Infection control

Kathy J. Eklund, RDH, MHP

Infection Control and Occupational Health, The Forsyth Institute, 140 Fenway, Boston,
MA 02115, USA
Preventing disease transmission is the primary goal of infection control.
Evidence-based strategies for disease prevention and risk reduction
comprise the foundation for an eective program. Policies, procedures,
and practices are designed to prevent work-related injuries and infections in
dental health care personnel (DHCP) and health care-associated infections
in patients. Site-specic standard operating procedures facilitate DHCP in
the day-to-day implementation of the program.
Rationale for infection control
Several key concepts support the rational for the need for infection
control:
Because of the nature of dental care, patients and DHCP have the
potential for exposure to a variety of microorganisms in dental health
care settings. Some of these microorganisms are or have the potential to
be pathogenic in humans.
Microorganisms may be transmitted in health care settings (including
dental health care settings) through several routes, including (1) direct
contact with blood, saliva, and other oral uids, or other body uids; (2)
indirect contact with contaminated instruments, operatory equipment,
or environmental surfaces; and (3) contact with airborne contaminants
present either in droplets (eg, spatter) or in aerosolization of micro-
organisms that can remain suspended for long periods of time [1].
After a route of transmission is established, the chain of infection
must be complete and intact for infection to occur [2]. The chain of
infection requires (1) a pathogenic organism of sucient virulence and
in adequate numbers (ie, dosage) to cause disease; (2) a suitable
reservoir or source that allows the pathogen to survive and multiply (eg,
E-mail address: keklund@forsyth.org
0011-8532/03/$ - see front matter 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0011-8532(03)00060-0
Dent Clin N Am 47 (2003) 697708
blood); (3) a mechanism of transmission from the source to the host; (4)
a portal of entry through which the pathogen may enter the host; and
(5) a susceptible host (ie, nonimmune individual).
Infection control strategies (policies, procedures, and practices) are
intended to break one or more of these links in the chain, thereby
preventing infection. Such strategies include immunizations; hand
hygiene and personal and environmental barrier techniques; eective
cleaning, disinfection, and sterilization procedures; and aseptic tech-
niques and practices to reduce the risk of exposure to blood, other body
uids, or infectious agents [1].
Infection control precautions
Infection control precautions consist of policy, procedure, and practice
strategies that are designed to prevent health care-associated infections in
health care personnel and patients. Previous Centers for Disease Control
and Prevention (CDC)established infection control precautions recom-
mendations are recognized as a standard of care in the United States. In the
1980s and into the early 1990s, the CDC primarily focused on the use of
universal precautions, or blood and body uid precautions, to reduce the
risk of transmission of bloodborne pathogens among health care personnel
and patients [36]. Rationale for universal precautions arises from the fact
that many persons with bloodborne infections cannot be identied due to
subclinical and undiagnosed infections. These recommendations emphasized
the need to treat blood and other body uids contaminated with blood from
all patients as potentially infectious [38].
In 1996, the CDC combined the major components of universal (blood
and body uid) precautions (designed to reduce the risk of transmission
of bloodborne pathogens) and body substance isolation precautions
(designed to reduce the risk of transmission of pathogens from moist body
substances) into one set of precautions known as standard precautions
[9]. Standard precautions apply to blood; to all body uids, secretions, and
excretions except sweat, regardless of whether they contain visible blood;
to nonintact skin; and to mucous membranes [1]. Standard precautions
are designed to reduce the risk of transmission of microorganisms from
both recognized and unrecognized sources of infection. As such, standard
precautions assume all patients are potentially infectious with a variety of
pathogenic microorganisms. Elements of standard precautions are then
determined by the infectious exposure risks of a procedure.
Standard precautions, put simply, are procedure-specic precautions
rather than patient-specic precautions. DHCP may decide to wear two pair
of gloves (double glove) for a surgical procedure. The decision to double
glove is based on the duration of the procedure and the anticipated exposure
to blood, not the known or perceived infectious serostatus of the patient.
698 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
Standard precautions are considered adequate for most infectious
diseases [1]. Additional precautions known as transmission-based precau-
tions are necessary for interrupting the spread of certain pathogens such as
tuberculosis, inuenza, and chicken pox that are transmitted by air, droplet,
and indirect or direct contact with contaminated sources [1,9]. These
precautions include a variety of strategies beyond standard precautions,
including ventilation requirements, special respiratory protection for health
care personnel, postponement of nonemergent dental procedures, and other
measures [1].
Exposure prevention
Primary methods used to prevent occupational exposures to infectious
agents in dental health care settings include engineering and work practice
controls and the use of personal protective equipment.
Engineering controls reduce exposure either by removing, eliminating, or
isolating the infectious hazard. These controls are frequently technology
based and often incorporate safer designs of instruments and devices.
Whenever possible, engineering controls should be used as the primary
method to reduce exposures to bloodborne pathogens by sharp instruments
and needles. Studies suggest that devices such as self-sheathing anesthetic
needles and dental units designed to shield burs in handpieces may reduce
percutaneous injuries [1012].
Work practice controls are behavior-based and are intended to
reduce the risk of exposure by changing the manner in which a task is
performed. Specic work practices must be provided to protect personnel
whose responsibilities include handling, using, assembling, or processing
contaminated patient care items and devices and environmental surfaces
[6,13,14].
Spaulding classication schemepatient care instruments, devices, and
environmental surfaces
Cleaning, disinfection, and sterilization of patient care items and surfaces
are integral components of an infection control program. DHCP should
have an understanding of the science behind these processes and their
application.
In 1968, Earle H. Spaulding devised a logical approach to disinfection
and sterilization of patient care instruments and equipment [2,15,16]. Based
on the risk of transmitting infection during use, Spaulding described three
categories of instruments and devices and the level of sterilization/
disinfection necessary for the safe use of each category: critical, semicritical,
and noncritical [2,17]. Table 1 summarizes how these categories apply to
processing patient care items.
699 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
In 1991, the Spaulding noncritical category was expanded to include
environmental surfaces to dene more clearly the relative risk of disease
transmission by these surfaces [2]. Noncritical environmental surfaces carry
the least risk of disease transmission. Environmental surfaces can be further
divided into clinical-contact surfaces and housekeeping surfaces (see Table 1).
In the United States, only those products and devices cleared for market
by the United States Food and Drug Administration (FDA) as medical
devices sterilizers and chemical sterilants/high level disinfectants should be
used to process critical and semicritical patients care items. Only those
chemical agents registered with the United States Environmental Protection
Agency (EPA) as hospital-grade germicides should be used in health care
settings for the decontamination of noncritical patient care items and
clinical-contact environmental surfaces. Manufacturers of products and
materials should provide information regarding materials compatibility with
chemical germicides, whether or not the equipment can be safely immersed
Table 1
Categories of patient care items and environmental surfaces
Category Denition Equipment examples
Critical
Patient care items Penetrate soft tissue; contact
bone; enter into or contact the
bloodstream or other normally
sterile tissue of the mouth
Surgical instruments, scalers,
scalpel blades, surgical
dental burs
Semicritical
Patient care items Contact mucous membranes
but will not penetrate soft
tissue; contact bone; enter into
or contact the bloodstream or
other normally sterile tissue
of the mouth
Dental mouth mirror,
amalgam condenser,
reusable dental impression
trays, dental handpieces
a
Noncritical
Patient care items Contact with intact skin Blood pressure cu,
stethoscope, pulse oximeter
Environmental surfaces
Clinical contact Dental equipment surfaces
b
that
are directly contacted by
contaminated instruments, devices,
dental materials, hands, or gloves
Light handles, switches on
dental equipment, drawer
handles, dental radiograph
equipment, countertops
Housekeeping Surfaces that require regular
cleaning and removal of
soil and dust
Floors, walls, sinks
a
Although considered a semicritical item, heat sterilization is recommended. See the specic
equipment and device manufacturers instructions for detailed processing information for
dental handpieces and other devices attached to air and/or waterlines.
b
Nonclinical surfaces (eg, pencil, telephone handle, doorknob) inadvertently contacted with
a contaminated hand/glove also should be cleaned and disinfected after patient treatment.
Modied from CDC Guideline for infection central in dental health-care settings. Atlanta
(GA): Centers for Disease Control; 2003, in press; with permission.
700 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
for cleaning, and how the equipment should be decontamintated or
protected with environmental surface barriers and covers [13]. A summary
of sterilization and disinfection methods is described in Table 2.
Infection control program development
An infection control program has several core elements:
An infection control health services program for health care personnel
Exposure prevention strategies including selection and use of engineer-
ing controls and safe work practices
Hand hygiene
Personal barrier protection
Infection control management of patient care instruments and devices
Environmental infection control
Program evaluation/program quality
These elements provide the broad template for developing an individual-
ized infection control program. Each of the elements has fundamental policy
and procedure components that are common to most health care settings. The
procedure- and device-specic issues of each element vary in the area of health
care services and, to some degree, in the setting (eg, ambulatory versus hos-
pital). Dental health care settings are primarily in ambulatory care settings.
The component content area for each of the core elements is determined
by (1) a systematic review of the literature, including guidelines and
recommendations of the CDC; (2) relevant regulations and statutes at the
federal, state, and local levels; (3) information regarding technology and
techniques from the scientic literature; (4) professional recommendations
and resources; and (5) setting-specic considerations.
Guidelines and recommendations from the CDC set the basis for
a standard of care in infection control in the United States. Guidelines are
developed in a systematic manner and reect current scientic evidence and
expert analysis. In 1993, the CDC published Recommended Infection Control
Practices for Dentistry [6], which is currently being revised and is scheduled
for publication in the fall of 2003. Dentistry-specic recommendations
provide direct guidance for dental health care settings. Other CDC
guidelines for health care settings also have implications for dentistry
(Table 3). CDC guidelines are accessible electronically on the CDC Web site
at http://www.cdc.gov/ncidod/hip/. The revised guideline for infection
control in dental health care settings will be available at this site when it
is ocially published in Morbidity and Mortality Weekly Report.
CDC guidelines and recommendations (and in particular, specic
recommendations for dentistry) form the foundation of any infection
control program. The CDC Division of Oral Health (http://www.cdc.gov/
OralHealth/infection_control/index.htm) provides such dental-specic in-
formation.
701 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
T
a
b
l
e
2
M
e
t
h
o
d
s
f
o
r
s
t
e
r
i
l
i
z
a
t
i
o
n
o
r
d
i
s
i
n
f
e
c
t
i
o
n
A
p
p
l
i
c
a
t
i
o
n
i
n
h
e
a
l
t
h
c
a
r
e
P
r
o
c
e
s
s
a
D
e

n
i
t
i
o
n
M
e
t
h
o
d
E
x
a
m
p
l
e
P
a
t
i
e
n
t
c
a
r
e
i
t
e
m
s
E
n
v
i
r
o
n
m
e
n
t
a
l
s
u
r
f
a
c
e
s
S
t
e
r
i
l
i
z
a
t
i
o
n
D
e
s
t
r
o
y
s
a
l
l
m
i
c
r
o
o
r
g
a
n
i
s
m
s
i
n
c
l
u
d
i
n
g
b
a
c
t
e
r
i
a
l
s
p
o
r
e
s
H
e
a
t
a
u
t
o
m
a
t
e
d
H
i
g
h
t
e
m
p
e
r
a
t
u
r
e
S
t
e
a
m
(
g
r
a
v
i
t
y
;
p
r
e
v
a
c
u
m
)
D
r
y
h
e
a
t
(
s
t
a
t
i
c
;
c
o
n
v
e
c
t
i
o
n
)
U
n
s
a
t
u
r
a
t
e
d
c
h
e
m
i
c
a
l
v
a
p
o
r
C
r
i
t
i
c
a
l
a
n
d
h
e
a
t
-
t
o
l
e
r
a
n
t
s
e
m
i
c
r
i
t
i
c
a
l
C
r
i
t
i
c
a
l
a
n
d
h
e
a
t
-
t
o
l
e
r
a
n
t
o
r
-
s
e
n
s
i
t
i
v
e
s
e
m
i
c
r
i
t
i
c
a
l
N
o
t
a
p
p
l
i
c
a
b
l
e
L
o
w
t
e
m
p
e
r
a
t
u
r
e
E
T
O
,
P
l
a
s
m
a
s
t
e
r
i
l
i
z
a
t
i
o
n
L
i
q
u
i
d
i
m
m
e
r
s
i
o
n
C
h
e
m
i
c
a
l
s
t
e
r
i
l
a
n
t
b
(
e
g
,
g
l
u
t
a
r
a
l
d
e
h
y
d
e
s
,
h
y
d
r
o
g
e
n
p
e
r
o
x
i
d
e
,
h
y
d
r
o
g
e
n
p
e
r
o
x
i
d
e
a
n
d
p
e
r
a
c
e
t
i
c
a
c
i
d
)
H
e
a
t
-
s
e
n
s
i
t
i
v
e
c
r
i
t
i
c
a
l
o
r
s
e
m
i
c
r
i
t
i
c
a
l
H
i
g
h
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
i
o
n
M
a
y
d
e
s
t
r
o
y
a
l
l
m
i
c
r
o
o
r
g
a
n
i
s
m
s
b
u
t
n
o
t
n
e
c
e
s
s
a
r
i
l
y
h
i
g
h
n
u
m
b
e
r
s
o
f
b
a
c
t
e
r
i
a
l
s
p
o
r
e
s
H
e
a
t
a
u
t
o
m
a
t
e
d
L
i
q
u
i
d
i
m
m
e
r
s
i
o
n
W
a
s
h
e
r
d
i
s
i
n
f
e
c
t
o
r
C
h
e
m
i
c
a
l
s
t
e
r
i
l
a
n
t
b
(
e
g
,
g
l
u
t
a
r
a
l
d
e
h
y
d
e
s
,
o
r
t
h
o
p
h
t
h
a
l
a
l
d
e
h
y
d
e
,
h
y
d
r
o
g
e
n
p
e
r
o
x
i
d
e
)
H
e
a
t
-
s
e
n
s
i
t
i
v
e
s
e
m
i
c
r
i
t
i
c
a
l
N
o
t
a
p
p
l
i
c
a
b
l
e
I
n
t
e
r
m
e
d
i
a
t
e
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
i
o
n
M
a
y
d
e
s
t
r
o
y
v
e
g
e
t
a
t
i
v
e
b
a
c
t
e
r
i
a
,
m
o
s
t
f
u
n
g
i
,
a
n
d
m
o
s
t
v
i
r
u
s
e
s
;
i
n
a
c
t
i
v
a
t
e
s
M
y
c
o
b
a
c
t
e
r
i
u
m
t
u
b
e
r
c
u
l
o
s
i
s
v
a
r
b
o
v
i
s
N
o
t
n
e
c
e
s
s
a
r
i
l
y
c
a
p
a
b
l
e
o
f
k
i
l
l
i
n
g
b
a
c
t
e
r
i
a
l
s
p
o
r
e
s
L
i
q
u
i
d
c
o
n
t
a
c
t
H
o
s
p
i
t
a
l
d
i
s
i
n
f
e
c
t
a
n
t
w
i
t
h
t
u
b
e
r
c
u
l
o
c
i
d
a
l
a
c
t
i
v
i
t
y
l
a
b
e
l
c
l
a
i
m
c
(
e
g
,
c
h
l
o
r
i
n
e
-
c
o
n
t
a
i
n
i
n
g
p
r
o
d
u
c
t
s
,
q
u
a
t
e
r
n
a
r
y
a
m
m
o
n
i
u
m
c
o
m
p
o
u
n
d
s
w
i
t
h
a
l
c
o
h
o
l
,
p
h
e
n
o
l
i
c
s
,
b
r
o
m
i
d
e
s
,
i
o
d
o
p
h
o
r
s
,
h
o
u
s
e
h
o
l
d
b
l
e
a
c
h
d
)
N
o
n
c
r
i
t
i
c
a
l
w
i
t
h
v
i
s
i
b
l
e
b
l
o
o
d
C
l
i
n
i
c
a
l
c
o
n
t
a
c
t
s
u
r
f
a
c
e
s
B
l
o
o
d
s
p
i
l
l
s
o
n
c
l
i
n
i
c
a
l
c
o
n
t
a
c
t
o
r
h
o
u
s
e
k
e
e
p
i
n
g
s
u
r
f
a
c
e
s
702 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
L
o
w
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
i
o
n
M
a
y
d
e
s
t
r
o
y
m
o
s
t
v
e
g
e
t
a
t
i
v
e
b
a
c
t
e
r
i
a
,
s
o
m
e
f
u
n
g
i
,
a
n
d
s
o
m
e
v
i
r
u
s
e
s
.
D
o
e
s
n
o
t
i
n
a
c
t
i
v
a
t
e
M
y
c
o
b
a
c
t
e
r
i
u
m
t
u
b
e
r
c
u
l
o
s
i
s
v
a
r
b
o
v
i
s
L
i
q
u
i
d
c
o
n
t
a
c
t
S
a
n
i
t
i
z
e
r
s
e
(
e
g
,
q
u
a
t
e
r
n
a
r
y
a
m
m
o
n
i
u
m
c
o
m
p
o
u
n
d
s
,
s
o
m
e
p
h
e
n
o
l
i
c
s
,
s
o
m
e
i
o
d
o
p
h
o
r
s
)
f
N
o
n
c
r
i
t
i
c
a
l
w
i
t
h
n
o
v
i
s
i
b
l
e
c
o
n
t
a
m
i
n
a
t
i
o
n
/
b
l
o
o
d
C
l
i
n
i
c
a
l
c
o
n
t
a
c
t
s
u
r
f
a
c
e
s
H
o
u
s
e
k
e
e
p
i
n
g
s
u
r
f
a
c
e
s
A
b
b
r
e
v
i
a
t
i
o
n
:
E
T
O
,
E
t
h
y
l
e
n
e
d
i
a
m
i
n
e
-
t
e
t
r
a
a
c
e
t
i
c
a
c
i
d
.
a
T
h
e
U
S
E
n
v
i
r
o
n
m
e
n
t
a
l
P
r
o
t
e
c
t
i
o
n
A
g
e
n
c
y
(
E
P
A
)
a
n
d
t
h
e
U
S
F
o
o
d
a
n
d
D
r
u
g
A
d
m
i
n
i
s
t
r
a
t
i
o
n
(
F
D
A
)
r
e
g
u
l
a
t
e
c
h
e
m
i
c
a
l
g
e
r
m
i
c
i
d
e
s
u
s
e
d
i
n
h
e
a
l
t
h
c
a
r
e
s
e
t
t
i
n
g
s
.
T
h
e
F
D
A
r
e
g
u
l
a
t
e
s
c
h
e
m
i
c
a
l
s
t
e
r
i
l
a
n
t
s
u
s
e
d
o
n
c
r
i
t
i
c
a
l
a
n
d
s
e
m
i
c
r
i
t
i
c
a
l
d
e
v
i
c
e
s
,
a
n
d
t
h
e
E
P
A
r
e
g
u
l
a
t
e
s
d
i
s
i
n
f
e
c
t
a
n
t
s
u
s
e
d
o
n
n
o
n
c
r
i
t
i
c
a
l
s
u
r
f
a
c
e
s
.
T
h
e
F
D
A
a
l
s
o
r
e
g
u
l
a
t
e
s
m
e
d
i
c
a
l
d
e
v
i
c
e
s
i
n
c
l
u
d
i
n
g
s
t
e
r
i
l
i
z
e
r
s
.
T
h
e
f
o
l
l
o
w
i
n
g
I
n
t
e
r
n
e
t
s
i
t
e
s
c
a
n
b
e
u
s
e
d
t
o
o
b
t
a
i
n
m
o
r
e
i
n
f
o
r
m
a
t
i
o
n
o
n
c
h
e
m
i
c
a
l
g
e
r
m
i
c
i
d
e
s
a
n
d
m
e
d
i
c
a
l
d
e
v
i
c
e
s
:
h
t
t
p
:
/
/
w
w
w
.
e
p
a
.
g
o
v
/
o
p
p
a
d
0
0
1
/
c
h
e
m
r
e
g
i
n
d
e
x
.
h
t
m
a
n
d
h
t
t
p
:
/
/
w
w
w
.
f
d
a
.
g
o
v
/
c
d
r
h
/
i
n
d
e
x
.
h
t
m
l
a
n
d
h
t
t
p
:
/
/
w
w
w
.
f
d
a
.
g
o
v
.
c
d
r
h
/
o
d
e
/
g
e
r
m
l
a
b
.
h
t
m
l
.
b
C
o
n
t
a
c
t
t
i
m
e
i
s
t
h
e
s
i
n
g
l
e
m
o
s
t
i
m
p
o
r
t
a
n
t
v
a
r
i
a
b
l
e
b
e
t
w
e
e
n
s
t
e
r
i
l
i
z
a
t
i
o
n
a
n
d
h
i
g
h
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
i
o
n
w
i
t
h
a
l
i
q
u
i
d
c
h
e
m
i
c
a
l
s
t
e
r
i
l
a
n
t
/
d
i
s
i
n
f
e
c
t
a
n
t
a
g
e
n
t
.
T
h
e
F
D
A
d
e

n
e
s
a
h
i
g
h
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
a
n
t
a
s
a
s
t
e
r
i
l
a
n
t
u
s
e
d
u
n
d
e
r
t
h
e
s
a
m
e
c
o
n
t
a
c
t
c
o
n
d
i
t
i
o
n
s
e
x
c
e
p
t
f
o
r
a
s
h
o
r
t
e
r
i
m
m
e
r
s
i
o
n
t
i
m
e
t
h
a
n
f
o
r
s
t
e
r
i
l
i
z
a
t
i
o
n
.
T
h
e
f
o
l
l
o
w
i
n
g
I
n
t
e
r
n
e
t
s
i
t
e
c
a
n
b
e
u
s
e
d
t
o
o
b
t
a
i
n
m
o
r
e
i
n
f
o
r
m
a
t
i
o
n
:
h
t
t
p
:
/
/
w
w
w
.
f
d
a
.
g
o
v
/
c
d
r
h
/
o
d
e
/
3
9
7
.
p
d
f
.
c
T
h
e
t
u
b
e
r
c
u
l
o
c
i
d
a
l
c
l
a
i
m
i
s
u
s
e
d
a
s
a
b
e
n
c
h
m
a
r
k
t
o
m
e
a
s
u
r
e
g
e
r
m
i
c
i
d
a
l
p
o
t
e
n
c
y
.
T
u
b
e
r
c
u
l
o
s
i
s
i
s
t
r
a
n
s
m
i
t
t
e
d
b
y
w
a
y
o
f
t
h
e
a
i
r
b
o
r
n
e
r
o
u
t
e
r
a
t
h
e
r
t
h
a
n
b
y
e
n
v
i
r
o
n
m
e
n
t
a
l
s
u
r
f
a
c
e
s
,
a
n
d
a
c
c
o
r
d
i
n
g
l
y
,
t
h
e
u
s
e
o
f
s
u
c
h
p
r
o
d
u
c
t
s
o
n
e
n
v
i
r
o
n
m
e
n
t
a
l
s
u
r
f
a
c
e
s
p
l
a
y
s
n
o
r
o
l
e
i
n
p
r
e
v
e
n
t
i
n
g
t
h
e
s
p
r
e
a
d
o
f
t
u
b
e
r
c
u
l
o
s
i
s
i
n
a
n
y
s
e
t
t
i
n
g
.
B
e
c
a
u
s
e
m
y
c
o
b
a
c
t
e
r
i
a
h
a
v
e
a
m
o
n
g
t
h
e
h
i
g
h
e
s
t
i
n
t
r
i
n
s
i
c
l
e
v
e
l
o
f
r
e
s
i
s
t
a
n
c
e
a
m
o
n
g
t
h
e
v
e
g
e
t
a
t
i
v
e
b
a
c
t
e
r
i
a
,
v
i
r
u
s
e
s
,
a
n
d
f
u
n
g
i
,
a
n
y
g
e
r
m
i
c
i
d
e
w
i
t
h
a
t
u
b
e
r
c
u
l
o
c
i
d
a
l
c
l
a
i
m
o
n
t
h
e
l
a
b
e
l
(
e
g
,
a
n
i
n
t
e
r
m
e
d
i
a
t
e
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
a
n
t
)
i
s
c
o
n
s
i
d
e
r
e
d
c
a
p
a
b
l
e
o
f
i
n
a
c
t
i
v
a
t
i
n
g
a
b
r
o
a
d
s
p
e
c
t
r
u
m
o
f
p
a
t
h
o
g
e
n
s
i
n
c
l
u
d
i
n
g
m
u
c
h
l
e
s
s
r
e
s
i
s
t
a
n
t
o
r
g
a
n
i
s
m
s
s
u
c
h
t
h
e
b
l
o
o
d
b
o
r
n
e
p
a
t
h
o
g
e
n
s
(
e
g
,
h
e
p
a
t
i
t
i
s
B
v
i
r
u
s
,
h
e
p
a
t
i
t
i
s
C
v
i
r
u
s
,
a
n
d
H
I
V
)
.
I
t
i
s
t
h
i
s
b
r
o
a
d
-
s
p
e
c
t
r
u
m
c
a
p
a
b
i
l
i
t
y
,
r
a
t
h
e
r
t
h
a
n
t
h
e
p
r
o
d
u
c
t

s
s
p
e
c
i

c
p
o
t
e
n
c
y
a
g
a
i
n
s
t
m
y
c
o
b
a
c
t
e
r
i
a
,
t
h
a
t
i
s
t
h
e
b
a
s
i
s
f
o
r
p
r
o
t
o
c
o
l
s
a
n
d
r
e
g
u
l
a
t
i
o
n
s
d
i
c
t
a
t
i
n
g
u
s
e
o
f
t
u
b
e
r
c
u
l
o
c
i
d
a
l
c
h
e
m
i
c
a
l
s
f
o
r
s
u
r
f
a
c
e
d
i
s
i
n
f
e
c
t
i
o
n
.
d
A
l
t
h
o
u
g
h
n
o
t
r
e
g
i
s
t
e
r
e
d
w
i
t
h
t
h
e
E
P
A
a
s
a
d
i
s
i
n
f
e
c
t
a
n
t
,
a
f
r
e
s
h
s
o
l
u
t
i
o
n
o
f
s
o
d
i
u
m
h
y
p
o
c
h
l
o
r
i
t
e
(
h
o
u
s
e
h
o
l
d
b
l
e
a
c
h
)
p
r
e
p
a
r
e
d
d
a
i
l
y
i
s
a
n
i
n
e
x
p
e
n
s
i
v
e
a
n
d
e

e
c
t
i
v
e
i
n
t
e
r
m
e
d
i
a
t
e
-
l
e
v
e
l
g
e
r
m
i
c
i
d
e
.
C
o
n
c
e
n
t
r
a
t
i
o
n
s
r
a
n
g
i
n
g
f
r
o
m
5
0
0
t
o
8
0
0
p
p
m
o
f
c
h
l
o
r
i
n
e
(
a
1
:
1
0
0
d
i
l
u
t
i
o
n
o
f
b
l
e
a
c
h
a
n
d
t
a
p
w
a
t
e
r
o
r
2
o
z
o
f
b
l
e
a
c
h
t
o
1
g
a
l
o
f
w
a
t
e
r
)
a
r
e
e

e
c
t
i
v
e
o
n
e
n
v
i
r
o
n
m
e
n
t
a
l
s
u
r
f
a
c
e
s
t
h
a
t
h
a
v
e
b
e
e
n
c
l
e
a
n
e
d
o
f
v
i
s
i
b
l
e
c
o
n
t
a
m
i
n
a
t
i
o
n
.
A
p
p
r
o
p
r
i
a
t
e
p
e
r
s
o
n
a
l
p
r
o
t
e
c
t
i
v
e
e
q
u
i
p
m
e
n
t
(
e
g
,
g
l
o
v
e
s
,
g
o
g
g
l
e
s
)
s
h
o
u
l
d
b
e
w
o
r
n
w
h
e
n
p
r
e
p
a
r
i
n
g
h
y
p
o
c
h
l
o
r
i
t
e
s
o
l
u
t
i
o
n
s
[
1
3
,
1
8
]
.
C
o
m
m
e
r
c
i
a
l
c
h
l
o
r
i
n
e
-
b
a
s
e
d
p
r
o
d
u
c
t
s
t
h
a
t
a
r
e
E
P
A
r
e
g
i
s
t
e
r
e
d
a
s
i
n
t
e
r
m
e
d
i
a
t
e
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
a
n
t
s
a
r
e
a
v
a
i
l
a
b
l
e
.
C
a
u
t
i
o
n
s
h
o
u
l
d
b
e
e
x
e
r
c
i
s
e
d
b
e
c
a
u
s
e
c
h
l
o
r
i
n
e
s
o
l
u
t
i
o
n
s
a
r
e
c
o
r
r
o
s
i
v
e
t
o
m
e
t
a
l
s
,
e
s
p
e
c
i
a
l
l
y
a
l
u
m
i
n
u
m
.
e
G
e
r
m
i
c
i
d
e
s
l
a
b
e
l
e
d
a
s

h
o
s
p
i
t
a
l
d
i
s
i
n
f
e
c
t
a
n
t

m
u
s
t
p
a
s
s
p
o
t
e
n
c
y
t
e
s
t
s
f
o
r
a
c
t
i
v
i
t
y
a
g
a
i
n
s
t
t
h
r
e
e
r
e
p
r
e
s
e
n
t
a
t
i
v
e
m
i
c
r
o
o
r
g
a
n
i
s
m
s
:
P
s
e
u
d
o
m
o
n
a
s
a
e
r
u
g
i
n
o
s
a
,
S
t
a
p
h
y
l
o
c
o
c
c
u
s
a
u
r
e
u
s
,
a
n
d
S
a
l
m
o
n
e
l
l
a
c
h
o
l
e
r
a
s
u
i
s
.
f
E
P
A
-
r
e
g
i
s
t
e
r
e
d
l
o
w
-
l
e
v
e
l
d
i
s
i
n
f
e
c
t
a
n
t
w
i
t
h
l
a
b
e
l
c
l
a
i
m
a
g
a
i
n
s
t
H
I
V
a
n
d
h
e
p
a
t
i
t
i
s
B
v
i
r
u
s
.
M
o
d
i

e
d
f
r
o
m
C
D
C
.
G
u
i
d
e
l
i
n
e
f
o
r
i
n
f
e
c
t
i
o
n
c
o
n
t
r
o
l
i
n
d
e
n
t
a
l
h
e
a
l
t
h
-
c
a
r
e
s
e
t
t
i
n
g
s
.
A
t
l
a
n
t
a
(
G
A
)
:
C
e
n
t
e
r
s
f
o
r
D
i
s
e
a
s
e
C
o
n
t
r
o
l
a
n
d
P
r
e
v
e
n
t
i
o
n
;
2
0
0
3
,
i
n
p
r
e
s
s
;
w
i
t
h
p
e
r
m
i
s
s
i
o
n
.
703 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
CDC is not a regulatory agency, and the guidelines and recommenda-
tions are not specically regulated unless an individual state adopts, in
whole or in part, CDC guidelines as regulation. Other agencies at the
federal, state, and local level, however, regulate various aspects of infection
control in health settings.
The Occupational Safety and Health Agency (OSHA) of the United
States Department of Labor develops standards for workplaces and
regulates employers to help assure safe and healthful working conditions
in places of employment in the United States. The most commonly cited
OSHA regulation in the professional dental literature is the Bloodborne
Pathogens Standard (1910.1030, 1991) [13] and revisions that took eect in
2001. Other standards apply to dental health care settings and can be found
on OSHAs Web site at http://www.osha.gov/SLTC/dentistry/index.html.
Some states have federally recognized state OSHA programs. In these
states, standards must minimally meet the federal OSHA standard but may
Table 3
Published guidelines for infection control in health care settings, with specic implications for
dental health care settings
Document title Year Reference
Guidelines for Handwashing and Hospital
Environmental Control
1985 [8]
Recommendations for Preventing Transmission of
Human Immunodeciency Virus and Hepatitis B
Virus to Patients During Exposure-prone Invasive
Procedures
1991 [19]
Guidelines for Preventing the Transmission of
Mycobacterium tuberculosis in Health-care Facilities
1994 [20]
Guideline for Hand Washing and Hand Antisepsis
in Health-care Settings
1995 [21]
Guideline for Isolation Precautions in Hospitals 1996 [9]
Guideline for Selection and Use of Disinfectants 1996 [22]
Immunization of Health-care Workers 1997 [23]
Guideline for Infection Control in Health-care
Personnel
1998 [1]
Guideline for Prevention of Surgical Site Infection 1999 [24]
Updated US Public Health Service Guidelines for
the Management of Occupational Exposures to HBV,
HCV, and HIV and Recommendations for
Postexposure Prophylaxis
2001 [25]
Guidelines for Environmental Infection Control in
Health-care Facilities
2003 [18]
Guideline for Cleaning, Disinfection, and
Sterilization in Health-care Facilities
in press [26]
Guideline for Hand Hygiene in Health-care Settings 2002 [27]
Guideline for Infection Control in Dental Health-care
Settings
2003 [In press]
Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus.
Adapted from http://www.cdc.gov/ncidod/hip/.
704 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
exceed the standard in regulation scope and stringency. Health care settings
in these states must comply with the state-specic standard. Links to the
state OSHA programs are available at www.osha.gov.
The FDA (www.fda.org) regulates food, drugs, medical devices, bio-
logics, and radiologic agents and devices [28]. Safety and ecacy require-
ments are used to clear products and devices for market to the public. A
variety of products that impact the practice of dentistry and infection
control is regulated by FDA. Some of the dental devices that are regulated
by FDA include medical gloves, face masks, sterilizers, sterilization
packaging material, sterilization process indicators, biologic indicators,
sharps devices with engineered safety features, chemical sterilants, and other
medical devices and adjuncts to devices.
The EPA is another regulatory agency. The EPAs mission is to protect
human health and to safeguard the natural environmentair, water, and
land. EPA develops and enforces regulations that implement environmental
laws enacted by Congress. The EPA is responsible for researching and
setting national standards for a variety of environmental programs [29].
The EPA regulates and registers disinfectants used for infection control
in health care settings (eg, hospital-grade disinfectants). A list of EPA-
registered disinfectants is available on the EPA Web site at http://
www.epa.gov/oppad001/chemregindex.htm.
The CDC does not regulate, test, evaluate, or recommend specic brand-
name products or devices for infection control in dental health care settings;
however, it does provide recommendations and guidance on application of
EPA- and FDA-regulated products and devices.
State and local regulations impact various components of an infection
control program. Each state may vary in the agency and scope of regulatory
authority in the area of infection control. The following are examples of
state and local agencies:
Department of Public Health and health departments
Department of Environmental Protection
Department of Waste Water Resources
Boards of registration and licensure
Other specic state and local agencies
Professional organizations disseminate topic- and profession-specic
information through newsletters, journal publications, Web-based informa-
tion, education programs, and position papers. Professional journals can be
a source of published scientic infection control information. Professional
organizations may also provide input in the development of guidelines and
regulations.
Table 4 provides a sample list of Web-based infection control resources.
These resources provide specic information from the organization and
agency, as well as links to related information.
705 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
Infection control program evaluation
The primary goal of an infection control program is to provide a safe
working environment that will reduce the risk of health care-associated
infections among patients and occupational exposures among DHCP.
A secondary goal is compliance with existing CDC recommendations,
federal, state, and local regulations, and professional standards of care.
Evaluation is an ongoing and dynamic process of collecting and analyzing
information and rening policies, procedures, and practices. Examples of
infection control information used for program evaluation include
Appropriate immunization of DHCP
DHCP adherence to hand hygiene policies
Appropriate use of personal barrier protection
Observation of DHCP work practices and compliance with written
policies and procedures
Table 4
Web-based infection control resources
Resource Web site
Advisory Committee on Immunization
Practices
http://www.cdc.gov/nip/ACIP/default.htm
American Dental Association http://www.ada.org/
American Institute of Architects
Academy of Architecture for Health
http://www.aahaia.org
American Society of Heating, Refrigeration,
Air-conditioning Engineers
http://www.ashrae.org
Association for Professionals in Infection
Control and Epidemiology, Inc.
http://www.apic.org/resc/guidlist.cfm
CDC Division of Health Care Quality
Promotion
http://www.cdc.gov/ncidod/hip/
CDC Division of Oral Health, Infection
Control
http://www.cdc.gov/OralHealth/
infectioncontrol/index.htm
CDC Morbidity and Mortality
Weekly Report
http://www.cdc.gov/mmwr/
CDC Recommends. . .Prevention
Guidelines System
http://www.phppo.cdc.gov/
cdcRecommends/AdvSearchV.asp
Environmental Protection Agency http://www.epa.gov/oppad001/
chemregindex.htm
Food and Drug Administration http://www.fda.gov
Immunization Action Coalition http://www.immunize.org/acip/
Infectious Diseases Society of America http://www.idsociety.org/PG/toc.htm
CDC National Institute for Occupational
Safety and Health
http://www.cdc.gov/niosh/homepage.html
Occupational Safety and Health
Administration, Dentistry
http://www.osha.gov/SLTC/dentistry/
index.html
Organization for Safety and Asepsis
Procedures
http://www.osap.org/
Society for Health Care Epidemiology of
America, Inc.
http://www.shea-online.org/
PositionPapers.html
706 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
Documentation of monitored procedures and technologies (eg, biologic
monitoring of sterilization; dental unit water quality monitoring)
Surveillance of work-related injuries and illnesses in DHCP
Health careassociated infections in patients
Summary
Information resources from a variety of governmental agencies and
professional organizations are available to facilitate development of site-
specic infection control programs. Using a strategic approach to organize
and apply the information can result in a comprehensive and eective
infection control program.
References
[1] Bolyard EA. Hospital Infection Control Practices Advisory Committee. Guidelines for
infection control in health care personnel, 1998. Am J Infect Control 1998;26:289354.
[2] Favero MS, Bond WW. Chemical disinfection of medical and surgical material. In: Block
SS, editor. Disinfection, sterilization and preservation. 4th edition. Philadelphia: Lea &
Febiger; 1991. p. 881917.
[3] Centers for Disease Control and Prevention. Recommended infection control practices for
dentistry. MMWR Morb Mortal Wkly Rep 1986;35:23742.
[4] Centers for Disease Control and Prevention. CDC update: universal precautions for
prevention of transmission of human immunodeciency virus, hepatitis B virus, and other
bloodborne pathogens in health care settings. MMWR Morb Mortal Wkly Rep 1988;
37:37788.
[5] Centers for Disease Control and Prevention. Guidelines for prevention of transmission of
human immunodeciency virus and hepatitis B virus to health-care and public-safety
workers. MMWR Morb Mortal Wkly Rep 1989;38(S-6):136.
[6] Centers for Disease Control and Prevention. Recommended infection-control practices for
dentistry, 1993. MMWR Morb Mortal Wkly Rep 1993;14(RR-8):112.
[7] Centers for Disease Control and Prevention. Recommendations for prevention of HIV
transmission in health-care settings. MMWR Morb Mortal Wkly Rep 1987;36(Suppl 2):
1S18S.
[8] Garner JS, Favero MS. Guideline for handwashing and hospital environmental control.
Atlanta (GA): US Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention; 1985. Infect Control 1986;7:23143.
[9] Garner JS. Hospital Infection Control Practices Advisory Committee. Guideline for
isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:5380.
[10] Cleveland JL, Lockwood SA, Gooch BF, et al. Percutaneous injuries in dentistry: an
observational study. J Am Dent Assoc 1995;126:74551.
[11] Cleveland JL, Gooch BF, Lockwood SA. Occupational blood exposure in dentistry:
a decade in review. Infect Control Hosp Epidemiol 1997;18:71722.
[12] Harte J, Davis R, Plamondon T, Richardson B. The inuence of dental unit design on
percutaneous injury. J Am Dent Assoc 1998;129:172531.
[13] Occupational Safety and Health Administration. Occupational exposure to bloodborne
pathogens: nal rule. Federal Register 29 CFR Part 1910.1030. Dec 6, 1991.
[14] Occupational Safety and Health Administration. Compliance instructions CPL 22.244D.
Washington, DC: US Department of Labor. November 5, 1999.
707 K.J. Eklund / Dent Clin N Am 47 (2003) 697708
[15] Garner JS. CDC guideline for prevention of surgical wound infections, 1985. (Supersedes
guideline for prevention of surgical wound infections published in 1982.) (Originally
published in 1985; revised.) Infect Control 1986;7(3):23143.
[16] Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence CA,
Block SS, editors. Disinfection, sterilization and preservation. Philadelphia: Lea & Febiger;
1968. p. 51731.
[17] Spaulding EH. Chemical disinfection of medical and surgical materials. In: Lawrence CA,
Block SS, editors. Disinfection, sterilization and preservation. Philadelphia: Lea & Febiger;
1968. p. 51731.
[18] Centers for Disease Control and Prevention. Guideline for environmental infection control
in health-care facilities. Recommendations of the Health-Care Infection Control Practices
Advisory Committee. MMWR Morb Mortal Wkly Rep 2003;52(RR-10):144.
[19] Centers for Disease Control and Prevention. Recommendations for preventing trans-
mission of human immunodeciency virus and hepatitis B virus to patients during
exposure-prone invasive procedures. MMWR Morb Mortal Wkly Rep 1991;40(RR-8):18.
[20] Centers for Disease Control and Prevention. Guidelines for preventing the transmission of
Mycobacterium tuberculosis in health-care facilities, 1994. MMWR Morb Mortal Wkly
Rep 1994;43(RR-13).
[21] Larson EL. 1992, 1993, 1994 Association for Professionals in Infection Control and
Epidemiology Guidelines Committee. APIC guideline for hand washing and hand
antisepsis in health care settings. Am J Infect Control 1995;23:25169.
[22] Rutala WA. 1994, 1995, 1996 Association for Professionals in Infection Control and
Epidemiology Guidelines Committee. APIC guideline for selection and use of disinfectants.
Am J Infect Control 1996;24:31342.
[23] Centers for Disease Control and Prevention. Immunization of health-care workers
recommendations of the Advisory Committee on Immunization Practices (ACIP) and the
Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb
Mortal Wkly Rep 1997;46(RR-18):142.
[24] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. The Hospital Infection
Control Practice Advisory Committee Guideline for prevention of surgical site infection,
1999. Infect Control Hosp Epid 1999;4:24777.
[25] Centers for Disease Control and Prevention. Updated US Public Health Service guidelines
for the management of occupational exposures to HBV, HCV, and HIV and recommen-
dations for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep 2001;50(RR-11).
[26] Rutala WA, Weber DJ. Guideline for cleaning, disinfection, and sterilization in health-
care. Atlanta (GA): CDC and Hospital Infection Control Practices Advisory Committee
(HICPAC); 2003, in press.
[27] Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care
settings. Recommendations of the Health-Care Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR
Morb Mortal Wkly Rep 2002;51(RR-16):146.
[28] US Food and Drug Administration. Medical devices, patient examination and surgeons
gloves. Adulteration, nal rule 21. Federal Register 55:512548 CRF Part 800. Dec 12,
1990.
[29] US Environmental Protection Agency. Guide for infectious waste management.
Washington, DC: US Environmental Protection Agency; 1986. EPA/5305W-86014.
708 K.J. Eklund / Dent Clin N Am 47 (2003) 697708