I N F E C T I O N I NNFTE RC O

C O T L
I O N C O N T RO L

Strategies for Dental Clinic

Infection Control
CHARLES JOHN PALENIK, F.J. TREVOR BURKE AND CHRIS H. MILLER

● killing or removal of oral microbes

Abstract: The application of proper infection control procedures helps to protect
practitioners, patients and the community. The goal is to minimize the spread of potentially
through proper disinfection;
pathogenic micro-organisms and to remove and/or kill organisms that have contaminated ● sterilization of reusable dental
objects and surfaces. Dental practitioners are aided in this process by the generation of rules, instruments and equipment.
guidelines and recommendations by regulatory agencies and professional organizations.
Ideally, each office/clinic would generate and maintain a written set of infection control Most dental clinics select a combination
procedures. of preventive procedures that best
serves their practices.
Dent Update 2000; 27: 7-15

Clinical Relevance: Infection control in dentistry is a complex, costly, yet highly

important activity. Each practice should regularly perform some type of strategic planning as to
the specific procedures needed. Both efficacy and efficiency could be positively affected.
nfection control in dentistry involves
I a series of procedures designed to
prevent transmission of potentially
pathogenic micro-organisms. The most
common sources of these microbes are
patients, the dental team and the
community water supply. If effective,
infection control procedures can
significantly reduce the chances of
cross-infections.1-5
Infection control involves two basic
approaches:
Charles John Palenik, MS, PhD, Director
Infection Control Research and Services,
Indiana University School of Dentistr y,
Indianapolis, IN, USA, F.J.Trevor Burke, DDS,
MSc, MDS, FDS MGDS RCS (Edin), FDS RCPS,
FADM, Glasgow Dental Hospital and Sc hool,
and Chris H. Miller, PhD, Professor of Oral
Microbiology and Associate Dean for Research
and Graduate Studies, Indiana University
School of Dentistry, Indianapolis, IN, USA.
● preventing the spread of micro-
organisms from their hosts (patients
and practitioners);
● killing or removal of microbes
found on objects and surfaces.
Numerous and sometimes pathogenic
micro-organisms are present in the oral
cavities of dental patients. Procedures
for minimizing release need to be
identified and performed on a regular
basis. These could include preoperative
mouthrinsing, application of rubber
dams and minimal use of three-way
syringes.1-5
Objects such as dental instruments or
light handles or environmental surfaces
can readily be soiled with oral fluids
during treatment. This problem can be
addressed in three ways:
● preventing contamination through
the use of environmental surface
barriers;
UNIVERSAL PRECAUTIONS
Universal precautions is a philosophy
that considers all patients to be infected
with pathogenic organisms and thus
maintains that certain basic infection
control procedures must be used during
the care of all patients. For the dental
team this usually includes the use of
personal protective equipment (PPE:
gloves, masks, clinic attire, protective
eyewear, etc.), some immunizations and
routine handwashing. If gloves can
prevent the spread of micro-organisms
present in oral fluids, they should also
prevent the transfer from practitioner to
patient.1,2
Even though barrier methods of
protection are effective, they
occasionally fail. It may be helpful to
review the recommendations of the US
Occupational Safety and Health
Administration (OSHA) concerning
potential work-related hazards. The
OSHA has developed a four-step
process that progresses from the more
effective to those less effective (see
Table 1).2,6,7 Employing processes that
minimize exposure through changing
engineering controls and work practices

Dental Update – January/February 2000 7

Downloaded from magonlinelibrary.com by 144.082.238.225 on May 9, 2018.

 I N F E C T I O N C O N T RO L

Steps Actions/reactions

Determination if The major routes of cross-infection are well known. However, new pathways of microbial spread continue to emerge (e.g. handpieces
there is a problem and dental unit water lines). Clinics must determine when such routes exist and to what degree they are present, and adequate
preventive methods initiated. A variety of effective responses can be used with equall y successful results.

Engineering Engineering controls are measures designed to isolate or remove a hazard from a workplace. The most effective and efficient method
controls for problem resolution is to remove or change a product or process or somehow to use it differently. A common dental example is
glutaraldehyde solution. Such sterilizing chemicals are harsh and can readily generate irritating fumes, which can cause allergies.
Direct contact with skin or mucous membranes could cause injur y. One possible engineering contr ol would be the elimination of
glutaraldehyde as a sterilizing agent for all instruments and the application of heat to sterilize heat-r esistant reusable items. If
glutaraldehyde is needed to treat heat-sensitive items, then special containment and rinsing pr ocedures must be used.

Work practices Work practice controls are methods that reduce the likelihood of exposure by altering the manner in which the w ork is performed.
An example would be the cleaning of instruments bef ore sterilization. The use of an ultrasonic cleaner is not onl y more effective and
efficient than hand scrubbing but is also saf er (reduced risk of sharps injuries). The use of trays or cassettes would also decrease
handling of soiled instruments, thus reducing exposure to contaminated items. Ideally, removing or changing a process should not
only be effective in reducing the chances of occupational exposur e but also should increase efficiency. However, productivity may be
negatively affected by the implementation of cer tain work practices.

Personal protective PPE includes specialized clothing or equipment w orn for protection against a specific hazar d: general work clothes usually are not
equipment (PPE) sufficiently protective. There are several reasons why PPE is considered to be the least effective and efficient method to pr event
occupational exposures. One reason is the lack of universal application: it may be unrealistic to expect all employees to wear the
proper PPE whenever a hazard is present. Also, PPE cannot usually prevent certain exposures, such as most needlestick accidents.
Another fault of PPE involves the physical nature of barriers. Eventually all barriers fail. Newer designs and fabrication materials ha ve
improved the longevity of some PPE but unfortunately PPE barriers will never be as effective as removing a hazard or changing a
work practice that reduces the chances of contact.
Table 1. OSHA resolution of a potential occupationally related hazard—a four-step process.2,6,7

helps make the use of PPE more
effective. Dental clinics can respond to
an infection-control problem in a variety
of ways. However, consideration should
first be given to engineering controls
and safer work practices.
PATHWAYS OF CROSS-
INFECTION
A dental clinic’s infection-control
programme needs to be designed to
prevent (or at least minimize) the spread
of micro-organisms. There are six
common pathways of cross-
contamination in dentistry (summarized
in Table 2). Pathways can be further
defined as to types of microbial source,
modes of disease transmission and
mechanisms of entry. Preventive
methods for each pathway can then be
identified.1,2
Patient to Practitioner
There are numerous opportunities for
the transmission of micro-organisms
from the patient through body fluids to
the practitioner. Because practitioner
exposure is continuous, and because the
numbers of infectious patients (both
known and unknown) continue to
increase, it is difficult to control this
form of microbial spread. Significant
effort has to be made to minimize
occupationally acquired infections.1-5
Micro-organisms in a patient’s mouth
can spread to the practitioner in three
ways:
● by direct contact;
● via droplets or aerosols;
● by indirect contact.
Direct contact (touching) involves
exposure of the practitioner’s skin and
mucous membranes to a patient’s saliva
or blood. Because the practitioner’s skin
is often not intact, the routine wearing of
gloves and proper handwashing
procedures are essential. Some diseases
can be prevented by immunization (e.g.
hepatitis B).
Spray, spatter and aerosols can be
released during treatment. Such
materials could be inhaled by the
practitioner and can be hazardous to his
or her skin and mucous membranes.
Masks and gloves should help prevent
infection. Of course, minimizing
microbial release through the use of
rubber dams, high-volume evacuation,
preoperative mouthrinsing and limited
use of three-way syringes are also
valuable.
Indirect contact transmission involves
the spread of disease agents through
inert environmental surfaces. A common
example is a cut or puncture caused by a
contaminated sharp object (needles,
sharp instruments, scalpel blades, wires,
etc.). Preventive measures include
careful handling of instruments before
sterilization. Holding instruments in
trays or cassettes for ultrasonic cleaning
may also limit sharps injuries.
Instrument holding solutions and
ultrasonic cleaning solutions containing
antimicrobial agents will further reduce
the numbers of contaminating micro-
organisms present.
Organisms can also be transferred
from skin lesions. Before glove usage
became common, the incidence of
herpetic whitlow was higher in dentists
than in the general population. Most
helpful would be prevention of direct
contact by PPE and proper
handwashing.2
Practitioner to Patient
Before glove usage became the rule,

8 Dental Update – January/February 2000

Downloaded from magonlinelibrary.com by 144.082.238.225 on May 9, 2018.

 I N F E C T I O N C O N T RO L

Pathways of Microbial Modes of Mechanisms of Preventive methods

of microbial sources disease entry
spread transmission

Patient to Patient’s oral Direct contact Breaks in the skin Routine wearing of gloves; proper handwashing, rinsing and drying; certain
practitioner cavity immunizations

Droplets Inhalation Wearing masks; using rubber dams; preoperative mouthrinsing by patient;
and/or aerosols using high-volume evacuation; minimizing use of three-way syringes

Breaks in the skin Routine wearing of gloves; proper handwashing, rinsing and dr ying; wearing
protective safety spectacles; using rubber dams; preoperative mouthrinsing by
patient

Indirect contact Cuts, punctures Safer handling of contaminated sharps; use of heavy-duty gloves for cleaning
or needlesticks up; cleaning instruments ultrasonicall y rather than by hand; using cassettes or
trays to reduce direct handling of instruments; antimicrobial instrument
holding solutions; antimicrobial ultrasonic cleaning solutions

Breaks in the skin Use of heavy-duty gloves for cleaning up; other forms of PPE; certain
immunizations

Patient skin Direct contact Breaks in the skin Use of heavy-duty gloves for cleaning up; other forms of PPE; certain
lesion immunizations; proper handwashing, rinsing and dr ying

Practitioner Practitioner’s Direct contact Mucosal membranes Routine wearing of gloves; safer handling of contaminated sharps; certain
to patient hands of patient immunizations

Indirect contact Bleeding onto items Routine wearing of gloves; proper handwashing, rinsing and drying;
used on patients instrument sterilization; proper surface disinfection; certain immunizations

Practitioner’s Droplets and/or Inhalation Wearing masks; using face shields/spatter guar ds
oral cavity aerosols

Mucosal membranes Wearing masks; using face shields/spatter guar ds

of patient

Patient to Patient’s oral Indirect contact Mucosal membranes Instrument sterilization; handpiece/angle sterilization; environmental surface
patient cavity of patients covers; surface disinfection; cleaning or replacing PPE; using sterile reusables
and clean disposable supplies and equipment; maintaining potable water
quality in/from dental units

Clinic to Patient oral Indirect contact Exposure of Proper handling of infectious waste; correct disinfection of impressions
community cavity individuals outside and soiled prostheses; proper handling of soiled laundr y
the office (e.g.
dental lab or
waste handlers)

Clinic to Practitioner’s Direct/indirect Intimate contact Proper handwashing, rinsing and drying; certain immunizations
practitioner‘s body fluids contact
family

Community to Community Direct contact Patient’s oral cavity Using new and separate water sources; purging waterlines between patients;
patients water regularly disinfecting unit water lines; filtering water before use; frequently
monitoring the potable quality of emitted water ; adding an antimicrobial
agent to water
Table 2. Disease spread processes and modes for prevention for dental environments.1,2

transmission of serious diseases (such as
hepatitis B and herpes simplex virus)
directly from a practitioner’s hands to
the mucous membranes of the patient
(and vice versa) was often reported.8,9
An outbreak of HIV occurred during the
period 1987 to 1990 in a Florida dental
clinic. Investigation by the US Centers
for Disease Control and Prevention
(CDC) indicated that the virus present in
the dentist was significantly similar to
samples taken from six of his
patients10,11 but unfortunately did not
reveal the exact mode of transmission.
The CDC suggested that direct
transmission from dentist to patient was
more likely than indirect spread by
contaminated instruments, equipment or
environmental surfaces.
In July 1995, an orthopaedic surgeon
in a suburban Paris hospital was
reported to have been occupationally
infected with HIV some time in 1983. In
1994 the surgeon experienced health
problems and was tested for HIV. He
asked his hospital to serologically
screen all his former patients. Of the
3004 patients he had treated since 1983,
one woman who was known to be HIV
negative before undergoing prolonged

10 Dental Update – January/February 2000

Downloaded from magonlinelibrary.com by 144.082.238.225 on May 9, 2018.

 I N F E C T I O N C O N T RO L
surgery in 1992 had subsequently
become HIV positive. The woman was
74 years old and had no other risk
factors. These elements warranted a
comparison of the HIV sequences of the
surgeon and the patient. Results
indicated that the viruses were closely
related, strongly suggesting practitioner-
to-patient transmission.12,13
Other investigations of patients of
healthcare workers infected with HIV
have been performed.14-16 These included
29 dental care workers, 15 surgeons and
obstetricians and over 23 000 patients. A
total of 113 patients were shown to be
HIV positive. Eight were negative
before treatment and had no other
defined risk factors. Three are still being
investigated. In three of the remaining
five cases the viruses present in the
patients and the healthcare workers have
been analysed. Viral isolates of the
patients and their healthcare providers
were not related according to DNA
sequence analysis. To date, no new
cases of nosocomial HIV transmission
have been identified.14-16
Practitioner blood may contaminate
instruments and equipment that come
into contact with their patients’ oral
tissues. Wearing gloves and
handwashing, and the use of proper
disinfection and sterilization procedures,
should significantly reduce the chances
of indirect spread of disease through
contact with contaminated items.
Practitioners can also emit infectious
droplets or aerosols, which the patient
could inhale. Wearing masks and using
face shields/spatter guards should help
to prevent this mode of transmission.
Patient to Patient
Disease agents (including hepatitis B
and C and HIV) could be transferred
from patient to patient by indirect
contact with improperly prepared
reusable instruments, handpieces and
attachments, surfaces and hands. In a
report from Australia concerning
patient-to-patient transmission of HIV it
was suggested that inadequate infection
control procedures were present during
dermatological surgery—and it was later
determined that one patient treated on
12
the day in question was HIV
positive.17,18
The British Dental Association (BDA)
has issued recommendations concerning
surface cleaning and disinfection.5 Use
of ‘zoning’ is advocated. This means
identifying areas that may be
contaminated during treatment and then
cleaning and disinfecting well only these
areas between patients. This should
increase clinic efficiency without
compromising infection control. The
BDA supports the importance of first
cleaning a soiled surface, then using a
detergent liquid and marked physical
wiping. The surface can then be
disinfected with an agent compatible
with the surface being treated and which
possesses sufficient antimicrobial
abilities. All products must be made and
handled according to the manufacturers’
instructions. Gloves and protective
eyewear must be worn during
disinfection. Adequate ventilation must
also be present.
In many areas it is a legal requirement
to sterilize instruments (and often
handpieces) between patients. Also
helpful in avoidance of cross-
contamination would be a combination
of surface covers and proper
environmental disinfection. Some PPE,
such as gloves and masks, need to be
replaced between patients. A patient’s
oral fluids can be aspirated (‘suck-
back’) into a handpiece or dental unit
water line and, unless water quality is
controlled, a patient could be exposed to
the oral flora of previous patients.
Flushing the lines between patients has
been advocated.1-5
Clinic to Community
Dental clinics produce relatively small
amounts of infectious waste (waste
shown to be capable of causing an
infectious disease). In many areas,
infectious waste is referred to as
regulated waste. Such waste requires
special handling, storage, neutralization
and disposal.
For dentistry in the USA, there are
five types of regulated waste:
● blood in a liquid or semi-liquid
Dental Update – January/February 2000
Downloaded from magonlinelibrary.com by 144.082.238.225 on May 9, 2018.
form;
● materials, such as gauze squares or
cotton rolls, that are contaminated
with large amounts of liquid or
semi-liquid blood/saliva and that
could release such fluids if the item
was squeezed;
● pathologic waste (teeth and other
tissues);
● sharps (e.g. needles, scalpel blades,
sutures, instruments and wires); and
● potential sharps, such as anaesthetic
ampoules, which if broken could
expose people to aspirated patient
body fluids.
Because of the enhanced ability to cause
infections after contact, regulated waste
must be handled, stored and disposed of
using proper procedures. Failure places
persons in the clinic and the local
community at risk of cross-infection.
A similar position exists in Scotland.
The term healthcare waste is used to
describe all waste generated during
healthcare activity. Clinical waste is a
small portion of healthcare waste that
requires special attention. Such waste
includes:
● human tissues;
● blood and other body fluids and
secretions;
● drugs and other pharmaceutical
products;
● swabs or dressings;
● syringes or needles and other sharp
instruments.
Segregation, storage, collection,
transport, treatment and disposal of
clinical waste is the responsibility of the
generating clinic.19
Segregation of clinical waste in
yellow or orange bags or containers
helps to keep such items from entering
the domestic (black bag) waste streams.
Clinical waste should be disposed of
as soon as is practicable. All workers
should know where and how clinical
waste is stored in their facility. Often,
clinical waste has to be transported out
for treatment. The clinic must be aware
of all community and national clinical
waste handling regulations. Treatment of
clinical waste is also regulated, but
 I N F E C T I O N C O N T RO L
clinics should use common sense when
selecting what procedures are most
effective and efficient.
Materials in yellow bags/containers
are to be incinerated in approved
facilities. Incineration can be used to
treat all dental clinical waste, but is
essential for human tissues, materials
from ‘highly infectious’ cases, all sharps
and pharmaceutical waste.
Orange bags/containers are used for
heat disinfection, which is designed to
render clinical waste safe and
unrecognizable (e.g. via maceration).
All clinic staff must be aware of all
community and national clinical waste
handling regulations.19
Clinic to Practitioner’s Family
If a practitioner suffers an
occupationally related infection, there is
a possibility that it could be transferred
to his/her family. Preventive measures,
such as adequate use of PPE, thorough
hand washing and immunizations should
help to reduce the chances of such
infections.
Community to Patients
A current area of research interest is the
quality of water used during treatment.
Waterborne organisms can colonize the
insides of dental unit water lines and
form an adherent biofilm. As water
moves through the water line to the
handpieces, three-way syringes and
ultrasonic scalers, micro-organisms shed
by the biofilm are picked up by the
water.
Improving dental unit water quality
has become a central issue for
practitioners and dental unit
manufacturers. Today, clinics should
regularly purge their water lines at the
start and the end of the working day and
after each patient. New units with self-
contained water sources are available.
Water could be treated with UV light or
filtered as it enters the clinic or just
before the handpiece or three-way
syringe. Some practices add an
antimicrobial agent to the water used. It
would be very valuable if rapid in-house
microbial detection methods could be
14
established. Such devices could
determine if dental units are emitting
drinking-quality water.
DENTAL SURGERY DESIGN
It is inevitable that potentially
contaminated gloved hands (of the
operator and dental assistant) will come
into contact with the switches and casing
of the dental unit—and only the most
disciplined practitioner does not touch
pens, record cards, radiographs, parts of
unprotected skin and items such as
spectacles and loupes with potentially
contaminated hands in the course of
routine dental care.20 It therefore follows
that all items which may be touched
should be covered, sterilized or
disinfected. Alternatively, overgloves
should be worn if any surgery items
such as phones or pens are to be
touched.
Changes in surgery and equipment
design should be implemented to
facilitate infection control. However,
changes in surgery design may require
changes in working practices—which
are, in effect, the reason for the design
changes.20
In any case, the dental surgery design
should be simple and uncluttered with
good ventilation (preferably air-
conditioned). The floor covering of the
operating area should be easily
cleanable and seam free, with curved
copings joining the floor to the walls.
Surgery design should help present a
comfortable and reassuring environment
to the patient.
The Dental Unit
The dental unit and surrounding
equipment should be designed in such a
way that the operator and nurse are
obliged to conform to all infection-
control recommendations. Potentially
contaminated parts of the dental unit
should be easily accessible for cleaning,
disinfection or, where appropriate,
sterilization and surfaces should be
smooth, easily disinfected and not
damaged by disinfecting solutions. The
spittoon should be made of a ceramic or
other disinfectant-resistant material.
Dental Update – January/February 2000
Downloaded from magonlinelibrary.com by 144.082.238.225 on May 9, 2018.
Controls should, ideally, be foot
operated or automatic—if operable by
hand they should have a smooth wipe-
clean surface. The foot control for
handpieces should not collect debris or
dust. The bracket table should be easily
cleaned and disinfected and should hold
trays which may themselves be
autoclaved. Where possible, controls
should be designed to obviate the need
for hand contact. The dental chair,
headrest and operators’ chairs/stools
should be covered by smooth upholstery
of a material which is non-absorbent and
resistant to the disinfecting solutions to
be applied between patients. State-of-
the-art controls for the dental chair may
be voice activated or capable of being
programmed to a given position.
Work Surfaces
Work surfaces should have curved
intersections between the vertical and
horizontal components. All unnecessary
equipment should be placed in cabinets
beneath the work surfaces to reduce the
number of items that require disinfection
between patients. Work surfaces should
be divided into designated clean and
contaminated areas, with a separate area
for the writing of notes. Drawers should
be designed with removable, easily
cleaned or disposable inserts: their
handles should be easily cleaned.
Other Equipment
Two sinks should be available, one for
handwashing and one for instrument
cleaning. Taps should be designed with
automatic controls. The operating light
presents a high potential for
contamination and should therefore be
designed for ease of cleaning or
autoclaving, or should be covered by a
plastic sleeve as part of the inter-patient
surgery routine. Dental workers should
be aware of the potential for
contamination of other surgery items
such as light-curing units, electrosurgery
units, ultrasonic scalers, automix guns
and pulp testers. Parts of such items
which become contaminated should be
autoclavable or disposable: the casing of
the unit should be easily disinfected

without damage to the unit. Handpieces
and air-water syringes should be
autoclavable or disposable.21
The ‘Ideal’ Surgery
Ideally, surgery equipment, design and
logistics should promote good infection
control by dental healthcare workers. A
surgery has therefore been designed to
change behaviour by reducing the
number of items that may be touched to
a minimum.22
This surgery is designed without
drawers, worktops, telephones and other
items that may be touched or
contaminated. All instruments are
obtained before commencement of a
patient’s treatment from an adjacent
dispensary. Given that there are no
worktops and drawers to become
contaminated, surgery cleaning between
patients becomes more
straightforward.22 A saving in equipment
and surgery cabinetry may also result.
For a more complete exposition of
dental surgery design in respect to
infection control, the reader is referred
to the work of Chant et al.17
ADDITIONAL COMMENTS
The practice of dentistry involves the
chance of cross-infection. The clinic
must accept responsibility to eliminate
or greatly reduce disease transmission.
ABSTRACT
REDUCING THE RISK OF POST
CROWN FAILURE
The Influence of Post Length and Crown
Ferrule Length on the Resistance to Cyclic
Loading of Bovine Teeth with
Prefabricated Titanium Posts. F. Isidor, K.
Brondum, G. Ravnholt. International
Journal of Prosthodontics 1999; 12: 78-82.
Root-treated teeth frequently require posts
to support the coronal tissue for restoration.
Loss of retention of these posts, or root
fracture, can pose a serious complication to
treatment. It has been known for some time
Dental Update – January/February 2000
I N F E C T I O N
Infection control includes a wide variety
of standardized procedures and specific
pieces of equipment. Each pathway of
microbial spread requires a set of
specific preventive processes to ensure
effective infection control.
R EFERENCES
1. Miller CH. Infection control strategies for the dental
office. In: ADA Guide to Dental Therapies. Chicago:
ADA Press, 1998.
2. Miller CH, Palenik CJ. Infection Control and
Management of Hazardous Materials for the Dental
Team, 2nd edn. St Louis: Mosby, 1998.
3. ADA Council on Scientific Affairs and ADA Council
on Dental Practice. Infection control
recommendations for the dental office and the
dental laboratory. J Am Dent Assoc 1996; 127: 672-
680.
4. Centers for Disease Control and Prevention.
Recommended infection control practises for
dentistry. MMWR 1993; 41 (RR-8): 1-12.
5. British Dental Association. Infection Control in
Dentistry. Advice Sheet 1996; A12: 7.
6. US Department of Labor, Occupational Safety and
Health Administration. All About OSHA (OSHA 2056).
Washington: US Government Printing Office, 1993.
7. US Department of Labor, Occupational Safety and
Health Administration. Chemical Hazard
Communication (OSHA 3084). Washington: US
Government Printing Office, 1995.
8. Terezhalmy GT. Other infectious diseases important
in dentistry. In: Cottone JA, Terezhalmy GT, Molinari
JA, eds. Practical Infection Control in Dentistry, 2nd edn.
Baltimore: Williams & Wilkins, 1996; pp.84-102.
9. Cottone JA, Puttaiah R. Viral hepatitis and hepatitis
vaccines. In: Cottone JA, Terezhalmy GT, Molinari JA,
eds. Practical Infection Control in Dentistry, 2nd edn.
Baltimore: Williams & Wilkins, 1996; pp.15-47.
10. Ciesielski C, Marianos D, Ou CY et al. Transmission
of human immunodeficiency virus in a dental
that increasing the length of the post results
in more favourable stress distribution and
increases retention. More recently it has
been shown that if the coronal tooth
structure is encircled within the crown,
creating a ferrule effect, the incidence of
root fracture is decreased.
The authors prepared 90 teeth for post
crowns, using a variety of lengths of both
post and ferrule. The teeth were then
subjected to cyclic loading of 400 N at an
angulation of 45° to the long axis of the
tooth, simulating the clinical situation. The
results show that ferrule length is more
important than post length in increasing
fracture resistance.
Peter Carrotte
Glasgow Dental School
Downloaded from magonlinelibrary.com by 144.082.238.225 on May 9, 2018.
C O N T RO L
practice. Ann Intern Med 1992; 116: 798-805.
11. Ciesielski C, Marianos D, Schochetmann G et al.
The 1990 Florida dental investigations. The press
and the science. Ann Intern Med 1994; 121: 886-
888.
12. Lot F, Seguier JC, Fegueux S et al. Probable
transmission of HIV from an orthopedic surgeon to
a patient in France. Ann Intern Med 1999; 130: 1-6.
13. Blanchard A, Ferris S, Chamaret S et al. Molecular
evidence for nosocomial transmission of human
immunodeficiency virus from a surgeon to one of
his patients. J Virol 1998; 72: 4537-4540.
14. Centers for Disease Control and Prevention.
Update: investigations of patients who have been
treated by HIV-infected health-care workers.
MMWR 1992; 41: 344-346.
15. Robert LM, Chamberland ME, Cleveland JL et al.
Investigations of patients of health care workers
infected with HIV. The Centers for Disease
Control Database. Ann Intern Med 1995; 122:
653-657.
16. Gerberding J. Provider-to-patient HIV
transmission: how to keep it exceedingly rare. Ann
Intern Med 1999; 130: 64-65.
17. Chant K, Lowe D, Rubin G et al. Patient-to-patient
transmission of HIV in private surgical consulting
rooms. Lancet 1993; 342: 1548-1549.
18. Chant K, Lowe D, Rubin G et al. Patient-to-patient
transmission of HIV. Lancet 1994; 343: 415-416.
19. Miller CH. Requirements behind regulated waste
protect fellow workers, environment. RDH 1996;
16: 38-40.
20. Burke FJT, Wilson NHF, Martin MV et al. The
influence of infection control on dental surgery
design. Dent Update 1997; 24 (Infection control
supplement 7).
21. Rothwell PS, Dinsdale RC. Cross-infection
control in dental practice. Part 1: The
practicability of a zone system to reduce cross-
infection risks in conventionally-designed dental
surgeries. Br Dent J 1988; 165: 185-187.
22. Worthington LS, Rothwell PS, Banks N. Cross-
infection control in dental practice. Part 2: A dental
surgery planned with cross-infection control as the
design priority. Br Dent J 1988; 165: 226-228.
Crown
Ferrule
Post & Core
Root
At least 5mm
of root filling
Figure 1. Illustration of the Ferrule effect in
crown design.
15