Purpose:

Pursuant to Department of Health (DOH)’s Administrative Order (AO) No. 4-A, series of 1998:
“Infection Control Measures for Dental Health Services” and in response to the emerging needs,
infection control measures for dental services have to be instituted to prevent cross-infection from
patient to patient, from dental clinic personnel to patient and from patient to dental clinic personnel.
This Infection Control Measures shall cover the Institutional Dental Health Clinic.

Policy/Procedures:

I. SPECIFIC CONTROL MEASURES

A. MEDICAL HISTORY

It is mandated for all dental health personnel to take a thorough medical history from
all patients (i.e. patient, employees and students). Include specific questions about
medications, current illnesses, hepatitis, recurrent illnesses, unexpected weight loss,
lymphadenophaty, oral soft tissue lesions or other infections. Referral for a medical
consultation may be needed when a history of active infection or systemic disease is
obtained out.

B. UNIVERSAL PRECAUTION

The oral secretions such as blood and saliva of all dental patients shall be considered
as infectious. It is therefore mandatory for all dental health personnel to use the same
infection control practices on all patients.

C. IMMUNIZATION

It is recommended that all dental health care personnel involved in patient care
delivery must receive the Hepatitis B vaccine, if they do not have immunity as a result of
previous exposure to the virus. However, the priority of immunization should be focused to
those dental personnel who are directly exposed to oral mucosa, spatter of blood and
saliva.

D. HANDWASHING

It is one of the most important procedures in preventing infection. Hands should be

washed with water and soap or any antibacterial agent before putting on gloves and after
their use because of the possibility of gloves defects or incur tears and perforated not
visible to the eye which may allow microorganisms to multiply and to contact skin. Hands
should be washed when a glove becomes torn, cut or punctured and as soon as patient
care permits. An antimicrobial surgical hand scrub should be used for surgical procedures.
Dental health personnel who have exudative lesions or weeping dermatitis should refrain
from all direct patient care and from handling dental care equipment until their condition
resolves.

USE OF SPECIFIC PROTECTIVE DEVICES AND BARRIER TECHNIQUES.

1. Gloves must be worn at all times when dealing with patients specially when touching
oral mucous membranes, blood, and saliva and when treating patients. Gloves must be
changed in between patients and procedures, whether they are worn for treatment or
 examination. Disposable gloves should not be reused since such use is likely to produce
defects in the glove material, which will diminish its value as an effective barrier.

2. A mask should be worn at all times during oral examination and dental procedures to
protect both patient and dental clinic personnel from exposure to blood and saliva and
from cross infection.

3. It is recommended that protective eyewear must be worn during oral prophylaxis and
restorative procedures to protect the eyes from the spatter of blood, saliva and oral
debris.

4. A protective gown or reusable gowns, laboratory coats or uniforms must be worn

during dental or clinical procedures to provide additional protection from possible
exposure to blood and other body fluids. The “isolation” type gown is ideal for special
dental surgical procedures since it covers the arms and fits closely around the neck. If
reusable gowns are worn, washed using a normal laundry cycle. Gowns must be
changed at least daily or when visibly soiled with blood.

5. Surface Barrier Technique must be used to cover surfaces. The environmental surfaces
predisposed to contamination with saliva, or blood during treatment and which may
impossible to disinfect with chemical solutions must be covered with materials like
plastic wrap, aluminum foil, impervious backed paper, polyethylene sheets or plastic
tubing (e.g. light handles or x-ray unit heads). After each clinical procedure, the
covering (while the DHP are gloved) must be removed, discarded and changed with a
new one (after un-gloving).

6. It is recommended that Anti-Retraction Valves (one-way flow check valves) should be

installed to prevent fluid aspiration and to reduce the risk of transfer of potentially
infective materials. In the absence of anti-retraction valve, flush out air and waterlines
of hand-pieces by running or operating it for (20) twenty to (30) thirty minutes.

7. All procedures and manipulation of potentially infective materials should be performed

carefully to prevent the formation of droplets, spatters, and aerosols. When
appropriate, the use of rubber dams, high-speed evacuation, and proper patient
positioning must be facilitated in each process.

E. INDICATIONS AND METHODS FOR CLEANING, STERILIZATION AND DISINFECTION

1. CLEANING

Cleaning should be a standard procedure before, during and after many dental
procedures and before application of high-level of disinfection or sterilization. Items
which are not directly associated with treatment such as sinks, walls, floors, furnishing

and the likes should be washed with water and soap or any low-level disinfectant
detergent (Clorox, or a cloth or pad soaked with any of the following solutions, 95%
Ethyl Alcohol, 70% Isopropyl Alcohol), or by using a mechanical device (e.g. ultrasonic
cleaner) this should be done routinely.

Cleaning up of visible spills of blood and other body fluids should be undertaken
using a high-level or hospital approved disinfectants (Hospital Grade Disinfectant of
2.5% Sodium Hypochlorite). Instruments should be cleansed under running water or
soaked in water to prevent drying of blood prior to disinfection or sterilization. Dental
health personnel involved in cleaning and decontaminating instruments must wear a
heavy-duty rubber gloves to prevent hand injuries prior to cleaning, decontamination,
disinfection and sterilization.
 2. DISINFECTION

High-level disinfection may be accomplished by immersion in either boiling water

for at least (10) ten minutes or disinfection (with Clorox, a cloth or pad soaked with any
of the following solutions, 95% Ethyl Alcohol, 70% Isopropyl Alcohol or with Hospital
Grade Disinfectant of 2.5% Sodium Hypochlorite) must be done to non-critical items
and equipment that are not intended to penetrate or contact mucous membranes and
oral soft tissues or bone (i.e. amalgam condensers, plastic instruments, and burs) and
but with exposure to spatter, spray, splashing of blood or are touched by contaminated
hands.

3. STERILIZATION

All critical items or instruments which penetrate oral soft tissues and bone, such as
surgical instruments such as forceps, scalpels, bone chisels, scalers and surgical burs),
periodontal knives and the likes and semi-critical items or instruments which come in
contact with the mucous membrane such as impression trays, amalgam carriers, plastic
filling materials and the likes should be sterilized after each use. Autoclave or dry heat
ovens are the recommended procedures for sterilization.

For metal and heat-stable dental instruments should be routinely sterilized

between used by steam under pressure (i.e. autoclaving), dry heat, or chemical vapor.
Adequacy of sterilization cycles should be verified by using a periodic spore-testing
device (i.e. weekly for most dental practices). Heat-and-steam-sensitive chemical
indicators are also recommended to use on the outside of each pack, ensuring the
exposure to a sterilization cycle.

For heat sensitive instruments i.e. mouth mirrors, non-autoclavable hand

pieces, burs and the likes, cold sterilization is recommended and may require up to (10)
hours exposure in a liquid chemical agent as a sterilant, followed by rinsing with sterile
water.

F. USE AND CARE OF SHARP INSTRUMENTS, NEEDLES AND DISPOSABLE INSTRUMENTS

Sharp items (i.e. needles, scalpel blades, and other sharp instruments) should be
considered as potentially infective and must be handled with extra-ordinary care to prevent
accidental injuries.

Disposable instruments (e.g. prophylactic angles; prophylactic cups and brushes; tips
for high speed air evacuators, saliva ejectors, and air or water syringes) should be used
once, not intended to be cleaned, disinfected, or sterilized for re-use.

Disposable needles should not be recapped to prevent needle-stick injuries or

purposefully bent or broken and removed from the disposable syringes. Needles of these
devices are likewise not to be recapped, bent or broken before disposal.

G. DECONTAMINATION OF ENVIRONMENTAL SURFACES

After each clinical procedure, environmental surfaces such as countertops and the
like may have predisposed to contamination with saliva or blood during treatment should
be wiped with absorbent towel to remove extraneous material, and then disinfected with a
 disinfectant detergent (Clorox or a cloth or pad soaked with any of the following solutions,
95% Ethyl Alcohol, 70% Isopropyl Alcohol or sodium hypochlorite – concentrations ranging
from 5,000 ppm, a 1:10 dilution to 500 ppm, a 1:100 dilution) routinely or prepared fresh
daily. The used of disinfectant detergent is the most effective, depending on the amount of
organic material such as saliva, mucus and blood present on the surface to be, cleaned,
decontaminated, or disinfected. Cleaning up of visible soiled materials with blood and
other fluids should be undertaken using a Hospital Grade Disinfectant of 2.5% Sodium
Hypochlorite; however, caution should be exercised since hospital grade disinfectant is
corrosive to metals like aluminum.

H. DECONTAMINATION OF LABORATORY SUPPLIES, MATERIALS AND INTRA-ORAL DEVICES

Blood and saliva should be handle thoroughly and carefully cleaned from laboratory
supplies and materials that have been used orally (e.g. impression materials, bite
registration), before polishing and grinding intra-oral devices.

Materials, impressions and intra-oral appliances must be cleaned from any debris,
saliva and blood with water and should be disinfected with an accepted disinfectant before
being handled, poured with cast stones, adjusted, or delivered to the dental laboratory and
the same procedure applies when returned from the dental laboratory and before
placement in the patient’s mouth.

A chemical germicide that is registered as a “hospital disinfectant” and that has a

label claimed for mycobacterial (e.g. tuberculocidal) activity is recommended as it is one of
the most resistant groups of microorganisms and the like are also effective against other
bacterial and viral pathogens. Prosthodontic and orthodontic appliances should be
disinfected with Iodophore before insertion.

Communication between a dental office and dental laboratory in relations to handling

and decontamination of supplies and materials is of the highest importance.

I. USE AND CARE OF ULTRASONIC SCALERS, HANDPIECES, AND DENTAL UNITS

Routine sterilization of hand-pieces between patients is preferable; however, not all

can be sterilized. The current physical designs of most hand-pieces can not readily
disinfected with high-level of disinfection to both external and internal surfaces since hand-
pieces cannot be sterilized, follow the cleaning and disinfection procedures after
completing clinical procedures in between each patient:

1. The hand-piece should be flushed after use, and then thoroughly scrubbed with a
detergent and water to remove adherent material.

2. Followed by thoroughly wiping with absorbent material saturated or soaked with a

chemical germicide that is registered as a “hospital disinfectant” (Hospital Grade
Disinfectant of 2.5% Sodium Hypochlorite) and is mycobactericidal at use-dilution.

3. As specified by the disinfectant’s manufacturer, the disinfecting solution must remain in

contact with the hand-piece for a time.

4. Ultrasonic scalers and air-or-water syringes must be treat in a similar manner between
patients.

5. Any chemical residue should be discarded and removed by rinsing with sterile water
following disinfection.
 6. Check Valves must be installed since water retraction valves within the dental units may
cause aspiration of infective materials and may creates backflow into the hand-piece
and water-line. Since the magnitude of this risk is unknown, it is sensible for water-
cooled hand-pieces to be run and to flush-out water into a sink or container for (20)
twenty to (30) thirty seconds after completing care on each patient to physically flush
out saliva, mucous or other fluids that may have been remained or aspirated into the
hand-piece or water line.

7. An overnight bacterial accumulation can be reduced by allowing water-cooled hand-

pieces to flush-out water into sink or container for several minutes at the beginning of
the clinic day. Sterile saline or sterile water should be used as a coolant or irrigator
when performing surgical procedures including the cutting of soft tissue or bone.

J. HANDLING OF BIOPSY SPECIMENS

Specimens should be put in a sturdy container with a secure lid to prevent leaking when
carrying and during delivery of specimens. To prevent contamination, extreme care should
be taken into consideration when obtaining and collecting specimens. If visibly
contaminated, clean and disinfect the container or keep it in an impervious plastic bag.

K. DISPOSAL OF WASTE MATERIALS

Disposable materials such as gloves, masks, wipes and surface covers which are
contaminated with blood or body fluids must be carefully handled and disposed with
special precaution in sturdy, impervious plastic bags to minimize human contact. Blood,
suctioned fluids, or other liquid waste maybe carefully poured or flush-out into a drain
connected to a sanitary sewerage system.

Extra care should be taken to ensure compliance with applicable local regulations.
Sharp items, such as disposable needles and scalpel blades, should be placed intact into
puncture-resistant containers before disposal in plastic bags.

Human tissues and other solid waste materials contaminated with blood maybe
handled in the same manner as sharp items and should be placed in sealed, sturdy
impervious bags to and be disposed using color coded bags (e.g. black bag – general waste;
yellow bag – infectious waste; red bag – sharp waste) to prevent leakage of contained
items in accordance to local government guidelines or state environmental regulatory
agencies

Infectious medical waste, including tissues and culture media, should be handled in a
manner consistent with local regulations before disposal.

Liquid chemicals should be carefully poured or flushed-out into a drain connected

sewer, while flushing with a generous amount of water.

L. PERSONAL GROOMING

It is mandatory for all dental health personnel to maintain proper personal grooming
whenever they are in the dental clinical field, i.e. trimmed fingernails, and properly combed
hair, cleaned clothes, among others.

II. GUIDELINES FOR MANAGEMENT OF PATIENTS WHO HAVE HIGH-RISK INFECTIOUS DISEASES
 Universal Precautions should be practiced and emphasized by all dental health
personnel who are in contact with potentially infectious materials. In general, blood, saliva
and gingival fluid from ALL patients must be considered infectious.
Known HIV positive patients should be given needed dental treatment. However,
patients requiring invasive treatment may be referred to the hospital provided that it has an
HIV AIDS Core Team (HACT). Management of patients with HIV AIDS should be subject to the
guidelines of DOH Administrative Order No. 18 series of 1995 (The Revised Guidelines in the
Management of HIV-AIDS Patients in the Hospital).

Strict adherence to all infection control measures needs to be followed when giving
patients with infectious diseases a dental treatment.

III. GUIDELINES FOR DENTAL HEALTH PERSONNEL (DHP) WHEN ACCIDENTAL INJURY OR
EXPOSURE TO HIV, HBV AND OTHER INFECTIOUS DISEASES HAPPEN DURING DENTAL
TREATMENT

Universal Precautions should be practiced and emphasized by all dental health

personnel who are in contact with potentially infectious materials. In general, blood, saliva
and gingival fluid from ALL patients must be considered infectious. The following
recommended steps should be undertaken:

A. POST EXPOSURE EMERGENCY AID

1. For Pre-cutaneous exposure:

a. Immediately induce bleeding, from the site of exposure.

b. Disinfect the site of exposure

2. For skin, wash the site liberally with soap and tap water.

3. For mucous membrane and eyes, expose site under running water for at least one minute
or longer if possible.

B. RECORD CIRCUMSTANCES OF EXPOSURE

1. This should be kept as a Confidential Record,

2. This should be done properly as it may be a medico-legal document,
3. The record will include the following details:
a. Name of patient
b. Date and time of exposure
c. Job duty being performed by worker at time of exposure
d. Details of exposure including:
 Amount of fluid or material (if actual amount cannot be given, then give
approximate amount)
 Type of fluid or material
 Type of exposure, and
 Severity of exposure, for instance:
- For a pre-cutaneous exposure, dept of injury and whether fluid was injected
- For a skin or mucous membrane exposure, the extent and duration of
contact and the condition of the skin, e.g. chapped, abraded, intact.
e. Description of source of exposure including, if known, whether the source material
contained HIV or HBV and other infectious diseases.
 4. Visit any Medical Facility or Agency for Examination, Counseling and Testing Titers.

IV. PROCUREMENT OF EQUIPMENT, SUPPLIES AND MATERIALS

It shall be the responsibility of the administration and occupational establishments to

provide the necessary equipment, supplies and materials needed in the efficient and
effective implementation of these infection control measures.

A regular procurement plan shall be prepared and submitted to property and supply
custodian or head concerned to ensure availability of supplies and materials at all times.

V. MONITORING AND SUPERVISION

Monitoring and supervision shall be in accordance with the guidelines for occupational
dental health services for effective enforcement and implementation of the Infection Control
Measures for Dental Health Services.