BDA advice

Infection control

December 2019
 Infection control Overview
The requirements for in-house decontamination are described in the following
Contents guidance:
3 Infection control in practice
• England – HTM 01-05: Decontamination in primary care dental practices and the
4 Professional responsibilities Health and Social Care Act 2008: Code of practice on the prevention and control
Patient information of health associated infection and related guidance
Health screening • Scottish Dental Clinical Effectiveness Programme – Decontamination into
Infected dental clinicians Practice
• Northern Ireland – HTM 01-05 as amended by PEL 13-13
5 Personal protection • Wales – WHTM 01-05: Decontamination in primary care dental practices and
Training and individual responsibilities community dental services
Immunisation
Inoculation injuries
Hand protection Key learning points
Eye protection and face masks
Surgery clothing This advice provides an overview of the requirements that you must follow to meet
Removing PPE the recommendations relevant to the country where you practice. It explains:
Aerosol and saliva/blood splatter
• The requirements that you must work to and the best practice requirements that
9 Equipment you should be working towards achieving
Decontamination process • The need to protect against unknown carriers of infection and the precautions you
Pre-sterilisation cleaning must take to manage risks
Inspection and function testing • The importance of staff training in all aspects of infection control to ensure
Sterilisation individual safety alongside a safe working environment for patients and team
Instrument packaging and storage members
• The decontamination process, the checks that are needed at each stage and the
12 Impressions, prostheses and appliances storage restrictions and timelines
• Practical advice for adverse incidents such as inoculation injuries and routine
14 Treatment areas procedures such as using and removing personal protective equipment.
Water supplies
Blood spillages

15 Common infections

16 National quality standards

© BDA December 2019 Infection control 2

 Infection control in practice
Policies and protocols Essential requirements and best practice

You must have an effective infection control policy that protects staff and patients
and satisfies legal requirements; it is a requirements of your GDC registration
(Standards for the Dental Team 1.5).
Your policy and procedures must include the following information:
• Minimising the risk of transmitting infection and sharps injuries, and occupational
health arrangements for staff at risk of hepatitis B
• Decontamination and storage of instruments
• Procedures for cleaning, disinfection and sterilisation of instruments
• Management and disposal of clinical waste
• Hand hygiene
• Decontamination of new reusable instruments
• Use of personal protective equipment
• Recommended disinfectants and their use, storage and disposal
• Spillage procedure
• Environmental cleaning.
Review your policy and procedures at least every two years.
A copy of the policy and associated protocols should be readily available to all staff.
All team members should be aware of the policy and understand their role in
ensuring that it is followed routinely. Periodic discussion at a practice meeting will
help to keep the team aware of current requirements.
The HTM guidance recommends compliance with essential quality requirements
and describes the benchmarks for best practice.
Essential requirements include:
• Cleaned instruments are free of visible contamination when inspected
• Instruments are reprocessed (decontaminated) using a validated decontamination
cycle including cleaning/washing and a validated steam steriliser
• Reprocessed instrument are stored in a way that protects them against
contamination
• A detailed plan for moving towards best practice.
Best practice requirements include:
• Instrument cleaning using a validated automated washer-disinfector
• Decontamination undertaken in a dedicated room away from the clinical
treatment area
• Instruments stored away from the clinical treatment area and in a facility that
reduces the likelihood of recontamination of sterilised instruments.
In Wales, essential requirements and best practice have been replaced with a
process of continuous improvement.

Audits
Review your processes by undertaking regular audits of your decontamination
processes (six-monthly in England and Northern Ireland and at least annually in
Wales). The results of audits should be retained for two years.

© BDA December 2019 Infection control 3

 Professional responsibilities All information disclosed by a patient during medical history taking, consultation
and treatment is confidential and must not be disclosed without the patient’s
You have an obligation to provide care to those in need, including those who are or permission (including to relatives). All members of the team must be aware of the
might be infected, and to offer the same high standard of care for all patients. It is duty of strict confidentiality and the need to keep secure any information provided
unethical to refuse dental care to patients who disclose a positive diagnosis for a by patients. The requirement to maintain confidentiality should be included in all
blood-borne virus (BBV) because it could expose you to personal risk. It is also contracts of employment and discussed at team meetings to ensure that all team
illogical as many undiagnosed carriers of BBVs attend for treatment every day and, members understand its importance.
because they remain untreated, may present a higher risk of infection. People living
with HIV and the hepatitis viruses who are otherwise well, may be treated without Health screening
any restrictions or modification to their dental treatment.
Before their appointment is confirmed, new members of the clinical team should
undergo health clearance checks for BBVs and TB.. Additional checks are required
Letting your patients know that you follow national guidelines on infection control
for those performing exposure prone procedures (EPPs) to establish that they are
– for example, by including a statement on your website or in your practice
non-infectious for hepatitis B, hepatitis C and HIV.
information leaflet or displaying a notice in the practice – and encouraging them to
ask questions will reassure them that you are confident about your infection control
EPPs are invasive procedures where injury could result in the clinician’s blood
procedures.
contaminating the patient’s open tissues. They include procedures where the
worker’s gloved hands may be in contact with sharp instruments, needle tips and
Patients trust that you (and members of the team) will employ effective infection
sharp tissues (spicules of bone or teeth) inside a patient’s open body cavity, wound
control measures to keep them safe. Letting them know that you are taking
or confined anatomical space where the hands or fingertips may not always be
appropriate precautions (for example, using disposable items or sealed single-use
completely visible.
items or sterilised items) can further enhance their trust and might mitigate the risk
of future complaints. Infected dental clinicians
Maintaining a consistent high standard depends on the team understanding the Consolidated guidance clarifies the BBV health clearance measures for new HCWs
importance of this aspect of patient safety and regular compliance audits. and the follow-up and management of HCWs living with HIV and/or hepatitis B who
perform EPP. Health clearance guidance for tuberculosis is available separately.
Patient information
A dental clinician who is, or may be, living with a BBV, TB or other infection must
You must take a detailed medical history when a patient first attends the practice
seek medical advice and undergo any necessary testing and counselling. Changes
and review it at subsequent appointments; it must be retained as part of the
to clinical practice may be required and may include ceasing or restricting practice,
patient’s dental records. Direct questioning and discussion in a confidential
the exclusion of EPPs or other modifications. An infected clinician must not rely on
environment will allow the patient to disclose sensitive and confidential personal
their own assessment of the possible risks to their patients. Failure to obtain
information. Using a questionnaire will ensure that you ask the same questions of
appropriate advice or act upon the advice given would almost certainly lead to their
each patient.
fitness to practice being questioned.
The medical history and examination may not identify asymptomatic carriers of
Dental nurses do not usually carry out EPPs as part of their routine work activities
infectious disease, so the same infection control procedures must be used for all
and can continue working in the surgery if found to be infected with hepatitis B or
patients. Those who reveal that they are infected are providing privileged
other BBV. However, personal protective equipment must be used routinely, and a
information that should only be used to make appropriate treatment decisions that
risk assessment carried out to identify work activities that may pose a risk to
benefit the patient and are in their best interests.
patients.

© BDA December 2019 Infection control 4

 Hepatitis B (HBV)
Clinicians who are hepatitis B surface antigen (HBsAg) positive should have their
HBV DNA viral load tested. If the viral load is above 200 IU/ml, they should cease
EPPs immediately. Initial clearance to perform EPPs requires two identified and
validated samples (IVS), taken at least four weeks apart with both showing a viral
load below 200 IU/ml.
Hepatitis C (HCV)
Clinicians who are HCV RNA positive should be restricted from performing EPPs.
Clinicians living with HCV who have been treated with antiviral therapy and who
remain HCV RNA negative for at least 6 months after cessation of treatment should
be permitted to return to performing EPPs. A further check three months later should
show them to be HCV RNA negative. A return to EPPs is a local decision and does
not require a referral to UKAP (although it can provide advice if needed).
HIV
Clinicians living with HIV who have a plasma viral load above 200 copies/ml should
not perform EPPs.
Initial clearance to perform EPPs requires the clinician to be on effective
combination antiretroviral therapy (cART) and to have had two IVS test results
taken at least 12 weeks apart – both must demonstrate a viral load below 200
copies/ml. The consultant occupational physician decides whether to permit the
clinician to undertake EPPs.
Clinicians who are restricted from EPPs and receiving cART and with a viral load
below 200 copies/ml, need one IVS (12-16 weeks since their last undetectable viral
load) for the consultant occupational physician to grant clearance for EPPs.
Clinicians living with HIV and performing EPPs should be periodically monitored in
line with UKAP Occupational Health Register requirements.
© BDA December 2019
Personal protection
Employers must ensure the personal protection of those working at the practice.
Where this requires the use of personal protective equipment (PPE), it is not
sufficient simply to provide PPE, the employer must ensure that it is being used
routinely and in the correct manner. All team members must understand the
principles of personal protection and that it is mandatory to use any PPE provided.
This requirement should be included in the employment contracts of affected
employees.
Training and individual responsibilities
All members of the team must understand how infections are transmitted, the
practice policy on decontamination and infection control, what personal protection
is required and when to use it, and how to deal with accidents and personal injury.
This training should be included in the practice induction programme for new staff.
Training records should show that all staff have been appropriately trained in
decontamination procedures and know how to decontaminate the reusable dental
instruments used at the practice.
Although the practice owner has overall responsibility for the decontamination
processes, support from team members is essential. Identifying individuals to take
on the following responsibilities will help to ensure that processes are up to date and
adopted routinely:
• Decontamination and infection control procedures within the practice
• Team training
• Daily and weekly periodic tests.
Infection control 5
 Immunisation
The Green Book provides information on recommended vaccinations for healthcare
professionals and advises that immunisation programmes be managed by
occupational health services with appropriately qualified specialists. The employing
dentist must meet any costs associated with vaccinations for work purposes. NHS
Health at Work Network lists providers of NHS occupational health services in England.
Employers must hold documentary evidence to demonstrate that all relevant
members of the dental team have been immunised and their responses to the
vaccine checked; post vaccination blood test results will show whether an adequate
level of immunity has been achieved. The employee’s consent must be obtained
before the occupational health department or GMP is approached; any information
provided is confidential.
Hepatitis B
The hepatitis B vaccination is recommended for those who have direct contact with
patients’ blood or blood-stained body fluids (including saliva). This includes contact
with blood-contaminated sharp instruments. New staff who have not been
immunised should start the vaccination course as soon as possible. Dental nurses
can assist chairside following the first vaccination if a risk assessment of their duties
has been undertaken and appropriate controls have been put in place.
Immunisation against infectious diseases (The Green Book) includes information
on hepatitis B immunisation. For pre-exposure prophylaxis, an accelerated schedule
should be used, with the vaccine given at zero, one and two months. A very rapid
schedule can be followed, with the vaccine given at zero, seven and 21 days, and a
fourth dose administered 12 months after the first dose.
Antibody titres for hepatitis B should be checked one to four months after completion
of a primary course of the vaccine. The results will inform decisions about post-exposure
prophylaxis following a known or suspected exposure to the virus. Immunocompetent
healthcare workers who have received a primary course of hepatitis B vaccine and are
known responders no longer require a booster dose 5 years later.
Non-responders (antibody titre below 10mIU/ml) must be tested for markers of
current or past infection; a repeat course of the vaccine may be required. They
should be briefed on the personal risk of working in dentistry and the importance of
following the practice inoculation injury protocol to allow timely post-exposure
prophylaxis.
© BDA December 2019
Tuberculosis
Tuberculosis (TB) is spread by water droplets or by direct contact and has been
transmitted by dental procedures. Dental professionals are more likely than the
general population to come into contact with the infection and unvaccinated. Those
who are tuberculin-negative and aged under 35 years should be vaccinated.
The current shortage of the BCG vaccine has interrupted the national immunisation
programme. Where immunisation is required, you should seek advice from your
local occupational health provider.
Inoculation injuries
Inoculation injuries are the most likely route for transmission of blood borne viral
infections in dentistry and include all incidents where a contaminated object or
substance breaches the integrity of the skin or mucous membranes or has contact
with the eyes – for example:
• Sticking or stabbing with a used needle or other instrument
• Splashes with a contaminated substance to the eye or other open lesion
• Cuts with contaminated equipment
• Bites or scratches inflicted by patients.
Inoculation injuries must be dealt with promptly and correctly:
• Allow the wound to bleed, then wash thoroughly with running water
• Assess the risks associated with the patient and the injury. Where transmission
of infection is a possibility, contact your local occupational health service for
advice on the necessary follow-up action, including serological surveillance and
post-exposure prophylaxis (PEP). Practices without an NHS contract may need
to arrange this privately. Details of your local contact should be displayed
prominently within the practice
• When local advice is not available, you should seek advice from your local
health protection team
• Record the incident in the accident book and include details of who was injured,
how the incident occurred, what action was taken, which dentists were informed
and when and, if known, the name of the patient being treated. Both the injured
person and the dentist in charge should countersign the record.
If the source patient is HIV infected and the injury is risk-assessed as significant,
PEP should start as soon as possible and ideally within an hour of the injury. You
should identify the local arrangements for urgent access to PEP before any incident
occurs.
Infection control 6
 Safer sharps
Guidance on the Health and Safety (Sharp Instruments in Healthcare) Regulations
2013 requires risk control measures:
• To avoid the use of sharps wherever possible
• When their use is necessary, to use safer sharps whenever practicable
• To not cap/re-sheath needles after use, unless a suitable appliance is used that
controls the risk. Some syringes include a shield that covers the needle after use
• To dispose of sharps safely.
If you decide that it is not practicable to use safer sharps and wish to substitute
traditional unprotected sharps:
• The device must not compromise patient care, must be reliable and easy to use,
and must not introduce other safety hazards or exposure to other sources of
blood
• You must be able to maintain appropriate control over the procedure
• The safety mechanism should be straightforward to use, integral to the device,
and activated automatically or single-handedly; if the mechanism can be
reversed, it is not effective
• An audible, tactile or visual signal indicates that the safety mechanism has
correctly activated.
Hand protection
Fingernails should be kept clean, short and smooth; false nails and nail polish should
not be used. If a wedding ring is worn, the skin beneath it should be washed and
dried thoroughly. Otherwise, rings, bracelets and wrist watches should be removed
during clinical procedures. Cuts, abrasions and cracked skin can offer a portal of
entry for microorganisms and should be covered before putting on gloves.
Clean hands complement the use of gloves; neither is a substitute for the other.
Hand hygiene should take place:
A poster illustrating effective hand hygiene should be displayed above every wash-
hand basin. Mild liquid soap reduces the risk of hand irritation and disposable towels
for drying helps prevent transfer of micro-organisms. Hand cream (preferably water-
based) will help to avoid chapped or cracking skin. Ideally, a wall-mounted hand-
cream dispenser with disposable cartridges should be used.
Gloves
Gloves must be worn for all clinical procedures and a new pair used for each patient.
Suitable gloves should be manufactured to European standard BSEN 455, be well-
fitted and non-powdered; the powder from gloves can contaminate veneers and
radiographs, disperse allergenic proteins into the surgery atmosphere and interfere
with wound healing. They should also be low in extractable proteins (<50µg/g) and
low in residual chemicals. Alcohol gels should never be used on gloves. Used gloves
must be disposed of as clinical waste.
Domestic household gloves should be used when processing contaminated
instruments and equipment. They should be washed with detergent and hot water
to remove visible soil and left to dry after each use. These gloves should be replaced
weekly or more frequently if torn or visible soil cannot be removed by washing.
Latex allergy
Allergic contact dermatitis is rare but, if it develops, it may cause the individual to
cease practice. If you suspect it, you should seek advice from a dermatologist.
Irritant contact dermatitis is more common but can be avoided by selecting good
quality gloves and meticulous hand care.
If a patient is allergic to latex or the chemicals used in glove manufacture, non-latex
gloves should be used. Additional precautions will also be needed to protect against
contact with latex through other sources – local anaesthetic cartridges, rubber dam
and eye protection, for example.

• Before and after each treatment session

• Before putting on and after the removal of PPE
• Following the washing of dental instrument
• Before contact with sterilised instruments (wrapped and unwrapped)
• After cleaning or maintaining decontamination devices used on dental instruments
• At the completion of decontamination work.

© BDA December 2019 Infection control 7

 Eye protection and face masks
Eye protection is essential for all clinicians and support staff to protect against
foreign bodies, splatter and aerosols especially during scaling (manual and
ultrasonic), the use of rotary instruments, cutting and use of wires and the cleaning
of instruments.
Protective eyewear should include side protection. The lenses of many prescription
glasses may be too small to provide protection; a visor or face shield can be worn
over glasses. Patients’ eyes must always be protected against possible injury and
tinted glasses may also protect against glare from the operating light.
Masks (to EN14683) must be worn during all operative procedures to help protect
against splash and splatter; they do not protect against aerosols. Masks are single
use so must be changed after every patient. Visors can be used in addition to masks
and cleaned between patients or, if single-use, disposed of as clinical waste.
Respirators (to EN149) should be used when treating patients with active
respiratory viral infections (e.g. active TB and pandemic influenza). Filtering
facepiece devices (such as FFP2 & FFP3) provide an effective barrier to both droplets
and fine aerosols.
Surgery clothing
Surgery clothing should not be worn outside the practice, so changing and storage
facilities must be provided. Short sleeves allow the forearms to be washed as part
of the handwashing routine whereas long sleeves may become contaminated
during clinical sessions.
Freshly laundered uniforms should be worn every day and, to reduce any potential
microbial contamination, laundered at the hottest temperature suitable for the
fabric. Disposable plastic aprons should be worn during decontamination processes.
© BDA December 2019
Removing PPE
You should remove PPE in the following order:
• Gloves – ensuring that the gloves end up inside out and without the hands
becoming contaminated
• If they become contaminated, wash them thoroughly before removing other
PPE
• Plastic disposable apron – by breaking the neck straps and gathering the apron
together touching the inside only
• Face mask – by breaking the straps or lifting over the ears, avoiding touching
the outer surface of the mask. Never allow a used mask to hang around your
neck
• Face and eye protection, taking care not to touch outer surfaces.
When all PPE has been removed, you should wash your hands thoroughly.
Aerosol and saliva/blood splatter
Good surgery ventilation and efficient high-volume aspirators reduce the risk of
infection by dispersing and eliminating aerosols. Aspirators should exhaust
externally but without risk to the public or re-circulation into any building. Aspirators
and tubing should be cleaned as recommended by the manufacturer and, at the
end of each session, be flushed through with their recommended surfactant/
detergent and/or non-foaming disinfecting agent.
Rubber dam virtually abolishes saliva/blood splatter and should be used whenever
practicable. When working without rubber dam, high-volume aspiration is essential.
Infection control 8
 Equipment Single-use (disposable) items
‘Single-use’ items must be used only on one patient during one treatment session
Only purchase equipment that is necessary and is right for the job. Unless the and then discarded. Items designated as single use will bear the international
equipment is designated single use, it must be able to withstand the symbol:
decontamination processes available at the practice. A practice protocol for
selecting new equipment will help to ensure that any equipment purchased meets
these criteria. You should consider the following:

• Will the equipment selected do what you need it to do?

• Is it compatible with other equipment in the surgery?
• How easy will it be to use and maintain?
• Is it CE marked?
• If the instrument requires dismantling before cleaning, are there manufacturer’s Equipment that cannot be safely decontaminated for re-use must be considered
instruction for how this is done? ‘single-use’. Where instruments are difficult to clean, single-use alternatives (if
• Does the manufacturer specify a limited life-cycle? available) should be considered – matrix bands, saliva ejectors, aspirator tips and
• Are the manufacturer’s recommendations for cleaning and decontamination three-in-one tips, for example.
achievable in practice?
• Will the instrument withstand automated washer-disinfector processes? Endodontic reamers and files should be treated as single-use. In England,
endodontic instruments that are designated reusable should be treated as single-
• Avoid difficult to clean serrated handles and check that hinges are easy to clean
patient use to reduce the risk of prion transmission. If reusing these items on a single
• If cleaning agents are recommended, will they pose a risk those using them and
patient, your practice systems must ensure that they are associated with the correct
will they be compatible with the washer-disinfector, ultrasonic cleaner and
patient. If cleaned manually, the instruments should be cleaned separately from
instruments already in use in the practice?
other instruments.
• Check with the manufacturer which cleaning agents are recommended for the
dental chair covering and work surfaces to ensure that they can be regularly
decontaminated without deterioration
• Select foot-controlled equipment whenever possible
• If training required, will the manufacturer provide it?
• The commissioning and validation requirements of the equipment
• Are there ongoing costs?
• What is the response time in the event of a breakdown?

© BDA December 2019 Infection control 9

 Decontamination process
At the end of each patient treatment, all instruments selected for use (used and
unused) must be cleaned and sterilised, following the manufacturer’s instructions
for decontamination. New instruments must be decontaminated before use.
You should have safe procedures for transferring contaminated instruments to the
decontamination area and for transferring sterilised instruments to the treatment
or storage area.
The decontamination process includes pre-sterilisation cleaning, disinfection,
inspection, sterilisation and storage. Where possible, these processes should be
validated. Validation shows that the process has been verified, tested and
documented and is consistently reproducible. Equipment that cannot be sterilised
must be thoroughly cleaned and disinfected in accordance with the manufacturer’s
instructions.
Decontamination processes should be undertaken away from the clinical work are
and, wherever possible, in a separate room. If decontamination takes place in the
surgery, the reprocessing area should be as far as possible from the dental chair and
undertaken when the patient is not in the surgery. The decontamination area should
include:
• Separate hand-washing sink
• Setting-down area for dirty instruments
• Washing and rinsing sinks (or one sink with a removable bowl that can
accommodate the instruments for rinsing)
• Ultrasonic cleaner (where used)
• Washer-disinfector (where used)
• An area with a task light for instrument inspection and function testing. Where
type B or S (vacuum) sterilizers are used, this area can also be used for wrapping
instruments prior to sterilization sterilizer(s)
• An area for setting down sterilised instruments prior to placing them onto trays
for use or storage if already wrapped
A dirty-to-clean workflow should be maintained throughout to minimise the
possibility of used instruments coming into contact with sterilised instruments. Air
movement should, ideally, be from clean to dirty areas.
© BDA December 2019
Pre-sterilisation cleaning
Cleaning instruments before sterilising them reduces the risk of transmission of
infectious agents and is easiest if undertaken soon after the instrument has been
used. Blood, saline and iodine are corrosive to stainless steel instruments and will
cause pitting and then rusting if allowed to remain on instruments for any length of
time. Where a delay cannot be avoided, the used instruments should be immersed
in water or an enzymatic cleaner but avoid lengthy periods of wet storage. Dental
materials should be removed from instruments as soon as possible after use (and
before they harden) to allow effective cleaning. After cleaning, instruments should
be rinsed in water (potable, reverse osmosis or freshly distilled).
Instruments and equipment with more than one component should, where the
manufacturer recommends, be dismantled to allow each part to be cleaned.
Washer-disinfectors
Washer-disinfectors offer the best option for a validated process and remove the
need for manual cleaning; where possible, they should be used. The installation of
a washer-disinfector must comply with the Water Fittings Regulations.
A typical washer-disinfector cycle includes five stages:
1. Flush - removes gross contamination using a water temperature of less than 45OC
2. Wash - removes remaining soil using detergents specified by the manufacturer
3. Rinse(s) – removes detergents
4. Thermal disinfection – temperature raised for required time: 80OC for 10 minutes
or 90OC for 1 minute, for example
5. Drying - heated air removes residual moisture.
Staff must understand how to use the washer-disinfector, following the
manufacturer’s instructions, and perform the daily tests. Keep records of training.
Washer-disinfectors must be loaded correctly to ensure effective cleaning by:
• Not overloading instrument carriers or overlapping instruments
• Opening instrument hinges and joints fully
• Attaching instruments requiring irrigation to the irrigation system correctly, and
ensuring filters are in place if required (for example, for handpieces).
Infection control 10
 Washer-disinfector logbooks and records should include cycle parameters and
details of routine testing and maintenance. Automated data-loggers or interfaced
small computer-based recording systems can be used, provided the records are kept
securely and replicated (to guard against fading). Records should be kept for at least
two years.
Ultrasonic cleaners
Ultrasonic cleaners are an effective means of cleaning dental instruments and
reduce contact with contaminated instruments. They must be maintained and
tested according to manufacturer’s recommendations. The results of all tests should
be recorded.
Prior to ultrasonic cleaning, briefly immerse used instruments in cold water (with
detergent) to remove visible soiling; a container with a sealing lid is recommended.
When placing instruments in the ultrasonic cleaner:
• Place the instruments in a suspended basket, not on the floor of the cleaner
• Do not overload the basket or overlap the instruments
• Open instrument hinges and joints and, where appropriate, disassemble
instruments
• Immerse fully in the cleaning solution
• Set the timer, close the lid and do not open until the cycle is complete
• Drain the basket of instruments and rinse to remove residual soil and detergent.
Where instruments require wrapping and sterilising in a vacuum steriliser, they must
be dried first using a disposable non-linting cloth.
The water/fluid must be changed at the end of the clinical session and more
frequently if it becomes heavily contaminated. At the end of each day, the
ultrasonic cleaner must be emptied, cleaned and left dry.
Manual cleaning
Manual cleaning carries a greater risk of inoculation injury than other cleaning
methods, but you should have the facilities, documented procedures and trained
staff to undertake manual cleaning alongside other cleaning methods. Where
manual cleaning is necessary, you should maintain a dirty-to-clean workflow and
follow written procedures to reduce variability in cleaning.
© BDA December 2019
Manual washing and rinsing require two dedicated sinks or one sink with a
removable bowl only used for final rinsing (and not instrument washing). Always
use detergents specifically made for the manual cleaning of instruments and follow
the manufacturer’s instructions for concentration and temperature (which should
not exceed 45OC). Submerge the instruments and scrub using long-handled brushes.
Rinse the instruments after cleaning.
Where instruments require wrapping and sterilising in a vacuum steriliser, they must
be dried first using a disposable non-linting cloth.
Dental handpieces
• Washer-disinfectors are preferred if the handpiece can withstand this cleaning
method and the washer-disinfector can clean handpieces
• Dedicated handpiece-cleaners can be considered where a washer-disinfector is not
recommended
• Commercial products for decontaminating handpieces can be used where the
product can be shown to reduce the risk of infection transmission or the process can
be validated.
• Follow manufacturer’s recommendations for lubrication; separate canisters of
lubricant should be used for unclean and cleaned handpieces.
Inspection and function testing
After cleaning and before sterilisation, inspect instruments for cleanliness (using a
magnifying glass and task lighting) and checked for wear or damage. Reclean any
instruments that remain contaminated. Working parts and joints should move
freely; a non-oil-based lubricant may be necessary where hinges are stiff. The edges
of clamping instruments and scissors should meet with no overlap or rough edges;
scissor edges should move freely across each other. Screws on jointed instruments
should be tight.
You must not use faulty or damaged instruments. Clean, sterilise and label the
instruments as ‘decontaminated’ before dispatch.
Infection control 11
 Sterilisation
Seek advice from the manufacturer on whether the daily tests can be undertaken
The preferred method of sterilisation in dentistry is saturated steam under pressure
while instruments are being processed. The results of checks must be recorded to
delivered at a temperature of 134-137OC with a holding time of 3-3.5 minutes.
demonstrate compliance. A steriliser that fails to meet any of the test requirements
should be withdrawn from service until the cause has been rectified.
Three types of steriliser are suitable for use in dentistry:

• Type N (displacement): designed for unwrapped, non-hollow and non-air retentive When first purchased, sterilisers should be commissioned to ensure that they are
instruments appropriately calibrated and functioning correctly; a Competent Person
(Decontamination) or service engineer must validate the steriliser to demonstrate
• Type B (vacuum): designed for hollow, air retentive and packaged loads
that the right conditions for sterilisation are achieved. The equipment must be
• Type S (vacuum): designed for specific loads (determined by the manufacturer).
maintained in line with the manufacturer’s instructions and periodically examined
by a competent person.
Effective sterilisation requires steam to contact all surfaces of the instrument so load
instruments into the chamber to allow free circulation of steam. Avoid overloading.
The parameters should be monitored for each cycle. Print-outs and automated data
loggers or interfaced computer-based recording systems are acceptable provided
Fill water reservoirs daily using fresh distilled or reverse osmosis (RO) water. Where
the records are kept securely and replicated. Where automatic data production is
possible, Discharge the sterilizer water after each cycle (where possible) and drain
not available, you should keep manual records of the temperature/pressure
the reservoir at the end of each working session to reduce the likelihood of toxin
achieved or an absence of failure. Records should be maintained for at least two
build up in the water supply. At the end of the day, drain, clean and dry the chamber
years.
and ensure the door is left open.

Dental handpieces Compare readings with the recommended values. If any are outside the specified
limits, the sterilisation cycle must be checked again. If it is unsatisfactory again, the
Handpiece manufacturers will provide advice on decontamination. If cleaned using
steriliser should not be used until the problem has been rectified by an appropriately
a validated washer-disinfector (if recommended by the manufacturer), further
trained engineer. Chemical indicators (TST strips, for example) demonstrate only
processing using a type B or type S steriliser is acceptable, although the presence of
that instruments have been through a sterilisation cycle, not that they have been
lubricating product means the handpiece is unlikely to achieve sterility.
sterilised.
Checks, tests and record keeping
Before turning on the power at the start of the day:

• Clean the rubber door seal of the steriliser with a clean, damp non-linting cloth
• Check the chamber and shelves for cleanliness and debris
• Fill the reservoir with freshly distilled or RO water.

Daily tests include:

• Automatic control test to demonstrate that the steriliser is working

• Steam penetration test (vacuum sterilisers only)
• Where recommended by the manufacturer, a warm-up cycle before instruments
can be processed.

© BDA December 2019 Infection control 12

 Instrument packaging and storage
Sterilised instruments must be protected to reduce the possibility of
recontamination. The area used for packing prior to storage should be wiped clean
with detergent and alcohol wipes at the start of each session. Where necessary, use
disposable non-linting cloths to dry instruments; a fresh cloth for each sterilised
load.
Wrapped instruments
You can store wrapped instruments for up to one year. The steriliser used
determines when instruments should be wrapped:
• Type N (displacement): dried instruments can be wrapped after sterilisation. If you
store instruments in trays, the entire tray should be placed in a sealed pack
• Type B (vacuum): dried instruments can be pre-wrapped
• Type S (vacuum): manufacturer’s guidance should be followed
Impressions, prostheses and appliances
You are responsible for ensuring impressions, prostheses and appliances have been
cleaned and disinfected prior to dispatch to the laboratory. You should agree the
cleaning and disinfection process with the laboratory and label the device to
indicate disinfected status. This removes uncertainty and, for impressions, the
possibility of repeated disinfection, which may affect quality.
• Immediately after removal from the mouth, rinse the device under clean running
water until it is visibly clean.
• Disinfect the device using cleaning materials specified by the manufacturer, then
rinse the device. This process should occur before and after any device is placed in
a patient’s mouth.
• If the device is to be returned to a supplier/ laboratory, a label to indicate that it has
been disinfected should be affixed to the package.

Packaging should display the date of decontamination and an expiry date.

Unwrapped instruments
After sterilisation, unwrapped instruments should be stored dry and be protected
from contamination – in mini racks placed in cupboards or in in covered drawer
inserts, for example – not on an open work surface.

If you store instruments in the surgery (in a cupboard or drawer, for example), you
should have the instruments you will need for the patient ready before treatment
starts, eliminating the need to open cupboard doors or drawers during treatment.
If you need additional instruments during treatment, you should ensure that your
hands are clean and put on a new pair of gloves before handling unwrapped
sterilised instruments. At the end of the working day (or at the beginning of the next
working day), you should process all unwrapped instruments regardless of whether
they have been used.

HTM 01-05 (England and Northern Ireland) recommends that instruments stored
away from the surgery (in a separate decontamination room, for example) should
be used within one week.

A storage system of first-in, first-out will help you to monitor storage times to ensure
that recommended intervals are not exceeded.

© BDA December 2019 Infection control 13

 Treatment areas
The layout of the surgery should be simple and uncluttered with distinct areas for
the operator and the dental nurse, each with a washbasin. The washbasins should
have sensor-controlled of elbow/foot-operated mixer taps and dispensers for
antimicrobial hand-wash solutions, liquid soap and hand rub/gel.
Work surfaces and floor coverings should be impervious and easy to clean and,
where possible, without joints. If present, joints should be sealed. Coving between
the floor and wall will help prevent accumulation of dust and dirt. The
manufacturer’s advice should be sought on the compatibility of detergents and
disinfectants.
Surfaces can be cleaned using commercial bactericidal cleaning agents and wipes.
If water with a suitable detergent is used, you should dry the surface after cleaning.
Do not refill disinfectant spray bottles as bacteria can contaminate the bottles and
grow in the spray mechanisms. Such bottles, whether supplied pre-filled or empty,
should be single use.
Defining the areas that become heavily contaminated during operative procedures
(zoning) will simplify decontamination: work surfaces, dental chair, curing lamp,
inspection light, hand controls, spittoons, and aspirator, for example. Light and chair
hand controls can be protected with disposable impervious coverings and changed
between patients or the controls cleaned.
At the end of clinical sessions, clean all work surfaces using disposable cloths or
microfibre materials, including the taps, drainage points, splashbacks, cupboard
doors and sinks. Aspirators, drains and spittoons should also be cleaned, following
the manufacturers’ instructions.
Computer keyboards should be washable or have covers that can be easily
decontaminated.
© BDA December 2019
Water supplies
Legionella
All businesses must assess the risks from legionella and prepare a course of action
for preventing or controlling the risk; you must have competent help to do this. The
HSE publication Legionnaire’s Disease: the control of legionella bacteria in water
systems (L8) provides further information.
Dental unit water lines (DUWLs)
The majority of dental units harbour biofilm – a source of microbial contamination
for the water produced by the unit. Contaminated water may harbour potentially
pathogenic organisms such as Legionella spp and Pseudomonas aeruginosa and is
a potential hazard to both patients and surgery staff. Further information can be
found in BDA advice Dental unit waterlines.
Blood spillages
Use hypochlorite at 1000 ppm available chlorine for cleaning blood spillages.
Solutions of hypochlorite can be made up freshly using hypochlorite-generating
tablets and should be used within a week. The hypochlorite solutions should be in
contact with the spill for at least five minutes.
Hypochlorite at a higher concentration of 10,000 ppm available chlorine is useful
for blood contamination. You should start the decontamination process quickly and
avoid corrosive damage to metal fittings etc. Do not use alcohol in the same
decontamination process.
Infection control 14
 Common infections
Herpes Simplex
Herpes simplex virus type 1 (HSV-1) is usually associated with infections of the lips,
mouth and face. It is the most common virus and is usually associated with
childhood. HSV-1 often causes lesions such as cold sores in and around the mouth
and is transmitted by contact with the lesion and infected saliva. By adulthood, up
to 90% of individuals have antibodies to HSV-1. The herpes virus can reside in the
body for years, appearing only as a cold sore when something provokes it, for
example, illness, stress, hormonal changes and sun-exposure. Individuals usually
experience a tenderness, tingling or burning before the actual sore appears, initially
as a blister which subsequently crusts over.
All stages of a herpes virus infection can be contagious although fluid-filled vesicles
are much more infectious than other stages of the herpes infection. Ideally, dental
treatment should not be undertaken but the decision lies with the individual
clinician – bearing in mind that:
• The herpes simplex virus is highly infectious and easily transmitted
• Manipulation of the facial and oral tissues can exacerbate the condition and
cause breakdown of the lesion and bleeding
• Spread of the virus to other areas of the skin can cause significant problems
(new primary lesions, for example); infection of the eyes is a rare but
significantly serious complication.
A patient requiring urgent dental care should not be denied it but, until the herpetic
lesions are healed, the dental team should take care to prevent the spread of the
virus. Reactivation of oral herpes can occur within three days of major dental
treatment (root canal treatment or surgery, for example). Dental treatment may
also cause intraoral recurrent herpes in the oral soft tissue (mucosa) adjacent to the
teeth.
Children are particularly vulnerable before they develop antibodies to HSV-1, so
extra care must be taken to avoid spreading the virus to other areas of the child’s
mouth and face. Gloves, mask, and eye protection are essential when treating a
child with an active infection.
© BDA December 2019
Influenza
Influenza is a respiratory illness characterised by rapid onset of a wide range of
symptoms including fever, cough, headache, sore throat and aching muscles and
joints. It has an average incubation time of two to three days and people are most
infectious soon after they develop symptoms.
Transmission is through close contact with an infected coughing or sneezing person.
Hand washing (with soap and water or alcohol hand rub) and environmental
cleaning will deactivate the virus and help control spread through contact.
The main measures for containing the infection include:
• Standard infection control measures and droplet precautions
• A ‘stay at home’ approach for anyone with flu-like symptoms
• Separating flu-infected patients from well patients when dental care is needed
• Preventing symptomatic visitors (accompanying well patients, for example) from
attending the practice.
MRSA
No additional infection control precautions are necessary for the dental treatment
of patients colonised with Meticillin-resistant Staphylococcus aureus (MRSA).
However, members of the dental team known to be colonised with MRSA should not
undertake or assist with invasive procedures. A clinical microbiologist or
communicable disease physician will be able to provide treatment to eradicate the
MRSA colonisation.
Infection control 15
 National quality standards
CQC inspections
The CQC will assess a dental settings against the code of practice on the prevention
and control of infections. The main purpose of the Code is to ensure that registered
providers understand the requirements for cleanliness and infection control and
how to comply. It also provides compliance guidance for the CQC and information
for patients, commissioners and the public. Appendix B of the Code provides
examples of how the requirements might apply in dental practices.

HIW inspections
Healthcare Inspectorate Wales undertakes inspections of NHS dentists and dentists
providing private care (or both). Inspections are carried out at least every three
years by an experienced HIW inspection manager and an external reviewer (a
dentist). The inspection will consider how practices meet the National Minimum
Standards to provide safe, quality standards. Inspectors will look for evidence of
compliance and availability of documents.

RQIA inspections
RQIA assess practices against the minimum standards for dental care and
treatment to ensure patients are not exposed to risks, including the risk of infection:

• The premises are clean

• The practice adheres to the appropriate infection control policies and
procedures, in line with current best practice and legislation
• Systems are in place, including induction and on- going training, to make sure
these policies and procedures are known, and are being used appropriately at
all times
• The practice meets current best practice guidance on the decontamination of
reusable dental and medical instruments
• Where required, patients are informed about the need for procedures designed
to prevent and control infection
• The dental team meets CPD requirements in relation to disinfection and
decontamination.

© BDA December 2019 Infection control 16