skin. In addition, when such gloves are donned
or removed, latex protein/ powder particles become aerosolized and can
be inhaled, contacting mucous membranes. HCP in work areas where

212
only powder-free, low-allergen latex gloves are used demonstrate few-
er symptoms related to natural rubber latex allergy. Other dental items
which can also put patients at risk of latex allergy include prophylaxis
cups, rubber dams, orthodontic elastics, and medication vials.
Dental health care personnel and patients should be screened for
latex allergy by taking medical history. Certain common predisposing
conditions for latex allergy include:
1. A history of allergic disorders such as hay fever, allergic asth-
ma, atopic dermatitis.
2. A history of allergic reactions to certain foods or grasses: avo-
cado, banana, chestnut, kiwi, papaya, potato or ragweed.
3. A history of spina bifida, urogenital anomalies, or myelomenin-
gocele/ meningocele.
4. A history of multiple surgical procedures, especially multiple
genito-uretal surgeries in children.
Medical consultation should be requested when allergy is suspect-
ed. Furthermore, workers with any of the above predisposing factors
should be periodically screened for latex allergy symptoms. Detecting
symptoms early and removing symptomatic workers from latex expo-
sure are essential to preventing long-term health effects.
To ensure a latex-safe environment for patients and DHCP with la-
tex allergy, HCP with latex allergy, as well as those caring for patients
with latex allergy, should be provided with reduced protein, powder-free
gloves, or nonlatex gloves (e.g., nitrile or vinyl). Furthermore, DHCP and
dental patients with latex allergy should not have direct contact with la-
tex-containing materials, and all latex-containing products should be re-
moved from their vicinity. Any latex-containing devices that cannot be re-
moved from the treatment environment should be adequately covered or
isolated. The following are further precautions which should be taken:
1. Patients with latex allergy can be scheduled for the first ap-
pointment of the day to minimize their inadvertent exposure to
airborne latex particles.
2. Other DHCP should be informed (e.g., by oral instructions, writ-

213
 ten protocols, and posted sign) regarding patients with latex
allergy to prevent them from bringing latex containing materials
into the treatment area.
3. All working areas contaminated with latex powder or dust should
be cleaned frequently.
4. Emergency treatment kits with latex-free products should be
available at all times.
5. If latex-related complications occur during or after a procedure,
manage the reaction and seek emergency assistance as indi-
cated.
Face Masks
Face masks protect the face and oral and nasal mucous membranes
during procedures likely to generate splashing or spattering of blood or
other body fluids. Masks also prevent particles (respiratory droplets,
skin squames) expelled into the environment by the wearer from con-
taminating the operatory field. Most masks produce a poor facial seal
and are not designed to filter the air as it is breathed into the lungs. So
they do not protect the wearer from aerosol inhalation.

Requirements of an Ideal Face Mask

1. Does not come into contact with nostrils or lips.
2. Has a high bacterial filtration efficiency rate.
3. Fits snugly around the entire periphery of the mask.
4. Does not cause fogging of eyewear.
5. Easy to put on and remove.
6. Is made of fabric that does not irritate the skin or induce al-
lergic reactions.
7. Made of fabric that does not collapse during wear or when
wet.

Types of Face Masks

1. Standard surgical facemasks.

214
 a. Provide no, or only partial, protection of the wearer from
respiratory pathogens such as Mycobacteria tuberculosis
or influenza.
b. May be dome shaped, or pliable.
c. May be secured with elastic bands, ear loops, or ties
d. Ties enhance stabilization during long procedures.
2. Respirator type masks.
a. Provide high filtration of aerosols, and thus offer a higher
degree of personal respiratory protection compared to a
standard facemask.
b. Recommended for DHCP for use whilst treating patients
with infections that are spread via aerosols e.g. tuberculo-
sis and influenza.

Indications for Wearing Face Masks

1. It is essential for DHCP to wear mask when:
a. Coming in close proximity to patient’s oral cavity.
b. Using handpiece, air/water syringe, or ultrasonic scaler.
c. Washing contaminated instruments.
d. Emptying a suction trap.
e. Disinfecting surfaces.
f. Taking radiographs.
g. Polishing with a lathe or a handpiece.
h. If DHCP is suffering from respiratory infection.
2. Masks should be worn properly and before gloving.
3. Masks should be changed between patients.
4. During patient treatment, masks should be changed at least
once every hour, and more often if the mask becomes damp or
wet, or if heavy spatter/ aerosol is generated during treatment.
5. Masks should not be touched or adjusted during procedures.
6. When removing masks, only the elastic bands or ties around
the head or ears should be touched. The body of the used
mask should not be touched with unprotected hands.

215
 Protective Eyewear, Face Shields
A variety of disease agents, such as the herpes simplex virus and
hepatitis B virus, may cause harmful infections of the eye or may pass
through ophthalmic mucous membranes and cause systemic infec-
tions. . Protective eyewear may provide protection against infectious
disease agents, splashes of chemicals during use of disinfectants and
radiograph processing chemicals, as well as against physical damage
to the eye by propelled objects, such as tooth fragments and restor-
ative materials.

Types of Eye Protection Devices

Table 12 compares different types of eye protection in relation to the
American National Standards Institute: Occupational and educational
eye and face protection, Z87.1-1989, New York, 1989. Due to the inad-
equate protection provided by glasses, they are unacceptable as eye
protection devices for DHCP. Either goggles or face shields should be
used for protection of the eye and face.
Table 12
Comparison of Eye Protection Devices
Front Side Front Side Neck and
Type Splash Splash Impact Impact Face Pro-
Protection Protection Protection Protection tection
Goggles Excellent Excellent Excellent Excellent Poor
Glasses Good Poor Excellent Poor Poor
(no shields)
Glasses Good Good Excellent Fair Poor
(w/ shields)
Face shield Excellent Good to Variable Variable Variable
excellent (depends (depends (depends
on thick- on thick- on type/
ness) ness) length)

Source: Miller and Palenik [5]

Indications for Wearing Eye Protection Devices

1. Whenever contamination of the eyes with aerosols, sprays or
splashes of body fluids is possible.

216
 2. Whenever projectiles may generated during any grinding, pol-
ishing or buffering procedure with rotary instruments or equip-
ment.
3. Whenever handling chemicals, such as during disinfection pro-
cedures for patient care items or surfaces, or when handling
radiography processing solutions.
4. When skin protection, is needed or desired, for example when
irrigating a wound or suctioning copious secretions, a face
shield should be used as a substitute to wearing a mask and
goggles. The face shield should cover the forehead, extend be-
low the chin, and wrap around the side of the face.
5. A face shield does not substitute for a surgical mask.
6. Reusable eye/facial protective equipment should be cleaned
with soap and water, or if visibly soiled, cleaned and disinfected
between patients.
7. Contaminated protective eye wear or face shield should not be
touched with unprotected hands.
Protective Clothing

Protective clothing, i.e. gowns and head covers, should be worn to

prevent contamination of street clothing and to protect the personal body
parts of DHCP which are likely to be soiled with chemicals or blood, sa-
liva or body substances during performance of the DHCP duties.

Requirements of Protective Clothing

1. Should cover personal clothing and skin including the head,
forearms, and chest area.
2. Veils worn by females outside the work area and ghutras worn
by males are not appropriate protective clothing, and must be
removed and replaced with appropriate well-fitting head covers.
3. Gowns and head covers may be reusable or disposable.
4. Disposable gowns and head covers must be discarded daily.

Indications for Wearing Protective Clothing

1. Whenever a chance exists for contamination of skin or clothing

217
 with spray or splashes of saliva, blood or other potentially infec-
tious materials.
2. Whenever a chance exists for contamination of skin or clothing
with spray or splashes of chemicals.
3. Female dental workers must wear a separate head cover for
the working area and must change this head cover before leav-
ing the clinic.
4. DHCP should change protective clothing at the end of each
clinical session, or when it becomes visibly soiled or is pen-
etrated by body fluids.
5. All protective clothing (gowns and head covers)should be re-
moved before leaving the work area.
Placing and Removing Barriers
Wearing or removing PPE should be done in a sequence that limits
further spread of microorganisms. The combination of PPE used, and
therefore the sequence, will be determined by the task to be performed,
and hence the PPE which need to be worn.

Sequence of Wearing PPE

1. Gown and head cover first.
2. Mask.
• The peripheries of the mask should be properly adjusted
to fit.
• The mask should not contact the nostrils or lips.
3. Goggles or face shield.
4. Gloves.
• Hand hygiene should be performed immediately before
donning gloves.
• If an alcohol rub was used for antisepsis, hands must be
completely dry before donning gloves because hands wet
with alcohol-based product may increase risk of glove
perforation.
• Gloves should be extended over protective clothing cuffs

218
 Sequence of Removing PPE
The sequence for removing PPE is intended to limit opportunities
for self contamination. The gloves are considered the most contami-
nated pieces of PPE and are therefore removed first. The face shield
or goggles are next because they are more cumbersome and would
interfere with removal of other PPE.
Disposable PPE should be discarded appropriately upon removal,
and not allowed to contact unprotected surfaces. Reusable PPE should
be set aside in an appropriate place pending decontamination, in order
to avoid contaminating unprotected surfaces.
1. Gloves.
• The left glove should be grasped near the edge of the cuff
and folded inside-out.
• The right glove should then be removed completely.
• The inverted inner aspect of the left glove may then be
grasped with the ungloved right hand and the left glove
removed completely
2. Face shield or goggles.
• The ear or head pieces may be grasped with ungloved
hands and lifted away from the face.
3. Gown.
• If the gown is disposable, it may be removed with the
gloves at the beginning in such a way that the gloves are
peeled off from the hands with the gown as it is removed.
• The gown is bundled with the contaminated surface folded
inwards, and discarded appropriately.
4. Mask.
• The mask should be removed by grasping the ties or
elastic bands or loops. The front of the mask should not
be touched with bare hands.
5. Head cover.
• If the head cover is of the type that is pulled on and re-

219
 moved over the head, care must be taken during removal
that the outer surface of the cover does not contact the
face.

220
 DESIGN OF CLINICS AND DENTAL UNITS
Clinic Design
[2, 10, 85, 94]
Infection control considerations should be borne in mind during the
designing of clinics within the College of Dentistry. The construction of
the clinical areas should be conductive to prevention of cross-contam-
ination, and the design of the clinic and dental units should utilize ma-
terials, surface textures, and shapes which permit easy and effective
infection control procedures.

Heating, Ventilation, and Air Conditioning Systems

Health-care Facilities
The clinic should be well ventilated. Air exchange in the operating
area should be adequate to prevent pollution by aerosols generated
during cavity preparation or by discharge from the evacuation (suction)
system. Inefficient ventilation systems and/or contaminated air condi-
tioning systems have been associated with increased levels of inhaled
bacterial endotoxins by dental professionals. And chronic endotoxin
inhalation is believed to represent an occupational respiratory hazard
to dental professionals, for significant relationships between the level
of endotoxin exposure and lung function decline have been reported in
a number of studies.
Microorganisms proliferate in environments wherever air, dust, and
water are present, and air-handling systems can be ideal environments
for microbial growth. Therefore, ventilation system design and main-
tenance should adhere to the guidelines on Ventilation Specifications
for Health-Care Facilities found in the American Institute of Architects’
(AIA) Guidelines for Design and Construction of Hospitals and Health-
Care Facilities (2010). Adequate records must be kept demonstrating
that building ventilation conforms to the AIA requirements regarding the
following:
1. Ventilation requirements for areas affecting patient care in hos-
pitals and outpatient facilities.

221
 2. Pressure relationships and ventilation of certain areas of nurs-
ing facilities.
3. Filter efficiencies for central ventilation and air conditioning sys-
tems in general hospitals.
4. Filter efficiencies for central ventilation and air conditioning sys-
tems in outpatient facilities.
5. Filter efficiencies for central ventilation and air conditioning sys-
tems in nursing facilities.

Clinical Plan
The design of the clinic should provide for adequate space to allow
dental health care workers (DHCP) to maneuver in the clinic without
inadvertently contacting contaminated surfaces.
The clinic should be divided into a “clean’ area where sterilized in-
struments and unused materials are placed and a “contaminated” area
where used instruments and materials are placed. The sharps contain-
er and contaminated waste container should be placed in the contami-
nated area (see MANAGEMENT of MEDICAL WASTE). Furthermore,
the treatment area should be used for treatment only. It should not be
used for storage of items, plants, or cleaning materials other than those
used within the clinic .

Clinical Facilities
Clinic surfaces (e.g. countertops, cabinets, walls, and floor) should be
of non-absorbent highly polished material and of a finish which may be
easily cleaned and disinfected. The clinic floor should not be carpeted.
Flooring material should be of a non-absorbent material and should con-
tain as few crevices and irregularities as possible. Clinic and equipment
surfaces should generally be smooth with as few joints as possible.
The clinic should be designed with sufficient cabinet and drawer
space to allow all devices and materials and, if necessary, instruments
to be stored inside the drawers or cabinets and not left exposed to the
clinic environment .
Hand hygiene facilities should have hands-free soap dispensers and

222
faucet controls so as to avoid their contamination by unwashed hands.
Sensor- operated or foot controls may be utilized as well as elbow-con-
trolled faucet handles. Sinks should be large enough and faucets placed
in such a way to allow washing of hands without contacting the faucet
or sink. Sinks should be constructed of a smooth, highly polished mate-
rial, such as stainless steel or porcelain, which is amenable to repeated
disinfection procedures. Furthermore, paper towel dispensers should be
designed and positioned to allow paper towels to be pulled out individu-
ally without contamination of the dispenser or the remaining contents .

Dental Unit Design

[6, 10, 95-99]

Dental Unit Waterlines and Hoses

Microbial contamination of specific component parts of dental units
is an important potential source of cross-infection. Of particular con-
cern are the unit components that come into direct contact with the
patient’s oral cavity, including dental unit handpieces, three-in-one air/
water syringes, and suction hoses. The dental unit output water is also
of concern as a source of potential cross-infection as it enters the oral
cavity.
Dental units should have anti-retraction valves (one-way flow check
valves) to prevent aspiration of fluid and microorganisms from the oral
cavity into the handpiece. Furthermore, dental instruments and equip-
ment that are connected to the dental unit and which enter the patient’s
mouth (e.g., ultrasonic scalers, turbine and conventional handpieces,
or air/water syringes) should contain integrated antiretraction valves
or devices to prevent backflow of oral fluids into the dental unit water
lines. This is important in light of the evidence that dental unit anti-
retraction valves have been shown to fail in large numbers .
Whenever possible, dental units should have sterilizable handpiece
hoses which may be removed and cleaned and disinfected and, if
necessary, sterilized. If non-sterilizable hoses are used, they should
preferably be strait, not coiled, and not covered, and of smooth outer
surfaces which allow adequate cleaning and disinfecting. Straight tub-

223
 ing is preferred over coiled because the size of the biofilm within coiled
tubing is larger relative to the amount of water passing through, thus
increasing the number of free-flowing bacteria exiting into the oral cav-
ity during use. Furthermore, the coiled design may allow stagnation of
more water inside the tubing during periods of rest, thus increasing the
number of proliferating bacteria inside the tubing.
Dental unit waterlines (DUWLs) are an ideal environment for pro-
liferation of microorganisms which enter them from the source water
supply, and the oral cavity during use of the handpieces or air-water
syringes. Therefore, the design of the dental units must facilitate treat-
ment of the water passing through them and/or their waterlines in order
to reduce the number of microorganisms exiting into the oral cavity to
minimum levels. Acceptable designs include:
1. Autoclavable hoses or hoses which may be removed and me-
chanically cleaned and disinfected.
2. Self-contained dedicated water systems (a supply system in
which the dental unit’s water supply comes from a closed sys-
tem such as a water bottle connected to the unit) which may be
filled water of known microbial and ionic quality, or which may
allow the introduction of solutions for treatment of the water or
waterlines.
3. Built-in reservoirs which communicate with the DUWLs and al-
low introduction of solutions for the treatment of the water exit-
ing the waterlines.
4. Micro-filters placed near the exit of water lines to reduce the
number of bacteria in the exiting water.
5. The preferred design which is units which may be used in com-
bination with fully automated cleaning and disinfection systems
that are validatable .
Self-contained delivery systems have the added benefit of enabling
the dental unit to continue to function if it is desired to avoid the mu-
nicipal water system . However, reservoir bottles can easily become
contaminated with pathogenic skin micro-organisms, thus introduc-
ing additional potential pathogens into DUWLs. Therefore, reservoir

224
bottles should be cleaned and disinfected regularly, and handled using
the aseptic technique. The reservoir bottles should be filled with fresh
water each morning and residual water discarded each night, storing
the empty bottle dry and inverted. Preferably, reservoir bottles that can
be sterilized by autoclaving should be used .
If the dental unit is to be supplied with source water from the mu-
nicipal supply, then the unit model must incorporate an air gap in the
DUWLs to prevent the possibility of retraction of contaminated fluids
into the main water supply .
If microbial filters are used, they must be changed regularly as they
become clogged readily. Filters do not manage the biofilm, and should
not be considered a substitute for biofilm treatments.
The temperature of the water in DUWLs has been shown to have an
effect on the microbial counts of certain strains of bacteria. Therefore
water heaters should not be used in dental units because warming the
water may amplify biofilm formation and select organisms pre-adapted
to growth in a human host. Water in the DUWLs should not be allowed
to be warmer than 20-25 oC.

Dental Unit Surfaces

Dental unit components which regularly become contaminated with
oral fluids during treatment (e.g. table, light switch, handles, saliva
ejector, and high-volume evacuator (HVE) tubings and connectors, air-
water syringes, and handpiece tubings) should, ideally, be detachable
and sterilizable. If, however, they are non-detachable or are heat sen-
sitive, they should be designed to allow easy and secure covering by
an impervious barrier. Detachable, sterilizable air-water syringes are
the ideal which must be pursued, if ever available. In their absence,
syringes should be fitted to allow the use of disposable tips or have
detachable, autoclavable tips.
To minimize contact of the operator’s hand with unit surfaces during
treatment, dental units should have sensor or foot controls for most of
the necessary functions required of the unit. If hand controls are uti-
lized, they should be designed such that they are amenable to being

225
 covered by a barrier easily and securely.
All unit surfaces, as well as the operator and assistant’s stools,
should be constructed of a material, which can withstand repeated
cleaning and disinfection with an appropriate disinfectant. The uphol-
stery should also be constructed of durable, non-organic materials, be
impervious to moisture, and seamless to reduce microbial entrapment
and increase disinfection efficiency.
X-ray viewers attached to dental unit tables have the potential for
higher rates of contamination compared to viewers placed away from
the unit. Such viewers, therefore, are more likely to cause contamina-
tion of radiographs placed on them. Hence, it is preferable to avoid
viewers attached to dental unit tables.

226
 DENTAL TREATMENT WATER
Clinical Water Supply
[10, 94-97, 100-101]
Microbial contamination of DUWLs originates principally from the
dental unit water supply, which usually contains low levels of micro-
organisms. These micro-organisms form microcolonies within DUWLs
that eventually give rise to multispecies biofilms. The poorer the quality
of water supplied to DUWLs, the more readily biofilm is likely to form
on its internal surfaces.
The quality of dental unit output water is directly influenced by the
quality of the incoming supply water. Such quality is determined by the
physical content (i.e. presence of suspended material and particulate
matter), chemical content (i.e. organic material and dissolved and sus-
pended inorganic compounds) and microbiological quality (i.e. density
of micro-organisms present) of the water. The condition of the water
distribution network pipes, and storage tanks, as well as water tem-
perature, also have a considerable role in water quality.
The microbial counts within the source water must be regularly
monitored, and the non-pathogenic bacterial count should not exceed
500 cfu/ml, (which is the regulatory standard for safe drinking water
established by the Environmental Protection Agency, American Public
Health Association, and American Water Works Association).
In the event that the municipal water supply has been judged to be
unfit for drinking, it should not be used as a source for dental treatment
water. A separate water reservoir should be used instead, or water of
known quality in a self-contained system. During these periods, tap
water should not be used to dilute germicides or for hand hygiene. For
hand hygiene, antimicrobial products that do not require water (e.g.,
alcohol-based hand rubs) can be used. If hands are visibly contaminat-
ed, bottled water and soap should be used for hand-washing. If bottled
water is not immediately available, an antiseptic wipe should be used.
After the municipal water has become safe for drinking, all incoming
waterlines from the public water system (e.g., faucets, waterlines, and

227
 dental equipment) should be flushed for 5 minutes. After the incoming
public water system lines are flushed, dental unit waterlines should be
disinfected.
Water softening applied to the dental unit supply water is vital in
hard water areas because mineral deposits inside DUWLs allow more
biofilm to form and may eventually result in clogging of DUWLs. If the
incoming water supply has a mineral hardness >200 ppm, water soft-
ening units which produce water suitable for the dental chairs should
be used to treat the water before it enters the dental units. The water
softening unit should have an integrated backwash facility timed to op-
erate when the softening unit is not being used. Water softening units
should receive periodic maintenance, regeneration and disinfection.
Proper maintenance is essential because biofilm can develop within
the water softening unit’s resin bed after a period of use, thus consid-
erably increasing the microbial loads in water entering the dental units
water downstream of the softening units.
Proper installation of water softening units is also important as their
location and set-up has often been found to be suboptimal, particularly
if used in combination with other types of filtration devices such as car-
bon filters, used to remove organic matter from water.
Sediment filters should be fitted in-line with the incoming dental unit
water supply before any other pretreatment system or device. Such
filters should be equipped with an integrated backwash function that
allows them to restore their full filtration capacity at times when there
is no demand on the water supply network. These sediment filters pro-
long the life of other water treatment systems which the water will pass
through by eliminating gross contaminants that would otherwise clog
either the resin beds of water softening units or activated carbon filters
by reducing the surface area available for absorption.
Activated carbon filters remove or reduce many volatile organic
chemicals, pesticides and herbicides, as well as chlorine, endotoxins
and solvents found in incoming water. They should be adequately sized
to cope with high contamination episodes.
Kinetic degradation fluxion (KDF) filters should be used for removal

228
of dissolved metals from the incoming water supply. Such filters con-
tain a high-purity copper–zinc matrix that uses the principle of oxidation
⁄ reduction (redox) to remove chlorine, lead, mercury, iron and hydro-
gen sulfide from water supplies. When placed inline before carbon fil-
ters, KDF filters can greatly extend the life and efficiency of the carbon
filters.
The order of treatment of the incoming water supply should be as
follows:
1. Sediment filter.
2. Water softening.
3. KDF and carbon filters.
4. DUWLs solutions for removal of the biofilm.
Periodic maintence of pretreatment facilities must be carried out.
If independent reservoirs are used, equipment used to produce dis-
tilled or deionized water for use in independent reservoirs should be
regularly maintained to ensure good quality output water. It must also
be ensured that the storage conditions within the reservoirs does not
result in deterioration of water quality.

Treatment of Dental Unit Waterlines

[5, 10, 94-100, 102-109]
The occurrence of high densities of microorganisms (up to 106 cfu/
mL) and bacterial endotoxins (500-105 endotoxin units (EU) per ml)
in dental unit output water has been reported in various literature, and
constitutes a potential risk of infection for dental patients and dental
healthcare and support staff. The onset of asthma in dentists may be
associated with occupational exposure to aerobic bacterial concentra-
tions in DUWLs > 200 cfu/ml, and a multitude of respiratory symptoms
may be caused by inhalation of airborne bacterial endotoxins. In the
absence of an adequate infection control regimen, the number of mi-
croorganisms has been found to increase to unacceptable levels. Bac-
terial endotoxins have also been found in the air of dental operatories
in amounts ranging from 2.7-625 EU/m3 of air, and DUWLs have been
identified as an important source of such endotoxins.

229
 The biofilm matrix within DUWLs also contains both inorganic and
organic material derived from supply water and dead microorganisms.
Such microbial content enters the oral cavity of the patient during treat-
ment, and the aerosols and droplets produced by dental instruments
connected to DUWLs may be inhaled by patients and dental health-
care personnel, leading to a variety of adverse medical problems and
consequences.
Therefore, the microbial count in dental unit output water must be re-
duced to levels suitable for the procedure being performed. The source
of the water used for dental treatment may be tap water, distilled water,
or sterile water, according to the procedure performed and the instruc-
tions of the delivery device’s manufacturer. Whatever the quality of the
source water or type of delivery system used in dental units, the biofilm
within the DUWLs must be removed by a proven method. The most
efficient means of achieving good quality DUWL output water is regular
treatment ⁄ disinfection of DUWLs with a chemical, biocide or cleaning
agent that removes biofilm from DUWLs effectively, resulting in good
quality output water.
The fluid used for irrigation of surgical wounds and during surgi-
cal procedures should be sterile water or saline solution. Furthermore,
the maximum acceptable level of endotoxins in sterile water used for
irrigation is 0.25 EU /mL , and for airborne endotoxins is 50 EU/m3
(based on personal inhalable dust exposure measured as eight hour
time weighted average. When sterile irrigating solutions are used, the
date of opening of the water bottle must be noted on the bottle. The
bottle should no longer be considered sterile at the end of the day, or
sooner if contamination is suspected.
For non-surgical procedures, regardless of the source water, the
number of bacterial counts of non-pathogenic bacteria in the water ex-
iting the device into the oral cavity be as low as reasonably achievable
without exceeding 500 cfu/ml.
The following approaches are acceptable methods for reduction of
the number of microorganisms and bacterial endotoxins exiting the wa-
terlines:

230
 1. Use of single-use disposable or sterilizable tubing,
2. Elimination of the biofilm,
3. Treatment of the waterlines chemically to reduce the viability of
the microorganisms in the biofilm, or
4. Use of microfiltration devices placed inside DUWLs to treat wa-
ter exiting the waterlines.

Single-use Disposable or Sterilizable Tubing

Whenever possible, single-use disposable or sterilizable tubes
which allow the cleaning and removal of the organic matrix of the bio-
film from their lumens, are the preferred method of controlling the mi-
crobial population within DUWLs. When used with a self-contained,
sterile water source, this type of system may even be used during sur-
gical procedures.

Elimination of the Biofilm

When using non-detachable tubings, management of waterline con-
tamination should aim at elimination of the biofilm. Attempting to elimi-
nate the resident bacteria without removal of the biofilm is an inade-
quate approach to DUWL treatment which may increase the hazards of
contaminated water. Biofilm re-growth in DUWLs usually occurs within
a week following disinfection/cleaning and so DUWLs need be treated
regularly
Elimination of the biofilm may be achieved through the use of a va-
riety of chemical products. Any product used must be:
1. Shown to be effective in the independent literature,
2. Compatible with the DUWL components (as recommended by
the dental unit manufacturer),
3. Non-toxic to patients or DHCP when used as recommended by
the dental unit manufacturer , and
4. Does not have adverse effects on the environment.
Research has shown that a range of disinfectants and cleaning
agents used to treat DUWLs may cause the release of mercury from
dental amalgam when tested in the laboratory. Thus, it is of concern

231
 that such agents could also mobilize mercury from dental amalgam
collected in amalgam filters, traps and separators and in dental unit
waste water lines and pipes and release it into the environment. Chlo-
rine containing products were shown to cause the release of more mer-
cury than other products.
Introduction of the chemical agent into the waterlines may be either
intermittent or continuous. The intermittent method involves place-
ment of the chemical agent in a self-contained water reservoir (the
source bottle) and flushing the water lines to allow the chemical to fill
all the tubings. The chemical is, then, left in contact with the tubings for
the appropriate contact time advised by the chemical’s manufacturer.
Afterwards, the chemical should be flushed out thoroughly with water,
and, depending on the type of chemical disinfectant, the unit is not put
into use for a specified number of hours. If the unit is connected to the
municipal water mains supply, it is imperative that the connection is
turned off prior to treatment of the waterlines to prevent contamination
of mains water with treatment agent.
The advantage of the intermittent method of treatment is that the
chemical is removed from the waterlines before patient treatment. Dis-
advantages are that it is time consuming and must be performed week-
ly to prevent surviving biofilm organisms from reforming the biofilm.
Furthermore, the exposure of DHCP to chemicals is a disadvantage
with any treatment modality which utilizes chemical agents. However,
if dental units with fully automated cleaning and disinfection systems
are used, the time and effort, as well as exposure to chemicals, re-
quired for intermittent cleaning are reduced.
The continuous method of waterline treatment involves mixing low
concentrations of the chemical agent with the dental treatment water.
This may be achieved either through mixing the chemical agent with
the source water in a self-contained system or through placement of
the agent in a reservoir inside the dental unit which provides for mea-
sured, continuous release into the water passing through the tubings.
The continuous method may be used alone or may be used after a sin-
gle regimen of the intermittent type. Advantages of the continuous type
are the reduced potential for recolonization of the waterlines and ease

232
of application. However, the continuous presence of the chemical and
its subsequent aerosolization during patient treatment leads to chronic
exposure of DHCP. Dental adhesive materials, also, may be affected
by the presence of such chemicals in the dental treatment water.
Once a dental unit is in place, the dental unit manufacturer’s instruc-
tions must be observed regarding the protocol and choice of chemical
for treatment of the DUWLs, while ensuring the method and chemicals
used have been proven to be effective. Adherence to maintenance
protocols is necessary as non-compliance has been associated with
persistence of contamination of the water.

Elimination of Viable Bacteria

Attempting to eliminate bacteria without removal of the biofilm will
only lead to quick re-colonization of the matrix with bacteria. Microor-
ganisms within the biofilm are more resistant to antimicrobial agents
than free-floating microbes. The chronic, continuous treatment of the
water with chemical disinfectants without removal of the biofilm may
lead to further microbial resistance, and may increase the hazards of
contaminated water and should, therefore, not be attempted. There-
fore, only DUWL cleaners that have been demonstrated to eliminate
both viable and biofilm bacteria should be used.

Microfiltration
Microfilters placed near the exit of waterlines may reduce the num-
ber of bacteria in dental treatment water. Sediment filters commonly
found in dental unit water regulators have pore sizes of 20-90 µm and
do not function as microbiological filters. Microfiltration commonly oc-
curs at a filter pore size of 0.03-10 µm.
Filters are usually installed on dental unit waterlines as retrofit de-
vices. The nearer the filters are placed to the exit of the tubings, the
lower the bacterial counts achieved. Filters have been shown to com-
pletely eliminate or reduce the microbial counts in water exiting DU-
WLs to < 200 cfu/ml.
Although filters prevent free-floating bacteria within the water lines
from exiting into the treatment area, the biofilm and bacteria are not

233
 eliminated from within the lines. Thus, bacterial endotoxins in the den-
tal treatment water are not reduced. However, filters have been devel-
oped which are able to remove endotoxins.
Disadvantages of filters are the persistence of the biofilm in the tub-
ings with the resultant risk of biofouling and clogging. Therefore, filters
are not sufficient to manage the water-line problem alone, but they
may be used in conjunction with other water-line treatment methods to
improve the quality of outgoing water.

Combined Approach
An ideal water-line treatment regimen would be filters combined with
an intermittent treatment of the water-lines to remove the biofilm. This
regimen combines the benefits of a) biofilm removal without chronic
exposure of DHCP and patients to chemicals, and b) delivery of chem-
ical-free, bacteria-free water in between treatment episodes.
Furthermore, flushing for 2 minutes in the morning and for 20–30
seconds after each patient should be considered the norm for dental
surgery procedures, and longer flushing is suggested after weekends.
Flushing at the beginning of the day should be performed without hand-
pieces connencted to the waterlines. However, flushing alone, without
concomitant treatment of the biofilm, is not an acceptable method to
reduce the microbial load in dental unit output water since it has been
reported to lead to a higher microbial load due to dislodging of pieces
of the biofilm during treatment.
At the end of each working day, the water supply should be discon-
nected and the water lines purged with air.
If the dental units have antiretraction devices, the manufacturer
must be consulted to determine whether testing or maintenance of an-
tiretraction valves or other devices is required. If required, efficacy
testing of antiretraction valves ⁄ devices should be performed yearly.

234
 CHEMICALS USED FOR DISINFECTION AND
STERILIZATION IN DENTISTRY
The choice of methods for cleaning, disinfection and sterilization
of patient-care medical devices and for cleaning and disinfecting the
healthcare environment should be based upon evidence-based rec-
ommendations. Furthermore, for maximum effectiveness when using
chemicals for such processes, health-care workers should adhere
strictly to the cleaning, disinfection, and sterilization recommendations
in this document and to instructions on product labels. [82]

Definition of Terms
[2, 10, 82]
• Sterilization: a process that destroys or eliminates all forms of
microbial life. When chemicals are used to destroy all forms
of microbiologic life, they can be called chemical sterilants.
These same chemicals used for shorter exposure periods also
can lead to disinfection.
• Disinfection: a process that eliminates many or all pathogenic
microorganisms, except bacterial spores, on inanimate ob-
jects.
• Decontamination: removal of pathogenic microorganisms on
a surface or item so that they are no longer capable of trans-
mitting infectious particles and the surface or item is rendered
safe for handling, use, or disposal.
- The decontamination procedure depends on the item or
surface being processed. For example, sterilization is the
appropriate decontamination procedure for surgical instru-
ments, whereas disinfection is sufficient for clinic surfac-
es.
• Sanitation: reduction of the numbers of bacterial contaminants
to safe levels as judged by public health requirements.
• Cleaning: the removal of visible soil (e.g., organic and inor-
ganic material) from objects and surfaces.

235
 • Disinfectants: antimicrobials applied only to inanimate objects.
Disinfectants are not used for skin antisepsis because they
can injure skin and other tissues.
• Antiseptics: antimicrobial chemicals applied to living tissue
and skin. Antiseptics are used only on the skin and not for
surface disinfection.
• Germicide: an agent that can kill microorganisms, particularly
pathogenic organisms (“germs”). The term germicide includes
both antiseptics and disinfectants.
- Terms with the suffix -cide or -cidal (e.g. virucide, fungicide,
bactericide, sporicide, and tuberculocide) indicate the abil-
ity to kill the type of microorganism identified by the prefix.
For example, a bactericide is an agent that kills bacteria.

Classification of Items and Surfaces

for Decontamination
[2, 10]
Patient Care Items
According to their uses and potential risk for transmission of infec-
tion, instruments, devices, and equipment used in healthcare settings
are classified as critical, semi-critical, or non-critical.
a. Critical instruments are surgical instruments and those instru-
ments that penetrate soft tissue or bone (e.g. forceps, scalpels,
bone chisels, scalers, burs).
- Critical instruments confer a high risk for infection if they
are contaminated with any microorganism, and should,
thus, be sterilized after each use.
b. Semi-critical instruments are those that do not penetrate soft
tissues or bone but contact oral tissues (e.g. mirrors and amal-
gam condensers) or non-intact skin.
- Semi-critical instruments, also, should be sterilized after
each use.

236
 - Heat-sensitive semi-critical items should be sterilized with
chemical sterilants, or, at minimum, undergo high-level dis-
infection.
c. Non-critical instruments are those that contact only intact skin
(e.g. external components of x-ray tubes).
- Such items may be disinfected between patients with a
low-level disinfectant (see below).
- If, however, the surface of the item is visibly soiled with pa-
tient material, then it must be disinfected with an intermedi-
ate-level disinfectant (i.e. one with a tuberculocidal claim)
(see following section). Pre-cleaning with a detergent be-
fore disinfection may be necessary depending on the type
of disinfectant used.

Environmental Surfaces
In the clinic, environmental surfaces are surfaces or equipment that
do not contact patients directly but may become contaminated with pa-
tient material indirectly via contaminated hands or patient care items.
Based on the potential risk of contamination, the various environmental
surfaces can be divided into clinical contact surfaces and housekeep-
ing surfaces (see section Environmental Surfaces). These two types
of surfaces require different types of cleaning/disinfecting agents and
protocols.
a. Clinical contact surfaces are those surfaces which risk being
contaminated with aerosols and spatter or touched with con-
taminated gloves during operation. Such surfaces, if contacted
with contaminated gloves, can be potential reservoirs of micro-
bial contamination.
b. Housekeeping surfaces are those surfaces which are less like-
ly to be contacted with contaminated gloves but may become
contaminated with aerosols, spatter, or spills. Examples of such
surfaces are floors, walls, and hand washing sinks.

237
 Classification of Antimicrobials
[10, 82]
In the United States, the Environmental Protection Agency (EPA) is
a governmental agency that regulates disinfectants that are used on
environmental surfaces (housekeeping and clinical contact surfaces),
and not those used on critical or semi-critical medical devices. The
Food and Drug Administration (FDA) is the governmental body which
regulates liquid chemical sterilants/ high-level disinfectants (e.g., glu-
taraldehyde, and hydrogen peroxide) used on critical and semi-critical
patient-care devices. Antiseptics are considered antimicrobial drugs
used on living tissue and thus are regulated by FDA.
The EPA and FDA classify disinfectants differently. The EPA regis-
ters environmental surface disinfectants based on the manufacturer’s
microbiological activity claims when registering its disinfectant. To be
labeled as an EPA “hospital disinfectant”, the product must have dem-
onstrated effectiveness against the following micro-organisms:
1. Salmonella choleraesuis (for effectiveness against gram-nega-
tive bacteria);
2. Staphylococcus aureus (for effectiveness against gram-positive
bacteria); and
3. Pseudomonas aeruginosa for effectiveness against a primarily
nosocomial pathogen.
The EPA also lists disinfectant products according to their labeled
use against organisms of interest (Mycobacterium tuberculosis, HIV,
HBV, HCV). Because Mycobacterium tuberculosis has among the high-
est levels of resistance among the vegetative bacteria, viruses, and fun-
gi, if a product is labeled as “tuberculocidal”, it is considered capable of
inactivating a broad spectrum of pathogens, including HBV, HCV, and
HIV. Although Mycobacterium tuberculosis is transmitted by the airborne
route, and not via environmental surfaces, disinfectants are tested for
their activity against it to determine if they have broad-spectrum capa-
bility. Updated lists of EPA registered products are available at the EPA
website at http://www.epa.gov/oppad001/chemregindex.htm.

238
 The FDA, on the other hand, defines antimicrobial potency as ster-
ilization, and high-, intermediate- and low-level disinfection. This differ-
ence has led to confusion on the part of users because the EPA does
not use such terms. The Center for Disease Control (CDC) of the U.S.
National Institute of Health designates any EPA-registered hospital dis-
infectant without a tuberculocidal claim as a low-level disinfectant and
any EPA-registered hospital disinfectant with a tuberculocidal claim
as an intermediate-level disinfectant. Furthermore, the FDA defines a
high-level disinfectant as a sterilant used under the same contact con-
ditions as sterilization except for a shorter immersion time.
Figure 2 demonstrates the relationship of the two classifications
with each other and with antimicrobial activity.
Figure 2
Decreasing
Figure 2 Order of Resistance of Microorganisms to Germicidal
Chemicals
Decreasing Order of Resistance of Microorganisms to Germicidal Chemicals

Organism Processing Level Required

___________________________________________________________________________________________ Sterilization

Bacterial spores __________________________________________________________ FDA sterilant/high-level disinfectant

Geobacillus stearothermophilus (= CDC sterilant/ high-level disinfectant)
Bacillus atrophaeus
Mycobacteria _____________________________________ EPA hospital disinfectant with
Mycobacterium tuberculosis tuberculocidal claim
Nonlipid or small viruses (=CDC intermediate-level disinfectant)
Polio virus
Coxsackie virus
Rhinovirus
Fungi
Aspergillus
Candida
Vegetative bacteria____________________ EPA hospital disinfectant
Staphylococcus species (=CDC low-level disinfectant)
Pseudomonas species
Salmonella species
Lipid or medium-sized viruses
Human immunodeficiency virus
Herpes simplex virus
Hepatitis B and hepatitis C
Coronavirus
!

Source: CDC
Source: CDC [10]
[10]

!
Uses of Antimicrobials [2, 5-6, 10, 82]
Antimicrobial formulations used in the College must be EPA reg-
istered or cleared by the FDA, or they must have had their efficacy
proven under conditions of use, as demonstrated by independent stud-

239
 ies in peer-reviewed journals.
In most instances, a given product is designed for a specific pur-
pose and is to be used in a certain manner. Therefore, users should
read labels carefully to ensure the correct product is selected for the
intended use and applied efficiently. Use of a product for purposes for
which it is not labeled is contraindicated. Furthermore, the component
materials of patient care items and environmental surfaces may be in-
compatible with certain disinfectants. Therefore the choice of disinfec-
tants used must take into account the instructions of the manufacturers
of the items and surfaces to be decontaminated.
Disinfectants have varying tissue toxicity, but personal protective
equipment (gloves, eye protection, mask, and protective clothing)
should be worn when using any disinfectant.
Depending on the item or surface to be disinfected, and the nature
of the contaminant, different levels of disinfection are required.

Patient Care Items

The use of high-level disinfectants/sterilants to sterilize patient-care
items is highly discouraged and should only be used if all the following
criteria are met:
a. The item is not a critical patient-care item (i.e. not intended to
penetrate tissues),
b. Item is not heat-tolerant,
c. There are no autoclavable options to replace the item, and in
the absence of other safer sterilization techniques.
Three levels of disinfection: high, intermediate, and low, are used for
patient-care devices that are not critical patient-care items. The intend-
ed use of the patient-care item should determine the recommended
level of disinfection (see section above, on Classification of Patient
Care Items).
Before any germicide formulation is used to decontaminate a den-
tal device, the device manufacturer ‘s instructions must be referred to
check for compatibility with the germicide.

240
 Environmental Surfaces
Depending on the surface and the nature of the contaminant, envi-
ronmental surfaces may be decontaminated by either intermediate- or
low-level disinfection.
For de-contamination of clinical contact surfaces, either an EPA-
registered hospital tuberculocidal disinfectant (intermediate-level dis-
infectant) or an EPA registered hospital disinfectant (low-level disinfec-
tant) labeled as effective against HIV and HBV is appropriate. Hospital
disinfectants with such HIV and HBV claims can be used, provided
surfaces are not contaminated with microorganisms for which higher
level (i.e., intermediate-level) disinfection is recommended (see Figure
2 for examples).
Housekeeping surfaces need to be cleaned only with a detergent
and water or an EPA-registered hospital disinfectant/detergent (low-
level disinfectant). If visibly soiled with patient material, in cases of
spills, either an EPA-registered hospital tuberculocidal disinfectant (in-
termediate-level disinfectant) or an EPA registered hospital disinfectant
(low-level disinfectant) labeled as effective against HIV and HBV may
be used.
The following table (Table 13) is a summary of the categories of dis-
infectants/sterilants and their recommended uses in dentistry.

241
 Table 13
Categories of Disinfectants/ Sterilants and Recommended Uses in
Dentistry

Category Definition Examples Uses

Gluteraldehydes Semi-critical heat

Destroys all micro-
sensitive items.
organisms- includ- Hydrogen peroxide
Sterilant
ing high numbers of Immersion only
(Depending on the
bacterial spores
contact time)
Destroys all micro- Gluteraldehydes Semi-critical heat
organisms- but not sensitive items.
High-level Hydrogen peroxide
necessarily high
disinfectant Immersion only
numbers of bacte- (Depending on the
rial spores contact time)
Inactivates Myco- Chlorine and chlo- Clinical contact
bacterium tubercu- rine compounds surfaces
losis (tuberculocid-
Intermediate- al)- and destroys Iodophors Non-critical items
level disin- vegetative bacteria, Phenolics visibly soiled with
fectant most fungi and patient material
Quaternary ammo-
most viruses Spills of patient
nium compounds
with alcohol material
Clinical contact
surfaces (if active
Does not inactivate against HBV, HIV)
Mycobacterium
Spills of patient
tuberculosis (is not
material (if active
tuberculocidal)- but
Low-level Quaternary ammo- against HBV, HIV)
destroys vegeta-
disinfectant tive bacteria, some nium compounds Housekeeping
fungi, and some surfaces (e.g. floors
viruses and walls)
Non-critical items
without visible pa-
tient material

Source: Adapted from Sehulster, et al. [2], CDC [10], CDC [82]

242
Factors Affecting the Efficacy of Chemical Disinfection
and Sterilization [10, 82]

The activity of germicides against microorganisms depends on a

number of factors, some of which are intrinsic qualities of the organism,
others of which are the chemical and external physical environment.
Awareness of these factors should lead to better use of disinfection and
sterilization processes. Factors that affect the efficacy of both disinfec-
tion and sterilization include prior cleaning of the object; organic and
inorganic load present; type and level of microbial contamination; con-
centration of and exposure time to the germicide; physical nature of the
object (e.g., crevices, hinges, and lumens); and presence of biofilms.

Number and Location of Micro-organisms

The larger the number of microbes, the more time a germicide
needs to destroy all of them. Reducing the number of microorganisms
that must be inactivated through meticulous cleaning shortens the ex-
posure time required to kill the entire microbial load.
This reinforces the need for scrupulous cleaning of medical instru-
ments before disinfection and sterilization.

Organic and Inorganic Matter

Organic matter in the form of serum, blood, pus, or lubricant mate-
rial can interfere with the antimicrobial activity of disinfectants by:
1. Reacting with the germicide (resulting in a complex that is less
germicidal and leaving less of the active germicide available for
attacking microorganisms). Chlorine and iodine disinfectants
are prone to such interaction.
2. Protect microorganisms from attack by acting as a physical bar-
rier.
Inorganic contaminants may also protect microorganisms from the
action of disinfectants. This further emphasizes the importance of me-
ticulous cleaning of medical devices before any sterilization or disin-
fection procedure because both organic and inorganic soils are easily

243
 removed by washing.

Pre-cleaning of Surfaces
Cleaning is the necessary first step of any disinfection process. The
physical action of scrubbing with detergents and rinsing with water
removes substantial numbers of microorganisms. Cleaning also re-
moves organic matter, salts, and visible soils, all of which interfere with
microbial inactivation. If a surface is not cleaned first, the success of
the disinfection process can be compromised. Removal of all visible
blood and inorganic and organic matter can be as critical as the germi-
cidal activity of the disinfecting agent. Some antimicrobial formulations
incorporate cleaners with the antimicrobial agent such that the clean-
ing and disinfection is performed simultaneously, and no pre-cleaning
is required.

Concentration and Potency of Disinfectants

With one exception (iodophors), the more concentrated the disin-
fectant, the greater its efficacy and the shorter the time necessary to
achieve microbial kill. Not all disinfectants, however, are similarly af-
fected by concentration adjustments.

Contact Times for Surface Disinfectants

Items must be exposed to the germicide for the appropriate mini-
mum contact time (duration of exposure). All applicable label instruc-
tions regarding contact time must be followed.
An important issue concerning use of disinfectants for non-critical
items and environmental surfaces in health-care settings is that the
contact time specified on the label of the product is often too long to be
practically followed. Product users should consider and use products
that have the shortened contact time. A contact time of 10 minutes
(as specified by many products registered use against HBV, HIV, or
M. tuberculosis) for such surfaces is not practical because the disin-
fectants are usually applied and allow it to dry (~1 minute). Currently,
some EPA-registered disinfectants have contact times of one to three
minutes.

244
 With FDA-cleared liquid chemical sterilants, contact time is the single
critical variable distinguishing sterilization from high-level disinfection.

Physical Nature of the Object

Crevices, joints, and channels are more difficult to disinfect than
are flat- surface equipment because penetration of the disinfectant of
all parts of the equipment is more difficult. Only surfaces that directly
contact the germicide will be disinfected.

Presence of Biofilms
See section “Treatment of Dental Unit Waterlines.”

Properties of Ideal Disinfectant [6]

The following are the properties of an ideal disinfectant:
• Broad Spectrum (tuberculocidal)
• Fast-acting
• Active in the presence of organic matter such as blood, spu-
tum, and pus
• Nontoxic
• Non-allergenic
• Surface compatibility
• Residual effect on treated surfaces
• Easy to use
• Odorless
• Economical

Chemical Disinfectants and Sterilants

Many disinfectants are used alone or in combinations (e.g., hydro-
gen peroxide and peracetic acid) in the health-care setting. Disinfec-
tants marketed for use in dental settings include alcohols, chlorine and
chlorine compounds, glutaraldehyde, hydrogen peroxide, iodophors,
phenolics, and quaternary ammonium compounds. Commercial for-
mulations based on these chemicals are considered unique products

245
 and only those products registered with the EPA or cleared by the FDA
should be used. [82]

Alcohols [2, 5-6, 82]

In the healthcare setting, “alcohol” refers to two water-soluble chem-
ical compounds—ethyl alcohol and isopropyl alcohol. Alcohols are tu-
berculocidal agents, but they are not sporicidal.
Alcohol evaporates rapidly, and although some products have ex-
tenders added which may retard evaporation, extended contact times
are difficult to achieve unless the items to be disinfected are immersed
in the alcohol solution.
Furthermore, alcohols are poor cleaners because of their inability
to penetrate or dissolve protein-rich materials. Such compounds, in
fact, denature and dehydrate proteins, making the proteins insoluble
and strongly adherent to most surfaces. In addition, the formation of
a coating of denatured protein may protect microorganisms from the
microbial action of the alcohol.
Because of their reduced activity in the presence of organic mate-
rial such as blood and saliva, poor cleaning property, and rapid rate of
evaporation, alcohols should not be used as large- area surface disin-
fectants. And because of their lack of sporicidal action and inability to
penetrate proteinaceous materials, they should not be used to sterilize
patient care items.
In dentistry these compounds are mainly used as antiseptics. Al-
though alcohols may cause skin dryness, some products have skin
moisturizers added to reduce this effect. When used as skin antisep-
tics, the formulations should have added antimicrobial ingredients to
achieve persistent activity on skin.

Advantages.
• Tuberculocidal (at 70% concentration).
• Fast-acting.
• Only slightly irritating to skin.
• Economical.

246
Disadvantages.
• Lack sporicidal action.
• Cannot penetrate or dissolve protein-rich materials, therefore
are poor cleaners.
• Reduction in activity by organic material.
• Evaporate rapidly.
• Swell and harden rubber and certain plastic tubing after pro-
longed and repeated use.
• Corrosive to metals.
• Cause skin dryness.
• Flammable; must be stored in a cool, well-ventilated area.

Uses.
• Mainly as skin antiseptics.
• Not recommended for sterilizing patient care items.
• Not recommended as single agents for environmental disin-
fection.

Chlorine and Chlorine Compounds [6, 10, 82]

Hypochlorites, the most widely used of the chlorine disinfectants,
are EPA registered intermediate-level surface disinfectants, and are
available as liquid (e.g., sodium hypochlorite) or solid (e.g., calcium hy-
pochlorite). Under certain conditions, these agents may be sporicidal.
The most prevalent chlorine products are aqueous solutions of
5.25%–6.15% sodium hypochlorite, usually called household bleach. A
1:1,000 dilution of household bleach provides about 53–62 ppm avail-
able chlorine, and a 1:10 dilution of household bleach provides about
5250–6150 ppm. Chlorine-based products that are EPA-registered as
intermediate-level disinfectants are available commercially. However,
in the absence of an EPA-registered chlorine-based product, a fresh
solution of sodium hypochlorite (e.g., household bleach) is an inexpen-
sive and effective intermediate level germicide. Concentrations ranging
from 500 ppm to 800 ppm of chlorine (1:100 dilution of 5.25% bleach

247
 and tap water) are effective on environmental surfaces that have been
cleaned of visible contamination.
“Superoxidized water” is electrolyzed saline which produces hy-
pochlorous acid (e.g., at a concentration of about 144 mg/L) and chlo-
rine. Such a disinfecting solution is nontoxic to biologic tissues. Super-
oxidized water is FDA cleared as a high-level disinfectant.
Caution should be exercised, however, because chlorine solutions
are incompatible with some clinical surfaces and are corrosive to met-
als, especially aluminum. Therefore, as with all disinfectants, the man-
ufacturer’s instructions must be referred to determine compatibility.
And as with all chemicals, appropriate personal protective equipment
should be worn when preparing hypochlorite solutions.

Advantages.
• EPA registered intermediate-level surface disinfectant.
• Broad spectrum of antimicrobial activity.
• Fast acting.
• Effective in dilute solution.
• Do not leave toxic residues.
• Unaffected by water hardness.
• Inexpensive.
• Remove dried or fixed organisms and biofilms from surfaces.
• Low incidence of serious toxicity.

Disadvantages.
• Chemically unstable solution (necessary to produce diluted
solutions fresh daily).
• Diminished activity by organic matter (longer contact time
required in presence of organic matter).
• Irritating to skin and mucosa.
• Unpleasant persistent odor at high concentrations.
• Corrosiveness to metals in high concentrations (>500 ppm).
• Discoloring or “bleaching” of fabrics.

248
 • Degrading to plastics and rubber.
• Release of toxic chlorine gas when mixed with ammonia or
acid (e.g., household cleaning agents).

Uses.
• Disinfection of surfaces and floors.
- Blood spills may be decontaminated with 1:10–1:100 dilu-
tion of household bleach, after cleaning with a detergent.
- For small spills of blood (i.e., drops of blood) on noncritical
surfaces, the area can be disinfected with a 1:100 dilution
of household bleach.
• Disinfectant in water treatment.
• Irrigating agent in endodontic treatment.
• Disinfectant for laundry.
• Disinfectant for dental appliances (if compatible with surfaces).
• Disinfectant for regulated medical waste before disposal.

Glutaraldehyde [2, 5-6, 10, 82]

Glutaraldehyde is a high-level disinfectant and chemical sterilant. If
used to sterilize patient-care items, only FDA approved products clas-
sified as sterilants/high-level disinfectants should be used.
Sterilization with gluteraldehyde is reliably only if cleaning precedes
treatment (because bioburden on the items interferes with the steriliza-
tion process) and if the manufacturer instructions are followed regard-
ing concentration, contact time, temperature, and pH.
Aqueous solutions of glutaraldehyde are acidic and generally in this
state are not sporicidal. Only when the solution is “activated” (made
alkaline) by use of alkalinating agents to pH 7.5–8.5 does the solution
become sporicidal. Once activated, these solutions have a shelf-life of
minimally 14 days. Some formulations have overcome the problem of
rapid loss of activity (e.g., use-life 28–30 days) while generally main-
taining excellent microbicidal activity. Antimicrobial activity of gluteral-
dehydes depends not only on age but also on dilution and organic

249
 stress.
Spore tests for biological monitoring of antimicrobial activity of chem-
ical sterilants are not available, therefore the best approach to monitor
microbial killing efficacy is to estimate chemically the concentration of
the active sterilant remaining in the used solution. Chemical test strips
or liquid chemical monitors are available for determining whether an
effective concentration of glutaraldehyde is present despite repeated
use and dilution.
Acute or chronic exposure to gluteraldehyde can result in skin irrita-
tion or dermatitis, mucous membrane irritation (eye, nose, mouth), or
pulmonary symptoms. Epistaxis, allergic contact dermatitis, asthma,
and rhinitis also have been reported in healthcare workers exposed to
glutaraldehyde. Healthcare workers can be exposed to elevated levels
of glutaraldehyde vapor when it is used in poorly ventilated rooms,
when spills occur, when glutaraldehyde solutions are activated or
changed, or when open immersion baths are used. Therefore, as with
all chemical disinfectants/sterilants, personal protective equipment
(e.g., goggles and nitrile or butyl rubber gloves but not natural latex
gloves) must be worn when handling gluteraldehydes.
Engineering and work-practice controls that can be used to mini-
mize the degree of gluteraldehyde exposure include ducted exhaust
hoods, air systems that provide 7–15 air exchanges per hour, ductless
fume hoods with absorbents for the glutaraldehyde vapor, tight-fitting
lids on immersion baths, and personal protection to minimize skin or
mucous membrane contact.
If glutaraldehyde disposal through the sanitary sewer system is re-
stricted, sodium bisulfate can be used to neutralize the glutaraldehyde
and make it safe for disposal.

Advantages.
• Broad-spectrum.
• Excellent materials compatibility (noncorrosive to metals and
does not degrade rubber and plastic).
• Relatively inexpensive.

250
Disadvantages.
• Solutions are highly toxic.
- Require special ventilation.
- Glutaraldehyde vapor monitoring recommended.
• Less reliable.
• Time consuming.
• Cannot be used with packaged items.
• Items must be rinsed with sterile water.
• The sterilization process with liquid chemical sterilants cannot
be verified with biological indicators.
• Reduced activity in the presence of heavy bioburden; coagu-
lates blood and fixes tissue to surfaces.
• Pungent and irritating odor.
• Relatively slow mycobactericidal activity.

Uses.
• Sterilization of heat-sensitive patient-care items.
• Should not be used as environmental disinfectants or as hold-
ing solutions for soaking items before cleaning.

Hydrogen Peroxide [5-6, 82, 110]

Hydrogen peroxide is active against a wide range of microorganisms
and is a component of FDA cleared sterilants/high-level disinfectants. It
is also an EPA- registered intermediate- and high-level disinfectant. If
used to sterilize patient-care items, only FDA approved products clas-
sified as sterilants/high-level disinfectants should be used. All chemical
sterilants/high-level disinfectants require immersion of the processed
item within the chemical for the appropriate contact time as recom-
mended by the chemical manufacturer.
Spore tests for biological monitoring of antimicrobial activity of chemi-
cal sterilants, however, are not available, therefore the best approach to
monitor microbial killing efficacy of such solutions is to estimate chemical-
ly the concentration of the active sterilant remaining in the used solution.

251
 Hydrogen peroxide is also used as an antiseptic because it serves
as an antimicrobial oxidant and debriding agent for treating infection.
Only formulations approved by the FDA for this purpose should be
used. Hydrogen peroxide formulations have also been developed and
found to be effective environmental surface cleaners and disinfectants.
Some formulations are EPA registered as active against Mycobacte-
rium tuberculosis, HBV, and HIV.

Advantages.
• FDA cleared sterilant/high-level disinfectant.
• EPA- registered intermediate- and high-level disinfectant.
• Broad antimicrobial spectrum.
• Does not coagulate blood or fix tissues to surfaces.
• Good cleaner for removal of bioburden.
• No activation required.
• Stable and effective intermediate-level disinfectant on environ-
mental surfaces.
• No odor or irritation issues.
• Biodegradable- no disposal issues.

Disadvantages.
• Material compatibility concerns (brass, zinc, copper, and
nickel/silver plating) both cosmetic and functional.
• Serious eye damage with contact.
• When used as a sterilant:
- Sterility cannot be verified.
- Cannot be used with packaged items.
- Items must be rinsed with sterile water.

Uses.
• Sterilization of heat-sensitive patient-care items.
• Environmental disinfectant.
• Wound debridement.

252
 Iodophors [5-6, 82]
Iodophors are EPA-registered intermediate-level antimicrobials (tu-
berculocidal) which may be used both as antiseptics and disinfectants.
Iodophors are compounds of elemental iodine, iodide, or triiodide, and
a polymer carrier. The amount of free iodine present determines the
iodophor level of antimicrobial activity. Combining iodine with various
polymers increases its solubility, promotes sustained release of iodine,
and reduces skin irritation.
The best-known and most widely used iodophor is povidone-iodine.
This product and other iodophors retain the germicidal efficacy of io-
dine but, unlike iodine, generally are nonstaining and relatively free
of toxicity and irritancy. The pH, temperature, exposure time, concen-
tration of total available iodine, and the amount and type of organic
and inorganic compounds present affect the antimicrobial activity of
iodine. Iodophors have significantly reduced efficacy in the presence
of organic substances such as blood or saliva. Detergents are added
to iodophor preparations used as surface disinfectants to enhance the
cleaning ability of the solutions. The subsequent improvement in the
surfactant properties make them excellent cleaning agents before dis-
infection and they have EPA- approved tuberculocidal activity as well.
Iodophors are prepared by combining iodine with a solubilizing
agent or carrier. Dilutions of iodophors demonstrate more rapid bac-
tericidal action than does a full-strength povidone-iodine solution; the
reason for the observation that dilution increases bactericidal activity is
unclear. Therefore, iodophors must be diluted according to the manu-
facturers’ directions to achieve antimicrobial activity. Fresh solutions
must be prepared daily because maximal tuberculocidal activity can
be variable in solutions older than 24 hours. Diluting iodophor disin-
fectants in hard water may cause rapid loss of antimicrobial activity,
therefore distilled water should be used to dilute iodophors.
Iodophors formulated as antiseptics contain less free iodine than do
those formulated as disinfectants. Therefore, antiseptic iodophors are
not suitable for use as hard-surface disinfectants because of concen-
tration differences.

253
 Advantages.
• EPA-registered intermediate-level disinfectants
• Broad-spectrum.
• Effective in dilute solution.
• Few adverse tissue reactions.
• Contains surfactant carrier that maintains surface moistness.
• Residual biocidal action.
Disadvantages.
• Unstable at high temperatures.
• Dilution and contact time critical.
• Daily preparation necessary.
• Discoloration of some surfaces (may be removed by wiping
with alcohol).
• Rust inhibitor necessary.
• Inactivated by hard water.

Uses.
• Antiseptic.
• Disinfection of environmental surfaces and medical equip-
ment.

Phenolics [6, 82]

Phenolic germicides are EPA-registered intermediate-level disinfec-
tants for use on environmental surfaces and noncritical medical de-
vices. Because of their toxicity, they are not used for antisepsis, and
appropriate utility gloves should be worn when phenolics are handled.
Phenolics serve as good surface cleaners, and are effective in the
presence of detergents. However, combinations of phenol in an alco-
holic base, although EPA-approved as tuberculocidal disinfectants,
are only fair to poor in cleaning surfaces. Thus when phenolic-alcohol
disinfectants are selected for use, surface cleaning should be done
initially with a water- based cleaning agent.

254
Advantages.
• EPA-registered intermediate-level disinfectants.
• Broad-antimicrobial spectrum.
• Useful on metal, glass, rubber, and plastic.
• Residual biocidal action.

Disadvantages.
• Can degrade certain plastics and etch glass with prolonged
exposure.
• Difficult to rinse off certain materials.
• Residual film on treated surfaces.
• Discoloration of certain plastics
• Irritating to skin and eyes.

Uses.
• Surface disinfectant.

Quaternary Ammonium Compounds [5-6, 82]

EPA-registered quaternary ammonium compounds are low-level
hospital disinfectants (non-tuberculocidal) which are good cleaning
agents, but high water hardness and materials such as cotton and
gauze pads can make them less microbicidal because of insoluble
precipitates or cotton and gauze pads absorb the active ingredients,
respectively. The newer quaternary ammonium compounds (i.e., fourth
generation) purportedly remain active in hard water. These disinfectants
may also be inactivated by organic materials and soaps. Therefore,
although they may be appropriate for disinfection of floors and walls,
they are less desirable for items more directly involved in patient treat-
ment that may be contaminated with body fluids . The American Den-
tal Association (ADA) Council on dental therapeutics even eliminated
them from the ADA acceptance program as disinfectants in 1978. They
are good cleaning agents, though, and may be used as such.
However, the addition of alcohol to quaternary ammonium com-
pounds enhances their microbial activity to become tuberculocidal. If

255
 such a product is EPA-registered, it may be used as an intermediate-
level disinfectant. The alcohol component of such products seems
to be primarily responsible for the extended antimicrobial spectrum,
with the quaternary ammonium portion serving as the surface cleaning
agent.

Quaternary Ammonium Compounds (Alcohol-free)

Advantages.
• EPA registered as low-level disinfectants for non-critical sur-
faces.
• Cationic detergents- good surface cleaners.
• Pleasant odor.
• Low tissue toxicity.

Disadvantages.
• Not tuberculocidal.
• Inactivated by anionic detergents (i.e. soaps and hard water).
• Inactivated by organic matter.

Uses.
• Ordinary environmental sanitation of noncritical surfaces, such
as floors, furniture, and walls.
• Disinfection of non-critical medical equipment.

Quaternary Ammonium Compounds (With alcohol)

Advantages.
• EPA registered as intermediate-level disinfectants for environ-
mental surfaces.
• Broad antibacterial spectrum.
• Rapidly tuberculocidal in 1-5 minutes.
• Available as prepared disinfectants.

Disadvantages.
• Variable alcohol concentrations in different products can affect

256
 surface-cleaning capabilities.
• Possible rapid evaporation from surfaces with solutions with
high alcohol concentrations.

Uses.
• Disinfection of clinical contact surfaces.

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 ENVIRONMENTAL INFECTION CONTROL

Maintenance of Heating, Ventilation, and Air

Conditioning Systems [2, 10]
Properly engineered heating, ventilation, and air conditioning
(HVAC) systems require routine maintenance and monitoring to pro-
vide acceptable indoor air quality and to minimize conditions that favor
the proliferation of health-care–associated pathogens. Preventive filter
and duct maintenance (e.g., cleaning ductwork vents, replacing filters
as needed, and properly disposing spent filters into plastic bags im-
mediately upon removal) is important to prevent potential exposures of
patients and staff during HVAC system shut-down.

Filters
For optimal performance, filters within central HVAC systems require
monitoring and replacement in accordance with the manufacturer’s rec-
ommendations and standard preventive maintenance practices. In ad-
dition, the need to change the filter is indicated if the pressure required
to push the air through the filter exceeds specifications (due to excess
accumulation of dust and particulates). Filters also require regular in-
spection for other potential causes of decreased performance. Gaps in
and around filter banks and heavy soil and debris upstream of poorly
maintained filters have been implicated in health- care–associated out-
breaks of aspergillosis, especially when accompanied by construction
activities at the facility . Upon removal, spent filters can be bagged and
discarded with the routine solid waste, regardless of their patient-care
area location.

Ducts
Ductwork in older health-care facilities may have insulation on the
interior surfaces that can trap contaminants. This insulation material
tends to break down over time to be discharged from the HVAC sys-
tem. Additionally, a malfunction of the air-intake system can overbur-
den the filtering system and permit aerosolization of fungal pathogens.
Keeping the intakes free from bird droppings, especially those from

258
pigeons, helps to minimize the concentration of fungal spores entering
from the outside .
Duct cleaning in health-care facilities has benefits in terms of sys-
tem performance, but its usefulness for infection control has not been
conclusively determined. No data indicate that duct cleaning, beyond
what is recommended for optimal performance, improves indoor air
quality or reduces the risk of infection. Duct cleaning has not been
shown to prevent any health problems, and EPA studies indicate that
airborne particulate levels do not increase as a result of dirty air ducts,
nor do they diminish after cleaning, presumably because much of the
dirt inside air ducts adheres to duct surfaces and does not enter the
conditioned space . However if disinfection of ductal systems is at-
tempted, only those chemical biocides that are registered for use in
HVAC systems should be used. Sanitizers and/or disinfectants whose
label indications do not specifically include the use of the product in
HVAC systems to treat the surfaces of ductwork should not be used.

Heating, Ventilation, and Air Conditioning

System Shutdown
Accumulation of dust and moisture within HVAC systems increas-
es the risk for spread of health-care–associated environmental fungi
and bacteria. If moisture is present in the HVAC system, periods of
stagnation should be avoided. Bursts of organisms can be released
upon system start-up, increasing the risk of airborne infection. Heating,
ventilation, and air conditioning systems should not be shut-down for
purposes other than required maintenance, filter changes, and con-
struction. If airflow needs to be reduced, sufficient supply, return, and
exhaust must be provided to maintain required pressure relationships
when the space is not occupied.
Contingency plans in case of disruption of HVAC services should
include back-up power generators that maintain the ventilation sys-
tem in high-risk areas (e.g., operating rooms). Alternative generators
are required to engage within 10 seconds of a loss of main power. If
the ventilation system is out of service, rendering indoor air stagnant,
sufficient time must be allowed to clean the air and re-establish the

259
 appropriate number of air changes/hour (ACH) once the HVAC system
begins to function again. Air filters may also need to be changed, be-
cause reactivation of the system can dislodge substantial amounts of
dust and create a transient burst of fungal spores.

Non-central Air-handling System

Non-central air-handling systems are prone to problems associated
with excess condensation accumulating in drip pans and improper filter
maintenance. The filters in these units should be cleaned or replaced
on a regular basis while the patient is out of the room.

Environmental Surfaces
[2, 5, 10, 82, 105]
In the clinic, environmental surfaces are surfaces or equipment that
do not contact patients directly but may become contaminated with pa-
tient material indirectly via contaminated hands or patient care items.
Based on the potential risk of contamination, the various environmental
surfaces can be divided into clinical contact surfaces and housekeep-
ing surfaces. These two types of surfaces require different types of
cleaning/disinfecting agents and protocols (see CHEMICALS USED
for DISINFECTION and STERILIZATION in DENTISTRY). However,
alcohol based disinfectants and high-level disinfectants should not be
used to clean any environmental surface.

Clinical Contact Surfaces

Clinical contact surfaces are those surfaces which risk being con-
taminated with aerosols and spatter or touched with contaminated
gloves during operation. Such surfaces include, but are not limited to,
the dental chair, light handles, switches, dental radiograph equipment,
dental chair-side computers, reusable containers of dental materials,
drawer handles, sinks and faucet handles used for processing con-
taminated items, countertops, pens, telephones, and doorknobs.
Such surfaces, if contacted with contaminated gloves, can be po-
tential reservoirs of microbial contamination. Dental health-care work-

260
ers’ hands are the primary vehicle for spread of microorganisms from
these surfaces to the nose, mouth, or eyes of patients and workers, as
well as to instruments and other surfaces. This spread can be mini-
mized by:
a. Using impervious barriers to cover the surfaces during treat-
ment, or
b. Cleaning and disinfecting such surfaces after patient treat-
ment.
Barriers:
When barriers are used to prevent cross-contamination, they must
be removed between patients. A new set of barriers should be placed
with each patient. Barriers should never be used for more than one
patient.
After removal of the barrier, the surface should be examined. If the
surface is found to have been inadvertently soiled, then it should be
cleaned and disinfected before placement of clean barriers for the next
patient.
Suitable materials for use as barriers include clear plastic wrap,
bags, sheets, tubing, and plastic-backed paper or other materials im-
pervious to moisture.
Cleaning and Disinfection:
Cleaning is using detergents or surface active agents to remove or-
ganic matter (e.g. saliva and blood), salts, and visible soils. The physi-
cal action of scrubbing with detergents and surfactants and rinsing with
water removes substantial numbers of microorganisms. Furthermore,
if a surface is not cleaned first, the disinfection process may be inef-
fective (depending on the type of disinfectant) because organic matter
interferes with the action of some disinfectants. Removal of all visible
blood and inorganic and organic matter can be as critical as the germi-
cidal activity of the disinfecting agent (see Chemicals Used for Disin-
fection and Sterilization in Dentistry).
However, effective cleaning and disinfection may be time consuming

261
 and difficult to achieve on some clinical contact surfaces. Furthermore,
the level of microbial killing actually achieved by disinfection cannot be
routinely determined in the clinic- i.e. it cannot be routinely determined
how well the disinfectant is working. Therefore, covering surfaces with
an impervious barrier is the preferred method of preventing cross-con-
tamination from clinical contact surfaces.
However, even if barriers are used, general cleaning and disinfec-
tion of clinical contact surfaces, dental unit surfaces, and countertops
is required at the end of the work session. If surfaces have become
contaminated, then cleaning and disinfection is required after each pa-
tient. Cleaning and disinfection of clinical contact surfaces should be
performed using the spray-wipe-spray technique. In this technique, the
detergent/disinfectant is sprayed onto the surface, wiped clean, then
sprayed on the same surface again and left untouched for the contact
time specified by the manufacturer of the solution.
To reduce the risk of surfaces and objects becoming unnecessarily
contaminated, equipment and supplies not needed during a particular
patient’s treatment should not be placed near the treatment area or on
the counters.

Housekeeping Surfaces
Housekeeping surfaces are those surfaces which are less likely to
be contacted with contaminated gloves but may become contaminated
with aerosols, spatter, or spills. Examples of such surfaces are floors,
walls, and hand washing sinks. Because housekeeping surfaces have
limited risk of disease transmission, they can be decontaminated with
less rigorous methods than those used on dental patient-care items and
clinical contact surfaces. The majority of housekeeping surfaces need
to be cleaned only with a detergent and water or an EPA-registered
hospital disinfectant/detergent (see Chemicals Used for Disinfection
and Sterilization in Dentistry), depending on the nature of the surface
and the type and degree of contamination.
Floors and sinks should be cleaned daily, and walls, window cover-
ings, and other vertical surfaces in healthcare areas should be cleaned
and disinfected every 3-6 months. However, when housekeeping sur-

262
faces are visibly contaminated by patient material, prompt removal and
surface disinfection should be carried out. Spills should be cleaned
up immediately when they occur. Cleaning methods which produce
minimal mists and aerosols or dispersion of dust in patient-care areas
should be employed.
During cleaning and disinfection of environmental surfaces, DHCP
should wear gloves and other PPE to prevent occupational exposure to
infectious agents and hazardous chemicals. Chemical- and puncture-
resistant utility gloves offer more protection than patient examination
gloves when using hazardous chemicals.
Cleaning and disinfectant solutions should be prepared and stored
correctly and in clean containers. The manufacturers’ instructions for
preparation and use should be followed closely. Solutions should be
freshly diluted at the start of each work day. At the end of the day, any
remaining solution should be discarded and the container scrubbed
clean and allowed to dry to minimize bacterial contamination.
Cleaning solutions and cleaning tools (e.g., mop heads or cleaning
cloths) may become soiled or contaminated during use and act as res-
ervoirs for spread of contamination. Therefore mops and cloths should
be cleaned and disinfected after use and allowed to dry before reuse.
Single-use, disposable mop heads and cloths may be used to avoid
spreading contamination. Non-disposable cleaning tools of the vari-
ous areas within the healthcare facility (clinics, theatres, laboratories,
hallways, offices, classrooms, and restrooms) should be separate and
not mixed with those of other areas.

Management of Spills
In the event of spills of contaminated fluids ( e.g. blood, saliva, or
pus), care should be taken not to spread the spill by wiping. Manage-
ment of the spills should be as follows:
1. Cautionary signs should be placed around the area until it is
completely cleaned and dried.
2. Cleaning personnel should use PPE throughout the proce-
dure.

263
 3. The contaminated fluid should be absorbed with absorbent pa-
per towels or cotton.
4. The area should be washed with an appropriate detergent or
disinfectant (see Chemicals Used for Disinfection and Steriliza-
tion in Dentistry) using disposable paper towels or large lumps
of absorbent cotton, taking care to avoid overextending onto
areas not affected by the spill. The disinfectant manufacturers’
instructions should be followed regarding the need to pre-clean
the area or not.
5. The area should then be covered with an acceptable disinfec-
tant and left undisturbed for the proper contact time.
6. The disinfectant should, then, be removed by absorbing it with
paper towels. Normal floor cleaning can then be resumed.

Pest Control [2]

In healthcare settings, insects can serve as agents for the me-
chanical transmission of microorganisms, or as active participants in
the disease transmission process by serving as a vector. Some of the
microbial populations associated with insects in hospitals have even
demonstrated resistance to antibiotics. Outbreaks of infection attrib-
uted to microorganisms carried by insects may occur because of infes-
tation coupled with breaks in standard infection-control practices.
From a public health and hygiene perspective, pests should be
eradicated from all indoor environments, especially health-care facili-
ties. Insects should be kept out of all areas of the health-care facility,
especially operating rooms and clinics. Insect habitats are character-
ized by warmth, moisture, and availability of food. Therefore, the pest
management approach should focus on:
a. eliminating food sources, indoor habitats, and other conditions
that attract pests;
b. excluding pests from the indoor environments; and
c. applying pesticides as needed.

264
 Doors communicating with the outdoor environment should close
automatically when not in use. Windows should be sealed whenever
possible. If windows need to be opened for ventilation, then screens
should be in place, and in good repair.
A pest-control specialist with appropriate credentials should provide
a regular insect-control program that is tailored to the needs of the fa-
cility and uses approved chemicals and/or physical methods.

265
 CLINICAL PRECAUTIONS DURING OPERATION

The Aseptic Technique [5]

Avoiding exposure of DHCP and patients to blood and other po-
tentially infective materials and surfaces through applying the aseptic
technique is the primary way to prevent transmission of disease-caus-
ing microorganisms in dental health-care settings.
The aseptic technique is performing all tasks while maintaining the
“aseptic to aseptic” relationship of contact, thus reducing or eliminating
the spread of microbes. It is the concept central to any program of in-
fection control, and it dictates that whenever handling patients, patient
materials, or instruments and devices used during patient treatment,
sterile, disinfected, and clean (aseptic) materials should not contact
contaminated materials and vice versa. If such contact occurs, the bar-
rier of infection control is broken and the possibility of cross contamina-
tion exists.

Examples of break in the aseptic technique are:

1. Use of unsterilized critical and semi-critical items during patient
care.
2. Contaminated hands or gloves touching sterile, disinfected,
or clean materials such as sterile instrument packages, dental
chairs, packages, and bottles, dental records.
3. Sterile materials touching unsterile surfaces such as sterile pa-
tient instruments contacting uncovered bracket table, counter-
top, or other non-sterile surface.
Each department and clinic of the college is unique in its working
conditions and infection control requirements. DHCP, therefore, may
encounter varying situations and challenges. Hence, even if particular
situations are not specified in these guidelines, DHCP are required to
exercise their judgment and apply the aseptic technique to all situ-
ations in which they come in contact with patients, patient materials,
instruments, or devices used in patient care.

266
 Sterility of Patient Care Items
[2, 6, 10, 82, 95-96, 98, 100, 105, 108, 111]
All critical and semi-critical patient care items must be sterilized be-
fore being used to treat patients. Before opening instrument packages,
the packages must be examined to ensure the seal is intact, and the
integrity of the package is not broken in any way (e.g. through tears,
perforations, or wetness).
After opening the package, the internal chemical indicator must
be checked to ensure the sterilization conditions have been reached
within the package (see Central Sterilization and Supply Department
(CSSD)- PACKAGING). If the chemical indicator does not indicate that
sterilization parameters have been met, the items should not be used
for patient care and the package, along with the internal indicator, must
be returned to the CSSD and the incident reported to the CSSD super-
visor.
Dental handpieces and other intra oral devices attached to air or
waterlines should also be sterilized between patients. Studies have in-
dicated that the inner surfaces of high-speed handpieces and prophy-
angles may become contaminated with patient material during function.
The only effective way of cleaning the lumen of a dental hand-piece is
to process it through a washer-disinfector with each lumen connected
to a flushing system. Surface disinfection or immersion in high-level
disinfectants is insufficient to adequately and safely process such de-
vices. Furthermore, restricted physical access to the internal surfaces
of the handpiece limits sterilization with chemicals; therefore, hand-
pieces must be heat sterilized (autoclaved) between patients. Hand-
pieces that cannot be sterilized should not be used.
Devices which come in contact with the oral cavity (e.g. apex locator
tips, electric pulp tester tips, irrigating units, electrosurgery tips) should
be sterilized if they are detachable and can withstand the sterilization
cycle. If they are not sterilizable, such tips must be disposable or cov-
ered with a protective barrier. Chemical disinfection of items which en-
ter the oral cavity is unacceptable.

267
 Disposable items should be used whenever possible to avoid the
need for barriers or sterilization. Needles and blades should never be
sterilized and re-used between patients; only disposable needles and
blades should be used.
If brush handles are not sterilizable, disposable brushes, Q-tips, or
cotton pellets should be used instead. Disinfecting brush handles be-
tween patients is unacceptable.

Contacting Surfaces During Patient Care [5]

During patient care, items which cannot be autoclaved such as com-
puter monitors, keyboard and mouse, light-cure units, amalgamators,
electric pulp testers, apex locators, etc. should not be touched with
contaminated gloves. Devices such as these may be:
a. covered with a barrier,
b. handled by overgloves,
or
c. handled by a circulating team member with uncontaminated
hands.
However, if such items become inadvertently contaminated, they
must be wiped with a disinfectant. Surface disinfection, though, should
not be employed as the principle infection control measure for clinical
contact surfaces because the level of microbial killing actually achieved
by disinfection cannot be routinely determined in the clinic- i.e. it can-
not be determined how well the disinfectant is working.
Anticipating the devices, items, and materials that will be used dur-
ing patient treatment and preparing them beforehand greatly reduces
the need to touch drawers and containers and other surfaces after the
start of treatment; thus the potential for spread of contamination is re-
duced.
If however, the need to touch uncovered surfaces or packages aris-
es, the operator’s gloves should be removed prior to contacting such
surfaces. If these items remain clean, then DHCP can touch them dur-

268
ing non-treatment periods safely without gloves.
An important point in maintaining the aseptic technique is to avoid
leaving the work area unnecessarily with the protective wear in order
to prevent contaminating clean zones via the contaminated protective
wear. When transporting contaminated items to the CSSD, care should
be taken to avoid touching surfaces with the contaminated items or
gloves.

Work Practices [1, 10, 100]

During preparation of the operating table, the ‘unit dose concept’ for
supplies should be used; meaning materials should only be dispensed
onto the table in the quantities needed with the containers kept away
from the operating table to prevent the contamination of the containers
and their contents. Cotton pellet dispensers and containers filled with
unpacked gauze or cotton rolls should not be placed on the table. Fur-
thermore, such materials should be used after the pack is opened im-
mediately; any remaining amount, even if not removed from the pack,
should be considered contaminated.
Sterilized burs should not be placed in an uncovered stand on the
operating table or near the operating area. This will lead to their pos-
sible contamination with spatter or aerosols. Burs should be packed
individually or in sets, according to the use, and only removed from
the sterile pack immediately before use (see section on processing of
instruments).
The use of a single endo box for multiple patients is unacceptable,
as the contents of the box are considered potentially infected after it is
opened. To reduce the amount of times the box contents are subjected
to the sterilization cycle, single sets of files and broaches may be pack-
aged individually inside autoclavable envelopes along with gauze to
absorb the excess moisture and reduce the potential for corrosion.
Root canal treatment instruments can become contaminated with
dental pulp containing nerve fibres, which may theoretically pose a risk
of transmission of variant Creutzfeldt Jakob disease (vCJD). Since en-
dodontic treatment instruments are difficult to clean, even with wash-

269
 ing machines or ultrasonic cleaners, barbed broaches should be used
once and discarded. No attempt to clean or sterilize barbed broaches
should be carried out. Endodontic files, on the other hand, should be
wiped with sodium hypochlorite after each insertion inside the canal so
they are submitted for sterilization without any visible debris.
Glass slabs, dappen dishes, and metal mixing spatulas used for
mixing should be sterilized between patients. Whenever possible, dis-
posable paper mixing pads should be used instead. When using paper
mixing pads, only the paper to be used should be dispensed to avoid
contamination of the whole pad.
Sterile tweezers should be available for picking up wooden wedges,
gutta percha cones, stainless steel bands and crowns, and other mate-
rials of which several of the items are stored together. This is to prevent
contamination of the unused material. The sterile tweezers should be
changed for each patient.
Reducing the amount of spray and spatter that exit the patient’s
mouth will reduce the amount of microbes contaminating the dental
team. This can be accomplished by use of rubber dam isolation (when
possible) and HVE during aerosol producing procedures (e.g. drilling,
finishing, polishing, irrigation, and ultrasonic scaling), along with the
regular suction tip (see the sections below on Reducing Aerosols and
Droplets and the HVE and Saliva Ejector).
Having patients rinse their mouth before treatment with an antimi-
crobial mouthwash (e.g. chlorhexidine) for one minute can reduce bac-
terial counts significantly and thus reduce spread of bacteria through
aerosols. Pre-procedural rinsing may also reduce the number of micro-
organisms entering the patient’s bloodstream from the oral cavity after
invasive procedures. Mouth rinses, however, only reduce the number
of viable bacteria in saliva and loosely attached to mucous membranes;
micro-organisms within the gingival sulcus, nasopharyngeal passages,
bloodstream, and DUWLs are not affected. Therefore, although rinsing
reduces the amount of bacteria in aerosols, it does not eliminate the
infectious potential of dental aerosols, and so pre-procedural rinsing
must be used in combination with other protective measures.

270
 Engineering Controls
[5, 10, 112-113]
When dealing with blood-borne pathogens, engineering controls
help to eliminate or isolate some of the hazards to DHCP. Engineering
controls act on the hazard itself so that the employee may not have to
take self-protective action. These controls are frequently technology-
based and often incorporate safer designs of instruments and devices
to reduce the risk of percutaneous and permucosal injuries. Examples
of such designs include a mechanical device designed for holding the
needle cap to facilitate one-handed recapping, needles with a needle-
retraction mechanism, self-sheathing anesthetic needles, blunt suture
needle, retractable scalpel, needleless IV systems, sharps containers,
dental units designed to shield burs in handpieces, and tip-protection
attachments to protect operator hands during insertion and removal of
ultrasonic scaler tips and to shield the tips when resting in the hand-
piece. Also, plastic irrigation tubes attached to disposable syringes
may reduce the risk of injury when disposable syringes are used for
irrigation procedures.

Desirable features to be sought in safety devices are :

1. The safety feature is an integral part of the device.
2. The device preferably works passively (i.e., it requires no ac-
tivation by the user). If user activation is necessary, the safety
feature can be engaged with a single-handed technique and al-
lows the worker’s hands to remain behind the exposed sharp.
3. The user can easily tell whether the safety feature is activated.
4. The safety feature cannot be deactivated and remains protec-
tive through disposal.
5. The device performs reliably.
6. The device is easy to use and practical.
7. The device is safe and effective for patient care.
Although each of these characteristics is desirable, some are not
feasible, applicable or available for certain health care situations. For

271
 example, a safety feature that requires activation by the user might be
preferable to one that is passive in some cases. Each device must be
considered on its own merit and ultimately on its ability to reduce work-
place injuries. The desirable characteristics listed above should thus
serve only as a guideline for device design and selection.
As safety devices become available in the market, they should be
promptly assessed and considered for possible usefulness. A stan-
dardized screening and evaluation program may be implemented to
assess such devices (see Acquisition of Devices and Materials).

Work-Practice Controls
[1, 5, 10, 112]
Engineering controls are not always available or appropriate. And
even when used, they do not completely eliminate the hazard risk to
DHCP. Understanding the factors that influence the safety of a device
and performing practices that will minimize the risk of exposures is also
of critical importance. Work-practice controls are an alteration in the
manner in which a task is performed which results in safer behaviors,
reducing the likelihood of exposure. Examples of work-practice con-
trols are use of personal protective equipment (e.g., protective eye-
wear, gloves, and mask), one-hand needle recapping, restricting use of
fingers in tissue retraction or palpation during suturing and administra-
tion of anesthesia, removing burs before disassembling the handpiece
from the dental unit, and minimizing potentially uncontrolled move-
ments of such instruments as scalers or laboratory knives.
For procedures involving multiple injections with a single needle,
the practitioner should recap the needle between injections by using
a one-handed scoop technique if no engineering controls are avail-
able for resheathing the needle or holding the needle cover. Used
needles should never be recapped or otherwise manipulated by using
both hands, or any other technique that involves directing the point
of a needle toward any part of the body. DHCP should never bend or
break needles before disposal because this practice requires unnec-
essary manipulation. Before attempting to remove needles from non-

272
disposable syringes, the needles should be recapped to prevent inju-
ries. Passing a syringe with an unsheathed needle should be avoided
because of the potential for injury.
The use of sharps should be avoided whenever possible. For exam-
ple, when disposable syringes are used for irrigation procedures, the
needle (along with its cover) should be detached from the syringe. The
solution may be expressed directly from the hub opening or a plastic
irrigation tube may be attached to the syringe.
Work-practice controls for needles and other sharps also include
disposing of used disposable syringes and needles, scalpel blades,
and other sharp items in appropriate puncture-resistant containers lo-
cated as close as feasible to where the items were used.

Reducing Aerosols and Droplets [1]

The microbial content of aerosols, spatter, and droplet nuclei is de-
rived from the oral cavity and DUWLs. Reducing the risk of infection
requires reduction of the microbial content within these two sources
and limiting the amount of aerosols and spatter which escapes the
vicinity of the oral cavity. While no single approach can eliminate the
risk of infection completely, several approaches using engineering and
work-practice controls, used in combination can considerably reduce
the risk of air-borne infections. The dental team should not rely on a
single precautionary strategy.
In the reduction of dental aerosols, the first layer of defense is per-
sonal protection barriers such as masks, gloves and safety glasses.
The second layer of defense is the routine use of an antiseptic pre-
procedural rinse with a mouthwash such as chlorhexadine and reduc-
ing the microbial content within DUWLs (see section on Treatment of
Dental Unit Waterlines). The third layer of defense is the routine use of
a high-volume evacuator (HVE).

273
 The High-Volume Evacuator and Saliva Ejector
[1, 10, 103, 114]
Filtering the air within the clinics to reduce airborne microbial con-
tamination has practical limitations and requires prolonged times to
achieve adequate air circulation. Therefore the most efficient method to
reduce airborne contamination is to control it before it escapes the im-
mediate treatment site. The use of an HVE has been shown to reduce
the contamination arising from the operative site by more than 90%.
However, only suction systems which remove a large volume of air
within a short period can be classified as HVEs. The wide bore suction
hose attached to dental units is usually efficient enough to be classi-
fied as HVE, but the small opening of a saliva ejector does not remove
a large enough volume of air to be classified as an HVE. Therefore,
when aerosol generating procedures are being performed, the HVE
should be used in addition to the saliva ejector, in order to minimize
spread and inhalation of aerosols and endotoxins.
However care must be taken when using the low-volume saliva
ejector because fluids and microorganisms may be retracted into the
patient’s mouth when:
1. A partial vacuum is created when the pressure in the patient’s
mouth is less than that in the suction tube. Such a condition can
occur when:

a. a patient closes their lips around the tip of the ejector, or

b. during simultaneous use of the HVE close to the suction tip.
2. A length of the suction tubing holding the suction tip is posi-
tioned above the patient’s mouth. Gravity may pull fluid back
from the tube toward the patient’s mouth.

This backflow can be a potential source of cross-contamination.

Thus, to minimize backflow of oral fluids and microorganisms from the
low volume saliva ejector:
1. Patients should not be allowed to close their lips tightly around
suction tips to evacuate fluids from the oral cavity.

274
 2. The HVE, when used simultaneously with the suction tip (as
is recommended during aerosol producing procedures) should
not be placed near the suction tip.
3. The tube should never be held at a higher level than the suc-
tion tip when the tip is inside the patient’s mouth. This may be
facilitated by bending the suction tip.

Transporting Contaminated Items [108]

Contaminated items should be cleaned and disinfected as soon as
possible after use. If the items will not be sent to the CSSD imme-
diately, they must be kept in a holding solution. In the case of heav-
ily contaminated items (e.g. those used for handling dental materials,
scalers and curettes, and oral surgical instruments), tissues, blood,
and material debris should be removed (by wiping with gauze) as soon
as possible, prior to transport to the decontamination area. All dispos-
able items should be removed from the kit prior to transportation, e.g.
disposable needles, cartridges etc.
After patient treatment, transport of contaminated items from the
point of use to the CSSD should be in an appropriate container to mini-
mize the risk of percutaneous injury. The container should be puncture
resistant and of adequate size and depth for the items to be stable and
rest safely within the container without protruding beyond its edges.
The transport container should, preferably, be covered and of the type
that can be locked, so that the courier will wear gloves in one hand and
the other hand used to touch clean surfaces such as doorknobs. The
transport container should be considered contaminated. During trans-
port of items to the CSSD, the courier’s gloves, contaminated items,
and container should not contact any surface en route to the CSSD.
Once the contaminated items have returned to the CSSD, the courier
must remove the contaminated gloves and wash their hands or perform
a disinfecting hand rub before contacting other surfaces and items.

Servicing Contaminated Items

Contaminated equipment that needs to be serviced by maintenance
or transported to another site outside the clinical halls and CSSDs

275
 must be decontaminated first. Contaminated handpieces should not
be serviced within the clinics because of the risk of cross-contamina-
tion between handpieces via the maintenance tools. Patient care items
should be returned to the CSSD where they may serviced after clean-
ing and decontamination and before packaging.

Storing Sterile Items in Clinics [105]

If sterile items are stored in a patient-care area, they must be in cov-
ered or closed cabinets. Sterile packages should not be stored under
the sink (or any location where they may become wet), on the floor,
windowsill, or any area other than designated shelving or cabinets.
Patient-care items should not be stored together with items not intend-
ed for clinical use. As a general rule, similar items should be stored
together.

276
 INFECTION CONTROL IN RADIOLOGY

Intra-Oral Radiography
[5-6, 10, 100, 105, 115-117]
Intraoral radiography involves direct contact with saliva which may
contaminate the films, film holders, position-indicating devices, x-ray
tube-head, door handles, as well as the timing controls and exposure
switch. Thus, when taking radiographs, the potential to cross-contam-
inate equipment (including the processor and processing solutions)
and environmental surfaces with blood or saliva is high if the aseptic
technique is not practiced. Efforts at prevention of cross-contamination
should be directed towards isolating or protecting:
1. items which directly contact the oral cavity, and
2. items which are contacted by the operator’s hands (contact sur-
faces).
Infection control procedures should be carried out such that contam-
inated items should not leave the immediate vicinity of the x-ray rooms.
All contaminated gloves, towels, and barriers should be disposed of
in the vicinity of the x-ray room so as to not contaminate other areas.
All areas beyond the x-ray room (especially the dark room) should be
considered clean and maintained as such.

Items Which Make Contact With the Oral Cavity

Items which enter the oral cavity must be either sterilizable, dis-
posable, or covered with a disposable barrier between patients. Such
semi-critical items should never be processed between patients with
disinfection alone. The following are items which contact the oral cavity
during intra-oral radiograph making:
1. Operator’s hands:
The radiographer must wear gloves when making intraoral radio-
graphs. Contaminated gloves must not contact any surface not pro-
tected by a barrier. If the operator needs to obtain more supplies, the
contaminated gloves should not contact containers, drawers or other un-

277
 protected surfaces. The contaminated gloves must be removed before
touching such surfaces or a colleague may obtain the needed items.
Used gloves must be removed and hands washed before entering
the dark room.
2. Film packets:
Intraoral films packets must be covered with a protective plastic
barrier before being placed inside the patient’s mouth. After removal
from the patient’s mouth, the excess saliva must be wiped off of the
outer barrier and the film dropped out of the barrier onto a clean paper
towel or into a clean plastic cup. The film must be dropped out without
touching it with the contaminated gloves in order to maintain the film’s
cleanliness. The clean film can, then, be taken to the dark room and
processed without contaminating the room’s surfaces or equipment.
When the film packets are kept clean, aseptic processing in daylight
loaders becomes easier and more practical. The clean films are in-
serted with the operator’s hands through the cuffs of the daylight loader
and processed with no resultant contamination of the loader, film hold-
ers, or solutions.
Aseptic handling of the films, protective barriers, and gloves must
be ensured to avoid contamination of the dark room or daylight load-
ers. It is not acceptable to contaminate processor rooms or daylight
loaders by introducing film packs or gloves still coated in saliva.
Due to the possible failure of barrier protection, new clean gloves
should be used to transport the films to the dark room in their clean
container.
3. Film holding devices and position indicating devices:
Film holding devices and position indicating devices should be ei-
ther disposable and not reused between patients or they may be au-
toclavable and heat-sterilized between patients. Disinfecting such
semi-critical items between patients is unacceptable and should not be
attempted.

278
 Contact Surfaces
Contact surfaces are those surfaces touched by the radiographer
during the making of intra-oral films. Such surfaces should be protect-
ed from contamination to avoid the need for repeated disinfection pro-
cedures which are time consuming and not full-proof (see ENVIRON-
MENTAL INFECTION CONTROL). However, in the event of surfaces
becoming inadvertently contaminated, they must be cleaned and dis-
infected with the spray-wipe-spray technique. X-ray unit components,
though, should not be sprayed directly as this may lead to a short-cir-
cuit so the wipe-discard-wipe technique should be used. They should
be disinfected by generously soaking paper towels with the disinfectant
and wiping the surface to reduce the microbial count, then wiping the
surface again and letting the surface remain wet for the appropriate
contact time. Although contamination of the following surfaces and
items should be avoided, they should be cleaned and disinfected at
the beginning and end of the work day.

The following surfaces are the most often touched contact surfaces:
1. X-ray tube-head
2. Control panel
3. Chair operating controls
4. Exposure buttons
5. Door handles
The above five components must all be covered by a barrier
before making the radiographs. Barriers must be removed im-
mediately after the patient exits the chair. Barriers should not
be left in place until after processing of the films as this may
lead to confusion whether the barriers are new or used.
6. Lead apron
Removal of the lead apron from the patient after making the
radiographs leads to its contamination by the radiographer’s
gloves. Therefore, to avoid the need for cleaning and disin-
fection, the radiographer should not touch the lead apron with

279
 gloves.
The apron should be placed onto the patient before donning the
new gloves prior to radiograph making. After the end of the exposures,
the method of removal of the lead apron depends on whether the radio-
graphs were taken in the radiology department or in a clinic.
a. In the radiology department:
If the patient has not been asked to hold the film, the patient
should be instructed to remove the apron and place it in its
appropriate place. If the patient has been asked to hold the
film, the radiographer should remove the apron after removal
of the contaminated gloves.
b. In the clinics:
The radiographer should remove the apron after removal of
the contaminated gloves.

Extra-Oral and Panoramic Radiography [6, 117]

If they are not detachable and sterilizable, non-critical items used to
stabilize and position the head such as ear rods, head positioners, and
chin rests(i.e. items that contact intact skin) should be covered with a
barrier or disinfected between patients.
Bite-blocks and any other item placed inside the oral cavity should
be covered with a barrier or sterilized between patients. Disinfection
of such items between patients is not sufficient; although they must be
disinfected in the event of failure of the barrier isolation.
During extra-oral radiography, the operator’s hands do not routinely
contact the oral cavity. However, if the operator’s gloves do become
contaminated, then contact surfaces should not be touched and pre-
cautions must be taken as with intra-oral radiography.

280
 Digital Radiography
[6, 10, 105]
Digital radiography is a form of intra-oral radiography; therefore, the
same infection control procedures apply to it as those pertaining to
intra-oral radiography.
With digital radiography, sensors replace film packets. Sensors come
into contact with mucous membranes and oral fluids; therefore they
should ideally be sterilized. However, as of yet, there are no sterilizable
digital sensors; therefore, sensors must be covered with disposable
barriers between patients. If commercial barriers are not available,
finger cots from latex gloves may be used to cover the sensor, and
household plastic wrap used to cover the attached wire for a minimum
length of 15 cm. To minimize the potential for cross-infection, after re-
moving the barrier, the sensor should be cleaned and disinfected with
an intermediate level disinfectant after each patient, but only according
to the manufacturer’s instructions.
The computer and work station components which may be contact-
ed by the operator’s gloves (e.g. keyboard, mouse, screen, and table)
should also be covered with a barrier. These barriers must be changed
between patients. The components of the digital system should never
be transported between clinics before removal of barriers and, if nec-
essary, disinfection.
Cleaning and disinfection of the components should be performed
if failure of the barrier has taken place (i.e. if patient materials have
contaminated the component). The manufacturer’s care instructions
should be consulted regarding appropriate disinfection/sterilization
procedures for digital radiography sensors and components.

Sialography [10, 82]

During sialography procedures, all clinical infection control proce-
dures should be followed as described in the section Clinical Consider-
ations. In addition, the following practices must be observed:
1. Probes which have contacted other surfaces in the oral cav-

281
 ity should not be used to explore or dilate the salivary gland
ducts so as to not introduce oral flora into the ducts. Only sterile
probes and dilators should be inserted into the ducts.
2. Cannulas for injection of the contrast media into the salivary
gland ducts should be used one time only then discarded. Due
to the difficulty of cleaning and sterilizing long narrow lumens,
cannulas should not be reused between patients.
3. Vials of contrast media used in sialography should preferably
be single-dose vials. If single-dose vials are used, their left-over
contents should not be reused.
4. If multi-dose vials are used, they should be handled in an asep-
tic manner and, before insertion of the needle, the rubber dia-
phragm should be cleaned with 70% alcohol. If sterility of the
vial is compromised, it should be discarded.

282
 INFECTION CONTROL IN PROSTHODONTICS
AND IN THE DENTAL LABORATORY
The practice of prosthodontics presents major challenges to the
prevention of cross contamination. Dental prostheses or impressions
can be contaminated with bacteria, viruses, and fungi. So, laboratory
technicians and patients are frequently exposed to pathogens from
dental impressions, stone casts, and appliances. Analysis of prost-
hodontic set-ups shows that many of the instruments and support
equipment carry the potential to transmit disease but are not amenable
to adequate sterilization or disinfection. The risk of potential disease
transmission can be reduced by improving some of the disinfection and
sterilization procedures used.
Dental impressions are contaminated with saliva and sometimes
blood. Prostheses and appliances often are “tried in” in the process of
their construction and thus go from laboratory to operatory and back
again. Some items used routinely in dental laboratory may become con-
taminated, however, they pose problems of disinfection or sterilization
such as shade guides, mold guides, indelible pencils, rulers, mixing spat-
ulas, knives, face-bows, articulators, and torches. A number of these are
composed of heat-sensitive materials and are subject to distortion. All
aforementioned items are potentially infectious and must be disinfect-
ed or sterilized before handling in the laboratory. In addition, the routine
cleaning and disinfection of environmental surfaces and equipment in the
dental laboratory should be comparable to that practiced in the dental
clinic.
A successful laboratory infection control program requires meeting
three major criteria:
1. The use of proper methods for handling soiled items (Aseptic
Technique).
2. The use of proper method and materials for decontaminating
soiled items.
3. The establishment of a coordinated infection control program
between dental clinic and dental laboratory. [5-6, 10, 21, 30,

283
 118]
The Use of Proper Methods for Handling Soiled Items
[5-6, 10, 27, 87, 118-123]
To minimize the potential for cross contamination and disease trans-
mission the following should be adhered to in the laboratory infection
control program.

Adherence to Standard Precautions

Adherence to standard precautions includes hand hygiene and the
use of personal protective equipments (see Standard Precautions).

Personal Protective Equipment:

Personal protective equipment (PPE) must be used when handling
contaminated items in the laboratory. Depending on the task being per-
formed PPE is indicated.
After decontamination of a laboratory item, the item can then be
handled as noninfectious if separate clean working areas are avail-
able. However the use of a gown or laboratory coat is still recommend-
ed, and other barriers are often required as a safety precaution. The
CDC, National Institute of Occupational Safety and Health (NIOSH)
approved dust/mist face mask and eye protection or a face shield must
be worn whenever operating lathes, model trimmers, or other rotary
equipment.

Task-Specific Designation of Work Areas

The laboratory should be composed of clearly specified areas, with
each area designated for particular tasks. Strict adherence to these
designated purposes acts as a barrier system, reducing the potential
for cross-contamination. Dental laboratories must operate using one of
two general approaches to manage infection control:
1. Clean dental laboratory: The laboratory can be maintained as
an isolated area and require all prostheses, impressions, and
other laboratory work to be disinfected before entering the
laboratory.

284
 2. Standard dental laboratory: This method requires a receiving
area to isolate, evaluate and decontaminate all materials en-
tering the laboratory. The design of a standard dental labora-
tory should include the following areas:
a. Receiving area.
b. Production area.
c. Shipping area.
d. Consultation room.
a. Receiving Area:
The receiving area should be separate from the production area.
Persons working in the receiving area should wear a clean uniform
or laboratory coat, a face mask, protective eyewear, and disposable
gloves.
Personnel working in the receiving area should remove their PPE
before moving to an uncontaminated area of the lab.
This receiving area should have running water and hand-washing
facilities. Countertops and work surfaces should be covered with im-
pervious paper if possible, cleaned and disinfected once or twice daily
with an EPA-registered tuberculocidal (intermediate level) disinfectant
according to the manufacturer’s directions (see section on Chemicals
Used for Disinfection and Sterilization).
Incoming cases should be unpackaged carefully and handled in an
aseptic manner. Unless the case was labeled as disinfected in the den-
tal clinic, it should be cleaned and disinfected immediately on receipt
with an EPA-registered tuberculocidal disinfectant. Items should be
disinfected before being transferred to case pans to avoid contamina-
tion of the pans. Case pans should be disinfected or sterilized after
each use. Packing materials should be discarded to avoid cross-con-
tamination.
b. Production Area:
Separate areas should be designated for new work and repairs in-

285
 side the production area. If this area is separated adequately and all
incoming cases are known to have been disinfected, DHCP can han-
dle new cases as noninfectious once they have been decontaminated.
Given the uncertainty of decontamination of devices that have been
worn by a patient, full PPE should be used when handling these items,
and every effort should be made to avoid cross-contamination from
such items.
All work surfaces should be cleaned and disinfected with an EPA-
registered tuberculocidal disinfectant on a regular basis but at least
once or twice daily. Plastic wrap or other barrier can be used to cover
work surfaces for simplifying cleanup.
Any instruments, attachments, and materials to be used with new
prostheses/appliances should be maintained separately from those to
be used with prostheses/appliances that have already been inserted in
the mouth. Equipments should be cleaned and sterilized or disinfected
as appropriate, usually once or twice a day and after each case for
repairs. Disposable items are available, such as polishing wheels and
brushes, eliminating the need for cleaning and disinfection of the reus-
able items.
c. Shipping Area:
This area is designed for final inspection, cleaning and disinfection
of prostheses and appliances.
The disinfected devices should be shipped in a labeled and sealed
plastic bag (information such as type of disinfectant used, disinfec-
tion method, and duration should all be mentioned). Disinfected acryl-
ic items should be stored and shipped in a sealed bag containing a
small amount of diluted mouthwash. Disinfected items should never be
shipped in sealed bag containing disinfectant. Only new packing mate-
rial should be used to avoid cross contamination.
d. Consultation Room :
If patients are seen in the dental laboratory for purposes of shade
verification, infection control procedures must be the same as those
used in the dental clinic, with proper cleaning and disinfection of work

286
surfaces after each patient appointment.

Aseptic Technique
Whenever handling patient materials, or instruments and devices,
sterile, disinfected, and clean (aseptic) materials should not contact
contaminated materials and vice versa. The laboratory technicians are
required to exercise their judgment and apply the aseptic technique
to all situations in which they come in contact with patient materials,
instruments, or devices.

Unit-dose Concept
The dispensing of an amount of a material or device which is suffi-
cient to accomplish the procedure and where excess may be discarded
at completion, is commonly referred to as a “unit-dose.” Items such as
denture adhesives for record trays, petroleum jelly, impression materi-
als, waxes, pumice, and indelible pencils are amenable to unit -dosage
with little or no change in the established routine.
Attention to when and by whom the material is dispensed is neces-
sary to avoid breaking the aseptic chain.

Barrier Technique
Instruments such as face-bows, articulators, torch handles, and im-
pression guns pose obvious problems for sterilization and disinfection
and should be covered with a plastic barrier to prevent contamination.

Avoiding Exposure Incident

Laboratory personnel may be exposed to pathogenic microorgan-
isms via:
1. Direct contact (through cuts and abrasions).
2. Aerosols created during lab procedures (inhaled or ingested).

The first layer of defense is personal protection barriers and the

second layer of defense is the routine use of evacuation system. The
use of sharps should be avoided whenever possible.

287
 When gloves are worn during operation of a lathe, extreme caution
must be taken to avoid injury resulting from the glove catching in the
lathe.
Wearing masks, and safety shields (or protective eye glasses), and
use of air-suction motors and ventilation systems are all required when
operating mounted rotary equipment, such as lathes, to reduce the risk
from aerosols, spatter, and projectiles.
The applied protocols and recommendations for vaccinating DHCP,
and for post exposure management, must be observed (see sections
on Vaccination and Occupational Exposure, Exposure Incident and
Documentation).
Sharp items (e.g., burs, disposable blades, and orthodontic wires)
should be disposed of in puncture-resistant containers (see section on
Management of Medical Waste).

The Use of Proper Method and Materials for

Decontaminating Soiled Items
[2, 6, 10, 29-30, 118-120, 123]
Steam Sterilization (Autoclave)
Routine sterilization of items that can withstand heat enhances the
overall laboratory infection control program and further reduces the po-
tential for cross-contamination. Heat tolerant items used in the mouth
and on contaminated laboratory items and materials should be cleaned
and sterilized before being used for another patient or another labora-
tory case. Examples of such items are:
1. Metal impression trays
2. Burs
3. Rag wheels
4. Polishing points
5. Laboratory knives
6. Facebow forks

288
 7. Handpieces and instruments
8. Polishing points
9. Water bath basins
10. Stainless steel bowels
11. Boley gauges
12. Metal rulers
13. Metal spatulas
14. Occlusal plane guides
15. Orthodontic pliers
16. Impression guns: It has been found that after routine clinical
use, bacteria, including MRSA, heavily contaminated the im-
pression guns. After the impression guns underwent disinfection
after each use, there was a 6 %decrease in bacterial counts.
The use of steam sterilization achieved sterility without harming
the impression guns. Use of steam-sterilized impression guns
with plastic impression gun covers for each patient decreased
bacterial isolates by approximately 60 %. Use of steam steril-
ized impression guns plus plastic covers for each patient and
disinfection after each use resulted in an approximately 95 %
reduction in contamination.

Disinfection
For items that will come in contact with mucous membranes, but
which are not used between patients (e.g., prostheses, custom trays,
and occlusal and orthodontic appliances), intermediate- to high-level
disinfection is sufficient, if laboratory infection control protocols are ad-
equate to prevent cross-contamination. However, items which are used
between patients, and which contact the mucous membranes, must be
sterilized between patients. Heat-sensitive semi-critical items should
be sterilized with chemical sterilants, or, at minimum, undergo high-
level disinfection in the CSSD. Items that do not normally contact the
mucous membranes but frequently become contaminated and cannot

289
 withstand heat-sterilization should be cleaned and disinfected between
patients and according to the manufacturer’s instructions. Spray-wipe-
spray method with phenolics or iodophors can be used for such items.
Equipment particularly suited to this procedure are:
1. Articulators
2. Face-bows
3. Lathes
4. Case pans
5. Pressure pots
6. Water baths
7. Shade guide (spray-wipe spray with phenolics or iodophors)
8. Wooden-handled spatulas
9. Rubber mixing bowls
10. Torch
Contaminated materials and items used intra-orally that cannot be
cleaned, sterilized, are to be discarded, for example:
1. Plastic impression trays
2. Custom trays
3. Disks
4. Brushes
5. Waxes

Chemical Disinfectants
Only EPA-registered hospital disinfectants with a tuberculocidal
claim should be used. Examples of acceptable disinfectants are so-
dium hypochlorite ( in concentrations ranging from 0.05% to 0.5% (500
to 5,000 ppm) diluted with water) , iodophor (1% stock iodine diluted to
the range of 0.05% to 0.5% in 70% isopropyl alcohol) and phenolics.
Removable partial denture frameworks, acrylic resin impression trays,
immediate dentures, and mold and shade guide teeth can be placed in

290
these solutions for adequate disinfection prior to use.
It should be cautioned; however, that occasional uptake of iodine
stain has occurred in some acrylic resin denture teeth. This has not
been observed after repeated disinfection of mold and shade guide
teeth in the iodophor solution. If iodophors are used on shade guide,
they should be wiped with water or alcohol after the exposure time to
remove any residual disinfectant.
While removable partial denture frameworks have shown no evi-
dence of corrosion in the sodium hypochlorite solution at the recom-
mended concentration and time intervals, this solution should not be
used on a regular basis due to corrosion potential.
Glutaraldehyde in 2% solutions is accepted as being effective disin-
fectants and unless used for 10 hours, is unacceptable for sterilization.
The use of glutaraldehydes, however, is discouraged because they
are toxic and require special precautions.
It is important to remember that most immersion disinfectants can
only be used once before they should be discarded. Concentrations of
solutions should be regularly assessed as dilutions will occur with time.
Items should never be shipped or stored in chemical disinfectants.

Disinfection of Dental Impressions

[3, 6, 10, 21, 29-30, 119, 121, 124-146]
Impressions and prostheses that have been inserted in a patient’s
mouth are contaminated with microorganisms. These can be transmit-
ted to dental personnel either by direct contact or as aerosols produced
during polishing and grinding procedures. This has obvious implica-
tions for cross contamination from the clinic to the laboratory.
Since impression material can act as a vehicle for the transfer of
both bacteria and viruses, it has been recommended that impressions
be cleaned and disinfected immediately after their removal from the
mouth, in order to avoid contamination of dental clinic staff and dental
technicians. Chairside rinsing of impressions is the first step in suc-
cessful infection control in the laboratory.

291
 Traditionally, impressions were rinsed under running water after
being removed from the mouth to visibly eliminate saliva and blood.
Although rinsing significantly reduces the numbers of microorganisms
in most cases (one in vitro study showed that simple washing of an im-
pression for 15 seconds produces approximately 90% reduction in the
number of surface-resident bacteria), it does not decontaminate the
impression. Although the intraoral effect of salivary mucins and other
adhesive salivary proteins may tend to interfere with simple washing,
rinsing impressions before and after disinfection is beneficial, in that it
removes organic matter (blood, saliva, etc) that compromises the activ-
ity of some disinfectants, reduces the load of virus and bacteria, and
removes residual disinfectant.
After rinsing, the impression should be disinfected using the proper
material and method. Trimming the excess of impression material from
noncritical areas might reduces the number of microorganisms and or-
ganic debris present. Given the porosity of impression materials, rec-
ommended exposure times probably should be greater than those for
hard surfaces.
A small dimensional change or effect on the physical properties of
the die stone may be within the acceptable range for the particular
impression material or stone and thus have no clinically discernible ef-
fect on the final product. Some significant differences (e.g., increased
hardness) are actually positive effects, resulting in an improved final
product. Those dimensional changes may however be of clinical sig-
nificance for procedures requiring a high degree of accuracy, for ex-
ample in fixed prosthodontics. The materials respond differently de-
pending on the disinfectant and the disinfection method used and it
may therefore be appropriate that manufacturers recommend the use
of particular disinfectants and the disinfection method for their products
in order to ensure optimum dimensional accuracy and stability.
Impression materials marketed as containing a disinfectant still need
to be rinsed and disinfected after removal from the oral cavity because
the disinfectant may reduce the numbers of microorganisms, but does
not totally eliminate those on the surface of the impression.

292
 An alternative to impression disinfection is to sterilize the stone cast
in any ethylene oxide sterilizer.

Disinfection Methods
The following techniques have been recommended for disinfection
of impressions:
1. Spraying Method.
2. Short-term Submersion.
3. Immersion Method.
Spraying Method :
The advantages of the spraying method are that the same disin-
fectant can be used to disinfect environmental surfaces, and less dis-
infectant is used. However, the spraying method poses the risk of not
covering all surfaces of the impression because the disinfectant runs
off and pools, and much of the impression is exposed to the disinfec-
tant for only a brief time, rather than the exposure time recommended
for disinfection. Furthermore, when the spraying method is used, the
disinfectant can be released into the environment, increasing occupa-
tional exposure.
The impression must be sprayed with disinfectant on all sides until it
is thoroughly wet and then covered (wrapped with plastic or otherwise
enclosed) to avoid drying and allow exposure for the recommended
disinfection time.
Some disinfectants, such as glutaraldehydes should never be
sprayed, as the fumes may rapidly reach a lethal level. The fumes may
also cause allergenic and other undesired reactions.
Short-term Submersion:
Short-term submersion is an alternative method to spraying. The
impression is immersed in the disinfectant solution and gently swirled
for less than a minute and then kept in a closed plastic bag for the rec-
ommended disinfection time.

293
 Immersion Method:
The immersion method is the preferred method of disinfection. Many
clinicians have expressed concern that immersion in disinfectants for
the recommended exposure time would result in distortion of hydrophilic
materials because the impression imbibed water or disinfectant solu-
tion. Research has shown this latter concern to be clinically unfounded
if short disinfection times are used, and in 1991, the ADA Council on
Dental Materials, Instruments, and Equipment recommended that all
dental impressions be disinfected by immersion.
The time for exposure to a particular disinfectant (i.e., the immersion
time) should be at least that recommended by the product manufac-
turer for tuberculocidal disinfection. Impressions can be immersed in
the disinfectant in a variety of containers including reusable plastic or
glass containers that can be disinfected and disposable zipper-closure
plastic bags.
The 1991 ADA council recommendation suggests use of disinfec-
tants requiring no more than 30 minutes for disinfection. Impression
materials that are hydrophilic should be disinfected with a product re-
quiring a minimum time for disinfection (preferably no more than 10
minutes).

Choice of Disinfectant for Impressions

No single disinfectant is compatible with all impression materials.
When selecting a disinfectant, one should consider the type of impres-
sion material, the disinfectants available in the dental clinic or labora-
tory, and the number of impressions to be disinfected per day. Table 14
lists the effect of various disinfectant treatments of impressions on the
resultant cast dimensions. Disinfectants should not be used repeatedly
for disinfection of impressions unless they are approved for reuse.
Where glutaradehyde is referred to in this section, the 2% acid-po-
tentiated glutaraldehydes or the 2% alkaline glutaraldehydes (not the
neutral glutaraldehydes) are preferred, as they produce an improved
cast surface. Conversely, a neutral glutaraldehyde should not be used
because of potentially adverse effects on the surface quality. However,

294
the use of glutaraldehydes is discouraged because they are highly tox-
ic and require special precautions when being used.
When using a newer disinfectant that has not been tested by re-
search studies, in-house studies must be performed to ascertain com-
patibility with the impression materials. When considering methods of
disinfection for impressions, two factors must be addressed:
1. The effect of the treatment on the dimensional stability and
surface detail of the impression.
2. The effectiveness of the antimicrobial agent, and the deac-
tivating effect of the impression material on the disinfecting
solution, which could reduce the efficacy of the process.
Dental materials’ manufacturers should be consulted regarding the
compatibility with different disinfectants and disinfection methods not
addressed in these guidelines.
Table 14
Effect Of Disinfectant Treatment on Cast Dimensions as Compared
with Room Temperature Controls

IMPRESSION MATERIAL
Polysulfide Polysilox- Polyether
DISINFECTANT Alginate
(Permalas- ane (Imp-
(Jeltrate)
tic) (Reflect) regum)
0.5% Sodium hypochlorite
NS* NS NS NS
(Clorox)
1% Sodium hypochlorite
NS NS NS NS
(Clorox)
0.5% Povidone-iodine Significant
NS NS NS
(Betadine) difference†
0.16% Halogenated
Significant
phenol NS NS NE*
difference
(CD-100)
*NS denotes no significant difference (P > .05) , and NE denotes not evaluated.

†Significant differences (P < .05) only in the anteroposterior dimensions as compared with room
temperature controls.

Source: Nisengard and Newman [21]

295
 Elastomeric Impressions
Polysulfide:
Continuing polymerization of some polysulphide impressions (which
is a hydrophilic material) may contribute not only to dimensional chang-
es observed over time, but also to adverse and inconsistent reactions
with many of the disinfecting solutions. However, studies have shown
that polysulfide impression material can be disinfected by immersion
with most of the disinfectants recommended for use in dentistry without
affecting accuracy and detail reproduction, but exposure time should
be kept to minimum (10 minutes) (Table 15). One group of investiga-
tors found that immersion in disinfectants increases the wettability of
polysulfide.

Silicones:
Studies have shown that addition silicone impressions can be dis-
infected by immersion with most of the disinfectants recommended
for use in dentistry without affecting accuracy and detail reproduction
(Table15). A large number of studies found that the greatest accuracy
was found with the addition-reaction silicone impressions. The greater
accuracy and stability of the addition-reaction silicone materials make
these the material of choice in many situations of enforced prolonged
storage or immersion of impressions.
However, increasing the contact time between a surfactant-contain-
ing impression material and a disinfecting solution can significantly al-
ter the resulting contact angle of the impression material and render it
similar to a material depleted of surfactant. Whereas, following manu-
facturer recommended chemical disinfection times reduces surfactant
loss and only minimally affects surface wettability.
It has also been found that immersion in disinfectants has no effect
on the wettability of hydrophobic addition silicones, and decreases the
wettability of hydrophilic addition silicones.
The evaporation of volatile by-products from condensation-reaction
silicone materials may contribute not only to dimensional changes ob-
served over time, but also to adverse and inconsistent reactions with

296
many of the disinfecting solutions. However, studies have shown that
condensation-reaction silicone impressions can be disinfected by im-
mersion with most of the disinfectants recommended for use in den-
tistry without affecting accuracy and detail reproduction.
Table 15
Recommendations for Disinfection of Polysulfide and Silicon Rub-
ber Impressions

Accepted Disinfectant Dilution Time

Sodium hypochlorite 5.25% 1:10 10 minutes

Iodophors 1:213 10 minutes

Combination synthetic phenolics 1:32 10 minutes

Glutaraldehyde with phenolic buffer 2%* 1:16 10 minutes

2% Glutaraldehyde acidic* 1:4 30 minutes

Recommended method for disinfecting polysulfide and silicon rubber im-
pressions :
Immersion in an accepted disinfectant (for ≤30 minutes).
* The use of Glutaraldehydes is discouraged because they are toxic and require special
precautions.

Source: Molinari and Harte [6], ADA [121], ADA [130]

Polyether :
Although hydrophilic, polyether impressions can be disinfected by
immersion, exposure times should be kept to a minimum (10 minutes).
Therefore, polyether would not be the material of choice when com-
plete sterilization is required.
Studies have shown that the effects of immersion disinfection on the
dimensional stability of polyether impressions are not clinically relevant
(dimensional accuracy measurements met the ADA standard of ≤0.5%
dimensional change). Acceptable disinfectants for polyether impressions
are listed in Table 16. One group of investigators found that immersion in
chlorine dioxide disinfectants increases the wettability of polyether.

297
 Table 16
Recommendations for Disinfection of Polyether Impressions

Accepted Disinfectant Dilution Time

Sodium hypochlorite 5.25% 1:10 10 minutes

Iodophors 1:213 10 minutes

Combination synthetic phenolics 1:32 10 minutes

Glutaraldehyde with phenolic buffer 2%* 1:16 10 minutes

Recommended method for disinfecting polyether impressions:
Immersion (with caution) in an accepted disinfectant (not more than 10
minutes).
* The use of Glutaraldehydes is discouraged because they are toxic and require special pre-
cautions.

Source: Molinari and Harte [6], ADA [121], ADA [130]

Hydrocolloid Impressions
Irreversible Hydrocolloid (Alginate):
Several studies have confirmed that alginates harbor significantly
higher levels of bacteria than silicon rubber impressions. It is postulated
that the porosity of alginate might account for this difference. Studies
have also shown that viruses adsorb to alginate, making disinfection of
paramount importance.
Recently, some manufacturers have begun incorporating disinfec-
tant into their impression powder.
A number of investigators have evaluated the effect of disinfection of
irreversible hydrocolloid (alginate) on dimensional accuracy, sometimes
with contradictory results. Results showed differences based on the
selection of alginate product and disinfectant. Differences noted were
generally not clinically significant for most applications of casts retrieved
from alginate impressions. Many studies showed that the dimensional
accuracy of the gypsum casts made from irreversible hydrocolloid (al-
ginate)impression is not significantly affected by the disinfection proto-
cols (most of these studies used sodium hypochlorite in concentration

298
≤1% applied for ≤ 10minutes).
Disinfectant solutions also did not have an effect on the surface
roughness of the cast. However, a significant increase in surface rough-
ness was observed with increasing immersion time (≥5 minutes).
Furthermore, it has been shown that irreversible hydrocolloid impres-
sions can be immersed up to 30 minutes in an iodophor without loss of
clinically significant linear dimensional stability. Given the hydrophilic
nature of the material, a minimal disinfection time should be used.
Some investigators, however, reported significant adverse effects
on specific materials with disinfectants that are nonreactive with other
alginates, suggesting that caution should be exercised. Hence, if fine
accuracy is required, immersion disinfection of irreversible hydrocolloid
materials produces unpredictable results. It is probable that the water
used for the dilution of the disinfectants, rather than the disinfectant per
se, is the factor causing the instability encountered with some hydrocol-
loid impression materials.
If dimensional changes are to be avoided or minimized, it appears
that spraying the surface of the impressions or short-term submersion
would be the viable methods of disinfecting irreversible hydrocolloid im-
pressions.
The American Dental Association (ADA) recommended disinfecting
alginates by immersion (not more than 10 minutes) in diluted hypochlo-
rite (which has been shown by many studies to be an effective disinfec-
tant for alginate impression), iodophor, or glutaraldehyde with phenolic
buffer (a product that is no longer available) (Table 17).

Reversible Hydrocolloid:
For reversible hydrocolloid impression materials, a further possible
source of contamination is the water bath used for liquefying and con-
ditioning. The recommended temperature ranges used support bacte-
rial growth, and the addition of a disinfectant solution to the water may
solve the problem.
Research data suggest that there is no effect on dimensional accu-
racy of reversible hydrocolloid impressions immersed in various disin-

299
 fectants (Table 17). However, immersion in 2% alkaline glutaraldehyde
has a significant adverse effects on the impressions and resultant dies.
Studies have shown that reversible hydrocolloid can be immersed up
to 30 minutes in an iodophor without loss of clinically significant linear
dimensional stability .
Table 17
Recommendations for Disinfection of Hydrocolloid Impressions

Accepted Disinfectant Dilution Time

Sodium hypochlorite 5.25% 1:10 10 minutes
Iodophors 1:213 10 minutes
Glutaraldehyde with phenolic buffer 2%* 1:16 10 minutes
Recommended method for disinfecting hydrocolloid impressions:
Immersion (with caution) in an accepted disinfectant (not more than
10 minutes).
* The use of Glutaraldehydes is discouraged because they are toxic and require special
precautions.

Source: Molinari and Harte [6], ADA [121], ADA [130]

Zinc Oxide Eugenol (ZOE) and Compound Impression

[6, 130]
Limited data are available on disinfection of ZOE and compound im-
pression. Adverse effects have been reported on ZOE immersed for 16
hours in diluted hypochlorite and on compound by all the disinfectant
tested (hypochlorite, formaldehyde, and 2% alkaline glutaraldehyde).
Zinc oxide eugenol impression materials may be disinfected by
immersion in glutaraldehyde or iodophor. The use of ADA accepted
disinfectants that require no more than 30 minutes for disinfection is
preferred (Table 18 ).
Spraying with phenolics, iodophors, or chlorine compounds can be
used to disinfect impression compound.

300
Table 18
Recommendations for Disinfection of ZOE

Accepted Disinfectant Dilution Time

Iodophors 1:213 10 minutes

Glutaraldehyde with phenolic buffer 2%* 1:16 10 minutes

2% Glutaraldehyde acidic* 1:4 30 minutes

Recommended method for disinfecting ZOE impressions:
Immersion in an accepted disinfectant (for ≤30 minutes).
* The use of Glutaraldehydes is discouraged because they are toxic and require special pre-
cautions.

Source: Molinari and Harte [6], ADA [121], ADA [130]

Disinfection of Wax Bites, Wax Rims, Casts, Custom

Impression Trays, and Bite Registration
[6, 10, 21, 29, 120, 130, 147]
Bite Registration
Wax rims should be disinfected by the spray-wipe-spray method
using an iodophors or phenolics. Rinse-spray-rinse-spray, with most
EPA-registered hospital-level tuberculocidal disinfectant, may be more
appropriate for wax bites. After the second spray, they can be enclosed
in a sealed plastic bag for the recommended time. These items prob-
ably should be rinsed again after disinfection to remove any residual
disinfectant.
Chlorine compounds should not be applied to bite registration made
of ZOE.

Stone Casts
Movement of microorganisms from the impression to dental casts
has been demonstrated. Certain microbes have also been demonstrat-
ed to remain viable within gypsum cast materials for less than 7 days.
It is difficult to disinfect casts without damaging the cast. In order to

301
 minimize the adverse effects on the cast, casts to be disinfected should
be fully set (24 hours after pouring). The ADA recommends that stone
casts be disinfected by spraying until wet or immersing in a 1:10 dilu-
tion of sodium hypochlorite or an iodophor (Table 19).
Immersion of set die stone in a 1:10 sodium hypochlorite or 1:213 io-
dophor solution has shown no, or minimal, undesirable physical effects
on the stone. Casts should be rinsed after disinfection to remove any
residual disinfectant, and they should be allowed to dry completely prior
to handling (casts should be placed on end to facilitate drainage).
Casts can be sterilized in ethylene oxide sterilizer.

Impression Trays
Custom acrylic resin impression trays should be disinfected by
spraying with a disinfectant or immersing in either 1:213 iodophor or
1:10 sodium hypochlorite (Table 19). They should be rinsed thoroughly
to remove any residual disinfectant and allowed to dry fully before use.
After use in the mouth, custom trays should be discarded. Metal trays
should be steam sterilized after each use.
Table 19
Recommendations for Disinfection of Stone Casts and Custom Im-
pression Trays (Acrylic)

Accepted Disinfectant Dilution Time

Sodium hypochlorite 5.25% 1:10 10 minutes

Iodophors 1:213 10 minutes

Recommended method for disinfecting stone casts and custom impres-
sion trays :
Spraying until wet or immersion in an accepted disinfectant.
Disinfectant for stone casts may be prepared using slurry water (saturated
calcium sulfate)

Source: Molinari and Harte [6], ADA [130]

302
 Disinfection of Dental Prostheses and Appliances
[5-6, 10, 21, 29, 120, 122]
Removable Prosthesis and Orthodontic Appliances
Prosthodontic and orthodontic appliances should be disinfected pri-
or to delivery and before and after any laboratory adjustments. Pros-
theses or appliances that have been worn by patients and require re-
pair should be handled as contaminated (even after disinfection) and
cleaned thoroughly before disinfection by scrubbing with a brush and
an antiseptic handwash chairside or by cleaning in an ultrasonic unit.
The best time to clean and disinfect prostheses, or appliances is as
soon as possible after removal from the patient’s mouth before drying
of blood or other bioburden can occur.
Severely contaminated prosthetic devices may have copious
amounts of calculus and other tenacious bioburden. This material must
be removed prior to attempts at disinfection, otherwise the decontami-
nation process will not be effective. Immersion of the prosthesis in a
beaker or plastic bag with stone and plaster removal solution, followed
by placing it in an ultrasonic cleaner for 3 to 5 minutes, will remove most
of the material. Cleaning and disinfection can, then, be performed.
Denture cleansers, including those made for ultrasonic cleaning in
the dental office, are cleaners, and cannot substitute for appropriate
disinfection. Some of these products now have limited antimicrobial
activity; however, they cannot be assumed to eliminate all classes of
microorganisms. After cleaning, the appliance is immersed in the cho-
sen disinfectant for a minimum of 10 minutes.
The porous nature of acrylic makes such devices difficult to disinfect
adequately. Given the tissue toxicity of glutaraldehydes and phenolics,
iodophors or chlorine compounds are preferred for disinfection of acryl-
ic appliances. Freshly diluted iodophor (povidone iodine), and chlorine-
based compounds (sodium hypochlorite 5.25%) are the disinfectants
most widely recommended for disinfecting those items. Because of the
porous nature of the acrylic, periodic disinfection of repair work after
grinding procedures is recommended. The clinician must be careful to

303
 rinse the appliance thoroughly with water prior to delivery.
The ADA recommends sterilization of removable prostheses by ex-
posure to ethylene oxide or disinfection by immersion in iodophors or
chlorine compounds. Although both of these disinfectants are some-
what corrosive, studies have shown little effect on chrome-cobalt alloy
with short-term exposures (10 minutes) to iodophors or 1:10 hypochlo-
rite.
Prostheses should never be stored in a disinfectant before insertion.
After disinfection and thorough rinsing, acrylic items can be stored in
diluted mouthwash until inserted.
Orthodontic appliances can be handled in a similar manner. Any
device that has been immersed in a disinfectant should be rinsed thor-
oughly before delivery to the patient.

Fixed Prosthesis
Fixed metal/porcelain prostheses are actually sterile following por-
celain firing/glazing, but if they are not handled aseptically after this
step, they must be disinfected before delivery to the patient.
Several clinical sources have confirmed that fixed prostheses may
be disinfected by short-term immersion in diluted hypochlorite without
apparent harm to the device. The higher the content of noble metal,
the less the likelihood of adverse effects on the metal. However, care
should be taken to minimize the exposure times of metals to potentially
corrosive chemicals.
Unglazed porcelain should not be exposed to any disinfectant; the
process of porcelain firing/glazing will sterilize the porcelain.
Fixed metal prostheses can be sterilized by autoclaving if desired.
Table 20 is a summary of the recommended disinfection protocols for
prosthodontic and orthodontic appliances.

304
Table 20
Recommendations for Disinfection of Prosthodontic and Orthodon-
tic Appliances
Accepted Disin-
Appliances Method Dilution Time
fectant
Sodium hy- 10
Immersion/ 1:10
Metal/acrylic pochlorite 5.25% minutes
spray until
All metal 10
wet Iodophors 1:213
minutes
Removable (acrylic/ Sodium hy- 10
1:10
porcelain) pochlorite 5.25% minutes
Removable (metal/
Immersion
acrylic) 10
Iodophors 1:213
Fixed (metal/porce- minutes
lain)
Never expose unglazed porcelain to any disinfectant

Source: Molinari and Harte [6]

Sterilization of Dental Impressions, Stone Casts, and

Dental Prostheses and Appliances
[82, 148-154]
Sterilization of impression materials; stone casts; and dental pros-
thesis and appliances have been recommended to minimize cross-
contamination in the dental facility. Although, there are few reports
about the effect of sterilization on these items. In addition to high-
temperature sterilization (e.g., autoclave), low-temperature sterilization
(e.g., hydrogen peroxide gas plasma, ethylene oxide gas, and immer-
sion in 2% glutaraldehyde for 10 hours) which is used for heat- and
moisture-sensitive devices have been suggested for sterilizing dental
impressions; casts; and dental prosthesis and appliances. Microwave
oven irradiation can also be used to sterilize rubber impression, gyp-
sum casts and acrylic prosthesis, and it has proved to be an effective
method. However, it might affect the porosity of the acrylic appliances.

305
 It has been shown that sterilization (using autoclave, ethylene ox-
ide gas, immersion in 2% glutaraldehyde for 10 hours, and microwave
radiation) reduces the reproducibility of rubber impressions. However,
the effect of microwave sterilization on both accuracy and wettability
was small. Furthermore, analysis of dimensional changes by another
study showed that casts made from impressions sterilized by ethyl-
ene oxide are acceptable for use in the construction of fixed or re-
movable prostheses. The drawback effects of autoclave sterilization
could be overcome by using ceramic trays rather than custom trays
and by spraying impression surfaces with surfactant before pouring the
gypsum mix. Glutaraldehyde still degraded dimensional accuracy even
with ceramic trays and surfactant.
When the effects of autoclave sterilization on dental elastomeric im-
pression materials (polysulfide, polyether, condensation silicone, addi-
tion silicone) were examined, the surface roughness and accuracy of
the impressions have been shown to be minimum with addition type
silicone impression materials. However, another study showed that the
accuracy of polyvinyl siloxane impression had been affected by ster-
ilization in a steam autoclave and it can be used for the fabrication of
diagnostic casts and some transitional prostheses, but not for routine
construction of crowns or fixed partial dentures.
At least one addition type polyvinyl siloxane impression material is
marketed as being autoclavable without affecting the impression repro-
ducibility when used in a rigid reinforced polycarbonate impression tray
or in a metal tray.

Communication with the Dental Laboratory

[6, 10, 155]
The dental practitioner should communicate with the dental labora-
tory regarding infection control procedures used in the dental clinic.
Communication and understanding can help to avoid duplication of ef-
fort and possible adverse effects on the materials. When a case is
transported from and to the dental clinic or dental laboratory, DHCP
should provide written information regarding the methods (e.g., type of

306
disinfectant and exposure time) used to clean and disinfect the mate-
rial (e.g., impression, stone model, or appliance); otherwise, the labo-
ratory or dental clinic should assume that the case is contaminated and
disinfect as appropriate.
If during manipulation of a material or appliance a previously un-
detected area of blood or bioburden becomes apparent, cleaning and
disinfection procedures should be repeated.
Transportation of contaminated items should be in a closed, leak
proof container which is either colored or identified with a biohazard
label. The CDC guidelines state that laboratory materials should be
cleaned and disinfected before being manipulated in the dental labora-
tory as soon as possible after removal from the patient’s mouth before
drying of blood or other bioburden can occur.
The American National Association of Dental Laboratories (NADL),
which has been instrumental in the development of infection control
protocols for dental laboratories, recommends disinfecting all items
received from the dental clinic and disinfecting all appliances before
shipping. NADL recommends that all items be shipped in heat-sealed
bags (to and from the laboratory).

307
 INFECTION CONTROL IN RESEARCH
ANIMAL FACILITIES

Zoonotic Considerations
[2, 156-157]
The presence of research animals in health-care facilities must be
accompanied by consideration for the potential transmission of zoonot-
ic pathogens (pathogens transmitted from animals to humans) in these
settings.
Zoonoses can be transmitted from animals to humans either directly
or indirectly via bites, scratches, aerosols, ectoparasites (a parasite that
lives on the exterior of its host), accidental ingestion, or contact with
contaminated soil, food, or water. Over 150 diseases may be classified
as zoonotic. Many of these diseases are of great concern and include
rabies, herpes B virus, tuberculosis, hepatitis, Q fever and cat scratch
fever. Table 21 shows examples of diseases associated with zoonotic
transmission from different animals which may be used in research
animal facilities. Such diseases often do not cause obvious signs and
symptoms in one species but may cause significant illness in another
species. Therefore, standard precautions should be applied and staff
members should follow safe work practices rigorously whenever work-
ing with animals, even though they may not show signs of illness.
Animals potentially can also serve as reservoirs for antibiotic-resis-
tant microorganisms, which can be introduced to the health-care set-
ting while the animal is present. Another potential source and mode of
transmission of zoonotic pathogens in health-care settings which must
be taken into consideration is colonization of the hands of health care
workers by pathogens acquired from pets in their homes.
Another health concern which must be considered in animal research
facilities is Laboratory Animal Allergy (LAA). Although not infectious in
origin, these reactions are significant and must be addressed because
they are among the most common conditions affecting the health of
workers involved in the care and use of research animals. Several spe-
cies of animals commonly used in animal research and teaching are

308
also species that frequently cause allergic reactions in people. Among
these species are the cat, rabbit, rat, mouse, and dog.

Table 21
Examples of Diseases Associated with Zoonotic Transmission+

Infectious disease Cats Dogs Rabbits Rodents

Viruses

Lymphocytic choriomeningitis +

Rabies + +

Bacteria

Campylobacteriosis + + +
Capnocytophaga canimorsus infec-
+ +
tion

Cat scratch disease (Bartonella

+
henselae)

Leptospirosis + +

Pasteurellosis + + +
Plague + +

Q fever (Coxiella burnetti) +

Rat bite fever (Spirrillum minus,

+
Streptobacillus monliformis)

Salmonellosis + + + +
Tularemia + + +
Yersiniosis + +
Parasites
Ancylostomiasis + +
Cryptosporidiosis +

309
 Giardiasis + +
Toxocariasis + +
Toxoplasmosis + +
Fungi
Blastomycosis +
Dermatophytosis + + +
+ This table does not include vectorborne diseases.
§ Rodents include hamsters, mice, and rats.
¶ The + symbol indicates that the pathogen associated with the infection has been isolated from
animals and is considered to pose potential risk to humans.

Source: adapted from Sehulster, et al. [2]

Administrative Considerations
[2, 156-157]
It is the responsibility of the principal investigator of each animal
care facility to approve a documented standard operating procedures
protocol which ensures that all workers under their supervision (co-in-
vestigators, staff, students and volunteers) handling animals or unfixed
animal tissue in the research laboratory are informed of the potential
dangers involved in contact with animals or unfixed animal tissue, and
are aware of the procedures available to prevent and treat such haz-
ards.

The operational protocol should include:

1. Training of animal handlers to recognize the signs and symp-
toms related to the zoonotic diseases that could potentially be
transmitted by the species of animals used in the facility.
2. Animal handling and how to work safely with animals.
3. Daily animal husbandry (e.g., protection of the employee while
facilitating animal welfare).
4. Management, cleaning, disinfecting and/or sterilizing equip-
ment and instruments.

310
 5. Employee training for laboratory safety and safety procedures
specific to animal research worksites.
6. Spill cleanup, and waste management.
7. Management of injuries.
In addition, established College of Dentistry infection control and
safety guidelines should be incorporated in the protocol as minimum
standards for personal protection, engineering controls, work-practice
controls, disinfection and sterilization.
The operational protocol should also include a clear policy regard-
ing vaccinations and routine testing of workers. The policy must be
approved by a certified veterinarian, and must address:
1. The availability of pre-exposure vaccines.
2. The need for routine tuberculosis testing.
3. Baseline serums.
4. Hearing and respiratory testing.
5. The need for pre-contact and post-employment testing.
6. Treatment to be provided for symptoms or injuries related to
animal allergens, bites, scratches, or other animal hazards.
7. An exposure incident report (formulated by the appropriate
health officials).
It is the responsibility of the principal investigator in a research facil-
ity (Director of the Research Chair) to ensure appropriate employee oc-
cupational health services are available to workers in the facility. Health
programs specific to the animal research facility must be established,
and management of postexposure procedures specific to zoonoses
must be coordinated with the occupational health service. All neces-
sary vaccinations, examinations, and treatment related to occupational
zoonoses must be provided to the employees by the health service.
Any employee who has an autoimmune disease (no matter how well
managed) or is taking immune suppressing medications or is pregnant
or planning conception should inform the occupational health service

311
 physician in order to analyze the specific medical concerns for the em-
ployee in relation to the workplace hazards so as to make recommen-
dations for accommodating the employee.
The standard operating procedures protocol must be disseminated
to all workers. New workers must be made aware of the contents of the
document before commencing work in animal facilities.

Engineering Controls
[2, 156]
All animals facilities should have proper ventilation achieved through
appropriate facility design and location. Animal rooms should be kept at
negative pressure relative to the surrounding corridors. The air should
be expelled to the outside environment, not recirculated through the
facility. The doors to animal research rooms should be kept closed and
access to animal facilities restricted to essential personnel.
When there is a very high potential for aerosol generation, addi-
tional facility related engineering controls such as sealed penetrations
through the walls, double door access to the rooms, or installation of
high efficiency particulate air (HEPA) filters in the exhaust air system
may be necessary. A facility can also apply engineering controls lo-
cally in the form of containment devices to reduce aerosol spread. All
devices and filters need to be certified and leak tested annually. When
applicable, biological safety cabinets may be used to provide near ster-
ile work environments that offer protection to the worker, the materials
they are manipulating, and the work area itself.
To maintain facility safety, the director should also review the re-
search protocols and, based on the anticipated procedures and risks,
the necessary engineering controls should be made available to con-
form with Infection Control Guidelines of the College of Dentistry (see
section Engineering Controls).

Animal Quarantine and Stabilization

[2, 156]
Only animals obtained from quality stock should be used or incom-

312
ing animals should be quarantined to detect zoonotic diseases. Quar-
antine is the separation of newly received animals from those already
in the facility until the health of the animal has been evaluated. The
quarantine period should be of sufficient duration to allow expression
of diseases present in the incubation stages. Some or all of the follow-
ing should be achieved during the quarantine and stabilization period:
diagnosis, control, prevention, and treatment of diseases; physiologi-
cal and nutritional stabilization; and grooming to include ectoparasite
control. All sick animals should be treated or removed from the facility.
Animals in which no disease has been detected should have routine
prophylactic vaccinations and kept under the regular care of a trained
person and a veterinarian.

Staff Considerations
[2, 10, 156-157]
Access to the laboratory or animal facility should be limited to ani-
mal-care staff, researchers, environmental services, maintenance, and
security personnel. All people with access to the facility must be ad-
vised of the potential risks. Immunocompromised persons or those for
whom infection might be unusually hazardous should not have access
to the animal room.
Personnel within the facility should always wear personal protective
equipment (PPE) (at the minimum: laboratory coat, gloves, mask and
eye protection or face shields) when working with animals. The labora-
tory director must ensure the appropriate PPE for the tasks performed
within the lab are provided.
In addition to protecting against splashes and spatters and provid-
ing protection for eye and mucus membranes, proper use of PPE can
greatly reduce the allergenic effects of animals in sensitive persons.
In addition, use of PPE can prevent sensitization in someone who is
not originally allergic to laboratory animals. All PPE (including lab coat)
must be removed before leaving the animal housing area.
Lab coats and other PPE should be removed before leaving the animal
housing area, and should be changed whenever damaged or visibly soiled.

313
 Work Practices and Procedures
[2, 156-157]
The laboratory and animal rooms should be posted with hazard
warning signs incorporating the following:
1. Universal biohazard symbol.
2. A list of the animals in use.
3. The personal protective equipment to be worn in the room.
4. Special required practices.
5. The names and phone numbers of persons to contact in case
of emergency.
There should be no eating, drinking, or smoking in areas where ani-
mals are used. Food must be stored in a separate refrigerator main-
tained for this purpose only and located outside of the area where
animals are used or housed. Handling contact lenses and applying
cosmetics should also be avoided in laboratories, as well as any other
activities that might involve hand-to-mouth or hand-to-eye contact.
When handling animals, standard precautions and the aseptic tech-
nique should be observed at all times. Work-practice controls should
be used as applicable to the specific tasks (for examples see section
Work-Practice Controls). Contact with animal saliva, dander, urine, and
feces should be minimized as much as possible. Staff members should
perform all manipulations of potentially infectious materials so as to
minimize aerosol production.
All work surfaces must be decontaminated after any animal use and
at the end of the workday. Environmental surfaces should be cleaned
thoroughly and disinfected by using an appropriate cleaner/disinfectant
(see sections Environmental Infection Control and Chemicals Used for
Disinfection and Sterilization in Dentistry).
Contaminated materials which will not be decontaminated in the
laboratory itself must be placed in containers that are both leak proof
and durable before they are removed from the laboratory. Disposable
equipment should be used whenever possible. Reusable instruments

314
that come in contact with the animal must be sterilized. Instruments
which have been used on animals should be restricted in future use to
animals only.
Careful hand washing must be done after handling animals , after
removing gloves or other PPE, and prior to leaving the laboratory, pro-
cedure room, or animal room for any reason.

Exposure Incident
[2, 156-157]
In case a worker experiences any of the following:
• Being bitten or scratched while working with an animal
• Experiencing signs and symptoms consistent with a work
related exposure to an animal or an infectious organism being
studied
• Known exposure to a zoonotic disease
• Scratches, bites, or other breaks in the skin,
the skin should be cleaned and treated immediately, and the ap-
propriate action must be taken as described in the standard operating
procedures protocol approved by the appropriate occupational health
service.
The incident must be reported to the lab supervisor and to the infec-
tion control officer. the exposure incident report must be filled out by
the worker or his/her supervisor and signed by both. The supervisor
or director must then arrange for immediate medical evaluation, treat-
ment, and subsequent surveillance as needed. All records of the inci-
dent and subsequent tests and clinical examinations must be provided
to the infection control officer.
At-risk personnel should inform supervisors of any febrile illness as
part of ongoing surveillance for potential laboratory associated infec-
tions. In addition, the director should maintain appropriate written re-
cords of all unintentional releases, spills, and exposures to biohazard-
ous materials.

315
 CENTRAL STERILIZATION AND SUPPLY
DEPARTMENT (CSSD)
Location and Design of the CSSD
[10, 17, 108]
Cleaning and sterilization of instruments should be carried out in
a designated area, the Central Sterilization and Supply Department
(CSSD) away from the clinic environment. The location and design of
the CSSD must be carefully planned in order to facilitate maintaining
strict standards of instrument sterilization and environmental infection
control. Entry to the CSSD should be restricted to authorized staff only.

Location of the CSSD

The CSSD should be easily accessible for clinical staff; but it must
be in a low-contamination area away from common walkways or traffic
flow. There should be a designated changing area in close proximity to
the CSSD for staff changing into work attire.
The CSSD should be separated from the external environment; no
doors should open onto the outside of the building and, if windows are
present, they should not be opened. This separation is to protect the
CSSD from dust and other external elements.

Workflow Pattern
The CSSD should be separated into four areas. These areas (from
the highest contamination to the lowest contamination) are:
1. The decontamination area.
2. The packaging area.
3. The sterilization area.
4. The storage area.
These areas should be physically separated from each other by
walls (with connecting doors or windows) or partitions in order to re-
duce the risk of re-contamination of processed items and devices (Fig-

316
ure 3). The CSSD should have separate receiving and issuing windows
physically separated from each other. The receiving window should be
located in the decontamination area while the issuing area should be
located in the storage area.
Figure 3
Figure 3
Diagrams of Recommended CSSD Work-Flow Patterns
Diagrams of Recommended CSSD Work-Flow Patterns
!

Receiving � � Issuing

DECONTAMINATION

STERILIZATION

STORAGE
.

and

PACKAGING

U- shaped workflow pattern

Receiving STERILIZATION Issuing

DECONTAMINATI
� ON
PACKAGING and
STORAGE!
�

Linear workflow pattern

Personnel staffing one area should not cross over to the other area
and back. The floor plan of the CSSD should allow transport of the
processed items from one area to the next without the need for staff to
exit their station. Once a staff member from a lower contamination area

317
 enters a higher contamination area, they must not return to the lower
contamination area without removing all personal protective attire and
washing hands well.
Furthermore, trays or containers used to transport items from one
area to another must be considered to be of the same degree of con-
tamination as the items they contain. They must be processed in the
same way the items are and should never go against the traffic flow of
the processing; i.e. they should never go from areas of low contamina-
tion to areas of high contamination. Such containers should be steril-
ized before being used again, but do not need to be packaged prior
to sterilization. After sterilization, they must be stored in clean, closed
cabinets or drawers in the storage area. Although they are not consid-
ered sterile (because they are not in sealed packages), they may thus
be considered clean, and may be used to transport packaged sterile
items from the CSSD to the clinics.

Design of the CSSD

The following features must be available in CSSDs:
1. Sufficient size to accommodate all of the devices, accessories,
cabinetry, storage areas, and personnel necessary for the con-
venient flow of the work while maintaining adequate separation
of the different work areas (see Workflow Pattern).
2. Good ventilation and air conditioning to control the heat gener-
ated by the sterilizers and other machines as well as for elimi-
nation of chemical fumes (see Section Heating, Ventilation, and
Air Conditioning Systems in Health-Care Facilities).
3. An uncontaminated work station for office work and documen-
tation.
4. Flooring of materials which are seamless, smooth, non-porous,
non-slip, scrubbable, non-adsorptive, non-perforated, and ca-
pable of withstanding repeated cleaning with harsh chemicals.
The surface of the floors should be self-finishing and require no
protective coating for maintenance. The flooring material should
be medical grade vinyl for the packing and storage area. Floors

318
 of decontamination area may be of epoxy or vinyl.
5. Ceiling of packing area and sterilization and storage areas
should be a single seamless surface, not squares, non-perfo-
rated, and amenable to cleaning. The ceiling is preferable to be
of medical grade stainless steel.
6. Walls and countertops of highly polished, non-porous, scrub-
bable, non-adsorptive, non-perforated, seamless surfaces re-
sistant to heat, chemicals, and moisture so as to be amenable
to repeated washing and/or disinfection with harsh chemicals.
7. Antibacterial paint for walls of the decontamination area.
8. Countertops and cabinetry of adequate size and space to ac-
commodate table-top devices and other work items.
9. Moisture-resistant cabinetry.
10. Multiple electric outlets.
11. Multiple water lines for the various sinks, washers, and steril-
izers. The water quality should be such that the total dissolved
solids is less than 20.
12. Floor drains placed in the area of highest contamination risk.
13. Hands-free controlled handwashing sink, trash receptable, dis-
pensers for soap and disinfectant solutions, and paper towels
in each area, as well as adjacent to the receiving window on the
outside of the CSSD.
14. An eye rinse station and an ER kit for management of percuta-
neous injuries in each area.
15. Closed storage areas of adequate size and number to accom-
modate the various sizes, types, and number of items to be
stored in the CSSD. Storage areas must be closed from all
sides to protect the sterilized packages from the surrounding
environment.
16. Storage facilities for bulk items should be provided external to,
but near to, the designated CSSD.

319
 17. Conveniently positioned hands-free trash receptacles in each
area.
18. A set of housekeeping cleaning items (towels, mops, contain-
ers, etc.) for cleaning of work surfaces and housekeeping sur-
faces should be available in each area; these cleaning items
should be stored in an isolated cabinet.
19. Required personal protective equipment should be easily ac-
cessible in each of the work areas.

The following are other features specific to the different CSSD areas:
1. The Decontamination Area:
The decontamination area should contain waste containers (bio-
hazardous and regular) and sharps disposal containers near the entry
point of the received items. Instrument processing sinks, holding solu-
tions, ultrasonic cleaners, and washers/thermal disinfectors (along with
the necessary detergents, disinfectants, towels, and brushes, contain-
ers and baskets) should also be placed in this area. The sinks should
be large, deep, and with hands-free controls. Sink and water controls
must both be of a surface resistant to moisture and chemicals.
Air and water lines should be available for running handpieces dur-
ing cleaning and lubrication.
Access to the decontamination area is preferably through dedicated
changing rooms provided with hand hygiene facilities and lockers.
2. The Packaging Area:
The packaging area should contain the packaging materials, heat
sealers, sealing (autoclave) tape, chemical indicators, biologic indica-
tors (see Sterilization Monitoring), as well replacement instruments,
burs, and instrument cassettes (for replacement of defective or missing
items in functional sets). Gauze pads and rust inhibitors should also be
available in this area. Lubricants should be available, as well as air and
vacuum lines, for running handpieces during cleaning and lubrication,
if necessary.
Access to the packaging area is preferably through dedicated chang-

320
ing rooms provided with hand hygiene facilities and lockers.
3. The Sterilization Area:
The sterilizing area should contain the sterilizers and necessary
accessories. The incubators for biological monitoring should also be
placed in this area.
This is considered a “clean” area, therefore, contaminated transport
trays or containers and sealed packages ready for sterilization should
be transported from the packaging area directly to the interior of the
sterilizer chambers without contacting any of the surfaces in this area.
Contaminated gloves, transport containers, and packages should
not contact any countertop, table, wall, or other surface in this area. If
the outer surface of a sterilizer becomes inadvertently contaminated, it
must be disinfected immediately with an appropriate surface disinfec-
tant.
4. The Storage Area:
The storage area should be an environmentally controlled area
which contains the closed storage cabinets, drawers, or slots in which
the sterilized instruments are kept until needed. If possible, clean sup-
plies and instruments should also be stored in closed or covered cabi-
nets. Processed items should not be stored under sinks or near sharp
edges or in other locations where they might become wet or torn (see
Storage and Shelf-Life for details).
A hand-washing sink, a regular waste container, and a set of house-
keeping cleaning items must be available in this area also.

CSSD Staffing and Attire [108]

The staff put in charge of operating this department should be
trained in the proper methods of cleaning of items, packaging, steril-
ization, process monitoring, and management of sterilized items such
that a standardized quality of sterilization is provided for all the clinics.
The CSSD should have a sufficient number of staff such that each step
of the processing sequence may be performed by a designated staff
member(s).

321
 Personal protective attire must be worn by CSSD staff to protect
against chemical and biological hazards. The following protective at-
tire must be worn by staff in the respective areas of the CSSD (for
specifications, see section on Personal Protective Equipment). Staff
who are involved in the maintenance of decontamination equipment
should be required to wear the same type of clothing.

The Decontamination Area

The protective attire to be worn by staff in this area should include
well-fitting puncture-resistant, heavy-duty utility gloves to prevent inad-
vertent percutaneous injury or contact with chemicals; face mask and
protective eyewear or face shield; a head cover, and a long-sleeved
gown or jacket should be worn. Hair should be entirely covered by the
head cover.
Shoes designated for use in this area should be considered as part
of the protective attire and should be non-slip, enclosed footwear that
are sufficiently robust to protect feet from injury or contact with sharp
objects (e.g. if sharps are dropped accidentally). Shoes that are made
from canvas or cloth material are unsuitable and should not be worn.
Shoes worn in the decontamination area are considered part of the
protective attire and should not be worn outside the work area. Or,
alternatively, disposable shoe covers may be worn over street shoes
when entering this area and removed when leaving.

The Packaging Area

Staff in this area must also wear a head cover, long-sleeved gown,
well-fitting puncture-resistant utility gloves, face mask, and eye or face
protection to protect against percutaneous or permucosal injury.

The Sterilization Area

Staff in this area need to wear gloves and a mask when transport-
ing the processed trays and packages to the inside of the sterilizers.
However, when monitoring the sterilizers and handling sterilized items,
gloves should not be worn.

322
 For all CSSD staff, protective attire should be changed daily or
whenever it becomes visibly soiled or wet. Staff should never leave the
CSSD or their respective work areas wearing the protective attire. All
protective attire must be removed and hands washed before leaving
the work area.
After removal, disposable attire should be discarded in the waste
receptacles. Reusable attire should be placed within the dirty laundry
receptacle in the changing rooms. The used attire should be sent for
laundry every day.

Environmental Disinfection of the CSSD [108]

Work surfaces (including sinks) must be cleaned and disinfected
daily at the end of the workday, and whenever necessary, with an inter-
mediate-level disinfectant using the spray-wipe-spray technique. Floors
must be wiped with an appropriate low-level disinfectant at the end of
the work day also (see Chemicals Used for Disinfection and Steriliza-
tion in Dentistry). The storage drawers and cabinets in the storage area
should be cleaned weekly with a low-level disinfectant (see Chemicals
Used for Disinfection and Sterilization In Dentistry). And each section
should be thoroughly cleaned annually. Air vents and filters should be
cleaned and serviced regularly.
Environmental cleaning procedures and schedules adopted must
ensure that contamination from dirty areas does not contaminate the
clean areas. Separate cleaning equipment should be used for the
different areas of the CSSD, and the equipment should be regularly
cleaned and maintained.
If spillage of contaminated solutions or material occurs, it must be
cleaned as described in Management of Spills. If gross debris is present
on the floor and washing is indicated, the flow of the washing solution
should be from the cleanest area to the dirtiest (the floor drain should
be in the area with the highest contamination risk). Housekeeping items
used for cleaning one area should not be used for another area.

323
 Presterilization Cleaning
[2, 5, 10, 98, 100, 108, 116]
By definition, sterilization is a procedure to destroy all microorgan-
isms- including viruses, bacteria, fungi, and spores.
According to their uses and potential risk for transmission of infec-
tion, instruments, devices, and equipment are classified as critical,
semi-critical, or non-critical.
Critical instruments are surgical instruments and those instruments
that penetrate soft tissue or bone (e.g. forceps, scalpels, bone chisels,
scalers, burs). Critical instruments should be sterilized after each use.
Semi-critical instruments are those that do not penetrate soft tissues
or bone but contact oral tissues (e.g. mirrors and amalgam condens-
ers) or non-intact skin. Semi-critical instruments, also, should be steril-
ized after each use.
Non-critical instruments are those that contact only intact skin (e.g.
external components of x-ray tubes). Such items may be disinfected
between patients with a low-level disinfectant. If, however, the surface
of the item is visibly soiled with patient material, then it must be disin-
fected with an intermediate-level disinfectant (i.e. one with a tubercu-
locidal claim). Pre-cleaning with a detergent before disinfection may be
necessary depending on the type of disinfectant used (see Chemicals
Used For Disinfection and Sterilization in Dentistry).
Cleaning or disinfection of certain non-critical patient-care items can
be difficult or may cause damage to the surfaces; therefore, barriers
should be used to protect these surfaces whenever possible.
Single use disposable instruments are not intended or designed to
be cleaned, disinfected, or sterilized (e.g. some prophy angles, cups,
brushes, saliva ejector tips, and air-water syringe tips). Therefore they
should be used once and discarded; they should not be “sterilized” or
“disinfected” and reused.
Contaminated items must be properly prepared before they are
sterilized to ensure the maximum benefit is obtained from the steriliza-

324
tion cycle. After being used, items must be adequately cleaned, rinsed,
dried, properly packaged, and sealed before being placed in a steril-
izer. New critical and semi-critical patient care items should also be
sterilized before being used to treat patients for the first time.
Cleaning should remove all visible soil, dirt, dust or other foreign
material. The presence of debris, especially if organic in nature, may
compromise or interfere with the sterilization process. Therefore, instru-
ments should be thoroughly cleaned of contamination prior to packag-
ing and sterilization.
If contaminated items will not be cleaned immediately, they must
be soaked in a holding solution, in a puncture-resistant container, to
prevent drying out of the dirt and debris and to make cleaning easier
and more effective . However, some plastic/resin cassette manufactur-
ers do not recommend presoaking, so the manufacturer’s instructions
must be followed, and such items must be cleaned immediately to pre-
vent drying out of the debris. Furthermore, extended presoaking for
more than a few hours is not recommended because this may enhance
corrosion of some instruments.
The holding solution used for presoaking should be a detergent, or
an enzymatic cleaner, or a surfactant (a chemical which reduces the
surface tension of surfaces of items increasing the wetting of the item
by the surrounding solution) . A disinfectant with no surfactant proper-
ties should not be used as a holding solution as some disinfectants co-
agulate proteins (found in patient debris) which makes cleaning more
difficult as well as making it more difficult for the sterilizing agent to
reach the embedded microorganisms . Use of solutions with fixative
and toxic natures such as chemical sterilant/high-level disinfectants, for
example gluteraldehyde, as a holding solution is not recommended.
During presoaking, loose instruments should be placed in a perfo-
rated basket in the holding solution in order to reduce direct handling
of sharp instruments. The presoaked instruments and holding solu-
tion must be considered contaminated. The holding solution must be
changed at least once a day (or earlier if visibly soiled).
During cleaning, care must be taken to minimize the amount of

325
 splashing of contaminated solutions. After cleaning, adequate rinsing
of the items to remove the cleaning solution before sterilization must
be ensured as any chemical residue may damage the surface of items
when they undergo the sterilization process . Rinsing and drying of
items should not be performed with high-velocity water or air spray;
such sprays lead to spatter and aerosolization and subsequent spread
of microorganisms.
Contaminated items must be handled with caution to avoid percu-
taneous injury. DHCP should wear puncture-resistant, heavy-duty util-
ity gloves when handling contaminated items. Because splashing is
sometimes unavoidable, a mask, protective eyewear or face shield,
and gown or jacket should also be worn. Operators should not reach
into holding solutions holding sharp instruments that cannot be seen.
Work-practice controls should include use of a strainer-type basket to
hold instruments and forceps to remove the items . Also, used instru-
ments should be transported in a rigid or puncture-resistant container.
Regardless of the cleaning process used, when cleaning and drying
of the items is complete, all the cleaned items must be transferred to
the packaging area immediately to avoid inadvertent confusion with the
unclean items.

Cleaning Methods
[5, 10, 98, 105, 108]
Cleaning may be done either by:
a. use of an ultrasonic cleaner,
b. use of a specially designed washing machine/ thermal disinfec-
tor, or
c. scrubbing with a detergent/surfactant and brush under running
water.
Cleaning should be automated whenever possible, because auto-
mated cleaning is more validated, more easily controlled, more efficient,
and decreases the risk of percutaneous injury and exposure of staff
to potentially infective material. Washing machines are the preferred

326
method of cleaning instruments, but an ultrasonic cleaner should be
used for pre-treatment of those items which are required to be cleaned
by this method according to the manufacturers’ instructions. Manual
scrubbing of contaminated items with a brush is the least preferred
method for cleaning of instruments. However, if necessary, manual
cleaning may be used if the necessary precautions are taken, and only
following pre-treatment in an automated cleaner.

Ultrasonic Cleaning
An ultrasonic cleaner should be provided for pre-treatment of those
items which are required to be cleaned by this method according to the
manufacturers’ instructions.
Not all items are amenable to ultrasonic cleaning; plastics and other
similar materials cannot be successfully processed by this method.
Chrome-plated items should also not be placed in the unit because the
mechanical vibrations can cause the plating to flake. Therefore items’
manufacturer’s instructions must be referred to in this regards. Fur-
thermore, items made of different metals should not be combined in
the ultrasonic cleaner in order to avoid ion transfer which may cause
etching and pitting of the items.
During operation, the cleaner must be covered with its lid to prevent
aerosolization of the contaminated contents into the workplace. There-
fore, preferably, the ultrasonic cleaner should be fitted with a lid which
is interlocked to prevent operation of the ultrasonic cleaner when the
lid is open.
Solutions used with this type of cleaner should be cleaning or enzy-
matic solutions specified for ultrasonic use to ensure they possess the
necessary surfactant property required for adequate cleaning of the in-
struments. Mere disinfectants are not sufficient if they do not have sur-
factant properties. Items should never be placed directly onto the base
of an ultrasonic washer or contact the walls; they should be placed in
an appropriate basket designed for the ultrasonic cleaner.
The ultrasonic cleaner should be operated according to the manu-
facturer’s instructions.

327
 It must be remembered that after ultrasonic cleaning, the instru-
ments are still contaminated. Also, the cleaning solution will be con-
taminated with live microorganisms. Thus ultrasonic cleaners should
be labeled with a biohazard label as well as a chemical label (because
of the chemical solution).
The ultrasonic cleaner should be tested when first purchased and,
afterwards periodically, to assure that it is operating properly. Testing
should also be conducted whenever there is reason to suspect a de-
terioration in the cleaner performance (such as if longer times become
necessary to remove soil, following repair, and following periods when
the cleaner has not been in use). The manufacturer’s recommended
testing procedure should be followed. In the absence of manufacturer
recommendations, the Foil Test should be used (see separate docu-
ment on Infection Control Policy and Procedures).

Washers-disinfectors
Choice of Washer:
Washing machines are the preferred method of cleaning instru-
ments prior to sterilization. However, only washers-disinfectors cleared
for use with medical devices should be used; household dishwash-
ers should not be used. The washing machine should be a washer-
disinfector which runs a washing cycle with detergent followed by a
thermal disinfection cycle and a drying cycle. All autoclavable patient
care items may be safely processed with a washer-disinfector.
Source Water:
Source water for the washer should be compliant with the manufac-
turer’s recommendations. Hard water should not be used with washers
because deposition of lime-scale on the washer components impairs
its performance. Furthermore, using hard water in the thermal disinfec-
tion and final rinse stages is one of the major causes of white powdery
deposits on load items. These deposits act as a focus for soiling and
recontamination of the item in use. In some applications (e.g. with opti-
cal systems) such deposits may seriously impair the utility of the item.
The temperature at which water is supplied to each stage of the

328
process has a major effect on the efficacy of the process. Water at
too high a temperature during the initial flushing stage may lead to
the coagulation of proteins and thus serve to “fix” proteinaceous soil
to the surface of the load items. The initial flushing stage should be
supplied with water from a cold supply so the temperature does not ex-
ceed 45°C. When enzymatic cleaners are used the water temperature
must be maintained close to the optimum temperature specified by the
manufacturer; too high a temperature will inactivate the enzymes.
Ionic contaminants in the water must be regulated because they
may react with materials such as stainless steel. Therefore, the wa-
ter supply used for washers should have a chloride concentration less
than 120 mg/l Cl- to minimize the risk of corrosion. Heavy metal ions
such as iron, manganese, magnesium, copper, or silicates present in
the water may cause tarnishing of stainless steel items. Total dissolved
solids should be checked with conductivity meter.
The microbial population in the water used in the washer-disinfector
particularly in the final rinse stage of process cycle should not increase
the bioburden of the load items. Water with < 100 cfu/ml is suitable for
the final rinse stage. Bacterial endotoxins are not readily inactivated at
the temperatures used for disinfection or sterilization. Therefore, when
the washer is being used to process surgically invasive items, water
used for the final stages of processing should not contain more than
0.25EU/ml.
Operation of Washer:
When placing items in a washing machine they should be placed
in a manner which ensures effective cleaning; all surfaces should be
exposed to the action of an automated cleaner. Overloaded baskets
will result in ineffective cleaning, therefore items should not be bundled
tightly together or placed one on top of the other.
When lumened devices (e.g. handpieces, high volume evacuators,
stainless steel suction tips) are being washed, the washer/disinfector
should be provided with load carriers that permit the irrigation of the
lumen. Jointed items should be processed in the open position. Sharp
items should be placed separately from other items in order to facilitate

329
 ease of identification after cleaning and prevent sharps injury.
With single-ended washer-disinfectors (washers with only one door),
care must be taken during insertion and removal of items to ensure ad-
equate segregation of processed from unprocessed items.
If a washing cycle is aborted for any reason, the incident should be
noted in a log book, along with the reason for termination of the cycle,
and any corrective action taken.

Manual Cleaning
Manual scrubbing of contaminated items with a brush is the least
preferred method for cleaning of instruments, and is strongly discour-
aged, because it increases the risk of injury to personnel by the con-
taminated items, and because of the amount of spatter and aerosoliza-
tion that might result. However, if necessary (e.g. if cleaning devices
failed to remove debris), hand scrubbing may be used if the necessary
precautions are taken, and only following pre-treatment in an automat-
ed cleaner.
Scrubbing should be done with a detergent or surfactant, and water.
When scrubbing items, heavy duty utility gloves should be worn, and
a long handled brush used. To reduce the amount of spatter, scrub-
bing should be done near the base of a deep sink with the instruments
soaked in a container and under running water.
In order to ensure consistent quality of manual cleaning, the vari-
ables that affect the manual cleaning process should be controlled as
much as possible in the following way:
1. Staff training/competence. Staff must be trained in a systematic
method of cleaning.
2. Water temperature. The temperature of the water used for
manual cleaning should be optimum and consistent throughout
the year.
3. Detergent concentration. The concentration of the detergent
used must be optimal and consistent.
4. Nature of debris. Different types of debris require different pre-

330
 soaking and scrubbing times. These times should be standard-
ized for the different types of debris.
If either the cleaning solution or rinse water becomes visibly soiled
or contaminated, it should be changed and the process repeated. After
manual cleaning, the brushes, detergent container, and sink should be
cleaned, disinfected, rinsed, and allowed to dry.
When drying the washed instruments, they should be allowed to
air-dry or be carefully patted with thick towels. Instruments should not
be rubbed or rolled in the towel as this increases the risk of accidental
injury.

Drying and Lubrication [5, 108]

After cleaning, items must be dried well before packaging because
water on the surface of items may interfere with the sterilizing agent
(e.g. steam or heat) reaching the items, or may cause tearing of the
paper wrapping material. After drying, non-stainless steel instruments
should be treated with a rust inhibitor.
A washer-disinfector with a drying cycle is the preferred method of
drying. If items cannot be processed in the washer-disinfector, manual
drying should be done using a clean disposable lint-free, absorbent
wipe, taking care to prevent percutaneous injury. If manual drying
is performed, items should be dried in a sloping position to facilitate
drainage.
Before packaging, burs and other carbon steel instruments may be
sprayed with a rust inhibitor or a small piece of gauze may be added
into the pack to absorb the excess moisture during steam sterilization.
Items which need to be lubricated prior to sterilization should be lubri-
cated at this point. Excess lubricant, however, should be removed prior
to packaging.

Preparation of Handpieces, Motors, and Couplings

[10, 95-96, 98, 108, 111, 116, 158]
New handpieces (including scalers) should be sterilized before be-
ing used for patient treatment for the first time. Also after treatment of

331
 each patient, the handpiece must be heat sterilized in an autoclave.
Studies have indicated that the inner surfaces of high-speed handpiec-
es and prophy-angles may become contaminated with patient material
during function. The only effective way of cleaning the lumen of a den-
tal hand-piece is to process it through a washer-disinfector with each
lumen connected to a flushing system.
Furthermore, restricted physical access to the internal surfaces of
the handpiece limits sterilization with chemicals; therefore, handpiec-
es must be heat sterilized between patients. Surface disinfection or
immersion in high-level disinfectants is insufficient to adequately and
safely process such devices.
When choosing the method of cleaning of handpieces or any de-
vice which enters the oral cavity, the instructions of the manufacturers
of both the handpiece and the cleaning device must be adhered to.
Failure to do so may result in failure of sterilization or damage to the
handpiece or both.

Inspection [10, 108]

After items are cleaned and dry, the used washer–disinfector and
the processed items must all be inspected for validation of the cleaning
process before the processed items are packaged. The area where in-
spection takes place should be designated and controlled to minimize
contamination of the processed items.

Inspection of Washers-disinfectors
A typical cycle comprises the following phases:
a) cold rinse,
b) warm wash,
c) rinse,
d) disinfection rinse, and
d) drying.
On completion of the washing cycle, it must be ensured that all pro-

332
cessing stages and parameters have been achieved. The effectiveness
of the washing-disinfection process cannot be verified by inspection or
testing of the processed items only; it can only be guaranteed if correct
conditions are created throughout the washer-disinfector chamber and
the load during every cycle.
The chart record for the cycle should be checked to ensure that all
recorded variables are within the parameters permitted and in accor-
dance with the specification for the load used. The rotation of the arms
should be checked. If arms do not rotate, loads should be rejected as
the load has not been exposed to the water spray effectively.
All documentation for automated cleaning should contain the follow-
ing information:
1. Washer-disinfector identification number.
2. Cycle number.
3. Type of washer-disinfector.
4. Type of cycle used.
5. Date and time of start of cycle.
6. Critical parameters for the specific washer disinfector cycle.
a. Temperature.
b. Time.
c. Enzymatic detergent concentration.
7. Results of washer-disinfector process (pass- fail).
8. Any notes or observation for the process cycle.
9. The identification and signature of responsible person confirm-
ing whether or not the process cycle was within recommended
parameters.
10. Aborted cycles should be noted in a log book, along with the
reason for termination of the cycle, and any corrective action
taken.

333
 Inspection of Processed Items
The processed items should be inspected to ensure they are dry, and
there is no obvious damage, staining or residue. Any patient care item
which needs maintenance or lubrication should be serviced at this stage.
If the load is damaged, this may be due to the configuration of the
load, i.e. rotating arm may be hitting off the items being processed, or
the items may not be compatible with automated washing. If staining
and/or residue are present, this may be due to the configuration of the
load, overloaded cart or malfunction in the washing cycle.
If a load is not properly cleaned, the entire load is rejected and re-
turned for re-cleaning. Any load or items rejected as unclean should be
documented as a non-conformance; this non conformance should also
be documented into the washer-disinfector log book for further investi-
gation by the relevant maintenance personnel.

Packaging
[5-6, 10, 82, 108, 116]
Pre-sterilization packaging ensures sterility of the items is main-
tained until the package is opened. Therefore, instruments that will not
be used immediately after sterilization should be wrapped or bagged
before sterilization in a material recommended by the manufacturer of
the sterilizer.

Selection of Packaging Material

Materials used for packaging should comply with European stan-
dards EN ISO 11607-1 and EN ISO 11607-2, 2006 and EN 868 parts
2-10, inclusive, or should be FDA- cleared.
The packaging material must be specified for the particular steril-
ization method used, and must allow the sterilization process to affect
the contents of the sealed package while adequately maintaining their
sterility during transport and storage. It must also facilitate the aseptic
technique at all times, including opening of package. Suitable materi-
als for packaging used with steam autoclaves include wrapped perfo-

334
rated instrument cassettes, peel pouches of plastic or paper, and paper
wraps. Unsuitable materials for use with steam autoclaves are closed
metal (unless proven otherwise by biological monitoring) or glass con-
tainers, thick cloth, and some plastic containers.
Packaging material used with steam autoclaves must be designed
for such use , and must conform to the following :
1. Maintain integrity of the pack through the following:
a. Provide adequate seal integrity.
b. Provide an adequate barrier to particulate matter and flu-
ids.
c. Be resistant to punctures, tears and other damage which
may break the barrier and cause contamination
d. Resistant to penetration by micro-organisms from the sur-
rounding environment.
e. Free of holes, tears, or flaws.
2. Be compatible with and able to withstand physical conditions of
steam autoclaving.
3. Allow penetration and removal of steam.
4. Permit use of material compatible (i.e. non-degradable) with
the sterilization process.
5. Be used according to the manufacturers’ instructions.
6. Be free of toxic ingredients.
7. Low-linting (wrapping material).
8. Tamper proof and able to seal only once.

Storage of Packaging Materials

Packaging materials should be stored at a temperature of 18ºC to
22ºC and at a relative humidity of 35% to 70% in order to maintain the
integrity of the product. They should be stored on shelves and not on
the floor or adjacent to external walls or other surfaces which may be

335
 at a lower temperature or a higher temperature than the ambient tem-
perature of the store room.
The packaging material stock should be rotated to ensure it does
not exceed its shelf life.

Process of Packaging
Items may be packaged in functional sets or individually, according
to their uses. Packing of items individually (e.g. handpieces) is recom-
mended whenever practical in order to avoid repeated sterilization of
unused items. Burs are best packed individually to prevent contamina-
tion of large numbers of burs once a container is opened. To minimize
corrosion, they may be sprayed with a rust inhibitor or a small piece of
gauze may be added into the pack to absorb the excess moisture. En-
dodontic files may be sterilized in unit sets, again with gauze, to avoid
contaminating the entire contents of an endo box once it is opened.
Hinged instruments should be processed open and unlocked. All ex-
amination sets should have a folded thick paper lining included within
the package in order to be used as a sterile lining to be placed under
the instruments.
Single use packages should be used once only then discarded. And
when double wrapping items using paper/plastic pouches, the paper
portions should be placed together to ensure penetration and removal
of steam and air, and to allow visibility of the inner contents.
If items are to be used immediately after the sterilization cycle, they
may be sterilized unwrapped provided they are handled after steriliza-
tion aseptically by sterile instruments and transported to the point of
use in a covered sterile container. Such items should not be stored
for longer than one work session; after the session they are no longer
considered sterile.
If sharps containers or biohazardous waste containers containing
regulated waste are to be sterilized before disposal, they should be left
open during sterilization to allow for penetration of the sterilizing agent.
Sealing may be performed after the end of the cycle. It must be noted,
however, that not all sharps and biohazardous waste containers can

336
withstand the high sterilization temperatures.
When packaging items, each package must have an external and
internal chemical indicator. Chemical indicators are substances, which
change color when they are exposed to temperature, moisture, and
time conditions necessary for sterilization. Chemical indicators should
be compatible with the packaging material. The type used should be
designed for use with steam autoclaves. The indicator should be stored
and used following the indicator manufacturer’s instructions. The use
of an inappropriate indicator may give dangerously misleading results;
indicator performance can be adversely affected by the storage condi-
tions and methods of use. Indicators should not be used beyond their
expiry date.
External chemical indicators should be present on the outer surface
of packages and are also called process indicators or rapid-change
indicators. Internal chemical indicators are placed with the items to be
sterilized within the packs and are also called integrating indicators
or slow-change indicators.
External indicators, e.g. autoclave tape and special markings on
commercially available packages, change color rapidly after a certain
temperature has been reached. They should be used as external indi-
cators applied to the outside of each instrument package to verify that
the package has been exposed to the sterilization process. However,
because they change color very soon after exposure to a high tem-
perature, these indicators should not be considered a reliable indicator
that sterility has been achieved
Internal indicators should be of the slow-change type, which are
multi-parameter indicators designed to react to two or more sterilizing
parameters and are a more reliable indicator that sterilization condi-
tions have been met. They should be used as internal chemical indica-
tors placed inside every single instrument pack to ensure the steam
has penetrated the packaging material and actually reached the in-
struments inside. If an internal indicator is visible from the outside, an
external indicator is not necessary.
Although chemical indicators may indicate that the necessary steril-

337
 ization parameters have been reached, they should not be considered
as an assurance of sterility because they cannot guarantee that the
packages have been exposed to the necessary parameters for the re-
quired time. However, they may be useful to identify instrument packs
that have been processed through the heat cycle . Since their results
are received when the sterilization cycle is complete, they are useful
in early identification of gross malfunctions in the sterilizing unit and
failures in packaging and loading. Thus they should be used with each
and every instrument pack entering the sterilizer.
Written and illustrated procedures for preparation of items to be
packaged should be readily available and used by personnel when
packaging procedures are performed.

Sealing Packages
The purpose of sealing is to provide an air-tight seal and maintain
pack integrity, this can be achieved by the use of heat sealers or steril-
izing chemical indicator tape. Heat sealing is preferred because it is
more reliable, but if heat sealing is not possible, triple folding and seal-
ing with indicator tape is an acceptable alternative. The indicator tape,
however, must be specific for use with steam autoclaves and change
color when exposed to autoclave parameters.
Self-sealing packs should not be used due to the difficulty of achiev-
ing an air-tight seal at the edges of the pack. Pins, staples, or paper
clips are unacceptable for “sealing” because they leave unsealed holes
which may allow for entry of microorganisms. Tape not designed for
use with autoclaves should not be used.
For heat-sealing pouches, the melting point of the heat-seal will ef-
fectively limit the maximum temperature at which the pack can be used.
Therefore, only heat-seal packaging which may be used at tempera-
tures achieved by steam autoclaves, as specified by the manufacturer,
should be used. Heat seal pouches should be sealed using suitable
heat sealing equipment, and should provide a seal of proven integrity
and not allow resealing.

338
 Process of Heat Sealing
As much air as possible should be removed from the pouches be-
fore sealing because air acts as a barrier to heat and moisture. Further-
more, expansion of air during the sterilization process may cause the
bag to rupture during the sterilization process.
When the open end of pouch is placed in the heat sealer, and the
heat and pressure are applied to the surface of the pouch, it must be
ensured that there are no creases in the packaging material. Creases
can result in inadequate or uneven seal.
Adequacy of the seal must be checked, especially near the corners.
In some types of pouches, weak spots of the seal are where the paper
is folded back on itself or where four thicknesses of material become
two. To minimize failure of sealing, the minimum number of thickness
of packaging material should be sealed together.
When double wrapping pouches, the outer package should be larger
than the inner, so as to avoid folding the inner package while attempt-
ing to fit it into the outer package. Folding the inner pouch should be
avoided because it may entrap air and inhibit sterilization.
If indicator tape is used to seal pouches, the corners at the open
end of the pouch should be folded diagonally, then the top of the pouch
folded over three times. The tape should then be used to fix the fold in
position, and must extend along the full length of the fold.
After sealing the pouches, they must be inspected to ensure ad-
equacy of the seal, in addition to absence of tears, flaws, or holes,
before transfer to sterilizers.

Monitoring of Heat Sealing

Routine monitoring of processed heat sealed products should be
undertaken by checking the quality of the output. Heat seal efficiency,
integrity and strength test should be performed as recommended by
the manufacturer on each heat sealer daily.
Heat sealers should be serviced yearly. This service includes tem-
perature calibration and heat seal integrity and strength of seal.

339
 Sterilization Process
[2, 5-6, 10, 82, 100, 105, 108, 111, 116, 159]
Whenever possible, only those critical items which may be sterilized
with steam should be used. For critical and semi-critical items, if heat-
stable alternatives are not available, then heat-sensitive objects can be
treated with hydrogen peroxide gas plasma sterilizers; or if gas plasma
is unavailable, by liquid chemical sterilants. The use of heat-stable items
is preferred because the process of steam sterilization has the largest
margin of safety due to its reliability, consistency, and lethality.
Critical and semi-critical dental instruments that are heat stable
should be sterilized between uses by steam autoclaving following the
instructions of the manufacturers of the instruments and the sterilizers.
Only autoclaves with a prevacuum and post-sterilization vacuum and
drying cycle should be used. Downward displacement (gravity dis-
placement) sterilizers are not appropriate for sterilizing wrapped loads
or for items that contain a lumen (e.g. handpieces, high volume evacu-
ators, stainless steel suction tips), and should not be used for these
purposes under any circumstances. Flash sterilizers rely on natural air
displacement and should not be used for wrapped goods, hollow devic-
es (e.g. handpieces) or tubing. Boiling water sterilizers, hot air ovens,
ultra violet light treatment, hot bead sterilizers and chemiclaves are not
appropriate for sterilizing dental items and should not be used.
When acquired, autoclaves should be subject to planned preventa-
tive maintenance through a comprehensive service plan, the equip-
ment should only be operated by trained and competent personnel.

Loading of Autoclave Chambers

The manufacturer’s recommendations for loading the sterilizer must
be followed. Packages to be sterilized should be placed in the cham-
ber in a way that allows free circulation of the steam. Overfilling of the
autoclave chamber should be avoided. Packages should be placed in
perforated or mesh bottom racks or baskets and should not contact the
chamber floor or walls, and should be loaded such that an air space of
a few centimeters is formed between each layer of packages.

340
 Packages should be separated from each other; they should be
placed on edge and not be stacked flat in layers. When loading paper/
plastic pouches into the sterilizer the packages should be placed in
the same direction, (i.e. paper/plastic, paper/plastic). Plastic surfaces
should not be placed facing each other because plastic impedes the
movement of the steam into and out of the package. Folded drapes
packs should also be loaded with the wrapping layers vertical, allowing
air to be removed for the drape pack rapidly.
Handpieces should be placed in the center or upper shelf of the au-
toclave chamber because the temperature at the bottom of the cham-
ber may rise above the set value.
Items with a lumen (e.g. handpieces, high volume evacuators,
stainless steel suction tips) should be placed upside-down or tilted,
to prevent collection of condensated steam. Heavy packages should
be placed below lighter ones to avoid the condensate wetting the light
packages. If using autoclaves without a post-sterilization drying cycle,
sterilized packs should be allowed to dry inside the sterilizer before
removing and handling because wet instrument packages are not con-
sidered an acceptable barrier against recontamination.

Operation of Autoclave
Autoclaves must be operated with strict adherence to the manufac-
turers’ instructions. Before operating the device, it must be ensured that
the cycle recorder(s) has sufficient paper and ink to record the cycle. A
Steam Penetration test (e.g. Bowie-Dick Test) must be carried out daily
at the beginning of the workday to ensure that the pre-sterilization vac-
uum is functioning properly leaving no residual air pockets in the cham-
ber. If an autoclave fails the air removal test during commissioning or
during routine (daily) testing, it should not be used until inspected by the
appropriate maintenance personnel and it passes the test . The Bowie
Dick test must also be repeated after maintenance of sterilizers.
After verification of proper function of the pre-sterilization vacuum,
the autoclave may be used to process instruments. The correct op-
erating cycle for sterilization must then be selected (Note: test cycles
such as a Bowie and Dick test and leak rate test cannot be used for

341
 sterilization) .
Maximum efficiency of the autoclave can only be achieved if suit-
able conditions are present in the chamber. The sterilization hold pe-
riod should be at 134-137ºC for not less than 3 minutes or 121-124ºC
for not less than 15 minutes . However the temperature of the chamber,
even during the drying phase, should not exceed 135ºC if handpieces
are being autoclaved, and should not exceed 140ºC if ultrasonic scaler
handpieces or air-water syringe components are being autoclaved .
The manufacturer’s instructions of sterilizable items regarding temper-
ature of sterilization must be adhered to.
The doors of autoclaves should be open only when loading and
unloading. An open door will cause the chamber to cool down and may
cause condensation during the subsequent process .
The following are some conditions which may compromise optimum
sterility, and thus must be monitored and avoided:
a. Faulty preparation of materials for sterilization (packaging
that does not allow for steam penetration).
b. Improper loading of unit chamber. Overloading or place-
ment of excessively large packages at the top of the cham-
ber can prevent the flow of steam from the top of the cham-
ber to the bottom.
c. Sterilizer malfunction (failure to reach temperature and/or
pressure).
d. The presence of air in the chamber, which may delay mi-
crobial destruction up to 10 times longer.
e. Excess water in the steam, which can serve as a passage-
way for microorganisms to penetrate wet instrument pack-
ages.
At the end of the sterilization cycle, items, especially handpieces,
should be removed from the autoclave chamber immediately. Care
must be taken to ensure the packages are dry before handling and
storage .

342
 Verification of Sterilization Cycle
Before the processed packages are labeled as sterilized and re-
leased for use, each sterilization cycle must be verified as satisfactory
in the following way:
1. The records obtained from the cycle recorders must be ex-
amined to confirm that the cycle variables were within the limits
established as satisfactory by the manufacturer. The variables
which need to be examined include:
a. The number and extent of air removal pulses.
b. The temperature and duration of the sterilization plateau
period.
c. The depth and duration of the drying vacuum.
Whenever possible, the data should be read from the independent
recorder not from the automatic controller record.
Correct time, temperature, and pressure readings do not guarantee
that sterilization has taken place but incorrect readings do indicate a
problem within the cycle . Failure of a test implies that the sterilizer is
not working to specification .
Any cycle not meeting the criteria, although indicated as a pass by
the automatic controller, should be rejected. The load processed during
that cycle should be considered not sterile, and the autoclave removed
from service until the cause of the fault has been identified and cor-
rected. A failure of the cycle recording device should also be a cause
to reject the sterilization cycle, and the autoclave should only be used
if the recording device is functioning properly.
2. The packaging should also be examined to ensure it is in-
tact (i.e. seals, taped joints have not come undone, packs are
not torn) and completely dry and free from visible dampness.
Any labels, if present, should also be intact and legible.
3. The chemical process indicators should be inspected to en-
sure they have changed color as described in the indicator man-
ufacturers’ instructions (see Section Process of Packaging).

343
 4. The biological monitoring test (spore test) result should
be obtained indicating there is no bacterial growth. Even if
mechanical monitoring and chemical indicators indicate that
sterilization conditions have been reached, biologic monitoring
(spore testing) remains the most reliable technique for evalua-
tion of whether or not sterilization is taking place.
Biologic indicators (BIs) come in the form of a paper strip impreg-
nated with bacterial spores and placed in glassine envelopes or a glass
vial containing a spore suspension embedded in culture media in a
plastic vial. BIs designed for use with steam autoclaves contain Bacil-
lus stearothermophilus spores. BIs designed and indicated for a par-
ticular type of sterilizer are not necessarily appropriate for another type
of sterilizer. However, dual-species biologic indicators contain two
types of spores and may be used to test several types of sterilizers, in-
cluding steam autoclaves. Thus, the biologic indicator’s manufacturer’s
instructions must be followed.

Procedure for Spore Test

Biologic indicators (BIs) should be placed in a typical load for the
sterilizer being tested. The BI should be placed in each type package
used and should be placed in the most difficult area for sterilization to
occur; it should never run in a separate load by itself. Afterwards, the
test specimen should be incubated in an incubator appropriate to the
test container.
After incubation, the test specimen should have no viable organisms
present. A control specimen from the same batch of vials, should be
incubated along with the test specimen to ensure the incubation condi-
tions are correct. The control specimen should yield growth of viable
microorganisms. Records should be kept for each autoclave indicating
the date and result of the spore test.
Action to be taken in the event of a positive spore test (sterilization
failure):
If the spore test is positive (i.e. spores are still alive at the end of
the sterilization cycle), definitive action must be taken. The Infection

344
Control Officer must be notified, and a tag or sign must be placed on
the unit to prevent its use and all items sterilized in the same unit since
the last negative test must be recalled and re-sterilized in another unit
(see Labeling of Packages). A second spore test must be run through
the same unit to verify the first result. If the result is positive again, the
following must be investigated:
1. Determine the reliability of the BIs.
a. Were the proper BIs used for the particular sterilizer?
b. Were the BIs stored properly before use?
c. Were the BIs used before the expiry date?
d. Were the BIs handled properly before and after processing
through the sterilizer?
e. Were the BIs incubated for the correct time at the correct
temperature?
f. Was the positive spore test confirmed by bacteriologic
means? (growth from positive BIs should yield gram-posi-
tive bacilli when smeared on a glass slide and viewed un-
der the microscope at a magnification of 1000x).
If the BIs were found to be reliable and a true failure of
sterilization has taken place, then the next step must be
performed.
2. Take the autoclave out of service.
3. Review loading and operator procedures and determine if they
were properly performed by the staff.
a. Were there any changes in packaging or loading proce-
dures?
b. Was sufficient steam available?
c. Were time and temperature readings correct?
d. Was there anything different about the cycle?
e. Was a new staff person involved with the instrument pro-

345
 cessing?
If problems are detected at this stage, the necessary cor-
rections must be made then the unit retested.
4. Retest and observe the cycle.
The sterilizer should be retested with another spore test using the
same cycle and approximate load that yielded the sterilization failure.
Sterilizer technical parameters must all be noted to determine if they
indicate proper sterilizing conditions.
If the spore test is still positive, then the sterilizer must be put out of
service, and its power cord must be unplugged to ensure it is not used
until after servicing and repair. After repair, proper function must be de-
termined by biologic testing before the unit is used to process items.

Timing of Biological Monitors

Biological tests must be done weekly on steam sterilizers to verify
proper use and functioning. If a sterilizer is used frequently (e.g.,
several loads per day), biological tests should be done daily. They
should also be performed:
1. Before use of a new sterilizer unit (for installation testing, three
consecutive cycles should be run with a biological indicator test
pack.
2. If the unit has been serviced, disconnected, or moved.
3. When a unit has been unused for some time.
4. Whenever a new type of packaging material or tray is used.
5. During and after training of new sterilization staff.
6. After any change in sterilizer-loading procedure.
7. When new sterilizer parameters are being used.
8. If implants are to be sterilized. A spore test should also be done
for every sterilizer load that contains an implantable device and
the implant withheld until results of the spore test are known.

346
 Causes of Sterilization Failure
Failure of sterilization may occur due to unit malfunction or opera-
tor errors. Care must be taken to avoid the frequent operational prob-
lems which may diminish the effectiveness of a sterilizer, and which
include:
1. Improper cleaning of instruments.
Presence of debris may insulate microorganisms from direct
contact with the sterilizing agent.
2. Improper wrapping of instruments.
a. Closed containers may not allow penetration of steam or
chemical vapor.
b. Some packaging materials can not withstand high temper-
atures.
c. Excessive packaging material may retard penetration of
the sterilizing agent.
3. Improper loading of the sterilizer.
a. Overloading increases the heat-up time and retards pen-
etration of the steam to the center of the sterilizer load.
b. Lack of separation between packages even without over-
loading may prevent the steam from reaching all items.
4. Error in timing the cycle (sterilizer timer malfunction).
5. Sterilizer malfunction.
6. Improper method of sterilization.
Processing heat-sensitive items with high temperatures will
cause them to melt or deform.
Thus, to reduce the chances or risk that a non-sterile item exists in
a sterilized load, the following must be ensured :
1. Use of quality sterilization equipment and following manufac-
turer’s maintenance recommendations.

347
 2. Operation of sterilizer correctly.
3. Training of sterilizer operators.
4. Monitoring the effectiveness of sterilization procedures routine-
ly.

Sterilization Cycle Records

For each sterilization cycle, the following information must be docu-
mented:
1. Sterilizer identification.
2. Cycle (batch) number.
3. Name of the loading operator and unloading operator.
4. Type of cycle used.
5. Date and time of start of cycle.
6. Contents of the load.
7. Chart record and/or print-out from sterilizer cycle.
8. Read out results of chemical and biological indicator test.
9. Signature of identified responsible person, confirming whether
or not the process cycle was within recommended parameters
and authorizing release or rejection of load contents.
10. Any notes or observation for the process cycle, including cy-
cles which were aborted, with the causes and corrective action
taken in a log book.

Flash Sterilization
Flash sterilization is a method of heat sterilizing unwrapped patient-
care items for immediate use. Flash cycles were originally designed
for emergency use such as when an instrument is in short supply and
is dropped on the floor during patient treatment and needs to be im-
mediately sterilized for continued use. With flash cycles, the steriliza-
tion time is reduced considerably, thus reducing the “safety factor” of
microbial killing.

348
 Items may be very hot at the end of a flash cycle, therefore care
must be taken during handling and transport, and items must be al-
lowed to cool before use. When flash cycles are utilized in steam auto-
claves, dryness of the items must be ensured before handling them.
Furthermore, items are sterilized unwrapped, therefore they should
be handled with sterile gloves or forceps and transferred immediately
to the actual point of use by a covered sterile container. Instruments
should not be stored unwrapped.
Mechanical monitors must be checked and chemical indicators used
for each flash cycle. Because all implantable devices which have been
sterilized must not be used until the results of biological monitoring of
their load are known, unwrapped or flash sterilization of implantable
items should not be performed (see Sterilization Monitoring).
Due to the reduction in the safety factor of microbial killing and haz-
ards of storing unwrapped items, flash sterilization of items should not
be used routinely as a substitute for purchasing additional instruments
or simply to reduce instrument processing time.

Chemical Sterilization
Liquid chemical germicides classified as high-level disinfectants/
sterilants may, under certain conditions, destroy all microorganisms, in-
cluding spores. If used to sterilize patient-care items, the items must be
cleaned well and totally immersed in the solution. The manufacturer’s
instructions must be adhered to closely regarding the necessary contact
time of immersion. Liquid chemical sterilants reliably produce sterility
only if cleaning precedes treatment (because bioburden on the items
interferes with the sterilization process ) and if proper guidelines are
followed regarding concentration, contact time, temperature, and pH.
After immersion for the appropriate contact time, adequate rinsing of im-
mersed items with sterile water is required to remove all residue of the
chemical. Furthermore, items must also be handled using sterile gloves,
dried with sterile towels, and placed within sterile containers, and de-
livered to the point of use in an aseptic manner. If the processed item
is stored before use, it should not be considered sterile and should be
sterilized again just before use.

349
 Sporicidal chemicals, however, are highly toxic; and glutaraldehydes
have been associated with dermatologic irritation, eye irritation, respira-
tory effects, and skin sensitization. Thus, containers of such chemicals
must be placed in well-ventilated areas and be covered at all times.
These solutions lose their potency and effectiveness over time so
chemical test strips or liquid chemical monitors are available for deter-
mining whether an effective concentration of glutaraldehyde is present
despite repeated use and dilution. The frequency of testing should be
based on how frequently the solutions are used (e.g., used daily, test
daily; used weekly, test before use; used 30 times per day, test each
10th use), but the strips should not be used to extend the use life beyond
the expiration date. Data suggest the chemicals in the test strip deterio-
rate with time and a manufacturer’s expiration date should be placed
on the bottles. The bottle of test strips should be dated when opened
and used for the period of time indicated on the bottle (e.g., 120 days).
The results of test strip monitoring should be documented. The test strip
manufacturer’s recommendations should be adhered to, including any
recommended quality-control procedures. The chemical sterilant’s con-
centration should be considered unacceptable or unsafe when the test
indicates a dilution below the product’s minimum effective concentration
(MEC) (generally to <1.0%–1.5% glutaraldehyde) by the indicator not
changing color.
The sterilization process with liquid chemical sterilants cannot be ver-
ified with biological indicators. For this reason, as well as the solutions’
toxicity and difficulty of actually maintaining the sterility of the processed
items after they are removed from the solution, the use of high-level dis-
infectants/sterilants to sterilize patient-care items is highly discouraged
and should only be used if all the following criteria are met:
1. Item is not heat-tolerant.
2. There are no autoclavable options to replace the item.
3. The item is not a critical patient-care item (i.e. not intended to
penetrate tissues).
4. In the absence of other safer sterilization techniques.

350
 Labeling of Packages
All packs subjected to a sterilization cycle should be labeled after they
are sterilized to indicate:
1. The sterilizer in which the pack was sterilized,
2. The date on which the package was sterilized, and
3. The numerical sequence of the particular load on that day (i.e.
first, second, third load, etc…).
Packages should never be labeled before they are sterilized so as
to avoid confusion whether or not they have been sterilized. Labeling
is important to help determine when and where a particular package
was sterilized; such that in the event of a malfunction of a sterilizer, all
packages processed in that unit after the last negative spore test may
be recalled.
Label information should be documented on sterilization indicator
tape or sticker label and not on the paper side of the packing material.
Plastic/paper pouches can be labeled on the plastic portion. Marking
pen or ink used to label the pack should be indelible, nonbleeding, and
nontoxic. Sharp tipped water based or ball type pens should not be
used as these may compromise the integrity of the pack.
If package contents are not visible through the packaging material,
then a label (using sterilization indicator tape or sticker label) which
identifies the package contents may be fixed to the surface of the
packaging material. The label should be able to withstand exposure to
the sterilization process. However, labeling with sterilizing information
(referred to above) must only be performed after sterilization.

Storage, Shelf Life, and Transport of Packages

[10, 82, 98, 105, 108, 120]

Storage
All decontaminated and sterilized items must be stored in such a
way that their integrity and decontaminated state is maintained. Improp-
er storage of sterilized instruments may lead to their contamination,

351
 therefore packages should be stored in a clean, dry environment and
protected from sharp objects that may puncture or tear the packaging.
Packages should be stored in closed or covered cabinets. The
amount of storage space should afford adequate room to store the
package supply. Shelving should be easily cleaned and maintained and
should enable items to be clearly labeled. Care must be taken that the
storage area is not exposed to moisture, so the packages should not to
be stored next to or under sinks, under water or sewer pipes, or in any
location where they can become wet. Sterile items that become wet are
considered contaminated because moisture contamination of the pack-
aging material allows microorganisms to penetrate the material barrier.
Sterile materials should be stored on appropriate designated shelv-
ing at least 20-25 cm from the floor, 12cm from the ceiling (45 cm away
from sprinkler heads), and 5 cm from outside walls. Items should be
positioned so that packaging is not crushed, bent, compressed, or
punctured and so that their sterility and integrity is not otherwise com-
promised. Compression of packages can force air and microorganisms
into the package contents, cause seals to burst, or puncture the pack-
aging, all of which lead to contamination.
Inspection of wrapper integrity should be performed before issuance
of packages. Any wet, soiled, torn or open package should have its con-
tents removed and re-sterilized. Packages which fall on the floor should
also have their contents re-sterilized.
Use of the instrument packs should be on a first-in/first-out basis, i.e.
the freshly sterilized packages are placed at the back so the previously
sterilized packages are used first. This ensures proper circulation of
packs as well as increases the time period between sterilization and
use. This is beneficial in cases of positive spore test of an autoclave,
because it increases the chances of recalling unused items sterilized in
the defective sterilizer.

Shelf-life
Shelf- life of sterilized items should be event-related. This means
that if the expiration date has not been exceeded, the contents of steril-

352
ized packages stored in the appropriate storage conditions (as stated
above) may be considered sterile until some event causes the items
to become contaminated. Examples of such events are a tear in pack-
aging, packaging becomes wet, presence of insects or vermin in the
storage space, or the seal is interrupted . Increased handling may lead
to contamination of items.
Items not packaged but kept in strictly sterile, environmentally con-
trolled areas can be considered sterile for that work shift only. After one
work shift, the items may be considered “clean” but not “sterile”. Criti-
cal or semi-critical items must be packaged before sterilization if they
will not be used immediately. Items removed from packaging but not
used must be reprocessed.

Transport
Sterilized packages should be allowed to cool down before they
are transported. Transport of items from the CSSD to the clinics or
other departments should be within closed solid walled containers, or
in covered or enclosed carts with solid-bottom shelves to protect them
from exposure to environmental contaminants along the transportation
route.

Maintenance of CSSD Devices [108]

Validation, maintenance, and record keeping are necessary to dem-
onstrate that equipment are functioning properly and that they will per-
form their intended function consistently.

Validation
Validation is the documented procedure for obtaining, recording
and interpreting the results of different CSSD device operational re-
cords needed to show that a process is yielding a product complying
with pre-determined specifications. It is considered as a process which
comprises:
1. Commissioning (installation qualification and operational quali-
fication).
2. Performance qualification.

353
 3. Periodic testing.
4. Annual and revalidation tests.

Commissioning
This is the process of obtaining and documenting evidence that the
equipment has been supplied and installed in accordance with its spec-
ifications by the supplier, that it is safe to operate (installation qualifica-
tion) and that it functions within predetermined limits when operated in
accordance with the manufacturer’s operating instructions (operational
qualification).
Installation qualification includes verification of calibration, auto-
matic control test, water quality tests, water supply temperature, water
supply pressure.

Operational Qualification tests should be carried out when:

1. a new device is purchased before it is used for the first time,
2. when a used device has been relocated to another premises,
or
3. following critical repairs.
Installation and commissioning checks and tests should be per-
formed by a person with specialist technical training. Data from the
commissioning tests provide assurance that device function efficacy
conditions are attained, i.e. the device is functioning correctly.
Even though the manufacturer should have tested a device before
it left the factory, there is no guarantee that it will function correctly fol-
lowing delivery. Therefore, it should be tested before use to ensure that
it is working correctly.

Performance Qualification
Performance qualification is required to show that function/efficacy
conditions are attained even for loads and test loads that are assessed
by the user to be difficult to process. Performance qualification is indi-
cated for initial use of a new/relocated device or when the load profile
changes (e.g. new type of items for processing). It should be carried

354
out by a suitably qualified person.

Periodic Testing
After validation, and when a device has been passed for use, it
should be subject to a schedule of periodic tests at daily, weekly quar-
terly and yearly intervals. The daily, weekly and quarterly tests should
supply evidence whether or not the device is still operating within the
limits established during commissioning.

Annual and Revalidation Tests

Annual tests (revalidation procedure) prove that the data collected
during commissioning and performance qualification are still valid. Re-
validation may also be required under certain circumstances.

Preventive Maintenance
A preventative maintenance schedule for all CSSD equipment and
utilities should be planned for periodic, annual, and revalidation test-
ing as recommended by the manufacturers’ instructions for the various
devices used in the CSSD. Whenever a new device is acquired, the its
maintenance schedule must be incorporated into the overall preventive
maintenance schedule of the CSSD. The documented plan of mainte-
nance tasks and the frequency at which they are carried out should be
clearly specified.
Maintenance tasks should be performed as recommended by the
manufacturers’ instructions, and documented by qualified personnel.
The CSSD devices should not be used to process contaminated items
until all maintenance tasks have been completed satisfactorily and re-
corded.
Re-evaluation of function is also required after equipment reloca-
tion, engineering work, repair work, and software control function modi-
fications.
A qualified staff member should review the maintenance plan and
procedures and maintenance records periodically.

355
 Record Keeping
A permanent record should be kept for each device within the CSSD
to provide evidence that it was/is functioning correctly and achieving its
intended results consistently. The record should include records of:
1. Commissioning and validation tests and checks.
2. A master process record (see below) should be provided by the
company that installed the sterilizer.
3. Routine monitoring of every operational cycle. (See Steriliza-
tion Process- Sterilization Cycle Records)
4. Actions taken to correct any cycle failure and details of what
happened to the unsatisfactory load.
5. Results of all periodic testing: daily, weekly, quarterly and an-
nual tests.
6. Maintenance, repair, or any modifications.
7. Operator training records, which should include name of train-
ee, name of trainer, date of competency achieved in param-
eters as detailed in the staff training section.

The Master Process Record

The master process record contains the information gathered dur-
ing commissioning by the manufacturer. It includes details of the val-
ues and permitted tolerances of the cycle variables for each correctly
functioning operating cycle, and for each load type that is to be pro-
cessed.
This is the record against which the following results should be com-
pared:
1. Production cycle records: to verify that cycle conditions have
been achieved for each load.
2. Results of weekly tests: to establish whether the device is func-
tioning correctly and achieving the intended results.
3. Results of periodic tests and performance re-qualification
tests.

356
 ACQUISITION OF DEVICES AND MATERIALS
Sufficient dental patient care items and accessories should be ac-
quired to allow adequate time for reprocessing without adversely affect-
ing the rate of patient flow. Items and materials should be assessed and
considered for possible usefulness. A standardized screening and evalu-
ation program may be implemented to assess such devices. [108, 113]

Screening of Devices and Materials

[108, 113]
When they are available on the market, new designs of patient care
items and safety devices should be screened by decision-makers and
potential users. Screening assists in making decisions about clinical
and safety considerations before evaluating a dental device in the clini-
cal setting. Screening usually consists of physically examining the “saf-
er” device, then comparing it to the traditional device and established
evaluation criteria (see Appendix A: Sample Device Screening Form).
Screening evaluation will help determine if the device is safe to use on
patients, has safety features to protect dental personnel from sharps
injury, is readily available for purchase, is easy and practical to use,
and is compatible with other equipment.
No new device should be used on a patient before it has been
screened to ensure that it meets clinical and patient safety needs.

Evaluation of Devices and Materials

[108, 113]
After the device has been screened by the decision makers and
some end-users, it should be evaluated for efficacy. Device evaluation
involves a trial by the end-users of the device (we should specify how
many) to determine the acceptability of a new design or “safer” dental
device in an actual clinical setting. This process includes identifying
the device to test, selecting the area of the facility to be used as the
test site, selecting the staff (end users of the device) who will test the
device, selecting evaluation criteria (see Appendix B: Sample Device
Evaluation Form), and determining how long the test will last. The tra-

357
 ditional device should be immediately available for use if the new den-
tal device is found to be unsafe or unpractical. The evaluation should
provide decision-makers with enough information to make an informed
decision on whether to continue using the safety device.

Devices of Central Sterilization and Supply Department

[108]
Acquisition, replacement, or upgrading equipment of the CSSD
should be performed in accordance to needs of the level of service
expected from the department, and should be compatible with exist-
ing items which need to be serviced. It should also be in accordance
to, and compatible with, the existing or modifiable infrastructure of the
building. As such any plan for acquisition, replacement, or upgrading
equipment should be reviewed by a panel of relevant specialists.

358
 MANAGEMENT OF MEDICAL WASTE
[13, 90, 160-163]
Waste items contaminated with body fluids and tissues harbor hu-
man pathogens and considered one of the major potential sources of
infection. Many human pathogens can be found in health care waste
items, e.g. staphylococcus sp., HIV, hepatitis B and C in blood; salmo-
nella, shigella sp. in feces and vomit; and streptococcus sp. in pus. The
transmission routes for these infection sources from waste to a patient
or health care worker are still uncertain. Only puncture injuries from
sharps have demonstrated a clear infection pathway. For other waste
items, if not by direct contact, the potential pathways are presumed to
be airborne (e.g. spores or aerosols) or vectorborne (e.g. flies) trans-
mission.
The safe and sustainable management of health-care waste is a
public health imperative and a responsibility of all. Improper manage-
ment of health-care waste poses a significant risk to patients, health-
care workers, the community and the environment. Health-care waste
can cause serious harm if not managed properly. For example, in 2000,
WHO estimated that injections with contaminated syringes caused 21
million hepatitis B virus (HBV) infections (32% of all new infections),
two million hepatitis C virus (HCV) infections (40% of all new infec-
tions) and 260 000 HIV infections (5% of all new infections). In addition,
health-care activities generate significant amounts of hazardous waste
such as mercury and expired pharmaceuticals.
The management of health-care waste is an integral part of a national
health-care system. A holistic approach to health-care waste manage-
ment should include a clear delineation of responsibilities, occupation-
al health and safety programs, waste minimization and segregation,
and the development and adoption of safe and environmentally-sound
technologies. The right investment of resources and commitment will
result in a substantive reduction of disease burden and corresponding
savings in health expenditures.
The healthcare waste producer has a duty of care to ensure all
healthcare waste is managed and disposed of properly in accordance

359
 with the current waste regulations.
The primary message in waste management strategies should take
into consideration:
1. Protecting the environment from pollution by hazardous effluents.
2. Minimizing the production, and reducing environmental impact
of waste by reviewing materials used and practices employed.
3. Ensure that hazardous and nonhazardous dental health-
care wastes are properly and efficiently segregated, packed,
handled, stored, transported and disposed.
4. Ensure that policies and procedures for waste management
are established, adopted, understood and implemented.
5. Provide information, instruction, training and supervision as
necessary to ensure the implementation of waste manage-
ment policy.
The healthcare waste policy should identify which member(s) of the
staff are responsible for overseeing the local management of health-
care waste including:
1. Identifying each waste stream as hazardous, or non-hazardous
(segregation).
2. Handling and on-site storing of the healthcare waste.
3. Arranging for waste collection.
4. Record keeping.

Definitions [77]
Generator:
Any legal individual or body, such as health care facilities and their
various departments, whose activity leads to generating healthcare
waste.

Waste Segregation:
This is the separation of the different groups of healthcare waste,

360
performed by the generator at the site of waste generation in the fa-
cility, and during the stages of collection, storage, and transportation
within the facility.

Transporter/Carrier:
The legal individual or body (company, public/private establishment)
working in the field of hazardous healthcare waste transportation to a
waste treatment and disposal facility.
Waste Treatment and Disposal Facilities:
These are the facilities in which the operations of changing biologi-
cal, chemical, or physical characteristics of healthcare waste are car-
ried out for elimination of its hazard, so that it can be safe to the envi-
ronment and health.

Transportation Document (Consignment Note):

It is the form that contains all data, duly completed and signed by
the generator, transporter/carrier, and waste treatment and disposal fa-
cilities. It is made up of several copies that travel with healthcare waste
shipment and are transported from the health care facility to the waste
treatment and disposal facility.

Dental Healthcare Waste

[5, 13, 77, 90, 160-161, 163-168]
Healthcare waste (HCW) is all waste produced as a consequence of
health care activities in hospitals and community settings, and requires
classification by the person generating the waste at the point of pro-
duction. Dental health-care waste is divided into two main categories:
hazardous and non-hazardous waste.

1. Non-hazardous Dental Healthcare Waste

Non-hazardous healthcare waste is described as waste that is gen-
erated by administrative departments and general cleaning work within
healthcare facilities, similar to normal household or municipal waste.
This constitutes the larger portion (75% - 90%) of healthcare waste and

361
 can be managed by the municipal waste services.

Non-hazardous dental healthcare waste includes:

a. Domestic waste: such as food, drinks, cans, bottles, plastics,
ink cartridges, shredded document papers, cardboard and pa-
per towels.
b. Offensive or hygienic waste: such as hygiene products and
nappies.

2. Hazardous Dental Healthcare Waste

Hazardous waste is waste with one or more properties that are haz-
ardous to the health or environment, e.g. explosive, oxidizing, flam-
mable, irritant, infectious, toxic, carcinogenic, teratogenic, and/or mu-
tagenic. Hazardous healthcare waste is the waste generated from
sources contaminated or potentially contaminated with infectious, or
chemical sources that poses potential health risk. They constitute a
small percentage of the total quantity of dental healthcare waste and
pose hazards to individuals, community, and the environment during
their generation, collection, handling, storage, transport or disposal.

Hazardous dental healthcare waste includes:

a. Infectious Waste:
This is the waste that contains biological agents such as bacteria,
viruses, parasites, and fungi which might cause a disease for individu-
als susceptible to get infected. Infectious waste includes the cultures
and stocks of infectious agents from laboratory work (highly infectious
waste) and any discarded contaminated instruments or materials that
have been in contact with blood or body fluids of infected persons (i.e.
contaminated clinical waste such as gloves, aprons, masks, dispos-
able bibs, swab, gauze, cotton, used impression and bite registration
materials, single -use materials and instruments, used custom trays,
sutures, and disposable gowns) or animals that might potentially trans-
mit infectious diseases.
According to the standard precautions concept, all patients should
be considered as potentially infective. Thus, all clinical waste produced

362
from the treatment of patients should be considered hazardous waste.
b. Pathological Waste:
This is the waste that contains human tissues (including extracted
teeth), animal carcasses, blood, blood components, and body fluids.
Within this category, recognizable human or animal body parts are also
called anatomical waste. Human anatomical wastes are required to be
handled according to Islamic Law (Sharia) and should be buried (ac-
cording to the Islamic Fatwa No. 8099 dated 21 safar 1405H).
c. Sharp Waste:
This is the waste that contains sharp items such as needles, glass
vials, scalpels, orthodontic wires, broken glass, or any other sharp ob-
ject that has the potential to cut or puncture through the body.
d. Chemical Waste:
This is the waste that contains discarded solid, liquid or gaseous
chemicals resulting from diagnostic, therapeutic (including local anaes-
thetic solutions), and laboratory activities or those used in cleaning and
disinfecting or sterilizing procedures. It also includes photographic and
radiographic chemicals (developer and fixer), lead foil (within intraoral
radiographic film packets), and waste amalgam. Chemical waste from
health care may be hazardous or non-hazardous.
Chemical waste is considered hazardous if it has at least one of the
following properties:
1. Toxic, flammable.
2. Reactive (explosive, water-reactive, shock-sensitive).
3. Corrosive (e.g. acids of pH <2 and bases of pH >12).
Non-hazardous chemical waste consists of chemicals with none of
the above properties, such as sugars, amino acids, saline, glucose,
and certain organic and inorganic salts.
e. Pharmaceutical Waste (Medications):
These are wastes resulting from preventive, therapeutic activities,
or from production and preparation of pharmaceutical products and

363
 medications, including also the expired materials.
f. Cytotoxic Waste:
Cytotoxic and cytostatic medicines are deemed hazardous wastes
but are not used in routine dentistry.
g. Compressed Gas Cylinders/Containers Waste:
These are the empty or damaged cartridges, cylinders of gas, disin-
fectant containers, and aerosol sprayers that may contain inert gases
or gases that might cause adverse health effects, and might explode
when exposed to high temperatures or to punctures.

Responsibilities of Hazardous Healthcare

Waste Generators [13, 77, 164-165]
• Hazardous healthcare waste generators must make efforts to
reduce the level of generation of hazardous healthcare waste
both in quantity and quality by developing the utilized equip-
ment and tools, adapting clean technology and use of raw
material and alternatives of lesser harm to both environment
and public health (environmental preferable purchasing).
• A comprehensive program for safe management of waste
materials must be established and clearly outlined and dis-
seminated to the relevant staff .
• Each health care facility should obtain a licence from the Sau-
di Arabian Presidency of Meteorology and Environment (PME)
before temporary storing or transporting hazardous healthcare
waste outside the location.
• All dental staff involved in handling healthcare waste need
training, information, and instruction in the risks associated
with healthcare waste, its segregation, handling, storage, and
collection; proper management of spillages; and any proce-
dures which apply to their particular type of work.
• Supervisors must ensure that procedures are followed by all
staff under their supervision. All staff who generate the waste
need to understand that they are personally responsible for

364
 complying with agreed local procedures.
• Health care workers who transport waste, especially haz-
ardous waste, including expired hazardous drugs, must be
trained for such tasks.
• The housekeeping and cleaning policies outlined in the sec-
tion on ENVIRONMENTAL INFECTION CONTROL of these
Guidelines must be adhered to by the janitorial staff. Each
janitorial staff member should be a given a copy of the clean-
ing protocols (based on these policies), as a hand out in their
own language, which they can refer to whenever they have
any queries about the required procedures.
• Continuing training programs should be conducted to improve
the knowledge of janitorial staff regarding:
1. The importance of cleaning and safe hospital environment
in the control of infection.
2. The risks associated with healthcare waste.
3. The proper ways of segregation, handling, storage and col-
lection of healthcare waste.
4. Personal hygiene.
5. Procedures for dealing with spillages and accidents.
6. The appropriate use of personal protective equipment
(PPE). Appropriate PPE, including heavy-duty utility gloves,
should be worn when handling and transporting clinical and
hazardous waste.

Health-Care Waste Management

[13, 77, 90, 161, 163-166, 169-171]
The effective management of health care waste must consider the
basic elements of waste minimization, segregation and proper identi-
fication.
1. Segregation of Hazardous Healthcare Waste Inside The
Health Care Facility

365
 Appropriate handling, treatment and disposal of waste by type re-
duces costs and aids in the protection of public health. Subsequently,
the amount of hazardous waste that needs to be treated will be mini-
mized or reduced prolonging the operational life of the disposal facility
and may gain benefit in terms of conservation of resources. A segrega-
tion plan must be developed that includes staff training on segregation
of waste.
Considering the transmission routes for infection, good health care
waste segregation requires that:
• Waste should be placed in containers (e.g. bins, boxes, strong
disposable bags) to prevent direct contact.
• Containers should be kept covered to prevent contact with the
open air.
• Sharps and potentially infectious waste should be kept in
separate containers in each medical area and located well
away from patients.
• Sharps containers should be clearly labeled.
• A color coding system should be established or clear signs
placed on containers and bags to differentiate between gen-
eral and hazardous health care waste.
Each healthcare waste generator must segregate hazardous from
non-hazardous waste at the generation site (e.g. clinic, laboratory,
CSSD, radiology deptartment). General waste containers placed be-
side infectious waste containers in patient care areas may aid in better
segregation. The waste generator holds the responsibility of segregat-
ing and collecting waste in containers specially made for this purpose
within the health care facility and its department’s as follows:
1. Non-hazardous healthcare waste is to be collected in black
plastic bags. These bags are not always doubled but double
bags should be used when bags are not sturdy. Non-hazard-
ous healthcare waste should be treated separately and must be
segregated from the hazardous healthcare waste in all stages
(packaging, collection and transporting inside the facility and

366
 storage) until it joins the stream of domestic refuse or municipal
solid waste, and transported to the final disposal places in the
landfill (e.g. municipal landfill).
2. Infectious waste is collected in orange- colored plastic bags
bearing the phrase “Hazardous Healthcare Waste” (in Arabic
and English) along with the biohazard logo (Figure 4) . The
infectious waste should be autoclaved before it is sent to the
Riyadh landfill area.
Figure 4
The Bio-hazard Logo

3. Highly infectious waste should, whenever possible, be treat-

ed immediately by method recommended in this guidelines. It
therefore needs to be packaged in bags that are compatible
with the proposed treatment process. Highly infectious micro-
bial cultures such as viruses, TB, or Brucella, are to be col-
lected in plastic bags suitable for pre-treatment by autoclaving
within the generation site in the generating department. Such
bags are orange in color and bear the phrase “Highly Infectious
Waste”, along with the biohazard logo. After autoclaving, the
bags are to be placed in orange bags bearing the phrase “Haz-
ardous Healthcare Waste” along with the biohazard logo.
4. Pathological waste: Tissues and human body parts to be placed
in red plastic bags bearing the phrase “Bio hazard” in Arabic
and English and the biohazard logo. After placing in the bags,
such wastes should be kept in special refrigerators until they
are buried in accordance to Islamic Sharia. Animal carcasses
and animal tissues are to be collected in red bags and pre-

367
 served isolated in a special refrigerator until they are treated
and disposed.
5. Sharps wastes should all be collected together, regardless of
whether or not they are contaminated. They are to be disposed
of in color-coded containers (usually made of metal or high-
density plastic), fitted with covers and bearing the phrase “Haz-
ard - Sharp Items” (in Arabic and English) and the biohazard
logo. The containers should be rigid, leak proof, and puncture
proof.
6. Pharmaceutical Waste (Medications):
a. Quantities of expired medications/materials should be re-
turned to the Pharmacy Department for proper disposal.
b. Trace medications and pharmaceutical items likely to be
contaminated are to be disposed of by collecting them in
leakproof containers, then in color-coded plastic bags bear-
ing the phrase “ Chemical Waste-Medications” in (Arabic
and English) as well as the biohazard logo.
7. Chemical Waste should be packed in chemical resistant contain-
ers and sent to specialized treatment facilities (if available). The
identity of the chemicals should be clearly marked on the con-
tainers. Hazardous chemical wastes of different types should
never be mixed. Liquid Chemical Waste is collected inside col-
or-coded and thick hermetically sealed, leak proof containers,
bearing the phrase “Chemical Waste” in (Arabic and English)
as well as the biohazard logo. Meanwhile, solid chemicals such
as powder materials’ waste are to be collected in color-coded
plastic bags bearing the phrase” Chemical Waste-Medications”
in (Arabic and English) as well as the biohazard logo. Waste
with a high content of heavy metals (e.g. cadmium or mercury)
should be collected separately. These wastes can be sent to a
waste treatment facility available in the area.
8. Aerosol containers may be collected with general health care
waste once they are completely empty. Aerosol containers
should not be burnt or incinerated.

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Dental Amalgam:
Dental amalgam is classified as hazardous waste and includes
amalgam in any form, as well as materials contaminated with amalgam.
Amalgam capsules are also classified as a hazardous waste. Mercury
in the environment is bioaccumulative, which means that it can build
up in fish and cause health problems in humans and other animals that
eat fish. Mercury is a naturally occurring metal; however, about half of
the mercury released to the environment comes from human activity.
Of that amount, 53% is emitted from combustion of fuels for energy
production and 34% is from the combustion of waste. Sources associ-
ated with manufacturers and consumers make up the remaining 13%,
with dentistry contributing less than one percent. Although mercury in
the form of dental amalgam is stable, amalgam should not be disposed
of in the garbage, infectious waste or sharps container. Amalgam also
should not be rinsed down the drain.
There are several ways that mercury from dental amalgam can
reach the environment:
1. Wastewater: Amalgam that is rinsed down drains or escapes
from poorly maintained chairside traps, vacuum pump filters,
and amalgam separators enters the wastewater stream and
eventually the wastewater treatment plant or the septic system.
Any mercury contained in treated wastewater will either end
up in the sewage sludge, which may be land applied, or in the
liquid effluent to be discharged into lakes or rivers.
2. Medical Waste: Scrap amalgam, both contact (amalgam that
has been in contact with the patient, e.g. extracted teeth with
amalgam restorations, carving scrap collected at chair side,
and amalgam captured by chair side traps, filters, or sepera-
tors) and non-contact (excess mix leftover at the end of a dental
procedure), should not be treated as infectious waste. Amal-
gam that is improperly put into biohazard bags might be either
incinerated or autoclaved. If amalgam is present in waste that
is incinerated, the mercury will volatilize and enter the atmo-
sphere. The volatilized mercury then precipitates to the ground

369
 or a waterbody. If amalgam is present in waste that is auto-
claved, the volatilized mercury will escape from the autoclave
when the door is opened, presenting an immediate health haz-
ard to dental office staff.
3. Garbage: If amalgam scrap is discarded into ordinary trash, it
may eventually be incinerated or placed in a landfill. If discard-
ed amalgam scrap ends up in a landfill, it may lead to soil and/
or water contamination.
Dental practices which place or remove amalgam fillings must install
chair-side traps, vacuum pump filters, or amalgam separators within
the dental unit filter and ensure the amalgam collected is disposed
of as hazardous waste. The ability of amalgam separators to remove
amalgam from the dental wastewater may be superior to filters and
traps used in chairside dental units and vacuum lines. These separator
systems are used to capture scrap amalgam in wastewater which is
too fine to be removed by a trap.
Amalgam waste should be collected by suitable licensed or permit-
ted waste management facilities where the waste undergoes a mercu-
ry recovery process prior to final disposal. The strategies of amalgam
waste management falls into two categories: pollution prevention ac-
tions and control actions, also called “best management practices.”
• Pollution Prevention: The goal of pollution prevention is to
reduce or eliminate the use of toxic or polluting substances at
the source. This can be achieved by using amalgam substi-
tutes in cases where they are appropriate, ethical, and eco-
nomically feasible.
• Best Management Practices: While pollution prevention is the
ideal solution for solving the mercury problem, it is not always
feasible in practice. Best management practices are economi-
cally achievable measures or actions that can be used to con-
trol or reduce the entry of pollutants (mercury, amalgam and
other dental office wastes) into the environment. The following
are best management practices for amalgam waste:
1. Amalgam waste, amalgam capsules and extracted teeth that

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 contain amalgam restorations should not be placed in biohazard
containers, infectious waste containers or regular garbage.
2. Amalgam waste should not be flushed down the drain or toilet.
3. Devices containing amalgam should not be rinsed under run-
ning water over drains or sinks as this could introduce dental
amalgam into the waste stream.
4. Precapsulated alloys and a variety of capsule sizes should be
used to minimize the amount of amalgam waste generated.
5. Bulk mercury should not be used.
6. Chair-side traps, vacuum pump filters, or amalgam separators
should be used to retain amalgam.
7. Line cleaners that minimize dissolution of amalgam should be
used. The use of bleach or chlorine-containing cleaners to flush
wastewater lines should be avoided.
8. All contact and non-contact scrap amalgam should be salvaged
and stored in separate, appropriately labeled containers.
9. Amalgam waste should be stored in wide-mouthed, covered,
rigid plastic container (preferably with mercury vapour suppres-
sant) labelled “Contact Amalgam for Recycling”, “Non Contact
Amalgam for Recycling”, or as directed by the recycler. The
container lid should be well sealed, and when the container is
full, it should be sent to the recycler.
10. After mixing amalgam, the empty capsules should be placed in
a wide-mouthed, container that is marked “Amalgam Capsule
Waste for Recycling.” The container lid should be well sealed.
When the container is full, it should be sent to a recycler.
11. Any defective capsules that cannot be emptied should be
placed with the non-contact scrap amalgam so they can be re-
cycled (the amalgam recycler should be asked if they will take
capsules with scrap amalgam).
12. The recyclers may have their own requirements for the storage,
disinfection and shipping of scrap amalgam. These require-

371
 ments should be followed.
13. Amalgam waste and used disposable amalgam capsules
should be recycled following the manufacturer’s recommen-
dations for maintenance and recycling procedures. Recycling
of dental amalgam waste is strongly recommended as a best
management practice which may help prevent the release of
mercury to the environment. The mercury can be recovered
from amalgam wastes through a distillation process and reused
in new products.

Radiographic Fixer and Developer Solutions:

• Used radiographic fixer, the solution left over from X-ray pro-
cessing, and developer solutions are classified as hazardous
chemical waste.
• The used fixer is considered a hazardous waste because of its
high silver content.
• X-ray developer and used X-ray fixer should not be mixed.
• The silver-laden used X-ray fixer cannot be flushed down the
drain.
• If X-ray developer is accidentally mixed with used X-ray fixer,
the mixture must be disposed of through a waste treatment
and disposal facilities.
• Waste radiographic developer and fixer solutions should be
stored in leak proof containers and collected by a suitably
licensed company or waste facility for material recovery.
• Material recovery of used fixer can be done off-site by another
company, or it can be done in-house.
• If the dental health institution is on a septic system, the liquid
that has gone through the silver recovery process should not
be washed down the drain. The recovery process waste may
disrupt the proper functioning of the septic system.

Lead Foils, Shields and Aprons:

• Any packaging containing residues of, or contaminated by,
dangerous substances are classified as hazardous waste. In

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 dentistry this includes the lead foil present in radiographs. The
lead content of these items makes them hazardous waste,
even if they are recycled for their scrap metal content.
• The lead foil that shields X-ray film, protective lead shields,
and lead aprons should not be placed into the trash or into
biohazard bags. They should be disposed of by suitable li-
censed or permitted waste treatment and disposal facilities.
• Manufacturer recommendations should be followed for re-
cycling possibilities for lead aprons that become worn out or
damaged.
• Documentation should be obtained from the company han-
dling the lead waste confirming that the waste has been
disposed of properly.
Chromium-Containing Cleaners:
• Many cleaners for x-ray developer systems contain chromium
which is considered a toxic substance.
• Pollution prevention can be achieved by using non-chromium
containing x-ray developer system cleaners.
• The package label or the material safety data sheet (MSDS) of
the cleaner should be checked to see if the cleaner contains
chromium, and if it does, it must be managed as a hazardous
waste.
• Chromium-containing cleaners should be disposed of by
suitable licensed or permitted waste treatment and disposal
facilities.

Chemiclave/Chemical Sterilant Solutions:

• Spent chemiclave solution, the liquid left over from the chemi-
cal sterilization of dental instruments, is an ignitable waste
because it contains more than 24% alcohol and has a flash-
point below 140ºF.
• The spent chemiclave solution should be diluted with at least
4 parts of water (4 parts water to one part chemiclave solu-
tion) or more before discharging down the drain.

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 • The chemiclave solution should not be washed down the drain
undiluted and should not be placed in the garbage.

Disinfectants, Cleaners and other Chemicals:

• The label directions on the product container should be fol-
lowed for guidance on the proper handling and disposal of
used disinfectants and cleaners, along with the residue re-
maining in the product containers.
• The empty container can be recycled or disposed of in the
trash.
• Alcohols, ethers, and peroxides are considered ignitable and
must not be discarded down the drain undiluted because they
could explode.
• These materials are considered to be hazardous waste. Un-
used products should be disposed of by suitable licensed or
permitted waste treatment and disposal facilities.
• Cleaning solution, disinfectant or any other process waste
should not be placed into a septic system, regardless of its
concentration, because they may disrupt the proper function-
ing of the septic system.

Fluorescent Bulbs:
Fluorescent bulbs are hazardous waste and a significant source of
mercury. They should not be placed in the trash, instead, they should
be recycled.

Batteries:
• Most, if not all, batteries have hazardous properties and
should be recycled.
• Batteries should not be placed in the trash, biohazard bag, or
sharps container.
• Certain kinds of batteries–including certain button batteries,
some medical batteries, small sealed lead-acid batteries, and
other specialty batteries–contain mercury and other metals
that are intentionally added, therefore, they should be re-

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 cycled.

Rechargeable Batteries:
Batteries such as nickel/ cadmium (Ni/Cd) that are no longer useful
are hazardous waste and should also be recycled since they contain
lead and cadmium.

2. Collection/Transportation Within the Health Care Facility

Proper collection and transportation is an important component of
health care waste management. Its implementation requires the di-
rect involvement of the health care facility maintenance services, and
housekeeping services, and cooperation of all the health care per-
sonnel. Health care waste collection practices should be designed to
achieve an efficient movement of waste from points of generation to
storage or treatment while minimizing the risk to personnel.
Collection and transportation of bags/containers of hazardous
healthcare waste within the health care facility require using specially
designed trolleys (see Specifications for Healthcare Waste Trolleys ) or
carts that are dedicated solely for that purpose, and well-trained janito-
rial staff in order to prevent any leak or spill out of the bags/containers
and to guarantee the highest degrees of safety during collection/trans-
portation within the health care facility.
Healthcare waste should be collected at regular intervals to reduce
its build up in the facility, and transported to the designated central
storage site or waste transfer station. If clinical waste is stored outside
the practice for collection, it must be secure and not accessible to out-
side interference. Suggested collection frequency is once every clinical
session or as often as necessary. Time of collection should be at the
end of clinical session. Prior to collection and transportation of bags/
containers of hazardous healthcare waste, they should be fully-sealed
and locked and it should be made sure that they have the data-sticker
that reveals their contents, as well as the presence of proper hazard
identification and its related labeling including the biohazard logo.
Waste bags should not be filled with more than ¾ of their capac-
ity and should not be pressurized or compacted. All hazardous health

375
 care wastes should be collected in double bags. Bags should not be
closed by stapling, and when doubled should be tied separately. Waste
bags should not be held close to the collector body or to be held from
their bottom. Bags should only be held at the top when handling. The
bags or containers should be replaced immediately with new ones of
the same type. A supply of new collection bags or containers should be
readily available at all locations where waste is produced.
In cases when hazardous healthcare waste spill or leak out of plas-
tic bags, containers, or trolleys, such waste must be considered as ex-
tremely hazardous. This requires an immediate action. Cleaning, disin-
fection, and safety measures must be taken when and where a leakage
is identified. Trolleys for collecting and carrying hazardous healthcare
waste are to be cleaned, washed, and disinfected on a daily basis with
an appropriate disinfectant (such as chlorine compounds, and pheno-
lic compounds), by trained janitorial staff, under the supervision of the
person responsible for hazardous healthcare waste in the health care
facility, and in a special location.
Cleaning and disinfectant solutions must be treated (e.g. diluted)
before drainage or disposal.
Data Stickers:
Hazardous healthcare waste generators must attach stickers to con-
tainers and bags of waste prior to their transportation to stores within
the health care facility or waste treatment and disposal facility. The
sticker attached to bags/containers should have the biohazard logo
and the sticker should be of proper size and the information on the
sticker must be written/ printed in waterproof and permanent ink. The
stickers should contain the following data:
a. Waste generator name (facility name).
b. Site name (section or department).
c. Generated waste type as per its classification as described ear-
lier.
d. Weight and quantity of waste in the bag/container.

376
 e. The name of the person collecting the waste and attaching the
sticker.
f. Date and time of collection.
g. Transportation date and time to the disposal facility.

3. Temporary Storage Inside The Health Care Facility

Every health care facility needs to store hazardous healthcare waste
temporarily inside the facility until they are transported to a Waste Treat-
ment and Disposal Facility. The bags or containers of waste should be
stored in a designated area, room, or building of a size appropriate to
the quantities of waste produced and the frequency of collection. In
cases where the health care facility lacks the space, daily collection
and disposal should be enforced. The health care facility should obtain
a licence from the PME before temporary storing hazardous healthcare
waste.
The hazardous waste and domestic waste should have different
rooms for storage. If not possible, a hard barrier made of impenetrable
material should separate the hazardous and non- hazardous waste.
Biodegradable general waste should not be stored longer than 1-
2 days to minimize microbial growth, putrefaction, and odours. The
storage period for hazardous heath care waste should not exeed 24
hours. If the waste must be stored longer than 1 day, refrigeration at
4ºC or less or application of treatment like chemical disinfection is rec-
ommended.
Requirements of the storage area:
1. Should be located within the health care facility so as to be a
temporary collection site/center for the health care hazardous
waste generated by that health care facility.
2. Location should be appropriate and cause no pollution or harm
to human health or environment.
3. Should be located away from dental clinics and direct patient
care areas, laboratories, operation rooms, or any public access
areas.

377
 4. Should be distant from food storage areas, kitchens, and plac-
es where food is prepared.
5. Should be easily accessible for storage, transport, and clean-
ing.
6. Must be in a well-sealed location with a durable concrete floor
and constructed with materials that protect the building against
water leakage, rain, spread of bad smells, and the access of
rodents, insects, birds, and stray animals; can stand frequent
cleaning, scrubbing, and disinfecting; and equipped with a
proper sewage system.
7. Should be equipped with safety and fire protection tools in ad-
dition to an emergency kit.
8. Should be equipped with proper lighting, ventilation, and air
conditioning, with the temperature being between 15-18°C.
9. Should have a water supply for cleaning purposes.
10. Should be equipped with the necessary protective clothing;
waste bags or containers; and cleaning tools and supplies for
frequent cleaning of the area, as well as cleaning of spills, and
any other emergency cleaning needs (see ENVIRONMENTAL
INFECTION CONTROL).
11. Should be managed by competent personnel specialized in
handling hazardous healthcare waste.
12. Should only store waste which has been filled in the recom-
mended containers or plastic bags.
13. Access should be restricted to the authorized personnel only.
14. The entry should have a clear hazard sign that states the stor-
age contents (in Arabic and English), e.g. “CAUTION: BIOHAZ-
ARDOUS WASTE STORAGE AREA- UNAUTHORIZED PER-
SONS KEEP OUT”
15. It should be possible to lock the storage area to prevent access
by unauthorized persons.

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4. Transporting Hazardous Healthcare Waste
If the generator of hazardous healthcare waste needs to transport
such waste to another site outside the facility in which it was gener-
ated, the generator is responsible for implementation of all of the fol-
lowing procedures related to the transportation of such waste:
1. Packaging hazardous healthcare waste and labelling it correct-
ly in accordance with the “Segregation of Hazardous Health-
care Waste Inside Health Care Facility” and “Data Stickers”
sections.
2. Taking adequate steps to ensure that the waste is managed
safely and kept secure.
3. Refraining from delivery of such waste to persons or parties not
licensed by the PME for transporting such types of waste.
4. Refraining from delivery of such waste for transport outside the
facility without an attached manifest paper or consignment notes
(see following section on “Documentation and Records”).
5. Refraining from delivery of such waste to a waste treatment
and disposal facility that is not licensed by the PME.

Documentation and Records:

A key element of the effective management of health care waste is
keeping track of the waste. The generator of the hazardous healthcare
waste should always keep records of the data pertaining to all related
aspects of the hazardous healthcare waste, such as generation, stor-
age, transport, and disposal. The generator of the hazardous health-
care waste should provide all concerned parties with a copy of such
records periodically, as determined by such parties.
The consignment system (utilization of consignment notes) for track-
ing of waste must be implemented. Each collection of hazardous waste
must be accompanied with a hazardous waste consignment note. The
generators of the hazardous healthcare waste may produce their own
consignment note or use consignment notes supplied by a waste con-
tractor.

379
 When the waste transporter receives the waste, the transporter
must provide the waste generator with a copy of the consignment note
for the generator’s waste records. The transporter and the generator
shall separately maintain a copy of the consignment note. The trans-
porter should have the consignment note in his possession in the ve-
hicle while transporting the waste. The tracking document should be
available upon demand by any traffic enforcement agency personnel.
The transporter shall provide the facility receiving waste with a copy of
the original tracking document. Copies of the consignment note should
be retained by all parties for a minimum of two years.
The consignment note shall include, but is not limited to, the follow-
ing information:
• The name, address, telephone number, and accreditation
number of the transporter.
• The name, address, and telephone number of the generator.
• The name, address, telephone number, permits number, and
the signature of an authorized representative of the approved
facility receiving the waste.
• The date that the waste is collected or removed from the
generator’s facility, the date that the waste is received by the
transfer station, and the date that the waste is received by the
treatment facility.
• Description of the waste:
- The type of waste transported.
- The quantity of waste transferred, by weight where pos-
sible.
- How it is packed.
- The type of container.
- The process that produced the waste.
- Anything unusual about the waste that may pose a problem.
- Any information, advice, or instructions about the handling,
recovery, or disposal of the waste.

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5. Treatment and Disposal of Healthcare Waste
Prior to disposal in landfill sites, the traditional method for reducing
the volume and mass of healthcare waste and making it safe has been
incineration. But a growing body of evidence has questioned the effica-
cy and safety of incineration. Of particular concern is pollution from ex-
haust emissions, especially when incinerators are located in residential
or environmentally sensitive areas. For instance, viable bacteria can
be released from exhaust flues under certain circumstances. Tempera-
ture gradients form in the incinerator exhaust stack, and pathogenic
bacteria can survive in the cooler zones at the base of the stack. These
and similar concerns have prompted the introduction of more reliable
and environment-friendly disinfection methods referred to collectively
as “alternative technology methods”, and which employ heat, chemi-
cals and irradiation. (Table 23)
Heat processes can be divided into high- and low-temperature
methods.

I. High Temperature Processes

1. Incineration
It is the process in which solid, liquid and gas wastes are disposed of
by burning at high temperatures, and which generates gas or other ma-
terials /components. Healthcare waste incinerators are required to meet
certain temperature and emission limits. Generally they have a primary
combustion chamber operating at 800–1000°C and a secondary cham-
ber that operates at a minimum temperature of 1100°C, with a retention
time for the combustion gases of two seconds.
The incinerator plant also includes gas-cleaning equipment to reduce
emissions into the air. This equipment deals with compounds such as
hydrogen chloride and sulphur dioxide, which form as a result of chlorine
and sulphur compounds present in the original waste material.

Incineration is the best method to treat metallic and chemical waste.

2. Pyrolysis
Pyrolysis involves the high temperature (545–1000°C) heating of

381
 waste in the absence of oxygen to produce a synthesis gas. The syn-
thesis gas produced by a pyrolysis system is mixed with air and com-
busted in a secondary chamber. For general wastes, the synthesis gas
produced by pyrolysis can be cleaned and combusted in an engine,
but this is avoided with healthcare waste where security of destruction
is paramount.
As with incineration, the secondary combustion component must meet
a temperature of 1100 degrees and retain the exhaust gases for two sec-
onds. By heating the waste at the initial temperatures, these systems
destroy pathogens and reduce the volume of clinical healthcare waste.
3. Plasma Technology
In a plasma system, an electric current is discharged through an inert
gas (for example argon) to produce a plasma with a temperature as high
as 6000°C. Healthcare waste is fed to the chamber where the plasma is
present and is heated to temperatures between 1300 and 1700°C, de-
stroying all pathogenic microbes and converting the waste into a glassy
rock or slag, ferrous metal (if present), and a synthesis gas.
As in the pyrolysis process, the synthesis gas produced is often
combusted in a secondary chamber, although the very high tempera-
tures in the plasma chamber mean the gas can be fed to an engine
generator as an alternative. The use of an engine generator can result
in plasma systems exporting power to the electric grid.
4. Gasification
The gasification process is similar to the pyrolysis process, except
for the fact that small amounts of air are introduced to the primary treat-
ment chamber. The air added does not support full combustion, but is
enough to release more energy from the waste in the primary chamber.
It therefore raises the temperature in the primary chamber to a higher
level (900–1100°C) and produces ash rather than char.

II. Non-Burn/Low Temperature Alternative Technologies

1. Heat (Thermal) Disinfection Systems
These systems rely on heating the waste to a fixed temperature for

382
a specified time to deactivate the infectious elements in the waste. The
continuous monitoring and recording of waste temperature and time
are critical to ensuring the required temperature level is achieved for
the entire body of the waste.
2. Autoclaves
In autoclaving, saturated steam is introduced into a vessel above
atmospheric pressure. Some autoclaves are designed to shred waste
during the treatment cycle; other systems rely on the use of a pre-
treatment process to macerate (soften, or break down by soaking) the
waste before the waste is heated.
The use of internal paddles/arms/ridges designed to mix the waste
inside the autoclave chamber may not meet the requirements for mac-
eration.
3. Steam Auger
This industrial thermal disinfection process operates at atmospheric
pressure using a combination of residence time and temperature to
treat the waste and render it safe. Waste is shredded prior to its entry
into a steam auger, where it is turned and treated with steam to achieve
the required inactivation of pathogens.
4. Dry Heat
Some waste treatment systems available for both large (for example
hospitals) and small-quantity generators (for example GP/dental practic-
es) thermally inactivate potentially pathogenic microorganisms through
the use of electrically-generated heated air, oil or molten plastic.
5. Microwaves
Microwaves are electromagnetic waves with a frequency between
radio waves and infrared waves on the electromagnetic spectrum.
When applied to the treatment of waste, the mechanism of microbial
inactivation is thermal (temperature in the range of 95-98°C).
It is important for the waste to be wet, either as a result of moisture
naturally occurring in the waste stream or by the addition of moisture
in the form of steam. The combination of the two – microwaves and

383
 moisture – creates the thermal process.
Some treatment processes utilize microwaves to heat water to form
steam, which is then applied to the infectious waste stream. “Dry” mi-
crowave systems are also available. These use direct microwave en-
ergy in a nitrogen atmosphere to treat the waste and produce higher
treatment temperatures than those used by “wet” microwave technolo-
gies.
6. Macrowaves
These systems apply low-frequency radio waves to inactivate mi-
crobes contained within the waste. The macrowaves heat the waste
from the inside of the materials to their external surfaces.
7. Chemical Disinfection Systems
Chemicals commonly used in the clinical setting in disinfecting en-
vironmental surfaces and medical devices are sodium hypochlorite,
chlorine dioxide, peracetic acid, glutaraldehyde, and quaternary am-
monium compounds.
The waste must first be shredded in order to bring all surfaces of the
waste into direct contact with the chemicals. Some systems combine
heat with the chemicals to reduce the treatment cycle. The key require-
ments are that:
a. the disinfectant has the ability to act on all the key pathogen
groups
b. the disinfectant is maintained in the waste at sufficient con-
centration or is given enough time to achieve the required
level of treatment for each of the key pathogen groups; and
c. the treated waste (which may be highly absorbent) should
not be rendered chemically hazardous due to the presence of
residual disinfectant.
8. Other Chemical Systems
Other chemical processes have a potentially wider application than
disinfection. Alkaline hydrolysis exposes the waste to hot alkali for a
period of several hours and can, for example, reduce carcasses to

384
bone shadows. The organic rich outflow from these units is likely to
have a very high biological oxygen demand, and should be subjected
to additional treatment to ensure that effluent is dewatered, with only
the water being discharged to foul sewer.
9. Landfill
Infectious waste is banned from landfill, although it can be pre-treat-
ed (for example by alternative treatment) so that it is non-infectious
and suitable for landfill. Some types of healthcare waste may be dis-
posed of directly to landfill (for example non-infectious offensive/hy-
giene waste).

Specifications of Plastic Bags and Containers

of Healthcare Waste
[13, 77, 165]
Plastic bags, and sharps containers should not contain Polyvinyl
Chloride.

1. Standards of the plastic cases/containers:

Plastic bags/containers used for collecting hazardous healthcare
waste should comply with the following standards:
a. Waste bags should be of good quality, and be water repellent.
b. The thickness should not be less than 100 micron for high den-
sity plastic, and not less than 200 microns for low density plas-
tic.
c. Bags should have ribbon or plastic lock tie to close the bag.
d. Maximum total capacity is 100 litres.
e. Should be compatible in size with the waste bin that it is placed
in.
f. Should be of the recommended color code for the type of waste
indicated (Table 22).
g. Should be marked as “Hazardous Waste” or “HIGHLY INFEC-

385
 TIOUS” with biohazard logo.
h. Bags used for collecting highly infectious waste (such as culture
plates with TB, Brucella, or viruses) and requires initial treat-
ment with autoclave (for example) must be made of a plastic
material that withstands high temperatures without melting, and
enhances the sterilization process by allowing easier passage
of steam into the waste.

2. Specifications of Waste Bins in Which Bags are Stored in:

a. The size should accommodate the bag used.
b. It should have a hermitical seal, foot pedal type.
c. It should be easy to clean and made of material that can be
disinfected.
d. The statement “hazardous healthcare waste” should be written
on the sides and cover of the waste bins used for orange bags
with a biohazard logo.

3. Sharp Waste Containers Standards:

a. Made of non-puncture, leak proof materials.
b. Equipped with a hermetic seal (attached cover with a hole that
allows inserting sharp tools).
c. Yellow in color with a biohazard logo and the following words
should be printed: “Hazard - Sharp Items “ (in Arabic and Eng-
lish).
d. Its size should be adequate so as to be carried by one hand
and it should be provided with a handle for that purpose.

4. Chemical Waste Containers Standards:

a. Made of strong leak proof materials.
b. Made of material non reactive with the chemical waste.
c. Equipped with a hermetic seal.
d. Maximum total capacity is 50 liters.

386
 e. The statement “ Chemical Waste” or “Medications” in (Arabic
and English) should be written on the sides of the container as
well as the biohazard logo.

5. Specifications for Healthcare Waste Trolleys (that will be

used inside the health care facility):
a. The trolleys should have clear indications (e.g., color codes) to
specify the category of waste they carry.
b. The trolley used for hazardous healthcare waste should be
clearly labled with the bio-hazard logo.
c. It should be made of a material not affected by acids or alkaline,
and easily cleaned/disinfected.
d. It should guarantee efficiency upon loading and unloading.
e. It should be leak proof
f. It should be equipped with a cover that can be hermetically
sealed.
g. It should have surfaces and angles that are easy to clean and
has no sharp edges that could damage waste bags or contain-
ers.
h. It should have an adequate size to accommodate the transpor-
tation of 10 bags (minimum) in one time.
i. It should be equipped with handles to ease the movement.
j. It should move smoothly and be equipped with wheels.

387
 Table 22
Color Coding Recommended for Waste Bags or Containers

Type of Waste Color Case or Container

Orange clearly marked «HIGHLY INFECTIOUS»

Highly infectious waste (Arabic and English) with biohazard logo.
(such as culture plates) Leak-proof and strong plastic bag, or container
for autoclaving

Orange clearly marked «Hazardous Waste»

Infectious waste (Arabic and English) with biohazard logo
Leak-proof plastic bag, or container

Red clearly marked «Hazardous Waste»

Human and animal
(Arabic and English) with biohazard logo
body parts and organs
Leak proof plastic bag or container

Yellow clearly marked « Hazard - Sharp Items «

Sharps (Arabic and English) with biohazard logo
Puncture-proof containers

Non-risk healthcare Black

waste Plastic bag or container

388
Table 23
Common Techniques to Treat Hazardous Medical Waste

Treatment Waste that can Advantages

Disadvantages
technique be treated
Chemical Infectious waste One of the effective Disinfectants used are
Treatment Sharp items methods to reduce hazardous chemicals that
the microbial load in should be used with cau-
hazardous medical tioun when storing or han-
waste. dling them.
The size of waste will not
be minimized if it is not
shredded.
Microwave Infectious waste Gases emitted to It requires shredding the
Sharp items the environment are waste and wetting it with
very low in levels. water.
The size of waste is It is not sufficient to treat
minimized around other kinds of hazardous
75% by shredding. medical wastes.

Autoclave Infectious waste Effective method to It is not sufficient to treat

Sharp items reduce the microbial other kind of hazardous
load in hazardous medical waste.
medical waste. The size of waste will not
Low operational be minimized if it is not
costs. shredded.
Incinera- All hazardous May be used to Gases emitted due to
tion medical waste treat most kinds of combustion are in very
except hazardous medical high levels that requires
for radioactive waste. use of an advanced tech-
waste, com- Minimizes the size nology (with high costs) to
pressed gas of waste greatly. control the gaseous emis-
cylinders/con- sions.
tainers waste,
amalgam and
liquid waste

Source: GCC [77]

389
 APPENDIX A
Sample Screening Form
( Name of Device )
This form collects your opinions and observations following screening of ( Name of
Device ) to determine its acceptability for use in a clinical setting.
The device must not be used on patients during this initial screening phase.
Date:
Product: Name, brand, company:
Your position or title:
Your occupation or specialty:
Does
Meets Exceeds
not Meet
Clinical Considerations Expecta- Expecta-
Expecta-
tions tions
tions
The device permits repeated use during
1. 1 2 3
treatment on the same patient.
The weight and size of the device is ac-
2. 1 2 3
ceptable.
Effectiveness of the device may be eval-
3. 1 2 3
uated by the operator during use.
The size and configuration of the device
4. permits a clear view of the work site and 1 2 3
instrument tip.
No excessive force is required to use the
5. 1 2 3
device.
The size and configuration of the device
6. permits use in all mouth sizes and ac- 1 2 3
cess to all areas of the mouth.
The worker’s hands can remain away
7. from danger during activation of the safe- 1 2 3
ty feature.
The device permits multiple uses on the
8. _____No _____Yes
same patient.
The device is capable of performing all
9. _____No _____Yes
tasks the traditional device performs.
The device is compatible with other items _____No _____Yes
10.
used during patient treatment.
The device may be decontaminated us- _____No _____Yes
11.
ing the facilities available in the College.
Does the product meet the needs of
your clinical practice based on the _____No _____Yes
above criteria?

390
Screening Form

( Name of Device )
Does
Meets Exceeds
not Meet
Safety Feature Considerations Expecta- Expecta-
Expecta-
tions tions
tions

The safety feature can be activated with one

12. 1 2 3
hand.

The safety feature is integrated into the

13. 1 2 3
device.

The safety feature provides a means of

14. 1 2 3
protecting the operator between uses.

A visible or audible cue provides evidence

15. 1 2 3
of safety feature activation.

The safety feature is easy to recognize and

16. 1 2 3
use.

Once activated, the safety feature perma-

nently isolates the danger and cannot be
17. 1 2 3
purposefully or accidentally deactivated
under normal use conditions.

18. The safety feature activates by itself. _____No _____Yes

Does
Meets Exceeds
not Meet
General Product/Manufacture Considerations Expecta- Expecta-
Expecta-
tions tions
tions

The manufacturer can provide the device in

19. 1 2 3
needed quantities.

20. A full range of sizes is available. 1 2 3

The company provides free samples for in-

21. 1 2 3
use evaluation.

The company has a history of responsive-

22. 1 2 3
ness to problems.
The manufacturer can provide information
23. on the necessary decontamination require- _____No _____Yes
ments

391
 Screening Form

( Name of Device )
Does
Meets Exceeds
not Meet
Practical Considerations Expecta- Expecta-
Expecta-
tions tions
tions

24. The device is packaged conveniently. 1 2 3

The device is easy to remove aseptically

25. 1 2 3
from the package.

26. Instructions are included in the packaging. 1 2 3

Instructions are easy to follow and com-

27. 1 2 3
plete.

Instructions are provided in more than one

28. form (paper, videotape, website, or com- 1 2 3
puter disk.)

Use of the safety device will not increase

29. 1 2 3
the volume of waste.

The shape and size of available waste

30. containers will accommodate disposal of 1 2 3
this device.

31. This is a single use, disposable device. _____No _____Yes

THE DEVICE SHOULD BE CONSIDERED FOR

____No ___Yes
FURTHER CLINICAL EVALUATION.

Additional comments for any responses of “Does Not Meet Expecta-

tions” or “No”
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

392
APPENDIX B
Sample Device Evaluation Form
( Name of Device )
This form collects your opinions and observations after pilot testing (name of device).
Date:
Product: Name, brand, company:
Number of times used:
Your position or title:
Your occupation or specialty:

1. Did you receive training on how to use this product?

o Yes [Go to next question] o No [Go to question 4]

2. Who provided this instruction? (Check all that apply)

o Product representative o Staff member o Other

3. Was the training you received adequate?

o Yes o No

4. Compared to other of your sex, how would you describe your hand size?
o Small o Medium o Large

5. What is your sex? o Female o Male

Please answer all questions that apply to your duties and responsibilities. If
a question does not apply to your duties and responsibilities, please leave it
blank.
Neither
During the Pilot Test of Strongly Dis- Agree Strong-
Agree
this Device... Disagree agree nor Dis- ly Agree
agree
The weight of the device
6. was similar to that of a 1 2 3 4 5
conventional device.
The device felt stable during
7. assembly, use, and disas- 1 2 3 4 5
sembly.

The device fit my hand

8. 1 2 3 4 5
comfortably.

The device was easily

9. 1 2 3 4 5
amendable to repeated use.

Effectiveness of the device

10. was easily determined dur- 1 2 3 4 5
ing use.

I had a clear view of the

11. 1 2 3 4 5
work site and instrument tip.

393
 Device Evaluation Form

( Name of Device )
Neither
During the Pilot Test of this Strongly Dis- Agree Strong-
Agree
Devices Disagree agree nor Dis- ly Agree
agree
The device did not appear to
12. 1 2 3 4 5
increase patient discomfort.

The device performed reli-

13. 1 2 3 4 5
ably
I was able to use the device in
14. all mouth sizes and all areas 1 2 3 4 5
of the mouth.
I used the device for all of the
15. same purposes for which I 1 2 3 4 5
use the conventional device.
Activating the safety feature
16. 1 2 3 4 5
was easy.

The safety feature was easy

17. 1 2 3 4 5
to recognize and use.
The safety feature did not ac-
tivate inadvertently, causing
18. 1 2 3 4 5
me to use additional devices
(units).
The safety feature functioned
19. 1 2 3 4 5
as intended.

The instructions were easy to

20. 1 2 3 4 5
follow and complete.
I could have used this prod-
21. uct correctly without special 1 2 3 4 5
training.
The “feel” of the device did
22. not cause me to change my 1 2 3 4 5
technique.
This device meets my clinical
23. 1 2 3 4 5
needs.

This device is safe for clinical

24. 1 2 3 4 5
use.

Additional comments for any responses of “Strongly Disagree” or “Disagree”

_______________________________________________________
_______________________________________________________
_______________________________________________________

394
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