A Clinical Asepsis Protocol
After completing this chapter, the student should be able to do the following:
Describe what type of infection control preparation is necessary for a patient appointment.
Describe infection control procedures used after the patient is seated but before beginning the actual treatment.
Describe the infection control procedures to be performed during patient treatment and when taking radiographs.
Describe infection control procedures to be performed after the patient appointment is completed.
Other parts of this book describe a variety of separate infection control procedures. The information in this chapter is intended to organize these procedures into a usable protocol based on the sequence of patient treatment activities. Some steps in the protocol may change from one office to the next. The procedures are grouped into five sets of activities that are conducted as follows:
BEFORE SEATING THE PATIENT
1. Put on protective clothing, protective eyewear, mask, and gloves, and clean and disinfect those surfaces that may be touched during patient treatment and will not be protected by surface covers. These surfaces may be the following:
2. Clean and disinfect items brought into the area to be used during patient procedures (e.g., articulators, casts, dies, custom impression trays, record bases, fixed and removable prostheses, and face-bows). Disinfection procedure is as follows:
a. Spray the surface with the surface disinfectant that has been prepared properly.
b. Clean the surface by vigorously wiping with paper towels or 4 × 4 gauze pads.
c. Disinfect the precleaned surface by respraying it and letting it air dry or by wiping it dry if it is still wet after the prescribed contact time.
d. Alternatively wipe with a disinfectant towelette, discard towelette, wipe with a second fresh towelette, and let dry.
3. Remove and discard mask and gloves and wash hands. Follow the procedure for removing gloves:
a. Pinch one glove in the wrist area on one hand with the thumb and forefinger of the other hand.
b. Stretch the glove out away from the wrist, slide it off toward the fingertips—but only halfway.
c. Repeat that step on the other hand, except slide that glove completely off and drop it directly into the waste receptacle.
d. Move back to the first hand and place the ungloved thumb under the edge of the glove, which now has the noncontaminated surface inside of the glove turned out. Stretch the glove out away from the hand, slide it completely off toward the fingertips, and drop it directly into the waste receptacle. Wash hands.
4. Obtain surface covers, supplies, and sterile instruments and other equipment from the supply area.
5. Cover the following surfaces with the appropriate cover:
b. Control buttons on side of chair
d. Unit light switch and view box switch
e. Air/water syringe buttons/handle
f. High-volume evacuator control
g. Unit control switches and handpiece, air/water syringe, and high-volume evacuation holders
6. Remove all items not used during patient treatment from countertops (e.g., datebooks, articulator boxes, and cardboard and plastic boxes).
AFTER SEATING THE PATIENT
3. Take or update medical history, discuss treatment, and do necessary paperwork.
4. Remove chart from the countertop.
5. Have patient rinse thoroughly with an antimicrobial mouth rinse.
6. Open instrument packages or tray without touching the instruments.
7. Put on mask and eyeglasses.
8. Wash hands (preferably in view of patient).
• Remove jewelry and gently clean your fingernails.
• Lather for 15 seconds with the liquid antimicrobial or non-antimicrobial detergent.
9. Put on gloves (preferably in view of patient). Use sterile gloves for procedures so indicated; otherwise, use nonsterile examination gloves.
10. Use powder-free gloves. Alternatively, rinse nonsterile, powdered examination gloves with plain, cool water (no soap) to remove excess powder and towel dry before making impressions and bite registrations. If desired, remove excess powder by rinsing with water and drying before other types of procedures. Explain to the patient that these are new gloves being rinsed to remove the powder.
11. Connect sterile handpieces and sterile or disposable air/water syringe tip, high-volume evacuation tip, and saliva ejector tip.
DURING PATIENT TREATMENT
1. Restrict spread of microorganisms from patient’s mouth.
b. Use high-volume evacuation.
c. Touch as few surfaces as possible with saliva-coated fingers.
d. Keep gloved hands out of hair, and do not rub eyes or bare skin or adjust mask or glasses.
e. If leaving chairside during treatment is necessary, remove and discard the gloves. Wash hands and reglove with fresh gloves on return. Do not wear protective clothing in lunchrooms, restrooms, or outside the building; change protective clothing if obviously soiled.
f. Remove contaminated gloves and wash hands before handling cameras for intraoral photographs.
2. Do not use items dropped on the floor or on other nonsterile surfaces. Obtain sterile replacements. Remove and replace gloves, preferably in view of the patient.
3. If gloves are torn during treatment, remove, discard, wash hands, and reglove with fresh gloves.
4. Do not recap needles by hand. Insert the needle into the cap using the one-handed “scoop” technique or a cap holder that will not permit contact of the needle with any part of the body. Do not pass syringes with uncapped needles to someone else.
5. Look first before reaching for a sharp instrument.
6. When placing sharp instruments back on the instrument tray, make sure sharp tips are not pointed up and make sure they are placed in a stable position.
7. If equipment is brought to chairside (e.g., light curing apparatus), make sure it is protected with a surface cover or has been disinfected before use.
8. Use an aseptic retrieval technique to obtain supplies from bulk containers at chairside.
9. If one must obtain supplies (e.g., amalgam, varnish, or cavity liner) from a central storage area, do not take a container to the unit unless it is covered with plastic wrap or is cleaned and disinfected after use.
10. Disinfect contaminated items before taking them to the dental laboratory.
11. Do not handle charts with contaminated gloves. Use an overglove or remove gloves and wash hands.
12. If exposed to a patient’s blood or saliva, immediately contact the appropriate person to institute a postexposure medical evaluation. An exposure is any sharps injury or contact with the eye, mouth, other mucous membrane, or nonintact skin involving blood or saliva.
AFTER PATIENT TREATMENT
Anyone who will be cleaning contaminated instruments must wear heavy utility gloves, protective clothing, a mask, and a face shield or protective eyewear. If instruments are hand scrubbed, they should be submerged in detergent while scrubbing with a long-handled brush to prevent splattering.
1. Remove gloves and then the mask by touching only the ties or elastic band and discard them in a plastic-lined waste container at the unit and then wash hands.
2. Send the patient to the front desk for dismissal or reappointment.
3. Put on fresh gloves and mask.
4. Place all instruments back in the tray.
5. Place all disposable sharps, including capped or uncapped needles, directly into the sharps container at chairside. Do not place needles or other sharps into the regular trash receptacle. This would be a serious violation of procedures. Sharps include needles, scalpel blades, carpules, broken instruments and files, burs, orthodontic wire, and other disposable items that could penetrate the skin.
6. Place nonsharp disposable items in the plastic-lined waste container at the unit.
7. Flush the air/water syringe, high-speed handpiece, and ultrasonic scaler into the sink, cuspidor, or container for 30 seconds and disconnect from hoses.
8. Remove all surface covers (without touching the underlying surface) and discard in plastic-lined waste container at the unit.
9. Clean and disinfect patient care–related surfaces that were not covered and were contaminated during treatment. Cleaning and disinfection of surfaces that were covered is unnecessary unless they become contaminated during removal of the covers (see the aforementioned disinfection procedures).
10. Take instruments and handpieces to the decontamination/sterilizing area.
11. Remove and wash contaminated eyeglasses, and rinse and dry them. Avoid contaminating hair.
12. Remove and dispose of the disposable gown (if used) in the plastic-lined waste container at the unit. Untie the gown and pull it off over gloved hands, and do not touch underlying clothing or skin.
13. Remove gloves and discard them in the plastic-lined waste container.
RADIOGRAPHIC ASEPSIS
1. Before seating the patient, prepare the unit by covering or disinfecting all surfaces that will be touched or exposed to potentially infectious fluids.
2. Review or update the medical history of the patient.
3. After washing hands, gowning, and gloving, determine the appropriate number and type of films to be taken.
4. Obtain the films from a central distribution area or film dispenser while wearing clean gloves or cover the digital x-ray sensor with the appropriate barrier.
5. Reglove and expose the films or sensor in the recommended manner.
6. Place exposed films on a paper towel or in a cup. If film packs are precovered with plastic protectors, carefully remove the contaminated covers after exposure and drop the film packs onto a clean surface. Do not touch the film packs with contaminated gloves.
7. Remove surface covers from the unit or disinfect contaminated surfaces.
Darkroom Processing
2. Carry the films to the darkroom using caution not to touch doors, walls, work areas, or processors with contaminated gloves.
3. With gloved hands, carefully open the film packets and drop the films onto a clean paper towel. Place contaminated film wrappers into the designated refuse containers.
4. Remove contaminated gloves and place the films in the processor.
5. After processing, place the films into the appropriate mounts using care not to contaminate the films, mounts, or charts with instruments that were used in the operatory.
Daylight Loader Processing
1. Because of the limited operating space inside the loader and because the hand insertion sleeves cannot be disinfected, place only films that are not contaminated in the loader. This can be accomplished in two ways:
a. Film disinfection: After the films have been exposed, rinse them with water, soak them in an appropriate bleach or iodophor solution for 10 minutes, and while wearing clean gloves, rinse them with water and dry them with a clean paper towel. Place the films into the loader through the top. (Only plastic film packets may be disinfected.)
b. Preexposure wrapping: Wrap the film in plastic before placing it in the patient’s mouth. Film packs already protected with a removable plastic cover are available. After exposure, carefully open the outer wrapping or remove the cover and drop the film packet onto a clean surface. Use caution so that the clean packets do not touch the contaminated gloves or wrapping. Place the films in the loader through the top, and after donning new gloves, pass the hands through the insertion sleeves.
1. Miller, C.H. Handling negative issues: Taking patient x-rays. Dent Prod Rpt. 2006;39:72.
2. Miller, C.H. Infection control strategies for the dental office. In Ciancio S, ed.: ADA Guide to dental therapeutics, ed 3, Chicago: ADA Publishing, 2003.
3. Miller, C.H., Prevent invisible problems: Follow standard operating procedures. Dent Prod Rpt, 2004;38:96.
4. Miller, C.H., Palenik, C.J. Sterilization, disinfection and asepsis in dentistry. In: Block S.S., ed. Sterilization, disinfection and preservation. ed 5. Philadelphia: Lippincott Williams &Wilkins; 2001:1049–1068.
5. Miller, C.H., Palenik, C.J., Schaaf, J.E. Infection control manual. Indianapolis: Indiana University School of Dentistry; 2003.
Review Questions
MULTIPLE CHOICE
______1. All of the following surfaces except one may need to be cleaned and disinfected before each patient appointment. Which one is the exception?
a. cuspidor rim and control knob
c. drawer pulls and top edges of drawers that may be used
______2. When should handpiece lines be flushed?
a. before attaching the sterile handpiece
b. after attaching the sterile handpiece
______3. Operatory surfaces that were covered with plastic barriers during patient treatment:
a. are to remain covered for the next patient
______4. Gloves to be used in the patient’s mouth are to be put on:
______5. When should an uncovered, contaminated operatory surface be cleaned and disinfected?