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Ten misconceptions about infection control: avoiding common errors and pitfalls in maintaining infection control in the dental practice.

Dental professionals must be confident they are providing safe dental care for every patient at every visit.

Recent breaches in dental infection control such as the Hepatitis C transmission at a Tulsa, OK, oral surgery office, and the Hepatitis B transmission at the Mission of Mercy Dental clinic in West Virginia, force us to look closely at how breaches occur in dentistry. As dental professionals, we must continually update our training and enhance our understanding of recognized infection prevention practices.

Misconceptions about infection control could compromise patient and dental worker safety. As a dental infection control consultant, I regularly visit dental practices to conduct training and workshops. When I uncover errors in recommended infection control practices, dental teams are quick to address and correct the issues. This article focuses on how to recognize these ten pitfalls in infection control in your dental practice.

Misconception #1: Gloves fully protect hands

A common misconception about wearing gloves is that it eliminates the need for hand hygiene. Hand hygiene should be performed immediately before donning gloves and immediately after removing and discarding gloves. Bacteria colonizes rapidly in the warm, moist environment under gloves. Gloves can also have small, unapparent defects or can be torn during use, and hands can become contaminated during glove removal. When dental professionals remove their gloves without washing hands, cross contamination can occur. Therefore hand hygiene after glove removal is essential. For routine 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. (1)

Because gloves are task-specific, their selection should be based on the type of procedure to be performed (e.g., surgery or patient examination). Sterile surgeons gloves must meet standards for sterility assurance established by the FDA and are less likely than patient examination gloves to harbor pathogens that could contaminate an operative wound. Medical gloves (patient examination and surgeons gloves) are manufactured as single-use disposable items that should be used for only one patient, and then discarded. Gloves should never be washed for re-use.

Heavy-duty utility gloves (Figure 1, page 10) are both chemical and puncture resistant, and are recommended when decontaminating instruments or environmental surfaces. It is a common misconception to think that patient exam gloves should be worn in the sterilization area. Only heavy-duty utility gloves protect hands from sharp instruments and potential sharps injuries.

Misconception #2: All soaps and hand lotions are created equal

Frequent and repeated use of hand hygiene products, particularly soaps and other detergents, are a primary cause of chronic irritant contact dermatitis among health care workers. (2) Discomfort due to irritation can interfere with adherence to recommended hand hygiene practices. Consequently, it is important to have different types of hand hygiene products available in the dental office.

Medical grade products have ingredients such as emollients and humectants that can reduce the potential for irritation and dryness. In addition to professional strength soaps and hand sanitizers, dental workers should choose lotions that are designed for health care providers. Lotions can ease dryness resulting from frequent hand washing and prevent dermatitis from glove use. Dental workers should avoid use of petroleum-based lotion formulations as they can weaken latex gloves and increase permeability.

The primary defense against infection and transmission of pathogens is healthy, unbroken skin. Therefore, dental professional should choose hand hygiene products that are designed for health care provider use rather than consumer use.

Misconception #3: Wearing artificial nails or nail polish is sanitary

Hand carriage of gram-negative organisms has been determined to be greater among wearers of artificial nails than among non-wearers, both before and after hand-washing. Fingernails should be short enough to allow dental workers to thoroughly clean underneath them and prevent glove tears. Sharp nail edges or broken nails are also likely to increase glove failure. Long artificial or natural nails can make donning gloves more difficult and can cause gloves to tear more readily. (1)

Freshly applied nail polish on natural nails does not increase the microbial load from periungual skin if fingernails are short; however, chipped nail polish can harbor added bacteria.

Misconceptions #4: Instruments must be scrubbed before placed in the ultrasonic or instrument washer

Ultrasonic cleaning is the most common type of automated cleaning system in dental offices. Any materials on the instrument should be removed chairside with a cotton gauze before it dries. After use, instruments and instrument cassettes should immediately be placed into the ultrasonic tank or instrument washer rather than rinsing or scrubbing.

The practice of pre-scrubbing instruments before placing in the auto mated systems is unnecessary and places the dental worker at risk for contact with infectious microorganisms. Let the automated system do its job and then inspect instruments or items for any residual debris. If needed, remove the debris (while wearing utility gloves) with a long handle scrub brush.

Misconception #5: The ultrasonic tank can be filled to top

Do not overload the ultrasonic tank as it can hinder the cavitation process that cleans the instruments.

Instruments should be completely submerged in the ultrasonic solution and the lid of the tank should always be closed during operation to avoid dental worker exposure to aerosol contamination (Figure 2, opposite page). Be sure to use the basket to suspend instruments and never place instruments on the floor of the tank.

Another misconception is that you can use dish detergent or disinfectants as ultrasonic solutions. Ultrasonic solutions must be designed for use on dental instruments and compatible with instruments and other items to be cleaned. Solutions must also be compatible with the tank or chamber where the instruments are placed, which is also metal. Using a solution that has a low pH or acid could potentially damage the instruments and the tank. (3)

Advances in ultrasonic solutions include the addition of enzymes. The enzymatic cleaning solutions help to break down organic materials such as blood and saliva. The use of dual enzymatic solutions enhance effectiveness and efficiency of the cleaning process. Ultrasonic solutions should be changed daily or more frequently depending on use. If the ultrasonic solution becomes cloudy, it is overburdened with material removed from instruments and is less effective at cleaning.

Misconception #6: Debris on instruments still gets sterilized

Debris that remains on instruments or patient care items provides a protective cover over infectious microorganisms that could shield them from the heat, chemical vapor, or steam used by your sterilizer. The sterilizing agent must actually touch the instruments in order to kill organisms.

One of the examples that I share to help illustrate how organisms survive under debris involves my husband Mike, who is a retired firefighter. In wild land fires, firefighters have protective gear called a "fire shelter." It is a tent-shaped covering that looks like solar blanket material. In a wild land fire, if the firefighter is trapped by flames and there is no escape, they can deploy the shelter and climb inside. The shelter protects the firefighter from the intense heat as flames pass over the top. Think of debris on instruments as a "fire shelter" allowing organism to survive the heat, chemical vapor or steam of your sterilizer.

Proper instrument processing begins at chairside. Cements or other dental materials should be removed as soon as possible so they don't set up on instruments. After instruments have been processed through the ultrasonic or instrument washer, they should be inspected before being packaged or wrapped for sterilization. Remove any remaining debris before sterilizing instruments, items or devices.

Misconception #7: Instruments do not need to be wrapped for sterilization

An unwrapped cycle (sometimes called flash sterilization) is a method for sterilizing unwrapped patient-care items for immediate use. Unwrapped sterilization should be used only under certain conditions: l) Thorough cleaning and drying of instruments precedes the unwrapped sterilization cycle; 2) Mechanical monitors are checked and chemical indicators used for each cycle; 3) Care is taken to avoid thermal injury to dental workers or patients; and 4) Items are transported aseptically to the point of use to maintain sterility. (1)

The CDC guidelines state that instruments should be wrapped or packaged before being placed in the sterilizer. Cleaned instruments and other dental supplies should be inspected, assembled into sets or trays, and wrapped, packaged or placed into container systems for sterilization. Cassettes help to keep instruments organized and protects them from damage, prolonging the life of the instruments and provides for safer handling of contaminated items.

Packaging materials (e.g., wraps or container systems) allow penetration of the sterilization agent and maintain sterility of the processed item after sterilization. Materials for maintaining sterility of instruments during transport and storage include wrapped perforated instrument cassettes, peel pouches of plastic or paper, and sterilization wraps (i.e., woven and nonwoven) (See Figures 3a and 3b, page 11).

Misconception #8: All sterilization packing material is the same

Packaging materials should be designed for the type of sterilization process. There are different types of materials that are used for packaging instruments depending on the type of sterilizer you use. Always follow manufacturer's recommendations for packaging. Using the wrong types of sterilization packaging material can hinder achieving sterilization. Factors to consider:

* Some packaging may prevent the sterilizing agent from reaching the instruments inside.

* Some plastics may melt.

* Some paper may bum or char.

* Thick cloths may absorb too much steam.

* Closed containers are not appropriate for steam or unsaturated chemical vapor sterilizers.

* Cloths could absorb too much chemical vapor.

* Lint fibers may cause post-operative complication and serve as vehicles for microorganisms, increasing the risk of infection for surgical patients.

Misconception #9: Color change on pouches or tape means "sterile"

Maximum patient protection with universal sterilization can be achieved only by practicing sterility assurance. Sterility assurance is the correct performance of the proper instrument processing steps and monitoring of the sterilization step with biologic, mechanical and chemical indicators. (4)

Biological indicators (BIs) are the most accepted means of monitoring the sterilization process because they directly determine whether the most resistant microorganisms (e.g., Geobacillus or Bacillus species) are present rather than merely determine whether the physical and chemical conditions necessary for sterilization are met. Because spores used in Bis are more resistant and present in greater numbers than are the common microbial contaminants found on patient care equipment, an inactivated BI indicates that other potential pathogens in the load have also been killed.

Mechanical techniques for monitoring sterilization include assessing the cycle time, temperature, and pressure of sterilization equipment by observing the gauges or displays on the sterilizer.

Chemical indicators, internal and external, use sensitive chemicals to assess physical conditions such as temperature during the sterilization process. Chemical indicators such as heat sensitive tape change color rapidly when a given parameter is reached (i.e., temperature). An internal chemical indicator should be placed in every sterilization package to ensure the sterilization agent has penetrated the packaging material and actually reached the instruments inside.

An external indicator should be used when the internal indicator cannot be seen from outside the package. Single-parameter internal indicators provide information on only one sterilization parameter and are available for steam, dry heat, and unsaturated chemical vapor. Multi-parameter internal indicators measure two to three parameters and can provide a more reliable indication that sterilization conditions have been met. Multi-parameter internal indicators are only available for steam sterilizers (i.e., autoclaves). Refer to manufacturer instructions for proper use and placement of chemical indicators.

Correct functioning of sterilization cycles should be verified for each sterilizer by the periodic use (at least weekly) of Bis. Two ways to process the biological monitors are in-office monitoring and mail-in monitoring. In-office monitoring systems allow you to test the sterilizer and obtain the results in 24 hours (Figure 4a and 4b, page 12). Mailin monitoring services can take up to a week to get results. A report of the results are sent back to the dental office.

In the event of a sterilization failure, immediate action must be taken to determine the reason for the failure. Also be sure to take the sterilizer out of service until the cause of the failure can be determined and corrected. Any items processed since the last spore test may not have been sterilized, so they will need to be repackaged and re-sterilized in a properly functioning sterilizer.

Misconception #10: It is okay to place as many instruments in the sterilizer as it will hold

Always follow the manufacturers directions for loading and operating your sterilizer. Too often, sterilizers are overloaded due to time constraints as some sterilizer cycles are about an hour from start to finish. Cassettes or packages must be placed in the sterilizer so the steam, chemical vapor, or heat is able to penetrate the wrap and circulate around the instruments.

In addition, the manufacturer may have special instructions for paper-plastic pouches such as paper side up or paper side down. Understanding how to load and operate your sterilizer is as simple as reading the owner s manual or contacting the manufacturer directly for advice.

Dental professionals are responsible for ensuring that infection control is performed correctly every time for every patient. Understanding how to use infection control products and equipment is essential for proper efficacy. Dental professionals must keep current in infection control training and education. The bottom line: keeping safety top of mind protects patients and dental workers from infection transmission.


(1.) Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health care setting--2003. MMWR Recomm Rep. 2003;52(RR17): 15-18 Available at: http://www. mmwr/preview/mmwrhtml/ rr5217al.htm.

(2.) Boyce, John. "Guideline for Hand Hygiene in Health Care Settings." Morbidity and Mortality Weekly Report 51(RR16)25 Oct 2002 27.1-30 Jan 2014 < PDF/rr/rr5116.pdf>.

(3.) Govoni, M. (2011, July l). Ultrasonic cleaning solutions: Are you getting the most from yours? Retrieved September 10, 2014, from http:// print/volume-101 /issue-7/practice/ ultrasonic-cleaning-solutions-are-yougetting-the-most-ffom-yours.html

(4.) Miller, Chris. Infection Control and Management of Hazardous Materials for the Dental Team. 4th. Canada: Mosby Elsevier, 2010.138. Print.

Leslie Canham, CDA, RDA, CSP, specializes in Infection Control, OSHA Compliance, HIPAA regulations and treating special needs patients. Her vast experience (in the dental field since 1972) along with her OSHA knowledge, gives Leslie a unique perspective on how dental practices can be safe, compliant, and productive. Leslie is recognized as a Certified Speaking Professional and has earned the reputation as an outstanding speaker in dentistry. Leslie is authorized as an OSHA Trainer andan AGD PACE provider.
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Title Annotation:Clinical
Author:Canham, Leslie
Publication:The Dental Assistant
Date:Nov 1, 2014
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