Managing Dental Infection Control

Documents to Request

• Current Exposure Control Plan (ECP)
• Sterilization monitoring logs (biological, chemical, mechanical indicators)
• DUWL testing results (heterotrophic plate count or ATP testing)
• Staff immunization records and HBV declination forms
• OSHA 300 log and sharps injury log
• Equipment maintenance records for autoclaves and handpieces
• Material Safety Data Sheets (SDS) for disinfectants and sterilants
• Previous inspection reports (state dental board, OSHA)

Step 1: Exposure Control Plan Review

Required ECP Components (29 CFR 1910.1030)

Exposure Determination Categories

• Category I: Tasks that always involve exposure (scaling, surgery, suctioning, instrument processing)
• Category II: Tasks that may involve exposure under certain conditions (radiography, lab work)
• Category III: Tasks that never involve exposure (scheduling, billing without patient contact)

Step 2: Instrument Processing and Sterilization Monitoring

Instrument Classification (Spaulding System)

Sterilization Monitoring — Three Tiers

1. Mechanical monitoring: Record time, temperature, and pressure for every cycle from autoclave gauges or printout
2. Chemical indicators: Use internal (Type 4/5) chemical indicator inside every package; external (Type 1) indicator on outside of every package
3. Biological indicators (BI): Run spore test (Geobacillus stearothermophilus for steam) at least weekly; process a BI with every implantable device load

Failed Spore Test Protocol

1. Remove autoclave from service immediately
2. Recall all items processed since last passing BI — do NOT use
3. Retest with three consecutive BI runs
4. If any BI fails again, have autoclave serviced and retested before returning to use
5. Document the entire incident including recall actions in the sterilization log

Step 3: Dental Unit Waterline Management

CDC Standard

Dental unit water must meet EPA drinking water standard: ≤ 500 CFU/mL of heterotrophic bacteria.

DUWL Protocol

1. Install anti-retraction valves on all handpiece connections
2. Flush waterlines for 20–30 seconds between patients
3. Flush all lines for 2 minutes at the start of each day
4. Treat waterlines with EPA-registered product per manufacturer's protocol (chemical tablets, continuous dosing, or cartridge filters)
5. Test water output at least quarterly using commercial HPC mail-in kits or in-office ATP testing
6. Use sterile water or sterile saline delivered through a separate sterile irrigation system for all surgical procedures
7. Document all test results; if > 500 CFU/mL, shock-treat and retest before clinical use

Step 4: Surface Disinfection and Clinical Contact Management

Surface Categories

• Clinical contact surfaces: Light handles, bracket trays, switches, chair controls, countertops in the operatory
• Housekeeping surfaces: Floors, walls, sinks (lower contamination risk)

Disinfection Protocol for Clinical Contact Surfaces

1. Clean with detergent to remove visible debris
2. Apply EPA-registered hospital disinfectant with tuberculocidal claim (or intermediate-level disinfectant)
3. Allow full wet contact time per manufacturer label — never wipe dry prematurely
4. Alternatively, use single-use barrier covers (plastic wrap, sticky backs) and replace between patients

Special Considerations

• Blood spills require intermediate-level disinfectant (tuberculocidal) at minimum
• SARS-CoV-2 and similar respiratory pathogens: follow current CDC supplemental guidance for enhanced PPE and aerosol management
• Impressions and prosthetics must be rinsed and disinfected before transport to lab

Step 5: Personal Protective Equipment (PPE) Standards

PPE Requirements by Task

PPE Donning and Doffing Sequence

Donning (in order): Gown → Mask → Eyewear → Gloves Doffing (in order): Gloves → Hand hygiene → Eyewear → Gown → Mask → Hand hygiene

Hand Hygiene Requirements

• Perform hand hygiene before donning gloves and after removing gloves
• Use alcohol-based hand rub (ABHR, 60–95% ethanol or isopropanol) for routine hand hygiene
• Wash with soap and water when hands are visibly soiled or contaminated with blood/body fluids
• Hand hygiene compliance target: ≥ 90% per direct observation audit

Step 6: Regulated Waste Management

Waste Classification and Disposal

Amalgam Separator Compliance

• EPA Dental Rule (40 CFR Part 441, effective July 2020): All dental practices that place or remove amalgam must install and maintain an ISO 11143-compliant amalgam separator
• Separator must capture ≥ 95% of amalgam particulate
• Maintain separator per manufacturer IFU; document replacement schedule
• Recycle collected amalgam through a certified recycler; retain recycling certificates

Step 7: Exposure Incident Management

Post-Exposure Steps (OSHA-required)

1. Immediate wound care: Wash puncture sites with soap and water; flush mucous membranes with water
2. Report: Employee reports incident to ICC; ICC completes sharps injury log entry
3. Source patient evaluation: Request consent for HBV, HCV, HIV testing of source patient
4. Exposed employee evaluation: Baseline blood draw for HBV, HCV, HIV; offer HBV post-exposure prophylaxis if non-immune
5. Healthcare professional evaluation: Refer to designated healthcare professional within 24 hours
6. Written opinion: Obtain healthcare professional's written opinion within 15 days
7. Follow-up testing: Per PEP protocol (typically 6 weeks, 3 months, 6 months)
8. Documentation: File incident in OSHA 300 log if it meets recording criteria; maintain records for duration of employment + 30 years

Checkpoint B: Post-Implementation Alignment (Mandatory)

1. Has the Exposure Control Plan been reviewed and updated within the past 12 months?
2. Are biological indicator results documented weekly with no unresolved failures?
3. Are DUWL test results all ≤ 500 CFU/mL, with corrective action documented for any exceedance?
4. Do all staff have current HBV vaccination or signed declination on file?
5. Has every sharps injury in the past year been logged with complete source patient and follow-up information?

Quality Audit

Guidelines

• Never flash-sterilize (immediate-use steam sterilization) as a substitute for proper instrument inventory management — use only when delay would harm the patient
• Treat all patients as potentially infectious regardless of disclosed history (Standard Precautions)
• Replace single-use items (needles, anesthetic carpules, prophylaxis cups, suction tips) after every patient — no reprocessing
• Dental handpieces MUST be heat-sterilized between patients — surface disinfection alone is insufficient per CDC guidance
• Maintain separate clean and dirty zones in the sterilization area with unidirectional instrument flow
• Document everything contemporaneously — retrospective reconstruction of sterilization logs is not defensible during an OSHA inspection
• Stay current with CDC updates, ADA guidance, and state dental board regulations — the 2003 CDC guidelines are the floor, not the ceiling
• When in doubt about a device's reprocessing instructions, consult the manufacturer's IFU (Instructions for Use) — deviations must be documented with a risk justification